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GRENFELL TOWER INQUIRY: PHASE 1 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 Chairman: The Rt Hon Sir Martin Moore-Bick October 2019 Volume 1 HC 49–I

GRENFELL TOWER INQUIRY: PHASE 1 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 Chairman: The Rt Hon Sir Martin Moore-Bick October 2019 Presented to Parliament pursuant to section 26 of the Inquiries Act 2005 Ordered by the House of Commons to be printed 30 October 2019 Volume 1 HC 49–I

This report contains images and content which some may find distressing. © Crown copyright 2019 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. This publication is available at www.gov.uk/official-documents Any enquiries regarding this publication should be sent to us at contact@grenfelltowerinquiry.org.uk ISBN 978-1-5286-1602-7 (Volume 1 of 4) 4 volumes not available separately CCS0719597372  10/19 Printed on paper containing 75% recycled fibre content minimum Printed in the UK by the APS Group on behalf of the Controller of Her Majesty’s Stationery Office

iii Contents Volume 1 Part I: Background matters Chapter 1: Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Chapter 2: Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Chapter 3: Grenfell Tower and the Surrounding Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Chapter 4: Fire Safety Design and the “Stay Put” Strategy. . . . . . . . . . . . . . . . . . . . . . . . . . 27 Chapter 5: The Regulatory Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Chapter 6: The Refurbishment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Chapter 7: The London Fire Brigade. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Chapter 8: Before Grenfell: the Lakanal House Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Volume 2 Part II: The events of 14 June 2017 Chapter 9: Introductory Note. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Chapter 10: Period 1: 00.54-01.30. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Chapter 11: Period 2: 01.30-01.40. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Chapter 12: Period 3: 01.40-01.50. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Chapter 13: Period 4: 01.50-02.00. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Chapter 14: Period 5: 02.00-02.20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 Volume 3 Chapter 15: Period 6: 02.20-02.50. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313 Chapter 16: Period 7: 02.50-03.00. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361 Chapter 17: Period 8: 03.00-03.30. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385 Chapter 18: Period 9: 03.30-04.00. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417 Chapter 19: Period 10: 04.00-05.00. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439 Chapter 20: Period 11: 05.00-08.10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463 Annex A: Table listing those who were in Grenfell Tower as at 00.54 on 14 June 2017. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489

The Grenfell Tower Inquiry: Phase 1 Report iv Volume 4 Part III: Conclusions Chapter 21: The Cause and Origin of the Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505 Chapter 22: The Escape of the Fire from Flat 16. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517 Chapter 23: The Subsequent Development of the Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541 Chapter 24: Internal Penetration and the Loss of Compartmentation . . . . . . . . . . . . . . . . 561 Chapter 25: Developing Conditions within the Building. . . . . . . . . . . . . . . . . . . . . . . . . . . . 573 Chapter 26: Compliance with Building Regulations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583 Chapter 27: Planning and Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585 Chapter 28: The Incident Ground. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595 Chapter 29: The Control Room. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635 Chapter 30: The Response of the MPS, the LAS, RBKC and TMO. . . . . . . . . . . . . . . . . . . . . 689 Chapter 31: Isolating the Tower from the Gas Supply. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721 Part IV: Remembering those who died Chapter 32: Remembering Those Who Died. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727 Part V: Recommendations Chapter 33: Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 771 Part VI: Looking ahead to Phase 2 Chapter 34: Looking Ahead to Phase 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 783 Appendices Appendix 1: Terms of Reference – 15 August 2017. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 791 Appendix 2: List of Witnesses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 793 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 835

1 Part I Background matters

2

3 Chapter 1 Introduction 1 .1 In the early hours of Wednesday 14 June 2017 a fire broke out in the kitchen of Flat 16 Grenfell Tower, a high-rise residential building in North Kensington, West London. Grenfell Tower was owned by the Royal Borough of Kensington and Chelsea (RBKC) and managed by the Royal Borough of Kensington and Chelsea Tenant Management Organisation (the TMO). Kitchen fires are not uncommon and in terms of its origin and magnitude this one was nothing out of the ordinary. However, the fire, which should have been contained within the confines of Flat 16, escaped from the kitchen into the external envelope of the building. The building was constructed of reinforced concrete, to which there had recently been added a cladding system comprising insulation boards attached to the outside of the concrete structure and protected from the weather by aluminium composite material rainscreen panels. The rainscreen panels contained a polyethylene core. Polyethylene is a highly combustible substance. The material from which most of the insulation boards were made, polyisocyanurate foam, is also combustible.1 1 .2 Firefighters from the London Fire Brigade (LFB) attended the fire and within minutes of their arrival had extinguished the fire within the kitchen of Flat 16, but by that time the fire had already escaped into the cladding where they were unable to fight it successfully. Once established within the cladding the fire spread rapidly up the outside of the building. Within 20 minutes a vertical column of flame had reached the top of the building on the east side from where it progressed around the rest of the structure, so that within a few hours it had engulfed almost the whole of the building. 1 .3 The fire claimed the lives of 71 people who were present in the tower that night, including the life of Logan Gomes, a child who was stillborn shortly after his mother had escaped and had been admitted to hospital. Another resident who had escaped from the building, Maria del Pilar (Pily) Burton, died seven months later. Although she had been seriously affected by smoke inhalation, her death was not directly caused by the fire, but she is mourned by her husband and friends as another victim of a terrible tragedy which affected the close-knit community living in and around the tower. A total of 227 people in all (residents and visitors) escaped from the tower. 1 .4 On the morning after the fire the Prime Minister announced that there would be a public inquiry into the circumstances surrounding the fire and on 28 June 2017 I was appointed to act as its chairman. On 15 August 2017 the Inquiry was formally set up under the Inquiries Act 2005 (the Act); its Terms of Reference can be found in Appendix 1 to this report. As is clear from those Terms of Reference, the primary focus of my task was to investigate the cause and origin of the fire, the means by which it was able to spread throughout the building and how the building came to be in a condition which allowed that to happen. Related matters, such as the response of the LFB, the scope and effectiveness of building regulations and the response of central and local government to the disaster also form part of my Terms of Reference. 1.5 A senior civil servant, Mr Mark Fisher, was appointed Secretary to the Inquiry. Ms Caroline Featherstone, a senior solicitor from the Government Legal Department was appointed Solicitor to the Inquiry and Mr Richard Millett QC was appointed Counsel to the Inquiry. They 1 A small number of insulation boards were made of phenolic polymer foam, which is also combustible.

The Grenfell Tower Inquiry: Phase 1 Report 4 have been ably supported by the members of their teams and I cannot speak highly enough of their dedication to the work of the Inquiry and the assistance I have received from every one of them. It has been, and continues to be, a great pleasure to work with them. 1.6 Pursuant to section 11 of the Act I appointed three assessors to advise me, Ms Joyce Redfearn, a highly respected former local authority Chief Executive, having served with Monmouthshire County Council, Gloucestershire County Council and Wigan Metropolitan Borough Council; Mr Joe Montgomery, an experienced housing professional who has more than 30 years’ experience leading large-scale housing, infrastructure and regeneration programmes in both the public and private sector; and Professor David Nethercot, a distinguished engineer and former Head of the Department of Civil Engineering at Imperial College, London. Other assessors may be appointed as the Inquiry progresses. I have had the benefit of discussing the evidence and my findings with the assessors and have found their contributions very helpful, although responsibility for the findings and conclusions rests entirely with me. 1 .7 Although there was much public speculation at the time about the origin of the fire and the role played by the cladding in its spread, it seemed to me that the first step must be to find out as far as possible exactly what happened during the early hours of 14 June 2017. Only when that had been done would it be possible to focus attention on the underlying causes and the decisions that gave rise to them. I therefore decided that the Inquiry should be conducted in two phases. Phase 1 would identify exactly how the fire started, how it escaped from the flat of origin and how fire and smoke was able to spread throughout the building in a manner and at a speed that prevented many people from escaping, despite the prompt attendance of the emergency services. Phase 1 would also examine the response of the emergency services so far as it bore on the decisions made and actions taken on the night of the fire. Phase 2 would ascertain the underlying causes of the disaster, including the decisions made in relation to critical aspects of the design and construction of the cladding system, the adequacy of the regulatory regime and the response of central and local government. 1 .8 The Inquiry is proceeding concurrently with an investigation by the Metropolitan Police Service (MPS) into whether any criminal offences have been committed by (among others) those who were responsible for the design, maintenance or construction of the building. The Inquiry’s task is to find out what happened and why. Section 2 of the Inquiries Act specifically precludes me from determining any person’s civil or criminal liability, but it also provides that I am not to be inhibited in the discharge of my functions by any likelihood of liability being inferred from the facts I find or the recommendations I make. The role of the Inquiry is, therefore, different from that of the police, but to the extent that each is carrying out an investigation into the same events, the two may be seen as complementary. The MPS have provided the Inquiry with every assistance and will no doubt continue to do so. In so far as there was concern on the part of the police that the Inquiry’s investigations might interfere with their own investigations, I believe that we have managed to find ways in which we can assist each other without compromising our respective functions. I am certainly very grateful for the way in which we have been able to work together in the public interest. 1 .9 Between 20 June and 22 November 2017 Her Majesty’s Senior Coroner for London (Inner West), in whose jurisdiction Grenfell Tower is situated, opened 70 separate inquests into the deaths of those who perished in the fire. She subsequently suspended those inquests pending the outcome of this Inquiry and, if necessary, that of the police investigation. I decided that, in discharging my Terms of Reference, I should carry out, as far as I properly could, an investigation into the deaths caused by the fire corresponding to that which the coroner would be required to undertake in order to discharge her responsibilities. By doing

Part I | Chapter 1: Introduction 5 so I hoped to minimise as far as possible the need for her to re-open any of the inquests and thereby to spare the relatives of those who died the need to endure further proceedings in relation to the deaths of their family members. 1 .10 The Inquiry is unusual in the number of its core participants. I have received applications for core participant status from 768 individuals, companies and institutions, most of which have been granted. Applications continue to be made from time to time, but at the end of September 2019 the number of core participants stood at 619. Most of the individuals who have been granted core participant status had either lived in the tower or were related to someone who had died in the fire, or had lived in one of the buildings adjacent to the tower known as “the walkways”, which were evacuated during the fire. Most of the applications were considered and determined during the latter part of 2018, but further applications have been received at intervals up to the present day. The bulk of the corporate and institutional core participants were involved in one way or another in the refurbishment or maintenance of the tower between 2012 and the present day, but they also include the LFB and three government departments, the Ministry of Housing, Communities and Local Government (MHCLG), the Home Office and the Cabinet Office. A current list of core participants is published on the Inquiry’s website.

1. 11

In keeping with the public nature of the Inquiry, arrangements were made for the hearings to be accessible to all who wished to follow them. All witness statements and documents put in evidence during the course of the hearings were published on the Inquiry’s website. For the convenience of those who live in the area surrounding the tower the proceedings were streamed live to the Methodist Church in North Kensington by kind permission of the minister, the Reverend Dr Michael Long. They were also streamed live on the internet. In addition, arrangements were made for the proceedings to be video-recorded and transcribed and for access to both the video-recording and the transcript to be available through the Inquiry’s website.

1. 12

The Inquiry was formally opened on 14 September 2017 in the Connaught Rooms, London WC2. Although I had hoped to be able to begin hearing evidence in late 2017 or early 2018, it soon became apparent that the volume of material that had to be collected, assimilated and digested would make that impossible. In the event, I was able to begin taking evidence on 21 May 2018 at the Millennium Gloucester Hotel in Kensington, when over a period of two weeks those who had lost friends and relatives in the fire described the people they had known and loved. This was above all a human tragedy which affected not only the lives of those who lived in the tower and its immediate surroundings but also many who lived at a greater distance, not only in this country but also abroad. The moving and dignified descriptions of the lives and personalities of those who had died, and of the community to which they belonged, brought the human dimension to the fore and ensured that it will never be lost to sight amid the many issues of a technical nature with which the Inquiry inevitably has to grapple.

1. 13

Between 4 June and 23 November 2018 the Inquiry sat for a total of 88 days at Holborn Bars, London WC2, during which I heard evidence from many of those who had been directly involved in the fire or the circumstances surrounding it. They included former residents of the tower who had survived the blaze, firefighters, control room officers and senior officers from the LFB, two officers of the MPS, one of whom was on duty at the scene during much of the night, the Director of Operations of the London Ambulance Service (LAS), many of whose members attended to treat casualties, and employees of RBKC and the TMO.

The Grenfell Tower Inquiry: Phase 1 Report 6 1 .14 The evidence of the survivors and the firefighters has been of particular importance, not least because they were able to describe conditions within the building at different times and in different places. In that way they provided an important part of the foundation on which the expert witnesses instructed to assist the Inquiry were able to base their opinions. No less important was the evidence given by the survivors of their experiences as the fire developed. In many cases they escaped due to their courage and determination in the face of daunting conditions and many provided statements describing their experiences in detail. A list of those who provided statements is set out in full in Appendix 2. Their testimony, which has proved to be of great assistance, stands as a permanent record of their individual and collective response to an overwhelming tragedy. The accounts given by many of the firefighters demonstrate that they displayed a remarkable degree of courage and devotion to duty. In many cases individual firefighters entered the burning building on several occasions in disregard of their own safety in an attempt to rescue those who were trapped. I am grateful to all those who gave evidence, both those called to give evidence in person and those who provided written statements but were not called. All the statements received by the Inquiry have been published on its website and form part of its formal record. As such they will be permanently available to those who may wish to read them. 1.15 The Inquiry was fortunate in obtaining the assistance of a number of leading experts in a wide range of fields, whose evidence is referred to in detail later in this report. Some of them gave initial presentations in June 2018 in order to provide a context for the subsequent evidence of the firefighters and survivors, but their formal evidence was reserved until after the close of the factual evidence. Between 20 and 29 November 2018 I heard evidence from the experts, which has proved invaluable in helping me to understand the nature and characteristics of the building, the development of the fire and the wider course of events surrounding it. 1.16 Given the complexity of the disaster, it is unlikely that it will ever be possible to establish with complete certainty some of the details of what occurred at Grenfell Tower during the early hours of 14 June 2017. Many of the experts who have given evidence to the Inquiry have indicated that they intend to carry out further research of one kind or another to validate or refine the conclusions they have reached at this stage. However, I am satisfied that there is enough information already available to enable findings to be made about the central events of the night with sufficient confidence to make recommendations at this stage and to set the direction for the investigation which the Inquiry will undertake in Phase 2. On the whole there have been fewer significant conflicts of evidence than might have been expected and most of those that have arisen can be attributed to differences in individual judgement, perception or recollection. It has been necessary to resolve such differences in the relatively few cases in which a definitive finding is required, but in many cases the differences can be noted without the need for me to decide which of two or more competing accounts is to be preferred.

1. 17

Since the Inquiry is inquisitorial in nature, there is no burden of proof and no fixed standard by reference to which findings of fact must be made. I have therefore adopted the flexible approach that has been followed in many other inquiries. That allows me to express my conclusions in terms of the likelihood that an event did or did not occur. In some cases I have been left in no doubt that an event occurred; in others, I think it more likely than not that it did; in others, that it is possible, and so on. In my view that is likely to be more helpful and to assist the reader to understand the complex factual circumstances which the Grenfell Tower fire presented.

1. 18

Some areas of investigation have given rise to clear conclusions, sometimes without any serious dispute. In such cases I have generally not thought it necessary to describe the evidence in great detail, since I do not think there is anything useful to be gained by doing

Part I | Chapter 1: Introduction 7 so. That is particularly so in cases where the evidence is of a highly technical nature and has been explained by one of the expert witnesses. All the evidence on which my conclusions are based has been published on the Inquiry’s website, where it remains available to anyone who is interested in examining it. In some cases, however, public interest in the matter under consideration is such that a fuller description of the evidence is required, even though the conclusion to be drawn is clear and relatively uncontroversial. Other areas of investigation have given rise to more complex questions and in those cases I have examined the evidence in greater detail in order to explain clearly the basis of my conclusions. Again, the relevant evidence is available on the Inquiry’s website. 1 .19 One purpose of this report is to set out in definitive terms, as far as is currently possible, the course of events at Grenfell Tower between 00.54 when the fire in Flat 16 was first reported to the LFB and 08.07 on 14 June 2017 when the last survivor escaped from the tower. That can best be done by providing a chronological narrative of events. Part II of the report contains that narrative. However, in order to enable the narrative to be properly understood, it is necessary first to describe certain aspects of the background to the events of the night, principally the building itself and the organisation of the LFB. My report therefore adopts that approach.

1. 20

In Part III of the report I set out my analysis and conclusions in relation to the origin and development of the fire and the response of the emergency services, principally the LFB, to the disaster. In the course of doing so I identify a number of serious shortcomings in the response of the LFB, both in the operation of the control room and on the incident ground, and to a lesser extent in that of the MPS, the LAS, RBKC and the TMO. My criticisms are inevitably grounded in my findings about how various individuals acted during the course of that night, but it is right to recognise that those shortcomings were for the most part systemic in nature. I am acutely conscious that those who were on duty that evening were faced with an unprecedented situation for which they were not properly prepared and that both personnel and systems were overwhelmed by the scale of the disaster. It is right to say at the outset that those in the control room and those deployed on the incident ground responded with great courage and dedication in the most harrowing of circumstances.

1. 21

I have also kept in mind the danger of judging with the benefit of hindsight the actions of those who were confronted on the night with a situation none of them had previously encountered. It is important to remember that they could only make use of the equipment and information available to them and were forced to respond to a situation with which, in many cases, they were ill-equipped to deal. I have been careful, therefore, to examine their response from the perspective they had of an unexpected and rapidly developing situation of a kind which none of them had previously encountered.

1. 22

Part IV of this report is a summary of the evidence I heard in May 2018 at the commemorations of the lives of most of those who died at Grenfell Tower. As a summary it self-evidently can never do them full justice, but it is right that the memories of those who knew and loved them stand as a permanent public record of who each of them was in life.

1. 23

Phase 2 of the Inquiry will involve investigating the underlying causes of the tragedy, but as is the case with any analysis of complex events, the distinction between the tragedy and its underlying causes is not easy to identify with precision. Much depends on the level of generality adopted. For that reason I have recognised throughout the hearings that the boundary between Phase 1 and Phase 2 should be kept flexible and, in particular, that it should be understood that much of the evidence given in the course of the Phase 1 hearings is likely to be as relevant, if not more relevant, to the issues that fall for consideration in Phase

1. That evidence has, however, been captured and will be considered in the context of the

The Grenfell Tower Inquiry: Phase 1 Report 8 Phase 2 investigations. In this report I have tried not to trespass more than necessary on the issues that will fall for consideration in Phase 2 and I have therefore refrained from making findings on some of the matters on which evidence was given during the hearings. 1 .24 Rule 13(3) of the Inquiries Rules 2006, which govern the procedure to be adopted in conducting public inquiries, prevents me from including any explicit or significant criticism of a person in my report unless I have sent that person a warning letter and he or she has been given a reasonable opportunity of responding to it. The rules do not explain what is meant in this context by the expression “explicit or significant”, but I have taken the view that it should be interpreted generously in order to ensure that anyone whose conduct might be considered to have been the subject of criticism should have a chance to respond. Accordingly, in July 2019, the Inquiry’s solicitors wrote to 41 individuals and organisations informing them of the specific criticisms that I proposed to make of them and providing them with the relevant sections of the draft report which identified the evidence on which they were based. 1.25 In August 2019 the Inquiry received responses from all those to whom warning letters had been sent. I have considered each of those responses with care and whenever appropriate I have reconsidered the evidence on which the particular criticism was based. In many cases I have modified my provisional conclusions in the light of the responses I received, in order to avoid any unfairness. I have not, however, taken into account fresh evidence or new arguments that could have been, but were not, put forward during the hearing. It is not the purpose of rule 13 to provide those who may be criticised with an opportunity to re-open the proceedings in order to justify their conduct. Although a public inquiry is an investigative, rather than an adversarial, process, which at one level must always be open to new insights, there must be a degree of finality if the process is to reach a conclusion within a reasonable time. Rule 13 itself recognises that in so far as it provides an opportunity to respond to criticism based on the material already before the Inquiry. I hope that this will be borne in mind as the Inquiry moves into Phase 2. 1.26 I am conscious that the Inquiry’s hearings have been followed closely by commentators in the media as well as the public at large. Some of my conclusions are therefore likely to come as no surprise to many, although others may be more unexpected. In either case, however, I hope it will be clear that this stage of the Inquiry’s investigations has been detailed and thorough and that every avenue of inquiry relevant to this stage of the process has been fully explored. A tragedy of these dimensions deserves no less.

9 Chapter 2 Executive Summary Overview

1. 1

This first report of the Grenfell Tower Inquiry is divided into six parts. Part I contains a broad introduction to the events that took place during the early hours of 14 June 2017. It contains a description of Grenfell Tower itself and of the organisation of the London Fire Brigade (LFB) and sets the scene for Part II, which contains a detailed narrative account of the fire and the steps taken in response to it. Part III contains my conclusions about the origin and development of the fire and my analysis of the response of the LFB and the other emergency services which attended the incident. The hearings commemorating those who died constituted an important part of the Inquiry’s proceedings. A summary of the tributes paid to their loved ones by their families and friends is contained in Part IV. Part V contains recommendations arising out of the findings made earlier in the report and Part VI looks ahead to identify some matters of particular importance on which the Inquiry will concentrate its attention in Phase 2.

1. 2

I am grateful to all those who gave evidence, both those called to give evidence in person and those who provided written statements but were not called. I am very conscious that many of those who gave evidence found it a challenging and emotional experience. Part I: Background matters

1. 3

Chapter 1 of the report contains a general introduction to the Inquiry. In it I explain why I decided to conduct the Inquiry in two phases and how the Phase 1 hearings were organised, beginning with commemorations of those who lost their lives in the disaster. I draw attention to the fact that the Inquiry is being conducted in parallel to investigations being carried out by the Metropolitan Police Service (MPS) and Her Majesty’s Coroner for Inner London (West), Professor Fiona Wilcox.

1. 4

Chapter 3 describes Grenfell Tower itself, completed in 1974, and the changes that were subsequently made to the building and its immediate surroundings, culminating in the tower’s most recent refurbishment, which was completed in 2016. It explains the mix of rental and leasehold properties in the tower, the community which lived there, and the different functions of the Royal Borough of Kensington and Chelsea (RBKC) as owner of the building and the RBKC Tenant Management Organisation (TMO) as its manager. 2.5 In Chapter 4 there is an explanation of the principles underpinning fire safety in high-rise residential buildings, such as Grenfell Tower, which have led to the adoption of the “stay put” strategy in response to fires occurring within individual flats. 2.6 A summary of the primary and secondary legislation relevant to the original construction and the later refurbishment of Grenfell Tower is to be found in Chapter 5, together with a reference to certain aspects of the relevant guidance on methods of complying with the legislative requirements.

The Grenfell Tower Inquiry: Phase 1 Report 10 2 .7 Chapter 6 provides an overview of the refurbishment. It contains a description of the new cladding system, associated changes to the windows and their surrounds, and the addition of an architectural crown, as well as other features of the building that were intended to promote safety in the event of a fire. 2 .8 The structure and organisation of the LFB, including its statutory responsibilities, the principles which govern its operations (particularly in relation to fighting fires in high-rise buildings) and the equipment at its disposal, are described in Chapter 7. That chapter also contains a description of the control room and its method of working. The chapter concludes with a description of some of the equipment used by the LFB to which reference is made in subsequent chapters. 2 .9 Chapter 8 refers to the Lakanal House fire, which represents an important aspect of the background to the Grenfell Tower fire. On 3 July 2009 a fire broke out on floor 9 of Lakanal House, a 14-floor building in Southwark. The fire spread rapidly to other floors and smoke affected large parts of the building. Six people died. The coroner made a number of recommendations for change following the fire, some of which were directed at the LFB. The LFB undertook a detailed internal review of its practices and policies relating to 999 call- handling in general and to those calls requiring potentially life-saving fire survival guidance (FSG calls) in particular. The review questioned whether the control room should assume that fire crews would reach FSG callers quickly and whether in general it correctly balanced the risk of staying put against the risk of attempting to escape. Despite changes in policy, similar shortcomings were displayed by the control room when responding to callers from Grenfell Tower. Part II: The events of 14 June 2017

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Chapters 9 – 20, which make up Part II of the report, contain a detailed narrative of the events organised into 11 separate periods between 00.54, shortly before the control room received the first call concerning a fire at Grenfell Tower, and 08.10, when the last survivor left the tower. The account relies on the evidence of survivors and firefighters, source material such as records of 999 calls, and the evidence of expert witnesses called to assist the Inquiry. Each period covers the behaviour of the fire, the events at the incident ground and in the control room, the conditions in the tower itself, the movement of the occupants, and the actions of the MPS, the London Ambulance Service (LAS), RBKC and the TMO. Annex A to Part II contains a list of those who were present in the tower as at 00.54 and the times at which they left the building.

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The following key events form the backbone of the Narrative: 00.54 Behailu Kebede calls 999 to report a fire in Flat 16, floor 4 Grenfell Tower. 00.59 First firefighters reach the tower. 01.09 Fire breaks out of Flat 16 into exterior cladding and starts to climb the east facade rapidly. 01.14 Firefighters enter the kitchen of Flat 16 for the first time. 01.21 First 999 call to the control room from an occupant in the tower (Naomi Li, Flat 195, floor 22). 01.25 First 999 call to report smoke coming into flat from lobby (Denis Murphy, Flat 111, floor 14).

Part I | Chapter 2: Executive Summary 11 01.26 MPS declares a Major Incident. 01.27 Fire reaches the roof and starts to spread horizontally. 01.29 WM Michael Dowden, the LFB incident commander, makes pumps 20 (having made up from 4 to 6, to 8, to 10 and to 15 between 01.13 and 01.28). 01.30 First 999 call reporting fire penetrating a flat (Mariem Elgwahry, Flat 196, floor 22). 01.31 WM Dowden makes pumps 25. By this time 110 out of 297 occupants have escaped; the fire starts to spread to the north elevation of the tower. 01.42 The LAS declares a Significant Incident. 01.45 First NPAS (police) helicopter arrives at the scene. 01.50 WM Dowden hands over incident command to SM Andrew Walton. By this time 168 of 297 occupants had escaped. 01.58 SM Walton hands over incident command to DAC Andrew O’Loughlin. 02.00 Flames travel across the north and east elevations of the tower, and start to spread around the crown and diagonally across the face of the building, affecting flats in the south-east and north-west corners. 02.04 GM Richard Welch declares himself incident commander, not knowing that DAC O’Loughlin has already assumed command. GM Welch makes pumps 40. 02.06 GM Welch declares a Major Incident. 02.11 DAC O’Loughlin takes handover from GM Welch. 02.15 SOM Joanne Smith arrives at the control room. 02.17 Bridgehead moves from floor 2 up to floor 3. 02.20 Flames start to spread to south elevation. 02.26 The LAS declares a Major Incident 02.35 Control room decides to revoke the “stay put” advice and tell all occupants calling 999 to leave the tower. 02.44 AC Andrew Roe takes over incident command from DAC O’Loughlin. 02.47 AC Roe revokes the “stay put” advice. 02.50 Fire spreads horizontally across the south elevation at the crown. Commissioner Dany Cotton arrives at Grenfell Tower. 03.00 Fire starts to spread across the west elevation of tower, from north to south. 03.08 Bridgehead relocates to ground floor lobby. 03.20 First Tactical Co-ordination Group (TCG) meeting. 03.30 Flames continue to spread across the south and west elevations of the tower.

The Grenfell Tower Inquiry: Phase 1 Report 12 04.02 Fires on the south and west elevations start to converge at the top of the southern corner of the west face. 08.07 Elpidio Bonifacio, the last survivor to leave the tower, is evacuated. Part III: Conclusions The cause and origin of the fire and its escape from Flat 16 2 .12 In Chapter 21 I consider the cause and origin of the fire and find that it was started by an electrical fault in a large fridge-freezer in the kitchen of Flat 16, for which Behailu Kebede bears no blame. I have not been able to establish the precise nature of the fault in the fridge‑freezer, but consider that to be of less importance than establishing how the failure of a common domestic appliance could have had such disastrous consequences. That question is pursued in Chapter 22, in which I find that: a. The fire is most likely to have entered the cladding as a result of hot smoke impinging on the uPVC window jamb, causing it to deform and collapse and thereby provide an opening into the cavity between the insulation and the ACM cladding panels through which flames and hot gases could pass. It is, however, possible (but less likely) that flames from the fire in the fridge-freezer passed through the open kitchen window and impinged on the ACM cladding panels above. b. The fire had entered the cladding before firefighters opened the kitchen door in Flat 16 for the first time at 01.14. c. A kitchen fire of that relatively modest size was perfectly foreseeable. The subsequent development of the fire

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The progress of the fire after it had entered the cladding is considered in Chapter 23. Once the fire had escaped from Flat 16, it spread rapidly up the east face of the tower. It then spread around the top of the building in both directions and down the sides until the advancing flame fronts converged on the west face near the south-west corner, enveloping the entire building in under three hours. I find that: a. The principal reason why the flames spread so rapidly up, down and around the building was the presence of the aluminium composite material (ACM) rainscreen panels with polyethylene cores, which acted as a source of fuel. The principal mechanism for the spread of the fire horizontally and downwards was the melting and dripping of burning polyethylene from the crown and from the spandrel and column panels, which ignited fires lower down the building. Those fires then travelled back up the building, thereby allowing the flame front to progress diagonally across each face of the tower. b. The presence of polyisocyanurate (PIR) and phenolic foam insulation boards behind the ACM panels, and perhaps components of the window surrounds, contributed to the rate and extent of vertical flame spread. c. The crown was primarily responsible for the spread of the fire horizontally, and the columns were a principal route of downwards fire spread.

Part I | Chapter 2: Executive Summary 13 The loss of compartmentation and the spread of fire through the tower 2 .14 In Chapter 24 I consider the evidence relating to the penetration of the building by fire and smoke and the rapid loss of compartmentation. The fire on the outside of the building quickly entered many flats and smoke spread rapidly through the interior of the building. As a result, effective compartmentation was lost at an early stage. Compartmentation failed because: a. The intensity of the heat was such that the glass in the windows inevitably failed, allowing the fire to penetrate flats. b. Extractor fan units in the kitchens had a propensity to deform and become dislodged, providing a point of entry. c. A number of key fire protection measures inside the tower failed. Although some fire doors held back the smoke, others did not. Some were left open and failed to close because they lacked effective self-closing devices; others were broken down by firefighters or wedged open with firefighting equipment. 2.15 The spread of fire and smoke within the tower is described in Chapter 25. Many lobbies had started to fill with smoke by around 01.20 and some were significantly smoke-logged by 01.40. By 02.00 a significant number were heavily smoke-logged. Until around 01.50 there was less smoke in the stairs; by then 168 people had been able to escape. After that time the stairs started to fill with smoke, particularly at lower levels. At some levels the smoke was thick and the heat considerable. By 02.20 the smoke in the stairs did pose a risk to life, but the stairs were not absolutely impassable to all even after that time. Compliance with the Building Regulations 2.16 It was not my original intention to include in Phase 1 of the Inquiry an investigation into the extent to which the building complied with the requirements of the Building Regulations. However, as I have explained in Chapter 26, there was compelling evidence that the external walls of the building failed to comply with Requirement B4(1) of Schedule 1 to the Building Regulations 2010, in that they did not adequately resist the spread of fire having regard to the height, use and position of the building. On the contrary, they actively promoted it. It will be necessary in Phase 2 to examine why those who were responsible for the design of the refurbishment considered that the tower would meet that essential requirement. The LFB: planning and preparation

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Planning and preparation by the LFB for fires in high-rise buildings is examined in Chapter 27. National guidance requires fire and rescue services to draw up contingency evacuation plans for dealing with fires in high-rise buildings that spread beyond the compartment of origin causing a “stay put” strategy to become untenable. They should understand, for any given high-rise building in their area, when a partial or full evacuation might become necessary and provide appropriate training to incident commanders.

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The LFB’s policy for fighting fires in high-rise buildings, PN633, envisages that evacuation of a high-rise residential building may be necessary and suggests that during familiarisation visits officers consider evacuation arrangements. However, the LFB’s preparation and planning for a fire such as that at Grenfell Tower was gravely inadequate. In particular: a. The otherwise experienced incident commanders and senior officers attending the fire had received no training in the particular dangers associated with combustible cladding, even though some senior officers were aware of similar fires that had occurred in other

The Grenfell Tower Inquiry: Phase 1 Report 14 countries, and of the fact that construction materials and methods of construction were being used in high-rise building facades with a limited understanding of their behaviour and performance in a fire. b. LFB incident commanders had received no training in how to recognise the need for an evacuation or how to organise one. c. There was no contingency plan for the evacuation of Grenfell Tower. d. Although the LFB purports to maintain an operational risk database (ORD) for buildings in London and has a risk assessment policy (PN800) accessible by all operational firefighters at an incident, the entry on the ORD for Grenfell Tower contained almost no information of any use to an incident commander called to a fire. Such information as was contained in the ORD was many years out of date and did not reflect the changes made by the refurbishment. e. In some cases, basic information relating to the tower held by the LFB was wrong and in others it was missing altogether. The LFB: at the incident ground 2 .19 My findings about operations on the incident ground are to be found in Chapter 28. The firefighters who attended the tower displayed extraordinary courage and selfless devotion to duty, but the first incident commanders, although experienced, were of relatively junior rank. They were faced with a situation for which they had not been properly prepared. In particular: a. None of them seem to have been able to conceive of the possibility of a general failure of compartmentation or of a need for mass evacuation; they neither truly seized control of the situation nor were able to change strategy. b. Once it was clear that the fire was out of control and that compartmentation had failed, a decision should have been taken to organise the evacuation of the tower while that remained possible. That decision could and should have been made between 01.30 and 01.50 and would be likely to have resulted in fewer fatalities. The best part of an hour was lost before AC Roe revoked the “stay put” advice. c. The LFB continued to rely on the “stay put” strategy in place for Grenfell Tower which was not questioned, notwithstanding all the early indications that the building had suffered a total failure of compartmentation. d. No systematic arrangements were made for information about the number and source of FSG calls to be communicated to the incident commanders. Similarly, information about the internal spread of the fire and the results of rescue operations was not effectively shared with incident commanders; pictures from the police helicopter were not available to them. e. There were serious deficiencies in command and control. Although additional resources arrived swiftly, some senior officers failed to give sufficient practical support or inform themselves quickly enough of conditions and operations within the building. f. Many of the physical or electronic communication systems did not work properly, such as the command support system (CSS) on the command units.

Part I | Chapter 2: Executive Summary 15 The LFB: in the control room 2 .20 Chapter 29 contains my findings about the operation of the control room. The control room staff faced an unprecedented number of 999 calls relating to the fire which posed a challenge wholly outside their long experience and training. Control room staff undoubtedly saved lives, but a close examination of the control room’s operations has revealed shortcomings in practice, policy and training. In particular: a. LFB policy on handling FSG calls requires control room operators (CROs) to stay on the line with callers until they are rescued or can otherwise leave the building, but the number of FSG calls received during the fire far exceeded the number of CROs available, putting them in an invidious position. b. Neither the application of the “stay put” policy nor the specific requirements that have to be followed if an FSG caller is to escape from a burning building are properly set out in the LFB policy documents. c. CROs did not always obtain necessary information from callers, such as flat numbers, the number of people present, or whether people were disabled; nor did they always assess conditions at the callers’ locations and hence the possibility of their escape. d. CROs had not been trained to handle numerous simultaneous FSG calls, on the implications of a decision to evacuate, or on the circumstances in which a caller should be advised to leave the building or stay put. They were not aware of the danger of assuming that crews would always reach callers, which was one of the important lessons that should have been learnt from the Lakanal House fire. As a result, they gave assurances which were not well founded. e. When the “stay put” advice was revoked and occupants were to be told to leave the building, the CROs did not all understand that they had to give that advice in unequivocal terms so that the caller would know that they had no choice but to leave the building. f. Channels of communication between the control room and the incident ground were improvised, uncertain and prone to error. CROs did not therefore know enough about conditions in the tower or the progress of responses to individual FSG calls, so they lacked a sound basis for telling callers whether help was on its way. g. Those on the incident ground did not have access to valuable information from the control room. The very fact that CROs had to terminate FSG calls in order to answer new calls ought to have alerted more senior control room officers to the fact that it had become impractical to give proper FSG advice. h. There was no organised means of sharing information obtained from callers among the CROs, and little access to information from other sources. As a result, CROs had no overall picture of the speed or pattern of fire spread. Early on in the incident CROs told occupants that the fire was still confined to floor 4 when in fact it had reached the top of the tower. i. Although the LFB has arrangements in place for handling a large number of 999 calls, routing them to other fire and rescue services, they do not provide for sharing information about conditions at the incident itself. Differing advice was given at important moments. j. There were weaknesses in the supervision of control room staff. Supervisors were under the most enormous pressure, but the LFB had not provided its senior control room staff

The Grenfell Tower Inquiry: Phase 1 Report 16 with appropriate training on how to manage a large-scale incident with a large number of FSG calls. k. Mistakes made in responding to the Lakanal House fire were repeated. The response of the other emergency services, RBKC and the TMO 2 .21 The response of the other emergency services, RBKC and the TMO is considered in Chapter 30, which describes the standing arrangements and protocols for joint operations between London’s emergency services. It is clear that although in some respects they were implemented successfully (for example, the management of the security cordon by the MPS), the response was unsatisfactory in other respects. The evidence does not show that any death or injury resulted from these failures but they contain important lessons for future major disasters in London. In particular: a. The MPS declared a Major Incident at 01.26 without telling the LFB or the LAS. The LFB declared a Major Incident at 02.06 without telling the MPS or the LAS; and the LAS declared a Major Incident at 02.26 without telling the LFB or the MPS. RBKC was not told about any of these declarations until 02.42. This lack of communication was a serious failure to comply with the joint working arrangements and protocols designed for major emergencies in London. b. The consequence of failing to share the declarations of a Major Incident meant that the need for a properly co-ordinated joint response between the emergency services was not appreciated early enough. That in turn led to a lack of shared understanding of the nature and effect of the fire. The conversations that should have taken place between the supervisors of the different control rooms did not happen. c. Communication between the emergency services on the night of the fire, both remotely and on the incident ground itself, did not meet the standards required by the protocols. A  single point of contact in each control room and direct communication between control room supervisors should have been established. d. The heli-tele downlink (the communication link with the police helicopter overhead) failed to function, which adversely affected LFB operations.

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RBKC is subject to certain obligations under the Civil Contingencies Act 2004 and had a formal “Contingency Management Plan” setting out what needed to be done in the event of an emergency. The TMO had no obligations under that plan. It had its own emergency plan, but it was not activated and was in any case fifteen years out of date. As RBKC’s response to the fire relied on key information held by the TMO, its plan was in certain respects ineffective. One particular cause for concern is the delay in obtaining the attendance of a Dangerous Structures Engineer (DSE), despite numerous requests from the LFB; another is the delay in obtaining plans of the building, which were not on site, not on the LFB’s ORD and not available to the LFB until around 08.00. Shutting off the supply of gas to the tower

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Chapter 31 describes the steps taken to isolate the tower from the main gas supply. Gas was supplied to the tower by Cadent Gas Ltd (Cadent). Cadent had a legal obligation to help the LFB, and had reported to the incident ground before 05.00. Fortunately, a key Cadent engineer, Jason Allday, who knew the area well, subsequently arrived unprompted, took charge, and stayed for 24 hours. Shutting off the gas to the tower ultimately involved Cadent’s

Part I | Chapter 2: Executive Summary 17 cutting and capping off three substantial pipes under nearby streets supplying gas to the whole area. The work was completed by 23.40 and the remaining flames in the tower died down almost immediately. Part IV: Remembering those who died

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Chapter 32 contains a summary of the tributes paid to those who died in the fire at the commemoration hearings with which the Inquiry opened. The Inquiry started its Phase 1 hearings at the Millennium Gloucester Hotel in Kensington with commemorations of all those who died and a celebration of their lives. This part of the report names each of those who died and, drawing on the evidence given by loved ones and friends, provides a brief summary of their lives. Part V: Recommendations 2.25 Although Phase 1 of the Inquiry has been limited to investigating the course of events during the night of 14 June 2017 and much work remains to be done, it has already become clear that some important steps need to be taken to improve fire safety, including the response of the LFB and other fire and rescue services to major disasters, including fires in high-rise residential buildings. Chapter 33 therefore contains recommendations arising out of the evidence heard in Phase 1 and the findings of fact based on it. It would not be appropriate to make recommendations at this stage in relation to matters that have not been the subject of investigation, such as the regime surrounding the testing and certification of building materials, even though there are grounds for thinking that changes may need to be made. 2.26 Chapter 33 does not lend itself to being summarised. It should be read in full, because it sets out my recommendations in detail and explains the basis on which they are being made (or in some cases why certain recommendations are not being made). In summary, however, I make recommendations for change in relation to the following matters: a. The information made available to fire and rescue services about the materials and methods of construction used in the external walls of high-rise residential buildings. b. The arrangements made by the LFB to discharge its duties under section 7(2)(d) of the Fire and Rescue Services Act 2004. c. The availability of plans of high-rise residential buildings to local fire and rescue services and the provision of premises information boxes in high-rise residential buildings. d. The regular inspection and testing of lifts designed for use by firefighters. e. Communication between the LFB control room and the incident commander. f. The way in which fire and rescue services handle emergency calls. g. The LFB’s command and control procedures and use of resources, in particular the capture of information from crews returning from deployments and the sharing of information between the LFB control room, the incident commander and the bridgehead. h. The communication equipment available to the LFB for use by crews deployed in firefighting and rescue operations in high-rise buildings. i. The evacuation of high-rise residential buildings, including the provision of equipment enabling firefighters to send an evacuation signal to the whole or a selected part of the building.

The Grenfell Tower Inquiry: Phase 1 Report 18 j. The provision of fire safety information to residents of high-rise residential buildings and the marking of floor levels in lobbies and staircase landings. k. The inspection of fire doors and self-closing devices. l. Aspects of co-operation between the emergency services. Part VI: Looking ahead to Phase 2 2 .27 In Phase 2 the Inquiry will seek to answer the various questions set out in the List of Issues which appears on its website, but as a result of what has been learnt from the work done in Phase 1, some questions have assumed greater prominence than had previously been thought and others have receded in importance. Accordingly, in the final chapter of the report, Chapter 34, there is a pointer to those aspects of the Inquiry’s investigations on which, in the light of Phase 1, particular attention will need to be focused in Phase 2.

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The first matter concerns the deceased. An important element of Phase 2 will be to complete the investigation of the circumstances in which those who died in the fire met their deaths. Many of the findings that are required by the coroner have been made in this report, but there remains the need for an investigation into the wider circumstances that can only be satisfied by the evidence that will emerge during the proceedings in Phase 2. In due course there will be an opportunity for the bereaved to draw together the threads of the evidence relating to those who died in order to enable the necessary findings of fact to be made.

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Other matters of particular concern include: a. The decisions relating to the design of the refurbishment and the choice of materials. b. The regime for testing and certifying the reaction to fire of materials intended for use in construction. c. The design and choice of materials. d. The performance of fire doors in the tower, in particular, whether they complied with relevant regulations, their maintenance and the reasons why some of the self-closing devices do not appear to have worked. e. The organisation and management of the LFB, in particular in relation to the formulation of policy in the light of experience, the arrangements for training firefighters and control room staff, and the arrangements for sharing information about the particular problems associated with fighting fires in high-rise buildings. f. The warnings of potential fire hazards given by the local community. g. The authorities’ response to the disaster.

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It has now become clear that some aspects of the building which were at one time thought to require careful investigation did not play a significant role in the disaster and will not therefore require further examination. They include: a. The width of the stairs. b. The supply of gas. c. The supply of electricity and the history of electrical surges.

19 Chapter 3 Grenfell Tower and the Surrounding Area The tower

1. 1

Grenfell Tower is a residential tower block built in 1974. It is located in the Lancaster West Estate in North Kensington, London W11. The Lancaster West scheme was designed by the architects Clifford Wearden & Associates in the late 1960s and consisted of Grenfell Tower itself and three low-rise residential blocks, sometimes referred to as “finger blocks”, but known locally as “the walkways”. The tower was built by contractors A. E. Symes of Leyton, London; building work commenced in 1972 and was completed by 1974. Grenfell Tower is owned by RBKC. The walkways

1. 2

The walkways extend 150 metres south from the tower and enclose two green spaces. They are Testerton Walk, Hurstway Walk and Barandon Walk. The original design concept for Grenfell Tower was to keep vehicle and pedestrian access separate and hence there was a walkway level running above the ground level and linking the low-rise blocks to the tower. However, in the early 1990s the estate was changed to create a series of independent blocks, each with their own secure entrance and the walkway connection to Grenfell Tower was closed off by the construction of an office. Thereafter, the only access to the tower for residents was through the entrance at ground level on the south side.1 The surrounding area

1. 3

RBKC is an inner London Borough providing the majority of local government services. Although geographically one of the smallest boroughs in London, it is one of the most densely populated areas in Europe.

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Grenfell Tower is located at the northern end of the Lancaster West estate. Grenfell Road runs up from the south and along the east side of Barandon Walk, towards the south-east corner of the tower. As Grenfell Road approaches the tower it turns to the west and runs towards the entrance to the tower, underneath the elevated concrete walkway which runs above the roadway. To the immediate east of the tower is Lancaster Green. To the north of the tower is Silchester Road running east-west, which joins Lancaster Road heading north-east. To the west there is a pedestrian walkway, Station Walk, which runs parallel to the underground railway line (70 metres from the tower) running south-west to north-east. Blechynden Street is also to the west and runs east-west, beyond the railway line. Latimer Road tube station is to the south-west on Bramley Road, which runs north-south and is approximately 200 metres’ walking distance from the entrance to the tower. 3.5 This is a map of the area around Grenfell Tower at the time of its construction: 1 Stage D Design Report Studio E, August 2013 [CCL00000028] paragraph 4.2.

The Grenfell Tower Inquiry: Phase 1 Report 20 Figure 3.1 The residents of the tower 3.6 The vast majority of the residential flats in the tower were part of RBKC’s provision of social housing within the borough. As at 14 June 2017 there were 14 leaseholders of flats within the tower; the remaining flats were home to social housing tenants.

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The occupants of the tower were a diverse group of people of all backgrounds, ages, ethnicities and origins. Some had grown up in North Kensington and had lived there all their lives. Others had come to this country as refugees, in many cases from North Africa, the Middle East, Afghanistan or further afield. Yet others had come to this country from Europe to enjoy living and working in London. Many were employed in the surrounding area or elsewhere in the capital and some had built up their own thriving businesses. No one who was present at the commemoration hearings or who read or heard their evidence to the Inquiry could fail to be impressed by their courage, their resilience and their regard for their neighbours. Together they formed a vibrant community with a strong sense of identity and considerable social cohesion. Management of the tower

1. 8

The TMO is a company limited by guarantee, incorporated on 20 April 1995. On 28 February 1996 RBKC entered into a Management Agreement with the TMO, under which it appointed the TMO to carry out certain housing management functions. Thereafter further agreements were entered into between RBKC and the TMO,2 including Modular Management Agreements in 2006 and 2015. At all relevant times the TMO’s housing management functions extended to Grenfell Tower. 2 A Deed of Variation dated 7 November 2002; a Modular Management Agreement entered into on 12 June 2006; a Deed of Variation dated 1 April 2010 and a Modular Management Agreement entered into on 26  November 2015; RBKC’s position statement dated 9 February 2018.

Part I | Chapter 3: Grenfell Tower and the Surrounding Area 21 The tower on completion of construction

1. 9

Grenfell Tower is just over 67 metres tall and has 25 storeys, including a basement and ground floor to floor 23.3 It has a plan floor area of approximately 22 metres by 22 metres. It has a central reinforced concrete core, reinforced concrete floors and perimeter reinforced concrete columns. These columns appear at each corner of the building, with two internal columns on the east and west faces and three internal columns on the north and south faces. The perimeter columns have been rotated by 45 degrees and appear as diamonds in plan. On their outer surface the columns have a ridged facing, which is a pre-cast concrete “biscuit”. This facing is permanently connected to the columns through the provision of metal wires embedded in the concrete of the columns.4

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At the time of construction the exterior of the building comprised horizontal structural concrete spandrel panels, sliding aluminium-framed windows and a number of non-structural white window infill panels.5 The spandrel panels were solid concrete with no cavities and had an outer surface of washed aggregate. This is a photograph of the external wall of the tower before the 2012-2016 refurbishment project:6 Figure 3.2 3 The original building elevations appear at Fig. 4.14 of Dr Lane’s supplemental report [BLAS0000004] p. 16. 4 Dr Lane supplemental report at 3.1.13 [BLAS0000003] p. 4. 5 The material for these infill panels is currently unknown, but possibly consisted of asbestos bearing cementitious materials: Dr Lane supplemental report at 8.4.7 [BLAS0000008] p. 6. 6 Dr Lane supplemental report [BLAS0000008] p. 6 Fig. 8.2 (and Stage D Report by Studio E, August 2013 [RBK00018840]).

The Grenfell Tower Inquiry: Phase 1 Report 22 3 .11 The following figure shows Grenfell Tower during construction, including the craning-in of the pre-cast “biscuit” cladding to the columns, the reinforced concrete columns and the horizontal structural spandrel panels:7 Figure 3.3

1. 12

At the top of the building is a pre-cast architectural “crown” which consists of tapered pilasters at the tops of the columns and a ring of perforated freestanding concrete beams.8

1. 13

Floors 4 to 23 were designed to accommodate residential flats, with six flats on each floor. Separating each flat at these levels are reinforced concrete cross-walls.9 The lower levels of the building were designed to provide more flexible community spaces, which subsequently accommodated a nursery, offices and a community health centre on the ground floor and floors 1 and 3.10 Floor 2 was originally left open as a continuation of the walkway connecting to the adjacent finger blocks.

1. 14

The basement is a large, open plan space, 5.3 metres high, which extends over the whole footprint of the building. It also has five small blockwork inner rooms and a central concrete core area.11 3.15 Each storey in Grenfell Tower is 2.6 metres high (floor to floor), except for floor 2, which is 4.3 metres high, and floor 3, which has a height of 3.9 metres. 3.16 The structural stability of the tower is achieved in a manner common to most conventional concrete buildings, with a lateral stability core in the middle of the building and concrete columns around the perimeter supporting gravity loads. Each floor has a flat, reinforced concrete slab transferring the floor loading directly to the core. At the outside of the building 7 Dr Lane supplemental report at 8.4.1 [BLAS0000008]. 8 The original perforated concrete beams around the crown can be seen in Fig. 35 of Professor Bisby’s supplemental report [LBYS0000001] p. 63. 9 The original plan for residential levels 4-23 appears at Fig. 4.13 of Dr Lane’s supplemental report [BLAS0000004] p. 15. 10 The original plans for levels 1-3 appear at Figs. 4.10-4.12 of Dr Lane’s supplemental report [BLAS0000004] pp. 12-14. 11 The original basement plan appears at Fig. 4.8 of Dr Lane’s supplemental report [BLAS0000004] p. 10.

Part I | Chapter 3: Grenfell Tower and the Surrounding Area 23 loads are transferred into the columns directly by the floor and by the pre-cast perimeter spandrel panels. Additional support to the floor is provided by the concrete cross-walls between the flats.12 3 .17 The original windows were aluminium-framed and were single glazed with a sliding opening. The metal window frames were fixed directly to the concrete structure on three sides and to the window infill panel on the fourth side. The original window sills, jambs and heads were lined in timber. Above and below the windows were panels of “Purlboard”, a product manufactured by ICI, which comprised a layer of plasterboard and a layer of polyurethane foam bonded to the rear. The strip of Purlboard above the windows extended the full perimeter of the external wall in each flat. This is a picture of the original interior finishes and windows:13 Figure 3.4

1. 18

Within the central core of the building was a single staircase and two lifts serving each floor of the tower and opening onto a central lobby surrounded by six individual flats. This floor plan shows the layout of the floors between floors 4 and 23, which was uniform throughout those levels.14 12 Dr Lane supplemental report at 3.1.18 [BLAS0000003] p. 4. 13 Dr Lane supplemental report [BLAS0000008] p. 7 Fig. 8.4. 14 Dr Lane supplemental report [BLAS0000004] p. 15 Fig. 4.13.

The Grenfell Tower Inquiry: Phase 1 Report 24 Figure 3.5

1. 19

The building was provided with a dry rising fire main15 which could be charged or pressurised with water during firefighting operations. On floors 4 to 23 dry riser outlets were provided in the lobbies on every floor. The common lobbies in the tower were also provided with a smoke control system. Later modifications

1. 20

Apart from the refurbishment carried out between 2012 and 2016, a number of major works were carried out on the tower by the TMO that are relevant to the work of the Inquiry.

1. 21

In 1985 the front doors of the flats were replaced. An application under the Building Regulations for the fitting of new self-closing, fire-resisting flat doors was made in 1985,16 but no further details are known about that work at this time. 15 This means that the pipe is not filled with water and is only charged or pressurised with water during firefighting operations. This is in contrast to a “wet” fire main where the pipe is constantly kept pressurised with water: Dr Lane supplemental report at 15.8.8 [BLAS0000015] p. 32. 16 [RBK00000275].

Part I | Chapter 3: Grenfell Tower and the Surrounding Area 25

1. 22

Between 2005 and 2006 both lifts were refurbished. The work appears to have included the “like for like” replacement of the two lift cars and the renovation of the lift motor room and associated equipment. It was carried out by Apex Lift & Escalator Engineers Ltd; Butler & Young Lift Consultants were the Planning Supervisors.

1. 23

Between 2011 and 2013 the TMO carried out a programme of replacing the entrance doors to the flats on floors 4 to 23 occupied by RBKC tenants. The purpose of the work was to replace 106 flat entrance doors with fire doors which complied with relevant fire safety standards.17 The manufacturer of the doors and contractor which carried out the work was Manse Masterdor.

1. 24

Between 2016 and 2017 a new tenant gas supply was installed to serve the “Flat 2s” in the tower (i.e. the flats in the south-east corner). The work was required because corrosion within one of the existing gas risers had led to a small leak in September 2016. The riser was isolated and a new riser was installed. The new riser enters the building on the south-east side at the basement level and rises vertically through the central staircase between floors 2 and 23. At certain floors it was necessary to install a new lateral gas pipe which passes out through the stair wall, across the lobby and into Flat 2.18 The boxing-in of this pipework in the lobbies had not been completed at the time of the fire on 14 June 2017. The work to replace this riser was commissioned by Cadent Gas Ltd, the relevant gas transporter. The new riser and laterals were designed and installed by tRIIO, a gas design, engineering and delivery business. Changes to the surrounding area 3.25 One of the most significant changes to the area immediately surrounding Grenfell Tower occurred between 2012 and 2015 when a new Leisure Centre and Academy School were built to the east and north of the tower respectively. This was known as the “Kensington Academy and Leisure Centre Project”. Studio E were the architects for the project; the building contractor was the Leadbitter Group. 3.26 To the east of Grenfell Tower there had been a sports centre on the Lancaster Green area. It had been built in the 1970s as a swimming pool and was further developed in the mid-1980s to include a sports hall and squash courts. Between 2012 and 2015 the existing sports centre was demolished and a new leisure centre was built which included two swimming pools and a multi-use sports hall.

1. 27

In September 2014 the Kensington Aldridge Academy opened to the north of the tower, on Silchester Road. This was part of the “Building Schools for the Future” government investment scheme. The lead sponsor was Aldridge Education; RBKC was a co-sponsor.19 The Academy has a capacity of over 1,000 students and is recognised as one of the top academies in the UK.20 After the fire at Grenfell Tower, the school had to relocate for the academic year 2017‑2018 and was unable to return to its original buildings until September 2018. 17 Dr Lane supplemental report at 4.6.9-4.6.10 [BLAS0000004] p. 29. The remaining flat entrance doors which were not listed for replacement in 2011 were the doors for Flats 56, 61, 86, 92, 105, 112, 142, 154, 156, 165, 166, 185, 195 and 206. Of these flats, 12 were leasehold flats and two were tenanted flats (Flats 154 and 166). 18 No laterals were required at floors 7, 15, 18, 19, 20, 22 and 23 and hence those compartment walls were not penetrated by these risers. 19 Kensington Aldridge Academy is recognised as one of the top academies in the UK. In 2017, Ofsted graded the school not only “outstanding” in all areas but “exceptional” and in 2018 it was awarded TES Secondary School of the Year. 20 In 2017, Ofsted graded the school not only “outstanding” in all areas but “exceptional”.

The Grenfell Tower Inquiry: Phase 1 Report 26

1. 28

Due to the presence of the Academy and Leisure Centre and the railway line to the west of the tower, the primary access route to Grenfell Tower for vehicles is Grenfell Road, that being the only route to the tower with unrestricted vehicle access. Although there are secondary access routes for vehicles via Bramley Road and Silchester Road, both of those are through pedestrianised areas, either Station Walk or a paved pedestrian area between the Leisure Centre and the Academy School which contains rising bollards.21

1. 29

This is a plan view of the area after completion of the Kensington Academy and Leisure Centre Project: Figure 3.6 21 Dr Lane supplemental report 17.5.20 [BLAS00000017] p. 50.

27 Chapter 4 Fire Safety Design and the “Stay Put” Strategy 1 Compartmentation and the “stay put” strategy

1. 1

High-rise residential buildings pose particular difficulties for effective firefighting because their upper floors are beyond the reach of established means of external rescue and firefighting. In order to ensure the safety of those within the building, therefore, it has been necessary to include features that will enable the occupants to remain safe until a fire has been extinguished or they can be evacuated. For some time it has been the practice to incorporate many different active and passive safety measures into a high-rise building in order to provide layers of protection that reinforce each other and are capable of maintaining a safe route by which the occupants can leave the building. In most cases that will be a protected stairway.

1. 2

The principle of the design known as “compartmentation” lies at the heart of these safety features. In essence it involves creating within the building a series of self-contained living spaces (usually individual flats) which are separated from all other similar spaces and from the common parts by fire-resisting barriers (walls, floor and ceiling), so that if a fire breaks out within one space it can be contained within that space for long enough to enable the fire and rescue service to extinguish it before it spreads to other parts of the building.

1. 3

The concept of compartmentation, combined with other supporting fire safety provisions, has given rise to the “stay put” strategy, under which, in the event of a fire elsewhere in the building, the occupants are advised to remain within their own flats unless they are directly affected by fire, heat or smoke. This safety strategy reflects the assumption that where traditional construction methods are used, a fire in such a building will usually be contained within the flat of origin and that it is safer for the occupants of other flats to remain where they are rather than leave the building.

1. 4

In its original form the design and construction of Grenfell Tower fully reflected these principles, which can be traced back at least as far as the beginning of the construction of high-rise residential buildings in the post-war years. The 1962 British Standard Code of Practice 3, Chapter IV, Precautions Against Fire, Part 1 (precautions in flats and maisonettes over 80 feet), provided that: “The assumption should no longer be made that buildings must be evacuated if a fire occurs, and high rise residential buildings should, therefore, be designed so that the occupants of a floor above a dwelling which is on fire may, if they choose, remain safely on their own floor. It may be necessary to evacuate the floor on which the fire occurs, and in some circumstances those floors which are in the immediate vicinity of the fire, but the occupants of these floors should be free to reach safety in any other part of the building via the staircase.” 4.5 In 1971, at around the time that Grenfell Tower was being designed, the British Standard Code of Practice CP3, Chapter IV Part 1 Flats and Maisonettes (in blocks over two storeys) stated that: “It has become apparent, and generally agreed, that external rescue by the fire service may not always be possible from blocks of flats and maisonettes, even when the dwellings are in reach of escape ladders … Also, the assumption should no longer be made that entire buildings, or even adjoining dwellings, need to be evacuated if a fire occurs. Owing to the high degree of compartmentation provided in dwellings in modern blocks, the spread of fire and smoke from one

The Grenfell Tower Inquiry: Phase 1 Report 28 dwelling to another and the need to evacuate the occupants of adjoining dwellings are unusual. The occupants should be safe if they remain where they are. Nevertheless the possibility that individuals may seek to leave the building cannot be overlooked and provision should therefore be made for the occupant of any dwelling to do so by his own unaided efforts, using adequately protected escape routes within the building without outside assistance.” 4.6 As Dr Barbara Lane said, this expression of the “stay put” strategy in CP3 1971 was a building safety condition, but it was dependent on the proper installation and operation of active and passive fire protection measures, such as fire-resisting construction around front doors, lobbies and the protected stairway.1 4 .7 In order to understand the actions of the LFB on the night of the Grenfell Tower fire, and in particular the decisions and actions of those on the incident ground and in the control room, it is necessary to consider how the “stay put” strategy was reflected in the guidance and policy documents in circulation at the time of the fire. 2 Guidance for building owners

1. 8

Following the fire at Lakanal House in July 2009, to which I refer in more detail below, the Local Government Association published guidance for building owners entitled Fire Safety in Purpose-Built Blocks of Flats (“the LGA guidance”). It was commissioned by the DCLG and published after wide consultation, including among the DCLG itself and the Chief Fire Officers’ Association. It included the following passage: “18.2 Compartmentation requires a higher standard of fire resistance than that normally considered necessary simply to protect the escape routes. This is to ensure that a fire should be contained within the flat of fire origin. Accordingly those in flats remote from the fire are safe to stay where they are. Indeed, in the majority of fires in blocks of flats, residents of other flats never need to leave their flats. 18.3 This is the essence of the “stay put” principle. It has underpinned fire safety design standards from even before the 1960s, when national standards were first drafted. It is still the basis on which blocks of flats are designed today. In the majority of existing blocks, it remains entirely valid.”

1. 9

Compartmentation has thus been an essential feature of the design of high-rise residential buildings for over 50 years and the “stay put” strategy, which is integral to that, has in general proved to be sound (although there have been important exceptions, such as the Lakanal House fire).

1. 10

Paragraph 19 of the LGA guidance points out that the alternative to a “stay put” strategy is one that involves simultaneous evacuation, which requires a means of alerting residents to the need to leave the building. Purpose-built blocks of flats are not normally provided with general fire detection and alarm systems because experience has shown that most residents do not need to leave their flats when there is a fire elsewhere in the building. Indeed, in some circumstances they might place themselves at greater risk if they were to do so.

1. 11

Paragraphs 18 and 19 of the LGA guidance suggest that the risk inherent in the absence of a fire-detection and alarm system in high-rise blocks is acceptable because it is very rare for there to be an extensive failure of compartmentation. That view is consistent with the absence from Approved Document B of any suggestion that high-rise residential buildings should be fitted with a means of communicating with all occupants simultaneously in order to facilitate a total evacuation. Indeed, total evacuation of a high-rise residential building is inconsistent with the principle underlying Approved Document B, which is that proper 1 Dr Lane supplementary report 3.2.15, 3.2.27, 3.2.28 [BLAS0000003].

Part I | Chapter 4: Fire Safety Design and the “Stay Put” Strategy 29 compliance with the guidance will achieve effective compartmentation and render total evacuation unnecessary. That balance of risk is carefully set out in Part A of the LGA guidance (particularly paragraphs 12 to 14) and is based on historical statistics. It appears to have been endorsed by central and local government and by fire and rescue services. 3 Guidance for fire and rescue services 4 .12 Guidance for fire and rescue services on fighting fires in high-rise residential buildings was published by the DCLG and the Chief Fire and Rescue Adviser in February 2014 in the form of Generic Risk Assessment 3.2 entitled “Fighting fires in high rise buildings (GRA 3.2)”. For present purposes, it is sufficient to note that it clearly contemplated the possibility that total or partial evacuation of a high-rise building might be necessary if compartmentation failed and required contingency plans to be formulated and training to be provided to enable fire and rescue services to take appropriate action in such an eventuality.

The Grenfell Tower Inquiry: Phase 1 Report 30

31 Chapter 5 The Regulatory Context 5.1 When Grenfell Tower was built in the early 1970s, London had its own system of building legislation, comprising the London Building Acts 1930-39 and associated by-laws which imposed technical requirements in relation to the performance of roofs, walls and other parts of buildings when exposed to fire.1 It was not until 1985 that building work in inner London was brought within the scope of the general Building Regulations. Section 34 of the London Building Acts (Amendment) Act 1939 (the 1939 Act) set certain requirements in relation to the means of escape in case of fire and section 20 imposed additional fire safety requirements for tall buildings. Designers of buildings could obtain assistance in discharging the relevant statutory obligations from guidance published by the London County Council and the Greater London Council2 and national guidance, in particular from British Standard Code of Practice CP3.3 According to Dr Barbara Lane, certain features of the building suggest that the architect was looking primarily to British Standard Code of Practice CP3 1971 when designing the building. In particular, CP3 1971 permitted the construction of high-rise residential buildings with a single stairway and a cross-ventilated single lobby on each floor. Travel distances up to 15 metres between residential apartments and the entrance to the escape route were permitted. In addition, section 20 of the 1939 Act and the associated Code of Practice required certain provisions to be made in the stairs for firefighting.4 5.2 By the time the main refurbishment of Grenfell Tower was carried out between 2012 and 2016, the Building Act 1984 (the 1984 Act) and the Building Regulations 2010 made under it governed the construction of such buildings. Pursuant to section 1 of the 1984 Act, the Secretary of State has power to make Building Regulations for a number of broad purposes, including securing the health, safety, welfare and convenience of persons in or about buildings and of others who may be affected by buildings or matters connected with them. The Building Regulations 2010 do not contain technical requirements, but set out in Schedule 1 a series of functional requirements which must be achieved, thereby allowing flexibility in the means by which the requirements are satisfied.5 5.3 Regulation 4(1)(a) of the Building Regulations 2010 requires building work to be carried out so that it complies with the applicable functional requirements in Schedule 1. “Building work” for these purposes includes the material alteration of an existing building, i.e. an alteration that would result in its ceasing to comply with a relevant requirement or becoming more unsatisfactory in relation to a relevant requirement than it was before (regulations 3(1)(a) and (2)). 1 [CTAR00000001] pp. 8-10 at 2.2-2.18; [BLAS0000003] pp. 8-10; [BLAS0000004] pp. 17-22. 2 The key London guidance was contained in (1) the London County Council (LCC) Guide “Means of Escape in case of Fire 1954” (amended in 1967 by the Greater London Council (GLC)), (2) the GLC section 20 “Code of practice for buildings of excess height” (1970). 3 National guidance for fire precautions (and particularly means of escape) was contained in either the 1962 or 1971 versions of a British Standard Code of Practice CP3, Code of basic data for the design of buildings, Chapter IV, Precautions against fire. This national guidance was relevant to the Public Health Act 1961 and the Building Regulations 1965. 4 The concrete depth to the stairs suggests e.g. that the higher standard of fire resistance required in the section 20 Code was, in fact, provided. Refer to Dr Lane [BLAS0000004] pp. 20-21 4.2.23-4.2.39, Appendix H [BLAS0000029] for a comparison of the section 20 Code and CP3 1971 requirements and also her oral evidence at Day 79/16/9-19/6. 5 Todd [CTAR00000001] pp. 10-12 at 2.19-2.34.

The Grenfell Tower Inquiry: Phase 1 Report 32 5.4 Requirement B3(4) of Schedule 1 is that the building shall be designed and constructed so that the unseen spread of fire and smoke within concealed spaces in its structure and fabric is inhibited. Requirement B3(3) requires measures to be taken, to an appropriate extent where reasonably necessary, to inhibit the spread of fire within the building and to subdivide the building with fire-resisting construction. Requirement B4(1) is that the external walls of the building shall adequately resist the spread of fire over the walls. 5.5 Section 6 of the 1984 Act provides for publication by the Secretary of State of documents providing practical guidance with respect to the requirements of the Building Regulations. That practical guidance is contained in a series of Approved Documents issued by the Secretary of State which refer to British Standards and other guidance material. Approved Document B (ADB) provides that practical guidance in relation to fire safety by setting out methods which, if correctly followed, can be expected to result in compliance with the Building Regulations. 5.6 The current version of ADB is that published in 2006 as amended in 2007, 2010 and 2013.6 A person designing a building is not obliged to follow its recommendations relating to methods of compliance and may choose to adopt other methods or materials provided that the building when completed complies with the functional requirements of the Building Regulations.7 5.7 Paragraph B3(3) of Schedule 1 to the Building Regulations requires measures to be taken, to an appropriate extent where reasonably necessary to inhibit the spread of fire within the building, to subdivide the building with fire-resisting construction. Such measures are likely to include the provision of fire-resisting partitions and doors. Table B1 of ADB 2010 (the version in force at the time the front doors to the flats in the tower were fitted) sets out the guidance on the standards to be met by fire doors. It recommends that if a door is in a compartment wall which separates a flat from a space in common use, it should have a minimum performance of “FD 30S” when tested in accordance with BS 476-22 (i.e. be capable of resisting fire under test conditions for a minimum of 30 minutes and limit the leakage of smoke to a prescribed extent). Paragraph 2 of Appendix B also recommends that (with certain limited exceptions) all fire doors should be fitted with self-closing devices. Similar provisions were contained in ADB 2013 current at the time of the fire. 6 Todd [CTAR00000001] p. 15 at 2.51. 7 Todd [CTAR00000001] p. 11 at 2.25.

33 Chapter 6 The Refurbishment 1 An overview 6.1 The most significant development, both in terms of the history of the building and relevance to the fire on 14 June 2017, was the refurbishment carried out between 2012 and 2016 (the main refurbishment). During that period Grenfell Tower underwent substantial change. The work affected both the outside and the inside of the building. Most significantly, it incorporated the over-cladding of every storey of the existing building with a new insulation and rainscreen cladding system. 6.2 Planning permission was first sought in 2012 and a lead contractor, Leadbitter Construction Ltd, was appointed. However, after a further procurement process, in June 2014 Rydon Maintenance Limited (Rydon) was eventually appointed the design and build contractor. 6.3 The architect for the main refurbishment was Studio E; the Employer’s Agent and Quantity Surveyor was Artelia Projects UK Limited (Artelia). The cladding subcontractor to Rydon was Harley Facades Ltd (Harley) (which succeeded Harley Curtain Wall Ltd). Some specialist fire engineering services were provided during the project by Exova Warringtonfire. 6.4 The client for the refurbishment works was the TMO. The works were funded by RBKC which released the funds for the project in May 2012. The Department of Building Control at RBKC acted as building control authority, conducting a number of inspection visits between August 2014 and July 2016. The Building Certificate for completion of the works was signed by RBKC on 7 July 2016. 6.5 In addition to the over-cladding of the building, there was a full refurbishment internally of the very lowest floors from the ground floor to floor 3 inclusive, including structural works. This included the creation of nine new flats on these lower floors and the relocation and refurbishment of the existing nursery and boxing club. Soft and hard landscaping works were also carried out in the area immediately surrounding the tower.   6.6 Building services works were carried out within every floor and within every flat. The mechanical and electrical services (M&E) engineer was Max Fordham (appointed by the TMO); Rydon also engaged JS Wright & Co. Ltd (JS Wright) to carry out detailed designs and installation of the M&E works. These internal building services works included the fitting of a new heating system to all areas, the provision of a new boosted cold water distribution system and the refurbishment and extension of the existing environmental ventilation and smoke control system, together with some alterations to the lifts and dry riser system. 2 The cladding system – design and materials 6.7 A central part of the main refurbishment was the addition to the tower of a ventilated rainscreen insulation and cladding system. Effectively a new external wall was created by attaching a number of components to the existing concrete facade. At floors 4 to 23 they comprised insulation materials, new windows, new window infill panels and outer aluminium composite material (ACM) rainscreen panels.

The Grenfell Tower Inquiry: Phase 1 Report 34 6.8 At floors 1 to 3 the outer wall was re-clad with glass-reinforced concrete castings on the columns and other types of rainscreen panels.1 In this report, and in what appears immediately below, it is appropriate to focus on floors 4 to 23 of the tower, because the lower external walls were not involved in the fire. 6.9 This is a close-up picture of the tower at the higher floors after the external cladding works had been completed:2 Figure 6.1 6.10 It will be necessary to examine in Phase 2 the precise reasons why it was decided to undertake the cladding work; no conclusions can be drawn about that at this stage. What follows below is a description of the cladding system, its design and geometry and the materials used. The rainscreen ACM panels 6.11 The outer layer of the new external facade, which covered the existing concrete spandrel panels and the columns, comprised ventilated rainscreen panels made of aluminium composite material. Before being fitted to the building the panels were fabricated into “cassettes”, i.e. three-dimensional shapes which can be hung on steel or aluminium supports fixed to the 1 Including Reynobond PE Aluminium Composite Panel RAL9010; refer to Professor Bisby at [LBYS0000001] p. 78 and CGL Wallplank (a type of ventilated rainscreen system): Dr Lane supplemental report [BLAS0000004] p. 33 Fig. 4.21. 2 Dr Lane supplemental report [BLAS0000004] p. 35 Fig. 4.22.

Part I | Chapter 6: The Refurbishment 35 concrete structure.3 In general this kind of system is called a “ventilated rainscreen system” because it is designed to shelter the building from the majority of direct rainfall but has gaps which are designed to permit the ventilation of the cavity behind the panels and ensure that water is collected and drained away.4 6.12 The rainscreen panels were manufactured as plain sheets by Arconic Architectural Products SAS (Arconic) and were fabricated into cassettes for use at Grenfell Tower by CEP Architectural Facades Ltd (CEP). The panels used on the columns and for the spandrels at floors 4 and above were known as “Reynobond 55 PE” Aluminium Composite Panels (ACP) and had an external finish referred to as “Smoke Silver Metallic Duragloss 5000 Satin”. Each panel consisted of a 3mm thick core of polyethylene bonded between two 0.5mm thick sheets of aluminium. To date, two different coloured PE cores have been found in panels fixed to the tower, one black and one translucent. Testing is being undertaken to establish whether there are any significant differences between the properties of these materials in terms of their reaction to fire.5 The results of those tests will be examined at Phase 2. 6.13 Polyethylene is a combustible synthetic thermoplastic polymer which melts and drips on exposure to heat. It can flow whilst burning and generate burning droplets. It has a high calorific value compared with other common construction materials and will provide a fuel source for a growing and spreading fire.6 It melts at 130-135°C and ignites at around 377°C.7 On exposure to heat aluminium melts at approximately 660°C.8 It has a comparatively high coefficient of thermal expansion, which means that it can be expected to warp and deform under the influence of heat.9 6.14 In the spandrel locations, the panels were formed with a 30° sloping return to the bottom of the window, and a 90° horizontal return to the top of the window.10 On all of the cut edges of the panels the polyethylene core was exposed and the polyethylene core was also exposed along the fold lines on the inside of each cassette.11 At the head of the window the design incorporated a 20mm gap between the panel and the window frame.12 The spandrel panels were hung on vertical cladding rails at approximately 1150mm centres; they were fixed to the building using steel angle pieces (at the window head and sill), brackets and cladding rails on which the panels were hung.13 The spandrel panels were of varying sizes depending on their locations. This is a close-up photograph of the panels on the tower:14 3 This is in contrast to a “riveted” system, where the panels are flat and are cut into pieces and are riveted or screwed onto the building through the face of the panel itself into the supporting bracket rail: Dr Lane oral evidence Day 79/118-12-119/25 and diagram [ARC00000368] p. 3, and Dr Lane supplemental report [BLAS0000008] pp. 52‑53 Figs. 8.57-8.58. 4 A useful definition of a ventilated rainscreen system and its components appears in the British Standard Code of Practice for the design and installation of natural stone cladding and lining: Rainscreen and stone on metal frame cladding systems, BS 8298-4:

1. It explains that such systems should include: a) an outer layer (the rainscreen) intended to shelter the building from the

majority of direct rainfall, b) a cavity which can include insulation, intended to collect any water which passes through the joints and to permit such water to be collected and drained from the system, and c) a backing wall, intended to provide a barrier to air infiltration and water ingress into the building. 5 Professor Bisby supplemental report [LBYS0000001] p. 77. 6 Professor Bisby supplemental report [LBYS0000001] p. 178 paragraph 860. 7 Professor Bisby supplemental report [LBYS0000001] p. 101 Table 3; Professor Torero supplemental report [JTOS0000001] p. 37 Table 1. 8 Professor Bisby supplemental report [LBYS0000001] pp. 104-105 4.12 paragraph 461. 9 Professor Bisby supplemental report [LBYS0000001] p. 105 4.12 paragraph 462. 10 Dr Lane supplemental report [BLAS0000008] p. 49 Fig. 8.53. 11 Professor Bisby supplemental report [LBYS0000001] p. 47 Fig. 20; Dr Lane supplemental report [BLAS0000008] p. 59 Fig. 8.65; Professor Bisby oral evidence Day 78/70-75. As explained by Professor Bisby in oral evidence, the sample ACM cassette which he was provided with had a bevelled edge (i.e. at an angle of approximately 45°), along one of its inner edges (all other edges were cut at 90°), but it was not possible to know if that was the case for other cassettes used in the refurbishment (Day 78/70/12-72/25). 12 Dr Lane supplemental report 8.10.7 [BLAS0000008] p. 50. 13 Dr Lane supplemental report 8.10.9-8.10.10 [BLAS0000008] p. 51. 14 Dr Lane supplemental report [BLAS0000008] p. 51 Fig. 8.56.

The Grenfell Tower Inquiry: Phase 1 Report 36 Figure 6.2 6.15 On the columns, the cassette panels were longer in shape, each one extending from halfway up the spandrel panel below the window, to halfway up the spandrel panel above the window, as can be seen from the image above. This meant that there was a continuous panel at the junction between the windows and the column.15 The column panels were also fixed to the face of the concrete columns using steel angle pieces and cladding rails.16 The columns were clad with one panel per face, i.e. two panels for the internal columns and three panels on the corner columns. There were gaps of between 15mm and 30mm between the panels, both on the spandrels17 and the columns,18 some of which can be seen in the image above.19 6.16 Dr Lane has compared the cassette panels installed at Grenfell Tower with Arconic’s standard details for modular cassette panels. There are a number of differences between the Grenfell Tower panels and standard Arconic cassette panels, including the return depth of the panel, which is significantly greater on the cassettes used on Grenfell Tower.20 It appears that both the shape of the cassettes and the method of fixing were designed specifically for the refurbishment project. Spandrel and column insulation 6.17 Behind both the spandrel and the column ACM panels was a layer of insulation fixed directly to the building. On the spandrels this consisted of two 80mm layers of insulation board, either Celotex RS5000 polyisocyanurate (PIR) polymer foam or (in very limited quantities) Kingspan K15 phenolic polymer foam, depending on the particular location. On the columns, the insulation consisted of one 100mm layer of Celotex RS5000 PIR. A small number of Kingspan K15 insulation boards have also been found on the columns.21 In some instances an additional 15 Professor Bisby [LBYS0000001] p. 55 Fig. 27. 16 Dr Lane supplemental report at 8.10.10 [BLAS0000008] p. 51 and the section view at [BLAS0000008] p. 49 Fig. 8.54. 17 Dr Lane supplemental report [BLAS0000008] pp. 58-59 Figs. 8.66 and 8.10.30. 18 Dr Lane supplemental report [BLAS0000008] p. 59 Fig. 8.65. 19 During her site investigations Dr Lane noted that the gaps between the panels ranged from 15mm to 30mm. 20 117mm on the spandrel panels compared to 50mm in the standard details: Dr Lane supplemental report at 8.10.16-8.10.27 [BLAS0000008] pp. 52-58. 21 Dr Lane supplemental report [BLAS0000008] 8.9.18 p. 34; Professor Bisby supplemental report [LBYS0000001] p. 84 paragraph 344; BRE Global Client Report dated 20 February 2019 [MET00039807] p. 46 paragraph 66.

Part I | Chapter 6: The Refurbishment 37 piece of insulation board was located adjacent to the windows, alongside the columns,22 but that varied across the building.23 The insulation was fixed to both the spandrels and the columns by means of 180mm stakes screwed into the face of the existing concrete.24 6.18 Between the inside face of the rainscreen panel and the outer face of the insulation there was a space or cavity, the width of which varied from 139mm on the columns to 156mm on the spandrels. These cavities were an integral part of the design, their purpose being to allow ventilation and the drainage of any water that penetrated the gaps between the rainscreen panels. Smaller cavities, which had no design function, were also created between the flat surfaces of the insulation boards and the ridged pre-cast biscuit facing of the columns.25 This is a horizontal section detail taken from Professor Bisby’s report, which shows the refurbished system at the junction between the concrete spandrel beam and the concrete column:26 22 Professor Bisby supplemental report [LBYS0000001] p. 44 Fig. 17. 23 Professor Bisby oral evidence at Day 78/82/16-83/14. 24 Dr Lane supplemental report [BLAS0000008] p. 28, 8.9.4. 25 Dr Lane supplemental report [BLAS0000008] pp. 32-33 Figs 8.35, 8.36 and 8.9.13. 26 Professor Bisby supplemental report [LBYS0000001] p. 43 Fig. 16.

The Grenfell Tower Inquiry: Phase 1 Report 38 Figure 6.3

Part I | Chapter 6: The Refurbishment 39 6.19 The front and rear faces of the insulation boards on both the spandrels and the columns were covered by aluminium foil with a thickness of less than 0.1mm.27 However, the edges of the insulation boards were exposed to the atmosphere.28 Although there is some evidence that foil tape was used to cover the joints between insulation boards, as shown in the photograph below,29 there is currently no evidence that foil tape was used to protect the edges. Figure 6.4 6.20 PIR and phenolic foam are both synthetic thermosetting polymers, which have surface temperatures at ignition in the range of 306-377°C and 429°C respectively.30 Both have a low thermal inertia. (The surface temperature of a material with low thermal inertia increases rapidly when heated.) As a result, they have a comparatively low time to ignition and can support rapid flame spread. They can also accelerate the spread of flame on adjacent materials by insulating the cavity and preventing energy from being lost from the system.31 27 Professor Bisby supplemental report [LBYS0000001] p. 80 paragraph 325. 28 Dr Lane supplemental report [BLAS0000008] 8.9.24 p. 34; Professor Bisby supplemental report [LBYS0000001] p. 147 paragraph 708 and p. 179 paragraph 871 and also Figs. 21, 25 and 84. 29 Dr Lane supplemental report [BLAS0000008] p. 35 Fig 8.37. 30 Professor Bisby supplemental report [LBYS0000001] p. 101 table 5 and p. 102 table 6. 31 Professor Bisby supplemental report [LBYS0000001] p. 101 paragraph 438.

The Grenfell Tower Inquiry: Phase 1 Report 40 6.21 An expanding polymeric spray foam was used to fill some of the gaps created at joints between insulation boards and more widely throughout the cladding system.32 Cavity barriers 6.22 Siderise RH “Open State” Horizontal Cavity Barriers were installed in the facade system in both the horizontal and vertical positions.33 These cavity barriers incorporate an intumescent strip which is designed to expand in the event of a fire and seal the gap between the barrier and the rear of the cladding.34 In the horizontal position they were installed approximately 700mm below the level of the windowsills and extended over the columns at that level.35 On both the columns and the spandrels they were mechanically fixed using metal support brackets which pierced the full depth of the barrier at 400mm centres.36 Cavity barriers were not provided for all the columns, however,37 and no cavity barriers were present at the nose of the columns,38 or at the head of the rainscreen cladding (i.e. the top of the building).39 6.23 Inspections of the cavity barriers have shown that: a. they were not continuous, because the cladding rails supporting the ACM panels broke through them at least every 1100mm;40 and b. in many cases they were poorly fitted, with gaps between them instead of being tightly abutted.41 3 Windows – design and materials 6.24 The main refurbishment also brought about significant changes to the windows of Grenfell Tower. New windows were installed on every floor. During the refurbishment the windows were moved outwards so that they no longer sat flush with the concrete but flush with the new cladding system.42 They were also smaller in size than the original windows. Repositioning the windows outside the line of the concrete structure without providing a non-combustible barrier between the interior of the building and the cavity within the cladding system undermined the effective compartmentation of the building. 6.25 These changes to the size and placing of the windows created gaps in what had as a result become part of the internal walls, as follows: 32 Dr Lane supplemental report [BLAS0000008] 8.9.6 p. 28; Professor Bisby supplemental report [LBYS0000001] pp. 89-90 paragraphs 370-372. 33 No cavity barriers designed to be used vertically were identified on site: Dr Lane supplemental report [BLAS0000008] 8.9.53 pp. 46-47. 34 Dr Lane supplemental report [BLAS0000008] 8.9.37 pp. 41-42 and Fig. 8.45; Dr Lane Day 79/143/3-15. 35 Dr Lane supplemental report [BLAS0000008] p. 12 Fig. 8.8 and [BLAS0000008] pp. 38-39 Fig 8.41 and paragraph 8.9.29; Professor Bisby [LBYS0000001] p. 57 Fig. 29. 36 Dr Lane supplemental report [BLAS0000008] 8.9.29 pp. 38 and 40 and Fig. 8.43. 37 Dr Lane supplemental report [BLAS0000008] 8.9.54-8.9.56 p. 47 and also [BLAS0000011] 11.20.83-11.20.87 p. 83 and p. 86 Fig. 11.31. 38 Dr Lane [BLAS0000010] 10.3.40 p. 21. 39 Dr Lane supplemental report [BLAS0000011] pp. 87-88 Figs. 11.32 and 11.33. 40 Dr Lane [BLAS0000008] 8.9.48 pp. 41-44 and Figs. 8.44, 8.47 and 8.48; Professor Bisby [LBYS0000001] p. 52 paragraph 243 and Figs. 25 and 29. 41 Dr Lane supplemental report [BLAS0000008] 8.9.49-8.9.51 p. 45 and Figs. 8.49 and 8.50, and also Lane Day 79/149-150. Dr Lane has also identified that horizontal cavity barriers were installed with the green manufacturer’s tape on the bottom (although this does not appear inconsistent with the manufacturer’s instructions) and she has indicated that she wishes to consider this further at Phase 2 [BLAS0000008] pp. 42-43. 42 Dr Lane supplemental report [BLAS0000008] p. 9 Fig. 8.6 for section views of the original and refurbished windows.

Part I | Chapter 6: The Refurbishment 41 a. Vertical gaps had previously existed between the outer corner of the concrete spandrels and the edges of the columns where the two abutted, but before the refurbishment they had formed part of the exterior wall. One result of repositioning the windows was to incorporate those gaps into the interior behind the new window frames.43 In some places the gaps were filled with an expanding polyurethane foam; in others they remained open.44 b. Before the refurbishment there had been a sloping lip on the outside of the building beneath the windows. Another result of repositioning the windows beyond the outside line of that lip was to create a horizontal gap below the windows.45 Spaces between windows and columns – EPDM membrane 6.26 The reduction in the size of the windows created a gap of between 30mm and 120mm between the sides of the windows and the adjacent columns.46 (The variation in the size of the gap was due to the fact that the columns were not all precisely aligned vertically.47) The gap was covered with a black EPDM (Ethylene Propylene Diene Monomer) synthetic rubber 48 weatherproofing membrane of 1mm thickness. EPDM is combustible and is thermally thin, which means it will burn quite rapidly.49 (The best indication available at present is that it has an ignition temperature of between 180°C and 378°C, but the precise figure does not matter for present purposes.50) The EPDM was bonded to the window frame and the face of the concrete column,51 but in some places it was bonded between the two layers of spandrel insulation.52 Around the columns the EPDM membrane covered the cavity between the insulation and the rainscreen panels without any additional protection.53 uPVC window surrounds 6.27 New uPVC (unplasticised polyvinyl chloride) window sills, jambs and heads were installed around each of the windows on top of the existing timber window surrounds, which were left in place.54 They had a uniform thickness of 9.5mm and a smooth white finish. No specific manufacturer has yet been identified. uPVC is a solid combustible polymer which begins to lose its stiffness at around 60°C and loses it entirely at about 90°C.55 It has an ignition temperature of between 318°C and 374°C.56 It chars when exposed to heat and generally displays limited surface spread of flame due to its high chlorine content.57 The uPVC window surrounds were glued partly to the pre-existing timber window sills, window heads and window jambs, and 43 Dr Lane supplemental report [BLAS0000009] pp. 12-13 and Figs. 9.8-9.10. 44 Dr Lane supplemental report [BLAS0000009] pp. 12-13 and Figs. 9.8-9.10. 45 Dr Lane supplemental report [BLAS0000009] p. 9 Fig. 9.6. 46 Dr Lane supplemental report [BLAS0000008] p. 10 Fig. 8.7 and p. 17 Fig. 8.15. 47 Dr Lane oral evidence Day 79/30/23-79/32/6. 48 Dr Lane supplemental report [BLAS0000009] pp. 20-25; Professor Bisby supplemental report [LBYS0000001] p. 90 paragraphs 373-376. 49 Professor Bisby oral evidence Day 78/133/10-13; Professor Torero oral evidence Day 77/137/3-11. 50 Dr Lane supplemental report [BLAS0000008] 8.8.2 p. 21; Professor Bisby oral evidence Day 78/64/1-22. 51 Dr Lane supplemental report [BLAS0000008] 8.8.5 p. 22. 52 Dr Lane supplemental report [BLAS0000008] 8.9.7 pp. 28-29 and Fig. 8.31. 53 Dr Lane supplemental report [BLAS0000008] pp. 22-23 Figs. 8.22 and 8.23. 54 Dr Lane supplemental report [BLAS0000008] 8.7.1-8.7.11 pp. 14-16. 55 Professor Torero [JTOS0000001] p. 36 lines 1104-1105 and p. 37 Table 1 and Professor Torero Day 77/54. Refer also to Professor Bisby’s presentation on 20 June 2018 where he stated that typical day-to-day upper service temperature limits for uPVC are in the range of about 50°C and its melting temperature is between 75-105°C. Refer also to Professor Bisby oral evidence Day 78/59/6- 60/19. 56 Professor Torero [JTOS0000001] p. 37 Table 1. 57 Professor Bisby supplemental report [LBYS0000001] p. 91 paragraph 379.

The Grenfell Tower Inquiry: Phase 1 Report 42 partly to 25mm insulation boards which were used to close off the opening into the cavity in the cladding caused by the repositioning of the windows. No mechanical fixings appear to have been used.58 The new window arrangement is illustrated in the following photographs:59 Figure 6.5 Figure 6.6 58 Professor Torero supplemental report [JTOS0000001] p. 42 Fig. 55; Professor Bisby’s supplemental report [LBYS0000001] p. 93 paragraph 384; Dr Lane Day 79/47/1; Professor Bisby Day 78/61/17-62/19. 59 Dr Lane supplemental report [BLAS0000008] p. 16 Fig. 8.14 and p. 24 Fig. 8.25.

Part I | Chapter 6: The Refurbishment 43 Window insulation 6.28 On both jambs and also at the head and sill of the windows, beneath the uPVC, was a 25mm layer of PIR insulation,60 either Celotex TB4000 or Kingspan Thermapitch TP. These are both types of PIR insulation, but were much thinner products than those used on the spandrels and the columns. The position of the insulation boards around the windows can be seen from these two photographs:61 Figure 6.7 60 Dr Lane supplemental report [BLAS0000008] p. 19 Fig. 8.18 and [BLAS0000009] p. 20 Fig. 9.13. 61 Dr Lane supplemental report [BLAS0000008] p. 19 Fig. 8.18 and [BLAS0000009] p. 6 Fig. 9.3.

The Grenfell Tower Inquiry: Phase 1 Report 44 Figure 6.8 Window infill panels 6.29 New white “window infill panels” were installed to close the spaces between the windows. These were approximately 1318mm in height and varied in width between 820mm and 1375mm.62 They were also installed flush with the outer face of the new cladding system. The original window infill panels were left in place, creating a cavity between the old and the new panels.63 These new panels were manufactured by Panel Systems Limited under the product name “Aluglaze”. They consisted of an insulating core of 25mm (blue) Styrofoam (extruded polystyrene, often referred to as “XPS”) between two sheets of 1.5mm thick aluminium finished with polyester powdered coating on both surfaces.64 Such panels are sometimes referred to as “sandwich panels” or “insulation core panels”.65 Extruded polystyrene is a closed cell rigid foam. It is a low thermal inertia thermoplastic polymer and therefore it rapidly melts at its surface when exposed to fire. When heated it is likely to form burning droplets or burn as a liquid pool.66 It has an ignition temperature of 356°C.67 62 Dr Lane supplemental report [BLAS0000008] p. 61 8.10.33. 63 Dr Lane supplemental report [BLAS0000008] p. 20 Fig. 8.19. 64 Dr Lane supplemental report [BLAS0000008] p. 61 8.10.32-8.10.36; Professor Bisby supplemental report [LBYS0000001] pp. 389‑402 paragraphs 95-97. 65 Dr Lane oral evidence Day 79/137/7-10. 66 Professor Bisby supplemental report [LBYS0000001] p. 101 paragraph 436. 67 Professor Bisby supplemental report [LBYS0000001] p. 101 Table 4.

Part I | Chapter 6: The Refurbishment 45 Aluminium windows 6.30 The windows themselves were manufactured by Metal Technology Limited and sold under the name “5-20 Hi+ Tilt and Turn Polyester Powder Coating Aluminium Thermally Broken Windows”. They are made mainly of extruded aluminium. The aluminium alloys used in the production of these windows have a melting temperature of around 660°C and will not directly contribute to fire development.68 Extractor fan and infill panel 6.31 Extractor fans set in an insulating core panel were incorporated into the new kitchen windows. The insulation material was again extruded polystyrene.69 The extractor fans themselves were manufactured by Nuaire as part of its CYFAN product range.70 The body and main structural components of these fans appear to be made primarily from polycarbonate-acrylonitrile butadiene styrene (PC-ABS) plastic, which is a blended, combustible, thermoplastic polymer. The properties of that material are still being investigated.71 Method of fitting windows 6.32 Parts of the original window detailing were left in place, despite the installation of new windows as part of the refurbishment. In particular, the original wooden sills and wood joinery were retained beneath the new uPVC heads, sills and jambs and existing Purlboard panels above and below the windows were left untouched.72 The original white window infill panels were retained behind the new infill panels. 6.33 The following figures show the position of the original window frames together with other features of the new window arrangement, including the windows themselves, the EPDM membrane and the gaps created by the reconfiguration of the windows:73 68 Professor Bisby supplemental report [LBYS0000001] pp. 94-95 paragraph 387. 69 Dr Lane supplemental report [BLAS0000008] pp. 62-63 8.10.39-8.10.42 and Figs. 8.72-8.73. 70 Professor Bisby supplemental report [LBYS0000001] p. 98 paragraph 415. 71 Professor Bisby supplemental report [LBYS0000001] p. 98 paragraph 417. 72 Dr Lane supplemental report [BLAS0000008] p. 16 Fig. 8.14. 73 Dr Lane supplemental report [BLAS0000008] p. 24 Figs. 8.24 and 8.25.

The Grenfell Tower Inquiry: Phase 1 Report 46 Figure 6.9 Figure 6.10 6.34 No cavity barriers were installed around the windows.74 74 Dr Lane supplemental report [BLAS0000011] p. 74 11.20.22-23.

Part I | Chapter 6: The Refurbishment 47 4 The architectural crown 6.35 The refurbishment of the building also involved changes to the pre-cast concrete architectural “crown” described earlier in this report. The concrete columns and beams at the top of the tower were wrapped in a band of tall, narrow Reynobond 55 PE ACM cassettes or “fins” which extended around the perimeter of the building above level 23. The “C”-shaped fins were fixed into reverse oriented “C”-shaped aluminium channels. In addition, the tops of the columns were provided with tapered detailing using the same material. The fins and the associated structure at the crown had no functional purpose and were purely aesthetic.75 6.36 Below is a design drawing of the architectural crown at roof level and showing the new “C”‑shaped ACM fins and the new detailing at the top of the columns.76 Figure 6.11 75 Dr Lane oral evidence Day 79/87/14-23. 76 Professor Bisby supplemental report [LBYS0000001] p. 61 Fig. 32.

The Grenfell Tower Inquiry: Phase 1 Report 48 6.37 In the following picture of the crown taken after the fire it is possible to see the remains of the ACM fins and aluminium rails, together with the original concrete behind.77 Figure 6.12 5 Other modifications Floors 1-3: stairs and new flats 6.38 The main refurbishment involved significant works at the lower floors of the tower. On the ground floor an original access stair was demolished and the nursery was relocated and refurbished. A new entrance lobby was created. At floor 1 a bridge connection was made to serve that floor and at floor 2 a new access route was created to the stairs in the core of the building. At floor 2 the boxing club was reduced and refurbished and an additional flat was inserted into the south-west corner of the building. At floor 3 the stairs that originally served the floor from the ground floor were removed and new residential flats were constructed. In total nine new residential flats were created in these levels. Lifts 6.39 In order to accommodate the new flats, the hydraulic lift that had served the non-residential lower floors of the building was removed and new door openings into the two lift shafts serving the main building were created at floors 1 and 3. As at the date of the fire in June 2014, there were two fire control switches; one on the ground floor between the lifts and one on the second floor. Heating and hot and cold water systems 6.40 A new heating system was created for the whole of the tower as part of the main refurbishment. The existing boilers were retained to continue serving the walkways and a new central gas- fired boiler to serve the tower was installed in the basement. Six new risers were put in to 77 Professor Bisby supplemental report [LBYS0000001] p. 63 Fig. 35.

Part I | Chapter 6: The Refurbishment 49 carry hot water to all floors and a new service cupboard was created in the lobbies on every level from level 4 upwards to accommodate the risers and return piping.78 In each lobby the pipes left the service cupboard and were concealed above a new plasterboard ceiling. They entered the individual flats through holes drilled through the concrete walls above the front door. Each existing residential flat was served by an individual heat interface unit (HIU), which was electrically operated and enabled the residents to control their heating and hot water. New pipework and radiators were installed in each flat.79 A new boosted cold water system was also installed which distributed cold water from a plant room at roof level. This also involved installing additional pipework in each of the lift lobbies which entered flats through holes drilled through the concrete walls.80 Environmental and smoke ventilation system 6.41 The environmental and smoke ventilation system was overhauled and modified as part of the main refurbishment. The original smoke control system had been designed as a “corridor smoke dispersal system” and was intended to serve one floor at a time. It was a natural ventilation system with fans providing smoke extraction in the event of a fire. There were a pair of smoke extraction shafts on the north side of the building and a pair of fresh air inlet shafts on the south side of the building. In each lift lobby there were two pairs of Automatically Opening Vents (AOVs) serving these shafts which were designed to open automatically when smoke was detected by sensors in a lobby. This allowed the extraction fans to pull smoke up the shafts on the north side of the building to the outside at roof level and fresh air to enter through the south shafts. There was also an override switch to enable firefighters to operate the system on the fire floor manually. This is a basic diagram of the original smoke control system:81 Figure 6.13 78 Dr Lane supplemental report [BLAS0000004] pp. 42-49. 79 Dr Lane supplemental report [BLAS0000004] pp. 47-48 4.7.60-4.7.63. 80 For a full description of these works refer to Dr Lane supplemental report [BLAS0000004] pp. 49-53 4.7.64-4.7.73. 81 Dr Lane presentation 18 June 2018 slide 173.

The Grenfell Tower Inquiry: Phase 1 Report 50 6.42 During the refurbishment it became apparent that it would be necessary to provide environmental air control in the common parts of the tower because the new services installed in the lobbies could cause them to become uncomfortably warm under normal conditions. As a result, the existing smoke control system was modified to become a combined environmental and smoke control system. It was designed and commissioned by PSB UK Ltd. Under normal circumstances the new system was designed to provide ventilation to the lift lobbies by drawing fresh air up the south shafts and expelling warm air up the north shafts, but, in the event of smoke being detected in a lift lobby, it was designed to act as a means of smoke control only by drawing smoke both up the north shafts and down the south shafts with replacement air being drawn from the stairs.82 As in the case of the original system, it was designed to operate on only one floor at a time. In order to clear smoke, the AOVs on the floor affected would all open and those on all other floors would all close. Fans at roof and second floor level would then draw smoke out of the lobby both through the north shafts to the top of the building and through the south shafts to louvres sited above the entrance at level 2. Below is a basic diagram of the new system.83 Figure 6.14 6.43 In order to provide for this new combined environmental and smoke control system, new features were introduced into the existing system including: new AOVs at floors 4 to 23, new exhaust fans and outlet on the roof, new exhaust fans at level 2, new ductwork at level 2 (connecting the south smoke shafts to louvres outside the building via smoke extraction fans), new builders’ work shafts (linking the bottom of the existing smoke shafts to each of the lift lobbies), a new environmental fan on floor 2, new fan shut-off dampers, a permanently open vent head at the head of the stairs and on the ground floor, and new control panels and detectors.84 These new control panels and detectors included a human machine interface panel (“HMI panel”) located in the ground floor lobby, smoke detectors in the lobbies and 82 Dr Lane Day 81/129/13-22. 83 Dr Lane presentation 18 June 2018 slide 179. 84 Dr Lane supplemental report J6.5.2 [BLAS0000031] pp. 52-53.

Part I | Chapter 6: The Refurbishment 51 yellow smoke vent key panels in each lobby. The latter were provided in order to enable firefighters to override the system if they wanted it to operate on a floor other than that which had been automatically selected. 6.44 It will be necessary to return to the design and operation of the smoke control system later in this report. Dry rising main 6.45 At ground floor level the main refurbishment included provision of a new dry riser inlet to serve the existing dry rising main in the core of the building. This required new pipework on the lower floors of the tower in order to connect with the existing pipework at floors 4 and above. The original inlet valve at ground level had been located opposite the entrance, inside the building. It had served floors 4 to 23, but not floors 1 to 3. During the main refurbishment, that inlet valve was relocated to the outside of the tower to the left of the entrance on the south side. New landing valves were created at floors 1 to 3 and new branches were installed at floors 1 and 2. A new drain for the system was also created at basement level. Landscaping 6.46 As part of the main refurbishment, soft and hard landscaping works were carried out around the immediate perimeter of the tower, including new areas of hardstanding and soft landscaping. To the east of the tower there was an area of hardstanding immediately adjacent to the building, with trees, grass and soft landscaping beyond. To the north was another area of hardstanding and a grassy slope which was steep enough to impede vehicle access. To the west was a children’s playground and to the south was the main entrance. An extended area of hardstanding was created to the south of the building linking up with the top of Grenfell Road.

The Grenfell Tower Inquiry: Phase 1 Report 52

53 Chapter 7 The London Fire Brigade 7 .1 In Part II of this report I set out in narrative form my conclusions about the origin of the fire, its development, the attempts made by the LFB to extinguish it and rescue those who were trapped in the building, and the steps taken by those in the control room to handle emergency calls relating to the incident. In order to provide the context for those Parts it is necessary to describe the organisation and structure of the LFB, the principles which govern its operations and the equipment at its disposal. 1 Statutory responsibilities 7 .2 Since 1 April 2017 the London Fire Commissioner (the Commissioner) has been the fire and rescue authority for Greater London. Part 2 of the Fire and Rescue Services Act 2004 (the 2004 Act) imposes certain obligations on the Commissioner as Greater London’s fire and rescue authority. They include the promotion of fire safety (section 6(1)) and making provision for extinguishing fires and the protection of life and property in the event of fires within Greater London (section 7(1)). In order to fulfil her obligations under section 7(1), section 7(2) requires the Commissioner (among other matters) to secure the provision of the personnel, services and equipment necessary efficiently to meet all normal requirements, to secure the provision of training for personnel, to make arrangements for dealing with calls for help and for summoning personnel, and to make arrangements for obtaining information needed for extinguishing fires and protecting life and property. This last obligation, imposed under section 7(2)(d), is of particular importance in relation to preparations for fighting fires in high-rise buildings.

1. 3

The Commissioner is appointed by,1 and accountable to, the Mayor of London (the Mayor).2 The Mayor may also give guidance and directions (both general and specific) in relation to the manner in which the Commissioner’s functions and duties are to be performed.3 Under the Greater London Authority Act 1999 (the 1999 Act) the Mayor must approve the final text of the London Safety Plan.4 7.4 The LFB is the fire and rescue service for Greater London. For the purposes of the 1999 Act, it comprises the personnel, services and equipment secured by the Commissioner for the purposes of carrying out her obligations, including those under sections 6 and 7 of the 2004 Act. The Commissioner is also responsible under section 327D(5) of the 1999 Act for ensuring that the LFB is “efficient and effective”. 2 Structure and organisation 7.5 The LFB has some 5,500 employees, of whom 4,600 are full-time operational firefighters and officers. For organisational purposes it divides Greater London into four geographical areas, North East, North West, South East and South West. Each area comprises a number of London Boroughs. 1 Subsection 327A(3) of the 1999 Act. 2 Subsection 327A(7) of the 1999 Act. 3 Subsections 327D(1) and (3) of the 1999 Act. 4 Subsections 327G(2) and (3)(b) of the 1999 Act; and also the Mayor’s Direction of 21 March 2017.

The Grenfell Tower Inquiry: Phase 1 Report 54 7.6 The Commissioner is the highest-ranking officer and is ultimately responsible for the running of the LFB. Immediately below the Commissioner are the following supporting ranks:5 a. eight Assistant Commissioners (AC), who are responsible for managing a range of departments and services within the LFB; b. 12 Deputy Assistant Commissioners (DAC), four of whom are responsible for the day-to- day management of the four geographical areas and eight of whom are responsible for operations or policy matters; and c. a number of Group Managers (GM), who, if they are Borough Commanders, manage groups of fire stations or, if they are not Borough Commanders, carry out day-to-day work in specific policy areas. 7 .7 The LFB’s operations involve two principal spheres of activity: the control room and the incident ground. In the control room the LFB takes emergency calls from the public, despatches fire appliances to incidents and maintains communications with the incident ground. At the incident ground firefighters acting under the direction of the incident commander and other officers take steps to extinguish the fire and, if necessary, carry out rescue operations. 7 .8 Ultimate responsibility for the control room and its operations lies with the DAC for Operations; reporting to them is the Principal Operations Manager (POM). The POM is responsible for “ensuring that Brigade Control,6 emergency calls and the mobilising of resources are managed efficiently and effectively”.7 Supporting the POM are two Senior Operations Managers (SOMs) and supporting them, in descending order of seniority, are the Operations Managers (OM), the Assistant Operations Managers (AOMs) and the Control Room Officers (CROs). The SOMs have overall responsibility for the management of the control room, its staff, policies, training and procedures.8 7 .9 Firefighting operations are organised around fire stations located in the various London boroughs, each under the direction of a Group Manager. At the time of the fire at Grenfell Tower there were 103 operational fire stations in London. Every fire station is on duty every day of the year. North Kensington is the nearest fire station to Grenfell Tower; the next nearest is Kensington. 7 .10 Individual fire stations are staffed by the following personnel: a. a Station Manager (SM), who is responsible for the overall management of the station; b. Watch Managers (WM), who are in charge of individual “watches”; c. Crew Managers (CM), who are in charge of the crews of fire appliances; and d. Firefighters (FF), who carry out firefighting and fire safety work. 7 .11 Some fire stations are equipped with two appliances and some with only one. Fire stations with two fire appliances have nine firefighters on each watch and those with one fire appliance have five firefighters on each watch. Each watch is under the direction of a Watch Manager. Watch Managers are divided into two categories, “A” and “B” (the latter being the more senior). A Watch Manager B is in charge of each watch at fire stations with two fire appliances 5 LFB’s Glossary of Terms (Sept 2017) [LFB00000008] p. 9. 6 I.e. the control room. 7 Control Report p. 177. 8 Smith Day 21/3/19-25-4/1-6.

Part I | Chapter 7: The London Fire Brigade 55 (such as North Kensington);9 a Watch Manager A is in charge of each watch at fire stations with one fire appliance (for example, Kensington).10 Watch Managers carry out day-to-day firefighting and fire safety work as well as junior work in policy areas. 7 .12 Each appliance has a crew of three or four firefighters under the direction of a Crew Manager (or Watch Manager A in the case of stations with only one appliance). Crew Managers carry out routine firefighting and fire safety work. At fire stations with two fire appliances, each watch has two Crew Managers; at fire stations with one fire appliance, each watch has one. Each fire station operates a two-shift, four-watch system. The watches are denoted Red, Blue, Green and White. Each watch works a two-day shift followed by two night shifts. Each series of shifts is followed by four days off. The change between the day and night shifts occurs at 09.30 and 20.00 each day. 3 The control room Staffing, layout and equipment 7 .13 OMs, AOMs and CROs constitute the day-to-day staff in the control room. They are divided into watches. The Deputy Commissioner, POM and SOMs work ordinary office hours.11 They are not a part of a watch and are not routinely required to work from the control room. 7 .14 The OM and AOMs (who are also referred to as supervisors or “Officer of the Watch” (OOW) when on duty) manage the control room. The OM has overall responsibility for the watch on duty and he or she is required to manage all the control room functions and staff.12 The OM is also responsible for the assessment of control room performance against agreed service levels and quality standards.13 The AOMs support the OM by overseeing the emergency call‑handling and incident management activities of the CROs. They provide guidance to the CROs to ensure that service level standards are achieved at all times.14 They are also required to maintain the reliability and readiness of relevant control and operations equipment and to work closely with the supervisory structure to ensure effective co-ordination of activities.15 An AOM can perform the role of an OM in times of sickness or annual leave and can also take calls in the role of a CRO during busy times.16 7.15 The CROs are the frontline control room staff. In any shift they can be assigned to one or two of the three core roles of call-taker, paging operator and radio operator. All CROs are trained to perform all these roles. 7.16 The control room, known colloquially within the LFB as “Brigade Control”, is usually located at the London Operations Centre in Merton, South West London. It is a large, modern purpose- built facility completed in 2012 which superseded the old Docklands-based control room. It also hosts the LFB’s Resource Management facility and the London Resilience Group, a London-wide organisation independent of the LFB.17 On the night of the Grenfell Tower fire, the control room was operating from its fallback facility in Stratford, East London because routine maintenance was taking place at Merton. The control room at Stratford is set up in 9 LFB organogram [LFB00000017]. 10 LFB organogram [LFB00000016]. 11 Control Report p. 176. 12 Control Report p. 176 and Norman witness statement [MET000080589] p. 2. 13 Control Report p. 177. 14 Control Report pp. 177-178. 15 Control Report p. 178. 16 Real witness statement [MET000080589] p. 2. 17 Control Report p. 174.

The Grenfell Tower Inquiry: Phase 1 Report 56 the Stratford Fire Station. It is not permanently staffed and is only used occasionally when planned maintenance is being carried out at Merton.18 It can also be brought into operation for a spontaneous or unplanned event that significantly affects the operation of the main facility.19 The photographs on the following pages show the two control rooms.20 7 .17 The facilities at the two sites are intended to replicate each other,21 so that the staff can carry out their roles in the same way wherever they are located. In most respects the facilities at the two sites are the same. CROs sit at banks of desks with three computer screens each and a headset. The layout enables at least two CROs to sit near to each other on each bank of desks. Figure 7.1: Merton Control Room interior, showing the Operations Manager and Assistant Operations Manager sitting next to each other, and Control Room Operators sitting next to each other on banks of desks Figure 7.1 The Merton Control Room 18 LFB Organisational Overview Report [LFB00001905] paragraph 7.3. To CRO Heidi Fox’s knowledge, it was used twice in 2017 by the time she made her statement on 5 October 2017 [MET00007764] p. 4. 19 LFB Organisational Overview Report [LFB00001905] paragraph 7.3. 20 Control Report pp. 173-174. 21 LFB IMP Incident Report [LFB00003114] p. 1.

Part I | Chapter 7: The London Fire Brigade 57 Figure 7.2: Stratford Control Room interior Figure 7.2 The Stratford Control Room 7 .18 The senior control room staff, namely the OM and AOMs, sit at their own bank of desks (known colloquially as “the head table”)22 from which they can see the whole of the room. They also have three computer screens and a headset each and are able to listen in to calls taken by the CROs. A “red phone” is located on their desk. That is the critical information line that is usually connected to the command units at the incident ground to allow communication of “risk critical” or “life risk critical” information by a direct line.23 It is also the line by which other control rooms can contact the LFB control room when they are assisting the LFB with calls and by which BT can also contact the control room. SM Jason Oliff explained that on the supervisors’ desk there is also a dedicated direct link to the National Police Air Service (NPAS) helicopter via an intercom radio system which has a tannoy-like microphone and speaker.24 7 .19 At each terminal a member of staff has access to the following computer and communications systems: a. On the first computer screen is the Integrated Control and Communications System (ICCS), which is the means by which members of staff, predominantly the CROs, access telephone and radio communications comprising incoming telephone calls, such as 999 calls and radio messages transmitted from an incident. It works by way of a touchscreen.25 b. The second computer screen is the VISION terminal. This is the LFB’s mobilising system and is the means by which CROs record calls coming in and mobilise the LFB’s appliances.26 22 Oliff Day 23/28/7-19. 23 Oliff Day 23/61. 24 Oliff Day 23/61, 64, 65. 25 Control Report p. 174. 26 Control Report p. 174.

The Grenfell Tower Inquiry: Phase 1 Report 58 The VISION system also contains a dynamic incident log of all the actions entered on the system associated with one event. Everyone in the control room is able to access the log of an incident, if they wish to do so.27 I was provided with copies of two documents based on this log which describe in different degrees of detail the events of the Grenfell Tower fire, the short incident log28 and the End of Incident Report.29 c. A third computer screen gives the CRO access to a standard desktop computer, which is connected to the LFB’s intranet.30 7 .20 It is evident from the photographs above (and was confirmed by a number of witnesses) that the two control rooms differ in size. Stratford is not only physically much smaller than Merton, but has only 16 mobilising positions as opposed to Merton’s 29 positions (22 positions in the main control room and seven in the training suite).31 OM Alexandra Norman described the Stratford control room as “a third of the size” of the Merton control room.32 Some of the CROs who gave evidence said that they felt that the smaller room enabled them to hear more easily what was going on around them and communicate better with colleagues.33 OM Norman said that the smaller size of the Stratford control room “helps to get a general overview of what is happening during a shift” and she believed that on the night it helped her to hear the conversations going on around her and to understand the nature of the calls.34 7 .21 Although much of the equipment in the two control rooms is the same, on the night of the fire the Stratford control room lacked certain key facilities. In Merton, as can be seen from the photograph, the control room staff would usually have access to two 70-inch television screens, one showing a 24-hour news channel, which is normally switched on, and one which can show the NPAS downlink when it is in use at an incident.35 The NPAS downlink transmits images from the NPAS helicopters. This is sometimes known as the “heli- tele”.36 SM Oliff said that the purpose of these screens is for the staff in the control room to have a “physical picture of the actual incident that’s being dealt with” and to give the senior control room officers an overview of the development of the incident.37 7 .22 The Stratford control room has a single television screen, which can be seen in the top right- hand corner of the photograph above, but it is smaller. The Stratford control room does not have access to the NPAS downlink, and so staff working there could not view images from a police helicopter if they were available.38 Nor does it have access to the Dynamic Cover Tool (DCT), a computer program providing interactive maps designed to assist CROs in moving appliances between locations during large incidents or at periods of peak demand.39 27 Norman Day 42/45/-46/1-11. 28 [MET00013830]. 29 [LFB00004496]. 30 Control Report p. 175. 31 Smith Day 21/40/15-21. 32 Norman witness statement [MET000080589] p. 2. 33 For example, Duddy witness statement [MET00007787] p. 5 and Norman witness statement [MET000080589] p. 2. 34 Norman witness statement [MET000080589] p. 2 and Norman Day 42/56/13-17. 35 Smith Day 21/94/8-19. 36 IMP Incident Report p. 2. 37 Oliff Day 23/35/1-25/35. 38 IMP Incident Report p. 2. 39 Control Report p. 175; Norman witness statement [MET000080589] p. 2 and Day 42/58-59.

Part I | Chapter 7: The London Fire Brigade 59 Duties and rostering 7 .23 As call-takers, CROs answer emergency (999) calls and other operationally urgent calls from other parts of the LFB and partner agencies, such as the MPS, the LAS or other control rooms outside London.40 They advise callers and mobilise resources appropriate to the type of incident. They respond to and process requests for resources and information coming from the incident ground. They are also responsible for updating the VISION mobilising system, which includes amending the system to show when officers and appliances are available, assigned to an incident, en route to an incident and in attendance at an incident.41 7 .24 One CRO on each shift is assigned as paging operator responsible for notifying LFB officers and staff about an incident using a paging system. The paging operator should follow Policy No. 412 (Mobilising Policy),42 which sets out when appliances, officers, equipment and external agencies are to be notified of an incident and of a need to attend. Most officers and staff who have been paged are required to acknowledge the alert by calling the paging operator. At that point the paging operator provides further details about the incident and updates the VISION mobilising system as appropriate, for example, to show that the officer is on their way to the incident.43 A CRO assigned as paging operator can also take calls. 7.25 Two CROs are assigned as radio operators on each shift. A radio operator receives and transmits messages on the LFB’s “main-scheme” radio. One radio operator handles the radio communications for North London (on channel 4, also known as “RT4”); the other handles communications for South London (on channel 2, also known as “RT2”). A third CRO provides cover for the radio operators when they take a break, although they will perform other roles as well.44 In periods of high demand it is possible for one radio operator to operate both channels, thereby allowing the other radio operator to take calls.45 A radio operator can also update the status and availability of appliances and senior officers on VISION.46 7.26 Each 24-hour period is divided into four shifts. There are six teams, known as “watches”; each watch works on a six-day shift rota.47 The shift pattern is set out below:48 Shift name Start time Finish time Days 08:00 hrs 20:00 hrs Early short 08:00 hrs 16:00 hrs Late short 14:00 hrs 22:00 hrs Nights 20:00 hrs 08:00 hrs 7 .27 In any 24-hour period, three watches are rostered to work. One watch takes the day shift, one watch takes the “short” shifts by splitting the team into two so that a team member will either work on the early shift or the late shift, and one watch takes the night shift.49 The day shift and the night shift are the core shifts; staff on the shorter shifts usually undertake administrative work or relieve those on the core shift throughout the day when they take a break.50 40 Control Report p. 178. 41 Control Report p. 178. 42 Ref. Issue date: 26 October 2005. Reviewed as current 15 July 2016. 43 Control Report p. 178. 44 Darby witness statement [MET00013961] p. 2. 45 Control Report p. 178. 46 Control Report p. 178. 47 Norman witness statement [MET000080589] p. 2 and Smith witness statement [MET00007766] p. 2. 48 Control Report p. 176. 49 Control Report p. 176. 50 Darby witness statement [MET00013961] p. 2.

The Grenfell Tower Inquiry: Phase 1 Report 60 7 .28 Each watch is composed of 16 members, but the minimum number required to be on duty in any shift is 1151 (two supervisors and nine CROs).52 However, it is usual to have three supervisors and eight CROs present.53 OM Norman explained that if there were a fourth supervisor present, they would act as a CRO, but it would not be normal for a supervisor to act in that capacity in any other situation.54 She explained that, provided a minimum of 11 staff members were present, there was some flexibility in relation to the ranks involved.55 7 .29 When the watch is split across the short shifts, and the minimum number of staff are on duty, six will be allocated to the early short shift and five to the late short shift.56 Using the minimum number of staff required in accordance with the LFB’s Control Report, one can deduce that the following number of staff required to be on duty during each period is as follows: a. from 08:00 to 14:00: 3 supervisors and 14 CROs; b. from 14:00 to 16:00: 4 supervisors and 18 CROs; c. from 16:00 to 20:00: 3 supervisors and 13 CROs; d. from 20:00 to 22:00: 3 supervisors and 13 CROs; e. from 22:00 to 08:00: 2 supervisors and nine CROs. 7 .30 During a 24-hour period, either the POM or one of the SOMs will provide cover to the control room on a rotational basis as the Brigade Control Senior Manager.57 In this role the Brigade Control Senior Manager has oversight of operations, providing a monitoring and supporting role to the OM on duty and undertaking the liaison role between the control room and the LFB’s principal management team.58 The POM or SOM is not required to be present in the control room outside normal working hours, but they must respond to pager communications and call the control room to assess the situation and decide whether it is necessary to attend.59 7 .31 The POM or SOM will automatically be mobilised to attend the control room in various circumstances, including:60 a. when an incident occurs requiring between 9 and 12 appliances (“pumps”); b. when a Major Incident is declared by the LFB; c. when there is a major loss or degradation of the control room’s communications or computer systems or the primary control centre has to be evacuated to the fallback site; or d. when several lengthy fire survival guidance (FSG) calls are in progress. 51 Smith witness statement [MET00007766] p. 2 and Control Report p. 176. 52 Control Report p. 176. 53 Smith Day 21/7/4-8; Norman Day 42/66/17-20. 54 Norman Day 42/62/1-42/66/17. 55 Norman Day 42/67/2-4. 56 Control Report p. 176. 57 Control Report p. 176. 58 Control Report p. 177 and Smith Day 21/34/20-25-21/36/8. 59 Smith witness statement [MET00007766] p. 1. 60 Control Report p. 177.

Part I | Chapter 7: The London Fire Brigade 61 7 .32 During a large operational or multi-agency incident, the LFB will set up a Brigade Coordination Centre.61 The purpose of the centre is to provide support to, and implement the decisions of, the duty AC.62 It also ensures that the LFB continues to provide the usual service and response across the whole of London.63 The centre will usually be located at one of the LFB’s facilities, either Merton or its headquarters at Union Street,64 but on 14 June 2017 it was set up in the same building as the Stratford control room. It is set up and managed by a duty DAC as Brigade Co-ordinating Manager.65 7 .33 When an incident requires eight or more pumps (fire appliances), a Station Manager66 is mobilised to the control room to act as duty Officer of the Day (OOD).67 The role of the OOD is to provide additional oversight and support to the Operations Manager in the control room and the duty Brigade Co-ordinating Manager in the Brigade Coordination Centre.68 The OOD will also resolve resourcing problems, carry out resource planning and provide a link between operational staff at fire stations and senior duty officers on call.69 The OOD does not advise control room staff about the advice they should give callers.70 VISION and other control room systems 7 .34 The VISION terminal is the LFB’s mobilising system. For each incident, a log is created on VISION which is updated as the incident progresses.71 The information included is varied and includes items such as the resources and officers requested and deployed, any messages received from the incident ground, such as increasing the number of pumps (e.g. make pumps 10), or informative messages describing the progress of an incident for the benefit of the control room and those monitoring it.72 The incident log can also include details of whether other agencies have been informed.73 It will also contain an action plan for the incident, if one exists.74 There is a live feed from the VISION system to an electronic viewing platform called BOSS.75 Senior officers and fire stations are able to access BOSS remotely in order to find out what is happening at an incident.76 7.35 The ICCS is the means by which CROs access telephony and radio communications. It works by way of a touchscreen. VISION and ICCS are integrated. The two systems enable the CROs to manage emergency calls and to mobilise the LFB’s operational resources and officers. Handling emergency calls 7.36 The LFB issues policy documents containing instructions about the way in which its personnel are expected to carry out their various duties. In June 2017, the two principal policies governing the handling of emergency calls by the control room were Policy No. 539 (Emergency Call Management) (PN539) and Policy No. 790 (Fire Survival Guidance Calls) (PN790). In addition, 61 Fenton witness statement [MET000080569] p. 3. 62 ORR v 0.7 p. 490. 63 Fenton witness statement [MET000080569] p. 3. 64 Fenton witness statement [MET000080569] p. 2. 65 ORR v 0.7 p. 490. 66 ORR v 0.7 pp. 34, 505. 67 Control Report p. 177. 68 Control Report p. 177 and Oliff Day 23/17/16-24. 69 Control Report p. 177 and Oliff Day 23/17/16-18/24. 70 Oliff Day 23/19/1-4. 71 Smith Day 21/46-47. 72 Smith Day 21/46/4-19, 21/74/1-16. 73 Smith Day 21/46/4-19, 21/74/1-16. 74 Smith Day 21/46/4-19. 75 Smith Day 21/46/21-25-21/47/1-17. 76 Smith Day 21/46/21-25-21/47/1-17.

The Grenfell Tower Inquiry: Phase 1 Report 62 two Reference Information Files (RIFs) were available to the control room to assist call- handling, the RIF for Operators and the RIF for Supervisors. Taken together, the policies and RIFs described in some detail how the LFB expected CROs and senior officers in the control room to conduct operations. PN790 had both been drafted in the light of national guidance on fire safety contained in Generic Risk Assessment 3.2 (GRA 3.2) published by the Department for Communities and Local Government in February 2014 with a view to helping fire and rescue services identify the significant hazards and risks likely to be encountered when fighting fires in high-rise buildings. PN539 had been updated in the light of that guidance. Neither policy is concerned solely with incidents in high-rise buildings. 7 .37 The policies to which I have referred are generally implemented in the following way. When a 999 call comes into the control room, a flashing red box appears on all the ICCS screens.77 The first available CRO responds by touching an icon on the screen, which opens a new entry on the call collection form (CCF) and enables details of the call to be entered on the system.78 As the ICCS and the VISION system are integrated, some details, such as the caller’s telephone number, are automatically entered on the CCF.79 The CRO then starts to gather information from the caller. 7 .38 Usually, a CRO first asks for the postcode or a road name to establish the location and obtain the relevant address.80 If the person is living in a flat, the usual practice is to ask how many floors the building has so that the CRO can determine if the building is a high-rise block.81 The CRO then obtains information from the caller in order to determine the type of incident that is taking place (e.g. a fire or a person trapped in a lift) in order to mobilise the appropriate appliances and officers and give the caller any necessary advice.82 7 .39 Once the CRO has determined what type of incident is taking place, they enter the “Incident Type Code” on the VISION system (e.g. A1 is for fire, A1HR is for a high-rise fire) which generates a pre-determined attendance (PDA).83 The PDA is the minimum level of response that the LFB is required to mobilise to a particular kind of incident.84 At the time of the Grenfell fire, a general fire had a PDA of three fire appliances; a high-rise fire had a PDA of four appliances, comprising three pumps and a pump ladder, under the direction of a Watch Manager.85 (The distinction between a pump and a pump ladder is explained below.) On the VISION screen the CRO can see which fire stations are nearest to the incident and, while speaking to the caller, can mobilise the nearest (in this case North Kensington).86 A live display shows the appliances mobilising. Once the CRO has mobilised the required appliances and officers, it is the responsibility of the incident commander to determine whether any additional resources are required. The incident commander requests whatever resources he or she considers necessary by radio message to the control room, which then sets about mobilising them.87 77 Duddy witness statement [MET00007787] p. 1. 78 Smith Day 21/42/20-25-21/43/1-5. 79 PN539 paragraph 4.4 [LFB00000737] p. 4; Smith Day 21/43/9-15. 80 Duddy witness statement [MET00007787] p. 1. 81 A building of more than five floors is classified as high-rise: Smith Day 21/44/12-25. 82 Duddy witness statement [MET00007787] p. 1. 83 Duddy witness statement [MET00007787] p. 1 and section 7 and Appendix 1 of PN412 [LFB00001531]. 84 Duddy witness statement [MET00007787] p. 1 and section 7 and Appendix 1 of PN412 [LFB00001531]. 85 The management of the LFB’s operational response to incidents is set out in PN412 (Mobilising Policy), and particularly Appendix 1 of PN412 (issue date 26 October 2015, reviewed as current 15 July 2016) [LFB00001531]. 86 PN412 paragraph 2.9 [LFB00001531] and Smith Day 21/45/9-20. 87 PN412 paragraph 2.10.

Part I | Chapter 7: The London Fire Brigade 63 7.40 During a call, a CRO provides advice to a caller depending on the situation in which they find themselves. CROs can obtain assistance from the RIFs available on their computer terminals; they can also seek help from a supervisor.88 Supervisors can monitor calls through the ICCS system or can speak directly to CROs at their desks.89 7.41 In the course of speaking to a caller a CRO may find that they need to communicate with the radio operator in order to send a message to the incident ground. The CRO sends the message to the radio operator by creating a “service request” on VISION.90 That is done by opening a service request box on the VISION terminal and entering the details.91 The CRO directs the message to the attention of the appropriate radio operator by adding a reference to the channel by which it is to be sent. Thus, a message will carry the prefix “RT4” if it is to be sent by the North London radio operator.92 The message will be displayed on VISION with the label “Service Request Created”. Once the message has been saved, it is added to a list of service requests which everyone in the control room with access to the VISION system can see. The radio operator responsible for the relevant channel is expected to pick up the message and transmit it.93 If a message has priority, such as an FSG message, the CRO may call out to the radio operator to alert them to it, saying something like “Message on 4”.94 The message can be amended by the CRO, in which case the system will show “Service Request Updated”. The status of the message can also be changed on VISION by a CRO or a supervisor to show that it is “In Progress”, meaning that the radio operator has picked it up and is dealing with it.95 7.42 When the radio operator has completed the request, they tick a box on the screen, thereby generating the message “Service Request Completed”, which is recorded on VISION.96 It is important to note that the radio operator does not change the details of the original service request and only ticks a box to indicate that it has been completed.97 The terms of the original service request become, in effect, a label by which to identify any subsequent actions taken in response to it. An example of how a service request message appears on VISION is shown below.98 88 Norman witness statement [MET000080589] p. 1, Reference Information File (RIF) Fire Survival Guidance (Supervisor) [LFB00003541]; Reference Information File (RIF) Fire Survival Guidance (Operator) [LFB00003542]. 89 Norman Day 42/43/23-42/44/3; Smith Day 21/36/12-19. 90 Darby Day 33/145/1-16. 91 Darby Day 33/145/1-16. 92 Darby Day 33/145/1-16. 93 Darby Day 33/145/1-16. 94 Darby Day 33/152/1-13. 95 For example, SIL p. 20, 01:53:52; Duddy Day 42/194/11-15; Smith Day 21/83/15-22. 96 For example, SIL p. 20. 97 Darby Day 33/159/2-7. 98 SIL p. 20.

The Grenfell Tower Inquiry: Phase 1 Report 64 Figure 7.3 7.43 The radio operator is primarily responsible for transmitting messages to and from the incident ground; they are the essential link between the two.99 Once a firefighting crew has been assigned to an incident, there should be a constant flow of information passing between them.100 The radio operator transmits messages passed to them by the CROs or the supervisor101 and the crews transmit messages from the incident commander to the control room. That may be a request for additional resources or what is known as an “Informative Message”, which is intended to provide the control room and officers not in attendance at the incident with an accurate description of the incident and the progress being made.102 All radio messages received from the incident ground are logged through VISION by the radio operator.103 They are then picked up by another CRO who takes the necessary action, e.g. by mobilising the required resources. The paging operator alerts senior officers to ensure their attendance, if necessary.104 7.44 The radio used by the radio operator is the main-scheme radio. The main-scheme radio uses the Airwave Network, a commercial radio network, and is usually referred to simply as Airwave. The channels used by the LFB are designated Fire London Operations (FLONOPS) with code names for individual channels available. “M2FN” is the code name for the channel 99 Darby witness statement [MET00013961] p. 2. 100 Darby witness statement [MET00013961] p. 2. 101 Darby witness statement [MET00013961] p. 2. 102 ORR v 0.7 p. 503. SOM Smith provided a definition of “informative message” at Day 21/29/12-13. 103 Darby witness statement [MET00013961] p. 4. Time marks on the SIL may appear later in time than the action to which they refer, given that the radio operator updates the incident log only once the action has been taken or, for example a message has been received. 104 Darby witness statement [MET00013961] p. 4.

Part I | Chapter 7: The London Fire Brigade 65 that covers North London.105 The channels are also known as “RT4” etc., shorthand for “radio transmission, channel 4”.106 These names are used interchangeably.107 Channel 1 is a spare channel, which can be used to transmit a large number of FSG calls or for communications relating to a single incident, if staffing numbers allow.108 Anyone who possesses a portable handheld Airwave radio can listen to the communications on any of these channels. Senior LFB officers of Station Manager rank and above are issued with Airwave radios and one is fitted in every appliance.109 The control room can therefore transmit messages to appliances by Airwave radio and senior officers can listen in, which may be necessary if they have been notified of the incident and need to monitor its progress in order to decide whether they need to attend. Senior officers can communicate with each over the Airwave radio but these communications are not recorded.110 4 The incident ground The incident commander: role and responsibilities 7.45 At every incident it is necessary for an officer to assume the role of incident commander and direct operations on the ground. Policy No. 431 (Incident Commander) describes the role and responsibilities of the incident commander, who is the person responsible for discharging fire service functions at the incident.111 The general rule is that the commander of the first fire appliance to attend an incident undertakes the role of incident commander unless and until relieved by a more senior officer.112 7.46 The responsibilities of the incident commander are described in paragraph 6 and Appendix 2 of PN431. For present purposes it is sufficient to say that they include: a. assessing the incident and deciding upon an operational plan; b. making dynamic risk assessments, which involve striking a balance between ensuring firefighters’ safety and discharging the responsibility of the fire and rescue service to extinguish fire and to save life and property; c. assessing the need for additional resources; and d. establishing an effective incident command structure and communications network. However, PN342 recognises that the incident commander may need to adapt or move away from operational policy if it is justifiable in terms of risk and benefit, but advises that any such move should be kept to the minimum necessary to achieve the desired objective in order to minimise exposure to the increased levels of risk.113 105 Darby witness statement [MET00013961] p. 2 and Day 33/134/20-23. 106 Darby Day 33/157/10-13. 107 Darby Day 33/135/4-6. 108 PN790 paragraph 5.13; Darby Day 33/134/14-23, 33/135/7-15. 109 Smith Day 21/65/24-25-21/66/1-8, 21/68/17-22. 110 Smith Day 21/136/4-8. 111 PN431 paragraph 5.1 [LFB00000174]. 112 PN431 paragraph 3.1 [LFB00000174]. 113 PN342 [LFB00000236] p. 3.

The Grenfell Tower Inquiry: Phase 1 Report 66 7.47 Communications on the incident ground and between the incident ground and the control room are of the utmost importance. Paragraph 7 of PN431 requires the incident commander to establish and maintain clear lines of communication throughout the incident, to ensure that communications are maintained between the incident ground and the control room, and to establish and maintain effective lines of communication with other services and agencies.114 7.48 In many cases the initial incident commander is likely to be a Watch Manager, but if the incident increases in scale or seriousness, a more senior officer is required to attend to ensure that the incident commander holds a rank appropriate to the gravity of the incident. If the number of appliances required to attend is increased, the seniority of the incident commander increases. As one would expect, the outgoing incident commander is expected to give their successor a full description of the operational situation when handing over command.115 The monitoring officer: role and responsibilities 7.49 When the number of pumps required at an incident reaches 15, the LFB’s practice is to appoint a monitoring officer, whose role and functions are described in Policy No. 424 (Monitoring Officer). The monitoring officer’s primary function is to measure the efficiency, effectiveness and, where possible, the economic performance of individuals and the organisation as a whole at an incident116 by applying the decision-making model and comparing their own conclusions with those of the incident commander.117 The monitoring officer and the incident commander are expected to discuss any differences between their assessments and decide what action is required to ensure safe systems of work. The monitoring officer is also expected to tour the incident ground, evaluate the operational plan and report back to the incident commander,118 and, if the incident escalates or its management is beyond the experience or ability of the incident commander, to assume command immediately.119 Sectors 7.50 At larger or more complex incidents the incident commander may divide the incident ground into sectors, each under the command of a sector commander, to enable a practicable span of control to be maintained. There are two types of sector: an operational sector, which is defined by reference to a physical area of the incident ground, and a functional sector, which is defined by reference to a support role and the resources it commands. The incident commander may also appoint one or more operations commanders to take responsibility for a number of sectors on the incident ground, thereby maintaining an effective span of control and providing a greater level of command. Incident command support 7.51 The LFB provides a variety of command support arrangements based on the size and nature of the incident. At smaller incidents, command support is provided by the Initial Command Pump (ICP),120 which provides the communications link between the control room and the incident ground. The ICP’s means of communication with the control room is the main- scheme radio, with its transmitter and receiver fixed in the front cab at head height where the 114 Paragraphs 7.1-7.3 respectively [LFB00000236] p. 10. 115 PN431 Appendix 1 [LFB00012840] p. 6. 116 PN424 paragraph 4.1 [LFB00004944]. 117 PN424 paragraph 4.5 [LFB00004944]. 118 PN424 paragraph 4.6 [LFB00004944]. 119 PN424 paragraph 4.7 [LFB00004944]. 120 PN238 (incident command procedures) paragraph 7 [LFB00013472] p. 5.

Part I | Chapter 7: The London Fire Brigade 67 driver and officer in charge sit.121 The ICP continues to perform its communications role until the incident is concluded or it is relieved by a command unit122 (a mobile control room), if the incident requires one. On arrival at the incident ground commanders of appliances and senior officers alike report to the ICP or the command unit, hand in their nominal roll boards and are given information about the incident. The nominal roll board is a physical plate carried on all LFB vehicles that provides details about the type of appliance, its call-sign and the names and rank of its crew. Senior officers also carry a nominal roll board which, in their case, records the officer’s name, call-sign, vehicle registration number and any specialist qualifications. 7.52 A command unit is mobilised to provide a dedicated and enhanced level of command support at larger incidents (typically those involving four or more appliances). It is staffed by at least two Watch Managers who provide command support for the incident commander. The command unit carries the Command Support System (CSS), together with other systems which are designed to provide the incident commander with access to the ORD, the primary purpose of which is to record significant hazards and risks, as well as what the LFB calls “less obvious hazards and any unique control measures in place”,123 and any particular tactical plans or command and control procedures that may be required. The CSS also carries other relevant information, such as data on water supplies and maps. 7.53 The officers on the command unit perform a number of important functions. These include recording preliminary details of the incident on the CSS, transmitting messages to and from the control room and maintaining the plan of the incident, including a record of the duties and location of senior officers and operational crews committed at the incident. The command units also play an important role in ensuring that the incident commander can communicate with the various parts of the incident ground. They should maintain radio contact with the incident commander if they leave the command unit; they also co-ordinate and maintain radio contact with the operations and sector commanders. Command units can also be used for logistical functions, such as marshalling and hosting tactical co-ordination group meetings. 7.54 At larger incidents additional command units will automatically be mobilised but they can, if necessary, be requested by the incident commander. When the control room is receiving FSG calls, an additional command unit will automatically be mobilised, together with a senior officer, to collate and manage FSG information. Each command unit is equipped with a Casualty Information Sheet, a laminated template which enables information to be recorded in respect of up to seven FSG calls.124 Provision of basic information to fire crews 7.55 The primary purpose of the Operational Risk Database (ORD) is to alert crews to risks and hazards at a particular building additional to those that are normally encountered, together with any less obvious hazards and unique control measures that may be in place. The ORD also contains any particular plans or command and control procedures required.125 7.56 The “tip sheet”126 is a document which is printed off in the watch room and gives the mobilised crews basic information regarding the incident, including the address, classification of the incident and the number of appliances attending, as well as the information about the relevant building recorded in the ORD. 121 Dowden Day 10/38/21-39/7. 122 PN238 paragraph 7.4 [LFB00013472] p. 5. 123 LFB Organisational Overview [LFB00001900] p. 20. 124 PN820 Appendix 1 (Forward Information Board) [LFB00000188] pp. 8-9. 125 Policy No. 800 (Information gathering/contingency plans) (dated 16 July 2012) [LFB00000705] pp. 7-8. 126 Dowden Day 9/147-148/11.

The Grenfell Tower Inquiry: Phase 1 Report 68 7.57 Once mobile and on their way to the incident, the initial incident commander (as well as other attending crews) have access to the Mobile Data Terminal (MDT). This is a vehicle-mounted fixed tablet computer which has a 12-inch touch screen. It is fitted to most operational vehicles.127 The MDT sits in the front of an appliance, between the driver and the officer commanding the crew. It provides the crew with access to the information recorded on the ORD in relation to the relevant building, including the tactical and any operational contingency plans.128 5 Equipment 7.58 When describing the response of the LFB to the fire at Grenfell Tower it is necessary to refer to some of the equipment in use, including, for example, the means of providing basic information about the relevant building, fire appliances and breathing apparatus. It may be useful at this stage, therefore, to provide a brief description of the more important pieces of equipment available to the LFB. Fire appliances 7.59 There are two basic types of basic fire appliance: a pump appliance (known simply as a “pump”) and a pump ladder. A pump carries a crew of up to six firefighters. It is equipped with an internal pump designed to supply water for firefighting operations and a 9-metre ladder. The pump carries several lengths of hose, nozzles (known as “branches”) for controlling the water, and other equipment, including breathing apparatus. A pump ladder is very similar. It can carry the same number of firefighters and similar equipment, but has a 13.5-metre ladder. 7.60 In addition to pumps and pump ladders some fire stations are equipped with Fire and Rescue Units (FRUs), which carry specialist rescue equipment for use at complex incidents.129 7.61 The LFB has 11 aerial appliances of which two types are relevant: turntable ladders (TLs) and aerial ladder platforms (ALPs). A turntable ladder is a vehicle equipped with a ladder that can reach 32 metres in height, i.e. to about the tenth floor of a modern high-rise building. An aerial ladder platform can reach the same height, but the ladder has a cage at its head, which can hold up to four people. The ladder may be operated from ground level or from the cage. Breathing apparatus 7.62 Given the nature of their work, firefighters need to use a variety of protective equipment, including breathing apparatus (BA). BA allows firefighters to breathe whilst working in an oxygen-deficient atmosphere (such as smoke) and is standard equipment when fighting fires or attending incidents involving an acute respiratory hazard. BA consists of a full-face mask, a cylinder containing compressed air with associated air tubes and a pressure gauge, body harness straps, a hand lamp and radio communications. BA sets also have a “bodyguard” distress signal unit which monitors the breathing rate of the wearer and the time the set was first activated. 7.63 The LFB uses two types of BA set: Standard Duration Breathing Apparatus (SDBA) and Extended Duration Breathing Apparatus (EDBA). SDBA is carried on all frontline appliances. It is a single-cylinder system, weighing approximately 15 kilograms, which provides a working 127 Refer to the definition in the LFB’s ORR v 0.7 p. 504. 128 Dowden Day 9/157/2-159/5. 129 Dowden Day 11/41.

Part I | Chapter 7: The London Fire Brigade 69 time of 31 minutes, assuming a consumption rate of 50 litres per minute. The actual working time available, however, depends upon a range of factors, including the wearer’s workload and the physical and environmental conditions (for example, the extent of smoke-logging and the temperature that firefighters are experiencing) as well as the wearer’s own physical fitness. The safety margin is 12 minutes. An alarm sounds when the pressure in the cylinder falls to 84 bar. When using BA, a firefighter is sometimes said to be operating “under air”. 7.64 EDBA is carried only on FRUs and is intended to give an enhanced capability at incidents involving long distances or conditions which make SDBA less effective. Specialist training is required to wear EDBA and is typically provided only to FRU crews. EDBA is a double- cylinder system, which weighs about 23 kilograms and provides a working time of 47 minutes, assuming a consumption rate of 56 litres per minute. As with SDBA, the actual duration of the set is determined in part by the circumstances confronting the firefighter. The safety margin is 18 minutes and, as with SDBA, an alarm will sound when the pressure in the cylinders falls to 84 bar. Ground monitor 7.65 In the following section of the report there are references to a piece of equipment called a “ground monitor”, a piece of equipment which allows a jet of water to be directed against a building without the need for constant attendance by firefighters. It consists of a nozzle fed by a hose and supported by a metal frame anchored to the ground. Once set up, it can be left unattended to maintain a constant stream of water. Radio equipment 7.66 The LFB uses two principal types of communications equipment. One is the digital Airwave radio system described earlier, which is generally used for communications between the control room and fire appliances and between senior officers; the other is an ultra- high frequency analogue radio system for use on the incident ground. Senior officers can communicate with each over the Airwave radio, but they do not use them on the incident ground and any communications between them using that method are not recorded.130 7.67 All operational firefighters, including senior officers, have their own handheld analogue UHF radios (sometimes known as “fireground radios”), which have eight channels: a. Channels 1 and 2 are dedicated to incident command. Channel 1 is the default channel for all initial incident command communications and remains the primary command channel until circumstances, or the incident commander, require additional radio capacity. If additional capacity is required, channel 2 is used. b. Channels 5 and 6 are used by breathing apparatus crews. c. Channel 3 is for firefighter crew communications. The main drawback of the fireground radios is that on any given channel they can transmit or receive only one voice transmission at a time. 7.68 The LFB’s fleet of command units also carries portable UHF radio repeaters and what is known as “leaky feeder” equipment. A leaky feeder is a coaxial cable, 175 metres long, which is normally connected to a radio repeater and extended as required. The radio repeater technology can be deployed to supplement or enhance communications. 130 Smith Day 21/136/4-8.

The Grenfell Tower Inquiry: Phase 1 Report 70 7.69 Some BA sets are fitted with a dedicated UHF Breathing Apparatus Radio Interface Equipment analogue radio known as a “BARIE set”. As breathing apparatus crews can be asked to operate in potentially explosive atmospheres, all BARIE sets must be intrinsically safe. In order to meet that requirement, they are limited to a power output of 1 watt per channel, which can affect their operational range. BA entry control equipment 7.70 When BA is in use, an entry control officer is appointed to manage the deployment of firefighters entering the relevant area under air by means of an entry control board (ECB). An ECB is an electronic telemetry board which displays real time information in relation to each BA wearer whose set has been logged on to it. 7.71 The ECB is a rechargeable, battery-powered unit incorporating a digital radio transmitter and receiver with integral antennae. Each ECB has 12 BA tally channel slots, each able to accept the encoded tally of one BA set. The data transmission link between the ECB and each BA set is activated by the insertion of the tally, which has a built-in encoded transponder, into one of the available sockets on the ECB. The ECB identifies the associated BA set and the individual BA wearer’s telemetry signal radio icon illuminates (green) continuously, confirming that a successful telemetry signal is established between the ECB and the BA set. The entry control officer is then able to monitor air consumption rates for each BA wearer and, therefore, the remaining time available to them. The individual BA tally channel LED display shows the end of the working duration of the cylinder used by that wearer. The ECB stores data that can be downloaded after an incident.131 6 Firefighting 7.72 The Narrative refers to various technical terms and certain equipment which was used by the LFB to support firefighting and search and rescue deployments on the night. It may assist if two of those terms and equipment are explained here. The bridgehead 7.73 The bridgehead is the forward command post, from which firefighters are committed to fight the fire and where the ECB is maintained. It must be established in safe air. When fighting a fire in a high-rise building, it is standard operating procedure to establish the bridgehead two floors below the fire floor, unless it is possible for safe air to be reliably maintained at a position closer to the fire.132 Crucially, when positioning the bridgehead, consideration should be given to the spread of smoke through doors that will be opened to enable hoses to be put in to the riser and which will have to remain open for firefighting purposes.133 Forward Information Board 7.74 Forward Information Boards (FIBs) are used by those in command of the bridgehead to record important information. An FIB consists of a Perspex back board and two double-sided laminated sheets, printed with four templates and is designed for gathering and recording 131 As it was for the Grenfell Tower incident. The data are contained in the evidence of AC Andrew Bell (Day 9/114/5-125/3 and [LFB00003588]) and Malcolm Stanton ([LFB00003587 and LFB00023330] and summarised in the LFB telemetry schedule [LFB00023326]). 132 PN633 paragraph 7.19 [LFB00000178] p. 11. 133 PN633 paragraph 7.20 [LFB00000178] p. 11.

Part I | Chapter 7: The London Fire Brigade 71 information. The use of FIBs is covered by Policy No. 820 (Forward Information Board),134 Appendix 1, figure 3 of which is a casualty information template with space for up to seven people. A record of people rescued and areas searched or partly searched should be made to share information generally, to assist with prioritising further rescues and to avoid repeated searches being made of the same areas. 134 Introduced in 2013 as part of the LFB’s response to the Lakanal House fire.

The Grenfell Tower Inquiry: Phase 1 Report 72

73 Chapter 8 Before Grenfell: the Lakanal House Fire 1 The Lakanal House fire and the ensuing inquests

1. 1

Lakanal House, Havil Street, Camberwell, London SE5 is a high-rise residential block containing 98 flats and maisonettes spread over 14 floors. On 3 July 2009 a fire broke out in a maisonette on floor 9 and despite the prompt attendance of firefighters, spread rapidly beyond the compartment of origin upwards to floors 10, 11 and 12 and downwards to floors 5 and 7. Within 30 minutes smoke had spread to involve floors 6 to 12 and smoke-logging affected large parts of the building, including the communal staircase, corridors and many of the flats. Six people died in the fire, three of whom were children. Fifteen people were taken to hospital suffering from the effects of smoke inhalation and one firefighter was admitted for treatment for heat exhaustion. A total of 38 people were assisted out of the building or were rescued by the LFB. At its height, more than 100 firefighters were in attendance at the scene, with 18 pumps, nine FRUs and other specialist appliances and officers.

1. 2

Following an investigation by the MPS and the Health and Safety Executive (with the involvement of the LFB), the Crown Prosecution Service decided in May 2012 that no prosecutions should follow. Thereafter dates were set for the inquests, which were heard by Assistant Deputy Coroner, Her Honour Frances Kirkham CBE, between 14 January and 28 March 2013. A full transcript of the coroner’s summing up to the jury of 20 and 21 March 2013 can be found at https://www.lambeth.gov.uk/elections-and-council/lakanal-house-coroner-inquest.

1. 3

On 28 March 2013, at the end of the hearings, the coroner made a number of recommendations under rule 43 of the then current Coroners’ Rules, some of which were directed at the LFB. So far as concerned the LFB control room, the coroner said that, in the light of the “extensive work [already] undertaken to learn from the experience with the fire at Lakanal House”, the introduction of new policies and the review of existing policies, she would make no recommendations in relation to communications between the control room and the incident ground, guidance on the handling of FSG calls or training for officers dealing with such calls.

1. 4

The Lakanal House fire was an important event in the history of the LFB’s response to firefighting in a high-rise residential block and to emergency call handling. It is no exaggeration to say that the Lakanal House fire is etched into the consciousness of the LFB as an institution and into the memories of those officers who attended it. Of the CROs on duty in the control room on the night of the Grenfell Tower fire, four (CROs Debbie Real, Heidi Fox, Angie Gotts and Peter May) had been on duty during the Lakanal House fire and had handled calls from people inside the building. 2 The LFB’s response to the Lakanal House fire 8.5 As a result of the Lakanal House fire, the LFB undertook a detailed internal review of its practices and policies relating to call management in general and FSG calls in particular. In November 2012 it produced a detailed report entitled “Fire at Lakanal, Havil Street, SE5 on 3 July 2009 – Role and Actions of the LFB Control” (the LFB Lakanal Report).1 1 [HOM00001124].

The Grenfell Tower Inquiry: Phase 1 Report 74 8.6 The LFB Lakanal Report examined the historic frequency of FSG calls received by the control room, the training and experience of the CROs in providing fire survival guidance and the nature of the essential advice to be given to callers. The statistics for the five years to 2009 revealed that the number of emergency calls in response to which fire survival guidance had been given was very small compared with the overall number received by the control room.2 In the five years to 2009 there were 77 FSG calls out of a total of 728,770 calls received, or 0.0101%, and a yearly average of 15.4 FSG calls out of 145,754 calls received (0.0105%). Of these, there was only one call where any fatalities (in that case two) had been recorded.3 8 .7 There is no evidence to suggest that the picture changed materially in the years between the Lakanal House fire (2009) and the Grenfell Tower fire (2017). It is also important to observe that, of the total of 60 emergency calls handled by the control room during the Lakanal House fire, only four were FSG calls.4 Even that number of FSG calls from a single incident and the pressure they created were described by one officer who assisted the LFB’s Lakanal House investigation as “unique”.5 8 .8 The other important aspect of the LFB Lakanal Report for present purposes was the examination of how the control room handled FSG calls during that fire. The report arrived at its conclusions at section F6. Paragraphs 290 and 293 to 2966 are worth setting out in full here: “290. Information gathering: The quality of the information gathered by [CROs] during the incident varied dependent on the type and length of call. Some calls only required the confirmation of the address to confirm it was a ‘duplicate’ to the Lakanal fire, whereas the FSG calls involved detailed information gathering. [CROs] often found out about the caller’s flat number, which floor they were located on, if they were on their own and their specific location in the flat. However, in the various source documents (e.g. MobIS report, FI report, recordings) there is reference to floor numbers being gathered from callers but these were not always passed to the incident ground in every instance. … 293. Expectations that callers would be rescued and ‘stay put’ advice: [CROs] had a clear expectation that fire crews would reach the callers quickly. Their experience was that fire appliances arrive quickly and that people are rescued by the Brigade. This is borne out by the fact that only rarely, where FSG is given, do people die in fires (see section E3). As rescues by crews were not immediate there is a question whether the [CRO] and/or callers, could have assessed the risk of attempting to escape from the flat and whether the risk of moving closer to the fire (but escaping) was less than staying put and awaiting rescue. [CROs] relied on advising callers to ‘stay put’ expecting that this would keep callers safe from the fire. 294. Escape/alternative escape routes: Many callers mentioned that there was smoke outside their flat or that there was smoke in the corridor preventing escape. This may have caused [CROs] to move straight into the ‘protect’ phase of FSG and not explore alternative escape routes with the callers. There is a real risk in attempting a self-evacuation from a building on fire that the occupant will move themselves into a position of greater harm rather than waiting in a safe location for rescue. 295. Assessment/re-assessment of the call/caller: Some [CROs] did repeat questions to find out what was happening at different stages of the call, including trying to find rooms with less smoke. National guidance (FSC 54/2004) suggests a model which has review of assessment/ initial decisions built into it [sic], although this was not included in LFB training materials. Moving to protect advice with the intent of keeping the caller safe may not always be the 2 Table 1 and paragraphs 149-152 [HOM00001124] p. 28. 3 LFB Lakanal Report paragraph 168 [HOM00001124] p. 31. 4 LFB Lakanal Report paragraphs 182, 185 and Chart 2 [HOM00001124] p. 37. 5 LFB Lakanal Report paragraph 287 [HOM00001124] p. 49. 6 Repeated at paragraphs 313 and 316-319 [HOM00001124] p. 54.

Part I | Chapter 8: Before Grenfell: the Lakanal House Fire 75 best solution and the call should be continually re-assessed. There may be a tendency to limit re-assessment due to the protect ethos, although there is evidence that some pro- active call handling techniques did take place.

Effective communication between Control and incident command: There is evidence of information passing from Control to the incident ground and only one occasion when the details of a flat with people trapped were not passed in a timely way. Control supervisors regularly tried to obtain information about the progress with the incident particularly in relation to callers being given FSG. In line with practice at the time, there was much less information being passed from the incident ground to Control about the progress of firefighting and rescue efforts. It is not clear that if [CROs] had been given information about progress that it would have influenced the advice given to callers.”

The Grenfell Tower Inquiry: Phase 1 Report 76

ISBN 978-1-5286-1602-7 (Volume 1 of 4) 4 volumes not available separately

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GRENFELL TOWER INQUIRY: PHASE 1 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 Chairman: The Rt Hon Sir Martin Moore-Bick October 2019 Volume 3 HC 49–III

GRENFELL TOWER INQUIRY: PHASE 1 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 Chairman: The Rt Hon Sir Martin Moore-Bick October 2019 Presented to Parliament pursuant to section 26 of the Inquiries Act 2005 Ordered by the House of Commons to be printed 30 October 2019 Volume 3 HC 49–III

© Crown copyright 2019 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. This publication is available at www.gov.uk/official-documents Any enquiries regarding this publication should be sent to us at contact@grenfelltowerinquiry.org.uk ISBN 978-1-5286-1602-7 (Volume 3 of 4) 4 volumes not available separately CCS0719597372    10/19 Printed on paper containing 75% recycled fibre content minimum Printed in the UK by the APS Group on behalf of the Controller of Her Majesty’s Stationery Office This report contains images and content which some may find distressing.

313 Chapter 15 Period 6: 02.20-02.50 1 External fire spread 15.1 At 02.23 the flame front had moved from the east face onto the south face of the tower. That can be seen in the following image taken from the NPAS helicopter footage:1 Figure 15.1 15.2 At the same time flames could be seen at the crown on the north face between columns A2 and A3 on the far west side of the north face.2 By 02.32 flames were extending beyond column A2 (the internal column on the west side of the north face) at the upper levels, the furthest horizontal progression still being at the crown,3 as can be seen in this image: 1 Professor Bisby supplemental report [LBYS0000001] p. 210 Fig. 129. 2 Professor Bisby supplemental report [LBYS0000001] p. 216 Fig. 134. 3 Professor Bisby supplemental report [LBYS0000001] p. 213 sections 1021-1023.

The Grenfell Tower Inquiry: Phase 1 Report 314 Figure 15.2 15.3 By 02.22 to 02.23 Flats 91, 101, 111, 121 and 131 on floors 12 to 16 in the centre of the east face of the tower and Flats 122, 132, 142, 152 and 162 on floors 15 to 19 at the south-east corner had become affected by the external flame front moving southward across the east face. On the north face Flats 95, 105, 115, 125, 135, 145, 155, 165 and 175 on floors 12 to 20 had also become involved in the fire.4 15.4 By 02.33 to 02.34 Flats 92, 102 and 112 on floors 12 to 14 in the south-east corner of the tower had been affected by the advancing flame front.5 15.5 At 02.39 on the south face, the furthest extent of the horizontal burning was at the crown and the fire had begun to spread vertically down column D5 at the south-east corner, as is shown in this image:6 4 Dr Lane supplemental report [BLAS0000012] p. 10 Fig. 12.3. 5 Dr Lane supplemental report [BLAS0000012] p. 10 Fig. 12.3. 6 Professor Bisby supplemental report [LBYS0000001] p. 229 sections 1063-1065 and p. 231 Fig. 150.

Part II | Chapter 15: Period 6: 02.20-02.50 315 Figure 15.3 15.6 By 02.45 the fire had spread from the north face over the top of column A1 at the north- west corner of the tower and had started to burn on the west face.7 Again, the horizontal progression was most advanced at the crown and the fire front lay diagonally, as can be seen in this image:8 7 Professor Bisby supplemental report [LBYS0000001] p. 213 sections 1024-1025. 8 Professor Bisby supplemental report [LBYS0000001] p. 218 Fig. 137.

The Grenfell Tower Inquiry: Phase 1 Report 316 Figure 15.4 15.7 At 02.40 and 02.43 smoke could be seen emerging from the windows of Flat 205 on the west face of the tower at floor 23.9 15.8 By 02.47 the fire had spread horizontally across the south face and had reached the top of column D4 (the internal column on the far east of the south face)10 as can be seen in the following image:11 9 Professor Bisby supplemental report [LBYS0000005] 02.08, 02.19 in the compilation; refer also to Professor Torero [JTOS0000001] p. 88 Fig. 50. 10 Professor Bisby supplemental report [LBYS0000001] p. 229 paragraph 1066. 11 Professor Bisby supplemental report [LBYS0000001] p. 232 Fig. 151.

Part II | Chapter 15: Period 6: 02.20-02.50 317 Figure 15.5 2 Events on the incident ground The system on CU7 for managing FSG information 15.9 On CU7, GM Tom Goodall had started to implement a procedure for managing the FSG information being received from the control room. At 02.22.54, a message was sent by radio from CU7 to the control room asking for all FSG calls to be sent to CU7.12 15.10 It is clear that communications between CU7 and the control room continued. WM Antony Peckham recalled that he had been sitting in the radio operator’s chair and had been inundated with calls with very few breaks between them.13 He used channel 4 on the main scheme radio to speak to the control room,14 recording the information on control information forms, which he then passed to other members of the team.15 WM Daniel Meyrick was also in separate communication with the control room, using the mobile telephone that he had taken with him when the management of FSG calls had been transferred to CU7.16 WM Meyrick could not recall what he had been doing with the information he had received from the control room in the early stages of operations on CU7. He could not say, for example, whether he had recorded it on blank pieces of paper, as he had while on CU8, or had passed it directly by 12 [LFB00002301]. SM Egan said that it was he who asked WM Meyrick to send that message (Day 15/109); GM Goodall also said that he asked for the message to be sent (Day 35/28). WM Peckham said that it was he who had spoken to the control room to send that message (Day 30/152). 13 Peckham witness statement [MET00007889] p. 3. 14 Peckham Day 30/160/4-9. 15 Peckham Day 30/161/2-23. 16 Meyrick Day 20/100/7-13.

The Grenfell Tower Inquiry: Phase 1 Report 318 word of mouth to other officers for them to record, either on the whiteboard or on control information forms.17 He was clear, however, that he had not been using control information forms himself18 and had not at that stage been recording information on the whiteboard. 15.11 In the early stage of the operation of CU7,19 information coming into CU7 was recorded in the form of a simple list on one of the whiteboards.20 WM Norman Harrison compiled the initial list in order to transcribe information that had been recorded on the 30 or so pieces of paper that SM Dan Egan had brought with him from CU8.21 As well as those pieces of paper, I am satisfied that WM Harrison must also have been transcribing onto this list the information that was being received on CU7 by WM Meyrick on the mobile and by WM Peckham on the radio. WM Harrison identified the initial list as the one shown on a laminated sheet in the following photograph: 17 Meyrick Day 20/105/1-7. 18 Meyrick Day 20/137/17-20. 19 As considered in more detail in Periods 10 and 11, at a later stage FSG information started to be recorded on a more sophisticated “grid” system on a whiteboard on CU7. It is likely that that was not before 03.00. 20 SM Egan, WM Harrison and GM Goodall are consistent in recalling that FSG information was first recorded in a list form on CU7: Egan Day 15/142/15-19; Harrison Day 45/120/17-24 and 120/12-16; Goodall Day 35/31/6-16. 21 Harrison Day 45/118/17-119/15.

Part II | Chapter 15: Period 6: 02.20-02.50 319 Figure 15.6

The Grenfell Tower Inquiry: Phase 1 Report 320 15.12 In his oral evidence, GM Goodall said that the writing on the laminated sheet shown in that photograph represented an initial attempt to record FSG information in the form of a list,22 but he accepted that it was possible that the laminated sheet had been brought over from CU8.23 SM Egan did not recall having seen the list shown in the photograph at all.24 15.13 The list was later replaced with a grid set out on one of the whiteboards when it became apparent that merely listing the flats from which FSG calls had been received was not a sufficiently systematic approach to identifying where people were trapped.25 However, it is likely that the grid system was not implemented until later in the incident, and probably not before 03.0026 for the reasons that are explained in this Narrative under Period 7. 15.14 WM Meyrick said that, as far as he was aware, the method of passing information to the bridgehead that had been used when he had been on CU8 continued following the move to CU7. He had his own line of communication with WM Mark Kentfield (as he understood it) and once the rest of the FSG crew were on CU8 they had also been passing information on. He said, however, that he did not know exactly how they had been doing it and would not have been aware if the system had changed in any way.27 WM Meyrick did not recall WM Kentfield having established a system for handling FSG information that involved WM Paul Sadler and thought that the only person to whom he had passed FSG information on the incident ground was WM Kentfield. He did not recall having had any contact with WM Sadler.28 15.15 WM Sadler for his part was clear that he had been in direct radio communication with CU7, which had been passing FSG information to him, but if he did speak to anyone on CU7 by radio, it could only have been to WM Meyrick.29 WM Kentfield’s evidence30 was that he had been on the incident ground with a radio link to WM Meyrick in CU8, and had provided the link between WM Meyrick and WM Sadler at the car bonnet. At some time after this, probably around 02.30, WM Kentfield returned to CU8 where he remained for the rest of the incident. Viewing the evidence as a whole, I think it is likely that although the original line of communication was between WM Meyrick and WM Kentfield, WM Sadler then took over and communicated directly by radio with WM Meyrick, even though at the time WM Meyrick thought he was speaking to WM Kentfield. 15.16 In addition to passing information by radio, GM Goodall used WM Shaun Coltress and FF Mandeep Singh as runners to take information to the bridgehead.31 FF Singh arrived at 01.35.3132 and CCTV images show him entering the tower holding small slips of paper as early as around 02.08,33 suggesting that the “runner” system was probably in place when FSG calls were still being managed from CU8. FF Singh in his witness statement described running 22 Goodall Day 35/31/6-32/5. 23 Goodall Day 35/52/16-53/6. 24 Egan Day 16/40/15-21. 25 E.g. Goodall Day 35/31/10-16. 26 Time based on the time stamp of the photograph at [MET00015934]. 27 Meyrick Day 20/103/4-104/3. 28 Meyrick Day 20/113/8-14. 29 WM Peckham said that he did not speak with anyone on the incident ground (Peckham Day 30/163/19-24); WM Harrison’s role was in populating the whiteboards with the information passed on to him by WM Meyrick and WM Peckham (Harrison Day 45/123/19‑25); GM Goodall described his role as co-ordinating and overseeing the activity on CU7 rather than having any communications himself (Goodall Day 35/90/9-17); SM Egan established a direct line of communication with SM Wolfenden on the incident ground, but that is likely to have been after 03.00 for the reasons set out in the body of the text (Egan Day 15/157/1‑25). 30 Kentfield witness statement [MET00023051] pp. 13, 14. 31 Goodall Day 35/39/9-13. 32 SIL p. 8. 33 ORR v.0.7 p. 142.

Part II | Chapter 15: Period 6: 02.20-02.50 321 information on paper from the command unit only to the bridgehead and to WM Glynn Williams in the lobby; he did not refer to WM Sadler or to the system set up by WM Sadler on the car bonnet.34 15.17 WM Coltress arrived at 02.21.00.35 Unlike FF Singh, his role initially entailed running FSG information from CU7 to WM Sadler,36 but later it involved running between what he referred to as ‘three FSG points’, namely CU7, WM Sadler and a person he referred to as “the search co-ordinator” (likely to have been WM Williams or SM Pete Wolfenden) inside the tower.37 He started as a runner some 10 to 15 minutes after his arrival at the incident.38 He went to CU7 where he said he had been briefed by a Station Manager, possibly SM Egan.39 He was told, in broad terms, about the system being operated by WM Sadler, although not “how that fed into the overall system”. 40 Most of the time the information that he carried from CU7 had been recorded on control information forms. Any information that had been recorded on pieces of paper had been transferred onto control information forms after he had reached what he called WM Sadler’s “forward fire survival point”41 before being sent into the building for the search coordinator.42 He also ran control information form duplicate copies back to CU7, when they had been created at the forward point on the basis of information obtained directly from members of the public.43 He was never asked to take any information about the outcome of deployments in response to FSG calls from the incident ground back to CU7.44 15.18 Finally, GM Goodall also recalled that some FSG information had been passed by SM Egan from CU7 directly to SM Wolfenden at the bridgehead using the radio.45 SM Egan explained in his evidence how he had established that line of communication,46 but SM Wolfenden said that he had become involved in handling FSG information only after he had presented himself at CU7, which was well after 03.00.47 I shall therefore return to this aspect of the matter later. 15.19 At that stage, therefore, it seems that there were two parallel lines of communication from CU7 to the incident ground: one involved WM Meyrick speaking by radio to WM Kentfield and WM Sadler outside the tower; the other involved runners carrying control information forms or other pieces of paper to WM Sadler (WM Coltress) or directly to the bridgehead and to WM Williams in the lobby (FF Singh). WM Sadler’s FSG system, contd 15.20 At around 02.25 to 02.30, WM Sadler moved from the car bonnet to a position under the covered walkway, where he carried on processing FSG information lying on the ground.48 At that point, he continued to work through the information recorded on the photograph of the A4 paper (the “envelope”) he had been given,49 the original document having by then been 34 Singh witness statement [MET000083327] p. 12. 35 He arrived on F241. SIL p.9. 36 Coltress Day 45/57/11-15. 37 Coltress witness statement [MET00010911] p. 10. 38 Coltress Day 45/43/5-6. 39 He was not briefed by GM Goodall: Coltress Day 45/39/19-40/6. 40 Coltress Day 45/43/15-23. 41 WM Coltress confirmed that that was the “car bonnet” system at the base of the tower: Coltress Day 45/45/14-16. 42 Coltress Day 45/44/24-45/7. 43 Coltress Day 45/55/4-11. 44 Coltress Day 45/52/6-11. 45 Goodall Day 35/37/8-17. 46 Egan Day 15/157/1-21. 47 Wolfenden Day 40/152/24. 48 Sadler Day 29/110/17-111/17. 49 Sadler Day 29/116/4-12.

The Grenfell Tower Inquiry: Phase 1 Report 322 sent up to the bridgehead with CM Charles Batterbee. It was also around that time, having reached control information form number 14, that he abandoned the numbering system that he had adopted at an early stage of his operations.50 15.21 CM Batterbee continued to carry control information forms from WM Sadler into the building, where they were taken from him by WM Williams in the ground floor lobby.51 At some point WM Sadler became aware that his control information forms were being intercepted in that way, rather than being taken directly to the bridgehead, but he assumed that that was because those responsible for acting on the information were “getting some kind of control on these searches”.52 15.22 Later on, it is not clear when, WM Sadler moved his area of operations to a bin area under the covered walkway and about five metres further back in order to avoid the water running off the tower. There the firefighters placed wooden boards over the bins to act as desks.53 WM Sadler estimated that he had remained there carrying out the same role for about another five or six hours.54 The bridgehead on floor 3: GM Richard Welch and GM Patrick Goulbourne 15.23 When the bridgehead was moved to floor 3, WM Louisa De Silvo realised that FSG information was going to continue arriving in great quantities. She therefore stopped using the FIB that she had been using to record information when the bridgehead had been on floor 2 and started to use the wall of the lobby on floor 3 instead, writing floor numbers from 3 to 23 in a vertical line and adding specific flats as the information came in.55 15.24 A photograph of the wall taken from later in the incident after FSG information had been recorded on it is reproduced below: 50 Sadler Day 29/60/3-18. [LFB00001922] p. 5. 51 Batterbee Day 12/150/2-15. 52 Sadler Day 29/73/4-8. 53 Sadler witness statement [MET00012481] p. 5; Batterbee Day 12/148/6-15. 54 Sadler witness statement [MET00012481] p. 5. 55 De Silvo Day 30/6/12-7/22; 8/15-23.

Part II | Chapter 15: Period 6: 02.20-02.50 323 Figure 15.7

The Grenfell Tower Inquiry: Phase 1 Report 324 15.25 WM De Silvo explained that a tick against a particular flat indicated that a BA crew had been sent there and a circle indicated that she had received further information, either by runner radio, or from the returning crew. A cross through the flat indicated that it had been searched and a rescue carried out.56 15.26 GM Goulbourne arrived at the bridgehead soon after it had been moved to floor 3, following his briefing from DAC Andrew O’Loughlin. CCTV images show him entering the tower for the first time at around 02.28.57 GM Welch’s recollection was that he had asked GM Goulbourne to take charge of managing FSG information to make sure that they were committing crews to the right floors at the right times.58 According to GM Goulbourne, however, although GM Welch had given him a general briefing about what was going on at the bridgehead, he had not given him any particular job to do59 and there had been no detailed discussion about FSG calls.60 GM Goulbourne said that, immediately on his arrival on floor 3, he had carried out some “supporting tasks” and that by the time he had been able to speak to GM Welch about his role in the Search Sector, the bridgehead had begun to be compromised by smoke, making it necessary to move it down to the ground floor.61 15.27 Once the bridgehead had been established on floor 3, GM Welch had a conversation with WM De Silvo about prioritising the young, elderly and those with mobility issues. Apart from that, calls were being responded to as they were received.62 GM Welch understood that WM De Silvo was receiving sufficient information over her fireground radio to enable her to decide which calls should be given priority. He did not see any runners at the bridgehead when it was on floor 3.63 15.28 GM Welch said that in the early stages BA crews were being committed to fight the fire as well as to carry out rescues, but that firefighting very quickly became a secondary consideration.64 He could not recall whether EDBA crews had been committed from floor 3 or whether they had been deployed only after the bridgehead had been moved to the ground floor, but he was clear that there had been enough EDBA wearers available to him.65 When shown the photograph of the lobby wall reproduced above, GM Welch said that his understanding of the ticks against the flats below floor 17 was that they indicated that BA crews had reached those floors and had rescued the occupants. He assumed that EDBA had been used, as would be appropriate, in order to reach the furthest destinations.66 He was not able to explain why one of three EDBA crews which had been deployed when the bridgehead was on floor 3 had been sent to floor 4 shortly after 03.00.67 The Paddington EDBA crew return to the bridgehead 15.29 Inside the tower, Paddington’s EDBA crew made their way back down to the bridgehead with Fadumo Ahmed, whom they had rescued from the stairwell landing between floors 20 and

1. On the way down the stairs she had initially been alert, but as the temperature increased

56 De Silvo/Day 30/5-15. 57 ORR v.0.7 p. 194. 58 Welch Day 44/174/13-23. 59 Goulbourne Day 41/129/13-130/2. 60 Goulbourne Day 41/133/13-20. 61 Goulbourne Day 41/130/17-131/24. 62 Welch Day 44/156/3-19. 63 Welch Day 44/157/18-158/20. 64 Welch Day 44/158/13-23. 65 Welch Day 44/160/7-21; WM De Silvo also said that she did not recall any problem with lack of EDBA wearers but that it would not be part of her role to assess BA resources: De Silvo/Day 30/14/6-11. 66 Welch Day 44/163/15-164/18. 67 Welch Day 44/164/19-165/6.

Part II | Chapter 15: Period 6: 02.20-02.50 325 she collapsed and became unconscious.68 When they reached the bridgehead FF  Martin Gillam and FF Dean Roberts carried her out onto the mezzanine and started to perform CPR, using the mask from FF Gillam’s BA set. She regained consciousness and they carried her out to the ambulance that was waiting about 150 metres away from the tower in the direction of the leisure centre.69 15.30 The “end of wear times” of the Paddington EDBA crew were recorded as between 02.21.49 and 02.23.12.70 CM Raoul Codd, who was one of the Chelsea FRU crew (G346) that had arrived at the incident at 01.47.33, saw the Paddington crew on their way out of the building while he was outside the entrance to the tower waiting to be deployed with the rest of his crew. CM Codd heard FF Tom Reddington, also from the G346 crew, say to the Station Manager who was in charge (probably SM Brett Loft): “That is your only FRU crew. We’re FRU and we need to get in there.”71 FF Nikki Upton similarly recalled FF Reddington telling the Chelsea crew to be more proactive, get their sets on and go in, as they had EDBA. They decided to go to the bridgehead and get involved, rather than wait for someone to call for them.72 FFs Katie Foster and Gregory Lawson return to the bridgehead 15.31 FFs Foster and Lawson returned to the bridgehead not long after the Paddington EDBA crew. Their “end of wear time” was 02.27.18 and 02.27.36.73 FF Foster was not involved in the debrief given by FF Lawson, who told her to return her tally and close down her BA set.74 FF Lawson delivered his debrief to an officer in a white helmet, and drew a plan on the wall of the bridgehead to indicate which flats they had been to and which were empty. He also explained why they had not taken the occupants to whom he had spoken down the stairs and said that it was necessary to send more crews back there immediately.75 15.32 On leaving the bridgehead and going back through the ground floor lobby, FF Lawson spoke to CM Batterbee. He drew another plan of floor 18 on a piece of paper, which he gave to CM Batterbee, repeating the information that he had given at the bridgehead.76 He did not see what CM Batterbee did with the information.77 Arrival of AC Andrew Roe on CU7 15.33 AC Roe arrived at 02.31.1878 and started to make his way towards the tower. He had in mind the LFB decision-making model which at that point he felt simply required him to get a proper understanding of what he was facing. He expected the senior officers already there to have put in place some form of plan to manage the incident.79 15.34 As he walked towards the tower, he saw that the whole of it was alight from floor 3 upwards and that there was fire inside many windows. That led him very quickly to the conclusion that the fire was inside the building. He said that it had been very obvious to him at that point that there had been a complete building system failure. He saw that the fire had broken out of the 68 Gillam witness statement [MET00008025] pp. 11-13. 69 Roberts witness statement [MET00007890] pp. 6-7; Gillam witness statement [MET00008025] p. 13. 70 BA Telemetry Schedule. 71 Codd witness statement [MET00012539] p. 3; Codd Day 39/76/3-17. 72 Upton witness statement [MET00007524] p. 5. 73 BA Telemetry Schedule. 74 Foster Day 39/118/20-119/6. 75 Lawson witness statement [MET00010815] p. 5; Lawson Day 39/156/19-157/4. 76 Lawson Day 39/157/5-23. 77 Lawson Day 39/158/9-11. 78 SIL p. 14. 79 Roe Day 48/227/10-25.

The Grenfell Tower Inquiry: Phase 1 Report 326 compartments initially affected and had entered the compartments beyond,80 and that the extent of the internal fire spread was significant.81 He said that at the same time he was very sure that they were no longer going to be able to advise people that they should stay put. That, he said, had been the first thing in his mind.82 He decided at the same moment that the only purpose of fighting the fire would be to maintain conditions, in order to mitigate the risk to BA crews when sending them in as far as they could.83 15.35 AC Roe went first to CU7, where GM Goodall told him that he thought there had been about 100 FSG calls.84 GM Goodall briefed him about the system he had put in place, including the system of running hard copy records of FSG calls into the bridgehead, and AC Roe was satisfied with that.85 AC Roe could not recall whether he had learnt at that stage or later on that GM Goodall had been finding it difficult to get information back from the bridgehead about the results of deployments.86 He remembered having reminded GM Goodall of the need to get information back to the control room, but said that he had been conscious that the officers handling FSG calls were working at absolute capacity and that “closing the loop was just very, very difficult”.87 It had simply been impossible to inform the control room about the outcome of every deployment in response to an FSG call.88 15.36 AC Roe then left CU7 to go to CU8.89 DAC O’Loughlin on CU8: make aerials 4 and the informative message 15.37 Meanwhile, on CU8, DAC O’Loughlin had remained in command. During that period, indeed during the entire period during which he had been in command, he had received no additional information from GM Goodall nor any information from GM Goulbourne on the fire sector90 and had not attempted to leave CU8 in order to speak in person to anyone on CU7.91 15.38 At 02.31.22, a radio message was sent from CU8 to the control room seeking confirmation that the request for four aerials had been received.92 That was one of the messages that DAC O’Loughlin recalled having asked WM Kentfield to send on his behalf, shortly after his arrival at the incident at around 02.00, but there is no record of its having been sent or received before 02.31. The request was entered in the VISION system at 02.32.01.93 In oral evidence DAC O’Loughlin said that he did not think that the delay had made any difference, because he felt that the appliances would not have been able to gain access to the building in any event.94 15.39 DAC O’Loughlin also asked for an informative message to be sent that was recorded in VISION by the control room at 02.42.03.95 It read as follows: 80 Roe Day 48/230/1-17. 81 Roe Day 48/233/5-10. 82 Roe Day 48/231/3-6. 83 Roe Day 48/231/9-14. 84 Roe Day 48/235/6-20. 85 Roe Day 48/236/1-21. 86 Roe Day 48/241/14-25. 87 Roe Day 48/247/5-248/1. 88 Roe Day 48/248/15-20. 89 Roe witness statement [MET00007520] p. 3. 90 O’Loughlin Day 48/13/12-14/5. 91 O’Loughlin Day 48/15/5-16/6. 92 [LFB00002258]. 93 SIL p. 23. 94 O’Loughlin Day 47/149/14-150/1. 95 SIL p. 23.

Part II | Chapter 15: Period 6: 02.20-02.50 327 “SUP CU8 FROM DAC OLOUGHLIN A RESIDENTIAL BLOCK OF FLATS 27 FLOORS 25M X 25M FIRE ON ALL FLOORS FROM 2ND TO 27TH FLOOR LARGE NUMBER OF PERSONS INVOLVED FSG CALLS BEING DEALT WITH MAJOR INCIDENT DECLARED HIGH RISE PROCEDURE IMPLEMENTED TL ALP EDBA MAIN CONTROL FSG GROUND MONITOR 5 JETS SAFETY CORDEN IN PLACE TACTICAL MODE OSCAR.” 15.40 DAC O’Loughlin said that when sending a “persons reported” message you should specify how many people you know are involved, but that at that stage of the incident the most he could say was that there was a large number of FSG calls.96 He explained that the message referred to 27 floors because the floor plaque, which had been brought from the building onto CU8 (probably by WM Kentfield), listed additional levels below the ground floor, making it appear that were more floors than was actually the case.97 15.41 Immediately after that message had been sent, DAC O’Loughlin recalled that someone from CU7 had come onto CU8 and provided him with a slip of paper on which it was recorded that FSG calls had been received from 58 adults and 16 children (as recorded on VISION at 02.42.5098). He had been shocked by the number,99 but it had not prompted him to think that firefighting was no longer a viable option. (He had not still received a briefing as to the extent of the fire.)100 Nor did it cause him to consider revoking the “stay put” advice. Notwithstanding that (as he accepted) some of the FSG calls might have come from parts of the building other the north-east corner, he maintained that at that time there had been no reason to think that it would not be safer for people whose flats were not directly affected by fire or smoke to stay in them.101 DAC O’Loughlin and withdrawal of the “stay put” advice 15.42 After the informative message had been sent, DAC O’Loughlin recalled that one of the Watch Managers on CU8, whose name he did not know, had told him that a message had been received from the control room notifying them that the “stay put” advice had been changed.102 DAC O’Loughlin’s recollection was that the control room had already made the decision and that he had not been asked for his permission.103 15.43 DAC O’Loughlin said he had been confused by that: his understanding was that people making FSG calls should be encouraged to find a way to escape if they thought they could.104 He therefore understood the message as meaning that people who called the control room from flats that were not affected by fire or smoke would also be told to leave,105 even though they were not actually FSG callers in the true sense of the term,106 and that people making “true” FSG calls should be encouraged to check again to see whether there was a way of leaving.107 He asked the Watch Manager on CU8 to call the control room again to clarify the position, since callers from flats that were not affected might be encouraged to enter 96 O’Loughlin Day 47/236/16-237/5. 97 O’Loughlin Day 47/237/23-238/24. 98 SIL p. 23. 99 O’Loughlin Day 47/240/3-14. 100 O’Loughlin Day 47/242/7-21. 101 O’Loughlin Day 47/244/6-23. 102 O’Loughlin Day 48/2/20-3/8. 103 O’Loughlin Day 48/4/25-5/7. 104 O’Loughlin Day 48/7/8-17; 11/19-12/4. 105 O’Loughlin Day 48/5/25-6/5. 106 O’Loughlin Day 48/8/10-11. 107 O’Loughlin Day 48/9/14-17.

The Grenfell Tower Inquiry: Phase 1 Report 328 a smoke-filled environment if they were told to leave.108 The second call did not resolve his confusion, however, because the control room continued to refer simply to “FSG callers”, but he did not take any steps to seek further clarification.109 15.44 Following the second call, therefore, DAC O’Loughlin understood that anyone who made an emergency call from inside the building would be told to leave110 and that callers who said they were trapped would be “encouraged” to leave.111 However, he also said that the change in the “stay put” advice amounted to saying: “If you feel you can escape, you should”, but did not involve telling people to enter a smoke-filled environment.112 He did not understand that the advice being given to occupants from that point onwards was that they must leave at all costs and that it was a matter of life and death. He thought that if occupants were telling CROs that they could not leave their flats, they would not be able to get out in any event.113 15.45 DAC O’Loughlin’s recollection was that AC Roe had arrived on CU8 within a few minutes of the message coming in from the control room.114 Arrival of AC Roe at CU8: the decision to revoke the “stay put” advice 15.46 AC Roe arrived on CU8 and immediately asked for a message to be sent confirming that he had taken over as incident commander.115 It was sent at 02.43.51.116 AC Roe said that as he entered the CU he had been thinking very clearly that he wanted to end the “stay put” advice.117 He said that he knew at that moment that it was “absolutely unsustainable”.118 15.47 AC Roe was given a briefing by DAC O’Loughlin, who told him that the tower was alight from floor 3 to floor 24, with many people trapped, and that GM Welch and GM Goulbourne were in command of the fire sector.119 He did not recall having discussed with DAC O’Loughlin whether the fire had penetrated the interior of the flats, as he thought there had been a general understanding that they were facing a building system failure.120 AC Roe recalled that DAC O’Loughlin had been able to tell him about the organisational structure that he had put in place and how he was ensuring that there was a supply of BA wearers to go into the tower and said that he had felt reassured by that.121 AC Roe said that he had not been told by DAC O’Loughlin that no information had come back to CU8 from either the fire sector or CU7 for the past 25 minutes.122 He also said that DAC O’Loughlin had not revoked the “stay put” advice at that time. 123 108 O’Loughlin Day 48/12/11-13. 109 O’Loughlin Day 48/12/13-25; O’Loughlin Day 48/13/2. 110 O’Loughlin Day 48/17/13-20. 111 O’Loughlin Day 48/18/24-19/4. 112 O’Loughlin Day 48/34/8-12. 113 O’Loughlin Day 48/32/13-16. 114 O’Loughlin Day 48/7/21-25; O’Loughlin Day 48/8/1. 115 Roe Day 48/254/10-16. 116 [LFB00002272]. 117 Roe Day 49/5/1-2. 118 Roe Day 49/26/7-8. 119 Roe Record of Actions p.2. 120 Roe Day 48/256/7-13. 121 Roe Day 48/256/13-23. 122 Roe Day 48/257/16-19. 123 Roe Day 48/257/13-14.

Part II | Chapter 15: Period 6: 02.20-02.50 329 15.48 AC Roe’s evidence about how the decision to change the “stay put” advice came to be made differed from that of DAC O’Loughlin. AC Roe did not remember a message from the control room saying that it had changed the advice being given to FSG callers. He said that immediately after he had told the crew on CU8 that he was taking over, he directed SM Jackie McConochie to act as his loggist and as a first step to record that he wanted to end the “stay put” advice.124 15.49 At that point, AC Roe recalled that he had turned to the officers on CU8 to give them the necessary instruction but had found that one of them was already on the telephone to the control room which was asking to withdraw the “stay put” advice. AC Roe told the officer that he wanted to end it anyway and to tell the control room that that is what they should do.125 He told SM McConochie to record the decision,126 which appears in his log timed at 02.47.127 15.50 AC Roe did not speak to the control room about withdrawing the “stay put” advice. In his view it was unnecessary to do so, because it was advice that could no longer properly be given.128 His decision to withdraw the advice was prompted by the fact that the fire had spread in all directions, resulting in a total failure of compartmentation.129 He acknowledged that by telling callers to leave there was a risk of sending them into a smoke-logged environment. He said that he had grappled with that dilemma, but had concluded that compartmentation had failed to such an extent that it was impossible to see how any flat in the building could be relied on to provide a survivable environment.130 Anyone who was in the building above floor 4 was “in great danger”.131 15.51 The officer on CU8 who took the call from the control room concerning the withdrawal of the “stay put” advice may have been SM Peter Johnson, who had arrived at the incident at 01.58.45132 and had boarded CU8 not long thereafter.133 He took a call from someone in the control room, whom he thought might have been DAC Adrian Fenton,134 informing him that the control room had taken the decision to tell callers to leave the building135 and passed the information on to AC Roe.136 As he recalled it, the control room had announced its decision; it had not asked for permission to withdraw the advice.137 15.52 GM Stephen West was also on CU8 at that time. He remembered that he had taken a call from DAC Fenton seeking the Commissioner’s permission to change the “stay put” advice, following which he had had a brief conversation with the Commissioner, who told him that they should do whatever was required. However, I think he must have been mistaken about that because the Commissioner did not arrive at the incident until 02.50.48138 and she said that AC Roe had told her shortly after she went on to CU8 that he had revoked the “stay put” advice.139 She did not recall having had any conversation with GM West of the kind he 124 Roe Day 49/5/7-13. 125 Roe Day 49/5/14-6/9. 126 Roe Day 49/5/7-13. 127 Roe Log [MET00005404] p. 1. 128 Roe Day 49/7/19-8/11. 129 Roe Day 49/19/18-21. 130 Roe Day 49/15/17-16/10. 131 Roe Day 49/12/12-13/2. 132 SIL p. 9 (SM Johnson was on CU2). 133 SM Johnson’s evidence was that he arrived some time after 02.11, when the message was sent confirming that DAC O’Loughlin had taken command, but before 02.43, which was the time that he sent the message confirming that AC Roe had taken command: Johnson Day 37/59/20-61/1. 134 Johnson Day 37/95/25-96/3. 135 Johnson Day 37/93/12-94/12. 136 Johnson Day 37/95/16-20. 137 Johnson Day 37/96/4-12. 138 [LFB00002814]. 139 Cotton Day 50/146/25-147/3.

The Grenfell Tower Inquiry: Phase 1 Report 330 described.140 In addition, DAC Fenton did not recall a conversation in which he had asked for permission to change the “stay put” advice, although his recollection of the calls he had made to CU8 was in some respects unclear.141 15.53 Although it is not entirely clear whether it was SM Johnson or GM West who took the call notifying the incident ground that the control room had withdrawn the “stay put” advice, nothing turns on the point. It is clear that someone in the control room, most likely DAC Fenton, spoke to someone on CU8 and told him of the control room’s decision.142 The fact is that DAC Fenton and SOM Joanne Smith together had made that decision and that the purpose of calling CU8 was to inform the incident commander of that fact. AC Roe made the same decision, independently, at almost the same time. Other significant BA deployments during this period CM Richard Evans and FF Gemma Bloxham 15.54 CM Evans and FF Bloxham were briefed to go to Flat 205 on floor 23143 and tallied out at 02.24.24 and 02.24.33.144 On their way up, somewhere between floor 18 and floor 20,145 the firefighters came across two casualties in the stairwell, a man and a woman (probably Shekeb (Farhad) Neda and Flora (Shakila) Neda). CM Evans and FF Bloxham took them into the lobby where the air quality was better. FF Bloxham recalled that the woman had been on the telephone to members of her family on floor 23 and that on overhearing the conversation CM Evans had tried to make radio contact with the bridgehead, but had not been able to obtain a response.146 15.55 The crew then started to take the two casualties down. On the way, they became separated from the man.147 They then came across an injured firefighter without his helmet (now known to be FF David Hill). FF Bloxham took hold of him in order to lead him down to the bridgehead while CM Evans looked after the woman, who by that point had collapsed.148 15.56 When the crew arrived back at the bridgehead CM Evans took the woman outside to the LAS149 while FF Bloxham gave FF Hill oxygen in the lift lobby. CM Evans then returned to the bridgehead and told the officer in charge that he and FF Bloxham had brought two people down but that they had not reached Flat 205.150 The crew’s “end of wear time” was 02.42.59 and 02.42.47.151 140 Cotton Day 50/156/4-10. 141 Fenton Day 24/153/10-19. 142 Fenton Day 24/154/11-155/2. 143 Evans witness statement [MET00010089] p. 7. 144 BA Telemetry Schedule. 145 CM Evans recalled that it was between floor 18 and floor 20 that they came across the casualties, FF Bloxham said that it was around floor 20: Evans witness statement [MET00010089] p. 9; Bloxham witness statement [MET00010866] p. 4. 146 Evans witness statement [MET00010089] pp. 9-10; Bloxham witness statement [MET00010866] p. 4. 147 CM Evans said that he handed the man to the Chiswick crew, while FF Bloxham recalled that the man ran off on his own down the stairs: Evans witness statement [MET00010089] p. 11; Bloxham witness statement [MET00010866] p. 5. 148 Evans witness statement [MET00010089] p. 11; Bloxham witness statement [MET00010866] p. 5. 149 Flora (Shakila) Neda’s exit time is 02.43.32. Annex A. 150 Evans witness statement [MET00010089] p. 12; Bloxham witness statement [MET00010866] p. 5. 151 BA Telemetry Schedule.

Part II | Chapter 15: Period 6: 02.20-02.50 331 FF Reddington and FF Upton 15.57 FFs Reddington and Upton tallied out at 02.44.07 and 02.44.39,152 deployed to two flats on floor 21. FF Upton’s recollection was that they had either been briefed to go to Flats 182 and 183 or to Flats 183 and 184.153 At about floor 18 the crew came across an unresponsive female casualty. Her leg was stuck in the bannister railings and the firefighters could not move her. FF Upton then discovered another casualty, this time a child, close to the woman. The crew decided that, since they could not move the woman, they had to leave her there in order to take the child down.154 It is likely that the woman was Farah Hamdan and the child Malak Belkadi, from Flat 175 on floor 20. 15.58 On their way down, the firefighters came across another crew on their way up and told them that they had left a woman behind who needed assistance. On reaching the bridgehead, FFs Reddington and Upton reported that they had not reached floor 21. Their “end of wear time” was 03.06.59 and 03.07.52.155 FF Leon Whitley and FF Ricky Nuttall 15.59 FF Whitley and FF Nuttall tallied out at 02.44.32 and 02.45.07 respectively,156 having been briefed to go to Flat 122 on floor 15 taking a hose with them.157 Once the crew were in the lobby on floor 15, they located the riser, rolled out the hose and waited until the water had charged the hose. They then located Flat 122, but at that point the whistles on their BA sets sounded, indicating that they were low on air.158 The firefighters decided that they would return to the bridgehead rather than trying to gain entry to Flat 122, as they were concerned that they would not have enough time to help the casualties out, particularly if they were elderly or there were a group of people.159 15.60 The crew reached the bridgehead, which by that time had been moved the ground floor. Their “end of wear time” was 03.10.03 and 03.10.49 (in Period 8).160 FF Nuttall recalled trying to tell WM Williams that they had not reached Flat 122 but that he had been too busy to take the information. The crew then left the building and FF Nuttall tried again to pass the information to a Crew Manager standing by some garages near the front of the tower. He said that he could not take the information either. Finally, FF Nuttall was able to give it to a Watch Manager who told him that he would deal with it.161 152 BA Telemetry Schedule. 153 Upton witness statement [MET00007524] p. 5; Upton Day 38/145/2-24. 154 Upton witness statement [MET00007524] p. 8; Upton Day 38/147/8-21. 155 BA Telemetry Schedule. 156 BA Telemetry Schedule. 157 Nuttall witness statement [MET00012561] p. 7. 158 Nuttall witness statement [MET00012561] p. 11. 159 Nuttall witness statement [MET00012561] p. 12. 160 BA Telemetry Schedule. 161 Nuttall witness statement [MET00012561] pp. 13-14.

The Grenfell Tower Inquiry: Phase 1 Report 332 3 Conditions in the tower and movement of occupants The progress of the fire on floor 23 Flat 205 15.61 At 02.25.38, CRO Christine Howson answered a 999 call from Mariem Elgwahry.162 During the call, she told CRO Howson that she was one of seven adults who were now cornered in the kitchen. They were running out of air and the whole flat was black. There were flames outside the window. Mariem Elgwahry said that she was with her mother who was diabetic and had asthma. She then said that the fire had reached a bedroom and confirmed to CRO Howson that the bedroom door had been closed. CRO Howson advised her to leave, if necessary. Mariem Elgwahry said those in the flat had already tried to leave, but that it was totally black outside the front door. CRO Howson advised using wet towels, which Mariem Elgwahry said they had done. CRO Howson then advised that, if the fire had reached the flat, everyone needed to leave. 15.62 While the call was continuing, Ahmed Elgwahry (Mariem Elgwahry’s brother) tried to telephone her. She called him back at 02.31. Ahmed Elgwahry felt that in this call his sister did not want to worry him. She told Ahmed Elgwahry that there were six or seven people in the flat. She was sitting in the kitchen. She could only see smoke from the window. It was not possible to leave because the area outside the flat was full of black smoke and it was impossible to see.163 15.63 Ahmed Elgwahry had a further telephone conversation with his sister, which began at 02.33. I return to this call later. 15.64 The bedroom in Flat 205 first reached by the fire was immediately opposite the front door. When Mohammed Amied (Saber) Neda discovered the fire he closed the bedroom door and told everyone not to enter it.164 By that point those in Flat 205 had moved into the kitchen as that was least affected by smoke. Farhad Neda decided that they could not stay. He estimated the time of that decision as around 02.15 based on a text exchange with a friend outside the tower. He grabbed his mother and shouted to his father to leave. His father agreed and told Farhad Neda that he would be right behind. As they were leaving, Saber Neda was handing out wet towels to the four women who had taken refuge in Flat 205.165 15.65 There was already thick smoke in the hallway of the flat when Farhad Neda opened the front door. The lobby was dark and thick with smoke. Flora (Shakila) Neda remembered that, in the hallway light, the smoke in the lobby looked greasy or shiny like glitter. The flat door did not close automatically and Farhad Neda left it open believing his father was following behind. The lobby was hotter than the flat and the smoke caused a burning sensation in the throat and lungs. It had a sour taste and made Flora (Shakila) Neda vomit and choke. They both had wet cloths over their mouths and noses but struggled to breathe. Carrying his mother, Farhad Neda felt his way to the stairwell door, which took him no more than 20 seconds. He pushed the stairwell door open.166 162 [LFB00000670]. 163 Ahmed Elgwahry first witness statement [IWS00000988] p. 10. 164 Farhad Neda Day 61/53/3-7; Day 61/63/1. 165 Farhad Neda first witness statement [IWS00000886] pp. 8-9; Farhad Neda Day 61/69/4-24; Day 61/71/1-75/9; Flora (Shakila) Neda first witness statement [IWS00000887] p. 10. 166 Farhad Neda first witness statement [IWS00000886] p. 9; Farhad Neda Day 61/75/14-21; Day 61/76/21-81/25; Flora (Shakila) Neda first witness statement [IWS00000887] pp. 10-11; Flora (Shakila) Neda Day 61/139/15-141/19; Day 61/144/4-145/11.

Part II | Chapter 15: Period 6: 02.20-02.50 333 15.66 The stairs were also thick with black smoke. There was no apparent lighting and the handrail was not visible. The smoke had a sour, acidic taste. Farhad Neda helped his mother down the stairs. As they descended it became just possible to make out the floor. At one point they tripped and saw an open stairwell door. They returned to that door and entered the lobby to try and find some air. There was less smoke there. They sat down by the air vents on the south side of the lobby. Within a minute or so they continued their descent. Two or three floors down they encountered two firefighters, probably FFs Bloxham and Evans, in the darkness of the stairwell. It was at that point that Farhad Neda realised his father was not following behind. When he told one firefighter that his father and four others were trapped in Flat 205, the firefighter wrote that information in a notebook.167 15.67 The two firefighters then assisted them down the stairs. The Nedas did not see any light into the stairwell until about floor 4. At about floor 2 or 3, they were handed over to other firefighters and helped out of the tower. As he was leaving the main entrance Farhad Neda told firefighters that there were still people in his flat.168 Farhad and Flora (Shakila) Neda are recorded as leaving the tower at 02.42.10 and 02.43.32 respectively.169 15.68 At 02.37, Saber Neda telephoned his nephew, Lotfrahman (Massi) Abdulrahman. He was still in Flat 205 and asked why no one had come to help. Massi Abdulrahman could hear female voices in the background.170 After this call had ended, Massi Abdulrahman tried repeatedly to call his uncle throughout the night. The telephone would ring but was not answered. After 05.00, the calls went straight to voicemail.171 15.69 At 02.40, Saber Neda left a voicemail for his brother in law, Habibrahman Abdulrahman. He said: “Goodbye. We are now leaving this world, goodbye. I hope I haven’t disappointed you. Goodbye to all.”172 15.70 At 02.41, the body of Saber Neda was found in the children’s playground on the west side of the tower.173 He had jumped from the tower after leaving the voicemail message. Flat 204 15.71 At 02.36.07, CRO Sarah Russell spoke to Hesham Rahman.174 She had difficulty hearing him because of the smoke alarm in his flat. He told her that smoke was coming into the flat but not flames. She suggested that it might be better to leave. He responded by saying that he could not see anything outside the door and had problems walking and so would need help on the stairs. He was in the sitting room. CRO Russell confirmed that she would pass on the information and advised Hesham Rahman about what to do while he waited in his flat. 15.72 At 02.36.12 a female relative of Hesham Rahman spoke to CRO Angie Gotts. Hesham Rahman had told his relative on the telephone that there was already a lot of smoke in the flat and that the fire was now travelling towards him.175 167 Farhad Neda first witness statement [IWS00000886] pp. 10-11; Farhad Neda Day 61/82/2-93/-25; Flora (Shakila) Neda first witness statement [IWS00000887] pp. 11-13; Flora (Shakila) Neda Day 61/145/12-148/5. 168 Farhad Neda Day 61/87/13-17; Day 61/93/6-23. 169 Annex A. 170 Lotfrahman Abdulrahman first witness statement [IWS00000882] pp. 2-3. 171 Lotfrahman Abdulrahman first witness statement [IWS00000882] p. 3. 172 As played at the Commemoration Hearing on 21 May 2018. Habibrahman Abdulrahman first witness statement [IWS00000883] p. 2; Lotfrahman Abdulrahman second witness statement [IWS00001132] p. 1. 173 CAD 428 [MET00023294] p. 16. 174 [LFB00000368]. 175 [LFB00000364].

The Grenfell Tower Inquiry: Phase 1 Report 334 Flat 203 15.73 At 02.42.06, Isra Ibrahim spoke to CRO Howson.176 She told her that the amount of smoke in the flat was increasing. They had put blankets by the front door. The flat next door (probably Flat 202) was on fire. There were five adults and two children in the flat. CRO Howson advised Isra Ibrahim about blocking out the smoke, told her that firefighters were making their way to her and said that, as long as there were no flames, the flat was the safest place “because you don’t know what’s going on outside”. The progress of the fire on floor 21 15.74 At 02.32, Marcio Gomes in Flat 183 made a 30-second video recording on his mobile telephone of his front door and that part of the lobby immediately outside the door.177 Just before he made that recording, he had tried to get to Flat 181, the home of his neighbour, Ligaya Moore, who lived alone. He had not gone beyond his own door.178 15.75 The video recording shows: a. smoke coming through the gap at the bottom of the front door where a towel has been laid across it;179 b. smoke coming through the left-hand side of the front door where a towel has been hung on a hook;180 and c. the area of the lobby outside the front door, which was pitch-black with no indication of functioning lighting.181 15.76 The threshold of Marcio Gomes’s front door was usually illuminated by a lobby light fixed to the wall on the right-hand side of the door. It had been working earlier when Helen Gebremeskel and her daughter had knocked on the door.182 15.77 On the recording, and before and after he opened the front door, traces of smoke are visible in the air as Marcio Gomes moves around the hallway.183 The front door of Flat 183 faced a white wall in the lobby. That wall cannot be seen in the recording. A shower can be heard in the background. As well as filling the bath, Marcio Gomes had turned on the shower because the smoke in the flat had made the air dry. He hoped that if he could get wet particles into the air it would make breathing easier. The shower stopped running 5 or 10 minutes after the video recording was made. It did not start again that night.184 15.78 At 02.46.58 Marcio Gomes made another 999 call.185 He told CRO Howson that the fire had reached the flat next door and was coming through the windows. At the time he could see from a bedroom window (which faced south) a bright light coming from Flat 182.186 CRO Howson told him that it might be necessary to leave the flat, to which he responded that there was too much smoke outside. CRO Howson gave further advice about using wet clothes 176 [LFB00000375]. 177 Marcio Gomes Exhibit MG/1 [IWS00000623]. 178 Gomes Day 71(Fri)/67/24; Gomes first witness statement [IWS00001078] p. 21; Gebremeskel [IWS00000933] p. 5. 179 At 0.03 seconds on recording. 180 At 0.05 seconds on recording. 181 At 0.20 seconds on recording. 182 Gomes Day 71(Fri)/43/12-44/25. 183 At 0.01 and 0.29 seconds on recording. 184 Gomes Day 71(Fri)/65/5-70/14. 185 [LFB00000672]. 186 Gomes Day 71(Fri)/73/7-74/25.

Part II | Chapter 15: Period 6: 02.20-02.50 335 as protection and making for the stairwell. She said firefighters were making their way up but that progress was slow. Marcio Gomes assumed that firefighters were still coming to flats and he had a choice whether or not to leave.187 He did not leave the flat at that stage. The progress of the fire on floor 18 15.79 Flat 152 had an open-plan kitchen and living room, the windows of which faced east.188 The kitchen shared a wall with the bedroom of Flat 151.189 Before 02.30, there had been no smoke in the flat, but it had begun to feel warm particularly on the north side of the flat. Rabia Yahya and her three children were in the living room. By reference to a 999 call she made at 02.34.42,190 Rabia Yahya thought that it had been at around 02.30 that she had seen sparks land on the outside ledge of the kitchen window. She estimated that within a minute the sparks had become a “full-blown fire” which came through the kitchen window. The window seemed to be melting. The fire appeared to be on the window frame and covered about 60 or 70 per cent of the window. The flames were a vibrant orange colour and were accompanied by dark grey smoke. The smoke had a similar smell to the smoke Rabia Yahya had encountered earlier and it triggered her asthma.191 15.80 Using wet towels to cover her and her children’s faces, Rabia Yahya immediately left for Flat

1. She decided to move there because the two firefighters who had earlier come to Flat

152 (FFs Foster and Lawson) had said that they would take everyone on floor 18 out together. She did not want to go to the stairwell as she did not know what conditions there were like. The smoke in the lobby had worsened since she had opened her door to the two firefighters. There was no visibility and she used the wall as a guide while pulling her children along as they were scared. The lobby felt hotter than a summer’s day.192 15.81 Everyone in Flat 153 was in the living room when Rabia Yahya and her children entered the flat. There was no smoke in Flat 153. Within minutes of arriving, Rabia Yahya called 999 to report that she had moved. She told CRO Heidi Fox that she was in Flat 153 and that the fire had reached Flat 152. CRO Fox advised that they should all try to leave. Rabia Yahya explained that they could not leave because of the thick, black smoke and added that the firefighters had said they would come back but had not. CRO Fox said she would alert the command unit to go directly to them. Rabia Yahya said that she understood that firefighters would come to Flat 153.193 15.82 Rabia Yahya’s 999 call overlapped with one made by Paulos Tekle, which CRO Yvonne Adams answered at 02.32.30.194 His confirmation of the number of people in his flat shows that Rabia Yahya was already in Flat 153. He told CRO Adams that the fire was coming near and that they could not leave. Her advice was to move to the safest room. Paulos Tekle said in evidence that when he made that call there had been no smoke or fire in Flat 153. From a window of the bedroom closest to Flat 152 he had been able to see orange flames coming from the direction of that flat.195 187 Gomes Day 71(Fri)/75/1-77/9. 188 Rabia Yahya Day 63/155/10. 189 Operation Northleigh report “External spread of fire at Grenfell Tower” v.4 [MET00012593] p. 12. 190 [LFB00000365]. 191 Rabia Yahya Day 63/156/5-15. 192 Rabia Yahya Day 63/157/2-161/5. 193 Rabia Yahya Day 63/157/2-161/5; Day 63/162/16-166/9; [LFB00000365]. 194 [LFB00000361]. 195 Tekle Day 63/56/25-67/24; Tekle Exhibit PT7 [IWS000010521] p. 24.

The Grenfell Tower Inquiry: Phase 1 Report 336 15.83 At 02.48.22, CRO Howson responded to a call which Rabia Yahya took over from her daughter. It was not a call, however, of which Rabia Yahya had any recollection. On being told that the fire was in the flat next door, CRO Howson advised Rabia Yahya to leave using the stairs. Rabia Yahya’s subsequent decision to leave was motivated by a desire to protect her children. In hindsight, she thought that being told that no one was coming to rescue them had affected her decision.196 Events on floor 17 15.84 At around 01.50 Husna Begum called her cousin Rohema Khanom to tell her that there was a fire in the building. After she had started to make her way to the tower, Rohema Khanom called Husna Begum between 02.20 and 02.50. She spoke to her aunt Rabeya Begum who told her that the fire was now in the flat. Her aunt said that the family were all in the bedroom used by Mohammed Hanif and Mohammed Hamid. She then handed the phone back to Husna Begum, who said it was pitch-black in the flat, before terminating the call.197 15.85 At 02.27, Husna Begum was connected to the LFB Control room. She told CRO Fox that they had been waiting for assistance for an hour.198 Events on floor 16 15.86 At 02.21, Sener Macit was still speaking to CRO Sue Pimblett of North West FRS in a 999 call which had begun at 02.10.33 and ended at 02.38.05.199 During that call, he told CRO Pimblett that his wife was speaking to relatives, who, he explained in evidence, had been telling them to leave. Their response was that the smoke was preventing them from doing so. Sener Macit was also worried that if they went down the stairs they might find themselves running into the fire.200 15.87 At a late stage in the call, CRO Pimblett told Sener Macit that the firefighters were working their way up from floor 14 and so should reach floor 16 soon. A few minutes later, she told him that she had been instructed to ask him and his wife to cover themselves with wet towels and leave the flat. Sener Macit said in evidence that he had been relieved to hear that help was on the way but that, when the advice changed, his first thought had been whether he and his wife would be able to survive the stairs.201 15.88 The Macits then tried to leave Flat 133. The lobby was still full of thick black smoke. It was difficult to breathe and they had to feel their way to the stairwell door. Sener Macit compared the temperature of the lobby at that time to “a sauna in a Turkish bath, much hotter”. When he pushed the stairwell door open, he found the stairwell to be no different from the lobby; it was dark, full of smoke and hot. Scared, faced with the conditions in the stairwell and concerned that he might not be able to reach the ground floor as he was already out of breath, Sener Macit decided to return to his flat with his wife. He had to search for the keyhole with his fingers to unlock his front door.202 196 Rabia Yahya Day 63/166/9-171/12; [LFB00000384]. 197 Khanom witness statement [COR00001147] pp. 3-5. 198 [LFB00000354].  199 [LFB00055499] Pimblett witness statement [MET00008034] p. 7. 200 Sener Macit Day 65/154/9-155/17. 201 [LFB00055499] pp. 24, 28; Sener Macit Day 65/156/9-158/13. 202 Sener Macit first witness statement [IWS00000069] pp. 14-15; Sener Macit second witness statement [IWS00001156] p. 4; Sener Macit Day 65/158/14-163/12; Hanife Macit first witness statement [IWS00000904] p. 10.

Part II | Chapter 15: Period 6: 02.20-02.50 337 15.89 On his return to Flat 133, Sener Macit made two further 999 calls, one at 02.41.31203 and another at 02.49.05.204 At that time, thick black smoke was still coming into the flat from the lobby.205 Sener Macit believed that he must have made the call timed at 02.41.31 immediately on his return to Flat 133.206 The earlier call with CRO Pimblett ended at 02.38.05, which provides an indication of how long it took the Macits to leave their flat, reach the stairwell and return. 15.90 The first of those 999 calls was taken by CRO Fox. When Sener Macit told her that he could not leave his flat, she advised him to put damp sheets around him and said that she would inform the command unit. Sener Macit understood from what she had said that the fire and rescue services would be told that he and his wife were still trapped in their flat. He could not remember why he had called 999 again a few minutes later. CRO Fox also answered that call. She told him a number of times that he had to leave the flat. She could not tell him whether there was smoke on the stairs but did tell him that firefighters were on different floors. Sener Macit told CRO Fox that he would try to leave, but he could not remember whether he and his wife had tried to do so at that time.207 The Macits remained in their flat for some time and I shall return to their accounts later. Deployments to, and evacuation of, Flat 113, floor 14 15.91 Two more crews were sent to floor 14. FFs Peter Herrera and Teresa Orchard tallied out at 02.26.44 and 02.27.08 respectively.208 FF Herrera recalled having been briefed by WM De Silvo to go to Flat 113 where a man, a woman and a child were in need of rescue.209 If that is right, it reflects the original FSG call made from Flat 113 and not the new information brought down to the bridgehead by FFs Desmond Murphy and Charles Cornelius. FF Orchard’s recollection was that the brief had been to rescue six people in Flat 113.210 It is unlikely that WM De Silvo would have given inconsistent briefs to two firefighters in the same crew, so either FF Herrera’s or FF Orchard’s recollection must have been mistaken. I am not able at present to resolve that question, but whichever of them is correct, it seems clear that neither FF Herrera nor FF Orchard was briefed to rescue eight people from Flat 113. 15.92 Very soon after, at 02.31.00, CM Benjamin McAlonen and FF Elliot Juggins tallied out.211 Both firefighters said they had been briefed to go to a woman and child in Flat 111 on floor 14,212 although their recollections of who had briefed them differed: CM McAlonen thought they had been briefed by WM Paul Watson on the mezzanine, whereas FF Juggins thought they had been briefed by WM Brien O’Keeffe at the bridgehead. Whoever gave it, however, the briefing was doubly erroneous, because Flat 111 had been occupied by a single man, Denis Murphy, who by that time had moved to Flat 113. Since it is unlikely that WM De Silvo briefed a crew to go to an empty flat, the errors probably stemmed from a separate briefing by WM Watson or (if FF Juggins’ recollection is correct) by WM O’Keeffe at the bridgehead, neither of whom had heard or taken in what FFs Murphy and Cornelius had reported when they were debriefed. Since it is unlikely that WM O’Keeffe would have failed to take in what 203 [LFB00000372]. 204 [LFB00000382]. 205 Sener Macit Day 65/163/19-164/8. 206 Sener Macit Day 65/164/21-165/4. 207 Sener Macit Day 65/164/20-167/24. 208 BA Telemetry Schedule. 209 Herrera witness statement [MET00010876] p. 3; Herrera Day 38/103/21-104/6. 210 Orchard witness statement [MET000086069] p. 4; Orchard Day 39/49/6-25. 211 BA Telemetry Schedule. 212 McAlonen witness statement [MET00012679] pp. 7-8; McAlonen Day 38/164/23-165/5; Juggins witness statement [MET00010879] p. 8; Juggins Day 40/64/7-19.

The Grenfell Tower Inquiry: Phase 1 Report 338 had been said at the debrief, it is more likely that CM McAlonen’s recollection that he and FF Juggins had been briefed by WM Watson is correct and that WM Watson on the mezzanine had not been aware of what FFs Murphy and Cornelius had said when they reported back to the bridgehead. Whatever the explanation, the fact remains that none of the four firefighters deployed to floor 14 knew that there were eight people to be rescued there. 15.93 It is likely that CM McAlonen and FF Juggins reached floor 14 first, as both FFs Orchard and Herrera recalled their being there when they arrived.213 CM McAlonen and FF Juggins went first to Flat 111, the door of which was open. They searched the flat, which was empty.214 CM McAlonen tried to make radio contact with the bridgehead to see if there was any more information in relation to Flat 111, but could not get through.215 The crew then decided to continue searching floor 14.216 They moved to Flat 112 which they also found empty.217 15.94 Meanwhile, FF Orchard and FF Herrera had also reached floor 14. They went to Flat 113 and knocked on the door, shouting “Fire brigade!”. FF Herrera’s evidence was that an adult opened the door and made it clear that the occupants were very reluctant to leave.218 15.95 There is a conflict of evidence about what happened after the firefighters reached Flat 113, but the upshot was that four of the occupants (Oluwaseun Talabi, Rosemary Oyewole, their daughter and Omar Alhaj Ali) were guided down the stairs by the firefighters and the other four (Denis Murphy, Mohammad Alhajali, Zainab Deen and Jeremiah Deen) were left behind. The mistake was reported to the bridgehead. FFs Jon Wharnsby and Terence Lowe were sent to Flat 113,219 but they did not reach it because they stopped on their way up to assist casualties from a different floor (as described in Period 8). Another crew consisting of CM Jamie Mayne and FF Marcus Lundquist were then initially briefed to rescue the occupants of Flat 113,220 but they then appear to have been redeployed to go to firefight on floors 3 and 4 instead, and did not go to Flat 113. 15.96 Denis Murphy, Mohammad Alhajali, Zainab Deen and Jeremiah Deen were all left behind in Flat 113 and lost their lives in the fire. It is therefore important that, as far as possible, findings be made about the circumstances in which they came to be left there. To do so, however, requires a more detailed examination of the evidence than can be undertaken at this stage. This matter will therefore be the subject of more detailed examination at a later date when, with the benefit of further submissions and perhaps additional evidence, the conflict of evidence including the dispute about what transpired between FF Herrera and Omar Alhaj Ali will be resolved. It is not in dispute that FF Herrera did not conduct a search or secondary sweep of Flat 113. The reasons why he did not do so will be considered as part of the more detailed investigation to which I have referred. The progress of the fire on floor 12 15.97 By 02.20 three flats remained occupied on floor 12, Flats 92, 94 and 95. 213 Orchard [MET000086069] p. 5; Orchard Day 39/53/20-23; Herrera witness statement [MET00010876] p. 4; Herrera Day 38/108/6‑8. 214 McAlonen Day 38/168/22-169/11; Juggins Day 40/70/4-11-71/1-8. 215 McAlonen Day 38/6-13. 216 Juggins Day 40/72/8-13. 217 McAlonen Day 38/169/21-24. 218 Herrera Day 38/109/7-21. 219 FFs Wharnsby and Lowe tallied out at 03.04.03 and 03.04.19: BA Telemetry Schedule. 220 CM Mayne and FF Lundquist tallied out at 03.29.05 and 03.29.29: BA Telemetry Schedule.

Part II | Chapter 15: Period 6: 02.20-02.50 339 15.98 Karen Aboud and her two sons had tried unsuccessfully to leave Flat 92 and had then made two 999 calls. Her elder son subsequently made three more 999 calls. In the first of those calls, timed at 02.15.07,221 he told CRO Gotts that the family could not leave their flat because there was too much smoke and they could not breathe. He could see “fireballs” falling past the window. In the second call, timed at 02.38.54,222 he told CRO Pam Jones that “fireballs” were now hitting the window from above. It appears that at that time smoke was not getting into Flat 92. 15.99 CRO Howson answered his third call at 02.50.48.223 He reported that the fire had reached a window and was coming into the flat. CRO Howson told him that if the fire was coming into the flat, they had to leave. She said that they should put wet towels over their mouths and leave by the stairs. That was the first time that they had been told in terms to leave the flat. 15.100 That sequence of calls indicates that it was not until relatively shortly before 02.50 that fire or smoke entered Flat 92. Karen Aboud recalled that it was at around 03.00 when smoke began to come under the front door and through a bedroom window. I return to events in Flat 92 later. 15.101 In Flat 94, having made an unsuccessful attempt to leave at some time between 01.35 and 01.45, Alemishet Demissie and Ethiopia Assefa sheltered in the living room.224 Alemishet Demissie made a 999 call at 02.24.19.225 Having obtained the location of the flat and the number of people in it, CRO Fox advised her to use towels to stop any smoke from coming in and said that she would pass the information to the command unit who would “come and check you”. 15.102 Alemishet Demissie did not tell CRO Fox that there was smoke in Flat 94, but her recollection was that by about that time it had been entering the flat. They had closed a bedroom window when the smoke had started coming in and had then noticed that it was coming under the front door from the lobby. The temperature in the flat had risen. Alemishet Demissie agreed it had been “hotter than a summer’s day”. The smoke had come into different rooms, including the living room, but it had still been possible to see. The smoke had a “chemical smell’, similar to the smell they had encountered in the lobby when trying to leave earlier, but stronger. It had made them both cough.226 Ethiopia Assefa described the smoke as light grey in colour and unlike that which she had seen in the lobby.227 15.103 Her exchange with CRO Fox led Alemishet Demissie to expect that firefighters would come shortly, even though she thought the flat was not easily accessible and that someone would need to take a risk.228 She made a second 999 call at 02.42.40, because firefighters had not yet come to the flat.229 It was answered by CRO Peter Duddy. By that time the smoke in Flat 94 had become thicker but fire had not entered it. CRO Duddy’s blunt advice was that they needed to leave and make for the stairwell. They would die if they did not.230 As the call continued, Alemishet Demissie and Ethiopia Assefa tried to leave the flat. They got no further than opening the front door. Alemishet Demissie described the conditions in the lobby as 221 [LFB00000346]. 222 [LFB00000370]. 223 [LFB00000673]. 224 Assefa first witness statement [IWS00000891] p. 5; Demissie Day 65/15/8-23. 225 [LFB00000353]. 226 Demissie Day 65/16/6-24/22. 227 Assefa first witness statement [IWS00000891] p. 8. 228 Demissie Day 65/34/23-25/5. 229 Demissie Day 65/25/6-24. 230 [LFB00000683] pp. 4, 5, 7, 8, 11, 12.

The Grenfell Tower Inquiry: Phase 1 Report 340 terrifying and worse than before. The smoke there was black and made them cough. It was impossible to walk through it. In the rush, the telephone connection with CRO Duddy was cut off.231 15.104 In Flat 95, Roy Smith was still speaking to CRO Duddy on the call which had begun at 01.54.14. Flat 95 had three bedrooms. One shared a wall with the bedroom of Flat 96. It had a window which faced north. In June 2017, that was the bedroom of Roy Smith’s younger daughter. His elder daughter’s bedroom had been created by converting an internal space. It did not have an external-facing window but also shared a wall with Flat 96.232 15.105 Standing in his elder daughter’s bedroom Roy Smith could hear a roaring sound through the shared wall with Flat 96. Looking through the spy-hole of his front door he had seen a bright light (the “yellow” he had previously described to CRO Duddy). That had led him to think that there was a fire in the lobby, although, with hindsight, he thought that the bright light might have been the lighting.233 15.106 The flames did not enter Flat 95. Roy Smith had seen them outside the window of his younger daughter’s bedroom. That was the window closest to Flat 96. The whole window including the glass looked as if it was burning.234 The explosions he reported to CRO Duddy had been noises outside the flat.235 15.107 Roy Smith said that before the fire it had been possible, when in his elder daughter’s bedroom, to hear the smoke extraction system running, particularly after the refurbishment. He had heard the system working on at least seven or eight occasions. The noise was a whirring sound as loud as a vacuum cleaner. Roy Smith had also heard the system operating while in the lobby on floor 12. On that occasion he had looked through the grille of one of the extraction vents and had heard the movement of air similar to a draught, but (contrary to some people’s recollection) it had not affected the operation of the lifts. Roy Smith had last heard the system working about two weeks before the fire. On the night of the fire he had listened to see if it came on but it had not.236 15.108 While his family sheltered in the living room,237 Roy Smith moved around the flat. As the call continued, he reported that: a. smoke was everywhere in the flat and that he and his family were struggling to breathe, even with wet towels. The smoke was continuing to come into the flat;238 b. it was hot; 239 c. the fire had reached the lobby of floor 12; he could not see flames at the front door but could see “dark and yellow”;240 d. the fire had reached the windows of the flat;241 231 Demissie first witness statement [IWS00000860] p. 4; Demissie Day 65/25/25-32/8. 232 Roy Smith first witness statement [IWS00000771] p. 2; Roy Smith Exhibit RS/1 [IWS00000931] p. 2; Roy Smith Day 64/8/23-9/17; Day 64/6/13-25. 233 Roy Smith Day 64/73/9-77/9. 234 Roy Smith Day 64/77/13-79/18; Day 64/84/14-85/3; Roy Smith Exhibit RS/1 [IWS00000931] p. 2; MPS Operation Northleigh report “External spread of fire at Grenfell Tower” v.4 [MET00012593] p. 32. 235 Roy Smith Day 64/81/2-13. 236 Roy Smith Day 64/22/12-28/24. 237 [LFB00055503] pp. 15, 24, 40. 238 [LFB00055503] pp. 10, 22, 23, 25, 26, 29, 32, 40, 41, 43. 239 [LFB00055503] pp. 21, 40. 240 [LFB00055503] pp. 9, 20, 22, 25, 26, 29, 32, 33, 42, 43. 241 [LFB00055503] pp. 18, 20, 31, 39, 42.

Part II | Chapter 15: Period 6: 02.20-02.50 341 e. he could hear explosions;242 and f. the smoke extraction system on the landing was not removing the smoke.243 15.109 During the call, CRO Duddy repeatedly advised Roy Smith that he and his family should stay in the flat, block any smoke coming in, keep low and put wet cloths over their faces.244 He assured Roy Smith that they were speaking to those at the scene and that firefighters were coming to rescue them.245 CRO Duddy tried to clarify Roy Smith’s precise location.246 During that call, Roy Smith was also speaking on another line to his sister, Sharon, who was outside the tower. She spoke to firefighters and also told her brother that firefighters were going to come to them.247 15.110 Towards the end of the call, the advice given to Roy Smith changed. CRO Duddy told him to leave but to stay on the telephone. As he was advising Roy Smith how to leave, a firefighter, probably FF Hill, arrived at Flat 95.248 The family followed him to the stairwell door. He told them to take a breath of oxygen from his mask and go down the stairs, where they would meet more firefighters. Roy Smith’s partner shut their flat door. The lobby was full of thick black smoke and very hot. They made their way across the lobby and he pushed the stairwell door open.249 15.111 The stairwell seemed even hotter than the lobby. There was dark smoke in the stairwell which had a smell of burning plastic similar to that of the smoke in the lobby. The smoke in the stairwell burned Roy Smith’s throat. It had the same effect on his younger daughter, who tried to go back up the stairs, before he picked her up and carried her. As he went down the stairs, Roy Smith recalled that the temperature seemed to rise. He noticed a bright orange glow through the glass of a closed stairwell door. He assumed that that was on floor 4. The smoke seemed to get thinner as they went down. There was little visibility in the stairwell.250 15.112 Roy Smith, his partner and their children left the tower between 02.40 and 02.41.251 Conditions on floor 11 15.113 Between 02.32 and 02.45 Natasha Elcock made three further 999 calls from Flat 82. In the first of them, timed at 02.32.41, she spoke to CRO Russell. Natasha Elcock was speaking to her partner while on the telephone to CRO Russell. He was moving around the flat. Although there was no smoke in the flat, flames had entered the kitchen through the extractor fan panel, but he was able to put them out with water. While in the kitchen he touched the wall between their flat and Flat 81, which felt hot. That prompted Natasha Elcock to tell CRO Russell that the fire was in the flat next door.252 15.114 CRO Russell asked Natasha Elcock if it was safer to leave. Natasha Elcock replied that she could not see anything. (She said in evidence that she had been referring to the lobby.) She trusted her partner’s judgement that they would not be able to leave through the lobby and 242 [LFB00055503] p. 39. 243 [LFB00055503] p. 24. 244 [LFB00055503] pp. 4, 5, 7, 8, 10-13, 29, 40, 42. 245 [LFB00055503] pp. 14, 16, 21, 28, 32, 37. 246 [LFB00055503] pp. 34-35. 247 Roy Smith Day 64/79/18-81/1. 248 [LFB00055503] pp. 43-45; Roy Smith Day 64/85/24-88/15. 249 Roy Smith Day 64/90/14-93/10. 250 Roy Smith Day 64/93/25-99/23. 251 Annex A. 252 [LFB00000360]; Elcock first witness statement [IWS00000310] p. 4; Elcock Day 70/63/15-66/15.

The Grenfell Tower Inquiry: Phase 1 Report 342 wanted the fire and rescue services to come to the flat. At the start of the call she had asked when someone would be coming to the flat. No one had given her any information about conditions in the stairwell and she was afraid of what was going on there.253 15.115 At 02.37.56, Natasha Elcock spoke to CRO Howson again and reported that the fire was on her landing (meaning in Flat 81). At that time, she and her partner had not tried again to leave the flat. Water sprayed by firefighters outside the tower was entering the living room of her flat through vents in the windows, which caused them to move into the hallway. During the call Natasha Elcock once again asked for someone to come to them. CRO Howson reassured her and advised her that if there was no fire in the flat it was better to stay there.254 15.116 Natasha Elcock was still in the hallway of the flat when she made her next 999 call at 02.44.41, which was again answered by CRO Russell. She told CRO Russell that the door was “popping”, by which she meant that the middle of the door was visibly bulging into the hallway and was hot to the touch. There was smoke in the living room and the kitchen. By now, the small pane in the kitchen window where her partner had previously put out the flames had lost its glass. Smoke was coming through the hole. During the call, which lasted 5 minutes and 23 seconds, Natasha Elcock asked when the firefighters were going to reach her. CRO Russell told her that they were on their way and were trying to reach everyone. She told the family to go into a room away from it all, block up any gaps and stay low. Natasha Elcock then moved into the bedroom closest to the front door.255 15.117 The kitchen of Flat 82 adjoined the single bedroom of Flat 81.256 Abdeslam Sebbar, who lived alone in Flat 82, made two 999 calls during the night. In the first, timed at 01.25.36, he reported a fire but said nothing about what was happening in his own flat.257 In the second call, timed at 01.33.12, he reported to CRO Gotts that the fire was inside his flat but then ended the call.258 Abdeslam Sebbar had no further contact with the emergency services, but he spoke to his son, Mohamed Sebbar. 15.118 Mohamed Sebbar was alerted to the fire and to the fact that his father was still in Flat 81 at around 01.15. He drove to the tower taking his own son with him. While on the way there, his father called him. Mohamed Sebbar tried to reassure him. He told him to leave although he knew his father would need assistance to do so. Mohamed Sebbar was still on the telephone to his father when he reached the tower at around 01.30.259 Police officers stopped him entering the building and told him that firefighters would help his father. Mohamed Sebbar heard his father choking and coughing on the telephone and there came a time when he was no longer responding.260 15.119 At 02.46.42, Merseyside FRS responded to a call from a person who reported that his grandfather was stuck in Flat 81. The call appears to have come from someone outside the tower, probably the son of Mohamed Sebbar, who had gone to the tower with his father. He explained that he had been advised to call 999 by a firefighter at the scene to report someone in need of rescue. The caller added that the occupant of the flat had stopped talking 253 [LFB00000360]; Elcock first witness statement [IWS00000310] p. 4; Elcock Day 70/66/18-68/24. 254 [LFB00000367]; Elcock first witness statement [IWS00000310] p. 4; Elcock Day 70/66/18-68/24-71/18. 255 [LFB00000377]; Elcock first witness statement [IWS00000310] p. 4-5; Elcock Day 70/71/19-78/12. 256 MPS Operation Northleigh report “External spread of fire at Grenfell Tower” v.4 [MET00012593] p. 20. 257 [LFB00000305]. 258 [LFB00000312]. 259 Sebbar first witness statement [IWS00000903] pp. 1-2. 260 Sebbar first witness statement [IWS00000903] pp. 1-2.

Part II | Chapter 15: Period 6: 02.20-02.50 343 and that help was needed urgently.261 Merseyside FRS passed this information on to LFB in a call answered by CRO Jones at 02.47.37.262 That evidence indicates that Abdeslam Sebbar stopped responding to his family shortly before 02.46. Conditions on floor 10 15.120 Having tried unsuccessfully to leave Flat 72, Antonio Roncolato went back in and shut the door to keep out the smoke.263 The smoke did not get past his door and it was not until around 02.30 that he noticed smoke coming into the flat around the windows. He took two photographs showing smoke coming through the bottom of an east-facing window in his living room.264 15.121 Shortly after, Antonio Roncolato took a third photograph showing his living room obscured by smoke.265 The smoke was different from that which he had found in the lobby when he had tried to leave. It was thick and grey in colour. It had a different smell from the black smoke in the lobby, which had felt hot and smelled like burning rubber. The smoke in the living room smelled more like burning rubbish. Although it burned his eyes and was uncomfortable, he was still able to breathe.266 At that point, the two smoke alarms in Flat 72 sounded for the first time. Antonio Roncolato was able to clear the smoke by opening the windows in his bedroom and kitchen while shutting the doors so as to create a draught.267 15.122 In Flat 74, Lina Hamide was in telephone contact with friends and relatives, including a cousin in Switzerland to whom she spoke twice at 03.31 and 03.38 (UK time, 02.31 and 02.38). It was after the second of these calls, which lasted 2 minutes and 54 seconds, that she heard what sounded like knocking on the front door. She and Meron Woldeselassie Araya looked through the door’s spy-hole, but could not see anything because of the smoke in the lobby. They shouted but got no response. At that point smoke started coming through the top of the closed front door. That and the absence of any response to their shouts caused Lina Hamide to wonder if the knocking sound had been the front door cracking as a result of heat from a fire in the lobby.268 15.123 The smoke continued to come into Flat 74 through the letterbox of the front door and around its edges. At some time after going to the front door in response to the knocking sound and before 03.00, Lina Hamide and Meron Woldeselassie Araya placed a mattress and a duvet, on which they threw water, up against the front door to try to stop the smoke.269 15.124 At 02.28.09, CRO Gotts answered a 999 call from Ann Chance who was with three members of her family in Flat 73.270 Ann Chance told CRO Gotts that it was beginning to get hot inside the flat. She also mentioned that she thought the fire was on the other side of the building. CRO Gotts told Ann Chance that, if she could not leave, it was better to remain in the flat and 261 [INQ00000532] p. 4. 262 [LFB00000543]. 263 Antonio Roncolato Day 52/40/20-41/1. 264 Antonio Roncolato third witness statement [IWS00001109] pp. 1-2; Exhibit AR8 [IWS00000892] p. 2, 17; Exhibit AR14 [IWS00000923] p. 2; Antonio Roncolato Day 52/43/13-44/24. 265 Antonio Roncolato third witness statement [IWS00001109] p. 1; Exhibit AR8 [IWS00000892] p. 2, 19; Day 52/44/25-45/12. 266 Antonio Roncolato Day 52/45/14-47/24. 267 Antonio Roncolato Day 52/48/14-49/16. 268 Hamide first witness statement [IWS00001175] pp. 5-6; Exhibit LH8 [IWS00001177] pp. 35-36. 269 Hamide first witness statement [IWS00001175] p. 6; Woldeselassie Araya [IWS00001193] p. 8. 270 [LFB00000356].

The Grenfell Tower Inquiry: Phase 1 Report 344 to block any smoke from coming in. Ann Chance thought that it was at about the time of that call that the family may have attempted to leave. However, on opening the front door, they found the heat in the lobby to be so unbearable that it was impossible to do so.271 15.125 Ann Chance made another 999 call a few minutes later, which was answered by CRO Duddy at 02.36.47.272 In it she did not say that the family had tried to leave, but she said that it was pitch-black in the lobby. She also confirmed that there was smoke coming into the flat, even though they had covered up the doors and windows, and that it was getting really hot and the smoke was increasing. CRO Duddy advised Ann Chance to use wet towels to cool down and to block smoke and to move to the room furthest away from it. He said that the fire was not on floor 10. Ann Chance told him that she thought the fire had gone beyond the fourth floor. She expressed concern that if they were to go down the stairs they would run into the fire. 15.126 At 02.43.08, CRO Jones answered the fourth emergency call made by Ann Chance,273 which lasted for 4 minutes and 20 seconds.274 Ann Chance reported that it was pitch-black, that there was a lot of smoke coming into the flat and that the front door was “completely hot”. A lot of smoke had come into the flat when they had opened a window and they were now able to see the fire.275 Initially CRO Jones advised her to go into another room, but then told her that they should cover their faces with wet towels and try to get out. Once again, Ann Chance expressed concern that she and her family might encounter a fire on floor 4 if they left.276 At the end of the call, she told CRO Jones that someone from the “fire department” was on the line. Asked if the fire and rescue services was with her, Ann Chance said not and then asked whether they had to leave now.277 15.127 In her statement Ann Chance said that smoke had come into the flat when they had opened a window and that there had been smoke in her aunt’s room, which had been in the north- west corner of the flat. Ann Chance did not explain her reference to the “fire department” and there is no evidence of a call to her telephone having been made from any fire and rescue service. It seems likely, therefore, that she was mistaken about that. 15.128 The family did make other attempts to leave, but, despite covering themselves with wet towels, found the heat on opening the front door so intolerable that they could not venture any further.278 4 Events in the control room 15.129 Between 02.20 and 02.50 the control room received 45 emergency calls, 35 of which were FSG calls from, or on behalf of, trapped residents.279 There were three calls from other fire and rescue services who had taken 999 calls on their behalf and five calls from the LAS and MPS control rooms passing on messages from trapped residents. 15.130 At 02.21.04, CRO Fox took a call from Marcio Gomes in Flat 183 on floor 21.280 He reported that he was there with his wife, who was seven months pregnant, three children and an adult neighbour and that they could not get out. She told him to block out the smoke coming in, 271 Chance first witness statement [IWS00000783] p. 5. 272 [LFB00000679]. 273 [LFB00000373]. 274 ORR v 0.7 p. 225. 275 [LFB00000373] pp. 2-3, 8. 276 [LFB00000373] pp. 4-8. 277 [LFB00000373] p. 9. 278 Chance first witness statement [IWS00000783] p. 6. 279 Control Report pp. 75-103. This does not include call backs. 280 [LFB00000348].

Part II | Chapter 15: Period 6: 02.20-02.50 345 that she would tell the command unit at the scene and that firefighters would come and take them out.281 After she had ended the call, CRO Fox created a service request in the incident log at 02.24.11; CRO Sharon Darby passed the message by radio to CU7 at 02.24.42.282 15.131 At 02.21.22, CRO Adams took a call from an operator in the LAS control room who reported for the first time that they were taking calls from trapped residents.283 The LAS operator told CRO Adams of people calling from Flat 102 and of people on floor 23 who were still alive. She also told her that there were people jumping out of windows.284 15.132 At 02.22.17, SM Paul McClenaghan was paged to attend control.285 SM Jason Oliff explained that he had asked for him to come to the control room as he was the inter-agency liaison officer and could therefore have assisted with contacting other agencies, such as the police and the ambulance service.286 However, at 02.23.55, GM Mark Hazelton, the Duty NILO for the LFB, was also paged by the control room to inform him of the incident.287 At 02.28.58, he confirmed that he was monitoring it.288 15.133 At 02.22.54, CRO Darby received a radio message from CU7 asking for all FSG messages to be sent to CU7 instead of CU8.289 CRO Darby logged this in the incident log at 02.23.33.290 From that point on, all FSG radio messages were sent to CU7, even though new service request entries on the incident log still indicated that messages should be sent to CU8.291 This does not appear to have had any adverse impact on CRO Darby sending FSG messages to the incident ground. All other messages and requests relating to the incident were sent to and from CU8, which had become the incident command unit. 15.134 At 02.23.30, an operator in MetCC spoke to CRO Adams to pass on a message from a caller trapped on floor 23 whose telephone had cut out.292 CRO Adams commented “I think they’re trapped everywhere”.293 15.135 While all that had been going on, SOM Smith had received a briefing from OM Alexandra Norman and had then given her attention to listening in to those calls on which CROs had been engaged for a long time, because they were a matter of great concern to her.294 AOM Peter May told her that CRO Jones and CRO Duddy had been on the telephone to single calls for longest.295 By 02.24, CRO Jones had been on the telephone to the El Wahabi family in Flat 182 on floor 21 for over 45 minutes since 01.38.38 and CRO Duddy had been on the telephone to Roy Smith in Flat 95 on floor 12 for almost half an hour since 01.54.14.296 CRO Russell had finished her call with Jessica Urbano Ramirez that had started at 01.29.48.297 SOM Smith listened to and assessed the calls being taken by both CRO Jones and CRO Duddy.298 She said: 281 [LFB00000348]. 282 SIL p. 22; Radio message [LFB00002303]. 283 [LFB00000349]. 284 [LFB00000349]. 285 End of Incident Report p. 287. SM McClenaghan has a call sign OF59. 286 Oliff Day 23/59/6-22. 287 End of Incident report p. 292. 288 End of Incident report p. 299. 289 Radio message [LFB00002301]. 290 SIL p. 22. 291 Darby Day 34/11/9-13. 292 [LFB00000350]. 293 Transcript [LFB00000350] p. 2. 294 Norman Day 42/140/2-20. 295 Smith witness statement p. 3 [MET00007766]; Norman Day 42/140/2-9. 296 [LFB00055503]. 297 [LFB00055504]. 298 Smith witness statement [MET00007766] p. 3.

The Grenfell Tower Inquiry: Phase 1 Report 346 “Both calls indicated that the situation was getting worse in terms of smoke and heat. Owing to the developing factors involved, namely the duration and nature of the situation, I became increasingly uncomfortable with the ‘stay put’ policy – the national policy for high rises.” 299 15.136 When SOM Smith gave evidence she explained that she had been uncomfortable with the situation because, although they had been trying to protect people in their flats, it was clear that the advice was not working.300 She said that she had considered whether compartmentation was failing or had failed,301 but that she had not tried to contact the incident commander to obtain more information because it was not common practice to do that.302 She accepted that she could have tried to contact him, but doubted whether he would have responded.303 Instead, she spoke to DAC Fenton about changing the “stay put” policy. 15.137 DAC Fenton had arrived in the control room at around 02.25 with the intention of setting up the Brigade Coordination Centre.304 However, he could see that the sheer number of FSG calls being received required a co-ordinated system, so he turned his attention to assisting the control room.305 He saw that CROs were writing FSG information on pieces of paper and believed that messages were being sent to the incident ground by radio.306 15.138 SOM Smith briefed DAC Fenton about the FSG calls. He decided to set up a system of recording the FSG information on two whiteboards so that it was not lost or duplicated and could be sent across to the incident ground in the most effective way.307 He said that he had thought there was a danger that CROs might become overwhelmed by the number of calls coming in and that collating the information in that way was likely to provide an effective solution. SOM Smith and OM Norman had agreed.308 SOM Smith and DAC Fenton both said that that was not normal procedure.309 15.139 DAC Fenton dragged two whiteboards on wheels to the corner of the room and sought to brief SM Oliff, who was on the telephone to the command unit at the time.310 When SM Oliff had ended his call, DAC Fenton briefed him.311 That must have happened between 02.25.40 when SM Oliff finished his second call to SM Meyrick on CU7 and 02.33.00 when he began his third call.312 DAC Fenton told SM Oliff to stay by the boards, write down on them the information that was brought to him and pass it on to the command unit.313 The information was to include flat numbers, floor numbers, the number of people inside the flat (including the number of adults and children) and any progress in carrying out rescues.314 However, DAC Fenton did not take any steps himself to ensure that the CROs were gathering all the necessary information to pass over to SM Oliff, because that was outside his role.315 Nor did he ask SM Oliff to do so, as he would have expected the right information to come across and he thought that double-checking information would cause delay.316 DAC Fenton assumed 299 Smith witness statement [MET00007766] p. 3. 300 Smith Day 22/107/2-10. 301 Smith Day 22/107/12-17. 302 Smith Day 22/112/11-24. 303 Smith Day 22/122/20-21. 304 Fenton Day 24/78/4-10; Day 24/80/15-19 305 Fenton Exhibit APF/1 [MET00005290] p. 2. 306 Fenton Day 24/83/18-85/7. 307 Fenton witness statement [MET000080569] p. 6; Fenton Day 24/81/5-11; Day 24/82/15-23. 308 Fenton Day 24/88/20-89/6. 309 Smith witness statement [MET00007766] p. 3; Fenton witness statement [MET000080569] p. 6. 310 Fenton witness statement [MET000080569] p. 6. 311 Fenton witness statement [MET000080569] p. 6. 312 Oliff Exhibit JAO/7 [MET00016910] p. 3. 313 Fenton witness statement [MET000080569] p. 6; Oliff day 23/72/14-19. 314 Fenton witness statement [MET000080569] p.6 315 Fenton Day 24/127/15-25. 316 Fenton Day 24/134/9-19.

Part II | Chapter 15: Period 6: 02.20-02.50 347 that, if any new information was received relating to flats already entered on the whiteboard, SM Oliff would make the necessary changes to the whiteboard and send the new information to the incident ground.317 15.140 SM Oliff said that when he had embarked on that task at around 02.33.00, he had recorded all the information in the paper messages he received from CROs straight onto the two whiteboards.318 At the end of the incident, the two whiteboards looked like this: Figure 15.8 Figure 15.9 15.141 SM Oliff remembered that he had started collating information on the whiteboard on the left and that the information relating to Flat 182 on floor 21 had been the first fire survival guidance information he had passed over to the command unit under the new system.319 As far as he was aware, he was the only person who had written on the whiteboards, although SOM Smith recalled that she and DAC Fenton had also made some entries.320 SOM Smith and OM Norman passed information to OM Oliff that had been obtained from calls taken by the CROs, using either notes that the CROs themselves had written or notes that they had made of conversations they had overheard.321 15.142 CRO Darby said that even after the whiteboard system had been set up, she was still passing FSG information to CU7 at the incident ground by radio.322 No one had asked her to stop sending radio messages and she did not tell SM Oliff what FSG information she was passing to the incident ground so that it could be recorded on the whiteboard.323 She considered that the fact that SM Oliff was passing FSG information by mobile telephone freed up the radio to some extent, so that she could concentrate more on the operational side of the incident.324 15.143 At 02.25.38, Mariem Elgwahry in Flat 205 on floor 23 called the control room for the fourth and final time.325 She spoke with CRO Howson for 4 minutes and 54 seconds. She explained that there were seven adults in the flat, that they were trapped in the kitchen and were running out of air and that the whole flat was black.326 CRO Howson reassured her that the crews were trying to get to them. When Mariem Elgwahry asked if they could get a helicopter to get them out, CRO Howson said: “There is one there”, although she said in evidence that 317 Fenton Day 24/143/1-19. 318 Oliff Day 23/106/2-9. 319 Oliff Day 23/75/19-25 320 Smith Day 22/48/16-19 321 Smith Day 22/46/2-25 322 Darby Day 34/8/10-12. 323 Darby Day 34/7/19-8/18; Day 34/14/19-22. 324 Darby Day 34/7/19-8/3. 325 [LFB00000670]. 326 [LFB00000670] p. 2.

The Grenfell Tower Inquiry: Phase 1 Report 348 it had not been her intention to give them hope or foster an expectation that they could be rescued in that way.327 Mariem Elgwahry then reported that there was fire in the flat. CRO Howson told them: “Listen, it’s your decision. If you need to leave, you need to leave”. She then continued to advise them to leave and to cover their mouths with clothes, blankets and towels before the call cut out.328 After the call ended, she did not create a service request and the message was not added to the whiteboards, but CRO Adams, who was sitting near CRO Howson, passed the call to CU7 in an admin line call at 02.28.27. 15.144 At 02.26.22, CRO Darby sent a radio message to CU7 relating to persons in Flat 192 on floor 22 who had said that the fire was in the flat next door to them.329 The message was not sent in response to a new service request, but probably in response to information obtained by CRO Gotts during her call with Isra Ibrahim at 02.21.32 and passed on orally to CRO Darby.330 Isra Ibrahim was in fact in Flat 203 on floor 23, as she had told CRO Gotts at the start of the call. She explained that the fire was in the flat next door to them. During the call CRO Gotts checked that she had the right information and advised Isra Ibrahim to block out the smoke.331 However, at the end of the call, when CRO Gotts repeated the address to Isra Ibrahim, she said: “22nd floor, Flat 192” and then the call ended.332 She did not create a service request in relation to either flat.333 It is possible that the radio message sent by CRO Darby resulted from CRO Howson’s call from Flat 192, which started at 02.18.06, because in that call Hashim Kedir had explained that their flat was on fire and had been advised by CRO Howson to get out. On the whole, however, I think that unlikely. 15.145 At 02.26.30, GM Nigel Dilley, the Essex FRS NILO, who was still trying to get hold of the LFB, contacted the MPS to ask them to contact “Silver on scene” (i.e. the Silver Commander in the LFB) to pass a message to the LFB.334 He gave the information he had relating to Flat 82 on floor 11 and Flat 193 on floor 22 and asked the MPS call operator to find another number for the LFB.335 15.146 At 02.27.04, as a result of a call she had received at 02.24.19 from Alemishet Demissie336 CRO Fox created a service request reporting two adults still trapped in Flat 94 on floor 12. The message was sent by radio to CU7 at 02.27.29.337 It did not appear on the whiteboards. 15.147 At 02.28.27, CRO Adams called CU8 on the admin line to pass on FSG information she had obtained from Mariem Elgwahry about seven adults in Flat 205 on floor 23.338 She was not aware that there had been a message from CU7 recorded in the incident log a few minutes earlier asking for all FSG information to be sent to CU7 instead of CU8.339 She said that she had not looked at the log all night and that it was very difficult to read.340 She gave CU8 the message that the fire was in the living room of Flat 205, that their position was becoming quite desperate and that they had been told to leave.341 CRO Adams explained that, although SM Oliff was in the control room passing on FSG information, she had decided to call the 327 Howson Day 80/162/1-23. 328 [LFB00000670] pp. 2-9. 329 Radio message [LFB00002090]. 330 [LFB00000663]. 331 [LFB00000663] pp. 1-2. 332 [LFB00000663] p. 5. 333 SIL p. 22. 334 Dilley Day 76/171/4-18; Transcript of call [INQ00000284] p.2. 335 [INQ00000284] p.2. 336 SIL p.22; [LFB00000353]. 337 Radio message [LFB00002602]. 338 [INQ00000204]. 339 Adams Day 80/78/9-15. 340 Adams Day 80/79/2-4. 341 [INQ00000204] pp. 2-3.

Part II | Chapter 15: Period 6: 02.20-02.50 349 command unit herself because she had overheard the call being taken by CRO Howson, who was sitting near to her. She said that it had been an extremely difficult call and she had thought it would be quicker to send the message herself.342 She did not tell SM Oliff or CRO Darby that she had communicated with CU8 in that way; she thought that CRO Darby was no longer passing FSG information by radio and SM Oliff seemed busy.343 15.148 At 02.28.53, Surrey FRS was contacted for the first time to take a 999 call from Chanade Prentice reporting that her father-in-law, Anthony Disson, who was 70 years old, was trapped in Flat 194 on floor 22.344 The Surrey call operator was not aware of the incident and said that she would contact London. Two minutes later, at 02.30.45, Surrey FRS managed to contact CRO Russell in the control room to pass on the details of the call.345 15.149 At 02.29.31, CRO Fox created a service request in relation to Flat 142 on floor 17, where five adults, including two elderly persons, were trapped. That was the result of a conversation at 02.27.12 with Husna Begum, who reported that she had been waiting for over an hour.346 CRO Darby sent the message to CU7 at 02.30.42.347 15.150 At around 02.30.00, GM Steve Leader arrived at the Stratford control room. DAC Fenton asked him to set up the Brigade Coordination Centre on the ground floor of the building, away from the control room on the first floor.348 15.151 By 02.31.00, Roy Smith in Flat 95 on floor 12, still on his call to CRO Duddy, reported that the fire had now reached the window outside his flat.349 15.152 At 02.31.49 and 02.32.30, CRO Gotts and CRO Adams received calls from people telling them that the fire was now in their flats.350 CRO Gotts spoke to Rosemary Oyewole in Flat 115 on floor 14 and CRO Adams spoke to Paulos Tekle in Flat 153 on floor 18, who reported that there were five adults and four children in his flat. They both advised them to get out if they could but, if not, then to block up any gaps around the doors and move to the place with the least smoke. No service requests were created when these calls ended and the messages were not passed to the incident ground by radio. However, both of these flats did appear on SM Oliff’s whiteboard and it is likely, therefore, that he sent the information to the incident ground using his mobile telephone.351 15.153 At 02.32.31, the MPS tried to speak to GM Dilley, following their call at 02.26.30, but the operator had to leave a voicemail telling him that the advice to give callers was to get to the fire exit and leave the building, if they could.352 That advice was given before anyone had decided to withdraw the “stay put” advice. GM Dilley gave that information to CRO Russ White in the Essex FRS control room and it was recorded in the Essex incident log at 02.40.00.353 342 Adams Day 80/81/9-21. 343 Adams Day 80/86/10-15. 344 [LFB00000649]. 345 [LFB00000357]. 346 [LFB00000354]. 347 Radio message [LFB00002784]. 348 Fenton witness statement [MET000080569] pp. 6-7; Leader witness statement [MET00016791] p. 7. 349 [LFB00055505] p. 45. 350 [LFB00000359]; [LFB00000361]. 351 Oliff Exhibit whiteboard [MET00016912]. 352 [INQ00000284] p. 3. 353 Essex incident log [LFB00003625] p. 2.

The Grenfell Tower Inquiry: Phase 1 Report 350 15.154 At 02.32.41, CRO Russell spoke to Natasha Elcock in Flat 82 on floor 11 and reassured her that there were a lot of fire engines present.354 She asked her to describe the conditions in her flat. Natasha Elcock told her that: “it’s okay at the moment, but the fire seems to be spreading and it’s blocking past the windows”. CRO Russell asked whether she thought it was safer for her to stay or to leave and Natasha Elcock said that she could not see outside and that she did not know what she was doing. CRO Russell checked that she was blocking all the gaps and told her to keep away from the windows and doors, to move to another room if smoke started to come in and to keep low.355 15.155 At 02.33.36, CRO Duddy, who was still speaking to Roy Smith in Flat 95 on floor 12, told him: “Right, we are going to tell you to leave, but you need to… stay on the phone”.356 CRO Duddy believed that it was about that time the “stay put” advice was changed.357 15.156 At 02.34.00, CRO Jones, who had been on the telephone to the El Wahabi family in Flat 182 on floor 21 since 01.38.38, and who had previously advised them to stay put, changed the advice and told them to put wet towels over them and to try and get out of the building.358 15.157 At 02.34.16, CRO Howson spoke to Hasham Kedir in Flat 192 on floor 22. He reported that there was fire in the flat and CRO Howson advised him to leave. She said:359 “… you need to get some wet towels, you need to put them around your mouth, you and the children, you need to leave, and you need to go down. All right? It’s going to be dark and that, so you need to stay together, hold hands, all right, but keep your mouth covered, all right?” 15.158 She told them that the firefighters were making their way and would come to meet them. CRO Howson said in evidence that she believed she had told the caller to get out before the “stay put” advice had been changed because he had said the flat was on fire.360 The decision to change the “stay put” advice 15.159 At 02.33.00, SM Oliff made a third call to WM Meyrick on his personal mobile telephone to pass over further FSG information.361 During their conversation he asked WM Meyrick where the bridgehead was so that he could build a picture of the incident as he had not heard any informative messages from the incident ground.362 WM Meyrick told him that the bridgehead was located on the ground floor and that fire crews were having difficulty going above floor 15 due to the intensity of the fire.363 SM Oliff considered that information to be important, so he gave the information to DAC Fenton, and possibly SOM Smith. 15.160 It was at about that time that DAC Fenton decided that he wanted to get a “pictorial view” of the incident, so he went to look at the television downstairs in the Brigade Coordination Centre, as the television in the control room was not on.364 He explained that he saw a picture 354 [LFB00000360]. 355 [LFB00000360] pp. 4-6. 356 [LFB00055503] p. 43; Control Report p. 55. 357 Duddy Day 42/221/20-23. 358 [LFB00055498] p. 90; Control Report p. 38. 359 [LFB00000363]. 360 Howson Day 80/171/14-17. 361 Oliff Exhibit JAO/7 [MET00016910] p. 3. 362 Oliff Day 23/124/4-25; Oliff Exhibit JAO/7 [MET00016910] p. 3. 363 Oliff witness statement [MET00012791] p. 5; Oliff Day 23/126/9-20. 364 Fenton Day 24/122/10-14.

Part II | Chapter 15: Period 6: 02.20-02.50 351 on Sky News showing one side of the tower fully engulfed in fire, with flames coming out of the windows.365 In evidence he said that he had been very surprised to see so much of the external envelope of the building alight.366 15.161 DAC Fenton returned upstairs to discuss matters with SOM Smith. He said that he had sought the advice of SOM Smith, whom he knew to be experienced in dealing with FSG calls and had been involved in the Lakanal House fire.367 During the conversation, DAC Fenton told SOM Smith that the crews could not get above floor 15. Although she had thought he said floor 18, she accepted in evidence that he could have said floor 15.368 DAC Fenton did not seek to ask anyone on the incident ground why crews could not go above floor 15, but he assumed that it was due to the fire.369 DAC Fenton and SOM Smith then discussed the fact that crews were unable to get above floor 15, the large number of FSG calls that were being received and the image that DAC Fenton had seen of the tower on fire and decided to change the “stay put” advice.370 SOM Smith explained the decision in her witness statement in these terms:371 “The decision was made owing to a variety of factors – the duration of calls, the content of the calls and the resources available. These factors and my years of experience formed the basis of my rationale and coincided with the recommendations following the Lakanal fire in 2009 in which certain questions were asked by the CROs regarding smoke and fire levels. The information that was fed back by the CROs from residents and the conditions they were in led me to believe that they had no way of waiting to be rescued. I was aware of the previous Lakanal incident in which residents were in cleaner situations, less smoke, who were unable to be rescued. This also formed part of my decision that the ‘stay put’ policy needed to be changed.” 15.162 DAC Fenton recounted that, for him, the visual image was the factor that had made all the difference when it came to making the decision to change the advice.372 15.163 After the decision had been made, DAC Fenton spoke to someone in CU8 to inform them of the decision. He also asked someone in the control room, possibly AOM May, to tell the incident ground by radio that the advice from the control room and the Duty DAC was that the “stay put” advice needed to change.373 He also remembered having told SM Oliff to tell CU7 and he himself informed AC Richard Mills, who was located at LFB headquarters, so he could tell the Commissioner’s group.374 All that is generally consistent with the conclusion that the control room took the decision itself rather than waiting to obtain the agreement of the incident commander. 15.164 From then on, the advice given by the control room to people still in the building was to put wet towels over their faces, hold hands and get out.375 SOM Smith also said that the CROs had been told that they might need to use more forceful and blunt language to emphasise the need to leave the building.376 The debrief notes, which were written at a meeting on 24 July 2017 some weeks after the fire, also recorded that the advice was to get out because it could 365 Fenton witness statement [MET000080569] p.7. 366 Fenton Day 24/145/18-146/1 367 Fenton witness statement [MET000080569] p. 7. 368 Smith Day 22/117/16-25. 369 Fenton Day 24/142/3-10. 370 Fenton witness statement [MET000080569] p. 7. 371 Smith witness statement [MET00007766] p. 4. 372 Fenton Day 24/149/13-150/3. 373 Fenton witness statement [MET000080569] p. 7; Fenton Day 24/154/11-155/2. It is clear from his evidence that this was not a suggestion or request but a statement to the effect that the advice had been changed in the control room. 374 Fenton Day 24/155/1-9. 375 Smith witness statement [MET00007766] p. 4. 376 Smith witness statement [MET00007766] p. 4.

The Grenfell Tower Inquiry: Phase 1 Report 352 be the last chance.377 SOM Smith admitted in the course of her evidence that she had known that the new advice might involve sending residents into conditions that were smoke-logged and hot. She said:378 “Yes, we knew that, and that’s why we instructed all the control officers to tell the callers to get blankets and towels, to wet them, to cover themselves with them, to keep low and more importantly to hold hands as they left so they wouldn’t lose each other, because visibility probably would be nil, and that they should just head to the stairwell.” 15.165 She had not obtained any information from the bridgehead about conditions in the stairwell, but believed that withdrawing the “stay put” advice was the only course that could be taken.379 15.166 As soon as the decision had been made, SOM Smith, OM Norman and AOM Debbie Real went around the control room telling the CROs that the advice they should give had been changed.380 SOM Smith also spoke to BT to make them aware of the change in advice. 15.167 OM Norman communicated the change in advice using an A4 piece of paper she showed to the CROs.381 She recalled that she had written words to the effect of: “Tell callers to put wet towels over their heads, cover their faces, hold hands, and leave”. She said she had chosen to do it in that way because it had been the easiest way to communicate with them at that point. She could not easily talk to any of them because they had been constantly on the telephone with calls coming in at a high rate.382 She said she had made sure that each CRO had understood the message.383 AOM Real said she had communicated the message orally to the CROs and CRO Russell recalled that SOM Smith had also given her the message orally.384 Later on, OM Norman also helped the CROs give advice to callers. She told them to use blunt and forceful language, emphasising to people that they had to leave the building because they really had no choice.385 15.168 When the “stay put” advice was changed, it took some time for the new advice to be disseminated to, and implemented by, all the CROs.386 15.169 At 02.36.07, CRO Russell took a call from Hesham Rahman in Flat 204 on floor 23, who reported that smoke was coming into his flat and that he was finding it difficult to breathe.387 She advised him to cover himself with a wet towel and to try and make his way out of the building. She couched the advice in the following terms: “Listen, the fire is getting quite bad. Do you think it would be better if you covered yourself with a wet towel and tried to make your way down out of the building?” He explained that he had a disability and needed assistance. CRO Russell therefore advised him to block out the smoke and told him she would tell the crews.388 The left-hand whiteboard in the control room was updated with the details “1 disabled male”.389 CRO Russell thought that, by the time she took this call, she had received the instruction from SOM Smith to change the 377 [LFB00003113] p. 6. 378 Smith Day 22/129/15-24. 379 Smith Day 22/130/8-17. 380 Fenton witness statement [MET000080569] p. 7; Smith Day 22/136/1-7; Day 22/139/5-7; Real Day 43/35/9-24; Russell witness statement [MET00007523] p. 7. 381 Norman witness statement [MET000080589] p. 7. 382 Norman witness statement [MET000080589] p. 7. 383 Norman Day 42/157/3-19. 384 Real Day 43/35/9-24; Russell witness statement [MET00007523] p. 7. 385 Norman Day 42/157/23-158/22. 386 Smith witness statement [MET00007766] p.4; [LFB00003113] p. 6-7. 387 [LFB00000368]. 388 [LFB00000368]. 389 [MET00016912].

Part II | Chapter 15: Period 6: 02.20-02.50 353 “stay put” advice.390 She recalled that the new advice had been to cover themselves, to not breathe in the smoke and to make their way down the stairs.391 She did not remember having been advised of the tone in which to convey the message and it appears from her evidence that she may have thought there was a chance that firefighters would still be able to rescue residents.392 15.170 Between 02.36.12 and 02.42.06, CROs Gotts, Duddy, Adams, Howson and Jones took six 999 calls between them and in none of those cases did they advise the caller to leave.393 Instead, they advised the resident, or family member of a resident, to remain in their flat or that the firefighters were coming to rescue them. 15.171 At 02.37.25, CRO Darby sent an informative message to CU7 about conditions in the tower, saying: “We’ve had a report that the south-east corner of the building is completely alight, and the western aspect is completely smoke-logged”.394 15.172 At 02.37.26 and 02.38.06, AOM Real contacted the LAS control room and MetCC respectively to inform them that the LFB had declared a Major Incident.395 That was more than 30 minutes after the LFB had taken that step at 02.06.38. She was not aware that the other emergency services had been taking calls from persons trapped in the tower.396 AOM Real did not tell either control room that the LFB had revoked the “stay put” advice and was now telling callers from the building to leave at all costs. 15.173 At 02.40.11, CRO Fox created a service request containing the information that the fire was in Flat 152 and four adults (including a pregnant woman) and five children aged between three and 11 years old were trapped in Flat 153 and unable to leave due to smoke. That was the result of a call she had received at 02.34.42 from Rabia Yahya.397 At 02.41.27, the service request was updated and completed by CRO Fox.398 The information in the service request did not appear in full on the whiteboard. The entry for Flat 153 read simply “153 18th flr. – 4 adults, 5 children”.399 SM Oliff did not have access to the incident log and therefore did not see any messages unless they were passed to him on paper.400 SOM Smith believed that CRO Fox had passed the message to SM Oliff in full but accepted that she did not know.401 The full details of the service request were not relayed in a radio message to CU7.402 CRO Darby explained that she did not send the message and she believed that CRO Fox had typed the message into the incident log in order to keep a record of it, but had then completed it herself to stop CRO Darby from sending it.403 390 Russell Day 76/62/8-23; Russell witness statement [MET00007523] p. 7. 391 Russell Day 76/61/6-12. 392 Russell Day 76/61/13-23. 393 [LFB00000364]; [LFB00000679]; [LFB00000366]; [LFB00000367]; [LFB00000370]; [LFB00000375]. 394 Radio message [LFB00002748]. 395 Admin line [INQ00000376]; [INQ00000375]. 396 Real Day 43/42/21-24. 397 [LFB00000365]. 398 SIL p. 23. 399 [MET00016912]. 400 Smith Day 22/71/13-72/25. 401 Smith Day 22/75/8-76/13. 402 The only radio message sent after that service request was sent at 02.48.07 by CRO Darby that there was a caller trapped in Flat 153 on floor 18 [LFB00002038]; [LFB00002340]; [LFB00002128]. 403 Darby Day 34/11/14-13/6.

The Grenfell Tower Inquiry: Phase 1 Report 354 15.174 At 02.41.46, CRO Russell took a call from the MPS who passed over information about two adults and three children in Flat 192 who had a fire in their living room.404 CRO Russell confirmed that she would pass the information to the crews. She did not advise the MPS call operator that the LFB advice to stay put had changed.405 The same occurred on a call that CRO Howson took with the MPS at 02.45.35.406 15.175 At 02.42.03, CRO Darby entered a new informative message in the incident log as a result of a series of informative radio messages that had been sent on behalf of DAC O’Loughlin between 02.39.17 and 02.40.37.407 That was the second informative message that the control room had received from the incident ground since the first one was sent at 01.14.21, 1 hour and 28 minutes earlier. Although set out above, it is useful to set out again the informative message as it illustrates the limited information that the CROs were receiving from the incident ground. The message, as recorded in the SIL, reads as follows:408 “SUP CU8 FROM DAC OLOUGHLIN A RESIDENTIAL BLOCK OF FLATS 27 FLOORS 25M X 25M FIRE ON ALL FLOORS FROM 2ND TO 27TH FLOOR LARGE NUMBER OF PERSONS INVOLVED FSG CALLS BEING DEALT WITH MAJOR INCIDENT DECLARED HIGH RISE PROCEDURE IMPLEMENTED TL ALP EDBA MAIN CONTROL FSG GROUND MONITOR 5 JETS SAFETY CORDON IN PLACE TACTICAL MODE OSCAR.” 15.176 At 02.42.40, CRO Duddy received a call from Alemishet Demissie in Flat 94 on floor 12.409 That was the second time she had called. The call lasted for 10 minutes and 49 seconds. By that point, he had been told by SOM Smith about the change in the “stay put” advice.410 Alemishet Demissie told him that the whole flat was full of smoke and CRO Duddy started to advise her to leave.411 She explained that she could not see anything and he told her to get to the stairwell. He said: “Feel your way along the walls; do anything you can. You need to make it to that stairwell.” Eight minutes into the call, at approximately 02.50.00, CRO Duddy told her: “If you don’t do what I tell you, you are going to die in that flat”. Alemishet Demissie told him that she would try to leave and the call ended.412 When he spoke to her again at 02.58.44, he relayed the same advice.413 15.177 CRO Duddy explained in evidence that he recalled that even though he had started to tell callers to leave, he and others still recorded the flat and floor numbers of the calls on the whiteboard.414 However, in this case the number of the flat was not recorded on the whiteboards and a service request was not created. 15.178 At 02.42.38, AOM Real contacted RBKC to inform them that a Major Incident had been declared. RBKC confirmed that it was already aware.415 15.179 At 02.42.50 another informative message was entered in the SIL stating that 58 adults and 16 children were believed to be involved.416 404 [LFB00000540]. 405 [LFB00000540]. 406 [LFB00000541]. 407 The series of radio message transcripts are: [LFB00002823], [LFB00002976], [LFB00002504], [LFB00002775], [LFB00002580], [LFB00002480], [LFB00002401], [LFB00002968]. 408 SIL p. 23. 409 [LFB00000683]. 410 Duddy Day 42/226/16-25. 411 [LFB00000683] p. 5. 412 [LFB00000683] p. 12; Brigade Control Report p. 96. 413 [LFB00000680]. 414 Duddy Day 42/228/9-16. Howson also explained that she adopted the same practice: Howson Day 80/173/24-174/8. 415 [INQ00000188]. 416 SIL p. 23.

Part II | Chapter 15: Period 6: 02.20-02.50 355 15.180 By 02.43.00, CRO Jones, Fox and Adams had been told about the change in the “stay put” advice as they all took calls during which they advised residents to leave. At 02.43.08, CRO Jones spoke to Ann Chance in Flat 73 on floor 10, who reported a lot of smoke coming into in her flat and that her front door was hot. CRO Jones advised her to leave; she repeatedly told her to use wet towels to cover herself and to try to get out.417 At 02.43.54, CRO Fox asked Nur Huda El Wahabi in Flat 182 on floor 21 whether she was able to get out of the property safely. She advised her how to get out but then the line cleared before she could say any more.418 At 02.43.55 CRO Adams told Bassem Choukair in Flat 193 on floor 22 that if it got very, very bad he needed to get all his people out. She said: “Cover yourself with wet towels, wet sheets, anything and try and get out”.419 15.181 At 02.43.51, CU8 sent a radio message to control informing them that AC Roe was now incident commander.420 CRO Darby entered that in the incident log at 02.44.18.421 15.182 At 02.44.41, CRO Russell took a call from Natasha Elcock in Flat 82 on floor 11, who reported that her front door was hot and “popping”.422 That was the eighth time that Natasha Elcock had called the LFB control room. CRO Russell told her that she thought that the heat and popping meant that the fire was on the other side of the door and asked her to stay away from it. CRO Russell advised her to block the gaps around the door and told her that the firefighters were “fighting their way up to get to everyone”.423 15.183 At 02.45.45, the Surrey FRS control room received another call from Chanade Prentice, the daughter-in-law of Anthony Disson, who was trapped in Flat 194 on floor 22.424 The operator took the mobile number for Anthony Disson and said they would pass it to London so that the LFB could call him to reassure him. No advice was given. Three minutes later, at 02.48.49, Surrey made contact with CRO Gotts in the LFB control room to pass on the message.425 15.184 At around 02.46.03, SOM Adam Crinion and POM Scott Hayward arrived in the control room. SOM Crinion had been first paged at 01.49.13 and POM Hayward had been first alerted by SOM Smith between 01.30 and 02.00.426 When SOM Crinion arrived in the control room he had a quick verbal briefing at the supervisors’ desks and logged on to Twitter to see the scale of the incident and to get images of the scene.427 He showed some of them to the supervisors to help them gain an idea of what they were dealing with.428 He spoke to SOM Smith about staffing levels and, as there was no “recall to duty procedure”, he rang four or five people who lived near Stratford to ask them to come in.429 He explained in evidence that he had not called any more people because there were not enough seats in the Stratford control room to accommodate them.430 He spoke to AOMs Pauline Warner and Kate Ranson, both of whom 417 [LFB00000373]. 418 [LFB00000374]; Fox Day 80/213/3-214/10. 419 [LFB00000376] p. 4; Adams Day 80/103-106. 420 [LFB00002272]. 421 SIL p. 23. 422 [LFB00000377]. 423 [LFB00000377] p. 7. 424 [LFB00000650]. 425 [LFB00000544]. 426 SIL p. 14, 23. SOM Crinion’s call sign is BC04; Hayward witness statement [MET00007894] p. 3. 427 Crinion witness statement [MET00008009] p. 3. 428 Crinion witness statement [MET00008009] p. 3. 429 Crinion witness statement [MET00008009] p. 4. 430 Crinion witness statement [MET00008009] p. 4.

The Grenfell Tower Inquiry: Phase 1 Report 356 volunteered to come in.431 POM Hayward then monitored the control room staff and kept in touch with senior officers, providing them with regular information. He also provided support and assistance to the CROs.432 15.185 SM Oliff remembered that at some point shortly after the advice to callers had changed, DAC Fenton and another DAC had held an informal meeting. They had told him that the FSG advice “would have to be changed” and that the CROs were now telling people to leave.433 It was around that time that SM McClenaghan arrived in the control room and showed SM Oliff pictures of the tower.434 SM Oliff said that he was quite astonished by what he saw and that seeing the pictures on his telephone had allowed him to see what they were up against.435 15.186 At 02.46.42, CRO Adams received a call from Nur Huda El Wahabi in Flat 182 on floor 21.436 She repeatedly advised her to cover herself up and get out of the building. When Nur Huda El Wahabi told her that she couldn’t leave, CRO Adams said: “I know you can’t but it’s – We’re not going to get to you. Get yourself out of the building as best you can, OK? Do you hear me? Try and get yourself out.”437 15.187 Members of the El Wahabi family were subsequently connected to the control room at 02.51.06, 02.53.57 and 02.57.34. CROs Adams and Howson were able to speak to the caller on the first two occasions; on the third occasion the line was silent. Each time, the CRO advised the caller to leave the flat, but on each occasion they were told that the caller had tried to leave but that it was too smoky in the lobby, which was filled with black smoke.438 15.188 At 02.46.42, a 999 call was put through to Merseyside FRS. (It was the only call from Grenfell Tower that they took on the night.)439 The call was from the grandson of Abdeslam Sebbar, who was trapped in Flat 81. He thought the flat was on either floor 11 or floor 14. He explained that “the person just stopped talking on the phone so it’s very critical that somebody gets there”.440 CRO Jeanette Pike took down the details and ended the call.441 At 02.47.37, CRO Pike called the LFB control room and spoke to CRO Jones to give her the information. When she was told the flat number, CRO Jones was horrified because she realised that the firefighters were not going to get there.442 She told CRO Pike that the advice was to “get out and go for it”.443 CRO Pike gave the caller’s number to CRO Jones and she said she would call him back.444 At 02.50.01, CRO Jones called the number but no one answered.445 No record of the flat number appears to have been made on the whiteboards. 15.189 At 02.46.58, CRO Howson received a call from Marcio Gomes in Flat 183 on floor 21, who told her that the fire had reached the flat next door to him.446 She told him that they had to leave but she left the decision in his hands. She said: 431 Crinion witness statement [MET00008009] p. 4. 432 Hayward witness statement [MET00007894] p. 4. 433 Oliff witness statement [MET00012791] p. 5. 434 Oliff witness statement [MET00012791] p. 5. 435 Oliff Day 23/147/1-17. 436 [LFB00000379]. 437 [LFB00000379] p. 4. 438 [LFB00000383]; [LFB00000387]. 439 [INQ00000532]. 440 [INQ00000532]. 441 Pike witness statement [MET00013002] p. 3. 442 [LFB00000543] p. 3. 443 [LFB00000543] pp. 3-4. 444 [LFB00000543] pp. 3-4. 445 Control Report p. 103. 446 [LFB00000672].

Part II | Chapter 15: Period 6: 02.20-02.50 357 “If you feel it’s not safe to be in the flat any more, OK, you, you may have to leave the flat.” He told her that it was impossible for them to leave the flat and she then gave him the following advice: “OK, what you will need to do, wet blankets, wet towels, tea towels, put them around your mouth and around the mouth of your family and make your way out and make your way down.” He asked if firefighters were going to come and meet them and she said: “We, we’ve got the firefighters who are making their way up, but it’s very slow progress at the moment.”447 15.190 It is not clear whether CRO Howson had been told of the change in the “stay put” advice at that time, but at all events she gave the caller the impression that firefighters were still making their way up the building. In evidence, she said that she remembered having been told by AOM Real, who was standing in front of her, about the change in the “stay put” advice. She recalled that AOM Real had said something to the effect of “Right, get them all out now… Tell them wet towels, blankets, cover their faces and get them out of their flats, we can’t get to them.”448 15.191 She said that when AOM Real had told her about the change in advice, it was the first time that she had realised that the firefighters would not be able to rescue people in the building. She was under the impression that they could not reach all the floors.449 15.192 The next call taken by CRO Howson was at 02.48.22, when she spoke to Rabia Yahya in Flat 153 on floor 18.450 She was told that there was a fire in the flat next door and she advised as follows: 451 “Listen, we’re not going to be able to get up there to you. You need to leave the flat and get out…. What you need to do, you need to get some wet towels and towels, put them around your mouth so you won’t inhale smoke and you need to get out, OK? Make your way down, don’t use the lift, use the stairwells, OK, but you need to put wet blankets and that around your mouth and the kids as well, OK, and make your way downstairs if the fire’s in the flat next door if that’s what’s going on, OK? Do you understand?” 15.193 In the light of the advice that CRO Howson gave Rabia Yahya, it is likely that she had just been instructed by AOM Real to tell residents who called that they had to leave. 15.194 At 02.48.07, CRO Darby sent a radio message to CU7 to say tell them there were about four persons trapped in Flat 153 on floor 18.452 It is unclear where that message originated as no service request was created in relation to it. 15.195 At 02.48.49, CRO Gotts took a call from Surrey FRS who passed over a message about a person who had called about their 70-year-old father-in-law who was trapped on floor 22. That was Anthony Disson in Flat 194.453 CRO Gotts told the operator about the change in the “stay put” advice. She said that they had just been told to tell people to put a wet towel over their heads and try and get out.454 CRO Gotts said in evidence that she believed that by that stage she must have been told about the change in the “stay put” advice, but she could not 447 [LFB00000672]. 448 Howson Day 80/168/3-15. 449 Howson Day 80/168/16-22. 450 [LFB00000384]. 451 [LFB00000384] p. 4. 452 Radio messages: [LFB00002340], [LFB00002128], [LFB00002031]. 453 [LFB00000544]. 454 [LFB00000544].

The Grenfell Tower Inquiry: Phase 1 Report 358 remember who had told her or whether the information had been given to her on a piece of paper.455 The call was the first occasion on which the Surrey FRS control room had been made aware of the change in the “stay put” advice, although they do not appear to have noted it on their system at that time.456 15.196 At the end of the call, the operator gave CRO Gotts Anthony Disson’s telephone number and at 02.51.38 CRO Gotts called him.457 He was very distressed and shouted that there were flames coming from next door. She told him to cover himself with wet towels and to get out, prompting the question whether she was serious. She asked if a neighbour could help him, but the call cut out.458 5 Actions of the MPS, the LAS, RBKC and the TMO 15.197 Throughout Period 6 (02.21 to 02.50) numerous radio messages were sent by police officers at the scene or on the cordon about individual occupants of the building who were trapped and in need of rescue. For example, at 02.26.44, a message was received concerning a woman who had an 81-year-old father with a heart condition who was believed to be in the lift on floor 12,459 and a number of messages about a woman whose partially-sighted husband was stuck in Flat 83. (That was Elpidio Bonifacio, who was the last person to be rescued alive from the tower at 08.07.) Those messages were received as a result of police officers at the cordon speaking to family or friends of those still trapped within the building. 15.198 At 02.21 Nickolas Layton called David Kerry, RBKC’s Contingency Planning Manager, to notify him of the fire. David Kerry despatched Nickolas Layton to attend the scene as LALO. David Kerry took on the role of organising the Borough Emergency Control Centre (BECC).460 15.199 At 02.22.29 Inspector Nicholas Thatcher began overseeing the evacuation of a building to the west of the tower, using the services of the TSG, which was on the scene by that stage (having been called just after 01.35, as recorded above). At 02.24 the NPAS helicopter sent a message that the fire was now in the south-east corner on the roof and also at least halfway along the northern aspect of the roof.461 There is no evidence that this message was passed to the incident ground, and CU7 could not access the heli-tele images, as was made clear to Inspector Thatcher by SM Johnson when he was in CU7 between 02.36 and 02.39.462 Inspector Thatcher thought that the line of communication at that point was from the NPAS helicopter to MetCC, from MetCC to the control room and then to CU7.463 However, it seems from the notation of entries on CAD482 that the NPAS helicopter was broadcasting direct to the police radio system and not going through a MetCC operator. Indeed, Inspector Thatcher himself said that he could hear the NPAS messages over the general MPS radio.464 The information in CRO Darby’s radio message at 02.37.25 may have originated from the NPAS helicopter because it cannot be traced to any 999 or admin line call. Accordingly, it is possible that the NPAS messages were picked up in the LFB control room at Stratford through the radio tannoy on the head table, which was on and audible. 455 Gotts Day 43/198/17-199/5. 456 Surrey FRS Incident log for this call [LFB00003629] p. 3. 457 [INQ00010865]. 458 Control Report pp. 106-107. 459 CAD 482 p. 14. 460 David Kerry’s Emergency Event Log Sheet entry 1 [RBK00028849]. 461 CAD 482 p. 13. 462 BWV clip [INQ00000520]. 463 Thatcher Day 71(Mon)/79/8-18. 464 Thatcher third witness statement [MET00023284] p. 11.

Part II | Chapter 15: Period 6: 02.20-02.50 359 15.200 At 02.23 Laurence Ioannou (LAS) went to CU8465 and made his first contact with the incident commander, who at that point was DAC O’Loughlin. That was the first face-to-face contact between LAS and LFB senior officers at the incident ground. 15.201 At 02.26.53 Laurence Ioannou declared a Major Incident on behalf of the LAS.466 That was as a result of his having gone back to CU7 and discovered that from the LFB that there were FSG calls reporting 40 people trapped and patients coming out of building unconscious.467 At 02.38.40 the LAS recorded that the LFB had itself declared a Major Incident,468 having been informed of that fact by telephone from the LFB control room at 02.37.26.469 15.202 Between 02.30.47 and 02.45 there were numerous radio messages from the NPAS helicopter broadcast over the MPS radio channel, identifying fire in certain locations on the southern elevation of the tower and the need for rescue, the fact that people were trying to escape by climbing down from flats on that elevation, and expressing the opinion that the fire was going to spread quickly.470 Again, there is no evidence that these messages were passed to, or acted on by, the control room. 15.203 At 02.30 Commander Neil Jerome, still at home in Kent, took a further call from Chief Inspector Duane Barrett at GT at Lambeth. He was told that a Major Incident had been declared and that many casualties had been reported, but not by whom.471 He did not in fact know that the MPS had declared a Major Incident an hour previously. He made a number of command decisions, in particular to establish a casualty bureau,472 and directed that a “full multi-agency response” was required.473 That included the activation of a strategic co-ordination group of senior representatives of the emergency services under the auspices of JESIP and the activation of the London Resilience Forum to provide support and the establishment of a special operations room for this incident at Lambeth in order to co-ordinate the response. Commander Jerome instructed Chief Inspector Barrett to take charge of ensuring that those steps were carried out.474 His call to Chief Inspector Barrett ended at around 02.40 or 02.45.475 Shortly afterwards he left for Lambeth under blue lights. He left Detective Superintendent Paul Warnett in charge as Gold Commander for the time being and intended to take over from him once he had arrived (which he later did, at 04.10) and had been briefed. 15.204 At 02.37.46 the MPS recorded that they had spoken to RBKC about “smoke screens” and water, but were yet to make contact with their LALO.476 At 02.38.04 a new radio channel was established by command support within the Pan-London response team in order to carry messages concerning residents displaced from Grenfell Tower and the surrounding blocks. The purpose of doing that was to keep the working channel free for operational requirements.477 15.205 At 02.38 Laurence Ioannou (LAS) was informed by the LFB that there were now 58 adults and 16 children, 74 people in all, trapped in the building.478 465 Laurence Ioannou’s reference in his statement [MET00010862] p. 6 to CU2 is incorrect since the incident commanders used CU8 for incident command throughout. 466 CAD 247 p. 7. Laurence Ioannou’s timing of that at 02.55 in his witness statement [MET00010862] p. 7 is probably incorrect. 467 Ioannou witness statement [MET00010862] p. 7. 468 CAD 247 p. 8 and the call transcript at [INQ00000380] p. 2. 469 [INQ00000376]. 470 CAD 482 entries at 02.30.47, 02.35.42, 02.37.39 and 02.39.05 pp. 14, 15. 471 Jerome witness statement [MET00023286] paragraph 42; Day 71(Mon)/175/7-25. 472 Jerome Day 71(Mon)/192/4-12. 473 Jerome witness statement [MET00023286] paragraph 43. 474 Jerome witness statement [MET00023286] paragraph 44. 475 Jerome Day 71(Mon)/202/11-12. 476 CAD 482 p. 13. 477 Winch witness statement [METS00020664] pp. 7-8. 478 Ioannou witness statement [MET00010862] p. 7.

The Grenfell Tower Inquiry: Phase 1 Report 360 15.206 At 02.38.21 CU8 made a further request for a DSE and LALO.479 15.207 At 02.39, Inspector Thatcher met DAC O’Loughlin, then the incident commander. That was the first meeting that he had had with any LFB officer since his arrival over an hour before.480 The meeting took place inside CU8 and was recorded on his body-worn video (as was the major part of his night at the incident).481 DAC O’Loughlin was still incident commander at that point, although very shortly afterwards he was to be relieved by AC Roe. DAC O’Loughlin told Inspector Thatcher that the LFB had declared a Major Incident. That was the first that Inspector Thatcher had heard of the fact. 15.208 At 02.42.38 RBKC was notified of the fire by the LFB. The caller (AOM Real) informed the RBKC operator using the control room “admin line” that a Major Incident had been declared and that a 40-pump fire had been reported with many persons trapped in flats. The RBKC operator “Annette” asked whether there was anything they needed. AOM Real said that she needed to inform the London Borough Duty Officer. The RBKC operator confirmed that they were already aware of the fire.482 It remains unclear why the LFB made contact with RBKC to tell it that it had declared a Major Incident only at that juncture and not soon after GM Welch had made the declaration at 02.06. It is also unclear why AOM Real failed to ask RBKC for a DSE at that point, notwithstanding the service requests from CU8 at 02.17.36 and 02.38.21. 15.209 At 02.43, David Kerry, at the RBKC BECC, called Michael Rumble, RBKC Parks Police Inspector and asked him to attend the scene as a second LALO.483 15.210 At 02.44 the NPAS helicopter left Grenfell Tower because of a fault and was replaced by another one (NPAS 13) from Lippitts Hill, which arrived at 02.58.01.484 That second helicopter did not provide any video downlink facility either, for reasons explained at the end of Chapter 17. 15.211 At 02.45 the LAS command unit arrived and shortly afterwards the LAS sectorised the incident for casualty handling, making the original casualty area to the east of the tower sector 1 and an area to the west of the tower as sector 2.485 15.212 At around 02.47 Nickolas Layton, the RBKC LALO, arrived at the scene.486 He went to CU8 and introduced himself to the incident commander (who by that stage was AC Roe) explaining that he was there to offer assistance.487 He was asked by AC Roe to open up the Kensington Leisure Centre as a temporary mortuary. He agreed and gave permission for the LFB to make a forced entry.488 479 SIL [MET00013830] p. 23. 480 Thatcher Day 71(Mon)/73/21-23; 74/4-75/5. 481 Clip at [INQ00000521]. 482 Control Admin Line [INQ00000188]. 483 David Kerry’s Emergency Log Sheet, entry 3 [RBK00028849]. 484 CAD 482 pp. 16, 18. 485 Ioannou witness statement [MET00010862] p. 8. 486 Thatcher body-worn video [INQ00000524]; Thatcher Day 71(Mon)/149/2-5. 487 Layton Day 74/26/11-19. 488 Layton Day 74/27/8-12.

361 Chapter 16 Period 7: 02.50-03.00 1 External fire spread 16.1 By 02.57 the flame front had continued to move across the south face from east to west and had spread beyond column D3 (the middle internal column on the south face), the furthest horizontal spread being at the crown,1 all of which can be seen in the following image:2 Figure 16.1 16.2 By 02.51 flames had appeared at the top of column A1 (the column on the north-west corner of the tower). Fire was also spreading down the edge of column A1 on the west face and there were flames at the horizontal joints between some of the ACM panels on column A1.3 Those burning patterns can be seen in this image taken at 02.51:4 1 Professor Bisby supplemental report [LBYS0000001] p. 229 at sections 1067-1069. 2 Professor Bisby supplemental report [LBYS0000001] p. 232 at Fig. 152. 3 Professor Bisby supplemental report [LBYS0000001] p. 221 sections 1034-1037; [LBYS0000001] p. 190 Figs. 110 and 111 show downward fire spread at the corner of column A1 at 02.50 and 02.52 (refer to Professor Bisby errata sheet). 4 Professor Bisby supplemental report [LBYS0000001] p. 222 Fig. 138.

The Grenfell Tower Inquiry: Phase 1 Report 362 Figure 16.2 16.3 By 02.53 Flats 51, 61, 71 and 81 on floors 8 to 11 and Flat 82 on floor 11 had become involved in the external flame spread.5 5 Dr Lane supplemental report [BLAS0000012] p. 10 Fig. 12.3.

Part II | Chapter 16: Period 7: 02.50-03.00 363 2 Events on the incident ground Arrival of Commissioner Dany Cotton 16.4 Commissioner Cotton arrived at the incident at 02.50.48.6 She took a photograph of the east side of the tower from where she had parked her car. That photograph, which bears a time stamp of 02.51, is reproduced below: Figure 16.3 6 Radio transcript [LFB00002814].

The Grenfell Tower Inquiry: Phase 1 Report 364 16.5 On looking at the tower, the Commissioner’s first thought was that there had been a complete failure of the building in which all the floors were alight, which she had not thought could ever happen to a building in England.7 She thought that nothing could be done to extinguish the fire; the only question was how firefighters could get into the building in order to carry out as many rescues as possible.8 At that point the Commissioner had not decided whether to take over command of the incident.9 Having taken the photograph, she made her way to CU8.10 Briefing of DAC Andrew O’Loughlin as operations commander 16.6 Meanwhile on CU8, AC Andrew Roe was briefing DAC O’Loughlin to take over as operations commander with responsibility for the fire sector, FSG management and BA main control. The Roe Log records that briefing as taking place at 02.54.11 DAC O’Loughlin explained that his new role had been to move between the different operational sectors on the fire ground12 and to take responsibility for tactical decision-making in each of them.13 16.7 They agreed that DAC O’Loughlin would be based on the incident ground for that role, rather than on the command unit. AC Roe asked him to focus on two things in particular: establishing a safe means of entering and leaving the tower and driving the rescue effort.14 DAC O’Loughlin did not recall his responsibility for the route into and out of the tower15 and said that his objective at that time had been trying to reach those who had made FSG calls, starting on the north-east side of the building and then systematically working through the other floors.16 He was unable to give AC Roe any information about the search and rescue strategies that until then had been adopted in the fire sector,17 and he did not tell AC Roe that he had not in fact received any information from the fire sector during his time as incident commander.18 16.8 AC Roe also asked DAC O’Loughlin to establish a dedicated command radio channel on channel 2, but that was not possible, and so channel 1 continued to be used.19 16.9 Having been briefed as operations commander, DAC O’Loughlin left CU8 for CU7.20 He saw that the fire had got significantly worse21 and that it was wrapping around the south and west sides of the building.22 It does not appear that he realised at that point that the fire had got into some of the flats, since he said that he had not seen that until he left CU7 and went to the tower. That was at some time after 03.00.23 7 Cotton Day 50/141/17-70; 141/24-142/3. 8 Cotton Day 50/142/5-19. 9 Cotton Day 50/142/20-143/4. 10 Cotton Day 50/144/7-145/1. 11 AC Roe record of actions [MET00005405] p. 3. 12 O’Loughlin Day 48/44/9-21. 13 O’Loughlin Day 48/50/1-15. 14 AC Roe record of actions [MET00005405] p. 3. 15 O’Loughlin Day 48/48/7-24. 16 O’Loughlin Day 48/52/8-17. 17 Roe Day 49/69/14-72/15. 18 Roe Day 49/72/16-25. 19 Roe Day 49/73/11-74/20. 20 O’Loughlin witness statement [MET00012563] p. 19. 21 O’Loughlin Day 47/169/19-23. 22 O’Loughlin Day 47/182/22-183/14. 23 Day 47/169/19-23.

Part II | Chapter 16: Period 7: 02.50-03.00 365 AC Roe briefs GM Stephen West as sector commander for command support 16.10 AC Roe then briefed GM West to take the role of sector commander for command support, with instructions to concentrate on ensuring that there was a continuous supply of resources to the operational sectors, in particular BA Main Control. AC Roe directed GM West to run command support from CU1, which had arrived at the incident at 02.59.36. The Roe Log records that briefing as having taken place at 02.57.24 DAC O’Loughlin on CU7 – GM Thomas Goodall’s grid 16.11 Meanwhile DAC O’Loughlin had arrived at CU7. He had a short discussion with GM Goodall to see if he needed anything,25 but there was no substantial discussion of the FSG calls. DAC O’Loughlin saw the list of FSG calls, but did not look at it in detail.26 He said that if at that time he had attempted to break down the calls and establish how they were going to prioritise them, he would have become caught up in managing them when he knew that he needed to go into the tower and acquaint himself with the firefighting and rescue operations.27 He understood that his role was to ensure that there was an effective system in place for managing FSG information,28 and in his view there was.29 He did not check any particular flat numbers or carry out any check to see whether the correct information was being passed on,30 because he did not see that as part of his role.31 16.12 Although DAC O’Loughlin referred to seeing a “list” of FSG calls on CU7, it is clear that it was at about that time that GM Goodall was implementing his whiteboard “grid” system containing all the flat and floor numbers together with any FSG information that had been received relating to them. GM Goodall recalled having started that system fairly soon after he had arrived at CU7, when it had become obvious that a simple list was not going to enable the FSG team to identify where people were trapped.32 GM Goodall took a number of photographs of the whiteboards on CU7 during the course of the incident, one of which, reproduced below, appears to show the beginning of the “grid” system. It bears a time stamp of 03.00: 24 AC Roe record of actions [MET00005405] pp. 3-4; SIL p. 9. 25 O’Loughlin Day 48/68/11-14. 26 O’Loughlin Day 48/70/8-12. 27 O’Loughlin Day 48/69/1-6. 28 O’Loughlin Day 48/74/18-25. 29 O’Loughlin Day 48/73/11-12. 30 O’Loughlin Day 48/73/20-25; 75/18-20. 31 O’Loughlin Day 48/74/23-25. 32 E.g. Goodall Day 35/31/6-16.

The Grenfell Tower Inquiry: Phase 1 Report 366 Figure 16.4 16.13 A photograph of the same whiteboard taken much later on shows how it looked after FSG information had been entered on it:

Part II | Chapter 16: Period 7: 02.50-03.00 367 Figure 16.5 Commissioner Cotton on CU8 and going to the tower with AC Roe 16.14 At about that time (03.00) Commissioner Cotton reached CU8. She thought that she had arrived at about the time that AC Roe was leaving to go to the tower. She went with him and as they walked he gave her a briefing.33 She recalled his telling her that the “stay put” advice had been revoked,34 but she did not recall any discussion about FSG calls or AC Roe’s tactical plan at that time.35 She did not ask him why the “stay put” advice had not been withdrawn sooner; nor did she ask when compartmentation had failed. BA deployments: FFs Michael Pole, Niki Mitchell, Chris Cheesman and Jessamine Bate 16.15 Inside the tower, FFs Pole, Mitchell, Cheesman and Bate from Euston Fire Station were at the bridgehead ready to go under air. All four recalled being briefed to go to floor 23.36 The photograph of the wall on floor 3 where the bridgehead was then positioned shows that the word “Euston” had been written against Flats 204 and 205 on floor 23. In the bottom right- hand corner of the photograph can be seen the words “23rd Euston 204 205”. 33 Cotton Day 50/146/3-14. 34 Cotton Day 50/147/1-2. 35 Cotton Day 50/146/20-24. 36 Mitchell witness statement [MET00039859] p. 5; Bate witness statement [MET00017072] p. 5; Pole witness statement [MET00039672] p. 8; Cheesman contemporaneous note [MET00005485] p. 1.

The Grenfell Tower Inquiry: Phase 1 Report 368 Figure 16.6 16.16 It seems likely, therefore, that the crew were briefed to go specifically to Flats 204 and 205, rather than to undertake search and rescue operations on floor 23 generally. The crew had tallied out by 02.53. FF Mitchell recalled thinking, when they set out, that they would struggle to reach floor 23 as they were wearing SDBA.37 At about floor 12 they came across another crew of two firefighters who were on their way down (possibly FFs Nikki Upton and Tom Reddington) carrying an unconscious girl, now identified as Malak Belkadi.38 One of the firefighters placed the child in FF Bate’s arms and she decided to carry her down, leaving the rest of her crew to continue up to floor 23.39 37 Mitchell witness statement [MET00039859] p. 6. 38 ORR v 0.7 p. 264. 39 Bate witness statement [MET00017072] p. 6.

Part II | Chapter 16: Period 7: 02.50-03.00 369 16.17 FFs Mitchell, Pole and Cheesman continued on their way up. They reached what they thought was floor 18, when they realised they would not have enough air to get all the way to floor 23 and back down again. They therefore decided to rescue anyone they could from that floor rather than go any higher.40 They opened the door to the lobby on floor 18. FF Mitchell said that it was at that point that he had been grabbed by a man who had told him that there were seven people in need of rescue;41 FF Pole said that they had come across the man after they had entered the lobby and knocked on the door of one of the flats.42 16.18 FF Mitchell decided that the crew would take the seven residents down in what he described as a “human chain”. He remembered having checked before they set off that all seven were there.43 16.19 On their way down, FF Pole, who was at the back of the chain with a woman and a boy, realised that the boy was no longer with them. He found him sitting on a step. He picked the child up and continued down the stairs. Further on he came across another firefighter whom he asked for help. The other firefighter took the child from FF Pole.44 16.20 FFs Mitchell and Cheesman had got back to the bridgehead before they realised that FF Pole was no longer with them. They went back up the stairs, found him, and brought him back down. FF Mitchell remembered telling WM De Silvo that they had not reached floor 23 but had got “fairly high up” and that they had rescued a family of seven.45 The crew’s “end of wear times” were between 03.15 and 03.17. I set out further details about this deployment and rescue in Period 8. 3 Conditions in the tower and movement of occupants Floor 23 Flat 202 16.21 In Flat 202, Gloria Trevisan began her last call to her parents at 02.45, which lasted 22 minutes 56 seconds, ending at 03.08. She told her mother, Emanuela Disaró, that the two people who had sheltered in Flat 202 (Majorie and Ernie Vital) were still with her as well as Marco Gottardi. He was speaking to his parents.46 Gloria Trevisan told her mother that smoke was coming from everywhere and that there was no way out. The flat was full of smoke and she could see the fire outside the window. They had shut a window because pieces of glass had been coming in.47 16.22 Emanuela Disaró asked her daughter if they had made others aware that they were in the flat. Gloria Trevisan said she had and while speaking to her mother she asked others in the flat the same question. Emanuela Disaró could not hear their response,48 but there is no evidence that any emergency calls were made by those trapped in Flat 202. 40 Mitchell witness statement [MET00039859] p. 7; Pole witness statement [MET00039672] p. 9; note that Cheesman in his contemporaneous note estimated that they were somewhere between floors 15 and 18 [MET00005485] p. 1. 41 Mitchell witness statement [MET00039859] p. 7. 42 Pole witness statement [MET00039672] p. 9. 43 Mitchell witness statement [MET00039859] p. 7. 44 Pole witness statement [MET00039672] pp. 11-12. 45 Mitchell witness statement [MET00039859] pp. 8-9. 46 Disaró first witness statement [IWS00000543] p. 8; Disaró second witness statement [IWS00001227] p. 7. 47 Disaró first witness statement [IWS00000543] p. 8; Disaró second witness statement [IWS00001227] p. 7. 48 Disaró first witness statement [IWS00000543] p. 8; Disaró second witness statement [IWS00001227] p. 7.

The Grenfell Tower Inquiry: Phase 1 Report 370 16.23 During the call, Gloria Trevisan told her mother that her eyes and throat were burning and hurting and that she was feeling unwell. Emanuela Disaró could tell her daughter was having problems speaking. Gloria Trevisan told her mother she was having difficulty breathing and could be heard coughing. At some point she told her mother that the fire had come through the window.49 Gloria Trevisan ended the call.50 16.24 That was the last contact that the parents of Gloria Trevisan had with their daughter. 16.25 At around 02.45 (probably before Gloria Trevisan’s final call to her mother), Emanuela Disaró called Giannino Gottardi, Marco Gottardi’s father, to tell him of the fire.51 He immediately called his son who sounded calm and said he had filled the bath with water. Marco Gottardi told his father that they had not evacuated because there was too much smoke and they had been told to stay put.52 16.26 Marco Gottardi made a further call to his father after Gloria Trevisan’s final call to her mother, to which I shall return later in this Narrative under Period 8. Flat 203 16.27 By this time, Isra Ibrahim had made a 999 call from Flat 203, timed at 02.42.06, and had been advised to stay there.53 At 02.58.42, a man called the control room and spoke to CRO Christine Howson. He told her that the police would not let him into the tower and had told him to call

1. The caller said that he had just spoken to someone in Flat 203 with two children. CRO

Howson told him that they needed to try to leave the building and that she would pass on the information that people were still in Flat 203.54 16.28 The caller must have been referring to Rania Ibrahim. It is not known if he was able to speak to her again to pass on CRO Howson’s advice. 16.29 Rania Ibrahim appears to have thought that the “stay put” policy was still in place at that time. Munira Mahmud, a close friend who had earlier left floor 5, called Rania Ibrahim at around 03.00. Rania Ibrahim was coughing a lot and Munira Mahmud could tell that she was finding it difficult to breathe. Munira Mahmud tried to persuade her to leave. Rania Ibrahim said she had called 999 and that whoever had answered the call had told her to stay inside and wait for help. She also said that the roof door was locked but that they were sending help, as she could see a helicopter. Munira Mahmud continued to tell Rania Ibrahim that she should try to leave. That was the last conversation Munira Mahmud had with Rania Ibrahim; she was unable to reach her by telephone again.55 16.30 Sayeda Ibrahim’s daughter spoke to her aunt Rania Ibrahim on several occasions (01.00, 02.50 and 03.00). Her last conversation was at 03.00.56 16.31 The contact Munira Mahmud and Sayeda Ibrahim’s daughter had with Rania Ibrahim is, on the evidence, the last known contact with those in Flat 203. 49 Disaró first witness statement [IWS00000543] pp. 8-9. 50 Disaró first witness statement [IWS00000543] pp. 8-9; Disaró second witness statement [IWS00001227] p. 8. 51 Gottardi first witness statement [MET00013011] p. 1. 52 Gottardi first witness statement [MET00013011] p. 1. 53 [LFB00000375]. 54 [LFB00000558]; ORR v 0.7 p. 252. 55 Mahmud first witness statement [IWS00000776] p. 9; Mahmud Day 54/108/20-111/2. 56 Ibrahim witness statement [IWS00000323] p. 9.

Part II | Chapter 16: Period 7: 02.50-03.00 371 Flat 204 16.32 Hesham Rahman had remained in Flat 204. Shafika Ragab, his aunt, lived close to the tower. Learning of the fire, and being concerned for her nephew, she called him at 02.59. She told him to leave as the tower was on fire. He said he had to wait. He told her that he had told the police that he had problems with his feet and could not walk, and that they had told him that they were coming to get him.57 Shafika Ragab pleaded with Hesham Rahman to leave. He said he would try his best.58 There is no record of an emergency call from Hesham Rahman having reached the MPS, so he must have been referring to his calls to the control room. Floor 22 Flat 193 16.33 At about this time, the Choucair family made an unsuccessful attempt to leave the tower. Before this, Nadia Choucair and Bassem Choukair had made two separate 999 calls. CRO Yvonne Adams responded to both of them. 16.34 In her call at 02.37.00 Nadia Choucair told CRO Adams that she could see fire, that there was a lot of smoke coming into the flat and that it was getting worse. CRO Adams advised her to block out the smoke coming in and to close the windows. Nadia Choucair confirmed that the door had already been blocked. At the end of the call, CRO Adams said: “We are coming to you. We will get to you, OK?”59 16.35 In the second call at 02.43.55, CRO Adams encouraged Bassem Choukair to try to find the stairs and get out. He told CRO Adams that it was not possible to leave because of the smoke; he could not see. CRO Adams ended the call saying, “I’m going to leave you now. You make the decision whether you think you need to leave or not. All right?” The call lasted 2 minutes and 26 seconds.60 16.36 In both calls, CRO Adams had been told there were eight people in the flat, which would correspond to the members of the Choucair family and Naomi Li and Lydia Liao. Nadia Choucair told Naomi Li that they needed to leave the building. Naomi Li refused to do so, because she had been told to stay by the emergency services and she did not feel prepared to run down the stairs at that time.61 16.37 Naomi Li’s understanding was that Nadia Choucair had spoken on the telephone to someone outside the building who had told her to get out. Naomi Li did not recall Bassem Choukair telling her that they had been advised by the emergency services to leave.62 The Choucair family accepted that Naomi Li and Lydia Liao were going to remain and left the flat with wet towels over their heads.63 57 Ragab first witness statement [IWS00000475] p. 3. 58 Ragab first witness statement [IWS00000475] pp. 2-3. 59 [LFB00000366] p. 7. 60 [LFB00000376] p. 4; ORR v 0.7 [LFB00032988] p. 225. 61 Li first witness statement [IWS00000515] p. 7; Li Day 62/192/18-22. 62 Li Day 62/183/15-23. 63 Li Day 62/182/17-62/186/24; Li first witness statement [IWS00000515] p. 7.

The Grenfell Tower Inquiry: Phase 1 Report 372 16.38 As they left, Naomi Li saw a lot of smoke enter the flat through the open door and enter the hallway. She and Lydia Liao tried to tape up the gap around the door to the living room where they were sheltering.64 Naomi Li said that, from the moment that the family had tried to leave, the smoke in the flat “felt toxic and spiky as if there was a lot of stuff going into your nose”.65 16.39 Naomi Li called 999 at 02.51.09 and spoke to CRO Sarah Russell.66 The call lasted 5 minutes and 32 seconds finishing at 02.56.41.67 Naomi Li asked for advice about what they should do and said it was smoky everywhere. CRO Russell told her, “You can do one of two things. You can either make your way into a room and shut the door, keep the smoke out, and stay low, or you can try and make your way out of the building. You have to decide which is safer. Okay?”68 Naomi Li did not feel able at that point to decide which option was the safer.69 16.40 When Naomi Li asked again for advice, CRO Russell said that her “best bet” was to get out. CRO Russell said that there was a lot of smoke coming in and it was dangerous. In oral evidence, Naomi Li said that she had not understood CRO Russell’s advice.70 16.41 While that call was in progress the Choucair family had returned to Flat 193. It is possible to time their return by reference to a 999 call answered by CRO Peter Duddy at 02.55.59. Lydia Liao confirmed in evidence that she was one of the two people who spoke to CRO Duddy on that call. The other was, she thought, Nadia Choucair. CRO Duddy’s advice was that all those in Flat 193 needed to leave and get to the stairwell, because it was their only chance of survival. Lydia Liao said that the smoke was now so heavy that those in the flat could not see each other. The fire was in the next room. She explained that the fire was outside Flat 193. She was walking around the living room and had seen the fire outside either from a window facing west or one facing south.71 16.42 Naomi Li’s recollection was that the family from Flat 192 had reached Flat 193 after her call to CRO Russell had ended. She had heard knocking on the door and had seen Nura Jemal and her daughter in Flat 193. She had not seen Hashim Kedir or the other children, but at that point the amount of smoke coming through the front door had made it difficult to see.72 Flat 194 16.43 Between 02.24 and 02.49, Anthony Disson had made three 999 calls,73 in which he had repeatedly asked for someone to come to the flat. In the first, timed at 02.24.35, he threatened to jump out of the window. In the last, he told CRO Adams that he could see flames coming out of the “top of the roof” and down his flat. 16.44 Anthony Disson also spoke to his family while he was still in Flat 194. He told his wife, Cordelia Disson, that he was going to jump out of the window and that the lights in the flat had gone out. While he was on the telephone he heard knocking at the front door. He thought it was firefighters. He kept the line open while he answered the door. Cordelia Disson was able to hear a man ask Anthony Disson by name to help him and a baby crying in the background. 64 Li Day 62/185/13-62/192/2; Li first witness statement [IWS00000515] p. 8. 65 Li first witness statement [IWS00000515] p. 11; Li Day 62/202/1-25. 66 [LFB00000386]. 67 LFB “Operational Response to Grenfell Tower” (v 7, 7 February 2019) [LFB00032988] p. 240. 68 [LFB00000386] p. 3. 69 Li Day 62/192/23-62/193/15. 70 Li Day 62/193/16-62/194/12. 71 [LFB00000389]; Liao second witness statement [IWS00001191] pp. 1-2; Liao Exhibit LL/6 [IWS00000503] p. 2. 72 Li Day 62/199/9-62/201/23; Li first witness statement [IWS00000515] p. 8. 73 [LFB00000352] p. 3.; [LFB00000695]; [LFB00000381] p. 3.

Part II | Chapter 16: Period 7: 02.50-03.00 373 Anthony Disson told the man “I can’t help myself”.74 Cordelia Disson did not hear the man again. She described Anthony Disson as becoming more desperate from that point. He told her that he could now see flames at the window. 16.45 Given what Anthony Disson had said in his 999 call at 02.49 and the evidence of Naomi Li about the time at which the Choucair family tried to leave, it is likely that the person who knocked at the door of Flat 194 was Bassem Choukair. 16.46 Shortly after his 999 call at 02.49, Anthony Disson was advised again to leave the building. At 02.51 CRO Angie Gotts called him using a number provided by Surrey FRS.75 He told her that the flames were coming from next door. He was advised to cover himself with wet towels and get out. Anthony Disson said that he was 67 years old. When CRO Gotts asked if a neighbour could help him, he said there was no one there and ended the call. Flat 192 16.47 By 02.51, the fire and rescue services had received a number of 999 calls from Flat 192. In two calls, timed at 02.03.4776 and 02.18.06,77 CROs were told that the fire had entered the kitchen of Flat 192. At 02.31.23, an MPS operator called and spoke to Nura Jemal, who reported that the fire had reached a bedroom.78 16.48 At 02.34.16, CRO Howson answered another 999 call from Flat 192.79 She was told that there were two adults and three children in the flat, that the fire was in the living room and that the family were being affected by the conditions. CRO Howson advised that the family needed to leave and make their way down. She said she would alert the firefighters, who would try to meet them. 16.49 At 02.45.22, CRO Fox took a further call from Flat 192. It is clear that the family had tried unsuccessfully to leave. CRO Fox said again that they needed to leave and that firefighters were on different floors.80 16.50 Hashim Kedir and Nura Jemal and their family were still in Flat 192 at 02.53.17 when CRO Pam Jones told them that they needed to leave. The caller told CRO Jones “We are in 192 Grenfell Tower”. CRO Jones advised the caller to try to leave. On that occasion the call lasted for 2 minutes and 32 seconds.81 16.51 In the light of those calls and Naomi Li’s recollection, it is likely that the family went to Flat 193 shortly before 03.00. They were certainly in that flat by 03.07, because Naomi Li made another 999 call at 03.07.13, in which she told CRO Howson that there were 12 people in the flat.82 The next call from the same caller was made at 03.08.56 when the caller said they were in Flat 193.83 74 Disson first witness statement [IWS00000242] pp. 11-12. 75 LFB Control Report pp. 105-106. 76 Transcript [LFB00000339]. 77 Transcript [LFB00000345]. 78 Transcript [INQ00000276]. 79 Transcript [LFB00000363]. 80 Transcript [LFB00000378]. 81 Transcript [LFB00000385]. 82 Transcript [LFB00000404]. 83 Transcript [LFB00000406].

The Grenfell Tower Inquiry: Phase 1 Report 374 Floor 21 Flat 182 16.52 In a call that had begun at 01.38.38, CRO Jones spoke to the El Wahabi family in Flat 182 for almost an hour.84 As the call progressed, CRO Jones was told that the fire had reached the kitchen and that the family had moved into a bedroom. Towards the end of the call her advice to them changed: she told them to try to leave the flat. Later 999 calls from Flat 182 (described in Periods 6 and 7) indicated the difficulties encountered by the family in following that advice. 16.53 At 02.39.09 (Period 6), a call from Flat 182 had been put through to the LAS. The operator was told that there were five people trapped in the flat.85 At 02.43.54 (Period 6), CRO Fox was also told that there were five people trapped in Flat 182. When asked if they could leave safely, the caller said they could not.86 16.54 At 02.44.4887, the family had made another emergency call, which BT put through to the LFB. It was answered by CRO Adams at 02.46.42 (Period 6). She was also told that there were five people trapped in the flat and that there was “too much smoke”. When the call was disconnected by the LFB the line remained open to the BT operator. The call was reconnected to the LFB control room on a further three occasions during this Period: a. It was reconnected to CRO Adams at 02.51.06, who was told “We’re dying, please help me, please”. She said that the family needed to get out, but was told that they could not do so, as it was too smoky. When CRO Adams repeated the advice, she was told that they would try to leave.88 b. At 02.53.57, CRO Howson was told that the family were stuck, that they could not breathe and that the fire was inside their flat. She said that in that case they needed to leave. She was told that they had tried, but that there was black smoke in the “corridors” and that they would faint. CRO Howson’s advice was to feel their way to stairwell and get down the building. She was told that they would try to do so.89 c. At 02.57.34, BT put the call through again to the LFB. The BT operator told CRO Russell that a female was on the line but that the line had gone silent.90 16.55 During exchanges with the BT operator while waiting for the call to be connected, Abdulaziz El Wahabi is heard to say: “We could have left a long time ago, we could have but they said stay in the flat, stay in the flat. We stayed in the flat; we didn’t leave.”91 84 Transcript [LFB00055498]. 85 Transcript [INQ00000383] 86 Transcript [LFB00000374]; LFB ORR v 0.7 p. 226. 87 Transcript [COR00000376] p.5. 88 Transcript [LFB00000383]. 89 Transcript [LFB00000387]. 90 Transcript [LFB00000390]. 91 [COR00000376]; Wahabi Day 70/187/6-10.

Part II | Chapter 16: Period 7: 02.50-03.00 375 Flat 183 16.56 In the adjacent flat Marcio Gomes had also made a number of 999 calls, most recently at 02.46.58. That call had left him with the impression that he had a choice about whether to stay or leave, if possible. He thought that it was after that call that all those in Flat 183 had made a second attempt to leave. When that attempt failed he called 999 again.92 The call reached CRO Gotts at 02.55.38.93 16.57 CRO Gotts asked Marcio Gomes if he had tried to leave. He told her that they were unable to get out of the flat. He added that smoke was still coming into the flat despite his using towels to block it out and that the flat next-door was on fire. CRO Gotts asked him to confirm he felt unable to leave and then advised him to go to a window where he could get some fresh air. She said “I’ll let the firemen know, OK, to come up to you”.94 16.58 As a result of that call Marcio Gomes was left with the impression that firefighters would be coming to rescue him and his family. He felt he was still as safe as he could be in the flat and he decided that he had some time to wait. Flat 173 16.59 At 02.26.48, CRO Russell had taken a call from Khadija Saye, who was in the living room of Flat 173 with her mother.95 Smoke was coming into the flat. CRO Russell told Khadija Saye that she could either stay or leave. Khadija Saye responded that they were too high up to go out and that, when she had opened the front door, there had been a lot of smoke and she had not been able to see anything. CRO Russell then advised her to block the doors to prevent smoke coming in and to move to a different room if flames came in. She said that she would send a message to the fire crews and added, “It might take a little while, but they are on their way”. 16.60 That was the only time at which those in Flat 173 made direct contact with the emergency services. Later, Khadija Saye posted messages on Facebook and friends called the emergency services on her behalf. There were five calls between 02.50 and 03.33. They reported that Khadija Saye and her mother were trapped in Flat 173 on floor 20. On each occasion the CRO who took the call advised the caller to tell Khadija Saye to try to get out of the flat.96 16.61 The advice to leave was posted on Khadija Saye’s Facebook wall at 02.55 and 02.57. At 03.02, Khadija Saye posted that she was scared to leave.97 I return to these Facebook exchanges later. Floor 15 Flat 124 16.62 Just before 03.00, Christos Fairbairn decided to leave his flat. Opening his front door he found that the lobby was filled with thick smoke. The lights were on, but it was dim and the lobby appeared dark.98 He tried to find his way to the stairs, but ended up in the bin room. Running out of breath, he returned to his flat.99 92 Gomes Day 71(Fri)/72/12-73/8; Gomes Day 71(Fri)/77/10-79/3. 93 Transcript [LFB00000392]. 94 Transcript [LFB00000392] p. 3. 95 Transcript [LFB00000355]. 96 Call at 02.50 – Transcript [LFB00000644]; Call at 02.56 – Transcript [LFB00000553]; Call at 03.04 – Transcript [LFB00000676]; Call at 03.18 – Transcript [LFB00000571]; Call at 03.33 – Transcript [LFB00000583]. 97 Exhibit of Marion Telfer [IWS00001188] pp. 3-21. 98 Fairbairn first witness statement [IWS00001025] p. 3. 99 Fairbairn first witness statement [IWS00001025] p. 3.

The Grenfell Tower Inquiry: Phase 1 Report 376 16.63 Christos Fairbairn then called 999. He was connected to the LAS at 03.00.55.100 During the call he told the operator that he could not breathe. The operator told him that they would get people to him and that they were also trying to get the latest information. The operator did not tell him to leave the building. The call ended abruptly. Flat 122 16.64 In Flat 122, Rebecca Ross and her father Steven Power were in her bedroom. Suddenly she saw a cloud of black smoke, which activated the smoke alarm. She thought that the smoke had got into the flat even though she had blocked up the front door with wet towels. It spread rapidly. She and her father agreed to leave. Rebecca Ross waited while he put on his shoes and soaked two towels, one for herself and one for him. At this time she was on the telephone to her brother, who urged her to leave. She thought the call from her brother had taken place at 02.22. 16.65 As Rebecca Ross moved to the front door, she became of aware of flames coming from the next-door flat, which looked as though they were about to come through the kitchen window.101 When she opened the front door, she found the lobby filled with black smoke, so that it was impossible to see. The smoke drifted into the flat. It made her eyes sting and smelled like burnt pork. Steven Power was still in his bedroom when she left the flat. She was still on the telephone to her brother and had to feel her way to the stairwell door and push it open.102 16.66 Having made her way down two or three floors, Rebecca Ross began to lose consciousness. Firefighters helped her down the stairs. Realising that her father was not behind her, Rebecca Ross told them that he was still in Flat 122 on floor 15.103 She left the tower at 02.53.104 Steven Power was later found in Flat 122 in his bedroom with his dogs close to him.105 Floor 12 Flat 94 16.67 In Flat 94 Ethiopia Assefa could see smoke coming into the living room from the hallway in the flat. It made her lungs feel tight; they were burning from the smoke and her eyes were watering.106 Alemishet Demissie and Ethiopia Assefa also noticed the wooden floor turning black with the smoke.107 Ethiopia Assefa could feel the heat through her shoes.108 16.68 Alemishet Demissie made another 999 call at 02.58.44109 and reached CRO Duddy for a second time. He repeated his advice that they should leave the flat. She told CRO Duddy that they could not leave; there was smoke coming into the flat and they could not see where they 100 Transcript [INQ00000384]. 101 Ross first witness statement [IWS00001036] pp. 12-13. 102 Ross first witness statement [IWS00001036] pp. 13-14. 103 Ross first witness statement [IWS00001036] p. 15. 104 Annex A. 105 Ross first witness statement [IWS00001036] p. 21. 106 Assefa first witness statement [IWS00000891] p. 8. 107 Demissie Day 65/32/9-65/34/2; Assefa first witness statement [IWS00000891] p. 10. 108 Assefa first witness statement [IWS00000891] p. 10. 109 Transcript [LFB00000680].

Part II | Chapter 16: Period 7: 02.50-03.00 377 were going. Both she and Ethiopia Assefa were resigned to not being able to leave.110 Shortly after that call had ended, however, they heard knocking and FFs Aston-O’Donovan and Green entered the flat and helped them to leave.111 16.69 At 03.05.27, a call from Alemishet Demissie’s telephone was connected to an MPS operator,112 but the caller did not respond. It is likely that that call took place as Alemishet Demissie and Ethiopia Assefa were leaving Flat 94 or going down the stairs. Ethiopia Assefa left the tower at 03.07; Alemishet Demissie left at 03.10. Flat 92 16.70 Karen Aboud’s elder son called 999 and spoke to CRO Howson at 02.50.48.113 He told her that the fire was on the window and coming in. CRO Howson told them to leave using the stairs. 16.71 A few minutes later at 02.57.59 Karen Aboud’s son spoke to CRO Adams again.114 She told him they must leave, but he said they could not; they had tried to run out, but there had been smoke in the lobby and the stairwell. CRO Adams kept trying to encourage them to leave.115 16.72 Karen Aboud thought that it had been around 03.00 when, looking out from her kitchen window, she had seen flames lower down the building. There was a lot of smoke coming into the flat under the front door.116 Floor 11 Flat 83 16.73 Meanwhile, in Flat 83 Elpidio Bonifacio was waiting for assistance from the firefighters. His daughter-in-law (Donna Bonifacio) had called to tell him that firefighters would be coming to get him.117 She first called 999 at 02.58,118 telling CRO Russell that he was blind and disabled and unable to leave without assistance. She said she had been in contact with him and that he had told her the flat was now very smoky. The smoke alarm was sounding. CRO Russell said that he should leave if he could; if not he should remain in the flat and the crews would be informed of his location.119 Floor 10 Flat 74 16.74 Despite their best efforts, Lina Hamide and Meron Woldeselassie Araya had not been able to stop smoke coming round the door of Flat 74. By around 03.00, and because of the amount of smoke in the flat, they had retreated to the bathroom and blocked the door with wet towels. 110 Assefa first witness statement [IWS00000891] p. 10; Demissie Day 65/28/15-29/24; Demissie first witness statement [IWS00000860] p. 5. 111 Aston-O’Donovan Day 32/7/18; Aston-O’Donovan first witness statement [MET00008002] pp. 5-6; Exhibit of Aston-O’Donovan MAD/2 [MET00013035]; Green first witness statement [MET000083297] p. 11. 112 Transcript [INQ00000281]. 113 Transcript [LFB00000673]. 114 Transcript [LFB00000391]. 115 Transcript [LFB00000391]. 116 Aboud first witness statement [IWS00000130] p. 8. 117 Bonifacio first witness statement [IWS00001085] p. 5. 118 Transcript [LFB00000559]. 119 Transcript [LFB00000559].

The Grenfell Tower Inquiry: Phase 1 Report 378 Despite friends and family advising them to leave, they considered that there was too much smoke to do so.120 Flat 72 16.75 On the same floor, at around 02.30 Antonio Roncolato saw smoke coming into his living room through gaps around the closed window. 16.76 A photo taken in his bedroom between 02.30 to 03.00 shows the conditions at the time. Figure 16.7 16.77 By opening windows and putting down wet towels and sheets, he was able to stop the smoke collecting in his flat.121 120 Hamide first witness statement [IWS00001175] pp. 5-6. 121 Roncolato Day 52/51/3-52/52/12.

Part II | Chapter 16: Period 7: 02.50-03.00 379 4 Events in the control room 16.78 During this time period, the control room took 26 emergency calls; twelve of those calls were from those trapped in the building and nine calls came from friends and family calling on behalf of trapped residents.122 The control room also took two calls from other fire and rescue services passing on details of trapped residents. 16.79 At 02.51.00, Essex FRS control room received a call from Paulos Tekle in Flat 153 on floor 18 who reported that the fire was all over the flat, which was full of smoke.123 CRO Russ White answered the call and told him to block out the smoke, to try to get some fresh air, or to leave the building if it was safe to do so. By that point, Essex FRS control room had received a message from GM Dilley, which had been logged in their incident log at 02.40.00, that the LFB was advising residents to “make their way to a fire exit, if safe to do so”. However, they had not yet received that message from the LFB control room.124 CRO White called the LFB control room at 02.52.51 and spoke to CRO Adams.125 She told him that they were now advising everyone to leave the building and that the callers should be told to cover themselves with wet towels and get themselves out. She told CRO White “I think it’s spreading through the building. It started on the fourth” and that if they received any more calls, they should tell the callers to leave.126 After their conversation CRO White added a note to the Essex FRS incident log at 02.56.00 recording what CRO Adams had told him.127 16.80 At 02.54.00 CRO White called Paulos Tekle and left a message on his voicemail telling him to make every possible effort to get out of the building and go to his nearest fire exit. He said that firefighters were in attendance dealing with the fire, but that he and his family should cover themselves with wet towels and make their way to the fire exit as soon as possible.128 He repeated that advice when Paulos Tekle called Essex FRS control room again at 02.56.00.129 16.81 At 02.51.09, CRO Russell received a call from Naomi Li in Flat 193 on floor 22.130 Naomi Li had previously called the LFB at 01.30.38. By the time she made the call she and Lydia Liao were in the same flat as the Choucair family.131 Naomi Li told her that it was “very smoky” in the room and outside. CRO Russell gave her the following advice:132 “Okay, listen. You can do one of two things. You can either make your way into a room and shut the door, keep the smoke out, and stay low, or you can try and make your way out of the building. You have to decide which is safer.” 16.82 Naomi Li asked for her advice and CRO Russell told her to wet blankets and towels, to cover everyone in the flat with them and to try to leave the building. She said: “There’s a lot of people inside and the firefighters are struggling to get to everyone, okay, so your best bet is to try and make your way out of the building.”133 She repeated the advice, but the line cleared. 122 Control Report pp. 102-112. This does not include call backs. 123 Transcript [LFB00000691]. 124 Essex FRS incident log LFB00003625 p. 2. 125 Transcript [LFB00000546]. 126 Transcript [LFB00000546] p. 3. 127 Essex FRS incident log [LFB00003625] pp. 1-2. 128 Transcript [LFB00000692]. White witness statement [MET00012847] p. 4. 129 Transcript [LFB00000380]. White witness statement [MET00012847] p. 5. The reference for the time is incorrect on the transcript. It has been taken from White’s witness statement. 130 Transcript [LFB00000386]. 131 The Kedir family were still in Flat 192 at this time. 132 Transcript [LFB00000386] p. 3. 133 Transcript [LFB00000386] pp. 7-8.

The Grenfell Tower Inquiry: Phase 1 Report 380 16.83 At 02.51.22, AOM Real contacted the Health and Safety Executive to report a Major Incident involving a 40-pump fire. She told them that the current advice being given by the LFB to residents was to leave the building.134 16.84 At 02.55.38, CRO Gotts received a call from Marcio Gomes in Flat 183 on floor 21.135 She advised him to try to leave, but he explained that they could not get out. She advised him to block out the smoke and to try to get some fresh air. She noted that there were three children, three adults and one heavily pregnant woman in the flat and told him that she would let the firefighters know that they were there. CRO Gotts did not create a service request in relation to that message, but passed it to CRO Darby on a piece of paper. CRO Darby sent it by radio to CU7 at 02.58.01.136 The information was also entered on the whiteboard.137 16.85 At 02.57.32, CRO Samson in the Kent FRS control room received a call from Ann Chance, who was trapped in Flat 73 on floor 10 with Adam, Chalalai and Waewta Supareogsanond.138 The call lasted over 90 minutes. Kent FRS had not yet been told about the change in the “stay put” advice and so, at first, CRO Samson told them to remain in their flat.139 Kent FRS were first told about the change of advice when a colleague of CRO Samson relayed the information about the call from Flat 73 to CRO Gotts in the LFB control room at 02.59.04.140 CRO Gotts asked if Kent FRS were still speaking to the caller. When she was told that they were, she told them of the new advice, saying that the best thing for them to do would be to get wet towels over their heads and try to get out.141 After Kent FRS had spoken to the LFB, CRO Samson told Ann Chance that they had passed on her details to the fire crews at the scene so they knew where she was. He did not advise her to leave.142 16.86 At that point, Ann Chance told CRO Samson that her brother was speaking to the LFB, who were advising him to get out and that she did not understand why CRO Samson was telling her to stay put. He said that his priority was to keep her as safe as possible. If the stairs were clear, she could leave, but if not, she should stay put and the crews would be making efforts to reach her.143 However, he told her that if the LFB was giving different advice to her brother, she should follow it.144 When she told CRO Samson that she understood that no one was coming to get them, he said “that’s not necessarily the case… They’ll be getting to you”.145 During the call she and her family attempted to leave but found that they were unable to do so. CRO Samson continued to provide FSG advice until they were rescued.146 16.87 At around 02.57.00, DAC Fenton received a call on his mobile from ORT Officer SM (now GM) Michael Mulholland, who told him that the stairwell at Grenfell Tower had been compromised with smoke. He asked for Positive Pressure Ventilation (PPV) fans to be brought to the incident, together with a Specialist Entry Recovery Team (SERT) Operator, to operate them. (PPV fans are used to clear smoke-filled environments.)147 Although DAC Fenton thought that he had received the request later in the incident, it is more likely that it was made at this time 134 Control Report p. 106. 135 Transcript [LFB00000392]. 136 Radio message [LFB00002017]. 137 Whiteboard [MET00016906]. 138 The call runs over two transcripts [LFB00055505] and [LFB00055502]. 139 Transcript [LFB00055505] pp. 3-8. 140 Transcript [LFB00000664]. 141 Transcript [LFB00000664] p. 2. 142 Transcript [LFB00055505] pp. 12-15. 143 Transcript [LFB00055505] pp. 16-17. 144 Transcript [LFB00055505] pp. 20-22. 145 Transcript [LFB00055505] p. 24. 146 Transcript [LFB00055505] pp. 22-74. 147 Fenton witness statement [MET000080569] p. 9.

Part II | Chapter 16: Period 7: 02.50-03.00 381 because the Roe Log recorded that the PPV fans were requested at 02.57 and 03.07.36. AOM May added a ‘turning out’ message to the incident log recording the request.148 SM Nicholas Harding, the SERT Operator, was mobilised to attend the incident at 03.35.32, which CRO Howson noted in the incident log at 03.36.06.149 DAC Fenton authorised WM Gary Wilson to be released from the Brigade Coordination Centre to collect the PPV fans from the LFB’s headquarters and deliver them to the incident.150 16.88 At 02.57.59, CRO Adams took another call from Karen Aboud’s son in Flat 92 on floor 12.151 He explained that the fire was getting worse, that they had tried to leave the flat, but that they could not get out because the smoke was too bad. She advised him repeatedly that he needed to try to run through the smoke and he asked what they should do if they could not leave. She told him that he had to try to leave, but it would have to be his decision about what the safest course was. She told him that they could not guarantee that the crews could get to him because they had so many people trapped in the building. She told him to be brave and get through the smoke. 16.89 At 02.58.01, CRO Darby passed on the information about Flat 183 on floor 21. That was the last FSG message that she sent by radio until she made contact again at 07.51.36 to ask about the rescue of Elpidio Bonifacio.152 16.90 At 02.58.52, CRO Russell took the first call about Elpidio Bonifacio, who was trapped in Flat 83 on floor 11. The caller was his daughter-in-law, Donna Bonifacio, who had been speaking to him by telephone. She called the control room three more times to provide current information and to seek advice. In the first call she explained that he was blind and disabled and “absolutely frantic”. She said that she had told him to block out the smoke and open the windows.153 CRO Russell told her that the firefighter were making their way up floor by floor searching for people, and going to the flats to which they had been directed.154 However, she advised that “if there’s any chance he can leave, that is the best thing, but if not stay put”.155 The information was added to the right-hand whiteboard.156 Ordering SDBA and EDBA: Periods 7 to 11 16.91 Although this section of the narrative is intended to be limited to the period between 02.50 and 03.00, it is convenient at this point to describe in one place the steps taken by the control room between 02.50 and 05.00 to ensure that there were a sufficient number of SDBA and EDBA wearers available to enable operations on the incident ground to be carried on without interruption. 16.92 At 02.51.38, CU8 sent a request by radio for two BA support units to be sent to the leisure centre.157 CRO Darby entered a “make-up” message in the incident log at 02.52.32.158 At 03.00.05, she asked whether the BA supports units were to be EDBA or SDBA and at 03.00.18 CU8 confirmed that both were required.159 148 Roe Log p. 1. SIL p. 24. 149 End of incident report p. 341. Harding witness statement [MET00012550]. 150 Fenton witness statement [MET000080569] p. 9. 151 Transcript [LFB00000391]. 152 Radio message [LFB00002017]. 153 Transcript [LFB00000559] pp. 2-3. 154 Transcript [LFB00000559] p. 6. 155 Transcript [LFB00000559] p. 6. 156 Whiteboard [MET00016906]. 157 Radio messages [LFB00002658], [LFB00002521], [LFB00002418]. 158 SIL p. 23. 159 Radio messages [LFB00002658], [LFB00002807] and [LFB00002835].

The Grenfell Tower Inquiry: Phase 1 Report 382 16.93 At 03.05.51, AOM May created the necessary service request, which CRO Darby relayed to CU8 at 03.11.50.160 16.94 Despite the message sent at 03.11.50 it appears that no appliances or units carrying BA equipment were assigned to the incident at that time. The only appliances that appear to have been ordered were two operational support units at 03.11.14 and 03.30.44 respectively, which carried only bottled water, another utility unit at 03.15.41 and a portable hygiene unit at 03.46.48. Unfortunately, AOM May was not able to attend in person to give evidence, but in his contemporaneous note he wrote the following:161 “0253 – 0438  I liaised with both Duty REPLO Geoff Avis and members of the BCC regarding the request for BA support units. I was told that these are no longer in brigade. However, there were already 2 x OSU’s in attendance with that also have the BAU attribute and a third was ordered shortly after the request. The duty REPLO was confident he had put in place the necessary resources to meet the requirement. We discussed the sourcing and ordering of all spare EDBA sets in the Brigade. I also spoke to CU8 on the radio to check if SDBA was also required as there had been confusion that they required both. I also had conversations … regarding EBDA.” 16.95 At 03.52.58, CU8 asked the control room if there was an estimated time of arrival for the EDBA cylinders. At 03.53.15, CRO Darby sent a message saying that they could try to get an estimated time of arrival and that “…the E-D-B-A, er, was gonna be an hour when I last passed you”.162 At 03.55.00, AOM May received a message from the BCC to “Mobilise all FRUs for EDBA”.163 Between 03.55.39 and 03.59.48, he mobilised four FRUs: E286, H316, F446 and A346.164 16.96 At 03.58.00, Commissioner Cotton decided to direct all EDBA resources to attend the incident ground.165 As a result, someone (it is not clear who) passed that message to DAC Fenton and at 04.00, AOM May was sent a message from the BCC instructing him to mobilise all OSU’s to attend with EDBA sets. He mobilised two operational support units (E29A and H38A) at 04.03.01 and 04.03.30 respectively and logged the message in the incident log at 04.03.01. 166 16.97 At 04.03.58, CU8 confirmed that the rendezvous point for the EDBA mobilisation was Ladbroke Grove on the junction with Elgin Avenue, but at 04.13.32, AOM May was informed by radio that 78 EDBA cylinders and 48 sets were in attendance at the incident, although not at the designated rendezvous point.167 It is unclear which units were in attendance when that message was sent, as none of the FRUs (only three of which booked status 3 times) arrived before 04.25.31 and the OSUs did not arrive until 04.45.25 and 04.50.49 respectively.168 16.98 At 04.13.47, CU8 sent a message that the rendezvous point was Elgin Crescent169 and at 04.18.56 CRO Darby entered another informative message in the incident log to confirm the position.170 160 SIL p. 24; Radio message [LFB00003021]. 161 May [MET00015882] p. 2. 162 Radio messages [LFB00002374]; [LFB00002432]. 163 May [MET00015882] p. 3; SIL pp. 9-10. 164 SIL p. 10; May [MET00015882] p. 3. 165 Roe Log p. 2; AC Roe record of actions [MET00005405] pp. 5-6. 166 SIL p. 10, p. 26. 167 SIL p. 27; Radio messages [LFB00002948], [LFB00002988], [LFB00002414]. 168 SIL p. 10. 169 Transcript [LFB00002800]. 170 SIL p. 27.

Part II | Chapter 16: Period 7: 02.50-03.00 383 16.99 At around 04.38.01,171 AOM May in the control room sent a message to CU8172 telling it that 60 EDBA cylinders were already on their way, that a further 36 would be collected from another depot at Park Royal and that another 51 were available at Barking, but that no means of transport were currently available. 16.100 The OSUs that had been ordered arrived at 04.45.25 and 04.50.49.173 5 Actions of the MPS, the LAS, RBKC and the TMO 16.101 At 02.54, Inspector Thatcher instructed PC Alice Jacobs, a very junior constable, to act as a link between the MPS and the LFB at the scene.174 In that role she was required to collect information about where residents were trapped in the building and relay it to the LFB in CU8 (the main command unit on Bomore Road).175 Between 02.54 and 03.20 she then moved to CU7 (the FSG command unit) on Grenfell Road. She said that she had passed messages about flats, floors and number of persons trapped to the officers on CU7 and had also been in contact by radio with the NPAS helicopter, which had given her information about the whereabouts of any residents the crew could identify. She had passed that information to the LFB.176 Inspector Thatcher was unaware that she had been passing on those messages until he discovered that she had moved to CU7 and that PC Neave, a more senior constable, was with her.177 He had joined her of his own volition at around 03.30178 and had undertaken the same task of passing to the LFB FSG messages that he had received from families and friends at the cordon.179 16.102 At 02.56 there was a discussion between Inspector Thatcher and Detective Superintendent Warnett about whether the latter, as Gold Commander, should go to the special operations room at Lambeth. They decided, however, that he should stay at the incident since they could not afford to be without a Gold Commander for the time it would take to travel there, and because in any event Commander Jerome was on his way to Lambeth.180 171 There is no radio message to this effect and therefore the exact time when this was sent is unknown, but the message was entered on the SIL at this time. It is also unclear how this message was sent to CU8. 172 SIL p. 31. 173 SIL p. 10. 174 Refer to Inspector Thatcher’s body-worn video footage [INQ00000525] at 02.54.25 to 02.54.59. 175 Jacobs witness statement [MET00012699] p. 3. 176 Jacobs witness statement [MET00012699] p. 3. 177 Thatcher Day 71(Mon)/106/10-14; 110/23-111/3. 178 Thatcher Day 71(Mon)/114/8-15. 179 Neave witness statement [MET00023633] pp. 5-6. Thatcher second witness statement [MET00023284] p. 9. 180 Thatcher second witness statement [MET00023284] p. 3.

The Grenfell Tower Inquiry: Phase 1 Report 384

385 Chapter 17 Period 8: 03.00-03.30 1 External fire spread The west face 17.1 By 03.03 the furthest extent of horizontal flame spread on the west face was at the base of the architectural crown and there were flames across the full height of the crown. The flame front was moving horizontally across the west face, from north to south.1 The image on the left below was taken at 03.03. (The image of the tower on the right helps to illustrate the location of the flame front at that time):2 Figure 17.1 17.2 By 03.08 to 03.09 a number of additional “Flat 5s” located at the north-west corner had become involved in the fire. In particular, as the fire moved diagonally down the north and west faces, Flats 15, 25, 35, 45, 55, 65 and 75 on floors 4 to 11 had become affected by the external fire front. By about the same time Flat 9 on floor 3 at the north-west corner of the tower had also been affected by fire.3 1 Professor Bisby supplemental report [LBYS0000001] p. 221 sections 1038-1040. 2 Professor Bisby supplemental report [LBYS0000001] p. 223 Fig. 139. 3 Dr Lane supplemental report [BLAS0000012] p. 11 Fig. 12.4.

The Grenfell Tower Inquiry: Phase 1 Report 386 17.3 By 03.12 there were flames at the edge and at the very top of column B1 (the internal column to the north side of the west face), as can be seen in this image taken at that time:4 Image showing burning at the top of column B1 Figure 17.2 4 Professor Bisby supplemental report [LBYS0000001] p. 221 section 1042 and p. 224 Fig. 140.

Part II | Chapter 17: Period 8: 03.00-03.30 387 17.4 There was also downward spread of flame along the corner and at the tip of column B1 on the west face. Burning debris falling and landing on surfaces below the windows caused fires to break out on previously uninvolved external areas, as can be seen in the following two images taken at 03.28 and 03.27 respectively:5 Figure 17.3 Figure 17.4 5 Professor Bisby supplemental report [LBYS0000001] p. 191 Figs 112 and 113; video of the west face at [LBYS0000005].

The Grenfell Tower Inquiry: Phase 1 Report 388 17.5 By 03.27 on the west face of the tower the flames had spread furthest horizontally at the base of the crown, but above the flame front there was a small section of the crown which had not yet become involved in the fire. This thermal image was taken by the NPAS helicopter at that time:6 Figure 17.5 The south face 17.6 At 03.15, the fire front stretched diagonally across the south face of the building, moving east to west. Dripping, burning material continued to fall from the building.7 At 03.18 it was clear that the furthest horizontal spread was at the crown. The flames extended to the full height of the crown, with burning below and behind it on the east side of the flame front.8 The same horizontal pattern of flame spread could also be seen at 03.26, with similar burning patterns at and behind the crown. These three images were taken at 03.15, 03.18 and 03.26:9 6 Professor Bisby supplemental report [LBYS0000001] p. 221 sections 1044-1046 and p. 225 Fig. 142 (NB. The time from the figure of 03.27 has been used). 7 Professor Bisby supplemental report [LBYS0000001] p. 229 sections 1070-1072 and p. 233 Fig. 153. 8 Professor Bisby supplemental report [LBYS0000001] p. 229 sections 1073-1075. 9 Professor Bisby supplemental report [LBYS0000001] p. 233 Figs. 153, 154, 155.

Part II | Chapter 17: Period 8: 03.00-03.30 389 Figure 17.6

The Grenfell Tower Inquiry: Phase 1 Report 390 Figure 17.7

Part II | Chapter 17: Period 8: 03.00-03.30 391 Figure 17.8 17.7 By 03.20 to 03.21 Flats 51 and 61 on floors 8 and 9 in the centre of the east face had become affected by the external flame front. In addition, some of the “Flat 4s”, in particular Flats 184, 194 and 204 in the centre of the west face on floors 21 to 23, had become affected by the fire for the first time.10 2 Events on the incident ground Request for SDBA and EDBA 17.8 At 03.11.50 the control room notified CU8 that a Respiratory Protective Equipment (RPE) Unit with SDBA sets was expected to arrive within 30 minutes and another carrying EDBA sets was due to arrive within an hour.11 That was in response to the request from CU8 at 02.51.54 for BA support units, as set out in Period 7. Commissioner Dany Cotton enters the tower 17.9 At 03.02 Commissioner Cotton entered the ground floor lobby of the tower with AC Andrew Roe. While AC Roe addressed the waiting firefighters, the Commissioner was briefed by GMs Matt Cook and Michael Mulholland, both members of the ORT.12 10 Dr Lane supplemental report [BLAS0000012] p. 11 Fig. 12.4. 11 ORR v 0.7, p. 279. 12 ORR v 0.7, p. 263.

The Grenfell Tower Inquiry: Phase 1 Report 392 Request for an additional Deputy Assistant Commissioner 17.10 At 03.08.30, following AC Roe’s request that DAC Lee Drawbridge attend the scene to act as his Sector Commander Command Support,13 CU8 sent an assistance message to the control room requesting the attendance of an additional Deputy Assistant Commissioner.14 Relocation of the bridgehead 17.11 At around 03.08 the bridgehead was moved to the ground floor.15 FF Alex De St Aubin moved the ECB to the wall next to the community room door.16 At around 03.13 four more ECBs were brought down to the ground floor.17 SM Peter Wolfenden starts his FSG role 17.12 Having arrived at the incident nearly an hour earlier, as addressed in Period 5, SM Wolfenden went onto CU7 some time after 03.00.18 GM Thomas Goodall asked him to go and oversee WM Glynn Williams and WM Paul Watson who were “co-ordinating the FSGs” in the ground floor lobby.19 SM Wolfenden then left CU7. CCTV images show him in the ground floor lobby with WM Williams at 03.23.20 Firefighter activity in, or near, the tower (c. 03.00-03.10) 17.13 The following are examples of what firefighters were doing in the tower during the period between around 03.00 and around 03.10: a. WM Brien O’Keeffe instructed WM Peter Clark and WM Alexander Cardy and FF Enrico Beltrami to go to floor 9 to conduct search and rescue operations.21 They tallied out at 03.01.13, 03.02.38 and 03.02.42. b. WM Marc Aston-O’Donovan (who had tallied out at 02.56.50 as part of an earlier deployment) recalled that as they had gone up the stairs from the bridgehead, visibility and air quality had been all right until the crew reached floor 5, which had been heavily smoke-logged.22 As they went up, the crew had wiped soot from the walls to see any numbering that might indicate which floors they were passing. WM Aston-O’Donovan recalled a scene of “organised chaos”, with the stairs being used mainly by firefighters.23 CM Martin Hoare (who had tallied out at 02.55.05) said that floor 5 had been clear, but that by floor 7 he had been able to see nothing at all.24 Conditions on floors 9 to 11 had been the same: no visibility and smoke so dense that it was irrelevant whether lighting in the stairwell worked or not.25 13 AC Roe record of actions [MET00005405] p. 4. That was reported to AC Roe at a briefing at 03.39 – refer to paragraph 13 below. 14 ORR v 0.7 p. 271. 15 This time is taken from a photograph of the floor 3 bridgehead wall taken by SM Cook as the bridgehead was being relocated to the ground floor: [MET00015779] p. 16. 16 CCTV Camera 4; ORR v 0.7 p. 276. 17 CCTV Camera 2; ORR v 0.7 p. 280. 18 Wolfenden Day 40/152/21-24. 19 Wolfenden Day 153/13-24. 20 [INQ00000304]. 21 Peter Clark witness statement [MET00017071] p. 3; Cardy witness statement [MET00010085] p. 7. 22 Aston-O’Donovan witness statement [MET00008002] p. 5. 23 Aston-O’Donovan witness statement [MET00008002] p. 5. 24 Hoare witness statement [MET00008027] p. 13. 25 Hoare witness statement [MET00008027] p. 13.

Part II | Chapter 17: Period 8: 03.00-03.30 393 c. WM Aston-O’Donovan, FF Neil Green, CM Hoare and FF Matthew Tanner entered the lobby on floor 12. On being told that the missing firefighter had been located, CM Hoare and FF Tanner returned to their original brief to search Flat 74 on floor 10.26 d. WM Aston-O’Donovan and FF Green stayed on floor 12 to search each of the flats. As part of their search, they opened the door to what is now thought to have been Flat 96. The crew found the flat fully alight. They immediately closed the door and proceeded to Flat 95. While they were trying to force the entrance door, they heard shouts for help from Flat 94 where they found two women, Alemishet Demissie and Ethiopia Assefa. They told the women that it would take about 90 seconds or so to reach breathable air and explained the escape route. The women were able to escape and leave the tower.27 e. When they reached floor 10 and opened the lobby door (which they then wedged open),28 CM Hoare and FF Tanner were confronted by intense heat. CM Hoare compared it to opening an oven door.29 FF Tanner recalled that every time he had tried to kneel, he had felt an intense heat in his helmet.30 They dived to the ground where they noticed that the smoke extended down to a foot from the floor. Despite the conditions, they brought a casualty, Ali Yawar Jafari (a resident of Flat 86, floor 11), out to the stairwell.31 f. FFs Leon Whitley and Ricky Nuttall (who had tallied out at 02.44.32 and 02.45.07) thought they had reached floor 15. FF Nuttall remembered that the thermal imaging camera had registered temperatures of 550-555°C in the lobby.32 FF Whitley connected his hose to the rising main outlet, but the alarm on their BA sets sounded so they returned to the bridgehead and tallied in.33 As they descended, they noted that visibility remained poor. FF Nuttall described radio communications as “an absolute nightmare”.34 g. CM Raoul Codd and FF John Joseph tallied out between 03.03.24 and 03.05.41.35 They had been briefed by WM Louisa De Silvo to go to floor 22 following receipt of an FSG call.36 h. During this period the MPS supplied riot shields to protect firefighters from falling (and often burning) debris as they moved in and out of the tower. i. CM Craig Eden and FF Tom Welch were helping to supply water to A245 (Soho’s aerial ladder platform), which was being used to direct water on to the tower’s eastern elevation. Urgent request for a DSE 17.14 At 03.12.52, at AC Roe’s direction,37 CU8 sent a priority message to the control room asking for the attendance of a DSE, if one had not already been requested. At 03.13.11 CU8, in response to a question from the control room, emphasised that it was “a matter of real urgency”. 26 Aston-O’Donovan witness statement [MET00008002] p. 6. 27 Aston-O’Donovan witness statement [MET00008002] pp. 6-7. 28 Hoare witness statement [MET00008027] p. 15. 29 Hoare witness statement [MET00008027] p. 15; Tanner witness statement [MET00010826] p. 7. 30 Tanner witness statement [MET00010826] p. 8. 31 Hoare witness statement [MET00008027] p. 16. 32 Nuttall witness statement [MET00012561] p. 11. 33 Nuttall witness statement [MET00012561] p. 11. 34 Nuttall witness statement [MET00012561] p. 10. 35 [LFB00023326] p. 2. 36 Codd witness statement [MET00012539] p. 4. 37 ORR v 0.7 p. 280. AC Roe times the message as being sent at 03.15 in his Record of Actions and his witness statement: Record of Actions [MET00005405] p. 4; Roe witness statement [MET00007520] p. 6.

The Grenfell Tower Inquiry: Phase 1 Report 394 Relocation of the entry control boards 17.15 At 03.17 or thereabouts, due to smoke-logging in the main lobby, the entry control boards were moved to the base of the stairs by a green wall. By 03.26 four entry control boards were operating in the stair lobby at the bottom of the stairs.38 First Tactical Co-ordination Group meeting (03.20 – 03.32) 17.16 The Roe Log records that at 03.20 AC Roe chaired the first Tactical Co-ordination Group (TCG) meeting.39 It was attended by representatives of the other emergency services (Detective Superintendent Paul Warnett and Inspector Nicholas Thatcher from the MPS, Geoff Long and Laurence Ioannou from the LAS) and by Nickolas Layton, RBKC’s LALO. 17.17 AC Roe briefed the meeting. There were a large number of people unaccounted for and some 100 people were believed to be trapped in the tower. At that stage it was understood that three people had died. The LAS confirmed details of the casualty handling arrangements at the Kensington Leisure Centre and Nickolas Layton reported that RBKC were making arrangements for setting up places to which residents could go. 17.18 AC Roe’s main priority at the meeting was to ensure that the MPS had set up an effective security cordon to manage what he considered to be a deterioration in public order. If that were done, he could concentrate on the very high-risk rescue operation, pushing crews up into the tower as high as he could.40 AC Roe’s recollection was that with that aim in mind he had asked Nickolas Layton for plans of the tower. I return to that subject later in this Period. 17.19 At the conclusion of the meeting AC Roe made three points: first, that the first priority was the saving of life over and above any effort to save the building itself; secondly, that there might come a point at which the building would no longer be sufficiently safe for him to commit crews into it; and, thirdly, those who called the control room seeking advice were being told to leave their flats, if it was safe to do so. The meeting ended at 03.32 with a second meeting fixed for 04.32. Firefighter activity in the tower (c. 03.10-03.30) 17.20 The following are examples of what firefighters were doing in the tower during the period between around 03.10 and around 03.30: a. WM Peter Clark’s crew reached floor 9. They entered the lobby on their knees. FF Enrico Beltrami tried to enter the first flat on the left-hand side using an enforcer. Each member of the crew remembered intense heat and very limited visibility in the lobby.41 At one point, their TIC recorded 1,080°C.42 They were unable to open the door of the flat, so WM Cardy returned to the stairwell to find a halligan bar. The visibility was very poor. As he was searching for the halligan bar on the floor he saw the legs of a child standing by the door to the stairs.43 The crew found two children (Karen Aboud’s two sons from Flat 38 ORR v 0.7, p. 299. 39 [MET00005404] p. 1; Roe witness statement [MET00007520] p. 6. 40 [MET00005405] p. 2. 41 Cardy witness statement [MET00010085] p. 8. 42 Beltrami witness statement [MET00008004] p. 8. 43 Cardy witness statement [MET00010085] p. 9.

Part II | Chapter 17: Period 8: 03.00-03.30 395 92) and three women, Karen Aboud herself and Naomi Li and Lydia Liao from Flat 195 on floor 22.44 The crew then went down the stairs with the casualties.45 b. FFs Jon Wharnsby and Terence Lowe, who were on their way to Flat 113 on floor 14, met an adult (Rabia Yahya) and a child and led them down the stairs.46 At that stage, FF Lowe noticed that the smoke was getting thicker and people were struggling to breathe.47 The crew were unable to reach Flat 113 and they later tallied in at the bridgehead at times between 03.17 and 03.19.48 c. As CM Hoare and FF Tanner brought Ali Yawar Jafari down the stairwell, CM Hoare was running out of air. They concluded that Ali Yawar Jafari had died, so they decided to leave him on the stairs for the time being. When they returned to the bridgehead they informed BA entry control that they had not reached Flat 74, as they had found a casualty in the area of the lobby on floor 10. d. CM Jamie Mayne and FF Marcus Lundquist were in the ground floor lobby, waiting to be deployed. They were initially briefed to go to Flat 113 on floor 14, either (as CM Mayne said)49 by a senior officer in the ground floor lobby (probably either WM Williams or SM Wolfenden), or by GM Patrick Goulbourne at the bridgehead itself (as FF Lundquist said)50. FF Lundquist recalled that the briefing had been to rescue a mother and baby or small child.51 That can only have been Zainab Deen and her son Jeremiah Deen. When the crew reached the front of the queue of BA wearers at the bridgehead, they were told to go to floors 3 and 4 to fight the fire and carry out search and rescue operations.52 CM Mayne said that GM Goulbourne had changed their instructions and although GM Goulbourne did not remember having done so, CM Mayne was probably correct, since GM Goulbourne was in charge of deployments at that time. CM Mayne and FF Lundquist tallied out at 03.29.05 and 03.29.29 respectively. The evidence does not enable me to say why their instructions were changed or why no further deployment was made to Flat 113. e. While helping with the management of casualties, FF Robert Dwyer was instructed to use a covering jet on the west face of the tower. He described what looked like sandwich panels, steel channels and metal balls falling off the building.53 Because of the falling debris, he was later withdrawn. 44 Cardy witness statement [MET00010085] p. 9. WM Cardy recalled only two women, but it is likely that the three identified in the body of the text were all present, as is addressed again in section (3) of this Period. 45 Cardy witness statement [MET00010085] pp. 9-10. 46 Wharnsby witness statement [MET000083336] p. 6; Lowe contemporaneous note [MET00005246] p. 1. 47 Wharnsby witness statement [MET000083336] p. 7. 48 [LFB00023326] p. 2. 49 [MET00008033] p. 5. 50 [MET00007888] p. 7. 51 Lundquist witness statement [MET00007888] p. 7. 52 Lundquist witness statement [MET00007888] p. 7; Mayne witness statement [MET00008033] pp. 5-6. 53 Dwyer witness statement [MET00012781] p. 9.

The Grenfell Tower Inquiry: Phase 1 Report 396 3 Conditions in the tower and the movement of occupants Conditions on floor 23 Flat 205 17.21 The last telephone call between Mariem Elgwahry and her brother Ahmed Elgwahry began at 02.33 and ended at 04.27. Ahmed Elgwahry described the background sound in Flat 205 as quiet. He could not hear any smoke alarms; he could hear coughing but no screaming or shouting. Ahmed Elgwahry noticed that his sister’s coughing was increasing. He repeatedly tried to encourage her to leave but she said: “No. I can’t get out. The landing is filled with thick black smoke and I can’t see”. Ahmed Elgwahry believed that his sister had not wanted to leave because it would have meant leaving Eslah Elgwahry, their disabled mother, behind.54 17.22 Ahmed Elgwahry believed that his sister was in the kitchen. He had heard others in the background and she had told him that she was with other people. From outside, he could see that the kitchen appeared to be the last room in the flat affected by the fire. At some point, Mariem Elgwahry began to panic. She did not tell her brother why.55 17.23 What followed was very quick. The panic was brief and then she began coughing. Others in the background were also coughing. Less than a minute later Mariem Elgwahry began mumbling and then making a deep humming sound. She was able to make banging noises at her brother’s request. Soon she stopped responding altogether. Twenty or 30 seconds later, Ahmed Elgwahry heard his mother, Eslah Elgwahry, say in Arabic: “I can’t breathe, I can’t breathe”. He thought that that had been at around 03.10 to 03.15.56 He did not hear his mother or his sister again. 17.24 Five to 10 minutes later, Ahmed Elgwahry heard what he believed was the sound of glass windows breaking and fire entering the flat. He remained on the phone long after he had ceased to hear from Mariem Elgwahry and his mother. At 04.27, he ended the call.57 17.25 Shahrokh Aghlani spoke to his mother, Sakina Afrasehabi, and his aunt, Fatemeh Afrasiabi, several times after she had first called him at around 01.20 to tell him of the fire. He went to the tower and told police officers there that his mother and aunt were on floor 23. They said that they were aware of that. During his last call to his mother and aunt, Shahrokh Aghlani heard them wheezing. He then heard his aunt say: “Forgive us.” before the line was disconnected. About 50 seconds before that he heard the sound of an explosion.58 It is difficult to determine with any precision when those conversations took place. Flat 204 17.26 After speaking to Shafika Ragab, his aunt, Hesham Rahman made two more 999 calls. In the first at 03.10.34 he told CRO Sarah Russell that he was in the living room and that there was a lot of smoke coming into the flat. He had blocked the front door but the smoke was still coming in. He confirmed that there were no flames in the flat. CRO Russell advised him to leave and told him that the firefighters were not able to reach everyone. Hesham Rahman said that he could not leave, because he could not see and he could not walk properly as he 54 Elgwahry first witness statement [IWS00000988] pp. 11-12, paragraph 38. 55 Elgwahry first witness statement [IWS00000988] p. 12, paragraph 39. 56 Elgwahry first witness statement [IWS00000988] p. 12, paragraph 39. 57 Ahmed Elgwahry first witness statement [IWS00000988] p. 12, paragraph 42. 58 Shahrokh Aghlani first witness statement [IWS00001200] pp. 3-4.

Part II | Chapter 17: Period 8: 03.00-03.30 397 was disabled. He was lying on the floor with a wet cloth over his nose and the windows were shut. CRO Russell told him that she would tell the crews. She said: “I promise you they’re coming up to you, but it’s a big fire, OK? They’re gonna get there as quickly as they can”.59 17.27 Ten minutes later, at 03.20.31, Hesham Rahman spoke to CRO Yvonne Adams. He told her that the flat was now full of black smoke and that he could not see anything. The fire was coming into his flat. 17.28 A relative, who identified herself as Hesham Rahman’s daughter, had called 999 and spoken to CRO Adams at 03.16.12. When told to call him back and tell him that he needed to leave, the caller explained that Hesham Rahman could not leave because of his disabilities.60 17.29 I return to the later 999 calls relating to Hesham Rahman elsewhere. Flat 202 17.30 Marco Gottardi spoke to his father, Giannino Gottardi, for the last time at 03.15 (UK time).61 Giannino Gottardi described the conversation as brief and he did most of the talking.62 The movement and partial evacuation of occupants on floor 22 Flat 193 17.31 By this time, everyone on floor 23 was together in Flat 193, apart from Anthony Disson, who was alone in Flat 194. 17.32 Those in Flat 193 were aware of the fire approaching from Flat 192. Between 02.5963 and 03.07, Naomi Li made calls to her husband, Lee Chapman, and then to the emergency services.64 During that time she could see the fire on the outside of the building coming from Flat 192 towards Flat 193. The smoke was so thick that those in Flat 193 could not see each other.65 17.33 Despite having been advised to leave by CRO Russell in a call timed at 02.51,66 Naomi Li made another 999 call because she was not sure whether it was safe to walk down the stairs.67 CRO Christine Howson answered that call and also urged her to leave. She told Naomi Li to cover her nose and mouth with a wet cloth to avoid inhaling smoke, to get to the stairwell and to make her way down. Naomi Li asked if the stairs were safe because of the fire. CRO Howson replied: “It’s not fire. It’s not fire, it’s smoke”. 17.34 Having been reassured, Naomi Li felt that it would be possible to run down the stairs. That and the proximity of the fire persuaded her that she needed to leave. She and her cousin, Lydia Liao, agreed to take the chance. Naomi Li told the other occupants, who were all in the living room, that they had been told to leave. She could not see any reaction because of the amount of smoke. By now it was also coming through the windows and was everywhere.68 59 [LFB00000409] p. 6. 60 [LFB00000417] pp. 2-3. 61 Gottardi first witness statement [MET00013011] p. 1. 62 Gottardi first witness statement [MET00013011] p. 1. 63 Li Day 62/203/2-204/14. 64 [LFB00000404]. 65 Li Day 62/208/12-208/25. 66 [LFB00000386]. 67 Li Day 62/207/17-208/11. 68 Li Day 62/209/6-62/212/3.

The Grenfell Tower Inquiry: Phase 1 Report 398 17.35 Naomi Li and Lydia Liao felt their way to the kitchen where she soaked a scarf. (She appears to have had no problem with the water pressure.)69 When they left the flat, the others were gathered in the corner of the living room near to the one window which was giving some air.70 17.36 The smoke in the lobby was light white or greyish in colour. Although it was possible to see the lighting, the density of the smoke reduced the visibility.71 17.37 Naomi Li’s call overlapped with a separate 999 call from Flat 193, which was answered by CRO Angie Gotts at 3.08.56.72 The callers repeatedly asked CRO Gotts to send a helicopter to rescue them and said that the fire had reached the flat. CRO Gotts told them to use wet towels and leave. She also said that she would give the information to the firefighters. 17.38 Another call was made from Flat 193 at 03.14.40. The caller was probably Nadia Choucair. She told the BT operator that her daughter was unconscious. Before putting the call through to the LFB, the BT operator said that the advice from the LFB was to get out of the building. The BT operator then repeated that advice adding: “If you can’t get out, you need to get wet towels and cover yourselves with wet towels”. The caller is then heard to say that everyone needed to get to the staircase. She was repeating that instruction when, at 03.15.51, CRO Howson answered the call. There was no exchange with CRO Howson before the line cleared.73 17.39 Nadia Choucair was still in Flat 193 at 03.21.50 when she received a call back from the MPS. At 03.14.07 a call had been put through to the police from Nadia Choucair’s telephone but the line cleared. In the call back, the MPS operator advised Nadia Choucair to try to escape by any means necessary. At the end of the call, Nadia Choucair is heard telling others that the police have said that they need to leave.74 17.40 I return to events in Flat 193 later. Flat 194 17.41 Anthony Disson had been told to leave in calls with CRO Adams and CRO Gotts at 02.49.2075 and 02.51.38.76 He made another emergency call, which was answered by CRO Heidi Fox at 03.01.20. Anthony Disson again asked for firefighters to come for him because the fire was by then next door. He said that he was unable to leave because it was “too dark and too hot”.77 17.42 Anthony Disson’s wife, Cordelia Disson, and their son, Alfie Disson, had tried to persuade him to leave his flat in the course of telephone calls they thought had been made between 01.00 and 01.22. He had refused to leave because the control room had told him to stay in his flat and that firefighters would come to him.78 Given that his first 999 call was made at 01.30.08, the conversations with Cordelia and Alfie Disson must have taken place after that time. 69 Li Day 62/212/4-16. 70 Li Day 62/213/16-215/5. 71 Li Day 62/212/19-62/213/23. 72 [LFB00000406]. 73 [COR00001081]; [LFB00000414]; Andrew Mobbs exhibit AM/1 [LFB00004695]. 74 [INQ00000377] p. 3. 75 [LFB00000381]. 76 [INQ00000469]. 77 [LFB00000395] p. 3. 78 Alfie Disson first witness statement [IWS00000241] p. 5, paragraph 65; Cordelia Disson first witness statement [IWS00000242] p. 10, paragraph 122.

Part II | Chapter 17: Period 8: 03.00-03.30 399 17.43 In later telephone calls to his family Anthony Disson told them that the conditions in his flat were becoming progressively worse and that it was filling up with smoke.79 At around 03.00 he told Alfie Disson that the firefighters were not coming for him and that he was going to try to leave.80 17.44 Alfie Disson’s partner, Chanade Prentice, made 999 calls at 02.28.23,81 02.45.45,82 and 03.05.38.83 On each occasion she was connected to her local fire and rescue service, Surrey FRS. She spoke with CRO Caili Beckham.84 In the first two calls she described Anthony Disson as panicking. In the third she told CRO Beckham that the fire was now in his flat and that he was having difficulty breathing. CRO Beckham did not advise that Anthony Disson should leave the flat. Chanade Prentice was told that the information she had previously given the control room had been passed to the firefighters and that it would be passed to them again. 17.45 Following a call to the LFB, in which Crew Commander Rob Brown of Surrey FRS was told that the “stay put” advice had been changed,85 CRO Beckham from Surrey called Alfie Disson at 03.09.17. She told him to tell his father to wrap something around himself and to leave. Alfie Disson said that his father would not leave, as he could not see enough to reach the stairs.86 17.46 Cordelia Disson called 999 at 03.22.51.87 As she was in Kent, she was put through to Kent FRS and spoke with CRO Zoe Martin.88 She gave Anthony Disson’s location as Flat 249 on floor 22. She said she had just spoken to him and he had told her that the fire had reached his front door. He was having difficulty breathing. CRO Martin said she would call him directly. Conditions on floor 21 17.47 At about this time, Marcio Gomes was waiting in the hallway of Flat 183, ready to open the front door should firefighters arrive and monitoring the smoke coming through the door. Everyone else was in the kitchen or living room as they had the clearest air.89 17.48 At 03.09.52, CRO Howson answered what was the fourth 999 call made by Marcio Gomes.90 At that time he could see the glow of the fire next door,91 but he could not remember what had prompted him to make the call. He told CRO Howson that there was no fire in the flat, but that he could see the fire next door. Smoke was coming into the flat. CRO Howson advised him to try to leave. He told her that his wife was panicking and could not do it. CRO Howson told him that she would inform the crews and make reaching him a priority.92 CRO Howson asked him to try again to leave the flat. 79 Cordelia Disson first witness statement [IWS00000242] pp. 10-11, paragraph 126; Alfie Disson first witness statement [IWS00000241] p. 5, paragraph 72. 80 Alfie Disson first witness statement [IWS00000241] p. 6, paragraph 78. 81 [LFB00000649]. 82 [LFB00000650]. 83 [LFB00000549]. 84 Beckham witness statement [MET00010784] p. 3. 85 [LFB00000685]. 86 [LFB00000654]. 87 [LFB00000659]. 88 Martin witness statement [MET00012678] pp. 3-4. 89 Gomes Day 71(Fri)/86/9-21. 90 [LFB00000412]. 91 Gomes Day 71(Fri)/80/7-71/81/17. 92 [LFB00000412] p. 9.

The Grenfell Tower Inquiry: Phase 1 Report 400 17.49 Marcio Gomes remembered having been told that he was a priority. That meant to him that firefighters were coming up to them and he felt that they had a bit more time to wait. He said in oral evidence that, if he had been told that crews were unable to reach floor 21, that would have affected his decision or at any rate his attitude to evacuation.93 17.50 Marcio Gomes described his flat as becoming steadily smokier during that time. His daughters were now sitting on the floor in the living room, because the density of the smoke was such that they could not comfortably stand. As far as he had been aware, the smoke was still coming through the front door but he could not be sure that it was not also coming through the windows.94 His last 999 call began at 03.25.45 and lasted 33 minutes and 53 seconds.95 I will return to that call and the evacuation of Flat 183 later. Conditions on floor 20 17.51 Khadija Saye, in Flat 173, learned of the change in the “stay put” advice through messages posted on her Facebook wall by a friend who had made 999 calls.96 At 03.02, she had posted that she was too scared to leave her home. There followed an exchange of messages with the friend which overlapped a 999 call made by that friend.97 At 03.05 Khadija Saye confirmed that there was a lot of smoke in her flat but no fire.98 Her friend told her that there was no fire in the stairwell, only smoke.99 17.52 Shortly before 03.14, Khadija Saye tried to leave her flat, but shortly afterwards posted that the smoke had been too strong. She had not been able to see the stairwell.100 At 03.20 she confirmed that her mother was with her. She made a second attempt to leave before posting another message at 03.27 in which she said that it had been impossible to do so.101 17.53 At 03.30, Khadija Saye posted: “It’s in my rooms”, but it is not known whether that was a reference to the fire or the smoke. 17.54 That was the last message Khadija Saye left on Facebook. She did not respond to any further Facebook messages, which were to the effect that “they” were advising evacuation if possible. 17.55 The body of Mary Mendy was later found in the lobby on floor 13. Khadija Saye’s body was recovered from the lobby on floor 9, having been moved there from the stairs by firefighters.102 The evacuation of Flat 153 17.56 By this time all those on floor 18 were in Flat 153. They remained in the living room. Paulos Tekle could see the fire coming from Flat 152 on the south side of the tower.103 He could also see it coming from the other side (the west side).104 He could not remember having seen any smoke coming into the flat, but he recalled Genet Shawo going to the kitchen and telling him that smoke was coming in through the kitchen window.105 93 Gomes Day 71(Fri)/84/19-85/11 and Gomes Day 71(Fri)/88/2-7; Perestrelo first witness statement [IWS00000349] p. 10, paragraph 62. 94 Gomes Day 71(Fri)/86/13-71/87/24. 95 [LFB00055501]. 96 Telfer Exhibit MT/2 [IWS00001188] p. 18. 97 Telfer Exhibit MT/2 [IWS00001188] pp. 18-19; [LFB00000676]. 98 Telfer Exhibit MT/2 [IWS00001188] p. 18. 99 Telfer Exhibit MT/2 [IWS00001188] p. 18. 100 Telfer Exhibit MT/2 [IWS00001188] p. 18. 101 Telfer Exhibit MT/2 [IWS00001188] p. 20. 102 DVI plan [MET00012528] p. 11. 103 Tekle Day 63/63/5-22, 63/67/4-10. 104 Tekle Day 63/76/1-21. 105 Tekle Day 63/64/2-22.

Part II | Chapter 17: Period 8: 03.00-03.30 401 17.57 By now, the people gathered in Flat 153 had made a number of 999 calls. Paulos Tekle spoke to CRO Russ White from Essex FRS at 02.51.00, who told him to block the entry of smoke and get fresh air from a window or leave if it was safe to do so. CRO White told Paulos Tekle that he would pass the information to the LFB. When he spoke to the LFB, CRO White was told that the advice to occupants was now to leave. 106 At 02.54, CRO White rang Paulos Tekle and left a message telling him to leave the flat, if possible.107 17.58 At 02.56 a CRO from Essex spoke to Paulos Tekle and told him that the current advice from the LFB was that occupants should cover themselves with wet sheets and go to the nearest fire exit.108 Having received that advice, Paulos Tekle and Genet Shawo made preparations to leave. They gathered towels for everyone.109 As they were preparing to leave, Yehualashet Enyew went to the front door. Paulos Tekle and Genet Shawo recalled having told him not to open the door because she did not yet have a wet towel.110 However, Yehualashet Enyew did open the front door and smoke immediately spilled into the flat. Paulos Tekle then saw a firefighter in the lobby through the open door. The firefighter did not say anything to him. Yehualashet Enyew was offering to take one of the children, so, as his younger child refused to go with Yehualashet Enyew, Paulos Tekle gave his elder son, Isaac Paulos, to him. Yehualashet Enyew then left first with Isaac. He was followed by the children of Rabia Yahya and then Rabia Yahya herself. Paulos Tekle, who was carrying his younger son, and Genet Shawo brought up the rear.111 17.59 Paulos Tekle remembered that the firefighter had been behind them at that stage. The firefighter then moved to the right corner of the lobby near to the staircase and showed them the stairs using a torch. Paulos Tekle could only remember seeing one firefighter, but said there may have been another. He could not see as it was very dark in the lobby.112 17.60 Paulos Tekle said that he had not been able to see anything through the dense smoke as they went down the stairs. He was carrying his younger son and as he went down the stairs he slipped and lost consciousness for a short time. He then got up and tried to walk, but found himself sliding down. He felt the smoke become denser at a certain level and was unable to breathe. He had to share the towel with his son who had lost his own towel on the way down.113 Genet Shawo recalled taking their younger son from Paulos Tekle when she saw that he had fallen to the floor. They then met a firefighter who took their younger son from her at the lobby.114 17.61 Yehualashet Enyew’s evidence was that he had been prompted to leave by Paulos Tekle, who had said that there were firefighters outside the door. They had assembled at the door and he had held the hand of Isaac Paulos. He went out, grabbing the firefighter by the hand. He had seen more than one firefighter in the lobby. He had held on to Isaac Paulos with his right hand. The firefighter had led him down the stairs while he held on to the firefighter’s arm. As they descended the smoke had become thicker. About halfway down he had realised that he had lost Isaac Paulos and he had begun to lose consciousness. He felt that he could not have survived without the help of the firefighter.115 106 [LFB00000546]. 107 [LFB00000692]. 108 [LFB00000380]. 109 Tekle Day 63/85/4-19. 110 Tekle Day 63/86/23-63/88/7; Tekle first witness statement [IWS00001051] pp. 12-13; Shawo first witness statement [IWS00001050] p. 12. 111 Tekle Day 63/86/23-63/88/10, 63/91/14-63/93/17; Tekle first witness statement [IWS00001051] pp. 12-13. 112 Tekle Day 63/93/22-63/94/6. 113 Tekle Day 63/91/14-63/93/17. 114 Shawo first witness statement [IWS00001050] p. 13. 115 Enyew first witness statement [MET00007347] p. 3.

The Grenfell Tower Inquiry: Phase 1 Report 402 17.62 Before leaving, Rabia Yahya had gone to the kitchen with Genet Shawo to wet towels for her children. Rabia Yahya noticed the same problem with water pressure in Flat 153 as she had experienced in her own flat after 02.00, when she had tried to wet blankets to block the door. Genet Shawo noticed similar problems with the water.116 17.63 Rabia Yahya recalled Yehualashet Enyew opening the door. She was not sure whether Yehualashet Enyew or Paulos Tekle had left first, followed by Genet Shawo. As she remembered it, she had been the last one to leave with her children. That was because she had wanted to prepare her children for the journey.117 Rabia Yahya was clear in her recollection that there had been no firefighters in the lobby when they left.118 She was sure of it, because she thought that the firefighters would have given them instructions if they had been there. She did not recall having seen any torches. Rabia Yahya said that it had been difficult going down the stairs and that one of her children had slipped. She was familiar with the building and had been able to feel her way out.119 17.64 Rabia Yahya said that she had first met a firefighter on floor 7. Her son had collapsed on that floor from the smoke. Her daughter had been shouting, asking what floor they were on. The firefighter came out of the lobby on floor 7 wearing a torch on his head. He had told her they were on floor 7 and that they should keep going. He had picked up her son and carried him down. 17.65 Rabia Yahya recalled that there had been thick black smoke in the lobby on floor 7. It had also been very hot, although not as hot as on the higher floors. Rabia Yahya did not remember seeing any stairwell doors being held open on the way down.120 17.66 FFs Niki Mitchell, Michael Pole and Chris Cheesman had tallied out at 02.51.01, 02.51.08 and 02.53.07 and had reached floor 18 at the time the occupants of Flat 153 decided to leave.121 17.67 There were significant differences between the recollections of the firefighters about what had taken place when they reached floor 18. FF Pole said that he had reached the door of Flat 153 first and had banged on it. It had opened straight away and FF Mitchell had spoken to a man who had told him that there were seven people in the flat. He described the lobby as filled with dark thick smoke. Initially he had thought it would be better to leave the occupants in the flat, because that floor did not seem to be affected by the fire, but ultimately they decided to take them down. He said that he had led the group to the stairs in single file, with FF Cheesman in the middle and FF Mitchell at the rear. However, he (FF Pole) had mistaken the front door of another flat for the door into the stairs and the order of firefighters had become reversed. As a result, FF Mitchell had been in the front, FF Cheesman in the middle and himself in the rear. FF Pole said he had seen a woman carrying a baby, a teenage girl, a five- or six-year-old boy (probably Rabia Yahya’s son) and two or three adults ahead of him. Both the woman with the baby and the girl had been wearing headscarves. He said that the girl had wanted to go back and that he had told her to cover her mouth with a headscarf. He had to keep persuading the woman to keep going. One point he had realised that the boy was no longer with them, so he had stopped, turned around and found him on the steps. The boy had become unconscious, so he told the woman and girl to keep going and picked up the boy and carried him down. He met another firefighter who had helped him. 116 Shawo first witness statement [IWS00001050] p. 12. 117 Yahya Day 63/173/6-24. 118 Yahya Day 63/173/25-63/174/20. 119 Yahya Day 63/175/13-19. 120 Yahya Day 63/175/13-63/182/14. 121 Pole first witness statement [MET00039672] p. 9; Mitchell first witness statement [MET00039859] p. 7.

Part II | Chapter 17: Period 8: 03.00-03.30 403 17.68 FF Mitchell recalled it differently. He remembered that when they opened the stairwell door on floor 18 he had met a resident, who had grabbed him. He said there had been seven people in the flat. It had been dark and smoky, but not hot. The firefighters had taken them down using a human chain, with FF Cheesman in the front, himself in the middle and FF Pole last. He was clear that none of the firefighters had gone into any of the flats and did not know how the group had come to be together.122 He said that he had seen a group of men and women, but could not remember having seen any children at any stage. Some of the women had been wearing sheets or scarves around their faces to help them breathe. 17.69 FF Mitchell said that as they had gone down the stairs, the man who had grabbed him when he first went into the lobby on floor 18 had been holding on to him tightly. He had been of Somali or Eritrean appearance, in his “40s, slim and about 5’9” tall”. Behind him had been a woman who had held on to his shoulder straps. The man had been very anxious as they were going down. FF Mitchell said that he had tried to stop him talking to avoid taking in smoke. He had not seen any other firefighters until he saw some light and heard other crews. The casualties had been handed over. They had to go back up again to find FF Pole, who was about two flights of stairs away. They had helped him out but FF Mitchell could not remember whether he had been with any casualties.123 17.70 FF Cheesman’s recollection, consistent with that of FF Mitchell, was that when they entered the stairs he had been leading, with FF Mitchell in the middle and FF Pole in the rear. However, FF Cheesman said that FF Mitchell had been behind him with a child.124 17.71 If FF Pole’s recollection that FF Mitchell led the group down the stairs is correct, then the man holding on to FF Mitchell is likely to have been Yehualashet Enyew, who was first out of the flat and who said that he had held on to a firefighter’s hand as he went down. However, FF  Mitchell did not mention having seen a child with Yehualashet Enyew at any stage, which might indicate that Isaac Paulos had become detached from Yehualashet Enyew very soon after leaving the flat. If FFs Mitchell and Cheesman are correct in recalling that it was FF Cheesman who led the group into and down the stairs, then it is very difficult to determine who assisted Yehualashet Enyew and who, therefore, was closest to Isaac Paulos either at the start of their journey or after the order of firefighters had changed before they entered the stairs. On one point these diverse recollections are consistent: that neither FF Mitchell nor FF Cheesman assisted a man with a child at any stage. 17.72 Paulos Tekle left the tower with Genet Shawo and their younger son at 03.12.125 Yehualashet Enyew followed them out a minute later at 03.13. Rabia Yahya left at 03.18. Her children left the tower between 03.15 and 03.18. Isaac Paulos was later found dead in the lobby of floor 13.126 17.73 I regret to say that the differences of recollection to which I have referred make it impossible to reach any clear conclusion about how or when Yehualashet Enyew let go of Isaac Paulos’s hand and Isaac Paulos became detached from the group. Nor is it possible to determine how he came to be in the lobby on floor 13. Although there remains some doubt about the order in which the occupants left Flat 153, it is likely that Yehualashet Enyew left the flat first holding Isaac Paulos’s hand. It is not possible to tell, however, which firefighter assisted them. Nor is it possible to determine with any confidence which firefighter led Yehualashet Enyew down the stairs. It is doubtful whether it was FF Pole because he said that at that stage he had been 122 Mitchell first witness statement [MET00039859] p. 8. 123 Mitchell first witness statement [MET00039859] pp. 6-11. 124 Cheesman first witness statement [MET00039905] p. 8. 125 Annex A. 126 DVI plan [MET00012528] p. 17.

The Grenfell Tower Inquiry: Phase 1 Report 404 assisting Rabia Yahya and one or more of her family.127 If that is right, it must have been either FF Cheesman or FF Mitchell and of the two, FF Mitchell seems the more likely because he says that he assisted a man who fits Yehualashet Enyew’s description in the stairs. However, as I have said, neither FF Mitchell nor FF Cheesman recalled having assisted a man with a child at any stage. 17.74 One of the mysteries surrounding the tragic death of Isaac Paulos is how none of those descending the stairs noticed that he had become detached from Yehualashet Enyew and was on his own. If they had been at the front of the group, it is difficult to see how those following could have failed to come across him. It is possible that, having lost his grip on Yehualashet Enyew’s hand, he continued to follow him down the stairs until he found the door to the lobby on floor 13 open, but that is little more than speculation. Yehualashet Enyew said that he had been badly affected by the smoke in the stairwell and was unable to remember where or when he had lost contact with Isaac Paulos. Unfortunately, there is insufficient reliable evidence to enable me to make any finding about that. The attempted evacuation from Flat 142 17.75 By 03.01 Flat 142 was the only flat on floor 17 which was still occupied. Kamru Miah, Rabeya Begum and three of their four children, Mohammed Hamid, Mohammed Hanif and Husna Begum, had remained in the flat together. Following a 999 call at 02.27.12, the family did not contact the emergency services again until 03.09.18. 17.76 Mohamed Hakim, the eldest son of Kamru Miah and Rabeya Begum, was at home when he received a call from a cousin telling him about the fire.128 He was about to get into a taxi to go to the tower when Husna Begum, his sister, called him at 03.08. She said there was a fire and they were all trapped in the flat. She said she did not think she would survive. She then ended the call.129 Husna Begum also called Rohema Khanom again. Rohema Khanom had previously spoken to Mohammed Hanif at around 03.00 when he had said that the family were all together. During the last call, Husna Begum told Rohema Khanom that it was smoky and dark. She could not see anything. Husna Begum was having difficulty breathing and was coughing continuously. It is not known what time this call took place.130 17.77 CRO Adams answered the 999 call from Flat 142 timed at 03.09.18. She was told that the fire had reached the hallway and kitchen of the flat. CRO Adams advised that the family should cover themselves with wet towels and leave. She was told that it was not possible to do so, as the smoke on the stairs was too thick.131 17.78 The last 999 call from Flat 142 came shortly afterwards. CRO Fox answered it at 03.18.45. She was aware that there were five people alive in the flat, including two elderly people. They were all by the front door. CRO Fox said that they should leave, but the caller said that it was too hot outside the front door. CRO Fox said that she would pass the message on by radio.132 17.79 After this time, no one in Flat 142 contacted the emergency services or anybody else outside the tower. Husna Begum was later found in the lobby on floor 17. The rest of her family were found inside Flat 142.133 127 That is consistent with the descriptions of those he was assisting and with the fact that he was originally last (and Rabia Yahya said that she left the flat last). 128 Hakim first witness statement [IWS00000019] p. 4. 129 Hakim first witness statement [IWS00000019] p. 5. 130 Rohema Khanom witness statement [MET00015675] p. 5. 131 [LFB00000408]. 132 [LFB00000419]. 133 DVI plan [MET00012528] p. 19.

Part II | Chapter 17: Period 8: 03.00-03.30 405 Conditions on floor 16 17.80 Sener Macit in Flat 133 spoke to CRO Adams at 03.02.27 and to CRO Gotts at 03.12.56. He told CRO Adams that there were two people in the flat; they had tried to leave but had gone back inside because of the smoke.134 CRO Adams advised Sener Macit that he should try to leave. When he said he could not, she told him to stop the smoke coming in and said: “We’ll get to you as soon as we can. We’ll tell the crews that you can’t get out”.135 17.81 During the call at 03.12.56,136 CRO Gotts tried to persuade Sener Macit to make another attempt to leave. When he told her he could not because he was nearly fainting, she again encouraged him to try. She told him to block out any smoke if he could not leave and said she would let the firemen know.137 17.82 At the time Sener Macit still thought that the firefighters were coming. In an earlier 999 call he had been led to believe that they were on floor 14138 and he had called again at 03.12.56 to ask where they were.139 He said that he had not left after being advised to do so because he was afraid that he and his wife would not survive the experience.140 17.83 At the time of his call to CRO Gotts he had felt dizzy and was having difficulty breathing. He had been coughing and had thought he would pass out.141 By that time, the smoke inside the flat was becoming very thick. He was on the floor trying to get more air. The smoke was so thick he was unable to see his wife’s face if she was standing up.142 17.84 After the call at 03.12.56, Sener Macit and his wife Hanife Macit made another attempt to leave.143 They managed to reach the stairwell. He did not think it was possible to go down, because he could still see black smoke in the stairs. He had been hoping that it would be clear in the stairs,144 but when he found that the conditions in the stairs were much the same as in the lobby, he and Hanife Macit returned to Flat 133. Conditions on floor 15 17.85 On the floor below, Christos Fairbairn was trapped in Flat 124. His first 999 call, made at 03.00.55, had reached the LAS. He had been advised to wait for assistance. He subsequently made four more 999 calls: a. At 03.04.00,145 he spoke to a CRO in North West FRS control room who told him to cover himself and to get out by whatever means he could. b. At 03.15.20146 he spoke to CRO Russell, who advised him to leave. He said that he could not breathe; he had tried to leave but had been unable to see anything. 134 [LFB00000398]. 135 [LFB00000398] p. 3. 136 [LFB00000416]. 137 [LFB00000416]. 138 [LFB00055499] p. 24. 139 Macit Day 65/170/17-65/171/10. 140 Macit Day 65/170/17-65/171/23. 141 Macit Day 65/171/17-23. 142 Macit Day 65/171/24-65/172/13. 143 Macit Day 65/173/23-65/176/12. 144 Macit Day 65/174/2-65/175/16. 145 [MET00018759]. 146 [LFB00000415].

The Grenfell Tower Inquiry: Phase 1 Report 406 c. At 03.18.43,147 Christos Fairbairn called 999 again and was put through to the LAS. Again, he said he could not breathe. He had tried to go outside but the smoke was too thick and he was slipping. He ran back to the door and nearly fainted. The operator then put him on hold and the line disconnected. d. At 03.22.35,148 Christos Fairbairn called 999 once more and spoke to CRO Russell for a second time. He told her that he had tried to leave but had nearly fainted and that he could not breathe. He was then by the front door. CRO Russell told him to go to another room, block out the smoke, stay low and cover his mouth. She explained that the two options were to stay and wait for the fire crews or to leave. He said he could not leave. CRO Russell then advised him to stay where he was and to keep away from the smoke. She told him that she would tell the firefighters where he was.149 Conditions on floor 14 17.86 Mahmoud Al-Karad shared Flat 112 with Omar Alhaj Ali and his brother, Mohammad Alhajali. He was not at home when the fire started. He spoke to Mohammad Alhajali for the first time at 01.39 and continued to call him throughout the night. While the brothers were still in the tower, he had approached a police officer to report that they were in their flat. The officer said he should tell Mohammad Alhajali and Omar Alhaj Ali to stay inside and block the smoke from coming into the flat. He approached the police a second time and the officer took a note of the number of the brothers’ flat.150 17.87 The events surrounding the rescue of four of the occupants of Flat 113 (including Omar Alhaj Ali) have been described elsewhere and aspects of it remain to be examined further. In this Period I am concerned with what those who were left behind in Flat 113 (Mohammad Alhajali, Denis Murphy and Zainab and Jeremiah Deen) experienced and the circumstances surrounding their deaths. 17.88 At 02.55, Mahmoud Al-Karad spoke to Mohammad Alhajali, who told him that he could not see Omar Alhaj Ali. He told Mahmoud Al-Karad that he was dying. Mahmoud Al-Karad spoke to Mohammad Alhajali for the last time at 03.19. He tried to urge him to leave the flat, but Mohammad Alhajali said: “I can’t leave. There is a mother and child with me. How can I leave them?” He asked that the LFB keep hosing Flat 113 with water.151 17.89 Mahmoud Al-Karad said that he went to the police and told them what Mohammad Alhajali had said. They said they would inform the control room. Meanwhile, at around 02.44, Omar had told WM Williams and other firefighters in the ground floor lobby that his brother was still in Flat 113.152 17.90 After he had spoken to Mohammad Alhajali, Mahmoud Al-Karad discovered that Omar Alhaj Ali was outside the tower. Omar Alhaj Ali was distressed and upset. He called his brother while Mahmoud Al-Karad was with him and tried to persuade him to leave. In one of the calls with Omar Alhaj Ali, Mohammad Alhajali said that smoke continued to come into the flat 147 [INQ00000385]. 148 [LFB00000421]. 149 [LFB00000421]. 150 Exhibit MAK/2 [IWS00000791] p. 2. 151 Al-Karad first witness statement [IWS00000821] p. 8. 152 [INQ00000450] and [INQ00000449]; Alhaj Ali Day 59/87/1-89/23.

Part II | Chapter 17: Period 8: 03.00-03.30 407 and that the others had stopped breathing.153 Mahmoud Al-Karad called Mohammad Alhajali eight times between 04.26 and 05.05 but there was no response. The phone went straight to voicemail.154 17.91 Francis Dean, a friend of Zainab Deen, was in contact with her during the night. He had first become aware of the fire at 01.38. Zainab Deen had called him and told him there was a fire and that she had her son Jeremiah Deen with her. Francis Dean went to the tower, arriving at around 02.00. He called Zainab Deen again at 02.03 and she told him she was in Flat 113. He continued to speak to Zainab Deen until around 02.44. 17.92 Francis Dean tried to tell firefighters that Zainab Deen was trapped in the tower by calling 999155 and also by telling police at the cordon. A police officer at the cordon recorded the number of the flat where Zainab Deen was and the number of the floor.156 17.93 Zainab Deen made two further 999 calls after 03.00. In a call made at 03.06.06, she said they were covered with smoke.157 During the call she told someone else in the flat not to open the door. She ended the call saying: “No, we can’t leave. Nobody is coming for us”.158 17.94 At 03.17.05, Zainab Deen made her last 999 call.159 CRO Howson advised her to cover herself with a towel and make her way down the stairwell. She told Zainab Deen to expect smoke in the stairwell. Zainab Deen appeared to agree to leave with Jeremiah.160 17.95 Zainab Deen then made her final telephone call to Francis Dean. That is likely to have taken place soon after 03.19 when her call to CRO Howson ended.161 Zainab Deen told Francis Dean that Jeremiah had collapsed. Francis Dean tried to tell her to cover herself and her son in wet blankets and leave, but she refused to do so because of the smoke. 17.96 Francis Dean went to the basement entrance on the south side of the building to try to gain entry to rescue Zainab Deen. While there he saw a firefighter, CM Christopher Batcheldor, who took the telephone to speak to Zainab Deen. He remained on the telephone to Zainab Deen for nearly an hour. 17.97 While speaking to Zainab Deen, CM Batcheldor gave WM Thomas Furnell her location. WM Furnell confirmed that he was already aware of a call from Zainab Deen. He did not know that firefighters had already been deployed to the flat but that their brief had been changed. 17.98 CM Batcheldor recalled that Zainab Deen had told him that she could not get out and had been told to stay in the flat, which had led him to believe that the “stay put” policy was still in place. He took her at her word that she could not leave the flat. During the call, Zainab Deen told him that her son had died. He passed the phone to Francis Dean briefly so that he could encourage her to keep fighting. CM Batcheldor kept speaking to her for another 35 to 40 minutes. He returned to WM Furnell for the latest information about rescue operations 153 Alhaj Ali Day 59/96/1-15. 154 Al-Karad first witness statement [IWS00000821] p. 9. 155 North West FRS voicemail for Francis Dean at 01.45 [MET00014978]; call from Francis Dean to North West FRS at 02.17 [LFB00000694]; BT report to North West FRS a call from Francis Dean which dropped out at 02.21 [MET00014980]. 156 Francis Dean first witness statement [IWS00001048] p. 5 and Exhibit FD/3 at 00.38 seconds [IWS00001005]; [LFB00001968] p. 17. 157 [LFB00000405]. 158 [LFB00000405]. 159 [LFB00000418]. 160 [LFB00000418]. 161 Exhibit of Francis Dean FD/1 [IWS00001048] p. 7.

The Grenfell Tower Inquiry: Phase 1 Report 408 and was told that crews could not get past floor 12 at that time. He then heard Zainab Deen screaming before the line went silent. When he could no longer hear her, he disconnected the call. 17.99 CM Batcheldor decided not to tell Francis Dean that the line had gone silent. He handed the phone back to him telling him that the battery had died. Francis Dean tried calling Zainab Dean again but the phone went to voicemail.162 On the evidence as it stands, that was the last contact with Zainab and Jeremiah Deen. Conditions on floor 12 17.100 At around 03.00, Karen Aboud in Flat 92 noticed black smoke coming through her children’s bedroom window and under the front door. By that time, they were struggling to breathe.163 She called 999 again because she was desperate to leave and was connected to CRO Duddy at 03.08.01.164 He immediately advised her that she needed to go to the staircase with wet cloths covering her face.165 She told him that the smoke was hurting their eyes and that they could not see. She tried to leave the flat, but said that she could not reach the door.166 She then confirmed that she had gone back into her flat.167 17.101 CRO Duddy continued to encourage her to leave. He told her: “Right. You need to make it to that staircase. OK? That’s your only chance.” 17.102 Halfway through the call, Karen Aboud confirmed that she and her sons had reached the stairs.168 She said that the stairwell was dark; the smoke was thick and hot and smelled like burning plastic.169 On the way down she met some firefighters, as she told CRO Duddy, who was still on the line.170 17.103 Karen Aboud and her sons came down from floor 12 at the same time as Naomi Li and Lydia Liao were coming down from floor 22. Naomi Li and Lydia Liao left the tower at 03.21. Karen Aboud and her sons left at 03.20 to 03.22.171 Karen Aboud’s son told her later that they had gone down the stairs with a Japanese couple.172 Naomi Li recalled having seen a young boy in front of her on the stairs.173 17.104 It is likely that it was WM Peter Clark, WM Cardy and FF Beltrami who met Naomi Li, Lydia Liao and Karen Aboud and helped them down the stairs. Naomi Li said that when she met the firefighters, they had asked her whether she could walk and whether she was with anyone else. When they reached the bottom of the stairs, she told the firefighters that she had come from Flat 193 on floor 22 and that there were more than 10 people there. She did not know what the firefighters had done with that information.174 162 Batcheldor Day 34/154/11-34/174/3. 163 Aboud first witness statement [IWS00000130] p. 8. 164 [LFB00000402]. 165 [LFB00000402] p. 2. 166 [LFB00000402] p. 5. 167 [LFB00000402] p. 6. 168 [LFB00000402] p. 8. 169 Aboud first witness statement [IWS00000130] p. 9. 170 [LFB00000402] p. 11. 171 Annex A. 172 Aboud first witness statement [IWS00000130] p. 9. 173 Li first witness statement [IWS00000515] p. 11. 174 Li Day 62/216/1-62/217/4; Li first witness statement [IWS00000515] p. 11.

Part II | Chapter 17: Period 8: 03.00-03.30 409 Conditions on floor 11 Flat 82 17.105 Between 03.00 and 03.30 Natasha Elcock in Flat 82 called 999 five times. 17.106 At 03.00.50, she was advised for the first time to try to get out.175 Her partner went to the bathroom and soaked something she could use to cover herself. He then went to the door and opened it. A huge amount of smoke came in and set off the smoke alarm. He immediately shut the door and they did not pursue their attempt to leave. Natasha Elcock could see into the lobby. It was still black176 and the heat was intense.177 17.107 At 03.03.05 she was advised for a second time to leave her flat.178 In her evidence she explained that she had not left, because she did not think she could.179 She still believed that the firefighters were coming for her. She called 999 again at 03.13.06 and asked CRO Pam Jones to send someone to them. That was the first call in which she reported fire inside the flat.180 CRO Jones told her to leave if the fire was in the flat. 17.108 Natasha Elcock said that her partner had been moving to the other rooms throughout this time checking whether the fire had spread into the flat. If he saw there was a fire, he put it out using water from the bath.181 She remained on the bedroom floor with her daughter trying to keep calm. She continued to call friends and family and to contact 999.182 Conditions on floor 10 Flat 73 17.109 By 03.01, the family in Flat 73 had been advised to leave a number of times. At 02.43.08, CRO Jones responded to a call from Ann Chance.183 Ann Chance said there was a lot of smoke coming through the front door which was “completely hot”. CRO Jones initially told her to go to a room where it was safe, but soon after she advised her to leave. Ann Chance asked if they would be prevented from leaving by the fire on floor 4. Ann Chance’s cousin, Adam Supareogsanond, raised the same concern during his call to CRO Fox at 02.56.184 17.110 Ann Chance recalled that the family had made an attempt to leave after her 999 call at 02.43.08. In her statement she said: “The heat was intolerable when we opened the front door and we could not persevere through it, even when we had put wet towels over our heads.”185 175 [LFB00000393]. 176 Elcock Day 70/81/2-70/86/7. 177 Elcock Day 70/86/8-70/87/20. 178 [LFB00000394]; Elcock first witness statement [IWS00000310] p. 5. 179 Elcock Day 70/87/21-70/88/18. 180 [LFB00000410]. 181 Elcock first witness statement [IWS00000310] p. 7 and Day 70/92/4-70/96/17. 182 Elcock Day 70/92/4-70/97/11. 183 [LFB00000373]. 184 [LFB00000388]. 185 Chance first witness statement [IWS00000783] p. 6.

The Grenfell Tower Inquiry: Phase 1 Report 410 17.111 The temperature in Flat 73 started to rise and the smoke became worse, making them cough. When Ann Chance called 999 again at 02.57.32, she told the CRO at Kent FRS, CRO Mitch Samson, that the door was hot.186 The intense heat they felt when they opened the door made her think that there must be flames outside. Ann Chance then told CRO Samson that the fire was getting worse. She said: “We can’t open the door. It’s completely hot, and when we tried to open it earlier the smoke come [sic] in, and there’s so much smoke.”187 He advised them to get low and put wet towels on their faces to keep out the smoke.188 Ann Chance told him they had already done all they could to block out the smoke. She then said: “Like I said, I’ve called about ten times. All you guys keep telling us [is] to stay put, but the fire’s getting worse, and there’s a lot of smoke, increasing by the minute.” 189 She asked him if they could use the stairs.190 CRO Samson was unable to answer the question. He offered instead to pass her details to the LFB.191 The call lasted over 90 minutes, ending at 04.30. 17.112 At 03.06.57, Adam Supareogsanond spoke again to CRO Fox.192 She advised him to leave. During the call, he explained that his mother and aunt did not want to go. They then spoke to CRO Fox directly and told her that there was too much smoke. CRO Fox told them that there was no one coming to get them. 17.113 Ann Chance said in evidence that about a quarter of an hour into her own call to CRO Samson she had become aware that her cousin and aunt were also speaking to the emergency services. She said that they were being told to get out. CRO Samson responded by saying that she should remain in the safest place.193 He said that if it was safe for them to leave they should do that, but that he did not want to put her in more danger.194 17.114 CRO Samson does not seem to have been aware at that point that the LFB had changed the “stay put” advice. He then asked Ann Chance to check whether her brother was speaking to the LFB and told her that they should follow the LFB’s advice if it was different.195 Ann Chance then told CRO Samson that they had been warned that no one was coming to get them, but he told her that that was not necessarily the case.196 17.115 CRO Fox had been trying to persuade Ann Chance’s mother and aunt to try to leave. Adam Supareogsanond told CRO Fox that they were frightened of attempting to leave and asked her to speak to them. CRO Fox spoke to them and said: “They’re not coming to get you at the moment. They’re not coming to get you, so you need to get out.”197 186 [LFB00055505] p. 3. 187 [LFB00055505] p. 3. 188 [LFB00055505] pp. 3-8. 189 [LFB00055505] p. 7. 190 [LFB00055505] p. 8. 191 [LFB00055505] p. 8. 192 [LFB00000413]. 193 [LFB00055505] p. 16. 194 [LFB00055505] p. 20. 195 [LFB00055505] pp. 22-24. 196 Chance first witness statement [IWS00000783] pp. 6-7; [LFB00055505] p. 24. 197 [LFB00000413] p. 14.

Part II | Chapter 17: Period 8: 03.00-03.30 411 When they had given the telephone back to Adam Supareogsanond, CRO Fox told him that she had warned them that nobody would be coming.198 CRO Fox encouraged him again to get them to leave. The call ended at 03.15. 17.116 Ann Chance said that at about 20 minutes into the call (i.e. at around 03.15) they tried to leave, but that they had found that the door was too hot. It had expanded and they could not close it again properly.199 The smoke became worse as it was coming around the door, even though they had put towels down to block the gaps. 200 17.117 About half an hour into the call with CRO Samson (i.e. at around 03.26) Adam Supareogsanond started to shout for help from the window.201 They all remained in the flat.202 Flat 72 17.118 Antonio Roncolato was still in Flat 72. He was in contact with his son Christopher Roncolato who was still outside the tower. At 02.59, Christopher Roncolato called 999 for the second time. He told CRO Jones that the fire had not yet reached his father. She advised him to tell his father to get a wet towel over his face and leave. He said that he would tell his father to try to get out.203 Antonio Roncolato said in evidence that he had not made a second attempt to leave until 04.00.204 4 Events in the control room 17.119 Between 03.00 and 03.30, there were 47 emergency calls, 28 of which were from trapped residents and seven of which were from relatives or friends of residents still trapped in the tower.205 For the most part CROs continued to advise residents to leave, but in some cases CROs were told that residents had tried to leave and could not get out. As a result, some of the CROs decided to tell people to remain in their flats and protect themselves, while others, such as CRO Peter Duddy, told them in no uncertain terms that they had to get to the staircase because it was their only option. 17.120 During this period, the MetCC, Kent FRS, Surrey FRS and North West FRS between them received and made seven calls which they passed on to the LFB control room.206 17.121 At 03.02.27 CRO Adams received a call from Sener Macit in Flat 133 on floor 16.207 He explained that he and his wife had tried to leave but had been forced to return to their flat. CRO Adams told him that, if he could not get out, he should try to stop the smoke from coming into his flat. She told him that she would tell the firefighters that they were trapped and that a crew would rescue them as soon as they could.208 When she asked if he was sure that they could not make a run for it he explained that they had tried twice but they couldn’t breathe as there was so much thick smoke. She told him to try again if the fire started to come into his flat.209 198 [LFB00000413] p. 16. 199 Chance first witness statement [IWS00000783] pp. 6-7. 200 Chance first witness statement [IWS00000783] pp. 6-7. 201 Chance first witness statement [IWS00000783] p. 7. 202 They left the tower at 04.18 and 04.20. 203 [LFB00000554]; Christopher Roncolato first witness statement [IWS00000840] p. 9. 204 Antonio Roncolato Day 52/59/7-52/60/24. 205 Control Report pp. 113-135. 206 Control Report pp. 113-135. 207 [LFB00000398]. 208 [LFB00000398] p. 3. 209 [LFB00000398] p. 4.

The Grenfell Tower Inquiry: Phase 1 Report 412 17.122 At 03.02.35, CRO Duddy called Paulos Tekle in Flat 153 on floor 18 after CRO White from Essex FRS had given him his mobile telephone number.210 CRO Duddy told him that the family should cover their faces with wet towels and leave the building. 17.123 At 03.03.05, CRO Gotts received a call from Natasha Elcock who was trapped in Flat 82 on floor 11 and who by that time had called nine times.211 CRO Gotts told her that they should put wet towels over their heads and run for it. At 03.04.52, Natasha Elcock called once more and CRO Gotts answered again. She established that she had just spoken to Natasha Elcock, who said that it was not possible to get out because it was “too hot”. CRO Gotts told her to block out the smoke and said that more aerial ladders were attending the incident and that she should stay calm. CRO Gotts said she would pass a message to the fire crews that she could not get out.212 17.124 At 03.03.56, 03.29.40 and 4.07.28 Kent FRS gave the LFB control room further information about the call with Ann Chance and asked for further advice. The details were added to the right-hand whiteboard. On each occasion, the LFB CRO told Kent to urge the caller to leave. In the last call, the Kent operator explained that the caller in Flat 73 had tried to leave the flat three times and that she had been on the phone for an hour and 10 minutes. They asked for further advice, but CRO Gotts explained that there was no other advice to give. 17.125 At 03.04.00, a North West FRS operator called back Christos Fairbairn, after a call passed to them by BT at 03.03.48 had dropped out. The BT operator who had connected the call believed that he was calling from Flat 123 on floor 15. When the North West FRS CRO spoke to Christos Fairbairn he said that he was calling from floor 16. The CRO told him to cover himself in wet towels and to get out by whatever means he could.213 It is not known how North West FRS had learned about the change in advice. At 03.09.17, a North West FRS CRO told the LFB that there was a person trapped in Flat 123 on floor 15. OM Alexandra Norman told him that the advice had been changed because the fire was out of control.214 She told him that they were advising people to cover their heads with wet towels and find any way out they could.215 17.126 At 03.05.09, CRO Duddy received a call from Bassem Choukair in Flat 193 on floor 22.216 Bassem Choukair told him that he could not get to the stairwell as there was smoke and he could not see. CRO Duddy told him to cover himself in wet towels and feel his way along the wall. He said that his only chance was to get to the stairwell. Bassem Choukair explained again that he would not be able to see as there was smoke in the stairs, but CRO Duddy told him: “I know there’s smoke and I know it’s gonna be hard, but this is your only chance, your only chance.”217 17.127 At 03.06.00, SOM Joanne Smith answered a call from CC Rob Brown in Surrey FRS who passed on details of a call they had received at 03.05.38 from Anthony Disson’s daughter- in‑law.218 He was trapped in Flat 194 on floor 22. While SOM Smith was on the phone, she told CC Brown about the change in advice and said that they were telling the residents to rescue 210 [LFB00000557] and Control Report p. 117. 211 [LFB00000394]. 212 [LFB00000401] pp. 3-4. 213 [MET00018759]. 214 [LFB00000690]. 215 [LFB00000690] p. 3. 216 [LFB00000400]. 217 [LFB00000400] pp. 3-4. 218 03.06.00 call; [LFB00000685]; 03.05.38 call [LFB00000651].

Part II | Chapter 17: Period 8: 03.00-03.30 413 themselves.219 She asked him to pass the message to the Kent and Essex FRS, which were also taking calls and to which they had not yet managed to communicate the change in advice. CC Brown spoke to Kent FRS at 03.09.03 and Essex FRS at 03.14.23.220 17.128 At 03.06.18, CRO Sharon Darby sent a radio message to CU7 passing on information given to the control room by the NPAS helicopter, which had identified people on floors 17, 21 and 22.221 17.129 At 03.08.30, CU8 requested an additional Deputy Assistant Commissioner to attend the incident. DAC Lee Drawbridge was assigned at 03.12.29222 and was mobilised at 03.14.57.223 17.130 At 03.08.56, CRO Gotts spoke with Nura Jemal and Hashim Kedir in Flat 193 on floor 22.224 They asked if they could escape by the helicopter they could see, but CRO Gotts told them that the firefighters were coming up to them on the inside. She also told them that the LFB were sending “more big ladders”. She asked them to try and get out by putting wet towels over their heads. Towards the end of the call, they asked again for the LFB to send a helicopter so they could escape. CRO Gotts said: “OK. All right. Well, I’ll pass that over”.225 17.131 At 03.09.17, CRO Beckham from Surrey FRS rang the Disson family to tell them that the advice had changed and that they should tell Anthony Disson, in Flat 194 on floor 22, to leave.226 They told him that Anthony Disson was not able to leave his flat, that he was 70, that he could not see in front of him and the flat underneath was burning. CRO Beckham said she would let the LFB know because he ought to be a priority.227 At 03.10.26, CRO Beckham contacted the LFB control room again and spoke to CRO Jones.228 She told her that Anthony Disson was trapped in his flat by smoke and flame and could not possibly get out.229 CRO Jones could not offer any further advice, but she offered to call Anthony Disson. At 03.15.58, she tried to call him but was put through to his voicemail.230 17.132 At 03.09.52, Marcio Gomes in Flat 183 on floor 21 called the control room and spoke to CRO  Howson.231 He explained that smoke was coming into his flat and that the fire had reached the flat next door. CRO Howson told him that the advice was to cover himself with wet sheets and leave, but he explained that he had already tried to leave and that when he had opened the door the smoke had been black and overpowering.232 CRO Howson told him that the firefighters were not going to reach him for some time and that he should make another attempt to leave. She told him that people on higher floors were making their way out of the building and she urged him once again to try to leave. But she also told him that she would tell the crews that he was still in his flat and that they would make it a priority to get to him.233 219 [LFB00000685] p. 2. 220 03.09.03 call [LFB00000653]; 03.14.23 call [LFB00000655]. 221 Radio message [LFB00002925]. 222 Radio message [LFB00002715] and SIL p. 14. 223 SIL p. 14. 224 [LFB00000406]. 225 [LFB00000406] p. 6. 226 [LFB00000654]. 227 [LFB00000654] p. 2. 228 [LFB00000407]. 229 [LFB00000407] p. 2. 230 Control Report p. 127. 231 [LFB00000412]. 232 [LFB00000412] pp. 2-5. 233 [LFB00000412] pp. 7-9.

The Grenfell Tower Inquiry: Phase 1 Report 414 17.133 At 03.10.34, CRO Russell received a call from Hesham Rahman in Flat 204 on floor 23.234 That was his fifth call to the control room since 01.39.15.235 CRO Russell tried to advise him to leave, but he explained that he was not able to get out because there was too much smoke coming into the flat and because he was disabled and could not walk. She took his details, told him to cover his mouth and nose and reassured him that the firefighters were coming to get him. 17.134 At 03.12.56, CRO Gotts received a call from Sener Macit, in Flat 133 on floor 16, who told her that he and his wife had tried to leave twice already but had been unable to get out. CRO Gotts tried to persuade them to leave with wet towels over their heads and said that she would pass his details to the firefighters.236 17.135 At 03.14.22, CRO Darby sent CU7 another message from the NPAS helicopter which had spotted several occupants three floors from the top on the west face of the building.237 17.136 At 03.15.32, CRO Darby recorded a message in the incident log repeating the request made a few minutes earlier at 03.12.52 for a DSE to attend the incident ground as a matter of “urgency and priority”.238 17.137 At 03.20.31, Hesham Rahman spoke to CRO Adams. He told her that the flat was now full of black smoke and that he could not see anything. The fire was coming into his flat. CRO Adams told Hesham Rahman that he needed to make his way out. He told her what he had told CRO Russell: that he could not see anything and he could not walk properly because he was disabled. CRO Adams told Hesham Rahman that they would try to get to him. He confirmed that he was alone and could not hear anything from any of the other flats. CRO Adams urged Hesham Rahman to try to leave. She repeated that she would give the information to the fire crews and that they would try to reach him.239 17.138 At 03.22.35, CRO Russell received a call from Christos Fairbairn in Flat 124 on floor 15.240 He told her that there was too much smoke; he could not breathe and he could not manage to get down the stairs. She gave him the following advice: “So, so your two options at the moment is to stay where you are and wait for the crews, they’re trying to get to everyone as quickly as they can, there’s a lot of people in the building, OK? The other option, like I said, you try to leave the building, that’s your only other option,OK?”241 He told her that he could not leave, so she told him to stay away from the smoke and said that she would pass the information to the fire crews. However, she could not tell him when the firefighters would get to him because they were also making their way to other people. She told him to wait away from the front door. At that point the call ended.242 17.139 At 03.25.45, CRO Fox took a call from Marcio Gomes who was trapped in Flat 183 on floor 21 with his pregnant wife and two children together with Helen Gebremeskel and her daughter.243 That was his fifth 999 call. Marcio Gomes explained that they had tried to leave the flat three times and CRO Fox told him that she would tell the command unit that he was a priority because he had tried to get out three times and because there were children with 234 [LFB00000409]. 235 [LFB00000329]. 236 [LFB00000416]. 237 Radio message [LFB00002592]. 238 SIL p. 24 and radio messages [LFB00002528]; [LFB00001977]; [LFB00002222]. 239 [LFB00000420]. 240 [LFB00000421]. 241 [LFB00000421] p. 6. 242 [LFB00000421] pp. 6-7. 243 [LFB00055501].

Part II | Chapter 17: Period 8: 03.00-03.30 415 him. He then reported that fire had entered the flat and she told him that he had to leave. She then stayed on the phone with him while they all escaped from the flat. The call lasted for 33 minutes and 53 seconds. 17.140 Substantial parts of the recording of that call were played at the hearing while Marcio Gomes was giving evidence. This is not the place to discuss what it tells us about conditions in the stairs at that time. It is appropriate, however, to pay tribute to his courage and willingness to assist the work of the Inquiry by reliving publicly what was clearly a terrifying experience. 5 Actions of the MPS, the LAS, RBKC and the TMO 17.141 During this period, police officers at the scene continued to generate messages about individuals trapped in the building. For example, at 03.15.06 (a woman in Flat 153 on floor 18 trapped with children), and at 03.21.32 (three children in Flat 193 on floor 22).244 17.142 Just after 03.00 it became clear that it was becoming difficult to control the crowd at the cordon near Barandon Walk and more police officers were needed, as shown by the entry in CAD 482 at 03.04.09.245 At about the same time, police officers began using riot shields to protect firefighters from falling debris as they entered and left the building and to protect casualties as they came out.246 It was about this time that a mortuary was set up at the Kensington Leisure Centre.247 17.143 Just after 03.00 three more senior LAS officers arrived, Tom Gleeson (IR71), Maria Conyers (IR51) and Graham Barwick (IR41), who would assist in the new sectors. Tom Gleeson was assigned as Bronze triage in sector 2 (the new casualty area on the west side of the building) with Maria Conyers assisting him, and Graham Barwick as the equivalent in sector 1 (the original casualty area on the east side of the building). The decision to create two casualty sectors had been made by Laurence Ioannou just after 02.45 248 17.144 At 03.08.27 a message was placed on CAD 482 stating that the LFB was now instructing those still in the building to escape by any means necessary.249 It is possible that that message was broadcast by MetCC on the general MPS radio channel, although Inspector Thatcher had no recollection of hearing it and his body-worn video did not record any such message on his radio. He thought that it had been a message from the LFB control room to the MetCC control room,250 which is supported by Chief Inspector Graham Winch’s evidence.251 It remains uncertain, therefore, whether the message was actually broadcast to officers at the scene at this time. 17.145 However, at 03.10.56, a further message in almost identical terms was sent by MetCC. It was clearly audible on Inspector Thatcher’s radio,252 although he had no recollection of hearing it.253 Accordingly, whether or not the first message was broadcast by MetCC to all police officers at the scene, there is no doubt that the second message was. 244 CAD 482 pp. 18-19. 245 Warnett witness statement [MET000080605] p. 11. 246 CAD 482 at 03.05.17; Thatcher second witness statement [MET00023284] pp. 8-9. 247 CAD 482 at 03.06.49 p. 17. 248 Ioannou witness statement [MET00010862] p. 8. 249 CAD 482 at 03.08.27 p. 17. The times recorded for this and other events in the Debrief of the Emergency Response Policing Team (ERPT) [MET00023576] are not reliable for the reasons explained by Inspector Thatcher at Day 71(Mon)/135/2-137/19. 250 Thatcher second witness statement [MET00023284] p. 10 and Day 71(Mon)/121/2-19. 251 Winch witness statement [METS00020664] p. 8. 252 CAD 482 p. 21 and Inspector Thatcher’s body-worn video [INQ00000517]. 253 Although as he said (Thatcher second witness statement [MET00023284] p. 10) he felt no surprise when he attended the first TCG meeting at 03.20 and was told about the change in advice. Thatcher Day 71(Mon)/126/12-127/1.

The Grenfell Tower Inquiry: Phase 1 Report 416 17.146 At 03.10 Michael Rumble, an RBKC Parks Police Inspector, arrived at the scene as a second LALO, following a call from David Kerry at 02.45. 17.147 At 03.17.21 the LFB made the first call to RBKC using the control room admin line254 to ask whether it was aware of the fire. The RBKC operator (Ashley) said that it was. The LFB caller asked for a DSE and a LALO. Ashley said that the LALO had already been requested, but that she would make the request for a DSE. Details were provided about the location. Ashley provided a reference number and said that the information would be passed to the building control officer, but she was not able to say when the DSE might arrive. It remains unclear why the LFB was still calling for a LALO when by that time Nickolas Layton had been at the incident for about half an hour. 17.148 At 03.20 both Inspector Thatcher and Detective Superintendent Warnett attended the first TCG meeting on CU8.255 By that time people were pushing against the police cordons trying to enter the building to find their loved ones. Crowd control and maintaining secure cordons to allow the LAS and MPS unimpeded access to the incident ground to carry out their respective operations was therefore a priority.256 Geoff Long and Laurence Ioannou attended the TCM for the LAS.257 They reported that the casualty handling area was in the Kensington Leisure Centre, that there were three known deceased and that there were up to 29 casualties (i.e. injured people). The LALO, Nickolas Layton, said that there were two buses at Clarendon Road to ferry residents to a rest centre. AC Roe pointed out that there was a risk that the building might collapse and that there was falling debris. He had already asked for a DSE to attend, but it was “blatantly obvious” that there was a danger that the building was going to collapse.258 The Roe Log clearly records that: “FSG has been deviated and persons are self-evacuating”.259 AC Roe’s recollection was that he had asked Nickolas Layton for plans of the tower at that meeting. 17.149 At 03.23.36 the special operations room sent a message that two portable downlinks or receivers were on the way for use by the LFB and the MPS to enable them to view heli-tele pictures.260 It is not clear when they arrived. According to the evidence of Daniel Arnold, an NPAS Sergeant and the Base Manager at Lippitts Hill, the portable downlinks had had the same encryption keys as the helicopter, enabling the video to be encrypted and viewed.261 However, all the LFB officers who were asked about it said that they had not been able to view the NPAS helicopter video at any stage of the incident. Inspector Thatcher did not know that the LFB could not view the heli-tele pictures and so he did not direct the portable downlink to be taken to them when it reached the incident ground.262 Although his timings were “very hazy”, SM Peter Johnson said that the LFB officers in the command unit could only access the heli-tele downlink at around 10.00 or 10.30am on 14 June 2017. They said they had been told by a police officer that the feed had been “scrambled” up to that point, but that it was now working.263 Commander Neil Jerome was not familiar with portable downlinks and received no briefing at any stage about the problems with viewing the helicopter video.264 254 Control admin line [INQ00000211]. 255 Laurence Ioannou says that the TCG meetings took place on CU2 ([MET00010862] pp. 9-11) but this is incorrect. 256 Roe Log [MET00005404] p. 1. 257 Ioannou witness statement [MET00010862] p. 9. 258 Thatcher body-worn video clip [INQ00000530]. 259 [MET00005404] p. 2. 260 CAD 482 p. 19. 261 [MET00039527] p. 2. 262 Thatcher Day 71(Mon)/89/8-18. 263 Johnson Day 37/21/6-25/1. 264 Jerome Day 72/22/12-24/13.

417 Chapter 18 Period 9: 03.30-04.00 1 External fire spread 18.1 At 03.34 the furthest extent of the horizontal flame spread on the west face was still at the base of the crown.1 Between 03.34 and 03.42 there were flames at the top of column C1 (the internal column on the south side of the west face). The fire front was also moving diagonally across the face of the building from north to south,2 as is shown very clearly in these two images, the first taken at 03.34 and the second between 03.34 and 03.42:3 Figure 18.1 1 Professor Bisby supplemental report [LBYS0000001] p. 221 section 1047. 2 Professor Bisby supplemental report [LBYS0000001] p. 221 sections 1047-1050. 3 Professor Bisby supplemental report [LBYS0000001] pp. 225-226 Figs. 143-144.

The Grenfell Tower Inquiry: Phase 1 Report 418 Figure 18.2 18.2 By 03.52 the furthest extent of the horizontal flame spread on the west face was still at the level of the crown. The fire front was moving horizontally across the face of the building from north to south,4 as can be seen in this image, which also captures the fire moving from the south face: 4 Professor Bisby supplemental report [LBYS0000001] p. 222 sections1051-1053; p. 226 Fig. 145.

Part II | Chapter 18: Period 9: 03.30-04.00 419 Figure 18.3 18.3 By 03.30 the fire had reached the top of column D2 on the south face (the internal column to the far west of that face) and the flame front continued to move diagonally.5 This thermal image taken by the NPAS helicopter at that time shows that pattern very clearly; it also shows the flame front on the west face wrapping around the building and moving towards the southern flame front:6 Figure 18.4 5 Professor Bisby supplemental report [LBYS0000001] p. 230 section 1080. 6 Professor Bisby supplemental report [LBYS0000001] p. 234 Fig. 156.

The Grenfell Tower Inquiry: Phase 1 Report 420 18.4 By 03.58 the fire on the south face had reached column D1 at the south-west corner and there was burning below and behind the architectural crown on the eastern side of the flame front, as can be seen in this photograph:7 Figure 18.5 18.5 By 03.43 Flats 124, 134, 144, 154, 164 and 174 on floors 15 to 20 in the centre of the west face had become affected by fire. In addition, the fire front had by that time also reached Flats 83, 93, 103, 113, 123, 133, 143, 153, 163, 173, 183, 193 and 203 located at the south- west corner of the south face.8 2 Events on the incident ground GM Matthew Cook and DAC Andrew O’Loughlin briefed AC Andrew Roe (c. 03.39) 18.6 At around 03.39 GM Cook and DAC O’Loughlin briefed AC Roe on what the latter described as “intermittent” radio communications, but the discussion ranged more widely and covered the adequacy of EDBA resources and access to the route into and out of the tower.9 They told AC Roe that GM Patrick Goulbourne had moved the bridgehead to the ground floor because its previous position had been compromised by fire.10 They told him that while that had been going on they had continued to send EDBA crews to floor 4 but that further resources would be needed. In response AC Roe asked them to obtain from the control room the latest information about the extent to which EDBA wearers were available in Greater London and, if necessary, to order all available EDBA equipment to the incident. If necessary, it was to be brought by minibus.11 7 Professor Bisby supplemental report [LBYS0000001] p. 230 sections 1081-1083; p. 235 Fig. 157. 8 Dr Lane supplemental report [BLAS0000012] p. 11 Fig. 12.4. 9 AC Roe record of actions [MET00005405] p. 4. 10 AC Roe record of actions [MET00005405] p. 4. 11 AC Roe record of actions [MET00005405] p. 4.

Part II | Chapter 18: Period 9: 03.30-04.00 421 18.7 GM Dave O’Neill (then Sector Commander with responsibility for safety) reported that the route into and out of the tower had become extremely hazardous due to the amount of falling debris, some of it alight.12 The officers reported that, although police riot shields provided some protection to crews, they would not guard firefighters from the larger, heavier debris.13 18.8 Having considered these reports, AC Roe formed the view that it was necessary to go into the tower and decide whether he could justify continuing the rescue effort in the face of such significant internal fire spread and the risk of partial collapse with the attendant creation of significant debris.14 18.9 At about that time (03.39), Commissioner Dany Cotton arrived on CU8.15 AC Roe told her that BA crews were being deployed, but that he was on his way to the tower to decide whether that could safely continue. They agreed that the Commissioner would not assume command of the incident but would handle “the wider political and media environment and pan-London picture”. She was satisfied that AC Roe had put appropriate structures in place to manage the incident and she was satisfied with his performance in command.16 To preserve continuity of command while AC Roe inspected the situation in the tower, the Commissioner remained on CU8.17 18.10 As he made his way to the tower, AC Roe noted that the MPS had effectively secured the cordon. Members of the public were no longer close to the tower and the police presence in the surrounding area was greater.18 AC Roe also noted what he described as the “visible worsening” of the fire which had, as he recalled it, reached all four sides of the building. It was clear that it had penetrated many of the flats.19 Figures 18.6 and 18.7 from Professor Bisby’s supplemental report show the extent of the fire on the west side of the tower at about the time that AC Roe went from CU8 to the tower: Figure 18.6 12 AC Roe record of actions [MET00005405] p. 4. 13 AC Roe record of actions [MET00005405] p. 4. 14 AC Roe record of actions [MET00005405] p. 5; Roe witness statement [MET00007520] p. 6. 15 AC Roe record of actions [MET00005405] p. 6; Cotton witness statement [MET00012492] p. 22. 16 AC Roe record of actions [MET00005405 p.6]; Roe witness statement [MET00007520] p. 7. 17 Cotton witness statement [MET00012492] p. 20. 18 AC Roe record of actions [MET00005405] p. 7. 19 AC Roe record of actions [MET00005405] p.5.

The Grenfell Tower Inquiry: Phase 1 Report 422 Figure 18.7 18.11 As he made his way to the tower, AC Roe stopped at CU7, where he asked GM Thomas Goodall for the latest information on FSG calls.20 GM Goodall told him that more than 100 occupants were the subject of FSG calls and, although the system for relaying information to the operational sectors was working, he was unable to provide definite information regarding the number of deployments that had led to rescues because the position was changing by the minute.21 Having listened to GM Goodall’s brief and having seen for himself the calm and orderly way in which information was being recorded on the whiteboards, AC Roe concluded that GM Goodall had a good working system, despite the pressure of the incident.22 18.12 AC Roe also inspected the BA main control area, which was under the command of SM Daniel Kipling. His view, again, was that despite the rate at which calls were being received the area was calm and well ordered. He was satisfied that he was on top of things and able to ensure that enough BA wearers could be provided to meet the requirements of the main operational sectors.23 18.13 It may be useful at this point to describe the situation that presented itself to AC Roe when he entered the tower. Not only does it illustrate conditions in the building at around 03.45, but it also provides the context in which his subsequent decisions were made. a. In relation to the route into and out of the tower, GM O’Neill had set up a system under which a firefighter would look out for falling debris. When he judged that it was safe, crews would run into or out of the tower under a riot shield held by either a police officer or another firefighter. Both AC Roe and GM O’Neill considered that to be an extremely risky practice, but they recognised that it was the only way to maintain rescue operations as there was no entry point other than the main door on the south side of 20 AC Roe record of actions [MET00005405] p. 5. 21 AC Roe record of actions [MET00005405] p. 5. 22 AC Roe record of actions [MET00005405] p. 5. 23 AC Roe record of actions [MET00005405] p. 5.

Part II | Chapter 18: Period 9: 03.30-04.00 423 the building.24 While AC Roe was assessing the position, a man jumped from the tower, striking a firefighter and narrowly missing DAC O’Loughlin and GM Cook.25 b. AC Roe’s view was that the bridgehead was operating calmly. He noted that the use of FIBs26 had been abandoned in favour of recording information on walls using a chinagraph.27 c. He also received a quick brief from GM Goulbourne and GM Richard Welch. In essence, they reported that crews had cleared the building as far as they could up to floor 8, but were having a hard job getting beyond that. Their aim was to fight through to floor 12, despite intermittent problems with water supply, which were thought at the time to have been caused by hoses being severed by falling debris or destroyed by fire.28 GM Goulbourne confirmed AC Roe’s view that more EDBA resources were required. Accordingly, AC Roe ordered a message to be sent seeking them.29 d. Neither GM Goulbourne nor GM Welch had received any reports of concerns about the stability of either the concrete superstructure, the columns or the floors. In the circumstances, they both thought that it was safe to continue to deploy crews, despite conditions within the building.30 e. AC Roe told GM Goulbourne and GM Welch that there were problems with communications.31 f. AC Roe agreed that firefighters could wear BA more often than permitted by existing policy, but directed that officers should keep a close eye on the physical condition of the firefighters they were deploying into the building.32 Before leaving the tower, AC Roe told them that, if there were any doubt about the structural integrity of the building, they must withdraw all crews and assess the position before deploying firefighters into the tower again, if it was safe to do so.33 He gave similar instructions to GM O’Neill and DAC O’Loughlin.34 18.14 At about that time AC Roe gave two briefings to the BA crews waiting to be deployed from the bridgehead. The thrust of those briefings was twofold: first, that despite the dangers they faced, they had a moral duty to those trapped in the tower to try to rescue them; secondly, that as they were working outside the normal limits of procedures in relation to the number of times they would be deployed in BA equipment, they had a personal responsibility to take care of themselves and their BA partners.35 Firefighter activity in the tower (c. 03.30 – c. 03.45) 18.15 The following are examples of what firefighters were doing in the tower between around 03.30 and 03.45. 24 AC Roe record of actions [MET00005405] p. 4. 25 AC Roe record of actions [MET00005405] p. 5. 26 AC Roe record of actions [MET00005405] p. 5. 27 AC Roe record of actions [MET00005405] p. 5; Roe second witness statement [MET00010065] p. 2. 28 AC Roe record of actions [MET00005405] p. 5. 29 AC Roe record of actions [MET00005405] p. 6. 30 AC Roe record of actions [MET00005405] p. 6. 31 AC Roe record of actions [MET00005405] p. 6. 32 AC Roe record of actions [MET00005405] p. 6. 33 AC Roe record of actions [MET00005405] p. 6. 34 AC Roe record of actions [MET00005405] p. 6. 35 AC Roe record of actions [MET00005405] pp. 7-8.

The Grenfell Tower Inquiry: Phase 1 Report 424 a. FFs Alan Sime and Ernest Okoh tallied out at 03.27.35 and 03.29.26 with instructions to fight the fire on floor 5.36 When they got there, a hose was already in place wedging open the door from the stairs into the lobby.37 They entered the lobby to carry out a right-hand search. The first flat they found was alight so they began to spray the fire with water within the lobby. FF Sime described the fire as “relentless” and their efforts failed to extinguish the flames.38 By that time, they were fighting the fire lying on their stomachs.39 Visibility was down to one foot and they could not see their hands.40 b. FFs Matthew Harold, David Friend and Richard Peacock tallied out at 03.31.09, 03.31.21 and 03.32.51 with instructions to carry out search and rescue operations from the ground floor upwards having originally been briefed to go to Flat 203 on floor 23. The firefighters were informed that their briefing had been changed just before they went under air.41 Having searched floor 4 (where they found no casualties), they went to floor 5, where they broke into each of the flats. Again, no casualties were found.42 c. FFs James Cuthbert, Dean Lawrence, Methusael Sonson and Michael Wood were also deployed to carry out search and rescue on those floors. They tallied out between 03.46 and 03.47.43 d. During that time, BA crews were helping casualties down the stairs and out of the tower. 18.16 Although it is not possible to be more precise, it was at about that time that DAC O’Loughlin informed GM Welch that AC Roe was the incident commander and DAC O’Loughlin the operations commander. In addition, GM Welch was told that AC Roe had ordered all remaining FRU and EDBA resources to the scene in order to ensure a ready supply.44 DAC O’Loughlin was satisfied as a result of his discussion with GM Welch that firefighters were being deployed on search and rescue operations to those people or flats about which they had specific information.45 GM Welch’s considered view was that by that time they were pushing safety to the limits; crews were deployed to floors above the fire but without water, which was not available. Crews were also working until the alarm sounded on their BA sets. Informative message sent to the control room (03.45) 18.17 At 03.45.31 the following informative message was sent from CU8 to the control room:46 “ … From AC Roe. A residential block of 24 floors. 25 by 25, two-five by two-five metres. fire from the second to the 24th floor. Approximately one hundred, one zero-zero individuals involved. F-S-G major incident declared. High-rise procedure implemented. TL, ALP, EDBA, main control. Ground monitors, five jets. Safety cordon in place. Tactical Mode Oscar.” 18.18 At 03.52.58 CU8 sent a message to the control room seeking the estimated time of arrival of EDBA. The response, at 03.53.15, was that the last information they had was that EDBA would be arriving in an hour.47 36 Sime witness statement [MET00010896] p. 6. 37 Sime witness statement [MET00010896] p. 7. 38 Sime witness statement [MET00010896] p. 7. 39 Sime witness statement [MET00010896] p. 7. 40 Sime witness statement [MET00010896] p. 7. 41 Harold witness statement [MET00010073] p. 3. 42 Harold witness statement [MET00010073] p. 4; Rice witness statement [MET00008038] pp. 9-10. 43 [LFB00023326]. 44 AC Roe record of actions [MET00005405] p. 8. 45 O’Loughlin witness statement [MET00012563] p. 21. 46 ORR v 0.7 pp. 317-318; SIL at 03.48.14, p. 25. 47 ORR v 0.7 pp. 326-327.

Part II | Chapter 18: Period 9: 03.30-04.00 425 18.19 At 03.58 the Commissioner confirmed that EDBA sets could be worn more than once, although that involved a departure from established practice.48 All EDBA sets were ordered to the incident. That order reflected AC Roe’s own assessment of the need for BA, having visited the tower and considered the reports of GM Goulbourne and Welch. At the same time, DAC Lee Drawbridge was appointed Sector Commander, Command Support. Firefighter activity inside the tower (c. 03.45 – c. 04.00) 18.20 The following are examples of what firefighters were doing in the tower between around 03.45 and 04.00. a. According to the LFB’s telemetry data, nine firefighters tallied out from the bridgehead during this period.49 One example of the deployments made during this period of 15 minutes is the instruction given to CM Paul Gray and FFs Daniel Pegram, Gary Hiscock, Benjamin Holehouse and Alan Hudson to carry out search and rescue operations on floor 9. They tallied out between 03.58 and 03.59.50 Although they did not carry water, they were allocated an SDBA crew to protect their means of escape, if the need should arise. b. CM Aldo Diana and FF Dean Nelson tallied back in at the bridgehead at 03.53.51 They informed the entry control officer that they had been unable to reach Flat 133 (floor 16) as they had helped a number of casualties out and down the stairs.52 c. As the crew ascended from floor 4 to floor 5, the heat and smoke had been intense. The smoke logging worsened: on floor 4, the smoke was said to have been wispy to thick, but on floor 5 it was so dense that firefighters could not see in front of them.53 FFs Cuthbert, Sonson, Lawrence and Wood searched floor 5, but the evidence of which flats they searched and whom, if anyone, they found is inconclusive. The crew’s “end of wear times” were between 04.02 and 04.12.54 3 Conditions in the tower and the movement of occupants Floor 23 Flat 204 18.21 The last call from Hesham Rahman received by any of the emergency services began at 03.20.3155 and lasted 2 minutes and 38 seconds.56 There followed two 999 calls from a caller who identified herself as Hesham Rahman’s daughter. In the first of those calls, timed at 03.38.26, the caller told CRO Angie Gotts that Hesham Rahman had not been able to leave his flat and was now struggling to breathe.57 In the second call, timed at 04.01.02, the caller told CRO Sarah Russell that Hesham Rahman was not responding at all any more. When the caller had last spoken to him, she could hear that he was struggling to breathe.58 The caller is likely to 48 Cotton witness statement [MET00012492] pp. 20-21. 49 [LFB00023326]. 50 [LFB00023326]. 51 [LFB00023326]. 52 Diana witness statement [MET00018800] p. 12. 53 Cuthbert witness statement [MET00012878] p. 5. 54 [LFB00023326]. 55 [LFB00000420]. 56 Mobbs Exhibit AM/1 [LFB00004695]. 57 [LFB00000584]. 58 [LFB00000596].

The Grenfell Tower Inquiry: Phase 1 Report 426 have been Anna Krivsoun who said she called 999 on Hesham Rahman’s behalf. Anna Krivsoun last spoke to Hesham Rahman at 03.43. On this occasion, she could hear him coughing and struggling to breathe. She kept trying to call Hesham Rahman after this call but the phone was ringing without answer until around 06.00. At this point it stopped connecting.59 Flat 203 18.22 I have described the circumstances in which the last known contact was made with those in Flat 203. Rania Ibrahim and her two daughters, together with Isra Ibrahim and her mother, Fathia Ahmed Elsanousi, died in Flat 203.60 The body of Abufras Ibrahim, the son of Fathia Ahmed Elsanousi and brother of Isra Ibrahim, was found outside the tower.61 He had sheltered with his mother and sister in Flat 203. Based on AC Roe’s contemporaneous note, it was at some time between 03.39 and 04.06 that Abufras Ibrahim fell from the tower. His body landed on the south side of the tower close to the walkway connecting it to Grenfell Walk. The body was subsequently moved by firefighters.62 Floor 22 Flat 193 18.23 The final call from Flat 193 was made at 03.24.02.63 It lasted 14 minutes and 40 seconds and was taken by CRO Peter Duddy. By this time, Naomi Li and Lydia Liao had left the tower.64 CRO Duddy asked how many people were left in the flat. The caller told him that there were 12 adults and seven children, but in fact there were five adults and six children.65 They were all members of two families: Nadia Choucair and Bassem Choukair, their three children, Mierna, Fatima and Zainab Choucair and Nadia Choucair’s mother, Sirria Choucair, and Nura Jemal and Hashim Kedir and their three children, Yaqub, Firdaws and Yahya Hashim. 18.24 It is likely that the caller was Hashim Kedir.66 The call began with him telling CRO Duddy that they were trapped in Flat 193.67 As it continued, CRO Duddy repeatedly advised that their only chance of survival was to cover their faces with wet cloths and make for the stairs. The option of a helicopter was not possible.68 The caller said that those in Flat 193 had tried to leave, but had been unable to do so because of the smoke. With the fire approaching the flat, it was difficult to breathe or see anything. He said that they could not reach the door, let alone the staircase.69 18.25 Towards the end of the call, CRO Duddy again tried to persuade the caller to leave and was again told that it was not possible. The caller then called out “I love you” to others in the room, probably his children.70 59 Krivsoun witness statement [MET00039926] pp. 1-2. 60 MPS DVI report [MET00012528] p. 2 61 MPS DVI report [MET00012528] p. 53. 62 AC Roe record of actions [MET00005405] p. 5; O’Loughlin witness statement [MET00012563] p. 20; Murphy witness statement [MET000080587] p. 3; Cook witness statement [MET00007948] p. 9; Reynolds witness statement [MET00010894] pp.7-8; Stern witness statement [MET00012483] pp. 22-24. 63 [LFB00000422]. 64 Annex A. 65 [LFB00000422] p. 4. 66 Duddy Day 42/239/4-10. 67 [LFB00000422] p. 2. 68 [LFB00000422] pp. 2, 3, 5-9. 69 [LFB00000422] p. 2, 3, 5, 6, 8, 9. 70 [LFB00000422] p. 8.

Part II | Chapter 18: Period 9: 03.30-04.00 427 18.26 The call ended at 03.37.42. It is the last known contact with the occupants of Flat 193. All the eventual 11 occupants of Flat 193 were found and identified there.71 Flat 194 18.27 At 03.31.23, a CRO from Kent FRS spoke to Anthony Disson, who said that he was now on the stairs.72 That appears to have been the last contact anyone had with him. He did not make any further 999 calls. Cordelia Disson, in a 999 call timed at 03.46.42, said that she had not heard any further from him.73 Alfie Disson’s partner, Chanade Prentice, told an MPS operator in a call at 03.54.00 that they had not had contact with him for the past half an hour.74 18.28 Anthony Disson was later found in the stairwell on floor 18.75 Floor 21 18.29 As I have said, Marcio Gomes’s last 999 call had begun at 03.25.45.76 It was taken by CRO Heidi Fox. By that time conditions in Flat 183 had worsened. It was no longer possible to stand comfortably because of the smoke, which was still coming in around the front door.77 While the call was in progress the two families sheltering in Flat 183 left and made their way down the stairs. 18.30 At the start of the call Marcio Gomes told CRO Fox that it was not possible to leave and that they had already tried three times. She told him that she would try to make them a priority.78 At about this point he told her that the fire had reached his home. His bedroom was opposite the front door. When he gave evidence Marcio Gomes said that, standing in front of his bedroom door, he had seen flames around the frame of the closed bedroom window, the glass of which had still been intact. Flames had begun to burn the curtain and other items in the bedroom. They had spread quickly along the ceiling of the bedroom.79 18.31 Everyone in Flat 183 covered themselves with wet towels. They opened the front door and made their way to the stairwell. It did not take long to cross the lobby to the stairwell door. Helen Gebremeskel went first followed by Andreia Perestrelo, then the three children and finally Marcio Gomes.80 Helen Gebremeskel recalled that the lobby had been so dark that she could not see the light. She was familiar with the location of the stairs because she regularly used them. She pushed open the stairwell door and immediately became aware of the heat in the stairwell. It got hotter as she made her way down, although she could still use the handrail.81 Andreia Perestrelo compared the conditions in Flat 183 before they left to a dry sauna. It was not possible to see anything in the lobby which was also as hot as a sauna. She could smell smoke and plastic and chemicals burning.82 71 MPS DVI report [MET00012528] p. 5. These were Sirria Choucair, Bassem Choukair, Nadia Choucair, Mierna Choucair, Fatima Choucair, Zainab Choucair, Hashim Kedir, Nura Jemal, Yahya Hashim, Firdaws Hashim and Yaqub Hashim. 72 [LFB00000660]. 73 [LFB00000661]. 74 [INQ00000293]. 75 DVI report [MET00012528] p. 6. 76 [LFB00055501]. 77 Gomes Day 71(Fri)/87/6-24. 78 Gomes Day 71(Fri)/92/3-93/24. 79 Gomes Day 71(Fri)/32/17-33/1; Day 71(Fri)/94/15-96/21. 80 Gomes Day 71(Fri)/97/4-102/23. 81 Gebremeskel Day 68/181/3-184/5. 82 Perestrelo first witness statement [IWS00000349] p. 11.

The Grenfell Tower Inquiry: Phase 1 Report 428 18.32 Marcio Gomes thought that there was little difference between the conditions in the stairs and those in the lobby. He too compared the heat to a sauna. It was a dry and intense heat. He could not see anything and was shouting encouragement to the group who he assumed were ahead of him. Breathing became more difficult and his eyes were stinging. He used the handrail when making his way down and kept as low as possible. The handrail was hot to the touch but not hot enough to burn. The density of the smoke did not change as he went down.83 18.33 Helen Gebremeskel recalled that, from the start, she could feel water on the floor of the stairs. There was thick black smoke in the stairwell. The smoke made her feel dizzy and she thought she would lose consciousness. Helen Gebremeskel could not remember a moment when it had been easier to breathe. Although she was struggling, she did call out to her daughter. She also heard Marcio Gomes shouting, but at some point she ceased to hear him. It was only when she reached about floor 1 or 2 that she found fresh air.84 18.34 CRO Fox continually encouraged Marcio Gomes to go on, noting at times to a colleague that he was struggling for breath. He kept urging his daughters to continue making their way down.85 Although he shouted out to his daughters, it was difficult for him to get enough air to do so.86 There came a point when he thought that his wife and daughters were behind him. He could see little or nothing, but thought they were a floor above him. By that stage he was not listening to what CRO Fox was saying. He called out to them, stopped and then began making his way back up. He went up about one flight. To encourage his daughters, he shouted out to them that there was better air further down, but he did so just to keep them moving down. There had in truth been no improvement in the breathability of the air on the stairs at that point.87 18.35 CRO Fox told Marcio Gomes that he was a priority.88 At about that time he noticed a light on the stairs and ran down. He met a firefighter whom he told about his daughters. He believed that had been at about floor 8. It was at that level or the one above that the smoke became thinner. A firefighter told Marcio Gomes that they would get his daughters. He therefore began to descend again. He then stood and waited and had a conversation with another firefighter who asked him which flat and floor his family had started from.89 He thought he had reached floor 4 or below when he saw firefighters carry his oldest daughter and Helen Gebremeskel’s daughter out. The air was breathable at that level.90 18.36 When he reached the mezzanine Marcio Gomes decided that he had to go back up the stairs to find his wife and his other daughter. He recalled that he had been panicking, which made his breathing more laboured. He did not go very far up the stairs before a firefighter took him out of the tower.91 Outside, with the assistance of police officers, Marcio Gomes was able to find his wife and daughters.92 83 Gomes Day 71(Fri)/102/24-115/13; Gomes first witness statement [IWS00001078] p. 31. 84 Gebremeskel Day 68/182/11-187/15. 85 [LFB00055501] pp. 9, 10, 11, 12. 86 Gomes Day 71(Fri)/116/3-7. 87 Gomes Day 71(Fri)/116/18-126/25; Gomes first witness statement [IWS00001078] p. 32. 88 [LFB00055501] p. 19. 89 Gomes Day 71(Fri)/127/7-131-136/15. 90 Gomes Day 71(Fri)/136/6-139/12. 91 Gomes Day 71(Fri)/139/13-148/19. 92 Gomes first witness statement [IWS00001078] pp. 34-35; Perestrelo first witness statement [IWS00000349] p. 13.

Part II | Chapter 18: Period 9: 03.30-04.00 429 18.37 The group came out of the tower at different times between 03.37 and 03.55, Marcio Gomes being the last of his family to leave at 03.55.01.93 Although he did not know it, his family was probably ahead of him throughout their descent. 18.38 For her part, Helen Gebremeskel became separated from her daughter during their escape from the tower. When she reached the outside, she looked for her daughter and eventually learnt that she had been taken to hospital.94 Floor 16 18.39 At 03.33.46, having returned to Flat 133 after what had been his third attempt to leave, Sener Macit made another 999 call,95 which was answered by CRO Gotts. Sener Macit told her that he and his wife had tried to leave three times. CRO Gotts advised him again to leave, to which he responded that they had nearly died when they had tried before. At that time, there was no fire in the flat, but it was all around and smoke was coming into the flat.96 The conditions in Flat 133 were almost the same as those in the lobby; it was still just about bearable in the living room.97 18.40 Sener Macit believed that he had made another 999 call, in which he had again been advised to leave and in which he had said that he and his wife would not survive in the smoke. He recalled that the operator had told him that if he did not try then he would not survive in his flat.98 However, there is no record of any such call having been made to any of the emergency services. 18.41 Sener Macit then heard cracking sounds and saw the windows on the south side of his living room shatter. Flames entered the living room. Hanife Macit saw the fire had reached one of the bedrooms. When Sener Macit looked into the other bedroom he saw that the curtains, bed and wardrobe were on fire. Paint was melting and dripping from the bedroom ceiling. He told his wife that they would have to leave and could not come back. They then doused themselves with buckets of water and left their home.99 18.42 The conditions in the lobby that the Macits encountered on this final attempt to leave were as before. It was very hot; they could not see for thick black smoke and had to feel their way to the stairwell.100 When Sener Macit pushed opened the stairwell door, he and his wife found that conditions were the same as in the lobby. The handrail felt hot to the touch. They struggled to breathe, although both had wet cloths over their faces. The smoke made them cough constantly. They came across the bodies of other people on the stairs. As he descended, Senet Macit counted the floors. At floor 10 he encountered two firefighters, one of whom looked as though he were about to faint. They did not acknowledge his shouts for help. Sener Macit thought that the smoke lessened below floor 10 and by floor 8 visibility became better. As they reached the ground floor, firefighters assisted them out of the building.101 Sener and Hanife Macit left the tower at 03.47.15 and 03.47.16.102 93 Annex A. 94 Gebremeskel first witness statement [IWS00000933] pp. 10-11. 95 [LFB00000423]. 96 Sener Macit second witness statement [IWS00001156] p. 5 and first witness statement [IWS00000069] p. 17. 97 Sener Macit Day 65/175/9-25. 98 Sener Macit Day 65/175/17. 99 Sener Macit first witness statement [IWS00000069] pp. 17-18 and second witness statement [IWS00001156] p. 5; Sener Macit Day 65/179/9-18; Hanife Macit [IWS00000904] p. 12. 100 Sener Macit first witness statement [IWS00000069] p. 18; Sener Macit Day 65/176/13-179/5; Day 65/181/9-13; Hanife Macit [IWS00000904] p. 12. 101 Sener Macit first witness statement [IWS00000069] pp. 19-21; Sener Macit Day 65/179/22-182/16; Hanife Macit [IWS00000904] pp. 12-13. 102 Annex A.

The Grenfell Tower Inquiry: Phase 1 Report 430 Floor 15 18.43 At 03.31.47 Christos Fairbairn in Flat 124 called 999.103 The call, which was taken by CRO Pam Jones, lasted 21 minutes and 34 seconds.104 Christos Fairbairn was alone in the kitchen.105 He reported that the lights had gone out, but later said that they had come back on.106 He thought that the fire was above him.107 The fire had not reached his flat, but it was full of thick smoke.108 During the call he repeatedly told CRO Jones that he was experiencing difficulty breathing.109 He told her that the stairs were full of smoke.110 18.44 CRO Jones tried repeatedly to persuade Christos Fairbairn to leave and told him that he had to do so.111 He was hesitant to leave because the smoke was too thick.112 He had tried before, but had nearly fainted because of the smoke and thought that if he tried again he would die.113 He told CRO Jones of a previous attempt to leave, in which he had managed to reach the stairs but had then been forced to retreat because there had been too much smoke.114 At the end of the call, he told CRO Jones that he would try again to leave. She remained on the line until the connection was cut.115 18.45 In preparing to give his evidence to the Inquiry, Christos Fairbairn did not feel able to read the transcripts of the calls he had made to the emergency services or listen to recordings of those calls.116 In his witness statement he described what can only have been his last call and his leaving the flat. He remembered the flat filling up with smoke and deciding that he had no choice but to make a run for it.117 18.46 He found the lobby on floor 15 full of smoke. With a wet t-shirt over his face, Christos Fairbairn then felt his way across the lobby and pushed the stairwell door open.118 There was even more smoke in the stairwell than in the lobby. He ran down the stairs and described the conditions as “going through fog”. He could not see through the smoke but could smell and taste it. He was not aware of anyone else, except on one occasion when he tripped and fell to the floor. He saw the body of a man with long hair, of large build and of Middle Eastern appearance.119 18.47 Christos Fairbairn thought that he had first seen light at about floor 3. There had been less smoke at that stage. He was feeling faint and calling for help. Two firefighters carried him down to the ground floor.120 Christos Fairbairn left the tower at 03.54.26.121 103 [LFB00000424]. 104 Mobbs Exhibit AM/1 [LFB00004695]. 105 [LFB00000424] pp. 11, 12, 23. 106 [LFB00000424] pp. 14, 16. 107 [LFB00000424] pp. 6, 10. 108 [LFB00000424] p. 14. 109 [LFB00000424] pp. 4, 7, 21, 27. 110 [LFB00000424] p. 2. 111 [LFB00000424] pp. 2-6, 8, 11, 15, 17-19, 21-22, 24, 26. 112 [LFB00000424] pp. 10-11, 13, 15, 16. 113 [LFB00000424] pp. 6, 8, 9, 12, 13, 21, 22. 114 [LFB00000424] pp. 24-25. 115 [LFB00000424] pp. 28-30. 116 Fairbairn first witness statement [IWS00001025] p. 8. 117 Fairbairn first witness statement [IWS00001025] pp. 4-5. 118 Fairbairn first witness statement [IWS00001025] p. 6. 119 Fairbairn first witness statement [IWS00001025] pp. 6-7. 120 Fairbairn first witness statement [IWS00001025] p. 7. 121 Annex A.

Part II | Chapter 18: Period 9: 03.30-04.00 431 Floor 11 18.48 At 03.33.46 Natasha Elcock in Flat 82 rang 999 again. She spoke to AOM Debbie Real.122 She told her that her flat was now full of smoke and that the fire had reached her daughter’s bedroom and the living room.123 When AOM Real told her to leave, she replied that she had tried, but had been unable to do so. She did not know if the stairs were safe and the “front door” (meaning the lobby) was full of smoke and “baking hot”.124 The bath had been left running and firefighters were using hoses on the building. The floor of the flat was now wet.125 Natasha Elcock asked for firefighters to be sent to the flat.126 AOM Real told Natasha Elcock that she should remain in the flat until firefighters arrived, but that if the fire began to affect those in the flat, they would need to leave.127 Asked by Natasha Elcock if firefighters had stopped evacuating people, AOM Real said that they were in the building and trying to get to all the floors.128 18.49 Flat 82 had two bedrooms, both facing south. Natasha Elcock’s daughter had the bedroom closest to the living room; her own bedroom was opposite the front door.129 At the time she made this call, Natasha Elcock was lying on the floor of her bedroom with her daughter. She was still receiving information from outside about the spread of the fire. She could see pieces of cladding falling past the bedroom window. The fire was in the panelling adjacent to the window. Natasha Elcock knew that the fire had reached her daughter’s bedroom because her partner had put a fire out in that room. It was getting warmer and smokier in the flat.130 18.50 Asked about the advice to leave, Natasha Elcock said that she had resigned herself to the fact that she was going to die. She had expected firefighters to reach her flat by now. She had given up but she knew she had to get out for the sake of her children.131 Floor 10 Flat 73 18.51 I referred earlier in this Narrative (Periods 7 and 8) to a 999 call between Ann Chance and CRO Mitch Samson from Kent FRS which started at 02.57.32. The call was still continuing at 03.31,132 at which time Ann Chance was still in Flat 73 with her cousin, mother and aunt. Later they moved to the living room.133 Adam Supareogsanond (identified by Ann Chance during the call as her brother) was shouting from the window to attract attention.134 Ann Chance told the CRO that she could see flames and debris outside the window. Smoke was coming through the front door into the flat. They were still unable to close the front door properly and the smoke had reached the living room.135 The smoke in the lobby was still thick and hot.136 Ann Chance reported that it was becoming cloudy in the living room. They were sitting 122 [LFB00000425]. 123 [LFB00000425] pp. 2-3, 5. 124 [LFB00000425] pp. 3-5. 125 [LFB00000425] pp. 5-6, 10-11. 126 [LFB00000425] pp. 7, 8, 9. 127 [LFB00000425] pp. 5-8. 128 [LFB00000425] p. 11. 129 Elcock Day 70/5/13-6/2; Elcock Exhibit NE1 [IWS00000306] p. 1. 130 Elcock Day 70/94/23-97/11. 131 Elcock Day 70/97/12-98/10. 132 [LFB00055505]. 133 [LFB00055505] p. 39. 134 [LFB00055505] pp. 33-35, 37. 135 [LFB00055505] pp. 42, 45-47, 50; Ann Chance first witness statement [IWS00000783] p. 7. 136 [LFB00055505] p. 52.

The Grenfell Tower Inquiry: Phase 1 Report 432 on the floor with the smoke at ceiling height. Later in the call she reported that the whole flat was cloudy.137 Ann Chance was aware that the firefighters were spraying the tower with water and said that she could feel the jets of water.138 18.52 Throughout the second part of this call, the advice from CRO Samson concentrated on measures such as blocking doors and windows and using wet towels.139 He told Ann Chance that Kent FRS had made the LFB aware of the situation.140 18.53 While Ann Chance was speaking to Kent FRS, other members of her family called 999. CRO Duddy took a call at 03.51.19 from Adam Supareogsanond. CRO Duddy made it clear from the start that the only option for the family was to leave the flat and make for the stairs.141 Adam Supareogsanond told CRO Duddy that they had been told to stay and were now being told to get out,142 how they had tried to get out several times,143 and how, when they had opened the front door, the heat in the lobby was “very powerful”.144 He said that when they opened the front door smoke would come in,145 that they could not see the stairs146 and that one member of the family was disabled.147 CRO Duddy repeated his advice to leave. 18.54 At around 04.00, Ann Chance, who was still talking to CRO Samson in the Kent FRS control room, told him “I’ve got the Fire Brigade saying I have to go down, I don’t have a choice … they’re telling me I have to go now”.148 That reflected the advice that other members of her family had been given by CRO Duddy in the LFB control room. He had told them that they had to get out and that it was their only choice.149 18.55 I return to the culmination of these two calls in Period 10 of this Narrative. Floor 7 18.56 The CCTV footage from the camera on floor 7 shows that the lobby became completely smoke-logged at around 03.35.150 4 Events in the control room 18.57 Between 03.30 and 04.00, the control room received 20 emergency calls. Half of them were from members of the public, many of whom reported that they could see people trapped in the tower signalling for help by waving, shouting or flashing lights. The rest of the calls were from residents trapped in the tower or family members and friends of residents who were passing on information about their location. CRO Sharon Darby did not send any radio messages to CU7 with FSG call information during this period. 137 [LFB00055505] pp. 54-55, 62-63. 138 [LFB00055505] pp. 59, 61, 67. 139 [LFB00055505] pp. 40, 42-45, 50-51, 65, 71-73. 140 [LFB00055505] pp. 48, 56, 70. 141 [LFB00000426]. 142 [LFB00000426] pp. 5-6. 143 [LFB00000426] pp. 2, 3, 6. 144 [LFB00000426] pp. 2, 3. 145 [LFB00000426] pp. 5, 10. 146 [LFB00000426] p. 11. 147 [LFB00000426] p. 7. 148 [LFB00055505] p. 4. 149 [LFB00055502]. 150 03.01.00 [INQ00010923]; 03.35.39 [INQ00010925]; 03.36.45 [INQ00010924].

Part II | Chapter 18: Period 9: 03.30-04.00 433 Requests for DSE 18.58 At 03.31.04, CRO Gotts completed the service request for the attendance of a DSE, representatives of the gas and electricity suppliers and a LALO. The service request had been created over an hour and 13 minutes earlier at 02.17.26 as a result of a request from CU8.151 CRO Gotts had already made a call to RBKC at 03.17.21 asking for a DSE and a LALO to attend the incident.152 18.59 At 03.36.21, someone on CU8 sent a radio message to control asking for the estimated time of arrival of a DSE. He asked for a contact number so that they could get in touch with the DSE directly and offered “blue light” assistance because his attendance was a matter of priority.153 CRO Darby added a message to the incident log at 03.37.32 containing the same information. 18.60 At 03.40.43, CRO Gotts called RBKC again and spoke to the same operator (Ashley). CRO Gotts emphasised the urgency of the matter and asked for an estimated time of arrival for the DSE.154 However, the RBKC operator could not provide one or a direct contact number. CRO Gotts offered “blue light” assistance and explained to Ashley that it was “a real emergency”, but she could not offer anything further.155 18.61 At 03.48.20, CU8 sent another radio message to the control room seeking further information about the attendance of a DSE.156 At 03.48.56, CRO Darby responded, saying that they had been in touch with RBKC several times but that it had not been possible to obtain a contact number.157 CU8 asked the control room to tell RBKC that it was vital that a DSE be obtained.158 18.62 As a result, at 03.48.57 CRO Gotts called RBKC again using the admin line. She spoke to an operator named Errin and asked once more for a DSE to attend and for an estimated time of arrival. CRO Gotts told Errin that they had a Major Incident at Grenfell Tower and really needed a DSE. In response, Errin told her that they had been making every effort to get hold of a DSE and were still doing so, and that she would “escalate” the matter.159 CRO Gotts responded by saying that they would ask the London Resilience Group for help.160 18.63 At 03.49.25 and again at 03.50.46, CRO Darby sent radio messages to CU8 explaining that they were going to contact the London Resilience Group to ask for a DSE.161 OM Alexandra Norman instructed CRO Gotts to page the London Resilience Group asking them to make contact with the Officer of the Watch.162 18.64 At 03.57.44, SOM Joanne Smith spoke to Matthew Hogan at the London Resilience Group and asked him to arrange for a DSE to attend the incident as they were having problems with the local council.163 She offered blue light assistance. She told him that the building might collapse 151 SIL p. 22. 152 SIL p. 24; Admin line call [INQ00000211]. 153 ORR v 0.7 p. 311. 154 [INQ00000210] p. 2. 155 [INQ00000210]. 156 Radio message [LFB00002843]. 157 Radio message [LFB00002880]. 158 [LFB00002735]. 159 [INQ00000212]. 160 Control admin line [INQ00000212]. 161 Radio messages [LFB00002605]; [LFB00002019]. 162 Norman witness statement [MET000080589] p. 8. 163 ORR v 0.7 p. 331.

The Grenfell Tower Inquiry: Phase 1 Report 434 at any moment.164 Matthew Hogan said he would give them a call.165 At 04.01.27, AOM Real noted in the incident log that the London Resilience Group had responded by telling them to contact RBKC.166 18.65 At 04.52.18, Matthew Hogan spoke to SOM Smith in the control room and confirmed that an engineer was now on site and had been given the details of AC Richard Mills.167 He could not give the engineer’s name. SOM Smith thanked him and told him that they would pass the message on to the command unit.168 Continuation of events in the control room 18.66 At 03.31.47, CRO Jones took a call from Christos Fairbairn in Flat 124 on floor 15 that lasted 21 minutes and 34 seconds.169 By that point Christos Fairbairn had already spoken to the LAS twice and North West FRS once, and he had also made two calls to the LFB control room.170 He explained that he could not breathe and that the stairs were “full up with smoke”. CRO Jones repeatedly told him to get wet towels to cover his mouth and nose and to feel his way down the stairs and out of the building.171 At the end of the call she said: “Right, Christos. Please, I really need, I really need you to go. I really need you to try. If you’re saying it’s that bad, I really need you try. You’ve got to go out there and try.”172 18.67 At 03.33.46, CRO Gotts spoke to Sener Macit in Flat 133 on floor 16, who reported that he and his wife had tried three times to get out but that they had run back inside as there was “so much smoke, we couldn’t come out”.173 He had been advised at 02.41.31 by CRO Fox to leave the flat, but he had called back three times since that call saying that he and his wife could not leave.174 Their daughter had also called the control room to report that her parents were on floor 16 and could not breathe.175 CRO Gotts told him that he should try to get out, but, when Sener Macit said they could not get out she told him to block out the smoke and said that she would let the firefighters know that they were in the flat.176 18.68 At exactly the same moment, AOM Real took a call from Natasha Elcock in Flat 82 on floor 11.177 That was Natasha Elcock’s thirteenth 999 call, having previously spoken to the Essex FRS control room and the LFB control room. Natasha Elcock said that her flat was full of smoke and that there was a fire in the bedroom and the front room.178 AOM Real told her to leave, but Natasha Elcock said that she had already tried and could not. Natasha Elcock asked her to take the flat and floor number. AOM Real did so and then advised her that if she could not get out, she should stay in the flat as long as she possibly could with all the gaps blocked 164 ORR v 0.7 p. 331. 165 ORR v 0.7 p. 331. 166 SIL p. 26. 167 ORR v 0.7 p. 382. 168 ORR v 0.7 p. 382. 169 [LFB00000424]. 170 [INQ00000384]; [LFB00000648]; [MET00018759]; [LFB00000690]; [LFB00000415]; [INQ00000385]; [LFB00000421]. 171 [LFB00000424]. 172 [LFB00000424] p. 29. 173 [LFB00000423] p. 3. 174 [LFB00000372]; [LFB00000382]; [LFB00000398]; [LFB00000416]. 175 [LFB00000560]. 176 [LFB00000423] pp. 5-6. 177 [LFB00000425]. 178 [LFB00000425] pp. 2-3.

Part II | Chapter 18: Period 9: 03.30-04.00 435 up and lie on the floor with something over her mouth.179 AOM Real then assured Natasha Elcock that she would tell the firefighters where they were and that the firefighters were trying to get to all of the floors.180 18.69 At 03.42.49, CU8 contacted CRO Darby to ask for the urgent attendance of a radio engineer to assist with channel 2, one of the channels on the fireground radios, which AC Roe wanted to set up as the command channel.181 The radio engineer, Robert Donovan, had been monitoring the incident since 01.43.31, when he had been contacted by AOM Real. At 03.44.37, CRO Darby created a service request in the incident log which was revised at 03.55.04, and at 03.55.27 Robert Donovan was assigned to attend the incident.182 He confirmed that he was on his way at 04.03.52.183 18.70 At 03.45.31, CU8 sent an informative message to the control room on behalf of AC Roe.184 It was the first informative message AC Roe had sent since he had taken over as incident commander at 02.44.18, and it was only the third informative message providing the control room with details of the incident.185 It was recorded in the SIL at 03.48.17.186 18.71 At 03.51.19, CRO Duddy received a call from members of the Supareogsanond family (Adam and Waewta) in Flat 73 on floor 10.187 CRO Duddy told them that they needed to cover themselves with wet towels and clothes and leave the flat. When the caller explained that his mother and aunt were in the flat and were scared he said: “I know they’re scared, OK, but you have to tell them this is their only choice”. He continued to repeat the same advice in the same direct language, explaining that they had to leave immediately, until the call ended.188 18.72 At 03.53.10, CRO Yvonne Adams received a call from Saba Araya who was outside the tower. She had called about her sister, Meron Woldeselassie Araya, who was trapped in Flat 74 on floor 10 with Lina Hamide.189 CRO Adams advised that they needed to leave the flat. Meron Woldeselassie Araya told CRO Adams that she had spoken to the police earlier on who had told them that they should not leave the flat. CRO Adams explained that the advice had changed and they needed to get out of the building.190 Meron Woldeselassie Araya told her that the door of the flat was jammed. CRO Adams told her that she would pass that information on to the crews and they needed to block out the smoke.191 The entry for Flat 74 on the right‑hand whiteboard in the control room has the phrase “door jammed” next to it, indicating that CRO Adams had given the information to SM Jason Oliff to relay to the incident ground.192 179 [LFB00000425] p. 8. 180 [LFB00000425] p. 11. 181 ORR v 0.7 p. 315; Johnson witness statement [MET00013235] p. 10; AC Roe record of actions [MET00005405] p. 3. 182 SIL pp. 25, 14. 183 SIL p. 14. 184 The informative message came by way of a series of radio messages which were then repeated back in two radio messages by CRO Darby: [LFB00003044] and [LFB00002750]. 185 SIL pp. 23-25. 186 SIL p. 25. 187 Control Report pp. 139-140; [LFB00000426]. 188 [LFB00000426] pp. 4-13. 189 [LFB00000592]. 190 [LFB00000592] p. 5. 191 [LFB00000592] p. 6. 192 Whiteboard Oliff Exhibit JAO/5 [MET00016906].

The Grenfell Tower Inquiry: Phase 1 Report 436 18.73 At 03.57.28, Donna Bonifacio, the daughter-in-law of Elpidio Bonifacio, who was trapped in Flat 83 on floor 11 called the control room and spoke to CRO Russell.193 That was her second 999 call. She told CRO Russell that she had spoken to her father-in-law and had passed on to him the advice to get out and go down the stairs that she had been given during her previous call, but, she said, he needed help and could not get out on his own.194 CRO Russell confirmed that the message had been passed to the crews, but said that she would remind them.195 However, the information on the whiteboard relating to Flat 83 was not altered as a result of that call.196 5 Actions of the MPS, the LAS, RBKC and the TMO 18.74 During this period, police officers at the scene continued to generate messages about individuals trapped in the building. For example, at 03.47.36 an officer sent a message to MetCC informing it that two adults were trapped in Flat 113 on floor 13.197 18.75 At 03.37 Nickolas Layton called David Kerry shortly after the first TCG meeting had finished. He gave him the latest information on the situation and told him that one corner of the building was in danger of collapse.198 In his evidence, he accepted that that had not alerted him to the urgent need for the attendance of a DSE, but conceded that it should have done so.199 He accepted that he had not responded to AC Roe’s request for a DSE at that stage, despite the fact that at the first TCG meeting AC Roe had asked for a DSE to attend. It is possible, however, that he had not heard AC Roe’s request on that occasion.200 18.76 At 03.38.06 the NPAS helicopter reported that the roof of the tower was “becoming very hot” and sought confirmation from the LFB that those flats had been evacuated. 18.77 As I have said, at 03.40.43 and again at 03.48.57 CRO Gotts spoke to RBKC and urged them to hasten the attendance of a DSE, emphasising the urgency, but at that stage RBKC had not been able to obtain anyone. 18.78 At 03.58.03 Detective Superintendent Paul Warnett relayed the following message from Commissioner Cotton, which was sent by general radio broadcast from the police incident control room at Lambeth:201 “THE ADVICE FROM THE LFB IS TO TRY AND SELF-EVACUATE, THERE IS NO GUARANTEE THAT THE LFB WILL BE ABLE TO GO IN AND EVACUATE PEOPLE DUE TO THE SAFETY OF THE BUILDING AND POSSIBLE COLLAPSE.”202 18.79 That message was prompted by a discussion that Detective Superintendent Warnett had had with Inspector Nicholas Thatcher a little earlier as a result of the latter’s concern that not all officers at the scene had heard or understood the message broadcast at 03.10.56 informing them about the change in the LFB’s advice. His concern arose from having heard a series of radio messages about the locations of trapped residents.203 The message had not been heard by Commander Neil Jerome, because he had still been on his way to Lambeth when it had 193 [LFB00000593]. 194 [LFB00000593] p. 3. 195 [LFB00000593] p. 5. 196 Whiteboard [MET00016906]. 197 CAD 482 p. 23. 198 David Kerry’s Emergency Event Log, entry 10 [RBK00028849]. 199 Layton Day 74/50/1-4. 200 Layton Day 74/49/5-50/4. 201 Jerome witness statement [MET00023286] pp. 11, 12 paragraph 39; Warnett witness statement [MET000080605] p. 11. 202 CAD 482 p. 28; Acting Inspector Thatcher’s body-worn video [INQ00000527]. 203 Thatcher second witness statement [MET00023284] p. 10; Thatcher Day 71(Mon)/131/1-132/11.

Part II | Chapter 18: Period 9: 03.30-04.00 437 been broadcast. Indeed, he had not received any messages about the change in advice to residents during the entire period between the end of his calls with Chief Inspector Duane Barrett at 02.40 or 02.45 and his arrival at Lambeth at 04.10.204 18.80 During this period, the only TMO employee previously at the incident, Hash Chamchoun, was joined by a number of senior TMO managers. Robert Black was unable to say with certainty at what time he had arrived, believing that it had been at around 02.30, but he sent an email at 03.26.45205 (corrected time) to colleagues informing them of the fire and saying “I am going in”. He sent that email from his handheld device while on his way to the incident.206 That broadly accords with the evidence given by other witnesses. Hash Chamchoun placed Robert Black’s arrival at around 03:30 and recalled having received a call from him asking to be collected from the police cordon.207 On arrival at the incident, Robert Black spoke to Hash Chamchoun who introduced him to Nickolas Layton.208 Nickolas Layton said he believed Robert Black had arrived between 03.30 and 03.45.209 18.81 Teresa Brown, Director of Housing for the TMO, put the time of her arrival at the incident at 03.50 on the basis of her cab receipt.210 204 Jerome Day 71(Mon)/202/19-204/2. 205 Email included as part of chain [TMO10036956]. 206 Black Day 74/160/15-16; 161/20. 207 Chamchoun Day 75/155/13-21. 208 Black Day 74/169/11-21. 209 Layton Day 74/36/14. 210 Brown Day 75/61/8-12.

The Grenfell Tower Inquiry: Phase 1 Report 438

439 Chapter 19 Period 10: 04.00-05.00 1 External fire spread 19.1 At 04.02 the fire on the south and west faces began converging at the top of the southern corner of the west face between columns C1 and D1, although at that time a small gap could still be seen between the two flame fronts, as shown in the following image:1 Figure 19.1 1 Professor Bisby supplemental report [LBYS0000001] p. 222 sections 1054-1056; Fig. 146 p. 227.

The Grenfell Tower Inquiry: Phase 1 Report 440 19.2 By 04.03 Flats 64, 74, 84, 94, 104 and 114 lower down on the west face had been affected by the diagonal movement of the fire between floors 9 and 14.2 19.3 By 04.08 the flames had converged at the top of the west face, between columns C1 and D1, as can be seen from this image taken from the footage captured at that time by the NPAS helicopter:3 Figure 19.2 19.4 At about the same time, the flames spread down columns C1 and D1 on the west face and on the south-west corner column, as can be seen from this image taken after 04.08:4 2 Dr Lane supplemental report [BLAS0000012] p. 12. 3 Professor Bisby supplemental report [LBYS0000001] p. 222 section 1057, Fig. 147 p. 227. 4 Professor Bisby supplemental report [LBYS0000001] p. 188 Fig. 109.

Part II | Chapter 19: Period 10: 04.00-05.00 441 Figure 19.3 19.5 By 04.31 Flat 73 on floor 10 and Flats 24, 34, 44 and 54 on floors 5 to 8 on the west and south- west faces of the tower respectively had become involved.5 19.6 By 04.44 Flats 43, 53 and 63 on floors 7 to 9 at the south-west corner of the building had been engulfed by the flames. 5 Dr Lane supplemental report [BLAS0000012] p. 12.

The Grenfell Tower Inquiry: Phase 1 Report 442 2 Events on the incident ground SM Peter Wolfenden’s FSG role in the ground floor lobby 19.7 As noted in Period 8, by around 04.00 SM Wolfenden was in the ground floor lobby, overseeing or assisting WM Glynn Williams and WM Paul Watson in the management of FSG information. WM Williams recalled that at around 04.00 the system had changed: instead of using runners to carry slips of paper, radio communication was established between SM Wolfenden and CU7 for the transfer of FSG information.6 19.8 At some point after SM Wolfenden had begun dealing with FSG information (although it is not possible to say precisely when) there was a discussion between the officers in the lobby managing that information and those at the bridgehead on the other side of the glass doors on the ground floor to whom it had to be conveyed. The discussion appears to have resulted from a concern that some BA crews were being briefed by WM Watson as they waited in the lobby but were being given a second, contradictory, briefing when they reached the bridgehead and were about to be deployed. The evidence relating to that discussion is patchy and does not enable me to make any more detailed findings about who was involved in it or when exactly it took place. The fact that concerns were voiced about such matters is significant, however, because there is evidence that at about that time BA crews who had initially been briefed to carry out rescue operations were given different instructions shortly before they left the bridgehead. Examples can be found in the deployments of CM Jamie Mayne and FF Marcus Lundquist and FFs Matthew Harold, Richard Peacock and David Friend. Deployment of SM Gareth Cook to floors 16 and 18 19.9 At 04.04.27 SM Cook tallied out from the bridgehead accompanied by CM Ben Gallagher.7 Following an earlier conversation between GM Patrick Goulbourne and GM Richard Welch, it had been decided that an experienced officer should be sent to investigate reports of 10 people trapped in one flat on floor 16 and 11 people trapped in another on floor 18. At some point between floors 6 and 12, SM Cook’s alarm sounded and CM Gallagher’s air level was also low.8 They decided to return to the bridgehead. Their “end of wear” times were 04.28.56 and 04.29.26.9 SM Cook was, therefore, unable to provide GM Goulbourne and GM Welch with any information about the occupants of the flats on floors 16 and 18, their physical condition or smoke conditions on those floors. It is worth noting, however, that the FSG information does not support the suggestion that so many people remained trapped on those floors at that time. AC Andrew Roe’s return to CU8 19.10 At 04.06 or thereabouts AC Roe returned to CU8 from his inspection of the tower.10 The Commissioner told him of her decision to allow firefighters to wear BA equipment more than once and of her order to call all those trained to wear EDBA to the incident.11 AC Roe, in turn, briefed her on his assessment of conditions inside the tower. He reported that the cladding and filler panels were burning and that there had been some spalling of concrete on what were described as the building’s “outer edges”, but his conclusion was that the tower’s 6 Williams Day 31/152/23-153/8. 7 [LFB00023326] p. 3. 8 G. Cook witness statement [MET00007882] pp. 14-15; Goulbourne witness statement [MET00010759] p. 7. 9 [LFB00023326]. 10 Roe witness statement [MET00007520] p. 8. 11 Cotton witness statement [MET00012492] pp. 20-21; Roe Log [MET00005404].

Part II | Chapter 19: Period 10: 04.00-05.00 443 structure, and in particular its core, remained sound.12 On the basis of what he had seen, AC Roe’s considered view was that, despite those conditions, and having regard to the 2004 Act13 and the Human Rights Act 1998, he was justified in continuing to commit crews into the building.14 Arrival of EDBA cylinders and sets 19.11 At 04.08.40 the control room sent CU8 a message to confirm that 78 EDBA cylinders with 48 sets had arrived at the fire ground (but not necessarily at the pre-ordained rendezvous point at Ladbroke Grove).15 AC Roe’s instructions to DAC Lee Drawbridge 19.12 DAC Drawbridge had earlier arrived at the scene and, in his role as Sector Commander for Safety, had reported to CU1, which was parked on Latimer Road. Unable to make radio contact with CU1, AC Roe went to CU1 at around 04.11 to brief DAC Drawbridge directly. The Commissioner remained on CU8.16 19.13 DAC Drawbridge’s instructions from AC Roe were, essentially, twofold. As an immediate priority he was to identify the available resources on the fire ground and find out how they were being deployed. In particular, he was to liaise directly with DAC Andrew O’Loughlin to find out how quickly BA resources were being used up.17 On the basis of the information he had obtained, he was to decide the nature and scale of the immediate requirement for relief crews and to report to AC Roe, who would make the necessary order and send the message to the control room.18 19.14 AC Roe returned to CU8 by way of the tower and BA main control.19 In the tower, at 04.22 he received a briefing from DAC O’Loughlin, the gist of which was recorded in his log.20 In short, AC Roe was told that there were no “active” FSG calls, but that the most recent had been on floors 7-9. The Roe Log also recorded a briefing from GM Michael Mulholland, who reported that EDBA crews had reached floor 10 and SDBA crews had been committed to floors 4 and 5 and 7 to 9.21 19.15 GMs Goulbourne and Welch also told AC Roe that BA crews were being deployed to floors 12 and 13.22 He instructed them to deploy SDBA crews as much as possible to follow behind EDBA crews, in order to make the best use of resources.23 He reiterated his view that the structure was sound and that they could therefore continue to commit crews. 19.16 Having visited BA main control, AC Roe was satisfied that this was “working well”, although he did not recall whether he had asked the officers in charge about the turnover of EDBA specifically. Firefighters were resting and cylinders were being stockpiled at a supply dump. He estimated there were 100 or so firefighters congregated in the holding area, so he gave 12 AC Roe record of actions [MET00005405]. 13 This has been defined in the Overview Chapter. 14 Roe witness statement [MET00007520] p. 9. 15 ORR v 0.7 p. 339. 16 Roe witness statement [MET00007520] p. 9. 17 Roe witness statement [MET00007520] p. 9. 18 Roe witness statement [MET00007520] p. 9. 19 Roe witness statement [MET00007520] p. 9. 20 Roe Log [MET00005404]. 21 Roe Log [MET00005404] p. 3. 22 Roe witness statement [MET00007520] p. 9. 23 Roe witness statement [MET00007520] p. 9.

The Grenfell Tower Inquiry: Phase 1 Report 444 them the latest information. He repeated his assessment that the building was sound and that, despite the difficult conditions, it was appropriate to continue to commit firefighters into the building in order to try to rescue those still trapped inside the tower.24 Arrival of UK Power Networks 19.17 At 04.11.40 the control room sent a message to CU8 to confirm that UK Power Networks had arrived on site.25 Firefighter activity inside the tower (c. 04.00-04.15) 19.18 The following are examples of what firefighters were doing inside the tower during the period between around 04.00 and 04.15: a. According to the LFB’s telemetry data, 5 (or perhaps 626) firefighters tallied out under air during this period.27 Between 04.12 and 04.14, or thereabouts, FFs Steven Page and Michael Worman together with FFs Oliver Desforges and Richard Mitchell, were deployed, first to fight the fire on floor 4 and then to find a working hose and proceed to floor 5 to fight the fire there.28 They were also directed to protect access routes for crews coming in and out of the tower.29 b. CM Paul Gray’s crew entered the lobby on floor 9, where visibility was said to be “about two feet”.30 Three flats on floor 9 were found to be empty.31 As they were searching a fourth flat, the crew received a priority radio message which was difficult to hear but which CM Gray interpreted as a direction to go up to floor 11.32 He did not hear why they were being sent to floor 11, but when they got there and entered the lobby, CM Gray encountered what he described as “extreme heat” and knew that “almost every flat on that floor was on fire”.33 CM Gray recalled that when he had stood up to speak to the crew he had instantly felt the heat on the back of his neck through his flash hood.34 As he had no firefighting equipment, CM Gray decided that the conditions were too dangerous to go further, so he instructed his crew to leave the lobby. c. At around 04.02, on his return to the bridgehead, FF Michael Wood told the bridgehead that floor 5 had been searched and was clear.35 d. FFs James Cuthbert and Methusael Sonson were instructed by radio to go to Flat 84 on floor 8, but soon after receiving the message their radio no longer worked. FF Sonson described that as “quite daunting”, as they could not make contact with entry control or anyone else and had no firefighting media.36 At around floor 10 (the precise location is not clear), they both heard cries for help. On entering the lobby on floor 10 they found the flats on the left-hand side of the lobby alight. The crew found two women in the 24 Roe witness statement [MET00007520] p. 9; AC Roe record of actions. 25 ORR v 0.7 p. 342. 26 The lack of clarity is due to corrupted data in the telemetry sheet. 27 [LFB00023326]. 28 [LFB00023326]. 29 E.g., Worman witness statement [MET00012575] p. 10. 30 Gray witness statement [MET00010806] p. 9. 31 These are thought to be Flats 61, 62 and 63. 32 Gray witness statement [MET00010806] p. 10. 33 Gray witness statement [MET00010806] p. 10. 34 Gray witness statement [MET00010806] p. 11. 35 Wood witness statement [MET00010928] p. 15. 36 Sonson witness statement [MET00010824] p. 8.

Part II | Chapter 19: Period 10: 04.00-05.00 445 lobby and brought them down the stairs.37 They were probably Lina Hamide and Meron Woldeselassie Araya, judging by the descriptions given by FF Cuthbert. Firefighter activity inside the tower (c. 04.15-04.30) 19.19 The following are examples of what firefighters were doing inside the tower during the period between around 04.15 and 04.30: a. FFs Page and Worman tallied out at 04.12.02 and 04.12.08 and reached floor 4 where they found a firefighting branch and hose. They conducted a right-hand search of the floor and found a flat, believed to be Flat 16, fully alight. Due to low water pressure, the crew were unable to extinguish even small pockets of fire. Using a thermal imaging camera they searched for casualties, but did not find any. Once they had completed their search of floor 4, FFs Page and Worman went to floor 5, where they searched the flats to which they were able to gain entry.38 b. FFs Desforges and Mitchell tallied out at 04.14.1239 having been told to break in doors and fight fire.40 They also reached floor 4, where they also found a hose and carried out a right-hand search of the floor. Both firefighters said that low water pressure had prevented them from effectively containing or extinguishing fires in the flats, all of which were completely alight. The pair left floor 4 and made their way to floor 5. As before, they carried out a right-hand search, but found no casualties. They then went up to floor 6 where, again, they carried out a right-hand search and found no casualties. FF Desforges’ alarm sounded, so they returned to the bridgehead.41 c. CM Melchizedek Anderson, FFs Dean Abbess, Robert Chart and Paul Harris were deployed to Flats 81, 82, 83 and 84 on floor 11. They tallied out at times between 04.19.01 and 04.22.52.42 On their way up the stairs, the crew found a female casualty, now known to be Khadija Saye.43 As they were unable to contact the bridgehead by radio, FFs Chart and Harris returned to the bridgehead to inform them of the casualty and to seek assistance.44 d. Soon after, a second crew of four firefighters (FFs Parvinder Singh, Paul Howard, Craig Edwards and Anthony Welden) were also deployed to search Flats 81 to 84 on floor 11. GM Goulbourne specifically briefed the crew that a mother and child were in Flat 82 in need of rescue.45 The crew tallied out from the bridgehead between 04.27.24 and 04.30.52.46 e. CM Gray’s crew had “end of wear times” between 04.22.25 and 04.23.28. CM Gray briefed GM Goulbourne about the deployment. f. CM Anderson and FF Abbess continued to floor 11. When they reached the level of the lobby, the heat was so intense that they could not enter it. They decided to go up to floor 12 and, once there, they conducted a right-hand search. They tried, but failed, to 37 Cuthbert witness statement [MET00012878] p. 10; Sonson witness statement [MET00010824] p. 9. 38 Worman witness statement [MET00012575] p. 11. 39 The LFB telemetry data has no entry for FF Richard Mitchell’s tally out time. 40 FF Richard Mitchell’s telemetry data is corrupted and his precise tally out time is unknown. As to instructions, refer to Richard Mitchell witness statement [MET000086063] p. 6. 41 Richard Mitchell witness statement [MET000086063] p. 6; Desforges witness statement [MET00008013] p. 6. 42 [LFB00023326] p. 3. 43 FF Harris believes that it might have been about floor 9, witness statement [MET000083298] p. 9, which is consistent with her being recovered from the lobby on floor 9: MPS DVI report [MET00012528] p. 11. 44 Paul Harris witness statement [MET000083298] p. 10. 45 Welden witness statement [MET00012574] p. 7. 46 [LFB00023326] p. 3.

The Grenfell Tower Inquiry: Phase 1 Report 446 break down the door of Flat 96, but by chance they met another crew who took over the attempt while they moved on to Flat 95. They gained entry to Flat 95 and carried out a search, but found no casualties. By that time FF Abbess was exhausted, so they decided to return to the bridgehead.47 g. Another crew consisting of four firefighters (CM Ian Barritt, FFs Robbie Gentry, Donovan Reid and David De Costa), were deployed to search floor 9.48 The crew tallied out from the bridgehead at times between 04.35.02 and 04.38.30.49 The second TCG meeting (04.34) 19.20 The Commissioner chaired the second TCG meeting while AC Roe was making his way back from CU1 by way of the tower and BA main control.50 The meeting started at 04.34; AC Roe arrived shortly after at 04.35 or thereabouts.51 The Commissioner reported that the DSE was on his way “under blue lights”. AC Roe provided the meeting with his assessment of the situation. He told those present that BA crews were reaching floors 12 and 13 and that there were many casualties. A 20-pump relief had been ordered and it was important to maintain discipline because falling debris was a danger. RBKC reported that rest centres had been set up on Shepherd’s Bush Green. The MPS said that 30 police officers were at the scene. The meeting concluded at 04.50.52 Request for fuel for pumping appliances 19.21 At 04.35.58 CU8 sent a message to the control room asking for an OSU to be sent with diesel to re-fuel the appliances. As all OSUs were at the incident, the control room suggested that one should be released to collect the necessary fuel.53 Firefighter activity in and around the tower (c. 04.30-04.45) 19.22 The following are examples of what firefighters were doing in and around the tower during the period between around 04.30 and 04.45: a. GM Goulbourne instructed FFs Alan Hanlon and Richard Benaicha to fight the fire on floor 5 and protect access and egress for those firefighters carrying out rescues.54 They tallied out at 04.40.17 and 04.40.18.55 They reached floor 4, which, although smoky, showed no signs of continuing fire.56 FF Benaicha recalled that, as he had gone up the tower, visibility had not been a problem until he reached floor 5.57 b. GM Goulbourne briefed FFs Ian Moore and Russell Hall to go to floor 11 in response to an FSG call.58 47 Anderson note [MET00005480]. 48 Barritt witness statement [MET000083284] p. 4. 49 [LFB00023326] p. 3. 50 Roe Log [MET00005404] and AC Roe record of actions [MET00005405]. 51 Roe witness statement [MET00007520] p. 10. 52 Roe witness statement [MET00007520] p. 10. 53 ORR v 0.7 pp. 361-362. 54 Benaicha witness statement [MET00012774] p. 10. 55 [LFB00023326]. 56 Alan Hanlon witness statement [MET00012549] p. 5. 57 Benaicha witness statement [MET00012774] p. 10. 58 Ian Moore witness statement [MET00010081] p. 6.

Part II | Chapter 19: Period 10: 04.00-05.00 447 c. Although deployed to floor 9, CM Barritt and FFs Reid, Gentry and Da Costa went to floor 11.59 They entered the lobby and started to carry out a left-hand search of the flats on that floor. As they entered the lobby, they saw Natasha Elcock, her daughter and her partner, Anthony Smith, leaving the first flat on the left. They escorted them to the stairs and took them down.60 d. Outside the tower, the crew of A245 were helping a casualty who could be seen from a window. 19.23 It is also clear that, around this time, decisions were being made not to deploy BA crews beyond certain upper floors in the tower. A photograph of one of the whiteboards on CU7 records the following: Figure 19.4 19.24 SM Wolfenden recalled that the officers in the ground floor lobby had discussed the second note regarding floor 11. SM Wolfenden also remembered that he, SM Daniel Egan and WM Williams only became aware of this decision about an hour after it had been made by the officers at the bridgehead. SM Wolfenden asked for the decision to be recorded. Arrival of the DSE 19.25 The Roe Log records that the DSE arrived at the leisure centre at 04.51 in preparation for providing advice about the structural integrity of the tower.61 59 Although CM Barritt and FF Gentry said they went to floor 12, FF Da Costa said in his CN [MET00005452] that they went to floor 11 which is the more likely, given whom they rescued. 60 Barritt witness statement [MET000083284] p. 4. 61 Roe Log [MET00005404]; Roe witness statement [MET00007520] p. 10.

The Grenfell Tower Inquiry: Phase 1 Report 448 UK Power Networks 19.26 At around 04.53, a representative of UK Power Networks arrived at CU8. In response to a question from AC Roe as to whether there was any particular hazard associated with the building, he said that there was a sub-station in the tower’s basement which supplied three other tower blocks. AC Roe concluded that, as the basement was not involved in the fire, the sub-station should remain in operation in order to provide lighting for operational crews and in the ground floor lobby.62 Information about resources 19.27 At around 04.53 SM Mulholland informed AC Roe about the current use of resources.63 AC Roe’s contemporaneous log recorded that 20 EDBA and 15 SDBA sets were in use every hour. EDBA crews were deployed up to floor 12 and SDBA crews were deployed up to floor 7. 19.28 At about that time AC Roe again asked for a PPV fan to clear smoke from the lobby and he asked the crew on the command unit why they still did not have plans of the building.64 A response was recorded in the Roe Log at 04.53 that “CU staff report building plans should be in fire box in the lobby”. As to this request, as noted in Period 8, AC Roe recalled having asked for plans at the 03.20 meeting, but the note of the 04.53 meeting was the first mention of plans to be recorded in the Roe Log. He also asked whether there was sufficient space to deploy an ALP.65 GM Mulholland said that he would pass the question about the deployment of an ALP to DAC O’Loughlin for an answer. The crew of the command unit confirmed that no plans were recorded on the ORD, but that a set should be in a premises information box in the lobby on the ground floor. AC Roe ordered that information to be sent to the fire sector and made a note to repeat his request for plans to RBKC’s LALO at the next TCG meeting.66 Firefighter activity inside and outside the tower (c. 04.45-05.00) 19.29 The following are examples of what firefighters were doing inside the tower during the period between around 04.45 and 05.00: a. FFs Hanlon and Benaicha, who had tallied out at 04.40.17 and 04.40.18, reached floor 5 where they found a discarded fire hose in the stairwell. They entered the lobby and carried out a right-hand search. The entrance door of the first flat which they found (probably Flat 26) was locked, so they moved to the next flat (probably Flat 25). They were able to enter it and found a fire, on which they sprayed water. By that stage FF Benaicha’s air was running low, so they left. As they did so, they banged on the front doors of the other flats on floor 11 and shouted through the letterboxes. There were no answers. As their alarms had sounded, they returned to the bridgehead. Their “end of wear time” is recorded as 04.59.30 and 04.59.51.67 b. FFs Moore and Hall reached floor 11. As they entered the lobby, the conditions were very hot. FF Hall checked the temperature on the TIC he was carrying, which showed a reading of 1,000°C.68 They went down low so that they could search the floor. They were unable to identify the numbers of the flats. In each case they made a noise to attract 62 Roe witness statement [MET00007520] p. 10; AC Roe record of actions [MET00005404]. 63 Roe witness statement [MET00007520] p. 10; [MET00005404]; AC Roe record of actions. 64 Roe witness statement [MET00007520] p. 10. 65 Roe witness statement [MET00007520] p. 10; AC Roe record of actions. 66 Roe witness statement [MET00007520] pp. 10-11. 67 [LFB00023326] p. 3. 68 Russell Hall witness statement [MET00012548] p. 7.

Part II | Chapter 19: Period 10: 04.00-05.00 449 attention, but there was no reaction from inside any of the flats. They left and made their way to floor 12.69 c. CM Paul Charity and FFs Nicky Sanders and Leslie Tucker were briefed to search Flats 81 to 84 on floor 11 and Flats 92, 94 and 95 on floor 12.70 The crew tallied out between 04.47.18 and 04.50.02.71 They searched floor 11 first, then floor 12, before returning to floor 11.72 FF Sanders recalled that the thermal imaging camera indicated that the temperature in the lobby on floor 11 was 1,000°C.73 FF Sanders tried to call the bridgehead by radio to ask for hose and water but the radio was not working.74 When they reached floor 12, they found the lobby door wedged open by an enforcer, but conditions were not as severe as those they had encountered on floor 11.75 The crew searched the flats to which they had been deployed, but found no casualties. d. Sometime during this period, FFs Singh, Howard, Edwards and Welden, who had been sent to floor 11, realised that they had gone to floor 12 by mistake and went back down to floor 11. FF Welden tried to enter the lobby on floor 11 but found the conditions too intense for him to go any further. As a result, the crew withdrew and went back down the stairs.76 e. FFs Kylei Holmes-Lewis and Richard Knight were briefed to go to floors 4 to 6 in order to fight the fire and search for any remaining occupants. They tallied out between 04.49.30 and 04.50.17. They searched floor 4, but found no casualties. FF Holmes-Lewis thought that floor 5 was smokier than floor 4. He noticed that on the left-hand side there was relatively little damage, whereas on the right-hand side all the flats were on fire. The crew searched all the flats but found no casualties. They then went to floor 6.77 f. FFs William Boulton, Dillesh Devani, Lawrence Pitt and Mark Beer were instructed to go to floor 12 to search for and rescue occupants. They were directed that, if they met another crew on floor 12, they were to move up to floor 13, which in due course they did. When they reached floor 13, they entered the lobby and carried out a right-hand search. The front door of the first flat they found was locked. Using a sledge-hammer and an enforcer, FF Boulton made a hole in it, reached through the hole, found the handle and opened it. As he went into the flat, he was confronted with extreme heat; his thermal imaging camera recorded a temperature of 1,000°C. However, FF Pitt was able to check the rooms in the flat.78 3 Conditions in the tower and the movement of occupants 19.30 At 04.00, occupants from floors 10, 11 and 14 were still in contact with the control room or with friends and family outside the tower, but there was no further contact with occupants above floor 14. 69 Ian Moore witness statement [MET00010081] p. 7. 70 Charity witness statement [MET00010790] p. 4. 71 [LFB00023326] p. 3. 72 Nicky Sanders witness statement [MET00010067] pp. 8-10. 73 Nicky Sanders witness statement [MET00010067] p. 10. 74 Nicky Sanders witness statement [MET00010067] p. 10. 75 Nicky Sanders witness statement [MET00010067] p. 9. 76 Welden witness statement [MET00012574] p. 9. 77 Holmes-Lewis witness statement [MET00015005] pp. 11-14. 78 William Boulton witness statement [MET00013222] pp. 6-8.

The Grenfell Tower Inquiry: Phase 1 Report 450 Contact with occupants on floor 14 19.31 Zainab Deen had remained in Flat 113 with her son, Jeremiah, and her neighbours Mohammad Alhajali and Denis Murphy. I have already referred in Period 8 above to Zainab Deen’s last call to Francis Dean (during which CM Christopher Batcheldor spoke to her), which began at some time after 03.19 and lasted for more than an hour and a quarter.79 Francis Dean tried to call Zainab Deen again sometime after 05.00 after CM Batcheldor had returned the phone to him, but he was not able to speak to her.80 His phone call logs show that he tried to call her again at 05.13, but again unsuccessfully.81 CM Batcheldor’s conversation with Zainab Deen was therefore the last recorded contact she had with a person outside the tower. 19.32 Mohammad Alhajali’s last contact with his friends and family took place over the same time. As set out above, Omar Alhaj Ali called his brother after he had left the tower. He said he had made many calls to Mohammad Alhajali. He did not say at what time he had called his brother, but it had been before he was taken to hospital. When Omar Alhaj Ali was with paramedics outside the tower he tried to call Mohammad Alhajali, but he did not answer.82 He was not able to call Mohammad Alhajali from the hospital.83 The LAS Patient Report Form (LAS4), completed by the paramedics treating Omar Alhaj Ali, records that he was taken to hospital at 04.26 and arrived at King’s College Hospital at 04.45.84 Omar Alhaj Ali is likely to have spoken to his brother Mohammad Alhajali for the last time before 04.26 at the latest. The paramedic who had been called formally to declare that Mohammad Alhajali had died did so at 04.56.85 19.33 Omar Alhaj Ali said that friends and family had still been in contact with Mohammad Alhajali after he had been taken to hospital. He believed that was at around 05.00. He was told that his brother Hashem had been the last person to speak to Mohammad Alhajali. Hashem told Omar Alhaj Ali that during his last conversation with Mohammad Alhajali he had said that he had watched the others in the flat stop breathing.86 There was no further contact with Mohammad Alhajali after that conversation. 19.34 Mahmoud Al-Karad, who lived with Omar Alhaj Ali and Mohammad Alhajali, also called Mohammad. The last time he spoke to Mohammad Alhajali was at 03.19. After that, he found Omar Alhaj Ali and was with him when he spoke to Mohammad Alhajali. Mahmoud Al-Karad tried to call Mohammad Alhajali eight times between 04.26 and 05.05, but the calls went to voicemail.87 19.35 Ammar Alkabib,88 who was a friend of both Omar Alhaj Ali and Mohammad Alhajali, was in contact with Mohammad Alhajali during the night. He spoke with him two or three times and after he had seen Omar Alhaj Ali outside the tower. Ammar Alkabib said he had tried to persuade Mohammad Alhajali to leave the flat, but he was too frightened to do so. Ammar Alkabib’s last call with Mohammad Alhajali was at around 04.30. Mohammad Alhajali said that he was in the corner of the building where the water was being sprayed. They had stopped spraying the water and he asked the firefighters to continue doing so.89 79 Batcheldor first witness statement [MET00007511] p. 7; Batcheldor Day 34/164/21-34/172/4. 80 Dean first witness statement [IWS00001048] p. 7. 81 Dean Exhibit FD/1 [IWS00001048] p. 16. 82 Alhaj Ali first witness statement [IWS00000781] pp. 15-16. 83 Alhaj Ali first witness statement [IWS00000781] pp. 15-16. 84 Alhaj Ali LAS Report Form (LA4) [LAS00000113]. 85 Sibthorpe witness statement [MET00015658] p. 5; Sibthorpe Exhibit IPS/1 [MET00023228]. 86 Alhaj Ali first witness statement [IWS00000781] pp. 15-16. 87 Al-Karad first witness statement [IWS00000821] pp. 8-9. 88 He appears to have signed his witness statement in the name of “A Alkhtihatib” but the statement purports to be that of Ammar Alkabib. 89 Alkabib first witness statement [MET00021446] p. 2.

Part II | Chapter 19: Period 10: 04.00-05.00 451 19.36 Ammar Alkabib approached a firefighter who took him to the command unit to tell the crew about Mohammad Alhajali. He told a firefighter where Mohammad Alhajali was and that the firefighters had stopped spraying water on that part of the building. The firefighter told him that it was not his job and asked him to leave.90 19.37 Ammar Alkabib recalled receiving a call from the MPS after having tried to call 999. He said that he had told the CRO which floor Mohammad Alhajali was on and that he was still alive. The MPS called Ammar Alkabib at 05.08.43 and during the call Ammar Alkabib said that he had last spoken to Mohammad Alhajali an hour earlier. He gave them Mohammad Alhajali’s name, floor number and flat number. The MPS operator confirmed that the message had been passed on to the police in the area.91 19.38 At 05.05.57, an unidentified caller spoke to CRO Heidi Fox and reported that a member of his family was in Flat 113 with three children.92 He told CRO Fox that the person who had called him had said that the firefighters had stopped spraying his flat with water and that they needed help. CRO Fox confirmed that she would pass the information on. 19.39 Mohammad Alhajali was later found by WM Steven Collins and CM Jamal Stern by the gate leading to Grenfell Tower from Grenfell Walk.93 They moved him into a protected area inside the lobby of one of the walkways. They found no signs of life and called a paramedic.94 19.40 Denis Murphy was with Mohammad Alhajali and Zainab Deen in Flat 113 throughout that time. Timothy Murphy and his wife spoke to Denis Murphy several times during the night. He was unable to recall the precise times of the calls or what they spoke about.95 Denis Murphy’s sister Anne Murphy, and his son, Peter Murphy, had last spoken to Denis Murphy at 02.30. Anne Murphy continued to try to call Denis Murphy’s telephone until 06.00, but received no answer.96 It is not possible to tell with any confidence exactly when Denis Murphy died, other than that it must have been after around 02.45 when he was left behind in Flat 113 with Zainab and Jeremiah Deen and Mohammad Alhajali. Floor 11 Evacuation of Flat 82 19.41 After her penultimate 999 call at 03.33.46 Natasha Elcock had remained in her bedroom with her partner and daughter. At around 04.15, Natasha Elcock’s partner told them to move to her daughter’s bedroom as there was no smoke in there. There was grey smoke in her bedroom by that time, but she could still see clearly. She stayed in her daughter’s room briefly before moving to the front room where she called her sister, Denise Daly, who was outside the tower.97 19.42 At 04.33.41, Natasha Elcock called 999 for the last time.98 CRO Peter Duddy took the call and he advised her to leave. Natasha Elcock said that there was fire on the stairs and her husband had gone out there. She asked CRO Duddy: “Please, just – can someone just find out what’s 90 Alkabib first witness statement [MET00021446] p. 3. 91 [INQ00010915]. 92 [LFB00000611]. 93 Collins first witness statement [MET00010086] p. 10; Exhibit SMC/5 of WM Collins [MET00015914] pp. 20-29; CM Stern first witness statement [MET00012483]. 94 Collins first witness statement [MET00010086] pp. 10-11; CM Stern first witness statement [MET00012483] p. 25. 95 Timothy Murphy first witness statement [IWS00001049] p. 3. 96 Anne Murphy first witness statement [IWS00001126] pp. 2-4. 97 Elcock first witness statement [IWS00000310] pp. 6-7. 98 Transcript [LFB00000429]; Elcock Day 70/100/18-70/101/24.

The Grenfell Tower Inquiry: Phase 1 Report 452 going on, please?”.99 CRO Duddy told her that her only choice was to wrap wet clothes and towels around herself and to make her way to the stairwell. Natasha Elcock asked him to send someone to come and help them. She then said: “Just find – can you just [find] out if they’re coming? I’m safe in my house at the minute. Honestly, I’m safe in my house at the minute, but I need to know if someone’s coming to get me, if you could just find that out.”100 CRO Duddy repeated that her only choice was to make her own way out.101 19.43 Both before and after her call to CRO Duddy, Natasha Elcock spoke to her sister Denise Daly. Denise Daly said that she was with firefighter crews and they were on their way up to her. Natasha Elcock prepared to leave with her family. Her partner stood by the door shouting “Hello”. Her sister remained with the firefighters on the ground helping to guide them to the right flat. 19.44 When they left the flat the front room was full of grey smoke and was really warm,102 but it was still possible to see through the smoke. On leaving the flat the smoke in the lobby was thick and black.103 Natasha Elcock could not see anything through it. CM Barritt and FFs Gentry and De Costa were on floor 11 and they asked them to walk towards the torch.104 Natasha Elcock was not able to see the torch, but her partner could see it. She followed him to the stairwell.105 She described the stairs as being “pitch black” until she reached floor 7 or 6 where the lights were on and there was less smoke. The conditions in the stairwell were the same as in the lobby for the first three floors until it suddenly began to get brighter.106 Natasha Elcock left the tower at 04.47.22, her daughter and her partner being a few seconds ahead of her at 04.47.16 and 04.47.17. Flat 83 19.45 In the neighbouring flat, Elpidio Bonifacio waited to be rescued from Flat 83. His son Gordon had told him at around 02.00 that firefighters at the scene had said they would come and rescue him.107 His daughter-in-law Donna Bonifacio had also passed on advice from the control room to stay put.108 Elpidio Bonifacio felt that he had no choice but to wait for rescue because he had very impaired vision and was elderly.109 19.46 Elpidio Bonifacio could feel the heat in Flat 83 before the fire alarm sounded. He could also see flames going past the window. He saw the colour of the fire and heard burning, which started to spread into the sitting room. He was then forced to retreat to his bedroom. It was at that point, he said, that he had no longer been able to call his wife and son, because the telephone was in the sitting room.110 99 [LFB00000429] p. 4. 100 [LFB00000429] p. 5. 101 [LFB00000429] p. 4. 102 Elcock first witness statement [IWS00000310] p. 6; Elcock Day 70/103/3-70/105/3. 103 Elcock first witness statement [IWS00000310] p. 7. 104 Elcock first witness statement [IWS00000310] p. 7. 105 Elcock Day 70/105/2-70/106/22. 106 Elcock Day 70/106/4-22. 107 Bonifacio first witness statement [IWS00001085] p. 5. 108 Bonifacio first witness statement [IWS00001085] p. 5. 109 Bonifacio first witness statement [IWS00001085] p. 5. 110 Bonifacio first witness statement [IWS00001085] pp.5-6.

Part II | Chapter 19: Period 10: 04.00-05.00 453 19.47 Elpidio Bonifacio recalled that the last time he had spoken to his wife was at 01.30. However, his daughter-in-law called 999 at 04.41.00 and spoke to CRO Duddy. She told him that she had been speaking to Elpidio Bonifacio until 2 minutes earlier.111 That is more likely to be the time at which Elpidio Bonifacio lost telephone contact with his family by phone, and as such it is likely that he was forced to retreat to the bedroom at around 04.40. 19.48 Elpidio Bonifacio said in his statement that he had signalled for help from his bedroom window by waving a white towel. He had done so for about an hour. He had been able to feel the water from a firefighter’s hose at the window. The water had been cold, so he had moved away from the window for warmth but would have returned for fresh air.112 He remained in his flat throughout this period. Floor 10 Evacuation from Flat 74 19.49 Meanwhile the occupants of Flat 74, Lina Hamide and Meron Woldeselassie Araya, were in contact with friends, including Ililta and her partner Musie, another friend Tsehay and Meron Woldeselassie Araya’s sisters Saba, Feven and Ghenet, all of whom were by now outside the tower.113 Lina Hamide’s friends had consistently tried to encourage her to leave the tower. While on a call to Musie (Ililta’s partner who was using Ililta’s phone) at 03.55, Lina Hamide heard a man tell her that they could not guarantee to get Lina Hamide and Meron Woldeselassie Araya out. The man told her that Meron Woldeselassie Araya and Lina Hamide needed to leave themselves. Ililta told Lina Hamide after the fire that the man had been a police officer.114 19.50 Lina Hamide said that, until she had heard that, she had believed that firefighters would rescue them. After having heard that, however, she persuaded Meron Woldeselassie Araya that they must try to leave. Meron Woldeselassie Araya also spoke to her sister Saba Araya, who told her that she had to get out and that no one was coming to save them. Lina Hamide then told her friends that they were going to try to leave and asked them to tell the firefighters in the hope that they would come up and help them.115 Meron Woldeselassie Araya remained on the phone to her sister Saba Araya (who was using Ililta’s phone) from 04.03.48.116 19.51 Lina Hamide and Meron Woldeselassie Araya wrapped themselves in wet towels and duvets and went to leave.117 It took some time to open the front door, since they had to move the wet mattress and duvet that they had used to stop smoke coming in. When they opened the front door, the lobby was “pitch black” with thick smoke. Lina Hamide tried to use the torch on her phone but it made no difference.118 Lina Hamide and Meron Woldeselassie Araya made three attempts to leave the flat, but returned each time. The smoke in the lobby was too thick and the heat caused them to retreat.119 111 [LFB00000605]. 112 Bonifacio first witness statement [IWS00001085] pp. 5-6. 113 Hamide first witness statement [IWS00001175] p. 6. 114 Hamide first witness statement [IWS00001175] pp. 6-7. 115 Hamide first witness statement [IWS00001175] p. 7. 116 Meron Woldeselassie Araya first witness statement [IWS00001193] pp. 7-8. 117 Meron Woldeselassie Araya first witness statement [IWS00001193] p. 8; Hamide first witness statement [IWS00001175] p. 7. 118 Hamide first witness statement [IWS00001175] pp. 7-8. 119 Hamide first witness statement [IWS00001175] pp. 7-8; Meron Woldeselassie Araya first witness statement [IWS00001193] pp. 7-8.

The Grenfell Tower Inquiry: Phase 1 Report 454 19.52 Lina Hamide then spoke to Musie again at 04.03. He persuaded her to try again to leave.120 For the fourth time she left the flat with Meron Woldeselassie Araya.121 Meron Woldeselassie Araya recalled that they had left the front door open and that it did not close automatically.122 Lina Hamide said that she had not been able to touch the walls as they were burning hot. Meron Woldeselassie Araya recalled that she had been able to touch the walls, which were warm.123 19.53 Lina Hamide found the stairwell door after walking around the cupboard in the hallway. Meron Woldeselassie Araya followed her to the stairwell door after first having found the door to the rubbish chute room by mistake.124 19.54 When they reached the stairwell, there was less smoke than there had been in the lobby.125 Lina Hamide said that it was still difficult to breathe or see the stairs, although Meron Woldeselassie Araya recalled being able to breathe and see in the stairwell.126 On the stairs they met two firefighters who were coming down from a higher floor.127 Lina Hamide was able to walk down the stairs for about two floors before she collapsed. The firefighters carried her the rest of the way down.128 Meron Woldeselassie Araya said that one of the firefighters shut the stairwell door to the landing behind her. She then followed them down the stairs.129 19.55 Meron Woldeselassie Araya left the tower at 04.12.34 shortly before Lina Hamide, who left at 04.13.32.130 Flat 72 19.56 At some time between around 04.00 and 04.30, Antonio Roncolato made a second attempt to leave his flat.131 He put on a rucksack and used a wet towel to cover his nose and mouth. When he opened the front door there was a lot of black, thick, hot smoke. He immediately shut the door again. He could hear screaming and banging from the stairwell.132 It is possible that what he heard was Lina Hamide and Meron Woldeselassie Araya trying to find the stairwell. The conditions in the lobby on that occasion were the same as when he first opened the front door.133 He decided not to leave because he thought that he would not be able to breathe if he did.134 19.57 At about that time, he went to check his son Christopher Roncolato’s bedroom. Antonio Roncolato said that despite the window being closed, smoke was pouring into the room from the window. Flames were also crawling down the side of the window.135 He then took a photograph which he exhibited to his witness statement. 120 Hamide first witness statement [IWS00001175] pp. 7-8. 121 Hamide first witness statement [IWS00001175] pp. 7-8; Meron Woldeselassie Araya first witness statement [IWS00001193] pp. 7-8. 122 Meron Woldeselassie Araya first witness statement [IWS00001193] pp. 7-8. 123 Meron Woldeselassie Araya first witness statement [IWS00001193] pp. 8-9. 124 Meron Woldeselassie Araya first witness statement [IWS00001193] pp. 8-9. 125 Hamide first witness statement [IWS00001175] pp. 7-9; Meron Woldeselassie Araya first witness statement [IWS00001193] p. 9. 126 Hamide first witness statement [IWS00001175] pp. 7-9; Meron Woldeselassie Araya first witness statement [IWS00001193] p. 9. 127 FFs Cuthbert and Sonson. Cuthbert first witness statement [MET00012878] p. 10; Sonson first witness statement [MET00010824] p. 9. 128 Hamide first witness statement [IWS00001175] pp. 7-9. 129 Meron Woldeselassie Araya first witness statement [IWS00001193] p. 9. 130 Annex A. 131 Roncolato Day 52/52/14-52/53/22; Day 52/60/19-25. 132 Roncolato first witness statement [IWS00000894] p. 14. 133 Roncolato Day 52/60/25-52/62/10. 134 Roncolato Day 52/60/25-52/62/10. 135 Roncolato third witness statement [IWS00001109] p. 2.

Part II | Chapter 19: Period 10: 04.00-05.00 455 Figure 19.5 19.58 Soon after seeing the fire approaching his son’s bedroom window, water from outside the tower poured into his and Christopher Roncolato’s bedrooms, extinguishing the fire there.136 The water entered through a small vent at the top of the bedroom windows. Antonio Roncolato noticed that the fire went out immediately and the smoke slowly disappeared. He took a second photograph showing the water coming into his bedroom from outside the tower. 136 Roncolato first witness statement [IWS00000894] p. 14; 52/57/3-21.

The Grenfell Tower Inquiry: Phase 1 Report 456 Figure 19.6 19.59 Antonio Roncolato’s sister-in-law called 999 at 04.46.42.137 She spoke to CRO Pam Jones and told her that he was trapped in his flat. She said that he could not come out and that he wanted to wait until someone came to rescue him.138 She gave Antonio Roncolato’s phone number to CRO Jones, who said she would call him back. 19.60 At 04.49.59, CRO Jones called Antonio Roncolato back.139 He told her that he had tried to leave but that he could not do so because it was pitch black. He said that it was very smoky and that if he went out and descended 10 floors he was likely to die.140 He told CRO Jones that he was safe in his flat.141 He considered that he was safe because he had a little air coming into the flat through the window, although there was already a lot of smoke inside the flat.142 He also told CRO Jones that there had been fire around his floor but that it had now been put out. CRO Jones confirmed she would let the firefighters know where he was and that he could call her back. 19.61 The front door continued to stop smoke entering the flat.143 Antonio Roncolato said in evidence that the fact that no smoke was coming in through the front door and that the fire outside Christopher Roncolato’s bedroom had been put out by firefighters outside the tower helped to make him feel safe. Antonio Roncolato was not advised at the time to try and get 137 [LFB00000608]. 138 [LFB00000608]; [INQ00000374]. 139 [INQ00000372]. 140 [INQ00000372]. 141 [INQ00000372] p. 3. 142 [INQ00000372] p. 3. 143 Roncolato Day 52/61/13-52/61/15.

Part II | Chapter 19: Period 10: 04.00-05.00 457 out. He said that if he had been advised to do so, he would have assessed the conditions again. He also said that the CRO did not know how bad the conditions were at the time.144 Antonio Roncolato remained in the flat throughout this period. Flat 73 19.62 At this time, the occupants of Flat 73 were speaking to CROs from different fire and rescue services. Ann Chance was still speaking to CRO Mitch Samson at the Kent FRS; Adam Supareogsanond was speaking to CRO Duddy in the LFB control room. His call had begun at 03.51.19 and ended at 04.00.26.145 When it ended Ann Chance, while still on the telephone to Kent FRS, also spoke to CRO Duddy. He repeated his advice to the family that they had to get to the staircase. Ann Chance acknowledged that advice.146 19.63 Ann Chance then returned to her call with CRO Samson. She told him that the family had been advised to leave. CRO Samson said they should follow that advice. He agreed to stay on the line.147 The family then tried to leave. After what Ann Chance estimated as 3 to 4 minutes, she returned to the call with CRO Samson. She told him that the family had been unable to leave as there had been too much smoke and it had been too hot.148 CRO Samson then said that if the family could not leave they needed to go through the safety procedures they had been following.149 Ann Chance reported that the smoke in the flat was getting worse.150 In her witness statement she described thick, dark-grey smoke in the hallway of the flat.151 19.64 As the call continued, firefighters arrived at Flat 73.152 Ann Chance described a “wall of firemen” between the front door of Flat 73 and the stairwell door. The lobby was hot and dark, the only light coming from firefighters’ torches. They were accompanied by firefighters as they made their way down the stairs. The line to Kent FRS remained open throughout and once outside, Ann Chance confirmed to CRO Samson that she was safe.153 19.65 A video-recording made by the family during their descent of the stairs shows that there was smoke which cleared lower down.154 4 Events in the control room 19.66 After 04.00, the number of calls to the control room started to decrease. There were 18 emergency calls.155 Most of the calls came from relatives of persons trapped in the building and members of the public who reported that they could still see persons trapped in the tower signalling for help. There were only two calls with residents, one from Natasha Elcock in Flat 82 on floor 11 and a call back to Antonio Roncolato in Flat 72 on floor 10, each of whom reported that they were still trapped. There was one long FSG call still in progress between Ann Chance and CRO Samson in the Kent FRS control room.156 144 Roncolato 52/67/9-52/68/10. 145 [LFB00055502]; Andrew Mobbs Exhibit AM/1 [LFB00004695]. 146 [LFB00055505] p. 16; Ann Chance first witness statement [IWS00000783] p. 7. 147 [LFB00055505] pp. 19-22. 148 [LFB00055505] pp. 22-25; Ann Chance first witness statement [IWS00000783] p. 7. 149 [LFB00055505] pp. 10-11, 13. 150 [LFB00055505LFB00055502] p. 14. 151 Ann Chance first witness statement [IWS00000783] p. 7. 152 [LFB00055502] pp. 19-20. 153 Ann Chance first witness statement [IWS00000783] pp. 8-9; [LFB00055502] pp. 20-24. 154 [INQ00010921]; [INQ00010922]. 155 Control Report pp. 143-149. This does not include call-backs. 156 Control Report pp. 143-149.

The Grenfell Tower Inquiry: Phase 1 Report 458 19.67 Just after 04.01, Ann Chance and Adam, Waewta and Chalalai Supareogsanond tried to leave Flat 73 on floor 10.157 CRO Samson in Kent FRS remained on the phone with her. After they had tried to leave, Anne Chance told CRO Samson that they had returned to the flat because it had been “too hot” and her brother had heard people screaming.158 CRO Samson advised that if it was too hot and she could not get out then they would have to return to the room they had been in and go through the same safety procedures that he had discussed with her earlier.159 He remained on the phone with her until they were rescued.160 19.68 At 04.10.57, CRO Sarah Russell took a second call from Saba Araya about her sister Meron Woldeselassie Araya and Lina Hamide in Flat 74 on floor 10, to report that they had managed to open the front door and that they was making their way down the stairs.161 CRO Russell said she would pass the information to the crews and the entry for the flat on SM Jason Oliff’s right-hand whiteboard was changed in faint marker pen to read “making their way out down stairwell”.162 19.69 During this period, off-duty control room supervisors started to arrive in the control room, having been called in by SOM Adam Crinion.163 At around 04.15, AOM Kate Ranson arrived.164 At around 04.28, with the approval of DAC Adrian Fenton, she implemented the “restricted attendance” procedure, by which the number of appliances and crews sent to other incidents were restricted so that the LFB could maintain fire cover across London.165 AOM Ranson then took charge of running the control room while OM Alexandra Norman took a break.166 She took internal calls and dealt with ensuring that there were enough EDBA and other resources at the incident; she also spoke to senior officers about equipment and relief.167 19.70 At 04.23.31, Surrey FRS control, on behalf of Assistant Group Commander Ian Ray, contacted the LFB control room to ask the LFB’s NILO to contact their NILO.168 They also offered their 42-metre aerial ladder platform. CRO Duddy, who took the call, spoke to someone in the control room and then responded to the caller by telling her that the officer in charge had decided that they did not need assistance at the moment, but that if they did, they would call back.169 It is not entirely clear who made that decision or the reason for it. There is no evidence that Surrey’s offer of an aerial ladder platform was communicated to the incident ground at that time. However, nearly two and a half hours later, at around 06.40.09, that offer was conveyed to the incident ground by the Brigade Coordination Centre and was accepted by AC Roe. SOM Joanne Smith then asked Surrey FRS to mobilise it.170 N245 Leatherhead ALP eventually reached the incident ground at 08.21.26.171 157 [LFB00055502] pp. 4-6. 158 [LFB00055502] p. 9. 159 [LFB00055502] pp. 9-10. 160 [LFB00055502] pp. 23-24. 161 [LFB00000600]. 162 Whiteboard [MET00016906]. 163 Norman witness statement [MET000080589] p. 8. 164 Ranson witness statement [MET00007864] p. 3; Norman witness statement [MET000080589] p. 8. 165 Norman witness statement [MET000080589] p. 8; Fenton witness statement [MET000080569] p. 8; Control Report pp. 144-145. PN412; pp. 2-3. 166 Ranson witness statement [MET00007864] p. 4. 167 Ranson witness statement [MET00007864] p. 4. 168 Control Report p. 145; Ray witness statement [MET00013100]. 169 Control Report p. 145. 170 Control Report p. 155; AC Roe record of actions [MET00005405] p. 10. 171 SIL p. 37.

Part II | Chapter 19: Period 10: 04.00-05.00 459 19.71 At 04.33.41, Natasha Elcock in Flat 82 on floor 11 made her fourteenth and final 999 call.172 She spoke to CRO Duddy and explained that they had tried to go down the stairs, but that it was still too hot and she wanted to know whether someone was coming to rescue them.173 CRO Duddy tried to advise her to leave the building and explained that it was her only choice. He told her she and her family should wrap themselves in wet clothes and towels and make their way to the staircase. She asked him whether he was saying that the fire and rescue services was not coming, to which he replied that they were trying to reach her, but that they needed to make their way down the stairs.174 She explained that she could not get out and that she had been told an hour earlier that firefighters were on their way up, but CRO Duddy continued to repeat the advice to get out and she ended the call.175 19.72 At 04.39.33, CRO Jones took a call from Abdeslam Sebbar’s grandson who had called to find out if there was any information about Abdeslam Sebbar, who was trapped in Flat 81 on floor 11.176 He wanted to know if somebody had checked his flat, but CRO Jones did not have that information. He also asked where casualties were being taken, but she did not have that information either.177 19.73 At 04.41.00, DAC Fenton asked for a dedicated contact point for the press to be set up as well as a Next of Kin line for family members of LFB staff, as they were calling in to ask about their welfare.178 19.74 At 04.41, the daughter-in-law of Elpidio Bonifacio rang the control room again to tell them that her father-in-law was still trapped in Flat 83 on floor 11.179 CRO Duddy took the call. Donna Bonifacio explained that she had been talking with him on his landline, but that the phone had just gone dead.180 She explained that he had told her that the front door and conditions generally were very hot and that she had told him to wet blankets, to shut the windows and to stay low. CRO Duddy told her that firefighters were working their way to everyone they could and that they were aware of him. It is likely that following that call the remark “Line gone dead” was added next to the flat number on the right-hand whiteboard in the control room.181 19.75 At 04.46.42, CRO Jones took a call from Gloria Wilson, the sister-in-law of Antonio Roncolato who was trapped in Flat 72 on floor 10.182 (That was the second call the LFB had received about Antonio Roncolato, his son having previously called at 02.59.10.)183 She explained that he could not get out because there was too much smoke. CRO Jones told her that she had let senior officers know and that they would pass the information on to the firefighters. She hoped they would get to him.184 Gloria Wilson gave CRO Jones her brother-in-law’s phone number and as she did so she said: “He doesn’t bear to come out. He says he’s going to wait until somebody rescues him and he’s very afraid and he won’t come out by himself”.185 172 [LFB00000429]. 173 [LFB00000429] p. 3. 174 [LFB00000429] p. 3-4. 175 [LFB00000429] p. 5. 176 [LFB00000604]. 177 [LFB00000604] p. 5. 178 Fenton witness statement [MET000080569] p. 9. 179 [LFB00000605]. 180 [LFB00000605] p. 3. 181 Whiteboard [MET00016906]. 182 [LFB00000608]; [INQ00000374]. 183 [LFB00000554]. 184 [LFB00000608] p. 2. 185 [INQ00000374] p. 3.

The Grenfell Tower Inquiry: Phase 1 Report 460 CRO Jones did not tell her that she must urge him to leave, but she did make a call to Antonio Roncolato at 04.49.59 to tell him that she had let the firefighters know he was there and that she hoped they would come to him.186 Antonio Roncolato explained that there was no fire in his flat but “plenty of smoke” and that there was no fire around him. He explained that he had tried to leave but that the stairwell was “totally pitch black and smoky”.187 He said he thought he was safe and said: “I don’t want anybody to come – you know, I don’t want any – to put anybody life at risk to come to the tenth floor…”.188 She told him to call back any time.189 After that call, Antonio Roncolato’s former wife, Maria, made a further 12 calls to the LFB control room before he was rescued at 06.20. 19.76 At around 04.50, DAC Fenton, in conjunction with AC Richard Mills, started to make arrangements to ensure that relief was provided to firefighters who had been attending the incident. 19.77 At 04.51.23, Gloria Wilson called again and spoke to CRO Duddy.190 She explained that she had recently called about her brother-in-law and that he would not leave his flat. CRO Duddy told her that if she spoke to him again, she needed to tell him to make his way outside and that it was “the only option at this stage”.191 19.78 At around 05.00, AOM Pauline Warner arrived at the control room, having also been contacted by AOM Crinion. She took over monitoring the radio channel while CRO Sharon Darby took a short break and then she began contacting those members of the control room staff who were due to start their shifts at 08.00 to ask them if they could come in earlier to relieve the night shift staff.192 5 Actions of the MPS, the LAS, RBKC and the TMO 19.79 At 04.10 Commander Neil Jerome arrived at the special operations room (GT) at Lambeth and at 04.20 he was briefed again by Chief Inspector Duane Barrett.193 He was told, among other things, that there were at least four deceased and that the fire was not going to be extinguished. He was also told that MetCC were taking 999 calls from the tower as a priority, although he did not know when Chief Inspector Barrett had arranged for that to be done.194 He could not recall whether he had been told that the “stay put” advice had been changed.195 It was following this briefing that Commander Jerome took over MPS Gold Command, and Detective Superintendent Paul Warnett became Silver Command, supported by Inspector Nicholas Thatcher.196 19.80 At 04.15 the LFB asked Nickolas Layton to arrange the attendance of a DSE.197 At 04.18 he informed David Kerry that the LFB urgently required a DSE. At 04.31 David Kerry called him back, 186 [INQ00000372] p. 2. 187 [INQ00000372] pp. 2, 4. 188 [INQ00000372] p. 5. 189 [INQ00000372] p. 5. 190 [LFB00000609]. 191 [LFB00000609] pp. 2-3. 192 Warner witness statement [MET00008043] pp. 4-5. 193 Commander Jerome’s incident management log [MET00023289] p. 8, which is his record of this briefing; Day 72/25/12. 194 Jerome Day 72/5/13-15; 10/16-21. 195 Jerome Day 72/7/7-12. 196 Jerome witness statement [MET00023286] paragraph 50; Day 72/25/20-27/14. 197 Layton Day 74/51/4-12.

Part II | Chapter 19: Period 10: 04.00-05.00 461 having spoken to Amir Fardouee, the Building Control Surveyor for Dangerous Structures198 on call, at 04.30. David Kerry told Nickolas Layton that the DSE was at the cordon.199 Nickolas Layton said that at around 04.30 he had seen John Allen and Amir Fardouee near CU8 talking to the LFB200 and he thought that it likely that the DSE had arrived just after the second TCG meeting had ended at 04.34.201 However, his recollection of those matters was not very clear (in his oral evidence he could not recall the names of the two people he saw), and in light of John Allen’s own evidence202 and other matters it is doubtful whether Nickolas Layton was correct in saying that John Allen was at the cordon at 04.30. John Allen’s recollection was that he was first notified of the incident at around 05.00 by Amir Fardouee. He put his time of arrival at between 06.00 and 06.30, when he had a conversation with Amir Fardouee (who was already there), took over from him and went into the building. That is consistent with the entries in the Roe Log for 05.32203 and 06.13, and other matters set out below, and I think John Allen’s evidence is more reliable than that of Nickolas Layton on that particular point. The reference in the Roe Log to “structural surveyor in attendance” at 04.51 is probably a reference to the attendance of Amir Fardouee. He was indeed there for that purpose but, according to John Allen, had been too distressed to enter the building, making it necessary for John Allen to attend. 19.81 At 04.34 the second TCG meeting began on CU8. There were 30 police officers at the scene and Barandon Walk was in the course of being evacuated, but there was still difficulty controlling the crowd.204 The LAS noted that the route by which LAS officers were going into and out of the building was being protected by police riot shields. They noted four fatalities, eight to 10 people taken to hospital and 25 people being treated at the scene. Laurence Ioannou (LAS) asked if the building was still structurally safe. He was told that it was, but that the DSE was still on his way.205 Nickolas Layton reported that rest centres had been set up on Shepherd’s Bush Green and that a DSE was being “blue lighted in” (which would not be the case if John Allen had already been at the incident and could in any event have been a reference to Amir Fardouee, who had not been long at the cordon). At the second TCG meeting, the Commissioner said that she had been asking for the attendance of a DSE for two hours. In evidence Nickolas Layton said that he had not been aware of this before.206 19.82 The second TCG meeting ended at 04.50, with the third meeting scheduled for 05.50. 19.83 It is likely that shortly after the second TCG meeting and before the third at 05.50 that Nickolas Layton was asked by the LFB for a list of residents of Grenfell Tower. He said that had happened at the meeting itself, but, as he conceded in his oral evidence, there was no record of any such request in the notes he had made.207 However, he was clear that the request had been made before the next such meeting which took place at 05.50.208 Robert Black had no recollection of these requests, but did not go so far as to deny that they had been made.209 In 198 This is how John Allen describes Amir Fardouee in his second witness statement [RBK00035691] p. 1. 199 David Kerry Emergency Event Log, entry 18 [RBK00028849]. 200 Layton Day 74/53/15-55/7. 201 Layton Day 74/57/14-25. 202 [RBK00035691] signed on 21 February 2019 after the Phase 1 evidence hearings. 203 The reference to “inbound John Allen structural engineer” here at [MET00005404] p. 4 is much less likely to signify his being inbound into the building, as Nickolas Layton suggested (Day 74/55/25-56/15), as opposed to inbound to the scene. John Allen’s recollection in his second witness statement [RBK00035691] p. 2 is that he went into the building between 06.00 and 06.30, which is consistent with the Roe Log entry at 06.13 at [MET00005404] p. 5. 204 Roe Log [MET00005404] p. 3. 205 Ioannou witness statement [MET00010862] p. 10. 206 Layton Day 74/57/6-9. 207 Layton Day 74/62/10-16; 74/62/17-63/8; his notes are at [RBK00029036]. 208 Layton Day 74/63-64. 209 Black Day 74/185/2-25.

The Grenfell Tower Inquiry: Phase 1 Report 462 his evidence Nickolas Layton had a clear recollection that he had asked Robert Black, whom he believed to have access to this information, to provide it to him immediately after he had been asked by the LFB for it, and that Robert Black had then made a telephone call. Nickolas Layton said that he had been “chasing” Robert Black for it. He said he had asked for the information three times over the course of the night, both before the TCG meeting at 05.50 and after it and again before he left the scene at 07.00, but that he had received nothing.210 His account was consistent with the other evidence and was in my view reliable. 19.84 At 04.51 the Roe Log records “structural surveyor in attendance at leisure centre and is to make decision on integrity of building”.211 As already noted, that is probably a reference to Amir Fardouee, not John Allen. 210 Layton Day 74/64/14-69/13. 211 Roe Log [MET00005404] p. 4.

463 Chapter 20 Period 11: 05.00-08.10 1 External fire spread 20.1 The following images taken from Dr Lane’s report show the north and west elevations of the building at 05.16, 06.07 and 07.55 respectively:1 Image of the north and west elevations of the building, showing the internal fires and the hose streams Figure 20.1 1 Dr Lane supplemental report [BLAS0000005] pp. 50, 52, 53 Figs. 5.52, 5.54, 5.55.

The Grenfell Tower Inquiry: Phase 1 Report 464 Figure 20.2

Part II | Chapter 20: Period 11: 05.00-08.10 465 Figure 20.3 20.2 By 08.10 the flames on the outside of the tower had largely subsided, although a number of internal fires were still burning and continued to burn for much of the rest of the day.

The Grenfell Tower Inquiry: Phase 1 Report 466 2 Events on the incident ground Informative message 20.3 Between 05.14 and 05.16 CU8 sent an informative message to the control room saying that fire was affecting floors 2 to 24 of a 24-floor tower block and that 100 individuals were involved. The message also stated that two ground monitors and five jets were in use and the tactical mode remained “Oscar”, that is to say, “offensive”.2 Briefing from DAC Andrew O’Loughlin 20.4 At 05.20 DAC O’Loughlin briefed AC Andrew Roe.3 He reported that there were still considerable numbers of casualties coming out and people visible at windows. He also reported that one deceased person was obstructing the stairs, which had presented difficulties for firefighters. AC Roe suggested that the removal of the deceased person from the stairs was a priority to enable progress to be made. DAC O’Loughlin also reported that all floors below floor 5 were clear, but that there was thick smoke on floor 5 and above. Even the central core was smoke-logged.4 AC Roe asked whether the “wet riser”5 was operational, but DAC O’Loughlin confirmed that, although it was working, the pressure was insufficient for the crews’ needs.6 20.5 At about that time AC Roe asked that all senior officers should be relieved at 08.00. He gave the latest information about the progress of operations to DAC Lee Drawbridge, who was concentrating on the consolidation of existing resources and the integration of the 20-pump relief, whose arrival was imminent.7 Discussion between AC Roe and the Commissioner regarding crew deployment 20.6 AC Roe’s contemporaneous log recorded that at 05.27 the Commissioner was considering requesting the attendance of firefighters from outside Greater London including, in particular, firefighters from Hertfordshire, who were all EDBA-trained.8 AC Roe and the Commissioner discussed whether it was justifiable to continue deploying crews into the tower. His assessment, with which the Commissioner agreed, was that while the structure remained stable, crews should be deployed.9 Firefighter activity inside the tower (c. 05.00-05.30) 20.7 The following are examples of what firefighters were doing in the tower in the period between around 05.00 and 05.30: a. As they made their way down from floor 11, FFs Parvinder Singh, Paul Howard, Craig Edwards and Anthony Welden realised that they had enough air to take the fire hose further up the tower. The crew spread out between floors 5 and 11 and hauled the hose up the middle of the stairwell to a point between floors 10 and 11. 2 ORR v 0.7 pp. 395-398. 3 Roe witness statement [MET00007520] p. 11. 4 AC Roe record of actions [MET00005405] p. 7; Roe witness statement [MET00007520] p. 11. 5 There was no wet riser at Grenfell Tower but AC Roe clearly thought that there was. He was of the view that there would never have been enough water [MET00010065] p. 4. 6 Roe witness statement [MET00007520] p. 11. 7 Roe witness statement [MET00007520] p. 11. 8 AC Roe record of actions [MET00005405] p. 4; Cotton witness statement [MET00012492] p. 28. 9 AC Roe record of actions [MET00005405] p. 8.

Part II | Chapter 20: Period 11: 05.00-08.10 467 b. CM Paul Charity and FFs Leslie Tucker and Harvey Sanders reached floor 12. FF Tucker protected their escape route while CM Charity and FF Sanders searched what was probably Flat 96. CM Charity remembered going into the flat and seeing that the window and what he described as parts of the “brickwork” had gone. As CM Charity was concerned about the risk of falling 11 floors, they left the flat. They returned to floor 11 but, again found that the temperature registered on the thermal imaging camera was 1,000°C. They withdrew and returned to the bridgehead.10 c. FFs Ian Moore and Russell Hall reached floor 12.11 They entered the lobby and carried out a left-hand search. They thought that Flat 92 was the first one they had come to. They found no casualties, so they left and tried to enter Flat 93 using an enforcer. FF Hall recalled that inside one of the flats there was a ruptured gas main which prevented a full search.12 d. As they went up the tower, FF William Boulton noticed that conditions had deteriorated from floor 7 onwards.13 The stairs were dark but not noticeably hot. He also remembered water pouring down the stairs. He thought the smoke had become thicker by the time the crew reached floor 9.14 e. FF Mark Beer recalled having reached a point between floors 8 and 9 where the smoke‑logging became heavier, thicker and lower. Although he said that many people had been coming down the stairs, there were only two more live evacuations during this period, and so the people on the stairs must have been firefighters. He said that a great amount of water had been pouring down the stairs. By the time he reached floor 11 FF Beer could not see anything.15 f. FFs Nicholas Kalirai and Nicholas Whiting were deployed to floor 5 to carry out search and rescue operations.16 They tallied out at 05.01.53 and 05.02.20 respectively and made their way up the tower. FF Whiting recalled water flowing down the stairs at a rapid rate and through the ceiling17. The water was hot and he could feel that heat through his uniform. When they reached floor 5, he observed that “the conditions are very hot and the water feels like boiling water on the back of my neck”.18 In each of the flats they found small pockets of fire, which they fought using a discarded firefighting branch they had found. Water pressure was weak.19 g. FFs William Boulton, Dillesh Devani, Laurence Pitt and Beer reached floor 13, entered the lobby and carried out a right-hand search. The front door of the first flat they found was locked. Using a sledge-hammer and an enforcer, FF William Boulton was able to break it open. FF Devani remembered that the intensity of the heat coming from the flat had been two to three times greater than the heat in the lobby.20 As FFs William Boulton and Pitt were suffering from the effects of heat, the crew decided to return to the bridgehead.21 10 Charity witness statement [MET00010790] pp. 6-8. 11 Ian Moore witness statement [MET00010081] pp. 7-8. 12 Russell Hall witness statement [MET00012548] p. 7. 13 William Boulton witness statement [MET00013222] p. 7. 14 William Boulton witness statement [MET00013222] p. 7. 15 Beer witness statement [MET000086031] p. 8. 16 Nicholas Whiting witness statement [MET00013957] p. 5. 17 Nicholas Whiting witness statement [MET00013957] p. 5. 18 Nicholas Whiting witness statement [MET00013957] p. 5. 19 Nicholas Whiting witness statement [MET00013957] pp. 5-6. 20 Devani witness statement [MET00007951] p. 11. 21 Devani witness statement [MET00007951] pp. 11-12.

The Grenfell Tower Inquiry: Phase 1 Report 468 h. CM Paul Marks and FFs Christopher Lang, Daniel Knapman and Steven Duncan were instructed to find a casualty (now known to be Khadija Saye) on the stairs near floor 10.22 They tallied out at 05.05 and found her but could detect no signs of life. Their evidence was that they had moved her body from the stairs to the lobby on floor 10, but since her body was recovered from the lobby on floor 9, I think it more likely that they moved her there. CM Marks said that in the area of floor 10 there had been smoke in the stairwell with visibility at no more than six feet. The lobby door had been wedged open by something which he had thought was a sheet or some bedding. Having moved Khadija Saye’s body out of the stairs, the crew returned to the bridgehead to tell entry control what they had done. They were then redeployed to floor 12 to carry out search and rescue activities. On that floor, the crew entered Flat 96, which was wholly alight. As they had no firefighting media, the crew withdrew and returned to the bridgehead.23 Their “end of wear times” were between 05.39.01 and 05.39.25. i. WM Wilson and an unidentified firefighter carried a Positive Pressure Ventilator (PPV) to the entrance to the building and placed it under Grenfell Walk facing the tower.24 Whether it had been brought in response to AC Roe’s request to SM Michael Mulholland at or around 04.53 or an order from the Commissioner is not clear.25 Briefing from GM David O’Neill 20.8 At 05.32 GM O’Neill, as Sector Commander for Safety, gave AC Roe a safety briefing.26 Three points are relevant for present purposes. First, GM O’Neill advised that the tower had up to four hours’ protection but that that might have been reduced by the scale and ferocity of the fire. He had no concerns about the risk of a total collapse but agreed that individual columns might fail, thereby causing an isolated, partial collapse.27 Secondly, he had instructed safety crews to look out for misplaced columns. If any were identified, the risk of collapse would be re-assessed. Thirdly, on the basis of the advice he had received about the state of the building, AC Roe approved the continued deployment of crews into the tower.28 20.9 AC Roe remembered at about that time having heard radio traffic relating to a problem with the supply of water and having committed firefighters without a supply of water in order to rescue a trapped casualty.29 Reports of a person on the roof of the tower 20.10 At 05.40 or thereabouts, AC Roe received two briefings.30 The first was from SM Mulholland. During the course of that briefing he asked SM Mulholland to find out whether crews were advancing with sufficient water supplies to known locations for rescue. He also asked him to emphasise to DAC O’Loughlin, GM Patrick Goulbourne and GM Richard Welch that, wherever possible, crews had to have water supplies ahead of them.31 22 Marks witness statement [MET00017068] p. 10. 23 Marks witness statement [MET00017068] pp. 11-16. 24 ORR v 0.7 p. 388. 25 Cotton witness statement [MET00012492] pp. 23-4. 26 Roe witness statement [MET00007520] p. 11; Roe Log [MET00005404] p. 4. 27 Cotton witness statement [MET00012492] p. 28. 28 AC Roe record of actions [MET00005405] p. 8; Roe witness statement [MET00007520] p. 11; Cotton witness statement [MET00012492] p. 28. 29 Roe witness statement [MET00007520] p. 11. 30 Roe witness statement [MET00007520] p. 12. 31 AC Roe record of actions [MET00005405] p. 8; Roe witness statement [MET00007520] p. 12.

Part II | Chapter 20: Period 11: 05.00-08.10 469 20.11 The second briefing was from GM Thomas Goodall. He told AC Roe that there was a report of a person on the roof of the building. AC Roe considered whether that person could be winched off using the coastguard helicopter as the LFB did not have the necessary capability.32 It is clear that AC Roe had reservations about the use of a helicopter: it would take at least 45 minutes to reach the tower and the downdraught might have an adverse effect on the fire at a time when many people, including firefighters, were still in the building. Despite his reservations, however, AC Roe asked AC Dan Daly to put the Maritime and Coastguard Agency on alert for a possible rescue, but directed that a helicopter was not to be deployed unless and until GM Goodall had verified the report.33 20.12 At around 05.50 GM Goodall returned to CU8 and reported that the request for a helicopter should be cancelled, as it had not been established that there was a person on the roof.34 At the same time GM Goodall briefed AC Roe regarding problems affecting water supplies. According to the log, GM Goodall reported that what he described as the wet riser was poor and that the water supply had been augmented by use of a lightweight portable pump from floor 6. The log also contained the following entry: “Crews committed with limited weight of attack and crews above fire close to life risk.”35 Third TCG meeting (05.50) 20.13 At 05.50 AC Roe convened the third TCG meeting,36 which was the first that GM Goodall had attended. The minutes record that there had been no change in the overall situation. Crews had reached floor 14 but that presented dangers as they had no access to water. AC Roe raised the prospect of not committing firefighters above floor 14 due to the risks. Further information about FSG calls was provided. At that stage 171 people were the subject of FSG calls, comprising 38 children and 133 adults from 45 flats. It was thought that 115 people were unaccounted for, although it was said to be difficult to confirm the precise number. AC Roe emphasised that the figures were based on information from the control room and members of the public reporting to CU7, so the true number of people trapped in the tower might be higher. 20.14 A rest centre had been set up on Freston Road to treat casualties and three further centres managed by the Red Cross were also available. AC Roe did not think that RBKC had adequate control of the rest centres or sufficiently accurate information about the number of casualties. 20.15 The meeting concluded at 06.08.37 The decision not to commit crews beyond floor 12 20.16 During the course of the TCG meeting, AC Roe had received information from the incident ground about problems with water supplies. At 06.10 he decided not to commit crews beyond floor 12. His reasoning was based on what he was being told by firefighters about the limitations of the water supply and pressure and was subject to re-assessment following an improvement in water supplies.38 32 AC Roe record of actions [MET00005405] p. 8; Roe witness statement [MET00007520] p. 12. 33 Roe witness statement [MET00007520] p. 12. 34 Roe witness statement [MET00007520] p. 12. 35 AC Roe record of actions [MET00005405] p. 9; Roe witness statement [MET00007520] p. 12. 36 Roe witness statement [MET00007520] p. 12; Roe Log [MET00005404] p. 5; AC Roe record of actions [MET00005405] p. 9. 37 [LFB00002081]. 38 Roe witness statement [MET00007520] p. 13; Roe Log [MET00005404] p. 5; AC Roe record of actions [MET00005405] p. 9.

The Grenfell Tower Inquiry: Phase 1 Report 470 Firefighter activity inside the tower (c. 05.30-06.00) 20.17 The following are examples of what firefighters were doing inside the tower during the period between around 05.30 and 06.00: a. FFs Joe Dean and Christopher Perez, who had tallied out at 05.26.38 and 05.26.42, 39 were deployed to fight the fire on floor 5.40 FF Dean recalled that as they had ascended the tower water had been running down the stairs. He noticed that the smoke had become denser the higher they went.41 By the time they reached floor 5, their radios were not working.42 They carried out a systematic search of that floor, moving from flat to flat extinguishing small fires. Water pressure was good.43 When they had completed that task, they found they had insufficient air to continue, so they returned to the bridgehead. They left their hose and firefighting branch in the stairwell near the door to the lobby on floor 5.44 b. A crew consisting of CM Timothy Cutbill and FFs Steven Boulton, Andrew Wright and Andrew Vango were instructed by GM Welch to go to floor 11 to search for casualties and, if possible, to go higher up the tower.45 The crew tallied out at or around 05.29.46 CM  Cutbill remembered that as they climbed the stairs there had been water on the floor and that visibility had been “not great”.47 FF Vango said that there were no communications at all throughout the course of the incident.48 The lobby was “pitch black”.49 When they reached floor 11, the crew searched only two flats as they had no firefighting equipment with them.50 They found no casualties. They then went to floor

1. They did not search the flats on floor 12 because of the density of the smoke in the

lobby and CM Cutbill’s assessment that, in such conditions, the prospects of survival were minimal.51 FF Steven Boulton recalled that the lobbies on floors 11 and 12 had been hot.52 As they were going up to floor 13, FF Andrew Wright’s BA set started to leak air and his alarm sounded. The crew then went far enough down the tower to ensure that he returned safely to the bridgehead. The rest of the crew then went back up the tower but, having gone up five or six floors, their own air levels ran low, so they too returned to the bridgehead.53 The crew’s “end of wear times” were between 05.58.03 and 05.59.34.54 c. FFs John Wright, Scott Bell, Neil Saunders and Zade Alassad were deployed to floor 4 and tallied out at between 05.45.56 and 05.47.45. It was the crew’s second time under air.55 When they got there they found the fire hose, but the water pressure was low.56 They 39 [LFB00023326] p. 4. 40 Dean witness statement [MET00008012] p. 4; Perez witness statement [MET00017426] p. 10. 41 Dean witness statement [MET00008012] p. 4. 42 Dean witness statement [MET00008012] p. 4. 43 Dean witness statement [MET00008012] p. 4. 44 Dean witness statement [MET00008012] p. 5. 45 Cutbill witness statement [MET00010872] p. 3; Steven Boulton witness statement [MET000080564] p. 7. 46 With the exception of FF Andrew Wright who had tallied out earlier (05.15) and joined CM Cutbill’s crew. 47 Cutbill witness statement [MET00010872] p. 4. 48 Vango witness statement [MET00012688] p. 4. 49 Cutbill witness statement [MET00010872] p. 4. 50 Cutbill witness statement [MET00010872] p. 5. 51 Cutbill witness statement [MET00010872] p. 5. 52 Steven Boulton witness statement [MET000080564] p. 8. 53 Vango witness statement [MET00012688] pp. 5-6. 54 [LFB00023326] p. 4. 55 [LFB00023326] p. 4. 56 John Wright witness statement [MET000083339] p. 5.

Part II | Chapter 20: Period 11: 05.00-08.10 471 did not find any casualties and, despite the low water pressure, they tried to extinguish the small fires they found there.57 d. FFs Albert Folivi and Luke Goddard were instructed to fight the fire on floors 5 and 6.58 They tallied out at 05.53.32 and 05.53.55.59 On floor 5 they met a crew who were not wearing BA and who assured them that floor 5 had been searched. FFs Folivi and Goddard then went to floor 6. FF Folivi recalled that it had not been very smoky and that the visibility had been good. FF Goddard, on the other hand, recalled that there had been thick, white smoke and that visibility had been almost non-existent.60 As they carried out their search, they noticed that the flats on the right-hand side were burnt out. Some doors were open and some were closed but unlocked. They found no casualties. In one flat (either Flat 30 or 31),61 having opened the front door they paused as conditions were smoky. They pulse-sprayed the flat several times, closed the door, left the hose and withdrew to the stairwell.62 FF Goddard recalled that conditions in the stairwell had deteriorated in the short time they had been fighting the fire, as the heat was oppressive and the smoke made it difficult to see.63 It struck him as strange that some of the flats on floor 6 were intact while others had been completely burnt out or were still ablaze.64 e. WMs Amanda Morrison, Mark Niblett and Richard Vanstone and FF Paul Harris had tallied out between 05.51.20 and 05.52.27 to go to Flat 72 on floor 10 and to run a 45mm hose up to floor 11.65 As there were various pieces of firefighting equipment on the stairs, the crew were able to pick up a 45mm hose to complete that aspect of their task.66 In WM Morrison’s words: “We extended our line to the 11th floor, but we had no water and we had no comms.”67 WM Niblett said that conditions in the staircase had been smoky and had got worse as they went up.68 Visibility was down to about two metres, but he had noticed that a few floors above them some firefighters were not wearing BA.69 As the crew entered floor 11 they found that the fire had done extensive damage to two of the flats along the left-hand side, although they were no longer alight.70 On the right-hand side, one of the flats was fully alight and flames were leaping out of the door.71 Despite the conditions, they found the flat on floor 10 to which they had been sent and rescued the occupant, Antonio Roncolato.72 WM Vanstone led him down the stairs while WMs Morrison and Niblett and FF Harris went to floor 11. 57 John Wright witness statement [MET000083339] p. 5. 58 Goddard witness statement [MET00010804] p. 2. 59 [LFB00023326] p. 4. 60 Goddard witness statement [MET00010804] p. 3. 61 Goddard witness statement [MET00010804] p. 3. 62 Goddard witness statement [MET00010804] pp. 3-4. 63 Goddard witness statement [MET00010804] p. 4. 64 Goddard witness statement [MET00010804] p. 4. 65 Morrison witness statement [MET000086066] p. 4. 66 Morrison witness statement [MET000086066] p. 5. 67 Morrison witness statement [MET000086066] p. 5. 68 Niblett witness statement [MET00010888] p. 10. 69 Niblett witness statement [MET00010888] p. 9. 70 Morrison witness statement [MET000086066] p. 6. 71 Morrison witness statement [MET000086066] p. 6. 72 Morrison witness statement [MET000086066] pp. 4-5.

The Grenfell Tower Inquiry: Phase 1 Report 472 The DSE’s advice 20.18 At 06.13 the DSE, John Allen, reported to AC Roe that he could not reach high enough to form a considered view of the state of the building.73 He was able to report that there was no indication that it was likely to collapse. In the light of his advice, AC Roe decided to continue committing crews. He repeated his order that no crews were to be committed beyond floor 12 and told DAC O’Loughlin to review the position as the incident developed.74 20.19 At 06.28 GM Goulbourne sent a message to the operational sectors at the request of AC Roe that when conditions changed they were to push beyond floor 12.75 AC Roe asked for this message to be sent because he wanted crews to be deployed above floor 12 as soon as possible.76 Operational sectors were directed to inform AC Roe when they considered they were able to extend operations above floor 12.77 Firefighter activity inside the tower (06.00-06.30) 20.20 The following are examples of what firefighters were doing inside the tower during the period between around 06.00 and 06.30: a. WMs Vanstone and Niblett had tried to find a rising main outlet to assist their crew’s firefighting efforts, but had been unable to do so because of the “punishing” heat and poor visibility.78 WM Vanstone did not recall hearing any radio transmissions while in the tower.79 b. FFs John Wright, Bell, Alassad and Saunders reached floor 4. They entered Flat 16 but found no casualties. They then entered Flat 15 and extinguished one small area of fire. They then made their way to floor 5. FF Bell said that the crew had been told to leave the building by firefighters who were not wearing BA but whom they did not recognise.80 c. Having withdrawn from floor 6, FFs Folivi and Goddard went to floor 7. FF Folivi described conditions as “very smoky”. As their levels of air were by then low, they decided to return to the bridgehead.81 The crew’s “end of wear times” were 06.13.43 and 06.13.48.82 d. WM Morrison and FF Harris reached floor 11. They searched the flats for casualties, calling out as they went to each flat. As she went down the stairs, WM Morrison handed her firefighting branch to a crew on their way up and told them that they would need a water supply as floor 11 was alight.83 e. As WM Morrison and FF Harris were carrying out their search of floor 11 a member of another crew, FF Colin Dowdall, entered the lobby.84 FF Dowdall turned left and left again and saw a flat door glowing with embers. He pushed the top of the door which collapsed inside like a pile of ashes.85 The flat was wholly alight so FF Dowdall returned to the stairwell on floor 11. FF Dowdall was later rejoined by FFs Simon Grant and Joe Worley, 73 Roe witness statement [MET00007520] p. 13; [MET00005404] p. 5; AC Roe record of actions [MET00005405] p. 9. 74 Roe Log [MET00005404] p. 5; Roe witness statement [MET00007520] p. 13. 75 Roe Log [MET00005404] p. 5. 76 AC Roe record of actions [MET00005405]; Roe witness statement [MET00007520] p. 13. 77 AC Roe record of actions [MET00005405]; Roe witness statement [MET00007520] p. 14. 78 Vanstone witness statement [MET00010827] p. 6. 79 Vanstone witness statement [MET00010827] p. 6. 80 ORR v 0.7 p. 433 suggests that the unidentified firefighters may have been FFs Aldridge, Cachia and Desmond. 81 Goddard witness statement [MET00010804] p. 4. 82 [LFB00023326]. 83 Morrison witness statement [MET000086066] p. 6. 84 Dowdall witness statement [MET00013231] p. 13. 85 Dowdall witness statement [MET00013231] p. 13.

Part II | Chapter 20: Period 11: 05.00-08.10 473 the other members of his crew. They had gone to find a rising main outlet on floor 10 to supply water to floor 11, but had failed to do so. As their air levels were running low, the three firefighters returned to the bridgehead.86 f. CM Carl Ramsay, FFs Andrew McArthur, Neil Franklin and Kenneth Le Marrec had tallied out between 06.04.58 and 06.08.41. They had been deployed to floor 11 to fight the fire and to carry out search and rescue operations.87 As they went up the stairs, the smoke gradually worsened as they went from floor 2 to floor 7. The walls of the stairwell were so blackened by smoke that firefighters did not know which floors they were passing. The heat became very intense on floors 10 to 12 and a stream of water flowed down from above.88 After some confusion about which floor they were on, the crew reached floor 11, where they found a discarded hose and connected it to a firefighting branch. The water pressure was “extremely low” and the effect was compared to that of a garden hose.89 There were no radio communications at this stage.90 The intensity of the heat and the absence of water led CM Ramsay to conclude that there was little more he and his crew could do so they returned to the bridgehead.91 The crew’s “end of wear times” were between 06.43.07 and 06.47.08.92 g. WMs Helen Christmas and Marc Aston-O’Donovan, CM Guy Tillotson and FFs Carrie Wright and Neil Green tallied out at between 06.18.13 and 06.19.48 with instructions to go to floor 6 to fight the fire. WM Christmas said that conditions had been “not too bad” as they ascended the stairs, but the smoke had gradually got worse as they reached floor

1. She also said that the lack of visible floor numbers on the walls or doors had hampered

their efforts to identify where they were. Once the crew had reached floor 6, the lobby was “very hot” and “unbearable” and Flat 31 was on fire. The crew extinguished the fire in Flat 31. h. CM Dominic Fearnley and FFs Martin Hooper, Ernest Okoh and Alan Sime were instructed to take a length of fire hose and a firefighting branch, connect to the rising main on floor 10 and fight the fire on floor 11. They tallied out between 06.23.41 and 06.24.15. i. FFs Thomas Bundey, Constantine Nwagwu, Thomas Dotchin and Kyle McClelland were briefed to go to floor 12 to carry out search and rescue operations. GM Goulbourne told the crew to do their best, but to expect little or no water. He also told them that neither the rising main, nor the radios, nor the telemetry were working. Report from GM Matthew Cook 20.21 At 06.31 GM Cook confirmed that the floors below floor 12 had been cleared with “saveable life achieved”. He also reported that the bridgehead was on the ground floor; that entry control was staffed with a complement of three Watch Managers and two Crew Managers; that the water sector had reported that there were good supplies together with safe means of entry and exit and that the sector safety was in place. In light of this information, the tactical plan was “EDBA moving forward”, that is to say the deployment of EDBA crews for the purposes of search and rescue.93 86 Dowdall witness statement [MET00013231] p. 13. 87 Ramsay witness statement [MET00012569] p. 6. 88 Ramsay witness statement [MET00012569] p. 6. 89 Ramsay witness statement [MET00012569] p. 7. 90 Ramsay witness statement [MET00012569] p. 7. 91 Ramsay witness statement [MET00012569] p. 7. 92 [LFB00023326] p. 4. 93 Roe Log [MET00005404] pp. 5-6.

The Grenfell Tower Inquiry: Phase 1 Report 474 20.22 The log recorded that, at 06.35, BCC had been stood up and would provide overall resources and relief options. DAC Fenton was instructed to brief DAC Drawbridge. SM Mulholland reported that, as the doors to some flats had been shut, it might be necessary to reconsider whether floors had indeed been fully cleared. GM Cook said that the next phase of operations would be a systematic search of the tower. 20.23 By this time, AC Roe had recorded that he was satisfied that sectors 1 to 494 had a sufficient number of officers allocated to them under the overall command and control of DAC O’Loughlin. In addition, an ALP was working in sector 4. At about this time AC Roe asked GM Keeley Foster to help DAC Drawbridge implement the relief.95 DAC O’Loughlin’s briefing for AC Roe 20.24 At around 06.42 AC Roe, accompanied by the Commissioner, left CU8 to receive a briefing from DAC O’Loughlin and the sector commanders.96 DAC O’Loughlin assured AC Roe that, notwithstanding major problems caused by burst hoses, water supply had improved. That was supported by SM Christopher Payton, the additional bulk media advisor, who also told them that Thames Water could not provide any additional pressure, as that risked bursting water mains further back in their network.97 20.25 AC Roe also received a briefing from GM O’Neill, whose overall assessment was that there had been no substantive change to the structure of the building, although a considerable amount of debris was still falling. GM O’Neill confirmed that he was in constant communication with the DSE and was monitoring the condition of the building. 20.26 Having received a briefing from senior officers outside the tower, AC Roe and the Commissioner ran, under the protection of riot shields, into the ground floor lobby. GM Goulbourne and GM Welch provided what AC Roe described as a very clear brief.98 Both officers were satisfied that water supply was sufficient to allow them to deploy crews beyond floor 12 with the aim of reaching floor 18, from which they had received the last recorded live FSG call, but they also reported that there were a significant number of deceased persons on the stairs. AC Roe confirmed that he was happy with the decision to push on to floor 18.99 He was not aware of any physical changes to the building that caused him to revise his assessment of its structural stability. AC Roe briefly discussed these matters with the Commissioner, who endorsed his assessment of the situation. AC Roe’s assessment was recorded on his log at 07.08.100 Firefighter activity inside the tower (06.30-07.00) 20.27 The following are examples of what firefighters were doing inside the tower during the period between around 06.30 and 07.00: a. CM Fearnley’s crew reached floor 11 where they attached their hose and firefighting branch to the rising main. They tested the branch, but it delivered very low pressure and could not be used for firefighting. During this time, at 06.34, the alarm on FF Sime’s BA 94 At this incident, the south side of the tower was designated as sector 1; the west side as sector 2; the north side as sector 3; and the east side as sector 4: O’Neill Day 51/19/11-19. 95 AC Roe record of actions [MET00005405] p. 10. 96 Roe witness statement [MET00007520] p. 15; Roe Log [MET00005404] p. 6. 97 AC Roe record of actions [MET00005405]. 98 Roe witness statement [MET00007520] p. 15. 99 Roe witness statement [MET00007520] p. 15. 100 Roe Log [MET00005404] p. 6; AC Roe record of actions [MET00005405] p. 10.

Part II | Chapter 20: Period 11: 05.00-08.10 475 set sounded,101 so CM Fearnley decided that the crew should return to the bridgehead. The crew members had “end of wear times” between 06.42.39 and 06.48.23.102 b. As the rising main on floor 10 was not providing an adequate supply of water, two crews consisting of FFs Denis O’Brian and Steven Ngo and FFs Stephen Dounias and Carl Clarke were instructed to extend a 45mm hose and firefighting branch from floor 6 to floor 12. They were told that the rising main was defective, as a result of which there was no water above floor 6. Once they had arrived on floor 6, they found a tangled fire hose with a firefighting branch attached. They unwound the hose and took it to floor 12. c. FF Bundey’s crew reached floor 12. They carried out a right-hand search and entered Flat 96 (the first flat they found) which was burnt out. The conditions were too hot to allow the crew to search the premises. They withdrew to the stairwell and then re‑entered floor 12 to carry out a left-hand search. The first flat they located (which is believed to have been Flat 91) was extremely hot. As they had no firefighting media, they withdrew to the stairwell again. They then went to floor 13. FF Bundey wedged open the lobby door with a halligan bar, but they encountered extreme heat in the lobby and decided to withdraw and return to the bridgehead. As they were descending, they received a radio message that a person had been seen waving from a window on floor 6. They decided to go to floor 6 to investigate. They carried out a left-hand search of floor 6 but no casualties were found. d. A crew consisting of FFs Benjamin Dotchin and Jonathan Earl searched floor 12 but found no casualties. They then went up to floor 13 where, from the stairwell, they saw black smoke coming from underneath the closed lobby door. They entered the lobby, but after four or five steps were forced to withdraw due to the extreme heat. Given the conditions, FF Benjamin Dotchin decided they should return to the bridgehead. FFs Benjamin Dotchin and Earl had “end of wear times” of 07.09.17 and 07.11.46 respectively.103 e. CM Thomas Atkins’ crew had been instructed to locate and rescue an individual on floor 9 or 10, who had been seen waving a flag or a shirt from his window. They tallied out at 06.44.04 and 06.44.35.104 When they reached floor 9, they found that the right‑hand side of the floor was completely on fire and that the left-hand side was heavily smoke‑logged. The crew carried out a left-hand search but found no casualties. f. At around 07.00 FFs James Geapin and Stephen Hayward tallied out. They were directed to go to floors 5 and 6 to rescue anyone still alive, since a person had been reported at a window on floor 6.105 Fourth TCG meeting (07.13) 20.28 The fourth TCG meeting took place at 07.13.106 AC Roe gave the meeting the latest information on the situation including, in particular, his decision to commit crews beyond floor 12. He reported that conditions within the tower had improved but that the fire was still burning between floors 22 and 24. As water supplies had improved, crews had been committed beyond floor 12 with the aim of reaching floor 18. 101 ORR v 0.7 p. 444. 102 [LFB00023326] p. 4. 103 [LFB00023326] p. 5. 104 [LFB00023326] p. 5. 105 [LFB00023326] p. 5. 106 Roe witness statement [MET00007520] p. 16; Roe Log [MET00005404] p. 6; AC Roe record of actions [MET00005405] p. 11.

The Grenfell Tower Inquiry: Phase 1 Report 476 20.29 The minutes record that the DSE had advised that, although parts, corners and slabs would fall, the building would not collapse.107 20.30 The MPS confirmed that civil unrest had “dissipated”. AC Roe asked the LAS to maintain its current resources at the tower as crews were still encountering many families within the tower. He said that a large number of fatalities were to be expected. 20.31 RBKC’s LALO, Nickolas Layton, provided more details about the numbers in rest centres, but AC Roe asked him for lists of addresses so that the LFB could cross-reference that to the information which they held. AC Roe again asked for plans of the tower to be produced. The meeting ended at 07.35.108 Strategy for a systematic search of cleared areas 20.32 At about the time the TCG meeting ended, AC Roe asked GM Cook and SM Mulholland to give DAC O’Loughlin some clear instructions to enable him to formulate and implement a strategy for the systematic search of previously cleared areas. He did so, because he felt that the incident had reached a point at which any remaining occupants’ prospects of survival were diminishing.109 Update on resources from DAC Drawbridge 20.33 At 07.44 DAC Drawbridge briefed AC Roe about resources.110 He reported difficulties in reducing the number of appliances to 20 pumps in order to accommodate the relieving pumps. They discussed and agreed that resources would be subject to a 3-hour rolling 10‑pump relief once the initial relief force of 20 pumps was in place. The practical result would be that 20 pumps would be on the incident ground for the foreseeable future. It was noted in the log that no SDBA was being used at this time. Update from DAC O’Loughlin 20.34 At around 07.55 DAC O’Loughlin attended CU8 together with GM O’Neill.111 As GM John Graham, the first relief officer attending the scene, had by then arrived, AC Roe wanted him to replace whichever of GM Goulbourne or GM Welch most needed relief. He directed DAC O’Loughlin and GM Graham to decide. GM O’Neill reported that conditions on floor 11 were “like a furnace”. The log also recorded that Andrew Cane, a new ORT officer at the incident, wanted a safety officer allocated to the fire sector due to the number of deceased on the stairs. Notification of mass fatalities 20.35 At 08.10 it was noted that the MPS had advised HM Coroner of mass fatalities at the tower. Accordingly, it was directed that no bodies were to be moved.112 107 Roe Log [MET00005404] p. 6. 108 Roe Log [MET00005404] p. 7. 109 Roe witness statement [MET00007520]; Roe Log [MET00005404] p. 7; AC Roe record of actions [MET00005405] p. 11. 110 Roe witness statement [MET00007520] p. 16; Roe Log [MET00005404] p. 7; AC Roe record of actions [MET00005405] p. 11. 111 Roe witness statement [MET00007520]; Roe Log [MET00005404] p. 7; AC Roe record of actions [MET00005405] p. 11. 112 Roe witness statement [MET00007520]; Roe Log [MET00005404] p. 7; AC Roe record of actions [MET00005405] p. 11.

Part II | Chapter 20: Period 11: 05.00-08.10 477 Firefighter activity in the tower 20.36 Between 07.00 and 08.10, the LFB’s telemetry data shows that crews were being committed to fight the fire and search for the deceased. Evidence from the firefighters committed during this time suggests that they could not get beyond floor 13 and that floors 11 and 12 remained alight. At one stage, CMs Philip Wigley, Clarke and Mark Stevenson met on floor 11 to discuss conditions. As firefighters were being soaked by hot water, the decision was made to withdraw existing crews to the bridgehead. 20.37 At around 07.47 a crew under the command of WM Andrew McKay searching floor 11 found Elpidio Bonifacio, who lived in Flat 83 on floor 11. He was helped down the stairs and, at 08.07, was taken to the community room at the base of the tower. He was the last surviving resident to leave the tower. 3 Conditions in the tower and movement of occupants 20.38 By 05.00, only two residents were still in contact with people outside the tower: Antonio Roncolato in Flat 72 on floor 10 and Elpidio Bonifacio in Flat 83 on floor 11. Evacuation of Antonio Roncolato from Flat 72, floor 10 20.39 At 05.05.45 Antonio Roncolato called 999 and spoke to CRO Angie Gotts.113 He told CRO Gotts that he was not in any danger.114 She asked him whether he could leave. He said: “No I cannot go out. If I go out, believe me I’m going to be on somebody else’s conscious. [sic] It’s totally – you know, my eyes started crying . . . and it’s impossible to breathe.”115 CRO Gotts told him that, if it was impossible to leave, he should stay in the flat and block everything up. She confirmed that she would let the firefighters know where he was. 20.40 Antonio Roncolato said in evidence that he wanted to speak to someone in charge who knew what was happening at the ground and could tell him what to do. At 05.46.35 he called his son Christopher, who was outside the tower. He asked him to find someone in charge. Christopher passed the phone to a firefighter whom he believed was a “fire marshal”. That was the second occasion on which Antonio Roncolato had such a conversation. He was told by the “fire marshal” that the firefighters were coming to get him. Christopher then told him that there was a pair of swimming goggles in his room that he could use to protect his eyes. 20.41 At 06.00, Antonio Roncolato was speaking by telephone to a friend when he heard a knock at the front door. Two firefighters came into the flat, closing the door behind them. They confirmed that he was the only person there and gave him instructions on how they should leave together, with one firefighter in front and another behind. Antonio Roncolato put on his son’s swimming goggles and a rucksack and a firefighter placed a wet towel over his head and gave him a smaller wet towel to cover his mouth and nose. They then left together.116 113 [LFB00000430]. 114 [LFB00000430] p. 2. 115 [LFB00000430] p. 3. 116 Antonio Roncolato first witness statement [IWS00000894] pp. 14-15.

The Grenfell Tower Inquiry: Phase 1 Report 478 20.42 Antonio Roncolato noticed that the temperature became very hot in the lobby. It then cooled down a little in the stairwell where there was a lot of water.117 He could not see if there was smoke through the goggles and the wet towel. The stairs were wet with water and debris as he came down.118 Antonio Roncolato left the tower at 06.05.15.119 Evacuation of Elpidio Bonifacio from Flat 83, floor 11 20.43 Elpidio Bonifacio had sheltered in his bedroom from where he continued to try to attract attention by waving a white towel.120 He had remained at the bedroom window for some hours and had begun to feel hopeless. He could feel the flat was becoming hotter. While he was in the bedroom, he heard the mirror in the sitting room shatter from what he assumed was the heat of the fire. He could also hear the crackling flames in the sitting room.121 20.44 He suddenly heard the sound of running water in the flat from the firemen’s hose. He opened the bedroom door and found four or five firefighters with a hose. They carried him out of the flat.122 Elpidio Bonifacio left the tower at 08.07.20.123 4 Events in the control room 20.45 After 05.00, the number of calls diminished and there was a lull in the control room.124 To many, the lack of calls made it seem “eerie”; CRO Christine Howson said that it was so quiet that you could hear a pin drop.125 The atmosphere among the control room officers was one of “stunned silence”.126 The CROs mostly received calls from family members of those in the tower. When it became quiet, some of the CROs searched for news about the fire on their phones and computers; for the first time they saw the image of the tower and realised that the whole building was on fire.127 20.46 Over the next three hours, the LFB control room received 24 emergency calls; only one was from a resident, Antonio Roncolato, still in the tower.128 They did not receive any calls from any of the other fire and rescue services or from any other agencies. At some point during this period, CRO Sarah Russell stopped taking calls and returned to her radio position on channel 2, where she had started at the beginning of the shift. She monitored the radio until around 07.20 or 7.30.129 20.47 At 05.05.45, CRO Gotts received a call from Antonio Roncolato in Flat 72 on floor 10.130 He told her that he was “not in any sort of danger” although there was a lot of smoke around.131 He said that he had been told to try to go downstairs but that it was “impossible” because there was so much smoke and so he wanted some advice.132 She asked if he could put a wet 117 Roncolato Day 52/71/2-52/72/25. 118 Antonio Roncolato first witness statement [IWS00000894] p. 15. 119 Annex A. 120 Bonifacio first witness statement [IWS00001085] p. 6. 121 Bonifacio first witness statement [IWS00001085] pp. 6-7. 122 Bonifacio first witness statement [IWS00001085] pp. 6-7. 123 Annex A. 08.07.13 (corrected from 08.07.49) [INQ00010899] and 08.07.20 (corrected from 08.07.56) [INQ00010906]. 124 Gotts witness statement [MET00007694] p. 7. 125 Gotts witness statement [MET00007694] p. 7; Howson witness statement [MET00007763] p. 7. 126 Gotts witness statement [MET00007694] p. 8. 127 Gotts witness statement [MET00007694] p. 7; Howson witness statement [MET00007763] p. 7; Fox witness statement [MET00007764] p. 5. 128 Control Report pp. 149-158. 129 Russell witness statement [MET00007698] p. 8. 130 [LFB00000430]. 131 [LFB00000430] p. 2. 132 [LFB00000430] pp. 2-3.

Part II | Chapter 20: Period 11: 05.00-08.10 479 towel over his head and get out, but he said he could not. She told him that he was “doing the best thing” because he had everything blocked up and a window open to get some fresh air. She told him that she would let the crews know. After his call, Antonio Roncolato’s family members called the control room a further 10 times to find out if crews had got to him. At 06.37.17, CRO Howson spoke to Maria, Antonio Roncolato’s former wife. She told her that the crews were doing a sweep search of all the flats on floors 8, 9, 10 and 11 and Maria told her that Antonio Roncolato had got out of the tower.133 20.48 At 05.18.11, CRO Sharon Darby logged an informative message in the incident log that had been sent by CU8 on behalf of AC Roe describing the current position.134 20.49 At 05.31.00, the control room received one further call from the daughter-in-law of Elpidio Bonifacio who was still trapped in Flat 83 on floor 11.135 CRO Gotts took the call. The caller, Donna, asked her to check if the crews had got to the flat. CRO Gotts told her that they had passed the flat number to the incident ground, but could not give her any more news. Donna asked her how she would find out eventually, but CRO Gotts was not able to tell her how the information would be made available.136 20.50 Between 05.32.38 and 05.38.14, the control room received a number of calls from members of the public about a person who was said to be on the roof of the tower waving for help. These messages were passed over to CU7. However, at 05.38.18, CRO Pam Jones received a further call from one of those who had reported the sighting. She confirmed that it was a piece of cladding, not a person, she had seen.137 At 05.46.15, WM Daniel Meyrick in CU7 asked for further information about the person said to be on the roof, but SM Jason Oliff confirmed that it had been a piece of cladding.138 20.51 At 05.55.11, AOM Kate Ranson received an admin line call from CU7 to ask whether there was only one current FSG call from Flat 72 (Antonio Roncolato).139 AOM Ranson told him that there were no current FSG calls.140 SM Oliff also recalled that he relayed this information to CU7 at around 06.00.00.141 20.52 At 06.01.21, CRO Darby received a request from CU8 for the attendance of a bulk media advisor, to provide tactical advice on how best to use the water supply. SM Payton was assigned to attend the incident at 06.02.53; he mobilised at 06.04.47.142 He had been following the incident since around 04.00 on the mobilising system, having been contacted by GM Welch at 01.30 and asked by the Officer of the Watch to return to duty.143 20.53 During this period, CU8 continued to order reliefs and resources to the incident and told the control room when the TCG meetings took place. There was also a request to contact the alarm company for further information.144 The Brigade Coordination Centre assisted in responding to the requests.145 133 [INQ00000191]. 134 SIL p. 32. 135 [LFB00000616]. 136 [LFB00000616] p. 4. 137 Control Report pp. 151-152. 138 Control Report p. 152. 139 Control Report p. 152. 140 Control Report p. 152. 141 Oliff witness statement [MET00012791] p. 8. 142 Radio message [LFB00002447]; SIL p. 14. 143 Payton witness statement [MET00010821] pp. 7-8. 144 SIL pp. 31-37. 145 Fenton witness statement [MET000080569] pp. 10-12.

The Grenfell Tower Inquiry: Phase 1 Report 480 20.54 At 06.41.46, SM Oliff ended his telephone contact with CU7.146 20.55 At 06.46.56, CRO Fox received a call from a relative of someone in the tower who asked for a number to obtain information about them. CRO Fox told her that the LFB did not have any numbers and that it would be for the MPS to make the necessary arrangements.147 20.56 At 06.48.43, CRO Darby entered a further informative message received from CU8 in the incident log.148 20.57 At 06.50.09, SOM Joanne Smith called Surrey FRS to take up the offer of a 42-metre aerial ladder platform. AC Roe had accepted the offer after he had been told of it by someone in the Brigade Coordination Centre.149 At 07.04.15, Surrey FRS contacted the control room and told them that the aerial appliance had been mobilised and that it would be at the incident in approximately 40 minutes.150 20.58 Between 07.00 and 08.00, control room staff, who had been due to start on the day shift at 08.00, came in early to start relieving the CROs who had been on the night shift. They were briefed on what had happened, but no formal handover took place.151 Before the CROs from the night shift went home they were given an opportunity to speak to a counsellor who had been brought in for the purpose by SOM Smith.152 20.59 At around, or shortly before, 07.43, AOM Peter May spoke to the NPAS helicopter by radio a number of times about reported sightings of persons still trapped in the building and about changing the angle of the hoses on the building to prevent the smoke from reaching the flat of Elpidio Bonifacio who was still waiting to be rescued.153 Radio messages were then sent to CU8 between 07.43.07 and 07.50.41 telling them that he was one floor below the window where the hose on the building was directed.154 CU8 said that they would pass the message to CU7.155 20.60 At 07.50.51, CRO Darby sent a radio message to CU8 to say that the police had seen Elpidio Bonifacio at the window on floor 11. She asked what the crews were doing to try to rescue him.156 At 07.51.02, CU8 told her that CU7 could provide her with the latest information.157 20.61 As a result, at 07.51.36, CRO Darby spoke directly to CU7 for the first time since she had sent an FSG message by radio at 02.58.01. She sent a string of radio messages to CU7 to ask for information about the rescue of the man in the window on floor 11.158 At 07.51.58, CU7 sent a radio message telling her that they were committing crews to floor 11 but that access was difficult.159 20.62 At 08.00.00, the control room’s day shift took over. 146 Oliff Exhibit [MET00016910] p. 3. 147 Control Report p. 156. 148 SIL p. 33. 149 Control Report p. 156. 150 Control Report p. 156. 151 Gotts witness statement [MET00007694] p. 8; Howson witness statement [MET00007763] pp. 7-8. 152 Howson witness statement [MET00007763] p. 8; Fox witness statement [MET00007764] p. 5; Smith witness statement [MET00007766] p. 5. 153 AOM May witness statement p. 5; contemporaneous note p. 4. AOM May stated in his witness statement that this conversation took place at around 06.30. Given the time of the radio messages to CU8, I think it is more likely that he spoke with the NPAS helicopter just before the radio messages to CU8 were sent. 154 Radio messages [LFB00002122]; [LFB00002685]; [LFB00003003]; [LFB00002399]. 155 Radio message [LFB00002000]. 156 Radio message [LFB00003069]. 157 Radio message [LFB00002727]. 158 Radio messages [LFB00003072]; [LFB00002204]; [LFB00002045]; [LFB00002945]; [LFB00002339]. 159 Radio message [LFB00002091].

Part II | Chapter 20: Period 11: 05.00-08.10 481 5 Actions of the MPS, the LAS, RBKC and the TMO 20.63 At 05.00 Commander Jerome attended the first strategic co-ordinating group meeting at which the agencies shared their understanding of the situation and put in place an initial “multi-agency” strategy. That was the first occasion on which all the elements of the London Resilience Forum, which involves bodies in addition to the first responders, were brought together.160 The meeting was chaired by AC Richard Mills of the LFB. Among others present were Stuart Priestly, David Kerry and Mark Sawyer of RBKC. Stuart Price represented the LAS. It was noted that there were difficulties getting access above floor 15 of the tower, that a DSE had been called and was now in attendance and that there were still people inside the building, but the LFB was waiting for a report from the incident ground. There was no discussion about whether the LFB had asked for plans of the building at any stage.161 It was noted that two rest centres were already open and that three more premises were to open to provide shelter for those evacuated from the tower and adjacent buildings. 20.64 In this period, a number of emails were sent between TMO staff about lists of residents and plans of Grenfell Tower. Teresa Brown’s recollection was that requests had been made early on for a list of residents together with floor numbers.162 She could not remember when the general list of residents had been asked for, but she did remember that she had been speaking to the LFB at frequent intervals about lists of those safe and missing. She did not know who in particular at the TMO had been asked for a general list of residents, but whoever had been at the cordon was the person responsible for dealing with such requests.163 20.65 At 05.24 (or possibly at 06.24)164 David Noble, a policy officer helping with the customer relations team, sent an email to TMO staff, including Robert Black and Teresa Brown, with the subject “Grenfell occupants”. A file with the name “Grenfell Tower.xlsx” was attached.165 The body of the email said: “All occupants of Grenfell as at 30 May 2017. Still trying to get live data to run. Looking for plans.” 20.66 At 06.38 David Noble sent a further email to TMO staff, including Robert Black and Teresa Brown, with the subject line “Grenfell residents”. Two files named “Grenfell tower short list. docx” and “Grenfell tower updated.xlsx” were attached.166 The body of the email said: “This is Up to date data. Use this one. Word version is name address and contact numbers only. Excel version has disability etc info on.” 20.67 Robert Black did not send the email at 05.24 (or possibly 06.24) to the LALO or the LFB because “they did not ask for it” and because he did not realise that they wanted it.167 He forwarded the email of 06.38 to the LFB only at 07.56,168 and then only, he assumed, because he had been asked for it.169 He did not forward that email to the LALO or the LFB at the time he received it because, as he told the Inquiry, he assumed that the email was for Teresa 160 Jerome witness statement [MET00023286] paragraph 54; London Resilience Forum Major Incident minutes of this meeting [MET00023287]; Jerome Day 72/29/2-25. 161 Jerome Day 72/34/21-23. 162 Brown Day 75/73/18-24, 75/4-76/2; Brown witness statement [TMO10048960] paragraph 12. 163 Brown Day 75/77/10-81/12. 164 It is not possible to tell conclusively whether this email was sent at 05.24 or an hour later at 06.24, unlike the email sent at 06.38 but bearing the time 05.38 for technical reasons. 165 An email contained in the string of emails [TMO10031176]. 166 An email contained in the string of emails [TMO10031176]. 167 Black Day 74/187/18-188/10, 189/5-13. 168 [TMO10031176]. 169 Black Day 74/193/6-194/25.

The Grenfell Tower Inquiry: Phase 1 Report 482 Brown to enable her to manage her role at the rest centres.170 However, he had been told by Nickolas Layton some time before 06.38 that the LFB wished to identify those residents who were missing,171 and he should therefore have realised at that stage that it would be of use to the LFB. 20.68 Teresa Brown did not send either of the emails from David Noble to the LALO and assumed instead that Robert Black had sent it on.172 She later handed Michael Rumble a hard-copy list of residents, which included information such as disabilities, but that was not until later in the morning, some time before 11.00.173 20.69 While these exchanges between the TMO staff were taking place, the Roe Log records, at 05.32, “… entry and inbound John Allen structural engineer”.174 Nickolas Layton said in his oral evidence that that referred to John Allen’s entering the building rather than arriving at the incident,175 but as I have noted above, I doubt that he was right about that. 20.70 At 05.50 the third TCG meeting took place on CU8. The MPS confirmed that the casualty bureau was open, that about 30 people had been evacuated from the surrounding area and that the crowd was now under control. The LAS reported that 50 people had been taken to hospital and that there were five fatalities. Nickolas Layton reported that there were rest centres on Freston Road and that there were three further rest centres being managed by the Red Cross.176 He said that at that meeting he had reported that a list of residents was still not available and that the LFB had been unhappy with that.177 He did not record that discussion in his log, but simply wrote “numbers all rest centres”, which might indicate no more than that he was to find out how many Grenfell Tower residents were at the rest centres. However, by that stage (but unknown to him) the full list of Grenfell Tower residents had been sent by David Noble at 05.24 to (among others) Robert Black. It could therefore be used to check off those at the rest centres and identify who was missing and from which flats. According to Nickolas Layton’s MPS witness statement,178 at that TCG meeting he was asked to gather the names and flat numbers of the survivors at the rest centres. He then asked Robert Black to find out from his staff at the rest centres which residents were there so that the emergency services could establish who was missing. It is clear from that evidence that the LFB wanted a full list of Grenfell Tower residents, and not only a list of those present in the rest centres, since without a full list they could not identify who was missing. It follows that Nickolas Layton had good reason to ask the TMO for a full list of residents as well as a list of those in the rest centres so that he could provide them to the LFB. 20.71 Nickolas Layton said that after that TCG meeting (which had ended at just before 06.08.09)179 he had gone straight to Robert Black to obtain the information about the residents, as the TMO was managing the property and he did not think that RBKC would have it. In his MPS witness statement180 he said that he had asked Robert Black “for details of residents in the centres” (meaning names and flat numbers) so that the emergency services could try to 170 Black Day 74/191/14-16. 171 Layton MPS witness statement [MET00007967] p. 5. 172 Brown Day 75/89/25-91/22. 173 Brown Day 75/98. 174 Roe Log [MET00005404] p. 4. 175 Layton Day 74/55/8-56/9. 176 Roe Log [MET00005404] p. 5. 177 Layton Day 74/67/12-68/3. 178 Layton MPS witness statement [MET00007967] p. 4. 179 The time of the radio message from CU8 to the control room to that effect [LFB00002081]. 180 Layton MPS witness statement [MET00007967] p. 5.

Part II | Chapter 20: Period 11: 05.00-08.10 483 establish how many persons were missing.181 Robert Black had told him that he had not yet received the information, but he made another call and said that he would get it. It is possible that at this point Robert Black understood that he had been asked only to obtain a list of those residents who were in the rest centres. However, given that he had received the full list of residents by email at 05.24 and that Nickolas Layton had told him what the LFB was attempting to do, it is unlikely that he misunderstood what he had been asked for. Neither his written nor his oral evidence positively suggested that he had thought that Nickolas Layton had asked him only for a list of residents who were at the rest centres. 20.72 At 06.00182 Robert Black emailed TMO colleagues Peter Maddison, Barbara Matthews, Janice Wray, and Yvonne Birch, copying in Teresa Brown and Hash Chamchoun. The body of the email is worth setting out in full. It said:183 “To update Teressa and Hash are mangling resources at the respite centres RFM and NPB are here.and making statements saying very little. Question S about the cladding and spec. Questions about how it spread. We need to pull some of this together pretty fast in terms of Health and Safety compliance ( Barbara and Janice) We need all the information about the refurbishment as this will be a primary focus ( Peter. And his team) RBKC will put out a holding state but already asking these questions Robert” 20.73 At 06.03 David Noble sent an email to Teresa Brown, Janice Wray and Nicola Bartholomew.184 The subject was “Grenfell Emergency Plan Section” and it contained information from the TMO’s Emergency Plan (TMOEP). The TMOEP185 was split into two sections. The first dealt with emergency planning and the second contained specific information relating to each of the properties managed by the TMO, including information useful for the emergency services and information about vulnerable occupants. The TMOEP had been revised most recently in February 2016, but the information relating to Grenfell Tower was dated 25 February 2002 and was over 15 years old. Unsurprisingly, therefore, it was significantly out of date in a number of critical respects, not least in relation to the number of flats, the number of residents, the number of those with disabilities186 and the means of escape.187 The text of David Noble’s email at 06.03 merely repeated the outdated information about Grenfell Tower contained in the TMOEP. As Robert Black confirmed when he gave evidence, the TMOEP had not been amended in relation to Grenfell Tower (or indeed many other RBKC-owned properties under the management of the TMO) since 2002. 181 Refer also to the note of his interview by RBKC on 1 March 2018 [RBK00029015] at p. 4, where he explained that the purpose of obtaining the list of residents at the rest centres was to work out how many occupants had not come out of the tower. 182 [TMO10031176]. 183 Reproduced here as the original citation, including errors. 184 [TMO10031176]. 185 [TMO10013898]. 186 Although these may have been kept up to date on a different TMO data system: Black Day 74/201/24-202/2. 187 [TMO10013898] pp. 139-140.

The Grenfell Tower Inquiry: Phase 1 Report 484 20.74 Robert Black said that he was “very disappointed”188 to see that the information about Grenfell Tower in the TMOEP189 was 15 years out of date and did not take account of the refurbishment. He did not have information that night about the number of vulnerable residents, nor had he given any specific instructions to his staff about that. He said that Teresa Brown was trying to get current information on vulnerable residents from the housing files.190 20.75 Meanwhile, at some time after around 06.00, but before 06.13, John Allen entered the building with a team of five or six, comprising an LFB Urban Search and Rescue team and a Health and Safety team from the LFB and the MPS, to ascertain the condition of the concrete floors and reinforced concrete columns. They got as far as floor 8.191 At 06.13 the Roe Log recorded John Allen’s advice about the building (“not saying will collapse”). It then recorded that he would try find the plans, followed by a note of John Allen’s mobile phone number.192 20.76 At 06.16.23 Robert Black forwarded an email to John Allen which he had received at 06.14 from David Noble. The subject was “Fwd: Fire access plans from the refurb” with two files attached named “fire access” and “fire strategy”.193 20.77 Robert Black said that he could not remember why he had sent plans to John Allen and that he must have been asked to do so.194 He did not know whether anyone from the TMO had sent them to the LFB or whether he had been asked to do so. He said that he had no recollection of having been asked for plans by Michael Rumble.195 For his part, John Allen could not remember having seen or having received the email at 06.15.23 from Robert Black, and so had not forwarded the attachments to the LFB. John Allen estimated that he had left the incident at around 07.00 (although it is likely to have been a little earlier) to go to the RBKC Town Hall to search for plans of the tower. He then spent 30 minutes or so looking for plans, found them and printed them off. He left the Town Hall at around 07.30 and, again by his own estimate, returned to the incident between around 07.45 and 08.00.196 20.78 At around 06.30 Graham Webb, the Managing Director of Repairs Direct Ltd (a subsidiary of the TMO) arrived at the scene.197 He was briefed by Teresa Brown, who told him that Robert Black was acting as support for the LALO to deal with any requests.198 There was no discussion about outstanding requests for information, although he was aware that such requests had been made before his arrival, including a request for a list of safe and missing residents.199 At around 09.00 he later took over from Robert Black as the TMO point of contact for the LALO and the emergency services. 20.79 At 06.30 the second strategic co-ordinating group meeting took place with, for the most part, the same people attending as had been at the earlier meeting.200 At the meeting AC Mills described developments since the previous meeting and assured everyone that the structural integrity of the building had been assessed and that at that moment there was no reason to assume that a catastrophic collapse would occur. He also reported that the casualty bureau 188 Black Day 74/201/12. 189 [TMO10013898] pp. 139-140. 190 Black Day 74/201/22-203/3. 191 Allen second witness statement [RBK00035691] p. 4. 192 Roe Log [MET00005404] p. 5. 193 [RBK00001468]. 194 Black Day 74/213/4-7. 195 Black Day 74//214/18-21. 196 Allen second witness statement [RBK00035691] pp. 8-10. 197 Webb witness statement [TMO10048963] p. 1. 198 Webb Day 75/13/16-14/25. 199 Webb Day 75/17/4-9. 200 London Resilience Forum Major Incident minutes of this meeting at [MET00023292].

Part II | Chapter 20: Period 11: 05.00-08.10 485 was in operation, that the LAS had 44 ambulances at the scene and the MPS had 100 officers present, that six persons had been declared dead, that RBKC was consolidating the rest centres into a single location, and that the RBKC BECC was now open. 20.80 At 07.00 Nickolas Layton left the scene and Michael Rumble took over as LALO. At that point no list of residents of any kind had been provided.201 Nickolas Layton said that he had made it clear to Michael Rumble that the absence of that information about the residents was a matter of concern and that Michael Rumble had understood the importance and urgency of obtaining it.202 However, Michael Rumble said that he had not been aware that Nickolas Layton had been asking Robert Black for information about the residents and he could not recall whether he had been specifically told about requests for details of the residents who were at the rest centres or about the request for a list of residents generally.203 He did not recall having been aware that the request for a list of residents had been outstanding at the time of the TCG meeting at 05.50.204 I am sure that both witnesses were doing their best to remember exactly what passed between them at that time. Nickolas Layton was well aware that a response to the request for information about the residents had been outstanding for some time (and why the LFB wanted it) and I have little doubt that the importance of obtaining it as soon as possible had been very present to his mind. It would be natural, therefore, for him to have sought to impress on his replacement the need to obtain that information as soon as possible. His recollection of these events was generally much clearer than that of Michael Rumble and, although he may not have succeeded to the extent he thought he had, I accept that he did do all that he reasonably could to impress upon Michael Rumble the need to obtain the information as a matter of urgency. 20.81 It is possible, as his MPS statement shows, that towards the end of his role in the incident Nickolas Layton was framing his request in terms of information only about residents at the rest centres. His MPS statement records that at 06.45 he had spoken to Robert Black and told him that he had not received any information “about residents in the rest centres and that the information was needed by 07.00 hours”.205 It also records that when he handed over to Mike Rumble at 07.00 he had “received no information about residents in the rest centres”. Accordingly, it is possible that Mike Rumble understood only that he was to seek a list of residents at the rest centres and not a full list. However, as I have already said, I doubt very much that Robert Black laboured under any such misunderstanding, not least because he knew that the full list of Grenfell Tower residents had been asked for, that he had received such a list and that the LFB wanted to find out who was missing from the rest centres. 20.82 I am conscious that over time Nickolas Layton’s evidence on what he said to Robert Black and Mike Rumble has changed and that there are inconsistencies between his accounts, but when he gave evidence he was challenged directly on his recollection about this issue and was unwavering.206 I accept his evidence on this issue because it is consistent with the purpose for which the information had been requested by the LFB. A list of residents at the rest centres was of little use without a full list of residents in the tower. 201 Layton witness statement [RBK00029034] p. 8 paragraph 29; Layton Day 74/71/6-18. 202 Layton Day 74/75/21-76/17. 203 Rumble Day 74/111/1-24. 204 Rumble Day 74/111/14-18. 205 Layton MPS witness statement [MET00007967] p. 5. 206 Layton Day 74/67/16-68/24.

The Grenfell Tower Inquiry: Phase 1 Report 486 20.83 The fourth TCG meeting began at 07.13 on CU8. Inspector Nicholas Thatcher and Detective Superintendent Paul Warnett attended for the MPS and Laurence Ioannou and another officer represented the LAS,207 and Michael Rumble was there as LALO.208 At that meeting John Allen’s advice that the building would not collapse but that there was a very real possibility that some parts might fall was summarised by AC Roe. By that time John Allen had left the incident to find the plans of the building in the RBKC Town Hall.209 Detective Superintendent Warnett reported that the civil unrest was “moving away”, that the cordons were being organised and that there were 65 “casualties” at the rest centres at Freston Road. The LAS reported 56 injured and six fatalities, and that they were “anticipating large numbers of deceased”. According to Michael Rumble, there were now six rest centres, the largest being at St Mark’s Church. Either Inspector Thatcher or Detective Superintendent Warnett asked Michael Rumble for an electoral roll for the tower and AC Roe demanded a set of plans, which he noted he had been asking for “for a very long time”. He expressed the view (though he did not want it to be formally recorded) that the absence of plans was a “major deficiency”.210 The fourth TCG meeting ended at 07.35; the next was scheduled for 08.40.211 20.84 Nickolas Layton was not aware that AC Roe had asked John Allen for plans of the building at 06.13212 and Michael Rumble could not say with certainty whether there had been a request for a floor plan from RBKC by the fourth TCG meeting.213 Neither LALOs were aware that Robert Black had sent an electronic version to John Allen at 06.16 by email.214 However, Michael Rumble said that it had been obvious at the fourth TCG meeting that plans were urgently required by the LFB,215 although he said that that was the first time he had been asked for them.216 He thought it was possible that he had become aware before the meeting that Robert Black had a copy of a plan of a typical floor of the tower on his phone and he accepted that it was possible that he might himself have spoken to TMO staff about plans sometime earlier.217 20.85 Following the fourth TCG meeting, Michael Rumble passed the request for plans to the TMO as he believed it was more likely to have access to plans of the tower than RBKC.218 He made a request through the BECC for a copy of the electoral roll, but did not know what came of the request.219 He saw Robert Black speaking to an LFB officer and believed that he had forwarded the floor plan by email. However, he did not see any plans himself.220 The floor plan and a copy of the electoral roll, both of which had been requested at the meeting at 07.13, were provided to the LFB “FSG sector” (i.e. CU7) at 07.57.221 207 Although Laurence Ioannou says that Colin Passey of LAS attended ([MET00010862] p. 11), that is not borne out by either the Roe Log [MET00005404] or Colin Passey’s witness statement [MET00013950]. 208 Layton witness statement [RBK00029034] paragraph 35. 209 Roe Log [MET0005404] p. 6; Roe Day 49/196/10-198/20. 210 An analysis of the evidence about when AC Roe and other LFB officers first started asking for plans of the building from RBKC is in Period 8 and Period 10. 211 Roe Log [MET00005404] p. 7. 212 Layton Day 74/74/20-25-75/1-12 213 Rumble Day 74/116/6-12 214 Rumble Day 74/120/17-19; Layton Day 74/75/13-15; [RBK00001468]. 215 Rumble Day 74/117/7-21. 216 Rumble Day 74/115/17-116/16; Rumble witness statement [RBK00029037] paragraph 11.1. 217 Rumble Day 74/119/1-16. 218 Rumble Day 74/119/17-120/5. 219 Rumble Day 74/114/7-17, 74/124/12-125/13. 220 Rumble Day 74/120/6-11 221 Roe Log [MET00005404] p. 7; [LFB00024370].

Part II | Chapter 20: Period 11: 05.00-08.10 487 20.86 Meanwhile, John Allen had been at RBKC Town Hall locating and printing off the plans of Grenfell Tower, which he had found in the “Means of Escape” files.222 He left the Town Hall at around 07.30223 and returned to the incident between 07.45 and 08.00.224 He took the plans to CU8, but the LFB had already obtained copies from the TMO and had them up on one of the screens in CU8.225 Exactly where the TMO had found the plans remains unclear, but it is possible that they were the ones of which Robert Black had earlier received copies on his phone. Whatever their source, it is likely that they were the plans that were provided to the LFB by email at 07.57. John Allen arrived back as CU8 between 07.45 and 08.00. 20.87 At 07.56 Robert Black forwarded the email sent to him by David Noble at 05.24 containing details of the occupants of the tower to GM Goodall, copying in Teresa Brown. The message read: “Hi from Teressa [sic] and getting a hard copy” 226 20.88 Robert Black said that there had been a delay in sending the information to the LFB because he had been asked for the information only at that point. He did not question why it had not been sent to the LFB by Teresa Brown earlier.227 Later she gave Michael Rumble a printed list of residents.228 He asked her to send it by email to the LFB and gave her a specific email address to which to send it. He believed that had happened just before the TCG meeting at 11.00.229 20.89 Colin Passey took over from Laurence Ioannou as the senior LAS officer (Bronze Medic) at 07.38, following a rolling handover that began at around 07.10.230 Colin Passey visited sector 1 and sector 2 and did not see any patients being treated, but at around 08.10 he saw one patient being treated at sector 2, whom he understood to be the last person to leave the tower, Elpidio Bonifacio.231 222 Allen second witness statement [RBK00035691] pp. 8-9. 223 He timed that by reference to his email to Graham Stallwood of 07.31 [RBK00035693]. 224 Allen second witness statement [RBK00035691] p. 10. 225 Allen second witness statement [RBK00035691] pp. 9, 10. These were like the plans at [LFB00001968] pp. 49, 51. 226 [TMO10031176]. 227 Black Day 74/193/23-194/12, 195/5-197/8. 228 Michael Rumble referred to a number of documents ([RBK00014629]) which had his signature on it (Rumble Day 74/127/24- 25-128/1-5). He believed he also received the documents at [LFB00024371] and LFB00024372. 229 Rumble Day 74/127/11-130/22. 230 Passey witness statement [MET00013950] p. 3. 231 Passey witness statement [MET00013950] p. 4.

The Grenfell Tower Inquiry: Phase 1 Report 488

489 Annex A Table listing those who were in Grenfell Tower as at 00.54 on 14 June 2017 Annex A lists all those present inside the tower as at 00:54 on 14 June 2017 together with their locations by flat and floor. The Annex gives the times, between 00:54 and 08:07, when survivors of the fire left the building or when the bodies of some of those who died were carried out. Some individuals listed were not in their flats on the night but elsewhere in the tower. In these cases, the flat where they were ordinarily resident is shown in brackets. There were a number of CCTV cameras located on the ground floor of the tower. The MPS has prepared a schedule of CCTV exit times from those cameras which contains a record of the times at which people left the tower.1 These times were not adjusted to reflect real time. The CCTV cameras on the ground floor of the tower were fast by 36 seconds. The exit times recorded in Annex A are therefore the last time a person is recorded on the MPS schedule, adjusted to take account of the 36-second discrepancy. In very few cases, survivors did not leave by the ground floor. Their exit times have been derived from other sources as explained in the Narrative. 1 [MET00016072].

The Grenfell Tower Inquiry: Phase 1 Report 490 Second Name First Name Flat Floor Survivor/ Deceased Male (M)/ Female (F) Adult/Child on 14.06.17 Adjusted Exit Time on CCTV (British Standard Time) (Source: MET00016072) 1 EGAL Mahad Mahamed 15 4 Survivor M Adult 0:59:12 2 MURRAY Jamie Lucy 15 4 Survivor F Adult 0:59:12

3

Child 15 4 Survivor M Child 0:59:12

4

Child 15 4 Survivor F Child 0:59:12 5 AFEWORKI Elsa Mebrahut 16 4 Survivor F Adult 0:59:22 6 ADAM Maryam Yusuf 14 4 Survivor F Adult 0:59:31 7 MOHAMMED Amna 14 4 Survivor F Adult 0:59:31 8 ABDULHAMID Abdulwahab Hassan 14 4 Survivor M Adult 0:59:31 9 BOAITEY Ishmael 13 4 Survivor M Adult 0:59:33 10 CHENTITE Jalal NK NK Survivor M Adult 0:59:33 11 YUSUF Saleh 21 5 Survivor M Unknown 1:01:29 12 HARIRI Mohamed 21 5 Survivor M Adult 1:02:24 13 KEBEDE Behailu 16 4 Survivor M Adult 1:03:01 14 ALVES Maria de Fatima (Fatima) 105 13 Survivor F Adult 1:04:19 15 ALVES Ines Tavares 105 13 Survivor F Child 1:04:21 16 ALVES Tiago 105 13 Survivor M Adult 1:04:25 17 KAFICHERAGHI Farshid 91 12 Survivor M Adult 1:06:23 18 MOSES Alison 11 4 Survivor F Adult 1:07:09 19 ALVES Manuel Miguel Ferreira (Miguel) 105 13 Survivor M Adult 1:08:34 20 KINFU Almaz 16 4 Survivor F Adult 1:10:13 21 SEDRATI Hafida 55 8 Survivor F Adult 1:10:14

22

Child 55 8 Survivor M Child 1:10:14 23 SEDRATI Sarah 55 8 Survivor F Adult 1:10:16 24 ZADA Eamon 53 8 Survivor M Adult 1:11:53 25 HIRSI Abdirahman Salah 7 3 Survivor M Adult 1:12:54

Part II | Annex A: Table listing those who were in Grenfell Tower as at 00.54 on 14 June 2017 491 Second Name First Name Flat Floor Survivor/ Deceased Male (M)/ Female (F) Adult/Child on 14.06.17 Adjusted Exit Time on CCTV (British Standard Time) (Source: MET00016072) 26 HIRSI Suhayb Salah 7 3 Survivor M Adult 1:12:55 27 BENJAMIN David Andrew 12 4 Survivor M Adult 1:12:58 28 DAINTON Zoe 12 4 Survivor F Adult 1:13:01 29 GRIFFIN Daniel 31 6 Survivor M Adult 1:16:04 30 SUAREZ-CHANS Dorinda Encarnacion 103 13 Survivor F Adult 1:16:41 31 COSTA COTELO Jose 103 13 Survivor M Adult 1:16:42 32 HAXHISEFA Alk 106 13 Survivor M Child 1:17:12

33

Child 106 13 Survivor M Child 1:17:12 34 ZYMBERAJ Adriana 106 13 Survivor F Adult 1:17:13 35 HAXHISEFA Avni 106 13 Survivor M Adult 1:17:15 36 CHEBIOUNI Zakariya 66 9 Survivor M Child 1:19:20

37

Child 66 9 Survivor F Child 1:19:20 38 DAGNACHEW Hiwot 26 5 Survivor F Adult 1:20:07

39

Child 26 5 Survivor F Child 1:20:07

40

Child 26 5 Survivor M Child 1:20:08 41 TEMESGEN Wintom 26 5 Survivor M Adult 1:20:13 42 MONTES Claudia Marina Cedeno 36 6 Survivor F Adult 1:20:34 43 TOWNER Luke 171 20 Survivor M Adult 1:20:37 44 O’CONNOR Emma 171 20 Survivor F Adult 1:20:38 45 URBANO Ramiro 36 (176) 6 (20) Survivor M Adult 1:20:50 46 MILLAN GONZALEZ Oscar 36 6 Survivor M Adult 1:20:52 47 WAHABI Hanan 66 9 Survivor F Adult 1:21:00 48 CHEBIOUNI Salah Eddine 66 9 Survivor M Adult 1:21:40

49

Child 102 13 Survivor F Child 1:21:41 50 RAIHANI Aziza El-Ouahabi 126 15 Survivor F Adult 1:21:42

The Grenfell Tower Inquiry: Phase 1 Report 492 Second Name First Name Flat Floor Survivor/ Deceased Male (M)/ Female (F) Adult/Child on 14.06.17 Adjusted Exit Time on CCTV (British Standard Time) (Source: MET00016072)

51

Child 125 15 Survivor F Child 1:21:59 52 JAFARI Fatima 86 11 Survivor F Adult 1:22:25

53

Child 102 13 Survivor F Child 1:22:27 54 MICHAEL Aida 102 13 Survivor F Adult 1:22:27 55 ALI Rashida Abdalla 125 15 Survivor F Adult 1:23:20

56

Child 54 8 Survivor M Child 1:23:42 57 HARZI Makrem 54 8 Survivor M Adult 1:23:42 58 KASOTE Betty 41 7 Survivor F Adult 1:23:51 59 SAID Rawda 54 8 Survivor F Adult 1:23:51 60 VIEIRO Jose 46 7 Survivor M Adult 1:23:56 61 VIEIRO Carmen 46 7 Survivor F Adult 1:23:56 62 WEST Hannah 45 7 Survivor F Adult 1:23:58

63

Child 45 7 Survivor F Child 1:24:00 64 PARAMASAVIAN Michael Thomas Phillip 45 7 Survivor M Adult 1:24:00 65 HANLEY Catherine 52 8 Survivor F Adult 1:24:01 66 HANLEY Mary 52 8 Survivor F Adult 1:24:03 67 JAMALVATAN Mahboubeh 10 3 Survivor F Adult 1:24:20 68 PATEL Shantilal Naranbhai 56 8 Survivor M Adult 1:24:22 69 THOMPSON William 52 8 Survivor M Adult 1:24:36 70 PATEL Chiraag Shantilal 56 8 Survivor M Adult 1:24:38 71 PATEL Kiran 56 8 Survivor F Adult 1:24:49 72 MOHAMED Amina 51 8 Survivor F Adult 1:24:50 73 AHMED Khalid 51 8 Survivor M Adult 1:24:54 74 AHMED Mohamed 102 13 Survivor M Adult 1:25:03 75 NAQSHBANDI Reshad 8 3 Survivor M Adult 1:25:18

Part II | Annex A: Table listing those who were in Grenfell Tower as at 00.54 on 14 June 2017 493 Second Name First Name Flat Floor Survivor/ Deceased Male (M)/ Female (F) Adult/Child on 14.06.17 Adjusted Exit Time on CCTV (British Standard Time) (Source: MET00016072) 76 LOKKO Monica 3 1 Survivor F Adult 1:25:28 77 KASSEMDJIAN Mesrob 141 17 Survivor M Adult 1:25:51 78 HARRIS Hermine 42 7 Survivor F Adult 1:26:03 79 JAFARI Maria 86 11 Survivor F Adult 1:26:07 80 AL-ARASI Randa 102 13 Survivor F Adult 1:26:09

81

Ahalam 102 13 Survivor F Adult 1:26:09 82 PAHLAVANI Gitiara 22 5 Survivor F Adult 1:26:11 83 SOBIESZCZAK Elizabeth 43 7 Survivor F Adult 1:26:24 84 SOBIESZCZAK Florentyna 43 7 Survivor F Adult 1:26:24 85 ROJO Rhea Iligan 91 12 Survivor F Adult 1:26:33 86 LAVINE Jean 42 7 Survivor M Adult 1:26:38 87 JAFARI Nadia 86 11 Survivor F Adult 1:26:39 88 TANKARIAN Rita 141 17 Survivor F Adult 1:26:48 89 HEE-CHEUNG Fung 141 17 Survivor F Adult 1:26:48 90 HO Van Quang 76 10 Survivor M Adult 1:26:58 91 QUANG Hoang Khanh 76 10 Survivor F Adult 1:27:24 92 SOBIESZCZAK Michael 43 7 Survivor M Adult 1:27:29 93 MAHMUD Munira 25 5 Survivor F Adult 1:27:32

94

Child 25 5 Survivor F Child 1:27:32

95

Child 25 5 Survivor M Child 1:27:32 96 BAYAM Sied 121 15 Survivor M Adult 1:27:35 97 YOUSEF Nadia 121 15 Survivor F Adult 1:27:36

98

Child 85 11 Survivor F Child 1:27:38 99 ABDULLAH Sabah 143 17 Survivor M Adult 1:27:38 100 EL-OGBANI Mouna 85 11 Survivor F Adult 1:27:39

The Grenfell Tower Inquiry: Phase 1 Report 494 Second Name First Name Flat Floor Survivor/ Deceased Male (M)/ Female (F) Adult/Child on 14.06.17 Adjusted Exit Time on CCTV (British Standard Time) (Source: MET00016072)

101

Child 85 11 Survivor M Child 1:27:39 102 KHALLOUD Youssef 85 11 Survivor M Adult 1:27:40

103

Child 85 11 Survivor F Child 1:27:40 104 LOUIS Damiana 96 12 Survivor F Adult 1:28:03 105 ABDU Mustafa Siraag 184 21 Survivor M Adult 1:28:21 106 DIAS Joao 104 13 Survivor M Adult 1:28:24 107 MANGOBA Marlon Snr 116 14 Survivor M Adult 1:29:45 108 MANGOBA Marlon Jnr 116 14 Survivor M Child 1:29:45 109 MINAEI MOGHADDAM Sepideh 4 1 Survivor F Adult 1:29:46

110

Child 4 1 Survivor F Child 1:29:47 111 MANGOBA Nida 116 14 Survivor F Adult 1:29:56

112

Child 145 17 Survivor M Child 1:29:56 113 JONES Corinne Simone 145 17 Survivor F Adult 1:30:00

114

Child 145 17 Survivor M Child 1:30:00 115 BATOAN Genaro 146 17 Survivor M Adult 1:30:11 116 RABAYA Elisa 146 17 Survivor F Adult 1:30:15 117 CASTRO Virgilio (Larry) 146 17 Survivor M Adult 1:30:37 118 LEWIS Rose 5 1 Survivor F Adult 1:31:25 119 LEWIS Octinia 5 1 Survivor F Adult 1:31:25 120 CHARLES Theodore 5 1 Survivor M Adult 1:31:27 121 GASHAW Hime Haymanot 131 16 Survivor F Adult 1:31:29 122 AHMED Sayeda 156 18 Survivor F Adult 1:31:29 123 AHMED Shahid (Shah) 156 18 Survivor M Adult 1:31:30 124 FLETCHER Richard 131 16 Survivor M Adult 1:31:31

125

Child 131 16 Survivor F Child 1:31:31

Part II | Annex A: Table listing those who were in Grenfell Tower as at 00.54 on 14 June 2017 495 Second Name First Name Flat Floor Survivor/ Deceased Male (M)/ Female (F) Adult/Child on 14.06.17 Adjusted Exit Time on CCTV (British Standard Time) (Source: MET00016072) 126 MEKONNEN Meron 163 19 Survivor F Adult 1:32:25

127

Child 163 19 Survivor F Child 1:32:25

128

Child 163 19 Survivor F Child 1:32:25 129 KHDEIR Walaa 64 9 Survivor F Adult 1:33:35 130 KHDEIR Lujain 64 9 Survivor F Child 1:33:37 131 DEDRICH Reem 123 15 Survivor F Adult 1:33:35 132 IGNACIO Wesley 62 9 Survivor M Adult 1:33:57

133

Child 62 9 Survivor F Child 1:33:57 134 IGNACIO Madylyn 62 9 Survivor F Adult 1:33:59 135 IGNACIO Erlinda 62 9 Survivor F Adult 1:34:00 136 DAFFARN Edward 134 16 Survivor M Adult 1:34:51 137 NALUKWAGO Nagawa (Prossy) 71 10 Survivor F Adult 1:35:03 138 KHDEIR Rawan 64 9 Survivor F Adult 1:35:36 139 ALKUEDI Iman 64 9 Survivor F Adult 1:35:36 140 RASOUL Mohammed 25 5 Survivor M Adult 1:35:58 141 ABD EL RASOUL Ahmed 25 5 Survivor M Adult 1:35:58 142 ATMANI Sid-Ali 125 15 Survivor M Adult 1:35:58 143 KHOUDAIR Maher 64 9 Survivor M Adult 1:36:38 144 DANIELS Samuel 135 16 Survivor M Adult 1:38:04 145 WAHBI Hamid 136 16 Survivor M Adult 1:38:13 146 MAMUDU Rukeyatu 2 1 Survivor F Adult 1:40:26

147

Child 2 1 Survivor M Child 1:40:26 148 AUGUSTUS Leroy 174 20 Survivor M Adult 1:41:25 149 DOULOVA Petra 174 20 Survivor F Adult 1:41:26 150 MENACER Paul 33 6 Survivor M Adult 1:43:55

The Grenfell Tower Inquiry: Phase 1 Report 496 Second Name First Name Flat Floor Survivor/ Deceased Male (M)/ Female (F) Adult/Child on 14.06.17 Adjusted Exit Time on CCTV (British Standard Time) (Source: MET00016072) 151 HALEY Sharon 24 (13) 5 (4) Survivor F Adult 1:44:12 152 SMITH Kenny 13 4 Survivor M Adult 1:44:14 153 O’HARA Kerry 34 6 Survivor F Adult 1:44:44 154 BEADLE John 13 4 Survivor M Adult 1:46:21 155 MAWIA Aimen NK NK Survivor F Adult 1:46:35 156 SHAH Josephine 32 6 Survivor F Adult 1:47:17 157 SHAH Avelina 32 6 Survivor F Adult 1:47:17 158 GIRMA Turufat Yilma 44 7 Survivor F Adult 1:48:00 159 ABEBE Abraham 44 7 Survivor M Adult 1:48:04

160

Child 44 7 Survivor M Child 1:48:04 161 ALLCORN Tania Jean 35 6 Survivor F Adult 1:48:22 162 NANA Suriya 35 6 Survivor F Adult 1:48:22 163 GHAVIMI Clarita 75 10 Survivor F Adult 1:49:09 164 LOVSIN Miran 84 11 Survivor M Adult 1:49:09 165 LUKIC Branislav 84 11 Survivor M Adult 1:49:09 166 LEWIS David 9 3 Survivor M Adult 2:07:15

167

Child 9 3 Survivor M Child 2:07:15

168

Child 9 3 Survivor F Child 2:07:15

169

Child 9 3 Survivor M Child 2:07:15 170 TOYOSHIMA-LEWIS Mariko 9 3 Survivor F Adult 2:10:14

171

Child 65 9 Survivor F Child 2:18:03 172 LACI Sharon 65 9 Survivor F Adult 2:19:08 173 KAREEM Milad 23 5 Survivor M Adult 2:19:00 174 SABIR Rebin Sartib 23 5 Survivor M Adult 2:21:00 175 AHMED Fadumo 164 19 Survivor F Adult 2:25:55

Part II | Annex A: Table listing those who were in Grenfell Tower as at 00.54 on 14 June 2017 497 Second Name First Name Flat Floor Survivor/ Deceased Male (M)/ Female (F) Adult/Child on 14.06.17 Adjusted Exit Time on CCTV (British Standard Time) (Source: MET00016072)

176

Child 175 20 Survivor F Child 2:25:55 177 TUCCU Mohamednur 166 19 Deceased M Adult 2:28:41 178 KHALLOUFI Khadija 143 17 Deceased F Adult 2:28:53 179 DEL PILAR BURTON Maria (Pily) 165 19 Survivor F Adult 2:32:35 180 BURTON Nicholas Trevanion 165 19 Survivor M Adult 2:32:47

181

Child 95 12 Survivor F Child 2:39:35 182 DABROWSKA Katarzyna 95 12 Survivor F Adult 2:40:48

183

Child 95 12 Survivor F Child 2:41:17 184 SMITH Roy 95 12 Survivor M Adult 2:41:41 185 NEDA Shekeb (Farhad) 205 23 Survivor M Adult 2:42:10 186 NEDA Flora (Shakila) 205 23 Survivor F Adult 2:43:32 187 ALHAJ ALI Omar 112 14 Survivor M Adult 2:45:02

188

Child 113 14 Survivor F Child 2:45:15 189 OYEWOLE Rosemary Olabisi 113 14 Survivor F Adult 2:46:03 190 TALABI Oluwaseun 113 14 Survivor M Adult 2:46:03 191 ROSS Rebecca 122 15 Survivor F Adult 2:53:57 192 BELKADI Malak 175 20 Deceased F Child 03.07.15 193 ASSEFA Ethiopia 94 12 Survivor F Adult 3:07:26 194 DEMISSIE Alemishet 94 12 Survivor F Adult 3:10:47

195

Child 153 18 Survivor M Child 3:12:55 196 SHAWO Genet Grebremaiam 153 18 Survivor F Adult 3:12:57 197 TEKLE Paulos Woldesilassie 153 18 Survivor M Adult 3:12:59 198 ENYEW Yehualashet 155 18 Survivor M Adult 3:13:50

199

Child 152 18 Survivor F Child 3:15:19

200

Child 152 18 Survivor M Child 3:17:25

The Grenfell Tower Inquiry: Phase 1 Report 498 Second Name First Name Flat Floor Survivor/ Deceased Male (M)/ Female (F) Adult/Child on 14.06.17 Adjusted Exit Time on CCTV (British Standard Time) (Source: MET00016072)

201

Child 152 18 Survivor F Child 3:18:22 202 YAHYA Rabia 152 18 Survivor F Adult 3:18:41

203

Child 92 12 Survivor M Child 3:20:06 204 ABOUD Karen 92 12 Survivor F Adult 3:20:10

205

Child 92 12 Survivor M Child 3:21:28 206 LI Chia-Yuan (Naomi) 195 22 Survivor F Adult 3:21:28 207 LIAO Chin-Hsuan (Lydia) 195 22 Survivor F Adult 3:21:38 208 JAFARI Ali Yawar 86 11 Deceased M Adult 3:33:47

209

Child 183 21 Survivor F Child 3:37:06 210 PERESTRELO Andreia 183 21 Survivor F Adult 3:37:24 211 GEBREMESKEL Helen 186 21 Survivor F Adult 3:37:30 212 MACIT Sener 133 16 Survivor M Adult 3:47:15 213 MACIT Hanife 133 16 Survivor F Adult 3:47:16

214

Child 183 21 Survivor F Child 3:51:06

215

Child 186 21 Survivor F Child 3:52:42 216 FAIRBAIRN Christos 124 15 Survivor M Adult 3:54:26 217 GOMES Marcio Paulo Da Silva 183 21 Survivor M Adult 3:55:01 218 HAMIDE Lina 74 10 Survivor F Adult 4:13:32 219 WOLDESELASSIE ARAYA Meron 74 10 Survivor F Adult 4:12:34 220 SUPAREOGSANOND Adam 73 10 Survivor M Adult 4:18:43 221 SUPAREOGSANOND Waewta 73 10 Survivor F Adult 4:20:18 222 CHANCE Ann 73 10 Survivor F Adult 4:20:18 223 SUPAREOGSANOND Chalalai 73 10 Survivor F Adult 4:20:18

224

Child 82 11 Survivor F Child 4:47:16 225 SMITH Anthony 82 11 Survivor M Adult 4:47:17

Part II | Annex A: Table listing those who were in Grenfell Tower as at 00.54 on 14 June 2017 499 Second Name First Name Flat Floor Survivor/ Deceased Male (M)/ Female (F) Adult/Child on 14.06.17 Adjusted Exit Time on CCTV (British Standard Time) (Source: MET00016072) 226 ELCOCK Natasha 82 11 Survivor F Adult 4:47:22 227 RONCOLATO Antonio 72 10 Survivor M Adult 6:05:15 228 BONIFACIO Elpidio 83 11 Survivor M Adult 8:07:20 229 JACKSON LE-BLANC Leanne Mya 6 2 Survivor F Adult NK

230

Child 6 2 Survivor M Child NK 231 JOHN Joseph 6 2 Survivor M Adult NK 232 SEBBAR Abdeslam 81 11 Deceased M

Adult

233 MURPHY Denis 111 14 Deceased M

Adult

234 ALHAJALI Mohammad 112 14 Deceased M

Adult

235 DEEN Zainab 115 14 Deceased F

Adult

236 DEEN Jeremiah 115 14 Deceased M

Child

237 POWER Steven 122 15 Deceased M

Adult

238

Sheila 132 16 Deceased F

Adult

239 DANIELS Joseph 135 16 Deceased M

Adult

240 BEGUM Rabeya 142 17 Deceased F

Adult

241 MIAH Kamru 142 17 Deceased M

Adult

242 HANIF Mohammed 142 17 Deceased M

Adult

243 HAMID Mohammed 142 17 Deceased M

Adult

244 BEGUM Husna 142 17 Deceased F

Adult

245 CHIEJINA Vincent 144 17 Deceased M

Adult

246 AFRASEHABI Sakina 151 18 Deceased F

Adult

247 AFRASIABI Fatemeh 151 18 Deceased F

Adult

248 PAULOS Isaac 153 18 Deceased M

Child

249 KANI Hamid 154 18 Deceased M

Adult

250 HAFTOM Biruk 155 18 Deceased M

Child

The Grenfell Tower Inquiry: Phase 1 Report 500 Second Name First Name Flat Floor Survivor/ Deceased Male (M)/ Female (F) Adult/Child on 14.06.17 Adjusted Exit Time on CCTV (British Standard Time) (Source: MET00016072) 251 HAFTOM Berkti 155 18 Deceased F

Adult

252 LAMPRELL Deborah (Debbie) 161 19 Deceased F

Adult

253 MAUNDERS Gary 161 19 Deceased M

Adult

254 VITAL Majorie 162 19 Deceased F

Adult

255 VITAL Ernie 162 19 Deceased M

Adult

256 AHMEDIN Amal 166 19 Deceased F

Adult

257 TUCCU AHMEDIN Amaya 166 19 Deceased F

Child

258 IDRIS Amna Mahmud 166 19 Deceased F

Adult

259 KING Victoria (Vicky) 172 20 Deceased F

Adult

260 ATALA Alexandra Catherine 172 20 Deceased F

Adult

261 MENDY Mary 173 20 Deceased F

Adult

262 SAYE Khadija 173 20 Deceased F

Adult

263 HAMDAN Farah 175 20 Deceased F

Adult

264 BELKADI Omar 175 20 Deceased M

Adult

265 BELKADI Leena 175 20 Deceased F

Child

266 URBANO RAMIREZ Jessica 176 20 Deceased F

Child

267 MOORE Ligaya 181 21 Deceased F

Adult

268 EL WAHABI Abdulaziz 182 21 Deceased M

Adult

269 EL WAHABI Faouzia 182 21 Deceased F

Adult

270 EL WAHABI Yasin 182 21 Deceased M

Adult

271 EL WAHABI Nur Huda 182 21 Deceased F

Child

272 EL WAHABI Mehdi 182 21 Deceased M

Child

273 CHOUCAIR Sirria 191 22 Deceased F

Adult

274 KEDIR Hashim 192 22 Deceased M

Adult

275 JEMAL Nura 192 22 Deceased F

Adult

Part II | Annex A: Table listing those who were in Grenfell Tower as at 00.54 on 14 June 2017 501 Second Name First Name Flat Floor Survivor/ Deceased Male (M)/ Female (F) Adult/Child on 14.06.17 Adjusted Exit Time on CCTV (British Standard Time) (Source: MET00016072) 276 HASHIM Yaqub 192 22 Deceased M

Child

277 HASHIM Firdaws 192 22 Deceased F

Child

278 HASHIM Yahya 192 22 Deceased M

Child

279 CHOUCAIR Nadia 193 22 Deceased F

Adult

280 CHOUKAIR Bassem 193 22 Deceased M

Adult

281 CHOUCAIR Mierna 193 22 Deceased F

Child

282 CHOUCAIR Fatima 193 22 Deceased F

Child

283 CHOUCAIR Zainab 193 22 Deceased F

Child

284 DISSON Anthony 194 22 Deceased M

Adult

285 ELGWAHRY Mariem 196 22 Deceased F

Adult

286 ELGWAHRY Eslah 196 22 Deceased F

Adult

287 BERNARD Raymond (Moses) 201 23 Deceased M

Adult

288 GOTTARDI Marco 202 23 Deceased M

Adult

289 TREVISAN Gloria 202 23 Deceased F

Adult

290 IBRAHIM Rania 203 23 Deceased F

Adult

291 HASSAN Fethia 203 23 Deceased F

Child

292 HASSAN Hania 203 23 Deceased F

Child

293 RAHMAN Hesham 204 23 Deceased M

Adult

294 NEDA Mohammed Amied (Saber) 205 23 Deceased M

Adult

295 IBRAHIM Isra 206 23 Deceased F

Adult

296 IBRAHIM Abufras Mohamed 206 23 Deceased M

Adult

297 AHMED ELSANOUSI Fathia 206 23 Deceased F

Adult

The Grenfell Tower Inquiry: Phase 1 Report 502

ISBN 978-1-5286-1602-7 (Volume 3 of 4) 4 volumes not available separately

FD05972 ｜ 2017_英国_UK_Grenfell_Tower_Inquiry_Phase_1_Report_Volume_4.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2017 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

GRENFELL TOWER INQUIRY: PHASE 1 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 Chairman: The Rt Hon Sir Martin Moore-Bick October 2019 Volume 4 HC 49–IV

GRENFELL TOWER INQUIRY: PHASE 1 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 Chairman: The Rt Hon Sir Martin Moore-Bick October 2019 Presented to Parliament pursuant to section 26 of the Inquiries Act 2005 Ordered by the House of Commons to be printed 30 October 2019 Volume 4 HC 49–IV

This report contains images and content which some may find distressing. © Crown copyright 2019 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. This publication is available at www.gov.uk/official-documents Any enquiries regarding this publication should be sent to us at contact@grenfelltowerinquiry.org.uk ISBN 978-1-5286-1602-7 (Volume 4 of 4) 4 volumes not available separately CCS0719597372    10/19 Printed on paper containing 75% recycled fibre content minimum Printed in the UK by the APS Group on behalf of the Controller of Her Majesty’s Stationery Office

503 Part III Conclusions

504

505 Chapter 21 The Cause and Origin of the Fire 21.1 The two principal matters to be determined are how the fire started and what caused it. In answering these questions I was assisted by expert evidence from Professor Niamh Nic Daéid (in relation to the origin, cause and initial internal spread of the fire) and Dr Duncan Glover (in relation to the electrical installations and certain appliances in Flat 16). Neither expert was involved in the investigations conducted by, or under the authority of, the MPS in the immediate aftermath of the fire. Therefore, although both experts were able to visit the tower to inspect and photograph Flat 16 and to carry out such tests as they considered necessary and appropriate, they were obliged to rely to a significant extent on the evidence gathered by others. The manner and means by which evidence was recovered from Flat 16 was, in certain respects, not ideal, but both experts considered that the available evidence was sufficient to allow them to reach their conclusions with confidence. 1 Where did the fire start? 21.2 It is quite clear, and indeed no one has suggested otherwise, that the fire started in the kitchen of Flat 16. That was the evidence of Mr Kebede, Ms Afeworki and Ms Kinfu, as well as the two fire crews who entered the flat and there is no evidence to suggest that it started anywhere else. It was the unchallenged view of Professor Nic Daéid that the fire started in the kitchen of Flat 16 and that was the equally clear conclusion of Bureau Veritas and Key Forensic Services, investigators retained by the MPS to examine the cause and origin of the fire.1 21.3 A slightly more contentious question is whether it is possible to determine exactly where in the kitchen the fire started. In this regard, there are four principal sources of evidence: (i) the evidence of the occupants of Flat 16, Mr Kebede, Ms Afeworki and Ms Kinfu and the evidence of the firefighters who first entered the kitchen, CM Charles Batterbee and FF Daniel Brown; (ii) the images captured by the thermal imaging camera used by CM Batterbee and FF Brown; (iii) the burn patterns on the kitchen floor and skirting board, the large fridge-freezer and other appliances; and (iv) the evidence of Dr Glover based on his examination of the relevant electrical installations and materials recovered from Flat 16. The evidence of the occupants of Flat 16 and the firefighters 21.4 The first source is that of the witnesses, Mr Kebede, Ms Afeworki, Ms Kinfu, CM Batterbee and FF Brown. In his call to the fire brigade and when urging Ms Kinfu to leave the flat, Mr Kebede stated unambiguously that the fridge was on fire. (He later made it clear that he was referring to the large fridge-freezer at the south-east end of the kitchen.) This evidence is consistent with WM Michael Dowden’s evidence about the information he had received from Mr Kebede very soon after arriving at the tower, namely, that the fire was in the kitchen and involved “the fridge”. 1 Bureau Veritas report (dated 7 November 2017) [MET00007996] paragraph 15.1 p. 37.

The Grenfell Tower Inquiry: Phase 1 Report 506 21.5 CM Batterbee, who had entered the kitchen soon after 01.14, recalled that the fire was in the area of the large fridge-freezer2 and, having put the fire out, he remembered telling FF Brown that: “I could see what I thought was the fridge and cupboards alight”,3 that is to say, the large fridge-freezer. It was this fridge-freezer that FF Brown inspected, noting heavy damage around the top 25%.4 The thermal imaging camera footage 21.6 The second source of evidence is the thermal imaging camera footage. CM Batterbee and FF Brown captured images, timed at 01.14, which showed an elevated temperature at the south-east end of the kitchen in the area of the window and the space between the window and the large fridge-freezer.5 Footage, captured at 01.15, showed the large fridge-freezer involved in the fire.6 No other area of the kitchen was shown to be involved in the fire at that stage. Burn patterns 21.7 The third source of evidence is the burn patterns in the kitchen, particularly those on the floor where the large fridge-freezer stood, which were the subject of evidence from Professor Nic Daéid. 21.8 The following photographs show the extent of the burn marks on the large fridge-freezer itself. 21.9 Figure 21.1 is a photograph of the side of the large fridge-freezer facing the kitchen window. There are no burn marks on the laminate floor to the left of the appliance. The burn marks illustrated in figure 21.1 are, as Professor Nic Daéid noted, mirrored on the opposite side of the appliance, as illustrated in figure 21.2. 21.10 Figure 21.3 shows the appliance’s door. In Professor Nic Daéid’s view, the fire pattern on the door suggests that combustible materials to the left of the large fridge-freezer (that is to say, between the large fridge-freezer and the south-east wall) were burning during the early stages of the fire. This fire pattern could also have been influenced by ventilation effects from the nearby open window. 2 Batterbee Day 12/73/11-21. 3 [MET00012871] p. 7. 4 [MET00005251] p. 3. 5 Professor Nic Daéid supplemental report [NNDS00000001] p. 32 Fig. 19(a) and (b). 6 Professor Nic Daéid supplemental report [NNDS00000001] p. 32 Fig. 19(c).

Part III | Chapter 21: The Cause and Origin of the Fire 507 Figure 21.1

The Grenfell Tower Inquiry: Phase 1 Report 508 Figure 21.2 Figure 21.3

Part III | Chapter 21: The Cause and Origin of the Fire 509 21.11 The following photographs show the burn pattern on the floor below the large fridge‑freezer. Figure 21.4 Figure 21.5

The Grenfell Tower Inquiry: Phase 1 Report 510 21.12 The burn pattern shows that the laminate floor beneath the large fridge-freezer was exposed to heat or flame to a greater extent than that on either side of the appliance. It is significant that the floor on either side of the place where the large fridge-freezer had been standing is undamaged. It is also of significance that the skirting board immediately behind the large fridge-freezer had been burnt away. In her oral evidence, Professor Nic Daéid carefully reviewed the burn patterns on the floor and on the large fridge-freezer, as well as the burnt- away skirting board behind the large fridge-freezer. She concluded as follows: “Looking at these burn patterns in particular, the burn pattern to the skirting board and also the damage to the sides in particular of the outside of the tall fridge freezer, where the damage runs from the bottom to the top, it would be my view that the fire was originally orientated in the base of the fridge freezer.”7 Dr Glover’s evidence 21.13 Professor Nic Daéid’s opinion is supported by the fourth principal source of evidence, namely, Dr Glover’s analysis of the electrical installations within, and certain artefacts recovered by the fire investigators from, Flat 16. 21.14 It should be noted that Dr Glover’s analysis was confined to the area of origin of the fire provisionally identified by Professor Nic Daéid and Professor Bisby in their first reports, that is to say, the south-east end of the kitchen of Flat 16. That was an appropriate basis upon which to proceed for three main reasons: first, because no one had identified any other potential area of origin; secondly, because Bureau Veritas had also identified the south-east end of the kitchen as the area of origin; and, thirdly, because neither Professor Nic Daéid nor Bureau Veritas had found any evidence to implicate any of the electrical appliances elsewhere in the kitchen (namely, the washing machine, sandwich maker, kettle, toaster, microwave and smoke detector) in the start of the fire. 21.15 The starting point of Dr Glover’s analysis is the consumer unit in Flat 16 containing the circuit breakers, which is illustrated in figure 21.6 below. 7 Professor Nic Daéid oral evidence Day 83/67/13-18.

Part III | Chapter 21: The Cause and Origin of the Fire 511 Figure 21.6 21.16 As can be seen, the following are in the “off” position: a. the main switch; b. the circuit breaker for Circuit No. 7, which operated on the electricity supply to the kitchen sockets; and

The Grenfell Tower Inquiry: Phase 1 Report 512 c. the circuit breaker for the residual current detector (RCCB). This circuit breaker protects Circuit No. 7 (the kitchen) and Circuit No. 8 (power sockets elsewhere in the flat). The other circuit breakers are in the “on” position. 21.17 As described above, Mr Kebede said that, before leaving Flat 16, he had turned off the electricity supply using the main switch. No evidence has been adduced that casts doubt on Mr Kebede’s recollection and there is no evidence that any firefighter, fire investigator or any other person turned off the main switch in the consumer unit. In the circumstances, I am quite satisfied that Mr Kebede did turn the main switch off before he left the flat. 21.18 This evidence is important in identifying the area of origin of the initial fire. If Mr Kebede did turn off the main switch, all the electrical circuits in Flat 16 would then have been disconnected from the electricity supply and would no longer have been capable of being energised. No circuit breaker could therefore have been tripped after the main switch had been turned off. Ms Afeworki had made herself a cup of tea (presumably using the kettle) earlier in the evening and had taken some bread out of the fridge-freezer.8 She confirmed that the fridge-freezer had been working at that time.9 Ms Kinfu had also used the kettle to make herself a cup of tea10 before going to bed at around 22.00 and when questioned by the police after the fire said that the fridge had been working normally.11 I can therefore confidently find that Circuit No. 7 had been energised until shortly before the fire. The circuit breaker protecting Circuit No. 7 must therefore have been tripped before the main switch was turned off and before or during the early development of the fire.12 21.19 Dr Glover identified two possible sequences by which the circuit breaker protecting Circuit No. 7 and the RCCB had both been tripped: a. the first was that the two circuit breakers had been tripped simultaneously by a single event, a short circuit or overcurrent in Circuit No. 7 (or an appliance connected to it) that also involved a live wire shorting or arcing to ground or a metallic connection to ground; and b. the second was that the circuit breaker for Circuit No. 7 had been tripped by a short circuit or overcurrent in that circuit without any shorting to ground and that the RCCB had been tripped by a second, separate event. 21.20 Dr Glover pointed out that the RCCB could not have been tripped before the circuit breaker protecting Circuit No. 7, because in that event that circuit would no longer have been energised and the circuit breaker protecting it could not have been tripped. The second sequence therefore involved an event which tripped circuit breaker No. 7 followed by a second event which tripped the RCCB. In his report Dr Glover expressed no preference between these two possible sequences,13 but in his oral evidence he said that in the light of other evidence he had since looked at he considered it more likely that there had been two separate events.14 For present purposes, however, nothing turns on this, because, whichever sequence is correct, the circuit breaker protecting Circuit No. 7 must have been tripped while the circuit was still energised. 8 Afeworki witness statement 18 June 2017 [MET00006341] p. 2. 9 Afeworki witness statement 21 May 2018 [IWS00000280] paragraph 10 pp. 3-4. 10 Kinfu witness statement 24 May 2018 [IWS00000457] paragraph 9 p. 1. 11 Kinfu witness statement 16 June 2017 [MET00006350] pp. 2-3. 12 This is a summary of the Glover report [JDGR0000001] pp. 10-11. 13 Glover report [JDGR0000001] p. 11. 14 Dr Glover oral evidence Day 82/3/18-34/3.

Part III | Chapter 21: The Cause and Origin of the Fire 513 21.21 To narrow down the area of origin Dr Glover examined the electrical appliances in the south-east end of the kitchen including those that were connected to Circuit No. 7. His main conclusions can be summarised as follows: a. The small fridge can be excluded from consideration as there is no evidence that it had been plugged into any socket on the night of the fire.15 b. The old freezer can also be excluded. Mr Kebede and Ms Afeworki said that this appliance was not in use and their evidence is corroborated by the absence of any indication that it had been plugged into any socket on the night of the fire.16 c. The extension lead was not implicated in the fire. No plug was found in any of the four sockets of the extension lead and no arc damage to the internal current-carrying components was found. In any event, the extension lead would have been supplied by a socket on Circuit No. 8 and, if at the time of the fire it had been plugged into a socket in the living room, it would have had nothing to do with whatever tripped the circuit breaker for Circuit No. 7. Moreover, Dr Glover considered it implausible that a fire could have begun in the living room (where Mr Kebede was sleeping) and progress through the sliding doors separating the living room from the kitchen without waking him before the smoke alarm in the kitchen sounded.17 d. The mitad did not cause the fire as there was no evidence that it had been plugged into any socket on the night of the fire and there is no evidence of any arc damage to it.18 e. The weight of the evidence indicated that the extractor fan (fixed in the kitchen window) was not involved in starting the initial fire. The short circuit or overcurrent that caused Circuit No. 7 to trip did not occur in the extractor fan or in any related component. If it had, the three-amp fuse in the isolator switch would have blown more quickly than the circuit breaker, which had not happened. Furthermore, no arc damage or any other signs of abnormal electrical activity were found in the components related to the extractor fan.19 f. The kitchen lighting did not cause the fire. The lighting was supplied by Circuit Nos. 2 and 3, both of which were found in the “on” position, thereby confirming that there was no short circuit or overcurrent sufficient to trip either of the six-amp circuit breakers protecting them.20 g. Similarly, the cooker can also be excluded from consideration.21 The cooker was supplied by Circuit No. 1 which was in the “on” position. This confirms that there was no short circuit or overcurrent sufficient to trip the 32-amp circuit breaker for Circuit No. 1. The evidence indicates that the four hob switches were “off” and that the heating plates were therefore not energised. The fact that the cooker only sustained superficial heat and fire damage is inconsistent with its having played any causative role. h. Finally, Dr Glover excluded the large fridge-freezer’s power supply cord as no arc damage was observed.22 15 Glover report [JDGR0000001] paragraph 7.3 p. 30. 16 Glover report [JDGR0000001] paragraph 8.3 pp. 33-34. 17 Glover report [JDGR0000001] paragraph 6.5 p. 27. 18 Glover report [JDGR0000001] paragraph 10.3 p. 39. 19 Glover report [JDGR0000001] paragraph 11.7 p. 49. 20 Glover report [JDGR0000001] paragraph 13.5 p. 64. 21 Glover report [JDGR0000001] paragraph 5.5 p. 23. 22 Glover report [JDGR0000001] paragraph 16.2(2) p. 77.

The Grenfell Tower Inquiry: Phase 1 Report 514 21.22 Dr Glover’s analysis (with which Professor Nic Daéid agreed23) therefore eliminated all the electrical appliances in the south-east end of the kitchen as possible sources of an electrical fire, apart from the large fridge-freezer. For this reason (as well as others) Dr Glover concluded (and Professor Nic Daéid agreed) that the most probable area of origin was the large fridge‑freezer.24 21.23 Dr Glover drew additional support for his conclusion from two exhibits, MJS/1, a section of electrical conductor taken from a collection of wiring recovered from bedroom 2 of Flat 16,25 and JDG/1, a small section of wire found in a plastic bag in the old freezer which had stood beneath the kitchen window. Analysis revealed that both showed arc damage. In Dr Glover’s view, it was improbable that the arc damage to MJS/1 had been sustained in the bedroom as circuit breaker No. 8, which protected all the sockets other than those in the kitchen, had not been tripped. It was also improbable that JDG/1 had suffered arc damage in the old freezer as there was evidence that the old freezer had not been plugged in on the night of the fire.26 Given that both exhibits consist of 24 strands of wire each approximately 0.16-0.18mm in diameter, both are consistent with a wire from either the run capacitor or an internal jumper wire within the relay compartment of the large fridge-freezer.27 Both exhibits are also consistent with a segment from the wiring of the large fridge-freezer. In the circumstances, the combination of evidence of arc damage and the similarity of the exhibits to wiring found in the large fridge-freezer point to the latter as the area of origin. 21.24 In its closing submissions Whirlpool Corporation (Whirlpool), the manufacturer of the large fridge-freezer, challenged Dr Glover’s conclusions in a number of respects, but since it had not asked me to consider evidence from any expert witness whose opinions differed from those of Dr Glover, it could do no more than argue that his reasoning was inherently unreliable. For example, it said that his preferred explanation of the tripping of circuit breaker No. 7 and the RCCB was implausible, because it was not reasonably possible in the time available for smoke to have entered one of the sockets served by Circuit No. 8 so as to trip the RCCB. However, that is a proposition that calls for the support of expert opinion evidence of a kind that was conspicuously lacking, and in any event takes the matter no further. Whirlpool also took issue with Dr Glover’s evidence about the significance of MJS/1 and JDG/1, but again without the support of any expert evidence, other than opinions expressed by Key Forensics and Bureau Veritas, neither of whose investigators I was asked to hear. 21.25 In general, I found Dr Glover a persuasive witness, but neither of these questions is ultimately of any significance in the light of the evidence relating to the tripping of circuit breaker No. 7. No explanation for that was put forward which did not involve the large fridge-freezer and as such it points strongly to an electrical fault having occurred within that appliance. Conclusion – the fire started in the fridge-freezer 21.26 Although some questions remain unanswered, the evidence, viewed as a whole, leaves me in no doubt that the fire originated in the large fridge-freezer. Although Whirlpool argued that no single piece of evidence pointed “irresistibly” or “uniquely” to that conclusion and that therefore it was not possible to determine the cause of the fire, in my view the combined force of the evidence as a whole points inexorably to that conclusion. It is true that the investigation of the fire scene was not carried out with the degree of rigour that Professor Nic Daéid would 23 Professor Nic Daéid oral evidence Day 83/76/1-4. 24 Glover report [JDGR0000001] paragraph 16.2(1) p. 77. 25 Summary of how the artefact was recovered in Glover’s report [JDGR0000001] paragraph 4.2 p. 17 and paragraph 4.4 p. 19. 26 In relation to both exhibits: Glover report paragraph 4.4 pp. 19-20. 27 Glover report [JDGR0000001] paragraph 12.9 p. 57.

Part III | Chapter 21: The Cause and Origin of the Fire 515 have wished and that her preliminary report was couched in cautious terms, but in her final report and her oral evidence she was able to express a firm conclusion based on the whole of the evidence. Dr Glover’s forensic electrical analysis persuasively identifies the area of origin as the large fridge-freezer. His conclusions are consistent not only with the evidence of Mr Kebede and the crew who first fought the fire but also with the physical evidence of the burn patterns both to the large fridge-freezer itself and to the floor where it had been standing and with the damage to the skirting board behind it. Whirlpool’s suggestion that the fire could have originated from a burning cigarette end thrown from a window higher up the building falling into the kitchen of Flat 16 and igniting unknown materials on the floor next to the large fridge-freezer is fanciful. Such an explanation is not consistent with Mr Kebede’s evidence or with the burn pattern on the floor and does not provide a convincing explanation for the tripping of circuit breaker protecting circuit No. 7. 2 How did the fire start? 21.27 Two important points need to be made at the outset. First, none of those who examined the large fridge-freezer, or the kitchen of Flat 16 more generally, found any evidence to suggest that the fire had been started deliberately or that it had been caused by an improvised or inexpert attempt to repair a defect in the appliance.28 Whatever the origin of the initial fire, the evidence indicates that it was accidental. Mr Kebede in particular bears no blame for what occurred in his flat, much less for the catastrophic events that followed. On the contrary, he did exactly what a responsible person might be expected to do in the circumstances and his presence of mind in switching off the electricity as he left the flat enabled important evidence to be gathered about the origin of the fire. 21.28 The second point arises from longstanding concerns raised by residents about electrical “surges” affecting appliances within the tower. RINA Consulting (RINA) were retained by the MPS to assess the electrical supply and distribution infrastructure.29 In short, RINA found no damage or significant degradation (other than that caused by the fire) nor any major defects in the electrical supply system. RINA found no evidence to suggest that the electrical infrastructure of the tower was in any way responsible for the fire.30 21.29 Identifying the precise point of ignition within the large fridge-freezer poses a significant challenge. In the light of Dr Glover’s evidence, and in the absence of any evidence suggesting some other cause, Professor Nic Daéid was satisfied that the cause of the fire was probably electrical. Beyond that she did not think that there was enough evidence to enable her to reach a more definite conclusion.31 21.30 In an addendum to his report Dr Glover put forward the hypothesis that the origin of the fire was the overheating of a defective crimp connection within a wire connector in the large fridge-freezer.32 Whirlpool strongly challenged that part of Dr Glover’s evidence, but again without the support of any expert evidence. Having considered the addendum to Dr Glover’s report as well as his oral evidence, I have come to the conclusion that further investigations would be required before any reliable conclusion could be reached on that question. That could involve considerable time and expense, which might, or might not, enable a firm 28 Professor Nic Daéid supplemental report, [NNDS00000001] paragraph 8.8.32 p. 79. 29 Report (dated November 2017) [MET00007807] paragraph 1 p. 4. 30 It is noted that a neutral cable feeding one of the main risers to the flats had been replaced sometime after 2002. This is broadly relevant to the surges reported in 2013 as a loss of continuity in the main neutral conductors may lead to voltage fluctuations which are revealed by events similar to those experienced in 2013. They are not, however, relevant to the cause of the fire. 31 Professor Nic Daéid supplemental report [NNDS00000001] paragraph 9.4 p. 97, and her oral evidence Day 83/76/1, 83/82/1-12. 32 Glover Addendum [JDGR0000019] section 2.

The Grenfell Tower Inquiry: Phase 1 Report 516 conclusion to be reached. Whatever the outcome, however, it could not detract from the overwhelming weight of the evidence that the fire started somewhere in the large fridge- freezer. A fire originating in an electrical domestic appliance is not an uncommon event; the important question for this Inquiry is how an ordinary domestic fire could have had such catastrophic consequences for the whole building and its occupants. Further examination of parts from the large fridge-freezer will not provide the answer to that question. In my view it is better to accept that it is not possible within the scope of this Inquiry to identify with confidence the precise nature of the defect in the large fridge-freezer which caused the fire.

517 Chapter 22 The Escape of the Fire from Flat 16 22.1 A key phase in the development of the fire was its escape from the kitchen of Flat 16 into the exterior cladding system. There is little or no direct evidence of how the fire developed between the time Behailu Kebede left the flat and the appearance of flame outside the kitchen window, but there is evidence from which it is possible to draw certain inferences about what occurred. It is important to understand as far as possible the process by which the fire escaped, not least because at that point it developed from a relatively minor domestic kitchen fire to a major fire within the external cladding system. 22.2 A number of the Inquiry’s experts addressed this in their written and oral evidence. Although they approached that task using different methods of analysis, those analyses were complementary and demonstrated that there was considerable agreement about the routes by which the fire is likely to have escaped. 1 Professor José Luis Torero 22.3 Professor Torero considered it unlikely that it would ever be possible to establish with precision how the fire developed in the first few minutes and he therefore based his analysis primarily on the potential range of fire dynamics within the compartment of origin. Using the available information about the dimensions of the kitchen, the probable size of the fire and the materials present in the windows and external cladding, he was able to draw conclusions about the likely sequence of events.1 22.4 In order to ignite the components of the windows and cladding it was necessary for them to be heated to ignition temperature by direct flame impingement or by some other means, such as heat radiated from the accumulated smoke produced by burning materials, generally known as the “smoke layer”. Buoyed up by hot gases, the smoke layer forms at ceiling level and increases in depth as the fire continues to produce smoke. If there is insufficient ventilation and the smoke cannot escape, the smoke layer will continue to descend, eventually extinguishing the fire due to lack of oxygen. However, if there is sufficient ventilation to allow the escape of some of the smoke, the smoke layer as it descends increases in temperature, with the result that heat is transferred to other combustible materials by radiation. If sufficient heat is transferred to the contents of the room, all the combustible materials in the room ignite.2 This is the phenomenon known as “flashover”, which occurs when the smoke layer heats the room to such an extent that all the combustible materials in the room ignite as a result of radiated heat.3 Professor Torero explained that by establishing the range of magnitude within which the size of the fire in Flat 16 must have fallen and calculating the resulting thermal conditions, it was possible to determine whether the various materials surrounding the windows and forming the cladding system could have been brought to ignition. The information required to carry out that calculation included the size and configuration of the kitchen, the likely sources of ventilation and the extent of the damage caused by the fire as shown in photographs taken after the event. 1 Professor Torero oral evidence Day 77/17/5-13, and his supplemental report [JTOS0000001] pp. 2/2-7. 2 Professor Torero supplemental report [JTOS0000001] p. 37 lines 1109-1122 and p. 38 Fig. 6. 3 Professor Torero oral evidence Day 77/18/1-2/13-15.

The Grenfell Tower Inquiry: Phase 1 Report 518 22.5 The kitchen is relatively small in size (4.8 metres long, 1.9 metres wide and 2.35 metres high4), with three principal ventilation sources: the door, the window and the sliding door to the living room. It is clear from photographs taken after the fire that it did not reach “flashover”.5 Had flashover occurred, the damage to the kitchen would have been much more extensive and would, for example, have included burning of the paintwork on some of the kitchen appliances which remained relatively unscathed.6 22.6 Based on that information and using basic computer modelling (referred to as a “simple zone model”) Professor Torero calculated that at one extreme the fire in the kitchen of Flat 16 was unlikely to have achieved a peak heat release rate (HRR) of more than 300kW (if an ultra-fast fire) and at the other extreme was unlikely to have achieved an HRR of less than 60kW (if a slow fire).7 In his view that indicated that the fire in Flat 16 was “relatively minor”8 and typical of a common kitchen pan fire.9 In layman’s terms an HRR of 60kW is “no bigger than a waste paper basket” and an HRR of 300kW “half a chair”10 Those fire sizes correspond to a hot smoke layer temperature of between 220°C and 110°C.11 22.7 These conclusions were verified by using more sophisticated tools, including computation zone modelling (CFAST) and computational fluid dynamics modelling (CFD).12 Those tools enable more complex scenarios to be considered,13 including the impact of opening and closing the doors and windows to the kitchen.14 That further modelling indicates that the kitchen door to Flat 16 could not have been open during the fire, since that would have brought the compartment to flashover.15 It also indicates that his conclusions are not significantly affected by whether the smaller window was open or closed.16 22.8 Professor Torero’s conclusions are further supported by the results of tests carried out by the MPS to establish the peak HRR of fridge-freezers comparable with the one that was present in the kitchen of Flat 16.17 Although he accepted in oral evidence that the temperatures in the kitchen could have been slightly higher than those indicated by the basic model (for example, if the window had been open), he was clear that any increase was not sufficient to make a material difference to his conclusions, given the range of temperatures involved.18 4 Professor Torero supplemental report [JTOS0000001] p. 32 line 1011. 5 Professor Torero supplemental report [JTOS0000001] p. 32 lines 1004-1007. 6 Professor Torero oral evidence Day 77/18/18-19/2. 7 Professor Torero supplemental report [JTOS0000001] p. 38/1155-1160 and p. 39 Table 2 and his oral evidence Day 77/22/23- 23/12. For this zone model all openings (doors and windows) are assumed to be closed – supplemental report [JTOS0000001] p. 37/1133-1134. 8 Professor Torero supplemental report [JTOS0000001] p. 131 line 3067. 9 Professor Torero supplemental report [JTOS0000001] p. 3 lines 35-36. 10 Professor Torero oral evidence Day 77/23/14-21. 11 Professor Torero supplemental report [JTOS0000001] p. 38 lines 1155-1160. 12 Professor Torero supplemental report [JTOS0000001] pp. 137-155 at Appendix B. 13 For an explanation of the three models: Professor Torero oral evidence Day 77/26-27. 14 A window identical to that in the kitchen of Flat 16 can be seen at Fig. 8.23 of Dr Lane’s supplemental report [BLAS0000008] pp. 8-21. This consisted of a larger window to the left (which could be tilted inwards or opened inwards), a smaller window to the right which could be opened inwards and an extractor fan unit to the top right. The evidence of Behailu Kebede indicates that the larger window was tilted inwards by a couple of inches (40-50mm) and the smaller window was open by approximately 10 inches: Professor Bisby oral evidence Day 78/118/4-10 and [MET00006339] p. 2. 15 Professor Torero supplemental report [JTOS0000001] p. 152/3439-3451. With the open door, temperatures would have been in the order of 400°C-500°C hotter near the compartment ceiling. The HRR necessary to deliver flashover would have been around 1000kW: Professor Torero oral evidence Day 77/24/17-19. 16 Professor Torero supplemental report [JTOS0000001] p. 152 lines 3435-3438. 17 After 7 minutes those tests showed a peak HRR of 400kW (which then diminished to approx. 300kW by 10 mins); results which were consistent with the 60-600kW range, given the different conditions in which those tests were carried out (i.e. under a hood rather than in a small space comparable to Flat 16): Professor Torero supplemental report [JTOS0000001] pp. 143-147 and his oral evidence at Day 77/32-34. 18 Professor Torero oral evidence Day 77/41/11-21.

Part III | Chapter 22: The Escape of the Fire from Flat 16 519 22.9 The central points which follow from Professor Torero’s analysis are: a. that a smoke layer with a temperature in the range of approximately 220°C to 110°C (based on fires with peak HRRs of 300kW to 60kW), is not hot enough to ignite any of the window or cladding components (i.e. the uPVC window surrounds, the PIR insulation or the polyethylene core of the ACM panels), given their ignition temperatures, which range from approximately 306°C to 415°C.19 (Professor Torero explained that a spill plume of hot smoke coming out of the compartment and mixing with cold air would be able to ignite the external ACP cladding only if there was a large fire with ventilation to support it and thus under post-flashover conditions.);20 b. that smoke temperatures in the range of approximately 220°C to 110°C are likely to have resulted in significant changes to the uPVC window surrounds, causing them to lose their stiffness21 and become in the words of Professor Torero “like gum…very, very viscous”.22 The fact that the uPVC window jambs were held in place by adhesive, with no mechanical fixings, made them all the more vulnerable to deformation in rising temperatures;23 and c. that once the uPVC melts, deforms and mechanically fails, “it opens a direct path for any flame to actually impinge on any of the combustible materials on the inside”.24 Photographs of the interior of the building taken after the fire show many examples of this type of failure: Figure 22.125 19 Professor Torero [JTOS0000001] p. 37 Table 1. 20 Professor Torero oral evidence Day 77/47/25-48/21 and his supplemental report [JTOS0000001] p. 154/3468-155/3483. 21 uPVC begins to lose stiffness at around 60°C, losing 80% by 80°C and 100% by 90°C. A total loss of mechanical strength will occur within 5-11 minutes: Professor Torero supplemental report [JTOS0000001] p. 44 lines 1261-1272 and oral evidence Day 77/52-56. 22 Professor Torero oral evidence Day 77/52/9-10. 23 Professor Torero oral evidence Day 77/56/17-57/12. 24 Professor Torero oral evidence Day 77/57/20-24. 25 Professor Torero supplemental report [JTOS0000001] p. 43-44.

The Grenfell Tower Inquiry: Phase 1 Report 520 Figure 22.2 Figure 22.3

Part III | Chapter 22: The Escape of the Fire from Flat 16 521 22.10 Professor Torero was of the opinion that, since the smoke layer itself was not hot enough to ignite any of the window or external cladding materials, ignition must have occurred as a result of direct impingement of flame. The impingement of flame may be direct (as when a fire which is unobstructed directly impinges on a material) or indirect (as when a fire which is obstructed by an obstacle impinges indirectly by migrating along a ceiling26 or wall).27 Based on the ignition temperatures of the materials present around the windows and in the cladding system, it is possible to determine whether any of them could have been ignited by direct or indirect flame impingement. Having carried out that exercise Professor Torero concluded that: a. An unobstructed fire of 300kW at floor level could not have ignited the ACM panels directly above the window, since to achieve that would have required a fire in the order of 830kW. A fire of that size would, in his view, have brought the compartment to flashover, which is not consistent with its condition after the fire.28 b. A fire of 300kW would have to be no farther than 3 metres from the window in order to ignite any of the combustible materials adjacent to the window (including the uPVC and the PIR insulation surrounding the windows).29 c. A fire as small as 20kW directly below the window would, in theory, be capable of igniting the combustible materials at windowsill level (including the uPVC and PIR insulation).30 d. If a fire that had started at floor level at the base of the fridge-freezer had found combustible materials enabling it to spread vertically it could eventually have produced temperatures high enough to ignite the Purlboard around the top of the windows. That remains a possible mechanism by which the fire spread to the window.31 22.11 Professor Torero accepted32 that hypotheses B1 and B2 put forward by Professor Bisby33 represented the most likely ways in which the cladding had been ignited. They were: a. the impingement on the ACM panels immediately above the kitchen window of flaming and hot gases, either through an open window or through the extractor fan or the extractor fan panel, and subsequent ignition of the external ACM panels – in layman’s terms “out through a hole in the window”34 (Hypothesis B1); or b. the failure of the uPVC window jamb and attached insulation board allowing fire to penetrate into the back of the cladding cavity where it could ignite combustible materials – in layman’s terms “out through the materials in the side of the window”35 (Hypothesis B2). 22.12 In Professor Torero’s opinion the latter was the more probable cause. He emphasised that in a compartment fire the compartment itself is always going to be hotter than the plume outside and that ignition from the inside was therefore more probable.36 The moment a fire 26 As explained in Professor Torero’s supplemental report [JTOS0000001] p. 51, lines 1425-1429, it is possible for fires to start behind an obstacle and migrate to the ceiling before travelling horizontally as a ceiling jet before reaching a combustible component. 27 Professor Torero oral evidence Day 77/66/18-67/1. 28 Professor Torero supplemental report [JTOS0000001] pp. 48-51, in particular at lines 1417-1423 and oral evidence Day 77/65/9- 68/12. 29 Professor Torero supplemental report [JTOS0000001] p. 50 Table 3 and Day 54/1537-1540. 30 Professor Torero supplemental report [JTOS0000001] p. 49 lines 1399-1400. 31 Professor Torero supplemental report [JTOS0000001] p. 51 lines 1449-1452 and oral evidence Day 77/77/15-78/13. 32 Professor Torero oral evidence Day 77/61/5-62/2. 33 Professor Bisby supplemental report [LBYS0000001] pp. 144-148. 34 Professor Bisby oral evidence Day 78/111/11-16. 35 Professor Bisby oral evidence Day 78/111/11-16. 36 Professor Torero oral evidence Day 77/63/2-64/14.

The Grenfell Tower Inquiry: Phase 1 Report 522 breaks out of a compartment, the fresh air will cool the temperature of the flame making ignition by that method less likely. He also considered that the ACM panels directly above the window would be quite difficult to ignite, since aluminium has a high thermal conductivity, which would carry heat away from the polyethylene.37 In his view, given the fire dynamics of the compartment, the path of flame spread had probably involved the melting and deforming of the uPVC around the windows, possibly as a result of temperatures imposed by the smoke layer itself, followed by the ignition of one of the combustible materials behind the uPVC, including the layer of PIR insulation around the windows and the EPDM membrane. The flame was then in the cladding cavity in the area of the column where it had been able to impinge on the insulation and the ACM panels.38 22.13 Professor Torero emphasised that a “sequence of ignitions” may have occurred whereby a flame had ignited different materials, eventually igniting the ACM panels on the outside.39 However, given the complexity and intricacy of the cladding system and the absence of any contemporaneous visual evidence, he thought that it would be impossible to know precisely which materials ignited first.40 Beyond recognising that the deformation of the uPVC is likely to have occurred first, Professor Torero did not consider it realistic or helpful to seek to analyse the precise sequence in which the materials had burned.41 The properties of the materials did not indicate which had ignited first; while those with a low thermal inertia will have ignited more quickly, the order of ignition would have depended where each material was in relation to the flame.42 Although the presence of exposed polyethylene edges in some parts of the ACM panels could have affected the outcome, given the proximity of all of the materials, the complexity of the cavity and the nature of the fire, it was extremely difficult to identify its significance.43 22.14 Finally, Professor Torero was clear that the extractor fan itself could be discounted as the ignition source for the ACM cladding panels. The temperature of any fire at the base of the extractor fan would have been insufficient to ignite the ACM panels present in the cladding system.44 2 Professor Luke Bisby 22.15 Professor Bisby based his opinion primarily on the available photographic and video evidence from the night of the fire combined with a detailed understanding of how the materials used in the refurbishment react to fire.45 In terms of the former he included in his written report a number of still images which show significant moments in the early development of the fire.46 He also prepared a compilation video which combined the available footage, both for the east face of the building where the fire began,47 and for each of the other faces, north, west and south.48 37 Professor Torero oral evidence Day 77/70/15-71/9. 38 Professor Torero supplemental report [JTOS0000001] p. 46 lines 1333-47 and line 1349. 39 Professor Torero oral evidence Day 77/64/10-14, 68/16-69/9. 40 Professor Torero oral evidence Day 77/74/22-24, 76/6-7. 41 Professor Torero oral evidence Day 77/78/3-13, 79/9-25, 81/5-15. 42 Professor Torero oral evidence Day 77/78/25-79/25. 43 Professor Torero oral evidence Day 77/82/20-83/13. 44 Professor Torero supplemental report [JTOS0000001] p. 52 lines 1466-0053 and line 1482. 45 Professor Bisby oral evidence Day 78/106/21-25. 46 Professor Bisby supplemental report [LBYS0000001] pp. 113-123. 47 [LBYS0000002]. 48 [LBYS0000004]; [LBYS0000005]; [LBYS0000006].

Part III | Chapter 22: The Escape of the Fire from Flat 16 523 The video evidence49 22.16 At 01.05.40 the first known video evidence of the fire was captured. This shows flames at the far-left side of the window of Flat 16 when looking from the outside and smoke is visible outside the compartment. This is a still timed at 01.05.49:50 Figure 22.4 22.17 At 01.06 the fire appears to be located towards the lower left-hand corner of the window. During this video, smoke is visible drifting below the window; the smoke is moving from south to north and a voice can be heard saying: “Look at that [inaudible] stinks”, suggesting that the individual standing on the ground could smell the fire.51 22.18 By 01.07 the window infill panel and mounting of the fan unit (or possibly the fan unit itself) appears to be burning; the fan unit appears to be absent, with flames passing through or around the extractor fan mounting board and out of the window below. Smoke is visible outside the compartment and the window pane below the fan unit appears to be absent, or the window fully open, swinging inward. These are stills taken at 01.07.51:52 49 [LBYS0000002]. 50 Professor Bisby supplemental report [LBYS0000001] p. 117 Fig. 58. 51 Professor Bisby supplemental report [LBYS0000001] p. 114 sections 548-550. 52 Professor Bisby supplemental report [LBYS0000001] p. 118 Fig. 59 and p. 114 sections 551-555.

The Grenfell Tower Inquiry: Phase 1 Report 524 Figure 22.5 22.19 By 01.08 there is more smoke, and the flames appear longer. The longer flames appear to extend farther out of the window, adjacent to the cladding and particularly to the left of the window. Burning material can be seen to fall from the region around the window opening, particularly on the left-hand side near the column. These are stills captured between 01.08.06 and 01.08.21:53 53 Professor Bisby supplemental report [LBYS0000001] p. 119 Fig. 60 and p. 114 sections 556-559.

Part III | Chapter 22: The Escape of the Fire from Flat 16 525 Figure 22.6

The Grenfell Tower Inquiry: Phase 1 Report 526 22.20 Between 01.09.30 and 01.09.40 the flames appear longer again and extend farther out of the window. A regular flow of burning material can be seen falling from the window opening, in particular from the bottom left-hand corner where the window meets the column. At around 01.09.36 flames appear to project out of the top of the extractor fan panel. These are stills captured between 01.09.30 and 01.09.40:54 Figure 22.7 Figure 22.8 54 Professor Bisby supplemental report [LBYS0000001] pp. 114/560-115/565 and p. 120 Figs. 61, 62.

Part III | Chapter 22: The Escape of the Fire from Flat 16 527 22.21 At 01.09.57, in this still burning material can be seen on the ground below the kitchen window:55 Figure 22.9 22.22 At 01.11 visible flames fill most of the observable window opening and smoke is escaping from the window. There is no external flaming on the cladding. At the top left of the window opening there is a darkened area with flame in the centre which corresponds to the location 55 Professor Bisby supplemental report [LBYS0000001] p. 121 Fig. 63 and p. 115 section 566.

The Grenfell Tower Inquiry: Phase 1 Report 528 of the extractor fan and mounting panel. Burning material continues to fall from the window opening, some of which continues to burn on contact with the ground. These are stills taken from that time:56 Figure 22.10 22.23 At 01.12.00 the flames appear to be longer than in previous images, but due to the over- exposure of the image it is not possible to determine to what extent they originate from the cladding or from the compartment. Immediately below the window opening, to the left, there appears to be burning material on the ACM spandrel cassettes. Burning material can be seen falling from the window opening and some is present on the ground. This is a still taken at that time:57 56 Professor Bisby supplemental report [LBYS0000001] p. 122 Fig. 64 and p. 115 sections 567-572. 57 Professor Bisby supplemental report [LBYS0000001] p. 122 Fig. 65 and p. 115 sections 573-577.

Part III | Chapter 22: The Escape of the Fire from Flat 16 529 Figure 22.11 22.24 At 01.13.29 intermittent flames can be seen extending up from the top left corner of the window at the re-entrant corner between the column and the spandrel panel above the window. In addition, intermittent flames can also be seen in the gap between adjacent spandrel panel ACM cassettes directly above the window. By 01.14.16 continuous flaming is established at the joint between the column and the spandrel panel. Burning material continues to fall from the window opening and some burning material is present on the ground. These stills are both taken from 01.13:58 58 Professor Bisby supplemental report [LBYS0000001] pp. 115/578-116/583 and p. 123 Fig. 66.

The Grenfell Tower Inquiry: Phase 1 Report 530 Figure 22.12a Figure 22.12b 22.25 From 01.14.16 the flames can be seen to grow longer in the re-entrant corner between the column and the spandrel sections of the building above the window. Continuous flaming also occurs at the joint between the column and the spandrel panel below the window opening.59 22.26 At 01.14.53, there is melting and burning material on the surface of the ACM cassette panels immediately below the kitchen window. By this time the fire has also spread downwards at the joint between the column and the spandrel panels below the window and gas (or smoke) 59 Professor Bisby supplemental report [LBYS0000001] pp. 129/605-606.

Part III | Chapter 22: The Escape of the Fire from Flat 16 531 can be seen rising from this area. The flames extend significantly above the window, but it is not possible to determine whether they are extending from within the compartment or the cladding materials have become involved in the fire.60 These are images taken from this time:61 Figure 22.13 60 Professor Bisby supplemental report [LBYS0000001] pp. 127/601-604. 61 Professor Bisby supplemental report [LBYS0000001] p. 128 Figs. 70, 71.

The Grenfell Tower Inquiry: Phase 1 Report 532 Figure 22.14 22.27 At 01.15.06 there is a noise which is likely to be the breaking of at least one pane of glazing within the kitchen window (this is also remarked upon by a voice in the video saying: “the glass is cracking”).62 This is immediately followed by an increase in flame length, which is also remarked upon by witnesses in the video, saying: “its [sic] getting bigger now”.63 By 01.15.36 the cladding can be seen to be burning with some intensity and external flames are extending approximately two floors above Flat 16. These are stills taken from that time:64 Figure 22.15 62 Professor Bisby supplemental report [LBYS0000001] pp. 129/608. 63 Professor Bisby supplemental report [LBYS0000001] p. 129 section 609. 64 Professor Bisby supplemental report [LBYS0000001] p. 131 Fig. 73.

Part III | Chapter 22: The Escape of the Fire from Flat 16 533 22.28 Professor Bisby drew attention to a number of events which provide some indication of the route by which the fire spread from the kitchen into the internal cladding. By 01.09.36 dripping, burning polyethylene can be seen originating from the window at its bottom left corner.65 He was of the opinion that, if the external cladding had ignited due to heat from flames venting directly through the open window, rather than down the side of the window, one would have expected to see the earliest evidence of dripping, burning, polyethylene originating from the ACM panels located directly above the window and not from the bottom left-hand corner of the window opening.66 That visual evidence was, in his view, more consistent with the conclusion that the ACM column cassettes along the sides of the window had become involved in the fire first.67 22.29 On that basis, Professor Bisby concluded that the most likely route of flame spread “by a nose”68 had been through the side of the window and into the column cavity following the deforming of the uPVC window surrounds.69 In reaching that conclusion he highlighted the particular configuration of materials at the sides of the windows,70 as shown in this diagram reproduced from his report:71 65 Professor Bisby supplemental report [LBYS0000001] p. 145/691 and oral evidence Day 78/122/21-23, 128/16-22. 66 Professor Bisby supplemental report [LBYS0000001] p. 145 section 693. 67 Professor Bisby oral evidence Day 78/135/17-136/7. Professor Torero’s supplemental report [JTOS0000001] p. 54 lines 1556- 1557. 68 Professor Bisby oral evidence Day 78/135/8-11. 69 Professor Bisby supplemental report [LBYS0000001] pp. 146-147 sections 696-712. 70 Professor Bisby oral evidence Day 78/135/24-136/7. 71 Professor Bisby supplemental report [LBYS0000001] p. 144 Fig. 84.

The Grenfell Tower Inquiry: Phase 1 Report 534 Figure 22.16 22.30 As he explained, if the uPVC had deformed as a result of the smoke layer temperatures in the kitchen, it would have exposed a sequence of combustible materials, including the 25mm thick PIR insulation board which was glued to the back of the uPVC and the EPDM weatherproof membrane. That membrane would, in his words, have provided negligible resistance to flame impingement and would have burned through quite rapidly. Once that had happened, the flame would have been able to enter the back of the cladding cavity around the column.72 In his written report Professor Bisby noted that the PIR insulation in the columns presented as a cut edge, unprotected by any foil facing.73 In addition, the ACM panels on the columns at the side of the window had cut edges with directly exposed polyethylene, as shown in figure 22.16 above.74 At this location, an extensive vertical cavity was also present running the full height of the building.75 72 Professor Bisby oral evidence Day 78/133/7-18 and his supplemental report [LBYS0000001] pp. 146/702-147/712. 73 Professor Bisby supplemental report [LBYS0000001] pp. 147/708. 74 Professor Bisby supplemental report [LBYS0000001] pp. 147/709. Dr Lane report [BLAS0000008] p. 59 Fig. 8.65. 75 Professor Bisby supplemental report [LBYS0000001] p. 147 section 710.

Part III | Chapter 22: The Escape of the Fire from Flat 16 535 22.31 However, Professor Bisby was at pains to emphasise that, in his view, flame also spread almost simultaneously through the open window to impinge on the ACM cassette immediately above and that a combination of the two routes was most likely to have led to the ignition of the cladding and the escalation of the fire up the building.76 That is consistent with the video evidence showing flames coming out of the building in the vicinity of the small left-hand window and extractor fan panel, together with melting and dripping polyethylene, which at around 01.11.45 can be seen burning to the left on the top of the ACM cassettes immediately below the window.77 Professor Bisby was of the view that this burning polyethylene, “a bright spot on the spandrel panel below”, as shown in the images at 01.11, indicated a significant exposure to flame of the ACM spandrel cassettes above the window and explained why polyethylene was burning in that way at that particular location.78 3 Dr Barbara Lane 22.32 Dr Lane also addressed this topic in her oral evidence to the Inquiry. She was also of the view that the most likely route of flame spread out of Flat 16 and into the cladding was through the side of the window following the deformation of the uPVC window surrounds and into the column cavity. She emphasised, by reference to the diagram reproduced below and the thermal images taken by the firefighters inside the kitchen, the proximity of the gap79 between the window surrounds and the column. Given the known propensity of uPVC to lose its stiffness at relatively low temperatures and the absence of mechanical fixings, she was of the view that there must have been a substantial transfer of heat to the top corner of the window adjacent to the column. In her opinion, by the time flames could be seen from the outside, it was likely that there had already been a significant transfer of heat into the cavity around the column.80 76 Professor Bisby oral evidence Day 78/133/1-135/2 and his supplemental report [LBYS0000001] p. 147 section 713. 77 Professor Bisby supplemental report [LBYS0000001] p. 145 section 692 and p. 122 Fig. 65, and his oral evidence Day 78/112/7- 113/5, 130/2-8, 133/19-134/1. 78 Professor Bisby oral evidence Day 78/129/20-130/8. 79 As set out in Chapter 6 of this report, that gap varied on site between 30mm and 130mm. 80 Dr Lane oral evidence Day 79/158/10-161/22.

The Grenfell Tower Inquiry: Phase 1 Report 536 Figure 22.17

Part III | Chapter 22: The Escape of the Fire from Flat 16 537 4 Other evidence 22.33 Tiago Alves, a resident of the tower, who escaped from the building with his parents and his sister at around 01.05, saw the fire as it was breaking out of Flat 16. His evidence is consistent with the video evidence summarised above. In paragraphs 37-38 of his witness statement he said: “I was standing on the grass area and could see smoke coming out of the 4th floor flat. There was a fire inside which I could see behind the window. Then the frame fell out and suddenly I could see smoke and the fire burst out… The window frame looked like it was melting and bubbling but didn’t look like it was on fire. I could tell it was cheap grade plastic. As I watched the window fall out of the flat, fire was coming out of the open window… I stood just looking up at Flat 16. The window frame had fallen out so it had created a gap between where the frame used to be and the outside cladding material. What I could clearly see was the fire “rolling under” the cladding. The fire would come out of the flat and kind of roll under or slightly disappear under the grey cladding. As it did this the cladding caught fire. I could see that fire was escaping into the cavity between the insulation and what I thought was aluminium cladding.”81 22.34 A number of firefighters and other local people also gave evidence about the early development of the fire. However, although their accounts provide helpful background to the mechanisms by which the fire progressed, none are particularly instructive in terms of determining the precise means by which the fire broke out of the kitchen and into the cladding. 22.35 It is clear from the available video evidence taken outside the tower that the fire had entered the cladding some time before 01.14.06 when FF Daniel Brown and CM Charles Batterbee first opened the kitchen door in Flat 16 at 01.14.06, as shown in the available thermal imaging camera (TIC) footage.82 In those circumstances, Professors Torero and Bisby were both of the view that the evidence from the firefighters about what they saw in the kitchen of Flat 16 (including the TIC images they took) was of little assistance in determining how the fire had escaped from the kitchen.83 5 Conclusions 22.36 Despite approaching this question from different perspectives, the experts agreed that the fire probably escaped from the kitchen of Flat 16 into the cladding in one or other of the two ways described by Professor Bisby, and that of those the more likely is that the deformation and collapse of the uPVC window jamb enabled it to bypass the window and enter the cavity around the column. Although they reached their conclusions by different processes of reasoning, it is striking that they have reached the same conclusions. It is also important to bear in mind that no one has sought to place before me evidence from any other expert witness that might contradict their evidence or in any way undermine their conclusions. 22.37 The windows of Flat 16, including the surrounds and insulation board attached to them, were destroyed in the fire, but there is no reason to think that either the materials themselves or the method of fixing the window surrounds in Flat 16 were different in any significant respect from those to be found in other flats. I have no difficulty in accepting that uPVC loses its stiffness entirely at a relatively low temperature, causing it to deform under the influence of gravity unless fixed in place by some means. Examples of this behaviour can be seen in the photographs in paragraph 9 taken inside some less seriously damaged flats. 81 [IWS00000123]. 82 [MET00005814]. 83 Professor Torero oral evidence Day 77/71/25-72/21; Professor Bisby oral evidence Day 78/141/10-142/14.

The Grenfell Tower Inquiry: Phase 1 Report 538 22.38 The evidence indicates that the window jambs were fixed with adhesive to the original timber window jambs over part of their depth and to insulation board over the remainder. No mechanical fixings were used. In those circumstances I think that it is more probable than not that the uPVC window jamb nearer the fridge-freezer deformed at an early stage as the result of the impingement of hot smoke. As it deformed it fell away from the old timber jamb carrying with it the insulation board to which it was still attached by adhesive. The result was to provide a means for the fire to gain access to the cavity between the insulation and the ACM panels, having overcome the insignificant resistance of the EPDM membrane. 22.39 In my view that mechanism is more consistent with the earliest video evidence, which shows polyethylene melting and dripping from the bottom left-hand corner of the window at 01.09. It is also consistent with the sides of the window (including the exposed polyethylene at the point where the column panels meet the window84) having become involved in the fire by that stage, although it is not possible to be certain where that polyethylene came from. The video evidence does show flames coming out of the window and impinging on the ACM panels directly above, so it is possible that the mechanism described in Professor Bisby’s Hypothesis B2 also played a significant role. Ultimately, however, that is of little significance, because in both cases it was the proximity of combustible materials to the interior of the compartment that allowed the fire to spread. I agree with Professor Torero that it is not realistic or helpful to seek to determine the precise sequence in which the materials ignited or burned. What really matters is that the design of the refurbishment, the choice of materials and the manner of construction allowed an ordinary kitchen fire to escape into the cladding with disastrous consequences. 22.40 How this state of affairs came about is for investigation in Phase 2, but at this stage I accept the evidence of all three experts that, if a fire started near a window, there was a disproportionately high chance of its spreading into the cladding, given the configuration and materials of the windows and of exterior cladding. In the view of Professor Torero it was almost certain, if not inevitable, that a kitchen fire of the magnitude he had postulated would occur in a building of this nature at some point in its lifetime and that such an occurrence was perfectly foreseeable.85 Dr Lane expressed the view that the construction detailing around the windows, including the materials and their arrangement, increased the risk of a fire within the flat breaking out into the large cavities surrounding the windows.86 She also emphasised that the windows were not provided with any fire-resisting cavity barriers and instead were surrounded by combustible materials, including the linings above and below the windows made of Purlboard. In her view, if a fire started near a window, there was a disproportionately high probability that it would spread into the cladding regardless of how it had started.87 Finally, Professor Bisby accepted that the majority of materials around the window had very little capacity to resist a fire and that it was likely that a fire anywhere near a window would break out of the flat and into the cladding.88 6 Postscript 22.41 After I had drafted this chapter, I received from the MPS at the end of June a report dated 24 May 2019 prepared by the BRE containing its description and analysis of a large scale reconstruction of the fire in Flat 16, Grenfell Tower and the conclusions it had drawn from 84 As shown in Dr Lane’s Fig. 8.65 [BLAS0000008] p. 59. 85 Professor Torero oral evidence Day 77/97/13-98/1 and his supplemental report [JTOS0000001] p. 55 lines 1563-1567. 86 Analysis of the potential fire spread routes through the window openings at Chapter 9 of her report [BLAS0000009] pp. 1-49 and, in particular, her conclusions at 9.6-9.7 pp. 48-49. 87 Dr Lane supplemental report [BLAS0000002] 2.9.10-2.9.14 and [BLAS0000009] p. 48 9.7.1-9.7.7. 88 Professor Bisby oral evidence Day 78/105/15-106/8.

Part III | Chapter 22: The Escape of the Fire from Flat 16 539 it. The reconstruction sought to reproduce as accurately as possible the configuration and contents of Flat 16 immediately before the fire and two storeys of the facade above, including the cladding. Basing itself solely on the results of that reconstruction, the BRE reached the following conclusion: “It appears from the reconstruction most likely that fire spread to the cladding via the extractor fan and infill panel into which it was mounted, and then ignition of the exposed edge of the polyethylene core of the ACM. The second most likely route evidenced by the reconstruction, and one which could have occurred if the polyethylene had not been the cladding component first ignited, is the route via the construction around the window (through the uPVC, insulation and gap between window frame and column).” (p. 3) 22.42 Without access to the whole of the information obtained from the reconstruction it is not possible to determine whether the test itself and the conclusions drawn from it have a bearing on the questions addressed in this Chapter. However, if that information can be made available, I shall ask Professor Torero and Professor Bisby to prepare short reports explaining whether it causes them to alter or refine the evidence they gave at Phase 1. I am also willing to receive submissions from core participants on the relevance of the reconstruction and the conclusions drawn from it at some convenient time during Phase 2. In those circumstances, the findings made in this Chapter remain provisional and I will express a final view in the Phase 2 report.

The Grenfell Tower Inquiry: Phase 1 Report 540

541 Chapter 23 The Subsequent Development of the Fire 23.1 Once the fire had escaped from the compartment of origin, it spread rapidly up the east face of the tower. It then spread around the top of the building in opposite directions and down the sides of the building until the advancing flame fronts converged on the west face near the south-west corner. The vertical spread of flame up the east elevation marked the first phase of the fire’s development and was generally consistent with the way in which a fire of this kind might be expected to behave. The spread of fire horizontally and downward, however, was unusual, since other fires of this kind, some of which are mentioned below, have tended to burn out after reaching the top of the building. 23.2 Each stage of the fire’s development contributed significantly to the ultimate disaster and it is therefore important to understand as clearly as possible the sequence of events by which they occurred and, insofar as is possible at this stage, the mechanisms behind them. 1 Vertical fire spread 23.3 Professor Luke Bisby, Professor José Luis Torero and Dr Barbara Lane all covered the subject of vertical fire spread in their written and oral evidence. They examined the available photographic and video evidence from the night of the fire in order to understand the way in which the external flame front had progressed. Professor Bisby, who took a leading role in analysing that evidence, produced a compilation of video recordings from various sources which highlights, in powerful terms, the rapid spread of flame vertically up the east face of the building in the first few minutes of the fire.1 Professor Torero and Dr Lane also addressed this topic in some detail in their reports. Again, although the experts approached their task from different perspectives, there was considerable agreement between them, particularly as to the mechanisms by which the flames were able to reach the top of the tower so quickly. Professor Bisby 23.4 In Professor Bisby’s opinion the most important factor by a considerable margin in the rapid spread of fire vertically (and the spread of fire across the exterior of the building more generally) was the presence of ACM panels with a polyethylene core. In his view the evidence strongly supported that conclusion and in reaching it he emphasised the characteristics of polyethylene, including its high calorific value (when compared with other common construction materials, including those used at Grenfell Tower), providing an ideal fuel source for a growing fire.2 It is a highly flammable synthetic thermoplastic polymer which has a heat of combustion similar to that of petrol or diesel fuel.3 23.5 He also identified a number of other factors which in his view had contributed to the vertical flame spread, namely, the presence of combustible PIR and phenolic insulation, the presence of continuous vertical channels and internal cavities in the cladding system and the specific 1 [LBYS0000002]. As explained in Professor Bisby’s report [LBYS0000001] pp. 154/774, a total of 40 videos have been considered as part of this analysis. 2 Professor Bisby supplemental report [LBYS0000001] pp. 178/859-860. 3 Professor Bisby expert presentation Day 7/67/15-68/13.

The Grenfell Tower Inquiry: Phase 1 Report 542 geometry of the tower, including its protruding column “wing walls”.4 Although he emphasised that the precise contributions of these different elements could not be quantified at this stage (and indeed might never be capable of quantification due to the complexity of the relationship between them), he was clear that all of them were likely to have contributed to the rate at which, and the extent to which, the fire spread vertically.5 23.6 Professor Bisby drew attention to two particular mechanisms by which the PIR and phenolic insulation behind the ACM panels might have contributed to the scale of the fire. The first was by pyrolysing6 and releasing combustible products, which ignited and thereby contributed to an increase in the overall local heat release rate.7 The second was by radiating heat back at the ACM panels, effectively insulating the cladding compartment, thus retaining heat in the system and contributing to the rate of heating of other combustible materials present.8 The latter was in his view a potential consequence of the low thermal inertia of both PIR and phenolic insulation boards, as a result of which their surface temperature rises very quickly when exposed to heat. 23.7 Professor Bisby drew attention to the number of exposed edges of insulation boards within the cladding system which were not covered with a foil facing, unlike the two main faces. Given the inherent combustibility and low thermal inertia of the materials, he considered that these exposed surfaces could be expected to spread flame in the presence of external heating. Although Professor Bisby noted that no obvious increase in the rate or extent of flaming had been apparent where PIR insulation had been present in tests carried out by the Department for Communities and Local Government during the weeks after the fire, he identified some important differences between the materials used in those tests and the materials that had been used in the work on the tower, including (in the case of the test materials) more extensive use of foil facings and foil tape.9 In oral evidence he said that in his view those tests had been of no utility other than to demonstrate that ACM panels with a polyethylene core cause the vertical spread of flame to escalate very quickly.10 23.8 He also concluded that the presence of continuous vertical channels and extensive internal cavities was “almost certain” to have contributed to the rate and extent of vertical flame spread.11 He drew attention, in particular, to two key locations at the columns, the column tips12 and the sides of the columns where vertical channels and extensive vertical cavities were present, and to the well-recognised phenomenon of flames elongating five to 10 times when confined in a vertical channel or cavity.13 The available video evidence also shows fire spread at 01.13 extending up the cavity behind the vertex between the columns and spandrels and the most rapid fire spread up column B5. He also considered that it was “very 4 Professor Bisby discounted a further hypothesis (C4) that the prevailing wind at the time may have played a role not least given the available Met Office data which shows low velocities of wind on the night when compared with the upward velocity of the buoyant plume: supplemental report [LBYS0000001] pp. 182/898-902. 5 Professor Bisby supplemental report [LBYS000001] pp. 180/880-881, 182/896-897, 183/912 and his oral evidence Day 78/168/25- 169/8. 6 As explained at section 2.2 of Professor Bisby’s supplemental report, pyrolysis is the process of thermal decomposition of a solid material: [LBYS0000001] pp. 18/110-19/123. 7 Professor Bisby supplemental report [LBYS0000001] pp. 179/869 and his oral evidence Day 78/173/18-176/12. 8 Professor Bisby supplemental report [LBYS0000001] pp. 179/870 and his oral evidence Day 78/173/18-176/12. 9 Professor Bisby supplemental report [LBYS0000001] pp. 180/877-879. He also highlighted that the DCLG tests appeared to have been conducted using riveted ACM panels and not cassette ACM panels as were to be found at Grenfell Tower: Professor Bisby oral evidence Day 78/178/12-179/2 and his supplemental report [LBYS0000001] p. 180, footnote 55. 10 Professor Bisby oral evidence Day 78/177/3-178/11. 11 Professor Bisby oral evidence Day 78/180/16-181/9 and his supplemental report [LBYS0000001] pp. 180/883-182/897. 12 As explained by Professor Bisby in his oral evidence Day 78/87/4-18, the cladding rail at the tip of the columns provided a continuous void running all the way from the base of the building to the roof and the cavity barriers were all cut around that u-shaped rail. 13 Professor Bisby supplemental report [LBYS0000001] pp. 181/885-886, p. 45 Fig. 18, p. 49 Fig. 22, p. 56 Fig. 28, p. 57 Fig. 29.

Part III | Chapter 23: The Subsequent Development of the Fire 543 likely” that the overall geometry of the building had contributed to the rate and extent of vertical flame spread.14 More specifically, he drew attention to the protruding column wing wall, which was inclined at 135 degrees to the spandrels.15 In his view it produces two specific effects. First, the fact that the fire is confined in a corner (even if not a right-angle corner) changes the way that fresh air is entrained into the fire. Because less air is available at its base, the flames elongate in the search for more air to continue burning, thereby increasing the vertical spread of flame. Secondly, the fact that the walls stand at an angle to each other allows heat to be radiated between them, thereby causing the temperature to increase locally.16 23.9 Professor Bisby thought it unlikely that the Aluglaze window infill panels had made any substantial contribution to the spread of flame, because the XPS inside the panels was of low density and the panels made up only a small proportion of the exterior envelope of the tower overall.17 He also emphasised that when XPS is exposed to heating it tends to shrink away from the heat source and then burn in situ.18 23.10 Professor Bisby agreed with Dr Lane that, if the rainscreen cladding panels could distort when heated, either through heating of the panel itself or as a result of the failure of the supporting fixtures, the space between the cavity barriers and the rainscreen cladding panels would be liable to increase in size, rendering the cavity barriers ineffective.19 He explained that under a high heat flux, “quite quickly the rainscreen cassettes are deforming or gone or burning and you no longer have a cavity, which defeats the purpose of a cavity barrier”.20 He also agreed with Dr Lane that the cladding rails bypass the cavity barriers and so also provided a route for flame to spread vertically within the system.21 Professor Torero 23.11 Professor Torero considered the vertical flame spread as part of his analysis of the development of the fire during the period from its breaching the compartment of origin to the approximate time when the flames reached the top of the east face of the building (his stage 2, 01.05- 01.30).22 He explained that, in general, the rate of vertical flame spread is at least 10 times faster than that of lateral flame spread and that the larger the burning zone, the faster the rate at which flames will spread vertically. In other words, vertical flame spread accelerates as the fire develops,23 because all forms of heat transfer, convection, conduction and radiation heat the material ahead of the flame. As a result, not only is there an increase in the heat flux applied to the unburnt surface, but the area being heated itself increases in size, thereby increasing the rate of flame spread. In contrast, lateral flame spread is controlled by radiated heat transfer from the flame to the unburnt material to the side of the flame and the area being heated is more limited because convection carries heat away from the material towards the flame, thereby reducing the size of the pre-heated area.24 14 Professor Bisby supplemental report [LBYS0000001] pp. 182/903-183/912. 15 The angle as between the spandrel ACM cladding panels and the column cladding panels. 16 Professor Bisby oral evidence Day 78/182/11-183/16. 17 Professor Bisby oral evidence Day 78/29/20-33/6. 18 Professor Bisby oral evidence Day 78/193/2-194/14. 19 Professor Bisby oral evidence Day 78/91/13-92/3. 20 Professor Bisby oral evidence Day 78/89/17-90/5. 21 Professor Bisby oral evidence Day 78/185/13-19. 22 Professor Torero supplemental report [JTOS0000001] pp. 2/14-15 and footnote 1. 23 Professor Torero supplemental report [JTOS0000001] pp. 57/1588-1598. 24 Professor Torero supplemental report [JTOS0000001] pp. 58/1610-1621, p. 60 Fig. 22(a)-(b) and his oral evidence Day 77/102/4- 104/18.

The Grenfell Tower Inquiry: Phase 1 Report 544 23.12 Professor Torero compared the Grenfell Tower fire with similar fires that have occurred in buildings in other countries. They demonstrate that the most common way in which a fire in the exterior of the building develops is by a flame spreading rapidly upwards with relatively limited lateral spread. This form of fire development occurred at The Torch building in Dubai, the Lacrosse building in Melbourne and The Address building in Dubai,25 as is shown in the following images:26 Figure 23.1 23.13 Although, in the view of Professor Torero, there is limited reliable data on the characteristics of these fires, he noted that the available video footage clearly shows that once the fire had spread to the top of each of those buildings it began to decay and eventually died out.27 25 Professor Torero supplemental report [JTOS0000001] pp. 58/1599-1609 and his oral evidence Day 77/104/19-107/20. 26 Professor Torero supplemental report [JTOS0000001] p. 59 Fig. 21 (a)-(f). 27 Professor Torero supplemental report [JTOS0000001] pp. 58/1599-1609.

Part III | Chapter 23: The Subsequent Development of the Fire 545 Considered in the context of these and other international fires, the rate of vertical fire spread at Grenfell Tower was not unusual and, in fact, was one of the slowest reported,28 as is illustrated by the following figure taken from Professor Torero’s report:29 Figure 23.2 23.14 As can be seen from that graph, at Grenfell Tower the rate of vertical flame spread was on average about 4 metres a minute, compared with the extreme case of the fire in The Address building in Dubai, which spread at about 22 metres per minute.30 23.15 Professor Torero explained that the presence of combustible materials in the cladding system, including the polyethylene core of the rainscreen panels, the PIR insulation and the EPDM membrane,31 would have sustained combustion of a kind that promoted vertical flame spread. In the presence of significant flame the aluminium plates forming the outer skin of the ACM cassette panels would melt and would provide no protection to the polyethylene core. The temperature of a flame is typically between 600-800°C, which is higher than the melting point of aluminium (580-650°C). Polyethylene melts at a much lower temperature and will therefore melt and drip both before and after it has been ignited. PIR insulation will char and remain in place. In the absence of significant heating it will generally stop burning, leaving a large proportion of its mass as residue.32 Having examined photographs of the tower taken 28 Professor Torero supplemental report [JTOS0000001] pp. 58/1622-1627. 29 Professor Torero supplemental report [JTOS0000001] p. 61 Fig. 23. 30 Professor Torero oral evidence Day 77/107/4-108/1. 31 In terms of the EPDM membrane refer to his oral evidence Day 77/136/19-137/11. 32 Professor Torero supplemental report [JTOS0000001] pp. 60/1645-61/1658.

The Grenfell Tower Inquiry: Phase 1 Report 546 after the fire, Professor Torero concluded that different areas had been exposed to different levels of heating: some had been exposed to intense local heating and others to only mild local heating.33 23.16 Professor Torero emphasised that the extremely complex characteristics of the cladding system made it difficult to identify the extent to which different parts had contributed to the vertical spread of flame. For example, although he was confident that the width of the cavities and the geometry of the column detailing had played a role, he was unable to say whether they had promoted or restricted the spread of flame.34 He explained that although extensive studies had been carried out on the spread of flame across flat plates, both vertical and horizontal, less attention has been paid to the width of the cavity, which plays a fundamental role in the rate of flame spread in any system of that kind. In simple terms, if the width of the cavity exceeds a critical size, radiative feedback and buoyantly driven “chimney” effects (the upward movement of hot air in an enclosed vertical space) disappear altogether. If the width of the cavity falls below a critical size, thermal expansion of the gases blocks their flow and the flames cease to spread internally.35 At Grenfell Tower the accelerated vertical flame spread could be explained by the presence of open vertical channels, which induced chimney effects associated with their width, and also by the fact that polyethylene burns more easily than PIR insulation based on their material properties.36 However, given the relatively slow rate of vertical flame spread at Grenfell Tower by comparison with other international fires, he concluded that the specific detailing of the cladding system had probably had only a minor effect on the evolution of the fire and that the important factor in the rate and extent of flame spread was the composition of the materials used in it.37 A simplified illustration of the different processes which may have occurred during the spread of flame over a version of the cladding system used at Grenfell Tower is shown below.38 33 Professor Torero supplemental report [JTOS0000001] pp. 61/1668-62/1677. 34 Professor Torero supplemental report [JTOS0000001] pp. 4/91-95 and his oral evidence Day 77/114/15-119/5 and the discussion about cladding rails penetrating cavity barriers at Day 77/142/22-144/1. 35 Professor Torero oral evidence Day 77/113/1-114/13. 36 Professor Torero supplemental report [JTOS0000001] pp. 63/1695-1709. 37 Professor Torero oral evidence Day 77/118/2-119/18. 38 Professor Torero supplemental report [JTOS0000001] p. 63 Fig. 26.

Part III | Chapter 23: The Subsequent Development of the Fire 547 Figure 23.3 23.17 Professor Torero explained that, in a system of this complexity, a large number of different processes come into play in addition to the width of the cavity. For example, the low melting temperature and high thermal conductivity of aluminium results in complex heat transfer from external flames into the polyethylene core. The polyethylene melts as it is heated and the rate of melting is influenced by how fast the heat travels through the aluminium, which itself can be influenced by a variety of different factors.39 In addition, differential deformation of the aluminium plates can occur, leading to splitting of the plates and exposure of the polyethylene.40 23.18 Inside the cavity, the PIR has a low thermal inertia, which favours rapid initial flame spread, but its propensity to char reduces the amount of fuel that is consumed and thus has a retarding effect on flame spread. The outcome of these two competing effects is determined by radiative feedback from the ACM panels to the insulation boards, because if the insulation is exposed to additional heat it will continue to burn. Thus, the way the ACM panels burn has an effect on the way in which the PIR will spread a flame. Conversely, the way in which the PIR burns has an effect on the rate at which the ACM panels degrade, allowing the polyethylene core to melt and burn. Faster degradation induces more rapid melting of the polyethylene, which may reduce the rate at which the flame spreads but will increase the rate at which molten debris falls with the potential to ignite further fires. During his oral evidence Professor 39 Professor Torero oral evidence Day 77/111/2-25. 40 Professor Torero supplemental report [JTOS0000001] pp. 64/1716-1721.

The Grenfell Tower Inquiry: Phase 1 Report 548 Torero made it clear that, although the precise nature of the interaction between the two components was unclear at this stage, he was of the view that the insulation had contributed to the external flame spread. However, he found it difficult to say whether its contribution had been of considerable or only minor significance. As he explained, “clearly there is burning of the PIR and there is evidence that it had been contributing to the energy that is being released”, but he was unable to quantify that contribution at this stage.41 23.19 Professor Torero was of the view that the Aluglaze window infill panels might have contributed to the total heat release rate during the fire and therefore to the vertical flame spread, but he emphasised that XPS is a low density material, the mass of which present in the cladding system was much smaller than that of the other materials. Any contribution it may have made was therefore likely to have been minor.42 23.20 Professor Torero was asked about the effectiveness of cavity barriers in a fire of this kind. He was of the opinion that, in circumstances where the flames could be seen taking hold of the outside of the ACM panels from the very early stages of the fire, the rate of vertical flame spread was unlikely to have been significantly affected by defects in the way they were sited or fitted.43 He pointed out that the use of a barrier to prevent flame spreading through a cavity would be ineffective if there were combustible materials on either side of the barrier itself which effectively allowed the fire to spread around it. He also pointed out that, if ACM panels deform, delaminate or become detached from the building, cavity barriers will not be effective.44 Dr Lane 23.21 Dr Lane agreed with Professor Bisby and Professor Torero that the ACM panels had contributed to the rapid fire spread, given the polyethylene core of those panels and its particular properties.45 She also agreed with them that the insulation played a role in terms of the speed and extent of flame spread. In particular, she emphasised that the insulation in the cavity behind the ACM rainscreen panels would produce pyrolysing material and gases, thereby creating a highly effective environment for flaming combustion.46 23.22 Based on a review of the photographic evidence, she identified a number of separate pathways by which flames were able to spread across the cladding system. Her assessment was that the columns were the principal route for vertical flame spread during the early stages of the fire.47 In particular, she relied on the fact that the cladding around the columns contained a number of combustible materials, including the core of the ACM panels, the PIR insulation and the EPDM membrane.48 She also drew attention to the fact that the panels on the columns were ventilated by means of gaps between them which allowed a flow of air into the cavity running the full height of the columns. Those gaps provided a continuous flow of oxygen capable of fuelling the fire.49 41 Professor Torero oral evidence Day 77/121/11-127/23. 42 Professor Torero oral evidence Day 77/131/10-136/18. 43 Professor Torero supplemental report [JTOS0000001] pp. 69/1950-70/1953. 44 Professor Torero oral evidence Day 77/138/19-140/15. 45 Dr Lane supplemental report [BLAS0000002] p. 16/2.9.20; [BLAS0000010] p. 11/10.3.9 and her oral evidence Day 79/100/7-11. 46 Dr Lane oral evidence Day 79/97/12-99/12. 47 Dr Lane supplemental report [BLAS0000010] p. 9/10.3.1-24/10.3.44 and her oral evidence Day 79/61/9-62/24. 48 Dr Lane supplemental report [BLAS0000010] p. 11/10.3.9-14/10.3.16. 49 Dr Lane supplemental report [BLAS0000010] p. 14/10.3.16-15/10.3.26.

Part III | Chapter 23: The Subsequent Development of the Fire 549 23.23 Dr Lane drew attention to other features of the cladding system which, in her opinion, also played a role in promoting the vertical spread of flame. In that regard she identified both the vertical cavities created by the cladding rails at the tips and edges of the columns50 and the Aluglaze window infill panels.51 However, although she thought they had played some role, in her view they had not been a significant or governing factor.52 Dr Lane emphasised that the Aluglaze panels had made up only 15-17% of the overall surface area of the tower53 and therefore were not a dominant feature, but the XPS core was combustible and in her view there was some visual evidence to suggest that they may have been a mechanism by which flame spread during the fire.54 23.24 Dr Lane expressed the opinion that the use of cavity barriers in cladding systems was “entirely problematic”, in essence because a cavity barrier cannot prevent a flame from propagating in a cavity if the surface of the wall itself is burning.55 She illustrated that by reference to a number of diagrams showing routes by which cavity barriers can be bypassed in a system of the kind installed at Grenfell Tower. They include flaming through the polyethylene core itself and the widening of the gap between the cavity barrier and the external surface as a result of the distortion of the panels.56 Her view was that it made no difference where the cavity barriers had been placed in the cladding at Grenfell Tower, because they had been installed in a system which used ACM panels with a polymeric core.57 Although there were defects in the way in which the cavity barriers had been installed, including examples of poor workmanship and the installation of horizontal cavity barriers in the vertical position, she considered them to be minor defects, which were eclipsed by the more fundamental problem that the barriers became ineffective once the flames had taken hold of the ACM panels themselves.58 2 Horizontal and downward fire spread 23.25 After the fire reached the highest point at the top of the east face of Grenfell Tower at approximately 01.29, it advanced north and south and wrapped itself around the building in two advancing flame fronts, before converging on the west face in just over two and a half hours at around 04.08. That rapid horizontal and downwards spread of flame was a unique feature of this particular fire, which sets it apart from many other international fires and is an important factor in making the outcome so devastating in terms of the loss of human life. In this Chapter I examine the expert evidence about the causes of the lateral and downward fire spread, noting again the considerable agreement between the experts about the primary factors which played a central role in enabling that to occur. Professor Bisby 23.26 In Professor Bisby’s opinion the architectural crown of the building played an important role in increasing the rate and extent of horizontal spread of fire around the building.59 He referred to extensive video evidence from the night of the fire showing that the most rapid fire spread was invariably at the location of the crown, which acted “like a linear fuse moving around the 50 Dr Lane oral evidence Day 79/64/3-22. 51 Dr Lane oral evidence Day 79/83/5-87/10. 52 Dr Lane oral evidence Day 79/64/9-22, 87/4-10. 53 Dr Lane oral evidence Day 79/79/19-22, 87/4-10. 54 Dr Lane supplemental report [BLAS0000010] p. 39/10.7.1-41/10.7.8 and evidence Day 79/85/19-86/23. 55 Dr Lane oral evidence Day 79/142/8-143/15. 56 Dr Lane supplemental report [BLAS0000010] p. 16/10.3.27-23/10.3.44, in particular Figs. 10.18-10.20 and oral evidence Day 79/143/16-144/17. 57 Dr Lane oral evidence Day 79/144/23-145/1. 58 Dr Lane oral evidence Day 79/147/20-152/14 and her supplemental report [BLAS0000002] p. 15/2.9.11. 59 Professor Bisby supplemental report [LBYS0000001 pp. 241/1139-242/1146.

The Grenfell Tower Inquiry: Phase 1 Report 550 top of the building”.60 In his view the elements of the crown, in particular the tall ACM fins at the top of the building, had been most susceptible to burning, dripping polyethylene onto the aluminium coping directly below61 and producing localised pool fires, which in turn ignited adjacent elements of the crown, allowing the fire to progress laterally around the building.62 He also drew attention to certain features of the crown which were likely to have played a role in facilitating the rapid progression of fire, including: a. the configuration and orientation of the C-shaped fins themselves as a semi-continuous path for fire to spread; b. the number of exposed ACM edges of polyethylene within the fins; and c. the fact that the fins themselves formed C-shaped chimneys, supporting flame extension and the spread of fire.63,64 23.27 Professor Bisby did not accept that the lateral progression of the fire around the top of the building could be explained simply by the propensity of flames to broaden out as they extended vertically. He believed that the crown was the dominant factor driving that lateral fire spread.65 23.28 He also concluded that the ACM cassettes and the presence of polyethylene within the panels was the dominant and decisive factor in facilitating downward fire spread. In his view there was strong evidence that the polyethylene within the cassettes had enabled the fire to spread downwards and across the building as a result of the polyethylene melting and dripping and collecting on lower surfaces, before forming localised fires which then progressed back up the building.66 That was particularly evident from the thermal images taken by the NPAS helicopter, which showed a “waterfall of molten, burning material falling off the side of the building”.67 He drew particular attention to the columns, where downward fire spread was very evident and where the pools of burning polyethylene could be seen accumulating at intervals down the columns on the cassette returns or the cavity barriers, before developing into localised pool fires which then spread sideways.68 It was also evident from photographs taken after the fire that debonding of the ACM panels had occurred as the flame front progressed downwards, together with a significant accumulation of polyethylene on horizontal surfaces below the fire front (e.g. below window ledges and window infill panels, on the top of ACM cassettes).69 The following photographs illustrate that:70 60 Professor Bisby oral evidence Day 78/197/17-198/4, 200/7-9. 61 This aluminium coping sat at the top of the building, below the crown: Dr Lane supplemental report [BLAS0000010] p. 48 Fig. 10.47. 62 Professor Bisby oral evidence Day 78/199/8-200/9 and his supplemental report [LBYS0000001] pp. 241/1145. 63 Professor Bisby supplemental report [LBYS0000001] pp. 241/1142-1143. 64 He also drew attention to the lack of any cavity barriers within the ACM cassettes at the tops of the columns: Professor Bisby supplemental report [LBYS0000001] pp. 241/1144. 65 Professor Bisby oral evidence Day 78/200/4-201/24. 66 Professor Bisby supplemental report [LBYS0000001] pp. 189/921-192/925, 198/948-949. 67 Professor Bisby oral evidence Day 78/192/5-8. 68 Professor Bisby oral evidence Day 78/186/14-189/5. 69 Professor Bisby supplemental report [LBYS0000001] pp. 193/933-196/935, 194-196 Figs. 115-119. 70 Professor Bisby supplemental report [LBYS0000001] pp. 194-195 Figs. 116-118.

Part III | Chapter 23: The Subsequent Development of the Fire 551 Figure 23.4 Figure 23.5

The Grenfell Tower Inquiry: Phase 1 Report 552 Figure 23.6 23.29 Professor Bisby considered that photographs taken after the fire, particularly of the lower parts of the building, also supported the conclusion that polyethylene had flowed downwards over the external surfaces of the columns and along the extensive vertical channels within those columns, including at the column tips.71 That was consistent with a number of photographs taken on the night, in which it is possible to see that downward vertical flame spread had occurred first at the column lines, including the column tips and at the vertices between the columns and the spandrels, i.e. at places where there were extensive vertical cavities inside the cladding.72 After the fire significant quantities of solidified polyethylene were discovered in these cavities lower down the building, which Professor Bisby thought was compelling evidence that those extensive channels had played a role in facilitating downward flame spread.73 He concluded that the continuous vertical channels and cavities within the columns had played a role in the downward spread of the fire, which would have been much slower if they had not been present.74 23.30 In Professor Bisby’s opinion, the advanced fire spread at the crown and the melting and dripping polyethylene from the crown and from the ACM cassettes at the upper levels of the building had been responsible for the diagonal flame effect which could be seen on all the faces of the tower as the fire progressed between 01.29 and 04.08.75 In his written report he explained that this horizontal line moving across the building was generally steeper over the column sections and shallower over the spandrel sections, possibly due to an acceleration of the downward fire spread at the column lines caused both by the presence of uninterrupted bands of polyethylene present in the columns and by the extensive vertical cavities and channels in those locations.76 71 Professor Bisby supplemental report [LBYS0000001] pp. 193/932. 72 Professor Bisby supplemental report [LBYS0000001] pp. 185/920, 189/923-924. 73 Professor Bisby oral evidence Day 78/195/8-23. 74 Professor Bisby supplemental report [LBYS0000001] pp. 200/959-962 and his oral evidence Day 78/195/8-195/23. 75 Professor Bisby supplemental report [LBYS0000001] pp. 235/1084-237/1111 and his oral evidence Day 78/201/1-202/12. 76 Professor Bisby supplemental report [LBYS0000001] pp. 239/1124.

Part III | Chapter 23: The Subsequent Development of the Fire 553 23.31 Although horizontal flame spread was also likely to have occurred as a result of flames progressing sideways across the ACM panels themselves (known as “opposed flow”), Professor Bisby was clear that it was the melting and dripping polyethylene and the resulting progression of the fire diagonally across the building which was the predominant cause of lateral flame spread.77 23.32 Professor Bisby thought that the insulation was likely to have played a minor (but as yet unquantified) role in exacerbating the melting and dripping of polyethylene, because it would have insulated the cladding cavity, thereby increasing the interior temperature.78 Similarly, although the insulation could have contributed to the lateral flame spread, particularly at the exposed edges of the insulation boards, he did not think it was possible to quantify that contribution at this stage. Any such contribution would have to occur by way of opposed flow, which would probably have required significant heating to cause flames to progress horizontally across its surface.79 23.33 In his opinion the XPS window infill panels were also likely to have contributed both to the melting and dripping of material downwards80 and the formation of pool fires promoting horizontal spread,81 but it was not possible to quantify their contribution, other than to say that is unlikely to have been significant, given the limits of opposed flow spread and the fact that those panels made up a small proportion of the external surface.82 23.34 Finally, Professor Bisby was of the view that the vertical cavity barriers (even if installed correctly in the vertical or horizontal position) were unlikely to have been effective in preventing lateral flame spread, because of the combustibility of the ACM cassettes and their tendency to warp, delaminate and de-bond under heating.83 In fact, there was evidence that melting and dripping polyethylene had formed pool fires locally on top of horizontal cavity barriers, thereby making matters worse.84 Professor Torero 23.35 Professor Torero considered the lateral development of the fire as part of Stage 3 of his analysis, when considering the period between 01.30-02.30.85 In his opinion, the architectural crown was responsible for the most rapid of the observed fire spread and behaved as a preferred path for lateral propagation.86 In his written report he illustrated this by reference to video evidence from the east face which showed the fire front moving towards the south across the crown, causing burning debris to fall and ignite floors beneath it and causing the flames to advance towards the south-east corner of the tower.87 He explained that the pooling of burning polyethylene below the crown effectively acted as a “feedback loop” which then served to accelerate the burning around the crown, causing fires to start at other places 77 Professor Bisby oral evidence Day 78/189/13-190/25. 78 Professor Bisby supplemental report [LBYS0000001] pp. 199/957. 79 Professor Bisby oral evidence Day 78/202/23-203/24. 80 Professor Bisby supplemental report [LBYS0000001] pp. 198/949-951 81 Professor Bisby supplemental report [LBYS00000001] pp. 238/1120, 242/1147-1150 and his oral evidence Day 78/204/22-206/17. 82 Professor Bisby oral evidence Day 78/206/1-17. 83 Professor Bisby supplemental report [LBYS0000001] pp. 240/1135. 84 Professor Bisby oral evidence Day 78/188/10-19, 189/23-190/5, 204/9-17. 85 Professor Torero supplemental report [JTOS0000001] p. 2 footnote 1. 86 Professor Torero supplemental report [JTOS0000001] pp. 71/2004-2013 and his oral evidence Day 77/146/7-147/15. 87 Professor Torero supplemental report [JTOS0000001] pp. 71/2014-73/2026.

The Grenfell Tower Inquiry: Phase 1 Report 554 below it.88 Once the falling debris had ignited fires at lower levels of the building, those new fires propagated upwards and joined up with other fires, thereby consuming entire sections of the building. 23.36 This pattern of flame development was demonstrated very effectively by two graphs in Professor Torero’s written report, one for each of the two advancing lateral flame fronts (i.e. east-north-west and east-south-west). By plotting the time that each sector of the building had become affected by the advancing flame fronts, it was apparent that, after the initial vertical flame spread up the east face between 01.08 and 01.30, the lateral spread was always fastest at the top of the building, the lower levels being affected later. The graphs also showed that the downward flame spread had affected floors in groups: a group of floors would rapidly become involved in the fire as molten, burning debris fell down a particular sector, before the fire would spread up the building again.89 23.37 In general, Professor Torero thought that the role of opposed flow flame spread was “very minor to negligible”90 and that the primary or governing mechanism91 of downward and lateral flame spread was debris falling down the building and igniting fires below, which then progressed upwards.92 Given the complexity of the cladding system, he accepted that there were instances where fire had spread laterally through pathways in that system, but in his view that had not been the dominant mechanism.93 23.38 Professor Torero’s analysis showed that the rate at which the flats at floors 20 and above had been penetrated by the fire was almost the same as that at which the fire had progressed around the crown. That indicted that the flats at the top of the tower had been particularly vulnerable to the effects of the melting, dripping and burning of the polyethylene emanating from the panels forming the crown.94 23.39 Professor Torero agreed with Professor Bisby that there were particular characteristics of the crown which had allowed faster lateral propagation than had occurred in other sections of the building, including its configuration, the exposed polyethylene edges and the C-shaped chimneys formed within it.95 He also agreed that the lateral development of the fire at the top of the building could not be explained by the propensity of a vertical fire plume to widen as it rises. He drew attention to the fact that in some other fires, including the fire at The Torch in Dubai, the fire plume remained very narrow as it climbed vertically up the building. Much depended on the propensity of the system to sustain burning in such a way that the energy from the advancing vertical flame front enhanced the flame spread at the upper levels.96 23.40 Although the lateral fire spread seen at Grenfell Tower was unusual when placed in the context of other international fires, there were some examples of previous fires where substantial lateral (and downwards) spread had occurred at the roof level of the building. In particular, the fire at the Monte Carlo Hotel and Casino in Las Vegas in 2008 had significant parallels to the fire at Grenfell Tower. In that incident the fire had spread laterally across the building’s parapet and through polystyrene and polyurethane sections of the exterior insulation and 88 Professor Torero oral evidence Day 77/148/7-149/4, 77/154/8-10. 89 Professor Torero supplemental report [JTOS0000001] pp. 77/2094-78/2110 and oral evidence Day 77/154/14-156/19. 90 Professor Torero oral evidence Day 77/157/21-23. 91 Professor Torero supplemental report [JTOS0000001] pp. 74/2038-2042. 92 Professor Torero oral evidence Day 77/157/21-159/7. In common with Professor Bisby, Professor Torero also highlighted the potential for the horizontal cavity barriers to act as a surface for the deposit of melting, dripping material, with the cavity barrier itself becoming a mechanism for flame spread: oral evidence Day 77/139/11-18. 93 Professor Torero oral evidence Day 77/159/8-20. 94 Professor Torero oral evidence Day 77/150/12-23. 95 Professor Torero supplemental report [JTOS0000001] pp. 74/2031-2035 and his oral evidence Day 77/149/6-150/11. 96 Professor Torero oral evidence Day 77/151/4-25.

Part III | Chapter 23: The Subsequent Development of the Fire 555 finishing system (EIFS) panels. Molten, burning material had run down the outside of the building, starting fires in similar panels below and eventually penetrating the interior of the building.97 That mechanism had also been observed in a fire at the Taksim Ilk Yardim Hospital in Istanbul, Turkey in April 2018, where the fire had started on the roof of the building and spread downwards and laterally to incorporate the external facade of the building.98 23.41 Professor Torero thought it possible that the insulation had played a role in promoting lateral flame spread, but again, he did not think that it had been a dominant factor.99 He did not accept that the rapid fire spread around the top of the building could be explained by the presence of insulation at the upper levels, despite the fact that some had been wrapped over the original concrete roof and placed below the architectural crown protected by a strip of aluminium flashing at the top of level 23.100 He did not think there was any conclusive evidence that the fire at those levels had emanated from the insulation and, in principle, the pool fire at the base of the crown was capable of producing much more severe heating than burning insulation in that location.101 His opinion about the role of the crown was not undermined by the fact that some parts of the aluminium flashing beneath it had not melted, by comparison with other places on the face of the building where it had. Professor Torero explained that polyethylene melts at very low temperatures and starts turning to gas at around 300°C, which is significantly below the melting temperature of aluminium.102 In those circumstances he was not surprised that in some places the flashing had not been affected; the polyethylene acted like a “heat sink” drawing energy away from the aluminium and preventing the flashing from reaching melting temperature.103 Dr Lane 23.42 In her written report Dr Lane drew attention to a number of potential pathways in the exterior cladding system and across the windows which could have facilitated lateral and horizontal flame spread. They included downward spread along the columns,104 horizontal spread across the ACM spandrel panels,105 horizontal spread along the heads and sills of the windows and of the XPS window infill panels106 and horizontal spread around the architectural crown.107 23.43 Dr Lane agreed with Professor Bisby and Professor Torero that the crown was highly effective in propagating the flame front across the tower and, at least in the early stages of the horizontal development of the fire, provided the primary route of fire spread.108 In her opinion, that rapid fire progression across the crown was particularly significant in its effect on the flats at level 23 of the tower.109 97 Professor Torero supplemental report [JTOS0000001] pp. 74/2045-2052 and his oral evidence Day 77/161/5-162/7. 98 Professor Torero supplemental report [JTOS0000001] pp. 74/2053-2055. 99 Professor Torero oral evidence Day 77/159/21-160/5. 100 Dr Lane supplemental report [BLAS0000010] p. 48 Fig. 10.47. 101 Professor Torero oral evidence Day 77/152/17-153/6. 102 On exposure to heat, aluminium melts at approximately 660°C: Professor Bisby supplemental report [LBYS0000001] pp. 104/461 and Professor Torero supplemental report [JTOS0000001] pp. 60/1648-1649, which puts the melting range for the aluminium plates of the ACM panels at 580-650°C. 103 Professor Torero oral evidence Day 77/153/6-154/4. 104 Pathway A: Dr Lane supplemental report [BLAS0000010] pp. 9-23 section 10.3. 105 Pathway B: Dr Lane supplemental report [BLAS0000010] pp. 24-29 section 10.4. 106 Pathway C: Dr Lane supplemental report [BLAS0000010] pp. 30-33 section 10.5. 107 Pathway F: Dr Lane supplemental report [BLAS0000010] pp. 42-50 section 10.8. 108 Dr Lane oral evidence Day 79/89/4-91/4. 109 Dr Lane oral evidence Day 79/89/12-90/3.

The Grenfell Tower Inquiry: Phase 1 Report 556 23.44 She also drew attention to other mechanisms for downward and lateral flame spread, particularly at a time when the crown had been consumed by the fire. They included fire spreading down the columns and smaller fires propagating outwards.110 In her opinion, the presence of polyethylene in the ACM panels on the columns, together with the radiation from the fire within the cavity, which raised the temperature of materials below the fire, were likely to have been responsible for the downward movement of flame along the columns.111 23.45 Dr Lane accepted that movement laterally across the ACM cassettes by way of opposed-flow flame spread would have been much slower than any spread of flame vertically.112 However, she drew attention to the fact that the vertical gaps between the spandrel cassettes may have acted as channels which attracted flame propagation, thereby causing heating behind and across them.113 In her view, the configuration of the spandrel panels created perfect conditions for flaming combustion, with fuel on the outside, insulation on the inside and ventilation gaps between them.114 23.46 Dr Lane also considered that all the materials surrounding the windows and the window infill panels, including the uPVC surrounds, the original timber frames and the insulation were capable of causing horizontal (and vertical) flame spread, particularly after the ACM panels had fallen away during the fire.115 She drew attention to the role of the XPS window infill panels in promoting horizontal fire spread and to photographs taken after the fire which showed them in a damaged condition. She emphasised, however, that those panels constituted only a relatively small proportion of the external surface of the tower.116 23.47 The fact that combustible ACM panels had been the main constituents of the crown led Dr Lane to doubt whether cavity barriers could have been installed within it to prevent the rapid spread of fire effectively,117 but she noted that no attempt appeared to have been made to prevent the spread of fire horizontally around the crown. The construction drawings she had reviewed contained no requirement for horizontal cavity barriers or fire stopping to be fitted above the windows at level 23.118 3 Conclusions 23.48 Although I have seen the video evidence taken on the night of the fire many times, I still find the speed at which the fire took hold of the building and the size of the flames as they accelerated up the east face, causing molten debris to rain down onto the ground below, profoundly shocking. Although the speed at which the fire clawed its way up the building may have been slower than in some similar cases, to any onlooker those first few minutes must have been truly terrifying. It is not surprising that there were desperate shouts from the crowd below as the flames began to take hold with such ferocity.119 23.49 In its closing statement Arconic argued that the evidence heard in Phase 1 was too provisional in nature to enable any firm conclusions to be drawn about the development of the fire. I do not agree. There are, of course, some aspects of the matter on which the experts candidly 110 Dr Lane oral evidence Day 79/91/5-91/23. 111 Dr Lane oral evidence Day 79/66/5-69/5 and her supplemental report [BLAS0000010] p. 11 Fig. 10.9 and 14/10.3.23. 112 Dr Lane oral evidence Day 79/72/6-73/3. 113 Dr Lane supplemental report [BLAS0000010] p. 26/10.4.8 and Fig. 10.26, and her oral evidence Day 79/69/6-72/5. 114 Dr Lane oral evidence Day 79/71/3-9. 115 Dr Lane oral evidence Day 79/73/4-77/3, 82/19-83/2. 116 Dr Lane oral evidence Day 79/77/18-82/18. 117 Dr Lane oral evidence Day 79/93/14-94/6. 118 Dr Lane supplemental report [BLAS0000010] p. 50/10.8.24-10.8.25. 119 For example, [LBYS0000002] at 01.19.34, 01.24.44.

Part III | Chapter 23: The Subsequent Development of the Fire 557 admitted that their views were provisional and that greater certainty would have to await the outcome of further investigations, but there are others on which I am satisfied that findings can and should be made at this stage. My conclusions on those matters are set out in the following paragraphs. The bulk of Arconic’s submissions, however, were directed to demonstrating that the ACM panels were not the primary cause of the disaster and that other materials used in the refurbishment, such as the PIR and phenolic foam insulation boards and the uPVC window surrounds, were just as much, if not more, to blame for what happened. I consider that submission below. 23.50 Celotex, the manufacturer of the majority of the insulation boards used in the refurbishment, also submitted that the evidence given by the experts was only preliminary in nature and said that it would comment on the issues raised at this stage later on when further evidence had been given. Similarly, Rydon argued that the evidence was insufficient to enable me to reach any firm conclusions on the reasons for the spread of fire on the exterior of the building. My response to both those submissions is the same: despite the preliminary nature of some of the expert evidence, I am satisfied that there are some findings that can, and should, be made at this stage of the Inquiry. 23.51 Kingspan, the manufacturer of the other insulation boards used in the refurbishment, was prepared to acknowledge that, although some of the evidence was of a preliminary nature, some matters had been established with sufficient certainty to justify making findings about them. In particular, it submitted that the evidence demonstrated that the most important contributor to the development of the fire was the presence of the ACM panels. It also submitted that the nature and extent of the fire would not have been different if mineral wool insulation had been used. 23.52 In the light of the video evidence itself and the expert evidence summarised above, none of which was challenged, I am satisfied that, although many different factors played a part, the principal reason why the flames spread so rapidly up the building was the presence of the ACM panels with polyethylene cores, which had high calorific value, melted and acted as a source of fuel for the growing fire. I also think it more likely than not that the presence of PIR and phenolic foam insulation boards behind the ACM panels (and perhaps the EPDM membrane and the Aluglaze window infill panels) contributed to the rate and extent of vertical flame spread, but it is not possible at this stage to quantify the extent of their respective contributions. Further investigation which is to be the subject of evidence in Phase 2 may enable me to come to a more definite conclusion about those matters in due course. I should like to be able to do so, because I think it would be in the public interest to obtain a better understanding of how these materials behave in conjunction with each other when exposed to fire. Further work also needs to be done on the extent to which exposed edges of the ACM panels and insulation boards may have contributed to the spread of flame. 23.53 It seems likely that some aspects of the design of the cladding system and the geometry of the tower also contributed to the speed at which the fire developed vertically, but the evidence currently available does not enable me to reach any firm conclusion at this stage. Although Professor Torero urged caution in determining the role played by the details of the design of the cladding, such as the width and length of the cavities, Professor Bisby was “almost certain” that the extensive vertical channels and cavities within the system had made a contribution. The video evidence tends to support the conclusion that the principal route of flame spread was initially in the area of the columns and given that flames are known to extend significantly when confined in a vertical channel, it seems to me to be very possible that the presence of the vertical channels in the cladding system around the columns was

The Grenfell Tower Inquiry: Phase 1 Report 558 indeed a contributing factor. The video evidence, which shows flames elongating up the wing wall in the re-entrant corners between the spandrel panels and the columns suggests that the geometry of the building may also have played a part. 23.54 In the light of the available video and photographic evidence, both during and after the fire, and the unchallenged expert evidence summarised above, I am satisfied that the main reason why flames spread so rapidly down and around the tower after reaching the top at around 01.30, was also the presence of ACM panels containing polyethylene cores. In particular, I am satisfied that the principal mechanism for horizontal and downwards flame spread was the melting and dripping of burning polyethylene from the crown and from the spandrel and column panels, which ignited fires lower down the building. Those fires then travelled back up the building, thereby allowing the flame front to progress diagonally across each face of the tower. The propensity of polyethylene to melt and drip and spread flame downwards was very clearly demonstrated in the course of Professor Bisby’s oral presentation in June 2018120 and was particularly evident on the night of the fire in the thermal images, where a “waterfall” of burning, molten material can be seen cascading down the tower, setting fire to lower levels.121 23.55 There is also compelling expert evidence, which I accept, that the crown was responsible for the most rapid of the observed lateral fire spread. That is supported by the many videos taken on the night and was a phenomenon observed consistently on each of the four faces as the flame front progressed around the top of the building.122 23.56 Arconic suggested in its closing statement that the lateral fire spread at the top of the building might have more to do with the insulation behind the ACM panels, but that is not consistent with the video evidence showing the leading flame front progressing around the crown and was firmly rejected by Professor Torero in the light of the burning properties of the respective materials. He was also clear that the condition of the aluminium flashing beneath the crown did not undermine his conclusions, given the very different melting temperatures of polyethylene and aluminium. 23.57 Rydon, the main building contractor for the refurbishment, submitted that the lateral progression of the fire around the crown was not significantly different from that which took place in other sections of the building and argued that the diagonal flame front could be explained by the normal fire dynamics of upward and lateral spread. Again, those contentions are inconsistent with the video evidence and were not accepted by the experts. Professor Bisby and Professor Torero, whose evidence I accept, were both clear that the diagonal progression of this fire could not be explained simply by the propensity of a flame to widen as it travels upwards. 23.58 I also accept the evidence of Professor Bisby and Dr Lane that the columns were a principal route of downwards fire spread and I think it more likely than not that the extensive vertical cavities in the columns (particularly at the tips and down the sides at the vertices with the spandrel panels) and the longer ACM cassettes within the columns contributed to the rate at which the fire spread downward. 120 Professor Bisby presentation 20 June 2018 Part 1 at slides 29-30 and Part 1 of his video presentation at 47:42-48:04 and 52:45- 55:55. 121 LBYS0000004 sequence 1 between 01.28 and 01.43 at 5:45 (time in the video), LBYS0000005 sequence 4 between 02.52 and 03.03 at 6:23, sequence 6 between 03.12 and 03.23 at 11:40, sequence 10 between 03.55 and 04.13 at 31:30, LBYS0000006 sequence 4 between 02.43 and 02.58 at 5:10, sequence 8 between 03.52 and 04.12 at 14:28 and 16:48. 122 Professor Torero supplemental report [JTOS0000001] pp. 71/2014-72/2026, and LBYS0000003 at 10:39 and 12:32 (time in the video), LBYS0000004 at 14.10 (time in the video), LBYS0000005 at 6:52 and 31:58, and LBYS000006 at 11:14.

Part III | Chapter 23: The Subsequent Development of the Fire 559 23.59 Given the complexity of the exterior cladding system, there may well have been other mechanisms at work by which the fire was able to spread downward and horizontally, particularly where localised fires occurred across the facade. They may have included opposed-flow flame spread across the ACM panels and the insulation and the spread of fire, both horizontally and downward, through the XPS window infill panels, but further work will be necessary to ascertain the significance of any contribution that either of those mechanisms may have made. Vertical cavity barriers were unlikely ever to have been effective once the fire was able to progress across the ACM panels and horizontal cavity barriers may have provided surfaces on which melting and dripping polyethylene could lodge, enabling localised pool fires to develop. 23.60 Finally, I accept the evidence of all three experts that there are fundamental problems with the use of intumescent horizontal cavity barriers to limit external flame spread in a cladding system of this kind. That being so, I think it unlikely that defects in the installation of the cavity barriers were of great significance in the rate of vertical flame spread, given the extent to which the flames took hold of the ACM panels from the very early stages of the fire. 23.61 I accept the evidence of Professor Bisby and Professor Torero that the Grenfell Tower fire was unusual in the way that it spread laterally and was able to envelop the entire building in under three hours. With that in mind, I intend in Phase 2 of the Inquiry to examine (among other things) the extent to which the regime for testing materials intended for use in external walls (including thermoplastic polymer materials such as polyethylene) and the regulations governing their use were, and are, adequate to identify and control the potential dangers from downward and horizontal as well as vertical flame spread. I shall also examine what was and should have been known, both by those in the construction industry and by those in central government responsible for setting fire safety standards, about the particular dangers posed by thermoplastic polymers. 23.62 In the context of analysing the behaviour of different parts of the cladding system, both Professor Bisby and Professor Torero were at pains to emphasise its complexity, not so much in terms of its structure, as in terms of the interactions between its various components when exposed to fire.123 I have asked them to carry out further work on that in the hope that a better understanding can be obtained of how systems of this kind respond under those conditions. That should not only tell us more about the fire at Grenfell Tower itself, but should also provide valuable information for those involved in future projects. In the next phase of the Inquiry I also intend to investigate the extent to which those complexities were recognised and understood by those involved in the design of the refurbishment and the extent to which the current evaluation and testing regime is capable of ensuring that they are properly assessed. 123 Professor Bisby oral evidence Day 78/163/4-165/11.

The Grenfell Tower Inquiry: Phase 1 Report 560

561 Chapter 24 Internal Penetration and the Loss of Compartmentation 1 Introduction 24.1 It is clear from the factual evidence that the fire on the outside of the building quickly entered many flats and that at a very early stage smoke spread widely through the interior of the building, with many lobbies becoming affected as early as around 01.20. It is difficult to draw reliable conclusions about what caused smoke to spread into particular areas of the tower, but a number of key matters have emerged from the evidence which help to explain why the smoke spread so rapidly and how breaches of internal compartmentation were able to occur. The Inquiry’s experts were largely in agreement about the circumstances which are likely to have led to that result. 2 Professor José Luis Torero 24.2 Professor Torero considered internal penetration of the fire as part of Stage 3 of his analysis, representing the period from 01.30-02.30.1 In his opinion, the flames generated by the fire in the cladding system are likely to have resulted in very significant heat fluxes, potentially in the range of 20 to 120kW/m2, which would have exceeded the amount of heat required to ignite the combustible materials present in the cladding, including those around the windows.2 In those circumstances there were many different routes by which fire could break into the building, given that the external envelopes of buildings of this kind are designed to withstand heat emanating from fires in adjacent buildings, rather than significant fires in their own facades, as occurred in this case.3 24.3 Professor Torero identified three principal routes by which the fire is likely to have penetrated the building from the outside: a. failure of the window glazing; b. failure of the kitchen extractor fans; and c. failure of the uPVC window surrounds. 24.4 Professor Torero explained that extensive studies had shown that all forms of glazing fail when exposed to a heat flux of between 5 and 10kW/m2 for between 60 and 300 seconds and that the higher the heat flux, the shorter the failure time. In those circumstances, once the windows became engulfed by the external flame front, the fire could be expected to enter the building.4 However, the exterior of the tower was particularly vulnerable in certain other important respects, principally the inclusion of extraction fans in the kitchen windows. Professor Torero described by reference to photographs taken after the fire the various mechanisms by which the extraction fans had allowed smoke and flames to enter flats, depending on the level of heating which had occurred at particular locations.5 The 1 Professor Torero supplemental report [JTOS0000001] p. 2, footnote 1. 2 Professor Torero supplemental report [JTOS0000001] pp. 78-79 lines 2112-2116, 2138-2142 and Table 4 p. 80. 3 Professor Torero supplemental report [JTOS0000001] p. 78 lines 2112-2115. 4 Professor Torero supplemental report [JTOS0000001] p. 79 lines 2145-2148 and evidence Day 77/162/10-24. 5 Professor Torero supplemental report [JTOS00000001] pp. 80-85 lines 2156-2205 and Figs. 36-45.

The Grenfell Tower Inquiry: Phase 1 Report 562 photographs indicate that the extraction fans were the weakest components in the window arrangement in terms of an ability to withstand heat and were potentially “a significant way for the fire to get back in”.6 24.5 The existence of uPVC window surrounds, which Professor Torero considered in the context of the means by which the fire had escaped from the compartment of origin, represented another point of vulnerability. The propensity of uPVC to melt and deform at a relatively low temperature meant that the window surrounds provided another route by which the fire could enter flats elsewhere in the tower.7 24.6 Professor Torero agreed that all the weaknesses in the window arrangement identified in Dr Barbara Lane’s report8 would have tended to increase the rate at which flames were able to enter the building. He emphasised, however, that, since none of the windows had been designed to withstand the level of heating to be expected from a fire in the cladding, it was not reasonable to expect them to have prevented flames breaking into flats.9 He accepted that smoke may have been able to enter the building through gaps around the sides of the window framing, even though they were not a significant route for the re-entry of flame.10 Professor Torero accepted that those characteristics of the window arrangements could have had a “more significant impact” in cases where falling debris had led to the downwards spread of flame. In those circumstances localised fires could have entered the building through the extraction fans or through gaps along the sides of the windows.11 24.7 Overall, while there were some components of the window systems, including the extraction fans, which were more vulnerable than others, there was no evidence that they were more likely to have provided a route for fire to enter and ignite the interiors of flats. Given the high levels of heat flux on the facade, a path for re-entry would inevitably have been created in one way or another.12 24.8 Professor Torero noted that there was evidence of smoke penetration through the lobbies and into flats located on the west side of the building long before the fire itself had reached the west face. In particular, he drew attention to night vision images taken by the NPAS helicopter which showed smoke coming out of several windows on the west face between 01.57 and 02.40, particularly at floors 12 and 20.13 In his view that indicated clearly that smoke had spread from one flat, across the lobby and into a second flat on the opposite side of the building. The boundaries of at least two flats had therefore already been breached by that time.14 24.9 Despite major damage to many of the flats, a significant number did not reach flashover, even though the fire had potentially resulted in a very hot, thin ceiling layer of smoke and gas capable of igniting other materials in the compartment.15 In circumstances where the extent of damage to flats in the tower ranged from minor to severe, he was of the opinion that the thermal loading imposed by the external fire was likely to have been a secondary factor in 6 Professor Torero supplemental report [JTOS0000001] p. 80 lines 2165-2166 and oral evidence Day 77/163/2-164/10. 7 Professor Torero supplemental report [JTOS0000001] p. 79 lines 2120-2121 and pp. 43-44 Figs. 11(a)-(c) of his report where a series of photographs show debonding and deformation of the uPVC due to exposure to heat. 8 Section 9 of Dr Lane’s supplemental report [BLAS0000009]. 9 Professor Torero supplemental report [JTOS0000001] p. 79 lines 2126-2133. 10 Professor Torero oral evidence Day 77/165/2-166/14. 11 Professor Torero oral evidence Day 77/169/20-170/12. 12 Professor Torero supplemental report [JTOS0000001] p. 86 lines 2212-2220. 13 Professor Torero supplemental report [JTOS0000001] pp. 88-89 Figs. 48-52. As is evident from the factual Narrative, the external flame did not reach the top of column A1 on the north-west corner until 02.51: Professor Bisby supplemental report [LBYS0000001] p. 221 lines 1034-1037. 14 Professor Torero supplemental report [JTOS0000001] p. 88 lines 2248-2256. 15 Professor Torero supplemental report [JTOS0000001] p. 91 lines 2328-2333 and pp. 92-97 Figs. 54-63.

Part III | Chapter 24: Internal Penetration and the Loss of Compartmentation 563 determining the severity of the fire in any particular compartment, the primary factor having been the thermal loading imposed when the contents of the flat ignited. In other words, the heat introduced by the external fire was significant only in that it acted as the source of ignition of the contents of the flat. The factor governing the intensity of the fire in any given compartment had been the distribution of fuel and the extent to which the furniture and fittings had been consumed. The first items to ignite typically determined whether a fire would grow to become fully developed.16 24.10 In Professor Torero’s opinion the early spread of smoke through the tower was most likely to have been a consequence of flat doors having been left open rather than having failed while closed due to exposure to heat or flame. Although deficiencies in the performance of flat doors had been identified during tests conducted by the BRE after the fire, he pointed to the fact that the door being tested had demonstrated approximately 15 minutes’ fire resistance before succumbing to flaming.17 That corresponded to a failure temperature of about 740°C, given the incremental temperature increases which are imposed when conducting those tests.18 Such a temperature was higher than that at which flashover is likely to have occurred and would correspond to that reached in flats which had sustained major damage.19 In flats which had sustained only moderate or severe damage, the fire was unlikely to have been hot enough to cause the door to fail.20 24.11 When explaining the early spread of smoke across lobbies and into other compartments, Professor Torero identified two possible explanations for flat doors having been open: the absence of working self-closing devices and the intervention of firefighters. He explained that, if self-closing devices had been missing from the doors of flats or had not been working properly, open doors would have provided a means by which large quantities of smoke could have moved through the building at an early stage.21 In his view that may have had a very significant effect on compromising the lobbies.22 24.12 In relation to the intervention of firefighters, Professor Torero referred to the standard practice of fire and rescue services of setting hoses into rising mains on the floor below the fire, with the result that hoses trailing between floors would have kept some of the doors to the stairs open. He also noted that there had been evidence of firefighters having to force entry into flats to carry out search and rescue operations. That would inevitably have left those flats without a fully functioning fire door to contain the smoke.23 If there were fires on several floors and the occupants were trying to leave the building, there was an obvious risk of a conflict between firefighting operations and the occupants’ need to escape.24 16 Professor Torero supplemental report [JTOS0000001] p. 93 lines 2364-2377. 17 BRE test report [MET00019996]. 18 Professor Torero supplemental report [JTOS0000001] pp. 90-91 lines 2305-2323 and pp. 98-99 lines 2409-2448. 19 Professor Torero supplemental report [JTOS0000001] p. 99 lines 2448-2449. Of 113 flats which were surveyed by Professor Torero where fire and smoke breached the compartmentation, 13 experienced minor damage, nine moderate damage and 91 major damage: [JTOS0000001] p. 92 lines 2342-2363 has a definition of those. 20 Professor Torero supplemental report [JTOS0000001] pp. 99-100 lines 2454-2460. This was evidenced by the fact that for the flat doors where the damage in the flats was of this nature (i.e. no post-flashover fire) the damage to the doors could be explained by firefighter intervention or thermal insult from the communal lobby side following failure of all the doors on that floor. 21 Professor Torero supplemental report [JTOS0000001] p. 100 lines 2493-2494 and p. 102 lines 2517-2524. 22 Professor Torero oral evidence Day 77/186/15-18, 77/176/11-22-185/1-16. Professor Torero Addendum report dated 20 October 2018 [JTOS000002] p. 2, section 1. 23 Professor Torero illustrated this in his report with particular reference to firefighter evidence from floors 4, 5, 9, 11 and 12: [JTOS0000001] pp. 102-104 lines 2525-2592 and Addendum report [JTOS0000002] p. 2, section 2. 24 Professor Torero oral evidence Day 77/189/8-190/9.

The Grenfell Tower Inquiry: Phase 1 Report 564 24.13 In her report Dr Lane had identified a “hot zone” in the stairwell between floors 13 and 16.25 Professor Torero thought that it was “perfectly possible” that it might have been due to firefighter activity, including the holding open of several stair doors at or near those floors.26 In general he was of the view that the activities of firefighters in holding open doors and forcing entry to flats made a potentially very significant contribution to the loss of compartmentation and the spread of smoke within the building during this third phase of his analysis.27 24.14 In an Addendum report, Professor Torero also identified the failure of doors caused by the effects of fire as a potential contributing factor to the spread of fire and smoke in the period leading up to 02.30, but he did not think it was likely to have been a significant factor in the earlier stages, given the likely performance of the fire doors.28 He also thought that the variation in the performance of flat doors was likely to have reflected differences in their construction and maintenance.29 24.15 Professor Torero identified other factors which could have contributed to the movement of smoke through the tower. They included the movement of occupants,30 smoke leakage through flat doors or the doors to the stairwell31 and smoke spreading through the smoke control system.32 He did not consider those factors to be as significant as the existence of open doors, however.33 24.16 Professor Torero explained that, in previous fires in which there had been a significant number of casualties (including major fires in South and Central America and the United States), breaches of compartmentation had occurred allowing smoke to spread into vital parts of the building, including the stairs and common parts.34 In contrast, in fires where compartmentation had not been breached and the common parts had remained clear of smoke, there had been no or only a limited number of casualties.35 For example, in The Address fire in Dubai one of the main structural walls had separated the apartments from the corridor, so there was a very significant compartmentation barrier.36 24.17 In his analysis of the fire Professor Torero described Stage 4, between 02.30 and the extinguishing of the fire,37 as “the untenable stage”. He noted that in that phase of the fire a very large number of flats had been affected by the external fire, compartmentation had been breached at many floors and the scale of the fire exceeded the firefighters’ capacity to contain 25 At paragraphs 14.4.8-14.4.36 of her report, [BLAS0000014] pp. 21-29, Dr Lane identified evidence of a “hot zone” or “hot spot” in the middle of the stairs around floors 13-16 with temperatures having reached above 150°C given, for example the melting to the stair lights and the damage to the lobbies and stair doors which had occurred in those locations. 26 Professor Torero oral evidence Day 77/196/8-197/13. 27 Professor Torero oral evidence Day 77/190/15-190/24. 28 Professor Torero Addendum report [JTOS000002] p. 2 section 1 and oral evidence Day 77/180/4-181/16. 29 Professor Torero oral evidence Day 77/183/15-184/2. 30 Professor Torero supplemental report [JTOS0000001] p. 102 lines 2510-2516. 31 Professor Torero supplemental report [JTOS0000001] p. 105 lines 2633-2637, with reference to section 19 of Dr Lane’s original report [BLAS0000019]. 32 Professor Torero supplemental report [JTOS0000001] p. 106 lines 2638-2645. In oral evidence he explained that it was difficult to know, at this stage, whether the evidence of smoke entering some of the lobbies through the dampers in the smoke control system (e.g. the oral evidence of Farhad Neda on floor 23: Day 61/40/25-41/2-21) was due to the fact that the system was designed to deal with a fire on only one floor, or whether there were non-compliances in the system which led to that smoke spread: Day 77/191/8-193/7. 33 Professor Torero oral evidence Day 77/184/3-185/4; Professor Torero supplemental report [JTOS0000001] p. 105 lines 2633-2637 and p. 106 lines 2638-2645. In his supplemental report Professor Torero also considered the possibility that large-scale effects (including the stack effect and the piston effect) may have influenced smoke migration, but did not consider these to be of any significance: [JTOS0000001] pp. 104-105 lines 2593-2632. 34 Professor Torero supplemental report [JTOS0000001] p. 89 lines 2258-2273. Professor Torero illustrated this by reference to a number of fires in other countries between 1972 and 1986. 35 Professor Torero supplemental report [JTOS0000001] p. 89 lines 2275-2284. 36 Professor Torero oral evidence Day 77/178/3-179/1. 37 Professor Torero supplemental report [JTOS0000001] p. 2, footnote 1 and pp. 122-130.

Part III | Chapter 24: Internal Penetration and the Loss of Compartmentation 565 and extinguish it.38 By “untenable” Professor Torero meant both conditions that were actually life-threatening and conditions that were perceived by occupants to be life-threatening (e.g. as a result of poor visibility).39 Consequently, although he described conditions as generally “untenable” during this phase, he acknowledged that they were dynamic and variable and that escapes were clearly possible after 03.00 if individuals “got the right window”.40 During that period evacuation remained “the preferred option”.41 3 Professor Bisby 24.18 In his Supplemental Phase 1 report Professor Bisby drew attention to some important evidence relating to the entry into the building of smoke and flames.42 He noted that a large number of witnesses had commented on the early ignition or failure of kitchen extraction fan units as a route by which fire and smoke had been able to gain entry during the early stages of the fire when it climbed over the east face of the tower. He referred specifically to evidence from the following floors of the tower:43 a. floor 7 (Jose Vieiro, Flat 46); b. floor 8 (Shantilal Patel, Flat 56); c. floor 9 (Zakariya Chebiouni, Flat 66); d. floor 10 (Hoang Khanh Quang, Flat 76); e. floor 11 (Nadia Jafari, Flat 86); f. floor 17 (Virgilio (Larry) Castro, Flat 146); and g. floor 21 (Helen Gebremeskel, Flat 186). 24.19 Floor 14 (Flat 116) can also be added to this list since Nida Mangoba reported that the extractor fan and the glass in her kitchen window smashed into her kitchen with a “loud… pop” when the external flame front reached her flat.44 24.20 Professor Bisby also drew attention to the fact that a large number of residents had referred in their evidence to draughts from gaps around the window frames in their flats.45 One witness, Antonio Roncolato (Flat 72, floor 10), had described smoke coming into his flat through gaps of that kind and referred to a video he had taken showing that happening at around 02.30.46 Evidence from residents living on floors 6 and 7 of the tower47 suggested that early failure of the uPVC window surrounds had occurred inside kitchens on the east face as the fire reached those floors. Professor Bisby also drew attention to examples of window panes having failed when exposed to the fire, referring, in particular, to evidence from residents on floors 11 (Flat 86)48 and 18 (Flat 156),49 who had witnessed the windows in their kitchens breaking due to 38 Professor Torero supplemental report [JTOS0000001] p. 122 lines 2888-2890. 39 Professor Torero supplemental report [JTOS0000001] p. 2 footnote 2 and oral evidence Day 77/193/20-195/5. 40 Professor Torero oral evidence Day 77/195/6-196/6. 41 Professor Torero supplemental report [JTOS0000001] p. 132 lines 3111-3112. 42 Professor Bisby supplemental report [LBYS0000001] pp.244-260 sections 1160-1223. 43 Professor Bisby supplemental report [LBYS0000001] pp. 254-256 sections 1180-1189. 44 Nida Mangoba first witness statement [IWS00001084] p. 4 sections 18-19. 45 Professor Bisby supplemental report [LBYS000000]1 p. 256 sections 1190-1193. 46 Professor Bisby supplemental report [LBYS0000001] p. 256 section 1194; Roncolato oral evidence Day 52/43/13-44/24. 47 Flats 36 (Ramiro Urbano first witness statement [IWS00000496] p. 5 section 21) and 46 (Jose Vieiro first witness statement [IWS00001122], p. 3 sections 12-13, 17). 48 Nadia Jafari first witness statement [IWS00000683] p. 4 section 18 and Day 54/25/16-31/13, 54/9/17-10/17. 49 Shah Ahmed first witness statement [IWS00000388] p. 10 section 33.

The Grenfell Tower Inquiry: Phase 1 Report 566 the advancing external fire.50 He also referred to evidence from several “Flat 6” residents who said that the self-closing devices on their front doors had not been not working on the night of the fire and that some of the doors had been left open as they left their flats.51 24.21 In Professor Bisby’s opinion, both the materials and products used in the refurbishment and its design were likely to have contributed significantly to the entry of both smoke and flames as the fire spread over and through the cladding.52 He also thought that the route by which they had entered the building probably changed as the fire developed: when it was in its early stages they were more likely to have entered by attacking the materials around and within the windows (including the extraction fans), but when it had grown larger, the route of entry had changed to breaking the window panes by the imposition of high levels of heating.53 Nonetheless, the materials and configuration of the cladding around the windows had continued to be important in relation to downward and horizontal fire spread due to the steady proliferation of smaller, local fires associated with them.54 4 Dr Lane 24.22 In Chapter 9 of her supplemental report Dr Lane identified a number of routes by which the fire could have penetrated the interior of the building. They included entering through the combustible materials in the window reveals, through the failure of window panes, through the kitchen extraction fans and through the XPS window infill panels.55 24.23 In that report Dr Lane identified a number of concerns about the ability of many of the front doors to the flats to withstand smoke and flames.56 In section 19 she concluded that it was likely that the doors had failed to control the spread of smoke and flames in the following ways:57 a. failing to prevent the spread of smoke and flames through gaps between the door leaf and the door frame; b. failing to resist the spread of fire and smoke from a flashover fire due to the presence of untested components (including, in a large proportion of the doors, glazing). Dr Lane noted that the testing of a glazed door taken from the tower by the BRE had achieved only 15 minutes’ fire resistance instead of the 30 minutes required by the standards in force when it was installed;58 and c. failing to self-close effectively after the residents had left. 24.24 Dr Lane explained that the significance of such defects was likely to vary depending on the location of the flat. In principle, a non-compliant door could have severe consequences in one location but none in another where the effects of the fire were not so serious.59 For example, she considered that the conditions that had been experienced by Antonio Roncolato in Flat 72 on floor 10 were very different from those that would have been experienced by the occupants 50 Professor Bisby supplemental report [LBYS0000001] pp. 256-257 sections 1197-1200. 51 Professor Bisby supplemental report [LBYS0000001] p. 257 sections 1201-1202. 52 Professor Bisby supplemental report [LBYS0000001] p. 257 section 1204. 53 Professor Bisby supplemental report [LBYS0000001] p. 257 section 1205 and oral evidence Day 78/207/8-208/15. 54 Professor Bisby supplemental report [LBYS0000001] p. 257 section 1207 and oral evidence Day 78/208/4-15. 55 Dr Lane supplemental report [BLAS000009] pp. 30-35 section 9.4. 56 Dr Lane supplemental report sections 15 [BLAS0000015] and 19 [BLAS0000019]. 57 Dr Lane supplemental report [BLAS0000019] p. 20 section 19.5.28 and oral evidence Day 81/30/2-36/3. 58 Dr Lane supplemental report [BLAS0000019] p. 19 section 19.5.16. 59 Dr Lane oral evidence Day 81/3/21-4/16.

Part III | Chapter 24: Internal Penetration and the Loss of Compartmentation 567 of Flat 201 on floor 23.60 She said that, in general, fire doors were a very significant fire safety measure.61 Although Dr Lane accepted that it was inevitable that the doors would fail at some point, she emphasised that their performance could be particularly important for those who were waiting in their flats.62 She did not accept that the failures to comply with appropriate standards she had identified had had only a limited effect on the development of the fire or on the outcome for residents.63 She emphasised in oral evidence that the self-closing devices on flat doors were very important for maintaining compartmentation; the whole point of having a functioning self-closing device was to ensure that the door closed behind a person as they left the flat, so ensuring that the protection it provided was maintained.64 24.25 Dr Lane recognised that firefighters had broken down the doors of some flats on various floors, but she cautioned against attributing too much significance to their activities. In her view other factors were likely to have contributed to the spread of smoke in the lobbies; it all depended on the particular location.65 In her opinion the primary route by which smoke and heat had spread into the stairwell was through the doors from the lobbies and was probably caused by many of those doors being opened by firefighters and occupants or held open by firefighting equipment or other objects.66 She explained that she would have expected to see more severe damage to the concrete in the stairwell if the doors from the lobbies to the stairs had failed entirely. Accordingly, the more likely explanation for the spread of smoke into the stairwell was activities associated with the doors, rather than a failure of the doors themselves.67 Despite that, she had a number of concerns about the doors into the stairwell,68 including the fact that, when tested by the BRE to current standards, one of the stair doors resisted fire adequately for only 16 minutes.69 24.26 During her inspection of the tower Dr Lane had identified particularly acute damage at floors 13 to 16. The plastic stair lights between floor 13 and floor 15 had been completely destroyed and severe damage had been caused to the lobbies on floors 13, 14 and 16. The pattern of damage differed from that seen in other parts of the stairs, including at higher floors, where the plastic lights had not suffered such severe damage.70 In her opinion the most likely explanation for this “hot zone” was smoke and heat entering the stairs when the stair doors were opened during the fire. She thought that that may have been linked to firefighting operations during the night, including operations around floors 10 to 14 at around 02.00.71 24.27 Other possible routes by which smoke could have spread within the building were identified by Dr Lane. They included: a. Through the ducting and vents of the smoke extraction system. Some residents said that they had witnessed smoke entering lobbies through the builders’ ducts and louvres for 60 Dr Lane oral evidence Day 81/35/9-19. 61 Dr Lane oral evidence Day 81/32/9-21. 62 Dr Lane oral evidence Day 81/33/2-12. 63 Dr Lane oral evidence Day 81/33/13-18. 64 Dr Lane oral evidence Day 81/38/4-18. 65 Dr Lane oral evidence Day 81/36/20-37/13. 66 Dr Lane supplemental report [BLAS0000019] p. 45 section 19.7.27 and oral evidence Day 81/39/19-41/15. 67 Dr Lane oral evidence Day 81/40/11-41/7, 81/45/2-25 and 81/63/19-64/15. 68 Dr Lane supplemental report [BLAS0000019] pp. 29-32 sections 19.6.11-19.6.29, Appendix M [BLAS0000034]. 69 Dr Lane supplemental report [BLAS0000019] p. 31 section 19.6.17.1; BRE Global Test Report [MET00021780]; oral evidence Day 81/61/3-63/13. 70 Dr Lane supplemental report [BLAS0000019] pp. 41-42 sections 19.6.92-19.6.98. 71 In particular Dr Lane noted the rescue operation described by FF Oliver Desforges at around floors 10-11 with the stair door being held open around 02.10 and also firefighter activity around floor 14 from 02.00 onwards: [BLAS0000019] p. 41 sections 19.6.93(e)-(f) and section 19.6.97; oral evidence Day 81/78/9-80/22.

The Grenfell Tower Inquiry: Phase 1 Report 568 the smoke control system.72 If so, that might indicate that there had been a failure of compartmentation in respect of the shafts in the smoke extraction system, but further work would be necessary to confirm whether that had been the case.73 b. Through the uncompleted boxing protecting the new gas riser in the stairs, which contained oversized holes on the lobby side which had not been fire-stopped. Dr Lane was very concerned about the potential for smoke to spread from one lobby to another through the boxing, although she was unable to form a final view about that at this stage.74 5 Conclusions 24.28 Although the fire at Grenfell Tower was not an event which the building had been designed to withstand, the rapid failure of compartmentation and the speed at which smoke was able to spread into the lobbies and stairs is of very considerable concern. As Professor Torero pointed out, in comparable fires in other countries (including, in particular, several of the large fires in Dubai), few casualties occurred because the buildings’ compartmentation was maintained. At Grenfell Tower, by contrast, a number of key fire protection measures, both active and passive, failed to operate as effectively as could reasonably have been expected, even taking into account the fact that they were required to respond to circumstances for which they were not designed in order to mitigate the effects of a fire which affected many floors at the same time. 24.29 I accept the evidence of Professor Torero that the glass in the windows could be expected to fail when it was exposed to high levels of heating resulting from the fire in the cladding and it is also clear from the evidence that some windows were open, providing a simple route for the fire to enter those parts of the building. The sad fact is that once the fire on the outside of the building had developed to any significant extent it was inevitable that it would find its way inside by one means or another, regardless of any weaknesses or defects in the windows or the construction of the external envelope. It is striking, nonetheless, that several residents described the fire coming into their kitchens through the openings caused when the extraction fans were dislodged. That is consistent with the pattern identified by Professor Bisby of such failures having occurred early in the development of the fire and tends to suggest that during those early stages the ease with which the fire was able to penetrate the building may have been greater because of the propensity of the fan units to deform and become dislodged when exposed to heat. I also accept the evidence of Professor Torero and Professor Bisby that the defects in the window arrangements and the configuration of the cladding around them may have contributed to the downward and horizontal progress of the fire. 24.30 If Professor Torero was right in saying that the external fire provided little more than the source of ignition for the contents of individual flats (and I have no reason to think that he was not), that raises the question why the heat and smoke generated by the fires in those flats were not contained by the compartmentation of the building, at least in the early stages. It is a difficult question to answer, but there is evidence to suggest that a number of factors are likely to have contributed to the loss of effective compartmentation. 72 In particular the evidence of Farhad Neda on floor 23, Day 61/40/25-45/18; Daniel Griffin on floor 6, first witness statement [IWS00000173] p. 7 section 48; Emma O’Connor on floor 20, first witness statement [IWS00000121] p. 6 section 27. 73 Dr Lane oral evidence Day 81/162/15-172/10. 74 Dr Lane oral evidence Day 81/69/6-75/14.

Part III | Chapter 24: Internal Penetration and the Loss of Compartmentation 569 24.31 In the early stages of the fire, when flames were accelerating up the east face of the tower, forcing the occupants of “Flat 6s” to leave, a number of the doors to those flats appear to have been left open due to the absence of effective self-closing devices.75 There is evidence that the doors to “Flat 6s” on the following floors remained open for this reason: a. Flat 76 on floor 10;76 b. Flat 86 on floor 11;77 c. Flat 116 on floor 14;78 d. Flat 136 on floor 16;79 e. Flat 146 on floor 17.80 As a result, smoke which had been able to enter those flats was able to get into the lobbies. 24.32 It is also possible that the doors to the following flats remained open for the same reason, although the evidence is less clear: a. Flat 36 on floor 6;81 b. Flat 96 on floor 12.82 24.33 After the fire the BRE carried out an examination of the remains of the doors to the flats in the tower in an attempt to determine whether they had been open or closed at the time of the fire and whether the self-closing devices had been present and working.83 In many cases the destruction or degree of damage to the door made it impossible for any conclusion to be reached. In some cases self-closing devices were found and in others they were not, but even where such a device was found it was not possible to decide whether it had been working at the time of the fire. It is possible that a door found by the BRE to have been closed may previously have been open for long enough to allow a significant amount of smoke to enter the lobby. Given the degree of uncertainty that surrounds the evidence contained in the BRE report, it is in my view reasonable to accept the evidence of those witnesses who are able to speak about the condition of their own doors and their actions at the time they left their flats. 24.34 In addition, there is evidence which suggests that the inability of flat doors adequately to resist the spread of smoke was also a factor in enabling the spread of smoke at an early stage. Thus: a. FFSs Richard Hippel and Jamal Stern gave evidence that they had seen smoke emerging from around the closed door of Flat 26 on floor 5 during the 10 minutes after 01.19 and Mohammed Rasoul (from Flat 25) also saw dark grey smoke leaking from the sides and foot of the door to the flat at some time between 01.15 and 01.30. 75 This was also identified as a likely source of smoke spread by Professor Purser in his Phase 1 report [DAPR0000001] summary at pp. 7-8 section 21(e)-(g). 76 Hoang Khanh Quang [IWS00000080] p. 6 section 31 and Day 67/85/9-67/86/24, 67/97/4-20; Van Quang Ho [IWS00000925] p. 5 section 25. 77 Nadia Jafari Day 54/14/3-15/6, 54/39/16-21. 78 Nida Mangoba supplementary witness statement [IWS00001145] pp. 1-2. 79 Hamid Wahbi first witness statement [IWS00001157] p. 6 sections 26 and 55 and Day 62/36/18-37/1, 41/11-42/10. 80 Larry Castro first witness statement [IWS00001091] p. 7 section 38. 81 Oscar Gonzalez first witness statement [IWS00001234] p. 5 section 17; Ramiro Urbano first witness statement [IWS00000496] p. 6 section 24; Claudia Montes first witness statement [IWS00001229] p. 2 section 9. 82 Roy Smith first witness statement [IWS00000771] p. 9 section 36 and Day 64/38/13-39/8, 64/43/24-44/9, 64/46/14-47/12, 64/49/13-52/12. 83 BRE Global Client Report dated 20 February 2019 [MET00039807] p. 73 section 5.1.

The Grenfell Tower Inquiry: Phase 1 Report 570 b. In a 999 call made at 01.37 Rosemary Oyewole in Flat 113 on floor 14 described smoke coming through her door and in her oral evidence she explained that smoke was “coming from any crack in the door”; both around the frame and through the letterbox.84 c. In a 999 call made at 01.37, Sener Macit in Flat 133 on floor 16 described smoke coming in under the front door.85 d. In a 999 call made at 01.38, a member of the El Wahabi family in Flat 182 on floor 21 said that smoke was coming from the front door. They had put down two blankets to block the smoke and it was not working.86 e. In a 999 call made at 01.40, Denis Murphy in Flat 111 on floor 14 explained that smoke was coming into the flat under the door.87 f. Ann Chance in Flat 73 on floor 10 recalled seeing smoke coming from underneath her front door at an early stage in the night.88 In a 999 call at 01.41 she said that smoke was “coming up” and that the door was completely hot.89 g. In a 999 call made from Flat 155 on floor 12 at 01.44 Roy Smith reported smoke coming in around the door, even though he was using wet towels in an attempt to keep it out.90 24.35 However, there is evidence which suggests that some flat doors were more effective. For example, the doors of Flat 72 (Antonio Roncolato), Flat 82 (Natasha Elcock) and Flat 165 (Nicholas Burton) appear to have resisted the passage of smoke for some considerable time, which demonstrates the need for caution before assuming that the deficiencies identified by Dr Lane made a difference in all cases. Overall, however, it is safe to say that at least some of the front doors to the flats failed to control the spread of smoke and fire effectively, which allowed smoke to spread in some areas at an early stage. I do not accept the submission made by the TMO that it is not possible to make any assessment of the performance of the doors at this stage.91 Although it may be necessary to ask the experts to look further into the performance of the front doors of the flats as part of their work in Phase 2, the evidence already available points to the conclusion that their deficiencies contributed to the early spread of smoke in some areas of the tower. 24.36 Firefighting operations undoubtedly played a part as well, because some doors to flats had to be broken down to enable firefighters to gain entry and the use of established firefighting techniques led to the doors to the stairwell being propped open by equipment, including hoses. However, that was limited to the floors on or adjacent to which active firefighting operations were being conducted. For example, on floor 5 FFs Wayne Archer and Thomas Abell forced the door of Flat 26 shortly after leaving the bridgehead at around 01.21. They attempted to fight the fire inside the flat for about 10 minutes, but by the time they left to return to the bridgehead conditions in the lobby were almost as bad as those in the flat. The front door of Flat 16 itself had been forced open as firefighters responded to the initial fire, which could have allowed smoke to spread into the lobby when the fire re-entered the compartment later in the night.92 It seems reasonably clear that, where firefighters forced 84 [LFB00000678] p. 2 and evidence Day 58/24/22-27/13. 85 [LFB00000326] p. 3. 86 [LFB00000677] pp. 15-16. 87 [LFB00000322] p. 3. 88 Ann Chance first witness statement [IWS00000783] p. 4 section 24. 89 [LFB00000319] p. 3. 90 Roy Smith first witness statement [IWS00000771] p. 12 section 57; [LFB00000324] p. 2. 91 TMO closing submissions [INQ00000543] p. 8 section 22. 92 As noted earlier in this Chapter, Professor Torero has given other examples of such activity including on floors 11 and 12.

Part III | Chapter 24: Internal Penetration and the Loss of Compartmentation 571 entry into flats, or where firefighting equipment such as hoses were being used on different floors, doors were propped open, which enabled smoke to enter areas that had previously been unaffected. 24.37 I accept the evidence of Professor Torero and Dr Lane that smoke is more likely to have entered the stairwell as a result of doors from the lobbies being held open than as a result of defects in the doors themselves. The evidence suggests that, in general, those doors performed reasonably well, provided they were kept closed. 24.38 It is possible that what Dr Lane described as the “hot zone” between floors 13 and 16 may have been a consequence of firefighting and rescue operations in those areas which involved holding doors open for lengthy periods during rescue attempts, but it is not possible to reach any definite conclusions about when or how those conditions came about. I accept the submission made by Rydon in their closing statement93 that it is difficult to know with any degree of certainty when the hot zone developed. 24.39 Many other factors may have played a part in the spread of smoke in the tower, such as the movements of occupants and leakage through the smoke control shafts and vents and other open channels, but it is not possible at this stage to determine the extent to which, if at all, they contributed to the outcome. It is clear from what has been learnt so far that the building suffered a total failure of compartmentation. How the building came to be in that state is the most pressing question to be answered in Phase 2. 93 [INQ00000557] pp. 19-21 section 60-63.

The Grenfell Tower Inquiry: Phase 1 Report 572

573 Chapter 25 Developing Conditions within the Building This chapter provides an overview of the developing conditions of fire and smoke inside Grenfell Tower as experienced by its occupants and the firefighters. 1 Overview of the evidence 25.1 This chapter describes the conditions encountered by occupants and firefighters inside the tower as the fire developed. In the Narrative section I have recorded in some detail the available evidence about the developing conditions within the building. Here I seek to draw conclusions from that evidence about the nature of the fire and smoke in key areas of the building, using the Periods into which the Narrative section is divided. My attention has been concentrated principally on conditions in the lobbies and the stairs, since they were the most important areas of the building, both for occupants attempting to leave the tower and for firefighters attempting to fight the fire or carry out rescues. 25.2 The spread of fire and smoke created a dynamic situation which evolved rapidly in different ways in different parts of the building and the evidence on which my conclusions are based was inevitably to some degree subjective and imperfect. For example, perceptions of the colour and density of smoke appear to have varied; what appeared very dark and dense to one person appeared lighter and thinner to another. There are no objective criteria by which to measure the density of the smoke encountered by individual witnesses, and the ways in which I describe it in the following paragraphs depend heavily on the impression it made on them at the time. Moreover, conditions appear to have varied, sometimes over very short periods of time, as doors were opened and closed in particular locations. I have tried to describe the conditions inside the building in as much detail and with such confidence as the evidence allows, but it is important to recognise that it will never be possible to identify with precision exactly what they were like at any particular place at any particular time. 25.3 The evidence indicates that: a. the lobbies on a significant number of floors had started to fill with smoke by around 01.20 or shortly after and that by 01.40 a number had become significantly smoke‑logged; b. in the early stages of the fire (before around 01.50) there was a marked difference between conditions in the lobbies and conditions on the stairs; generally, the smoke in the stairs was less dense than in the lobbies, allowing 168 people to escape the tower by 01.50; c. by 02.00 a significant number of lobbies had become heavily smoke-logged, with conditions both in the lobbies and in the stairs continuing to deteriorate thereafter; d. by 01.50 the stairs started to become significantly more affected by smoke, particularly at lower levels and between 02.00 and 02.20 conditions continued to deteriorate to the point at which there was thick smoke and considerable heat at some levels; e. at some time between 02.20 and 02.50 some parts of the stairs were very hot, in some cases hotter than the adjacent lobbies;

The Grenfell Tower Inquiry: Phase 1 Report 574 f. although the lobbies and stairs were significantly compromised by smoke and heat by 03.00, 15 people were able to leave the building using the stairs between 03.00 and 03.30; and g. some occupants who tried to escape died on the stairs, but throughout the night occupants managed to leave the building by the stairs until 08.07 when the last surviving occupant left the tower. 25.4 Those facts suggest that: a. until 01.30, the building was fully passable; b. between 01.30 and 01.50 it remained passable, although conditions in many lobbies were becoming more difficult; c. after 02.00 conditions in most lobbies and in the stairs deteriorated to the point at which by 02.20 the smoke in the stairs posed a risk to life; and d. after 02.20 conditions deteriorated further, but not to such an extent as to create an impassable barrier to everyone who attempted to leave the building after that time. 2 Period 1: 00.54-01.30 25.5 The evidence suggests that between 01.20 and 01.30 some lobbies became significantly smoke-logged while others remained relatively clear of smoke. Thus: a. firefighters reported heavy smoke-logging of the lobbies on floors 5, 6, 8, 10, 11, 12, 15 and 16 by around 01.30; and b. the evidence of former residents and those who made 999 calls suggests that the lobbies on floors 8, 10, and 12 had become significantly smoke-logged by this time, with at least light smoke also reported in the lobbies on floors 5, 11, 14, 17, 19, 21, 22 and 23. 25.6 The speed at which smoke penetrated particular lobbies varied. The smoke that billowed from the north lift when it reached the ground floor at 01.26 is broadly indicative of the volume of smoke in the lobby on floor 10 when it stopped there during its descent. Smoke is likely to have begun to penetrate floor 10 after 01.20 when the external flame front reached that floor. By 01.22 the external flame front had reached the top of floor 11. The rapid accumulation of smoke in the lobby on floor 10 was sufficient to trap three people (Mohamednur Tuccu, Khadija Khalloufi and Ali Yawar Jafari) in that lobby. 25.7 By contrast, the lobby on floor 7 appeared to be clear of smoke at 01.25.01, when a firefighter can be seen on the CCTV leaving Flat 46, even though the external fire had reached the flat by that time.1 25.8 By 01.30 the LFB control room had received 28 calls about the fire, of which eight2 were from people in various parts of the building, including some near the top and therefore at a considerable distance above Flat 16. Separately, four 999 calls from floor 10 and above were put through to the MPS control room, two of which reported smoke coming into flats. 25.9 Although there is some evidence that the stairs were beginning to be affected by light smoke at certain levels by 01.30 and particularly at the level of floors 4 to 5 and above, the weight of the evidence suggests that the stairs were relatively free of smoke during this period and 1 [INQ00010835]. 2 The figure does not include call-backs.

Part III | Chapter 25: Developing Conditions within the Building 575 that they remained passable to those who wanted to leave. That is supported by the fact that by 01.15, 26 people had left the tower using the stairs and that between 01.15 and 01.30 a further 77 people left the tower in the same way (and a further seven by the lifts). A total of 112 people left the tower between 00.54 and 01.30, of whom 103 left by the stairs and nine by the lifts. 3 Period 2: 01.30-01.40 25.10 Between 01.30 and 01.40 conditions in the lobbies continued to deteriorate, with a number filling with smoke. During this period: a. the evidence of the firefighters indicates heavy smoke-logging of the lobbies on floors 5, 8 and 16; and b. the evidence of former residents and those who made 999 calls (and the video made by Rania Ibrahim) indicates that the lobbies on floors 5, 6, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22 and 23 had become significantly smoke-logged. Lighter smoke was reported in the lobbies on floors 7 and 9. Some occupants were able to reach the stairs despite heavy smoke in the lobbies; others were deterred by the conditions from leaving their flats. 25.11 Between 01.30 and 01.40 the emergency services received 18 calls from people in the tower, including a number in which occupants reported that they were trapped.3 In particular: a. callers from flats on floor 11,4 floor 12,5 floor 206 and floor 237 all reported fire and smoke entering either their flats or a flat close by; b. callers from floor 14,8 floor 16,9 floor 2110 and floor 2211 reported smoke coming into their flats from the lobby; and c. callers from flats on floors 1112 and 1813 said they were trapped by smoke in the lobbies or in the stairs, but that smoke had not actually entered their flats at that time. 25.12 Occupants who passed through the stairwell during this period have different recollections of the conditions they encountered. Some recalled there having been no14 or very little smoke in the stairwell;15 others described thick smoke.16 Residents on higher floors who made 999 calls were reporting that they had tried to leave their flats but had found the stairs full of smoke.17 3 This figure does not include call-backs. 4 01.33.12: Abdeslam Sebbar Flat 81 [LFB00000312]. 5 01.38.37: Roy Smith Flat 95 [LFB00000318]. 6 01.30.02: Farah Hamdan, Flat 175 on floor 20 [LFB00000314]. 7 01.32.10: Biruk Haftom, Flat 155 but on floor 23 [LFB00000667]; 01.38.16: Mariem Elgwahry [LFB00000317]; Jessica Urbano Ramirez [LFB00055504] p. 9. 8 01.37.58: Rosemary Oyewole Flat 113 [LFB00000678]; 01.38.18: Zainab Deen Flat 115 [LFB00000321]; 01.40.17: Denis Murphy Flat 111 LFB00000322. 9 01.37.28: Sener Macit Flat 133 [INQ00000280]. 10 01.38.38: El Wahabi family Flat 182 [LFB00055498]. 11 01.34.50 Hashim Kedir Flat 192 [LFB00000315]. 12 01.33.01: Natasha Elcock Flat 82 [LFB00000313]. 13 01.33.55: Rabia Yahya Flat 152 [LFB00000662]. 14 Jones first witness statement [IWS00000033] p. 8; Nalukwago first witness statement [IWS00000009] section 21; Rasoul first witness statement [IWS00000670] pp. 6-7; Khoudair Day 55/138/1-142/3; Dedrich first witness statement [IWS00000102] p. 9. 15 Shah Ahmed first witness statement [IWS00000388] p. 11; Wesley Ignacio first witness statement [IWS00000826] pp. 11-12; Daffarn first witness statement [IWS00000169] p. 6; Atmani Day 67/133/15-134/16; Daniels Day 56/70/14. 16 Rawan Khdeir first witness statement [IWS00000204] p. 4; Mekonnen Day 55/32-38; Mekonnen first witness statement [IWS00000912] p. 3; Castro first witness statement [IWS00001091] p. 8 section 43. 17 [LFB00000315] and [LFB00000662].

The Grenfell Tower Inquiry: Phase 1 Report 576 Those who used the stairs moved at different speeds and their impressions of conditions in the stairs could have been affected by factors such as whether a lobby door was open or had been opened recently. 25.13 Overall, the evidence of the firefighters, former residents and those who made 999 calls suggests that during this period the smoke in the stairs was thinner than that in the lobbies. All 36 people18 who left the tower during this period were able to do so safely. 4 Period 3: 01.40-01.50 25.14 The overall picture during this period is one of lobbies continuing to fill with smoke, and in some cases starting to have an effect on conditions inside flats. In particular: a. the evidence of the firefighters indicates heavy smoke-logging of the lobbies between floors 4 and 10. The lobby on floor 10 was so heavily smoke-logged that firefighters could not enter it. On floor 20 the smoke in the lobby was such that firefighters’ visibility was significantly reduced; b. the evidence of surviving occupants and the transcripts of 999 calls indicate that the conditions in many lobbies continued to worsen with significant smoke‑logging of the lobbies on floors 4, 7, 10, 11, 12, 14, 16, 20, 21, 22 and 23; and c. the transcripts of 999 calls suggest that a number of occupants on different floors spanning floors 10 to 23 were experiencing smoke coming into their flats through their front doors and sometimes around the windows. 25.15 The evidence suggests that conditions on the stairs between 01.40 and 01.50 were generally better than in many of the lobbies and that conditions may have been worse lower down in the building. A number of former residents who gave evidence said that conditions in the stairs had been very different from those in the lobbies during that time. Between 01.40 and 01.50, 20 people left the building. 5 Period 4: 01.50-02.00 25.16 The evidence suggests that during this period conditions in the lobbies were variable, with heavy smoke-logging in some and clearer conditions in at least one: a. the evidence of the firefighters suggested that during this period conditions in the lobbies varied; for example, there was heavy smoke-logging of the lobbies on floors 9 and 18, but clearer conditions in the lobby on floor 14; and b. the evidence of former residents and those who made 999 calls suggested that many of the lobbies were significantly smoke-logged at this time, with particularly heavy smoke- logging on floors 9, 11, 12 and 21. 25.17 Of particular note is the fact that people in different parts of the tower were repeatedly calling the control room reporting significantly worsening conditions. A cumulative survey of how particular calls had developed is revealing. For example, Mariem Elgwahry’s calls from Flat 205 on floor 23 show that: 18 This figure includes Joseph John, Leanne Jackson Le-Blanc and their child, whose exits are not recorded on the CCTV footage because they climbed out of a window on the second floor and onto the gated walkway connecting Grenfell Walk.

Part III | Chapter 25: Developing Conditions within the Building 577 a. at 01.30.00, having reached Flat 205 from her own flat on floor 22, there was “smoke everywhere’’;19 b. at 01.38.16, when she called again there was no smoke in Flat 205;20 and c. at 01.54.23, when she called again, Flat 205 was “full of smoke” and they were stuck.21 25.18 The El Wahabi family in Flat 182 on floor 21, who had started an hour-long call to CRO Pam Jones at 01.38.38, described worsening conditions throughout the call:22 a. in the first few minutes, Abdulaziz El Wahabi described smoke coming into the flat and said that it was “very smoky” on the landing outside. He had discovered that because he had attempted to leave by the stairs but had been forced by the smoke to retreat and because he was able to see the smoke through the spyhole in his front door; b. soon after 01.45 he explained that the fire was nearby: “Something is right next door to us. It’s burning, it’s really burning.”; and c. at approximately 02.00, the caller said that the fire was in the flat next door and that conditions in their flat were now “really smoky”. 25.19 Roy Smith, who was in Flat 95 on floor 12, also called the control room three times and described deteriorating conditions on his floor: a. at 01.38.37, he told CRO Angie Gotts that the fire was spreading and that it was on his floor now and had come through the next-door kitchen. He said: “… It’s started on the 16th floor and it’s just spreading – all the stuff’s flying out of the windows”. He said it was “all smoke” outside;23 b. at 01.44.33, he explained to CRO Peter Duddy that there was smoke in his flat and that “the fire embers have started a fire in the flat next door as well. The front – it’s come up through the windows, it’s gone into number 96 Grenfell Tower”. He said the fire was in the kitchen next door;24 and c. at 01.54.14, he called a further time and explained to CRO Duddy early on that it was “getting worse”, that he could hear the fire next door through his wall and that there was black smoke in the corridor outside the flat. He then said: “It’s coming in the window now. It’s burning our windows now. It’s like an explosion or something”.25 25.20 The evidence of the firefighters suggests that, during this time, they were concerned about the ability of people to leave safely by the stairs, given the conditions that were being encountered. Their evidence also suggests that the conditions in the stairs were at their worst around floor 4 and bad between floors 4 and 14 (including being hotter and more densely smoke-logged), but improved higher up the tower. 25.21 There is very limited evidence from occupants about conditions in the stairs at this time since no one left the building during this period. 19 [LFB00000310]. 20 [LFB00000317]. 21 [LFB00000333]. 22 [LFB00055498]. 23 [LFB00000318]. 24 [LFB00000324]. 25 [LFB00055503] p. 3.

The Grenfell Tower Inquiry: Phase 1 Report 578 6 Period 5: 02.00-02.20 25.22 During this period a large number of lobbies were becoming heavily smoke-logged: a. the evidence of the firefighters indicates there was particularly heavy smoke‑logging of the lobbies on floors 4, 5, 20 and 21; b. the evidence of former residents and those who made 999 calls suggests that the lobbies on floors 11, 12, 16, 18, 19, 20, 21, 22 and 23 were all heavily smoke-logged. Less dense smoke was observed on floor 5, 14 and 15 in this period; and c. NPAS footage taken outside the tower showed that smoke was emerging at floors 12 and 21 from the west face of the building, indicating that there had been two breaches of compartmentation at those levels and strongly suggesting that the lobbies at those levels were smoke-logged. 25.23 That conditions in the building fluctuated is illustrated by the evidence of occupants on floors 5 and 14 who recalled there being less smoke in their respective lobbies during this period than they (and other witnesses) had seen at earlier times. 25.24 During this period, callers from flats in the north-west and south-west corners of the tower reported significant smoke penetration in their flats: a. at 02.05.22, Isra Ibrahim in Flat 203 on floor 23 reported smoke around her face when she was standing in her living room; b. at 02.10.33, at an early stage in a call that lasted for 27 minutes and 32 seconds, Sener Macit in Flat 133 on floor 16 described “black smoke” in the flat which was getting worse;26 c. at 02.11.42, Farah Hamdan in Flat 175 on floor 20 reported that there was “loads of smoke” in the flat;27 and d. at 02.13.03, Nicholas Burton in Flat 165 on floor 19 reported smoke in the whole of his flat.28 25.25 In a call at 02.15.07, the eldest son of Karen Aboud calling from Flat 92 on floor 12 reported that conditions in the lobby were so bad that they were trapped and could not leave. He reported that when they had tried to go out they could not breathe.29 25.26 During this period, conditions in Flat 192 on floor 22 changed rapidly. In a call at 02.03.47, Hashim Kedir said that there was no smoke in the flat but there was “too much smoke” in the corridor to leave.30 He described being able to see the fire but said that it was not in the property yet.31 Seven minutes later, at 02.10.31, the fire had entered the kitchen of Flat 192. Hashim Kedir also described smoke in the flat and said that everyone was coughing.32 When he called again at 02.18.06 Hashim Kedir repeated that there was fire in the flat. 26 [LFB00055499] pp. 4-8. 27 [LFB00000342]. 28 [LFB00000344]. 29 [LFB00000346] pp. 2-4. 30 [LFB00000339] p. 4. 31 [LFB00000339] p. 4. 32 [LFB00000345].

Part III | Chapter 25: Developing Conditions within the Building 579 25.27 The conditions in Flat 201 on floor 23 also deteriorated significantly during this period. Jessica Urbano Ramirez and Debbie Lamprell reported having difficulty breathing throughout their respective calls with the emergency services. They were sheltering with others in the bedroom of the flat. After describing thick smoke in the bedroom and the fire breaking in, Debbie Lamprell said that the smoke was making others in the bedroom sick. In this period Jessica Urbano Ramirez and Debbie Lamprell both stopped responding before their respective calls ended. 25.28 It is clear that during this period conditions in the stairs had deteriorated to the point at which they posed a risk to anyone who attempted to escape. Those survivors who used the stairs during this time spoke of encountering smoke which thickened as they descended and which made breathing difficult. Nicholas Burton struggled to breathe and was assisted all the way down by a firefighter. He described significant heat which increased as he descended to the point at which the handrail became so hot that he could not hold on to it. During this 20-minute period only eight people left the tower, all with the assistance of firefighters.33 7 Period 6: 02.20-02.50 25.29 During this period the overall picture of conditions in the lobbies is one of heavy smoke‑logging in a number of lobbies at lower, middle and higher levels of the tower: a. the evidence of former residents and those who made 999 calls suggests that the lobbies on floors 10, 11, 12, 14, 16, 18, 20, 21 and 23 were heavily smoke-logged and a number of those were also reported to be very hot; and b. at around 02.40 the NPAS helicopter video showed smoke emerging from flats on the west face of the tower at floor 23, indicating that smoke had migrated across the lobby and into west-facing flats at the top of the tower. 25.30 Those who managed to leave during this period described thick, black smoke in the stairs as high up as floor 23, with very poor visibility and no light until they had reached somewhere between floors 2 and 4. The stairs are also described as having been very hot during this time, sometimes hotter than the lobbies from which individuals had come. The smoke in the stairs made breathing difficult and caused a burning sensation in the throat and lungs. 25.31 During this period 15 survivors left the tower.34 8 Period 7: 02.50-03.00 25.32 This is a short period and information relating to it is necessarily limited. However, the evidence suggests a pattern of heavy smoke-logging in a significant number of lobbies, with smoke penetrating many flats: a. the evidence of former residents and those who made 999 calls indicates that the lobbies on floors 10, 11, 12, 15, 21 and 23 were heavily smoke-logged with smoke penetrating many flats beneath or around front doors; and b. those occupants who made 999 calls during this time (there were 12 from people trapped in the tower during this period) frequently reported significant smoke entering their flats. 33 Including Milad Kareem who is not shown on the CCTV, but is timed from Rebin Sabir’s video as leaving at 02.19. 34 This figure includes Rebin Sabir whose exit on his own video is timed at 02.21.

The Grenfell Tower Inquiry: Phase 1 Report 580 25.33 Smoke conditions everywhere on floors 21 to 23 had become very bad. Occupants trapped on floors 21 and 23 were having difficulty breathing. On floor 22 callers reported that conditions inside flats were so bad that the occupants could no longer see each other. 25.34 During this period only one person left the tower. 9 Period 8: 03.00-03.30 25.35 The evidence of the firefighters relating to this period indicates that conditions at lower levels of the tower between floors 5 and 11 (and particularly between floors 7 and 11) were generally poor with heavy smoke-logging and greatly reduced visibility. On floors 9 and 10 there was intense heat in the lobbies. 25.36 The evidence from 999 and other calls and messages from those in the tower indicates that floors 10, 12, 14, 15, 16, 17, 20, 21, 22 and 23 remained extremely heavily smoke‑logged both in the flats and in the lobbies. On floors 7, 11 and 18 the lobbies were also filled with dense smoke. 25.37 Those who managed to escape or who attempted to do so during this period described dense smoke in the stairwell. Some described the smoke as varying in density and as being thicker at lower levels. Some said the stairs were hotter on the higher floors of the building. 25.38 A total of 16 people left the tower during this period. 10 Period 9: 03.30-04.00 25.39 During this period there is evidence from firefighters describing the smoke and heat as worsening as they reached floor 4, with the smoke on floor 5 being so thick that they could not see in front of them. 25.40 999 calls from those on floors 15, 16, 22 and 23 indicated that callers were struggling to breathe in flats at those levels. Occupants in Flat 82 on floor 11 and Flat 73 on floor 10 told the LFB that their flats were full of smoke. 25.41 CCTV footage from the lobby of floor 7 shows that it became completely smoke-logged during this period.35 25.42 Those who entered or looked into lobbies on floors 10, 11, 15 and 16 during this period consistently described thick, black smoke; some also described intense heat. 25.43 The few occupants who managed to escape during this period, principally from floors 15, 16 and 21, described intense heat on the stairs. Some said there was little difference between conditions in the stairs and conditions in the lobbies and in some cases that conditions in the stairs were worse. All described thick, black smoke in the stairwell. Some occupants said that conditions improved at around floors 8 to 10 and below. 25.44 During this period nine people successfully escaped from the tower. 35 03.00.20 (corrected from 03.01.00) [INQ00010923]; 03.34.59 (corrected from 03.35.39) [INQ00010925]; 03.36.05 (corrected from 03.36.45) [INQ00010924].

Part III | Chapter 25: Developing Conditions within the Building 581 11 Period 10: 04.00-05.00 25.45 By 04.00 occupants on floors 10, 11 and 14 were still in contact with the control room or with friends and family outside the tower, but there was no further contact with occupants above floor 14. 25.46 Those survivors who were able to give evidence about conditions in the lobbies during this period described thick, black smoke on floors 10 and 11 and significant heat. 25.47 Some described conditions in the stairs as similar to those in many of the lobbies, particularly at the level of floors 8 and above. Others described the conditions as better in the stairs than in the lobbies. Video evidence shows visible smoke in the stairwell below floor 10 which clears lower down.36 25.48 Nine people from floors 10 and 11 escaped from the tower during this period. 12 Period 11: 05.00-08.10 25.49 There is limited evidence from survivors of the fire about conditions within the building during this period, but there is some evidence from firefighters, particularly about conditions in floors 5 to 13. It is clear that conditions at these lower levels were extremely poor and that some of the lobbies were very hot. In particular: a. firefighters described thick smoke in floors 5 and 6 and above, with thicker and heavier smoke in floors 8 and above; b. firefighters also described the lobbies at floors 11 to 13 as being hot and full of dark smoke. Floors 5 and 10 to 13 were described as particularly hot. On floor 11 a thermal imaging camera registered a temperature of 1000°C; and c. several firefighters described significant quantities of water pouring down the stairs during this period. 25.50 Firefighters described conditions in the stairs above floor 4 as poor, with visibility of no more than 6 feet on floor 10. 25.51 Antonio Roncolato on floor 10 said that the temperature was very hot in the lobby, but cooler on the stairs where there was water. 25.52 Two people escaped from the tower during this period. 36 [INQ00010922]; [INQ00010921].

The Grenfell Tower Inquiry: Phase 1 Report 582

583 Chapter 26 Compliance with Building Regulations 1 Non-compliant facade: functional requirement B4(1) 26.1 It is apparent from the findings made in earlier chapters that the external walls of the building did not resist, and indeed actively promoted, the spread of fire. That was principally due to the presence of ACM panels with a polyethylene core, but other materials and other features, including the design and geometry of the facade, also played a role. 26.2 A group of core participants1 submitted that the construction of the Building Regulations 2010 is ultimately a question of law which I can decide at this stage of the Inquiry. They argued that there is clear evidence that the facade did not meet functional requirement B4(1) of Schedule 1 to the Building Regulations,2 which requires the external walls of a building “to adequately resist the spread of fire over the walls … having regard to the height, use and position of the building”. 26.3 Both Dr Barbara Lane and Professor Luke Bisby have expressed the view that functional requirement B4(1) was not met3 in this case and a number of core participants, including RBKC,4 C. S. Stokes5 and Kingspan,6 have accepted that that was the case. 26.4 Although it was not originally my intention to reach conclusions in Phase 1 about the tower’s compliance with the Building Regulations, I can see no good reason why that question should not be determined now so far as it relates to the external facade. I accept that the construction of the Building Regulations is ultimately a question of law and there is compelling evidence that requirement B4(1) was not met in this case. It would be an affront to common sense to hold otherwise. Although in another context there might be room for argument about the precise scope of the word “adequately”, it inevitably contemplates that the exterior must resist the spread of fire to some significant degree appropriate to the height, use and position of the building. In this case, whether one considers the rainscreen panels alone or the cladding system as a whole, or even the complete external envelope, including the original concrete structure, it is clear that the walls did not resist the spread of fire. On the contrary, they promoted it, as can be seen in the video recordings of the rapidly developing fire which engulfed the building in just over 2.5 hours. 26.5 In addition, I accept that the cladding of the external walls constituted “building work” within the meaning of regulation 3 of the Building Regulations, because it involved a “material alteration” of the building which resulted in its ceasing to comply with requirement B4(1).7 In 1 Represented by the solicitors Bhatt Murphy, Bindmans, Hickman & Rose, and Hodge, Jones & Allen [BSR00000004]. 2 G4 BSR closing submissions [INQ00000563] p. 11 section 2.30 and p. 24 section 2.80. 3 Dr Lane supplemental report [BLAS0000002] p. 15 section 2.9.8; [BLAS0000011] p. 96 section 11.23.7(b), p. 97 section 11.23.12 and oral evidence Day 79/109/21-110/8; Professor Bisby [LBYS0000001] p. 152 section 748-750 and oral evidence Day 78/157/23-158/9. 4 Oral opening statement 6 June 2018 Day 3/94/15-21; written opening statement [RBK00026858] p. 5 section 19; Phase 1 closing statement [INQ00000553] p. 3 section 10. 5 Closing statement [INQ00000568] p. 10 section 38. 6 Phase 1 closing submissions [INQ00000565] pp. 3-4 section 2.1. 7 Regulation 3(1)(c) and 3(2)(a) of the Building Regulations.

The Grenfell Tower Inquiry: Phase 1 Report 584 particular, before the fire, the exterior walls of the building, being constructed of concrete, complied fully with that requirement, since concrete does not support combustion, but that changed fundamentally when the cladding system was added during the main refurbishment. 26.6 Arconic alone submitted that I should not at this stage of the Inquiry make any findings about the compliance of the external walls of the building with the Building Regulations. In paragraph 19 of its closing statement it submitted that certain aspects of Dr Lane’s evidence went beyond the scope of Phase 1, including Appendix O of her supplemental report, in which she expressed certain views about the Certificate for Reynobond Architecture Wall Cladding Panels issued by the British Board of Agrément (BBA) in 2008. However, although the questions she has raised may have a bearing on whether the ACM panels reflected the guidance given in Approved Document B, they have no bearing on whether functional requirement B4(1) of Schedule 1 to the Building Regulations was met. In circumstances where Arconic does not, and could not sensibly, dispute the rapidity and extent of the spread of fire over and around the building (and indeed in its closing statement put forward a number of mechanisms by which it says that could have occurred8), I can see no rational basis for contending that the external walls of the building met requirement B4(1), whatever the reason for that might have been. There is therefore no good reason for deferring to a later report what is no more than a self-evident conclusion. For the same reason I do not think there can be any unfairness in stating that conclusion at this stage. If any of the core participants had put forward a reasoned argument to the effect that the exterior walls of the building complied with requirement B4(1), the position might be different, but none has sought to do so. I think it is right therefore that I should say at this stage that on completion of the main refurbishment the external walls of the building did not comply with requirement B4(1) of Schedule 1 to the Building Regulations. 26.7 A separate question is how those responsible for the design and construction of the cladding system and the work associated with it, such as the replacement of the windows and infill panels, satisfied themselves that on completion of the work the building would meet requirement B4(1). That is a matter for investigation in Phase 2. Dr Lane has expressed certain views on some aspects of that question in her supplemental report, but it is a question which I have yet to consider and on which there is still much evidence to be obtained. It may also be a question on which various core participants may wish to address me. It would therefore not be right for me to express any view about it at this stage. 8 Closing submissions [INQ00000558] pp. 16-20 sections 71-93, in particular sections 71, 82, 88, 93.

585 Chapter 27 Planning and Preparation This chapter considers the preparations made by the LFB for recognising and responding to the risk of fires in the external envelopes of high-rise residential buildings. 1 Generic Risk Assessment 3.2 27.1 The purpose of Generic Risk Assessment (GRA) 3.2 was to assist fire and rescue services in drawing up their own assessments of risk to meet their statutory obligations under the relevant Health and Safety at Work legislation. It recommended that contingency plans should be drawn up for individual premises, which should cover the spread of fire beyond the compartment of origin, the possible need for multiple rescues and the need for an operational evacuation plan in case “stay put” became untenable. It follows that fire and rescue services were expected to provide those who might become incident commanders at fires in high-rise buildings with training in evacuation and casualty removal tactics, as well as training to enable them to recognise when a full or partial evacuation has become necessary. 27.2 GRA 3.2 covers a substantial amount of ground relevant to the LFB’s knowledge of the risks at Grenfell Tower and their operations on the night of the fire itself which are examined elsewhere in this report. For present purposes, it clearly contemplated that total evacuation of a high-rise building should be an important part of any fire and rescue service’s contingency plan for such a building. I refer to pages 15, 16, 17, 19-20, 27, 29 and 49 of GRA 3.2. I need only quote three passages. a. Page 17: “Contingency plans for particular premises should cover: • fire spread beyond the compartment of origin and the potential for multiple rescues • an operational evacuation plan being required in the event the “Stay Put” policy becomes untenable

… • alternative communication arrangements to overcome any radio ‘blind spots’” b. Pages 19-20: “Training, which will cover high rise incidents must include: … • Evacuation and casualty removal tactics. Incident Commanders should understand when a partial or full evacuation strategy might become necessary in a residential building where a “Stay Put” policy is normally in place.” c. Page 29: “The advice offered to callers to remain in their property during fire survival guidance calls must be re-evaluated throughout an incident. Where circumstances make it necessary, an Incident Commander may need to consider changing the advice given. For example, callers may need to be advised to leave their property or to be guided from it by firefighters. The Incident Commander should also consider making use of all available systems within the building to communicate with occupants.”

The Grenfell Tower Inquiry: Phase 1 Report 586 27.3 It is quite plain that, as a matter of national policy and guidance, a fire and rescue service is obliged to ensure that it has contingency plans in place for the partial or full evacuation of high-rise buildings in its area in the event that the “stay put” strategy becomes untenable. It follows that fire and rescue services, and incident commanders in particular, cannot take it for granted that the building is adequately compartmented in accordance with the Building Regulations and that therefore the standing “stay put” advice will hold reliably. Nor can they justify failing to consider a full or partial evacuation on the grounds that the building will not enable it to be accomplished successfully. On the contrary, fire and rescue services are required to understand, of any given high-rise building in their area, when a partial or full evacuation might become necessary and to provide training to incident commanders in evacuation and casualty removal tactics. 2 LFB Policy No. 633 27.4 The GRA 3.2 is national guidance from which local fire and rescue services derive their own policies. As I have explained elsewhere in this report, PN633 is the LFB’s policy for high-rise firefighting. 27.5 In its approach to the “stay put” principle and the question of contingency planning for the evacuation of a high-rise building, PN633 is neither as clear nor as extensive as GRA 3.2 (and certainly does not mirror its provisions exactly). In particular, it does not spell out what LFB officers should do to prepare and initiate a contingency plan for evacuation. However, it clearly does envisage that evacuation of a high-rise residential building may be necessary. In particular: a. Appendix 1 requires that during visits to premises carried out pursuant to section 7(2) (d) of the FRA officers must ensure that they are familiar with a long list of matters and their impact on firefighting and search and rescue operations. One of those items is “evacuation arrangements which may include phased evacuation”. b. The section entitled “Evacuation” provides: “7.45 The IC should consider following the evacuation plan devised as part of the occupier’s fire risk assessment unless the fire situation dictates otherwise. 7.46 It may be necessary to undertake a full or partial evacuation in a residential building where a “Stay Put” policy is normally in place. 7.47 … The IC should consider: (a) the effect of firefighting tactics on evacuation (and vice-versa); (b) the resources required to support the evacuation.” c. The section entitled “Fire Survival Guidance” provides: “7.51 The advice offered during fire survival guidance calls should be re-evaluated throughout an incident and this may require a change in the advice given. In exceptional circumstances an IC may consider informing control that their advice to FSG callers should be altered, e.g. to attempt to leave their property. The IC should remember that this advice may be contrary to national policy for control staff on FSGs and liaison with the officer in charge at control will be required for agreement to change the prescriptive advice.” 27.6 One major weakness of PN633 is that, although it refers to a potential need to evacuate a building to which a “stay put” strategy applies (paragraph 7.46), it does not make it clear to incident commanders that the existence of such a strategy should not deter them from undertaking a full or partial evacuation if the behaviour of the fire justifies it. Another is that it does not require any contingency planning for evacuation to be undertaken or give

Part III | Chapter 27: Planning and Preparation 587 any guidance to incident commanders on how to go about carrying one out. Despite those weaknesses, PN633 proceeds on an assumption that compartmentation may fail and that under those circumstances an incident commander must be prepared to carry out a full or partial evacuation. 27.7 Paragraph 4.8 of PN633 deals with particular aspects of planning and preparation for fighting fires in high-rise buildings. It says: “4.8 The tactics and resources required to mount safe rescue and fire fighting operations should be assessed, practised and confirmed where necessary for the building concerned. This may include the following considerations: (a) Planning for fire spread beyond the compartment of origin and the potential for multiple rescues. . . 4.10 . . . Premises evacuation procedures and their impact on firefighting tactics should be considered as part of 7(2)(d) visits . . .” 27.8 There were no tactical or contingency plans for the evacuation of Grenfell Tower. No satisfactory reason for that significant omission was given but a partial explanation may lie in the absence from PN633 of any reference to the need for an operational evacuation plan if “stay put” became untenable. 3 The LFB’s knowledge of cladding fires 27.9 The absence of an operational evacuation plan was a major omission in the LFB’s preparation for a fire at a building such as Grenfell Tower, but, since there was no attempt to carry out a managed evacuation of the building, it is less significant than the absence of any training for incident commanders in how to recognise the need for evacuation. That absence in turn reflects a failure to recognise the risk of fire taking hold on the outside of modern buildings. Several LFB witnesses said in one way or another that they did not understand what was happening as the fire spread up the building and that buildings “should not behave like that”. That reflected a failure to educate firefighters in the dangers associated with combustible cladding systems. 27.10 That failure is surprising, given the long history of fires involving cladding on high-rise buildings both in this country and abroad, a history of which some senior figures within the LFB were aware. The risks of fire breaking out in external cladding have been known in the UK since at least 1991, when a fire at Knowsley Heights, an 11-storey block of flats on Merseyside, spread vertically up the building’s entire face within the cavity behind the rainscreen, but without penetrating the interior of the building.1 27.11 On 11 June 1999 a fire broke out at Garnock Court, a high-rise residential building in Irvine, Ayrshire. It spread externally through spandrel panels below windows and up a strip of wall from floors 5 to 13.2 As a result of the fire, a Parliamentary Select Committee investigated the risks arising from cladding systems and the extent to which they were subject to regulation. The Select Committee recommended that all external cladding systems should either be made of non-combustible materials or shown not to present an unacceptable risk of fire spread.3 Thereafter, in 2000 certain amendments were made to Part B of Schedule 1 of the Building Regulations and Approved Document B. 1 Refer to paragraph 2.40 of Colin Todd’s report (dated 2018) [CTAR00000001] p. 13. 2 Refer to paragraphs 2.45-2.49 of Colin Todd’s report (dated 2018) [CTAR00000001] p. 14. 3 First report: The Environment, Transport and Regional Affairs Committee “Potential Risk of Fire Spread in Buildings via External Cladding Systems” https://publications.parliament.uk/pa/cm199900/cmselect/cmenvtra/109/10907.htm

The Grenfell Tower Inquiry: Phase 1 Report 588 27.12 From 2012 onwards, there were more fires involving cladding systems on high-rise residential buildings, some abroad and some in the UK. Some of those fires were discussed in a presentation, entitled Tall Building Facades, apparently prepared by the LFB’s Fire Safety Regulation department in the latter quarter of 2016, although dated 13 July 2016.4 One of the fires discussed in the presentation occurred at Shepherd’s Court in Shepherd’s Bush, London in August 2016. It had started in the kitchen of a two-bedroom flat on floor 7 and spread rapidly up the facade to floor 11. The LFB’s response involved 20 appliances, one ALP, five water jets and the deployment of BA crews. The general conclusions of the Tall Building Facades slide presentation provide a useful indication of the lessons that had been learnt from recent fires, including that at Shepherd’s Court:5 “As a general principle the external envelop [sic] of the building should not contribute to the fire spread along the façade. New construction material and method of construction are being used in facades and with a limited understanding of their fire behaviour/performance. There is a need to understand: • What products are being used in the façade system and their fire behaviour; and • If they are used appropriately and meet the relevant guidance. These could affect the way fires develop and spread in a building.” [Original emphasis] 27.13 Following the fire at Shepherd’s Court, in May 2017 AC Dan Daly, then Head of the LFB’s Fire Safety Regulation department, wrote to the Chief Executives of all London boroughs.6 The letter was headed “Tall Buildings – External Fire Spread” and made three essential points. First, as a result of certain recent incidents, the LFB had found that the level of fire protection provided by the external surfaces of tall buildings did not comply with the requirements of Part B of the Building Regulations in terms of limiting the speed at which fire could spread externally. Secondly, testing of the external panels following the Shepherd’s Court fire had disclosed that they did not satisfy the requirements of the Building Regulations in terms of combustibility. Thirdly, Chief Executives should consider carefully their arrangements “for specifying, monitoring and approving all aspects of future replacement and improvement to building facades and construction of new buildings”. In relation to buildings within local authorities’ control, AC Daly encouraged Chief Executives to think about including in their risk assessment processes consideration of the extent to which external panels complied with the Building Regulations. In his concluding remarks, AC Daly said that: “where no reliable information is available for a given property, it is our general expectation that a strategy to assess the risk and where necessary implement short, medium and long term actions to address the risk [sic]. This assessment will need to take account of other fire safety measures already in place in the building as well as potential mitigation measures to ensure that any potential fire spread does not pose a risk to health and safety.” 27.14 Notwithstanding this history of fires involving cladding systems, the LFB’s experience and assessment of the Shepherd’s Court fire in August 2016 and the letter to the Chief Executives of the London boroughs, very few (if any) of the incident commanders or senior officers who attended the fire at Grenfell Tower were aware of the risks posed by exterior cladding. Certainly, none of them had received any training in recognising or assessing risks of that kind or in the steps that should be taken in response to a fire in the envelope of a high-rise building. Even the Commissioner herself, who had been in charge of Safety and Assurance at 4 [LFB00003521]. 5 [LFB00003521] p. 25: the emboldening is in the original text. 6 [LFB00000224].

Part III | Chapter 27: Planning and Preparation 589 the LFB at the time of the production of the Tall Building Facades slide presentation in 2016, admitted that she was unfamiliar with it at the time of the Grenfell Tower fire.7 She could not explain why its circulation had been limited to a small group of fire engineers.8 Her response was that nobody would expect an incident like Grenfell Tower to occur or a building to be covered in such a highly flammable product and to fail so spectacularly.9 27.15 It is also clear from the terms of AC Daly’s letter that the LFB could not safely assume that external cladding complied with the relevant requirements of the Building Regulations. 4 Training 27.16 Furthermore, despite the clear terms of paragraphs 4.8, 4.10 and 7.45-7.47 of PN633, which envisaged a potential need to evacuate a high-rise building subject to a “stay put” policy, there is no evidence that any of the officers who attended the fire (with perhaps one exception) had received any training in the principles of evacuation, how to decide whether evacuation was necessary or how to carry it out safely and efficiently. 27.17 Despite the terms of GRA 3.2, the relevant paragraphs of PN633, the contents of the Tall Building Facades slide presentation and AC Daly’s letter, the LFB’s basic attitude to planning for the evacuation of high-rise buildings was summed up by the Commissioner in her oral evidence. She said that although cladding fires were a known and material risk to high-rise residential buildings, in which fires could behave unpredictably, the LFB would not develop a training package to respond to “something that simply shouldn’t happen”, or as she put it more graphically, “for a space shuttle to land on the Shard”.10 That evidence betrayed an unwillingness to confront the fact that by 2017 the LFB knew (even if she personally did not) that there was a more than negligible risk of a serious fire in a high-rise building with a cladding system. The evidence also revealed a reluctance to accept that there was a risk that a fire of this kind and scale might occur in any building that had been provided with exterior cladding. Although the wholesale failure of every layer of fire safety in the building may not have been reasonably foreseeable by the LFB, the risks of rapidly developing facade fires in high-rise buildings and a consequent deluge of FSG calls were well known to the LFB in June

1. The question why that knowledge had not informed relevant policies (pre-eminently

PN633), training and operational procedures and practice will be considered in Phase 2. 27.18 The Commissioner went on to say that, even if the incident commanders had known about these risks and had understood the nature of the fire when it was in its early stages, that would not have made any difference, since it was always incapable of being extinguished.11 However, I have no doubt that to have known what he was facing once the fire had broken out of Flat 16 would have assisted WM Michael Dowden and those who succeeded him as incident commander in assessing the need to evacuate the building and formulating an appropriate strategy, even if its execution had presented serious challenges. 27.19 There is one final point which arises in relation to the LFB’s knowledge of the risks posed by cladding. GRA 3.2 includes cladding among the things to be examined on a visit under section 7(2)(d) of the Fire and Rescue Services Act 2004. The Commissioner explained the absence from Appendix 1 to PN633 of any reference to cladding by suggesting that at the time it was not perceived to be a risk.12 If she is correct, that suggests that the LFB did not 7 Cotton Day 50/47/2-14. 8 Cotton Day 50/51/7-20. 9 Cotton Day 50/51/7-20. 10 Cotton Day 50/51/21-52/11. 11 Cotton Day 50/52/12-53/10, 62/21-64/4. 12 Cotton Day 50/40/20-41/1.

The Grenfell Tower Inquiry: Phase 1 Report 590 become aware of cladding as a risk which deserved attention in a section 7(2)(d) visit until after June 2015, when latest version of PN633 was produced. That in turn raises the question why it was perceived to be a risk at national level but not in London. This question will require investigation in Phase 2. 27.20 The failure to train firefighters in how best to fight cladding fires was the inevitable consequence of the LFB’s institutional failure to inform its firefighters about the risks they present. That failure to train is usefully illustrated by the actions of the first four crews which attended the fire. The members of these crews were all experienced firefighters. WM Dowden had joined the LFB in June 2003 and, at the time of the fire, had been a Watch Manager (whether in a temporary or substantive rank) for some seven years.13 WM Brien O’Keeffe joined the LFB in 1993 and had been a Watch Manager for six or seven years at the time of the fire.14 Similarly, CMs Charles Batterbee, David Davies, Christopher Secrett and Jamal Stern had a combined service of 52 years as firefighters. Notwithstanding their experience, none had received any training on the risks posed by exterior cladding or the techniques to be deployed in fighting fires involving cladding. None had received any training in when to withdraw “stay put” advice or how best to evacuate residents from high-rise buildings. None had seen or had received training on the Tall Building Facades slide presentation.15 The training provided to the first four crews (including, in particular, the first incident commander, WM Dowden) did not adequately prepare them for the nature, speed and ferocity of the fire they faced. 5 Section 7(2)(d) visits to Grenfell Tower before the fire 27.21 The failure to appreciate the nature of the risks posed by the cladding at Grenfell Tower was due in part to the approach adopted by the LFB to the discharge of its obligations under section 7(2)(d) of the 2004 Act. That provision required the LFB to make arrangements for obtaining information needed for the purpose of extinguishing fires and protecting life and property in the event of fires in Greater London. 27.22 The LFB sought to discharge this duty by sending fire crews to inspect buildings in the areas of individual fire stations. Appendix 1 to PN633 contained a list of things to be inspected on these visits. Paragraph 1 provided that: “During 7(2)(d) visits personnel should ensure they are familiar with the following and their impact on firefighting and search and rescue operations.” There followed a list of 22 matters which reflected many of those identified in GRA 3.2. The language of the opening sentence indicated that what followed was not by way of mere guidance but was mandatory. In this context “should” means “must”. 27.23 The following matters identified in paragraph 1 of Appendix 1 are particularly relevant: • the location and accuracy of information available on the site; • the location and availability of water supplies; • hydrant locations and size of main; • location and function of firefighting lifts; • the likelihood and impact of any fire spread beyond the compartment of origin and the potential for multiple rescues; 13 Dowden Day 9/4/11-5/13. 14 O’Keeffe Day 17/125/6-126/24. 15 [LFB00003521].

Part III | Chapter 27: Planning and Preparation 591 • occupancy and use profile; • floor layouts and any building construction features which may promote rapid or abnormal fire spread; • plans to show flat number, by floor and in relation to each other; • means of ventilation and smoke control including the location of operating switches; • fire-engineered solutions within the building design; • potential communication problems; • identification of areas that would be suitable as rendezvous points and appliance marshalling. The list culminated in the advice that: “These points should also form the basis and be included as part of any site-specific plan that is necessary.” Again, in this context “should” means “must”. 27.24 The Commissioner said that no training was given to firefighters in how to go about conducting a visit.16 That much was clear from the evidence of firefighters, not only of those from North Kensington fire station who had carried out section 7(2)(d) visits to Grenfell Tower, but others as well. She, in common with other firefighter witnesses, also expressed scepticism about how realistic it was to expect frontline firefighters (who are usually no more senior than Watch Managers) to undertake the lengthy survey of the numerous different fire safety aspects of a high-rise building set out in Appendix 1 to PN633. The Commissioner described many of the aspects of the building which the policy requires them to examine during a visit as “incorrect” and “not realistic.”17 If that is so, it is not clear how the LFB came to produce such a flawed policy. This issue will be investigated further in Phase 2 together with two other points arising from the evidence: first, what type of information and in what detail needs to be gathered under section 7(2)(d) to ensure the effective performance by the LFB of its duty under section 7(1), and, secondly, to what extent does PN633 and the LFB’s training and practice ensure that such information is properly gathered in relation to high-rise buildings. 27.25 Although the language of paragraph 1 of Appendix 1 requires personnel to familiarise themselves with all the listed matters, it is equally clear that as a matter of practice LFB officers conducting visits did not consider all of them but tended to concentrate on those relating to the particular cause or event that had prompted the visit. In relation to Grenfell Tower, although the local fire station (in this case North Kensington) was aware of the nature and extent of the refurbishment project, there was no attempt to carry out a visit which comprehensively addressed each of the listed matters to ensure that the information relating to the refurbished building and the assessment of the risks it presented was accurate and up to date. It is a cause for concern that, although the station managers at North Kensington fire station were aware of the scale of the refurbishment being carried out on the tower, and on one occasion shortly before the completion of work met one of the managers of Rydon Maintenance Ltd on site, no good explanation was given for the failure to carry out a comprehensive assessment of the tower after the refurbishment had been completed.18 16 Cotton Day 50/40/15-19. 17 Cotton Day 50/84/14-86/2. 18 Ricketts Day 51/84/5-19.

The Grenfell Tower Inquiry: Phase 1 Report 592 27.26 WM Dowden and his crew, and others from North Kensington who conducted section 7(2)(d) visits to the tower, had received no training on how materials used in exterior facades might behave in fires and could not be expected to assess the risks created by the cladding system or how they might relate to other aspects of the building’s fire safety measures. That is not something for which they can be blamed. It is equally plain, however, that they had been given no training in the evacuation of high-rise buildings generally, or in how to recognise the need to evacuate such a building or how to carry out such an operation safely. These failings were institutional in nature and no personal criticism can be made of WM Dowden or any other firefighter who visited the tower before the fire. 27.27 In this respect the LFB as an institution failed to implement the requirements of GRA 3.2 and PN633 by failing to train frontline officers in how to carry out proper section 7(2)(d) inspections. One question which arises in light of developments in construction techniques and practices is whether, and if so to what extent, section 7(2)(d) visits should be conducted by suitably qualified professionals in addition to fire crews. That issue will be examined at Phase 2. 27.28 However, most of the matters identified in Appendix 1 to PN633 were well within the experience and knowledge of rank and file officers. The North Kensington crews who carried out section 7(2)(d) visits to the tower before the fire failed to identify and correct inaccuracies in basic information relating to the tower itself (for example, that it had 25, including the basement, not 20, floors); they also failed to identify and make good deficiencies in the LFB’s information, such as the absence of basic floor plans showing flat numbers and floor layouts. Presumably, such plans could have been easily provided by the TMO to North Kensington fire station in paper form or by email, but no determined effort appears to have been made by the LFB to obtain them. No concerns appear to have been raised during visits made before the fire about the absence of any tactical or contingency plans for evacuation. Nor was any attempt made to ensure that emergency contact details were kept up to date. There is no reason why that information could not have been routinely provided by the TMO to North Kensington fire station as the need arose. 27.29 Inevitably the question arises whether the cancelled practice drill at the tower that was due to take place on 8 June 2017, six days before the fire, would have revealed the inaccuracies and omissions in the LFB’s information relating to the building. However, bearing in mind the previous failures to identify incomplete and inaccurate information about the tower and the narrow approach adopted in practice to section 7(2)(d) visits by North Kensington fire station (as well as crews from many other fire stations in relation to buildings within their areas), I think it unlikely. That serves to support my concern that section 7(2)(d) visits, as presently conducted by the LFB, are not fulfilling the purpose for which they are designed, namely to collect information that allows the LFB to extinguish fires and to protect life and property. 6 Section 7(2)(d) visits and the Operational Response Database 27.30 The purpose of section 7(2)(d) visits is to gather accurate information that will allow the fire and rescue service (in this case the LFB) to extinguish fires and to protect life and property. The information collected by the LFB during those visits is to be recorded on the ORD, so that if a crew is despatched to a fire at a high-rise building, it has the basic information about the building to enable it to fight the fire. As indicated above, the ORD entry for the tower dated 15 February 2017, which was available to crews attending the fire, contained minimal, and

Part III | Chapter 27: Planning and Preparation 593 in places inaccurate, information about the tower itself and no tactical plan for fighting the fire.19 In summary: a. There were no plans of the tower on the ORD, despite the fact that under the “earlier visit comments” for 10 May 2015 SM Nicholas Davis had noted: “plans are required for MDT”.20 b. The only photograph of the tower was a small aerial image which gave no information about the building or access to it. c. The number of floors in the tower was incorrectly recorded as 20. d. Under the overall heading “Tactical plan” the subheading “Operational contingency plan” contained simply a blank box dated 30 October 2009. As the Commissioner accepted in her evidence, no detail was provided of the objective or the basic elements of the tactical plan.21 There simply was no operational contingency plan. e. The emergency contact details were out of date and related to individuals involved in the refurbishment, which had been completed in 2016. 27.31 After the fire, the LFB conducted a Performance Review of Command (PRC), which considered, amongst other things, the quality of command decisions on the night and the adequacy of the information available to incident commanders and monitoring officers.22 The PRC concluded (and the Commissioner agreed)23 that the information available to WM Dowden was insufficient, particularly in relation to the tactical plan and floor plans of the tower.24 Each of these deficiencies in the tower’s ORD rendered it woefully inadequate, as the Commissioner rightly accepted.25 Cumulatively they were inexcusable, and indeed no LFB officer who gave evidence about them sought to defend them. 27.32 On the night of the fire AC Andrew Roe was particularly exercised by the absence of any plans of the tower until very late in the incident. Had the LFB maintained a proper ORD for, and ensured that the TMO had provided it with plans of, the tower, AC Roe would not have had cause to complain on that score. It will be a matter for Phase 2 exactly what efforts the LFB made with the TMO to obtain plans and what efforts the TMO made to provide them during the two years before the Grenfell Tower fire in which their absence had been noted. 27.33 The question then arises whether and, if so, to what extent, the deficiencies in the ORD and the absence of plans hindered effective command decision-making, the deployment of search and rescue crews and the firefighting response more generally. In relation to the response to the initial fire in the kitchen of Flat 16, there is no evidence that the deficiencies in the ORD had any effect at all on the speed or effectiveness of the response. In relation to the response to the catastrophic fire in the cladding that ensued, undoubtedly it would have assisted incident commanders, those in charge of the bridgehead and the crews deployed to search for and rescue residents to have had accurate drawings of the floor layout and an accurate statement of the number of floors. It would also have helped to have had up- 19 [LFB00003116]. 20 MDT (the Mobile Data Terminal) [LFB00003116] p. 1. 21 Cotton Day 50/89/1-4. 22 A PRC is held for all incidents involving six or more pumps. Its purpose is to provide a constructive and supportive environment within which the performance of command function can be discussed openly. The objectives are to identify good practice and points for improvement: refer to LFB PN421 “Performance reviews of the Command Function”, paragraphs 2.1 and 2.2 [LFB00001563]. 23 Cotton Day 50/91/10-13, 50/92/17-93/5. 24 [LFB00003121] point 3, and the IMP Report [LFB00003114]. 25 Cotton Day 50/92/17-93/5.

The Grenfell Tower Inquiry: Phase 1 Report 594 to-date emergency contact details for a caretaker or someone else who knew not only the tower but also the residents and which ones were vulnerable or had children. However, there is no reliable evidence to suggest that the inaccurate and incomplete information materially hindered the firefighting and rescue efforts. 27.34 It is worth noting that the London Safety Plan published by the LFB on 31 March 201726 made a virtue of the presence of premises information plates in high-rise residential buildings in the following terms: “From previous consultations, London Fire Brigade also knows that some people may still feel vulnerable from fires in high-rise buildings. The Brigade understands this concern and that is why it is one of the key concerns captured in the assessment of risk toolkit. The London Fire Brigade would like to reassure Londoners that it has effective measures in place for dealing with incidents in high-rise buildings and this includes a pre-determined attendance of four fire engines to any high-rise incident. The Brigade has also developed premises information plates for residential high-rise buildings, which provide vital information about layout, dimensions, dry riser outlets, hydrant locations and whether the building has any lifts. These are available electronically to crews, enabling firefighters to familiarise themselves with the building while on route and to get to work quickly on arrival.” [Emphasis added] 27.35 In the light of the evidence of the lack of information available to the LFB crews attending Grenfell Tower on the night of the fire, these words will provide scant comfort to any Londoner. There is no legal obligation on a building owner or manager to provide a premises information box or plate and according to AC Roe they are not common in high-rise buildings.27 How it came about that RBKC and the TMO failed to provide the LFB with even a fraction of this information, and that the LFB failed to demand it of them and ensure that the ORD reflected it, is a matter of the utmost seriousness. That question will be examined at Phase 2. 27.36 The failure to appreciate the nature of the danger at Grenfell Tower was due in part to the LFB’s narrow understanding of section 7(2)(d) of the 2004 Act. The subsection is couched in general terms (“. . . a fire and rescue authority must in particular . . . make arrangements for obtaining information needed for the purpose mentioned in subsection (1))”, that purpose being extinguishing fires in its area and protecting life and property in the event of fires in its area. There is an obligation to gather relevant information in respect of all matters falling within the scope of the subsection from wherever it may be found (as indeed is recognised by PN800). That may well include the owner or manager of the building in question. Such information includes, but is not limited to, the matters listed in Appendix 1 to PN633. 27.37 It appears to be generally understood within the LFB that section 7(2)(d) is satisfied by sending fire crews to inspect buildings in their area, the frequency of such inspections depending upon an assessment of the risks identified in relation to those buildings. Such visits are of importance, because they enable the building to be examined by someone with a trained eye, but they are not the only potential source of information and some information of importance cannot be obtained by means of a visit of that kind. In the present case one cannot criticise WM Dowden or his crew for failing to discover on a visit to Grenfell Tower that combustible materials were being used in the cladding, much less that the particular configuration of the cladding system made it particularly susceptible to fire. However, information about the materials being used in the cladding system could and should have been obtained direct from the TMO. If it had been obtained, it should have alerted senior officers to the possibility of a cladding fire of the kind illustrated in the Tall Building Facades presentation. 26 [LFB00000225] p. 27. 27 Roe Day 49/91/23-25.

595 Chapter 28 The Incident Ground This Chapter analyses the events on the incident ground, the responses of the LFB to the developing fire and the systems of communication between the control room and the incident ground and within the incident ground itself. 1 Introduction 28.1 There can be no doubt that the rank and file firefighters who attended the fire displayed enormous courage and selfless devotion to duty. In many cases they pushed themselves to, and even beyond, the limits of endurance in their attempt to fight the fire and to rescue those who remained in the building. At the end of his evidence, AC Andrew Roe paid the following tribute to his junior officers and crews: “I think there is always room in big organisations for improvement to systems, to improve training. I think there’s always room for improvement to the underlying conditions in which our people operate. But, actually, in terms of the response of the night, I could not have been prouder to be a London firefighter, nor lead the men and women of the London Fire Brigade, because I felt that they operated in the best traditions of our 150-year history and put themselves at enormous risk for hour after hour after hour, and that we were battling against what was frankly an absolute failure of the building system, and they had done their absolute best in intolerable circumstances. I have nothing but praise for my junior officers and my crews who performed well beyond what was acceptable in terms of their physical and mental capacity, and, actually, in some numbers have paid the price consequently. It was a privilege to lead them and I’m very proud of what they did.”1 28.2 AC Roe’s words and sentiments are, on the whole, well justified and the firefighters who attended the tower deserve the gratitude of the local community and London as a whole. 28.3 I also bear in mind the following words of Dr Lane: “I do not consider it reasonable that in the event of the installation of a combustible rainscreen system on a high rise residential building, the fire brigade should be expected to fully mitigate any resulting fire event. That is particularly so in circumstances where the fire brigade had never been informed that a combustible rainscreen system had been installed in the first place.”2 28.4 It is also worth repeating that, when analysing the events on the incident ground, it is necessary to guard against making judgements with the benefit of hindsight about decisions made under the pressure of the moment. There is a difference, elusive though it may be, between legitimate criticism of the LFB’s performance on the night and the formulation of best practice for the future in the light of what is now known from the evidence. I have, therefore, taken care to evaluate command decisions by reference to the information that was, or should have been, available to the incident commanders at the time. The importance of context is illustrated by the fact that WM Michael Dowden was called out to an ordinary domestic fire in the kitchen of a lower floor flat of a high-rise residential block, a fire which appeared to have been successfully extinguished. He had no reason to think that it might develop into a catastrophic fire which would engulf the whole building. The development 1 Roe Day 49/199/2-22. 2 Dr Lane supplementary report [BLAS0000002] paragraph 2.10.1.

The Grenfell Tower Inquiry: Phase 1 Report 596 of that fire and the ferocity and speed of its spread were wholly outside his experience and training. These matters form part of the context in which the LFB’s actions on the night and, in particular, the decisions of the incident commanders, should be viewed. 28.5 However, hindsight provides no answer to the significant systemic and operational failings revealed by the evidence. The bravery and commitment to duty shown by individual firefighters cannot mask or excuse the deficiencies in the command and conduct of operations. Once it was clear that the fire had spread out of control, that compartmentation had extensively failed, but that evacuation remained possible, a decision should have been made to evacuate the tower. In arriving at that conclusion I am conscious that I have received no expert evidence to guide me on it and that a qualitative judgement on the approach of the LFB at the Grenfell Tower fire might be thought to be a matter better reserved for Phase 2. However, I am confident that, on the clear and extensive evidence about the events of the night that I have heard at Phase 1, I can and should reach that conclusion at this stage. It is not in the public interest to wait until the conclusion of Phase 2 to express a view about it. 28.6 The reality was that, before AC Roe assumed command, none of the incident commanders had been able to conceive the possibility of mass compartmentation failure and the consequent need to consider, and then order, a total evacuation of the building. There came a point when it was, or should have been, reasonably obvious that operational responses to individual FSG calls were, or were likely to be, ineffective and that the stairs would remain passable for only a limited period of time. In those circumstances, it was, or should have been, obvious that only a supervised mass evacuation would minimise the number of casualties. That point had been reached by 01.30 at the earliest and by 01.50 at the latest. The result is that by 02.47 when the “stay put” advice was withdrawn the best part of an hour had been lost without any evacuation plan having been considered. By 02.44 when AC Roe arrived and assumed command it was too late to carry out a managed total evacuation. 28.7 Mass evacuation of the occupants of the tower would no doubt have presented serious risks to the lives of both residents and firefighters, given the internal layout of the building and the absence of any kind of communication system. Nonetheless, it is likely that, in the face of a rapidly developing fire on the exterior of the building and an increasingly pervasive spread of smoke and fire throughout the interior, prompt evacuation would have resulted in the saving of many more lives. 28.8 Although I take account of the significant difficulties confronting an incident commander faced with a rapidly deteriorating situation, there were many failures of response on the incident ground on the night. Before the arrival of AC Roe the principal failure was one of command. WM Dowden had sent the “persons reported” message at 01.28, but until AC Roe’s arrival none of them had formulated a clear and effective plan directed to saving as many lives as possible in the light of the deteriorating circumstances and none of them had formulated an effective plan for deploying to best advantage the resources that had been summoned to achieve that aim. In short, before AC Roe assumed command, none of the incident commanders had, for a variety of reasons, effectively seized control of the situation. 28.9 The consequences of that failure of command were significant. They included a failure effectively, efficiently and swiftly to deploy the first EDBA crews to reach the incident ground in response to FSG calls, a failure to implement effective and efficient arrangements for the communication of FSG messages between the control room and the incident ground, a failure to ensure that information about the internal spread of the fire was communicated from the bridgehead to the incident commander, and a failure to obtain and assess up-to‑date

Part III | Chapter 28: The Incident Ground 597 and accurate information about the effectiveness of search and rescue operations, all of which were compounded by failures of communication between the incident commanders themselves. 28.10 It would be impracticable to identify and analyse the causes of each and every failure of action and error of judgement in responding to a mass emergency involving hundreds of officers over a seven-hour period. Instead, one must stand back and examine the LFB’s operational response from a broader perspective. 2 Command and control The response to the fire in Flat 16 28.11 There was no suggestion that the response to the fire in the kitchen of Flat 16 could have been materially quicker, having regard to the preparations necessary to allow firefighters to reach the building and enter the room safely with an adequate supply of water. WM Dowden formulated and implemented his plan to fight the fire on the understanding that it was nothing more than a routine fire in a domestic appliance. An appropriate number of firefighters were deployed to fight such a fire and, although there was some initial difficulty in securing entry to the tower, that did not unduly delay the crews. Although CM Christopher Secrett was unable to secure control over the lifts (for reasons that remain under investigation), the crews were able to use them to go to floor 2 and set up the bridgehead in accordance with the LFB’s normal operating procedure. It should be noted at this point that the firefighters’ inability to bring the lifts under their control is relevant to the circumstances in which some residents came to lose their lives. 28.12 Thereafter, there was no significant delay in the crews’ reaching floor 4, setting in a hose and entering Flat 16. Once CM Charles Batterbee and FF Daniel Brown had entered the flat, they carried out a methodical search of the premises carefully and thoroughly. By the time CM Batterbee and FF Brown had entered Flat 16 and had started their search (01.09), the fire had broken out of the kitchen and ignited the cladding. That appears clearly in the video recording showing the east face of the tower.3 By 01.20 (or thereabouts), when the crew entered the kitchen, the external fire had already rapidly developed. In short, CM Batterbee and FF Brown acted as swiftly as they reasonably could but, by the time they had entered Flat 16, it was already too late to stop the fire from escaping from the kitchen into the cladding. 28.13 Likewise, once they had put out the remaining flames in the large fridge-freezer and could see the external fire, FFs John O’Hanlon and Nicholas Barton (the first crew’s back-up) tried to direct water towards what they thought was the window surround. As with CM Batterbee and FF Brown, FFs O’Hanlon and Barton did all that they reasonably could, but by 01.30 or thereabouts it was too late to prevent the rapid development of the fire on the exterior of the building. The initial response to the external fire: 00.54 to 01.50 28.14 By 01.30 the following principal events had occurred: a. The fire had broken out of the flat of origin on floor 4 and into the cladding by 01.09. b. It had reached floor 5 by 01.13 and had spread with increasing speed and ferocity to the very top of the building by 01.26, i.e. in under 20 minutes. 3 [LBYS0000002].

The Grenfell Tower Inquiry: Phase 1 Report 598 c. All the “Flat 6s” were exposed to the flame front. Some 20 flats on the east elevation had become involved in the fire. d. The exterior fire was beginning to spread laterally around the crown towards the north facade, and southward along the east facade. e. WM Dowden had made pumps up from (an already increased) six pumps (at 01.12) to 20 pumps (at 01.29) within some 16 minutes. He had ordered two FRUs and one ALP. There were six pumps and 30 firefighters (excluding those above the rank of Watch Manager) in attendance on the incident ground. A total of nine firefighters had been deployed into the tower from the bridgehead, including those crews deployed to fight the fire in Flat 16 and FF Justin O’Beirne who was not wearing BA. At 01.31.30 WM Dowden made pumps 25, only some two minutes after making pumps 20. f. The lobbies as high as the top floor (floor 23) were either smoke-logged or beginning to be affected by smoke and firefighters were experiencing smoke as high as floor 16. g. The LFB control room had received 29 calls about the fire, of which 124 had been received from occupants in various locations up to the top of the tower at a considerable distance above Flat 16. At least two were FSG calls properly so called (where the caller had said they were trapped). A number of the calls had reported the whole building on fire. The CROs were already overwhelmed with calls. h. The stairs were beginning to be affected by smoke to different degrees at different levels but remained passable to evacuating residents. i. The development of the external fire up the east face of the tower, coupled with the number of residents evacuating the tower who had been the subject of smoke inhalation, caused WM Dowden to send the “persons reported” message at 01.28.40. j. A total of 112 people had left the tower in the 35 minutes that followed Behailu Kebede’s first 999 call at 00.54.29, representing some 38% of the total of 297 people present in the building on the night of the fire. Of those, 84 had escaped between 01.15 and 01.29.59.5 k. The MPS had declared the fire to be a Major Incident (although the MPS had not told the LFB this at the time).6 28.15 The information objectively available by 01.30, certainly when taken cumulatively,7 ought to have caused WM Dowden to consider whether an alternative strategy to firefighting should be adopted, and specifically, whether the building should be partially or wholly evacuated and, if so, how. By 01.30 it was or should have been obvious to WM Dowden that the external fire had reached the crown, that there was at least a significant risk that the fire would penetrate the interior of the building, given the strength and speed of its development, that firefighting measures were failing to contain or extinguish the external fire, and that residents (some 4 Including the call from Shah Ahmed in Flat 156 on floor 18, which was connected by BT but on which nobody spoke directly, although people could be heard saying “fire” in the background [INQ00000263]. 5 The exit statistics are based on Annex A which is derived from the MPS’s Schedule of CCTV exits [MET00016072] and other sources where appropriate. 6 Inspector Thatcher’s declaration was at 01.26 but it was not shown on CAD 482 until 01.32. 7 WM Dowden cannot be criticised for not knowing that the MPS had declared a major incident: the MPS had not told the LFB of the fact.

Part III | Chapter 28: The Incident Ground 599 of whom were suffering from the effects of smoke inhalation) were leaving in substantial numbers. He had also seen occupants coming out of the building suffering from the effects of smoke inhalation, which for him was, as he said, “a big change”.8 28.16 The magnitude and speed of the external fire did, to an extent, inform WM Dowden’s response. Throughout his time in command he positioned himself outside the tower at or near its south-east corner. He could see the fire’s swift development and behaviour on the outside of the tower. What he saw was reflected in his pump make-ups and orders for other resources such as the ALP, two FRUs and the command units. Regardless of what he actually knew, however, the fact that he considered it necessary to increase the number of pumps in attendance from 15 to 25 in three steps within a period of little more than two minutes should alone have been sufficient to prompt him to reconsider what his overall strategy should be. Similarly, although he considered that sending a “persons reported” message at 01.28 and making pumps 15 was, in his words, “a pivotal change”,9 and although he could by then see that the fire was “getting into flats”,10 he did not consider a change in strategy. 28.17 Nor did WM Dowden discuss evacuation with any other officer who was there, such as WM Paul Watson (who had more experience than him) or SM Brett Loft (who was senior to him), despite his appreciation that his firefighting efforts were having no effect at all on the spread of fire up the exterior of the east facade. 28.18 I take account of the danger of judging with hindsight the very rapidly changing conditions, the scale of the incident, WM Dowden’s relatively junior rank despite his 14 years’ experience, and the fact that by that time only six appliances had arrived at the tower. Although I doubt that there was a sufficient number of firefighters at the scene by 01.30 to have allowed a safe and efficient assisted evacuation of all of the tower’s occupants, WM Dowden should already have begun to review the quickly deteriorating scene and should have been giving thought to a possible evacuation of the building, either in whole or part. That should have involved consideration of how to deploy and co-ordinate the incoming resources in order to ensure a safe and efficient evacuation. I will return below to the question of how a full building evacuation might have been achieved. 28.19 By the time WM Dowden handed over command at 01.50 matters had deteriorated significantly. The position was as follows: a. The fire was spreading southwards across the east face, both at the crown and at the lower floors, towards column C5 and had spread to the north face at the upper and lower floors, reaching column A4. b. The LFB control room had received a total of 87 emergency calls relating to the incident. Of those, 37 had come from the tower relating to 23 particular flats in all (repeat calls had been received from Flats 82, 95, 111, 115, 175 and floor 16).11 Of those 37 calls, some 20 were calls in which the caller reported being trapped and affected by fire, heat or smoke or the CRO stayed on the line, and were therefore unambiguously FSG calls. The 20 flats from which those calls had come ranged from Flat 9 (floor 3) at the lowest to Flat 205 (floor 23) at the highest. Nine of those were from flats on or above floor 2012 and four were from floor 23. 8 Dowden Day 11/13/25-14/9. 9 Dowden Day 11/11/11-12/2 and note of the PRC meeting of 3 July [LFB00003117] p. 7. 10 Note of the PRC meeting of 3 July [LFB00003117] p. 7. 11 This total includes the call from Debbie Lamprell from Flat 201 on floor 23 taken by Aisha Jabin in the North West FRS control room at 01.41.18 [LFB00055500]. Jessica Urbano Ramirez’s call from Flat 201 with CRO Russell had already started (at 01.29.48) and was continuing [LFB00055504]. 12 Flats 175, 182, 192, 193, 194, 201, 204, 203 and 205.

The Grenfell Tower Inquiry: Phase 1 Report 600 c. CU8 had received six messages from the control room relating to FSG calls from 10 identified flats across a total of 10 different floors. d. Firefighters within the building had found many lobbies smoke-logged as high as floor 20, with increasing amounts of smoke in the stairs, particularly at lower levels. e. The resources available on the incident ground were: i. A total of 22 pumps which had arrived at the scene,13 together with CU8 and CU7, Paddington’s turntable ladder (A213), and two FRUs (A216 and G346); 114 firefighters and 10 EDBA wearers were therefore available. ii. Ninety-one firefighters were available for deployment into the tower, and a further 21 firefighters had already been deployed under air into the tower. f. By 01.50 168 of the 297 occupants of the building had escaped.14 They had come down from as high as floor 20. Some were suffering from the effects of smoke inhalation. 28.20 That deterioration in conditions had led to a situation in which a full evacuation of the building had become the only realistic way of minimising loss of life and serious injury. It is doubtful whether WM Dowden ever had in mind the possibility of a full evacuation, since from his perspective such a course was contrary to all the established wisdom about fighting fires in high-rise residential buildings and there is no doubt that nothing in his training or experience had equipped him to deal with an incident of that kind. However, in his role as incident commander he can be criticised for failing to obtain certain important information that was available to him in addition to his own observation of the behaviour of the fire on the outside of the tower. If he had obtained and considered that information, it should have led him to consider evacuating the building, assess the risks involved and then make an informed decision to adopt it as his strategy in place of concentrating on individual rescues. It is difficult to say exactly when WM Dowden should have realised that that point had been reached, but it had certainly been reached by the time he relinquished command. 28.21 The most important information that WM Dowden lacked related to the receipt of emergency calls. Information about the increasing number of calls received by the control room from around 01.30 onwards would have told him three things of importance. First, the fact that by 01.50 the number of FSG calls properly so called dwarfed the number made at the Lakanal House fire15 would have made him aware that the number of occupants already known to be at risk far exceeded those threatened by any previous fire. That alone might have prompted him to consider a full evacuation of the building, whether it could be carried out safely and if so, how. Secondly, the rate at which the number of FSG calls was rising would have alerted him to the fact that conditions in the building were not being stabilised by effective firefighting but were continuing to deteriorate. Thirdly, the source of the calls would have revealed that many callers were high up in the building, many floors above the floor of origin, and that the flats from which the calls were being made were not limited to those immediately above Flat 16 but included flats in the south-east corner16 and the north-west corner.17 There was, therefore, no clear pattern to the locations from which FSG calls were coming to indicate that any particular part of the building was or would remain safe. 13 ORR p. 108. 14 There were 56 exits between 01.30 and 01.50. The exit times of the occupants of Flat 6 on floor 2 are not exactly known but occurred in Period 2. They are included in this total. 15 There were four FSG calls at Lakanal House. 16 For example, Flats 82 and 142. 17 For example, Flats 175 and 205.

Part III | Chapter 28: The Incident Ground 601 28.22 WM Dowden did not speak to the senior officer in the control room (OM Alexandra Norman), or indeed anybody else in the control room, in order to find out whether any FSG calls had been received and if so from which parts of the building. Paragraph 5.9 of PN790 required all FSG information to be passed to the incident commander, who would then decide what action to take. No information of that kind was passed to WM Dowden and he did not himself ask for it. Although the control room passed numerous messages to CU8 once it had been set up (and there was a short delay while that was done) at no point did WM Dowden himself speak to WM Daniel Meyrick on CU8 to find out what 999 callers were telling the control room about the conditions in the building and where and why they were trapped. 28.23 It was only when CU8 arrived at around 01.30, and when SM Loft arrived shortly after that, that WM Dowden became aware at all that there were “multiple” FSG calls,18 but at no point did he learn how many were in progress or from which part of the building they had come.19 One possible reason for his failure to obtain that information was that he had put SM Loft in charge of managing the response to FSG calls as well as liaison with the bridgehead. This decision introduced an additional and unnecessary link in the chain of communication between himself and the bridgehead; it also denied him as incident commander of first-hand knowledge of the number of FSG calls, the locations of callers and the rate at which the number of calls was increasing. 28.24 When he instructed SM Loft to take responsibility for the management of FSG calls, WM Dowden did not give him sufficiently detailed instructions about how he was to carry out that role, contrary to the requirements of PN790. For example, he did not tell SM Loft how to obtain information from CU8 or how to forward it to the bridgehead. Nor did he tell him how to record information relating to FSG calls, how to keep the control room informed of actions taken in response or how to keep the incident commander informed of any relevant information derived from them. Similarly, WM  Dowden did not establish a clear line of communication between himself and SM Loft and gave him no directions about how or on what basis FSG calls were to be prioritised. 28.25 The absence of any detailed instructions regarding the arrangements by which each link in the chain of communication was to be kept informed as the incident developed suggests that, when he briefed SM Loft, WM Dowden was not fully aware of the arrangements that had been put in place for the communication of information relating to FSG calls. The practical consequence was that, as incident commander at a dangerous fire which was already out of control, WM Dowden was not aware of current conditions within the tower or of the number and location of residents who considered themselves to be trapped. I return to the subject of the FSG communications on the incident ground and their effectiveness later in this chapter. 28.26 Information about FSG calls was not the only information that WM Dowden lacked. He did not seek or receive reports from the bridgehead about the conditions in the lobbies and the stairs higher up in the building. Information of that kind should have informed his decision-making in the latter stages of his time in command, but he did not ask those at the bridgehead what crews had reported about conditions in the building. To that extent, therefore, WM Dowden failed to ensure that, as incident commander, he had taken steps in accordance with paragraph 7 of PN431 to maintain clear lines of communication throughout the incident between the incident ground and the control room and between the LFB and other emergency services. 18 Dowden Day 10/149/2-152/12. 19 Dowden Day 10/152/1-154/12.

The Grenfell Tower Inquiry: Phase 1 Report 602 28.27 Even if WM Dowden could not see or know the precise number of people leaving the building, he should have been aware from his vantage point at the south-east corner of the tower that during the period between 01.30 and 01.50 many of the occupants had left the building. That might have suggested that conditions in the building had deteriorated to the point at which the occupants had decided to ignore the “stay put” advice, although in many cases they were not prepared to remain in the building once they had become aware of a fire. More importantly, however, the fact that so many people had left the building shows that at least up to 01.50 the stairs remained passable. There is no evidence that the stairs were blocked by firefighting activity or that movement was unduly hampered by congestion caused by the number of occupants leaving. 28.28 To evacuate a building of this kind in the face of an established “stay put” policy would have required a cool head and a great amount of self-confidence. By 01.50 WM Dowden had been acting as incident commander for the best part of an hour with little or no support from more senior officers. The behaviour of the fire was outside his experience and nothing he had done appeared to be having any effect. He was at a loss to understand what was happening or to know how to respond. However, by 01.50 at the latest he should have realised that the fire had begun to enter the interior of the building and that compartmentation, which underpins the “stay put” advice, had been breached. In those circumstances, he should have spoken to OM Norman in the control room and, having obtained the most recent information, should have decided to evacuate the building and set about ensuring, through the control room, that all callers from the building were told to leave come what may. However, that would not have guaranteed that all occupants still in the building at 01.50 would have been saved. 28.29 Two questions then arise: what could WM Dowden have done to evacuate the building and why did he not do it? 3 Evacuation The building 28.30 The capacity of the stairs was sufficient for simultaneous total evacuation of the building. That was the view of Dr Lane,20 and is supported by the fact that 77 people came down them in the 15 minutes between 01.15 and 01.29.59. Furthermore, evacuation may in many cases have been made easier by the fact that many of those escaping would have been family, friends and neighbours familiar with the building and with each other. 28.31 Until around 01.35 the stairs were substantially free of smoke and provided a means of escape before visibility was materially impaired.21 Although conditions then began to deteriorate, the stairs remained substantially free of smoke until around 01.50. Available evacuation methods 28.32 Although conditions in the stairs did not present an insurmountable hurdle, carrying out an organised evacuation of the building would have been by no means straightforward. Any plan would have required two practical elements: informing the occupants that they must make every effort to leave with the assistance of firefighters and deploying firefighters to inform the occupants that they must leave and to assist them in doing so. The two elements would have had to work together for the plan to be effective, but for neither of them was there any clear policy, training or well established method by which to carry them out. The challenge was 20 Dr Lane supplementary report [BLAS0000019] 19.6.71. 21 Dr Lane supplementary report [BLAS0000014] 14.4.188(b) and (c); Professor Purser [DAPR0000001] 153(a).

Part III | Chapter 28: The Incident Ground 603 compounded by the fact that there was no reliable means by which the incident commander or the control room could tell the occupants that they needed to leave. These obstacles do not mean that a complete evacuation of the tower was impossible, but they do suggest that its execution would have been difficult and would have given rise to dangers, including a risk to life. 28.33 The need to inform the occupants that they must leave the building required a reliable means of communication. There was, however, no alarm or public address system serving the whole building which could have been used for that purpose. Although it was possible for firefighters on the ground to use loudhailers (and one was used early on in the night by FF Patrick Murray to advise occupants to leave)22 or to ask the MPS to ask the NPAS helicopter crew present at 01.44 to use the “skyshout” on-board broadcaster, it is unlikely that any advice broadcast by these devices would have been clearly heard by all occupants above the noise of vehicle engines, pumps, sirens and the NPAS helicopter’s rotor. It might also have been possible to use the flat entry intercom systems to speak to individual residents, but that depended on whether they could or would get to the entry phone to answer it. All these methods of communication would have been essentially improvisations and would probably have been unreliable to some extent. 28.34 As I have already observed elsewhere in this Report, there is nothing in the Building Regulations or in Approved Document B which requires the owners of high-rise residential buildings such as Grenfell Tower to have sounders or public address systems for the whole building or any means of communicating with all the occupants in order to facilitate a total evacuation. Accordingly, WM Dowden was always going to be restricted in what he could do to achieve full evacuation by the limitations inherent in the building itself. Furthermore, although GRA 3.2 makes it plain in several places that the incident commander should have contingency plans for the evacuation of a high-rise building, should circumstances require it, it provides very little practical guidance on how to go about it. GRA 3.2, section 2, paragraph 23 contemplates expressly that a “Stay Put policy may become untenable due to unexpected fire spread”, but the control measure it then provides is to “consider all means of contacting persons within [the] building, such as intercom telephones, loud hailers etc”. In other words, an incident commander is expected to consider revoking “stay put” and moving to evacuation if the circumstances so require but must resort to improvisation to carry it out. That is not to suggest that these methods of communication should not have been tried. On the contrary, if a decision to evacuate had been taken, they should all have been used or tried in the hope of reaching as many occupants as possible as early as possible. 28.35 If WM Dowden had decided to evacuate the tower there were in reality two possible ways of contacting the occupants, in addition to resorting to improvisation of the kind I have mentioned. One was to ask the control room to tell anyone calling from the building that the fire brigade had decided to evacuate the building and that they should leave. Although the message would have reached only those who had made an emergency call, it would have been received by those who were sufficiently concerned for their safety to make such a call. The other was by the deployment of firefighters into the building to inform occupants that they needed to leave and to assist with evacuation where necessary. 22 Murray witness statement [MET00010925]; Rania Ibrahim’s Facebook post at around 01.40 which picked up this broadcast: Ismail Exhibit SI/2 [IWS00001232] at 05.05.

The Grenfell Tower Inquiry: Phase 1 Report 604 28.36 The first way of contacting occupants was only ever likely to be a partial solution. Some 999 callers did not call for the first time until some time after 01.50.23 The later that such callers called, the worse the conditions they would have encountered in the lobbies and, possibly, the stairs and therefore the greater the disincentive for any occupant to take the advice to leave. The element of chance could, therefore, not be wholly eliminated by using the control room to communicate with callers. 28.37 There was a partial solution to the problem of depending on people making calls, at least where they had rung previously. If the decision to evacuate at 01.50 had been made by WM Dowden, OM Norman, who was at that stage in command in the control room, could and should, where possible, have departed from the custom (prevalent in the LFB if not generally in other fire and rescue service control rooms in the UK) not to call 999 callers back. Once it became obvious that all available measures had to be taken to inform occupants of the need to evacuate, there was no good reason to cling to this anachronistic custom. The VISION system in the control room had captured the numbers of callers who had already made calls on their system, but it would have been difficult to identify earlier callers from within the tower. Accordingly I cannot accept the Commissioner’s evidence that the only means of communicating with occupants who did not ring the control room again was by a “door-knock”.24 I do accept her evidence25 that finding previous callers’ phone numbers in the VISION system by scrolling through the log would have been difficult, but not impossible. But as I say, this partial solution was only workable at all for those who had already called. 28.38 The second possible route to achieving communication with occupants to effect a full evacuation would have been through the physical deployment of firefighters into the building both to inform occupants that they needed to leave and to assist with evacuation where necessary. SM Daniel Egan, in his oral evidence, explained his thought processes about how a full building evacuation could have been carried out. He said: “…they would systematically go through a couple of floors at a time, with crews going along, banging on doors, giving people a chance, you know, trying to cajole them out if they was in there, and then trying to escort them down. And then perhaps do three floors at a time, depending on how it was working…”26 28.39 Making every allowance for the lack of numbers of firefighters available to him during his time in incident command, WM Dowden could have sent as many firefighters as he had as high as possible into the tower to knock on people’s doors on each floor and alert the occupants to the need to leave, and assisting them where necessary. 28.40 The method of contacting occupants described by SM Egan, although hypothetical, was at least possible and should have been attempted by WM Dowden at the latest by 01.50 while the stairs were relatively clear. In addition, WM Norman Harrison had had previous experience of a full evacuation of a six-storey building at night by using a similar procedure.27 28.41 By 01.50, 22 pumps had arrived at the incident ground, so WM Dowden had about 114 firefighters at his disposal, including 10 EDBA wearers. At that stage he should have sent as many crews as were reasonably available into the tower to knock on doors, alert the occupants 23 For example, Marcio Gomes (Flat 183, floor 21) whose first call was at 02.21.04; Khadija Saye (Flat 173, floor 20) whose first and only call was at 02.26.48. 24 Cotton Day 50/183/1-23. 25 Cotton Day 50/183/1-23. 26 Egan Day 16/49/7-20. 27 Harrison Day 45/101/6-20.

Part III | Chapter 28: The Incident Ground 605 to the need to leave, and assist them to do so where necessary. Indeed, that approach was one which DAC Andrew O’Loughlin himself suggested in his evidence (although he did not adopt it on the night).28 28.42 Although this strategy might have exposed firefighters (very few of whom had EDBA by 01.50) to serious danger higher up in the building, it was still at least a possible use of the gradually increasing number of incoming crews. On any view it was far more preferable to WM Dowden’s continued pursuit of firefighting while positively encouraging occupants to remain in the building by maintaining the “stay put” advice. 28.43 An important question which remains is how WM Dowden could have ensured the safety of those occupants of the tower whose impaired mobility or other health difficulties meant that they needed help to get out. Although GRA 3.2 provides a nod in that direction on page 18, it provides no practical assistance to an incident commander about how to rescue such people if they need to be evacuated. They will always need firefighter assistance, but any incident commander in WM Dowden’s position will first need to know which flats they are in and what kind of difficulties they have before he can deploy crews to assist them. That information, specific to each occupant and up-to-date, should have been provided long in advance to the LFB by the TMO or RBKC and been available to WM Dowden in the ORD. It was not. Even if it had been, it is unclear even with the benefit of hindsight how WM Dowden could have achieved assisted evacuation of such occupants on the higher floors given the low numbers of EDBA wearers he had at his disposal by 01.50. I return later in this chapter to the attempts to prioritise rescues. 28.44 In summary, a mass evacuation was not something for which WM Dowden or any of the other officers present that night (including AC Roe) had been trained. It would have posed formidable practical difficulties, but it was possible and to attempt it was preferable to telling occupants to stay in their flats. Why was evacuation of the tower not pursued? Lack of training 28.45 The primary obstacle in the way of WM Dowden’s carrying out a full evacuation of the building was that he had not been trained for it. The mere existence of the decision-making model in PN341 was not of itself enough. In simple terms, the decision-making model failed not only because WM Dowden did not “recognise and react quickly to changing circumstances”, but because he did not know what to do. Similarly, there is nothing in PN633 or the various incident command policies that assists incident commanders in that respect. Having seen and heard WM Dowden over three days, I do not think that his failure was due to any personal lack of ability or commitment. Rather, it was due to deficiencies in his training which failed to equip him with the means of deciding when to switch from the “stay put” strategy to one of partial or total evacuation. His extensive oral evidence about his training and its limits, particularly in relation to evacuation and contingency planning in relation to fires in high-rise buildings,29 strongly supports that conclusion, as does the evidence of other senior firefighters. Many senior firefighters said that they had not been trained in recognising the circumstances in which an incident commander should consider instructing the control room to abandon the “stay put” advice, as contemplated by paragraph 8.7 of PN790.30 28 O’Loughlin Day 47/76/11-77/21, 161/1-163/9. 29 Dowden Day 9/21/22-40/19. 30 For example, O’Loughlin Day 47/25/11-27/1.

The Grenfell Tower Inquiry: Phase 1 Report 606 28.46 Although he recognised that the scale of the incident required greater resources, his training did not equip WM Dowden with the means of understanding the nature of the fire or how best to combat and contain it. Nor did it equip him to decide whether to undertake an evacuation of the tower or how best to do so. His failure to appreciate the significance of the information available to him must be attributed to inadequate training rather than incompetence on his part. He himself was candid in his PRC debrief, saying that at the point when he made pumps 15 (at 01.27.26) he “felt helpless”.31 28.47 That conclusion is strongly supported by the fact that WM Dowden had plenty of more experienced officers around him during his time in command, such as WM Brien O’Keeffe, WM Watson, and latterly SM Loft and SM Gareth Cook, all of whom could see what he could see and none of whom took him to task over his methods or advised him to evacuate the tower. If WM Dowden had fallen below the standards expected of him, it would have been obvious to his fellow officers, who I am sure would have said something to him. I can only infer, therefore, that his actions were regarded as competent by the LFB’s own standards. Indeed, the positive appraisal given by the LFB to his command in the LFB’s incident report focused on firefighting and command structures and said nothing about considering alternative strategies or use of the decision-making model.32 Lack of support from more senior officers 28.48 It is a strikingly unsatisfactory feature of the incident that WM Dowden was left in command of this incident for so long after it had become quite apparent that it was a fire of unprecedented scale and not remotely under control and so long after he “felt helpless” at make pumps 15 (01.27.26). That was due in part to the sheer speed at which additional pumps were requested (which itself has a bearing on the attendance of more senior officers) and the time it took to summon more senior officers to the incident ground. However, when more senior officers did arrive shortly after 01.30, WM Dowden did not receive the assistance and support that he was entitled to expect from them. 28.49 LFB policy required the attendance of a monitoring officer. SM Andrew Walton assumed that role at 01.02.43 when he was paged by the control room, but could do little until he got to the incident ground at 01.40.12, and even then did not assume command in accordance with PN412. I appreciate that on arrival he may have wished to acquaint himself with the incident and the extent of the fire, but he could and should have taken steps to assume command more swiftly following his arrival. At 10 pumps a DAC was supposed to assume command monitored by an officer of AC rank, and at 16 pumps an AC was supposed to take incident command.33 The fact that a Watch Manager was left in command, without any effective remote monitoring assistance, for the first hour of the incident and for a full 20 minutes or so after the make-up had reached 25 pumps displays a shortcoming in the LFB’s mobilisation arrangements. 28.50 At 01.32 SM Loft arrived at the scene. Although PN431 suggests that the incident commander need not always be the most senior officer present, the fact that WM Dowden felt so out of his depth by 01.31 should have led SM Loft, as the more senior officer, to take command, but he did not do so.34 Given the scale of events, WM Dowden could and should have discussed with SM Loft the strategic and tactical response to the fire, but did not do so. Equally, SM Loft could and should have forced a discussion with WM Dowden on these matters or, at least, 31 [LFB00003117] p. 7. 32 LFB’s incident report [LFB00003114] pp. 4, 5. 33 PN412. 34 PN431, paragraph 1.2.

Part III | Chapter 28: The Incident Ground 607 raised the question of evacuation, but he did not do so. Instead, SM Loft agreed to leave WM Dowden in command and was instructed by him to assume responsibility for managing FSG information. He accepted that role without any wider discussion of its purpose and without ensuring that he put in place a system whereby the incident commander would receive accurate and up-to-date information about the success or otherwise of deployments in response to FSG calls. 28.51 SM Cook arrived at 01.38. He attended as Press Officer and so was not entitled to assume command. However, his role was nonetheless to provide command support to WM Dowden in his decision-making, but he provided no such support, although he clearly understood that 35 that was his role. He was not able to provide any satisfactory explanation for that. 28.52 Having not assumed command themselves as policy required, neither SM Loft nor SM Cook gave WM Dowden any practical or effective advice about how to attempt to take control of the incident, whether to evacuate the building and, if so, how best to deploy the incoming resources to assist such an operation. No good reason was put forward to explain why WM Dowden was not relieved of command by SM Loft or SM Cook, although it is fair to say that there is no evidence that either officer had a better informed or a more positive plan to combat the fire or to save life. “Stay put”: an article of faith 28.53 There is in my view a further underlying reason why WM Dowden, and indeed the incident commanders after him, did not change strategies, quite apart from the fact that he (and they) failed to appreciate the significance of much of the information which demanded it. The absence of any policy guidance on how to carry out a full building evacuation with no evacuation plan in place and no means of telling the occupants to leave can only have discouraged him from contemplating the possibility of a full evacuation. The knowledge that high-rise buildings are constructed on the basis of effective compartmentation itself created a barrier to thinking about evacuation. 28.54 Similarly, one could occasionally detect in the evidence of senior officers a reluctance to believe that a building could ever fail to comply with the Building Regulations.36 The evidence taken as a whole strongly suggests that the “stay put” concept had become an article of faith within the LFB so powerful that to depart from it was to all intents and purposes unthinkable. That itself helps to explain why it was not thought about until it was too late for many of the occupants of the tower. The fact that the Commissioner was compelled to ask the rhetorical question: “It’s all very well saying ‘Get everybody out’, but then how do you get them all out?”37 emphasises that the LFB had never itself sought to answer that question in its preparations and training and had not equipped itself to carry out a total evacuation of such a building. The requirements of GRA 3.2 and some of the provisions of its own PN633 demand an answer to that question, which will be investigated in Phase 2. 28.55 Quite apart from its remarkable insensitivity to the families of the deceased and to those who had escaped from their burning homes with their lives, the Commissioner’s evidence38 that she would not change anything about the response of the LFB on the night, even with the benefit of hindsight, only serves to demonstrate that the LFB is an institution at risk of not learning the lessons of the Grenfell Tower fire. 35 [MET00007882] p. 4. 36 For example, O’Loughlin Day 47/20/11/-21/5. 37 Cotton witness statement [MET00012492] p. 38. 38 Cotton Day 50/236/8-17.

The Grenfell Tower Inquiry: Phase 1 Report 608 4 Handing over command 28.56 Efficient handover of command from one incident commander to the next is essential if firefighting and rescue operations are to be conducted effectively and with the minimum of disruption. That requires the incoming commander to obtain from the outgoing commander a clear understanding of the nature and development of the fire, the resources available, the measures that have been, and are currently being, taken to fight it, the number of people trapped in the building and the steps being taken to rescue them. These are all matters covered by PN431. The handover of command to SM Walton 28.57 The principal characteristic of the handover of command from WM Dowden to SM Walton was its brevity. There was no discussion about the progress of the fire, which was still developing, the number and source of FSG calls, the practicalities of evacuation or withdrawal of the “stay put” advice. In the absence of any information about conditions within the tower, it was reasonable and necessary for SM Walton to despatch WM Dowden to collect that information, as he did. Although there is evidence that external firefighting had, to a limited extent, been successful in containing the fire on the east face below floor 17, there was no reason to think that the external fire was under control at all. On the contrary, it was continuing to develop at pace. In these circumstances, the risk of fire breaking back into flats and the consequential risk to life was plain. Indeed, SM Walton’s main consideration was whether the fire was breaking back into flats; if it had been, he would have declared a Major Incident, because he would have considered that the whole building needed to be evacuated. However, he was not in command long enough to establish the facts or to formulate a plan for evacuation. 28.58 Given what SM Walton could see and given his concern about the risks of fire entering flats, the possible need for evacuation and its practicalities should have been explicitly raised during his assumption of command from WM Dowden. When DAC O’Loughlin relieved SM Walton very shortly afterwards, evacuation should have been the first matter discussed and, with the benefit of information about internal conditions, a decision should have been made. It is possible that it was not raised because SM Walton did not think that the fire was getting into flats. Laurence Ioannou, the LAS Incident Response Officer, arrived on scene at 01.49 and had a brief conversation with a firefighter, probably SM Walton, who said: “It’s not as bad as it looks. We believe it is an external fire and has not penetrated internally”.39 It is possible, however, that SM Walton told Laurence Ioannou that the fire might be breaking back into flats and that the LAS should be prepared to deal with multiple casualties,40 but if that was the subject of discussion, SM Walton did not act on it during his brief period of command, nor did he brief DAC O’Loughlin about it when he took over. 28.59 SM Walton’s evidence about whether to mount a full evacuation was telling. He considered that a full building evacuation was to all intents and purposes impossible.41 He told the Inquiry not only that he had received no training in how one might be carried out,42 but also that in a high-rise building only the compartment of origin and the surrounding flats were ever evacuated, not the whole building. SM Walton thought that, as he put it, there was “no option to evacuate a building where the building principle has failed to the extent that the means of 39 Ioannou witness statement [MET00010862] pp. 3, 5. 40 Walton witness statement [MET00010828] p. 27. 41 Walton Day 46/14. 42 Walton Day 46/37, 64.

Part III | Chapter 28: The Incident Ground 609 escape don’t exist”.43 However, at the time he took over from WM Dowden, they did exist, and although by that stage the conditions in the lobbies and stairs had deteriorated markedly, they never became completely impassable, as the escapes later in the night attest. The handover of command to DAC O’Loughlin 28.60 DAC O’Loughlin assumed incident command at around 01.56. The two defining characteristics of the handover from SM Walton to DAC O’Loughlin were, again, its brevity and, more importantly, the failure of DAC O’Loughlin to obtain the information required to exercise effective command over an obviously deteriorating situation. 28.61 By 02.00, a few minutes after DAC O’Loughlin had assumed incident command, the following principal events had occurred: a. Flames had reached the crown on the south side of column C5 and its base was burning. Flats 151, 161, 171, 181, 191 and 201 had become involved in the fire, having been affected by the flame front as it spread southwards across the east face of the tower. b. The flame front had begun travelling across the north face in a westerly direction. c. The control room had received a further eight emergency calls since 01.50, two from members of the public and six from trapped residents. There were no new flats from which calls were emanating, but the conditions at different places in the building were rapidly deteriorating, as is shown by the developing information about repeated calls from Flats 196 (floor 22), 182 (floor 21) and 95 (floor 12). Forty-five adults and 16 children had been reported to be within the building. d. On the incident ground: i. CU8 had been given FSG information in the form of a total of six further radio messages or admin line calls in relation to people on floor 10 and Flats 133, 182 (twice), 111, 115, 95, 205 and 201. ii. Twenty-five pumps and a second command unit (CU7) were in attendance. Since 01.30 some 30 firefighters had tallied out wearing BA and been deployed into the tower, including the EDBA crew of five from Paddington A216 who had been sent to the roof. iii. Evacuations from the tower had ceased from 01.49 (and did not resume until 02.07).44 28.62 DAC O’Loughlin’s position was very different from that of WM Dowden when he had arrived at 00.59. From the outset, DAC O’Loughlin was faced with an uncontrolled, still-developing external fire. The state of the external fire should have spoken for itself, but during the course of the handover from SM Walton and WM Dowden there was no discussion of evacuation, the number and source of FSG calls or what arrangements had been put in place to prioritise FSG calls. If DAC O’Loughlin had stood back and considered what was in front of him, if he had asked WM Dowden about the rate of development of the fire, if he had asked the control room about the number of FSG calls that had been received, if he had considered the need for EDBA resources, if he had noted the fact that many residents had already left the building and their condition at the time, he would have had enough information to know that the risk 43 Walton Day 46/146. 44 There is an 18-minute gap between the exit of Branislav Lukic at 01.49.09 and David Lewis, a visitor, at 02.07.15.

The Grenfell Tower Inquiry: Phase 1 Report 610 of continuing to give “stay put” advice was greater than that of evacuating the tower. Even if SM Walton and WM Dowden had not raised the question of evacuation, an officer of DAC O’Loughlin’s seniority and experience should have done so. 28.63 I fully recognise that, even if an order to evacuate (whether total or partial) had been given by 02.00, some lives might still have been lost. I also recognise that the mechanics of carrying out an evacuation of any sort in rapidly deteriorating conditions would have presented its own risks to the lives of residents and firefighters. However, I have little doubt that fewer people would have died if the order to evacuate had been given by 02.00. The time between 02.00 and 02.47, when AC Roe ordered the “stay put” advice to be withdrawn, was effectively lost. The assumption of command by GM Richard Welch 28.64 Before returning to examine DAC O’Loughlin’s actions in command, it is necessary to refer to the parallel assumption of command by GM Welch at around 02.00, the defining feature of which was that he purported to relieve SM Loft, who was not, and never had been, incident commander. Remarkably, GM Welch did not first seek to confirm with SM Loft that he was in command (which in fact he was not). This unfortunate episode, in which there were two incident commanders each operating in ignorance of the other, illustrates not only the extent of the confusion about who was in command of the incident at 02.00 or thereabouts, but also the potentially serious consequences that might have ensued if they had given contradictory orders. Thankfully, that did not happen, but the potential for confusion would have been avoided if GM Welch had asked SM Loft whether he was, in fact, the incident commander and followed the basic requirements of PN431 governing the handover of command. 28.65 Like SM Walton, GM Welch’s view of the possibility of a full evacuation was negative. He said that he had no reason to think that the compartmentation of the building was failing and that fire might be spreading internally because “it’s not something that we see”.45 He had not thought, on his arrival, that the fire was penetrating flats and throughout the brief period he was acting as incident commander he thought that the fire was remaining on the exterior, although he had not been into the building to investigate.46 He considered that the calls from the tower were from occupants in a panic about smoke coming in through their open windows.47 The handover of command to AC Roe 28.66 When he assumed command at 02.43 AC Roe was briefed by DAC O’Loughlin about the state of the fire, the command and organisational structure that had been implemented as well as about the arrangements for the supply of BA equipment. Although AC Roe had assumed command with a clear idea of the strategy to be adopted (to which I turn later in this chapter), it is regrettable that DAC O’Loughlin did not tell him that no information had come back to CU8 from either the fire sector or CU7 for the previous 25 minutes. That piece of information might have identified, at the start of AC Roe’s time in command, the communication difficulties that were hampering an informed response to the incident. 45 Welch Day 44/72. 46 Welch Day 44/55/4-56/1 and notes from 3 July 2017 PRC meeting [LFB00003117] p. 17. 47 Welch Day 44/55/20-56/1.

Part III | Chapter 28: The Incident Ground 611 5 DAC O’Loughlin as incident commander 28.67 DAC O’ Loughlin assumed incident command at around 01.56 and remained in that role until 02.44, when AC Roe took over. It was during his time in command that the principal failures of the LFB up to that point became a continuing and ineffective strategy. In summary, the failures were distinct but closely related: not revoking the “stay put” advice (and instructing the control room accordingly), not adopting an evacuation strategy as far as resources and the internal conditions would allow, and continuing to carry out targeted rescues in circumstances where the FSG information was changing and unreliable and there was no effective communication between the control room, the bridgehead and himself. DAC O’Loughlin concentrated on establishing command structures, but he did not gather the available information about conditions inside the building, fire spread, the nature, number and source of FSG calls and the results of BA deployments before formulating a strategy based on it. A sophisticated command structure was of little value unless it supported an informed strategy for fighting the fire and rescuing occupants. Although, ordinarily, command decisions about how to tackle a substantial fire should not normally be made in the absence of an appropriate command and control structure, there will be rare occasions (such as the fire at Grenfell Tower) when the urgency and threat to life is so great that decisions need to be made before such a structure has been established. 28.68 DAC O’Loughlin’s period in command was marked by a number of errors. First, on taking command he did not discuss the strategy then in place and examine whether it needed to change. Given the information available at 02.00, that was a serious mistake. Although during his journey to the tower he had heard over his Airwave radio numerous FSG messages being passed to CU8, he did not consider whether the “stay put” advice needed to change. Indeed, he did not discuss that subject at all in the course of the handover with either WM Dowden or SM Walton. He told the Inquiry that his reason was (or “would have been”) that there had been people in their flats who were unaffected by smoke, heat or fire and were in a safe environment. He said that he had had no reason to think that those on the south-west corner of the building would be at risk (i.e. the “Flat 3s”) either from external fire spread or from internal smoke spread across lobbies.48 He would, on the other hand, have expected those on the north-east corner (i.e. the “Flat 6s”) to have left their flats.49 However, these were unverified and erroneous assumptions. Had he spoken at the start of his command to OM Norman in the control room, or indeed WM Meyrick on CU8, he would have discovered that before 02.00 no fewer than seven FSG calls had come from “Flat 3s”, including two on floors 22 and 23 (Flats 193 and 203), and five FSG calls from the “Flat 4s”, i.e. on the west side of the tower, including two calls from Flat 194 (on floor 22) and two calls from Flat 204 (on floor 23).50 28.69 It was not until 02.41, just before AC Roe took over command, that DAC O’Loughlin became aware of the number of FSG calls that had been received and the number of occupants trapped in the building, when CU7 sent a runner to CU8 to tell him that there were as many as 58 adults and 16 children trapped. DAC O’Loughlin said that that had come as a complete surprise to him. He had thought the number was in double figures, but the figure he was 48 O’Loughlin Day 47/136/22-138/7. 49 O’Loughlin Day 47/138/7-12. 50 That of course assumes that the control room and CU8 were collating the FSG information in an organised way, which is itself a matter of doubt.

The Grenfell Tower Inquiry: Phase 1 Report 612 given was “an horrendous number”.51 However, despite his surprise, he continued to believe that there were flats where occupants remained safe, and called for a “clear briefing” on how the fire had progressed since he had last seen it.52 28.70 Secondly, if he had been able to establish contact with the NPAS helicopter, even by radio, he would have discovered that flats on the west and south-west aspects of the tower were affected by fire. At 02.07.25 there was a message that “flats [sic] from 115 are trapped, unable to get out”, and at 02.09.32 the NPAS helicopter reported that “residents on the top 6 floors of the west and south-west aspect all leaning out of open windows, they will be in danger of the fire inside”. At this point DAC O’Loughlin was still of the view that flats on the south-west corner would provide refuge for those in them.53 That shows not only how important it was for him to have had the heli-tele downlink in operation at that time, but also that the NPAS helicopter was a vital source of visual information available to him that he did not try to use. There is no evidence that he made any effort to establish contact with the helicopter to ask the crew to tell him what they could see which he could not. 28.71 Thirdly, DAC O’Loughlin knew from the moment he arrived that the fire was spreading extensively on the exterior. It was, as he put it in his contemporaneous notes, “wrapping round the building.”54 However, he appears to have laboured under the mistaken impression that compartmentation had not wholly or substantially failed. His error resulted from a failure to pay adequate attention to whether the fire was breaking into the interior of the building. DAC O’Loughlin’s evidence about his knowledge of that important development was inconsistent. His recollection as recorded in the notes of the PRC meeting on 3 July 2017 was unambiguous: “Fire was in flats. No clear indication of how many involved”.55 However, the gist of his subsequent witness statement was that he had thought that the cladding had caught fire and had burnt away and that the fire had remained on the outside of the building and had not got into many, if any, flats.56 When he came to give evidence in person, he settled for a position somewhere between those extremes. He said that he had known that there was a risk that fire and smoke would get into flats through open windows and that although he had not expected that the fire would penetrate flats where the windows were closed, the risk of that happening was “on his radar” and something that he needed to establish.57 He had been well aware in general terms that there were a number of FSG calls from the building in progress because he had heard them over his Airwave radio on his way to the incident. He had also been well aware that there were occupants trapped on high floors and were affected at least by smoke.58 He said that he had understood from the radio messages about FSG calls that the “products” of fire (presumably hot gases and smoke) had got into some of the flats,59 but he also said that he did not think that fire would “necessarily” be getting in.60 That was hard to follow. His evidence struck me as an unsuccessful attempt to reconcile what he had heard by way of FSG information with his assertion that he had not realised that the fire had broken into the interior of the building, possibly extensively so. When asked about his conversation with GM Welch on CU8 he said that he had not been able to see the fire breaking into flats, but from the contents of the FSG messages he had assumed that it was. 51 O’Loughlin Day 47/240/1-241/18. 52 O’Loughlin Day 47/244/6-23. 53 O’Loughlin Day 47/137/9-139/9. 54 [MET00005213] paragraph 10. 55 [LFB00003117] p. 19. 56 [MET00012563] p. 8. 57 O’Loughlin Day 47/52/17-53/1. 58 O’Loughlin Day 47/41/24-42/2, 45/6-47/15. 59 O’Loughlin Day 47/48/11-18. 60 O’Loughlin Day 47/50/12-18.

Part III | Chapter 28: The Incident Ground 613 28.72 To be fair to DAC O’Loughlin, there were others present on the incident ground who also thought that the fire had not penetrated the interior, including GM Welch and probably also SM Walton. However, as he accepted, given what he knew from the FSG calls, it was his responsibility to establish the extent to which that had occurred and to gather as much information as he could about conditions inside the building. The fact is that he did not do so. 28.73 Furthermore, the question of whether the fire was or was not limited to the exterior of the building, although vital, was not the only question. Another question of equal importance was the smoke conditions in individual flats and particularly whether the air continued to be safely breathable or there was an appreciable risk that flats were becoming unsafe for their occupants. It is clear that by 02.00 there were many occupants of flats throughout the building who were experiencing significant smoke ingress, either from the lobbies, under and around their front doors or from the windows. DAC O’Loughlin did not address that question, although the information was available from the various 999 calls and from firefighters returning to the bridgehead. It was critical to balancing the risk of advising occupants to leave their flats and entering smoke-filled lobbies and a deteriorating staircase against the risk of advising them to remain in increasingly smoke-filled flats. For much of DAC O’Loughlin’s command that was to say the least a difficult choice, but it was one that needed to be confronted with the fullest information possible.  28.74 Fourthly, DAC O’Loughlin’s assumption that there had been no failure of compartmentation affecting the whole building and that there were still flats in which the occupants remained safe resulted in his continuing with a strategy of targeted rescues rather than calling for a full evacuation. That strategy, such as it was, does not appear to have been the result of any specific decision by DAC O’Loughlin; rather it was a continuation of the strategy that had evolved under WM Dowden, SM Walton and GM Welch. It was also inconsistent with his own evidence that in the case of a 40-pump fire61 the whole building would have to be evacuated.62 It was pursued in the absence of proper information, because he had received no reports from the bridgehead about conditions in the building and he had received no information from the control room about the nature, number and source of FSG calls. There were other officers present, such as SM Egan and possibly also WM Harrison, who expressed the view at or shortly after 02.00 that the “stay put” advice should be revoked and a full evacuation ordered, but their views were never discussed with or considered by DAC O’Loughlin.63 28.75 That raises the question why DAC O’Loughlin did not revoke the “stay put” advice and order a full evacuation of the tower either upon or soon after taking command. The answer is because at no stage did he obtain a proper understanding of the nature of the conditions inside the building, whether from information available from FSG calls, information obtained by the bridgehead from crews returning from rescue operations, or information available from the control room. The value of the information available from the control room is demonstrated by the decision of SOM Joanne Smith, taken at around 02.35 in conjunction with DAC Adrian Fenton, to advise everyone to leave, come what may. It was made at a place remote from the incident ground with no visual aids to help them understand what was happening and no information from the bridgehead about conditions within the building. Yet the information they were receiving from callers was sufficient to convince them that nowhere in the building could be regarded as a place of safety and that the “stay put” advice should be revoked. 61 As it was at 02.03 [LFB00002631]. 62 Day 47/124/20-125/15. 63 Note also the fact that, as referred to above, FF Murray was using a loudhailer at around 01.40 to advise occupants to leave the tower, although it is not clear on whose orders he was acting.

The Grenfell Tower Inquiry: Phase 1 Report 614 28.76 The whole of DAC O’Loughlin’s period in command was devoted to establishing a command structure from a single location inside CU8, which he entered at around 02.03 and did not leave until after AC Roe had taken over command at 02.44. DAC O’Loughlin’s contemporaneous notes describe what he did by way of sectorisation and delegation of duties.64 Although it may all have been in accordance with LFB incident command policy, the consequence of his actions was that at no point was he able to make an informed assessment of what was happening in the building. His surprise on learning at around 02.41 of the number of people trapped in the building and his need at that stage for a “clear briefing” on the progress of the fire, demonstrate how out of touch he had been up to that point. His role as incident commander required him to ensure that all the appropriate systems were in place and (so far as he could ascertain) were properly functioning, particularly in relation to the management of FSG calls. He said in evidence that he had considered that there was an effective system for managing FSG information, but it is not clear how he had satisfied himself that that was so. 6 AC Roe as incident commander Revocation of the “stay put” advice 28.77 By the time AC Roe assumed command, the fire on the exterior of the building had spread from the north face and had started to burn down the west face. In relation to the stairs, there was black smoke as high up as floor 23 with very poor visibility and no light from somewhere between floors 2 and 4 to the top of the building. By that time it was no longer practicable to carry out a supervised mass evacuation due primarily to the deterioration in conditions in the stairs. In those circumstances AC Roe’s strategy of carrying out individual rescues in response to FSG calls was the only practicable means of saving those who remained trapped in the tower. 28.78 The first thing AC Roe did on assuming command was to revoke the “stay put” advice. His decision was based on his assessment of the extent to which the fire had spread and what he considered to be a total failure of compartmentation.65 He considered that the “stay put” advice was “absolutely unsustainable”.66 As he put it: “We were no longer going to be able to reasonably advise people they should stay put. That was the first thing in my head”.67 However, when asked what advice the control room should then have given he gave a more qualified answer which recognised that some people might do better to remain in their flats.68 That qualification was not consistent with his decision to revoke the “stay put” advice to all callers from the building and his view that that advice was “absolutely unsustainable” and “unreasonable”. The strong terms in which he expressed the need to change the advice (and the speed at which he did so on assuming command) strongly suggest that DAC O’Loughlin’s continued maintaining of the “stay put” advice, at least towards the end of his time in incident command, was incapable of being defended. 28.79 AC Roe’s decision to revoke the “stay put” advice was made independently of the decision made in the control room. It was made without hesitation, based on what he could see in front of him. He considered it unnecessary to discuss the matter with the control room because he was sure in his own mind that such advice could no longer properly be given.69 He acknowledged that by telling callers to leave there was a risk of sending them into a smoke- 64 [MET00005213] paragraph 11. 65 Roe Day 49/19/18-21. 66 Roe Day 49/26/8. 67 Roe Day 48/231/3-6. 68 Roe Day 49/10/19-11/14. 69 Roe Day 49/7/19-8/11, 26/7-8.

Part III | Chapter 28: The Incident Ground 615 logged environment. He said that he had grappled with that dilemma, but had concluded that compartmentation had failed to such an extent that it was impossible to see how any flat in the building could be relied upon to provide a safe environment.70 In his view, anyone in the building above floor 4 was “in great danger”.71 AC Roe’s strategy 28.80 AC Roe’s strategy was to flood the building with as many EDBA wearers as were available and to provide as much assistance as possible to the remaining occupants. The strategy was both bold and necessary. However, it meant that firefighters would be deployed into the tower without any firefighting equipment, which was both contrary to policy and created a very significant risk to their safety. 28.81 It was not a wholly unsuccessful strategy, in that some 36 occupants escaped from the tower between 02.53 and 08.07,72 including eight from floors 21 and 22 and eight from floor 18. Although AC Roe did not consider how those who had previously been told to stay put or those who were not in contact with control could be told that they now had to leave the building, his plan to send EDBA wearers into the building to assist the evacuation of all the remaining occupants was a partial solution to that problem. 7 Communication and use of FSG information 28.82 It is necessary to examine two particular aspects of the way in which FSG information (i.e. information from or about callers from the tower) was managed once it reached the incident ground. The first is the system for receiving and recording that information and communicating it to the bridgehead; the second is the system for recording it at the bridgehead and the manner in which it was used to implement rescues. The system for managing FSG information 28.83 There were principally two, but in practice sometimes three, methods by which FSG information was transmitted from the control room to the incident ground: by radio, by an admin line call and by mobile telephone call from SM Jason Oliff to WM Meyrick. Each of these methods originally resulted in information reaching CU8 or (from around 02.20 at the latest) CU7. Sometimes all three methods were employed at the same time. 28.84 From the command unit the information was transmitted to the bridgehead by various means which changed over the course of time. Differences of recollection and the absence of any means of ascertaining times with any accuracy make it very difficult in the case of some FSG calls to piece together exactly how the information passed down the chain of communication and when. The best description of the basic system, such as it was, that can be given on the basis of the available information is as follows: a. CU8 arrived at 01.30.48. When it was in operation WM Meyrick received FSG information from the control room on the main scheme radio and by the admin line and passed that information by radio to WM Mark Kentfield, who was standing near the tower. WM Meyrick recorded the information he had received on a blank piece of paper. WM Kentfield wrote down on pieces of A4 paper the information he had been given by 70 Roe Day 49/15/17-16/10. 71 Roe Day 49/12/12-13/2. 72 The total number of occupants escaping after the control room revoked the “stay put” advice at around 02.35 was 46.

The Grenfell Tower Inquiry: Phase 1 Report 616 WM Meyrick and gave them to SM Loft. At that time there was no system in place on CU8 for collating FSG information in one place. b. It is not entirely clear how information passed from SM Loft to the bridgehead at this time. Until around 02.17 the bridgehead was on the second floor and in the early stages of the incident there was “an incident plan board” there. It is likely that SM Loft relayed the information using channel 3 of the fireground radio. The pieces of paper contained lists of flats and one of them may have been the so-called “Sadler envelope”.73 SM Loft received two or three such sheets of paper from WM Kentfield while he was carrying out that role. It was because some of them lacked flat numbers that at around 01.49 SM Loft took a photograph of a plaque showing flat and floor numbers that was fixed to the wall of the ground floor lobby.74 c. When WM Louisa De Silvo arrived at the bridgehead at 01.50 she was told to keep a record of the FSG information received by the bridgehead and was given an FIB which had a list of flats on it. WM De Silvo received FSG information directly by radio,75 as well as by pieces of paper carried to the bridgehead by “runners” such as CM Batterbee. She kept a record of the information on the FIB. It appears that some FSG information had already been recorded on the wall of the lobby on floor 2 by FF O’Beirne before her arrival.76 d. Some time after 02.10 but before 02.22,77 CU7 was established as the designated FSG call-handling command unit. SM Egan and WM Harrison moved to it, taking with them the 30 or so pieces of paper containing the FSG information that WM Meyrick had recorded together with the plaque that WM Kentfield had by then removed from the wall of the ground floor lobby and brought back to CU8 earlier.78 e. At some point shortly before 02.13 WM Kentfield instructed WM Paul Sadler to set up an “FSG point” to collate information before transmitting it to the bridgehead. WM Sadler made use of the bonnet of a car parked near the south-east of the tower as a desk. He obtained a control information form (quadruplicate) pad and a forward information board to record the information he received and sent CM Batterbee to the bridgehead to check that the FSG information held there was the same as that which he had. CM Batterbee copied the information on the forward information board at the bridgehead and recorded it in his notebook.79 WM Sadler received FSG information from CU7 (and probably CU8 as well) both by fireground radio on channel 3 and on control information forms brought to him by runners. He then recorded that information on a control information form and sent the white top copy by runner into the tower. He used a second runner to take the yellow copy back to CU7, retaining the blue and green copies in his own possession. He also transmitted information by radio to the bridgehead. Shortly after he had started to carry out that role he saw what became known as the “Sadler envelope”, which he photographed on his mobile telephone at 02.19. He then used the photograph to transcribe the information onto control information forms. 73 [MET00016967]. 74 [MET00015644]; CCTV image [INQ00000302]. 75 De Silvo witness statement [MET00010913] p. 6. 76 [MET00013074]. 77 It was at 02.22.54 that CU7 sent the radio message to the control room asking for all FSG messages to be sent to CU7 [LFB00002301]; SIL p. 22. 78 CCTV image [INQ00000360]. 79 [MET00015731].

Part III | Chapter 28: The Incident Ground 617 f. Meanwhile from around 02.15 WM Glynn Williams had set up a system inside the tower for recording FSG information using the wall of the ground floor lobby. WM Williams received information sent into the tower by WM Sadler as well as from CU7, wrote it on the wall and then shouted it up to WM Watson who was based on the second floor mezzanine. WM Watson then wrote down the information, originally on the mezzanine wall, but later in his notepad, and then briefed crews to go to the bridgehead for deployment in response to those FSG calls. He kept no record of which slips he had given to which crews. g. WM Williams did not have an Airwave radio and, due to the congestion on the fireground radios, his preference was to receive information on paper.80 In the main he received it in the form of white control information form sheets from runners directly from CU7.81 He also received control information forms sent into the tower by WM Sadler, but it is very difficult to identify which, if any, of those seen by the Inquiry he received by that route. Indeed, WM Williams did not even know that WM Sadler was operating as an intermediate FSG link outside the tower.82 h. WM Williams recalled that when he had started handling FSG information he had seen a list of numbers that CM Batterbee had brought to him from the bridgehead which he said he had cross-checked against the FSG information he had recorded on the wall. However he did not see the “Sadler envelope” and in any event the first numbers he wrote on the wall did not match what was on it.83 i. Although WM Williams said that he attempted to prioritise responses based on vulnerability and age,84 the information with which to do so was often incomplete and it was a matter of chance to which floors crews were sent, particularly higher up in the tower.85 In fact, throughout the night he responded to calls in the order in which the information had arrived.86 j. Once WM Watson had briefed a crew, he would shout down to WM Williams the number of the flat to which he had sent it and WM Williams would write “BA” next to the flat number on the lobby wall. k. The results of deployments were sometimes collected by WM Williams from returning crews and where he had done so he placed a tick next to the relevant flat on the lobby wall. Much of the same procedure was used by WM De Silvo at the bridgehead, but it was unreliable due to the physical condition of many of the returning crews. In no case did WM Williams report back to CU7 the results of a deployment because it was “nigh on impossible” for him to match flats to which he had called for deployments to survivors coming out of the tower.87 28.85 After 02.22, when the control room began sending FSG information to CU7, the communication and collation system seems to have been as follows: 80 Williams Day 31/62/13-64/10 and Williams witness statement [MET00008045] p. 7. 81 Williams Day 31/67/22-68/3, 69/9-23. 82 Williams Day 31/76/14-15, 129/4-8. 83 Williams Day 31/77/18-79/13. 84 Williams Day 31/57/12-19. 85 Williams Day 31/59/14-60/2. 86 Williams Day 31/166/9-20. 87 Williams Day 31/107/8, 172/1-6.

The Grenfell Tower Inquiry: Phase 1 Report 618 a. WM Antony Peckham received FSG information from the control room by main scheme radio channel 4; he wrote the details down on control information forms, which he passed to other officers in CU7. b. WM Meyrick continued to speak to SM Oliff in the control room by mobile telephone and transmitted the information he received by fireground radio to WM Sadler in place of WM Kentfield, who had left for CU8 at around 02.30. c. Information was also carried directly to the bridgehead from CU7 by runners, such as WM Shaun Coltress and FF Mandeep Singh; it was also carried to WM Williams in the ground floor lobby, sometimes via WM Sadler. At around 04.00, SM Peter Wolfenden, who by then was assisting WM Williams, established a clear radio link to CU7. He received FSG information by that radio link and recorded it on the white wall of the ground floor lobby.88 It is not clear why a direct radio link had not been established earlier. WM Williams was confident that any FSG information that reached him had been sent to the bridgehead, although there is no way of verifying that.89 Certainly, not all FSG information did go to him; for example, FF Singh noted some FSG information on a piece of paper from his firefighter’s notebook showing “15th floor 122 x2 people x 2 dogs”.90 That piece of paper was not seen by WM Williams and the information was not added to the wall of the ground floor lobby. d. It is possible that within CU7, FSG information was from that time also recorded on the laminated board in CU7,91 which was replaced with the grid whiteboard system from around 03.00.92 Although WM Williams did not send any information back to CU7, GM Goodall on CU7 did receive the results of some deployments, because once his grid system had been set up he was able to record whether BA wearers had gone to particular flats.93 That information came from runners coming back to CU7 or by radio to SM Egan or from information obtained from rescue centres later in the night. However, the evidence about that is very unclear.94 WM Harrison recorded the information on the whiteboards. 28.86 After the bridgehead had moved up to the lobby on floor 3 at around 02.17, WM De Silvo gave up using a forward information board to record FSG information and began using the lobby wall.95 She put a tick against a flat to show that it had been visited, a circle indicated that further information had been received and a cross through the flat indicated that it had been searched and a rescue carried out. 28.87 After the bridgehead had moved down to the ground floor lobby at around 03.10, the system continued in substantially the same way: FSG information was passed by WM Williams or SM Wolfenden to WM Watson, who passed it to GM Welch and GM Patrick Goulbourne at the bridgehead, which was by then at the foot of the stairs by the green wall. FSG information was recorded on the green wall there by WM De Silvo and others. 88 Williams Day 31/153/4-20. 89 Williams Day 31/158/8-11. 90 [MET00013089]; Williams Day 31/160/15-161/6. That was a reference to Steven Power, the resident of Flat 122. That flat was referred to with the information “smoke-logged” in the middle column of his wall list. WM Williams said that that came from the command unit (which was CU7): Williams Day 31/162/9-22. 91 For example, [MET00015930]. This could in fact have come over from CU8. 92 [MET00015934]. 93 [MET00015924]. 94 Goodall Day 35/80/3-81/18. 95 [MET00015819].

Part III | Chapter 28: The Incident Ground 619 Defects in the system 28.88 It will be readily apparent from this broad and necessarily incomplete summary of what occurred that successive incident commanders and others responsible for managing FSG information failed to establish a clear and efficient system at the incident ground for receiving, recording and transmitting such information to the bridgehead and recording the results of deployments to individual flats. Far too much was left to the initiative of individual officers, who improvised methods of handling information that were disorganised and, in some cases, inconsistent with each other. Individual officers worked extremely hard to implement as good a system as they were able to devise under very difficult circumstances, but the fact remains that they were acting on their own initiative and with very little understanding of how their roles fitted into the wider chain of communication. As a result it is very difficult to trace the movement of any particular piece of FSG information from the point at which it reached the command unit96 to a deployment from the bridgehead. 28.89 That deplorable state of affairs can be attributed to a number of factors. First, there were at least two, and possibly three, separate lines of communication between the control unit and the ground floor lobby, where a separate position had been set up for collating and managing the information. Although that may have reflected in part the fact that there were two or three lines of communication coming into the command units from the control room, that did not justify the officers on the command units in sending FSG information to the tower by different means and by different routes. No one appears to have noticed that that in itself posed a risk of duplication and loss of information and therefore no one attempted to impose some order on it. It continued all night: there was never a time when a single line of communication was established by which all FSG information travelled from CU7 to the bridgehead. As a result, the officers at the bridgehead continued throughout to receive FSG information both by radio and on slips of paper. 28.90 Secondly, there were too many links in the chain between the command units and the bridgehead. It is hard to know whether WM Sadler’s activities outside the tower helped or hindered the management of FSG information, but it created a risk of confusion and duplication, particularly because there were at certain times two routes by which FSG information was being passed to him by the control units. Moreover, he communicated with the tower both by radio and by the use of runners to carry sheets of paper, which increased that risk yet further. 28.91 Another link in the chain was the introduction of WM Williams receiving and recording information at the ground floor lobby wall. WM Williams’ record was only as good as the information that he had received, which came from at least two sources: on paper from WM Sadler or CU7 and later in the night by radio. To add to the confusion, some information on paper went by runner directly from CU7 to the bridgehead without going past WM Sadler or WM Williams and was therefore not recorded by either of them. 28.92 Thirdly, at no stage was the bridgehead in direct contact with either command unit. The evidence about the source of the information recorded on the walls of the lobbies on floors 2 and 3 where the bridgehead was located was not clear, other than that those sources did not remain constant. Again, the reliability of information reaching the bridgehead depended on the last link in the chain. 96 Which is itself difficult to link with particular 999 calls coming into the control room.

The Grenfell Tower Inquiry: Phase 1 Report 620 28.93 The variety of methods used to record FSG information on the relevant command unit and on the incident ground meant that it was not possible to keep track of what was coming in, let alone what was going out. That meant that if anyone had wished to check with the command unit whether an FSG call from a particular flat had been passed to the bridgehead, it would not have been possible to do so until after the grid system had been established after 03.00. Even then there was no record of when the relevant information had left the command unit, where it had gone and by what means. The use of control information forms on the incident ground (although required by the terms of PN790)97 did not make things any easier, as an attempt during the hearings to trace the movement of some of the information on WM Sadler’s control information forms to WM Williams’ wall attested. In these circumstances, any tried and tested method of recording information would have proved problematic and human error was likely. 28.94 Fourthly, there was no overall command structure from the outset. During the first hour of the incident many officers decided for themselves what tasks to perform or to whom to delegate tasks. A good example of that is the way that the links in the chain developed. WM Kentfield decided to instruct WM Sadler to pass messages to the bridgehead but left it to WM Sadler to devise a system for doing so. SM Loft had agreed with WM Dowden that he would take overall responsibility for managing FSG information, so he should have regarded himself as an FSG co-ordinator as contemplated by paragraph 7.6 of PN790, which required him to “collate, record and retain all the information on FSG calls received”. Although that may in practice have been an impossible task for one officer, given the volume of FSG information constantly coming to the incident ground, the function still needed to be carried out. There was never any attempt to establish a coherent and all-embracing system for gathering and communicating FSG information under the supervision of one officer. A stark illustration of the absence of effective command and control was the fact that it was not until around 02.41 that DAC O’Loughlin discovered the number of FSG callers still in the tower, which came as a surprise to him. 28.95 Fifthly, many of the physical or electronic systems on the command units were not working, such as the CSS and the heli-tele downlink. According to paragraph 7.4 of PN790, the CSS was meant to be used to record messages sent to and from the incident ground, including messages sent by radio relating to FSG calls. Had the CSS worked, it would have given the officers on the command units access to the VISION system maintained by the control room, which included some of the FSG information being received, and to other tactical and command decisions made by senior officers. Remarkably, even before the Grenfell Tower fire, the CSS system had never worked at larger incidents involving more than six pumps. It had a history of unreliability and, despite attempts to get it to work on the night of the fire, it could not be started up.98 The heli-tele downlink from the NPAS helicopter also failed to function, a matter to which I refer in detail elsewhere. Other technology, such as Toughbooks, Meshnode and the “striker camera” with which the command units were equipped did not work either.99 Due to these equipment deficiencies, some of which had been well-known within the LFB for some time, the officers on CU8 and CU7 were deprived of ready access to vital information about FSG calls (the details of some of which were on VISION in the early part of the incident), conditions in or outside the building, and command decisions. Why the LFB was deploying emergency equipment which did not work in accordance with its own policy requirements is a question which will be examined further at Phase 2. 97 PN790, paragraphs 5.7 and 7.1. 98 Johnson Day 37/7/20-11/11. 99 Johnson Day 37/5/8-15/3.

Part III | Chapter 28: The Incident Ground 621 28.96 Lastly, but most fundamentally, there was poor and sporadic communication by the bridgehead to the improvised link points in the FSG communications chain or to the command units of information about the results of deployments to particular flats and no communication at all of such information to the control room. The “information loop” from the control room, to the command units, to the bridgehead, to the command units and back to the control room was never completed.100 That was contrary to PN790, in particular paragraphs 7.10 and 9.1 and 9.3, which emphasise in clear terms the “vital” need for control to be kept informed of the actions being taken to resolve each call. AC Roe, at least, recognised that “the closing of that loop is a very important part of FSG”.101 The failing was particularly serious in this case. The failure of the incident commander, or anyone else, to tell the control room that the fire had spread well beyond the flat of origin meant that the CROs continued to give wrong information and advice to callers because they had no means of knowing whether the advice that they were giving callers was appropriate to the conditions in the building, or whether their frequent assertions that the firefighters were on their way were well-founded or not. It also meant that neither the officers on the command units nor the incident commander had any idea whether individual crew deployments into the tower had been successful and if not, why. There was an attempt at both the bridgehead and by WM Williams in the ground floor lobby to gather that information from returning firefighters and evacuees, and the results were recorded where they could be. Indeed, in the vast majority of cases at least one of the crew members recalled some kind of debriefing at the bridgehead. However, although some information did start coming back to CU7 after around 03.00, once GM Goodall had taken over command of it and had established his whiteboard grid, it was late and piecemeal. No information about the result of deployments was passed back from CU7 to the control room. At no stage was CU7 able to communicate basic details of the fire to the control room. Even rudimentary information about the progress of the fire through the tower would have assisted the CROs to form a collective understanding of the gravity of the incident at an early stage. In the absence of even basic information CROs were left to piece together a confusing and often incomplete picture. 28.97 Although it is plain that the number of FSG calls and the constantly developing information from callers represented a significant challenge to the officers on the fireground,102 that challenge was not insurmountable with the tools that were, or should have been, at their disposal. What was required was a single system of collating FSG information on the relevant command unit, a single and consistent line of communication to the bridgehead, and a single system for ensuring that the results of deployments were communicated to the command units and from them back to the control room. The fact is that the LFB was unprepared for an event involving a large number of FSG calls, despite the lessons which were said to have been learnt from the Lakanal House fire. In short, the LFB failed to put in place an adequate system on the incident ground for handling FSG messages. Some consequences of the defects 28.98 The chaotic nature of the communication links meant that neither the control room nor the command units nor the incident commander could know whether rescue attempts had been made in response to calls, or if they had, what had been the outcomes. 100 For example, Goodall Day 35/120/10-123/9. 101 Roe Day 48/247/3-4. 102 As GM Goodall explained in his evidence at Day 35/120/10-123/9.

The Grenfell Tower Inquiry: Phase 1 Report 622 28.99 In particular, the fact that neither the incident commander nor the control room had access to any reliable information about the results of rescue missions meant that, when it became necessary to deploy crews for a second time, the bridgehead did not have all the information needed to brief them properly. It also meant that CROs in the control room could not have regard to the results of earlier deployments when deciding what advice to give callers. 28.100 It is not possible to catalogue comprehensively all the consequences for particular individuals or flats or floors of the inadequacies in the systems for handling FSG call information, but two in particular call for comment as being illustrative of a broader picture. The top floors 28.101 Mariem Elgwahry and Naomi Li called the control room (separately) to report a fire on floor 22.103 A service request reflecting those calls was entered at 01.32.29.104 Furthermore, OM Norman spoke to WM Meyrick on CU8 on the admin line at 01.35.24 to tell him that smoke was coming in on the top floor where Mariem Elgwahry and her mother Eslah Elgwahry had by then taken refuge. The “Sadler envelope” contained references to Flats 204 and 205 on floor 23 and Flat 195 on floor 22, but a crew was not deployed to floor 23 until 02.08, when FFs John Wright, Scott Bell and Zade Alassad tallied out.105 In the event, that crew was diverted at floor 10 by the discovery of casualties coming down and as a result did not reach floor 23. There were no further deployments to floor 23 until 02.24 (CM Richard Evans and FF Gemma Bloxham) and 02.51 (FFs Michael Pole, Chris Cheesman and Niki Mitchell, who in fact went to floor 18). There was no deployment to floor 22 until 03.03, just after Naomi Li and Lydia Liao had started to escape, when CM Raoul Codd and FF John Joseph tallied out under instructions to go there. No firefighter ever did reach floor 23, and CM Codd and FF Joseph did not reach floor 22. The family in Flat 142 28.102 Kamru Miah, Rabeya Begum, Mohammed Hanif, Mohammed Hamid and Husna Begum lived in Flat 142 on floor 17. All five members of the family died in the fire. The relevant communications can be identified as follows: a. At 01.29.02 Husna Begum was connected to MetCC after calling 999. She reported that smoke was entering their flat and that they could see flames from their window. The MPS operator told them that they had spoken to the LFB and that someone was coming up to help them.106 b. At 01.38.02 MetCC contacted the LFB control room and told them that smoke was coming into Flat 142 on floor 17 and that there were five people in the flat.107 c. That information was passed to CU8 at 01.43.14 by OM Norman on the admin line, together with information relating to other flats.108 The timing may explain why the information was not on the “Sadler envelope”, which was probably created before 01.40, but it does not appear from the evidence that it was recorded on any piece of paper that went into the tower. It does not appear among the early information recorded on the white ground floor lobby wall after 02.15 either. WM Meyrick may have passed the 103 [LFB00000310]; [LFB00000311]. 104 SIL p. 18. 105 [MET00013074] contains a photograph of the FSG information on the wall of the floor 2 lobby showing Flats 201 and 205. 106 [INQ00000264]. 107 [LFB00000668]. 108 [LFB00002726].

Part III | Chapter 28: The Incident Ground 623 message to WM Kentfield, who delegated the task of sending it to the bridgehead to another Watch Manager, probably WM Sadler.109 Indeed, the words “17th Fl, 142 FSC” do appear on the wall of what is likely to be the second floor mezzanine, where the bridgehead was sited before it moved up to floor 3 at 02.20. However, no deployment was made to floor 17 before 02.20, despite the fact that the information had reached the bridgehead, and by that time the best chance of rescuing the family in Flat 142 had been lost. It is possible that the information was lost in the move of the bridgehead to floor 3, since it does not appear on the wall on the third floor or on any forward information board of which I have seen evidence. d. At 02.27.12 Husna Begum was connected to the LFB’s control room. She told CRO Heidi Fox that they had been waiting for an hour, that the fire was right next to their window and that they were afraid that they were going to die.110 CRO Fox took the flat and floor number and the number of people present and told them that they were not going to die and that she would pass the information to the command unit. e. At 02.29.31 CRO Fox created a service request on the VISION system asking for a radio message to be sent to CU8 relating to Flat 142 and saying: “five adults including 2 elderly persons inside flats”. At 02.30.42 CRO Sharon Darby sent the message to CU7 by radio;111 it appeared as a service request on VISION at 02.31.07. It is not possible to say what happened to that information once it had been received by (at that stage) CU7. Since it was sent by radio, it would have been received by WM Peckham, who made a note of it on a control information form,112 but there is no evidence about whether he then transmitted it, and if so, to whom. f. Flat 142 appears on a laminated whiteboard on CU7 in a photograph taken at 02.59 showing what looks like 8 (or possibly 7) people as being present, corrected possibly to 5,113 and indeed there is evidence that it was already on that list at 02.32.114 Accordingly, it is clear that by that time the message had got through to CU7 that Flat 142 was the source of an FSG call. The laminated whiteboard might have been brought across from CU8 to CU7 by WM Harrison, but, given the low position of Flat 142 on the list, is likely to have been put there after the move to CU7 had been made. Accordingly, the reference to Flat 142 on the laminated whiteboard probably resulted from Husna Begum’s call at 02.27.12. g. At that time the bridgehead was on floor 3. Flat 142 does not appear on the list of FSG information kept by WM De Silvo on the wall of the lobby on floor 3. The list on that wall contains a gap for floor 17 which was still there when the bridgehead was moved to the ground floor at around 03.10. There is no evidence that the information contained in Husna Begum’s call from Flat 142 at 02.27.12 had been communicated beyond CU7. It is possible that it was captured by the photograph of the whiteboard taken by WM Thomas Furnell which he then showed to WM Sadler who made a note of it.115 It is likely that this was the photograph taken at 02.59 which WM Furnell recognised when giving evidence. If that is so, the information taken from the call at 02.27.12 was received by WM Sadler at some time after 02.59. 109 [MET00023051] pp. 13-14. 110 [LFB00000354]. 111 [LFB00002784]. 112 [LFB00001955] p. 12. 113 [MET00015930]. 114 According to Inspector Thatcher’s body-worn video. 115 Furnell witness statement [MET00008022] pp. 4-5.

The Grenfell Tower Inquiry: Phase 1 Report 624 h. Husna Begum and her brother made a further 999 call which was taken by CRO Yvonne Adams at 03.09.18.116 She said that there were five people in the flat and that there was fire in the kitchen and hallway of the flat. CRO Adams advised her to “make a run for it”. There is no record of this call being passed to CU7. i. At 03.18.45 Husna Begum made a further call and spoke again to CRO Fox, who advised the family to leave.117 The caller said that they were unable to do so and that there were five people in the flat. CRO Fox said that she would “tell them on the radio”. There is no entry on the SIL of any service request to that effect and no other record of any such radio call. j. However, Flat 142 appeared as an entry low down on SM Oliff’s second whiteboard and therefore it is likely that the information was transmitted by him by mobile telephone to WM Meyrick on CU7 at some point after around 02.33 when the control room whiteboards had been set up and had started operating. It is possible that that entry recorded the call to CRO Fox at 02.29.31 (in which case it was duplicated with CRO Darby’s radio message), but it is much more likely, in view of its low position on the second whiteboard, that it reflected one of the later calls made by Husna Begum at 03.09.18 and 03.18.45. At both of those times SM Oliff was still speaking to WM Meyrick on his mobile telephone.118 Flat 142 also appears on the whiteboard grid on CU7,119 showing five persons and a “P” for priority, which might indicate the presence of elderly persons.120 The photograph of the whiteboard grid was taken between around 03.15 and 04.00. It is therefore at least possible that it recorded the FSG information contained in Husna Begum’s call at 03.18.45. That is also consistent with WM Peckham’s notation of Flat 142 on the yellow sheet of a control information form at 03.23 showing five persons in Flat 142.121 k. CU7 received information that there were five people in Flat 142 and entered it in the whiteboard grid. The information may have come from the MPS, because there was an MPS memo referring to Flat 142, floor 17 and six people.122 However, on balance I think it more likely that the information reached WM Meyrick on CU7 from SM Oliff in the control room by mobile telephone and was then recorded by one of the officers on the whiteboard grid and also by WM Peckham on the yellow control information form. (Matters are confused by the fact that on a blue copy of the relevant control information form somebody has superadded “8 people”.)123 l. Critically, however, the information received by CU7 does not appear to have reached the bridgehead until later. By the time Husna Begum made her last call at 03.18.45 the bridgehead had moved to the ground floor. It appears that the information about Flat 142 did reach WM Williams at some time after 04.00,124 because it appeared on the right-hand part of the wall in the box for floor 17.125 The inscription “142” also appears on the green wall on the ground floor by the bottom of the stairs (the location of the 116 [LFB00000408]. 117 [LFB00000419]. 118 On the call lasting 1 hour and 35 mins starting at 02.44. 119 [MET00008663]. 120 The information about there being elderly persons was not given in the call at 03.09.18 but only in the call at 03.18.54. 121 [LFB00001955] p. 13. 122 [LFB00001968] p. 11. 123 [LFB00001955] p. 14. 124 [MET00005776]. 125 WM Williams said that the right-hand grid format on the white lobby wall was not put up until the latter stages of the incident, between 04.00 and 04.30: Williams Day 31/101/6-103/6.

Part III | Chapter 28: The Incident Ground 625 bridgehead) in a photograph taken by GM Michael Mulholland at either 04.45 or 04.49.126 It is not clear when it was put there. 28.103 This intricate tracing exercise shows that the information obtained from the 999 calls from the family in Flat 142 was successfully transmitted from the control room to the command units but got lost thereafter in the subsequent morass of communications on the incident ground. The information contained in the final call was probably communicated to the bridgehead at some point, but, whenever that was, it was too late. The last deployment of crews who were able to reach floor 17 or above involved FFs Mitchell, Cheesman and Pole, who were deployed to floor 23 between 02.51 and 02.53. They stopped at floor 18 and helped evacuate occupants in Flat 153 when they realised they did not have sufficient air to reach floor 23. The last chance of rescue for the family in Flat 142 lay in the timely communication to the bridgehead of the information provided in Husna Begum’s second call at 02.27.12 and its being acted upon swiftly. The information did eventually arrive, but there is no evidence that it was acted on. 28.104 I doubt that the family in Flat 142 were an isolated case, but their experience reflects a fundamental failure of command and control. It demonstrates that at no stage did any incident commander ask themselves whether every FSG call of which the relevant command unit had been informed had led to a deployment from the bridgehead, and if not, why not. Nor did they ask themselves whether the control room had been informed of the results of such deployments. Had any incident commander, or anybody charged with responsibility for handling FSG calls, asked those questions, it might have been possible to establish a better and closer link between control room, command unit and bridgehead in both directions. It might also have been possible to prompt an early review of the FSG communications structure and, more importantly still, the overall strategy. Deploying crews in response to FSG calls 28.105 The approach adopted by successive incident commanders was one of making deployments in response to individual FSG calls, as opposed to devising and applying a strategy relevant to the whole building. Overall, of the 17 deployments to flats from which FSG calls had been made only three were wholly successful. Two were partly successful, in that some occupants were rescued, and 12 were unsuccessful. It is useful to break this overall picture down by reference to different phases of incident command. 28.106 During the first hour, when WM Dowden was incident commander, no organised deployments were made in response to the mounting number of FSG calls. I bear in mind that until 01.50 little or no FSG information had reached the bridgehead but that in itself is an indication that the system for transmitting FSG information was still in the process of being established and was not functioning fully or effectively during that period. The three crew members that went to floor 20 to rescue Jessica Urbano Ramirez (CM Christopher Secrett and FFs David Badillo and Christopher Dorgu) were acting on their own initiative in response to information that FF Badillo had received from Jessica’s sister rather than any FSG information. Similarly, CM Tillotson’s crew, who ultimately rescued Sharon Laci and her daughter from floor 9, were acting, as I have found, under instructions from CM Tillotson himself rather than on any specific briefing from the bridgehead. None of the other crews deployed during that period was instructed to search and rescue above floor 5, and the five-member Paddington 126 [MET00018739].

The Grenfell Tower Inquiry: Phase 1 Report 626 EDBA crew was sent to the roof of the tower in a vain attempt at firefighting. No crews were deployed to floors 22 or 23 despite the fact that CU8 had received FSG information relating to floor 23 at 01.35.24, and that both appeared on the “Sadler envelope”. 28.107 In the hour or so between WM Dowden’s relinquishing incident command at 01.50 and AC Roe’s assuming it at 02.44 the approach of responding to individual FSG calls remained the same. That approach was only minimally successful. In summary: a. It resulted in fully successful rescues from only two flats to which the crews that rescued the occupants had been deployed: Flat 95 on floor 12 (Roy Smith and his family) and Flat 9 on floor 3 (David Lewis and Mariko Toyoshima-Lewis). b. It resulted in partly successful rescues from two flats to which the crews that rescued the occupants had been deployed: Flat 175 on floor 20 (a child) and Flat 113 on floor 14 (Rosemary Oyewole and Oluwaseun Talabi and their daughter, and Omar Alhaj Ali). However, four occupants from Flat 175 and four occupants from Flat 113 were not rescued. c. The rest of the deployments resulted in the evacuation of occupants other than those of the flats to which they had been deployed, normally as a result of crews coming across casualties from other floors on the way to their assigned destinations. d. Only one EDBA crew was deployed during this period to carry out a rescue, namely FF Tom Reddington and FF Nikki Upton, who were briefed to go to floor 21 but failed to reach it because (at some point) they met Malak Belkadi and helped to take her out. e. Of the 17 SDBA crews deployed from the bridgehead in that period 13 reached the floor to which they had been sent.127 A further crew reached floor 3 as instructed (FFs Oliver Desforges and Wright) but they were then instructed to go to floor 24, which they did not reach. 28.108 It appears that at no stage did the officers at the bridgehead communicate the results of these deployments, or even the overall outcome of the strategy, to CU8 or CU7 or to the incident commander (principally DAC O’Loughlin during this period), nor did the incident commander seek to obtain the information for himself. Certainly, the control room never received any information of that kind. It showed that deployments were not being carried out, either because of an insufficiency of EDBA wearers (although CM Evans and FF Bloxham may have got up to between floors 18 and 20 after 02.20), or because crews were being diverted on the way up by deciding to rescue people they encountered on the stairs instead of making their way to the flats or floors to which they had been deployed. There was also a marked slowing of deployments above floor 14 between 02.15 and 02.44, with only four deployments to those floors.128 The control room did not receive any of that information. 28.109 After AC Roe assumed command at 02.44 there were no successful rescues from flats to which crews had been deployed in response to FSG information. a. Very few SDBA crews reached the floors to which they had been despatched and they carried out no rescues from any of them. Only one SDBA crew appears to have reached floor 15 (FFs Ricky Nuttall and Leon Whitley, deployed at 02.44). 127 This included the West Hampstead crew of FFs Brian Flanagan and Luke Cook who were sent to take hoses to floor 20. They made it to that floor and did random “door knocks” on the way down (on floors 17 or 18) but did not evacuate anybody: Flanagan witness statement [MET00007765] pp. 5, 6. 128 CM Evans and FF Bloxham to Flat 205 at 02.20; FFs Nuttall and Whitley to Flat 122 at 02.44; FFs Upton and Reddington were deployed at 02.44; and FFs Cheesman, Pole, Jessamine Bate and Mitchell were also deployed by 02.53.

Part III | Chapter 28: The Incident Ground 627 b. There were numerous floors on which rescues were carried out by crews who had been sent to other floors, for example: i. FFs Reddington and Upton, who had been sent to floor 21, rescued Malak Belkadi in the stairs. ii. FFs Richard Peacock and Matthew Harold, who had been sent to floors 5 and 6, assisted casualties on floor 7. iii. FFs Paul Gray, Benjamin Holehouse, Gary Hiscock, Alan Hudson and Daniel Pegram, who had originally been despatched to floor 9, but had been diverted by radio to floor 11, went to floor 10, where they carried out a rescue. iv. After the bridgehead had been moved to the ground floor at 03.17, the first crew despatched (CM Aldo Diana and FF Dean Nelson, an EDBA crew) was briefed to go to floor 16, but got only as far as floor 13. After that there appear to have been no deployments above floor 11. 28.110 Those are no more than examples of the way in which deployments failed to reach their objectives, but they are sufficient to enable some clear conclusions to be drawn. Deployments in response to specific FSG information intended to rescue occupants from particular flats were largely failing. A number of people were rescued from other flats and from other floors, particularly occupants who had left their flats, and that pattern increased during AC Roe’s time in command after the “stay put” advice had been revoked and EDBA crews began to be sent up the tower in any numbers from around 03.20. However, it should have become apparent at an early stage that attempts to rescue individuals from specific flats in respect of which there was reliable FSG information at the bridgehead was not succeeding, because of a shortage of EDBA wearers and because many crews were taking it upon themselves to depart from their instructions in order to assist occupants who had left their flats. In addition, revised instructions were given to crews by radio after they had been deployed, without any records being made. 28.111 A strategy of deploying crews in response to FSG calls at a time when occupants were already leaving the building on their own initiative was, viewed objectively, always likely to have limited success because for understandable reasons crews were likely to depart from their instructions in order to assist occupants that they met on the stairs. Given the inevitably chaotic circumstances, the unreliability of communications between the bridgehead and firefighters and the absence of instantly available replacement crews, the consequence of the strategy pursued by successive incident commanders was that occupants who might have been rescued were not. 28.112 Moreover, although in some cases returning crews were debriefed at the bridgehead, in the vast majority of cases the information they gave was of doubtful reliability because the firefighters were exhausted and in many cases suffering from the effects of heat stress. Many were incapable of speaking coherently and many were in urgent need of oxygen and water. There was no comprehensive or wholly reliable system at the bridgehead for recording information obtained from returning crews or the results of deployments. That in turn meant that the officers at the bridgehead had no reliable means of measuring the success or failure of the strategy. They appear never to have grasped the fact that most of the occupants who had managed to leave the tower had done so largely without assistance or that those who had been assisted to leave had not come from the flats (or often even the floors) to which crews had been sent.

The Grenfell Tower Inquiry: Phase 1 Report 628 28.113 Finally, it is necessary to point out that the effectiveness of the strategy of deploying crews in response to specific FSG information depended critically on the bridgehead not only receiving accurate and timely FSG information but also on its acting on it promptly. There are a number of cases where that simply did not happen, either because the bridgehead acted on unsound information or because it failed to act on sound information. For example, at 04.04.37 SM Cook and CM Ben Gallagher were deployed to investigate reports of 10 people trapped on floor 16 and 11 people trapped on floor 18. The officers did not reach those floors, but they should not have been sent to them at all, because the reports, which cannot be traced to any 999 call or related FSG information, were wrong. It is of course possible that the information came from friends and family outside the tower passing messages to the LFB at various points (such as at CU7), but that only serves to highlight further the absence of a robust system for the flow of reliable FSG information to the bridgehead. 28.114 Flat 113 provides a tragic example of the failure of the bridgehead to act on sound FSG information. After FF Peter Herrera had returned from his deployment to Flat 113 Omar Alhaj Ali told him that he had not rescued all the occupants. FF Herrera passed that information to WM Williams and WM De Silvo, and CM Jamie Mayne and FF Marcus Lundquist were briefed by WM Williams or SM Wolfenden to rescue a woman and child in Flat 113. However, their instructions were changed at the bridgehead and they were sent to fight the fire on floors 3 and 4. It is not clear who at the bridgehead changed their instructions, or why; nor is it clear why CM Mayne and FF Lundquist did not press the case for carrying out the rescue or whether the officer at the bridgehead even knew that he or she was deploying a crew who had already been instructed to carry out a rescue. It is also a mystery why an EDBA crew was deployed to fight the fire low down in the building, a point that exercised CM Mayne at the time but which he felt constrained by his junior rank from raising with the more senior officers at the bridgehead. Since it is highly unlikely that any bridgehead commander would deliberately have preferred to use an EDBA crew to fight the fire low down in the building129 instead of rescuing occupants on a higher, but probably reachable, floor, the decision was probably not deliberate. The decision to redeploy CM Mayne and FF  Lundquist and the confusion surrounding it reflects a failure to process FSG information in a systematic way at the bridgehead (at least by around 03.25) and an absence of a robust command structure there. 8 The use and misuse of EDBA 28.115 There were deficiencies in the management and use of EDBA resources on the incident ground in the following respects: a. The first EDBA crew was deployed for firefighting purposes in pursuance of an objective that it failed to achieve and should have been recognised at the time as unrealistic. b. There was a failure to identify the need for EDBA resources at an early stage and to take appropriate measures to obtain them. c. There was a failure to deploy the EDBA resources that were in attendance promptly after their arrival. d. There was a failure to establish a system that ensured that EDBA resources were used for the purpose of rescues on the higher floors of the tower. 129 Indeed, GM Goulbourne’s evidence was that he would not have deployed an EDBA crew to floors 3 and 4: Day 41/175/8-176/12.

Part III | Chapter 28: The Incident Ground 629 Paddington A216 crew: the “roof” mission 28.116 The nature and circumstances of WM Dowden’s briefing of Paddington’s FRU crew, the first EDBA crew to arrive at the scene at 01.35, has been described elsewhere. When he gave evidence WM Dowden very candidly accepted that in hindsight the task was never going to succeed due to the speed at which the fire was spreading. He also had no information about the layout of, or access to, the roof. Deploying the crew in that way was not a good use of valuable EDBA resources, which could have been deployed to carry out search and rescue operations on the higher floors of the tower or sent to specific flats in response to the FSG calls which by that time had already been received. The need for increased EDBA resources 28.117 The need for EDBA crews was caused by the extent to which fire and smoke were spreading inside the tower and the locations within the tower from which FSG calls were being made. As a result of these factors SDBA crews were running low on air during their deployments and were struggling to complete them: see, for example, the deployments of FF Geoffrey Campbell and FF Steven Mills, who were unable to reach floor 20 and had to turn back. 28.118 The fact that this incident required, or was likely to require, a significant number of EDBA wearers was apparent by the time the request to make pumps 20 and for two FRUs was made at 01.29. By that time the following had taken place: a. CM Jamal Stern had sent an urgent radio message to the bridgehead from the lobby on floor 6 saying that there was smoke and fire there and that firefighting media were needed. As a result, WM O’Keeffe immediately contacted WM Dowden to tell him: “The fire’s jumping”. b. Externally, the fire could be seen to have reached floor 23 and to be developing with a ferocity that WM Dowden described as “just relentless”. c. The control room had received six 999 calls from residents inside the tower, including reports of fire and smoke on the upper floors of the building. d. WM Dowden had seen a number of residents leaving the tower showing signs of smoke inhalation. 28.119 These factors, and specifically the reports of rapidly deteriorating conditions within the building that the bridgehead had received by 01.29, had already led WM O’Keeffe to expect the need for many rescues and to seek to implement a strategy accordingly. However, at that time no officer appears to have recognised that the location of those who needed to be rescued and the extent to which fire and smoke had spread within the building presented particular challenges to SDBA crews. The need for a greater number of EDBA wearers than would be provided by the two FRUs that WM Dowden had requested could and should have been recognised by that time. Despite that, it does not appear to have been discussed during the handover between WM Dowden, SM Walton and DAC O’Loughlin. When GM Welch understood that he was taking over from SM Loft, he was aware that there were some EDBA wearers present, but he likewise took no steps to establish how many or to call for any more. 28.120 Subsequently, WM O’Keeffe did seek to increase the number of EDBA wearers at the incident when he asked GM Welch to request “all the EDBA in London”, when he arrived at the bridgehead shortly after 02.10. It is not clear whether that exchange between WM O’Keeffe and GM Welch prompted the request that was sent on behalf of DAC O’Loughlin by CU8 at 02.11 for six FRUs, or indeed that which was sent at 02.16 for 10 FRUs, but that does not

The Grenfell Tower Inquiry: Phase 1 Report 630 matter. The decision to request more EDBA resources was correct but the additional FRUs did not begin to arrive at the incident ground until 02.29.130 That was over an hour and a half into the incident and an hour after the “persons reported” message had been sent at 01.29. Those requests ought to have been made and implemented sooner. 28.121 GM Welch did not in fact request all the EDBA in London (even if he was responsible for the make-up messages of 02.11 and 02.16), as WM O’Keeffe had told him was necessary. That is particularly significant in light of his observation on entering the tower (and even before he had spoken to WM O’Keeffe) that BA crews would never be able to get to the upper floors and back wearing SDBA, or perhaps even EDBA. 28.122 It is not possible to say whether the failure to ensure attendance by additional EDBA crews at an earlier time had any direct effect on the number of casualties. All BA wearers, both of EDBA and SDBA, who were committed under air over the course of the incident encountered enormous challenges and it does not necessarily follow that more rescues would have been carried out had EDBA crews alone been used. Nonetheless, the failure to take steps to obtain more EDBA crews within the first hour of the incident was a serious omission. Delay in deploying EDBA crews 28.123 A repeated pattern revealed by the telemetry data is that (with the exception of the crew which was sent to the roof to fight the fire) there was a consistent delay between the arrival of EDBA crews at the incident and their subsequent deployment to carry out rescues inside the tower. That delay is particularly remarkable in the case of the first EDBA crews on the scene, when there was a shortage of EDBA wearers. That shortage ought to have led to an effort to ensure that such resources as were available were promptly used, but it did not, as the following shows: a. Chelsea’s FRU, G346, arrived at the incident at 01.47.33. The crew was initially given the task of gathering equipment from parked appliances. FF Alan Sime also assisted in setting up Soho’s ALP. They subsequently waited for some time outside the tower to be deployed. While waiting FF Reddington stressed to SM Loft that the crew needed to be deployed as a matter of urgency and encouraged the rest of the crew to “be more proactive” in getting themselves up to the bridgehead in the absence of any instructions. The crew eventually tallied out at 02.44 (FF Upton and FF Reddington), 03.03 (CM Codd), and 03.27 and 03.29 (FF Sime and FF Ernest Okoh). The failure to deploy the Chelsea crew any earlier was due to simple lack of direction and, in particular, the lack of any system for identifying EDBA resources on their arrival. b. Euston’s FRU, A236, arrived at 02.29.50. None of the firefighters describe doing anything in particular on arrival, apart from locating the BA holding area and finding their way to the entrance to the tower. They tallied out at 03.04 and 03.05 (FF Andrew Brooks, FF James Morcos and CM Charlie Rawlings) and at 03.05 (CM Joseph and FF Codd). That delay was less pronounced than in the case of the Chelsea crew, but in the context was nonetheless significant. Again, the delay appears to have been due to a lack of direction and the absence of an effective system of expediting EDBA deployments. 28.124 Meanwhile, inside the tower, while those and other EDBA crews were waiting, SDBA crews were still being deployed until around 03.03, when the EDBA deployments began in earnest. Despite the fact that the additional FRUs that had been requested at 02.11 and 02.16 started 130 The first FRU to arrive in response to the “make FRUs 6” request was Euston’s A236 at 02.29.50: ORR p. 196.

Part III | Chapter 28: The Incident Ground 631 to arrive at 02.29, only one of the nine crews deployed before 03.03 were using EDBA. It was for the bridgehead to tell SM Daniel Kipling at BA Main Control what resources were required and when, and he was always able to meet the demand. 28.125 It follows that the significant delays between the arrival of EDBA crews and their deployment were not caused by deficiencies in the way BA Main Control was organised. Rather, they resulted from a combination of two factors. First, there was no system for ensuring that EDBA wearers were directed immediately to BA Main Control on arrival, with the result that crews found themselves assisting with menial tasks at various other locations around the incident ground. Secondly, before 03.00 the officers at the bridgehead were failing to ensure that EDBA wearers were sent up to the bridgehead for deployment as soon as they entered the building, rather than waiting in line in the lobby or outside the entrance in the second holding area being managed by SM Loft. Inadequate system for allocating deployments to SDBA or EDBA crews 28.126 Finally, there appears to have been no consistent system for ensuring that EDBA resources were used for deployments specifically to higher floors, and no system at all in the earlier stages of the incident. The bridgehead did not have a significant number of EDBA wearers to deploy to higher floors, initially (until 02.29) because there were only two EDBA crews at the incident and later (between 02.29 and 03.03), because there was no system for ensuring that EDBA crews were despatched promptly into the tower to be deployed. As a result, there was an over-reliance on SDBA crews, which were frequently deployed to carry out rescues from the higher floors of the building. 28.127 For example, the following crews were deployed using SDBA: a. FFs Campbell and Mills were deployed to Flat 175 on floor 20; b. FFs Katie Foster and Gregory Lawson were deployed to floor 18; c. CM Craig Eden and FF Tom Welch were deployed to floor 20; d. FFs Williams and Agnel Fernandes were deployed to Flat 175 on floor 20; e. FFs Cook and Flanagan were deployed to floor 20; f. FFs Desforges and Mitchell were deployed to floor 21; g. FFs Wright, Alassad and Bell were deployed to floor 23; h. CM Evans and FF Bloxham were deployed to Flat 205 on floor 23. 28.128 On the other hand, the deployment of CM Mayne and FF Lundquist, an EDBA crew, to fight fires and clear floors 3 and 4 at 03.29, shows that on at least one occasion EDBA resources which could have been used in an attempt to save life were wasted. 28.129 All BA wearers encountered difficulties of various kinds within the tower and it cannot be said with any confidence that greater use of EDBA would have resulted in a larger number of successful rescues. However, the over-reliance on SDBA crews before 03.03, particularly for the purpose of rescue operations on higher floors, placed unnecessary strain on those firefighters when EDBA crews would have been better placed to carry out those deployments. If, earlier on, the bridgehead had employed a system for managing crews that distinguished clearly between SDBA and EDBA wearers and had allocated deployments accordingly, it could both have reduced the pressure on SDBA wearers and made better use of the available

The Grenfell Tower Inquiry: Phase 1 Report 632 resources. That distinction was eventually made in the form of a decision to deploy SDBA crews as far as floor 10 and EDBA crews above floor 10. It is likely that that was not until after 04.30 although it is not possible to be more precise.131 9 Communications 28.130 The Narrative section makes it clear that from the earliest stages of the incident the deployment of firefighters inside the tower was plagued by generally ineffective communications. Although it is not possible to identify any precise time or place, the overwhelming weight of the firefighters’ evidence was that as conditions deteriorated they found that it was impossible to communicate with the bridgehead using their BARIE sets or that not long after they had left the bridgehead it became practically difficult to do so. The result was that crews could not inform the bridgehead about conditions in the stairs, lobbies and flats, about casualties they had found on their way to and from any search and rescue deployments or about the results of their deployments. Crews were unable to call the bridgehead for additional resources or advice. The difficulties with communications significantly limited the efficiency of search and rescue operations inside the tower. 28.131 It is equally plain that it was well known within the LFB that BARIE sets performed badly in concrete high-rise buildings. Given that knowledge, greater efforts should have been made to establish and maintain effective communications inside the tower on the night. Whether that should have been achieved by using devices such as “leaky feeders” or providing Airwave radios to all crews working inside the tower or using other technology is a matter for investigation in Phase 2, together with a broader assessment of the adequacy of the communication systems in use by the LFB. 10 Equipment 28.132 The effectiveness of the equipment in use by the LFB will be considered in Phase 2, but, in addition to the defective or inoperable equipment on command units that I have already mentioned, there are two particular matters that arise from the evidence heard in Phase 1 that need to be addressed at this stage. 28.133 First, the ALPs mobilised by the LFB to the incident ground could reach a maximum height of 32 metres, which meant that they could not reach beyond floor 10 of the tower. In a city such as London, where there is a considerable and ever-increasing number of high-rise buildings, it is obviously unsatisfactory for the LFB not to have an ALP with a reach of 42 metres, like the one made available by Surrey FRS, or even higher. It is an open question whether a 42-metre ALP could have been safely deployed earlier on the night of the fire and, if so, whether it would have helped contain the spread of the fire on the exterior of the building. The essential fact, however, is that the LFB should have been able to deploy an ALP which was capable of reaching the higher floors of a high-rise residential building. I note that following the Phase 1 hearings the LFB announced its decision to acquire new ALPs, including three with a reach of 64 metres. On any view, that decision is a welcome and necessary one. 28.134 Secondly, the Inquiry heard evidence about the use of secondary masks attached to firefighters’ BA sets as a means of helping casualties escape from the tower and in closing statements questions were raised about the use of secondary BA sets to assist the evacuation of occupants. The Fire Officers’ Association, in particular, emphasised that secondary BA sets 131 Refer to the photograph at [MET00005774]. The writing on the lobby wall “ABOVE 10 EDBA BELOW 10 SDBA” was not written by WM Williams, and he did not recall its being there before he left at around 04.30: Williams Day 32/42/3-22.

Part III | Chapter 28: The Incident Ground 633 are not designed for that purpose but are intended for use in rescuing firefighters, but in any event there were not enough secondary BA sets available to make a significant difference.132 The use of secondary masks and secondary BA sets for the purposes of rescuing occupants is not a straightforward matter and is one that deserves more detailed consideration in Phase 2. 11 Water supply and pressure 28.135 The effectiveness of some of the equipment used by the LFB is dependant on obtaining access to adequate supplies of water at the necessary pressure. The supply of water in large quantities for the purposes of firefighting while maintaining supplies required to meet domestic and commercial requirements is a complex task. Whether there was an adequate volume and pressure of water available to the LFB for carrying out firefighting operations at Grenfell Tower is another matter that will be examined in Phase 2 of the Inquiry. 132 Paragraph 97 of the FOA’s closing submissions (dated 6 December 2018).

The Grenfell Tower Inquiry: Phase 1 Report 634

635 Chapter 29 The Control Room This Chapter examines the operation of the control room on the night of the fire, in particular how it handled emergency calls and communicated with the incident ground. 1 Introduction 29.1 It is clear that the control room was faced with, and overwhelmed by, an unprecedented number of 999 calls, which presented each member of the LFB control room team on duty on the night with a challenge wholly outside their experience and training. The magnitude and speed of spread of the fire and the volume of calls to which it gave rise presented each member of the LFB control room team on duty on the night with a challenge wholly outside their experience and training. It cannot be doubted that CROs saved the lives of many, and some of the residents of Grenfell Tower have been able to express their gratitude to the CROs who helped them. A notable example is the courage and calm of CRO Heidi Fox in coaxing Marcio Gomes and his family out of Flat 183 and down from floor 21.1 The CROs have borne the personal consequences of that night with remarkable fortitude and the psychological cost to them must not be underestimated. 29.2 Nonetheless, there were serious shortcomings in the operation of the control room which cannot all be attributed to the scale of the incident, although that undoubtedly played a significant part. Those shortcomings can often be gathered only from a close examination of the ways in which individual CROs handled calls throughout the night, but they were in the main systemic in nature. 29.3 It is self-evident that the conclusions in Section F6 of the LFB Lakanal Report were critical of the control room’s response to the Lakanal House fire. They were also strikingly prescient. Each of them applies with equal, if not greater, force to the Grenfell Tower fire. The evidence heard by the Inquiry at Phase 1 shows that, despite changes to certain LFB operational policies and the introduction of new training packages, few if any lessons were learnt by the LFB. 29.4 In the case of the Grenfell Tower fire, about 120 calls were received from occupants in the building in addition to the many calls made by members of the public from outside. It is clear, therefore, that the number and frequency of 999 calls, and in particular of FSG calls properly so called, was wholly unprecedented, exceeding by many times the number received in connection with the Lakanal House fire, which itself was a major event. If lessons are to be learnt for the future, however, it must be recognised that unprecedented and large-scale emergencies demanding a swift and effective response by the fire and rescue services may occur from time to time in London and other major UK cities. The circumstances surrounding the fire at Grenfell Tower and the LFB’s response to it should not lead us to think that the unusual scale and speed of smoke and fire spread, the particular nature of the building and the unprecedented number of FSG calls conspired to create challenges that could not be repeated in a different form on another occasion. 1 [LFB00055501]; Gomes Day 71/92/3-148/19; Fox Day 80/227/19-228/19.

The Grenfell Tower Inquiry: Phase 1 Report 636 29.5 One of the matters to be investigated during Phase 2 of the Inquiry is why, at least so far as the control room is concerned, the fire at Lakanal House did not lead to changes in practice and why the same mistakes were repeated in relation to the fire at Grenfell Tower. That investigation will involve an examination of the changes to policy and training programmes introduced as a result of the LFB Lakanal Report and the extent to which they achieved their objective. 29.6 For the purposes of Phase 1 the LFB’s conclusions in the LFB Lakanal Report and the policies current at the time of the Grenfell Tower fire provide a useful lens through which to examine both the formal guidance given to CROs and the extent to which they followed it. That in turn provides the basis for a critical assessment of the response of the control room and enables a view to be taken about whether any steps should be taken immediately to improve its functioning. 2 LFB policies on managing emergency calls 29.7 The starting point for any analysis of the operations of the control room on the night of the Grenfell Tower fire must be PN539 and PN790, together with the “RIF for Operators” and the “RIF for Supervisors”, to all of which reference has already been made. Taken together, they describe in some detail how the LFB expected CROs and senior officers in the control room to conduct operations. They should be understood in the context of the national guidance for fire and rescue services contained in Generic Risk Assessment 3.2. It is worth observing at this point, however, that the LFB has no specific policy to govern emergency calls from high‑rise buildings. Generic Risk Assessment 3.2 29.8 GRA 3.2 provides, at page 18: “Fire and Rescue Authorities must also have effective arrangements in place to handle fire survival guidance calls from residents and others when they believe they are unable to leave the building due to disability, poor mobility, illness or the affects [sic] of fire. Fire and Rescue Authorities should consider both generic procedures for persons expected, likely or advised to remain in their homes (unless directly affected by heat, smoke or fire) as well as bespoke arrangements for specific buildings. Fire survival guidance call arrangements should include: • details of how calls will be passed to and recorded at the incident • their impact on resources and mobilising • a re-evaluation process to ensure the balance of risk to the public is reviewed if circumstances change (which may result in a change to the advice previously given) • how information will be exchanged between callers, Fire Control and commanders at the incident.” 29.9 It also provides, at pages 28 to 29: “Fire Control rooms may receive numerous fire survival guidance calls during a high rise incident and these calls can provide vital information, which the Incident Commander can use to locate and prioritise persons requiring rescue. Considering the life threatening circumstances, fire survival calls are likely to be extremely stressful. Control operators may obtain more accurate information as to the location of the fire and/or persons in need of rescue or reassurance than that gathered by an Incident Commander who is on scene.

Part III | Chapter 29: The Control Room 637 A clear record should be made of all fire survival guidance calls and relevant information on the location and circumstances of the callers. This is both at the fire service control room and at the incident ground. This will assist in the Incident Commander’s confirmation of priorities and any subsequent reassessment of those priorities should information change as the incident develops. The advice offered to callers to remain in their property during fire survival guidance calls must be re-evaluated throughout an incident. Where circumstances make it necessary, an Incident Commander may need to consider changing the advice given. For example, callers may need to be advised to leave their property or to be guided from it by firefighters. The Incident Commander should also consider making use of all available systems within the building to communicate with occupants. Whenever fire survival guidance calls are being received, the Incident Commander must liaise closely with Fire Control.” 29.10 I set this text out in full because it encapsulates both the importance of CROs’ obtaining accurate and detailed information from callers and the need for close liaison between the control room and the incident commander so that the latter may act upon that information. PN539 29.11 Paragraphs 4.20 to 4.24 of PN539 contain, among other things, a clear recognition that emergency call-handling skills are important. As paragraph 4.20 provides: “How effectively the emergency call is handled in terms of questioning and listening skills, capturing information accurately, creating a caring and professional experience are just some of the critical skills required for control room officers.” 29.12 The skills are set out in paragraph 4.23: to listen, to maintain dialogue, to record “the relevant details accurately in the appropriate place on the mobilising system”, to think about what information is and is not being given, and what is required to make decisions. Paragraph 4.24 of PN539 sets out basic concepts and principles and the questioning protocol in paragraph 4.25 encourages the use of open questions. 29.13 Fire survival guidance is referred to specifically in paragraph 5.19 of PN539, which provides: “Detailed information, advice and guidance for control room officers is set out in accordance with Fire Service Circular 10/93 appendix A. Guidance can also be found in appendix 3 of this policy and Reference Information File (Fire Survival Guidance).” 29.14 Fire Service Circular 10/93, which some witnesses referred to as the “Dear Chief Fire Officer letter”,2 was a letter dated 12 October 1993 from the Home Office to the Chief Executives of County Councils in England and Wales, the Clerk to the Fire and Civil Defence Authority and the Chief Fire Officer. Its focus was the regularity and content of training of control room staff and its main purpose appears to have been to report on the review of an earlier circular issued in February 1987. Contrary to what paragraph 5.19 of PN539 says, Appendix A to Fire Service Circular 10/93 was not “information, advice or guidance for control room officers”, but rather a list of topics to be covered in initial or recruit training. Its relevance to PN539 is unclear. 29.15 More pertinently, the text of Fire Service Circular 10/93 said: “In the situation where, for example, the caller is prevented from escaping due to location (such as high rise flats) and/or smoke density or for some other reason is in danger, the operator taking the call may need to give very specific safety instructions in addition to establishing the location 2 [LFB00003617]; for example, Smith Day 21/20/9-18.

The Grenfell Tower Inquiry: Phase 1 Report 638 of the incident for mobilising purposes. Additionally, in circumstances such as these a fire control operator may need to take into account that the normal procedure of calming the caller may not be appropriate, and may even be dangerous in some circumstances.” [Emphasis added] 29.16 Appendix 3 to PN539 is of central importance, not least because it enshrines the LFB’s “stay put” advice to callers and, critically, the points of departure from it. The whole text is relevant, but the most pertinent parts are as follows:3 “The London Fire Brigade define a Fire Survival Guidance call as being a call to Brigade control where the caller believes they are unable to leave their premises due to the effects of fire, and where the control room officer remains on the line providing appropriate advice until either the caller is able to leave by their own means, is rescued by the Fire brigade or the line is cleared.” … Brigade Control advise callers to “Get out and Stay out”, however if a call is received from a High rise building where Fire, Heat and Smoke are not affecting the caller, LFB would advise that: ‘You are usually safest to remain in your premises unless affected by fire, heat or smoke. If the situation changes you should leave your premises and dial 999, if you need further assistance.’ Should the caller be unable to escape, an information file containing prompts are in place on the computer-aided mobilising system to assist the control room officer in • Providing guidance to assist the caller to safety • Providing timely and relevant information to the attending resources • Provide reassurance to the caller that help and assistance is forthcoming. … Control Room officers will always use the four principles of Escape, Assess, Protect and Rescue to provide guidance to these callers. Firstly by assisting the caller to help identify a safe alternative ESCAPE route for them to leave their premises. If this is not possible, then ASSESS the situation by asking the caller direct questions. … Begin to PROTECT the caller by providing current safety advice to attempt to keep the caller safe. Reassure the caller and REASSESS the callers situation. … Control room officers will remain on the telephone with the caller and assist with RESCUE. [Original emphasis] … General Other control room officers and supervisory staff will assist the CRO carrying out the Fire Survival Guidance call by ensuring all relevant information regarding the caller’s situation is passed via both the airwave radio and via telephone when a command unit is in attendance. Relevant information to be passed to the incident ground: • Number of persons involved • Names if known (by telephone only, not by radio) • Condition of their location i.e. heavy smoke, thick smoke • Location of caller within premises • Callers proximity to fire 3 They are faithfully reproduced here, including the drafting errors.

Part III | Chapter 29: The Control Room 639 • Latest FSG advice given by Control • Time of FSG call The callers premises number will be used as the single reference for each circumstance where guidance is provided to avoid confusion with names.” 29.17 In general terms, it is clear from this policy that there is a three-stage process in respect of a 999 call from a high-rise building: a. The working assumption is that in a high-rise building, the standing advice is that the caller should remain in their flat unless they are affected by fire, heat or smoke. Most CROs understood this to be what they called the “stay put” advice.4 b. Once the caller is “affected” by fire, heat or smoke, they should leave, unless they believe that they cannot leave. It is at that point that the first of the four principles applies, namely, to explore with the caller whether there is a safe alternative escape route. c. Once the CRO has established that the caller cannot leave, or at least believes that they cannot leave, the call becomes an FSG call.5 Only when there is no safe alternative route of escape should the CRO turn to “assess”, “protect”, “reassess” and “rescue”. PN790 29.18 PN790 was introduced in response to the Lakanal House fire and specifically in response to recommendation 7 in the LFB Lakanal Report.6 It deals with fire survival guidance, although not specifically in the context of calls from or in respect of high-rise buildings. It broadly follows the generic advice for fire and rescue authorities contained on page 8 of GRA 3.2. 29.19 The purpose of the policy is set out at paragraph 1.1 as follows: “The purpose of this policy is to explain what a Fire Survival Guidance (FSG) call is and to describe how critical information should be exchanged between Brigade Control and the incident ground. It provides guidance on how this information is to be recorded for use by incident commanders (IC).” 29.20 The central message of PN790 is, therefore, of the need for clear lines of communication between the control room and the incident ground. What should be done to achieve that is expressed in clear and detailed terms in paragraphs 4.2, 5, 7 and 9. In particular, paragraph 9, entitled Communication with Control, provides: “9.1 It is vital that control is kept informed of the actions being taken to resolve each FSG call. The fact that control is aware of the actions being carried out on the incident ground will greatly enhance the advice given to FSG callers. 9.2 Informative messages from the incident ground should also contain an update on progress relating to those specific FSG calls by both the flat/house number to avoid confusion. 9.3 The outcome of every FSG call must be communicated to control.” 29.21 In a similar vein, the following provisions of PN790 also deserve attention: “4.1 Occasionally control receives multiple calls at an incident. All FSGs received by control are treated with the same level of urgency, however, in certain circumstances, the officer in charge of control may direct call handlers to terminate a call to answer another. 4 For example, Real witness statement [MET00007696] p. 3. 5 This took some teasing out in the evidence: Smith Day 22/5/21-13/22. The essence of FSG is that the caller is or believes they are trapped. For example, Norman witness statement [MET000080589] p. 2; Fox witness statement [MET00007764] p. 2; Adams witness statement [MET00007762] p. 4. 6 [HOM00001124] p. 55. Recommendation 7 was: “Operational policies should better reflect the need for two-way communication between Control and the incident ground when FSG calls are underway”.

The Grenfell Tower Inquiry: Phase 1 Report 640 4.2 The IC, based on their situational awareness and the information provided by control, will decide how to prioritise FSG calls and the actions to be taken on the incident ground. ICs should direct their resources to those callers at greatest risk (high priority) if practicable … … 5.1 As soon as control has confirmed that a FSG call is in progress they will contact the incident ground and start to pass over the initial details. At this stage it is likely to be basic information relating to the number of persons involved and their location within the property. … 5.4 Control will contact the Initial Command Pump (ICP) and pass the information below by appliance radio for each separate FSG call. When passing this information, control will reference the information using the relevant flat/house number. 5.5 Control will attempt to gather all the information on the Control Information Form (see Appendix 2) and relay this information to the incident as and when it becomes available: • Number of flat/house7 • Number of persons involved • Location of caller within premises and access point • Condition of their location i.e. heavy smoke, thick smoke • Callers proximity to fire if known • Latest FSG advice given by Control • Time of FSG call • Time updated … 5.7 All FSG call information must be passed to the IC who will decide what action should be taken. The expectation is that all ICs will treat FSG calls as a priority and consider deploying and increasing resources accordingly. … 7.10 All actions taken on the incident ground to resolve the situation should be relayed back to control whilst a FSG call is still in progress. This is so that control can pass information which may be beneficial to the caller, e.g. the crew are en route.” 29.22 Paragraph 8 of PN790 is entitled Advice to Fire Survival Guidance callers. It sets out, in clear terms, the four stages of “Escape, Assess, Protect and Rescue”. Paragraph 8.3 makes it clear that if there is no safe alternative escape route the operator should ask the caller direct questions (i.e. move to the assessment stage). This broadly mirrors the contents of PN539 set out above. Both PN790 and Appendix 3 of PN539 require the operator to reassess the caller’s situation, although this is not listed as one of the core principles. 29.23 Paragraph 8.7 of PN790 provides that: “In exceptional circumstances an IC may consider informing control that their advice to FSG callers should be altered e.g. to attempt to leave their property. The IC should remember that this advice may be contrary to National Policy for control staff on FSGs and liaison with the officer in charge at control will be required for agreement to change the prescriptive advice.” 7 The list set out in PN790 does not exactly match the list in Appendix 3 to PN539. For example, the number of the flat or house is not a required data point in Appendix 3 of PN539 and Appendix 3 of PN539 does not require the CRO to obtain information about the “access point” or to relay information of the “time updated”.

Part III | Chapter 29: The Control Room 641 RIF for Operators 29.24 The RIF for Operators (dated 3 April 2014)8 was a prompt sheet or script for CROs handling FSG calls. The pertinent provisions in it are as follows: The heading of paragraph 1.3 is “When it may be safer to stay put”, beneath which it says: “Purpose built flat/maisonette – not affected by heat or smoke If a caller is inside a purpose built flat/maisonette that is not on fire or affected by heat or smoke, advise caller: It is USUALLY SAFER to stay inside flat/maisonette. But if they feel unsafe or they become affected by heat or smoke, then advise caller to GET OUT AND STAY OUT All premise property types – if escape routes are blocked by fire If escape routes are blocked by fire it maybe safer to stay put until the fire brigade arrives.” 29.25 The essential information which it instructs CROs to obtain from callers includes information about whether they are able-bodied, whether there are hazards or pets, and the layout of the property. 29.26 The reassurance to the caller is scripted as example statements: “The firefighters are on their way “The firefighters know where you are “The firefighters are there “The firefighters are dealing with the fire…” RIF for Supervisors 29.27 The RIF for Supervisors was also dated 3 April 2014 and (unlike the RIF for Operators) was updated on 2 April 2016.9 The following are its most pertinent provisions: “If caller is ringing from a property that is on fire or they or their property is being affected by heat/ smoke/flames from a fire elsewhere ensure that the CRO identifies if they are able to escape by primary or other means (ideas to prompt caller are provided in the FSG Operator RIF). The Incident Commander (IC) is informed that an FSG call is in progress and is provided with the information obtained so far, including the caller’s flat/house number (this will be the unique identifier) … … Supervisor … to ensure that: An assessment of the situation is made by the CRO BEFORE they provide standard Fire Survival Guidance as detailed in FSG Operator RIF … Supervisor or nominated person to consider: • Dedicating a supervisor to act as a sole contact point between Control and ICP/CU or officer nominated by IC to pass all relevant information • Using M2FH or FLONOPS1 (if sufficient staff available) where a large number of FSG calls are being received as this will free up the main scheme radio … 8 [LFB00003542]. 9 [LFB00003541].

The Grenfell Tower Inquiry: Phase 1 Report 642 • Supervisor or nominated person to ensure that the IC is kept informed of critical information passed to and from each FSG caller, including where available: • Number of flat / house (unique identifier for each call) • Name of caller (not to be passed by Radio) Number of persons involved [sic] • Location of caller within premises • Conditions within premises e.g. heavy / black smoke • Proximity to fire • Latest advice given to caller • Time of FSG call10 The above information to be passed to the lead appliance at the incident. If unable to raise the lead appliance – Page the IC and call any other attending appliances and pass information to that resource. A message acknowledging receipt must be sent from the incident. Ensure that attending Command Units are kept informed of messages to and from the incident.” 3 The experience and training of CROs Experience 29.28 Taken as a group, the CROs on duty on the night of the Grenfell Tower fire had decades of control room experience between them. That included handling calls from high-rise residential blocks, the make-up of pumps and other appliances at large incidents, resourcing and communications generally. As the statistics demonstrate, however, their experience of handling FSG calls was very limited. That was borne out by the evidence of the most experienced CROs themselves, who said that they had handled no more than a small number of FSG calls in the course of their long careers. 29.29 Even the most experienced members of the control room staff had no real understanding of how the control room would handle a large number of FSGs generated simultaneously by a single, or perhaps more than one, incident. CRO Adams recalled one occasion, some years before the fire at Grenfell Tower but after that at Lakanal House, when the control room took several calls from a high-rise residential building,11 but beyond that, none could recall any previous experience of such a situation, other than in connection with the Lakanal House fire itself. Training 29.30 All the CROs who gave evidence in person were asked about their training. It is right to point out that none of them were shown any training records or materials to refresh their memories and their evidence was therefore based entirely on their recollection and their individual impressions. It is understandable that they may not have remembered in any detail the occasions on which training was given in one form or another. Their evidence, therefore, is not necessarily a reliable basis for determining what training was in fact delivered, when, or what it contained and to that extent it must be approached with some caution. Nor have I yet had a chance to explore with those responsible for developing and delivering training what arrangements were made to ensure that control room officers generally, and supervisors in particular, understood what was expected of them. It would be inappropriate at this stage, 10 There is then a list of information points similar to (but not exactly the same as) that contained in PN539 and PN790. 11 Adams Day 80/9/15-10/10. The fire was in the Fred Wigg Tower in Leytonstone, London E11 in December 2011.

Part III | Chapter 29: The Control Room 643 therefore, to make any findings about those matters, but the evidence heard in Phase 1 explains why these are matters that will need to be investigated in Phase 2. For present purposes it is more important to understand what the CROs thought they were supposed to do in response to FSG calls and whether they were adequately prepared to deal with what happened in the control room on the night of the fire. An objective assessment of the training that was provided and the extent to which (if at all) they fell short of it is a matter for Phase 2. 29.31 CRO Sarah Russell described the nine-week training which she had started in September

1. She completed her probationary period shortly before June 2017. Her training was

therefore both recent and fresh in her memory and involved the following:12 a. A day’s training on FSG calls by reference to both PN539 and PN790, in the course of which working practices were explained and example calls were played. Trainees were instructed how to handle FSG calls, but there was no role-play.13 b. No specific instruction on the lessons to be learnt from Lakanal House, beyond being told that it was a “hard example” (because calls ended with fatalities). c. “Brief” training on how to assist a caller in identifying a safe alternative escape route (such as by asking questions to find out if there is smoke or fire outside the door) but not specifically relating to a high-rise building. 29.32 As far as she could recall, however: a. She had not received any training on assessing a potential escape route or on how to exhaust the possibilities of escape before moving to reassure the caller. b. She had not been warned about the risk of lulling the caller into a false sense of security by moving too quickly to reassure them that rescue was on its way, thereby causing them not to examine with sufficient care the possibility of escape. c. She had received no training specifically relating to FSG calls from high-rise residential buildings. d. Nor had she received any training on how a control room should handle a large number of simultaneous FSG calls, or on how a CRO should act in that situation, or on how to prioritise calls. e. She could not recall having received any training on how to obtain or respond to information from the incident ground or how to read and use the information from the heli-tele downlink in the control room. f. She had received no training which enabled her to understand the significance of fire and smoke development. 29.33 The first FSG call of CRO Russell’s career was with Jessica Urbano Ramirez. The call started at 01.29.48 and ended when CRO Russell terminated it at 02.24.45 after Jessica had become unresponsive. On any view this would have been a challenging call for even the most seasoned CRO, and the courage and calm professionalism with which CRO Russell handled it reflects great personal credit on her. When asked whether she would have liked to have had any additional training to prepare her for this call, she identified (i) more training in dealing 12 Russell Day 76/3/14-6/11. 13 Russell Day 76/52/24-53/6.

The Grenfell Tower Inquiry: Phase 1 Report 644 with such calls following her initial training; (ii) training on high-rise FSGs and multiple FSGs; and (iii) a set procedure to follow in order to prioritise FSG calls when many came in at the same time.14 29.34 CRO Peter Duddy was also a comparatively recent recruit to the control room, having been trained in 2015. He said that his training on FSG calls had comprised one afternoon session, which included what advice to give and what questions to ask.15 29.35 FSG refresher training for CROs who had completed their initial training and were now “on the Watch” appears not to have been regular or even annual. Their individual recollections of when they received training tended to vary, although it is possible that the dates on which they received training did vary. 29.36 Concern also arises about the training of supervisors. OM Alexandra Norman recalled a significant FSG training session in 2011 or 2012, but nothing since. She had the same training as the CROs.16 The LFB Lakanal Report recorded (at page 53) that the LFB had “… introduced a supervisor’s course, focussing on leadership and general supervisory actions and role within the Control room including FSG”. It is not clear on the evidence at the moment whether OM Norman or other LFB officers of similar rank received such training and her evidence suggests that she did not. That is a matter which will have to be examined at Phase 2. 29.37 All the CROs who gave evidence in person were asked in general terms about the content of their training in relation to handling FSG calls and communication with the incident ground. Again, their accounts and recollections tended to vary in many respects and there was very little consensus about what their training had actually covered. 29.38 CRO Yvonne Adams and CRO Christine Howson recalled training sessions with the command units on handling multiple FSG calls which took place in January 2017.17 They recalled that the number of FSG calls assumed for the purposes of those exercises did not exceed “six at most” (CRO Adams)18 or “two or three” (CRO Howson).19 One CRO recalled being trained on just a single FSG call.20 Some CROs had undergone FSG role-play training sessions in 2016, but those were for the benefit of command unit officers rather than CROs.21 29.39 The CROs’ evidence about their training can be summarised as follows: a. CROs had been trained, at least in general terms, on PN539 and in some (but not all) cases on PN790,22 but not necessarily on the RIFs provided for their use when handling calls.23 They appeared to be familiar with the provisions of the policies when asked about them. Some CROs said that they had received training on PN790 in terms of what questions to ask trapped residents and how to extract the best information from them,24 but some recalled no such training at all.25 14 Russell Day 76/52/9-23. 15 Duddy Day 42/175/5-176/11. 16 Norman Day 42/13/2-16. 17 Adams Day 80/5/21-25; Howson Day 80/123/9-16. 18 Adams Day 80/6/11 (as part of the command unit training sessions for training command unit officers). 19 Howson Day 80/124/12-15; Gotts Day 43/114/21-23. 20 Darby Day 33/115/19-23. 21 Howson Day 80/123/7-124/1; Adams Day 80/4/2-20. 22 For example, OM Norman was not trained on PN790: Norman Day 42/12/16-22. 23 For example, Gotts Day 43/112/14-18. 24 For example, Duddy Day 42/176/6-18. 25 For example, Gotts Day 43/113/7-13.

Part III | Chapter 29: The Control Room 645 b. None of them recalled having received any training on how to advise occupants to evacuate a building in the event that the incident commander decided to alter the “stay put” advice and order a partial or full evacuation of the building.26 c. None of them had received training on what advice to give if the building had a single exit route, particularly where that was smoke-logged.27 d. No training had been given on how to judge whether a caller should be advised to evacuate or stay put.28 e. No specific training had been given on how CROs were to assess the safety of the exit routes or whether there were possible alternative exit routes for trapped residents.29 f. CROs had not been trained to understand that, when advising a caller who believes they are trapped, to move too quickly to the “reassurance” phase may unwittingly lull the caller into a false sense of security.30 g. None of their training appears to have been specifically directed to how a CRO should reassure callers without unfairly or falsely raising their expectations of rescue.31 h. They do not appear to have received any training on how to handle numerous simultaneous FSG calls other than (in the case of CROs Adams and Howson) in the training sessions with the command units which had taken place in 2017.32 However, that training had been designed mainly to enable the command unit officers to understand their role and CROs Adams, Howson and AOM Peter May mainly participated in and facilitated the workshop.33 In any event, that training did not cover more than, at most, six FSG calls at any one time. i. They had received no training in how to make use of information obtained elsewhere in the control room or from the incident ground.34 j. Some CROs had received training in the lessons learned from the Lakanal House fire,35 although their recollection of the specific content of that training was limited to generalities about what questions to ask callers. Some CROs recalled no specific Lakanal‑based training.36 CRO Angie Gotts’s personal lesson from Lakanal House was that the assumption that crews would reach callers was not always reliable,37 a lesson which, although contained in paragraph 293 of the LFB Lakanal Report itself, appears either not to have been taught in training or else had been forgotten by many CROs when advising callers from Grenfell Tower on the night of the fire. 26 Given that paragraph 8.7 of PN790 anticipates that the incident commander could alter the FSG advice, it is reasonable to expect that CROs would be trained on how to give advice if that happened. 27 Gotts Day 43/113/7-114/4; Adams Day 80/7-8. 28 Norman Day 42/13/20-24. 29 Duddy Day 42/176/12-18; Russell Day 76/40/5-10. 30 Russell Day 76/40/11-19. 31 Howson Day 80/163/6. 32 Adams Day 80/5/21-25; Fox Day 80/183/1-4. 33 Adams Day 80/6/1-7/12; Norman Day 42/7/2-10. 34 Duddy Day 42/180/18-25; Gotts Day 43/121/22-122/4. 35 For example, CRO Gotts in 2012: Day 43/112/7-9; Fox Day 80/182/8-10. 36 Howson Day 80/124/16-20; Gotts Day 43/113/14-18. 37 Gotts Day 43/117/1-13.

The Grenfell Tower Inquiry: Phase 1 Report 646 k. Some, but not all,38 CROs thought that they had probably received training in asking callers about whether they had mobility difficulties or whether there were children in the property, but not elderly people.39 l. They had received no training in how to communicate with callers whose first language is not English, although there had been training on how to set up a “Language Line” whereby an interpreter can be obtained.40 The LFB’s awareness of the deficiencies 29.40 The absence of satisfactory procedures and training for handling large numbers of FSG calls appears to have been a cause of concern to some within the LFB following the Lakanal House fire. In 2014 SM Peter Johnson took the initiative to remedy what he saw as a deficiency by producing a Tactical Decision Exercise training programme41 involving seven FSG calls (the number that could be accommodated on the FSG sheet in the command units under Appendix  1 of PN820). The purpose of the programme was to ascertain the maximum number of FSG calls the control room and incident ground could handle satisfactorily at any one time and to clarify the roles of the operational officers at an incident in handling FSG information coming from the control room. He also wished to demonstrate that the current FSG procedures could not adequately cope with a high-rise incident which gave rise to numerous calls and many casualties.42 29.41 SM Johnson’s training programme was never implemented, but the real significance of his evidence lies in his realisation that even seven simultaneous FSG calls is a very large number. As he said, his aim had been to show that the existing policies needed to be changed, so that if the number of FSG calls did exceed three or four, the LFB could deal with them properly.43 SM Johnson sat on the LFB’s FSG policy group in 2014 and discussed this programme with senior officers at the time. 29.42 At Phase 2 it will therefore be necessary to examine whether, when and to what extent there was, within the LFB, an awareness of deficiencies in the FSG policy and training of the kind identified by SM Johnson and, to the extent that there was, what the LFB did or proposed to do about it. It will also be necessary to inquire why the LFB itself or Babcock International Group, as its training provider, decided not to proceed with SM Johnson’s programme or something similar to it. For present purposes it is enough to say that SM Johnson’s views on the subject proved to be remarkably prescient. 29.43 The evolution of CRO training between 1993 and 2009 (the date of the Lakanal House fire) is summarised at Section E of the LFB Lakanal Report and may also require closer examination at Phase 2. The point for present purposes is that the warning identified in the passage of the Fire Service Circular 10/93 emphasised above was, by reference, an applicable principle in the version of PN539 current at the time of the Grenfell Tower fire, as paragraph 5.19 of PN539 referred CROs to the Fire Service Circular 10/93 for detailed information, advice and guidance. However, according to SOM Joanne Smith’s evidence,44 the practice of calming the caller that Fire Service Circular 10/93 deprecated was removed from the policy in 2011 and 38 For example, CRO Duddy: Duddy Day 42/177/6-11. 39 Darby Day 33/140/15-141/13. 40 Darby Day 33/118/2-119/9; Duddy Day 42/176/19-177/5; Norman Day 42/59/9-60/14; PN539 paragraphs 4.7-4.8. 41 Johnson witness statement [MET00013235] pp. 2-3, 5 and PMJ/7: [MET00016997]; [MET00016998]; [MET00016999]; [MET00017000]; [MET00017001]; [MET00017002]; [MET00017003]; [MET00017004]; [MET00017005]; [MET00017006]; [MET00017007]; [MET00017008]. 42 Johnson Day 36/219/17-21; 224/2-10. 43 Johnson Day 36/233/22-234/11. 44 Smith Day 22/18/2-20/19.

Part III | Chapter 29: The Control Room 647 replaced with a process of more assertive reassessment of worsening conditions, which she said was now reflected in current LFB training. It is possible that this change in policy was prompted by the conclusion at paragraph 293 of the LFB Lakanal Report to which I have referred. That is another matter for investigation in Phase 2. 4 Deficiencies in the LFB policies 29.44 Having considered the LFB policy documents relating to the management of emergency calls, in the light of events on the night of the fire, I have reached the conclusion that they are deficient in a number of respects in relation to FSG calls. Policy No. 539 29.45 PN539 is deficient in the following respects: a. It defines an FSG call by reference to a combination of the caller’s belief that they are trapped and the response of the operator in remaining on the line, but that involves defining the nature of the call by reference to the response it receives. In my view that makes no sense. Almost by definition, anyone who calls the fire and rescue service in the belief that they are trapped in a burning building is seeking fire survival guidance, whatever the nature of the response, but the policy tells CROs how to respond to such calls, and remaining on the line until the caller is able to leave without assistance or is rescued or the line is cleared is in reality part of that response. b. The terms of the definition, however, point to an underlying reality, namely, that an FSG call is one which requires the continued telephone presence of a CRO. It follows that, if the policy is to be fully complied with, the number of simultaneous calls from people who believe they are trapped cannot exceed the number of CROs available to handle them. This important factor is not reflected anywhere in the LFB policy documents, but it suggests that, if the number of calls waiting to be answered exceeds the number of CROs on duty, the operations manager should inform the incident commander immediately, who can then decide what steps should be taken in the light of the way in which the fire is developing. That might include a partial or full evacuation. c. It requires CROs to advise callers to leave if “the situation changes” and the caller is “affected” by fire, heat, or smoke, but it gives no guidance on what “affected” means for these purposes. As a result, too much is left to the individual CRO’s interpretation of the policy. In particular, it is unclear whether, before the caller is advised to evacuate, they should be affected by fire, heat or smoke originating in their own flat or whether it is enough that they are affected by smoke emanating from elsewhere in the building. The evidence suggests that the majority of CROs thought it was the former. CRO Howson went as far as to say that she thought that it referred only to a fire in the caller’s flat, and that, if a caller from a high-rise building said that they had smoke coming into their flat, she would advise them not to leave but to stop the smoke coming in.45 d. It contains no clear statement that the CRO must thoroughly explore the basis of the caller’s belief that they cannot escape before moving to the “assess”, “protect” and “reassess” phases. Given that a call is an FSG call if the caller believes that they cannot leave their flat, it is essential that the CRO taking the call does all they reasonably can to assess the safety of possible routes of escape in conjunction with the caller. CROs need 45 Howson Day 80/127/8-129/24, and her witness statement [MET00007763] pp. 5, 7.

The Grenfell Tower Inquiry: Phase 1 Report 648 to satisfy themselves that callers are really unable to leave the premises, rather than simply taking their assertions at face value. e. It refers to the four principles of “escape, assess, protect and rescue”, but the implementation of those principles requires continual reassessment of the caller’s situation: see paragraph 295 of the LFB Lakanal Report. The RIFs emphasise the importance of regular reassessment46 during the call as a separate phase after the CRO has started to protect the caller. f. PN539 does not warn that an assumption that the fire and rescue service is on its way to rescue the caller is not always well-founded. That danger, which was identified in paragraph 293 of the LFB Lakanal Report, does not appear to have found its way into PN539, with the consequence that CROs often provided reassurance to callers that was not founded on any information from the incident ground. g. It contains nothing to assist CROs and senior managers in handling a large number of FSG calls concurrently. h. Contrary to the guidance given at page 18 of GRA 3.2, the policy does not require CROs to find out whether the caller is, or has with them, a person who is disabled, has poor mobility or has an illness that would impede their ability to leave or who for some other reason would require assistance in the event of an evacuation. i. It does not provide guidance on how to communicate with persons whose first language is not English. Although paragraph 4.8 of PN539 states that agreements are in place for the use of an interpreter service (the “Language Line”), the evidence was that this was a “quite long winded” process, and too slow for the purposes of an FSG call.47 Although CROs in London have wide experience of speaking to callers whose first language is not English,48 that is not a sufficient substitute for clear guidance supported by effective training. 29.46 These deficiencies in PN539 support the conclusion that it did not articulate the “stay put” advice well and did not make clear to CROs certain crucial requirements that had to be met in order to maximise the chances of escape from a high-rise building. The reasons why PN539 was unsatisfactory in these respects will have to be explored in Phase 2. Policy No. 790 29.47 PN790 is deficient in the following respects: a. Although it contemplates the possibility of several concurrent FSG calls, it gives no guidance on what action the control room should take to deal with further calls when the number of FSG calls currently in progress are occupying all the CROs on duty. b. In particular, it contains no specific reference to the need to inform the incident commander when the number of FSG calls from a single incident is approaching, or has reached, the number of CROs available to handle them to enable the incident commander to take appropriate action. c. PN790 does not give guidance to control room supervisors on what to do when a large number of FSG calls are received in order to ensure that they have enough resources 46 [LFB00003542] p. 3; [LFB00003541] p. 3. 47 Smith Day 21/130/19-131/3. 48 Smith Day 21/131/1-3.

Part III | Chapter 29: The Control Room 649 available. The RIF for Fire Survival Guidance (Supervisor) provides that when many FSG calls are received the supervisor should consider “placing all non-event radio traffic onto one channel” and “varying paging operator to any available staff”.49 It was thus envisaged that supervisors would need to take further action, although the measures suggested in the RIF do not address the question of how the limited resources within the control room could be expanded to absorb the extra demand. OM Norman suggested a recall system for control staff in large-scale incidents.50 d. Like PN539, PN790 fails to provide for any arrangements for assessing whether a caller may be unable to leave the building due to disability, poor mobility, illness or the effects of the fire, as required by GRA 3.2. e. PN790 does not set out how FSG information should be recorded in the control room even though that is required by GRA 3.2 and by paragraph 7.50 of PN633. 29.48 For present purposes it is enough to note that PN790 was, subject to these flaws and within the assumptions on which it was based, for the most part a clear framework for the handling of FSG calls both in the control room and on the incident ground. It represents a reliable standard against which to undertake an assessment of what the control room and the officers at the incident ground did on the night of the fire by way of collecting, handling and communicating FSG information. RIF Fire Survival Guidance (Operator) 29.49 The RIF for use by CROs is unsatisfactory in a number of respects: a. It contains no clear guidance on what “affected” by heat, smoke or fire means or how it is to be assessed. b. It contains no clear guidance on how to go about assessing the safety of routes of escape if the caller is, or says that they are, affected by heat, smoke or fire, or “feel unsafe”. c. It contains no warning that assurances that firefighters will rescue callers should be based on information from the incident ground rather than on their own expectations or assumptions. d. It contains no guidance about what information the CRO should gather in order to assist the control room supervisor or incident commander to decide whether a partial or total evacuation of the building should be carried out. e. It contains no guidance about what advice the CRO should give a caller once a decision has been made to carry out a full or partial evacuation of the building. RIF Fire Survival Guidance (Supervisor) 29.50 The RIF for Supervisors suffers from similar defects. Like the RIF for Operators, it provides no guidance on how supervisors should gather information from CROs to enable them to form an overall assessment of the situation in order to assist the incident commander to decide whether the “stay put” advice should be revoked. 49 RIF Supervisor p. 2. 50 Norman contemporaneous notes [MET00005199] p. 5.

The Grenfell Tower Inquiry: Phase 1 Report 650 29.51 However, the RIF for Supervisors does repeatedly make it clear that even in the case of “a large number of FSG calls” it is essential that the fullest information possible be passed from the control room to the incident ground and vice versa. As in the case of the word “multiple” in paragraph 4.1 of PN790, the expression “a large number” is not defined, but (as in the case of PN790) it is unlikely to have contemplated more than about seven at any one time. 29.52 The reasons for the deficiencies in the RIFs will be explored at Phase 2. 5 Deficiencies in handling FSG calls 29.53 In the light of the deficiencies in policies and training identified above, it is perhaps no surprise to find that in many respects the CROs’ handling of FSG calls was unsatisfactory. Their actions, as evidenced by their own accounts, the transcripts of the 999 calls and the contents of the SIL, showed that: a. They were not sufficiently familiar with what the relevant LFB policies required them to do and the order in which to do it. b. There was no consistent understanding among them of some of the basic concepts underlying the advice to be given to a caller, or the information to be gathered and at what stage. c. As a body, they frequently failed to apply the policy requirements consistently. 29.54 These failings can be grouped around five distinct features of the advice that CROs gave to emergency callers from within the building. In general: a. When callers said that they could hear, smell, feel or see (i.e. were affected by) fire, heat or smoke, CROs did not try to find out to what extent they were directly affected; often they did not advise them to leave their premises but instead told them to stay where they were. b. CROs did not carry out a proper assessment of the safety of the escape route but advised the caller to stay put or moved immediately to the “protect” phase. All calls of that kind were treated as FSG calls, even though the caller may not in fact have been trapped. c. CROs invariably told callers that firefighters were on their way without having any sound basis for doing so. As a result, some callers were lulled into a false sense of security, remained in their flats and did not attempt to leave with sufficient vigour, or at all, despite the fact that escape was possible. d. CROs did not take in what callers were telling them about the location of fire and smoke; instead they too often treated what callers were telling them with scepticism, in some cases contradicting the caller. e. CROs did not take adequate details of flat numbers, the number of people present or whether people were disabled or had health or other conditions that might impede escape, and they often did not take sufficient information about conditions in the flat. 29.55 The unprecedented volume of calls from people trapped inside the building placed enormous pressure on the control room, but in many cases that does not provide an excuse for these shortcomings, all of which involved significant departures from established policy in one way or another. The evidence which leads to these conclusions is summarised below.

Part III | Chapter 29: The Control Room 651 Failure to ascertain the extent to which callers were affected by fire, heat or smoke 29.56 In early calls to the control room callers told CROs that they could smell or see smoke in their flats, but not that they were trapped. CROs advised callers to stay put without exploring and assessing the conditions, contrary to the advice set out in Appendix 3 of PN539 and the RIF for Operators. 29.57 In some instances that was a result of the CRO’s failure to understand the policy. One example was CRO Howson, who would advise a caller that if smoke was coming into their flat, either through the door or the window, she would not consider that the caller was “affected” by it within the meaning of PN539 and would therefore not start to explore with the caller whether it was safe to leave. Instead, she would advise them to stop the smoke coming in and await rescue. The critical question, in her view, was whether the flat was on fire; only at that point would she begin to explore the possibility of escape.51 She explained that that was because she assumed that in a high-rise building a caller is safe if they are not directly affected by fire, even if there is smoke coming in.52 On that kind of call she would not usually take any further details. The calls at 01.32.10 from Biruk Haftom on the top floor and at 02.00.33 from Anthony Disson in Flat 194 on floor 2253 provide two examples of CRO Howson’s assumption that, because the flat was not affected by fire (as she understood it), there was no need to explore whether the caller could leave the building safely. In both calls, the callers had reported that they were affected by smoke. Her understanding of the policy in this narrow way was not supported by SOM Smith54 and was a serious error. 29.58 CRO Adams, on the other hand, did think that a caller was “affected” by fire if they could see fire coming.55 CRO Fox thought that a caller who had smoke in their flat was “affected” by smoke.56 However, in practice, the CROs did not always apply their understanding of the policies to the calls they took. a. During a call made at 01.26.58 from Flat 95 on floor 12,57 Katarzyna Dabrowska told CRO Fox that her neighbour’s kitchen was on fire and that smoke was coming into her own flat through the floor from the main door. Katarzyna Dabrowska did not tell CRO Fox that she was trapped. CRO Fox did not advise her to leave now that smoke was entering her property. b. Similarly, Anthony Disson58 calling at 01.30.08 from Flat 194 on floor 22 said to the control room that “you could not see a hand in front of ya”, and yet CRO Fox did not tell him to leave the flat or explore whether he could safely do so. She explained her failure to do so by the number of calls needing to be answered. c. At 01.30.38 CRO Gotts took a call from Naomi Li in Flat 195 on floor 22,59 in which she was told that there was smoke in the flat and that the fire was in next door’s kitchen. She did not tell CRO Gotts that they were trapped. Naomi Li asked CRO Gotts “Do we stay in the flat” to which CRO Gotts replied “Well, I obviously can’t advise you but I’ll let the 51 Howson Day 80/127/8-129/17, 80/139/23-140/4. 52 Howson Day 80/137/8-138/16. 53 Howson Day 80/152/9-23. 54 SOM Smith said that being affected by fire, heat or smoke meant that the caller should be advised to leave and assisted in assessing the safety of the exit route: Day 22/5/9-20. 55 Adams Day 80/16/4-17. 56 Fox Day 80/189/1-10, 80/191/4-19, 80/227/1-6. 57 [LFB00000309]. 58 [LFB00000459]. 59 [INQ00000472]; [LFB00000311].

The Grenfell Tower Inquiry: Phase 1 Report 652 firemen know you’re there, ok?” That response did not comply with PN539 and the RIF for Operators, which required her to advise them to leave the flat unless they thought they were trapped, and then to explore with her whether there was a safe means of escape, and, if not, to give FSG advice. She declined to give any advice. She explained that omission by reference to her not having had a clear picture of the conditions in the exit route,60 but that was because she did not engage Naomi Li in making an assessment together. She could not explain why she had not pressed Naomi Li to assist her in that exercise.61 SOM Smith accepted that the approach taken on this call represented a departure from normal practice.62 d. Even OM Norman departed from policy in her advice to Farah Hamdan in Flat 175 on floor 20 who called at 01.30.02.63 Farah Hamdan told her that the fire was in her neighbour’s flat but that there was smoke coming into her own flat. She did not tell OM Norman she was trapped, but she did ask her what she should do. OM Norman advised her to stay in the flat unless it was safe to leave. She did not tell her that, because her property was now affected by smoke, that she should leave, nor did she assess with Farah Hamdan whether it was safe to leave. Inadequate assessment of escape routes 29.59 CROs did not adhere to the requirements of PN539 or the RIF for Operators in properly moving through each of the three stages explained above.64 Once callers reported that they were affected by fire, heat or smoke and that they believed that they were trapped, CROs failed to assess the safety of escape routes with them. Some CROs said when giving evidence that they knew that the policy required them to assess conditions and whether there was a safe exit route, for example, by asking callers about the situation, alternative exit routes and the severity of the smoke,65 but in practice they took callers’ statements that they were trapped at face value and too often jumped to the conclusion that no escape route existed. It was clear from the evidence that the reason they failed to adhere to the policy was due to the sheer number of calls that needed answering coupled with an assumption that crews would reach the occupants. In the absence of information from the incident ground that crews were having difficulties or that people were able to escape from the tower despite the conditions, the CROs were left to make assumptions based on their experience of previous fires and the belief that compartmentation would hold. The following are some examples from the evidence which show how widespread the problem was: a. During a call at 01.30.00 with Mariem Elgwahry66 on floor 23, CRO Duddy was told that there was smoke entering the flat and that there was fire in her own flat on the floor below, but he did not ask her whether there was any safe exit route.67 60 SOM Smith similarly attempted to defend CRO Gotts’s approach by reference to CRO Gotts not knowing the conditions in the escape route (Day 22/14/14-16/22) and by reference to the volume of calls (Day 22/16/25-17/12). 61 Gotts Day 43/172/8-173/2. 62 Smith Day 22/16/13-17/12. 63 [LFB00000314]. 64 Namely, stage 1 (the caller is safe to remain in their flat); stage 2 (the caller is affected by fire, heat or smoke and may need to evacuate), and then stage 3 (the caller is trapped in their flat). 65 For example, CRO Fox Day 80/189/1-10, 191/4-19, 227/1-6; CRO Howson Day 80/130/9-25; CRO Russell Day 76/10/15-15/18. 66 [LFB00000310]. 67 Duddy Day 42/209/15-20.

Part III | Chapter 29: The Control Room 653 b. CRO Gotts took another call at 01.43.19 from Natasha Elcock during which she reported that there was now smoke entering her flat.68 She accepted that she had not explored alternative escape routes with her.69 c. CRO Gotts took a call at 01.47.49 from Meron Woldeselassie Araya and Lina Hamide70 in Flat 74 on floor 10; again, she failed to explore alternative routes of escape. She put her omission down to the number of calls waiting and to accepting the caller’s own assessment that they were trapped rather than testing it with them.71 d. In a call made at 02.13.03,72 Nicholas Burton in Flat 165 on floor 19 told CRO Adams that he was trapped. She accepted what he said without exploring precisely why he thought he was trapped. She explained that she had assumed that he was trapped because he had said so and did not explore that in detail with him because there were more calls waiting. He said that he was safe and she expected the crews to get to him.73 e. During a call at 02.32.41 from Natasha Elcock74 CRO Russell simply asked her whether she thought it was safer for her to stay or to try to leave.75 She failed to ask for an assessment of the safety of escape routes. CRO Russell explained that CROs rely heavily on what the caller can see and leave the decision to them. She also blamed her failure to assess the prospects of escape on the volume of calls being received.76 29.60 The failure of CROs to assess the prospects for escape in accordance with the policies had two potential consequences in the period before the “stay put” advice was changed. First, occupants may have stayed in their flats when they could have escaped to safety, even though the conditions in the lobbies and stairs were increasingly hostile after around 01.40 and certainly much more difficult after 02.00. Secondly, the incident ground was told that all 999 calls from the tower were FSG calls and that occupants therefore needed rescuing, whereas some could in fact have escaped without assistance. That could have led incident commanders to adhere to the strategy of responding to FSG information relating to individual callers for longer than might otherwise have been the case. Assurances to callers that the firefighters would rescue them 29.61 A widespread feature of the exchanges between callers from the tower and the control room is that callers were routinely told that firefighters were on their way to rescue them, or knew where they were, or would be told where they were, or some other variant of that advice. However, all that was said without any reliable information from the incident ground to back it up. As SOM Smith accepted, there was an expectation that crews had been and would continue to be committed and that people would be rescued, but the control room did not know what was happening on the incident ground, where the firefighters were, or which floors they could reach.77 The following are some examples of the advice given throughout the night: 68 [LFB00000323]. 69 Gotts Day 43/177/23-178/1. 70 [LFB00000330]. 71 Gotts Day 43/180/8-181/10. 72 [LFB00000344]. 73 Adams Day 80/90/10-91/11. 74 [LFB00000360]. 75 Russell Day 76/57/23-58/18. 76 Russell Day 76/58/6-18. 77 Smith Day 22/97/19-98/6, and the control room Debrief Report [LFB00003113] p. 4.

The Grenfell Tower Inquiry: Phase 1 Report 654 CRO Duddy: a. At 01.34.50, CRO Duddy took a call from Hashim Kedir in Flat 192 on floor 22, in the course of which he advised him to stay put, telling him that the fire brigade had “people coming to you now”.78 b. At 01.44.43, CRO Duddy spoke to Roy Smith in Flat 95 on floor 12 and told him that “we’ve got a lot of people to get out and we’re coming up … we’re clearing everybody out as we go”.79 c. At 01.50.00, CRO Duddy spoke to Anthony Disson in Flat 194 on floor 22 and told him that: “we’re gonna come up, we’ve got firefighters coming to the 22nd floor already”.80 CRO Howson: a. At 01.32.10 CRO Howson told Biruk Haftom (who had by then moved from Flat 155 to the top floor): “I’ll get the fire brigade to come along and check that everything’s OK once they’ve put the fire out”.81 b. At 02.18.06 she took a call from Hashim Kedir, in the course of which she advised him that: “they’re making their way now … it’s slow progress, I’m afraid, but they will get to you as soon as they can”.82 c. At 02.25.38 she took a call from Mariem Elgwahry, in which she asked: “Can you get us a chopper or something, could you get a helicopter or something to get us out?”, to which CRO Howson responded: “There is, there is one there, OK, all right, the fire brigade are on their way now, they’re making their way”.83 CRO Gotts: a. At 02.15.07 CRO Gotts took a call from the elder son of Karen Aboud, in the course of which he asked CRO Gotts: “Are the fireman going to come?”, to which she replied: “Yes, they, the firemen are there. They know you are there. They’re going to come and find you, OK. There’s just lots of floors, isn’t there?” The caller then asked: “Is all going well?”, to which she replied: “Yeah, they’re putting the fire out. They’re trying to put the fire out, OK?” Towards the end of the call, having been asked again whether the firemen will come, she said: “Yes, the firemen will come, okay? And they’re on the 12th – they’re - - they know you’re on the 12th floor”.84 b. At 02.42.14 she took a call from Paulos Tekle in Flat 153 on floor 18, who said that nobody was evacuating them and requested assistance for evacuation. CRO Gotts assured him that she would pass the message on to the firefighters and that “they can come up and 78 [LFB00000315]. 79 [LFB00000324]. 80 [LFB00000328]. 81 [LFB00000667]. 82 [LFB00000351]. 83 [LFB00000670]. This advice was early in the call, before CRO Howson learned that the fire was in Flat 205 and advised the occupants to leave (p. 7). For further instances of requests for helicopters by trapped occupants, Bassem Choukair asked for a helicopter at 02.43.55 [LFB00000376] and again at 03.02.06 [LFB00000396]; Nadia Choucair asked for a helicopter at 02.37.00 [LFB00000366]; Nura Jemal asked for a helicopter at 02.31.23 [INQ00000276]; Hashim Kedir asked for one (with Nura Jemal) on a call at 03.08.56 [LFB00000406]; the daughter of Hesham Rahman asked if a helicopter would be used at 02.36.12 [LFB00000364]; Paulos Tekle requested a helicopter at 02.42.14 [LFB00000371]; Lydia Liao requested a helicopter to be sent at 02.55.59 [LFB00000389]. 84 [LFB00000346].

Part III | Chapter 29: The Control Room 655 find you”. By that point the “stay put” advice had been revoked and CROs had been told that they should advise people to leave the building (see below).85 CRO Russell: At 01.29.48 CRO Russell took a call from Jessica Urbano Ramirez (who by then had moved to Flat 201 on floor 23), in the course of which she told Jessica that the crews were coming for her and were fighting the fire and making their way up.86 CRO Russell accepted that she had had no hard information on which to base those statements but said that they reflected what she had expected to happen and that she was trying to give reassurance.87 29.62 The CROs were well aware that no information about the response to FSG information, and in particular whether crews had been deployed in response to particular FSG calls, was being passed to the control room from the incident ground. The assurances they gave were based solely on what they expected or assumed to be happening or, in some cases, were given simply to calm worried callers. As the CROs who were asked about those calls accepted, their assurances were in fact likely to be misleading, because they were not based on any information coming from the incident ground. 29.63 After the “stay put” advice had been changed, SOM Smith and OM Norman told the CROs that callers had a “last chance” to leave the building and should do so without waiting for assistance. That message implied, or was at least intended to imply, that no one would be coming to rescue them. CROs were advised to use blunt language to get the message across to the callers. However, CROs did not always follow that advice and some continued to reassure callers that firefighters were coming to rescue them. For example: a. At 02.55.38, after the “stay put” advice had been withdrawn, CRO Gotts took a call from Marcio Gomes in Flat 183 on floor 21 who told her that he and his family could not leave; she advised him that she would “let the firemen know, OK, to come up to you”.88 b. At 03.08.56 (again, after the “stay put” advice had been withdrawn) CRO Gotts took a call from Flat 193 on floor 22. The callers asked her whether they could escape through the window to a helicopter that they could see. CRO Gotts told them that “We’re coming up to you inside” and that “big ladders” were coming. Both callers could see a helicopter and asked for one to be sent to rescue them, to which CRO Gotts answered: “Okay, I’ll let them know” and “Okay. All right, well I’ll pass that over”.89 CRO Gotts was unable to explain why she had told the callers that big ladders were coming.90 She also accepted that she had not intended to leave the callers with the impression that they could be rescued by helicopter. She had assumed that helicopter rescues were not possible because the rotor would fan the flames. She said that the reason that she had not advised the callers in clear terms that they would not be rescued by helicopter was to avoid causing them additional panic.91 85 [LFB00000371] p. 8. 86 [LFB00055504]. 87 Russell Day 76/33/1-4, 38/7-20. 88 [LFB00000392] p. 3. 89 [LFB00000406]. 90 Gotts Day 43/213/13-214/6. 91 Gotts Day 43/216/2-15.

The Grenfell Tower Inquiry: Phase 1 Report 656 29.64 Some of the occupants who gave evidence told the Inquiry that these assurances had created an expectation of rescue and had thereby deterred them from taking active steps to escape at an earlier stage. They therefore increased the risk that callers would die in their flats waiting for help that would never come or, if it came, would come too late. Examples of such evidence include the following: a. Andreia Perestrelo said: “We only stayed in the flat as long as we did because Marcio had spoken to 999 and he told me that help was coming.”92 b. Marcio Gomes said in his written statement to the Inquiry: “I wish the operators had been honest and more knowledgeable about the situation from the first phone call as, had I known that no help was coming, I would have handled the situation differently. I believe that there was a miscommunication between the call centre and the command centre on the ground and this is why we were still being told that help was coming. I appreciate that the operators started to change their advice on my third 999 call, but the operator still said she would let the crews know and would make us a priority. At no point did she say no help was coming and we had no choice but to try and get out ourselves. If I knew that no help was coming I would not have stayed in the burning tower with my family a minute longer.”93 He told the Inquiry in his oral evidence that if he had known that the firefighters could not make it to their floor, he would have changed his approach.94 a. Roy Smith spoke to the LFB control room four times during the night. He said in his oral evidence that the advice from the CROs that firefighters were coming had influenced his actions.95 b. Karen Aboud, after a failed attempt to evacuate, was told by CRO Gotts during the call she made at 02.06.55 that she should stay put and that the firefighters would come up to her.96 In her statement to the Inquiry, Karen Aboud said: “So at this stage I was thinking I should stay because of waiting for the firemen who I’d been told were coming. I didn’t want my kids to get hurt – I thought it was just too risky to try and go without the firemen.”97 c. Karen Aboud eventually escaped with her two sons after being told by CRO Duddy, in a call made at 03.08.01, that it was their only chance of survival.98 d. Meron Woldeselassie Araya and Lina Hamide called 999 at 01.47.49. CRO Gotts told them that she could not advise them to leave and that she would let the firefighters know that they were there.99 According to Lina Hamide’s evidence, they refused to follow advice from friends outside the tower telling them to get out because they had been advised to stay and thought that the LFB would rescue them. They eventually left the building after Lina Hamide, who was speaking on the telephone to her friend Musie, overheard a policeman tell Musie that they could not guarantee that the firefighters would reach them and they had to get themselves out.100 92 [IWS00000349] paragraph 62. 93 [IWS00001078] paragraph 134. 94 Gomes Day 71(Fri)/88/2-7. 95 Smith Day 64/81/23-82/11. 96 [INQ00000371] p. 3. 97 [IWS00000130] paragraph 28. 98 [LFB00000402]. 99 [LFB00000330]. 100 [IWS00001175] paragraphs 17, 18, 27.

Part III | Chapter 29: The Control Room 657 29.65 On the night of the fire the CROs received no concrete information from the incident ground beyond that which was contained in the formal and relatively anodyne “informative messages”. Their advice to callers that firefighters were on their way was based purely on their personal expectations and assumptions.101 That was very dangerous, because the whole concept of fire survival guidance rests on a well-founded expectation that the caller will ultimately be rescued. The purpose of PN790 is to ensure an exchange of information between the control room and the incident ground so that appropriate advice can be given.102 Without it, there can be no reliable grounds for such an expectation and the caller must be told to leave at all costs. However, it is not possible to say with any confidence whether unsupported assurances of that kind caused or contributed to any particular fatality. 29.66 Given the stark warning in paragraph 293 of the LFB Lakanal Report about the dangers of assuming that firefighters are on their way to rescue the caller, it is clear that that lesson had not been learned by the LFB, which repeated the mistake many times over in response to the fire at Grenfell Tower. Dismissing information from callers about the location of the fire 29.67 A striking feature of many of the 999 calls in the early stages of the fire was that in many cases CROs insisted that the fire was on floor 4 of the building, contrary to what they were being told by the caller. They appear to have been unable to grasp the fact that it had spread rapidly up the building so that by 01.30 it was affecting (and indeed had entered) flats on the uppermost floors. Instead, CROs treated what callers were saying about the location of the fire with scepticism and in some cases actually contradicted them. 29.68 Furthermore, the CROs did not take in what they were being told by callers from outside the building so as to build up a broader picture of what was happening. There was no organised means of sharing with other CROs information obtained from callers, with the result that the CROs had no overall picture of the speed or pattern of fire spread. For too long they continued to think that the fire was still contained on the lower floors of the building. CROs consistently described being unable to understand what was happening on the incident ground. That was partly because they were getting no information from the command units at the incident ground. 29.69 These shortcomings emerge clearly from the evidence relating to the calls received in the 40 minutes or so after they started coming in to the control room at 01.21.103 The following are particular examples: a. At 01.30.38 CRO Gotts received a further call from Naomi Li, who told her that there was smoke on floor 22. CRO Gotts said that the fire was on floor 4.104 Naomi Li told her that her neighbour had said that the fire was actually in her kitchen. CRO Gotts registered that fact, but immediately said that “You’ve just got some smoke up there”. She told the Inquiry that she may not have understood what Naomi Li was saying and thought that some smoke had just travelled up to that part of the building.105 She did not know that at the same time CRO Duddy had been speaking to the neighbour in Flat 196, Mariem Elgwahry, who had told him that her flat was on fire.106 101 For example, Adams Day 80/91/15-19. 102 Lakanal Control Report Recommendation 7 and Action 7 p. 55; PN790 p. 2. 103 The first 999 call from the building was at 01.21.24 from Naomi Li (Flat 195, floor 22) [LFB00000303]. 104 [LFB00000311]. 105 Gotts Day 43/169/19-171/10. 106 [LFB00000310].

The Grenfell Tower Inquiry: Phase 1 Report 658 b. At 01.30.00 CRO Duddy took a call from Mariem Elgwahry from Flat 196 on floor 22, who told him that the fire was in her flat and that she and others were now on floor 23.107 CRO Duddy corrected her, saying: “Okay, the fire’s on the 5th [sic] floor so you’re well away from the fire, OK?” She responded: “No it’s not. It’s in our flat, we ran out of our flat. It’s in our kitchen.” He still questioned whether it really was fire or whether it was smoke. When giving evidence he explained that he had corrected her because in his experience people on upper floors of high-rise buildings often think there is fire when in fact there is only smoke and because at that point he still believed that the fire was on floor 4.108 That was despite having taken a call at 01.26.54 from Helen Gebremeskel, in which he had been told that Flat 186 on floor 21 was on fire and that the whole building was on fire,109 and despite having also taken a call at 01.28.26 from Natasha Elcock in Flat 82 on floor 11,110 who had told him that she was stuck because of smoke in the lobby. His explanation was that he had been relying on information that they had received from the incident ground and there had been no confirmation of the extent of fire spread.111 c. At 01.34.50 CRO Duddy took a call from Hashim Kedir in Flat 192 on floor 22, in which he told him that he and his family were trapped because the stairs were full of smoke.112 CRO Duddy replied that the fire was on floor 5 and that the smoke could be coming up from there. He was unable to explain why he had told him that the fire was on floor 5 (or floor 4) when only four minutes earlier he had been told by Mariem Elgwahry113 that the fire was already in her flat on floor 22.114 He told Rosemary Oyewole115 in Flat 113 on floor 14 that the fire was on floor 3 when responding to the call she made at 01.37.58116 and told Roy Smith in Flat 95 on floor 12 that it was on floor 4 when responding to the call he made at 01.44.33.117 CRO Duddy said that Roy Smith was “well away from” it. d. While responding to the call made by Jessica Urbano Ramirez at 01.29.48 CRO Russell told her that the fire was on floor 4,118 because she thought that, although it might have moved, it was not anywhere near where Jessica was.119 Jessica told CRO Russell that “there’s fire in the house”, but she repeated her assurance to Jessica that the fire was below her, on floor 4. e. When he called the control room at 01.25.16 from Flat 111 on floor 14, Denis Murphy told OM Norman that fire was “coming right past my window from next door”, but she told him that the fire was actually on floor 4.120 Denis Murphy repeated that it was on floor 14, but she corrected him, saying, “No, it’s on the 4th – 1, 2, 3, 4”. OM Norman told 107 [LFB00000310]. 108 Duddy Day 42/207/22-208/5. 109 [LFB00000306]. 110 [LFB00000307]. 111 Duddy Day 42/208/6-209/2; also in relation to the call at 01.44.43 from Roy Smith in Flat 95, floor 12 [LFB00000324]; Duddy Day 42/219/25-220/5. 112 [LFB00000315]. 113 [LFB00000310]. 114 Duddy Day 42/215/1-6. 115 [LFB00000678]. 116 Duddy Day 42/218/11-19. 117 [LFB00000324]. 118 [LFB00055504] p. 3. 119 Russell Day 76/29/1-6. 120 [LFB00000308] p. 2.

Part III | Chapter 29: The Control Room 659 the Inquiry that she thought that Denis Murphy had meant that smoke was outside his window, not fire, and that she had not learnt from her discussion with him that the fire had spread.121 She said that it was her sense of disbelief that the fire could have reached floor 14 that had led her to correct him.122 The upshot was that in her call to CU8 at 01.35.24 she did not pass on the information that the fire had already reached floor 14.123 f. At 01.30.02 OM Norman took a call from Farah Hamdan in Flat 175 on floor 20, in which she reported that her neighbour’s flat was on fire and that smoke was coming into her own flat.124 OM Norman told her, however, that the fire was on floor 4. Like CRO Gotts, OM Norman was unaware of the call CRO Duddy had received at the same time from Mariem Elgwahry, in which she had told him that the fire had reached the top of the building.125 Moreover, she did not put the information she had obtained from Farah Hamdan together with the information she had obtained from her recent conversation with Denis Murphy and still thought that more smoke than fire had reached that far up the building.126 In hindsight, OM Norman accepted that there was a risk that, in telling the caller that the fire was far away, she had given her to understand that she should not be concerned.127 g. When responding to the call made at 01.39.15 by Hesham Rahman from Flat 204 on floor 23, OM Norman told him that the fire was on floor 4.128 h. In a call made at 01.46.18 Sener Macit in Flat 133 on floor 16 told CRO Adams that there was smoke coming under his door.129 She told him that the firefighters were dealing with a fire on floor 4. He questioned that, but she confirmed it, despite the fact that during a call made at 01.38.18 Zainab Deen in Flat 115 on floor 14 had told her that fire was coming through her door.130 CRO Adams accepted in her evidence that by that time she had known that the fire was not contained on floor 4 and that that was probably the wrong information to give the caller. She could not explain why she had said it otherwise than by saying that she did not have any other information and that was what she definitely knew at the time.131 She blamed the lack of information from the incident ground, saying: “…we had no clarification at that point as to where the actual fire was spreading to, other than what was coming in from the callers. But nothing specific from the ground itself.”132 i. CRO Howson was told in a call at 02.10.31 from Hashim Kedir in Flat 192 on floor 22 that the fire was in their kitchen.133 However, about a quarter of the way into the call, CRO Howson insisted that the fire was on floor 4. She explained to the Inquiry that (even after some 40 minutes of continuously handling FSG calls)134 she had not appreciated that the fire was affecting flats that high up in the building. She had assumed that the 121 Norman Day 42/105/16-106/3, 107/3-6. 122 Norman Day 42/144/1-145/13. 123 [INQ00000194]. 124 [LFB00000314]. 125 Norman Day 42/85/17-86/24. 126 Norman Day 42/66/8-9. 127 Norman Day 42/108/12-110/4. 128 [LFB00000329]. 129 [LFB00000326]. 130 [LFB00000321]. 131 Adams Day 80/52/19-53/23. 132 Adams Day 80/53/25-54/3. 133 [LFB00000345]. 134 As OM Norman put it in her witness statement [MET000080589] p. 5 “[B]etween 01.20 to 2ish all hell broke loose”.

The Grenfell Tower Inquiry: Phase 1 Report 660 fire was still on floor 4 because that was where the original fire had been and that, as she put it: “… it did not do what other fires do. It just, it shouldn’t have happened, you know, the fire shouldn’t have been there.”135 29.70 CRO Howson’s evidence stands in striking contrast with that of OM Norman, who said that shortly after 01.30 she had started to become aware that the control room was receiving calls saying that the whole block was on fire from top to bottom.136 Indeed, by 01.33, there 137 had been calls reporting fire in a number of flats involving 15 adults and three children. By 02.00 those numbers had grown significantly. It is apparent that the control room as a whole had failed to understand that the fire had spread a long way from its point of origin and was affecting occupants right up the tower. OM Norman ought to have ensured that what she had learnt about the development of the fire was swiftly made known to all the CROs. Failing to obtain sufficient information 29.71 On the night of the fire CROs routinely failed to ask callers for their flat numbers, the number of people in the flat, and information about people whose mobility or other health or personal problems might impede their escape. CROs also failed to obtain or provide the command units with sufficient information about conditions being experienced by callers in order to enable them to prioritise rescues. Flat numbers 29.72 It is obvious that CROs answering calls from high-rise residential buildings must at least obtain the flat numbers of callers who are reporting fire or smoke. SOM Smith confirmed that in the case of FSG calls she would be surprised if CROs were providing advice to callers for whom they had no flat number.138 29.73 However, on the night of the fire some CROs frequently failed to ask callers for their flat numbers. For example, CRO Gotts did not seek that information from Naomi Li during the call she made at 01.30.38139 but was unable to explain that omission. Nor did she seek that information from Meron Woldeselassie Araya and Lina Hamide during the call they made at 01.47.49.140 In that case she attributed her omission to the volume of calls coming in.141 Nor, again, did she seek that information from Karen Aboud’s elder son during the call he made at 02.15.07;142 again, she could give no reason for not having obtained the caller’s flat number.143 CRO Gotts was by no means the only one who failed to obtain that information. CRO Fox failed to obtain the number of Anthony Disson’s flat when he called at 01.30.08144 and CRO Duddy failed to obtain the location of Mariem Elgwahry, who had moved from Flat 196 on floor 22 to Flat 205 on floor 23 by the time she called at 01.30.00.145 135 Day 80/154/21-155/10. 136 Day 42/84/12-14. 137 Damiana Louis (Flat 96, floor 12) at 01.24.57; Helen Gebremeskel (Flat 186, floor 21) at 01.26.54; Katarzyna Dabrowska (Flat 95, floor 12) at 01.26.58; Shah Ahmed (Flat 156, floor 18) at 01.27.26; Zainab Deen (Flat 115, floor 14) at 01.29.02; Jessica Urbano Ramirez (Flat 176, floor 20) at 01.29.48; Mariem Elgwahry (Flat 196, floor 22) at 01.30.00; Farah Hamdan (Flat 175, floor 20) at 01.30.02; Biruk Haftom (Flat 201, floor 23) at 01.32.10; Abdeslam Sebbar (Flat 81, floor 11) at 01.33.12. 138 Smith Day 22/80/1-25. 139 [LFB00000311]; Gotts Day 43/168/24-169/5. 140 [LFB00000330]. 141 Gotts Day 43/179/23-180/6. 142 [LFB00000346]. 143 Gotts Day 43/187/21-188/1. 144 [LFB00000459]. 145 [LFB00000310].

Part III | Chapter 29: The Control Room 661 29.74 It is not easy to understand why in each case the information was not sought when it was obviously essential, nor why the omission was so widespread. Although the sheer press of calls might have provided an explanation later in the night, it does not satisfactorily explain why the information was not obtained in the early stages of the incident. Number of persons 29.75 Both PN539 and PN790 require CROs to ask the caller how many people are involved, but some CROs frequently did not seek that information. Again, by way of example only, CRO Gotts failed to obtain that information from Naomi Li during a call made at 01.30.38,146 or from Roy Smith during a call made at 01.38.37 (even though he told her that there were children in the flat),147 or from Meron Woldeselassie Araya and Lina Hamide during a call made at 01.47.49.148 CRO Duddy failed to obtain that information from Natasha Elcock in the course of a call made at 01.28.26,149 or from Mariem Elgwahry during a call made at 01.30.00,150 or from Hashim Kedir during a call made at 01.34.50.151 Similarly, CRO Russell failed to obtain that information from Natasha Elcock in the course of a call made at 02.32.41.152 Mobility, health or other vulnerabilities 29.76 CROs were not trained to ask callers whether they had any physical disabilities or other personal attributes (such as old age, the presence of young children or pregnancy) which might hamper their escape. It is therefore unsurprising that they did not ask callers about such matters, but left it to them to volunteer that information.153 OM Norman said that they would expect the caller to tell the CRO “pretty quickly” that they had impaired mobility if they thought they were trapped.154 Likewise, CRO Gotts said that she did not explore with callers whether they had impaired mobility but that it was something they normally mentioned themselves.155 That was not invariably the case, however. Sometimes callers did raise it: for example, Mariem Elgwahry told CRO Howson of her mother’s medical conditions during the call she made at 02.25.38 and Hesham Rahman told CRO Russell about his mobility problems when he called at 02.36.07.156 Sometimes, however, they did not: Nicholas Burton did not mention his wife Pily’s disability either when he called at 01.56.20 or when he called again at 02.13.03. 29.77 If callers did volunteer information of that kind, they often did so only when the CRO had got to the point of exploring whether they could leave, which itself depended on the CRO’s considering that question before moving to the next phase. In practice, however, CROs routinely moved to the “protect” phase without first investigating fully the possibility of safe escape. In such cases they were unlikely to have reached the point of discovering whether the caller had personal difficulties of a kind that might need to be taken into account by firefighters. That seems to have been the practice in other control rooms too, but it was exactly what paragraph 294 of the LFB Lakanal Report warned against. 146 [LFB00000311]. 147 [LFB00000318]. 148 [LFB00000330]. 149 [LFB00000307]. 150 [LFB00000310]. 151 [LFB00000315]. 152 [LFB00000360]. 153 For example, Adams Day 80/91/20-92/6; Howson Day 80/139/23-140/4; Gotts Day 43/208/5-25. 154 Norman Day 42/60/15. 155 Gotts Day 43/208/11-25. 156 [LFB00000368].

The Grenfell Tower Inquiry: Phase 1 Report 662 Conditions at the caller’s location 29.78 PN539 and PN790 require CROs to obtain information about conditions at the caller’s location. Both policies give examples, such as heavy smoke, thick smoke, slight smoke, as well as the caller’s proximity to the fire, if known. However, that information was not always obtained by CROs on the night of the fire. When they were told that smoke was entering a flat or that the caller was trapped by smoke, they often did not seek any more precise information about conditions,157 with the result that such information could not be passed to the incident ground. Its absence led WM Meyrick to ask CRO Adams at 01.50.09 to obtain information from callers about smoke logging and the nature of the smoke to enable him to prioritise calls. However, CRO Adams did not pass that message on to anyone else in the control room and so that information was not obtained, unless the caller volunteered it. Failing to remain on the line with the caller 29.79 As already mentioned, PN539 defines an FSG call as one where the CRO stays on the line with the caller. It is an unsatisfactory definition, but it is reasonably clear that a CRO handling a call from a caller who is trapped and cannot escape should normally stay on the line. However, on the night of the fire, CROs were generally unable to do that. Instead, they advised callers to seal the places where smoke was getting in with wet towels and await rescue, before ending the call in order to take the next one in the queue. That departure from policy was necessary to enable the control room to cope even at a basic level with the number of FSG calls being received from the tower. Between 01.26.27 and 06.14.47 CRO Gotts handled the highest number of 999 calls, about 70 in all, and there is no doubt that the control room was overwhelmed.158 Very few calls lasted more than about three minutes because the CROs did not have the luxury of time. They were trying to get through as many calls as possible and pass the relevant information to the incident ground to enable rescues to be carried out. It was a matter of judgement for each CRO whether and when to let callers go.159 29.80 The exceptions, such as CRO Russell’s 55-minute call with Jessica Urbano Ramirez and CRO Fox’s 33-minute call with Marcio Gomes, appear to have occurred at random. When asked why she had stayed on the line with Marcio Gomes but with none of the other callers she had spoken to that night, CRO Fox had no explanation and described the circumstances as “very alien to all of us in the control room that night”.160 29.81 The one benefit of CROs’ not staying on the line with callers was that other callers did at least get through to the control room and were able to give information to the CROs which in general was passed on to the incident ground. However, it also meant that the CROs almost never gave proper FSG advice tailored to the individual caller and the changing conditions they faced as the call progressed, as contemplated in the RIFs. 29.82 Individual CROs cannot be blamed for not staying on the line to continue what were on any view FSG calls. PN790 and PN539 did not contemplate that there would ever be more FSG calls than the number of CROs available to handle them in accordance with the guidance they provided. It was a problem caused by the volume of calls generated by the fire and not intrinsically a shortcoming in the way that CROs carried out their role. However, the very fact 157 For example, call at 01.26.58 with Katarzyna Dabrowska [LFB00000309]; call at 01.30.38 between Naomi Li and CRO Gotts [LFB00000311/INQ00000472]; call at 01.28.26 between Natasha Elcock and CRO Duddy [LFB00000307]; call at 01.34.50 between Hashim Kedir and CRO Duddy [LFB00000315]; call at 01.38.37 between CRO Gotts and Roy Smith [LFB00000318]; call at 01.40.17 between CRO Howson and Denis Murphy [LFB00000322]. 158 LFB Control Report. 159 Adams Day 80/94/15-18. 160 Fox Day 80/227/19-228/8.

Part III | Chapter 29: The Control Room 663 that FSG calls were almost invariably being terminated prematurely by CROs in order to enable them to take incoming calls ought to have alerted the more senior officers in the control room to the fact that it had become impracticable to give proper FSG advice to callers; and that in turn ought to have prompted them to inform the incident commander, who might then have considered whether a full or partial evacuation of the building should be undertaken. The fact that that did not happen represented a failure of communication between the control room and the incident ground. 6 Managing information Failing to share information 29.83 In the early stages of the fire, FSG information relating to individual calls was passed to the incident ground by radio. Before long, however, members of the control room attempted to collate FSG information from several calls for transmission to the incident ground. OM Norman collected information from four calls to pass to the incident ground by admin line at 01.35.24, although she said that she had done so because she had not thought that CRO Sharon Darby had been able to get through to the ICP on the radio.161 She did the same again at 01.47.44. CRO Adams took information from CRO Pam Jones who was responding to a call from the El Wahabi family and passed it to CU8 at 01.50.49 using the admin line, together with information from a call she had taken herself.162 Following that, CRO Adams went round the control room on her own initiative just before 02.00 and collected details of flats from which FSG calls had come. At 02.00.34 she called CU8 on the admin line and passed information relating to five flats to the officer in charge.163 However, neither OM Norman or AOM Real, nor CRO Darby, the radio operator, was aware of what CRO Adams had done. CRO Adams accepted that it was likely that information had been duplicated, but thought that it was better for CU8 to have had it twice than not at all.164 29.84 One significant matter that emerges from the evidence is that, apart from those early improvised efforts to organise the transmission of FSG information, CROs were unable to compare what they were being told by callers with the information obtained by their colleagues or with the limited information being received from the incident ground. As a result, they did not grasp the scale of the fire and continued to assume that it could not have spread as quickly and as far as it had. However, the CROs also failed to compare what they were told about the development of the fire with what they themselves had been told by previous callers. They were unable to explain that omission otherwise than by saying that they had received no confirmation from the incident ground of what they had been told. 29.85 Their difficulty in understanding the development of the fire resulted from three things: first, an unquestioned assumption that fires in high-rise buildings will not in any circumstances spread through the building, either quickly or at all; secondly, a complete lack of information from the incident ground; and thirdly, the absence of any system enabling CROs to share information obtained from callers in order to gain an understanding of what was happening inside the building. 161 Norman Day 42/76/18-77/4. 162 [INQ00000203]. 163 [INQ00000195]. 164 Adams Day 80/67/1-70/14.

The Grenfell Tower Inquiry: Phase 1 Report 664 29.86 For reasons that have already been explained, by 2017 the assumption that fires in high-rise buildings would not in any circumstances spread through the building was no longer one that could properly be made, given that by that time the LFB knew that certain kinds of high-rise buildings could present a risk of rapid and unpredictable fire spread.165 Whether CROs were given any information on that subject is a question that must be explored in Phase 2. 29.87 The lack of information from the incident ground represented a signal failure to observe some of the key principles of PN790. One of the main purposes of PN790 was to ensure that critical information about the incident and the progress of FSG calls was exchanged between the incident ground and the control room. The requirement to send the control room information about the action being taken in response to FSG calls was set out in mandatory terms in PN790,166 which recognised that it would enable the control room to give callers information that would be beneficial to them.167 For the first hour and a half of the incident the only information about the fire which the incident commander sent to the control room was that which was received in the informative message recorded at 01.16.02: that a fourth floor flat was 75% alight. Despite four telephone conversations between WM Meyrick and OM Norman and CRO Adams, WM Meyrick gave them no information about the development of the fire, the conditions in the building or the progress of crews deployed in response to FSG calls and neither OM Norman nor CRO Adams asked for it. Similarly, SM Jason Oliff was not given information of that kind when he started to speak to WM Meyrick by mobile phone at 02.06. At some point he was told that firefighters were having difficulty reaching floor 15, but that appears to have been all. The failure of the incident commander, or anyone else, to tell the control room that the fire had spread well beyond the flat of origin meant that the CROs continued to give wrong information and advice to callers. It was a failure on the part of OM Norman not to press the officers in the command unit (principally WM Meyrick) to give her the information that her CROs needed. Access to NPAS helicopter information 29.88 The lack of information available to control room officers could have been mitigated by access to national television news and by the availability of a functioning link to the NPAS helicopter. The Stratford control room, unlike that at Merton, had no heli-tele downlink facility, a fact identified as an action point in the LFB’s post-incident IMP Report.168 As matters turned out, the presence of a functioning heli-tele downlink in the Stratford control room would have made no difference on the night of the Grenfell Tower fire, because the NPAS helicopter images of the fire could not be received by the LFB due to a technical defect explained elsewhere in this Report.169 However, had a heli-tele downlink been available to the control room, it would have provided valuable information to the CROs, because the images transmitted by the helicopter after its arrival at around 01.44 clearly showed that the fire had reached the top of the building.170 It would immediately have made the CROs aware that the fire was no longer contained on floor 4. OM Norman said that the heli-tele downlink was never used and that she had never had any experience of using it in relation to a fire in a high-rise building,171 but the incontrovertible evidence was that, if the control room had been located at Merton and the technical defect had not arisen, it would have been available to the CROs. 165 Refer to LFB’s Tall Building Facades slide presentation of October 2016 [LFB00003521]. 166 Paragraphs 9.1 to 9.3. 167 Paragraph 7.10. 168 [LFB00003114]; [MET00012593] p. 62. 169 Chapter 30. 170 [MET00012593] p. 62 (image 5). 171 Norman Day 42/170/1-14.

Part III | Chapter 29: The Control Room 665 Access to broadcast information 29.89 The Stratford control room was equipped with a 45-inch screen television. It also had a smaller portable television.172 The normal practice in Merton is for the television to be on all the time to provide control room staff with up-to-date news feeds from public television news providers.173 On the night of the fire, the large television screen in the Stratford control room was not working and OM Norman decided at the start of the shift not to turn on the small television.174 Whether it would have been helpful for the CROs to have had images of the fire available throughout the night was a difficult question for them to answer. Although a number of them said they could not be sure if it would have helped,175 CRO Adams said that she had had experience of watching the television on the night of the riots in London and thought that it was always good to be aware of what was happening.176 Despite the obvious risk that disturbing images might have distracted some, seeing the pictures on television would have helped to avoid the confusion and bewilderment felt by many CROs who were unable to understand what was happening. As CRO Adams said: “So when they’re telling us that the fire’s on the top floors, you could see they really do mean it’s on the top floors. And knowledge is always good. The more knowledge you have, it’s always helpful.”177 29.90 The first recorded images of the fire taken by the Press Association and recorded by the BBC are timed at 01.30.178 It is therefore likely that if the television had been on, it would have enabled the CROs to understand better the situation in which they were placed and would have helped them to give accurate and realistic advice to callers, at least in the early stages of the fire. 29.91 The lack of any means whereby CROs can share important information calls for a technological solution. In order to provide high quality FSG advice it is also necessary to devise a system of information collection, collation and dissemination in the control room so that the information provided by callers is gathered together and made available to all CROs and the incident ground continuously as an incident progresses. Conclusions 29.92 On the evidence, I am unable to reach any conclusive findings about whether the failures by CROs to obtain and share information about the matters I have identified led to adverse consequences for any particular individual, let alone materially contributed to any death. However, those omissions in information-gathering not only reveal a widespread failure to comply with the relevant requirements of GRA 3.2 and PN790 but also meant that at no time did any incident commander have the information required to prioritise rescues should they have wanted to use it. GRA 3.2 emphasises that control operators are in a much better position than those on the incident ground to obtain more accurate information about the location of the fire and persons in need of rescue, and that it is that information that should be used by the incident commander to confirm and reassess priorities. WM Meyrick told the 172 Norman Day 42/1-13. 173 By comparison Merton had two 70-inch televisions, one of which showed news coverage and the other operational information: Smith Day 21/94/12-19, 21/95/16-98/16; Adams Day 80/111/9-11. 174 Norman Day 42/98/1-24. 175 Howson Day 80/144/14-18, 166/23-167/9; Gotts Day 43/147/9-14. 176 Adams Day 80/112/3-10. 177 Adams Day 80/112/18-113/2. 178 BBC Timeline images [MET00004561].

The Grenfell Tower Inquiry: Phase 1 Report 666 Inquiry that, on the night, he was unable to prioritise calls effectively due to the lack of vital information about conditions,179 although in fairness to the control room staff it seems that he only asked about priorities once.180 29.93 The CROs’ failure to provide the basic information that each of them should have obtained from callers meant that the incident commander had little chance of being able to establish an effective system of prioritisation. In the final analysis, that may not have mattered much because, despite some effort in CU7 to establish priorities by reference to whether those trapped were children and elderly, the system of deploying crews in response to FSG information on the incident ground never evolved much beyond “first come first served”. 7 The revocation of the “stay put” advice The decision made by SOM Smith and DAC Fenton at around 02.35 to revoke the “stay put” advice represented a fundamental change in the LFB’s response to the incident. They made that decision on the basis of the nature and length of the FSG calls, the limited information they had received from the incident ground that crews could not get above floor 15 and SOM Smith’s experience of the Lakanal House fire. They did so without any visual information about the building and without any discussion with the incident commander (at that point DAC O’Loughlin), as required by paragraph 8.7 of PN790. As SOM Smith explained, there was “no way” that callers could wait to be rescued. It cannot have been an easy decision to make, and it was one for which there was no precedent or established guidance. I pay tribute to the judgement of SOM Smith and DAC Fenton in making it. The communication of the new advice to CROs 29.94 Following the decision to abandon the “stay put” advice at around 02.35, SOM Smith instructed OM Norman to tell the CROs that the advice to callers was now that they must leave the building. SOM Smith’s evidence was that the CROs “might need to use more forceful and blunt language to emphasise the necessity to evacuate the building”.181 Never before in the history of the LFB had such an instruction been given by a control room senior officer and there is no doubt that implementing it and giving advice of that kind to callers was stressful and difficult for most CROs, as well as wholly outside their experience. 29.95 Although the senior control room staff did not know exactly what conditions were like in the communal lobbies and stairs (since they had not received any relevant information from the incident ground), they were aware that they were poor and that there was heavy smoke logging.182 SOM Smith was right to tell CROs to use forceful language because callers would realise that they were being asked to go out into extremely hostile conditions and might otherwise retain a lingering hope that they might be rescued. She told OM Norman that CROs should tell callers that they had no choice but to leave the building and when she gave evidence, strongly resisted any suggestion that CROs should leave the decision to the callers themselves.183 29.96 OM Norman communicated the new advice to CROs by showing each of them a message on an A4 piece of paper and asking them to confirm that they understood it.184 As she recalled it in her witness statement, the new advice was that callers should get out of the building, 179 Meyrick Day 20/75/3-20. 180 In his admin line call with CRO Adams at 01.50.49 [INQ00000203]. 181 Smith witness statement [MET00007766] p. 4. 182 Smith Day 22/127/24-129/24, 139/11-140/8. 183 Smith Day 22/165/18-167/14. 184 Norman Day 42/157/3-22.

Part III | Chapter 29: The Control Room 667 putting wet towels over their heads.185 In her oral evidence she also recalled that she had told CROs to advise callers to hold hands. Her near-contemporaneous note records that she told each CRO individually that callers “had to try and leave the building” and “try and get out”.186 29.97 AOM Real also played a part in instructing the CROs that the advice they were to give had changed. However, as she said, she had simply passed on the new advice to CROs without telling them what kind of language or tone to use, leaving it to each individual CRO to decide how to deliver it.187 29.98 It seems that the message to be blunt and forceful with callers may not have reached all CROs, because they did not in fact always give the new advice in the uncompromising language SOM Smith had required. In some cases the urgency reflected in the warning recorded in the control debrief notes that it could be the caller’s last chance was lacking. That much appears clearly from the tenor of some of the advice given to those who called after about 02.35. Although in the end it was for the CRO handling the call to decide how best to deliver advice of that kind, SOM Smith accepted that some CROs were left with the impression that callers still had to decide for themselves whether it was safe to leave.188 How the new advice was communicated to callers 29.99 Many CROs did not fully grasp the uncompromising nature of the advice they had been instructed to give, or were understandably reluctant to give it. As a result, after about 02.35 many CROs continued to give callers the impression that they should decide whether to leave or not. That was contrary to SOM Smith’s instructions. Making reasonable allowance for the time required to enable the new instructions to reach all CROs, some of the advice subsequently given by CROs was far from unequivocal. Three examples suffice: a. During the call made by Bassem Choukair at 02.43.55 and taken by CRO Adams189 she told him: “Well, we are trying to get to you but it’s very difficult…you make the decision whether you think you need to leave or not”. b. When responding to the call made at 02.51.09 by Naomi Li CRO Russell advised her that “your best bet is to try to leave”,190 and used the expression “best bet” three times. She explained in her oral evidence that that was “because no choice is 100% safe, but that was the best one I was offering”. She also told Naomi Li that it was for her to decide whether it was safer to leave or to stay. CRO Russell explained that she had put it in that way because sending the caller out into the fire and smoke could have led to her death, whereas she had thought there was a chance of rescue if she stayed.191 She could not recall in any detail what advice SOM Smith had told her to give or whether she had been told to advise callers that they should leave at all costs. She thought that there would always be an element of judgement, rather than just advising them to get out, come what may.192 c. In the call she made at 03.03.05 Natasha Elcock told CRO Gotts that she could not get out. Although CRO Gotts did advise her to leave, she also told her that she would tell the crews which flat she was in. The advice given was not the unequivocal advice that she 185 [MET000080589] p. 7. 186 [MET00005199] p. 3. 187 Real witness statement [MET00007696] p. 6; Real Day 43/51/20-53/1. 188 Smith Day 22/166/7-18. 189 [LFB00000376] p. 4. 190 [LFB00000386] p. 8. 191 Russell Day 76/63/17-64/1. 192 Russell Day 76/64/13-65/8.

The Grenfell Tower Inquiry: Phase 1 Report 668 had no choice but to leave. When giving evidence Natasha Elcock said that if someone had told her that there was no fire in the stairs she would have tried to go down.193 At the time, she believed that the fire was below her and had therefore thought that she should stay in her flat, where she was relatively safe. 29.100 On the other hand, some CROs did use blunt and forceful language. For example: a. When answering the call made by Alemishet Demissie at 02.42.40,194 CRO Duddy said: “If you don’t do what I tell you you’re going to die in that flat. Okay? I know it’s really harsh but that’s the truth. Right?” He told her to cover her face with a wet towel, leave her flat and get to the stairwell. b. CRO Duddy took a second call from Alemishet Demissie shortly afterwards at 02.58.44,195 in which he told her that she should cover her face and get to the stairwell and that that was her “only option”. He said: “Listen carefully, okay. Your only chance of surviving this fire is to cover your face with a wet towel and get to the stairwell and make your way downstairs, okay?” He went on: “this is your only chance”.196 c. CRO Howson adopted the same approach in a number of calls, forcefully telling callers that they had to listen to her while she gave them instructions to leave their flat, go down the stairs, keep their nose and mouth covered with wet towels and stay together.197 29.101 As the incident progressed, CROs also faced a dilemma when they were told by a caller that they had tried to leave but had been unable to do so because of conditions outside or that they could not leave because of a disability. In some instances CROs reverted to advising the caller to protect themselves, suggesting that there was a chance of rescue, even though they had not received any information from the incident ground on which to base it. For example: a. When in the call he made at 02.55.38 Marcio Gomes told CRO Gotts that they had tried to leave but could not get out, she advised him to block out the smoke and to get fresh air. When she gave evidence, she explained that in such cases she had taken callers at their word because she had thought that they would know the situation outside better than she did. She was not sure if she had been told at any time that crews could not get above floor 15 and she accepted that she should have advised Marcio Gomes more forcefully to leave. She accepted that she had not sought help or advice from a supervisor.198 b. Similarly, in a call she made at 03.04.52, Natasha Elcock199 told CRO Gotts that she could not get out because it was too hot and begged her to send a forklift truck or cherry picker to get her out. In response, CRO Gotts advised her to stop the smoke coming in and told her that there were more aerial ladders coming. The caller was not advised to leave; on the contrary, she was given unfounded assurances that rescue ladders were arriving. c. CRO Gotts gave similar assurances about the imminent arrival of long ladders to the callers from Flat 193 on floor 22 during the call they made at 03.08.56.200 193 Elcock Day 70/99/22-70/101/24. 194 [LFB00000683] p. 12. 195 [LFB00000680] p. 2. 196 Alemishet Demissie and her friend Ethiopia Assefa were rescued by FFs Sanders, Tucker and Charity shortly after 03.00. 197 Refer to calls at 03.07.13 [LFB00000404] and 03.17.05 [LFB00000418]. 198 Gotts Day 43/210/6-211/23. 199 [LFB00000401] p. 3. 200 [LFB00000406] p. 3.

Part III | Chapter 29: The Control Room 669 d. When responding to the call made by Hesham Rahman201 at 03.10.34, CRO Russell advised him that his “best bet”202 was to leave. He explained that he could not see because of the smoke and that he was disabled. She assured him that the crews “... are coming to you, I promise they are coming to you”. 29.102 The difficulties in providing clear and unequivocal advice to leave at all costs were not limited to CROs. In the call made at 03.33.36, Natasha Elcock told AOM Real that she had already tried to leave but had been unable to do so. AOM Real advised her repeatedly to leave but Natasha Elcock told her that she could not do so. AOM Real then changed her approach and advised her to stay in the flat as long as she possibly could and told her that firefighters were trying to get to all floors.203 AOM Real explained in evidence that, when Natasha Elcock had told her that she could not leave, she had believed that she could not get out and so did not try to assist her to assess the conditions outside her flat. She explained that she had advised her to lie on the floor and stay there as long as possible in order to protect her. She thought that was consistent with the instruction given to the CROs to tell callers to leave, because she had already told her that the advice was to leave.204 29.103 It is important neither to underestimate the pressures on CROs working under such difficult circumstances nor to overlook the unprecedented nature of the advice. However professional the CROs may have been and however experienced and well trained, it must have been extremely difficult for them to give advice and support to people whom they knew were likely to die in the building if they were unable to escape without assistance. It is understandable that, if a CRO was persuaded that the caller was indeed trapped with no realistic possibility of escape, they should offer such comfort as they could. However, as became clear in due course, some of those, such as Natasha Elcock, who said they were trapped and who received comforting advice, were in fact able to escape when urged strongly enough to do so. 29.104 All this points to the conclusion that although SOM Smith had attempted to convey to CROs through OM Norman and AOM Real the importance of emphasising to callers that they needed to leave the building at all costs, she and they had failed to bring it home to them clearly enough. The change of message from advising people to remain in their flats and protect themselves to advising them to leave the building even though in the face of thick smoke was, no doubt, a wholly new and unprecedented experience for most CROs and one not covered by any policy or training. In those circumstances the senior control room officers should, where possible, have monitored the advice being given by individual CROs to ensure that they understood that they were expected to tell callers in simple and direct terms to leave the building regardless of the conditions they encountered in the lobbies and on the stairs and not appear to leave it to their own judgement. Although it would have been impossible to monitor each and every call, the senior managers should have ensured that the CROs as a group were able to convey that message in the right terms and seek assistance and support if they encountered difficulties in conveying it to a particular caller. That was particularly so, given that CROs had never previously had to advise occupants of a high-rise block to make their own way out without help from firefighters. 201 [LFB00000409] p. 3. 202 The same expression she had used on her call with Naomi Li at 02.51.09: [LFB00000386] p. 8. 203 [LFB00000425]. 204 Real Day 43/47/4-24.

The Grenfell Tower Inquiry: Phase 1 Report 670 Calling back 29.105 According to SOM Smith it was a longstanding, historic custom and practice of the LFB’s control room not to call previous callers back. The practice dates from a time when most calls were made from landlines and was based on the notion that it is dangerous to call a landline in a building on fire, since returning to answer it might expose the occupant to danger.205 29.106 It is possible that this antiquated practice may have been part of the reason why CROs did not in general call back those who had previously called from the tower and it is certainly the case that neither SOM Smith nor OM Norman instructed CROs to try to call previous callers back. However, the practice was not invariably followed in respect of those who had called using mobile telephones and CRO Russell went as far to say that it did not apply to mobile numbers.206 CROs did generally call back those using mobile telephones if they had been unable to obtain enough information from a caller or a call had been abandoned.207 In some instances on the night of the fire some CROs did call people back. For example, CRO Duddy called back the Tekles at 03.02.35, following a call to him by Essex FRS (CRO Russ White) at 03.00.10.208 (CRO White had already received calls from Paulos Tekle at 02.48 (abandoned) and 02.51 and had himself called back three times at 02.50, 02.54 and 02.56.)209 In the call with CRO Duddy at 03.00.10, CRO White gave him Paulos Tekle’s mobile telephone number and told CRO Duddy that he had spoken to a caller in Flat 153 who was trapped together with three other adults and five children.210 CRO Duddy told CRO White that the advice was now to get out and he then rang the number that CRO White had given him. In general, however, calling previous callers back to advise them of a change in advice was outside the experience of control room staff.211 29.107 The main obstacle in the way of calling back previous callers was that only the numbers of the last four callers were readily accessible on the VISION system.212 If a CRO wanted to find the number of any earlier caller they would have to search the incident replay section on the ICCS screen (which contains a log of all telephone numbers that have previously called in), which would have been a time-consuming and somewhat uncertain exercise.213 There was therefore no easy way for CROs to find the telephone numbers of previous callers, even if they had wanted to call them back. 29.108 It must be borne in mind that by 02.35 when the “stay put” advice was changed, the control room had received approximately 140 calls from members of the public, residents, relatives and family members and other control rooms and calls continued to come in. Any search for numbers of previous callers would have been a time-consuming exercise which would have diverted CROs from the important task of responding to new calls.214 It would have been made immeasurably more difficult by the fact that the telephone numbers held in the system did not distinguish between callers trapped in their flats and members of the public outside the building, who did not need to be told that the “stay put” advice had been changed.215 205 Smith Day 21/25/25-26/12, 109/8-21, 22/152/13-15. Refer also to Norman Day 42/115/21-24. 206 Russell Day 76/67/25-68/6. 207 Smith Day 21/109/8-21; Norman Day 42/115/3-5. The practice is not set out in PN539 in the section that explains “Abandoned Calls” (paragraphs 4.62-4.64) or PN412 to which paragraph 4.64 refers. 208 [LFB00000557]. 209 [MET00018266] p. 5; LFB00000691; LFB00000692; LFB00000380. 210 This was CRO White’s call back to Paulos Tekle at 02.56: refer to [MET00018266]. 211 Norman Day 42/115/11-24. 212 Norman Day 42/114/14-15, 116/17-18. 213 Smith Day 22/151/14-21; Norman Day 42/116/6-13. 214 Smith Day 22/151/14-21, 153/5-19. 215 Smith Day 22/152/25-153/19.

Part III | Chapter 29: The Control Room 671 29.109 It is therefore understandable that the control room staff did not attempt to call previous callers back to tell them that the advice had changed. The fact that CROs in control rooms of other fire and rescue services did call previous callers back was of occasional assistance to the LFB, but the fact that they did so does not invite adverse comparison with the LFB’s control room, which was faced with many more calls. 29.110 The problems associated with calling back highlight the difficulties encountered by the control room as a result of a decision to change the “stay put” advice at a relatively late stage in the incident. CROs were left without the means to communicate easily with those who remained in the building. 8 Communications with other control rooms The LFB’s policy on “spate conditions” and mutual assistance 29.111 At the time of the Grenfell Tower fire the problems presented by an unusually large number of 999 calls were neither new nor unforeseen. On the contrary, they were the subject of detailed LFB policy provision and formal and informal arrangements with control rooms of other fire and rescue services. 29.112 Paragraph 3.8 of PN539 contemplates that “spate conditions” may arise if there is a surge in incoming calls due to a large number of calls relating to many incidents, or many calls relating to the same incident. In such circumstances the number of calls received may exceed the number of CROs available to answer them. PN539 does not specifically address what should be done if there is a spate of FSG calls requiring CROs to stay on the line. Paragraph 3.9 says that under spate conditions the OM may decide to “queue” non-urgent calls, rather than answering them immediately, but it does not say how an OM should determine whether a call is “non-urgent”. It strongly suggests that LFB did not contemplate spate conditions involving a large number of FSG calls as distinct from “ordinary” 999 calls. 29.113 Under spate conditions paragraph 3.10 of PN539 requires the OM to consider, among other things, recalling “all on duty shift related personnel to Brigade Control”, liaising with BT and establishing critical contact arrangements, the details of which are set out in paragraphs 3.12 and 3.13 (in short, establishing direct lines of communication between the OM in the control room and BT and the MPS respectively, commonly known as the “red phone”). 29.114 Paragraphs 5.12 to 5.14 and Appendix 1 of PN539 describe how the LFB control room should handle requests for assistance received from other fire and rescue services when major incidents occur. It says nothing, however, about how the LFB control room should go about seeking assistance from other fire and rescue service control rooms where that is needed, although it did receive assistance from North West FRS as provided for in the agreement between them, to which I refer below.

The Grenfell Tower Inquiry: Phase 1 Report 672 LFB’s arrangements with other fire and rescue services control rooms The agreement with North West FRS and Staffordshire and West Midlands FRS 29.115 At the time of the Grenfell Tower fire the LFB had a tripartite contract (albeit unsigned and undated) with North West FRS and Staffordshire and West Midlands FRS, under which each control room agreed to provide reciprocal services to the others during “spike” and “spate” conditions,216 which were defined at paragraph 1.2 of the agreement as follows: “(a) Spike conditions [occur] where a high volume of emergency calls is received for one or more incidents over a short period of time,  e.g. a vehicle fire on a motorway generating multiple emergency calls, or (b) Spate conditions [occur] where a high volume of emergency calls are received over a sustained period of time, e.g. abnormal weather conditions (electrical storm) generating multiple emergency calls to multiple incidents involving properties struck by lightning, flooded premises, people trapped in floodwater…” 29.116 The “vision” for these arrangements was described (at paragraph 1.12) as follows: “to develop and deliver a resilient relationship between the three busiest Fire Service Control Rooms in England, to provide support to each other and to the communities they serve, through receiving emergency calls and responding to emergencies on behalf of each other when required.” 29.117 The services set out in Schedule 1 to the agreement were to be delivered in accordance with “pre-agreed protocols” that had yet to be agreed. Critically, under paragraph 5 of Schedule 1 the “Host Control Room” (in this case that of the LFB) was (by its senior officer) to ensure that: “a. The Assisting Control Rooms are notified of the expectation that emergency calls for the Host Control Room are likely to be received; b. British Telecom (BT) is informed and instructed of the situation and that if it is not possible to connect to the Host Control Room, emergency calls are to be directed to the Assisting Control Rooms (using agreed predefined telephone contact numbers or BT Smart Numbers). c. The appropriate Police and Ambulance Services whose areas are covered by the Host Control Room Service are instructed to pass emergency calls to the Assisting Control Rooms (using agreed predefined telephone contact numbers or BT Smart Numbers)…” 29.118 It was the obligation of the “Assisting Control Room” to: a. Take and process emergency calls destined for the Host Control. b. Complete emergency call details using agreed documentation. c. Mobilise a response (if appropriate) in accordance with the criteria set out in this Agreement. d. Record all subsequent radio traffic and requests. 29.119 Paragraph 7 of the Schedule to the agreement required training and exercises at least annually.217 216 [LFB00003607]. This was in place by October 2016 at the latest, since it is referred to in the Home Office’s “Future Control Room Improvements” national document of that month [https://assets.publishing.service.gov.uk/government/uploads/system/ uploads/attachment_data/file/492400/151215_Future_Control_Rooms.pdf] p. 57. SOM Smith said that it dated back to 2012: Day 21/63/16-25. 217 [LFB00003607] p. 10, paragraph 7.1.

Part III | Chapter 29: The Control Room 673 29.120 In light of what happened on the night of the Grenfell Tower fire, it is clear that there are certain aspects of these arrangements with North West FRS which make them vulnerable to failure. First, although Schedule 1 provides that the control room senior manager218 of the host control room should notify the assisting control rooms that they should expect to receive emergency calls, it does not contain any procedure for how assisting control rooms are to obtain details about the incident and how the host control room is to keep the assisting control rooms informed about the development of a complex incident. For example, in the case of the LFB, assisting control rooms do not appear to have automatic access to the VISION system and may therefore not know the status of the incident (e.g. in relation to the number of pumps, informative messages and FSG calls). What is more, although paragraph 5 of Schedule 1 requires that a “standard and consistent” set of documents should be used by each control room, which includes “access to pre-determined hazard and risk information as agreed by the parties”, it does not require each control room to have access to the other’s ORD. Indeed, the LFB’s control room did not even have access to the LFB’s own ORD. 29.121 Secondly, since all policies are designed individually and training is provided at a local, rather than a national, level, there is no guarantee that the way in which an FSG call is handled in (say) West Midlands will be the same as in London. An emergency caller during spike or spate conditions may be “tipped over” to an assisting control room, which may have a different policy or training regime governing how to deal with the call. For example, North West FRS used a coloured flow chart to guide CROs giving FSG advice that was not used by the LFB, and contained more detailed advice in clear and separate steps.219 SOM Smith told the Inquiry, in the context of answering questions about Essex FRS control room (with whom LFB had no reciprocal agreement), that all control room staff would follow national guidance and that LFB CROs could safely assume that the Assisting Control Room had asked the right questions.220 That may or may not be correct, but there appears to have been no significant divergence of approach between the LFB control room and the control rooms of other fire and rescue services, as the Control Room Debrief report records (“Other FRS did know guidance”).221 29.122 Thirdly, there was no evidence that any LFB control room officers of any rank had ever received training in the operation of these arrangements, whether specifically in respect of the contract with North West FRS or the general arrangements for spate conditions and mutual assistance under paragraph 3 of PN539. 29.123 Fourthly, the agreement contained no procedure to enable an assisting CRO to obtain information rapidly about conditions on the incident ground, since all communications are routed through the host control room222 and telephone lines may become congested. The assisting control room is dependent on the host control room to inform it of any developments, such as a change in advice.223 29.124 I have set out these criticisms of the system, not because they all necessarily played a material role on the night of the fire, but so that they can be taken into account in any future discussion of how to improve control room policy and training. 218 Capitalised terms in this section are terms defined in the agreement. 219 [MET00018245]. 220 Smith Day 21/107/21-108/22. 221 [LFB00003113] p. 4. 222 Smith Day 21/102/7-11. 223 Smith Day 21/102/20-103/7.

The Grenfell Tower Inquiry: Phase 1 Report 674 Arrangements with other non-LFB control rooms 29.125 Other than the contract with North West FRS and Stafford and West Midlands FRS the LFB had no formal agreements or standing arrangements with any other fire and rescue services control rooms. It was reliant on BT, as the primary call-taker for all 999 calls, to route the call to another emergency service control room if the number of calls exceeded the capacity of the control room assisting the main control room. 29.126 At the time of the Grenfell Tower fire the procedure was as follows. The OM or SOM would speak to BT and ask it to connect calls to neighbouring fire and rescue services, whose CROs would take the calls and pass the relevant information to the LFB control room. The call would be picked up by an LFB CRO on the ICCS system and appear as, for example, a call from Essex FRS.224 The LFB CRO would then create a new incident call record for that caller and record the details that Essex FRS had provided. There were no means by which Essex FRS could provide that information electronically; it could be transmitted only by telephone. Even though the LFB CRO would be getting the information second hand, they would assume that the Essex CRO had asked the same detailed questions of the caller that the LFB CRO would have asked had the call come through directly to the LFB control room. The caller would, or at least could, be connected directly to the LFB control room and Essex FRS would then drop out.225 Involvement of other FRS control rooms on the night of the fire 29.127 On the night of the Grenfell Tower fire the following control rooms handled the following number of calls relating to the fire:226 FRS No. of calls North West 19 Kent 7 Surrey 7 Essex 5 Merseyside 1227 29.128 Staffordshire and West Midlands FRS handled no Grenfell Tower calls despite being a party to the reciprocal agreement with LFB and North West FRS. OM Norman explained that that was because only North West FRS receive the LFB’s overflow calls whereas the Staffordshire and West Midlands FRS send their overflow calls to the LFB.228 Call-handling by North West FRS 29.129 As the table above shows, most of the calls handled by control rooms other than the LFB were handled by North West FRS, presumably under the contractual arrangements I have described. CRO Aisha Jabin of North West FRS gave evidence about how those would normally work in practice.229 In summary: 224 Smith Day 21/105/13-106/18. 225 Smith Day 21/110/7-111/6. 226 Newman witness statement [LFB00004691] paragraph 16 and Appendix 1 thereto. Calls to a fire and rescue service where it has had to call back the caller because the call dropped have been counted as one call only. 227 Pike witness statement [MET00013002]. 228 Norman Day 42/118/4-7. 229 Jabin witness statement [MET00008028] and Day 43/60/4-67/22.

Part III | Chapter 29: The Control Room 675 a. If the LFB was experiencing delays of more than five minutes in answering calls, BT would pass the call to North West FRS. b. BT would connect the call (giving the caller’s number) to any CRO in the North West FRS control room, telling them that the call was for London;230 it would also call the critical line to let the senior officers in the LFB control room know. The control room might also call the senior officer in the North West FRS control room directly to inform them of the incident, as in fact happened in the case of the Grenfell Tower fire. c. The North West FRS CRO would record the location and nature of the incident and pass the information to the LFB control room. d. The North West FRS CRO would then notify the LFB control room that they had received a call destined for London using the critical line.231 The LFB control room number would be visible to the North West FRS control room on a whiteboard. Emails could also be sent. 29.130 However, on the night of the Grenfell Tower fire the arrangements between North West FRS and LFB proved to have limitations. First, there was no system whereby the North West FRS control room could communicate with the incident ground, or receive information directly from the incident ground about the progress of the fire or any rescue carried out in response to a call it had handled.232 The only way in which the North West FRS CROs could monitor events was by using Airwave radio to listen to the LFB’s channel carrying incident ground radio traffic,233 but that was essentially reactive. Furthermore, there was no information available to the North West FRS CROs about the nature of the premises which were the subject of the calls, other than it was a high-rise residential building. 29.131 Secondly, there were at least two serious breakdowns in communication between the two control rooms: a. During the call from Debbie Lamprell that started at 01.41.18 and was taken by CRO Jabin, the information she obtained about Debbie Lamprell’s location changed as the call progressed. After CRO Jabin had ascertained that she was in Flat 201 on floor 23, it appears that she did not pass that information to the LFB control room and a crew was deployed to the wrong flat. It may not have been possible for CRO Jabin to give the right information to London in time for it to reach the bridgehead before the crew was deployed,234 but in any event, it is not clear why it was not passed on to London at all or, if it was, why it was not recorded anywhere. b. A North West FRS CRO called Zainab Deen back at 02.21.50,235 the connection having failed when BT had tried to make it. Zainab Deen told the CRO that she was in Flat 115 on floor 14.236 There is no evidence that that information was passed to the LFB, although by that point it was likely that Zainab Deen had already been moved to Flat 113. 230 For example, the call at 01.43.14 from Flat 175, floor 20 (Farah Hamdan) [LFB00000444]. 231 For example, the call at 01.43.00 taken by OM Norman from North West FRS, passing on details of Flat 9, floor 3 (Mariko Toyoshima- Lewis) [LFB00000688]. North West FRS had taken this call from the Glasgow BT operator at 01.36.23 [LFB00000506]. 232 Jabin Day 43/64/20-65/12. 233 Pomponi witness statement [MET000080600] p. 6; Basson witness statement [MET00008003] p. 4. 234 Possibly the deployment of FFs Roots and Johnson, deployed at 02.02 to Flat 161 on floor 19, which was Debbie Lamprell’s flat from which she had fled up to Flat 201 on floor 23. 235 [MET00017520]. 236 [MET00017520]. In the transcript, it appears that Zainab Deen says she was in Flat 115, but it is likely that by that time she had been moved to Flat 113.

The Grenfell Tower Inquiry: Phase 1 Report 676 29.132 Despite those defects in its operation, the system for communicating between the LFB and the North West FRS on the night of the Grenfell Tower fire was reasonably effective. Calls and information were generally passed by North West FRS to the LFB control room and the LFB did tell North West FRS when the “stay put” advice had been changed.237 Within the North West FRS control room that change in advice was shouted out by the team leaders and the North West FRS CROs knew they were expected to deliver the advice to get out in no uncertain terms. It seems that they did so.238 Call handling by other FRS control rooms 29.133 Apart from North West FRS, the other FRS control rooms which took calls from or about Grenfell Tower (Kent, Surrey, Essex and Merseyside) had no formal reciprocal agreements or arrangements with the LFB. Those control rooms were contacted on an ad hoc basis either by BT or by family members who were living in the area covered by those fire and rescue services. 29.134 Essex FRS was the first to be contacted by BT at around 01.30. By 01.47, Kent FRS had also been contacted by BT. Both had been asked if they could take calls because there were too many for the LFB and its fallback services to answer. In both instances, the control rooms were given next to no information by BT about the incident. That caused CRO Katrina Marshall in the Essex FRS to ask BT more about the incident, but BT gave her little by way of information and no help about what advice to give callers. Kent FRS was able to obtain information from CRO Howson in the LFB control room in a call at 01.47.13, but Essex FRS was not able to speak with the LFB control room and experienced difficulty in obtaining information about the incident. 29.135 The CROs in the Essex FRS control room made continual efforts to get in touch with the LFB control room using the admin line and the emergency line and through GM Nigel Dilley, the Essex FRS NILO. Eventually, CRO Sharon Lancaster resorted to searching for information about Grenfell Tower on the internet at around 02.14. In the meantime, Essex FRS had taken calls from trapped residents (at 01.48 from Nadia Choucair and at 02.13 from Natasha Elcock). In both cases the CROs were unable to provide any information to the residents about the incident or reassurance about rescue efforts; they did not provide any advice to help the callers to protect themselves. 29.136 OM Norman does not appear to have been specifically aware that control rooms of fire and rescue services other than North West FRS were taking calls on behalf of the LFB as she did not speak to them or set up any arrangements for them to take calls on behalf of the LFB. It is unclear why GM Dilley had such difficulty in contacting the LFB using the direct line and the dedicated Airwave channel. The consequence of these breakdowns in communications was that callers who were put through to other control rooms were not able to obtain any information about the incident or advice about what to do. 29.137 Furthermore, the difficulties experienced by Essex FRS meant that the information it had received from those who were calling from the tower was not passed to the LFB control room, and subsequently to the incident ground, in a timely manner. Indeed, there was a 30-minute delay between Essex FRS receiving the first FSG call from Nadia Choucair at 01.48.00 and the information reaching the LFB at 02.18.55. The failure was further compounded by the fact that when the information relating to those two calls was given to the LFB, CRO Marshall in the Essex FRS control room did not include the flat number given by Nadia Choucair because 237 CRO Jabin put the timing of that at between 02.30 and 03.00: Day 43/89/14. 238 Jabin Day 43/89/18-90/14.

Part III | Chapter 29: The Control Room 677 it had not been recorded on the Essex FRS incident log and she had not taken the original call. Nadia Choucair did not make any further calls to the LFB until 02.37, so the LFB control room and the incident ground remained ignorant of the location of her flat for around 46 minutes.239 29.138 When the “stay put” advice was revoked at around 02.35, LFB CROs informed the other fire and rescue services and by approximately 03.09 at the latest all those taking calls on behalf of the LFB had become aware of the change in advice.240 However, the need to advise people in forceful and blunt terms to leave the building does not always appear to have been fully understood by the CROs of the other fire and rescue services (apart from North West FRS). For example: a. At 02.56, CRO White of Essex FRS spoke to Paulos Tekle and advised him to leave, but when Paulos Tekle told him that the lobby was full of smoke, CRO White advised him to block out the smoke rather than leave at all costs. b. At 02.57.32, CRO Mitch Samson of Kent FRS spoke to Ann Chance for over 90 minutes while her brother, who was in the same flat, was on the phone to the LFB. During the course of the call, a colleague of CRO Samson in Kent FRS was told that the LFB had changed its advice. Although CRO Samson did tell Ann Chance to follow the advice being given by the LFB to her brother, he continued to reassure her that crews would be coming to her assistance. 29.139 Undoubtedly, it was difficult for other control rooms to know exactly what advice CROs in the LFB control room were giving callers, but given that they were acting on its behalf, it was important for the LFB to ensure that they knew the severity of the situation and what advice to give callers. The role of BT 29.140 It would be normal practice in spate conditions for the LFB control room to establish critical contact arrangements with BT, in accordance with paragraph 3.10 of PN539. SOM Smith kept in contact with BT via the “red phone” during the night of the fire and BT routinely told her to which control rooms they were directing Grenfell calls.241 BT passed calls to three neighbouring fire and rescue services control rooms: Surrey, Essex and Kent. At some point SOM Smith asked BT to stop directing calls to North West FRS because she thought that they were overrun.242 29.141 The communication between the LFB and BT would not normally extend to giving BT detailed information about the incident, although BT would often be able to discern from callers something of its nature.243 BT would not normally handle calls itself and would not give advice to callers or take information from them, but on the night of the Grenfell Tower fire, its operators did in some cases provide advice to callers.244 29.142 OM Norman told BT operators what to say to callers before the “stay put” advice changed, but she did not keep in contact with BT during the night to give its operators the latest information about the incident or to obtain information from them about the calls that had 239 Naomi Li, who moved to the flat of Nadia Choucair during the fire, had made a call at 01.30.38 to report that she was in her neighbour’s flat but she did not provide the flat number, only the floor number: [LFB00000311]; [INQ00000472]. 240 North West FRS were told at 03.04; Essex FRS at 02.40.00 (by GM Dilley), 02.52.51 (by CRO Adams) and 03.14.23 (by Surrey FRS); Surrey FRS at 03.06.08 (by SOM Smith); Kent FRS at 02.59.04 (by CRO Gotts) and again at 03.09.03 (by Surrey FRS); Merseyside FRS at 02.47.37 (by CRO Jones). 241 Smith Day 21/63/7-10, 112/16-25. This must have been after her arrival at around 02.15. 242 Smith Day 21/112/21-23. 243 Smith Day 21/113/23-115/8. 244 Smith Day 21/111/9-24.

The Grenfell Tower Inquiry: Phase 1 Report 678 been taken.245 SOM Smith had no discussion with BT about what advice their operators should give to callers, although after the “stay put” advice had been revoked she did tell BT that people calling from within the tower were now being told to leave.246 29.143 After the event, some concern was expressed within the LFB that BT had not known what advice to give callers,247 but SOM Smith could not recall having had any concerns about that. It is right to say, however, that neither she nor OM Norman had spoken to BT to find out how calls were being handled, nor had they discussed with BT the substance of any calls.248 In any cases where BT may have taken information from callers it remains unclear whether, and if so how, that information was transmitted to the LFB control room. 9 Advice given to callers by other emergency services 29.144 The LAS and MPS control rooms also handled a number of calls from occupants of the tower, but there was a lack of co-ordination between the three emergency services, particularly in the area of communication between control rooms and in relation to the advice to be given to callers trapped in the tower. 29.145 Unfortunately, the LFB did not in general communicate efficiently with the other emergency services. That may be because it does not share an established communications link with the MPS or the LAS, which themselves share a CAD link,249 or because there was no joint Airwave channel, as required by paragraphs 4.1.2 and 8.10.2 of the LESLP Major Incident Manual.250 The MPS 29.146 The MPS control centre (MetCC) took 13 emergency calls in the course of which an operator gave advice to callers.251 As is evident from the transcripts, the advice given by the operators varied widely; it included both unequivocal advice to get out of the building252 and advice to leave if the caller wished.253 In some cases the caller was put through to the LFB control room for advice.254 According to Chief Inspector Graham Winch, that was in accordance with their training and the guidance given to MetCC operators and despatchers to use their common sense and to involve the LFB if specialist advice is needed.255 29.147 Beyond that generic guidance, MetCC operators did not understand the “stay put” concept and were not trained in giving fire survival guidance.256 They were not trained to confirm with the LFB what advice the control room was giving callers and disseminate that information to all police operators dealing with calls,257 and there was no statement of practice within the MPS to that effect.258 245 [MET000080589] p. 5 and Norman Day 42/122/24-124/19. 246 Smith Day 21/113/1-8. 247 Control Room Debrief notes [LFB00003113] p. 4 and [LFB00003119] p. 2. 248 Smith Day 21/112/11-25; Norman Day 42/124/12-16. 249 Winch witness statement [METS00020664] pp. 5-6. 250 [RBK00013294] pp. 13, 28. 251 NAJ/2 MET00023291. For individual calls, refer to: CAD 533 [INQ00000282]; CAD 542 [INQ00000264]; CAD 543 [INQ00000270]; CAD 578 [INQ00000280]; CAD 611 [INQ00000287]; CAD 801 [INQ00000284]; CAD 823 [INQ00000276]; CAD 828 [INQ00000266]; CAD 867 [INQ00000470]; CAD 932 [INQ00000281]; CAD 980 [INQ00000275]; CAD 1093 [INQ00000293]; CAD 1104 [INQ00000291]. 252 CAD 533 [INQ00000282]. 253 CAD 611 [INQ00000287]. 254 CAD 578 [INQ00000280]. 255 Winch witness statement [METS00020664] p. 10. 256 Winch witness statement [METS00020664] p. 9. 257 Winch witness statement [METS00020664] pp. 8-9. 258 Winch witness statement [METS00020664] p. 10.

Part III | Chapter 29: The Control Room 679 29.148 Commander Neil Jerome said that although it would be common for MetCC to receive “fire calls about tower blocks”, it would be rare for an operator to give advice to callers.259 Indeed, Inspector Nicholas Thatcher was unaware what the acronym “FSG” stood for.260 Some of the advice given by MetCC operators was inexplicable, such as the advice to Zainab Deen during the call made at 02.01.40 to wave at the police helicopter.261 29.149 Despite separate declarations of a Major Incident by the MPS and the LFB, there is no evidence that the LFB contacted the MPS or the LAS control rooms at any time to tell them what advice to give callers or how to advise callers once the “stay put” advice had changed. 29.150 Commander Jerome was unable to explain why, on his evidence, MetCC was still giving “stay put” advice as late as 03.05.262 It was not until 03.08.27 that MetCC broadcast that change over the general MPS radio channel.263 The message was repeated at 03.10.56, and then again with emphasis at 03.58.03,264 and it is telling that the two MPS officers in charge at the incident, Detective Superintendent Paul Warnett and Inspector Thatcher, did not appreciate that the advice had changed until 03.58. Even though the LFB was in contact with MetCC, for example, to tell it that the LFB had declared a Major Incident,265 there is no clear evidence of how the messages that the “stay put” advice had been revoked were relayed by the LFB to the MetCC control room.266 It is possible that the message was sent by an officer at the scene who had in some way picked it up from the LFB.267 29.151 One of the consequences of the declaration of a Major Incident by the emergency services is that there should be a conversation as soon as possible between the supervisors of all the relevant control rooms. That is one of the joint operating requirements established under the Joint Doctrine Interoperability Framework agreed under JESIP.268 I return to the topic in Chapter 30. 29.152 That is not to say that there was no communication at all between MetCC and the LFB control room. There are sporadic examples of contact, such as the call between the MPS and the LFB at 01.46.18, in which the MPS operator asked CRO Adams whether there was any advice they could give callers, as there was a distressed caller stuck on floor 16 (Sener Macit).269 The MetCC operator then set up a conference call in the course of which CRO Adams gave “stay put” advice. The MetCC operator remained on the line and took the call back at its conclusion. MetCC also called GM Dilley, the Essex FRS NILO at 02.26.30 and 02.32.31 to pass on information, including the fact that the advice to callers had changed. However, the impetus for that is likely to have come from a decision made unilaterally by an MPS supervisor rather than from the LFB.270 29.153 In addition to MetCC operators, MPS officers on the incident ground also gave advice to callers from the building. The MPS’s principal role on the night of the fire was to keep order outside the building and in the surrounding area in order to ensure a safe and unimpeded 259 Jerome Day 72/15/7-14 260 Thatcher Day 71(Mon)/113/3-4. 261 [INQ00000270]. Commander Jerome was unable to explain that advice: Jerome Day 71(Mon)/207/12-15. 262 Jerome Day 71(Mon)/213/11-25, 72/17/17-18/8. This was by reference to his own exhibit NAJ/2 [MET00023291] and CAD 932 [INQ00000281]. Although the transcript of that call does not actually record “stay put” advice being given, equally the operator did not advise the caller to leave at all costs. 263 CAD 482 [MET00023294] p. 20. 264 CAD 482 [MET00023294] pp. 21, 28. 265 AOM Real called the LAS at 02.37.26 [INQ00000376] and the MPS at 02.38.06 [INQ00000375]. 266 Jerome Day 71(Mon)/211/19-25; Winch witness statement [METS00020664] p. 8; Woodrow Day 72/135/16-19. 267 That was Chief Inspector Winch’s view: [METS00020664] p. 8. 268 Joint Emergency Services Interoperability Principles, 2nd Edition, 2 July 2016 [MET00023290]. 269 [LFB00000326]. 270 Winch witness statement [METS00020664] p. 9. That would be consistent with the MetCC’s uneven approach to advice to callers.

The Grenfell Tower Inquiry: Phase 1 Report 680 operating environment for the LFB and the LAS that was large enough for their purposes.271 Many of the officers were asked by families of those trapped in the building what advice to give them or were handed mobile phones and asked to speak to them directly. The Inquiry received some 35 witness statements from police officers who had attended the incident and gave evidence about communications they had had with callers or their family members, or about similar communications with their fellow police officers.272 The overall picture derived from that evidence is that the advice they had given was a mixture of stay put and evacuation, in accordance with what each officer thought the LFB position was at the relevant time. Many of the officers recall the LFB advice changing at some point during the night and some of them said that they had heard it over the MPS radio.273 Understandably, none of the police officers were able to put a precise, or even reasonably accurate, time on those conversations; nor was any of them able to put a time on the change of advice. 29.154 Finally, unlike the LFB, MetCC did not appear to operate a policy of not calling callers back. For example,274 on CAD 578 (a call at 02.01.40) MetCC called back Zainab Deen.275 The LAS 29.155 As of 14 June 2017 there was no formal policy within the LAS requiring call-handlers to pass on information from 999 calls to the LFB, but ordinarily that should have been done.276 The LAS was not expecting to receive calls from within the tower,277 but, when they handled calls themselves, they were trained to go through triage protocols.278 Within the triage protocol, there is a “critical danger” prompt which is a scripted message.279 Call-handlers are not allowed to go off script and should have gone through the protocols before passing information on to the LFB if needed.280 It was not possible to transfer a call directly to the LFB.281 29.156 As at 14 June 2017 the LAS provided no training to their call-handlers on giving FSG advice or indeed any guidance outside that which was scripted.282 It is therefore unsurprising that those who took the calls gave no FSG advice. They had received no guidance from the LFB about how to advise callers from the building because the LFB had assumed that they would be handling the calls themselves.283 Moreover, there is no evidence that the LAS had been told of the change to the “stay put” advice by the time it received the three calls mentioned below. The evidence suggests that the LAS control room was not formally told of the change in the “stay put” advice, although Laurence Ioannou, the LAS senior officer for the incident,284 was informed of it at the scene. 271 Warnett witness statement [MET00008065] p. 3; Jerome witness statement [MET00023286] paragraph 26. 272 These are listed, and the key segments of evidence quoted, in Jerome witness statement exhibit NAJ/3 [MET00023285]. 273 For example, PC Kiran Sangha [MET00007837] p. 5; PC David Heffernon [MET00007832] p. 2. 274 These call times are those recorded on the relevant CAD file. 275 [INQ00000270]. 276 Woodrow Day 72/117/13-25. 277 Woodrow Day 72/124/24-125/3. 278 Woodrow Day 72/125/19-126/17. 279 Woodrow Day 72/127/15-128/2. 280 Woodrow Day 72/126/11-127/4, 130/10-133/4. 281 Woodrow Day 72/126/11-12. 282 Woodrow Day 72/127/5-128/2. 283 Woodhouse witness statement [MET00015657] p. 2. 284 Incident Response Officer (or IRO), in LAS terminology.

Part III | Chapter 29: The Control Room 681 29.157 The LAS handled 28 emergency calls relating to the fire at Grenfell Tower, of which three calls were from flats within the tower itself.285 The details of those three calls are as follows: a. At 02.39.09 Elizabeth Woodhouse received a call from a woman286 in Flat 186 on floor 21 reporting five persons in the flat.287 She overheard a man shouting that they were dying. She told them that the emergency services were there, that they would be rescued and that she should be reassured that help was coming. She did not know what further advice to give and put the call on hold while she consulted her supervising officer. The line then went dead, but contrary to LAS protocol she did not call the caller back and complete the call.288 b. At 03.00.55 the LAS control room received another call from inside the tower.289 The caller reported that he was on floor 15 and was stuck in the flat alone.290 He said there was smoke but that he could see no flames. The call was triaged under the LAS protocols. The call-handler told him that there were a lot of firefighters there and that they were trying to get people to him. The call-handler remained on the line until the line was disconnected at approximately 03:05 before further instructions could be provided. The call-handler provided reassurance throughout the call and asked if the caller was by the window. There is no record of any attempt by the call-handler to call back. c. At 03:18.43, Gayna Morris, an LAS control room operator, received a call from the same person on floor 15.291 He asked for an update and said that he could not breathe. The call-handler said that the LFB would try to help him. The call was triaged through LAS’s Protocol 6 – Breathing Problems. Gayna Morris placed the caller on hold and spoke to her supervisor, but the call was disconnected before any further instructions had been given. She tried to ring back. She got through to his voicemail, but did not leave a message. 29.158 Nobody in the control room informed the LAS of the decision to revoke the “stay put” advice and consequently the new advice to leave the building at all costs was not communicated to those callers. AOM Real’s call to the LAS control room at 02.37.26 was probably the most opportune time at which to tell the LAS that the LFB’s advice to callers had changed. If she had done so, the LAS operators would have advised those callers to leave the building. 10 Communications within the control room and between the control room and the incident ground Lines of communication on the night of the Grenfell Tower fire 29.159 The scale of the Grenfell Tower fire and the speed at which it developed meant more emergency calls came in than the established systems could handle effectively. As a result, the manner in which information was communicated, both within the control room itself and between the control room and the incident ground, was to a large extent improvised. 285 The full list of such calls, their times and CAD references and other details is set out at Table 1 to the witness statement of Paul Woodrow [LAS00000009]. 286 Possibly Helen Gebremeskel, who moved with her daughter to Flat 183 and escaped with the Gomes family at 03.38.06. 287 CAD 392 [INQ00000383] p. 4. 288 Woodhouse witness statement [MET00015657] p. 3. 289 CAD 448 [INQ00000384]. 290 It can be deduced from the earlier exit times of the other occupants of floor 15 present on the night of the fire that the only occupants still on floor 15 at the time of this call were Steven Power (Flat 122), who perished in his flat, and Christos Fairbairn (Flat 124), who left the tower at 03.55.02. The call is likely to be from Christos Fairbairn. 291 CAD 486 [INQ00000385], and Gayna Morris witness statement [MET00016785] p. 2.

The Grenfell Tower Inquiry: Phase 1 Report 682 It is appropriate to look first at how information obtained from callers was transmitted from the CRO by whom it was received to the incident ground, and secondly at how, if at all, information was communicated from the incident ground to the control room. Information transmitted from the control room to the incident ground The chain of communication 29.160 The steps by which information travelled from CROs through the control room and then on to the command unit at the incident ground were, in summary, as follows:292 a. The CRO taking the call recorded certain details in the incident log on the VISION system by creating a “service request”, which would then be completed by the radio operator (CRO Darby) sending a radio message to the command unit. b. Before SM Oliff began using whiteboards the information was passed either: i. by OM Norman or CRO Adams on the admin line to CU8,293 or ii. by CRO Darby by radio, originally to pump G261, then to CU8 and finally to CU7, thereby completing the service request relating to that call. c. Once the use of whiteboards to record FSG information had been introduced, CROs recorded FSG information on scraps of paper, which were either collected by a senior officer (such as SOM Smith)294 and taken to SM Oliff or were taken by CROs themselves. Having recorded the information he had received on one of the whiteboards, SM Oliff transmitted it to the command unit using his brigade mobile telephone. d. However, even after mobile telephone communication with the command unit had been established, CROs also made service requests on the VISION system, to which CRO Darby would respond by sending the information by radio.295 An example is the service request created by CRO Fox at 02.24.11296 for Flat 183 on floor 21,297 which was completed by CRO Darby at 02.25.32298 when she sent the message by radio to the command unit (by then CU7). SM Oliff also added Flat 183 to the right-hand whiteboard at some point,299 although exactly when is not known. e. The information on the whiteboard was changed by SM Oliff or one of the senior officers (including SOM Smith300) to reflect the information derived from FSG calls. f. According to SM Oliff’s mobile telephone records,301 his first call to the command unit (probably still CU8 at that stage) was at 02.06 and lasted some 15 minutes. There were then shorter calls to the command unit (probably by then CU7) at 02.23 (2 mins 40 secs), 02.33 (8 mins 44 secs), 02.44 (1 hr 35 mins 12 secs) and 04.34 (9 mins). Thereafter, the calls became shorter and increasingly sporadic. 292 Smith Day 22/41/12-55/25. 293 CU8 arrived on scene at 01.30.48 and CU7 at 01.42.04 (SIL p. 8). 294 Also FFs Scott Hayward and Adam Crinion, once they had arrived. 295 Darby Day 34/7/21-9/1. 296 SIL p. 22. 297 The Gomes’s flat. 298 SIL p. 22. 299 [MET00016906] p. 3. 300 She wrote “10 people” next to Flat 193: Smith Day 22/87/10. 301 [MET00016910].

Part III | Chapter 29: The Control Room 683 g. In the command unit, FSG information was written down both by the officer in mobile phone contact with SM Oliff (in the early stages WM Meyrick) and by the radio operator (WM Antony Peckham), probably using a pad of control information forms.302 After GM Thomas Goodall had taken over responsibility for the management of FSG information on the incident ground at around 02.20303 he and WM Norman Harrison began to collate the details of FSG calls on a whiteboard in CU7.304 The information was then despatched to the tower either by runner or fireground radio contact, as described earlier. Defects in the chain of communications 29.161 The improvised nature of the communications between the control room and the incident ground makes it unsurprising that the system as it developed over the night had deficiencies. The most obvious were as follows. a. There were at any one time at least two (and at times three) lines of communication between the control room and the incident ground: i. Between 01.30 and 02.06, FSG information was sent to the incident ground both by radio and by means of the admin line. ii. Between 02.06 (when SM Oliff began to communicate by mobile telephone with CU8) and 02.58 there were three separate lines of communication: radio, the admin line and mobile telephone. iii. Notwithstanding that SM Oliff was passing FSG information by mobile telephone to the command unit, CRO Darby continued to send service requests by radio until at least 03.10.305 There was therefore a period of over an hour during which there were two simultaneous channels by which FSG information was being sent to the command unit.306 The entry in the Control Room Debrief307 to the effect that all FSG information was sent by SM Oliff’s mobile telephone and in “no other way” is wrong, as CRO Darby told the Inquiry.308 iv. At the same time (i.e. after 02.06) the control room was also passing messages to CU7 by the admin line. b. There was no system of collating the information sent by different routes in order to ensure that there was no inconsistency or duplication.309 Although the whiteboards that were set up in the control room at around 02.30 were the first attempt systematically to collate the information, the system was not helped by the fact that SM Oliff did not know that when he was sending FSG information by mobile telephone, CRO Darby was also sending FSG information by radio to a different officer.310 c. SM Oliff was not able to see the incident log showing service requests and completions and therefore did not know what information had been sent to the command unit by 302 Peckham Day 30/161/3-23. 303 For example, Goodall Day 35/28/1-17. 304 A photograph of the whiteboard taken at 02.59.58: [MET00015930]. 305 03.10.51 was the last time recorded on the SIL at which an FSG was marked as completed and therefore passed by radio to the incident ground. WM Peckham could not explain why that was since he was receiving radio messages in the radio operator’s chair on CU7 all night until at least daybreak: Day 30/173/6-25. 306 SIL p. 24 and Darby Day 34/13/18-14/11. 307 [LFB00003113] p. 4 308 Darby Day 34/17/13-18/2. 309 Darby Day 34/14/12-18. 310 Darby Day 34/14/12-15/1.

The Grenfell Tower Inquiry: Phase 1 Report 684 radio.311 He was therefore unable to compare the information he had received on paper with service requests being created by CROs to avoid duplication and avoid mistakes. However, the incident log was not an easily navigable source of information and even if he had had access to it, he would not have been able to check whether any particular information had already been sent by radio. But the point remains that he was left in ignorance of the substance of the parallel radio communications with the command unit. d. The rather primitive system of transferring information by scraps of paper was reliant on individual CROs making accurate notes of what they had been told while answering calls and operating the incident log. The accuracy of the information which SM Oliff passed to the incident ground depended on the care taken by CROs when writing it down. e. For one reason or another FSG information was not always recorded fully or accurately on the whiteboards. The following are examples of different kinds of recording error: i. At 02.42.40, CRO Duddy took a call from Alemishet Demissie who was trapped in Flat 94 on floor 12. The details of the call were not recorded on the whiteboard at all. ii. At 02.46.42, CRO Jones took a call from Merseyside FRS who had received a message about Abdeslem Sebbar who was trapped in Flat 81 on floor 11. The details of the call were not recorded on the whiteboard. iii. At 01.54.14, CRO Duddy started a 40-minute call with Roy Smith in Flat 95 who reported that he was trapped with his wife and two children. The message on the whiteboard about his flat read (incorrectly): “95 – 12th flr – 1 male, 1 child”. iv. Calls about Anthony Disson’s flat, Flat 194 on floor 22, received by the LFB between 02.49 and 03.10 reported a change in conditions from heavy smoke to flames at his door. The whiteboard entry was as follows: “194 – 22 flr – heavy smoke. 1 adult”. It was not changed to reflect the deteriorating conditions. 29.162 The overall consequence of these various deficiencies was that in many cases the incident ground was given duplicate or incomplete information.312 However, the evidence as it stands does not make it possible to say whether that contributed to any death. Information transmitted from the incident ground to the control room 29.163 Despite the requirement in paragraph 9.1 of PN790 that the control room be kept informed of the action taken to resolve every FSG call, in practice the control room rarely received information from the incident ground about such matters. SOM Smith said that in her experience the control room did not normally have much contact with the incident ground in relation to FSG calls and that it would learn of a rescue when the CRO taking the call heard firefighters in the background or the caller told the CRO that the firefighters had arrived.313 29.164 Similarly, despite the requirement in paragraph 9.3 of PN790 that the outcome of every FSG be communicated to control, SOM Smith said at one point in her evidence that she “had never experienced that happening”.314 The same applies in relation to paragraph 9.2, which requires 311 Smith Day 22/71/9-23, 49/3-10, 50/3-6. In fact, SM Oliff could have been logged on to the incident log, but it would have taken him time to familiarise himself with what was on it and how it worked, and it would not have eliminated the risk of incompleteness: Smith Day 22/72/23-73/11. 312 Smith Day 22/71/25-72/19. Examples are CRO Adams’s admin line call at 02.00.34 [INQ00000195] and CRO Darby’s radio message at 01.59.05 [LFB00002786]. 313 Smith Day 21/185/18-186/15. 314 Smith Day 21/188/18-23.

Part III | Chapter 29: The Control Room 685 that informative messages must contain an update on each specific FSG call. SOM Smith said that she had never personally experienced any of the requirements of paragraphs 9.1, 9.2 or 9.3 being followed in practice.315 Later in her evidence, however, she said that she would ordinarily expect that on a smaller-scale incident information would be sent to the control room from the incident ground about the progress of an FSG call if the call had been prolonged and the firefighters were having trouble reaching the floor in question.316 Viewed overall, my understanding of her evidence is that, although she had no personal experience of information about the response to an FSG call being sent from the incident ground to the control room, she would expect that to be done in less demanding circumstances, if firefighters were significantly delayed in reaching the caller. 29.165 PN790 was introduced specifically in response to the experiences of the LFB at the Lakanal House fire and the conclusions in the LFB Lakanal Report. It is founded on the principle expressed on page 18 of GRA 3.2 that as part of FSG arrangements “information will be exchanged between callers, Fire Control and commanders at the incident”. It is hard to understand why, having gone to the trouble of formulating and introducing PN790, LFB’s officers then routinely failed to follow it. The need for clear lines of communication between the incident ground and the control room is obvious and of vital importance, especially if there is to be a change in the advice given to callers. As SOM Smith accepted, since the incident commander is responsible for decisions affecting the advice given to people trapped in a burning building (including, if appropriate, a decision to abandon the “stay put” advice), it is necessary for them to be in active communication with the control room to enable proper advice to be given to callers.317 It is a serious criticism, therefore, that the LFB habitually failed to ensure that the control room was informed about the progress of responses to FSG calls, which was one of the fundamental tenets of PN790. 29.166 On the night of the Grenfell Tower fire no information of that kind, nor indeed any information about conditions within the building more generally, was transmitted from the incident ground to the control room, despite there having been regular communication throughout the incident between the control room and the command unit dealing with FSG calls by radio, the admin line318 and mobile telephone. It is a remarkable fact that none of the first three incident commanders (WM Michael Dowden, SM Andrew Walton or DAC Andrew O’Loughlin) made any attempt to contact the control room, either directly or indirectly, to provide information about conditions at the incident ground and the progress of operations. As a result, it was not possible for the control room to give callers reliable advice about the progress of the firefighters through the building. It is fair to say, however, that senior managers in the control room did not attempt to obtain information of that kind from the incident ground, despite the fact that it was a clear policy requirement to do so319 and despite the various lines of communication which had been established with the command units. 29.167 As a result, CROs received no information at all about the development of the fire other than that which could be gathered from the formulaic and brief informative messages sent sporadically by the incident commander.320 Those messages told CROs nothing of any value about the conditions within the building, in particular in the lobbies or stairs, the spread of 315 Smith Day 21/188/25-189/4. 316 Smith Day 22/27/2-23. 317 Smith Day 22/28/19-29/5. 318 For example, OM Norman’s call with CU8 at 01.47.44 [INQ00000208]. 319 PN790 paragraphs 9.1, 9.2 and 9.3. 320 There were three within the first two hours following the first call at 00.54.29, namely at 01.16.02, 02.04.20 and 02.42.03.

The Grenfell Tower Inquiry: Phase 1 Report 686 fire on the exterior of the building or the progress of firefighters in reaching residents or tackling the fire. They were therefore given nothing that would have enabled them to give more timely and focused advice to callers. 11 Deficiencies in the supervision of the control room 29.168 The recommendations of the LFB Lakanal House report included a recommendation that there should be a review of Fire Survival Guidance training for supervisors. A new course for supervisors focusing on leadership and the general supervisory role within the control room, which included the management of FSG calls, was said to have been introduced in response.321 29.169 However, the evidence of SOM Smith, OM Norman and AOM Real suggested that they had not received any specific training on the role of a supervisor, particularly in relation to FSG calls. SOM Smith said that she had not received any specific training from the LFB on the role of a senior operations manager; she had received training on the role of a supervisor only in 2005 when she had been working for Essex FRS.322 OM Norman described receiving only “on-the-job training” and “experiential” training but no formal training for the role of operations manager. She said that she had been trained on PN539 when she joined the LFB in 2003 and had since developed her own additional training on that policy.323 She had never received any formal training on PN790 (although she was aware of it), but had undergone a big FSG training session in 2011 or 2012.324 She received the same FSG training as the CROs and did not have any additional training for her role as an operations manager.325 She said she had never received any training in how to handle many FSG calls at the same time or in how to manage a control room dealing with a large incident of 10 pumps or more.326 AOM Real also described the training she received as “on-the-job” training. She also said she had not received any training on how to manage a control room handling numerous FSG calls.327 29.170 I have already said that on the night of the Grenfell Tower fire the supervisors, like the CROs, faced an unprecedented and extremely difficult situation in which the control room was quickly overwhelmed by the number of emergency calls it received. I make every allowance for the fact that AOMs May and Real were also absorbed in management tasks such as requesting additional resources to be sent to the incident, despatching senior officers, liaising with other control rooms and agencies and maintaining fire cover across the rest of London. Nonetheless, despite all the difficulties, there were certain respects in which the supervisors failed to manage the control room adequately and perform the functions required of them by PN790. In particular: a. The supervisors generally, but OM Norman in particular, failed to seek information from the incident ground about the progress of operations, the development of the fire and the actions being taken to resolve FSG calls. Although the incident commander had a duty to keep the control room informed of those matters, OM Norman, as the senior member of the team, ought to have asked the command unit to obtain that information to assist the CROs in providing advice to callers. The LFB Lakanal Report concluded that during the Lakanal House fire, control supervisors “regularly tried to obtain information about the progress with the incident particularly in relation to callers being given FSG”.328 That 321 LFB Lakanal Report [HOM00001124] pp. 52-53. 322 Smith Day 21/8/23-9/19. 323 Norman Day 42/12/13-22. 324 Norman Day 42/12/13-13/8. 325 Norman Day 42/13/1-16. 326 Norman Day 42/13/17-14/6. 327 Real Day 43/3/15-22. 328 LFB Lakanal Report [HOM00001124] paragraph 319.

Part III | Chapter 29: The Control Room 687 did not happen on the night of the Grenfell Tower fire, despite the fact that at an early stage in the incident OM Norman had set up a direct telephone link with WM Meyrick by way of the admin line call and spoke to him on two occasions (at 01.35.34 and 01.47.44). Proper supervision would have involved ensuring that the officers in the command units were regularly pressed for information about the resolution of FSG calls relating to specific flats. b. Because of the increasing flow of FSG calls to the control room after 01.30, OM Norman became involved in taking 999 calls. That was understandable, but undermined her ability to maintain managerial supervision. When the flow of FSG calls became a flood between around 01.30 and 01.40, OM Norman should have stood back and decided how to manage the collation and transmission of FSG information to the incident ground in a way that ensured that clear lines of communication were established between the control room and the command unit. c. OM Norman failed to ensure that CROs obtained from callers all the information required by PN539 and PN790. Sometimes that was not possible because callers abandoned the line, but there were instances in which CROs simply did not ask all the questions required by the policies. OM Norman said that she expected CROs to obtain all the relevant information and did not think it necessary to remind them or chase them for more.329 In the ordinary way that might not be an unreasonable attitude to take, but given the volume of calls, the fact that CROs were terminating FSG calls to take new calls and the fact that the information being passed to the incident ground was not complete, OM Norman ought to have realised that in some cases CROs were not obtaining all the necessary information and should have reminded them of the need to do so, even on the briefest of calls. 29.171 After the “stay put” advice had been revoked, the supervisors provided little or no supervision or assistance to the CROs in giving effect to the change. That was partly because they were extremely busy managing the incident and partly because the number of calls being received made it impossible for them to supervise them individually. However, in some cases it was, or should have been, apparent that CROs had not understood clearly enough the need to advise occupants in direct and forceful terms to leave the building immediately and not wait to be rescued. It was the responsibility of the supervising officer to listen to the tenor of the conversations between CROs and callers to ensure that unwelcome advice was being given clearly and unequivocally. Without adequate support and supervision, the CROs, who were faced with handling some very difficult calls, were left to do their best. Unfortunately, in some instances they failed to give the necessary advice in the right way. 29.172 The underlying reasons for these failures of supervision are not entirely clear, but on the basis of the evidence given by control room staff of all levels of seniority, it seems at least possible that they were attributable to a failure on the part of the LFB to provide its senior control room staff with appropriate training on how to manage a significant incident with a large number of FSG calls. 329 Norman Day 42/79/17-80/2.

The Grenfell Tower Inquiry: Phase 1 Report 688

689 Chapter 30 The Response of the MPS, the LAS, RBKC and TMO This Chapter examines the joint working arrangements in place for emergency services in London and the response of the emergency services other than the LFB on the night of the Grenfell Tower fire. It examines in particular how and the extent to which they communicated and co-operated with the LFB and with each other. It also examines the responses of RBKC and the TMO on the night of the fire. 1 Introduction 30.1 The Inquiry received witness statements from officers of the MPS who attended the incident on the night of the fire, from National Police Air Service (NPAS) pilots and from other personnel. They included statements from two senior police officers, Chief Inspector Graham Winch,1 who explained certain aspects of the MPS’s communications and call-handling systems, and Detective Superintendent Paul Warnett, who was the MPS Gold Commander at the scene until around 04.20.2 The Inquiry also received written and oral evidence from two senior officers, namely Inspector Nicholas Thatcher3 and Commander Neil Jerome.4 30.2 The Inquiry also received written evidence from officers of the LAS who attended the fire, including a statement from Laurence Ioannou, the LAS senior officer at the scene,5 as well as written and oral evidence from Paul Woodrow, the LAS’s Director of Operations.6 30.3 Of particular value have been the main CADs for both the MPS (CAD 482) and the LAS (CAD 247).7 Although they do not record all the transmissions during the night, they are the principal communications logs for the two services relating to the incident. The Inquiry has proceeded so far on the basis that the contents of CAD 482 are a reasonably reliable record of the relevant MPS communications on the night of the fire. However, in the light of further potentially relevant evidence received very recently, I am not entirely confident that the record of relevant MPS communications is complete. 30.4 The Inquiry received written witness statements from employees of RBKC and both written and oral evidence from Nickolas Layton and Michael Rumble, the Local Authority Liaison Officers (LALOs) at the scene up to 08.00. 30.5 The Inquiry also received witness statements from employees and officers of the TMO and heard oral evidence from Robert Black (Chief Executive), Teresa Brown (Director of Housing), Graham Webb (Managing Director of Repairs Direct Ltd, the company responsible for carrying out domestic repairs in properties managed by the TMO) and Hash Chamchoun (Head of Supported Housing). 1 [METS00020664]. 2 [MET000080605]. 3 [MET00012582]; [MET00018201]; [MET00023284]. 4 [MET00023286]. 5 [MET00010862]. 6 [LAS00000009]. 7 CADs are computer-aided dispatch logs used by the LAS and the MPS. CAD 482 [MET00023294]; CAD 247 [MET00019931].

The Grenfell Tower Inquiry: Phase 1 Report 690 2 The Joint Working Arrangements for the Emergency Services in London 30.6 The actions of the MPS, the LAS and the LFB are to be assessed against the standing arrangements in place at the time of the Grenfell Tower fire for joint operations between London’s emergency services. Those arrangements are principally contained in the following three documents: a. Joint Doctrine: The Interoperability Framework (2 July 2016).8 b. The LESLP Major Incident Procedure Manual (July 2015).9 c. The London Resilience Partnership Strategic Co-ordination Protocol (February 2017).10 30.7 The principles set out in those documents are intended to reflect and discharge the overarching obligations placed on certain public bodies by the Civil Contingencies Act 2004 (the CCA). The LFB, MPS, LAS and RBKC are Category 1 Responders within the meaning of Part 1 of Schedule 1 to the CCA. By virtue of section 2(1) each is under a statutory duty to assess the risk of an emergency of a kind that would be likely seriously to obstruct it in the performance of its functions and to maintain and publish plans for ensuring, so far as reasonably practicable, that, if such an emergency does occur, it will be able to continue to perform its functions, mitigate the effect of the emergency and take any necessary action in relation to it without the need for additional resources, if it considers that to be necessary or desirable. 30.8 Section 2(3) gives the government power to make regulations about the extent of the duties imposed by section 2(1) and the manner of their performance. Regulations made under that section govern joint working, co-operation, the entry into protocols and the maintaining of plans between Category 1 Responders in what is known as a local resilience area. Under the regulations then in force in 2017 the LFEPA11 had lead responsibility for maintaining emergency plans in the case of a pan-London emergency, as well as carrying out exercises and training if requested by another Category 1 Responder. 30.9 The legislation comprising the CCA and the regulations made thereunder is complex. Whether the three sets of arrangements to which I have referred were adequate to fulfil the statutory purposes for which they were introduced and maintained lies outside the scope of the Inquiry’s Terms of Reference. What matters for present purposes is to understand the nature of those arrangements and their intended purpose in order to assess their effectiveness in relation to the Grenfell Tower fire. Joint Doctrine: The Interoperability Framework 30.10 The document entitled Joint Doctrine: The Interoperability Framework (the Joint Doctrine)12 was produced and maintained by those agencies responsible for Joint Emergency Services Interoperability Principles, or JESIP. JESIP is a programme run by the emergency services nationally with the support of the Home Office, the MHCLG and the Cabinet Office.13 The Joint Doctrine was first published in 2013 and was revised in July 2016. Its status is explained 8 [MET00023290]. 9 [RBK00013294]. 10 [MET00023288]. 11 The London Fire and Emergency Planning Authority. 12 [MET00023290]. 13 For a full description of JESIP refer to www.jesip.org.uk

Part III | Chapter 30: The Response of the MPS, the LAS, RBKC and TMO 691 in its section 2 as supporting the guidance entitled Emergency Preparedness and Emergency Response and Recovery issued by the Cabinet Office under the CCA.14 The Joint Doctrine describes itself on page 2 as “an essential element in the hierarchy of guidance. It provides commanders, at the scene and elsewhere, with generic guidance on the actions they should take when responding to multi-agency incidents of any scale... ... It should be embedded in individual organisation policies and procedures and in their training and exercise programmes, for all levels of response staff.” 30.11 The basic principles of joint working are set out in section 3 as “co-locate”, “communicate”, “co-ordinate”, “jointly understand risk” and “shared situational awareness”. 30.12 Section 4 deals with the early stages of a Major Incident and emphasises the importance of recognising that the incident will involve working with other emergency services or responder agencies. It points out that the sooner other responder agencies are notified of the incident the sooner joint working arrangements can be agreed and put into place. 30.13 Section 4 also sets out the principles of joint working at a Major Incident, which it defines as an event or situation with a range of serious consequences which requires special arrangements to be implemented by one or more emergency responder agencies.15 The declaration of a Major Incident triggers a pre-determined strategic and tactical response from each of the emergency services and other responder agencies. The section goes on to point out that declaring that a Major Incident is in progress as early as possible means these arrangements can be put in place as soon as possible. 30.14 To that end, the Joint Doctrine espouses a framework of common messaging or reporting called METHANE, which stands for: Major incident Exact location Type of incident Hazards Access Number of casualties Emergency services.16 In section 5 of the Joint Doctrine each element of METHANE is broken down and explained. Each responder should send a METHANE message to their control room as soon as possible. The first resources to arrive at the scene should send the METHANE message so that situational awareness can be established quickly. 30.15 Section 6 of the Joint Doctrine governs control rooms and communications between emergency services, and prescribes five “supporting principles”. It explains how control rooms are the key communication links between agencies and points out that there cannot be a co‑ordinated multi-agency response or effective communication if control rooms do not deliver a swift and joint approach to handling them. The first supporting principle is that a dialogue between control room supervisors must be established as soon as possible in order 14 Emergency Preparedness and Emergency Response and Recovery. 15 The definition is taken from the Cabinet Office’s “Lexicon of UK civil protection terminology”, at www.gov.uk/government/ publications/emergency-responder-interoperability-lexicon 16 It is also possible that the incident is not yet a Major Incident, in which case the message should be ETHANE, but commanders should monitor the incident in case it exceeds the threshold.

The Grenfell Tower Inquiry: Phase 1 Report 692 to start sharing information about the incident. The discussions must be frequent and cover specific points, such as who is the lead agency, what information and intelligence each agency shares, what hazards and risks are known by each agency, what resources are being deployed and why, how the agencies will continue communicating with each other, and the point at which multi-agency interoperable voice communications will be required and achieved. Section 6.1.1(b) calls for the nomination of a single point of contact in each control room and the establishment of a method of communication between them all. 30.16 Supporting principle 5 requires the lead responder (in the case of the Grenfell Tower fire, the LFB) to suggest a location for commanders to “co-locate” in the early stages of the incident, and “if early location information is unverified” then the lead responder and other control rooms should agree an initial rendezvous point and communicate it to the commanders as soon as possible. That reflects supporting principle 4, that it is always preferable for commanders to meet and speak to each other directly. 30.17 The Joint Doctrine then sets out the framework for establishing “a common operating picture” (section 7), “arrangements for joint working” (section 8), a “joint decision model” (section 8.1), and under section 8.1.3 a “working strategy”, namely, an action plan that commanders develop and agree together. It sets out key steps in the establishment of an effective, integrated multi- agency operational response plan, which involves identifying hazards, carrying out a dynamic risk assessment, identifying tasks, applying risk control measures, formulating an integrated multi-agency operational response plan, and recording decisions. It then sets out further principles relating to “briefings, supporting joint decision making, information sharing and tiers of command, including operational, tactical and strategic principles, and inter-agency resources and information sharing under a multi-agency information cell (MAIC)”. 30.18 The Joint Doctrine is well-intentioned, but it is not an easy document to navigate or penetrate beyond the first few pages. The basic principles are clear enough, but the repetition of the same ideas in numerous different guises, and the bewildering array of management language and acronyms, often at a high level of abstraction, makes practical application something of a challenge. I hope it is not unfair to say that it bears all the hallmarks of managerial conceptualism, designed to fulfil a statutory requirement in a vacuum, and does not appear to be based on the experience of those who operate on the incident ground in the real world. 30.19 Two things at least are, however, plain from the Joint Doctrine. First, if an emergency service declares a Major Incident, it is essential that that fact is communicated to the other emergency services as soon as possible. That is a simple rule to follow in practice and the consequences of failing to do so would be obvious to any responder at the scene. The declaration of a Major Incident is all but useless if it is not communicated to other Category 1 Responders as soon as possible. 30.20 Secondly, it is vital that clear lines of communication between control rooms are established as soon as possible once a Major Incident has been declared, so that each emergency service knows what the others are doing at any given stage. The LESLP Major Incident Procedure Manual 30.21 LESLP is the London Emergency Services Liaison Panel, which was formed in 1973 and consists of representatives from the MPS, the City of London Police, the British Transport Police, the LFB, the LAS and local authorities, as well as other public bodies. The LESLP Major Incident Procedure Manual (the Procedure Manual),17 version 9 of which was released in July 2015, was 17 [RBK00013294].

Part III | Chapter 30: The Response of the MPS, the LAS, RBKC and TMO 693 produced to incorporate the JESIP principles contained in the Joint Doctrine.18 As paragraph 1.8 of the Introduction to the Procedure Manual says, each emergency service has its own arrangements for responding to a Major Incident. The purpose of the Procedure Manual is to describe the agreed procedures and arrangements for the effective co-ordination of the joint efforts of those who operate within the London Resilience Strategic Co-ordination Protocol, with which it is designed to be read (and to which I will return in detail below). 30.22 The Procedure Manual is a more accessible and pragmatic document than the Joint Doctrine. The important sections for present purposes are as follows: a. Section 2, Major incidents, contains the JESIP definition of a Major Incident and goes on to explain what it typically involves, such as the large-scale combined resources of the police, the LFB and the LAS. It states that a Major Incident can be declared by one or more of the emergency services. Although what is a Major Incident to one emergency service may not be so to another, each of the emergency services will attend with the appropriate pre-determined response. b. Section 3, The main functions of the emergency services and other agencies, contains clear guidance on the role of each emergency service, the NHS and the local authority. It also creates the role of LALO (section 3.9) and provides for their functions. c. Section 4, Working together, summarises in a more digestible form the Joint Doctrine requirements, including, in particular, the requirement to communicate (including meeting face to face: section 4.1.1), to establish a Joint Emergency Service Airwave channel through MetCC (section 4.1.2) and to share information and situational awareness with partner services by use of the METHANE model of reporting (section 4.2.2). d. Section 5, Scene management, sets out how a scene will be managed by the use of cordons and access points, RVPs, marshalling areas for multi-agency resources and a forward command point. e. Section 8, Communication systems, describes the various methods of communication that the emergency services use, in particular for inter-agency command (section 8.10). Section 8.10.2 provides for all emergency services to be able to communicate on Airwave interoperability talkgroups, such as Talkgroup IC1 for tactical commanders, the ES Talkgroups for operational commanders and IAT1 for all Airwave users. f. Section 9, Casualty clearance, provides for a system of sorting casualties in order of seriousness, triage, the creation of the casualty clearing station and matters such as the involvement of the coroner and disaster victim identification. Sections 9.5, 9.6 and 9.7 contain procedures in respect of evacuees, rest centres and survivor reception centres, responsibility for which lies with the MPS supported by the local authority. Section 9.9 provides procedures for the establishment of the casualty bureau by the MPS, where details on all dead, casualties, survivors and evacuees are to be collated and where telephone enquiries from friends and relatives are to be handled. It is essential, in order to match enquiries with details of persons involved, that all casualty information be routed through the casualty bureau (section 9.9.5). g. Section 10, Helicopters, provides for helicopter assistance in the Greater London area. Section 10.1.2 sets out what equipment NPAS helicopters have on board, including a public address system (known as “skyshout”) and video transmission equipment to ground-based receiving stations, which include the MPS and LFB command vehicles 18 Presumably the 2013 version and not the July 2016 version of the Joint Doctrine, which post-dated the 2015 Procedure Manual.

The Grenfell Tower Inquiry: Phase 1 Report 694 and a number of police patrol supervisor vehicles. It also provides for mobile receivers which can be delivered close to the scene. Section 10.1.3 describes the ten types of support facilities that NPAS helicopters can provide. They are all assessment facilities designed to provide information and intelligence about the incident (such as casualty search and assessment of numbers), but not to carry out physical rescue of those in danger. Sections 10.2 and 10.3 provide for military helicopters and LAS HEMS (Helicopter Emergency Medical Services), principally for the mass transport of high numbers of casualties rather than rescues (although military helicopters have winch capabilities). Section 10.4 provides that HM Coastguard’s search and rescue helicopters may be called upon to assist in marine or land rescue incidents in the London area. 30.23 The remainder of the Procedure Manual deals with investigation, safety, other assistance, media liaison and public information, occupiers’ response to an incident, debriefing and the welfare of responders (sections 11 to 17). The London Resilience Partnership Strategic Co-ordination Protocol 30.24 The London Resilience Partnership Strategic Co-ordination Protocol version 7.3 dated February 201719 (the Protocol) is published by the London Resilience Group (LRG). The LRG is part of the London Resilience Forum established under the CCA. The LRG is jointly funded by the Greater London Authority, London local authorities and the LFB (but at the time of the Grenfell Tower fire by its predecessor, the LFEPA). The LRG had its headquarters at the LFB’s head office. 30.25 The Protocol establishes the escalating co-ordination arrangements for London’s response to a disruptive incident, including a Major Incident and is intended to complement the Procedure Manual (section 1.1). It lays down the principles for establishing command structures through strategic co-ordination groups (SCGs), which are the top tier of command of multi-agency co-ordination, below which sit the Tactical Co-ordinating Group (TCG) and Operating Co‑ordinating Group (section 1.3.3-1.3.7). 30.26 The Protocol distinguishes between a Critical Incident (as defined by the MPS) and a Major Incident (using the JESIP definition set out above). A Critical Incident is any incident where the effectiveness of the police response is likely to have a significant effect on the confidence of the victim, their family and/or the community. 30.27 This shows that although each emergency service has its own definition of different gravities of incident, a Major Incident always gives rise to a multi-agency response. The Protocol proceeds under Part 2 to set out some 15 “core functions”, including notification of strategic co-ordination arrangements, carrying out the detailed roles and responsibilities of the SCG, TCG and OCG, creating and maintaining shared situational awareness, determining strategy and decision-making. 30.28 At the front of the Protocol there is a schematic colour-coded six-page guide under six heads: Notification, Assessment, Co-ordination Level, Activation, Response Strategy and Recovery. Beyond this, as with the Joint Doctrine, much of the Protocol is at a high level of abstraction containing little beyond statements of the obvious, and does not appear to leave much to common sense. But, like the Joint Doctrine, the basic imperative is plain enough: for emergency services to communicate with each other properly and in a timely fashion in the event of a Major Incident in order to formulate and execute a co-ordinated plan. 19 [MET00023288].

Part III | Chapter 30: The Response of the MPS, the LAS, RBKC and TMO 695 3 Arrangements for Inter-agency Communications 30.29 Before embarking on an examination of the actions of the MPS and the LAS on the night of the fire it is necessary to understand the key elements of the communications systems used by the various emergency services. The systems used by the LFB have been described in Chapter 7. The systems used by the MPS and the LAS are described below. The MPS communications systems 30.30 In his written witness statement to the Inquiry Chief Inspector Winch described in general terms the MPS’s systems for handling emergency calls and communicating both internally and with the other emergency services.20 For present purposes his evidence can be summarised as follows: Emergency calls a. When someone dials 999 the call is answered by a BT emergency operator, who finds out which emergency service the caller requires. If the caller is unable to say which service they require, or the line is cut, the call is put through to the police control room. The MPS has two automated systems for handling calls: the Call Handling System (CHS) and the Computer-Aided Despatch (CAD) system. b. BT puts the call through to CHS in the police control room at one of three locations in London: Bow, Lambeth and Hendon (collectively known as MetCC). The system automatically enters details of the caller, their location and certain other matters. c. Once the minimum amount of information has been obtained the call is “passed” by the CHS call handler to the borough “pod” for the location of the incident. (“Passing” is a technical term; it means that the call has been transferred to a pod and entered on the CAD system, but the original call handler remains on the line to the caller.) d. If the call is passed to a pod it becomes a CAD and is given a CAD number, time and level of importance.21 The location to which the police officers have been called is entered. The person organising the response to the call (known as the “despatcher”) then acknowledges the CAD. Where there are a large number of calls to the same incident the first CAD number generated for that incident is the “working CAD”; in the case of Grenfell Tower it was CAD 482. That CAD is the place where MPS operators (MetCC) subsequently record their actions and additional information. Later CADs relating to the same incident are linked to the “working CAD”. e. The MPS has a standard operating procedure (SOP 300) for abandoned calls from landlines or mobile telephones, which require the MetCC operator to try to call the caller back twice before referring the matter to a controller to decide whether to close the call.22 Radio communications Every borough within the area covered by the MPS has a main channel known as Despatch 1, which is then identified by its borough code. The borough code for Kensington and Chelsea on the night of the Grenfell Tower fire was BS Despatch 1. Communications on that channel 20 [METS00020664]. 21 There are four grades of call: Immediate, Significant, Extended and Referred. 22 Refer to the flow charts at GNW1; [METS00020665] and [METS00020666].

The Grenfell Tower Inquiry: Phase 1 Report 696 were monitored constantly by MetCC and could be heard by all police officers monitoring the channel. In addition to the main channel the MPS operated a support channel, which could be used for non-urgent matters such as Police National Computer checks. Further, officers could use despatch channels for other boroughs if need be, and there were various additional channels which could be used by officers for longer discussions without impeding the use of the despatch channel. Liaison with other emergency services a. The MPS has a CAD link with the LAS, which allows call handlers and despatchers to send a message to the LAS by means of the CAD instead of having to make a telephone call. It is designed to deal with individual 999 calls where the MPS decides that the incident requires the attendance of the LAS and vice versa. This facility is independent of the call passing, so an ambulance can be called even before the incident is passed. When a CAD is passed to the LAS the LAS receives the pre-formatted dialogue box with the details of the caller, location and an assessment of their medical condition. b. The MPS has no CAD link with the LFB, possibly because of the incompatibility of systems. MetCC communicates with the LFB by telephone, usually through a unit called DI/10 (sometimes known as the contact desk) which sits at the MetCC room at Lambeth, as well as by other methods, including radio. If a Major Incident occurs, the emergency services commanders normally gather in the special operations room at Lambeth, as they did during the night of the Grenfell Tower fire. The LAS communication systems 30.31 Evidence about the LAS’s communication systems was given orally by its Director of Operations, Paul Woodrow, who also provided a witness statement to the Inquiry.23 The LAS’s Incident Response Procedures comprise Annex C to his statement. In summary: a. The LAS control room communicates with the LFB by telephone, not by CAD.24 b. The LAS can also communicate with the LFB by Airwave radio and there is also a “tri‑agency” channel, on which critical information can be shared. That channel is monitored at the LAS incident management desk or, once an incident has been declared a “significant incident”, by the special operations centre.25 c. The LAS has an electronic CAD link to the MPS, which allows each service to transfer messages directly into the other’s CAD system, although it does not allow either of them to view the other’s CAD log.26 30.32 The LAS Incident Response Procedures contemplate two types of serious incident, “Significant Incidents” and “Major Incidents”. Significant Incident The LAS27 definition of a Significant Incident is: “Any incident which from initial intelligence will require attendance of a number of resources along with a management presence or dedicated response.” 23 [LAS00000009]. 24 Woodrow Day 72/66/2-11. 25 Woodrow Day 72/66/2-67/5. 26 Woodrow Day 72/67/6-25. 27 Section 1.1 of the LAS Incident Response Procedures [LAS00000008] p. 21.

Part III | Chapter 30: The Response of the MPS, the LAS, RBKC and TMO 697 Significant Incidents include fires where there are “persons reported” and fires which are attended by six pumps, as well as any incident which another emergency service has declared to be a Major Incident. The declaration of a Significant Incident triggers a pre-determined response of four ambulances, two Incident Response Officers (IROs) and two Operational Commanders28 and requires consideration to be given to the attendance of specialist resources such as a Hazardous Area Response Team (HART).29 It also puts control of the incident into the hands of the Special Operations Centre.30 The Special Operations Centre is based at Bow and at Waterloo Road. It is a dedicated management suite within the control room. It has numerous functions including the central co-ordination of incident activity and the management of Airwave talkgroups and communication. Major Incident The LAS adopts the NHS’s definition of a Major Incident, namely,31 “A Major Incident is any occurrence that presents serious threat to the health of the community, or causes such numbers or types of casualties, as to require special arrangements to be implemented.” This is not the same as the JESIP and LESLP definition, but the JESIP principles are embedded in all LAS Incident Response plans and training and the LESLP Procedures Manual governs the LAS response at the scene of a Major Incident.32 30.33 The LAS expects the LFB to be the lead emergency service for a fire of the kind that occurred at Grenfell Tower. As such it expects to be told how much of the building is affected, how many flats are in the building, broadly how many casualties there are, how many people have left the building unaided or with assistance and how the LFB intends to fight the fire or evacuate the residents.33 In terms of the LAS’s experience of communications with the LFB, the reality is that there is very little joint operation between them, not least because less than 1% of the 1.9 million emergency calls received by the LAS annually are to fire‑related incidents. Paul Woodrow rejected the suggestion that historically there had been any “overarching problems” with communication with the LFB at incidents.34 30.34 The LAS expects the MPS to manage access and to cordon off the scene of the incident to ensure the safety of its personnel. It looks to the local authority as a fellow Category 1 Responder to provide reception centres for patients who are mobile and are not in immediate need of being taken to hospital.35 4 The response of the MPS and the LAS 30.35 In the light of all the evidence it is clear that on the night of the fire the responses of the Category 1 Responders (i.e. the MPS, the LAS and RBKC, in addition to the LFB), did not fully adhere to the principles contained in the Joint Doctrine, the Procedure Manual or the Protocol. The principal flaw, common to all, was poor communication, both at control room level and on the incident ground, which meant that individual organisations were often working in isolation and in ignorance of what the others were doing. 28 Section 4.6.3 of the LAS Incident Response Procedures [LAS00000008] p. 73. 29 Woodrow Day 72/83/21-85/1. 30 Woodrow Day 72/88/14-89/2. 31 Section 1.2 of the LAS Incident Response Procedures [LAS00000008] p. 22. 32 Sections 1.13 and 1.14 of the LAS Incident Response Procedures [LAS00000008] pp. 27-30. 33 Woodrow Day 72/73/22-74/1-18. 34 Woodrow Day 72/75/22-25. 35 Woodrow Day 72/62/3-20.

The Grenfell Tower Inquiry: Phase 1 Report 698 Separate declarations of a Major Incident 30.36 The concept of a Major Incident lies at the heart of the joint emergency services’ response enshrined in the Joint Doctrine, the Procedure Manual and the Protocol. Declaring a Major Incident, even where it has previously been declared as a “Critical Incident” (the MPS) or a “Significant Incident” (the LAS), is, as Inspector Thatcher said, a massive step.36 30.37 As is clear from section 2 of the Procedure Manual, a Major Incident can be declared by any one or more of the emergency services. What appears to be a Major Incident to one may not appear so to another and each of the emergency services should attend in accordance with the appropriate pre-determined response without necessarily themselves declaring a Major Incident.37 However, if one emergency service declares a Major Incident that fact must be communicated to the others immediately so that they can respond appropriately and establish inter-agency communication. 30.38 In the case of the Grenfell Tower fire, a. the MPS declared a Major Incident at 01.26.32; b. the LFB declared a Major Incident at 02.06.38; and c. the LAS declared a Major Incident at 02.26.53.38 30.39 In no case did the emergency service making the declaration take immediate steps to inform either of the others that it had done so. In no case did the emergency service making the declaration know when it took that step whether either of the others had already done so, or take any steps to find out whether that was the case. The declaration of a Major Incident by the MPS 30.40 In the case of the MPS, Inspector Thatcher said that he had not given a second thought to whether the LFB or the LAS had already declared a Major Incident.39 He had received training on JESIP, which is why he recognised that it fell to him to make the declaration,40 but he did not appear to realise that the Joint Doctrine required him to send a METHANE message to his own control room as soon as possible. He simply trusted MetCC to send it.41 MetCC did not send it, and neither he nor, it appears, Detective Superintendent Warnett checked with MetCC that it had been sent.42 30.41 For their part neither the LAS43 nor the LFB44 was aware that the MPS had declared a Major Incident, either at the time it was declared or at any later stage during the night. At 01.41.42, when the LAS declared a significant incident, it did not know that the MPS had already declared a Major Incident, a fact that Paul Woodrow told the Inquiry was unusual. As he said, 36 Thatcher Day 71/36/5-37/4. 37 For example, section 1.6 of the LAS Incident Response Procedures [LAS00000008] p. 25 and the Strategic Co-ordination Protocol [MET00023288] paragraph 1.4.7 p. 12. 38 It should be noted that the time recorded on the CAD for a particular event is the time when the entry is recorded by the operator. 39 Thatcher Day 71/39/11-13. 40 Thatcher Day 71/37/5-18. 41 Thatcher Day 71/42/6-20. 42 Thatcher Day 71/49/14-50/4. 43 Woodrow Day 72/89/3-5. 44 O’Loughlin Day 47/186/1-4.

Part III | Chapter 30: The Response of the MPS, the LAS, RBKC and TMO 699 he would have expected that information to be conveyed to them.45 That information could have been communicated to the LAS through the shared Airwave channel 3 which was up and running by that time.46 30.42 If the LFB had known that the MPS had declared a Major Incident some 35 minutes before GM Richard Welch took that step at 02.06.38, it is a fair inference that he would not have thought it necessary to send his own METHANE message. 30.43 When Chief Inspector Duane Barrett briefed Commander Jerome about the incident at 02.30, he told him that the MPS had declared a Major Incident.47 The declaration of a Major Incident by the LFB 30.44 The following sequence of events occurred: a. The LFB first alerted the LAS to the fire at Grenfell Tower as a 20 (then 25) pump fire with “persons reported” at 01.29.06.48 Paul Woodrow’s evidence was that the LFB should have called the LAS earlier to alert them to the fire.49 b. When GM Welch declared a Major Incident at 02.06.38, he did not know that the MPS had made a similar declaration at 01.26.32, or at all, since the MPS had not communicated that fact to the LFB. c. At 02.27.39, some 20 minutes later, the LFB informed the LAS by telephone call from AOM Debbie Real in the LFB control room that it had declared a Major Incident,50 but it was not accompanied by a METHANE message from the LFB. d. Although GM Welch asked for a METHANE message to be sent, that was not done.51 He had given the task to GM Stephen West, who was only part way through writing the contents of the message on a whiteboard on CU8 when he was distracted by an attempt (in the end unsuccessful) to make channel 2 on the fireground radio available for use by the commanders.52 The incident commander (then DAC Andrew O’Loughlin) failed to follow the matter up and ensure that the METHANE message was sent. e. At 02.38.06 the LFB informed the MPS that it had declared a Major Incident.53 Inspector Thatcher was told about the declaration by DAC O’Loughlin soon afterwards when they met at 02.39 on CU8. The declaration of a Major Incident by the LAS 30.45 The LAS did inform both the LFB and the MPS of its declaration of a Significant Incident,54 in the case of the LFB at 01.52 and in the case of the MPS at about the same time (around 10 minutes after the event). Paul Woodrow said that it was “imperative” that the information that a significant event had been declared should be communicated to partners as soon as 45 Woodrow Day 72/89/3-10. 46 Woodrow Day 72/89/11-16. 47 Jerome witness statement [MET00023286] p.12. 48 [INQ00000378]. 49 Woodrow Day 72/76/23-24. 50 [INQ00000380] and CAD 247 [MET00019931] p. 8. Refer also to Woodrow Day 72/118/6-119/12. Paul Woodrow said that he did not think that it would have changed anything that the LAS had done at that point. 51 Welch Day 44/59/18-60/20. 52 West witness statement [MET00017073] pp. 5-6. 53 In AOM Real’s admin line call [INQ00000375]. 54 Which it had declared at 01.41.42.

The Grenfell Tower Inquiry: Phase 1 Report 700 practicable.55 The LAS then confirmed the declaration of a Significant Incident and sent a METHANE message over the radio. There is no evidence that either the LFB or the MPS picked up the fact that the LAS had sent a METHANE message. 30.46 After a further 30 minutes the LAS declared a Major Incident at 02.26.53. That declaration occurred as a result of Laurence Ioannou’s visit to CU7 and his discovery that there were FSGs reporting 40 people trapped in the building and patients coming out unconscious. He gave another METHANE message reporting 40 people trapped and two unconscious children.56 The purpose and effect of his declaring a Major Incident was to increase the resources at the incident to 20 ambulances, eight officers, a HART (although four were despatched at 01.34 and one was already at the scene from 01.45), specialist vehicles and equipment, and a Medical Emergency Response Incident Team.57 Four hospitals were put on standby and more staff had been allocated to the LAS special operations room at Waterloo Road.58 30.47 For its part the LAS did communicate its declaration of a Major Incident to both the MPS and the LFB, or so Paul Woodrow believed.59 Although there is no record of these communications in the CADs or the SIL, the information may have been communicated by telephone or some other means. If LAS did tell the LFB, it is likely that Laurence Ioannou told the LFB incident commander on the fireground (at that point DAC O’Loughlin). RBKC 30.48 It was only at 02.42.38 that RBKC was told by the LFB (AOM Real)60 that a Major Incident had been declared. One can well see that the LFB control room had been swamped with calls up to that point and that AOM Real may not have been able to get around to notifying RBKC until that time (not least because the LFB control room had been occupied with instructing CROs to change the advice they were giving to 999 callers from “stay put” to “get out”), but there is nothing to explain why neither the MPS nor the LAS saw fit to tell RBKC as a fellow Category 1 Responder that a Major Incident had been declared. Major Incident: consequences and conclusions 30.49 There is much to commend about the emergency services’ joint working on the night of the fire. For example, the TCG meetings which were effectively led by AC Roe provided a useful and substantially effective forum in which the emergency services’ senior representatives were able to share information and seek to co-ordinate their respective responses. The MPS’s policing of the incident ground was particularly sensitive to the demands of the situation. It should also be borne in mind that the circumstances which the emergency services faced were undoubtedly challenging. As Paul Woodrow said in evidence:61 “So I think this was unprecedented. So from my experience … the emergency services have a close relationship, they do work together, we do exercise together. I just think that the nature and scale of this incident, and I think that there were other environmental challenges that were in play there, which just made it very difficult. Information was shifting and it was changing constantly, and I just think that just created a very difficult environment to maintain those clear communication challenges” 55 Woodrow Day 72/94/22-25. He could not explain the delay. 56 Ioannou witness statement [MET00010862] p. 7. 57 Section 4.6.3 of the LAS Incident Response Procedures [LAS00000008] p. 74; Woodrow Day 72/104/17-105/5. 58 Ioannou witness statement [MET00010862] p. 7; this is broadly reflected the section 4.6.3 of the LAS Incident Response Procedures p. 74 although not in terms. Refer to Woodrow Day 72/109/1-4. 59 Woodrow Day 72/109/5-15. 60 [INQ00000188]. 61 Woodrow Day 72/102/7-16.

Part III | Chapter 30: The Response of the MPS, the LAS, RBKC and TMO 701 30.50 Although I accept that, in the circumstances, it would be unrealistic to expect complete compliance with each and every aspect of the Joint Doctrine and its supporting manuals and procedures, there were failings in the operation of the inter-service arrangements. The disjointed and haphazard nature of the various declarations of a Major Incident involved a significant departure by each of the emergency services from the principles set out in the Joint Doctrine, the Procedure Manual and the Protocol. That departure may be explained by the rapidly escalating nature of the incident and the need of each senior officer present to attend to more pressing matters, but it is precisely for Major Incidents such as the fire at Grenfell Tower that the Joint Doctrine was designed. 30.51 In terms of their operational response, it is difficult reliably to identify the consequences of the departures from the Joint Doctrine. There is little doubt that, if the LAS had known about the declaration of a Major Incident by the MPS at 01.32, or the declaration by the LFB at 02.06.38, far greater LAS resources would have been available at Grenfell Tower much earlier, but it is difficult to say precisely when. It was only at around 03.00, some 35 minutes after the declaration by the LAS that, as Paul Woodrow put it, the “full predetermined attendance for a Major Incident was met”.62 It is therefore reasonable to infer that if the LAS had known about and had responded to the declaration of a Major Incident by the MPS at 01.26, resources appropriate for a Major Incident would have been at the tower by around 02.00, an hour earlier than in fact was the case. However, there is no evidence that a departure from the Joint Doctrine by any of the emergency services caused or contributed to the death or injury of any person at Grenfell Tower. 30.52 It is also likely that the disjointed timing of the METHANE messages meant that the nature of the hazards (H) and the possible numbers of casualties (N) were not the subject of the shared understanding which the joint operability documents all treat as essential to the formulation of a joint strategy. For example, it was only when the LAS discovered the number of casualties and of people trapped in the building that, at 02.26.53, it declared a Major Incident. If it had heard the LFB declaration at 02.06.38, and if the LFB had then sent a METHANE message, the LAS would probably also have declared a Major Incident at that stage, with the consequent increase in resources. 30.53 Although the MPS did not send a METHANE message following its declaration of a Major Incident at 01.32, it is not clear what information which would have made a significant difference to the actions of the LFB or the LAS would have been contained in it, not least since the LFB had increased its resources to 25 pumps at 01.31.48. 30.54 There remains the question why the LFB did not declare a Major Incident before 02.06.38. At 01.38.51 AC Andrew Roe, having been called to the incident by radio pager, called the control room and spoke to AOM Peter May.63 He told the Inquiry that, as a result of what he heard on that call, “All of my instincts as a professional officer told me I was driving towards a Major Incident”.64 Yet neither WM Michael Dowden nor SM Andrew Walton nor DAC O’Loughlin, all of whom were at the incident ground and had held incident command at some point before 02.06, took it upon themselves to declare a Major Incident. 30.55 That is much less a criticism of the joint working arrangements between Category 1 Responders than it is of the LFB, but it does lay bare one truth about the concept of a Major Incident, namely, that it may be easier to make a judgement about whether to declare a Major Incident when one is at a distance from the scene rather than in the midst of the action having to 62 Woodrow Day 72/107/15-25. 63 [INQ00000202]. 64 Roe Day 48/198/16-18.

The Grenfell Tower Inquiry: Phase 1 Report 702 make command decisions in a rapidly changing and dangerous environment. It is perhaps no coincidence that Inspector Thatcher declared a Major Incident before he arrived at the tower on the basis of what he could see at a distance from the top of Ladbroke Grove. 30.56 One of the consequences of the declaration of a Major Incident by the emergency services is that there should be a multi-agency conversation between the control room leads. This was a requirement of the joint operating requirements established under the Joint Doctrine, particularly sections 5, 6 and 6.1.1, which requires that following the declaration of a Major Incident a dialogue between control room supervisors should be established as soon as possible. That was also a requirement of the Procedure Manual (section 4, and particularly section 4.2). Commander Jerome told the Inquiry that the Grenfell Tower fire was an incident that particularly called for such a conversation.65 The evidence that such a conversation ever took place is at best unclear.66 Communications between the emergency services 30.57 Communication between the emergency services on the night of the fire, both remotely and on the incident ground, was poor. It did not meet the standards expected by the provisions of the Joint Doctrine, the Procedure Manual and the Protocol. Indeed, Paul Woodrow (LAS) accepted in his witness statement that communication between the emergency services could have been better on the night.67 Remote communications 30.58 The LAS control room normally communicates with the LFB control room by telephone.68 Paul Woodrow accepted that the LFB should have called the LAS earlier to alert them to the fire (the first call that the LFB made to the LAS was at 01.29).69 Although LFB communications could have been recorded on the MPS’s CAD if that information had been entered by MPS operators located on DI/10 or DI/9 (about which the evidence remains incomplete), the absence of a direct CAD link between the LFB and either the LAS or the MPS which did not depend upon the intervening actions of MPS operators meant that the LFB’s communications could not be directly recorded on the MPS or LAS CADs. 30.59 The LAS has a CAD link with the MPS and vice versa and these emergency services can update each other’s CADs although they cannot see them. Of course, the CAD was not the sole means of communication between the three emergency services and information could be (and was) shared by telephone or shared radio channels. That was demonstrated by the use of one of the two shared tri-agency radio channels, both of which were being monitored. 30.60 However, despite the fact that the tri-agency radio channels were being used and monitored by the LAS control room,70 as was normal,71 it is not clear from the evidence how widely they were actually used on the night. Paul Woodrow’s evidence was that he would have expected messages from the tri-agency radio channels to be recorded in LAS CAD 247 by the loggist,72 and indeed CAD 247 records some messages on channel ES3, mainly from the NPAS 65 Jerome witness statement [MET00023286] pp. 6, 12; Jerome Day 71/172/20-179/6. 66 Winch witness statement [METS00020664] p. 10. 67 Woodrow witness statement [LAS00000009] p. 27. 68 Woodrow Day 72/66/2-7. 69 Woodrow Day 72/76/9-24. 70 CAD 247 entry at 01.57.52 noting that the MPS were asking the LAS to liaise with the NPAS helicopter on one of the tri-agency channels [MET00019931] p. 5; Woodrow Day 72/111/19-112/4. 71 Woodrow Day 72/66/7-22. 72 Woodrow Day 72/112/18-113/1.

Part III | Chapter 30: The Response of the MPS, the LAS, RBKC and TMO 703 helicopter to the LAS.73 Critically, the tri-agency radio channels do not appear to have been used to inform either the LAS or the MPS control room about the abandonment of the “stay put” advice.74 There is only one instance of the LFB using channel ES3 to communicate with the other services, which occurred at 04.38.46. 30.61 It seems that any information that the LAS had about patients which it decided to pass to the LFB was communicated by telephone on a case-by-case basis.75 Three emergency calls received by the LAS from people inside the tower were not passed on to the LFB, based on individual decisions made by the LAS’s despatch deployment sector. There is no evidence as to how those decisions were made, but Paul Woodrow told the Inquiry that there was no protocol or policy in place requiring the LAS to pass all FSG callers to the LFB. This was, as he fairly accepted, an area where improvement was required.76 30.62 It is not clear that Supporting Principle 1 in paragraph 6.1.1 of the Joint Doctrine (see above) was fully satisfied. There should have been a single point of contact in each control room and the establishment of a method of communication between them. Paul Woodrow, on behalf of the LAS, did not know if appropriate arrangements had been in place on the night.77 He accepted that it would have helped to have had a single point of contact in place and that its absence clearly contributed to difficulties in communication.78 In relation to the LFB, the evidence indicates that there was no single point of contact in its control room who was communicating with counterparts in the LAS or the MPS. Therefore, irrespective of the arrangements that the MPS may have had in place, it is not clear whether the other two emergency services had implemented the requirements of Supporting Principle 1. 30.63 Similarly, it is clear that Supporting Principle 2 in section 6.3.1 of the Joint Doctrine, which requires control room supervisors to engage in multi-agency communications and carry out the initial actions to manage the incident, was never complied with properly. 30.64 One possible reason for these failures of communication is that the Joint Doctrine was not engaged at the earliest opportunity. Given the independent declarations of a Major Incident by each emergency service and the fact that they were not communicated to either of the others, it is hard to pinpoint when anyone realised that a co-ordinated response was required. Inspector Thatcher recognised it and declared a Major Incident at 01.26.32. It was recorded on CAD 482 at 01.32.27 but that was not communicated to the other services.79 It is obvious that a declaration of a Major Incident which is not communicated to the other emergency services is all but useless for the purposes of engaging the Joint Doctrine principles. 30.65 That is not to say that there was no communication at all between the MetCC and the LFB control room. There are sporadic examples of contact, such as the call between the MPS and the LFB at 01.46.18, in which the MPS operator asked CRO Yvonne Adams whether there was any advice they could give callers, as there was a distressed caller stuck on floor 16 (Flat 133, Sener Macit).80 The details of this call are set out in Chapter 29. 73 CAD 247 [MET00019931]. For example, refer to the messages at 01.57.52 and 01.59.43. There were then seven further entries on CAD 247 recording the use of channel ES3 between 02.10.20 and 04.38.46. 74 Woodrow Day 72/111-116. 75 For example, at 02.21.41 LAS’s despatch deployment sector desk sent a telephone message to the LFB about “patients alive on 25th floor”: refer to Woodrow witness statement [LAS00000009] p. 10 and Day 72/115/10-116/21. 76 Woodrow Day 72/116/22-117/25. 77 Woodrow Day 72/71/12-72/9. 78 Woodrow Day 72/119/13-120/10. 79 Thatcher Day 71/35/2-18. 80 [LFB00000326]. The MPS recording of this call is CAD 578 [INQ00000280] p. 4, which has a slightly different time of 01.45.28.

The Grenfell Tower Inquiry: Phase 1 Report 704 The heli-tele downlink 30.66 I have touched on the heli-tele downlink in Chapter 28 and Chapter 29 so far as its failure to function on the night of the Grenfell Tower fire adversely affected LFB operations. Here I examine in more detail why it did not work. 30.67 The heli-tele downlink is an encrypted visual communication system which enables the NPAS helicopter to transmit images from its video cameras to the LFB’s receiving equipment in the command units and control room. Each of the NPAS helicopters present at Grenfell Tower on the night of the fire was fitted with an airborne data link. Fixed receivers are fitted in 10 MPS vehicles and LFB command units. A series of channels and encryption protocols are built into the airborne data link systems. There are four channels used across the UK, of which channel D is the default. Within each channel is a series of encryption keys, the two main keys being the National Emergency Service user key, which is installed in every piece of transmitting and receiving equipment used by the emergency services throughout the country, and the National Police user key, which is installed in all MPS equipment (fixed and portable) but for reasons of security not in the equipment used by the other emergency services. In order for an LFB command unit to receive video signals from an NPAS helicopter and watch the live feed it is necessary for the both the transmitter and the receiver to have the same encryption keys installed. When the equipment fitted to the MPS helicopters is switched on it defaults to channel D, and within it to the National Emergency Service encryption, which all emergency service vehicles have and which allows access to the helicopter video link.81 30.68 Unfortunately, on the night of the fire the three MPS helicopters were being serviced. The helicopters that attended the incident were equipped with an airborne data link system which did not default within channel D to the National Emergency Service user encryption but to the National Police user encryption. That meant that the LFB did not have the relevant encryption key in its receiving equipment. That was not evident to the NPAS crews at the time because they had never received any training on the differences between the two systems.82 Accordingly, until the MPS provided the LFB with portable downlinks using the correct National Police user encryption, the firefighters could not view the images. 30.69 It is unclear when, if ever, the portable downlinks actually reached the incident ground, and a serious question arises about whether the video feed from the helicopters was ever available to the LFB. Daniel Arnold, an NPAS Sergeant and the Base Manager at Lippitts Hill (the NPAS London base), said that the portable downlinks had the same encryption keys as the helicopter, which enabled the video to be viewed.83 However, the LFB officers who were asked about it said that they could not receive the NPAS helicopter video at any stage of the incident and, although his timings were “very hazy”, SM Peter Johnson said that the LFB officers in CU8 could not view the heli-tele pictures until around 10.00 or 10.30 on 14 June 2017, when they were told by a police officer that it was now working and that the feed had been “scrambled” up to that point.84 81 Arnold second witness statement [MET00039527] pp. 1-2. 82 Arnold second witness statement [MET00039527] p. 2. 83 [MET00039527] p. 2. 84 Johnson Day 37/21/6-25/1. SM Johnson can clearly be seen on the Thatcher body-worn video footage at 02.37 [INQ00000520] inside CU8 telling Inspector Thatcher that the helicopter downlink was not working. Some BSRs suggested that the clip reveals that the LFB officers on CU8 said that they did not have time to use it, but it is not easy to see or hear where in the clip this appears.

Part III | Chapter 30: The Response of the MPS, the LAS, RBKC and TMO 705 30.70 I tend to prefer the LFB’s evidence on this question, not least because, if the portable downlinks had been working by around 04.00, it is probable that the fact would have been recorded in the Roe Log and that at least some of the LFB officers who gave evidence would have recalled it. Further, Sergeant Arnold does not say when the portable downlinks did successfully provide the LFB with video images. 30.71 It remains wholly unclear whether having access to the NPAS video feed at that stage of the incident would have had a material bearing on the outcome. However, it must remain a matter of criticism that the NPAS helicopters which did attend all defaulted to a channel which disabled the LFB from being able to view the live feed until many hours into the incident. The first NPAS helicopter to arrive at Grenfell Tower (NPAS 44) was there before 01.45.25 and it would have been extremely valuable, at that crucial stage in the incident, for the LFB to have been able to obtain an aerial view of all four sides of the tower. It is not clear whether that would have made any difference to the strategy which WM Dowden had adopted up to that point, but it might well have assisted both him and succeeding incident commanders. If nothing else, it might have enabled them to appreciate that the fire was not confined to the exterior of the building, as they appear to have believed, but had penetrated a large number of flats, with the result that the compartmentation of the building had completely failed. Their failure to appreciate that the fire had penetrated the interior of the building contributed to the delay in the decision to revoke the “stay put” advice to residents. Seeing the visual images might also have brought forward the point at which the LFB declared a Major Incident. Communications on the incident ground 30.72 Paul Woodrow’s evidence was that, in ideal circumstances, the LFB and LAS would have had their control units close together, but it had not happened on the night.85 He said that the first person to attend from the LAS should make an initial assessment of the scene, report back, and then speak to the LFB incident commander.86 30.73 That did not happen and, even allowing for the exigencies of the night, it is unfortunate that there was no communication between senior officers from the three emergency services at the scene until well into the incident (although there was of course communication between more junior officers from each service at much earlier stages of the incident). In particular: a. The first face-to-face meeting between the senior LAS officer and the LFB incident commander did not occur until around 02.23, when Laurence Ioannou went to CU8 and spoke to DAC O’Loughlin. Until that point it appears that he had not known who was in command,87 although he had arrived at 01.49. According to Paul Woodrow that meeting was unusually late, but he attributed the delay to the “unprecedented” nature of the incident. Laurence Ioannou tried, initially without success, to find and talk to the LFB’s incident commander, but did manage to have a brief conversation with SM Walton shortly after arriving.88 b. The MPS Silver Commander (Inspector Thatcher) first spoke to DAC O’Loughlin at around 02.39. The MPS Gold Commander (Detective Superintendent Warnett) first met the LFB incident commander at the first TCG meeting, which took place at 03.20. c. It is uncertain whether, and if so when, Laurence Ioannou met or spoke to either Inspector Thatcher or Detective Superintendent Warnett before the first TCG meeting at 03.20. 85 Woodrow Day 72/63/13-22. 86 Woodrow Day 72/63/13-64/19. 87 Ioannou witness statement [MET00010862] p. 6. 88 Woodrow Day 72/101/12-102/3; refer also to Ioannou witness statement [MET00010862] p. 7.

The Grenfell Tower Inquiry: Phase 1 Report 706 30.74 It is possible that an examination of the CAD messages to and from MPS officers in addition to those shown on CAD 482 and other linked CADs might reveal that the emergency services were communicating with each other on the incident ground to a greater extent than CAD 482 itself indicates, and I recognise that CAD 482 may not fully convey the sheer volume of communications between the emergency services. However, what matters is not how often officers from the different emergency services communicated with each other but whether important information and decisions were shared at a senior level. I think it unlikely that the detailed and time-consuming analysis of all the available CAD messages that would be required would identify any further important communication of that nature of which I am currently unaware. 30.75 Section 6.3.2 of the Joint Doctrine (Supporting Principle 4) makes it clear that it is desirable for commanders to meet in person and speak directly to each other. These delays in face-to- face communication between the senior officers for the three emergency services present on the incident ground constituted a failure to comply with sections 6.3.1 and 6.3.2 (Supporting Principle 5) of the Joint Doctrine. Section 6.3.2 required the LFB as the lead responder to suggest a location for commanders to co-locate in the early stages of the incident, or agree an initial rendezvous point with the other control rooms and communicate it to the commanders as soon as possible. That did not happen. It was a further departure from the fundamental principles of the Joint Doctrine by each emergency service, but primarily by the LFB. Change to the “stay put” advice 30.76 There is no evidence to explain why the LFB did not tell either the MPS or the LAS about its decision to abandon the “stay put” advice, either after SOM Joanne Smith had made the decision in the LFB control room at around 02.35 or after AC Roe had made the same decision on the incident ground at 02.47. 30.77 The LFB did not tell the MPS about its decision to abandon the “stay put” advice until shortly before 03.08.07, when MetCC broadcast the message to all police officers. Inspector Thatcher knew by the time of the first TCG meeting at 03.20 that the advice had changed, possibly because he had heard the information when it was broadcast a second time by MetCC at 03.10.56.89 The consequences of this delay in the MPS learning about the change in “stay put” advice are examined in Chapter 29 but, in summary, it is possible that it resulted in “stay put” advice still being given by MetCC operators as late as 03.05.90 That is not something for which the MPS can be criticised. 30.78 So far as concerns the LAS, Paul Woodrow said that it would be “reasonable” for the LAS to be informed if the “stay put” advice were changed during an incident,91 but there is no evidence that the LFB did in fact tell the LAS about it before the first TCG meeting, and indeed Paul Woodrow could identify no formal record of the LAS having been told about it at any time.92 The Roe Log93 refers to the change in advice and Laurence Ioannou’s recollection was that he had learnt of it at the first TCG meeting.94 89 Although he did not recall having heard the message. Thatcher second witness statement [MET00023284] p. 10 and Day 71/126/12-127/1. 90 CAD 932 [INQ00000281]. Although the transcript of that call does not actually record “stay put” advice being given, equally the operator did not advise the caller to leave at all costs. Refer to Exhibit NAJ/2 [MET00023291] in which Commander Jerome refers to that call as giving “stay put” advice. 91 Woodrow Day 72/127/9-12. 92 Woodrow Day 72/133/20-21, 135/19-19. 93 [MET00005404] p. 2. 94 Ioannou witness statement [MET00010862] p. 10. Laurence Ioannou actually refers to the second TCG meeting but that is likely to be incorrect given the contents of the Roe Log and Inspector Thatcher’s recollection that it was mentioned at the first TCG meeting.

Part III | Chapter 30: The Response of the MPS, the LAS, RBKC and TMO 707 30.79 Given that the LAS’s procedure was to stick to their triage scripts, it is not clear whether LAS call-handlers would have handled emergency calls from the tower differently if they had been told earlier that the “stay put” advice had been abandoned. However, as Paul Woodrow accepted in oral evidence, it might have affected their appreciation of the severity of the incident more generally.95 Logistical problems at the incident ground Congestion 30.80 There were a number of logistical problems at the incident ground. The primary challenge for the emergency services was congestion resulting from parked emergency and ancillary vehicles in the narrow streets around the tower and the number of firefighters attending the incident. This made it difficult to establish rendezvous points and caused some delay to firefighters attending the incident, because they had to park at a distance and proceed on foot. However, it is difficult to identify any specific instances in which congestion had any particular effect on the delivery of emergency services and in the case of the LAS there appears to have been no significant effect on patient care.96 Cordons and crowds 30.81 The second major logistical challenge was putting cordons in place to keep people at a safe distance from the building and maintaining public order. The effect on family and friends of watching a tall building burning out of control with their loved ones trapped inside is unimaginable in its horror, and it was wholly understandable that they would wish at all costs to attempt to enter the building and assist with rescue. However, not only would that have put their own lives and the lives of others in danger, it would also have seriously impeded the LFB’s operations. The task of the MPS was to establish and maintain cordons at a safe distance from the tower and secure a safe working environment for the LFB.97 That was hard to achieve, not only because of burning debris falling from the tower, but because there were occasions during the night (e.g. at around 03.00) when the threat of public disorder was very real. The incident required both the intelligent location of cordons and firm but sensitive policing, both of which were achieved, principally due to the impressive leadership of Inspector Thatcher. There were no public order offences; the crowd was kept away from the tower and in the end became supportive and helpful. In addition, the MPS provided riot shields to protect firefighters and casualties from the falling burning debris. All those aspects of the policing of the Grenfell Tower fire reflect great credit on the MPS and on Inspector Thatcher and Detective Superintendent Warnett in particular. The identification of casualties 30.82 A further question arising out of the emergency services’ response to the fire is whether the LAS could have obtained quicker and more reliable information about which flats patients had come from. There is evidence to suggest that survivors, families and friends were unable to find their loved ones because they were not told which hospitals they had been taken to and that it was a difficult and time-consuming exercise to find out where they were.98 The anxiety 95 Woodrow Day 72/134/2-16. 96 Woodrow Day 72/155/1-7. 97 Warnett witness statement [MET00080605]. 98 For example, Helen Gebremeskel [IWS00000933] p. 11 and Nicholas Burton [IWS00000064] p. 21.

The Grenfell Tower Inquiry: Phase 1 Report 708 born of not knowing what had happened to those caught in the fire in the hours immediately after their evacuation must have been immense and in the case of those occupants who had successfully escaped can only have added to their trauma. 30.83 Sections 9.6 to 9.11 of the Procedure Manual call for a number of different kinds of facilities to be established in response to a Major Incident. One (section 9.9) is a casualty bureau to be established by the police at which details of all dead and injured, survivors and evacuees, are collated and which can provide information in response to inquiries from friends or relatives of those believed to be involved in the incident. To avoid discrepancies in casualty numbers all information ought to be routed through the casualty bureau which acts as the sole source of information. The function of the casualty bureau to some extent overlaps with the function of the Survivor Reception Centre (section 9.7) and the Friends and Relatives Reception Centre (section 9.8) in so far as it is a source of information for survivors, friends and relatives. 30.84 Having considered the available evidence, I do not think it is possible to say that the casualty bureau was not set up as quickly as reasonably practicable in accordance with sections 9.6 to 9.11 of the Procedure Manual. I have little doubt that it was extremely difficult to obtain all the information required to provide an effective casualty bureau in this case and that when dealing with an incident of this kind it may not always be possible to obtain the information needed to dispel the anxieties of friends and family as quickly as one might wish. However, if there are ways of improving the speed and accuracy of matching casualties with inquiring friends and relations, which is, after all, the aim of sections 9.6 to 9.11 of the Procedure Manual, they ought to be explored and adopted without delay. Helicopter rescue 30.85 Some who lost members of their families in the fire want to know whether people trapped in flats high in the tower could have been rescued by helicopter from the roof of the building or directly from their flats. That is in part because some of those who made emergency calls from within the tower were given the impression that rescue by helicopter might be possible, or at least were not told in clear terms that it was not. 30.86 Section 10 of the Procedure Manual deals with the use of helicopters in a pan-London Major Incident. Section 10.1.2 describes the equipment NPAS helicopters usually have on board, and section 10.1.3 lists the support functions that NPAS helicopters can provide. They amount to providing further information and analysis, among other things, to support emergency rescue at the scene and to recording data for later analysis. They do not include actively engaging in rescues, for which NPAS helicopters are not equipped. 30.87 If rescue by helicopter had been considered feasible, it would have been possible to call on the services of HM Coastguard’s search and rescue helicopters, as contemplated by section 10.4.1 of the Procedure Manual. Under section 10.4.2, for a land-based rescue the MPS would have to alert HM Coastguard helicopters via the Aeronautical Rescue Co-ordination Centre at RAF Kinloss. There can be little doubt, therefore, that even if the rescue of occupants from high in the tower had been possible, the NPAS helicopters at the scene could not have carried it out. 30.88 AC Roe did, briefly, consider whether to summon HM Coastguard helicopters. The Roe Log records at 05.40 “AR: MCA hele to consider winching off – investigating” and at 05.45 “Potential deployment of MCA SAR hele”.99 AC Roe told the Inquiry100 that he considered it briefly at that time mainly because he had information that there were people trapped on the 99 [MET00005404] p. 4. 100 Roe first witness statement [MET00007520] p. 12 and Day 49/204/10-208/25.

Part III | Chapter 30: The Response of the MPS, the LAS, RBKC and TMO 709 roof of the building. However, as he explained, he quickly discounted helicopter rescue from the roof because of the minimum 45-minute arrival time, the potentially aggravating effect of the rotor downdraft on the fire, the risk to the crew, firefighters and remaining occupants of the building and the inherent difficulty of such a rescue operation. As he put it, “it was going to be almost impossible to put someone on the end of a winch to get someone out. Let alone, you know, effectively dropping a line into a fire environment.”101 30.89 I accept AC Roe’s evidence on that point. A helicopter rescue by HM Coastguard would have been perilous and extremely uncertain, a fact confirmed by the evidence of two officers from the Maritime Coastguard Agency.102 In any event no occupants of the tower were able to get on to the roof of the building. Calling a rescue helicopter would therefore have been a waste of time. The gate on floor 23 closing off the stairs from the lobby to the roof was locked on the night of the fire, which may explain why no one was on the roof at any time, but even if it had it been open, I am satisfied for the reasons given by AC Roe that it would not have been possible for anyone who had reached the roof and had survived the conditions that they would have encountered there to have been rescued safely. 5 RBKC and the TMO The role and emergency plans of the RBKC and TMO 30.90 RBKC, as the local authority in whose area Grenfell Tower lies, was a Category 1 Responder as defined in the CCA and was subject to the corresponding civil protection duties. RBKC had a formal “Contingency Management Plan”,103 which contained the procedure to be followed in the event of an emergency. 30.91 The TMO was not a responder under the CCA and therefore was not subject to the corresponding duties. Its functions were set out in the Modular Management Agreement104 and did not extend either to assuming RBKC’s obligations under the CCA or to assisting RBKC in the discharge of those obligations. That was despite the fact that RBKC’s Contingency Management Plan required its departments and service providers to maintain service emergency plans and procedures. Nor did the TMO have any obligation under the Modular Management Agreement to keep emergency plans and procedures. Although the TMO was not identified in the Contingency Management Plan as a department or a service provider, however, its contact details were listed in RBKC’s Contingency Management Plan105 and RBKC’s Duty Silver Manual.106 30.92 At the time of the fire the TMO had an emergency plan,107 but it was not activated in response to the fire because, it was said, of the scale of the incident.108 Both the TMO emergency plan and the RBKC Contingency Management Plan were silent about how, if at all, they were intended to complement each other in the event of an emergency. There was no reference to the circumstances in which one or other plan would take precedence or whether they were 101 Roe Day 49/208/19-22. 102 Witness statements of Philip Hanson [MET00013123] pp. 2-3 and Douglas MacDonald [MET00013126] p. 4. 103 [RBK00004396]. 104 [RBK00018796]. 105 Annex 01 provided, at p. 22, contact details for the TMO’s “TMO Contact Centre (24/7)” [RBK00014620]. 106 “TMO Out of Hours Service” contact details are listed at p. 40 [RBK00029034]. 107 [TMO10013898]. 108 Black Day 74/147/12-20; Brown Day 75/54/5-56/11.

The Grenfell Tower Inquiry: Phase 1 Report 710 intended to operate simultaneously and if so how. Given the extent of RBKC’s reliance on the TMO for information, the fact that the TMO emergency plan was not activated meant that in certain respects there was no emergency plan at all. 30.93 The TMO emergency plan, for what it was worth, was some 15 years out of date. The information about Grenfell Tower on which it was based therefore failed to reflect the changes to the building brought about by the refurbishment in 2016. It contained the wrong number of flats (120 rather than 129) and contained materially inaccurate and out of date details of the numbers of vulnerable residents who would need assistance to evacuate in the event of an emergency. Teresa Brown, who was present at the incident from 03.50, did not realise that the section of the plan containing details of the property was out of date or that it was the responsibility of the Health and Safety team led by Barbara Matthews to make sure that it was correct.109 How it came about that the TMO allowed such a potentially important document to remain obsolete for so many years is a question which will be explored at Phase

1. Certainly none of the TMO witnesses who were asked about it could offer any explanation.
2. 94

It cannot have helped that the most senior TMO executives present at the incident, Teresa Brown and Robert Black, had no clear idea of the TMO’s functions in relation to it. Teresa Brown described the role of the TMO staff on the night of the fire as “voluntary”.110 She thought that they were there to enable them to respond to requests for information from the emergency services and to co-ordinate the rest centres.111 She told the Inquiry that the role of Robert Black was to be the point of contact outside CU8.112 30.95 For his part, Robert Black told the Inquiry that the TMO had “no role” in responding to the fire, as the LALOs were present acting on behalf of the local authority. 113 He described the role of the TMO as a “spare part”. He said that the TMO emergency plan was not activated because it did not apply,114 and that nobody at the TMO expected it to be activated.115 He also said that, as he was not at any of the TCG meetings, his role was to try and help. He, together with Teresa Brown, was trying to mobilise staff to work within RBKC’s plan, mainly to help at rest centres, but he appeared to think that the TMO had “nothing else to offer”.116 I can well see that it might have been potentially confusing to activate the TMO emergency plan in parallel with the RBKC plan, but that does not explain why Robert Black thought that the TMO had “no role”. 30.96 The fact that the TMO had no formal role as a responder, combined with the absence of documented clarity about the applicability of its emergency plan or any contractual obligation to have a plan in place, meant that its senior executives did not have a clear view of what they were supposed to do on the night of the fire. Robert Black, in particular, did not appear to have any clear perception of how he personally, or the TMO as an organisation, could assist either RBKC or the LFB and he had no plan by which he could lead his staff. Critically, his view that the TMO had nothing else to offer was incorrect. It was in possession of, or had access to, important information, such as plans of the building, a list of residents and a list of survivors at rest centres, that had been repeatedly requested by the emergency services and by Nickolas Layton as LALO. That information was unsatisfactorily late in coming to the incident ground. 109 Brown Day 75/111/10-20. Teresa Brown said that the correct details about numbers of properties were provided early in the morning: Brown Day 75/113/13-114/3. 110 Brown Day 75/56/21. 111 Brown Day 75/57/4-16. 112 Brown Day 75/57/23. 113 Black Day 74/156/21-158/12. 114 Black Day 74/156/8-157/16. 115 Black Day 74/156/21-158/12. 116 Black Day 74/158/1-12.

Part III | Chapter 30: The Response of the MPS, the LAS, RBKC and TMO 711 The LALOs The role of a LALO 30.97 The Inquiry heard from Nickolas Layton117 and Michael Rumble,118 each of whom acted as a LALO for RBKC on the night of the fire and gave evidence about RBKC’s immediate response to the incident. Upon notification from the RBKC out of hours call centre, Nickolas Layton, the Borough Duty Officer, informed his superior, David Kerry,119 who set up the Borough Emergency Command Centre (BECC). 30.98 Nickolas Layton was sent to the scene as the first LALO,120 arriving at 02.47.121 His role as LALO was to represent the council as “Council Silver” (second level decision-maker), liaise with the emergency services and determine the initial response and call forward resources through the BECC.122 He described his role as the “eyes and ears for the BECC”.123 That was an important role because he was the sole link between the emergency services and the council. The LALOs’ training 30.99 Both Nickolas Layton and Michael Rumble were trained LALOs, Nicholas Layton since 2002124 and Michael Rumble since October 2015.125 There were, however, differences in the training they had received. Notably, Michael Rumble had undergone a four-day practical multi-agency disaster training course with the LFB. Nickolas Layton had not undertaken such training and said he was not familiar with the JESIP principles.126 Neither LALO had previously dealt with a major fire on this scale, although Nickolas Layton had acted as LALO at the fire at Trellick Tower in April 2017.127 Record keeping 30.100 Nickolas Layton recorded his notes128 from the night in a personal notebook, as at that time RBKC did not have its own LALO pack. It has, however, since introduced one.129 By contrast, Michael Rumble used a LALO pack from another council (Lambeth), which he said he found helpful in that it provided an aide-memoire of things to consider. Significantly, that included a reference to the potential need for the attendance of a Dangerous Structures Officer.130 A LALO pack or notebook would have greatly assisted Nickolas Layton when confronted with such a serious and difficult incident. Such an item would have encouraged a better contemporaneous record of events and in particular may have prompted an early recognition for the need for the attendance of a DSE (a topic to which I return in more detail below). It is surprising and unsatisfactory that RBKC did not have its own incident pack for LALOs and that Michael Rumble was forced to use a Lambeth LALO pack that he had picked up at an LFB training exercise.131 117 Layton Day 74/3. 118 Rumble Day 74/84. 119 He was employed as a Contingency Planning Officer for RBKC. Layton witness statement [RBK00029034] p. 4. 120 Layton Day 74/22. 121 Layton Day 74/26. 122 Layton Day 74/11. 123 Layton witness statement [RBK00029034] p. 4. 124 Layton Day 74/5. 125 Rumble Day 74/88. 126 Layton Day 74/7/2-11. 127 Layton Day 74/ 8/20-9/21. 128 Exhibit NL/1 of Nickolas Layton [RBK00029036]. 129 Exhibit NL/4 of Nickolas Layton [RBK00029033] and Day 74/22/22-24/10. 130 Exhibit MJSR/4 of Michael Rumble [RBK00029039] p. 6. 131 Rumble witness statement [RBK00029037] paragraph 8.3 p. 4 and Day 74/99/2-7.

The Grenfell Tower Inquiry: Phase 1 Report 712 Initial attendance at the scene 30.101 It is clear from the evidence that, until he reached the scene of the fire, neither LALO had appreciated the scale of the incident. Michael Rumble arrived at approximately 03.10, before the first TCG meeting, in the role of a second LALO, following a call from David Kerry at approximately 02.45. He had not been made aware of the severity of the incident or of the fact that it had been declared a Major Incident by the police and the LFB.132 More effective sharing of information before their arrival at the scene might have equipped them better for their initial duties. 30.102 The LALOs did not specifically divide responsibilities between them.133 It would appear that a significant amount of time was devoted to the location and setting up of rest centres for displaced residents. Nevertheless, although substantial demands were made on the LALOs, better co-ordination and division of roles might have made more use of their expertise and might have ensured that information which the LFB had asked for was provided more quickly. For example, when Michael Rumble took over from Nickolas Layton as senior LALO at 07.00, a clearer handover would probably have resulted in his knowing that Robert Black had been repeatedly asked for a list of residents and that the request had been outstanding at the time of the third TCG meeting at 05.50. That in turn might have prompted Michael Rumble to press harder for the list of residents at the fourth TCG meeting. However, I am satisfied that Nickolas Layton did all he could to ensure that Michael Rumble was aware of the need to obtain the information, even if Michael Rumble’s own recollection of events was not as clear. The LFB’s requests for information or action Request for the attendance of a Dangerous Structures Engineer (DSE) 30.103 The LFB requested the attendance of a DSE at 02.17.38, but some hours elapsed before the eventual arrival of the first structural engineer (Amir Fardouee) at the cordon at around 04.30. He was unable to assist and a further delay occurred before John Allen, the RBKC DSE, was able to enter the building and assess its structural integrity at around 06.00. It is necessary to examine the reasons for that delay. 30.104 A request for the attendance of a DSE was sent by CU8 to the control room by radio at 02.17.36, but the first call to RBKC was not made until 02.42.38 when AOM Real contacted RBKC using the “admin line” to inform them that a Major Incident had been declared (a matter of which RBKC was already aware).134 The reason for that delay is unexplained, but it is possible that it was caused by the pressure on the control room. By the time of AOM Real’s call a second request for a DSE had already been sent by CU8 to the control room (at 02.38.21).135 When AOM Real reached RBKC the operator asked her whether there was anything she wanted at that moment, but AOM Real did not ask for a DSE to attend. It is unclear why she did not do so, not least because a second service request for a DSE to attend had been created by CRO Angie Gotts only 4 minutes earlier. 132 Rumble Day 74/96. 133 Layton Day 74/32/17-35/8. 134 [INQ00000188]. 135 SIL p. 23.

Part III | Chapter 30: The Response of the MPS, the LAS, RBKC and TMO 713 30.105 At 03.15.32136 CU8 made a third, urgent request to the control room for the attendance of a DSE, which appears to have prompted the control room to pass the request on to RBKC for the first time at 03.17.21,137 very shortly after CRO Sharon Darby had created the urgent service request in response to the message from CU8.138 30.106 The control room repeated its request to RBKC at 03.40.43139 and again at 03.48.57.140 During the first of those calls the RBKC operator was pressed with the urgency of the matter, but could not provide either an estimated arrival time or a direct number for the DSE. During the second call the RBKC operator (Erin) said that she had not been able to contact a DSE and was going to “escalate” the matter.141 30.107 It is not clear from the evidence when Amir Fardouee, the RBKC surveyor on call that night, was first asked to attend the incident. It must have been at some time before 04.30, because it was at about that time that David Kerry, RBKC’s Contingency Planning Manager, spoke to him when he was at the police cordon. It is probable that he was contacted by RBKC not long after the call from the control room at 03.48.57. 30.108 Nickolas Layton told the Inquiry that he had not been aware of the requests for a DSE until 04.15 when he was asked to call one.142 It is unfortunate that he did not hear about the request made to RBKC at 03.17.21 or recall AC Roe’s mentioning at the first TCG meeting at 03.20 that a DSE had been requested.143 At 03.37 Nickolas Layton called David Kerry, by then in charge of the BECC. David Kerry’s log contains the note “One corner in danger of collapse”.144 Although Nickolas Layton provided that information to David Kerry, it did not prompt him to ask for a DSE to be sent urgently, but he accepted in evidence that it should have done so.145 30.109 Similarly, when he arrived and spoke to Nickolas Layton at around 03.10, Michael Rumble (who did not attend any of the TCG meetings before 07.10) thought that there might be a risk of the tower collapsing.146 However, he did not ask for a DSE or suggest that it might be necessary to call one, despite the fact that it was the first item on the list of immediate problems to consider that were identified in the Lambeth LALO pack he was using that night.147 30.110 It was only after the LFB made a direct request to Nickolas Layton at 04.15 to arrange the attendance of a DSE that he called David Kerry to ask for one to attend.148 It appears that Nickolas Layton had not been informed by the BECC or the RBKC call centre that there had been a number of requests from the LFB for a DSE to attend, let alone that the first request had been made some hours before.149 Nor could he recall being told even then that the LFB had been calling for a DSE for some time.150 He did not know at that time that Amir Fardouee was on his way to the cordon and learnt that he was there only when David Kerry called to 136 SIL pp. 22-24. 137 [INQ00000211]. 138 SIL p. 24. 139 [INQ00000210]. 140 [INQ00000212]. 141 [INQ00000212]. 142 Layton witness statement [RBK00029034] p 7, Day 74/45/24-52/24, and Layton log at [RBK00029036] p. 1 item 9 (“DS REQ URGENT BLUE LIGHT 016.15”). 143 Thatcher body-worn video clip [INQ00000530]; Layton Day 74/49/15-21. 144 Kerry Log [RBK00028849]. 145 Layton Day 74/50/5-51/3. 146 Rumble Day 74/105/3-8, 134/2-135/3. 147 [RBK00029039] p. 6; Rumble Day 74/133/4-134/1. 148 Layton witness statement [RBK00029034] pp. 7-8 and Day 74/46/3-52/9. 149 Layton Day 74/46/7-47/24. 150 Layton Day 74/52/10-19.

The Grenfell Tower Inquiry: Phase 1 Report 714 tell him so at 04.31.151 At the second TCG meeting at 04.34, Commissioner Dany Cotton drew attention to the fact that the LFB had been asking for the attendance of a DSE for the past two hours and that one was then en route.152 That was the first that Nickolas Layton had heard of any earlier requests.153 However, although he had just been told that Amir Fardouee was at the cordon, he did not tell the Commissioner that a structural expert was already at the scene.154 He was unable to explain why he had failed to pass on that important piece of information to the LFB.155 30.111 The confusion surrounding the response to the request for a DSE to attend at the incident ground demonstrates a worrying failure of communication between RBKC and the LFB. The LFB should have made its request to RBKC for the attendance of a DSE an hour earlier than it did and the request, when it finally was made, did not result in the attendance of a structural engineer until 04.30. The LALOs, for their part, had not picked up the need for the urgent attendance of a DSE, despite its having been raised at the first TCG meeting and, in the case of Michael Rumble, despite his own recognition that the building might collapse. Nickolas Layton was unable to explain why he did not tell Commissioner Cotton that a DSE was already at the cordon, particularly in the light of his evidence that at around 04.30 he had seen Amir Fardouee and a person he thought was John Allen near CU8 talking to the LFB.156 30.112 These deficiencies suggest the need for standardised instruction manuals to be provided for use by LALOs at large-scale incidents instead of leaving it up to individual local authorities to decide how to prepare and equip them. They also indicate the need for far better direct communication between fire and rescue services and local authorities and for LALOs to take a more active role in ascertaining and meeting the needs of the lead responder. It is easy to understand the natural desire of a LALO not to get in the way of the emergency services, particularly at such an horrific event, but LALOs play an important role in supporting them and must be ready to obtain vital information and make sure it reaches the person who needs it. 30.113 In the event, although GM Dave O’Neill, Sector Commander Safety, had been advised by John Allen by telephone that the building had two to four hours’ fire protection,157 Amir Fardouee was too traumatised by events at the scene of the fire to enter the tower and carry out a structural inspection (for which he cannot be criticised.) Although the advice from John Allen was communicated by GM O’Neill to AC Roe at 05.32,158 John Allen did not arrive at the scene until around 06.00. He was quickly taken to the building, where he carried out an inspection to establish whether the central core was intact. He was able to provide his initial advice to AC Roe at around 06.13.159 30.114 Poor communications both within the LFB and between the LFB and RBKC meant that there was an unacceptable delay between the first request by CU8 for a DSE at 02.17.36160 and AC Roe being personally briefed by the DSE at 06.13. The whole point of obtaining advice from a DSE who had personally viewed the building was to enable the incident commander 151 Kerry Log [RBK00028849] p. 4. 152 Roe Log [MET00005404] p. 3. 153 Layton Day 74/57/6-8. 154 Kerry Log [RBK00028849]. 155 Layton Day 74/58/1-4. 156 Layton Day 74/53/15-55/7. It is more likely that John Allen was not in fact there at that time. 157 O’Neill Day 51/47/14-20. 158 Roe Log [MET00005404] p. 4. 159 Roe Log [MET00005404] p. 5. 160 SIL p. 22.

Part III | Chapter 30: The Response of the MPS, the LAS, RBKC and TMO 715 and other emergency services to know whether it was at imminent risk of collapse. Such information would inevitably affect the incident commander’s strategy and that of the other emergency services. 30.115 AC Roe’s evidence was that the delay in the DSE’s arrival had not affected his plan or his understanding of the stability of the building, because he took the view that DSEs are invariably cautious, whereas LFB commanders are prepared to accept greater risks and prefer to rely on their own professional judgement when deciding whether to commit firefighters to a potentially dangerous building.161 However, that is an approach which should be treated with scepticism, since it overestimates the ability of frontline firefighters, even senior commanders, to understand the behaviour of complex building structures. Firefighters are not structural engineers or construction professionals and do not have the training needed to understand the response to fire of complex buildings constructed using modern materials. This was, indeed, a point that Commissioner Cotton was at pains to make in the course of her evidence.162 What is more, if the opinion of a DSE about whether a building was at risk of collapse was not something that an incident commander would place firmly at the centre of their strategy, it is most unlikely that CU8 would have made repeated requests for a DSE throughout the night; and it is most unlikely that Commissioner Cotton herself would have demanded a DSE in such strenuous terms at the second TCG meeting, emphasising the long delay that had already occurred in summoning one. The extraordinary nature of the Grenfell Tower incident and the very fact that urgent requests for the attendance of a DSE were made throughout the night suggest that advice about the structural integrity of the building was regarded by the LFB as important. 30.116 In the final analysis, the absence of a DSE until after 06.00 did not affect AC Roe’s decisions because his plan was to continue to commit crews into the tower unless and until he was told that there was real doubt about the structural integrity of the building. His strategy was supported by the assessment of GM O’Neill, at 05.32, that there was no concern about total collapse.163 AC Roe’s strategy was admirable as an example of willingness to commit firefighters in an attempt to save lives, even when the risks to their safety were high, but as it turned out, the risks were in fact not as serious as was feared. In that respect the LFB was fortunate. However, the long delay in the arrival of a DSE in this case is not excused by the fact that it had no serious consequences. In another major building fire delay of that kind could have proved disastrous. The request for a list of residents RBKC’s role 30.117 Shortly after the second TCG meeting at 04.34 and before the third TCG meeting at 05.50 Nickolas Layton was asked by the LFB for a list of residents of Grenfell Tower. Immediately after receiving the request he asked Robert Black for the information because he believed that he would either have it or could get it. He chased Robert Black for this information three times during the course of the night, but when he left the incident at 07.00 he had still not received it.164 He asked Robert Black for the information rather than David Kerry because he thought that RBKC would not have a full list of residents, since it was not managing the tower; he assumed that only the TMO would have it.165 It is not clear from the evidence whether 161 Roe Day 49/194/13-195/15. 162 Cotton Day 50/84/14-87/6. That was in the context of dismissing as impracticable the requirement for firefighters to examine some aspects of a building’s construction when carrying out an inspection under section 7(2)(d) of the FRA. 163 Roe Log [MET00005404] p. 4. 164 Layton Day 74/64/4-69/13. 165 Layton Day 74/69/14-16.

The Grenfell Tower Inquiry: Phase 1 Report 716 RBKC did in fact have a complete list of current residents and therefore it is not possible to say whether, if Nickolas Layton had approached RBKC earlier, he would have been able to obtain a list of residents sooner than he did. 30.118 Although the account given by Nickolas Layton in his witness statement and in his oral evidence to the Inquiry was not fully reflected in his original evidence to the MPS or in his contemporaneous notes, it is clear that he did ask Robert Black repeatedly for a full list of residents of Grenfell Tower and not only for a list of residents at the rest centres. The TMO had been asked for such a list and had provided it to Robert Black and he knew at least after the third TCG meeting that the LFB wanted to compare the names of those who were at the rest centres with a full list of residents so that it could identify who was missing. The TMO’s role 30.119 Robert Black held an important position, both as Chief Executive of the TMO and as the primary point of contact between the TMO and the LFB at CU8. As Chief Executive he either had, or should have had, ready access to important information about the Grenfell Tower and its residents. He was present at the incident from around 03.30 and waited outside CU8 in order to be able to speak to the LALOs or the LFB as necessary. However, despite being the link between the TMO and the LALO, Robert Black played an essentially passive role and failed to display effective leadership. I recognise, however, that the RBKC Contingency Plan did not require him to act in a formal capacity, at an incident such as the Grenfell Tower fire and that omission may have contributed to his lack of leadership. However, the lack of a formal role designated by RBKC does not explain why, by his own account, he did not oversee any of his staff in their roles and did not get involved in collecting information about residents who had survived. His recollection was very limited and, although he accepted that while he had been present at the command unit he might have overheard requests for information about the building and its occupants being made by the LFB and the MPS, he was not sure whether he could obtain it, or if he could, how to get it to the scene.166 Robert Black said that he had not become involved in understanding the system set up by his staff to identify survivors to assist the LFB. He left that task to Teresa Brown who was collecting information and could provide it.167 He placed a heavy burden on Teresa Brown, leaving her to obtain a list of residents of the tower for the purpose of use at the rest centres while she was also under enormous pressure to establish them. I take account of the fact that she was assisted by a team from the TMO, but that does not detract from the conclusion that Robert Black remained essentially detached. 30.120 In particular, Robert Black did not ensure that important emails were forwarded to the LALO or the LFB, assuming (but never checking) that Teresa Brown had done it. One striking example is provided by the emails sent to him by David Noble at 06.24 and 06.38 containing the list of residents as at 30 May 2017.168 Robert Black failed to pass on either of them to the LALO or the LFB until 07.56. His reasons for not acting sooner were that in the first email the LFB had not asked for the information and that he assumed that Teresa Brown would send on the second email. His evidence displayed a lack of direction on his own part and an almost casual assumption that someone else would take responsibility for doing what needed to be done. 166 Black Day 74/181/17-183/23. 167 Black Day 74/175/11-177/14. 168 Emails contained in a chain of emails [TMO10031176]. The email of 06.38 is marked as sent at 05:38 but for technical reasons the time is shown as GMT and not BST. The position is less clear for the email marked as sent at 05:24 but it is possible that this was in fact also sent at 06.24 for the same reasons.

Part III | Chapter 30: The Response of the MPS, the LAS, RBKC and TMO 717 30.121 Teresa Brown for her part was more active in taking responsibility for collating information at St Clement’s Church. As requests for information were referred to her, a direct line of communication appears to have evolved between her and the LFB. She said that she had spoken to the LFB and had initially provided sheets of handwritten notes to LFB officers Chris Line and Vincent Bell until a colleague bought a laptop enabling an electronic list to be kept.169 Despite this direct line of communication, she did not forward to the LFB the emails sent by David Noble170 at 06.24 and 06.38 containing the list of residents of the tower, because she had assumed (quite fairly) that Robert Black had sent them on.171 He eventually did so at 07.56.172 30.122 During the fourth TCG meeting at 07.10, Michael Rumble was asked for a floor plan of the tower and a copy of the electoral roll.173 Following the meeting, he asked the TMO for a list of residents. He made a request through the BECC for a copy of the electoral roll but was unable to say what had come of the request. Teresa Brown provided him with a hard copy list of residents before 11.00. He asked her to email it to the LFB and provided a specific email address for that purpose. He said that that had all happened just before the TCG meeting at 11.00.174 30.123 The delay in providing the LFB with a list of residents was unacceptably long. It was caused by an unjustifiable failure on the part of Robert Black to appreciate its importance to the LFB and to act upon the repeated requests from Nickolas Layton for the information. He appears simply to have assumed that Teresa Brown would deal with it, but without actually checking with her that she had done so. She for her part assumed that Robert Black was dealing with it, which in the circumstances was not entirely unreasonable of her. The result was that despite pressure from the LALO to obtain the information, the request fell between the cracks and the information was not provided until many hours later. Plans of the building RBKC’s role 30.124 An enduring feature of the incident was that the LFB had no floor plans or drawings of the tower. There was no information of that kind on the ORD and the building had no premises information box. These fundamental failings by the LFB and the TMO175 have been addressed at Chapter 27 of the Report. The consequence was that the LFB was forced to seek plans from the LALO and from the TMO, but could only do so once the relevant staff had arrived. 30.125 The evidence is not entirely clear about when the LFB started asking for plans of the building. Nickolas Layton’s evidence was that he had not been asked about the layout of the tower or for detailed plans at any point. He did not have any record of this request being made during any of the TCG meetings he had attended and said that he did not overhear any requests for plans.176 Indeed, there is no record by anyone else of such a request having been made at any of the TCG meetings he attended before he left the scene at 07.00, either in the Roe Log177 or elsewhere. On the other hand, as was recorded by Inspector Thatcher’s body-worn video 169 Brown Day 75/58/17-60/3, 78/12-80/21 and Brown witness statement [TMO10048960] p. 3. 170 A TMO policy officer helping with the “customer relations team”; Brown Day 75/83/8-15. 171 Brown Day 75/89/21-91/22. 172 [TMO10031176]. 173 Rumble Day 74/114/15-23. 174 Rumble Day 74/124/10-130/22. 175 As I have pointed out in Chapter 27, the TMO was not legally obliged to provide a premises information box, and they were not common in high-rise buildings. 176 Layton Day 74/74/7-75/20. 177 [MET00005404].

The Grenfell Tower Inquiry: Phase 1 Report 718 recorder, AC Roe told those present at the fourth TCG meeting at 07.10178 that he had been asking for plans for “a very long time” and that the continuing failure to provide a full set of plans would be recorded as a “major deficiency”. 30.126 On balance, I think that AC Roe probably had asked someone to obtain plans of the tower before the fourth TCG meeting at 07.10 but that he had done so in a less formal context than the earlier TCG meetings which Nickolas Layton had attended. The entry in the Roe Log at 06.13179 refers to the attendance of the DSE, John Allen, and notes that he “will attempt to locate plans”. There is also an email shortly afterwards at 06.16 in which Robert Black forwarded to John Allen an email which he had received at 06.14 from David Noble with the subject “Fwd: Fire access plans from the refurb” with two attachments entitled “fire access” and “fire strategy”.180 Although Robert Black said that he could not remember why he sent plans to John Allen, it seems very likely, in view of the timing of the messages, that he had been asked to do so.181 It remains unclear when the first request for plans was made; it may not have been as long before the fourth TCG meeting as AC Roe thought. 30.127 There appears to have been some confusion about the supply of plans to the LFB. John Allen had no recollection of receiving the email from Robert Black timed at 06.16.182 He was clear that he had not forwarded it to the LFB and the fact that he did not receive it may explain why he returned to the RBKC Town Hall to search for plans of the building, returning with them between 07.45 and 08.00. On the other hand, Michael Rumble, who attended the fourth TCG meeting at 07.10, said that he had been made aware at about that time that Robert Black had a copy of the plan of one floor of the building on his phone. After the meeting he relayed the request to Robert Black. He saw Robert Black speaking to an LFB officer and he believed that he had sent the plans to the LFB by email (although he never saw any plans himself).183 Plans of the building had been provided to the LFB before the next TCG meeting at 08.45.184 For his part, when John Allen returned to CU8 between 07.45 and 08.00 with the plans he noticed that the LFB already had the plans that he was about to give them up on a screen inside CU8.185 As a result, he did not provide further copies.186 30.128 I think it likely that the LFB were provided with plans of the building between 07.35, when the fourth TCG meeting ended,187 and around 08.00. The evidence suggests that the plans were probably provided by the TMO, although RBKC had by then been able to find them in its files. It would therefore have been able to make them available at about the same time, but not any earlier. The TMO’s role 30.129 The TMO was unable to obtain accurate information about the layout of Grenfell Tower with any speed. It is apparent that one of its employees, David Noble, who was assisting remotely, had accessed the emergency plan and sent a “cut and paste” version of its contents to Teresa Brown and two other members of staff, Janice Wray and Nicola Bartholomew.188 The section of the emergency plan containing details of the properties managed by the TMO was 178 [INQ00000518]. 179 Roe Log [MET00005404] p. 5. 180 [RBK00001468]. 181 Black Day 74/213/4-7. 182 Email [RBK00035692]; Allen second witness statement [RBK00035691] p. 9. 183 Rumble witness statement [RBK00029037] p. 6 and Day 74/117/7-121/19. 184 Roe Log [MET00005404] p. 8. 185 [LFB00001968] pp. 49, 51. 186 Allen second witness statement [RBK00035691] p. 9. 187 Roe Log [MET00005404] p. 7. 188 [TMO10031176].

Part III | Chapter 30: The Response of the MPS, the LAS, RBKC and TMO 719 intended to include important information about the buildings, including information useful to the emergency services. That included a specific section to which plans of the buildings were to be attached. However, in the case of Grenfell Tower that was blank. There was clearly a system in place which could have assisted the emergency services, if the information had been regularly reviewed and kept up to date, but regrettably that had not been done. 30.130 There is no evidence to suggest that David Noble’s email timed at 06.03 containing this inaccurate and obsolete information was forwarded to the LFB, and they did not rely on it. However, Graham Webb, who was part of the TMO leadership team and attended the incident at a later time, said that the TMO also kept an asset register which held structural plans of the building. This system was managed by the TMO asset team, but anyone who had the necessary approval could obtain access to the information and send it to the LFB as an attachment to an email.189 30.131 Graham Webb’s evidence raises concerns about why the TMO failed to keep the relevant section of the emergency plan up to date and why at the time of the incident its employees were able to gain access to out of date information about the building but not, as it seems, to up-to-date and readily accessible information about it. It also raises the question whether RBKC maintained a similar asset register and if not, whether it should have done so. 189 Webb Day 75/24/10-25/6.

The Grenfell Tower Inquiry: Phase 1 Report 720

721 Chapter 31 Isolating the Tower from the Gas Supply 31.1 Gas was supplied to the tower by Cadent Gas Ltd (Cadent). At 03.22 on 14 June 2017 the LFB contacted the Gas Emergency Call Centre and asked Cadent to attend.1 By 03.50 an Emergency Response Team from Cadent was present at the incident.2 Between 04.30 and 05.00 they reported to the LFB command unit on Bramley Road and were told to stand by and await further instructions. At all material times Cadent was a Category 2 responder within the meaning of Part 3 of Schedule 1 to the CCA and as such had an obligation to assist the LFB in the performance of its duties under the Act. In practice, that meant that Cadent was required to support the LFB by cutting off the gas supply to the tower when required to do so. 31.2 Jason Allday, a Level 7 Network Engineer and member of Cadent’s Emergency Response Team, gave written and oral evidence describing the operations that were carried out in order to shut off the supply of gas to the tower.3 A number of written statements from Cadent personnel also addressed that topic.4 31.3 Although Jason Allday was not on standby for the Emergency Response Team that night, he attended the incident because he was very familiar with the area as a result of his involvement in gas repair work on Bramley Road near to the tower. He had also attended training in managing an emergency incident in conjunction with other emergency services, including the LFB. Having seen news reports about the fire in the early hours of 14 June, he realised that his assistance would be required and decided to attend the incident.5 He reached the incident ground at around 07.20 and, after gathering key information about the situation and the resources available to him,6 reported to CU8, where he was told that the LFB wanted the gas supply to the tower to be cut off.7 31.4 In principle there were three methods by which that might be achieved: (1) by closing the pipeline isolation valves (PIVs) immediately outside the perimeter of the tower, (2) by shutting off the gas governors serving the local area and (3) by cutting the gas mains in the streets adjacent to the tower. In the event, neither of the first two methods could be adopted. PIVs are normally located within one or two metres of the building they serve and in this case they were completely inaccessible due to falling debris.8 The gas governors are pressure-reducing valves within the gas network9 which operate, in effect, like taps, so that if one is closed the others open more widely in order to maintain the pressure in the system. It would have been necessary to close at least 10 governors in order to shut off the gas supply to the tower and it would also have been necessary to place physical isolations behind each of them.10 In those circumstances, Jason Allday and his team quickly rejected that option.11 1 [CAD00000002]. 2 [MET00007821] p. 2; [MET00007956] section 20. 3 Day 73; [MET00012710]; [CAD00003018]. 4 Read into the record on Day 73 (14 November 2018) https://www.grenfelltowerinquiry.org.uk/hearings/evidence-cadent-gas-ltd- and-bsrs 5 Day 73/14/17-15/18. 6 Day 73/30/15-24. 7 Day 73/31/2-32/10. 8 Day 73/32/20-36/9. 9 Shown in Exhibit JMA/3 [CAD00003012]. 10 Day 73/37/14-42/14. 11 Day 73/41/25-42/7.

The Grenfell Tower Inquiry: Phase 1 Report 722 31.5 The third method, which involved cutting and sealing the pipes supplying gas to the area of the tower at suitable points in streets nearby, was therefore chosen as the best option for isolating the tower. There were three gas mains serving the area of the tower and it was therefore necessary to cut all three in order to achieve complete isolation.12 By using a combination of electric laptop devices (known as “Go-Books”) and hard copy maps, Jason Allday and his team identified three locations, on Grenfell Road, Testerton Walk and Station Walk respectively, at which it was safe to excavate the roadway and expose the pipes for work to be carried out on them. 31.6 The pipes beneath Testerton Walk and Station Walk were both made of ductile iron. In order to stop the flow of gas in metal pipes of up to 12 inches in diameter, a “bagging off” system is used, which involves drilling six holes in each pipe, three on either side of the point at which it is intended to make the cut, inserting four air bags and inflating them to create a seal and creating a bypass line to check that the flow of gas has ceased. Once a tight seal has been created, the pipes can be cut and capped.13 The pipe beneath Grenfell Road was made of polyethylene. Pipes of that kind can be compressed using a special tool to cut off the flow of gas to enable the pipe to be cut and capped off. 31.7 At 08.50 Jason Allday discussed with the LFB safety officers his proposal to cut the three gas mains and obtained their approval to do it. He said that until that time cutting off the gas supply to the tower had not appeared to be a priority for the LFB, given the more immediate pressures of fighting the fire and attempting to save life.14 No concerns were raised by the LFB at that time about the possibility that gas could be fuelling the fire or reigniting sections of the tower.15 31.8 It was not until later in the day, at some time between 14.00 and 15.00, that Jason Allday became aware that the LFB was concerned about gas burning inside the tower,16 when orange flames, which appeared to be fed by gas, could be seen in some compartments.17 That was consistent with his own view that it was not until that stage that gas had been contributing to fires in the tower. 31.9 At around 14.00 Jason Allday was asked by the LFB for the first time whether there were any valves in the building which could be used to shut off the gas. After consulting his colleagues, he explained that there were four risers in the building serving the residential flats, with a separate gas supply for the communal boilers.18 The LFB asked him whether he was prepared to go into the basement to try to operate the valves to shut off the risers. That was the first time he had considered entering the basement because up to that point burning debris falling from the building had made it impossible to approach it.19 At around 15.50, Jason Allday and Patrick Kelly, a member of the contract management team at Cadent, approached the basement together with three LFB officers. In order to gain access to the entrance door on the east side of the tower, they were escorted by LFB officers carrying riot shields to protect them against the risk of falling debris. 12 As shown in Exhibit JMA/1 [MET00012914] at points 3, 4 and 5 on the map. 13 Day 73/72/4-73/22. 14 Day 73/62/18-65/3 and [MET00012710] section 38. 15 Day 73/65/4-10. 16 Day 73/66/12-16, 81/24-82. 17 Day 73/108/9-109/3. 18 Day 73/92/19-24. 19 Day 73/82/10-19.

Part III | Chapter 31: Isolating the Tower from the Gas Supply 723 31.10 Once inside the basement Jason Allday was able to identify three of the four gas risers, which were located in the corners of the room with valves at a high level,20 but conditions in the building prevented him from carrying out anything more than a cursory inspection. There was a significant quantity of water present and he realised that the electricity was still on, which immediately gave him cause for concern. Apart from that, after no more than 5 minutes, the LFB advised everyone to leave the building because there were fears that it was about to collapse. In those circumstances it was not possible for him to try closing the valves, which would have involved taking ladders down into the basement to enable people to climb up to them. The risk to life posed by the conditions in the basement made that impossible.21 (When later that evening at around 20.15 the LFB asked Jason Allday to consider re-entering the basement, he declined to do so in view of the serious risks to safety, a decision which was supported by his line manager, Tony Day.)22 31.11 The team from Cadent therefore turned their attention to cutting off the supply of gas at the locations that had been identified in Grenfell Road, Testerton Walk and Station Walk. They had difficulty gaining access to the excavation sites in Grenfell Road and Testerton Walk because both were brought within the inner exclusion safety cordon around the tower when it was extended during the afternoon. In addition, the activities of other emergency services made it difficult to bring the vehicles and equipment needed to carry out the excavations into the area.23 As a result, part of the excavation had to be carried out by hand at both sites and at one stage the Cadent team had to pull back when it was considered too dangerous to remain within the inner cordon because of fears for the stability of the building. Work could continue only with the help of a team of LFB “spotters” who were deployed to watch for signs of instability in the tower. Jason Allday described a number of tense moments when difficult decisions had to be taken on whether it was safe to carry on with the work.24 In the event, excavations in both locations started at around 14.30 and the work was completed by 20.00 that evening. 31.12 The work to cut the gas main on Station Walk also proved difficult. Both the Go-Book electronic map and the paper maps showed it as a 12-inch main, which was consistent with the size of pipe marked as branching off the nearby governor at Latimer Road.25 However, after some difficulty finding the pipe (five attempts were needed to locate it and it lay deeper in the ground than had been expected),26 the team from Cadent discovered that the pipe was in fact 15 inches in diameter. They did not have the proper equipment to isolate a main of that size, but they decided to adopt an improvised method which involved over-inflating the air bags designed for use on a 12-inch pipe. That enabled them to avoid waiting for a specialist subcontractor to arrive, which would have caused further delay. In the event, their plan was successful and at 23.40 the flow of gas to the building ceased. In the early hours of 15 June a more permanent solution was achieved with the assistance of Cadent’s specialist subcontractor.27 20 Day 73/92/9-14. 21 [MET00012710] section 57. 22 Day 73/95/7-96/14; [MET00012710] section 64. 23 [MET00012710] sections 47-49. 24 Day 73/96/25-100/5. 25 Day 73/50/22-62/17, 103/1-104/22. 26 Day 73/76/18-80/15. 27 [MET00012710] sections 66-73; Day 73/100/11-107/10, 111/8-112/7.

The Grenfell Tower Inquiry: Phase 1 Report 724 31.13 When the gas was cut off at 23.40, Jason Allday described seeing the flames in the tower die down almost immediately,28 demonstrating the contribution that gas had been making to the fires at that time. He remained on hand to supervise the permanent work on the pipe beneath Station Walk and eventually left at 07.15, having been on site for around 24 hours.29 31.14 There can be no doubt that the Cadent team did an excellent job in finding the local gas mains and cutting off the supply of gas to the tower. They succeeded in completing a challenging task over a long period of time in difficult and sometimes dangerous conditions. Their success was to a large extent due to Jason Allday’s inspirational leadership, clarity of planning and careful execution. 28 [MET00012710] section 72; Day 73/107/11-108/8. 29 [MET00012710] sections 72-74; Day 73/111/23-112/7.

725 Part IV Remembering those who died

726

727 Chapter 32 Remembering Those Who Died 1 Introduction 32.1 Everyone who has had anything to do with this Inquiry has been reminded day by day that 70 people failed to escape from the building and lost their lives as a result. A child was later stillborn as a result of the trauma suffered by his mother in the course of her escape and another resident, Maria del Pilar (Pily) Burton, who had escaped from the burning building, died some months later in hospital. 32.2 Between 21 and 30 May 2018 a series of hearings took place at the Millennium Gloucester Hotel in Kensington to commemorate those who had died, to hear evidence about them as individuals, friends and neighbours and to celebrate their lives and their contributions to the wider local community. 32.3 It is fitting that this report should not only name each of those who died but should celebrate their lives as individuals, drawing on the evidence given by loved ones and friends at the commemoration hearings and in witness statements made to the Inquiry. No summary of the moving tributes delivered during those hearings could hope to do full justice to the memory of those who were lost in the fire, but I hope that this chapter, which forms part of the permanent public record of these proceedings, will bring some comfort to those who knew and remember them. Some bereaved relatives did not feel able to commemorate those whom they had lost publicly at those hearings, but in order that the record may be complete, and in accordance with what I understand to be the wishes of their relatives, I set out brief details of the person who died. 32.4 The following people died in the building, or following attempts to escape from it. I list them in the order in which their names were read by Bernard Richmond QC at the end of the commemoration hearings and the flats in Grenfell Tower which were their homes: Floor 23 Fathia Ahmed Elsanousi (Flat 206) Abufras Mohamed Ibrahim (Flat 206) Isra Ibrahim (Flat 206) Mohammed Amied (Saber) Neda (Flat 205) Hesham Rahman (Flat 204) Rania Ibrahim (Flat 203) Fethia Hassan (Flat 203) Hania Hassan (Flat 203) Marco Gottardi (Flat 202) Gloria Trevisan (Flat 202) Raymond Herbert (Moses) Bernard (Flat 201)

The Grenfell Tower Inquiry: Phase 1 Report 728 Floor 22 Eslah Elgwahry (Flat 196) Mariem Elgwahry (Flat 196) Anthony Keith Disson (Flat 194) Bassem Choukair (Flat 193) Nadia Choucair (Flat 193) Mierna Choucair (Flat 193) Fatima Choucair (Flat 193) Zainab Choucair (Flat 193) Hashim Kedir (Flat 192) Nura Jemal (Flat 192) Yahya Hashim (Flat 192) Firdaws Hashim (Flat 192) Yaqub Hashim (Flat 192) Sirria Choucair (Flat 191) Floor 21 Abdulaziz El Wahabi (Flat 182) Faouzia El Wahabi (Flat 182) Yasin El Wahabi (Flat 182) Nur Huda El Wahabi (Flat 182) Mehdi El Wahabi (Flat 182) Ligaya Moore (Flat 181) Floor 20 Jessica Urbano Ramirez (Flat 176) Omar Belkadi (Flat 175) Farah Hamdan (Flat 175) Malak Belkadi (Flat 175) Leena Belkadi (Flat 175) Mary Ajayi Augusta Mendy (Flat 173) Khadija Saye (Flat 173) Victoria King (Flat 172) Alexandra Atala (Flat 172) Floor 19 Mohamednur Tuccu (Flat 166) Amal Ahmedin (Flat 166) Amaya Tuccu Ahmedin (Flat 166) Amna Mahmud Idris (Flat 166) Majorie Vital (Flat 162) Ernie Vital (Flat 162) Debbie Lamprell (Flat 161) Gary Maunders (Flat 161)

Part IV | Chapter 32: Remembering Those Who Died 729 Floor 18 Berkti Haftom (Flat 155) Biruk Haftom (Flat 155) Hamid Kani (Flat 154) Isaac Paulos (Flat 153) Sakina Afrasehabi (Flat 151) Fatemeh Afrasiabi (Flat 151) Floor 17 Vincent Chiejina (Flat 144) Khadija Khalloufi (Flat 143) Kamru Miah (Flat 142) Rabeya Begum (Flat 142) Mohammed Hamid (Flat 142) Mohammed Hanif (Flat 142) Husna Begum (Flat 142) Floor 16 Joseph Daniels (Flat 135) Sheila (Flat 132) Floor 15 Steven (Steve) Power (Flat 122) Floor 14 Zainab Deen (Flat 115) Jeremiah Deen (Flat 115) Mohammad Alhajali (Flat 112) Denis Anthony Peter Murphy (Flat 111) Floor 11 Ali Yawar Jafari (Flat 86) Abdeslam Sebbar (Flat 81) 32.5 Logan Gomes was delivered stillborn on 14 June 2017. Pily Burton was evacuated from her flat with the assistance of firefighters. She died in hospital on 29 January 2018. 32.6 I turn now to the individual deceased in the order set out above. 2 Floor 23 Fathia Ahmed Elsanousi, Abufras Ibrahim and Isra Ibrahim (Flat 206) 32.7 Isra Ibrahim lived in Flat 206 with her mother, Fathia Ahmed Elsanousi. Abufras Ibrahim, the son of Fathia Ahmed Alsanousi, was visiting his mother and sister on 14 June 2017.

The Grenfell Tower Inquiry: Phase 1 Report 730 Fathia Ahmed Elsanousi 32.8 Fathia Ahmed Elsanousi was born in 1940 in Al Nuhood, a town in the West Kordofan province of Sudan.1 Fathia married a military officer, who died in 1984.2 Fathia was the mother of two daughters and three sons.3 She was 77 years old at the time of the fire. 32.9 On 24 May 2018, Fathia’s friend, Wafa Osman, read in both English and Arabic a commemoration of her friend on behalf of Fathia’s younger sister, Hayat Elsanosi.4 Wafa also shared some of her memories of Fathia. On 29 May 2018 Fathia’s son, Abu Baker Ibrahim, presented his commemoration.5 32.10 As a young woman living in Sudan, Fathia trained to be a school teacher. A successful educator, she rose to become headmistress of a primary school. Fathia moved to the Sudanese capital, Khartoum. After her husband died, she lived on a farm outside the city, rearing chickens and growing cattle feed. At that time she was still teaching and raising her children. Fathia was also a mother figure for her sister Hayat. Hayat suffered serious injuries at the age of 13 during a fire and Fathia was a key figure in supporting her through her education and into work.6 32.11 Two of Fathia’s children left Sudan to study in eastern Europe and in the 1990s she decided to move with her family to the United Kingdom to escape the civil war in Sudan. She made her life in London, becoming a British citizen in about 2000. She moved to Flat 206 in 2007. Fathia was remembered as a lynchpin of the Sudanese community in Kensington and Chelsea. Drawing on her professional background, she helped to establish and run the Azza Supplementary School, which has the aim of educating children of Sudanese origin in Kensington and Chelsea to understand their heritage as well as British culture.7 32.12 Fathia would visit her family in Sudan on a regular basis and was able to have a house built for her sister Hayat, where she would stay on her long visits home. Fathia was skilled at cooking, jewellery-making and sewing. She had been taught to sew as a young woman by Italian nuns. Fathia will be remembered by her family and friends as a loving mother, an educator committed to her community and a welcoming host who always had a tin of Quality Street available.8 Abufras Mohamed Ibrahim 32.13 Abufras Mohamed Ibrahim was born on 8 January 1978. He was 39 years old at the time of the fire. In June 2017, he was living with his brother, Abu Baker Ibrahim, who gave a commemoration for him on 29 May 2018.9 32.14 Abufras was known as Fras to his friends and family. He was described as a tough man with a very soft centre. He cared very deeply about his family. Abu Baker recalled a time when he was unwell and Fras looked after him. Abu Baker woke up in the middle of the night to find Fras awake sitting by the window, watching over him.10 1 Commemoration hearing 24 May 2018 [CH4/33/8]. 2 Commemoration hearing 24 May 2018 [CH4/36/6]. 3 Commemoration hearing 29 May 2018 [CH6/88/23-89/5]. 4 Commemoration hearing 24 May 2018 [CH4/31/10-13]. 5 Commemoration hearing 29 May 2018 [CH6/88/12-16]. 6 Commemoration hearing 24 May 2018 [CH4/33/19-34/18]. 7 Commemoration hearing 24 May 2018 [CH4/32/1-25-33/2]; Commemoration hearing 29 May 2018 [CH6/89/19-90/20]. 8 Commemoration hearing 24 May 2018 [CH4/35/3-14]; Commemoration hearing 29 May 2018 [CH6/90/17-23]. 9 Commemoration hearing 29 May 2018 [CH6/90/7-11]. 10 Commemoration hearing 29 May 2018 [CH6/92/23-93/19].

Part IV | Chapter 32: Remembering Those Who Died 731 32.15 Fras loved to cook for his family and was due to start working at the fishmonger’s business that Abu Baker ran. He was remembered as a brave man who would put the welfare of others before that of himself.11 Isra Ibrahim 32.16 Isra Ibrahim was born on 8 August 1983. She was 33 years old. 32.17 Remembering his sister on 29 May 2018, Abu Baker Ibrahim described her as a loving and compassionate person. She carried those qualities into her working life where she helped to care for elderly people, reflecting her altruistic nature.12 32.18 On 30 May 2018, Said Essaouini delivered his commemoration for Isra. He was Isra’s partner; they had met in 2014. He described Isra as having a very strong faith in God and taking religion very seriously. She would wake early to perform an extra hour of morning prayers.13 32.19 Isra was a very generous person, often donating money to people whom she thought needed it more than she did. Her last job was as a salesperson and she also spent time working at the St Charles Hospital caring for elderly people.14 32.20 Fit and healthy, Isra enjoyed spending time outdoors. She enjoyed trips out of London and would often visit Brighton. She loved Regent’s Park, feeling it was a place where she could get away from the world.15 32.21 Isra enjoyed cooking Sudanese food for her friends and family and loved her family above all.16 Mohammed Amied (Saber) Neda (Flat 205) 32.22 Mohammed Amied (Saber) Neda lived with his wife Flora (Shakila) Neda and son Shekab (Farhad) Neda in Flat 205. His friends and family knew him as Saber. 32.23 Saber Neda was born on 3 May 1960 in Afghanistan. He was 57 years old at the time of the fire. On 21 May 2018, commemorations for Saber were presented on behalf of his brother Aref, his son Farhad and his wife Flora. 32.24 One of 10 children, Saber grew up in Afghanistan. He and Flora met in 1989 in Kabul when he was 28 and she 26 years old. At the time he was a high-ranking officer in the Afghan army and had just returned from Czechoslovakia where he had spent two years training. Saber and Flora married in 1991 in Kabul and were husband and wife for over 27 years. Flora recalled the pride and joy Saber felt when their son Farhad was born in 1993.17 32.25 Saber and his family left Afghanistan in 1998 because of the risk they faced from the Taliban. He was targeted as an army officer and Flora was no longer able to work as a primary school teacher. The family were able to claim asylum in the United Kingdom.18 11 Commemoration hearing 29 May 2018 [CH6/93/419]. 12 Commemoration hearing 29 May 2018 [CH6/91/8-13]. 13 Commemoration hearing 30 May 2018 [CH7/68/24-69/5]. 14 Commemoration hearing 30 May 2018 [CH7/69/23-70/2]. 15 Commemoration hearing 30 May 2018 [CH7/70/16-19]. 16 Commemoration hearing 30 May 2018 [CH7/70/3-6]; [CH7/70/20-23]. 17 Commemoration hearing 21 May 2018 [CH1/43/1-12]. 18 Commemoration hearing 21 May 2018 [CH1/44/1-2].

The Grenfell Tower Inquiry: Phase 1 Report 732 32.26 Saber immediately threw himself into life in this country. He attended English and computer classes in a desire to better himself and to provide a good quality of life for his family. In 1999 the family moved into Flat 205, which was to be their home for 18 years.19 32.27 Saber was very hardworking and in those early years in the United Kingdom would take whatever work he could find to support his family. He spent time cleaning, delivering pizzas and working for a minicab firm as a driver. His experience as a driver led Saber to establish his own chauffeur business where he continued to work hard for his last 10 years. Saber was always impeccably turned out, wearing a smart suit and a range of colourful ties even when not at work. He developed a loyal group of customers drawn to his warm personality and professionalism.20 32.28 Saber’s hard work underpinned his dedication to his family. Many of his siblings settled in the United Kingdom, Netherlands and Germany and the extended family often took holidays together. Saber was most proud of the achievements of his son Farhad. He encouraged Farhad with his studies and interests. He would take him to Taekwondo competitions throughout the United Kingdom and Europe, always finding time for his son amid a busy working life. Farhad worked alongside his father while studying at university and Saber was there to see his son graduate. He was also extremely proud to throw his son an engagement party and the family explained that their successes were a product of Saber’s hard work and positive attitude to life.21 Hesham Rahman (Flat 204) 32.29 Hesham Rahman lived in Flat 204. He was born on 30 January 1960 in Egypt.22 He was 57 years old at the time of the fire. 32.30 A video tribute to Hesham, prepared by his cousin Noha el Baghdady and her young son, was played at the hearing on 22 May 2018.23 A moving and powerful tribute was delivered by Hesham’s nephew, Karim Mussily.24 32.31 Hesham always considered himself to be Noha’s big brother and he loved and cared for her very deeply. He would do anything for his family, especially for Noha’s mother, who was also a mother-figure for Hesham. Hesham’s own mother had died in childbirth when he was three years old and he was primarily raised by his maternal grandmother and aunt.25 He joined the family in the United Kingdom in the mid-1980s and set out to make a life for himself in his new country. 32.32 A talented hairdresser, Hesham had a kind and generous approach to life. He had a love of music and wrote poetry. Noha recalled that Hesham used to sing to her until she fell asleep. They would go on long walks together during which she would share her troubles and hopes. 32.33 Noha’s young son described his uncle Hesham as the kindest man he had ever met. He remembered the fun they used to have together and how Hesham’s personality made him stronger whenever he was with him. 19 Commemoration hearing 21 May 2018 [CH1/46/9-13]; Flora (Shakila) Neda first witness statement [IWS00000887] p. 3. 20 Commemoration hearing 21 May 2018 [CH1/45/10-13]; [CH1/36/8-17]. 21 Commemoration hearing 21 May 2018 [CH1/39/9-11]; [CH1/46/20-47/9]. 22 Ragab witness statement [IWS00000475] p. 1. 23 Commemoration hearing 22 May 2018 [CH2/90/16]. 24 Commemoration hearing 22 May 2018 [CH2/89/22-90/16]. 25 Ragab witness statement [IWS00000475] p. 1.

Part IV | Chapter 32: Remembering Those Who Died 733 Rania Ibrahim, Fethia Hassan and Hania Hassan (Flat 203) 32.34 Rania Ibrahim lived in Flat 203 with her husband Hassan Awadh Hassan and their two daughters, Fethia, and Hania. Hassan was not in Grenfell Tower on the night of 13-14 June 2017. 32.35 Rania Ibrahim was born on 3 March 1986 in the city of Aswan in Egypt. She was 31 years old. Her eldest daughter, Fethia, was born on 5 October 2012. She was four years old. Her younger daughter, Hania, was born on 4 June 2014. She was three years old. 32.36 The commemorations for Rania, Fethia and Hania were given over three days. First, on 22 May 2018, from Rania’s sister, Rasha Ahmed Adly Ibrahim.26 Then on 23 May 2018 there was a video tribute prepared on behalf of Rania’s sister, Sayeda Ibrahim.27 Finally, on 29 May 2018, Hassan, Rania’s husband and father to Fethia and Hania,28 and Rania’s good friend and neighbour, Munira Mahmud, shared their commemorations.29 32.37 Rania grew up in a large family. She was an active and adventurous child who enjoyed swimming and riding her bicycle in the mountains and was a keen member of the Egyptian Scouts. As a child she enjoyed school and was a supportive student who would stand up for those in need. Her love of learning persisted throughout her life.30 32.38 This quality led Rania to choose to study law and she successfully gained admission to university in Cairo to do so. Rania was a hard worker and while studying she also worked part-time in a pharmacy with her sister, Rasha.31 32.39 In 2009, Rania came to the United Kingdom to help care for her eldest sister Sayeda’s four children, while Sayeda recovered from a serious illness. Sayeda recalled how Rania’s caring and optimistic nature helped her to focus on her recovery.32 32.40 Rania met Hassan in 2010 and they married the following year in the Al Manaar Mosque.33 Hassan recalled that on the first day they met he knew from Rania’s smile that she had a big heart. Their first daughter, Fethia, was born in 2012.34 32.41 Fethia was an active and outgoing child who reminded her family of Rania. Known as “Fou‑Fou” by Rania’s family, she inherited her mother’s playful personality. Rania’s sister, Rasha, remembered a time when they had been visiting their family in Egypt. Rania, Fethia, Rasha and her son had had a food fight throwing eggs at each other. They still have video footage of the aftermath showing them covered in broken eggs.35 32.42 Fethia was a confident child and Hassan told us about her first trial day at nursery, which was a week or so before she was due to start attending regularly. Fethia had a wonderful time and could not understand why she could not return the following day.36 Hassan also remembered one morning when they had been rushing to their destination. They reached a quiet road with a pedestrian crossing indicating not to cross. When Hassan went to cross he was reprimanded by Fethia, who said: “Daddy, the man is red.”37 26 Commemoration hearing 22 May 2018 [CH2/33/16-20]. 27 Commemoration hearing 23 May 2018 [CH3/6/11-22]. 28 Commemoration hearing 29 May 2018 [CH6/21/3-4]. 29 Commemoration hearing 29 May 2018 [CH6/27/16-20]. 30 Commemoration hearing 23 May 2018 [CH3/6/22]. 31 Commemoration hearing 23 May 2018 [CH3/6/22]. 32 Commemoration hearing 23 May 2018 [CH3/6/22]. 33 Commemoration hearing 22 May 2018 [CH2/34/3]. 34 Commemoration hearing 29 May 2018 [CH6/26/6]. 35 Commemoration hearing 22 May 2018 [CH2/35/17]. 36 Commemoration hearing 29 May 2018 [CH6/24/9-20]. 37 Commemoration hearing 29 May 2018 [CH6/24/21-25/5].

The Grenfell Tower Inquiry: Phase 1 Report 734 32.43 Rania and Hassan had their second daughter, Hania, in 2014. She idolised her elder sister and would copy everything Fethia did. Even at her young age Hania had a very grown-up attitude and would roll her eyes to show her disapproval. Hania was very happy when she could join her sister at nursery, where they were able to play together. The children had good manners, were respectful and were extremely happy in each other’s company.38 32.44 The family moved into Flat 203 in 2015.39 Rania quickly established herself with new friends gained through her open and inquisitive nature together with her love of food and cooking for others. Her friend, Munira, said that even though Rania had a busy life, she would always find time for others. She would help Munira by looking after her father-in-law while she was away, cooking for him, making sure he had his medication and taking the time to talk to him, all while raising a family.40 Above all, she spoke of Rania’s kindness; her sister, Rasha, said that no one would sit with Rania and not smile.41 Gloria Trevisan and Marco Gottardi (Flat 202) 32.45 Gloria Trevisan and Marco Gottardi lived together in Flat 202. Gloria was born on 2 December 1990 in Camposampiero, in the province of Padua, Italy.42  She was 26 years old. Marco Gottardi was born on 26 June 1989. He was 27 years old. 32.46 On 29 May 2018, Gloria’s mother and father, Emanuela Disaró and Loris Trevisan, gave a video tribute to their daughter followed by a short statement. Emanuela Disaró also spoke about Gloria and Marco in the witness statement she gave to the Inquiry. 32.47 Gloria’s parents remembered how from a young age she had shown an interest in and exceptional talent for art. Gloria could produce incredibly accurate pencil drawings that looked like photographs. Upon leaving school she studied at art school and then decided to pursue architecture. Gloria studied at the University Institute of Architecture of Venice.43 32.48 At university Gloria met Marco, a fellow architecture student, and they became a couple. After much hard work and sacrifice they both graduated in 2016 with degrees in architecture.44 32.49 Gloria’s main professional interest was in the restoration of old buildings rich in history and art. She had a very happy life in Italy. She had wonderful friends who cherished her advice. She was extremely close to her family and enjoyed the sunshine, food and lifestyle that Italy had to offer.45 32.50 Marco and Gloria were very happy together and planned their lives as a couple.46 In December 2016 they decided to move to the United Kingdom to learn English and to develop their professional skills; they felt the opportunities for work here would be better than in Italy. They eventually moved to London on 4 March 2017. They stayed with one of Marco’s cousins for their first few weeks before moving into Grenfell Tower.47 38 Commemoration hearing 29 May 2018 [CH6/26/6]. 39 Commemoration hearing 29 May 2018 [CH6/21/22]. 40 Commemoration hearing 29 May 2018 [CH6/32/22-33/4]. 41 Commemoration hearing 22 May 2018 [CH2/35/17]. 42 Disaró first witness statement [IWS00000543] pp. 1-2. 43 Disaró first witness statement [IWS00000543] p. 2. 44 Disaró first witness statement [IWS00000543] p. 2. 45 Commemoration hearing 29 May 2018 [CH6/36/12]. 46 Disaró first witness statement [IWS00000543] p. 2. 47 Disaró first witness statement [IWS00000543] p. 3.

Part IV | Chapter 32: Remembering Those Who Died 735 32.51 Gloria obtained a position at Peregrine Bryant Architects, a firm specialising in the conservation and restoration of historic buildings. For Gloria this was her dream job and the reason she had left her happy life in Italy. Peregrine Bryant spoke of Gloria’s exceptional talent and how in the short time she had worked at the firm she had made a significant contribution to the development of the Royal Hospital, Chelsea.48 32.52 Marco also found work in London, securing a position as an architect at Creative Ideas and Architecture Office.49 32.53 Marco was a sound, grounded person. Gloria’s mother referred to him as very rational; someone who never exaggerated and who used reason rather than instinct. He was very calm and sensible.50 32.54 In their video presentation, Gloria’s family described her as a simple girl who loved laughing and joking. She loved and was thoroughly loved in return by her friends and family.51 Raymond Herbert (Moses) Bernard (Flat 201) 32.55 Raymond (Moses) Bernard lived in Flat 201 with his dog Marley.52 He was born on 22 May 1954 in a small village in Penal on the island of Trinidad in the West Indies.53 He was 63 years old. 32.56 The commemorations for Moses were heard on 30 May 2018. The address given by his sister, Sheramin Bernadette Bernard,54 included a video of the remembrance service held for Moses and messages from his mother, Rose Bernard, and another sister, Marva Bernard, both of whom now live in Trinidad.55 We also heard from Moses’ son, Julian Bertin,56 and his daughter, Marlene Bernard Anderson, who attended with Ashley Anderson.57 32.57 Moses was the third of the seven children of Rose and Ben Bernard.58 He spent his early life in Trinidad, where he attended the Penal Roman Catholic School,59 leaving at the age of 14 to become an apprentice car mechanic.60 In 1969 he joined his parents in London, where they were working. Raymond then attended Isaac Newton Boys’ School in Ladbroke Grove.61 32.58 At the age of 16 Moses began an electrical engineering apprenticeship at the House of Lords. He qualified as an electrician and worked at the Houses of Parliament and Buckingham Palace.62 He met Sonia, whom he went on to marry, in 1973 and they had two daughters, Marlene and Selina. He had two other children including his son, Julian, born in 1978.63 48 Commemoration hearing 29 May 2018 [CH6/36/12]. 49 Disaró first witness statement [IWS00000543] p. 3. 50 Disaró first witness statement [IWS00000543] p. 6. 51 Commemoration hearing 29 May 2018 [CH6/36/12]. 52 Commemoration hearing 30 May 2018 [CH7/15/3]. 53 Commemoration hearing 30 May 2018 [CH7/7/11-12]. 54 Commemoration hearing 30 May 2018 [CH7/6/3]. 55 Commemoration hearing 30 May 2018 [CH7/20/13]. 56 Commemoration hearing 30 May 2018 [CH7/21/10-12]. 57 Commemoration hearing 30 May 2018 [CH7/23/2-4]. 58 Commemoration hearing 30 May 2018 [CH7/23/14-15]. 59 Commemoration hearing 30 May 2018 [CH7/7/24]. 60 Commemoration hearing 30 May 2018 [CH7/8/10-12]. 61 Commemoration hearing 30 May 2018 [CH7/9/18-19]. 62 Commemoration hearing 30 May 2018 [CH7/9/20-21]; [CH7/23/20-21]. 63 Commemoration hearing 30 May 2018 [CH7/23/22-24]; [CH7/10/3-7].

The Grenfell Tower Inquiry: Phase 1 Report 736 32.59 Moses had a deep love of music. He had been a sound man for the Gemini Sound System and his sister remembered him in his early twenties having long flowing locks resembling a free-spirited lion.64 With his close friends, he also ran a nightclub called “The Embassy” in Shepherd’s Bush, playing reggae and soul music. Moses was an intrinsically happy person, his happiness stemming from being with those he loved and being surrounded by music.65 32.60 Moses had lived on the top floor of Grenfell Tower for more than 30 years.66 It was while living there that he met Karen, his partner for over 20 years.67 Moses’ personality was warm and affectionate, like the Caribbean island where he had been born.68 He never lost his love for Trinidad or the West Indian cricket team, which he supported with passion.69 Moses was a charismatic, kind-hearted and warm person. He was a peaceful protector of his friends and family who would help anyone in need.70 3 Floor 22 Eslah Elgwahry and Mariem Elgwahry (Flat 196) 32.61 Eslah Elgwahry and her daughter Mariem Elgwahry lived in Flat 196. Eslah, born on 1 December 1952, was 64 years old. Mariem was born on 11 April 1990 in London. She was 27 years old. 32.62 On 29 May 2018, Ahmed Elgwahry, the son of Eslah and brother of Mariem, spoke of his mother and sister but explained that he did not feel ready to speak in too much detail about his mother.71 32.63 Eslah had lived in Grenfell Tower for 34 years; Mariem had lived there for all her life.72 When Mariem was eight years old her father died and Eslah raised her two children alone. She instilled in them a strong family bond, so that they would support each other, come what may.73 32.64 Mariem was a single-minded and ambitious young woman.74 A graduate of Roehampton University, she went on to establish a successful career as a marketing manager.75 She was a positive force with a mischievous sense of humour, who would not hesitate to play the fool if it made her friends and family smile.76 32.65 Ahmed described his sister as a brave and adventurous woman who loved to travel the world. While on her travels, she climbed an active volcano, abseiled, paraglided, jet-skied and cycled around Mexico. Mariem loved adventures and lived for the moment.77 She loved sport, particularly tennis.78 Her drive and determination were shown by her efforts in raising money 64 Commemoration hearing 30 May 2018 [CH7/24/1-2]. 65 Commemoration hearing 30 May 2018 [CH7/11/12-22]; [CH7/22/17-19]. 66 Commemoration hearing 30 May 2018 [CH7/16/8-10]. 67 Commemoration hearing 30 May 2018 [CH7/14/22-24]. 68 Commemoration hearing 30 May 2018 [CH7/22/9-16]. 69 Commemoration hearing 30 May 2018 [CH7/24/6-8]. 70 Commemoration hearing 30 May 2018 [CH7/20/13]. 71 Commemoration hearing 29 May 2018 [CH6/17/8-17]. 72 Commemoration hearing 29 May 2018 [CH6/18/15-16]; [CH6/2/11-12]. 73 Commemoration hearing 29 May 2018 [CH6/1/20-2/6]. 74 Commemoration hearing 29 May 2018 [CH6/4/12-14]. 75 Commemoration hearing 29 May 2018 [CH6/19/22-20/1]. 76 Commemoration hearing 29 May 2018 [CH6/3/9-16]. 77 Commemoration hearing 29 May 2018 [CH6/4/19-5/2]. 78 Commemoration hearing 29 May 2018 [CH6/2/17]; [CH6/10/17-21].

Part IV | Chapter 32: Remembering Those Who Died 737 for those charitable causes close to her heart – even running the final four and a half miles of an obstacle course after receiving treatment for an asthma attack.79 32.66 Mariem and Eslah had an extremely close relationship. Even in adulthood, Mariem continued to live with her mother in order to care for her.80 Eslah was a strong woman and though she had raised two children on her own she remained young at heart. She was known for her authentic Egyptian cuisine. She wanted to maintain and share her Egyptian culture and tradition and was always cooking for neighbours, friends and family.81 32.67 Mariem’s caring nature was most strongly focused on her family. In the midst of a busy life she would always drop whatever she was doing to put her family first.82 She was an ambitious, talented and confident woman who was a credit to the mother who had raised her. Anthony Disson (Flat 194) 32.68 Anthony Disson lived in Flat 194. He was born on 27 November 1951 in North Kensington. Known to everyone as Tony, he was 65 years old. 32.69 On 23 May 2018, Tony’s eldest son, Lee Disson, gave a commemoration for his father.83 A video commemoration from his wife Cordelia and their three sons, Harriboy, Alfie and Charlie was also shown.84 32.70 Tony was the youngest of seven children.85 As a young man he met his first wife in 1967 and they had a son, Lee, who was born in February 1970.86 They lived together in Shepherd’s Bush and then in 1974 moved to Fulham.87 32.71 Tony’s love of sport endured throughout his life. He coached various sports at the Brunswick Boys’ Club in Fulham.88 A loyal supporter of Fulham Football Club, he would attend their matches and lend his vocal support whenever he could.89 Lee Disson recalled happy weekends and summer holidays spent at a chalet in Leysdown on the Isle of Sheppey and further afield in Gran Canaria.90 32.72 Tony and his first wife divorced amicably and on New Year’s Eve 1987 he married Cordelia. The couple had a beautiful wedding with well-wishers celebrating their union into the new year, although Cordelia did say that not many people remembered the clock striking 12.91 32.73 Tony and Cordelia had three sons together: Harriboy, born in 1993, Alfie, born in 1994 and Charlie born in 1998.92 Tony was a good dad who loved his children and would do anything for them. He encouraged his sons’ love of boxing, taking them to the Dale Youth boxing club 79 Commemoration hearing 29 May 2018 [CH6/6/22-7/11]. 80 Commemoration hearing 29 May 2018 [CH6/5/14-15]; [CH6/17/18-18/2]. 81 Commemoration hearing 29 May 2018 [CH6/18/8-19]. 82 Commemoration hearing 29 May 2018 [CH6/18/4-7]. 83 Commemoration hearing 23 May 2018 [CH3/8/4-7]. 84 Commemoration hearing 23 May 2018 [CH3/16/20]. 85 Commemoration hearing 23 May 2018 [CH3/8/14-15]. 86 Commemoration hearing 23 May 2018 [CH3/8/22-24]. 87 Commemoration hearing 23 May 2018 [CH3/9/4-5]. 88 Commemoration hearing 23 May 2018 [CH3/9/11-14]. 89 Commemoration hearing 23 May 2018 [CH3/9/18-22]. 90 Commemoration hearing 23 May 2018 [CH3/10/19-11/6]. 91 Commemoration hearing 23 May 2018 [CH3/16/20]. 92 Commemoration hearing 23 May 2018 [CH3/16/20].

The Grenfell Tower Inquiry: Phase 1 Report 738 at the bottom of Grenfell Tower. His sons excelled in the world of amateur boxing and Tony would drive them all over the country to take part in competitions. He always made his voice heard in support of his sons, even in the face of a partisan local crowd.93 32.74 Tony had an excellent sense of humour which he passed on to his sons. Cordelia remembered her sons laughing while watching Tony trying to turn on a computer by talking to it; they had tricked him into thinking that that was the way to do it. They enjoyed teasing Tony, but he was a patient father, ready to watch their choice of television programmes so that he could spend time in their company. Tony became a proud grandfather and great-grandfather and idolised the younger members of his family.94 32.75 Those closest to him described Tony as a generous man with a good heart. He would never see anyone go without, because he knew what it was like to be without. He was a good dad, a brilliant husband and a wonderful grandfather. He was not the richest man in the world, but he was rich with love for those he held closest.95 The Choucair/Choukair Family (Flat 193 and Flat 191) 32.76 Nadia Choucair, Bassem Choukair and their daughters Mierna, Fatima and Zainab lived in Flat 193. Nadia’s mother Sirria Choucair lived in Flat 191 on the same floor. 32.77 Sirria Choucair was born on 25 October 1956 in Lebanon. She was 60 years old. Her daughter Nadia was born on 14 January 1984 in London.96 She was 33 years old. Bassem Choukair was born on 1 December 1976 in Lebanon and was 40 years old. Their three daughters were born in London; Mierna Choucair, born on 22 November 2003, was 13, Fatima Choucair, born on 1 March 2006, was 11 and Zainab Choucair, born on 17 May 2014, was three. 32.78 As well as Nadia, Sirria had three other children: her sons, Nabil and Hisam, and her daughter, Sawsan. Hisam and Sawsan Choucair presented their commemoration on 22 May 2018.97 Nabil Choucair gave a separate commemoration on 30 May 2018.98 A letter written by Bassem’s parents was also read out by Mr Aboudihaj on 30 May 2018.99 32.79 The second eldest child in her family, Sirria took responsibility for her younger siblings from an early age. She would cook, clean and get them ready for school and because of these responsibilities was not able to attend school herself.100 Sirria moved to the United Kingdom at the age of 17 and married her husband. They set up home in Redcliffe Gardens, Earl’s Court, where they brought up their four children.101 As soon as Sirria arrived in the country she enrolled herself on an English course.102 Education was something that she held in very high regard throughout her life. 32.80 Sirria very soon realised that to give her children a good life, she would need to find paid work alongside raising her family. She followed her husband into the food industry. Sirria spent all of her working life in the catering department at the Royal Marsden Hospital and loved her job very much.103 93 Commemoration hearing 23 May 2018 [CH3/16/20]. 94 Commemoration hearing 23 May 2018 [CH3/16/20]; [CH3/13/14]. 95 Commemoration hearing 23 May 2018 [CH3/16/20]. 96 Commemoration hearing 30 May 2018 [CH7/74/5]. 97 Commemoration hearing 22 May 2018 [CH2/62/4-18]. 98 Commemoration hearing 30 May 2018 [CH7/72/16-21]. 99 Commemoration hearing 30 May 2018 [CH7/82/4-7]. 100 Commemoration hearing 30 May 2018 [CH7/74/5]. 101 Commemoration hearing 22 May 2018 [CH2/63/7-14]. 102 Commemoration hearing 22 May 2018 [CH2/63/14-17]. 103 Commemoration hearing 22 May 2018 [CH2/63/18-64/2].

Part IV | Chapter 32: Remembering Those Who Died 739 32.81 Sirria’s life was characterised by hard work. She was the first to wake up in the morning and would cook delicious meals for the family, filling their home with appetising smells. She would then go to work and complete a full shift at the hospital before returning home to complete the housework.104 Sirria wanted her children to have the opportunities that she had not enjoyed. Together with her husband she worked hard to put all four children through private schools.105 32.82 Bassem lived in Lebanon where he worked as a welder. He also spent time in the military and was very well known in his town.106 While Nadia was visiting her family in Lebanon she met Bassem and they agreed to marry.107 Bassem came to live with Nadia in the United Kingdom where they had their three daughters. Bassem was an extremely hard worker and his priority was to make a good life for his family.108 Waking early every morning, he would cycle to his job at Marks & Spencer. There he was quickly promoted to the position of Section Co‑ordinator, where his strict approach, respected by those he managed, could not have been more different from the caring and affectionate man he was at home with his family.109 32.83 Nadia and Bassem moved to Grenfell Tower in around 2006.110 When Mierna was old enough, she attended nursery at Avondale Park Primary School. Nadia had always wanted to work with children and she started working at Avondale as a nursery officer.111 She was a valued member of staff, loved by parents, colleagues and children for her keen, positive approach and her desire to develop in her career.112 32.84 Mierna was a student at Kensington Aldridge Academy.113 She was a clever and fun-loving young woman who was a caring and compassionate friend.114 Mierna worked hard at school and excelled academically. Ambitious for her future, she was in the process of deciding whether to pursue a career in law or medicine.115 It is clear from a video she made about her morning routine that Mierna had a witty and keen eye for the details of life.116 She was also very active; she loved to go swimming at the weekends and she was extremely protective of her younger sisters.117 32.85 Fatima was a student in Year 6 at Avondale Park Primary School where her mother worked.118 She was much quieter than her sisters and was extremely active. She loved to participate in sports and played in the school football team. Fatima was an excellent gymnast and wanted to pursue the sport professionally.119 She had lots of friends who would often visit her and she always worked very hard to do her best at school. It was said that if something did not come naturally to her, she would do everything in her power to master it.120 104 Commemoration hearing 22 May 2018 [CH2/64/22-23]. 105 Commemoration hearing 22 May 2018 [CH2/65/14-16]. 106 Commemoration hearing 30 May 2018 [CH7/74/5]. 107 Commemoration hearing 22 May 2018 [CH2//79/18-20]. 108 Commemoration hearing 22 May 2018 [CH2/79/20-23]. 109 Commemoration hearing 22 May 2018 [CH2/80/1-6]. 110 Commemoration hearing 22 May 2018 [CH2/74/13-14]. 111 Commemoration hearing 22 May 2018 [CH2/67/24-68/3]. 112 Commemoration hearing 22 May 2018 [CH2/83/21]. 113 Commemoration hearing 22 May 2018 [CH2/70/24-71/1]. 114 Commemoration hearing 22 May 2018 [CH2/83/21]. 115 Commemoration hearing 22 May 2018 [CH2/71/6-7]. 116 Commemoration hearing 30 May 2018 [CH7/74/5]. 117 Commemoration hearing 22 May 2018 [CH2/83/21]. 118 Commemoration hearing 22 May 2018 [CH2/83/21]. 119 Commemoration hearing 22 May 2018 [CH2/78/12-14]. 120 Commemoration hearing 22 May 2018 [CH2/83/21].

The Grenfell Tower Inquiry: Phase 1 Report 740 32.86 Zainab was described as the spark of the family.121 She attended the nursery at Avondale. Zainab was a good actor who did not shy away from the limelight. She would delight in reciting her favourite nursery rhyme, “The Three Little Pigs”, to her family, who always enjoyed her performance.122 She would put olives on the ends of her fingers and eat them one by one. Zainab loved to make things; she also loved the company of her sisters, whom she would seek to imitate.123 She had a very close relationship with her grandmother, Sirria, who would look after Zainab while Nadia and Bassem were at work. The two shared a very special bond.124 32.87 Sirria’s husband died when he was 52 and that put considerable strain on her. She developed arthritis and was not able to continue working.125 When Nadia and Bassem moved into Grenfell Tower, Sirria was able to move into Flat 191 on the same floor as her daughter.126 It was here that she found a new role as a caring grandmother. She took great pleasure in being close to her daughter’s young family and helping to raise her grandchildren.127 Sirria would travel every year to Lebanon to visit her own mother and the warmer climate helped to alleviate her arthritis.128 32.88 The family was extremely close and would always be in and out of each other’s flats, cooking for one another, watching films and going to the park together.129 They were a close knit, supportive family; a solid unit whose members adored each other.130 Sirria instilled in her family a culture of respect for those around them and, in turn, they were respected by their community.131 The family spent their holidays in Lebanon and invested whatever money and time they could spare building a home for themselves by hand from the foundations up.132 It is clear that each member of the family lived their lives for others and that was the foundation upon which this strong and loving family was built. The Jemal/Kedir Family (Flat 192) 32.89 Nura Jemal, Hashim Kedir and their children Yahya, Firdaws and Yaqub lived in Flat 192. 32.90 Nura Jemal was born on 1 August 1981 in Ethiopia. She was 35 years old. Hashim Kedir was born on 7 March 1973 in Addis Ababa, Ethiopia. He was 44 years old. Their children were all born in the United Kingdom; Yahya Hashim, born on 5 August 2003, was 13, Firdaws Hashim, born on 13 January 2005, was 12 and Yaqub Hashim, born on 18 May 2011, was 6. 32.91 On 25 May 2018 commemorations for the family were given on behalf of Hashim’s sister and brothers, Assema Habib, Shemsu Kedir Habib, and Redwan Kedir and on behalf of Nura’s sisters and brother, Bedriya Jemal Kelbeto, Nurya Jemal Kelbeto and Sadik Jemal Kelbeto. The commemorations included a video presentation.133 32.92 Hashim was the eighth of nine children born to Aisha and Kedir Habib.134 The family sadly lost Aisha when Hashim was very young and his father raised him with the help of his older 121 Commemoration hearing 22 May 2018 [CH2/83/21]. 122 Commemoration hearing 30 May 2018 [CH7/74/5]. 123 Commemoration hearing 22 May 2018 [CH2/83/21]. 124 Commemoration hearing 22 May 2018 [CH2/76/22-77/4]. 125 Commemoration hearing 22 May 2018 [CH2/66/11-14]. 126 Commemoration hearing 22 May 2018 [CH2/66/14-18]. 127 Commemoration hearing 22 May 2018 [CH2/66/19-23]. 128 Commemoration hearing 22 May 2018 [CH2/67/8-9]. 129 Commemoration hearing 22 May 2018 [CH2/77/6-11]. 130 Commemoration hearing 22 May 2018 [CH2/83/21]. 131 Commemoration hearing 30 May 2018 [CH7/74/5]. 132 Commemoration hearing 22 May 2018 [CH2/81/4-10]. 133 Commemoration hearing 25 May 2018 [CH5/54/4-5]. 134 Commemoration hearing 25 May 2018 [CH5/72/25].

Part IV | Chapter 32: Remembering Those Who Died 741 siblings.135 Hashim’s older siblings gave up the chance of an education to help raise the younger children. This had a lasting impact on Hashim, who was able to attend school, where he thrived.136 Hashim was always top of the class and received high grades in his final exams. He went on to study electrical engineering.137 2.93 Hashim came to the United Kingdom in 2000 and immediately threw himself into the world of 3 work.138 He was a construction worker, a parking attendant and an electrician. He then passed the Knowledge exam to become a black cab driver.139 In 2002, Hashim met Nura in London through a mutual friend.140 32.94 Nura was one of eight children born in a rural part of southern Ethiopia called Silte.141 The family shared a one-room house in a farming community.142 Nura did not attend school as a child but was very bright. At the age of 14 she moved to Addis Ababa to work as a housekeeper.143 She then managed to open up a small shop where she sold tea and coffee.144 Dedicated to her family, Nura sent the money she earned home to help support her entire family.145 Nura then left Addis Ababa and went to work in Saudi Arabia before moving to the United Kingdom. She continued to support her family financially, morally and emotionally when living in London.146 32.95 Nura and Hashim married and had three children. Yahya was described as kind, polite, loving, generous, thankful and pure-hearted.147 He was a student in year nine at Kensington Aldridge Academy where his favourite subject was maths.148 Yahya was a competitive boy who enjoyed playing basketball and football.149 He was a unique character with a big heart who was always making people laugh.150 A devout Muslim, he would lead the family in prayer.151 His wish when he grew up was to become an Ustaz, which is an Islamic scholar and teacher.152 32.96 Firdaws’ aunt Assema described her as intelligent, wise and eloquent with a wonderful singing voice.153 She was a student in Year 7 at Kensington Aldridge Academy, where she excelled academically.154 Firdaws was a voracious reader who would be perfectly happy concentrating on a book in the midst of a social gathering.155 Even at her young age she was a gifted public speaker and was awarded a prize by Bill Gates for best floor speech when taking part for her school in Comic Relief’s “The Big Debate”. The journalist, Jon Snow, one of the judges, commented that Firdaws stood out above everybody else; she was spellbinding and confident and he felt she was going to go far.156 135 Commemoration hearing 25 May 2018 [CH5/73/2-8]. 136 Commemoration hearing 25 May 2018 [CH5/73/8-23]. 137 Commemoration hearing 25 May 2018 [CH5/73/21-23]. 138 Commemoration hearing 25 May 2018 [CH5/74/5-9]. 139 Commemoration hearing 25 May 2018 [CH5/74/9-12]. 140 Commemoration hearing 25 May 2018 [CH5/71/3-4]. 141 Commemoration hearing 25 May 2018 [CH5/70/1-4]. 142 Commemoration hearing 25 May 2018 [CH5/89/17-21]. 143 Commemoration hearing 25 May 2018 [CH5/89/24-90/9]. 144 Commemoration hearing 25 May 2018 [CH5/98/25-99/2]. 145 Commemoration hearing 25 May 2018 [CH5/90/5-9]. 146 Commemoration hearing 25 May 2018 [CH5/92/6-10]. 147 Commemoration hearing 25 May 2018 [CH5/65/21-22]. 148 Commemoration hearing 25 May 2018 [CH5/66/3-4]. 149 Commemoration hearing 25 May 2018 [CH5/103/17]. 150 Commemoration hearing 25 May 2018 [CH5/103/17]. 151 Commemoration hearing 25 May 2018 [CH5/66/13-14]. 152 Commemoration hearing 25 May 2018 [CH5/69/6-7]. 153 Commemoration hearing 25 May 2018 [CH5/61/7-8]. 154 Commemoration hearing 25 May 2018 [CH5/61/17-18]. 155 Commemoration hearing 25 May 2018 [CH5/62/9-13]. 156 Commemoration hearing 25 May 2018 [CH5/103/17].

The Grenfell Tower Inquiry: Phase 1 Report 742 32.97 Yaqub was a bundle of energy with a spirited, sharp mind; he was an inquisitive child able to make reasoned arguments even at his young age.157 A student in Year 1 at Avondale Park Primary School, Yaqub was well liked by teachers and his classmates.158 Yaqub was an extremely active child; he played football and loved to dance. His favourite song was “Watch Me” by Silentó – a song to which he knew all the choreography.159 As the youngest child, he was determined to show that he could do whatever his elder siblings could do.160 Yaqub was always laughing and brought a spark of happiness into the family.161 32.98 Nura was a positive-minded, devout and courageous mother and wife who loved her friends and appreciated the small things in life.162 Hashim was described as a smart, soft-hearted and generous man who loved football (he was a lifelong Arsenal supporter). He maintained a close relationship with his family in Ethiopia, whom he supported whenever he could.163 Nura and Hashim encouraged all their children to learn Amharic so they could maintain a relationship with their extended family in Ethiopia.164 The family would regularly return to Ethiopia to see friends and relations and make sure everyone was well cared for.165 32.99 It is clear that the family were warm, close-knit and generous with both their time and their money. Firdaws is recorded at “The Big Debate” competition as saying: “We have so much and we’re so fortunate to have it, and we all have it, and we’re lucky to, so why shouldn’t others?”166 32.100 These sentiments reflect the kindness, compassion and humanity of the family she grew up in. 4 Floor 21 Logan Gomes (Flat 183) 32.101 Logan was the son of Andreia Perestrelo and Marcio Gomes, who lived in Flat 183 with their two daughters. The family’s commemoration for Logan took place on 21 May 2018.167 32.102 Logan was due to be born on 21 August 2017.168 Marcio recalled how happy the family were about the prospect of their new arrival. He had cried when he found out he was going to have a son.169 They held a baby shower for their friends and family and received lots of presents in anticipation of Logan’s birth.170 32.103 The family had made detailed plans for Logan. Not only had they prepared the nursery, but they had decided that Logan would support Benfica and Liverpool.171 He would be Marcio’s 157 Commemoration hearing 25 May 2018 [CH5/56/11-57/1]. 158 Commemoration hearing 25 May 2018 [CH5/58/21-25]. 159 Commemoration hearing 25 May 2018 [CH5/57/12-16]. 160 Commemoration hearing 25 May 2018 [CH5/57/19-21]. 161 Commemoration hearing 25 May 2018 [CH5/58/19-20]. 162 Commemoration hearing 25 May 2018 [CH5/69/23-24]; [CH5/70/17-18]. 163 Commemoration hearing 25 May 2018 [CH5/72/18-24]. 164 Commemoration hearing 25 May 2018 [CH5/101/9-11]. 165 Commemoration hearing 25 May 2018 [CH5/86/6-8]. 166 Commemoration hearing 25 May 2018 [CH5/103/17]. 167 Commemoration hearing 21 May 2018 [CH1/14/16]. 168 Commemoration hearing 21 May 2018 [CH1/17/7-9]. 169 Commemoration hearing 21 May 2018 [CH1/18/13-14]. 170 Commemoration hearing 21 May 2018 [CH1/18/17-19]. 171 Commemoration hearing 21 May 2018 [CH1/18/1-2].

Part IV | Chapter 32: Remembering Those Who Died 743 Xbox gaming buddy and his sisters wanted to help look after him.172 They were most excited about a planned trip to Disneyland the summer after Logan was due to arrive.173 32.104 Logan was delivered stillborn on 14 June after his mother had escaped from the tower. Marcio described how he was able to hold his son. Logan was beautiful and restful; it was as if he was asleep.174 Logan will always be with his family in their hearts. He was their little star.175 The El Wahabi Family (Flat 182) 32.105 Abdulaziz and Faouzia El Wahabi lived in Flat 182 with their three children, Yasin, Nur Huda and Mehdi. As a family, the El Wahabis were a big, well-loved part of their community. 32.106 Abdulaziz El Wahabi was born on 1 December 1964 in Larache, in northern Morocco.176 He was 52 years old. His wife Faouzia was born on 1 June 1975, also in Larache. She was 42 years old. Their son Yasin was born at St Mary’s Hospital, Paddington, on 9 August 1996. He was 20 years old. Their daughter Nur Huda was born in St Mary’s Hospital, Paddington177 on 27 June 2001. She was 15 years old. Their youngest child Mehdi was born at Chelsea and Westminster Hospital on 22 February 2009. He was eight years old. 32.107 On 25 May 2018, several family members of the El Wahabis gave commemorations in person and by way of two video presentations. 32.108 Abdulaziz was described as a simple man who loved to travel. In 1976, when he was 11 years old, Abdulaziz and his family moved to the United Kingdom from Morocco.178 Abdulaziz had a strong attachment to his British and Moroccan identity and filled his home in London with Moroccan décor.179 He loved taking photographs at family gatherings and had many pictures, especially of his children, on his walls.180 He was a kind, loyal family man, who was so proud when anyone in the family achieved anything in life.181 Abdulaziz was particularly close to his mother182 and was loving and supportive to his wife and children.183 32.109 Abdulaziz worked in various trades throughout his life, including as a butcher, a mechanic, and a porter at University College Hospital London, where he remained for 22 years.184 Marcel Levi, Chief Executive of UCLH Trust, described Abdulaziz as a popular colleague known for being kind to his patients.185 Colleagues recalled that he brightened up the workplace with cheerful and cheeky banter, and was relaxed, chatty, and friendly to staff and patients alike. He went above and beyond what was required of him and his colleagues felt honoured to know and work with him.186 32.110 Faouzia was the third of five children. She was artistic and creative. Her mother, Menana, recounted that by the age of seven Faouzia was already doing her own embroidery. She always wanted to stay indoors and help with adult tasks; she especially enjoyed helping out in 172 Commemoration hearing 21 May 2018 [CH1/18/20-22]. 173 Commemoration hearing 21 May 2018 [CH1/18/3-7]. 174 Commemoration hearing 21 May 2018 [CH1/17/13-16]; [CH1/19/25-20/1]. 175 Commemoration hearing 21 May 2018 [CH1/17/7]. 176 Commemoration hearing 25 May 2018 [CH5/15/12-16]. 177 Commemoration hearing 25 May 2018 [CH5/28/1-2]. 178 Commemoration hearing 25 May 2018 [CH5/39/17-18]. 179 Commemoration hearing 25 May 2018 [CH5/15/17-22]. 180 Commemoration hearing 25 May 2018 [CH5/15/21-24]. 181 Commemoration hearing 25 May 2018 [CH5/18/5-6]. 182 Commemoration hearing 25 May 2018 [CH5/43/1-7]. 183 Commemoration hearing 25 May 2018 [CH5/40/8-14]. 184 Commemoration hearing 25 May 2018 [CH5/16/14-20]. 185 Commemoration hearing 25 May 2018 [CH5/16/21-24]. 186 Commemoration hearing 25 May 2018 [CH5/17/4-18/1].

The Grenfell Tower Inquiry: Phase 1 Report 744 the kitchen.187 Faouzia moved to London aged 20,188 where she married Abdulaziz in 1994.189 She was a lively, friendly woman who loved her role as a mother and wife. Described as the anchor of her family, she was always laughing and joking with her three children.190 32.111 Faouzia continued to pursue her creative interests as an adult and was especially good at crochet and knitting, as well as having her own sewing machine. She was a natural teacher who was calm and patient when teaching her young niece how to knit.191 Faouzia used her skills to benefit others; she sold some of the items she made at Portobello Market, with the profits going back to her local community.192 32.112 A famously good cook, Faouzia enjoyed making meals from different cuisines from all over the world. She was in demand as a baker and on 13 June 2017 had made cakes for a family friend’s engagement party.193 She used to cook every day for Abdulaziz’s mother, to whom the whole family were very close.194 32.113 Yasin was Abdulaziz and Faouzia’s eldest child. He was studying accountancy part-time at Greenwich University. Alongside his studies, Yasin trained as a football referee and officiated at adult and children’s games.195 He was said to be just like his father in both looks and personality; both lit up the room when they walked in.196 32.114 Joe Ward, a friend of Yasin, recalled how Yasin taught him to be confident at a time when he was struggling with anxiety due to the trauma of having lost his own father. Yasin and his family had treated him with great kindness and generosity. He remembered a particularly happy day which he and Yasin had spent riding around Yasin’s estate on the back of a BMX, laughing, talking and getting chased by a group of girls. He described Yasin’s strength of character and positive approach to life as an inspiration.197 Another friend recalled how Yasin would lend a hand to anyone who needed it.198 32.115 Nur Huda went to Thomas Jones Primary school and Holland Park Secondary School, where at the time of the fire she had been in the middle of taking her GCSEs.199 She was remembered as a loyal and supportive friend.200 When her younger cousin had started at Holland Park, Nur Huda, like a big sister, had offered to take her to her classes, even though she knew it would make her late for her own.201 32.116 Nur Huda’s teacher, Ms Hirst, felt that Nur Huda had empathy well beyond her years, whilst her inherent sense of right, wrong and justice stood her in good stead. Nur Huda was industrious, ambitious and diligent at school; she wanted to earn her successes through her own hard work and hoped to become a PE teacher. Ms Hirst used to look forward to seeing the El Wahabis at parents’ evenings, not least because the love between the whole family was palpable.202 187 Commemoration hearing 25 May 2018 [CH5/46/22-24]. 188 Commemoration hearing 25 May 2018 [CH5/20/4]. 189 Commemoration hearing 25 May 2018 [CH5/47/14]. 190 Commemoration hearing 25 May 2018 [CH5/20/6-10]; [CH5/23/12-14]. 191 Commemoration hearing 25 May 2018 [CH5/20/16-25]. 192 Commemoration hearing 25 May 2018 [CH5/21/14-17]. 193 Commemoration hearing 25 May 2018 [CH5/22/4-21]. 194 Commemoration hearing 25 May 2018 [CH5/43/12-14]. 195 Commemoration hearing 25 May 2018 [CH5/24/4-9]. 196 Commemoration hearing 25 May 2018 [CH5/41/6-8]. 197 Commemoration hearing 25 May 2018 [CH5/25/2-22]. 198 Commemoration hearing 25 May 2018 [CH5/26/25-27/1]. 199 Commemoration hearing 25 May 2018 [CH5/28/2-4]. 200 Commemoration hearing 25 May 2018 [CH5/32/5-6]. 201 Commemoration hearing 25 May 2018 [CH5/28/6-20]. 202 Commemoration hearing 25 May 2018 [CH5/30/5-31/17].

Part IV | Chapter 32: Remembering Those Who Died 745 32.117 Mehdi was the baby of the family. He was mothered by both his parents and his siblings.203 He enjoyed playing Minecraft and Lego. Mehdi was like a collector, and had arranged his toys all over his desk – it was completely full.204 He enjoyed ice cream, curry and couscous. His young cousin thought that Mehdi would have become a comedian, though he would have needed to do some work on his jokes first.205 32.118 Mehdi’s teacher from Oxford Gardens Primary School, Ms Trabelsi, thoroughly enjoyed teaching him. She felt that one of Mehdi’s strongest qualities was his ability to make everyone laugh and smile; his smile lit up any room he entered and his kindness and generosity to others made him a very popular person.206 Oxford Gardens has dedicated a plaque to Mehdi and his family.207 Ligaya Moore (Flat 181) 32.119 Ligaya Moore lived alone in Flat 181. She was born on 28 October 1938 in the village of San Luis, Pampanga, in the Philippines.208 She was 78 years old. 32.120 On 25 May 2018, a commemoration for Ligaya was delivered by her friend Nenita Bungay on behalf of herself and Ligaya’s niece, Caroline Custodio.209 32.121 Ligaya was the second of four children. As a young woman she had dreamt of travelling the world and exploring new places.210 She left the Philippines in 1972 and travelled to London where she secured work as a nanny.211 32.122 Shortly after arriving in London she met her husband Jim. Having married, they spent many happy years together and explored the United Kingdom. They did not go further afield because Jim did not like to fly.212 32.123 Ligaya was a stylish and sociable woman. She loved fashion and would always wear heels, claiming that she did not know how to walk in flat shoes.213 She enjoyed shopping and would often visit the Westfield shopping centre with her friend Nenita.214 Ligaya had a passion for ballroom dancing and others remarked that she was full of energy and enthusiasm. She would explore London on foot, often walking from Holland Park all the way to Trafalgar Square.215 32.124 Ligaya loved living in Grenfell Tower. From her flat she enjoyed wonderful views across London and would often say to her friends that she felt on top of the world.216 Ligaya was heavily involved in charity work and did a great deal to help those less fortunate than herself. She did not forget her early life in the Philippines and had set up a savings account to provide help to those in need in her country of origin.217 203 Commemoration hearing 25 May 2018 [CH5/34/5-6]. 204 Commemoration hearing 25 May 2018 [CH5/34/21-25]. 205 Commemoration hearing 25 May 2018 [CH5/35/1-5]. 206 Commemoration hearing 25 May 2018 [CH5/35/6-17]. 207 Commemoration hearing 25 May 2018 [CH5/36/23-25]. 208 Commemoration hearing 25 May 2018 [CH5/6/18]. 209 Commemoration hearing 25 May 2018 [CH5/5/12-18]. 210 Commemoration hearing 25 May 2018 [CH5/6/19-20]; [CH5/7/3-5]. 211 Commemoration hearing 25 May 2018 [CH5/7/9-10]. 212 Commemoration hearing 25 May 2018 [CH5/7/10-14]. 213 Commemoration hearing 25 May 2018 [CH5/6/22-25]. 214 Commemoration hearing 25 May 2018 [CH5/8/1]. 215 Commemoration hearing 25 May 2018 [CH5/9/5]; [CH5/8/9-11]. 216 Commemoration hearing 25 May 2018 [CH5/8/16-9/1]. 217 Commemoration hearing 25 May 2018 [CH5/10/8-15].

The Grenfell Tower Inquiry: Phase 1 Report 746 32.125 Above all, she is remembered as a wonderful loving friend who was always generous with her time and affection. 5 Floor 20 Jessica Urbano Ramirez (Flat 176) 32.126 Jessica Urbano Ramirez lived in Flat 176 with her family.218 Jessica was born on 4 July 2004 in London. She was 12 years old. 32.127 Jessica’s sister, Melanie, her mother, Adriana Ramirez and her father, Ramiro Urbano, presented a commemoration for Jessica on 25 May 2018. 32.128 Adriana described how Jessica had brought joy to the family’s lives from the day she was born. She was bubbly and cheeky and always willing to meet a challenge. Jessica loved to make her family happy and was a selfless and caring girl. She enjoyed cooking, especially baking cakes. She always offered her father the chance to try what she had made, and if he was cooking, she would always want to be involved.219 32.129 Jessica also loved to go out, either with her family or her friends. She liked to try out different food at different restaurants, but also enjoyed shopping. Melanie remembered how her sister always managed to keep up with the latest trends and hairstyles.220 32.130 Adriana described how Jessica especially enjoyed lazy Sundays with her mum, watching movies under the duvet and eating popcorn. Despite this, she also found time to join in many after-school activities such as swimming. Her father described her as a “busy bee”.221 32.131 Melanie said that her sister was full of joy and laughter. She remembered listening to Jessica singing and called her a “real diva”.222 32.132 Jessica was looking forward to turning 13 and having a party with her friends.223 She was already planning her Quinceaňera, which is a traditional coming-of-age party held when a girl turns 15. Jessica said that she wanted to wear a beautiful yellow dress.224 Jessica had begun to make plans for her future. Her family miss her terribly.225 The Belkadi/Hamdan Family (Flat 175) 32.133 Omar Belkadi, Farah Hamdan and their daughters, Malak and Leena Belkadi, lived in Flat 175 with Omar and Farah’s third daughter who survived the fire. 32.134 Omar was born on 1 August 1984 in Morocco. He was 32 years old. He worked at a pizza restaurant.226 Farah was born on 23 February 1986 in London. She was 31 years old. She was a teacher.227 Malak was born on 26 September 2008 at St Mary’s Hospital, London. She was eight years old when she died. Leena was born on 14 December 2016 at St Mary’s Hospital, London. She was six months old when she died. 218 Adriana Ramirez witness statement [IWS00001116] p. 1. 219 Commemoration hearing 25 May 2018 [CH5/53/18]. 220 Commemoration hearing 25 May 2018 [CH5/53/18]. 221 Commemoration hearing 25 May 2018 [CH5/53/18]. 222 Commemoration hearing 25 May 2018 [CH5/53/18]. 223 Commemoration hearing 25 May 2018 [CH5/53/18]. 224 Commemoration hearing 25 May 2018 [CH5/53/6-10]. 225 Commemoration hearing 25 May 2018 [CH5/53/18]. 226 Commemoration hearing 30 May 2018 [CH7/31/2-3]. 227 Commemoration hearing 30 May 2018 [CH7/27/19-20].

Part IV | Chapter 32: Remembering Those Who Died 747 32.135 On 30 May 2018, Farah’s father, El Alami Hamdan, gave a commemoration for Omar, Farah, Malak and Leena. 32.136 El Alami Hamdan said that his daughter Farah had lived in West London all her life.228 A good student at school,229 she was a respectful person to whom family was very important.230 Farah went on to become a teacher.231 32.137 Farah enjoyed holidays with her family, particularly to Morocco, where Omar’s family lived. She was pleased that as part of these trips her children would learn to speak Arabic.232 Her father described Farah as the best mother to her girls;233 she was always fair with them.234 32.138 El Alami Hamdan spoke fondly of how much Farah and Omar loved each other,235 and reflected that Omar’s parents themselves were very good people.236 Farah and Omar had a “magic” wedding, and El Alami Hamdan was very proud of their union.237 He had a really good bond with his daughter. His bond with Omar was also strong. Omar called him “Uncle”238 and, in turn, El Alami Hamdan thought of Omar as his son. Omar would do anything for him.239 32.139 Omar was someone with a reputation for honesty and integrity within the community.240 He was popular at work, and when he used to deliver pizza, he always got a tip. El Alami Hamdan reflected that “everyone loved him”.241 32.140 Malak, Leena and their sister knew El Alami Hamdan as “Jiddi”, meaning Grandpa.242 He loved being a grandfather and thought of the girls as his children.243 He spoke of how Malak was always smiling.244 She used to go to karate lessons with her sister on Saturday mornings and on Sundays they would go to the mosque to study Arabic.245 The family would enjoy their main meal together in the evenings, after which the children were allowed to enjoy some sweets or crisps.246 32.141 El Alami Hamdan last saw his daughter on the afternoon of 13 June 2017 as he was on the way to the mosque. Leena was in a buggy and they were on the way to collect Malak and her sister from school. He had played peek-a-boo with Leena and hugged his daughter. 247 Mary Mendy and Khadija Saye (Flat 173) 32.142 Mary Mendy and her daughter, Khadija Saye, lived in Flat 173. Mary was born on 11 June 1963 in Long Street, Gambia and was 54 years old. Khadija was born on 30 July 1992 in Hammersmith. She was 24 years old. 228 Commemoration hearing 30 May 2018 [CH7/27/4-6]. 229 Commemoration hearing 30 May 2018 [CH7/27/19]. 230 Commemoration hearing 30 May 2018 [CH7/28/6-12]; [CH5/28/15]. 231 Commemoration hearing 30 May 2018 [CH7/27/19-20]. 232 Commemoration hearing 30 May 2018 [CH7/27/25-28/5]. 233 Commemoration hearing 30 May 2018 [CH7/28/10-12]. 234 Commemoration hearing 30 May 2018 [CH7/31/23]. 235 Commemoration hearing 30 May 2018 [CH7/29/16-19]. 236 Commemoration hearing 30 May 2018 [CH7/29/21-22]. 237 Commemoration hearing 30 May 2018 [CH7/30/4-8]. 238 Commemoration hearing 30 May 2018 [CH7/30/15-20]. 239 Commemoration hearing 30 May 2018 [CH7/31/15-19]. 240 Commemoration hearing 30 May 2018 [CH7/32/8-13]. 241 Commemoration hearing 30 May 2018 [CH7/31/11-13]. 242 Commemoration hearing 30 May 2018 [CH7/33/23-24]. 243 Commemoration hearing 30 May 2018 [CH7/33/25-34/1]. 244 Commemoration hearing 30 May 2018 [CH7/32/21-24]. 245 Commemoration hearing 30 May 2018 [CH7/33/1-4]. 246 Commemoration hearing 30 May 2018 [CH7/33/15-18]. 247 Commemoration hearing 30 May 2018 [CH7/34/2-13].

The Grenfell Tower Inquiry: Phase 1 Report 748 32.143 Mary and Khadija’s friends and family gave commemorations for them on 21 and 22 May 2018. 32.144 Mary moved to the United Kingdom in the 1980s.248 Her cousin Ambrose recalled how the two of them worked together for around 18 months when Mary first arrived in the country.249 Mary was the first of six siblings to settle in the United Kingdom.250 In 1992, her daughter Khadija was born and her niece Marion Telfer moved to live with them. They moved into Grenfell Tower in about 1993.251 32.145 Mary enjoyed sightseeing around London with her eldest brother, Pa Sarr, but liked reminders of her home country too. She was a very good cook and used to make Gambian food for her family members when they came to see or stay with her.252 32.146 Family members remembered Mary as the best aunt and sister they could have asked for; she was warm and kind, and was always there to provide support for them.253 Her cousin Clarrie Mendy described Mary’s smile as “like sunshine”254 and Mary as well-loved within her community, in part due to her “Christian nature”.255 As a carer, Mary worked to help those less fortunate than herself, and she frequently travelled to Gambia and offered donations to hospitals and other organisations.256 32.147 The day Khadija was born was the proudest day of Mary’s life.257 At 14, Khadija won a scholarship to Rugby School and was recognised as an excellent student.258 Her father, Mohammadou Saye, recalled that growing up, Khadija’s burning passion was for photography. It gave her great happiness and satisfaction. After school, Khadija went on to study the subject at the University for Creative Arts in Farnham.259 32.148 Khadija was developing an exciting career in photography and exhibited her work at the Venice Biennale in May 2017. In preparation for the festival, Khadija was interviewed and filmed by the BBC. We were shown part of the footage, in which she spoke of how her work had developed over the years. She explained that her photography explored her British-Gambian identity and the duality she felt from this and her family’s different faiths (her mother was a Christian, and her father is a Muslim). The film revealed that several people had sought to purchase Khadija’s work at the festival.260 32.149 At the commemoration, Damel Carayol, a relative of Mary and Khadija, presented the Inquiry with a painting of Grenfell Tower.261 It was hung on the wall of the main hearing room at the start of the Phase 1 hearings, where it remains as a permanent reminder to all present of the horrors of the night and its aftermath. Victoria King and Alexandra Atala (Flat 172) 32.150 Victoria (Vicky) King lived in Flat 172 with her daughter Alexandra Atala. Born on 12 June 1946, she was 71 years old. Alexandra Atala, born on 24 April 1977, was 40 years old.  248 Commemoration hearing 21 May 2018 [CH1/51/5-7]. 249 Commemoration hearing 22 May 2018 [CH2/50/7-8]. 250 Commemoration hearing 22 May 2018 [CH2/39/17-18]. 251 Commemoration hearing 21 May 2018 [CH1/51/18-20]. 252 Commemoration hearing 22 May 2018 [CH2/40/1-5]. 253 Commemoration hearing 21 May 2018 [CH1/52/2-5]. 254 Commemoration hearing 22 May 2018 [CH2/44/24]. 255 Commemoration hearing 22 May 2018 [CH2/56/12-18]. 256 Commemoration hearing 21 May 2018 [CH1/52/9-10]. 257 Commemoration hearing 21 May 2018 [CH1/51/7-9]. 258 Commemoration hearing 22 May 2018 [CH2/56/19-20]. 259 Commemoration hearing 21 May 2018 [CH1/53/14-17]. 260 Commemoration hearing 21 May 2018 [CH1/55/3]. 261 Commemoration hearing 22 May 2018 [CH2/59/11-12].

Part IV | Chapter 32: Remembering Those Who Died 749 32.151 On 24 May 2018, Penny Pearce, Vicky’s sister, gave a short commemoration for them.262 32.152 At one time Penny had lost touch with her sister Vicky and niece Alexandra, but was able to re-establish contact with the help of the Salvation Army.263 It meant a great deal to the family to be reunited.264 32.153 Vicky and Alexandra had a very close relationship and stayed together throughout their lives.265 The family shared pictures of Vicky and Alexandra at different stages in their lives when they looked very happy.266 6 Floor 19 Mohamednur Tuccu, Amal Ahmedin and Amaya Tuccu Ahmedin (Flat 166) 32.154 Amal Ahmedin and Amaya Tuccu Ahmedin lived in Flat 166. Amaya’s father Mohamednur Tuccu was also at the flat on the night. Amal was born on 1 January 1982 in Sudan and was 35 years old. Mohamednur was born 24 May 1973 in London. He was 44 years old. Amaya was born on 25 February 2014 in London. She was 3 years old at the time of her death. 32.155 On 24 May 2018, Winta Afewerki,267 Feruza Afewerki, Amal’s sisters,268 and Ibrahim Toukou, Mohamednur’s brother269 presented their commemorations. 32.156 Feruza explained that Amal had four sisters: herself, Fatima Ahmedin, Winta Afewerki and Hawa Ahmedin.270 Winta praised her sister’s capacity to love, which she described as “unmatchable”.271 She and Amal had shared a room growing up and she recalled that, if she had nightmares as a child, Amal would hold on to her and squeeze them out for her.272 32.157 Amal loved to have a good time and to surround herself with positive, amazing people.273 She lived each day as if it was her last, and was the life of the party.274 She did not judge others and she would help anyone regardless of their background.275 She learned five languages so that she would be able to communicate with as many people as possible, and because she loved making new friends.276 32.158 Mohamednur had eight siblings. They grew up in a small city in Eritrea. Mohamednur’s brother described him as a very funny person; he loved to entertain others, and did whatever he thought might make them happy, including singing and making up jokes. As a child he used to perform for the local children, sometimes making a screen with curtains and a light.277 262 Commemoration hearing 24 May 2018 [CH4/8/1-8]. 263 Commemoration hearing 24 May 2018 [CH4/9/1-8]. 264 Commemoration hearing 24 May 2018 [CH4/9/9-10]. 265 Commemoration hearing 24 May 2018 [CH4/9/10-11]. 266 Commemoration hearing 24 May 2018 [CH4/9/14-15]. 267 Commemoration hearing 24 May 2018 [CH4/11/2-3]. 268 Commemoration hearing 24 May 2018 [CH4/13/15-19]. 269 Commemoration hearing 24 May 2018 [CH4/16/7]. 270 Commemoration hearing 24 May 2018 [CH4/10/16-19]. 271 Commemoration hearing 24 May 2018 [CH4/11/7]. 272 Commemoration hearing 24 May 2018 [CH4/11/14-16]. 273 Commemoration hearing 24 May 2018 [CH4/11/11-12]. 274 Commemoration hearing 24 May 2018 [CH4/14/15-16]. 275 Commemoration hearing 24 May 2018 [CH4/11/7-10]. 276 Commemoration hearing 24 May 2018 [CH4/14/24-15/2]. 277 Commemoration hearing 24 May 2018 [CH4/16/2].

The Grenfell Tower Inquiry: Phase 1 Report 750 32.159 Mohamednur moved to the United Kingdom in around 1991. He studied Genetics at Queen Mary University and Informatics at the University of Westminster. As well as his ability to entertain, Mohamednur was known for being well-mannered and kind.278 32.160 Despite living in different countries, Mohamednur remained close to his parents and family and spoke to them regularly. His mother was especially pleased when Mohamednur and Amal brought Amaya to Eritrea.279 Mohamednur was also close to Amal’s family; Winta recalled how he would treat her like a little sister, buying Amal’s sisters gifts when they came round, and talking to them as if they were his friends.280 32.161 Amal and Mohamednur adored their daughter, Amaya. She was the first baby in their respective families and was surrounded by love from all her relatives.281 Winta remembered how Amaya’s infectious laugh would make her whole body shake and she would jump up and down. Amaya loved to play with anyone, young or old, and had a cheeky side to her. She was an intelligent child, and the family were enjoying seeing her personality develop as she grew older; it was already very clear that she was her mother’s daughter.282 32.162 Amaya loved music, singing and dancing. When she saw someone busking in the street she would often stop and break into dance. She especially loved to sing along to the “Frozen” soundtrack at the top of her lungs.283 Amna Mahmud Idris 32.163 Amna Idris did not live in Grenfell Tower. She was visiting her cousin Amal Ahmedin at the time of the fire. Amna was born on 1 January 1990 in Eritrea. She was 27 years old. 32.164 Her husband, Ibrahim Abdulkerim, spoke about Amna at the commemoration hearing on 24 May 2018.284 Amna had moved to Sudan from Eritrea in 2010. She met Ibrahim while in Sudan and they married there in January 2012.285 They lived together for some years before being separated when Ibrahim moved to London. In March 2016, Amna was able to join Ibrahim in the United Kingdom where they were very happy together.286 32.165 Amna especially loved the arts and her ambition was to become an art designer. Amna also enjoyed reading and walking and like her cousin, Amal, was always willing to help those around her.287 Maria del Pilar (Pily) Burton (Flat 165) 32.166 Maria del Pilar Burton was born in the town of Ferrol, Galicia, Spain.288 Known to all as Pily, she lived in Flat 165 with her husband Nicholas Burton. They both survived the fire on 14 June

1. Pily died on 29 January 2018.289

278 Commemoration hearing 24 May 2018 [CH4/16/2]. 279 Commemoration hearing 24 May 2018 [CH4/16/2]. 280 Commemoration hearing 24 May 2018 [CH4/12/12-15]. 281 Commemoration hearing 24 May 2018 [CH4/12/5-11]. 282 Commemoration hearing 24 May 2018 [CH4/12/16-20]. 283 Commemoration hearing 24 May 2018 [CH4/15/10-16]. 284 Commemoration hearing 24 May 2018 [CH4/16/8-16]. 285 Commemoration hearing 24 May 2018 [CH4/16/16-18]. 286 Commemoration hearing 24 May 2018 [CH4/17/5-8]. 287 Commemoration hearing 24 May 2018 [CH4/16/21-25]. 288 Commemoration hearing 22 May 2018 [CH2/20/5-7]. 289 Pily Burton is not counted among those who died as a direct result of the fire. Nonetheless, she is much missed and was commemorated as a member of the Grenfell Tower community by her husband Nicholas Burton.

Part IV | Chapter 32: Remembering Those Who Died 751 32.167 On 22 May 2018, Nicholas Burton delivered his commemoration for Pily.290 32.168 Pily was an only child, but when she was growing up, her parents cared for two boys, Mani and Jose Maria, whom they brought up as her brothers.291 When Pily was a teenager, she moved with her parents to London, settling into a large house in North Kensington.292 Pily was a very outgoing young person, a trait that persisted throughout her life. She quickly learnt to speak English without a Spanish accent, in addition to being able to speak Portuguese, Italian and French.293 32.169 After leaving school, Pily entered the catering industry and at the age of 17 met her first husband. Soon after, she fell pregnant and gave birth to her son, Victor.294 Pily and her husband divorced and in the early 1970s, she moved into Grenfell Tower.295 32.170 Pily and Nicholas met in 1983 at a discotheque while he was studying in the sixth form.296 She was friendly and flamboyant, an excellent dancer with a magnetic personality.297 As he put it, Nicholas moved into Pily’s flat in Grenfell Tower, “sock by sock”. They were together for 16 years before marrying in 2000.298 32.171 Their home was a colourful place, full of music, food and friends.299 Pily and her family loved traditional Galician music but she especially loved reggae.300 Food was of paramount importance to Pily and she enjoyed cooking for friends and family; her paella was internationally known and sought-after.301 Pily also had a passion for fashion and was a flamboyant and colourful dresser with a sense of style which others would often praise.302 32.172 Pily spent many years working as a contract manager in the NHS. In her final job she worked at St Charles Hospital with responsibility for the porters, domestic and catering staff. Pily was loved and respected by those she worked with because she looked after everyone.303 32.173 Family was extremely important to Pily and she was a proud mother, grandmother and great‑grandmother. She cared for both of her parents before they died.304 The death of her brother, Jose Maria, in a road accident shortly after the loss of her parents affected her very deeply.305 32.174 After a wonderful trip round France, Switzerland and Italy, Pily was diagnosed with dementia and she had to leave work in 2015.306 After escaping the fire at Grenfell Tower, her condition deteriorated and she suffered a severe stroke in early January 2018. Having waited to see her son, Victor, she died on 29 January 2018 with Nicholas by her side.307 290 Commemoration hearing 22 May 2018 [CH2/17/15]. 291 Commemoration hearing 22 May 2018 [CH2/20/16-21]. 292 Commemoration hearing 22 May 2018 [CH2/20/22-24]. 293 Commemoration hearing 22 May 2018 [CH2/21/1-4]. 294 Commemoration hearing 22 May 2018 [CH2/21/8]. 295 Commemoration hearing 22 May 2018 [CH2/19/24-20/1]. 296 Commemoration hearing 22 May 2018 [CH2/19/13-16]. 297 Commemoration hearing 22 May 2018 [CH2/19/17-22]. 298 Commemoration hearing 22 May 2018 [CH2/21/13-18]. 299 Commemoration hearing 22 May 2018 [CH2/21/19-23]. 300 Commemoration hearing 22 May 2018 [CH2/22/11-15]. 301 Commemoration hearing 22 May 2018 [CH2/22/25-23/1]. 302 Commemoration hearing 22 May 2018 [CH2/23/23-24]. 303 Commemoration hearing 22 May 2018 [CH2/24/16-24]. 304 Commemoration hearing 22 May 2018 [CH2/25/1-11]. 305 Commemoration hearing 22 May 2018 [CH2/25/14-16]. 306 Commemoration hearing 22 May 2018 [CH2/25/23-26/15]. 307 Commemoration hearing 22 May 2018 [CH2/29/16-19].

The Grenfell Tower Inquiry: Phase 1 Report 752 32.175 Pily was remembered as a magnetic,308 talkative and gregarious person with an enthusiasm for life. It was said that the song she sang most often, “Three Little Birds” by Bob Marley and the Wailers, encapsulated her approach to the world: “Don’t worry about a thing, cause every little thing gonna be all right.”309 Majorie Vital and Ernie Vital (Flat 162) 32.176 Majorie Vital lived in Flat 162. Her son Ernie Vital was staying with her on 13 June 2017. 32.177 Majorie, born on 14 November 1948, was 68 years old. Ernie, born on 11 January 1967, was 50 years old.310 32.178 On 23 May 2018, two commemorations were presented on behalf of the family of Majorie and Ernie Vital: first, a commemoration written by Paula Bellot, Majorie’s sister and Ernie’s aunt, and secondly, a video commemoration from Majorie’s other son, who did not wish to be named during the commemoration hearings. 32.179 Majorie was born the fourth of nine siblings in Soufrière, Dominica.311 Her parents moved to the United Kingdom when Majorie was seven,312 leaving the children with their grandparents, so Majorie took on a maternal role within the family caring for her younger siblings. Paula recalled how Majorie would comb and braid her hair for her and how she even sewed Paula’s school uniform.313 32.180 Majorie was a quiet but strict person and a good cook. She took on the responsibility of cooking for her whole family when her grandmother was out at work.314 She enjoyed Home Economics lessons at school and often cooked a meal to practise what she had learned that day.315 32.181 Majorie had her first child aged 15 and left school at 16. She was pregnant with her second son when she travelled to London.316 Initially she lived with her parents in North Kensington, before moving to her flat in Grenfell Tower where she lived for the rest of her life.317 She was proud of her home and her family used to tease her about it, calling it “Majorie’s Tower”.318 Majorie worked very hard on behalf of her family; she continued to make clothes throughout her life, using her early talents as a seamstress to her advantage.319 32.182 Ernie lived for his mother, to whom he was very close; his brother said that “Ernie’s umbilical cord was never cut”. The family had many moments of happiness; Majorie’s son could remember walking towards Grenfell Tower at around Christmas one year and seeing the star on top of their Christmas tree through the window from the road.320 308 Commemoration hearing 22 May 2018 [CH2/19/21]. 309 Commemoration hearing 22 May 2018 [CH2/30/6-9]. 310 Commemoration hearing 23 May 2018 [CH3/34/19]. 311 Commemoration hearing 23 May 2018 [CH3/30/18-22]. 312 Commemoration hearing 23 May 2018 [CH3/30/22-25]. 313 Commemoration hearing 23 May 2018 [CH3/30/25-31/1]. 314 Commemoration hearing 23 May 2018 [CH3/31/6-9]. 315 Commemoration hearing 23 May 2018 [CH3/31/9-10]. 316 Commemoration hearing 23 May 2018 [CH3/32/3-6]. 317 Commemoration hearing 23 May 2018 [CH3/32/7-10]. 318 Commemoration hearing 23 May 2018 [CH3/32/10-13]. 319 Commemoration hearing 23 May 2018 [CH3/34/19]. 320 Commemoration hearing 23 May 2018 [CH3/34/19].

Part IV | Chapter 32: Remembering Those Who Died 753 32.183 He remembered spending lots of time watching television with Ernie as children, and described how the band Earth, Wind and Fire reminded him of his brother. Ernie was a lively, engaging and expressive person who loved to dance. When he danced, his brother said, the universe flowed through him.321 Debbie Lamprell (Flat 161) 32.184 Deborah (Debbie) Lamprell lived in Flat 161. She was born on 3 August 1971 in Walthamstow, London and was 45 years old. 32.185 On 22 May 2018, Michael Volpe, of Holland Park Opera, delivered a commemoration on behalf of Debbie’s mother, Miriam Lamprell.322 It included a video recording from a memorial service held at Holland Park Opera, where Debbie worked as a safety officer.323 32.186 Debbie was an only child and grew up in Highams Park.324 Her mother recalled that she was always extremely popular and loved other people’s company.325 The large park opposite their home was the perfect place for Debbie and her friends to play and Debbie would grumble at having to be the first person to go home, just because she lived so close.326 32.187 Debbie’s parents encouraged her to do a variety of things, such as Sunday school, ballet and tap lessons, learning the guitar and taking trips to the theatre.327 However, it was sport that Debbie adored: in particular, she played tennis and snooker and loved watching darts, snooker, drag racing and, as a Spurs fan, football.328 32.188 Debbie lived at home until she was 31.329 Her mother recalled how Debbie had “worshipped” her dad, and that she was his “treasure” in return.330 When her father passed away in 2010 it was difficult for both her and her mother, but the loss brought them closer together.331 They were always in contact and Miriam would often stay with Debbie for up to a week at a time. Debbie would text her mother each night to let her know she was home safely.332 32.189 Debbie was an integral part of the team at Holland Park Opera. She was well-loved by staff, performers and patrons not just because she looked after them, but because she was always interested in them and their lives.333 Holland Park Opera laid a stone at the theatre in Debbie’s memory.334 32.190 Debbie’s kindness touched the lives of many people; her mother believes that she was so positive not because of money or material things, but because she had her freedom, she did what she wanted to do and she loved people.335 321 Commemoration hearing 23 May 2018 [CH3/34/19]. 322 Commemoration hearing 22 May 2018 [CH2/7/22-25]. 323 Commemoration hearing 22 May 2018 [CH2/17/7]. 324 Commemoration hearing 22 May 2018 [CH2/8/5-14]. 325 Commemoration hearing 22 May 2018 [CH2/8/17-18]. 326 Commemoration hearing 22 May 2018 [CH2/9/2-4]. 327 Commemoration hearing 22 May 2018 [CH2/9/25-10/7]. 328 Commemoration hearing 22 May 2018 [CH2/10/8-10]. 329 Commemoration hearing 22 May 2018 [CH2/8/9-10]. 330 Commemoration hearing 22 May 2018 [CH2/10/15-17]. 331 Commemoration hearing 22 May 2018 [CH2/12/12-17]. 332 Commemoration hearing 22 May 2018 [CH2/13/2-3]. 333 Commemoration hearing 22 May 2018 [CH2/14/22-15/2]. 334 Commemoration hearing 22 May 2018 [CH2/15/2-4]. 335 Commemoration hearing 22 May 2018 [CH2/15/24-16/5].

The Grenfell Tower Inquiry: Phase 1 Report 754 Gary Maunders 32.191 Gary Maunders was visiting Debbie Lamprell on 14 June 2017. He was born on 4 January 1960 in London, the eldest of four children. He had lived in North Kensington all his life. He was 57 years old. 32.192 On 23 May 2018, Gary’s former partner, Ana Pumar, and his nieces, Kenita and Channel Spence, presented their commemorations. A commemoration on behalf of his sister, Tammie Maunders, was presented on 30 May 2018.336 32.193 Tammie addressed her brother directly, telling him: “I hope you’re with Dad, still nagging his ear off like you always did.”337 Gary was a great family man. Tammie said that their mum had always supported him and had his back and Tammie herself loved the bond he shared with her own children. She remembered Gary’s funny ways and stories338 and his love of Marvin Gaye.339 32.194 Ana and Gary had two children together.340 She recalled how their early years as a couple were filled with happiness and laughter.341 Gary was a devoted and loving father,342 who considered his children to be his greatest achievement in life.343 He was physically and verbally very affectionate to his children, and they knew how much he loved them as a result.344 Gary was the life and soul of everything he did and everywhere he went.345 He was a devoted Manchester United fan346 with a great sense of humour.347 32.195 Gary’s nieces remembered their uncle as a man with values and a huge character. They spoke of how involved he had been in their lives when they were growing up and the bonds he formed with the next generation of the family. A talented footballer in his youth, Gary became a painter and decorator. He was outgoing and quick-witted. His nieces remembered how they were sometimes on the receiving end of Gary’s jokes. They shared memories of how the entire family would spend Christmas together and the family tradition of sitting around the kitchen table playing cards together. They fondly recalled how Gary took pride in his appearance and never liked to see a crease in his clothing. He would take great care to dress smartly and used to joke, “I’ve still got it, ain’t I?” Similarly, he took great care to keep his home neat and tidy.348 32.196 In their video commemoration, Gary’s nieces interviewed his mother. She and Gary had been very close and spoke every day. Gary’s mother said that he would make sure that everyone around him was always laughing; she felt that “you could never be sad, not when he was around”.349 336 Commemoration hearing 30 May 2018 [CH7/65/2]. 337 Commemoration hearing 30 May 2018 [CH7/65/15-16]. 338 Commemoration hearing 30 May 2018 [CH7/66/5]. 339 Commemoration hearing 30 May 2018 [CH7/66/23]. 340 Commemoration hearing 23 May 2018 [CH3/26/22]. 341 Commemoration hearing 23 May 2018 [CH3/27/1-2]. 342 Commemoration hearing 23 May 2018 [CH3/27/17-18]. 343 Commemoration hearing 23 May 2018 [CH3/27/16-17]. 344 Commemoration hearing 23 May 2018 [CH3/27/20-22]. 345 Commemoration hearing 23 May 2018 [CH3/27/7]. 346 Commemoration hearing 23 May 2018 [CH3/27/4-6]. 347 Commemoration hearing 23 May 2018 [CH3/27/9]. 348 Commemoration hearing 23 May 2018 [CH3/28/17]. 349 Commemoration hearing 23 May 2018 [CH3/28/17].

Part IV | Chapter 32: Remembering Those Who Died 755 7 Floor 18 Berkti and Biruk Haftom (Flat 155) 32.197 Berkti Haftom and her son, Biruk lived in Flat 155 with Berkti’s partner, Michele Chiapetto. He was out on the night of the fire. Berkti’s lodger, Yehualashet Enyew, survived the fire.350 32.198 Berkti was born on 2 November 1987 in Asmara, Eritrea. She was 29 years old. Biruk, was born on 27 April 2005. He was 12 years old. 32.199 A commemoration for Berkti and Biruk was given on behalf of their family on 29 May 2018. Berkti was one of eleven children growing up in Eritrea.351 She was very young when she gave birth to her son Nahome and had to flee Eritrea as a result of the war in 1998.352 Berkti’s mother raised Nahome in Eritrea from the age of two.353 Berkti settled in London, where her son Biruk was born.354 She had a strong work ethic and most recently had worked in catering in the NHS.355 Berkti’s sisters, Negeste, Salam and Asiema also settled in the United Kingdom, where they became once again a close and loving family supporting each other.356 32.200 Berkti remained close to Nahome and spoke to him at least twice a week on the telephone whilst he was growing up. She sent money home to pay for his schooling, and Nahome recalled what a nice voice his mother had.357 After Berkti’s mother died in 2016, she was hoping to bring Nahome to London to live with her, but the plan never came to fruition.358 32.201 Biruk spent most of his life living in Grenfell Tower. He went to the nursery school in Clarendon Walk and to school nearby.359 His aunts, Berkti’s sisters, remember him playing with Lego cars, and how on occasions he would throw them all over the flat where they would all trip over them.360 He was close to all his aunts and would call each of them “mummy”, greeting them with a smile and a hug when they came to pick him up from nursery school.361 32.202 Biruk was described as having empathy for others, wise beyond his years and a very happy and contented little child.362 He often talked of his brother, Nahome, and asked his mother if Nahome could come to live with them.363 His family described him as a promising boy close to his cousins and with lots of friends. Biruk dreamed of being a professional footballer, and he supported Chelsea.364 Biruk’s aunts used to laugh because Biruk was “very British”; he did not like Eritrean food, and instead loved chicken and chips.365 32.203 Berkti was pregnant at the time of the fire.366 Biruk was delighted that his mother was pregnant and was looking forward to having another sibling.367 350 Semre witness statement [IWS00000954] p. 2. 351 Commemoration hearing 29 May 2018 [CH6/56/24]. 352 Commemoration hearing 29 May 2018 [CH6/51/14-16]; [CH6/52/7-9]. 353 Commemoration hearing 29 May 2018 [CH6/52/7]. 354 Commemoration hearing 29 May 2018 [CH6/51/21-22]. 355 Commemoration hearing 29 May 2018 [CH6/59/5-15]. 356 Commemoration hearing 29 May 2018 [CH6/58/6-9]. 357 Commemoration hearing 29 May 2018 [CH6/54/8-11]. 358 Commemoration hearing 29 May 2018 [CH6/52/12-14]. 359 Commemoration hearing 29 May 2018 [CH6/59/1-2]. 360 Commemoration hearing 29 May 2018 [CH6/60/12-17]. 361 Commemoration hearing 29 May 2018 [CH6/60/17-19]. 362 Commemoration hearing 29 May 2018 [CH6/60/22-23]. 363 Commemoration hearing 29 May 2018 [CH6/61/5-7]. 364 Commemoration hearing 29 May 2018 [CH6/51/25]; [CH6/61/16-17]. 365 Commemoration hearing 29 May 2018 [CH6/61/20-21]. 366 Commemoration hearing 29 May 2018 [CH6/56/7]. 367 Commemoration hearing 29 May 2018 [CH6/60/7-8].

The Grenfell Tower Inquiry: Phase 1 Report 756 Hamid Kani (Flat 154) 32.204 Hamid Kani lived in Flat 154. He was born on 24 January 1956 and was 61 years old. 32.205 On 29 May 2018, Masoud Shahabeddin read a commemoration for his cousin Hamid on behalf of their family.368 32.206 Hamid was born and brought up in Tehran, Iran, the youngest of four children. The baby of the family, he was adored by his mother and two older sisters and by all accounts he could wrap them around his little finger.369 32.207 Masoud described his cousin as someone who loved to make people laugh. Hamid was a real extrovert who enjoyed being surrounded by other people. His father was a shopkeeper and Masoud recalled the times when, growing up, he and Hamid would be left in charge of the shop whilst Hamid’s father went out to buy more stock. Somehow, Hamid always tricked Masoud into doing all the work in the shop.370 32.208 The two cousins came to London in the 1970s to study. Once here, Hamid began to explore his love of the arts, acting and music. He went on to have a major role in the 1980s in comedies which were critical satires of the regime in Iran. The videos of these comedies became very popular in Iran and led to Hamid being blacklisted for some time by the Iranian government. He later changed careers, becoming a chef and sharing his love of cooking with customers in restaurants in London for many years.371 32.209 Although London was Hamid’s adopted home,372 he always looked forward to his annual visit to Tehran to see his family, all of whom were very important to him.373 Knowing his love of Iran, Hamid’s family ensured he was buried in his home country.374 32.210 Hamid was a happy and easy-going man. He used to say: “Everything’s going to be all right in the end, and if it’s not all right yet, it’s because it’s not the end”.375 32.211 Masoud Shahabeddin told us that Hamid will always be remembered for his humour, his warmth, his smile, his love of family and his compassion for others.376 Isaac Paulos (Flat 153) 32.212 Isaac Paulos lived in Grenfell Tower with his mother Genet Shawo, his father Paulos Tekle, and his younger brother. He was born on 22 September 2011 at Chelsea and Westminster Hospital, London. He was 5 years old. 368 Commemoration hearing 29 May 2018 [CH6/69/8-10]. 369 Commemoration hearing 29 May 2018 [CH6/69/19-23]. 370 Commemoration hearing 29 May 2018 [CH6/69/23-70/4]. 371 Commemoration hearing 29 May 2018 [CH6/70/13-19]. 372 Commemoration hearing 29 May 2018 [CH6/70/24-25]. 373 Commemoration hearing 29 May 2018 [CH6/71/14-15]. 374 Commemoration hearing 29 May 2018 [CH6/72/3]. 375 Commemoration hearing 29 May 2018 [CH6/71/3-6]. 376 Commemoration hearing 29 May 2018 [CH6/70/4-6].

Part IV | Chapter 32: Remembering Those Who Died 757 32.213 On 29 May 2018, Paulos Tekle377 together with a relative, Nardos,378 delivered a commemoration for Isaac. There was also a video tribute which featured other family members, including Isaac’s mother Genet.379 Isaac’s cousin Helen recited a poem she had written.380 32.214 Paulos explained that, in Amharic, Isaac meant “joy” and “love”. Isaac was his “spitting image” and they were very close.381 Isaac would always be the first person to welcome Paulos through the door when he got home. He would jump into his arms and give him a big hug.382 Teachers commented that Isaac “adored his dad”, and was proud that he spoke the same language as his mother. He referred to Ethiopia as “my country”. Although Genet would say that Isaac was a Chelsea supporter, he was really an Arsenal fan like his father.383 Isaac was also close to his brother, who was only two years younger than him.384 32.215 Isaac was a talented boy385 who loved Taekwondo, swimming, and football. He enjoyed school and would not leave his seat without finishing his homework.386 Teachers recalled that he was especially gifted at maths and reading. He was the child who stood out in his year group, not only because of his intellectual capacity, but also his emotional maturity that could have taken him far in life.387 32.216 Isaac was very popular and loved spending time with his friends.388 Nardos remembered how, when visiting her family, Isaac never wanted to leave their house. Isaac and her brother would always come up with plans to trick their parents into letting Isaac stay longer.389 He used to make everyone laugh. 32.217 Judith Rashed, Isaac’s teacher, read from Isaac’s work: “I like to play outside and with the capes ... and I know how to go on the tunnel and the climbing frame… My favourite toys are cars.” With his friends, Isaac enjoyed playing “It”, football, and “Duck, Duck, Goose”. He was either going to be Professor Isaac or a footballer. His parents and teachers reflected that, either way, Isaac had a bright future ahead of him. He was very special.390 Sakina Afrasehabi and Fatemeh Afrasiabi (Flat 151) 32.218 Sakina Afrasehabi was born on 4 April 1952 in Iran. She was 65 years old. She lived in Flat 151 in Grenfell Tower.391 Her sister, Fatemeh Afrasiabi, was born on 15 November 1957 in Iran. She was 59 years old. Fatemeh was staying with her sister on the night of 13 June 2017. 32.219 Sakina’s children gave commemorations for their mother on 29 May 2018 and 30 May 2018. On that day there was also a video commemoration for Fatemeh featuring her friends and family presented by her son, Mohammad Samimi. 377 Commemoration hearing 29 May 2018 [CH6/40/18]. 378 Commemoration hearing 29 May 2018 [CH6/45/11]. 379 Commemoration hearing 29 May 2018 [CH6/48/8]. 380 Commemoration hearing 29 May 2018 [CH6/47/2-48/5]. 381 Commemoration hearing 29 May 2018 [CH6/40/21-24]. 382 Commemoration hearing 29 May 2018 [CH6/48/8]. 383 Commemoration hearing 29 May 2018 [CH6/48/8]. 384 Commemoration hearing 29 May 2018 [CH6/40/24-25]. 385 Commemoration hearing 29 May 2018 [CH6/45/2]. 386 Commemoration hearing 29 May 2018 [CH6/45/21-24]. 387 Commemoration hearing 29 May 2018 [CH6/48/8]. 388 Commemoration hearing 29 May 2018 [CH6/48/8]. 389 Commemoration hearing 29 May 2018 [CH6/46/2-5]. 390 Commemoration hearing 29 May 2018 [CH6/48/8]. 391 Mona Aghlani witness statement [IWS00000774] p. 1.

The Grenfell Tower Inquiry: Phase 1 Report 758 32.220 Nazanin Aghlani recalled that her mother, Sakina, had a happy childhood in Iran. One of six children, she was a bit of a tomboy with a mischievous sense of humour. As an adult she was able to travel in Europe.392 Both Sakina and Fatemeh lived through the revolution and Iran‑Iraq war in Iran, times where they faced bombings. Ultimately the family fled to Shiraz, a rural area of Iran, where they settled for some time and both sisters had children.393 32.221 Fatemeh’s children spoke of the challenges the family faced in Shiraz. They were displaced and when their father found it difficult to find work, their hardworking mother would sometimes support the whole family from her income as a tailoress.394 32.222 Fatemeh loved her children very much and would do anything for them. Her daughter Masoumeh remembered her mother buying her a doll as a present when she was a little girl. She would sleep with the doll next to her because it made her remember the smile her mother wore when she gave it to her.395 32.223 Sakina moved to the United Kingdom in 1997 and saw it as a new beginning.396 Her children recalled that as well as being kind and softly spoken,397 she was a very charitable person who gave to those in need.398 On one occasion, Sakina was visiting a friend’s neighbour on a visit to Iran, when she noticed the family did not have a working fridge. She purchased one for them as well as several other household goods.399 32.224 Sakina was an excellent cook, and her daughter, Nazanin, spoke of her many “secret recipes”.400 Nazanin and her sister Mona especially enjoyed their mother’s fish stew, an Iranian delicacy. Sakina also cooked for her neighbours in Grenfell Tower, and she soon became very popular.401 Her daughter, Shiva, described her as “everyone’s grandma”.402 Nazanin recalled that initially their mother was not pleased to be living in Grenfell Tower, but after redecorating her flat and settling in, she came to enjoy the height of the building, even purchasing binoculars so that everyone could enjoy the view.403 32.225 Shiva described how close Sakina was to her sister, Fatemeh, who had also moved to the United Kingdom. The two sisters were always together. Sakina had even bought a special seat which she had placed in front of her large windows so that they could sit together, chatting, enjoying snacks and looking out across London. Her mother described it as being better than any TV show.404 32.226 Fatemeh loved creativity and the arts; she was an excellent painter, but also used to make decorative flowers and dolls. Fatemeh’s daughter, Raheleh, recalled many happy hours spent making things with her mother in the evenings. Fatemeh encouraged her grandchildren to be expressive and creative. Her granddaughters would draw designs for new Barbie Doll outfits, which Fatemeh would then make for them. Fatemeh’s daughter, Sara, said that her mother had a beautiful voice and used to sing at home whilst doing the chores.405 392 Commemoration hearing 30 May 2018 [CH7/39/5-13]. 393 Commemoration hearing 30 May 2018 [CH7/39/16-21]. 394 Commemoration hearing 30 May 2018 [CH7/53/12]. 395 Commemoration hearing 30 May 2018 [CH7/53/12]. 396 Commemoration hearing 30 May 2018 [CH7/40/2-5]. 397 Commemoration hearing 29 May 2018 [CH6/66/5]. 398 Commemoration hearing 30 May 2018 [CH7/45/2-4]. 399 Commemoration hearing 30 May 2018 [CH7/45/4-11]. 400 Commemoration hearing 30 May 2018 [CH7/44/4-5]. 401 Commemoration hearing 30 May 2018 [CH7/44/7-13]. 402 Commemoration hearing 29 May 2018 [CH6/66/23/17-24]. 403 Commemoration hearing 30 May 2018 [CH7/42/12-43/23]. 404 Commemoration hearing 29 May 2018 [CH6/65/17-23]. 405 Commemoration hearing 30 May 2018 [CH7/53/12].

Part IV | Chapter 32: Remembering Those Who Died 759 32.227 Sakina and Fatemeh had a large and loving family who spoke fondly of their memories of them both. 8 Floor 17 Vincent Chiejina (Flat 144) 32.228 Vincent Chiejina lived in Flat 144. He was born on 1 June 1957 in Nigeria and was 60 years old. A video commemoration prepared by his sister, Obi Chiejina, was shown on 25 May 2018. 32.229 Vincent spent his early years in Nigeria before travelling to the United Kingdom with his mother Mary and his sister Maria.406 32.230 As a teenager he enjoyed science fiction and was an avid fan of Star Trek, making sure to watch it every Saturday. At school in Ramsgate, he excelled at mathematics and went on to study Electrical and Electronic Engineering at Sheffield University in the 1970s.407 32.231 Obi spoke of Vincent’s kind nature, remembering that when she broke her leg as a child he went out and bought her a big bar of chocolate, but unfortunately of the wrong kind! He used to look after his sisters when their mother had to work as a nurse at night. He made them brush their teeth and tucked them in nicely.408 32.232 These acts of kindness permeated all aspects of Vincent’s life. He was someone who was good at looking after people who were vulnerable. He would never reject anyone and was adept at spotting ways in which others needed support, quietly making them feel good about themselves. Vincent was a member of the 50+ Open Age group in North Kensington and was particularly good at making new members feel welcome. When any new person came into the room, wherever he was Vincent would stand up and offer his chair to them to ensure they felt included.409 32.233 Because of, and in spite of, his own vulnerabilities, Vincent was “ahead of the curve”; he made sure he guided other people to their paths. For that, his family thanked him.410 Khadija Khalloufi (Flat 143) 32.234 Khadija Khalloufi lived in Grenfell Tower with her husband Sabah Abdullah. She was born on 6 September 1964 and was 52 years old. 32.235 On 25 May 2018, Sabah Abdullah introduced a video commemoration that he had prepared for his wife. On 30 May 2018, a commemoration was read on behalf of her brother, Karim Khalloufi.411 32.236 Khadija was the eldest of seven siblings and grew up in Mohammedia in Morocco.412 Her younger siblings thought of Khadija as a second mother because of her big heart and impressive sense of responsibility.413 After finishing her schooling she obtained a degree in 406 Commemoration hearing 25 May 2018 [CH5/4/15]. 407 Commemoration hearing 25 May 2018 [CH5/4/15]. 408 Commemoration hearing 25 May 2018 [CH5/4/15]. 409 Commemoration hearing 25 May 2018 [CH5/4/15]. 410 Commemoration hearing 25 May 2018 [CH5/4/15]. 411 Commemoration hearing 30 May 2018 [CH7/55/6]. 412 Commemoration hearing 30 May 2018 [CH7/55/20-21]. 413 Commemoration hearing 30 May 2018 [CH7/56/6-9].

The Grenfell Tower Inquiry: Phase 1 Report 760 accountancy and commerce in Casablanca before taking a job as manager of a pharmacy in Mohammedia.414 32.237 Khadija had ambitions to travel and work abroad and after several years moved to live with her uncle in Holland, before settling in London.415 She found her first few years in the United Kingdom a challenge, not least because of the language barrier.416 It was at a centre which assisted immigrants to integrate into society by offering them studies in English that Khadija met her future husband, Sabah Abdullah, who was originally from Iraq.417 32.238 Sabah fondly remembered how Khadija would look after everyone. His two children thought of her as their own mother; to them, he said, she was more than an angel. Khadija also supported Sabah’s mother when she was unwell, often cooking and caring for her. He shared video footage showing Khadija painting their home in Grenfell Tower. Khadija would not let Sabah do it, because she thought he was too clumsy.418 32.239 Khadija and Sabah travelled regularly to see her family and friends across Europe.419 She made sure she visited her family in Morocco two or three times a year.420 Her brother Karim recalled that, despite being a strong, independent woman, Khadija never ceased to help her family emotionally or financially, and worked hard to support them in whatever way she could.421 Sabah described Khadija as someone who would make everyone around her feel comfortable and who loved to make others laugh. She was a unique person.422 Kamru Miah, Rabeya Begum, Mohammed Hamid, Mohammed Hanif and Husna Begum (Flat 142) 32.240 Kamru Miah, Rabeya Begum, Mohammed Hamid, Mohammed Hanif and Husna Begum lived in Flat 142. Kamru and Rabeya’s oldest son, Mohammed Hakim, lived nearby in London, but his wife Farhana lived with his family in Flat 142. She was not present on the night of the fire.423 32.241 Kamru Miah was born on 12 August 1937 in Sylhet, Bangladesh. He was 79 years old. He moved to the United Kingdom in 1963. Kamru was a retired baker and Tandoori chef.424 Rabeya Begum was born on 15 November 1952 in Bangladesh. She was 64 years old. She came to London after marrying Kamru and was a housewife raising the couple’s four children.425 32.242 Mohammed Hamid, born on 19 January 1989, was 28 years old. Mohammed Hanif, born on 20 February 1991, was 26 years old. Husna Begum, born on 4 February 1995, was 22 years old. 32.243 On 24 May 2018, Mohammed Hakim gave a commemoration for his parents and three siblings. He explained that his father had moved from Bangladesh to London in 1963 in the hope of a better life.426 There was nothing more important to Kamru than his family and his 414 Commemoration hearing 30 May 2018 [CH7/56/17-23]. 415 Commemoration hearing 30 May 2018 [CH7/57/5-16]. 416 Commemoration hearing 30 May 2018 [CH7/57/17-20]. 417 Commemoration hearing 25 May 2018 [CH5/52/1]. 418 Commemoration hearing 25 May 2018 [CH5/52/1]. 419 Commemoration hearing 25 May 2018 [CH5/52/1]. 420 Commemoration hearing 30 May 2018 [CH7/59/21-25]. 421 Commemoration hearing 30 May 2018 [CH7/60/14-18]. 422 Commemoration hearing 25 May 2018 [CH5/52/1]. 423 Hakim first witness statement [IWS00000019] pp. 1-3. 424 Commemoration hearing 24 May 2018 [CH4/20/7-11]. 425 Commemoration hearing 24 May 2018 [CH4/23/7-9]. 426 Commemoration hearing 24 May 2018 [CH4/20/7-10].

Part IV | Chapter 32: Remembering Those Who Died 761 religion.427 He gave his children the best of everything and liked to take them to parks around Chelsea and the neighbouring area while they were growing up. On those trips he would always buy his children more ice cream than they could eat.428 32.244 Kamru was someone with a heart of gold who made everyone his friend. He had a gentle and sweet nature, was well-respected by his family and in his community, and would always help anyone in need.429 He especially loved both nature programmes and action movies; James Bond films were a particular favourite, especially those featuring Sean Connery or Roger Moore.430 32.245 Hakim recalled how his father was not only good to his children, but also to his wife, Rabeya,431 who in turn was loyal and loving to Kamru, not leaving his side when he fell ill.432 32.246 Hakim described Rabeya as a generous, caring and loving mother.433 She was the person the children would run to after a fall and who would “kiss everything better” and “scare away the monsters from under our bed with a giggle”. Hakim and his siblings always felt safe with Rabeya.434 As adults they would go to her for advice and wisdom and she was always able to give them individual attention and care.435 32.247 Rabeya was also a fantastic cook, who would add her magic touch to each dish she created. Hakim’s favourite was lamb curry and he told us that his mum would make it the best. She filled the flat with her laughter and jokes, and had a beaming smile that could put anyone at their ease.436 32.248 Speaking of his brother Hamid, Hakim recalled favourite moments from their childhood, from looking for ants and building them fortresses with moss and sticks to riding in their cousin’s car together as teenagers. Hamid had a fun-loving personality and was a fascinating person to talk to.437 32.249 Hamid was his mother’s friend and his father’s guardian angel. He cared for Kamru following his strokes438 and always took the time to make sure his mother was OK and to laugh with her. He cared deeply for all his family; his brothers were his best friends, and his sister Husna was his buddy. He could make them all laugh for hours.439 Hamid was a loyal friend with a lion heart. To Hakim, it sometimes felt like Hamid was the older brother because of the wise advice he offered.440 32.250 Hakim also told us how he benefited from the friendly advice of his younger brother, Hanif.441 Hanif had a gentle and kind approach to those around him and like his mother he quickly 427 Commemoration hearing 24 May 2018 [CH4/21/5-7]. 428 Commemoration hearing 24 May 2018 [CH4/21/13-18]. 429 Commemoration hearing 24 May 2018 [CH4/22/2-12]. 430 Commemoration hearing 24 May 2018 [CH4/21/19-22/1]. 431 Commemoration hearing 24 May 2018 [CH4/21/5]. 432 Commemoration hearing 24 May 2018 [CH4/24/6-8]. 433 Commemoration hearing 24 May 2018 [CH4/23/10-11]. 434 Commemoration hearing 24 May 2018 [CH4/23/13-18]. 435 Commemoration hearing 24 May 2018 [CH4/23/18-19]. 436 Commemoration hearing 24 May 2018 [CH4/23/21-24/4]. 437 Commemoration hearing 24 May 2018 [CH4/24/21-25/2]. 438 Commemoration hearing 24 May 2018 [CH4/25/3-9]. 439 Commemoration hearing 24 May 2018 [CH4/25/11-15]. 440 Commemoration hearing 24 May 2018 [CH4/25/17-23]. 441 Commemoration hearing 24 May 2018 [CH4/26/14-16].

The Grenfell Tower Inquiry: Phase 1 Report 762 made others feel comfortable and at their ease.442 Hanif was passionately committed to his faith and to God, which shone through in his commitment to helping others in need.443 32.251 Hanif was also very creative: he had a talent for drawing and particularly loved animation. He often spent time making beautiful images for his family. Not only did he love creating his own animations, he enjoyed watching Marvel and sci-fi films. He also enjoyed playing PlayStation, sometimes with his brothers.444 32.252 Husna was the youngest of the siblings. Hakim recalled bringing her home from the hospital after she was born and holding her in his arms; he was full of joy at having a baby sister.445 He described Husna as the epitome of adventure and spirit; one of her ambitions was to travel and see the world.446 She learned about the world around her through studying history, but also enjoyed creative writing.447 She had a cheeky sense of humour, just like her parents and brothers.448 32.253 Husna was a thoughtful friend and sister, never forgetting an anniversary or birthday.449 Like her mother she was an excellent cook. She could always get a new recipe right first time and if anyone ever ate her food, they would always ask for more.450 Hakim said that Husna was the best sister anyone could ask for.451 32.254 Hakim ended his commemoration by explaining how proud he is that his family remained so close in their final moments: his siblings stood by his elderly parents, rather than attempting to escape themselves. His family were the bravest amongst everyone he knows.452 9 Floor 16 Joseph Daniels (Flat 135) 32.255 Joseph Daniels moved into Flat 135 with his family in 1983. He was born on 10 February 1948 and was 69 years old. In June 2017, Joseph Daniels shared Flat 135 with his son Samuel who was his carer.453 32.256 Samuel Daniels gave a short commemoration for his father on 21 May 2018. He said that Grenfell Tower had been his father’s only home since he moved to London in 1982.454 Sheila (Flat 132) 32.257 Sheila lived alone in Flat 132 on floor 16 of Grenfell Tower. She was born on 17 September 1932 and was 84 years old. 32.258 Sheila’s family did not wish to give a commemoration in May 2018. 442 Commemoration hearing 24 May 2018 [CH4/26/11-16]. 443 Commemoration hearing 24 May 2018 [CH4/26/17-18]. 444 Commemoration hearing 24 May 2018 [CH4/26/19-25]. 445 Commemoration hearing 24 May 2018 [CH4/27/21-25]. 446 Commemoration hearing 24 May 2018 [CH4/27/9-11]. 447 Commemoration hearing 24 May 2018 [CH4/27/12-13]. 448 Commemoration hearing 24 May 2018 [CH4/27/19-21]. 449 Commemoration hearing 24 May 2018 [CH4/27/18-19]. 450 Commemoration hearing 24 May 2018 [CH4/27/13-17]. 451 Commemoration hearing 24 May 2018 [CH4/28/1-2]. 452 Commemoration hearing 24 May 2018 [CH4/28/9-21]. 453 Daniels first witness statement [IWS00000608] pp. 1-5. 454 Commemoration hearing 21 May 2018 [CH1/49/14-15].

Part IV | Chapter 32: Remembering Those Who Died 763 10 Floor 15 Steven Power (Flat 122) 32.259 Steven Power lived in Flat 122 on floor 15 with his children, Bobby and Rebecca, and their three dogs, Stevie, Diva and Jess.455 Known as Steve, he was born on 18 August 1953 in London.456 He was 63 years old. 32.260 On 25 May 2018, Steve’s former partner, Claudia Davis, and his daughter, Sherrie Power, gave a commemoration on behalf of his family.457 32.261 Steve’s family originated from Waterford in Ireland.458 However, he grew up in Ladbroke Grove and by June 2017 had lived in Grenfell Tower for 32 years.459 He was a retired driver and a keen DJ.460 He had five children: Wayne Power-Davis, Craig Power, Sherrie Power, Bobby Ross and Rebecca Ross.461 32.262 Steve’s love of music was a dominant factor in his life. His daughter Sherrie remembered how friends and family would often come round to listen to music, eat good food and enjoy themselves.462 Steve exposed his children to a wide variety of music. When DJ’ing he would shout things such as “rewind” and “Rastafari”, which led his children to tell him he was a West Indian man trapped in an Irishman’s body.463 32.263 Steve also loved to fish. He would fish along the canal in Ladbroke Grove and always took his radio and a flask of Tetleys with him, because he believed that that was the only tea anyone should drink. He loved to tell stories of the fish he had caught and his front room was filled with photographs of his catches over the years.464 32.264 Steve enjoyed playing jokes. Sherrie recalled how he particularly loved winding up his friend JJ with her.465 Despite his pranks, Steve was a genuine man with a good heart.466 In addition to his children, Steve considered his dogs to be part of the family. He was given Diva by a friend because her previous owners had not treated her properly. Steve took it upon himself to look after Diva. As a result of his care all three dogs were extremely friendly and liked to socialise with people. He even became known locally as “the man with the dogs”.467 32.265 Sherrie described her father as “just high on life” and nothing short of a character: someone about whom everyone always had a story to tell.468 She said that Steve was like Marmite; he was outspoken and direct and would fight for his family and what he believed was right.469 Sherrie had no doubt that, if Steve were here, he would be chairman of Grenfell United: “He was a man of the people, especially for the neighbours and residents of Grenfell.”470 455 Ross witness statement [IWS00001036] p. 5. 456 Commemoration hearing 25 May 2018 [CH5/106/19]. 457 Commemoration hearing 25 May 2018 [CH5/104/20-24]. 458 Commemoration hearing 25 May 2018 [CH5/106/19-22]. 459 Commemoration hearing 25 May 2018 [CH5/111/16-18]. 460 Commemoration hearing 25 May 2018 [CH5/107/3-8]. 461 Commemoration hearing 25 May 2018 [CH5/104/20-24]. 462 Commemoration hearing 25 May 2018 [CH5/107/9-13]. 463 Commemoration hearing 25 May 2018 [CH5/107/17-24]. 464 Commemoration hearing 25 May 2018 [CH5/110/9-23]. 465 Commemoration hearing 25 May 2018 [CH5/108/9-12]. 466 Commemoration hearing 25 May 2018 [CH5/112/2-3]. 467 Commemoration hearing 25 May 2018 [CH5/109/11-22]. 468 Commemoration hearing 25 May 2018 [CH5/108/9]; [CH5/109/24-110/2]. 469 Commemoration hearing 25 May 2018 [CH5/108/17-109/10]; [CH5/112/1-2]. 470 Commemoration hearing 25 May 2018 [CH5/111/22-112/10].

The Grenfell Tower Inquiry: Phase 1 Report 764 11 Floor 14 Zainab Deen and Jeremiah Deen (Flat 115) 32.266 Zainab Deen lived in Flat 115 with her son, Jeremiah. She was born on 25 May 1985 in Sierra Leone.471 She was 32 years old. Jeremiah was born on 4 December 2014 at Chelsea and Westminster Hospital, London.472 32.267 On 23 May 2018 a commemoration for Zainab and Jeremiah was read on behalf of Zainab’s parents, Zainu and Hannah.473 32.268 Zainab grew up in Freetown, the capital of Sierra Leone; her ambitions were to travel abroad and to become a pop star.474 She achieved the former after she finished school and moved to the United Kingdom aged 16.475 32.269 The family described how Zainab “had it all”: she had a lively personality and a great sense of humour, enjoyed by all who met her. She was a smart, warm, outgoing and caring person. Zainab came from a loving family, in which she had a special place as her grandparents’ first grandchild.476 32.270 In a message to his daughter, Zainu told her that he was so proud to be able to call her his daughter and that the family were grateful for the brief time they had had with her.477 32.271 Zainab’s son, Jeremiah, was two and a half years old at the time of the fire. He attended Clare Garden Nursery and was loved by all.478 The family recalled how he was overprotected by his mother, who treasured and adored him.479 32.272 Jeremiah loved to explore and go on adventures and enjoyed playing football. He was a very loving and handsome little boy, who was full of life and brought his family much happiness.480 32.273 Zainab and Jeremiah’s family said how glad they are that Zainab and Jeremiah are together and that they are sure Zainab will continue to keep Jeremiah safe, just as she protected him in life.481 Mohammad Alhajali (Flat 112) 32.274 Mohammad Alhajali lived in Flat 112 with his brother, Omar Alhaj Ali, and their childhood friend, Mahmoud Al-Karad.482 32.275 Mohammad was born on 27 November 1993 in Damascus, Syria. He was 23 years old. In June 2017 he was working while also studying engineering at university.483 471 Commemoration hearing 23 May 2018 [CH3/18/23]. 472 Commemoration hearing 23 May 2018 [CH3/19/20-22]. 473 Commemoration hearing 23 May 2018 [CH3/17/19-18/7]. 474 Commemoration hearing 23 May 2018 [CH3/18/24-19/2]. 475 Commemoration hearing 23 May 2018 [CH3/19/2-3]. 476 Commemoration hearing 23 May 2018 [CH3/19/3-11]. 477 Commemoration hearing 23 May 2018 [CH3/19/12-18]. 478 Commemoration hearing 23 May 2018 [CH3/19/19-25]. 479 Commemoration hearing 23 May 2018 [CH3/19/25-20/1]. 480 Commemoration hearing 23 May 2018 [CH3/20/1-9]. 481 Commemoration hearing 23 May 2018 [CH3/20/9-14]. 482 Al-Karad witness statement [IWS00000821] p. 1; Alhaj Ali witness statement [IWS00000781] p. 1. 483 Commemoration hearing 29 May 2018 [CH6/75/17-19].

Part IV | Chapter 32: Remembering Those Who Died 765 32.276 On 29 May 2018, Mohammad’s brother Hashem Alhajali,484 his friend Mahmoud Al-Karad485 and Mohammad’s father, Nidal Alhajali,486 gave a commemoration on behalf of Mohammad’s entire family. 32.277 Mohammad grew up in Daraa, a small city in the south of Syria. He was the second eldest of five children. He had two brothers, Omar and Hashem, and two sisters, Kenda and Sham.487 Mohammad’s father, Nidal, remembered how, even from a young age, Mohammad would naturally think of others. When he received his pocket money, he would buy four lollipops and give one to each of his siblings, rather than having any himself.488 32.278 Mohammad’s brother, Hashem, spoke of how Mohammad always loved to be grown up. Even as a child he would want to wear suits to be like their father. Sometimes he would even put his father’s suit on, despite it being far too big for him.489 32.279 Mohammad left Syria with his brother Omar and arrived in the UK in 2014.490 Omar explained that he and Mohammad were only a year apart in age and had one of those rare relationships where they could share absolutely everything.491 Mohammad was close to his other family members as well. He spoke to his family in Syria every day, telling his sisters that he loved London, but that it was very cold compared to Syria.492 32.280 Mahmoud described Mohammad as good-natured, ambitious and a perfectionist. He hoped to become an engineer and build a life for his family in the United Kingdom.493 32.281 To that end he was engaged to be married to Amal Al Huthaifi, whom he had met at work. Amal recalled how Mohammad and his huge smile had made her look forward to going to work and how he had a real presence in any room he entered. Mohammad always supported and encouraged her. Even now, if she feels she cannot accomplish something, she thinks of Mohammad and knows that he would tell her she can do anything she wants.494 32.282 Mohammad’s family’s tribute to him painted a picture of a sociable, fun-loving and thoughtful person who was a big part of each of their lives. His mother, Heam, said of her son: “He was distinguished in every way… his smile never leaves me.”495 Denis Murphy (Flat 111) 32.283 Denis Murphy lived alone in Flat 111. He was born on 10 October 1960 at Queen Charlotte’s Hospital in Hammersmith. He was 56 years old. 32.284 On 21 May 2018, Denis’s sister, Anne Murphy, gave a commemoration on behalf of his family.496 32.285 Denis’s mother was also called Anne. He was the eldest of her four children. As well as his sister, Denis had two brothers, Mick and Tim. 484 Commemoration hearing 29 May 2018 [CH6/73/2274/1]. 485 Commemoration hearing 29 May 2018 [CH6/75/2-3]. 486 Commemoration hearing 29 May 2018 [CH6/77/9-10]. 487 Commemoration hearing 29 May 2018 [CH6/77/17-78/2]. 488 Commemoration hearing 29 May 2018 [CH6/78/8-13]. 489 Commemoration hearing 29 May 2018 [CH6/74/22]. 490 Alhaj Ali witness statement [IWS00000781] p. 1. 491 Commemoration hearing 29 May 2018 [CH6/74/22]. 492 Commemoration hearing 29 May 2018 [CH6/74/22]. 493 Commemoration hearing 29 May 2018 [CH6/75/14-22]. 494 Commemoration hearing 29 May 2018 [CH6/74/22]. 495 Commemoration hearing 29 May 2018 [CH6/74/22]. 496 Commemoration hearing 21 May 2018 [CH1/22/14-29/9].

The Grenfell Tower Inquiry: Phase 1 Report 766 32.286 The family lived in North Kensington until 1968. They then moved to Dorking and subsequently Gravesend. The family returned to West London in 1977.497 At school, Denis excelled in history and maths, but his true passion was for sports, in particular football, cross-country and distance running. He ran for his school and district and won many medals and trophies.498 32.287 Anne recounted how Denis’s running skills came in handy outside school too. Once, when Denis was just 10, his brother Mick lost his bus fare. Denis gave Mick his bus money and then ran the five mile journey home.499 To his siblings, Denis was a caring big brother. As their father was not in their lives, Denis took on additional responsibility in the family. He had had a very strong set of values, which he not only adhered to himself, but instilled in his siblings, including good manners, respect for others, to help and care for others and to love each other. Anne felt that Denis had nurtured and taught his siblings to become the adults they are today.500 32.288 Denis had left school by the time the family moved back to West London. He had trials with Crystal Palace and Charlton Athletic football clubs but did not become a professional footballer. He worked as a painter and decorator until his health forced him to retire.501 32.289 Aged 22, Denis met his future wife, Tracey and in 1984 they moved into Grenfell Tower. Their only child, Peter, was born in 1989. The family lived in Mitcham and Tooting while Peter was young. After Denis and Tracey amicably separated, he moved back to Grenfell Tower in 1997, where he remained for the next 20 years.502 32.290 Denis was extremely close to his family; he would talk to or visit his mother daily and he would speak to his son and his siblings at least once a week. His sister Anne recalled how he would always end his calls to her with “Love you, sis”.503 32.291 Denis’s keen interest in sports continued into adulthood. He played Sunday League football into his thirties and though health problems stopped him playing sport in later life,504 he continued to help out at his local boxing club.505 Denis was an avid Chelsea supporter and even travelled to Europe several times to see them play. He had many light-hearted debates with his son Peter about their respective clubs and he always took great delight in Chelsea beating Peter’s team, Tottenham.506 32.292 Many people around Denis benefited from his caring nature. Not only was he considered the “heart” of the Murphy family,507 always putting others first and regularly carrying out errands for his elderly mother who lived nearby,508 but he also carried out voluntary work within the local community. He worked with adults with learning disabilities, supporting them to take part in activities in the community.509 To his family Denis was their hero; there was no better role model.510 497 Commemoration hearing 21 May 2018 [CH1/22/24-24/5]. 498 Commemoration hearing 21 May 2018 [CH1/23/3-13]. 499 Commemoration hearing 21 May 2018 [CH1/23/14-18]. 500 Commemoration hearing 21 May 2018 [CH1/23/19-24/2]. 501 Commemoration hearing 21 May 2018 [CH1/24/3-14]. 502 Commemoration hearing 21 May 2018 [CH1/24/20-25/7]. 503 Commemoration hearing 21 May 2018 [CH1/27/11-18]. 504 Commemoration hearing 21 May 2018 [CH1/24/11-14]. 505 Commemoration hearing 21 May 2018 [CH1/27/3-5]. 506 Commemoration hearing 21 May 2018 [CH1/26/19-27/2]. 507 Commemoration hearing 21 May 2018 [CH1/25/16]. 508 Commemoration hearing 21 May 2018 [CH1/27/7-10]. 509 Commemoration hearing 21 May 2018 [CH1/24/15-19]. 510 Commemoration hearing 21 May 2018 [CH1/28/7-9].

Part IV | Chapter 32: Remembering Those Who Died 767 12 Floor 11 Ali Yawar Jafari (Flat 86) 32.293 Ali Yawar Jafari moved into Flat 86 with his wife Fatima, and daughters Maria and Nadia Jafari in 2003. 32.294 He was born on 1 January 1936 in Kandahar, Afghanistan and was 81 years old. The family built a happy life in London and Ali enjoyed living here.511 32.295 On 23 May 2018, Fatima and her children shared their memories of Ali Yawar in a video commemoration.512 His daughter, Maria, and son, Hamid, also spoke of the impact of the loss of their father.513 32.296 Fatima said Ali Yawar was the “love of my life”. Nadia, Maria and Hamid described their father as a calm and gentle man. Maria, in particular, remembered that he would never refuse his children anything when they were growing up. He was happiest when his family were together. Mealtimes were a big part of family life and were often filled with laughter.514 32.297 Ali Yawar loved travelling; he visited Iran and Germany and took a holiday in America with his son Hamid in 2012. Together with his wife Fatima he was able to make the Hajj pilgrimage to Mecca. Fatima recalled how, the day after the fire, she met a couple who told her that Ali had brought their son, who had had cancer at the time, some holy water and dates from that trip. They told her they had always remembered his kindness.515 32.298 Ali Yawar was also fond of animals and gardening. Fatima remembered one occasion where he saw a pigeon with string tied around its legs. He waited for days to catch it and cut the string off. He told his family that he was pleased the pigeon was now free to go wherever it wanted.516 32.299 Ali Yawar was someone who could communicate with everyone, despite language barriers, because of his kindness and generosity towards others. He would always put others before himself. He had a particularly close bond with his grandson and Hamid told us that, when he holds his son now, he thinks of his father.517 32.300 The family are proud of Ali Yawar’s desire to wake and warn his neighbours on the night of the fire and Hamid explained that they are glad that every year people around the world will remember him and know that he was a good person.518 Abdeslam Sebbar (Flat 81) 32.301 Abdeslam Sebbar lived alone in Flat 81 Grenfell Tower. He was born on 11 September 1939 and was 77 years old. 32.302 His family did not wish to give a commemoration for him in May 2018. 511 Commemoration hearing 23 May 2018 [CH3/22/25]. 512 Commemoration hearing 23 May 2018 [CH3/22/25]. 513 Commemoration hearing 23 May 2018 [CH3/22/10-24/20]. 514 Commemoration hearing 23 May 2018 [CH3/22/25]. 515 Commemoration hearing 23 May 2018 [CH3/22/25]. 516 Commemoration hearing 23 May 2018 [CH3/22/25]. 517 Commemoration hearing 23 May 2018 [CH3/22/25]. 518 Commemoration hearing 23 May 2018 [CH3/22/25].

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771 Chapter 33 Recommendations 1 Introduction 33.1 Phase 1 of the Inquiry has been concerned with investigating the cause of the fire, its subsequent development and the steps taken by the LFB and the other emergency services in response to it. In the course of it I have touched on the training given to the firefighters and CROs in relation to responding to fires in high-rise buildings and other incidents of a kind that may generate a significant number of calls from people seeking advice and assistance. Phase 2 will involve a more detailed examination of certain aspects of the management of the LFB (in particular its understanding of modern methods of construction and of the way in which some of the materials currently in use behave when exposed to fire) and the steps that were taken to train its officers to respond to fires in high-rise buildings. However, the evidence put before me in Phase 1 is already sufficient to demonstrate that a number of improvements can be made both in the way in which high-rise residential buildings are designed, constructed, approved and managed and in the way in which fire and rescue services respond to fires in such buildings. 33.2 The core participants and the experts who gave evidence in Phase 1 have suggested many steps which in their view can and should be taken to improve the safety of those who live in high-rise buildings and should therefore form the subject of immediate recommendations. However, they exhibited a wide divergence of views. It is important that any recommendations I make at this, or indeed any other, stage should be based firmly on the facts that have emerged from the evidence obtained by the Inquiry in the course of its investigations. I also think it important that they command the support of those who have experience of the matters to which they relate. Recommendations that are not grounded in the facts are of no value and recommendations that do not command the support of those who are experts in the field are likely to be ignored and, if not ignored, risk giving rise to adverse unintended consequences. 33.3 The recommendations set out below are therefore based entirely on the evidence I have heard in relation to the particular issues that were investigated in Phase 1 and on the findings and conclusions I have been able to reach in this report. They do not attempt to anticipate the evidence to be called in Phase 2 or the conclusions that may be drawn from it, and when deciding what recommendations should be made at this stage I have had regard in particular to their capacity for making a significant contribution to the safety of those who live in high- rise buildings. I am grateful to those of the core participants who made submissions on this subject, all of which I have considered carefully before making my recommendations. I refer to some of them in more detail in later paragraphs. 33.4 In England and Wales, high-rise buildings have conventionally been defined for the purposes of fire safety as buildings over 18 metres in height. In Scotland, however, the regulations have recently been changed so that the requirements relating to high-rise buildings apply to buildings over 11 metres in height. It is for consideration whether the position in England should now also be changed and, if so, what height should be adopted for that purpose. However, that question was not the subject of examination in Phase 1 and it is therefore not possible for me to make a recommendation about it at this stage. It is, however, a matter which will be examined in Phase 2.

The Grenfell Tower Inquiry: Phase 1 Report 772 33.5 When considering steps that might be taken to improve safety in relation to high-rise buildings generally it is important not to lose sight of certain matters. The first is that, although not unprecedented, fires of the kind that occurred at Grenfell Tower are rare. The widespread use of combustible rainscreen cladding panels and insulation on the exterior of buildings and the introduction of new kinds of building materials in external walls may have increased the risk of similar fires, but improvements in the regulations relating to fire safety and the requirements for testing and certification of materials, which will be a particular focus of attention in Phase 2, should be capable of mitigating that risk in the future. Effective compartmentation is likely to remain at the heart of fire safety strategy and will probably continue to provide a safe basis for responding to the vast majority of fires in high-rise buildings. However, in the case of some high-rise buildings it will be necessary for building owners and fire and rescue services to provide a greater range of responses, including full or partial evacuation. Appropriate steps must therefore be taken to enable alternative evacuation strategies to be implemented effectively. 2 Use of combustible materials 33.6 It is clear that the use of combustible materials in the external wall of Grenfell Tower, principally in the form of the ACM rainscreen cladding, but also in the form of combustible insulation, was the reason why the fire spread so quickly to the whole of the building. Surveys undertaken since the fire have established that external wall materials similar to those used on Grenfell Tower have been used on over 400 other high-rise residential buildings around the country. From the evidence put before me in Phase 1, two very important matters have come to light: first, that in its origin the fire at Grenfell Tower was no more than a typical kitchen fire; second, that the fire was able to spread into the cladding as a result of the proximity of combustible materials to the kitchen windows. It is not possible to say whether the same or a similar combination of design and materials is to be found on any other buildings, but it would be sensible for those responsible for high-rise buildings with similar cladding systems, if they have not already done so, to check whether the same or a similar combination exists. However, even if they do not, fires can occur in a wide variety of circumstances and in cases where the exterior walls of the building include combustible materials of a similar kind, might gain access to it by a variety of different routes. It is not surprising, therefore, that people living in such buildings are concerned for their safety. It is unnecessary for me to recommend that panels with polyethylene cores on the exterior of high-rise buildings be removed as soon as possible and replaced with materials of limited combustibility because it is accepted that that must be done. It is essential that it be done as quickly as possible and concern has been voiced publicly, most recently by the House of Commons Communities and Local Government Select Committee, about the apparently slow rate of progress in carrying out the work.1 In the light of what has been learnt in Phase 1 about the behaviour of ACM panels with polyethylene cores when exposed to fire, I wish to add my voice to that of the committee in expressing the view that the programme of remedial work should be pursued as vigorously as possible. In view of the part played by the architectural crown in the spread of the fire at Grenfell Tower, particular attention must be paid to decorative features composed of combustible materials. 33.7 It has been suggested by certain core participants that I should recommend that no materials be permitted for use in the external walls of high-rise buildings that are not of Euro class A1 (the highest classification of reaction to fire in accordance with BS EN 13501-1). That is a matter on which views differ, however, and following a consultation the government has already prohibited the use on certain types of new buildings of materials whose classification 1 https://publications.parliament.uk/pa/cm201719/cmselect/cmcomloc/2546/254602.htm

Part V | Chapter 33: Recommendations 773 of reaction to fire is lower than A2s1, d0. Having regard to the outcome of that consultation, and in the absence of any examination of the competing views, I do not think it appropriate at this stage for me to recommend any change to the regulations in this respect. Nor, for similar reasons, do I think it appropriate for me to recommend an immediate moratorium on the use of materials of Euro class A2 pending the outcome of Phase 2 of the Inquiry, despite the submissions pressed upon me by some of the core participants. 3 Testing and certification of materials 33.8 The regulation of the use of materials and products by reference to their fire classification depends to a large extent on the efficacy of the testing requirements and how they are interpreted by professionals. Early in Phase 2, the Inquiry will investigate the methods of testing and certifying materials for use in high-rise buildings. It will also investigate whether a prescriptive regime is the most effective way in which to ensure the safety of those who live and work in high-rise buildings and whether the current guidance on how to comply with the Building Regulations is sufficiently clear and reliable. None of those questions have been examined in Phase 1 and at this stage, therefore, I am not in a position to make any recommendations about any of those matters. 4 Fire and rescue services: knowledge and understanding of materials used in high-rise buildings 33.9 Although some senior officers within the LFB were aware of the dangers of cladding fires in high-rise buildings, the majority, particularly at the more junior levels, were unaware of them and were not trained to recognise the nature of the fire that occurred at Grenfell Tower. Moreover, the LFB was unaware of the combustible nature of the materials used in the cladding of Grenfell Tower and was therefore not in a position to formulate a contingency plan for a fire of this kind. 33.10 A sound understanding of the materials used in the construction of any high-rise building is essential if the fire and rescue service is to be properly prepared to carry out its function in relation to that building. The risk of fire of the kind that occurred at Grenfell Tower may be low, but knowledge is the key to proper planning and effective training. I therefore recommend: a. that the owner and manager of every high-rise residential building be required by law to provide their local fire and rescue service with information about the design of its external walls together with details of the materials of which they are constructed and to inform the fire and rescue service of any material changes made to them; b. that all fire and rescue services ensure that their personnel at all levels understand the risk of fire taking hold in the external walls of high-rise buildings and know how to recognise it when it occurs. 5 Section 7(2)(d) of the Fire and Rescue Services Act 2004 33.11 Section 7(2)(d) imposes a general duty on fire and rescue authorities to make arrangements for obtaining information needed for the purposes of extinguishing fires and protecting life and property. The LFB appears to have thought that it required nothing more than sending crews to inspect individual buildings in accordance with Appendix 1 to PN633. However,

The Grenfell Tower Inquiry: Phase 1 Report 774 this essential duty is not circumscribed in that way. Moreover, crews who visited Grenfell Tower during its refurbishment were not trained to carry out the inspections properly: see Chapter 27, paragraphs 24-27. I therefore recommend: a. that the LFB review, and revise as appropriate, Appendix 1 to PN633 to ensure that it fully reflects the principles in GRA 3.2; b. that the LFB ensure that all officers of the rank of Crew Manager and above are trained in carrying out the requirements of PN633 relating to the inspection of high-rise buildings. 6 Plans 33.12 No plans of the internal layout of the building were available to the LFB until the later stages of the fire. However, because each floor of the building above floor 3 was laid out in the same way, the LFB was not unduly hampered in its attempt to fight the fire and rescue occupants by the absence of those plans. In another case, however, the lack of floor plans might easily have far more serious consequences. It should be a simple matter for the owners or managers of high-rise buildings to provide their local fire and rescue services with current versions of such plans. I therefore recommend that the owner and manager of every high-rise residential building be required by law: a. to provide their local fire and rescue services with up-to-date plans in both paper and electronic form of every floor of the building identifying the location of key fire safety systems; b. to ensure that the building contains a premises information box, the contents of which must include a copy of the up-to-date floor plans and information about the nature of any lift intended for use by the fire and rescue services. I also recommend, insofar as it is not already the case, that all fire and rescue services be equipped to receive and store electronic plans and to make them available to incident commanders and control room managers. 7 Lifts 33.13 When the firefighters attended the fire at Grenfell Tower they were unable to operate the mechanism that should have allowed them to take control of the lifts. Why that was so is not yet known, but it meant that they were unable to make use of the lifts in carrying out firefighting and search and rescue operations. It also meant that the occupants of the tower were able to make use of the lifts in trying to escape, in some cases with fatal consequences. The ability of fire and rescue services to take control of firefighting or fire lifts in a high-rise building is often key to successful operations. I therefore recommend: a. that the owner and manager of every high-rise residential building be required by law to carry out regular inspections of any lifts that are designed to be used by firefighters in an emergency and to report the results of such inspections to their local fire and rescue service at monthly intervals; b. that the owner and manager of every high-rise residential building be required by law to carry out regular tests of the mechanism which allows firefighters to take control of the lifts and to inform their local fire and rescue service at monthly intervals that they have done so.

Part V | Chapter 33: Recommendations 775 8 Communication between the control room and the incident commander 33.14 The evidence shows that although both national policy and the LFB’s policies call for a free flow of information between the control room and the incident commander, in practice that does not occur, at least when one or the other (or both) are operating under significant pressure. I therefore recommend: a. that the LFB review its policies on communications between the control room and the incident commander; b. that all officers who may be expected to act as incident commanders (i.e. all those above the rank of Crew Manager) receive training directed to the specific requirements of communication with the control room; c. that all CROs of Assistant Operations Manager rank and above receive training directed to the specific requirements of communication with the incident commander; d. that a dedicated communication link be provided between the senior officer in the control room and the incident commander. 9 Emergency calls 33.15 Even allowing for the fact that the control room was operating under great pressure, it is clear that in many cases CROs failed to handle FSG calls in an appropriate or effective way. I therefore recommend: a. that the LFB’s policies be amended to draw a clearer distinction between callers seeking advice and callers who believe they are trapped and need rescuing; b. that the LFB provide regular and more effective refresher training to CROs at all levels, including supervisors; c. that all fire and rescue services develop policies for handling a large number of FSG calls simultaneously; d. that electronic systems be developed to record FSG information in the control room and display it simultaneously at the bridgehead and in any command units; e. that policies be developed for managing a transition from “stay put” to “get out”; f. that control room staff receive training directed specifically to handling such a change of advice and conveying it effectively to callers. 33.16 The handling of emergency calls by other fire and rescue services was hampered by their lack of information about the nature of the incident and the way in which it had developed. Those who respond to emergency calls on behalf of the LFB need to have as much information as possible about the incident in order to be able to give appropriate advice. I therefore recommend that steps be taken to investigate methods by which assisting control rooms can obtain access to the information available to the host control room.

The Grenfell Tower Inquiry: Phase 1 Report 776 33.17 On occasions, MetCC operators and LAS CROs handled calls from people in the tower seeking FSG advice. Sometimes they gave advice that was not consistent with the advice that the LFB was giving or should have been giving in accordance with its policies. I therefore recommend that the LAS and the MPS review their protocols and policies to ensure that their operators can identify FSG calls (as defined by the LFB) and pass them to the LFB as soon as possible. 10 Command and control 33.18 The evidence of the way in which firefighters were deployed indicates that those in command exercised insufficient control over their actions to ensure that resources were used efficiently. Too often firefighters or junior officers acted on their own initiative, resulting in confusion and duplication of effort. In many cases instructions to crews deployed into the building were not carried out because firefighters came across people needing help and departed from their instructions in order to carry out what they regarded as a more important task. I therefore recommend: a. that the LFB develop policies and training to ensure better control of deployments and the use of resources; b. that the LFB develop policies and training to ensure that better information is obtained from crews returning from deployments and that the information is recorded in a form that enables it to be made available immediately to the incident commander (and thereafter to the command units and the control room). 33.19 LFB policies recognise that regular communication between the control room and the incident commander and between the incident commander and the bridgehead are essential to successful firefighting and rescue operations, particularly when dealing with large-scale incidents. However, at Grenfell Tower there was no regular communication between the control room and the incident commander or between the incident commander and the bridgehead. I therefore recommend that the LFB develop a communication system to enable direct communication between the control room and the incident commander and improve the means of communication between the incident commander and the bridgehead. 33.20 The methods used for transmitting from the control room to the bridgehead information about people needing rescue were disorganised and the line of communication was too extended. The arrangements for receiving and recording that information at the bridgehead were prone to failure and there was little, if any, means of capturing and transmitting to the control room information about the results of deployments to specific flats. I therefore recommend that the LFB investigate the use of modern communication techniques to provide a direct line of communication between the control room and the bridgehead, allowing information to be transmitted directly between the control room and the bridgehead and providing an integrated system of recording FSG information and the results of deployments. 11 Equipment 33.21 Some of the equipment in use by the LFB, in particular the radio equipment, was unreliable or in some cases failed to work at all. I therefore recommend: a. that the LFB urgently take steps to obtain equipment that enables firefighters wearing helmets and breathing apparatus to communicate with the bridgehead effectively, including when operating in high-rise buildings;

Part V | Chapter 33: Recommendations 777 b. that urgent steps be taken to ensure that the command support system is fully operative on all command units and that crews are trained in its use. 12 Evacuation 33.22 There were no plans in place for evacuating Grenfell Tower should the need arise. I therefore recommend: a. that the government develop national guidelines for carrying out partial or total evacuations of high-rise residential buildings, such guidelines to include the means of protecting fire exit routes and procedures for evacuating persons who are unable to use the stairs in an emergency, or who may require assistance (such as disabled people, older people and young children); b. that fire and rescue services develop policies for partial and total evacuation of high-rise residential buildings and training to support them; c. that the owner and manager of every high-rise residential building be required by law to draw up and keep under regular review evacuation plans, copies of which are to be provided in electronic and paper form to their local fire and rescue service and placed in an information box on the premises; d. that all high-rise residential buildings (both those already in existence and those built in the future) be equipped with facilities for use by the fire and rescue services enabling them to send an evacuation signal to the whole or a selected part of the building by means of sounders or similar devices; e. that the owner and manager of every high-rise residential building be required by law to prepare personal emergency evacuation plans (PEEPs) for all residents whose ability to self-evacuate may be compromised (such as persons with reduced mobility or cognition); f. that the owner and manager of every high-rise residential building be required by law to include up-to-date information about persons with reduced mobility and their associated PEEPs in the premises information box; g. that all fire and rescue services be equipped with smoke hoods to assist in the evacuation of occupants through smoke-filled exit routes. 13 Personal fire protection 33.23 It has been suggested by some core participants that every flat and every public space in a high-rise residential building should be equipped with a fire extinguisher and that a fire blanket should be present in every kitchen. It has also been suggested that hose reels and fire buckets containing water or sand should be kept in the public parts of all such buildings. 33.24 On the face of it there is much to be said in favour of householders obtaining fire blankets and fire extinguishers for their own use and if they live in high-rise buildings a strong argument can be made that such equipment, if appropriately used, may provide protection not only to the occupants of the flat in which a fire occurs but to the occupants of the building as a whole. However, the view of many is that people should not be encouraged to fight fires themselves but should leave the building as quickly as possible and call the fire and rescue service. None of the experts supported the provision of fire extinguishers, hose reels or fire

The Grenfell Tower Inquiry: Phase 1 Report 778 buckets, which, in my view, provide obvious potential for misuse. The government publishes advice on fire safety in the home and neither the evidence nor the scope of the investigations in Phase 1 provides a basis for the suggested recommendation. 14 Sprinkler systems 33.25 The coroner who conducted the inquests arising out of the Lakanal House fire heard evidence about the installation of sprinklers and recommended that the government encourage housing providers responsible for high-rise buildings containing multiple domestic premises to consider fitting them. It is not surprising, therefore, that some core participants have urged me to go a step further and to recommend that such systems be installed in all existing high- rise residential buildings. 33.26 Sprinkler systems no doubt have a very valuable part to play in the overall scheme of fire safety measures, but whether such a system would be likely to have suppressed the fire in Flat 16 or prevented it from escaping into the cladding before the firefighters could extinguish it is not something that was investigated in Phase 1. I have therefore heard no evidence about the use of sprinklers generally, their effectiveness under different conditions, or about the cost and disruption that would be caused by installing them in existing buildings. In those circumstances I cannot make any recommendation at this stage about the installation of sprinklers in existing buildings, although the government’s response to previous recommendations will form an important part of the investigation to be carried out at Phase 2. 15 Internal signage 33.27 The landings in the staircase at Grenfell Tower were not clearly marked with the relevant floor number and where floor numbers were marked they did not reflect the additional floors created during the refurbishment. As a result, firefighters were unable to identify floors clearly when carrying out firefighting or search and rescue operations within the building. I therefore recommend that in all high-rise buildings floor numbers be clearly marked on each landing within the stairways and in a prominent place in all lobbies in such a way as to be visible both in normal conditions and in low lighting or smoky conditions. 33.28 The evidence put before me in Phase 1 indicates that many occupants of Grenfell Tower were unable to read or understand the fire safety instructions placed in the lobbies throughout the building. Such information is important because it helps to save lives. In the case of Grenfell Tower, fire safety advice was prominently displayed in the lobbies, but it was written only in English, despite the fact that many of the occupants were unable to read English easily or at all. These considerations apply to residential buildings of all kinds containing separate dwellings. I therefore recommend that the owner and manager of every residential building containing separate dwellings (whether or not it is a high-rise building) be required by law to provide fire safety instructions (including instructions for evacuation) in a form that the occupants of the building can reasonably be expected to understand, taking into account the nature of the building and their knowledge of the occupants. 16 Fire doors 33.29 In Phase 2, the Inquiry will investigate the extent to which at the time of the fire the entrance doors to the flats in Grenfell Tower complied with the relevant legislative requirements and, to the extent that they did not, will investigate the reasons for that failure. However, it has already become apparent from the evidence obtained in Phase 1 that ineffective fire doors allowed smoke and toxic gases to spread through the building more quickly than should have

Part V | Chapter 33: Recommendations 779 been possible. One important reason why fire doors failed to perform their essential function was the absence of effective self-closing devices, some of which were broken or had been disabled or removed. Fire doors play an essential role in preventing or inhibiting the spread of smoke and toxic gases and in preserving effective compartmentation of buildings. In many cases they are critical to saving life. I therefore recommend: a. that the owner and manager of every residential building containing separate dwellings (whether or not they are high-rise buildings) carry out an urgent inspection of all fire doors to ensure that they comply with applicable legislative standards; b. that the owner and manager of every residential building containing separate dwellings (whether or not they are high-rise buildings) be required by law to carry out checks at not less than three-monthly intervals to ensure that all fire doors are fitted with effective self-closing devices in working order. 33.30 Effective fire doors are particularly important in those high-rise buildings that are exposed to an increased risk of fire because the external walls currently incorporate unsafe cladding. Among the experts, views differ about the desirability of requiring existing fire doors to be brought up to modern standards and if necessary be replaced with doors that comply with the requirements currently in force in relation to new buildings. However, the importance of fire doors in maintaining compartmentation and protecting parts of the building other than that in which a fire has occurred is plain and in my view justifies the expense that would inevitably be incurred. I therefore recommend that all those who have responsibility in whatever capacity for the condition of the entrance doors to individual flats in high-rise residential buildings, whose external walls incorporate unsafe cladding, be required by law to ensure that such doors comply with current standards. 17 Co-operation between emergency services 33.31 A point of concern that has emerged from the evidence heard in Phase 1 is that the emergency services failed to co-ordinate with each other and share information as intended, particularly during the early phases of the incident. Most seriously, each declared a Major Incident without immediately informing the others that it had done so. These failures represent weaknesses in the arrangements under which Category 1 Responders are to work together in response to a serious incident. I therefore recommend that the Joint Doctrine be amended to make it clear: a. that each emergency service must communicate the declaration of a Major Incident to all other Category 1 Responders as soon as possible; b. that on the declaration of a Major Incident clear lines of communication must be established as soon as possible between the control rooms of the individual emergency services; c. that a single point of contact should be designated within each control room to facilitate such communication; d. that a “METHANE” message should be sent as soon as possible by the emergency service declaring a Major Incident.

The Grenfell Tower Inquiry: Phase 1 Report 780 33.32 The MPS and the LAS have access to each other’s CAD logs but neither was accessible to the LFB. Co-operation between the emergency services would be improved if the LFB had access to the CAD logs of the MPS and LAS. I therefore recommend that steps be taken to investigate the compatibility of the LFB systems with those of the MPS and the LAS with a view to enabling all three emergency services’ systems to read each other’s messages. 33.33 Although an NPAS helicopter was deployed to observe the development of the fire, the pictures it transmitted could not be viewed by the LFB because the encryption was incompatible with its receiving equipment. Incident commanders and CROs responding to emergency calls might have been assisted by seeing those pictures and in any event they should be available to fire and rescue services as a matter of routine. I therefore recommend that steps be taken to ensure that the airborne datalink system on every NPAS helicopter observing an incident which involves one of the other emergency services defaults to the National Emergency Service user encryption. 33.34 Many people had difficulty in establishing the whereabouts of friends and relatives who had been taken to hospital after escaping from the building. It is important that in the aftermath of a disaster people are able to ascertain as quickly as possible where their loved ones are and are able to make contact with them. I therefore recommend that the LFB, the MPS, the LAS and the London local authorities all investigate ways of improving the collection of information about survivors and making it available more rapidly to those wishing to make contact with them. 18 Other matters 33.35 Some of the core participants suggested that I should make recommendations on a range of other matters, including amendments to the Regulatory Reform (Fire Safety) Order 2005 to ensure that it applies to the external walls of residential buildings and the testing and certification of building materials. Although they are all matters of potential importance, none of them were examined in the course of Phase 1 and cannot therefore be the subject of recommendations in this report.

781 Part VI Looking ahead to Phase 2

782

783 Chapter 34 Looking Ahead to Phase 2 1 Introduction 34.1 Having completed Phase 1 of the Inquiry it is useful to look ahead briefly to Phase 2 to identify some areas that will be of particular interest and importance and some that will not now call for investigation to the degree previously thought likely. Most of the questions on which attention will be focused closely relate to the building itself, but it is appropriate to begin with a reminder that important work remains to be done in order to complete the Inquiry’s findings about the circumstances in which the deceased lost their lives. 2 The deceased 34.2 At the beginning of the Inquiry I expressed the hope that I would be able in due course to make sufficient findings about those who died and the circumstances in which they met their deaths to make it unnecessary for the coroner to resume the investigations which she opened in 2017. I had hoped to be able to make findings in this report in relation to all those matters, save for the wider circumstances that would in any event be the subject of investigation in Phase 2. However, although it has been possible for me to find many of the relevant facts, it has become clear that some aspects of the circumstances in which the deceased met their deaths require a more detailed examination of the evidence than has yet been possible. Within Phase 2 there will therefore be an examination of the evidence relating to the circumstances in which the deceased met their deaths generally with a view to making the findings which the coroner requires. 3 The remaining scope of Phase 2 34.3 I decided to begin the Inquiry with an investigation of the events which occurred during the night of the fire because only a detailed understanding of what had happened would enable me to identify effectively those aspects of the design, construction and management of the building that were primarily responsible for the disaster. As a result of the investigations carried out in Phase 1 it has become clear that some aspects of the building played a more significant role than others in bringing about the events which occurred on 14 June 2017. 34.4 Since the primary cause of the rapid spread of fire up, around and down the building was the use of ACM rainscreen panels with a polyethylene core, to which the use of combustible insulation contributed, the principal focus of Phase 2 will be on the decisions which led to the installation of a highly combustible cladding system on a high-rise residential building and the wider background against which they were taken. However, a number of other matters have emerged from the evidence gathered in Phase 1 which, although not yet fully explored (and therefore not capable of being the subject of findings at this stage), also give rise to significant concern and call for more detailed investigation. I identify below some of those that I consider particularly important, but must emphasise that it is not an exhaustive list.

The Grenfell Tower Inquiry: Phase 1 Report 784 4 Matters of particular concern The London Fire Brigade 34.5 In the preceding chapters of this report I have referred to a number of respects in which the performance of the LFB fell below the standards set by its own policies or national guidance. In the case of the control room, there were signal failures to comply with policies that had been recently introduced or modified in response to criticisms of its performance in connection with the Lakanal House fire, giving rise to justified concern that the LFB as an institution had failed to learn or put into practice the lessons of that event. The need for regular active communication between the control room and the incident ground to exchange information about the development of the fire, although required by policies PN633 and PN790, appears to have been routinely ignored. There appears to have been a failure properly to understand the risk of cladding fires in high-rise buildings, despite the fact that by 2017 many buildings of a similar kind in other countries had suffered fires in cladding, some of which had been well publicised. Although some senior officers in the LFB had become aware of the risk, as appears from the Tall Building Facades presentation, there had been no attempt to disseminate the information to potential incident commanders and no attempt to equip them with the knowledge or skills needed to recognise and respond to such fires. Questions have also been raised about the LFB’s understanding of the nature of the obligation imposed by section 7(2)(d) of the 2004 Act and its approach to discharging it. In that context, as in many others, there appears to have been a significant divergence between policy and practice. 34.6 These and other shortcomings described earlier in this report raise far-reaching questions about the LFB as an organisation. Some may question whether its training is adequate in the light of experience; others may question whether it is capable of learning from its mistakes. No conclusion can be reached on questions of that kind at this stage because there has been no examination of the way in which the LFB is managed and no opportunity to question those who are responsible at the highest level for its operations about these apparent shortcomings. However, they are matters of the greatest importance to all who live and work in the capital and will be an important aspect of Phase 2 of the investigation. Testing and certification of materials 34.7 In the light of the expert evidence, in particular Dr Barbara Lane’s supplemental report, there are already grounds for thinking that the current regime for testing the combustibility of materials and cladding systems, particularly those chosen for use in high-rise buildings, may be neither as rigorous nor as effectively enforced as it should be. Doubts have also arisen about the reliability of the certification of certain materials for use in high-rise buildings. Grave concern inevitably arises simply from the fact that it was possible for highly combustible materials to be used for the purposes of refurbishing and cladding a building like Grenfell Tower. How that was possible is a question that may be relevant to many aspects of the construction industry, including manufacturers of products currently widely available on the market. Pending further investigation it would clearly be sensible for anyone who is responsible for the fire safety of an existing building or who is considering the use of products on high‑rise buildings to scrutinise the information about them provided by the manufacturers and exercise considerable care to ensure that they meet the required standards. These concerns extend to the adequacy of the regulations themselves, the quality of the official statutory and non-statutory guidance currently available, the effectiveness of the tests currently in use, the

Part VI | Chapter 34: Looking Ahead to Phase 2 785 arrangements for certifying the compliance of materials with combustibility criteria and the manner in which materials are marketed. They are questions that will lie at the heart of the Inquiry’s investigations in Phase 2. Design and choice of materials 34.8 A number of aspects of the design of the refurbishment and the choice of materials will need to be examined. The choice of ACM panels with a polyethylene core, the choice of combustible insulation and XPS window infill panels, a design which incorporated many vertical channels and the decision to incorporate an architectural crown composed of ACM fins, all of which made a major contribution to the extent of the fire, are just examples. An examination of the relevant building regulations and the guidance to the construction industry published by the government in support of them will form an important part of this aspect of the Inquiry’s work. Fire doors 34.9 In her supplemental report Dr Lane drew attention to serious questions that arise in relation to the fire doors throughout the tower, both the entrance doors to individual flats opening into the lobbies and the doors opening from the lobbies into the stairs. In Phase 2 it will be necessary to investigate whether those doors complied with the regulations and guidance applicable at the time they were installed, whether they were able to provide appropriate protection against the spread of fire and smoke and if not, why that was so. There is evidence that in many cases self-closing devices were broken or had been disconnected, rendering the doors useless if left open in an emergency. It will be necessary to investigate how that situation came about and why it was allowed to continue. Window arrangements 34.10 As part of the refurbishment the windows were moved outwards so that they no longer sat flush with the original concrete wall but flush with the new cladding system. That alteration, together with the materials used in creating the window surrounds, created certain weaknesses to which Dr Lane and Professor José Torero drew attention. In particular, the use of uPVC in close proximity to combustible insulation and other materials of a combustible nature made it possible for the fire to escape into the cladding from its original location in the kitchen of Flat 16. The design of the window arrangements will therefore be another important focus of investigation in Phase 2. Lifts 34.11 The lifts in Grenfell Tower appear to have been designed as “fire lifts” and lacked some of the protective features such as a secondary power supply, water ingress protection, or FD60 performance for the lift landing doors which would be present in “firefighting lifts”.1 They did, however, include a “fireman’s switch”, which should have enabled the firefighters to take control of them and prevent further use by the occupants of the building. In the event, the firefighters were unable to take control of the lifts, but they were able to use them in their normal mode of operation to take crew and equipment up to the bridgehead on floor 2.2 It does not appear, therefore, that their inability to take control of the lifts significantly affected their operations, but the lifts remained available for use by occupants, as described earlier, in 1 Dr Lane explained the difference between a “firefighter lift” and a “fire lift” at p. 116 in her presentation on 18 June 2018. Refer also to [BLAS0000033] p. 7, 10 Figs. L1 and L2. 2 Dr Lane supplemental report [BLAS0000019] p. 25 19.5.71.

The Grenfell Tower Inquiry: Phase 1 Report 786 some cases with fatal consequences. Given the importance of such equipment to safety in a high-rise building, it is necessary in Phase 2 to investigate whether the lifts were appropriately maintained and, in particular, why the fireman’s switch apparently did not work properly on this occasion. Smoke extraction system 34.12 Suggestions have been made that the smoke extraction system failed to operate in accordance with its design and even contributed to the spread of smoke between different floors of the building. Systems of this kind are an integral part of the fire safety measures in most, if not all, high-rise buildings. Although the system at the tower was designed to operate on only one floor and was not intended to deal with smoke extraction on multiple floors at the same time, it is important to understand whether, in this case, it was capable of operating in accordance with its design and whether it did so. These questions will therefore form part of the investigation in Phase 2. The warnings of the local community and the authorities’ response to the disaster 34.13 From the outset members of the local community have said that they warned the TMO on many occasions about fire hazards, both those arising from the refurbishment and more generally. There is a strong feeling among them that their voices were ignored and that if attention had been paid to them the disaster could have been avoided. There is also a strong view in many quarters that in their response to the disaster the authorities failed the community by not providing adequate support in the days immediately following the fire. These are both important matters for further investigation in Phase 2, not least because they reflect what is said to be a general lack of concern on the part of the authorities for the residents of the tower and the wider community. 5 Matters no longer requiring investigation Stairs 34.14 A question was raised about the width of the stairs, given that they provided the sole means of access to the upper floors of the tower for firefighters as well as the sole means of escape for the occupants. However, the stairs appear to have complied with requirements of the legislation in force at the time of their construction and the expert evidence supports the conclusion that they had sufficient capacity to enable all the occupants of the building to escape within a reasonable time. This aspect of the building will not, therefore, be the subject of further investigation in Phase 2. Gas 34.15 It was thought at one time that the supply of gas to the tower might have played a significant part in the outbreak and development of the fire, but as a result of the investigation carried out in Phase 1 it has become clear that that was not the case. Although the supply of gas allowed fires within individual flats to continue to burn until it was shut off at 23.40 that day, its contribution to the fire which consumed the tower appears to have been minimal. However, some works associated with the installation of the new gas riser were incomplete and may have contributed to the spread of smoke. In those circumstances it will be necessary at Phase 2 to consider whether the installation of the gas services complied with the relevant regulatory regime, but the focus of those investigations can be relatively narrow.

Part VI | Chapter 34: Looking Ahead to Phase 2 787 Electricity 34.16 There was a widespread suspicion, based on events that were said to have occurred in 2013, that the fire had been caused by a surge in the supply of electrical power to the building. In the event, no evidence has emerged to support that suspicion and I am confident that the true cause of the initial outbreak of fire has been correctly identified in Chapter 21. As a result, I do not think it necessary to undertake any further investigation into that aspect of the matter.

The Grenfell Tower Inquiry: Phase 1 Report 788

789 Appendices

790

791 Appendix 1 Terms of Reference – 15 August 2017 The Inquiry’s Terms of Reference are: 1. To examine the circumstances surrounding the fire at Grenfell Tower on 14 June 2017, including: a. the immediate cause or causes of the fire and the means by which it spread to the whole of the building; b. the design and construction of the building and the decisions relating to its modification, refurbishment and management; c. the scope and adequacy of building regulations, fire regulations and other legislation, guidance and industry practice relating to the design, construction, equipping and management of high-rise residential buildings; d. whether such regulations, legislation, guidance and industry practice were complied with in the case of Grenfell Tower and the fire safety measures adopted in relation to it; e. the arrangements made by the local authority or other responsible bodies for receiving and acting upon information either obtained from local residents or available from other sources (including information derived from fires in other buildings) relating to the risk of fire at Grenfell Tower, and the action taken in response to such information; f. the fire prevention and fire safety measures in place at Grenfell Tower on 14 June 2017; g. the response of the London Fire Brigade to the fire; and h. the response of central and local government in the days immediately following the fire. 2. To report its findings to the Prime Minister as soon as possible and to make recommendations.

The Grenfell Tower Inquiry: Phase 1 Report 792

793 Appendix 2 List of Witnesses List of FF witnesses FF (called) witnesses Witness Name Statement Reference Contemporaneous Note Reference Exhibit Reference Date of Oral Evidence 1 Thomas Abell, FF MET000080558 MET00005699 MET00013034 02.07.18 MET00005700 2 Yvonne Adams, CRO MET00007762 23.11.18 3 Marc Aston‑O’Donovan, FF MET00008002 MET00005465 MET00013035 31.07.18 MET00013036 4 David Badillo, FF MET00010080 MET00005347 MET00015603 29.06.18 MET00012654 MET00005348 MET00015637 5 Christopher Batcheldor, CM MET00007511 MET00005388 02.08.18 6 Charles Batterbee, CM MET00012871 MET00005674 MET00015732 28.06.18 MET00005675 MET00015731 7 Stuart Beale, WM MET00007512 MET00005358 02.08.18 MET00012994 8 Scott Bell, FF MET00012995 MET00005686 MET00017022 11.09.18 9 Harry Bettinson, FF MET00007879 MET00005727 MET00015786 19.07.18 MET00007943 MET00015787 MET00015788 MET00015789 10 Rob Brown, Crew Commander (Surrey FRS) MET00010868 MET00018263 19.11.18 MET00010786 11 Daniel Brown, FF MET00010867 MET00005251 28 and 29.06.18 MET00005252 12 Raoul Codd, CM MET00012539 MET00005624 10.09.18 13 Shaun Coltress, WM MET00010911 MET00005656 MET00015903 19.09.18 14 Gareth Cook, SM MET00012779 MET00005717 MET00015779 24.07.18 MET00007882 15 Charles Cornelius, FF MET00012663 MET00005590 MET00015734 06.09.18

The Grenfell Tower Inquiry: Phase 1 Report 794 Witness Name Statement Reference Contemporaneous Note Reference Exhibit Reference Date of Oral Evidence 16 Dany Cotton, Commissioner MET00012492 MET00015756 MET00015754 27.09.18 MET00015755 MET00015756 MET00015757 MET00015758 MET00015759 MET00015760 MET00015761 17 Sharon Darby, CRO MET00013961 01 and 02.08.18 18 Nicholas Davis, GM LFB00004829 02.10.18 19 Louisa De Silvo, WM MET00010913 MET00005634 MET00015813 25 and 26.07.18 MET00013233 MET00015814 MET00015815 MET00015816 MET00015817 MET00015818 MET00015819 MET00015820 MET00015821 MET00015823 MET00015824 20 Oliver Desforges, FF MET00008013 MET00005706 31.07.18 21 Nigel Dilley, GM (Essex FRS) LFB00024396 LFB00024419 19.11.18 22 Christopher Dorgu, FF MET000086037 MET00005314 09.07.18 MET00015663 23 Michael Dowden, WM MET00010915 MET00005453 MET00015597 26, 27 and 28.06.18 MET00005454 MET00015608 24 Peter Duddy, CRO MET00007787 13.09.18 25 Daniel Egan, SM MET00007515 MET00005263 MET00015598 03 and 04.07.18 MET00015634 MET00015636 MET00015639 MET00015642 26 Adrian Fenton, DAC MET000080569 MET00005290 MET00017094 17.07.18 MET00019921 MET00017390 MET00023231 MET00023232 27 Agnel Fernandes, FF MET000083292 MET00005645 MET00013053 10.09.18 MET00015611 28 Katie Foster, FF MET00010084 MET00005736 MET00015807 10.09.18 29 Heidi Fox, CRO MET00007764 23.11.18

Appendix 2: List of Witnesses 795 Witness Name Statement Reference Contemporaneous Note Reference Exhibit Reference Date of Oral Evidence 30 Thomas Furnell, WM MET00008022 MET00005316 MET00017033 11.09.18 MET00017035 MET00017036 31 Ben Gallagher, CM MET00010083 MET00005536 10.09.18 MET00040215 MET00005537 32 Martin Gillam, FF MET00008025 MET00005696 23.07.18 MET00005697 33 Thomas Goodall, GM MET000083296 MET00005435 MET00015923 03.09.18 MET00015923 MET00015924 MET00015925 MET00015926 MET00015927 MET00015928 MET00015929 MET00015930 MET00015931 MET00015932 MET00015933 MET00015934 MET00015935 MET00015936 34 Angie Gotts, CRO MET00007694 17.09.18 35 Patrick Goulbourne, GM MET00010759 MET00015873 12.09.18 MET00013111 MET00015874 MET00015875 36 Norman Harrison, WM MET00007885 MET00005271 19.09.18 MET00007886 MET00015872 MET00023341 37 Peter Herrera, FF MET00010876 LFB00032237 (Rule 9) MET00005520 06.09.18 38 Richard Hippel, FF MET000083300 MET00005209 MET00013057 19.07.18 MET00015593 39 Martin Hoare, CM MET00008027 MET00005424 MET00015844 10.09.18 MET00015845 MET00015846 40 Christine Howson, CRO MET00007763 23.11.18 41 Aisha Jabin, CRO (North West FRS) MET00008028 17.09.18 42 Adam Johnson, FF MET00010082 MET00005575 MET00015691 19.09.18

The Grenfell Tower Inquiry: Phase 1 Report 796 Witness Name Statement Reference Contemporaneous Note Reference Exhibit Reference Date of Oral Evidence 43 Peter Johnson, WM MET00013235 MET00005344 MET00016970 04 and 05.09.18 MET00016971 MET00016972 MET00016974 MET00016975 MET00016997 MET00016998 MET00016999 MET00017000 MET00017001 MET00017002 MET00017004 MET00017005 MET00017006 MET00017007 MET00017008 MET00017598 44 Elliot Juggins, FF MET00010879 MET00005735 MET00015772 11.09.18 45 Raymond Keane, FF MET00007782 MET00005593 MET00013058 18.07.18 46 Jason King, FF MET00010813 MET00005663 MET00015796 04.09.18 MET00015797 MET00015798 MET00015800 MET00015801 MET00015802 47 Daniel Kipling, SM MET00012557 MET00005635 MET00015750 04.09.18 MET00015749 48 Sharon Lancaster, CRO (Essex FRS) MET00018755 19.11.18 49 Gregory Lawson, FF MET00010815 MET00005326 MET00016881 10.09.18 MET00016882 MET00016883 50 Matthew Leaver, WM MET00007781 MET00007857 MET00012838 MET00012839 MET00005757 270 exhibited photos which have been disclosed but not formally read into the record - do we want to read in now? Leaver was not referred to any of these in oral evidence 11.09.18

Appendix 2: List of Witnesses 797 Witness Name Statement Reference Contemporaneous Note Reference Exhibit Reference Date of Oral Evidence 51 Brett Loft, SM MET00007518 MET00005294 MET00015594 05.09.18 MET00015595 MET00015600 MET00015601 MET00015602 MET00015604 MET00015605 MET00015607 MET00015614 MET00015617 MET00015619 MET00015620 MET00015621 MET00015627 MET00015628 MET00015632 MET00015633 MET00015635 MET00015638 MET00015640 MET00015643 MET00015644 MET00015645 MET00015647 52 Zoe Martin, CRO (Kent FRS) MET00012678 19.11.18 53 Benjamin McAlonen, CM MET00012679 MET00005406 MET00015729 06.09.18 MET00015729 54 Nicke Merrion, FF MET000086060 MET00005470 MET00015865 06.09.18 MET00005471 55 Daniel Meyrick, WM MET00007760 MET00005459 10.07.18 MET00005460 56 Gary Moore, FF MET00007761 04.09.18 57 Alan Moore, WM MET00010819 MET00005208 MET00013060 04.09.18 MET00013061 58 Daniel Morrison, CM MET000080586 MET00005414 MET00015753 12.09.18

The Grenfell Tower Inquiry: Phase 1 Report 798 Witness Name Statement Reference Contemporaneous Note Reference Exhibit Reference Date of Oral Evidence 59 Michael Mulholland, SM MET00007865 MET00005218 MET00018713 to MET00018751 inclusive 01.08.18 MET00018756 MET00005219 MET00005220 MET00005221 MET00005222 MET00005223 MET00005224 MET00005225 MET00005226 60 Desmond Murphy, FF MET00010820 MET00005350 MET00013062 06.09.18 MET00013063 MET00013064 61 Nicholas Myatt, SM MET00007783 MET00005231 MET00013067 03 and 04.09.18 MET00007860 MET00013069 MET00013070 MET00015612 62 Alexandra Norman, OM MET000080589 MET00005199 13.09.18 63 Justin O’Beirne, FF MET000083321 MET00005337 MET00013071 02 and 03.07.18 MET00005338 MET00013074 MET00013076 MET00013076 MET00013077 MET00013078 MET00013080 MET00015596 MET00015624 MET00015625 MET00015629 64 Stephen O’Donoghue, FF MET000080591 MET00005339 MET00013081 23.07.18 65 John O’Hanlon, FF MET000080592 MET00005407 MET00015806 04.07.18 66 Brien O’Keeffe, WM MET00010762 LFB00001970 LFB00001929 05, 06 and 09.07.18 MET00013967 MET00005284 LFB00001961

Appendix 2: List of Witnesses 799 Witness Name Statement Reference Contemporaneous Note Reference Exhibit Reference Date of Oral Evidence 67 Andrew O’Loughlin, DAC MET00012563 MET00005213 MET00015702 24 and 25.09.18 MET00015703 MET00015705 MET00015706 MET00015707 MET00015708 MET00015709 MET00015710 MET00015711 MET00015713 MET00015704 68 David O’Neill, GM MET00010758 MET00005281 MET00015762 02.10.18 69 Jason Oliff, SM MET00012791 MET00005247 MET00016906 16.07.18 MET00016908 MET00016909 MET00016910 MET00016911 MET00016912 70 Theresa Orchard, FF MET000086069 MET00005610 MET00017360 10.09.18 71 Antony Peckham, WM MET00007889 MET00005420 26.07.18 72 Debbie Real, CRO MET00007696 MET00013083 17.09.18 MET00013082 73 Dean Ricketts, WM LFB00004825 02.10.18 74 Dean Roberts, FF MET00007890 MET00005669 23.07.18 75 Andrew Roe, AC MET00007520 MET00005405 MET00005404 25 and 26.09.18 MET00007521 MET00007522 MET00010065 76 Sarah Russell, CRO MET00007698 19.11.18 77 Paul Sadler, WM MET00012481 MET00005565 MET00015641 25.07.18 MET00012684 MET00016967 78 Christopher Secrett, CM MET00010105 MET00005384 MET00013086 04 and 05.07.18 MET00039598 MET00039593 MET00015646 MET00039594 MET00039593 MET00039594 79 Joanne Smith, SOM MET00007766 11 and 12.07.18 80 Jamal Stern, CM MET00012483 MET00005493 MET00016890 19.07.18 MET00039568 MET00016891 MET00016890 MET00016893 MET00018457 MET00018458

The Grenfell Tower Inquiry: Phase 1 Report 800 Witness Name Statement Reference Contemporaneous Note Reference Exhibit Reference Date of Oral Evidence 81 Nikki Upton, FF MET00007524 MET00005625 MET00015868 06.09.18 MET00019974 MET00005626 MET00015869 82 Andrew Walton, SM LFB00023365 MET00005712 MET00005713 20.09.18 MET00010828 MET00005714 MET00015725 MET00018460 MET00005715 MET00018455 MET00005716 MET00018456 MET00015724 83 Paul Watson, WM MET00008044 MET00005273 MET00015606 24.07.18 84 Richard Welch, GM MET00007525 FOA00000002 18.09.18 MET00013007 85 Jon Wharnsby, FF MET000083336 MET00005379 06.09.18 86 Glynn Williams, WM MET00008045 MET00013095 MET00013093 30 and 31.07.18 MET00013096 MET00015613 87 Peter Wolfenden, SM MET00017428 MET00017596 11.09.18 MET00017597 88 Michael Wood, FF MET00010928 MET00005469 MET00015860 12.09.18 MET00015862 MET00015863 FF (read) witnesses Witness Name Statement/ Contemporaneous Note Reference 1 Dean Abbess, FF MET00005477 2 Terry Abnett, FF (Surrey FRS) MET00013108 3 Zade Alassad, FF MET00012991 4 Jon Aldridge, FF MET00010864 MET00005726 MET00016915 5 Daniel Alie, SM MET00012772 6 Andrew Alliston, FF MET00012459 7 Melchizedek Anderson, CM MET00012652 8 Stephen Apter, Deputy Commissioner MET00012532 9 Wayne Archer, FF MET00008001 10 Nathan Ashe, WM MET0012653 11 Gregory Ashman, GM MET00007509 MET00012533 12 Thomas Atkins, CM MET00010103 13 Ian Barritt, CM MET000083284 14 Nicholas Barton, FF MET00007942 MET00005214 15 John Barwis, WM MET00007510

Appendix 2: List of Witnesses 801 Witness Name Statement/ Contemporaneous Note Reference 16 Gerard Basson, OM (North West FRS) MET00008003 17 Jessamine Bate, FF MET00017072 18 Caili Beckham, Call Operator (Surrey FRS Control Room) MET00010784 19 Mark Beer, FF MET00086031 20 Enrico Beltrami, FF MET00008004 21 Richard Benaicha, FF MET00012774 22 James Berry, WM MET00012657 23 Daniel Bills, FF MET00005490 24 Gemma Bloxham, FF MET00010866 25 Stephen Boulton, FF MET000080564 26 William Boulton, FF MET00013222 27 Brian Bradshaw, Control Room Operator (NWFC) MET00008005 28 Benjamin Broderick, FF MET00012658 29 Mark Brodrick, FF MET00016789 30 Andrew Brooks, FF MET00005262 31 Gary Brooks, WM MET000080565 32 Russell Brown, FF MET00010910 33 Stewart Brown, WM MET00013965 34 Thomas Bundey, FF MET00012537 35 Russell Butler, FF MET00007880 36 Geoffrey Campbell, FF MET00010788 37 Andy Cane, GM MET00007881 38 Alexander Cardy, WM MET00010085 39 David Carroll, WM MET000083285 40 Paul Charity, CM MET00010790 41 Robert Chart, FF MET00005230 42 Chris Cheesman, FF MET00039905 MET00005485 43 Stuart Chessun, CM MET00013236 44 Neil Chisholm, GM MET00007513 45 Helen Christmas, WM MET00014999 46 Peter Clark, WM MET00017071 47 Adam Clarke, CM MET00015004 MET00005340 48 Carl Clarke, FF MET00012462 49 Sam Coaker, OM MET00007767 50 Steven Collins, WM MET00010086 51 Luke Cook, FF MET00012855 52 Matthew Cook, GM MET00007948 53 Peter Cracknell, FF MET00010912 54 Paula Craig, Team Leader (North West FRS) MET00008008 55 Adam Crinion, SOM MET00008009

The Grenfell Tower Inquiry: Phase 1 Report 802 Witness Name Statement/ Contemporaneous Note Reference 56 Timothy Cutbill, CM MET00010872 57 James Cuthbert, FF MET00012878 58 Dan Daly, AC MET00012857 59 Tristan Daoud, FF MET00008010 60 David Davies, CM MET000010793 61 Ian Davis, FF MET00010794 62 David DeCosta, FF MET00005452 63 Alex De St Aubin, FF MET00012464 64 Joe Dean, FF MET00008012 65 Patrick Delaney, WM MET00005235 LFB00024415 66 Michael Denny, CM MET00013232 67 Aldo Diana, CM MET00018800 68 Devani Dillesh, FF MET00007951 69 Anthony-Mawusi Doe, FF MET00010797 70 Thomas Dotchin, FF MET00012542 71 Benjamin Dotchin, FF MET00010072 72 Stephen Dounias, FF MET00010914 73 Colin Dowdall, FF MET00013231 74 Lee Drawbridge, DAC MET00010104 75 Stephen Dudeney, GM MET00007514 MET000010873 76 Steven Duncan, FF MET00010874 77 Robert Dwyer, FF MET00012781 78 Jonathan Earl, FF MET00012782 MET00005478 79 Craig Eden, CM MET00008019 80 Craig Edwards, FF MET00013224 81 Scott Elliott, FF MET00012544 82 Dominic Ellis, AC MET00007693 83 Grant Evans, CM MET00012466 84 Richard Evans, CM MET00010089 85 David Farr, SM MET00013112 86 Dominic Fearnley, CM MET00008020 87 Benjamin Felton, FF MET00012467 88 Nicholas Ferguson, FF MET00015669 89 Brian Flanagan, FF MET00007765 90 James Flin, SM MET00012998 MET00017084 MET00017099 MET00018818 91 Albert Folivi, FF MET000086041

Appendix 2: List of Witnesses 803 Witness Name Statement/ Contemporaneous Note Reference 92 Piers Foster, FF MET00086042 93 Keeley Foster, GM MET00013963 94 Neill Franklin, FF MET00008021 95 David Friend, FF MET00012470 96 Jason Frisby, SM MET00010800 97 Christopher Frost, CM MET00083294 98 Timothy Frost, GM MET00010802 99 James Geapin, FF MET00010099 100 Robbie Gentry, FF MET00019991 101 David George, SM MET00007768 102 Paul Godber, WM MET00012546 103 Luke Goddard, FF MET00010804 104 Ennio Gonnella, FF MET00012785 105 Russell Gonzalez, FF MET00012861 106 John Graham, GM MET00017432 MET00005257 MET00017432 108 Simon Grant, FF MET00007883 109 Paul Gray, CM MET00010806 110 Neil Green, FF MET00083297 111 Matthew Gregory, WM MET00012877 112 Edward Haines, FF MET00012547 113 Russell Hall, FF MET00012548 114 Christian Hall, WM MET00010808 115 Charles Hanks, SM LFB00032724 116 Alan Hanlon, FF MET00012549 117 Nicholas Harding, SM MET00012550 118 Matthew Harold, FF MET00010073 119 Daniel Harriman, CM MET00007867 120 Andrew Harris, FF MET00007884 121 Duane Harris, FF MET00010809 122 Paul Harris, FF MET000083298 123 Stephen Hayward, FF MET00012552 124 Scott Hayward, POM MET00007894 125 Matthew Hayward, WM MET00012551 126 Oliver Henley, FF MET00010810 127 David Hill, FF MET000083299 128 Jordan Hill, FF MET00010919 129 Gary Hiscock, FF MET00010877 130 Benjamin Holehouse, FF MET00012672 131 Kylei Holmes-Lewis, FF MET00015005 132 Martin Hooper, FF MET00010920

The Grenfell Tower Inquiry: Phase 1 Report 804 Witness Name Statement/ Contemporaneous Note Reference 133 Paul Howard, FF MET00010087 134 Alan Hudson, FF MET00012673 135 Tyrone Jackdeo, FF MET000012999 136 Marcus Johnson, CM MET00010921 137 Pam Jones, CRO LFB00032090 138 Ian Jones, FF MET00017431 MET00005264 139 John Joseph, FF MET00005568 140 Nicholas Kalirai, FF MET00005622 141 Edric Kennedy-MacFoy, CM MET00010761 MET00010760 142 Mark Kentfield, WM MET00005353 MET00023051 143 Daniel Knapman, FF MET00010814 144 Richard Knight, FF MET00083307 145 Christopher Lang, FF MET00012674 146 Dean Lawrence, FF MET00012873 147 Steve Leader, GM MET00016791 148 Terence Lowe, FF MET00007969 149 Marcus Lundquist, FF MET00007888 150 Damian Magee, CM MET00010882 151 Abdul Malik, FF MET00008032 152 Paul Marks, CM MET00017068 153 Katrina Marshall, Fire Control Operator (Essex FRS Control Room) MET00012848 154 Peter May, AOM MET00007895 MET00015882 155 Jamie Mayne, CM MET00008033 156 Andrew McArthur, FF MET00012680 157 Kyle McClelland, FF MET00010924 158 Jacqueline McConochie, SM MET00017430 159 Andrew McKay, WM MET00010077 160 Richard McShee, CM MET00012789 161 Paul Meyrick, WM MET00010818 162 Richard Mills, AC MET00013119 163 Steven Mills, FF MET000080584 164 Niki Mitchell, FF MET00005483 MET00039859 165 Richard Mitchell, FF MET000086063 166 Graham Moore, FF MET00012477 167 Ian Moore, FF MET00010081 168 James Morcos, FF MET00005585 169 Amanda Morrison, WM MET000086066

Appendix 2: List of Witnesses 805 Witness Name Statement/ Contemporaneous Note Reference 170 Sean Murphy, CM MET000080587 171 Patrick Murray, FF MET00010925 172 Dean Nelson, FF MET00010926 173 Anthony Nelson, FF MET00007785 174 Steven Ngo, FF MET00010887 175 Mark Niblett, WM MET00005299 MET00010888 176 Ricky Nuttall, FF MET00012561 177 Constantine Nwagwu, FF MET00012562 178 Denis O’Brien, FF MET00010889 179 Sean Oakley, FF MET00010890 180 Rick Ogden, DAC MET00007657 MET00010891 181 Earnest Okoh, FF MET000080593 182 Vanessa Osborne, Fire Control Operator (Essex FRS Control Room) MET00012849 183 Helen Oulton, Control Room Operator (North West FRS) MET000080595 184 Steve Page, FF MET00012870 185 Jonathan Parker, WM MET00012566 186 Anthony Parkin, WM MET00012567 187 Christopher Payton, SM MET00010821 188 Richard Peacock, FF MET00010079 189 Andrew Pearcy, CM MET00010075 190 Daniel Pegram, FF MET000080597 191 Christopher Perez, FF MET00017426 192 Jeanette Pike, Control Operator (Merseyside FRS) MET00013002 193 Sue Pimblett, Team Leader (North West FRS) MET00008034 194 Lawrence Pitt, FF MET000080599 195 Michael Pole, FF MET00005540 MET00039672 196 Natalie Pomponi, Team Leader (North West FRS) MET000080600 197 Daniel Poullais, CM MET00012682 198 James Power, FF MET00007786 199 Suzanne Pursey, FF MET00010893 200 Carl Ramsay, CM MET00012569 201 Kate Ranson, AOM MET00007864 202 Charlie Rawlings, CM MET00005588 203 Tom Reddington, FF MET00005476 204 David Reed, FF MET00007697 MET00017346 MET00017353 MET00005514 205 Christopher Reynolds, FF MET00010894

The Grenfell Tower Inquiry: Phase 1 Report 806 Witness Name Statement/ Contemporaneous Note Reference 206 Lewis Rice, FF MET00008038 207 Terence Roots, FF MET00012876 208 Harvey Sanders, FF MET00012482 209 Mitch Samson, CM (Kent FRS Control Room) MET00012796 210 Jonathan Saunders, FF MET00012797 211 Neil Saunders, FF MET000080602 212 Nicholas Saunders, SM MET00013234 213 Michael Skorzewski, FF MET00012570 214 Matthew Sephton, FF MET00010895 MET00016948 215 Thomas Sharp, CM MET00010074 216 Graeme Shaw, FF MET00012798 217 Alan Sime, FF MET00010896 218 John Simpson, GM MET00008040 219 Mandeep Singh, FF MET000083327 MET00013089 220 Parvinder Singh, FF MET00005204 221 Michael Smith, FF MET00017069 222 Steven Somers, FF MET00015001 223 Methusael Sonson, FF MET00010824 224 Julian Spooner, GM MET000086071 MET00005259 225 Laurence Stavely, FF MET00005250 226 Martin Stevenson, CM MET00012860 227 John Stewart, WM MET000083329 228 Rodney Stuart, FF MET00005429 229 Bryan Swaddling, WM MET00019066 MET00019952 230 Matthew Tanner, FF MET00010826 231 Michael Terry, Fire Control Officer (Essex FRS) MET00007758 232 Marc Thorpe, FF MET00005430 233 Guy Tillotson, CM MET000080603 234 Adrian Toppin, FF MET00012854 235 Paul Trew, GM MET000086073 236 Leslie Tucker, FF MET000080604 237 Phillip Turcsi, WM MET00010899 238 Adrian Tyldesley, FF MET000083333 239 Andrew Vango, FF MET00012688 240 Richard Vanstone, WM MET00010827 241 Simon Vincent, CM MET00016790 242 Steven Vydelingum, WM MET00012572

Appendix 2: List of Witnesses 807 Witness Name Statement/ Contemporaneous Note Reference 243 Rod Wainwright, SM MET00014998 MET00005356 MET00017078 244 David Watts, WM MET00012689 245 Tom Welch, FF MET000080606 246 Antony Welden, FF MET00012574 247 Stephen West, GM MET00017073 248 Russ White, Senior Fire Control Operator (Essex FRS Control Room) MET00012847 249 Nicholas Whiting, FF MET00013957 250 Leon Whitley, FF MET00005613 251 Philip Wigley, CM MET00010927 252 Vincent Williams, FF MET00010829 253 Andrew Williams, SM MET00013008 254 Adam Wilson, FF MET000083337 255 James Wolfenden, FF MET00010831 256 Joe Worley, FF MET00007891 257 Michael Worman, FF MET00012575 258 Andrew Wright, FF MET00010076 259 Carrie Wright, FF MET00010096 260 John Wright, FF MET000083339 261 Richard Wybrow, FF MET000086079 262 Gregory Yeoman, CM MET00007862 MET00005309

The Grenfell Tower Inquiry: Phase 1 Report 808 List of BSR witnesses BSR (called) witnesses Witness Name Statement Reference Exhibit Reference Date of Oral Evidence 1 Omar Alhaj Ali (IWS1) IWS00000781 (OM/1) IWS00000780 16.10.2018 (IWS2) IWS00001052 2 Rashida Ali IWS00000003 (RA/1-6) IWS00000003 05.11.2018 3 Maria de Fatima Alves IWS00000443 (MA/1-2) IWS00000441 03.10.2018 4 Manuel Miguel Ferreira Alves IWS00000538 (MMFA/1-3) IWS00000536 04.10.2018 5 Sid-Ali Atmani IWS00000070 05.11.2018 6 Nicholas Trevanion Burton IWS000000064 (NTB/1) IWS00000063 06.11.2018 (NTB/2) IWS00000065 7 Hiwot Dagnachew IWS00000845 09.10.2018 8 Samuel Daniels IWS00000608 10.10.2018 9 Alemishet Demissie IWS00000860 01.11.2018 10 Petra Doulova IWS00000835 (PD/1) IWS00000832 17.10.2018 (PD/2) IWS00000833 11 Natasha Elcock (IWS1) IWS00000310 (NE/1-5) IWS00000306 08.11.2018 (IWS2) IWS00001186 12 Richard Fletcher IWS00000913 11.10.2018 13 Helen Gebremeskel (IWS1) IWS00000933 (HG/1) IWS00001140 06.11.2018 (IWS2) IWS00001141 (HG/2) IWS00001139 (HG/3) IWS00001142 14 Marcio Gomes (IWS1) IWS00001078 (MG/1) IWS00000623 09.11.2018 (IWS2) IWS00001184 (MG/2) IWS00000621 15 Nadia Jafari IWS00000683 (NJ/1) IWS00000681 08.10.2018 16 Maher Khoudair IWS00000182 09.10.2018 17 Chia-Yuan (Naomi) Li (IWS1) IWS00000515 (NL/1) IWS00000520 29.10.2018 (IWS2) IWS00001152 (NL/2) IWS00000513 (IWS3) IWS00001231 (NL/3) IWS00000516 (NL/4) IWS00000514 (NL/5) IWS00000517 (NL/6) IWS00000512 (NL/7) IWS00000518 18 Branislav Lukic IWS00000770 (BL/1-3) IWS00000770 10.10.2018 19 Sener Macit (IWS1) IWS00000069 01.11.2018 (IWS2) IWS00001156 20 Munira Mahmud IWS00000776 (MM/1) IWS00000777 08.10.2018 21 Meron Mekonnen IWS00000912 (MM/1(a)) IWS00000449 09.10.2018 (MM/1(b)) IWS00000451 (MM/1(c)) IWS00000452 (MM/1(d)) IWS00000453

Appendix 2: List of Witnesses 809 Witness Name Statement Reference Exhibit Reference Date of Oral Evidence 22 Shekeb (Farhad) Neda (IWS1) IWS00000886 18.10.2018 (IWS2) IWS00001134 23 Flora (Shakila) Neda (IWS1) IWS00000887 18.10.2018 (IWS2) IWS00001133 24 Rosemary Olabisi Oyewole IWS00000852 15.10.2018 25 Hoang Khanh Quang (English) IWS00000080 (HKQ/1) IWS00000081 05.11.2018 (Chinese) IWS00001170 26 Antonio Roncolato (IWS1) IWS00000894 (AR/1-12) IWS00000892 03.10.2018 (IWS2) IWS00000922 (AR/13) IWS00000924 (IWS3) IWS00001109 (AR/14) IWS00000923 27 Roy Smith (IWS1) IWS00000771 (RS/1) IWS00000931 31.10.2018 (IWS2) IWS00001169 28 Elizabeth Sobieszczak IWS00001105 07.11.2018 29 Oluwaseun Talabi IWS00000851 16.10.2018 30 Paulos Woldesilassie Tekle (IWS1) IWS00001051 (PT/1-7) IWS00001051 30.10.2018 31 Mariko Toyoshima- Lewis (IWS1) IWS00000304 (MTL/1) IWS00000907 11.10.2018 (IWS2) IWS00001092 (MTL/2(1)) IWS00000909 (MTL/2(2)) IWS00000911 (MTL/2(3)) IWS00000905 (MTL/2(4)) IWS00000910 (MTL/3(a)) IWS00000906 (MTL/3(b)) IWS00000908 32 Jose Vieiro IWS00001122 17.10.2018 33 Hanan Wahabi (IWS1) IWS00000074 08.11.2018 (IWS2) IWS00001146 34 Hamid Wahbi IWS00001157 29.10.2018 35 Rabia Yahya (IWS1) IWS00000498 30.10.2018 (IWS2) IWS00001144 BSR (read) witnesses Witness Name Statement Reference Exhibit Reference 1 Mustafa Siraag Abdu IWS00000307 (MA/1-3) IWS00000308 2 Raby Abdulrahman IWS00000881 3 Habibrahman Abdulrahman IWS00000883 4 Lotfrahman Habibrahman (Massi) Abdulrahman (IWS1) IWS00000882 (IWS2) IWS00001132 5 Abraham Abebe IWS00000847 6 Karen Aboud (IWS1) IWS00000130 (KA/1-7) IWS00000130 (IWS2) IWS00001123 7 Maryam Yusuf Adam (IWS1) IWS00000128 (IWS2) IWS00001204

The Grenfell Tower Inquiry: Phase 1 Report 810 Witness Name Statement Reference Exhibit Reference 8 Yasin Yusuf Adam (IWS1) IWS00000185 (IWS2) IWS00001205 9 Feruza Afewerki IWS00000331 10 Elsa Mebrahut Afeworki IWS00000280 (EA/1-3) IWS00000280 11 Shahnaz Afraseyabi IWS00000767 12 Mona Aghlani IWS00000774 13 Shahrokh Aghlani (IWS1) IWS00001200 (SA/1) IWS00001203 (IWS2) IWS00001202 (SA/2) IWS00001201 (SA/3) IWS00001198 14 Nazanin Aghlani IWS00001074 15 Shahid (Shah) Ahmed IWS00000388 (SA/1-5) IWS00000388 (SA/6) IWS00000500 16 Zaki Ahmed IWS00000389 17 Sayeda Ahmed IWS00000676 18 Mohamed Ahmed IWS00001113 (MA/1-4) IWS00001155 (MA/5) IWS00000011 (MA/6) IWS00000012 19 Fadumo Ahmed IWS00000729 20 Khalid Ahmed IWS00000859 21 Elias Aitequakrim IWS00001030 (EA/1) IWS00001028 (EA/2) IWS00001027 (EA/3) IWS00001026 (EA/4) IWS00001029 22 Ibtisam Alfawaz IWS00000026 (IA/01) IWS00000031 (IA/02) IWS00000029 (IA/03) IWS00000027 (IA/04) IWS00000024 (IA/05) IWS00001174 (IA/06) IWS00000022 (IA/07) IWS00000030 (IA/08) IWS00000028 (IA/09) IWS00000025 23 Ammar Alkabib MET00021446 24 Ahmad Al Sadi IWS00000645 (AA/1) IWS00000644 (AA/2) IWS00000647 25 Randa Al-Arasi IWS00000005 (RAA/1-4) IWS00000005 26 Zohra Al-Assad IWS00000110 27 Ahmed Al-Assad IWS00001158 28 Rania Al-Douri IWS00000915 29 Amal Al-Huthaifi IWS00000637 30 Mahmoud Al-Karad IWS00000821 (MAK/1) IWS00000819 (MAK/2) IWS00000791 31 Susan Al-Safadi IWS00000598 (SA-S/1-7) IWS00000599 32 Aesem Alhajali MET00039851

Appendix 2: List of Witnesses 811 Witness Name Statement Reference Exhibit Reference 33 Shukri Ali IWS00000897 34 Iman Alkuedi IWS00000205 35 Arsiema Alula IWS00001115 36 Tiago Alves IWS00000123 (TA/1 - 4) IWS00000124 37 Ines Tavares Alves IWS00000436 (ITA/1-6) IWS00000437 38 Ethiopia Assefa IWS00000891 39 David Andrew Benjamin IWS00000876 40 Elpidio Bonifacio IWS00001085 (EB/1-2) IWS00001085 41 Christine Bonnett IWS00000699 (CB/1-3) IWS00000696 42 Aziza Boudafcha IWS00000015 (AB/2) IWS00001068 43 Fatima Boujettif IWS00000469 44 Joseph Bryan IWS00000553 45 Alison Burke IWS00000277 (AB/1) IWS00000277 46 Virgilio (Larry) Castro IWS00001091 (VC/1) IWS00001091 (VC/2) IWS00001091 (VC/3) IWS00001091 47 Amina Chaer-Yemlahi IWS00000956 48 Ann Chance IWS00000783 (AC/1) IWS00000782 49 Lee Jonathan Chapman IWS00001000 (LC/1) IWS00000740 (LC/2) IWS00000737 (LC/3) IWS00000734 (LC/4) IWS00000730 (LC/5) IWS00000731 (LC/6) IWS00000738 (LC/7) IWS00000739 (LC/8)IWS00001002 (LC/9)IWS00001001 (LC/10) IWS00000999 50 Salah Eddine Chebiouni IWS00000945 51 Zakariya Chebiouni IWS00001076 52 Ahmed Chellat IWS00001006

The Grenfell Tower Inquiry: Phase 1 Report 812 Witness Name Statement Reference Exhibit Reference 53 Hicham Cherbika IWS00000038 (HC/01) IWS00000051 (HC/02) IWS00000048 (HC/03) IWS00000036 (HC/04) IWS00000054 (HC/05) IWS00000055 (HC/06) IWS00000050 (HC/07) IWS00000059 (HC/08) IWS00000049 (HC/09) IWS00000053 (HC/10) IWS00000039 (HC/11) IWS00000046 (HC/12) IWS00000040 (HC/13) IWS00000044 (HC/14) IWS00000047 (HC/15) IWS00000056 (HC/17) IWS00000072 (HC/18) IWS00000073 (HC/19) IWS00000079 (HC/20) IWS00000061 (HC/21) IWS00000057 (HC/22) IWS00000037 (HC/23) IWS00000042 (HC/24) IWS00000041 (HC/25) IWS00000043 (HC/26) IWS00000052 (HC/27) IWS00000058 (HC/28) IWS00000045 (HC/29) IWS00000060 54 Hanan Cherbika IWS00000016 55 Yousra Cherbika IWS00001032 (YC/1) IWS00001019 (YC/2) IWS00001020 (YC/3) IWS00001021 (YC/4) IWS00001022 (YC/5) IWS00001023 56 Michele Chiapetto IWS00000679 57 Sawsan Choucair IWS00001080 58 Nabil Choucair IWS00001069 59 Malak Choucair IWS00001070 60 Hisam Choucair IWS00001197 (HC/1) IWS00001194 (HC/2) IWS00001195 61 Jose Costa Cotelo IWS00000984 62 Edward Daffarn IWS00000169 (ED/1-26) IWS00000169

Appendix 2: List of Witnesses 813 Witness Name Statement Reference Exhibit Reference 63 Zoe Dainton IWS00000806 (ZD/1) IWS00000800 (ZD/2) IWS00000801 (ZD/3) IWS00000802 (ZD/4) IWS00000803 (ZD/5) IWS00000804 64 Jenny Beatrice Dainton IWS00000939 (JD/1) IWS00000936 (JD/2) IWS00000937 65 Francis Kapri Dean IWS00001048 (FD/1) IWS00001048 (FD/2) IWS00001004 (FD/3) IWS00001005 66 Reem Dedrich IWS00000102 (RD/1) IWS00000097 (RD/2) IWS00000095 (RD/3) IWS00000096 (RD/4) IWS00000099 (RD/5) IWS00000093 (RD/6) IWS00000092 (RD/7) IWS00000100 (RD/8) IWS00000103 (RD/9) IWS00000101 (RD/10) IWS00000098

The Grenfell Tower Inquiry: Phase 1 Report 814 Witness Name Statement Reference Exhibit Reference 67 Thomas Joseph Michael (Joe) Delaney IWS00000265 (TJD/1) IWS00000414 (TJD/3) IWS00000405 (TJD/4) IWS00000254 (TJD/5) IWS00000722 (TJD/6) IWS00000271 (TJD/7) IWS00000267 (TJD/8) IWS00000256 (TJD/9) IWS00000266 (TJD/10) IWS00000262 (TJD/11) IWS00000268 (TJD/12) IWS00000270 (TJD/13) IWS00001137 (TJD/14) IWS00000253 (TJD/15) IWS00000258 (TJD/16) IWS00000260 (TJD/17) IWS00000264 (TJD/18) IWS00000259 (TJD/19) IWS00000255 (TJD/20) IWS00000252 (TJD/21) IWS00000257 (TJD/22) IWS00000263 (TJD/23) IWS00000269 (TJD/24) IWS00000398 (TJD/25) IWS00000396 (TJD/26) IWS00000415 (TJD/27) IWS00000397 (TJD/28) IWS00000403 (TJD/29) IWS00000402 (TJD/30) IWS00000407 (TJD/31) IWS00000408 (TJD/32) IWS00000413 (TJD/33) IWS00000412 (TJD/34) IWS00000406 (TJD/35) IWS00000399 (TJD/36) IWS00000401 (TJD/37) IWS00000400 (TJD/38) IWS00000411 (TJD/39) IWS00000404 (TJD/40) IWS00000409 (TJD/41) IWS00000422 (TJD/42) IWS00000416 (TJD/43) IWS00000418 (TJD/44) IWS00000420 (TJD/45) IWS00000421 (TJD/46) IWS00000419

Appendix 2: List of Witnesses 815 Witness Name Statement Reference Exhibit Reference 68 Emanuela Disaró (IWS1) IWS00000543 (IWS2) IWS00001227 69 Alfie Disson IWS00000241 70 Cordelia Disson IWS00000242 71 Harriboy (Harry) Disson IWS00000672 72 Charles (Charlie) Disson IWS00000239 73 Winston Dowarris IWS00000916 (WD/1) IWS00000916 74 Salah Duale IWS00000795 75 Mahad Mahamed Egal IWS00001010 (ME/1) IWS00001013 (ME/2) IWS00001009 (ME/3) IWS00001011 76 Noha El Baghdady IWS00000671 77 Mariama El Hassani IWS00000966 78 Karema El-Sawy IWS00000424 79 Zakaria Kamel El-Sawy IWS00000427 80 Karim El-Ansari IWS00000088 81 Mouna El-Ogbani IWS00000844 (ME0/1) IWS00000287 (ME02) IWS00000285 82 Nadia Elbouti (IWS1) IWS00000947 (NE/1) IWS00001128 (IWS2) IWS00001129 (NE/2) IWS00001131 (NE/4) IWS00001125 (NE/5) IWS00001127 83 Ahmed Elgwahry IWS00000988 (EA/1-69) IWS00000988 84 Ferzana Elgwahry IWS00000995 85 Thomas Etienne IWS00001163 (TE/1) IWS00001159 (TE/2) IWS00001160 (TE/3) IWS00001161 (TE/4) IWS00001162 86 Daniel Eudey IWS00000090 87 Christos Fairbairn IWS00001025 (CF/1) IWS00001024 88 Mary Folan IWS00001088 (MKF/1(a)) IWS00000136 (MKF/1(b)) IWS00000137 89 John Gerald Folan IWS00000132 90 Hime Haymanot Gashaw IWS00000990 91 Clarita Ghavimi IWS00000943 92 Maria Gil IWS00000554 (MG/1) IWS00000565 (MG/2) IWS00000556 (MG/3) IWS00000566 (MG/4) IWS00000557 (MG/5) IWS00000558 (MG/6) IWS00000559 (MG/7) IWS00000555 (MG/8) IWS00000562 (MG/9) IWS00000563 (MG/10) IWS00000560

The Grenfell Tower Inquiry: Phase 1 Report 816 Witness Name Statement Reference Exhibit Reference 93 Turufat Yilma Girma IWS00000848 (TG/1) IWS00000934 94 Giannino Gottardi MET00013011 95 Daniel Griffin IWS00000173 (DG/1, 2, 3, 6-8, 9) IWS00000173 (DG/4) IWS00000174 (DG/5) IWS00000175 96 Mojda Habib IWS00000917 (MH/1) IWS00000750 97 Ismail Hadgay IWS00000200 (IH/1) IWS00000199 (IH/3) IWS00000197 98 Mohammed Abdul Hakim IWS00000019 (MAH/1) IWS00000017 (MAH/2) IWS00000018 99 Sharon Haley IWS00001219 (SH/1) IWS00001222 100 El Alami Hamdan IWS00000176 101 Samira Hamdan IWS00001180 102 Lina Hamide IWS00001175 (LH/1-8) IWS00001177 103 Mohamed Hariri IWS00001094 (MH/1) IWS00001097 (MH/2) IWS00001098 (MH/3) IWS00001108 (MH/4) IWS00001095 (MH/5) IWS00001099 (MH/6) IWS00001096 (MH/7) IWS00001104 (MH/8) IWS00001100 (MH/9) IWS00001107 (MH/10) IWS00001106 104 Hermine Harris IWS00000087 105 Helene Hartley (IWS1) IWS00000492 (HH/1) IWS00001055 (IWS2) IWS00001054 (HH/2) IWS00001053 106 Makrem Harzi IWS00000952 107 Avni Haxhisefa IWS00000296 (AH/1) IWS00001117 108 Jacqueline Haynes IWS00000127 109 Abdesalam Hedioued IWS00000651 110 Samira Hemmid IWS00000311 111 Eman Hijazi IWS00000639 112 Lucy Ho IWS00000655 (LH/1-2) IWS00000656 113 Van Quang Ho IWS00000925 114 Sayeda Ibrahim IWS00000323 115 Abu Baker Mohammad Ibrahim IWS00001238 (AB/1) IWS00001238 116 Erlinda Ignacio IWS00000830 (EI/1) IWS00000827 (EI/2) IWS00000828 117 Wesley Ignacio IWS00000826 (WI/1) IWS00000824 118 Salma Ismael IWS00000745

Appendix 2: List of Witnesses 817 Witness Name Statement Reference Exhibit Reference 119 Sohaila Ismail IWS00001230 (SI/1) IWS00001233 (SI/2) IWS00001232 (SI/3-7) IWS00001233 (SI/8) IWS00001233 IWS00001240 IWS00001240 120 Leanne Mya Jackson Le-Blanc IWS00000177 121 Maria Jafari IWS00000744 122 Sahar Jamalvatan IWS00000325 123 Mahboubeh Jamalvatan IWS00000078 124 Sajad Jamalvatan IWS00000068 (SJ/1) IWS00000068 125 Joseph John IWS00000062 126 Simon Jolly IWS00001216 (SJ/1) IWS00001211 (SJ/2) IWS00001210 (SJ/3) IWS00001213 (SJ/4) IWS00001212 (SJ/5) IWS00001215 (SJ/6) IWS00001214 (SJ/7) IWS00001217 127 Corinne Simone Jones IWS00000033 (CJ/1) IWS00000035 (CJ/2) IWS00000032 (CJ/3) IWS00000034 128 Milad Kareem IWS00001077 129 Betty Kasote IWS00000768 130 Mesrob Kassemdjian IWS00000951 (MK/1) IWS00000950 131 Behailu Kebede IWS00000490 (BEK/1) MET00017055 (MPS1) MET00007340 (BEK/2) MET00005190 (MPS2) MET00006339 (BEK/3) MET00012983 (MPS3) MET00007339 (BEK/4) MET)0012984 (MPS4) MET00008030 (BEK/5) MET00012985 (MPS5) MET00008029 (BEK/6) MET00012986 (MPS6) MET00012893 (BEK/7) MET00012987 (MPS7) MET00013022 (BEK/8) MET)0012988 (MPS8) MET00015023 (BEK/9) MET00012989 (BEK/10) MET00012982 (BEK/11) MET00017049 (MH/11) MET00014833 132 Youssef Khalloud IWS00000473 (YK/1) IWS00000471 133 Rohema Khanom COR00001147 (RRK/1) MET00040121 (RRK/2) MET00040119 (RKK/3) MET00040120 134 Rawan Khdeir IWS00000204 135 Walaa Khdeir IWS00000208

The Grenfell Tower Inquiry: Phase 1 Report 818 Witness Name Statement Reference Exhibit Reference 136 Almaz Kinfu IWS00000457 (AK/1) IWS00000610 MET00006350 137 Philip King (IWS1)IWS00000592 (PK/1) IWS00000593 (IWS2) IWS00001057 (PK1) IWS00000593 (PK2) IWS00001067 (PK3) IWS00001065 (PK4) IWS00001056 (PK5) IWS00001059 (PK6) IWS00001058 (PK7) IWS00001064 (PK8) IWS00001066 (PK9) IWS00001063 (PK10) IWS00001062 138 Anna Krivsoun MET00039926 139 Sharon Laci IWS00000818 (SL/1) IWS00000808 (SL/2) IWS00000809 (SL/3) IWS00000810 (SL/4) IWS00000811 (SL/5) IWS00000812 (SL/6) IWS00000813 (SL/7) IWS00000814 (SL/8) IWS00000815 (SL/9) IWS00000816 140 Mushtaq Lasharie IWS00000603 (ML/1) IWS00000605 141 Beinazir Lasharie IWS00000634 142 Marcia Levi IWS00000430 143 David Lewis IWS00000297 (DL/1) IWS00000303 144 Chin-Hsuan (Lydia) Liao IWS00000505 LL/1- IWS00000509 IWS00001191 LL/2 - IWS00000506 LL/3 - IWS00000508 LL/4 - IWS00000510 LL/5 - IWS00000507 LL/6 - IWS00000503 LL/7 - IWS00000501 LL/8 - IWS00000504 LL/9 - IWS00000502 145 Monica Lokko IWS00000138 (MK/1) IWS00000141 (MK/2) IWS00000139 146 Hanife Macit IWS00000904 (HM/1-3) IWS00000685

Appendix 2: List of Witnesses 819 Witness Name Statement Reference Exhibit Reference 147 Saira Malik IWS00001087 (SM/1) IWS00000144 (SM/2) IWS00000154 (SM/3) IWS00000143 (WA/0000) IWS00000147 (WA/0001) IWS00000145 (WA/0002) IWS00000147 (WA0003) IWS00000157 (WA0004) IWS00000153 (WA0005) IWS00000146 (WA0006) IWS00000156 (WA0008) IWS00000142 (WA0012) IWS00000151 (WA0013) IWS00000152 148 Rukeyatu Mamudu (IWS1) IWS00000067 (IWS2) IWS00001221 149 Nida Mangoba (IWS1) IWS00001084 (IWS2) IWS00001145 150 Nina Masroh IWS00000792 151 Jacqueline McGrath IWS00000914 152 Paul Menacer IWS00001031 153 Ambrose Mendy IWS00001075 154 Clarrie Mendy IWS00001185 155 Sarah Mensah IWS00000590 (SM/1-3) IWS00000652 156 Oscar Millan Gonzalez IWS00001234 (OMG/1) IWS00000117 (OMG/2) IWS00000120 157 Jason Miller IWS00000495 158 Joanne Minton IWS00000284 (JM/1-2) IWS00000281 159 Sepideh Minaei Moghaddam IWS00000392 (SMM/1) IWS00000392 160 Amina Mohamed IWS00000857 161 Kim Monte IWS00000659 162 Claudia Marina Cedeno Montes IWS00001229 163 Alison Moses IWS00000301 164 Mohamed Mrimou IWS00001172 (MM/1) IWS00000196 (MM/2) IWS00000189 (MM/3) IWS00000195 (MM/4) IWS00000188 (MM/5) IWS00000194 (MM/6) IWS00000190 (MM/7) IWS00000191 (MM/8) IWS00000187 165 Peter John Murphy IWS00000675 166 Anne Murphy IWS00001126 167 Timothy Murphy IWS00001049

The Grenfell Tower Inquiry: Phase 1 Report 820 Witness Name Statement Reference Exhibit Reference 168 Jamie Murray IWS00001008 (JM/1) IWS00001012 (JM/2) IWS00001014 169 Tagwa Mutwali IWS00000942 170 Nagawa (Prossy) Nalukwago (IWS1) IWS00000009 (NPN/1,2,4-6) IWS00000009 (IWS2) IWS00001118 (NPN/3) IWS00000008 171 Siar Naqshbandi IWS00000327 172 Samera Dawlatzai-Naqshbandi IWS00000328 173 Reshad Naqshbandi IWS00000329 174 Masi Naqshbandi IWS00000334 175 Mohammed Aref Neda IWS00000880 176 Paul Norbert IWS00000667 177 David O'Connell IWS00000166 (DO/1) IWS00000167 178 Emma O'Connor IWS00000121 179 Kerry O'Hara IWS00000991 180 Sophia Olliverre IWS00000463 181 Lillian Olwa (IWS1) IWS00000856 (IWS2) IWS00001181 182 Tamora Hurjak Oni IWS00000896 183 Gitiara Pahlavani IWS00000929 184 Michael Thomas Phillip Paramasavian IWS00001003 185 Chiraag Shantilal Patel IWS00000855 186 Shantilal Naranbhai Patel IWS00000798 187 Andreia Perestrelo IWS00000349 188 Mahamad Amin Popal IWS00000884 189 Jenny Quang IWS00000766 190 Shafika Ragab IWS00000475 191 Mohammed Ragab IWS00000477 192 Layla Raihani IWS00000180 (LR/1) IWS00000180 193 Hind Raihani (IWS1) IWS00000330 (IWS2) IWS00001190 194 Adriana Ramirez IWS00001116 195 Cesar Ranito IWS00000532 (CR/1-4) IWS00000530 196 Isabel Ranito IWS00000533 197 Mohammed Rasoul IWS00000670 (MR/1-5) IWS00000669 198 Rhea Iligan Rojo IWS00000066 199 Christopher Roncolato IWS00000840 (CR/1) IWS00000836 (CR/2) IWS00000837 (CR/3) IWS00000838

Appendix 2: List of Witnesses 821 Witness Name Statement Reference Exhibit Reference 200 Rebecca Ross IWS00001036 (RSR/1) IWS00001040 (RSR/2) IWS00001044 (RSR/3) IWS00001041 (RSR/4) IWS00001045 (RSR/5) IWS00001039 (RSR/6) IWS00001043 (RSR/7) IWS00001035 (RSR/8) IWS00001033 (RSR/9) IWS00001034 (RR/10) IWS00001046 201 Viviana Rullo IWS00000161 (VR/1-VR/16) IWS00000163 202 Dawn Ryan IWS00000250 (DR/1-2) IWS00000247 203 Jean Saalabi IWS00000648 204 Rebin Sartib Sabir (IWS1) IWS00001224 (RS/1) MWP00000027 (IWS2) IWS00001237 205 Nasrin Sadat IWS00000885 206 Rawda Said IWS00000920 207 Salma Said IWS00000919 208 Yousif Saig IWS00000314 IWS00000581 IWS00000575 IWS00000580 IWS00000584 IWS00000585 IWS00000574 IWS00000579 IWS00000577 IWS00000583 IWS00000576 IWS00000578 IWS00000586 IWS00000582 209 Mohammad Samimi IWS00000298 210 Virginia Sang IWS00000773 211 Solmaz Sattar IWS00000769 212 Robert Schwillens IWS00000854 213 Mohammed Sebbar IWS00000903 214 Negeste Semre IWS00000954 215 Alejandro Serrano IWS00000853 216 Farah Serroukh IWS00000784 217 Bernard Shaw IWS00000461 218 Genet Grebremaiam Shawo IWS00001050 (GS/1-4) IWS00001050 219 Florentyna Sobieszczak IWS00000831 220 Michael Sobieszczak IWS00001111 221 Channel Spence IWS00001235 (CS/1) IWS00001235

The Grenfell Tower Inquiry: Phase 1 Report 822 Witness Name Statement Reference Exhibit Reference 222 Effi Stergiopoulou IWS00000432 223 Dougal Steward IWS00000602 224 Ivan Costa Suarez IWS00000986 225 Dorinda Encarnacion Suarez-Chans IWS00000985 226 Rita Tankarian IWS00000434 227 Gimja Tekie IWS00000992 228 Marion Telfer (IWS1) IWS00001182 (MT/1-2) IWS00001188 (IWS2) IWS00001188 229 Wintom Temesgen IWS00000382 (WT/1) IWS00000383 230 Nahom Tesfay Gebreegziabher IWS00001086 231 Yohannes Tesfaye IWS00001089 232 Selamawit Tesgay IWS00000955 233 William Thompson IWS00000158 (WT/1 -WT/5) IWS00000158 234 Ibrahim Toukou IWS00000335 235 Loris Trevisan IWS00000541 236 Ramiro Urbano (IWS1) IWS00000496 (IWS2) IWS00001207 237 Vanessa Vieiro IWS00000874 238 Walid Wahbi IWS00000113 (WW/1) IWS00000111 (WW/4) IWS00000116 239 Hannah West IWS00000021 240 Meron Woldeselassie Araya IWS00001193 (MWA/1-5) IWS00001193 241 Amina Yabajadda IWS00000785 242 Ismail Yagci IWS00000549 (IY/1-6) IWS00000547 243 Hulya Deniz Yagci IWS00000641 244 Mohamed Yahya IWS00000567 (MY/1-2) IWS00000570 245 Khadija Yahya IWS00000664 (KY/1) IWS00000665 246 Nadia Yousef IWS00000338 247 Eamon Zada IWS00000989 (EZ/1) IWS00000978 (EZ/2) IWS00000979 (EZ/3) IWS00000980 (EZ/2) IWS00000982 248 Adriana Zymberaj IWS00000878 249 CCC IWS00000478

Appendix 2: List of Witnesses 823 List of MPS witnesses MPS (called) witnesses Witness Name Statement Reference Exhibit Reference Date of Oral Evidence 1 Neil Jerome (MPS1) MET00023286 (NAJ/1) MET00023288 12.11.2018 – 13.11.2018 (MPS2) MET00023694 (NAJ/2) MET00023291 (NAJ/3) MET)0023285 (NAJ/4) MET00023294 (NAJ/5) MET00023293 (NAJ/6) MET00023290 (NAJ/7) MET00023287 (NAJ/8) MET00023292 (NAJ/9) MET00023289 2 Nicholas Thatcher (MPS1)MET00012582 (NT/1) MET00023282 12.11.2018 (MPS2) MET00023284 (NT/2) MET00023283 (MPS3) MET00023692 INQ00000209 (MPS4) MET00018201 MET00023576 MPS (read) witnesses Witness Name Statement Reference Exhibit Reference 1 Daniel Baker MET00023354 2 James Bourne MET00007706 3 John Burrows-Smith MET00007306 4 Shawn Chapman MET00012694 5 Michael Chattenton MET00023693 6 Eddy Clifford MET00023356 7 Steven Collins MET00007907 8 Rebecca Crowe MET00013132 9 Adrian Daniel MET00012695 10 Mark Dudley MET00007710 11 Francesca Elliott MET00012954 12 Andy Fairbrother MET00012698 13 Christopher Gillies MET00007711 16 Martin Hart MET00007954 17 David Heffernon MET00007832 18 Sarah Hoyle COR00000955 19 Anu Ibraham MET00012961 (ANI/1) MET00024028 (ANI/2) MET00024025 (ANI/3) MET00024029 (ANI/4) MET00024027 (ANI/5) MET00024026 20 Alice Jacobs MET00012699 21 Tony Jones MET00007915 (TJJ/1) MET00023663 (TJJ/2) MET00023662

The Grenfell Tower Inquiry: Phase 1 Report 824 Witness Name Statement Reference Exhibit Reference 22 Dan Keane MET00007916 23 Natasha Langley MET00007717 24 Darren Larder MET00007917 25 Ian McGowan MET00007718 26 Ashley Meek MET00023353 27 Iain Nicholls MET00007720 28 Anthony Neave MET00023633 29 Patrick O'Riordan MET00013130 (1st witness statement) MET00013136 (2nd witness statement) 30 Maarku Paajarvi MET00012705 31 Ross Parker MET00013134 32 Michael Pearce MET00007606 33 Graham Price MET00012967 34 Joshua Rees MET00017468 (1st witness statement) MET00017463 (2nd witness statement) 36 Ian Reeve MET00023352 (IR/1) MET00023625 (IR/2) MET00023627 (IR/3) MET00023626 37 Chris Rigg MET00012706 38 Kiran Sangha MET00007837 39 Mark Simpson MET00012581 40 Steven Spiteri MET00007610 41 Rebecca Stead MET00007925 42 Charles Stockford MET00012707 43 Philip Stone MET00013129 44 Tanya Valente MET00012801 45 Paul Warnett MET000080605 MET00018082 46 Chris Watts MET00023355 47 Graham Winch METS00020664 (1st WS) (GNW/1.1) METS00020665 MET00039532 (2nd WS) (GNW/1.2) METS00020666 (GNW/2) METS00020662 (GNW/3) METS00020663 (GNW/4) MET00039533

Appendix 2: List of Witnesses 825 List of LAS witnesses LAS (called) witnesses Witness Name Statement Reference Exhibit Reference Date of Oral Evidence 1 Paul Woodrow LAS00000009 (A) LAS00000005 13.11.2018 (B) LAS00000001 (C) LAS00000008 (D) LAS00000002 (E1)LAS00000003 (E2) LAS00000006 (E3) LAS00000007 (F) LAS000000004 LAS (read) witnesses Witness Name Statement Reference Exhibit Reference 1 Graham Barwick MET00013951 (GCB/1) MET00023193 2 Maria Conyers MET00013955 (MAC/1) MET00019057 (MAC/2) MET00019058 (MAC/3) MET00019054 3 Stuart Chrichton MET00017535 4 Jennifer Doidge MET00016783 5 Sarah Galka MET00019945 6 Andrew Godfrey MET00014994 (ANG/1) MET00023194 7 Paul Hammond MET00014408 (PRH/1) MET00023195 8 Mark Hodson MET00017061 (MH)/1) MET00023339 9 Laurence Ioannou MET00010862 (LJI/1) MET00019056 (LJI/2) MET00019059

The Grenfell Tower Inquiry: Phase 1 Report 826 Witness Name Statement Reference Exhibit Reference 10 Russell Lobjoit MET00014397 (RSL/1) MET00023199 (RSL/2) MET00023200 MET00023201 MET00023202 MET00023203 MET00023204 MET00023205 MET00023206 MET00023207 MET00023208 MET00023210 MET00023211 MET00023212 MET00023213 MET00023214 MET00023215 MET00023216 MET00023217 MET00023218 MET00023219 MET00023220 MET00023221 MET00023222 MET00023223 MET00023224 MET00023225 MET00023226 (RSL/3) MET00023198 11 Kevin Mansford MET00015659 (KWM/1) MET00023340 12 Stuart Matthews MET00013948 (SJM/1) MET00019055 13 Gayna Morris MET00016785 (GJM/1) MET00023338 14 Mifta Murad MET00014412 (MMM/1) MET00023227 15 Colin Passey MET00013950 (CAP/1)MET00019932 16 Colin Pinnington MET00012651 17 Ian Sibthorpe MET00015658 (IPS/1) MET00023228 18 Elizabeth Woodhouse MET00015657 19 Simon Woodmore MET00010781 (SPW/1) MET00019935

Appendix 2: List of Witnesses 827 List of RBKC and TMO witnesses RBKC and TMO (called) witnesses Witness Name Witness Organisation Statement Reference Exhibit Reference Date of Oral Evidence 1 Robert Black TMO TMO10048961 15.11.2018 2 Teresa Brown TMO TMO10048960 TMO00840342 16.11.2018 3 Hash Chamchoun TMO TMO10048962 16.11.2018 4 Nickolas Layton RBKC (MPS) MET00007967 (NLE/1) MET00018301 15.11.2018 (IWS) RBK00029034 (NL/1) RBK00029036 (NL/2) RBKC00029035 (NL/3) RBK00029032 (NL/4) RBK00029033 5 Michael John Scott Rumble RBKC (MPS) RBK00028988 (MJSR/1) RBK00029038 15.11.2018 (IWS) RBK00029037 (MJSR/2) RBK00004396 (MJSR/3) RBK00013294 (MJSR/4) RBK00029039 (MJSR/5) RBK00028838 6 Graham Webb TMO TMO10048963 16.11.2018 RBKC and TMO (read) witnesses Witness Name Witness Organisation Statement Reference Exhibit Reference 1 John Allen RBKC RBK00035691 (JA/1) RBK00035692 (JA/2) RBK00035693 (JA/3) RBK00035694 (JA/4) RBK00035695 (JA/5) RBK00035696 (JA/6) RBK00035697 (JA/7) RBK00035698 (JA/8) RBK00035699 (JA/9) RBK00035700 (JA/10) RBK00035701 (JA/11) RBK00035702 (JA/12) RBK00035703 (JA/13) RBK00035704 (JA/14) RBK00035705 (JA/15) RBK00035706 (JA/16) RBK00035707 (JA/17) RBK00035708 (JA/18) RBK00035709 (JA/19) RBK00035710 (JA/20) RBK00035711 (JA/21) RBK00035712 (JA/22) RBK00035713

The Grenfell Tower Inquiry: Phase 1 Report 828 Witness Name Witness Organisation Statement Reference Exhibit Reference 1 John Allen RBKC (JA/23) RBK00035714 (JA/24) RBK00035715 (JA/25) RBK00035716 (JA/26) RBK00035717 (JA/27) RBK00035718 (JA/27) RBK00035728 (JA/28) RBK00035719 (JA/29) RBK00035720 (JA/30) RBK00035721 (JA/31) RBK00035722 (JA/32) RBK00035723 (JA/33) RBK00035724 (JA/34) RBK00035725 (JA/35) RBK00035726 (JA/36) RBK00035727 (JA/38) RBK00035729 (JA/39) RBK00035730 (JA/40) RBK00035731 (JA/41) RBK00035732 (JA/42) RBK00035733 (JA/43) RBK00035734 (JA/44) RBK00035735 (JA/45) RBK00035736 (JA/46) RBK00035737 (JA/47) RBK00035738 (JA/48) RBK00035739 (JA/49) RBK00035740 (JA/50) RBK00035741 (JA/51) RBK00035742 (JA/52) RBK00035743 (JA/53) RBK00035744 (JA/54) RBK00035745 (JA/55) RBK00035746 (JA/56) RBK00035747 (JA/57) RBK00035748 (JA/58) RBK00035749 (JA/59) RBK00035750 (JA/60) RBK00035751 (JA/61) RBK00035752 (JA/62) RBK00035753 (JA/63)RBK00035754 (JA/64) RBK00035755 (JA/65) RBK00035756 (JA/66) RBK00035757 (JA/67) RBK00035758

Appendix 2: List of Witnesses 829 Witness Name Witness Organisation Statement Reference Exhibit Reference 1 John Allen RBKC (IWS2) RBK00035691 (JA/68) RBK00035759 (JA/69) RBK00035760 (JA/70) RBK00035761 (JA/71) RBK00035762 (JA/72) RBK00035763 (JA/73) RBK00035764 (JA/74) RBK00035765 (JA/75) RBK00035766 (JA/76) RBK00035767 (JA/77) RBK00035768 (JA/78) RBK00035769 (JA/79) RBK00035770 (JA/80) RBK00035771 (JA/81) RBK00035772 (JA/82) RBK00035773 (JA/83) RBK00035774 (JA/84) RBK00035775 (JA/85) RBK00035776 (JA/86) RBK00035777 (JA/87) RBK00035778 (JA/88) RBK00035779 (JA/89) RBK00035780 (JA/90) RBK00035781 (JA/91) RBK00035782 (JA/92) RBK00035783 (JA/93) RBK00035784 (JA/94) RBK00035785 (JA/95) RBK00035786 (JA/96) RBK00035787 (JA/97) RBK00035788 (JA/98) RBK00035789 (JA/99) RBK00035790 (JA/100) RBK00035791 (JA/101) RBK00035792 (JA/102) RBK00035793 (JA/103) RBK00035794 (JA/104) RBK00035795 (JA/105) RBK00035796 (JA/106) RBK00035797 (JA/107) RBK00035798 (JA/108) RBK00035799 (JA/109) RBK00035800 (JA/110) RBK00035801 (JA/111) RBK00035802 (JA/112) RBK00035803

The Grenfell Tower Inquiry: Phase 1 Report 830 Witness Name Witness Organisation Statement Reference Exhibit Reference 1 John Allen RBKC (IWS2) RBK00035691 (JA/113) RBK00035804 (JA/114) RBK00035805 (JA/115) RBK00035806 (JA/116) RBK00035807 (JA/117) RBK00035808 (JA/118) RBK00035809 (JA/119) RBK00035810 (JA/120) RBK00035811 (JA/121) RBK00035812 (JA/122) RBK00035813 (JA/123) RBK00035814 (JA/124) RBK00035815

Appendix 2: List of Witnesses 831 List of Helicopter Pilot witnesses Helicopter Pilot (read) witnesses Witness Name Statement Reference Exhibit Reference 1 Jason Appleton MET00017487 2 Colin Barker MET00007705 3 Lynne Callaghan MET00013128 4 Lucy Creed MET00013245 5 David Crisall MET00015672 6 Bradley Franklin MET00021777 MET00018084 7 Scott Glasscock MET00012957 SPG/1 MET00018156 SPG/2 MET00018147 SPG/3 MET00018136 SPG/4 MET00018152 SPG/5 MET00018153 SPG/6 MET00018143 SPG/7 MET00018137 SPG/7 MET00018137 SPG/8 MET00018142 SPG/9 MET00018140 SPG/10 MET00018146 SPG/11 MET00018145 SPG/12 MET00018160 SPG/13 MET00018139 SPG/14 MET00018141 SPG/15 MET00018151 SPG/16 MET00018144 SPG/17 MET00018148 SPG/18 MET00018138 SPG/19 MET00018158 SPG/20 MET00018157 SPG/21 MET00018149 SPG/22 MET00018150 SPG/23 MET00018154 SPG/24 MET00018159 SPG/25 MET00018155 SPG/28 MET00018172 MET00018168 MET00018173 MET00018167 MET00018177 MET00018182 MET00018180 MET00018179 MET00018181

The Grenfell Tower Inquiry: Phase 1 Report 832 Witness Name Statement Reference Exhibit Reference 7 Scott Glasscock MET00012957 MET00018165 MET00018161 MET00018166 MET00018164 MET00018171 MET00018176 MET00018175 MET00018169 MET00018178 MET00018162 MET00018170 MET00018163 MET00018184 MET00018183 MET00018185 MET00018186 MET00018188 MET00018187 MET00018189 8 Philip Hanson MET00013123 9 Simon Hepworth MET00012959 MET00018761 MET00018200 10 Gavin Holmes MET00007714 11 Andrew Hutchinson MET00012960 12 James John MET00013238 MET00018762 13 Tony Johnson MET00012962 14 Douglas MacDonald MET00013126 15 Roisin Morgan MET00021778 MET00018093 MET00018094 MET00018095 MET00018096 MET00018097 MET00018098 MET00018099 MET00018100 MET00018101 MET00018102 MET00018103 MET00018104 MET00018105 MET00018106 MET00018107 MET00018108 MET00018109 MET00018110

Appendix 2: List of Witnesses 833 Witness Name Statement Reference Exhibit Reference 16 Michelle Helen Pearce MET00023249 MET00023636 MET00023635 17 Paul Sochon MET00021776 MET00021518 MET00021517 18 Nicholas Spencer MET00007728 MET00021516 MET00018086 MET00018089 19 Shaun Turner MET00012970 MET00018127 MET00018131 MET00018113 MET00018117 MET00018122 MET00018135 MET00018124 MET00018121 MET00018126 MET00018118 MET00018129 MET00018119 MET00018116 MET00018112 MET00018133 MET00018130 MET00018114 MET00018115 MET00018132 MET00018134 MET00018123 MET00018128 MET00018125 MET00018120 20 Paul Watts MET00012891 MET00018092 MET00015676

The Grenfell Tower Inquiry: Phase 1 Report 834 List of Gas Operative witnesses Gas Operative (read) witnesses Witness Name Statement Reference Exhibit Reference 1 Pete Baynard MET00012826 MET00018454 2 Chris Cuthbert MET00012824 3 Tony Day MET00012830 4 Dave Edwards MET00007956 MET00012912 5 James Harrison MET00012831 MET00018804 MET00018311 CAD00003019 MET00018307 MET00018304 MET00018308 MET00018306 MET00018305 MET00018303 MET00018310 MET00018309 MET00018302 6 Ryan Hill MET00012829 7 Patrick Kelly MET00012836 8 Jason Knightley MET00007821 9 Neale Milam MET00012828

835 Glossary 135 ladder A ladder which is 13.5 metres in length AC Assistant Commissioner ACM Aluminium Composite Material ACP Aluminium Composite Panel ADB Approved Document B ADSU Automatic Distress Signal Unit Aerial appliance A vehicle-mounted ladder with a reach of 32 metres AFA Automated Fire Alarm ALP Aerial Ladder Platform AOM Assistant Operations Manager AOV Automatic Opening Vent Appliance Fire engine BA Breathing Apparatus BAECP Breathing Apparatus Entry Control Point BARIE Breathing Apparatus Radio Interface Equipment BCC Bridge Co-ordination Centre BECC Borough Emergency Control Centre BRE Building Research Establishment BSR Bereaved, Survivors and Residents CAD Computer-Aided Dispatch (System) CCTV Closed-circuit television CM Crew Manager CN Firefighter’s Contemporaneous Notes CP/CPs Core Participant(s) CRO Control Room Officer CSS Command Support System CU Command Unit DAC Deputy Assistant Commissioner DCI Detective Chief Inspector Department for Communities and Local Government (see MHCLG) DCLG

The Grenfell Tower Inquiry: Phase 1 Report 836 DIVOS Voice recorder which records 999 calls DPA Data Protection Act 2018 DRM Dry Rising Main DSE Dangerous Structures Engineer DVI Disaster Victim Identification ECB Entry Control Board ECO Entry Control Officer EDBA Extended Duration Breathing Apparatus Enforcer Battering ram used to break down doors EPDM Ethylene Propylene Diene Monomer (rubber) FBU Fire Brigades Union FERG Forensic Examination Reference Group FF Firefighter FRA Fire risk assessment FRS Fire and Rescue Service FRU Fire Rescue Unit, an emergency vehicle that carries specialist rescue equipment and is the only emergency vehicle to carry EDBA. It does not carry a ladder or water. FSG Fire Survival Guidance GM Group Manager GRA 3.2 Generic Risk Assessment 3.2 Halligan bar Similar to a crowbar, used to force entry by a door HART Hazardous Ambulance Response Team IC Incident Commander ICCS Integrated Control and Communications System IEC Immediate Emergency Care ITC Incident Type Code (LFB 999 operations attribute a type code to an incident which creates a pre-determined attendance, i.e. the number of appliances which are despatched) JESIP Joint Emergency Services Interoperability Principles LALO Local Authority Liaison Officer LAS London Ambulance Service LESLP London Emergency Services Liaison Panel LFB London Fire Brigade MDT Mobile Data Terminal

Glossary 837 METHANE (message) Major incident declared, Exact location, Type of incident, Hazards, Access, Number and type of casualties, Emergency services present and required MHCLG Ministry of Housing, Communities and Local Government (previously DCLG) MMA Modular Management Agreement MPS Metropolitan Police Service NILO National Inter-Agency Liaison Officer NPAS National Police Air Service (Police helicopter) NPCC National Police Chiefs’ Council OM Operations Manager ORD Operational Risk Database ORR Operational Response Report ORT Operational Review Team OSU Operation Support Unit PDA Pre-determined attendance PEG Protective Equipment Group PIR Polyisocyanurate POM Principal Operations Manager PPV Positive Pressure Ventilation PRC Performance Review of Command Pump Appliance with a 9-metre ladder Pump ladder Appliance with a 13.5-metre ladder RBKC Royal Borough of Kensington and Chelsea RCCB Residual Current Circuit Breaker RfC/RFC Request for Change RIF Reference Information File (999 call guidance for operator) RLR Recognised Legal Representative RSO Resource Support Officer RVP Rendezvous Point SAI Senior Accident Investigator SDBA Standard Duration Breathing Apparatus SIL Short Incident Log SM Station Manager SOM Senior Operations Manager

The Grenfell Tower Inquiry: Phase 1 Report 838 Tally A piece of equipment which contains a record of the name and rank of a firefighter and the amount of air in their BA cylinder. It is given by the firefighter to the ECO at the point of entry and is retrieved by the firefighter on exit. TCG Tactical Co-ordination Group TCM Tactical Co-ordination Meeting TIC Thermal Imaging Camera TMO/KCTMO Tenant Management Organisation (Kensington and Chelsea Tenant Management Organisation) TSG Territorial Support Group (a specialist unit of the MPS) Turntable ladder A vehicle with a ladder which has a reach of 32 metres. It has a detachable cage which can contain three people uPVC Unplasticised Polyvinyl Chloride URN Unique Reference Number VISION A system which records the location of an incident and despatches the nearest appropriate resources in response to emergency calls WM Watch Manager XPS Extruded Polystyrene

ISBN 978-1-5286-1602-7 (Volume 4 of 4) 4 volumes not available separately

FD05973 ｜ 2017_英国_UK_Grenfell_Tower_Inquiry_Phase_2_Report_Volume_2.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2017 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Volume 2 Part 3 – The testing and marketing of key products GRENFELL TOWER INQUIRY: PHASE 2 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 The Panel: Chairman: The Rt Hon Sir Martin Moore-Bick Ali Akbor OBE Thouria Istephan September 2024 HC 19–II

Volume 2 Part 3 – The testing and marketing of key products HC 19–II GRENFELL TOWER INQUIRY: PHASE 2 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 The Panel: Chairman: The Rt Hon Sir Martin Moore-Bick Ali Akbor OBE Thouria Istephan September 2024 Presented to Parliament pursuant to section 26 of the Inquiries Act 2005 Ordered by the House of Commons to be printed 4 September 2024

© Crown copyright 2024 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. This publication is available at www.gov.uk/official-documents. Any enquiries regarding this publication should be sent to us at contact@grenfelltowerinquiry.org.uk. ISBN 978-1-5286-5080-9 (Volume 2 of 7) 7 volumes not available separately E03165832 09/2024 Printed on paper containing 40% recycled fibre content minimum. Printed in the UK by HH Associates Ltd. on behalf of the Controller of His Majesty’s Stationery Office. This report contains content which some may find distressing.

5 Part 3 The testing and marketing of products

6

7 15.1 Safety in the built environment depends in a large measure on designers being able to assess with confidence how particular materials and products will behave when incorporated into a building. Safety from fire, therefore, depends in part on knowing how materials and products react to fire. It is therefore essential that they be tested in accordance with appropriate methods and that if manufacturers make claims about their performance they are supported by reliable information about the results of those tests. 15.2 In his Phase 1 report the chairman found that the principal reason why the flames spread so rapidly up, down and around Grenfell Tower was the presence of aluminium composite material (ACM) rainscreen panels with polyethylene cores that acted as a source of fuel. He also found that the presence of polyisocyanurate and phenolic foam insulation boards behind the ACM panels, and perhaps components of the window surrounds, contributed to the rate and extent of vertical flame spread. 15.3 One might legitimately ask how products which had such a propensity to support fire were chosen for use in the refurbishment of Grenfell Tower, whether they had been subjected to appropriate testing and, if so, whether the results of the tests had been made available to those who specified their use. In this Part of our report, therefore, we examine the way in which the products principally involved in the fire were manufactured, tested and presented to the market. We have concentrated our attention on the two products that were most heavily involved in the fire, the Reynobond rainscreen panels and the Celotex RS5000 insulation. We have also examined closely the role of Kingspan K15 insulation. Although it was not used on the building in any quantity, the way in which it was tested and marketed created conditions that encouraged unethical practices in the supply of insulation for use on high-rise buildings. 15.4 Two aspects of the way in which products are typically presented to the market have attracted our particular attention. One is the distribution of marketing literature of the kind produced by most manufacturers, in which the product and the uses for which it is suitable are described. Marketing material of that kind was produced by the manufacturers of both insulation products and we pay particular attention to what it contained and the effect it is likely to have had on potential purchasers. 15.5 The other is the use of certificates of conformity certifying that the product complies with particular standards or the requirements of legislation or statutory guidance. Such certificates are issued by commercial bodies and are used by manufacturers to provide potential customers with a form of independent assurance that their products meet appropriate standards. As such, by the time of the Grenfell Tower refurbishment they had become a powerful marketing tool. We have examined certificates of compliance issued by the British Board of Agrément in respect of Reynobond 55 PE and Kingspan K15 and by Local Authority Building Control in respect of Celotex RS5000 and Kingspan K15. 15.6 For completeness we have included a short chapter in which we examine the testing and marketing of the cavity barriers used in the refurbishment and a further chapter in which we examine the part played by the United Kingdom Accreditation Service in monitoring the activities of the conformity assessment bodies with which we are concerned. Chapter 15 Introduction to Part 3

8 The Grenfell Tower Inquiry: Phase 2 Report 15.7 Finally, we express our conclusions on the extent to which these interlocking parts of the system designed to ensure the safety of buildings, in this case from fire, failed to achieve the outcome reasonably to be expected of them.

9 16.1 As the chairman found in the Phase 1 report,1 the rainscreen panels used on the external walls of Grenfell Tower were aluminium composite material (ACM) with a polyethylene (PE) core. They acted as a source of fuel and were the principal reason why the fire spread so rapidly up, down and around the building.2 The material, which consisted of a 3mm sheet of polyethylene bonded between two 0.5mm sheets of aluminium,3 was manufactured in France and sold in the UK by Arconic Architectural Products SAS (“Arconic”)4 under the product name Reynobond 55 PE. 16.2 Arconic sold Reynobond in the form of flat panels with a view to their being cut to size and fixed to buildings in one of two ways. Riveted fixing, as the name suggests, involved fixing a flat panel of an appropriate size and shape to an underlying frame with rivets. Cassette fixing involved scoring and folding the material into an appropriate shape and hanging it on concealed rails. In either case any necessary cutting, drilling or folding was carried out by a specialist fabricator. In this case Arconic sold the material to CEP Architectural Facades Ltd (CEP), a specialist fabricator, which made it into cassettes and sold it to Harley for installation as a protective rainscreen for the facade of Grenfell Tower. The colour was described as Smoke Silver Metallic Gloss 5000. 16.3 Reynobond 55 PE ACM panels were marketed in this country from early 2008 until after the Grenfell Tower fire with the support of certificate number 08/4510 issued by the British Board of Agrément (BBA) on 14 January 2008.5 Arconic provided a copy of the certificate to Harley on 23 April 2014 specifically to support the use of Reynobond panels on the exterior of Grenfell Tower and Harley in turn passed it on to Rydon and Studio E.6 Although Arconic did not itself cut or shape the panels for either of the fixing systems, the panels were subjected to fire performance tests only in their fabricated form and the BBA certificate applied to the panels in a fabricated form. We have seen no evidence of any fire performance testing to British or European standards of Reynobond 55 PE in the form in which it left Arconic’s factory and we are not aware of the existence of any BBA (or other) certification of Reynobond 55 PE in its unfabricated form. 16.4 As the chairman concluded in the Phase 1 report, the external walls of Grenfell Tower did not comply with functional requirement B4(1) of the Building Regulations in that they did not adequately resist the spread of fire over the walls.7 In this Part of the report we examine the history of Arconic’s fire safety tests on Reynobond 55 PE, what Arconic knew about the results and how that product came to be sold in this country at the time it was specified and supplied for use on Grenfell Tower. However, before we turn to the principal events in the later chapters in this Part it is necessary to say something about the process by which we obtained evidence from Arconic. That is because that evidence was materially incomplete. 1 Phase 1 Report Volume I, paragraphs 6.11 to 6.16. 2 Phase 1 Report Volume I, paragraph 2.13(a). 3 Phase 1 Report Volume I, paragraph 6.12. 4 Previously called Alcoa Architectural Products. 5 {BBA00000047}. 6 {RYD00003932}. 7 Phase 1 Report Volume I, paragraph 26.6. Chapter 16 Arconic - evidential matters

The Grenfell Tower Inquiry: Phase 2 Report 10 The French Blocking Statute 16.5 In January 2018, DLA Piper, Arconic’s solicitors, wrote to the Inquiry to raise the issue of Article 1 bis of French Law No. 68-678 of 26 July 1968 (as modified in 1980), which is more commonly referred to as the French Blocking Statute (“the FBS”). That is a French law which provides: “Subject to international treaties or agreements and applicable laws and regulations, any individual is prohibited from requesting, seeking or disclosing, in writing, orally or in any other form, documents or information of an economic, commercial, industrial, financial or technical nature, with a view to establishing evidence in foreign judicial or administrative proceedings or in relation thereto.” 16.6 Article 3 imposes criminal sanctions for breach of the statute, which is punishable by a maximum of six months’ imprisonment or a fine or both. It extends to both natural and legal persons. The gathering of documents and witness statements 16.7 Arconic asserted that the statute prevented it from disclosing a large number of relevant documents to the Inquiry. It suggested that the Inquiry should try to reach an agreement with the French government to waive the prohibition imposed by the statute. Without conceding that the statute had the effect for which Arconic contended, in April 2018 the Solicitor to the Inquiry confirmed that there was no objection to Arconic’s representatives contacting the competent French authorities with a view to facilitating a discussion between the Inquiry and representatives of the French Ministry of Justice. 16.8 Arconic was also content that the Inquiry should work with the Metropolitan Police Service to see whether a mechanism could be found to obtain relevant documents through the concurrent criminal investigation in a way that allowed them to be shared with the Inquiry. The Inquiry team thereafter worked closely with the police to assist them in obtaining witness statements and a significant volume of relevant documents. 16.9 In 2017 and 2019, the police obtained two European Investigation Orders, which enabled them to obtain relevant documents held by Arconic at its offices at Merxheim, France and to obtain witness statements from its employees. The documents and witness statements were then disclosed to the Inquiry by the police. Arconic’s solicitors appear to have co-operated with the police in the preparation of witness statements and the police assisted the Inquiry’s investigations by putting to witnesses questions proposed by the Inquiry and by obtaining further witness statements and documents and disclosing them to the Inquiry. Obtaining evidence from Arconic’s employees 16.10 On 25 November 2019 the Inquiry indicated that it proposed to call six current or former employees of Arconic to give evidence, three of whom were resident in France (Claude Wehrle, Claude Schmidt and Gwenaelle Derrendinger), one of whom was resident in Germany (Peter Froehlich) and two of whom were resident in the United Kingdom (Deborah French and Vince Meakins). 16.11 In May 2020, Arconic told the Inquiry that it would reconsider the applicability of the French Blocking Statute to the oral evidence of those witnesses in light of the decision by the Attorney-General to extend to legal as well as natural persons her undertaking that those who gave evidence to the Inquiry would not have their evidence used against them in any future prosecution in this country.

Part 3 | Chapter 16: Arconic - evidential matters 11 16.12 In early June 2020, however, Arconic’s solicitors again asserted that the evidence of the witnesses whom the Inquiry wished to call would engage the French Blocking Statute. Those witnesses included Deborah French, Vince Meakins and Peter Froehlich, even though they were not resident in France. They suggested that the Inquiry should seek the help of Her Majesty’s Government to reach an agreement with the French Government in order to overcome the constraints of French law. As a consequence, the Inquiry sought the assistance from the Foreign, Commonwealth and Development Office to explore the possibility of an agreement between Her Majesty’s Government and the French Government that would permit the witnesses to attend to give oral evidence to the Inquiry without risk of prosecution in France. 16.13 Those discussions took a number of months and resulted in a note verbale of 7 December 2020 from the French Embassy to the Foreign, Commonwealth and Development Office, a copy of which was received by the Inquiry on 8 December 2020, which stated that it was the opinion of the French government that the proceedings of the Inquiry did not appear to fall within the scope of Article 1 bis of the French Blocking Statute and that consequently the French authorities did not consider that it constituted an obstacle to the examination of Arconic’s employees before the Inquiry. However, the note verbale also said that the statute did not confer any power on the French administration to remove a prohibition thereunder, and that the French courts alone had authority to interpret the criminal law. The note verbale did not go so far as to confer immunity from prosecution under the statute on Arconic’s witnesses because the French government said it had no power to provide that. Accordingly, although Arconic’s witnesses would have the protection of the Attorney General’s undertaking in relation to the use against them of their evidence in a prosecution in England, they would not have the benefit of any protection in respect of a prosecution in France under the French Blocking Statute, which might be infringed by the giving of any information, whether it incriminated the witness or not. 16.14 Arconic disputed the position taken by the French Government in the note verbale and relied on an opinion it had obtained from an eminent French lawyer and a senior member of the Paris Bar, Maitre Noelle Lenoir.8 16.15 It was not possible for the chairman to decide at that stage whether witnesses who gave evidence to the Inquiry might expose themselves to a real risk of prosecution under the French Blocking Statute. He therefore decided that in the first instance orders for their attendance to give evidence should be made. Notices under section 21 of the Inquiries Act 2005 were duly served on Deborah French and Vince Meakins within the jurisdiction. They instructed solicitors, accepted service of the notices and duly attended to give evidence without challenge. 16.16 Mr Wehrle, Mr Schmidt and Ms Derrendinger all live in France. Mr Froehlich lives in Germany. The position in relation to them was rather different because, having taken legal advice, the chairman was satisfied that no legal mechanism existed to compel their attendance in this country. They were all asked to attend to give evidence voluntarily, or to give evidence by video-link from abroad, but with the exception of Mr Schmidt, who gave evidence by video-link from Merxheim on behalf of Arconic rather than in a personal capacity, none of them was willing to do so, relying on the advice of their lawyers and the existence of the French Blocking Statute. It is regrettable that in the face of a disaster in which so many people died they were willing to put the debatable requirements of French law above the interests of the survivors in discovering the true 8 {ARC00000793}.

The Grenfell Tower Inquiry: Phase 2 Report 12 cause of their terrible experience. As a result, we were deprived of the opportunity to hear from Mr Wehrle, Mr Froehlich and Ms Derrendinger but we had their witness statements, the contemporaneous documents and the oral evidence of the other Arconic witnesses. Mr Schmidt initially demanded that he be allowed to give evidence only on certain conditions relating to its use, but he eventually dropped that demand and gave oral evidence in French by video-link through interpreters. 16.17 The most important by far of the absent witnesses was Claude Wehrle. As will become clear, there are many questions on which his assistance would have been of very great help to us in understanding the documents or the things he said (or chose not to say) in his witness statement, but we are satisfied that even without the benefit of hearing from him the contemporaneous documents enable us to reach clear conclusions with a high degree of confidence.

13 Chapter 17 Arconic’s testing of ACM panels 1997 to 2006 17.1 The fire testing carried out by Arconic on various forms of ACM panels between 1997 and 2006 forms an important part of the background to its application for a BBA certificate. It is also relevant to the way in which it promoted Reynobond 55 PE in the years that followed. January 1997: Reynobond 160 PE 17.2 Before the early 2000s, Arconic did not produce ACM panels with polyethylene cores. It manufactured coated aluminium sheets at its factory at Merxheim, in France, which it then sent to a sister company in the United States, Arconic Architectural Products LLC, previously Reynolds Metals Company, which bonded them to a polyethylene core made in the United States to form sheets of composite material. The finished sheets were then transported back to Arconic for storage at Merxheim.9 We understand that the product, which was sold by Arconic from Merxheim, was known as Reynobond 160 PE. It was 4mm thick and comprised a 3mm core of low-density polyethylene sandwiched between two 0.5mm aluminium sheets. 17.3 In January 1997, Reynobond 160 PE was tested by Warrington Fire Research Centre in accordance with BS 476 Parts 6 and 7 and achieved results which enable it to be rated Class 0.10 17.4 In about 2000, Arconic began producing sheets of ACM material with a polyethylene core at its Merxheim factory.11 It was sold by Arconic under the name Reynobond 55 PE.12 The reasons for changing the name of the product are not clear. There is evidence that Reynobond 55 PE was not in all respects the same as Reynobond 160 PE, or at least that the two were not directly comparable.13 In particular, the core of the product manufactured in the United States was linear low density polyethylene (LLDP), whereas the core of the material produced by Arconic in France was low density polyethylene (LDP).14 Mr Schmidt’s evidence initially was that he believed that the two products were the same but ultimately accepted that the chemical compositions of Reynobond 160 and Reynobond 55 PE were different.15 9 Schmidt {Day91/35:7-13}. 10 {ARC00000355}; {ARC00000356}; {ARC00000357}. 11 Schmidt {Day91/13:7-15}. 12 Schmidt {Day91/38:17}-{Day91/39:6}. “Reynobond 55 PE” was used when the aluminium sheets were 0.5mm. Other variants, such as Reynobond 33 PE, refer to a signage product with 0.3mm aluminium sheets. 13 Lane, Supplemental Phase 1 Report {BLAS0000011/33} paragraph 11.9.18; Lane, Phase 1 Report, Appendix O {BLAS0000036/103} paragraph O19.1.5. 14 Declaration of Kevin Juedeman {INQ00014554} (declaration from the civil proceedings against Arconic in the Eastern District of Pennsylvania, Case No 219-cv-02664-MMB) paragraphs 6, 8, 11. 15 Schmidt {Day91/12:22}-{Day91/13:15}; {Day93/10:3}-{Day93/11:10}; See also declaration of Kevin Juedeman {INQ00014554} (declaration from the civil proceedings against Arconic in the Eastern District of Pennsylvania, Case No 219-cv-02664-MMB) paragraphs 6, 8, 11.

The Grenfell Tower Inquiry: Phase 2 Report 14 17.5 There were differences between the coatings of Reynobond 160 PE and Reynobond 55 PE16 and as a result the test data relating to Reynobond 160 PE did not apply to Reynobond 55 PE.17 17.6 Mr Wehrle claimed that he had no reason to suppose that there was any material difference between the fire performance of Reynobond 160 PE and that of Reynobond 55 PE,18 but we doubt that that can be correct. There is reason to believe that both the cores and the coatings of the two products were different and we do not think that it was reasonable for him to have assumed that the reaction to fire of the product installed on Grenfell Tower was the same as that of Reynobond 160 PE, which had been tested about 20 years earlier. 17.7 In any event, it was not appropriate for Arconic to rely on test data obtained in relation to a different product when assessing the performance of Reynobond 55 PE. That much is clear from BS 476-1019 and from the wording of Warrington Fire’s report, which expressly provided that its results were applicable only to the specimens tested.20 July 2006: Colin Southgate’s warnings 17.8 On 26 July 2006, Colin Southgate, then the UK sales representative for Reynobond,21 sent an email to Guy Scheidecker (a senior executive), Gérard Sonntag, Claude Wehrle and others at Arconic about the position in relation to the fire certification of Reynobond.22 In it he pointed out that Reynobond 160 PE had been certified in 1997 and that the certificate was due to expire in 2007 at the latest. He also pointed out that the certificate did not apply to Reynobond 55 PE with either a PVdF or Duragloss coating. He then admitted that Arconic had provided certificates that did not apply to the products being sold to see if that would keep customers happy and expressed concern that it was misleading the market in certain respects. 17.9 The document shows quite clearly that by July 2006 at the latest personnel at Arconic, including senior executives, were aware that it had no valid certification of the fire performance of Reynobond 55 PE with a Duragloss 5000 finish and that its marketing materials were apt to mislead customers into thinking that some Reynobond PE products (including those with a Duragloss 5000 coating) possessed certifications that they did not have. The following day, 27 July 2006, Mr Sonntag wrote to Mr Southgate,23 explaining that Arconic had asked Warrington Fire to carry out tests on Reynobond 33 PE and Reynobond 55 FR. No steps appear to have been taken to organise tests on Reynobond 55 PE, although Arconic was aware that the UK construction industry almost invariably purchased panels with PE cores.24 16 Lane, Supplemental Phase 1 Report {BLAS0000011/30} paragraphs 11.9.1-11.9.18; Lane, Phase 1 Report, Appendix O {BLAS0000036/103} paragraph O19.1.5. 17 Lane, Supplemental Phase 1 Report {BLAS0000011/30} paragraphs 11.9.1-11.9.18; Lane, Phase 1 Report, Appendix O {BLAS0000036/103} paragraph O19.1.5. 18 Wehrle {MET00053190/14} page 14, paragraph 47. 19 That addresses ‘Fire tests on building materials and structures’ and consists of a ‘Guide to the principles, selection, role and application of fire testing and their outputs’ {BSI00001757/20}. 20 {ARC00000355/3}; {ARC00000355/5}. 21 French {MET00053162/2} page 2, paragraph 7. 22 {MET00064988/19}. 23 {MET00064988/20}. 24 Derrendinger {MET00053191/4} page 4, paragraph 17; French {Day87/67:19-24}; {Day88/195:15-16}.

Part 3 | Chapter 17: Arconic’s testing of ACM panels 1997 to 2006 15 17.10 In his statement, Mr Wehrle said that the results of the tests carried out on Reynobond 33 PE in 2006 had satisfied the requirements for Class 0.25 That gave him confidence that Reynobond 55 PE would achieve the same classification, because it had thicker aluminium skins and a proportionally lower polyethylene content.26 However, no one at Arconic explained what, if any, steps had been taken at that time to analyse the results of the tests on Reynobond 33 PE and apply them to Reynobond 55 PE. It seems unlikely that any such steps were taken but in any event the two products were different and test results on one could not be applied to the other. As Mr Schmidt accepted, the test reports relating to Reynobond 33 PE were simply irrelevant to Reynobond 55 PE.27 17.11 On 30 June 2017, in the wake of the Grenfell Tower fire, Claude Wehrle sent an email to Diana Perriah,28 the President of Arconic Building and Construction Systems in the USA, attaching what he described as a list of all relevant certifications possessed by Arconic.29 The list did not contain any reference to a test carried out on Reynobond 160 PE in 1997 or to a test carried out on Reynobond 33 PE in 2006, which suggests that Mr Wehrle did not think that either was relevant to products being sold by Arconic (including Reynobond 55 PE) at that time. In our view, his assertion that historic test data relating to Reynobond 160 PE was relevant to Reynobond 55 PE was simply an attempt to justify the sale of that product. 17.12 Indeed, the results of the separate European tests that Arconic had carried out on Reynobond 55 PE in late 2004 made it clear how that product would react to fire. Arconic knew very well that the earlier tests on other products to which we have referred above could not be relied on to market Reynobond 55 PE. We now turn to examine those tests. European testing: 2004 to 2006 December 2004: Tests 5A and 5B 17.13 In December 2004, on the instruction of Arconic, the French national testing organisation for the construction industry, the Centre Scientifique et Technique du Bâtiment (“CSTB”), conducted tests on Reynobond 55 PE in accordance with the European testing regime. The European single burning item test (EN 13823) required the product to be tested in its fabricated form, that is, in riveted or cassette form, and each test to be conducted on at least three specimens.30 The classification was derived from the mean of the results of the three samples. However, if the mean of those three results did not meet the required standard, two further specimens could be tested, in which case the highest and lowest results were excluded from consideration and the remaining three results used to determine the classification.31 On 2 December 2004 CSTB conducted two EN 13823 tests on Reynobond 55 PE, one on a panel which had been fabricated for riveted fixing (Test 5A), the other on a panel which had been fabricated for cassette fixing (Test 5B). It is important to note that from the outset in 2004 Reynobond PE 55 was always tested by Arconic in one of the two ways in which it was intended to be used, riveted fixing or cassette fixing, and never as a simple sheet of material in the condition in which it left the factory. That was 25 Wehrle {MET00053190/9} page 9, paragraph 34. 26 Arconic Module 2 Closing Submissions {ARC00000770/22} paragraph 103; Overarching Closing Submissions {ARC00000797/37} paragraph 141. 27 Schmidt {Day91/44:20}-{Day91/45:1}. 28 {META00001104}. 29 {META00001106}. 30 {BSI00000620}. See also Part 2, Chapter 5. 31 {BSI00000620/15} Section 7.

The Grenfell Tower Inquiry: Phase 2 Report 16 necessary because the single burning item test is a test on a product in the form in which it is designed to be used. If Arconic had wished to test the product in the condition in which it left the factory it could have done so in accordance with BS 476-6 and 476-7, but it did not choose to do so. That is a matter of some significance in the light of the way in which Arconic described Reynobond 55 PE to the BBA and its closing statement in the Inquiry. Test 5A 17.14 In Test 5A the riveted specimen achieved results that were, or appeared to be, consistent with European classification B-s2, d0.32 However, in April 2013, Mr Wehrle wrote in an internal email that the tests had not been “really reflective of the riveted system in general”.33 In June 2016, he wrote in another internal email that Arconic had achieved Euroclass B for Reynobond 55 PE in rivet form by manipulating the test (in his words, ““arranging” the system to pass”).34 We do not know what form the manipulation of the test took, but it seems clear that, by 2013 at the very latest, Mr Wehrle did not think that a B classification was truly representative of how the product in riveted form would typically behave. 17.15 Mr Schmidt accepted that it appeared that Mr Wehrle had known or suspected that the Euroclass B classification had not been honestly achieved.35 There is further support for the view that the test had been manipulated in the fact that the end use condition was a minimum air gap of 50mm,36 whereas in later tests it was reduced to 20mm, which was more realistic.37 Mr Wehrle’s emails to his colleagues had become very frank by 2013 and we consider that we are justified in placing a good deal of weight on what he said. We think it more likely than not that the original Test 5A for riveted panels, which was said to justify a European Class B classification, was in some respects not representative of how the product would be used in practice. The results were therefore unreliable, as Arconic was aware. Test 5B 17.16 Test 5B, in which the specimen was fixed in cassette form, was stopped after 850 seconds because the heat release rate had exceeded 400 kW.38 The test report recorded that the results could not be used but gave an idea of the way in which the product would behave in a fire.39 In his witness statement Mr Wehrle said that he understood that those words meant that Arconic could not use the result to get a classification because it “did not reflect the product’s real fire performance”40 That strikes us as an odd way to read the report. It plainly meant that the results could not be used to obtain a B classification, but that the record of what had happened during the test provided an insight into the product’s actual fire performance. 32 {ARC00000535}; {ARC00000358}. 33 {MET00064988/121}. 34 {MET00064988/129}. 35 Schmidt {Day91/76:5-9}. 36 Test 5A classification report dated 7 January 2005 {ARC00000358/4} paragraph 4.3. 37 Wehrle {MET00053190/19} page 19, paragraph 64; Email chain between Mr Wehrle and Maxine Bauer of CSTB of 1 July 2011 {MET00053158/184}. 38 {ARC00000536}. 39 {ARC00000536/7}. 40 Wehrle {MET00053190/15} page 15, paragraph 52.

Part 3 | Chapter 17: Arconic’s testing of ACM panels 1997 to 2006 17 17.17 Neither Mr Wehrle nor anyone else at Arconic attempted to discuss the result with CSTB or carry out any further tests on the product in cassette form.41 Mr Wehrle said that everyone at Arconic was puzzled by the result but justified the decision not to carry out further tests by treating it as a rogue result and therefore unrepresentative. That conclusion was based mainly on the expectation that the product in cassette form would perform better than in the riveted form product because it had fewer exposed edges. Mr Wehrle said that no one else in the industry had obtained similar results, although he admitted that his understanding was based only on information in the public domain and what he had picked up in conversation.42 The outcome was that Arconic’s marketing, technical and management teams decided that it was permissible to claim that Reynobond 55 PE was Class B, whether in rivetted or cassette form, and no further testing in cassette form was considered at that time. 17.18 In our view, Arconic had no reasonable excuse for failing to confirm by further testing that the result of the only test it had carried out on the product in cassette form was indeed unrepresentative. If it had genuinely thought that to be the case, there was every reason to carry out further tests to establish that. Moreover, the expectation that cassette- fixed panels would perform better because they had fewer exposed edges ignored the fact that the aluminium skin had to be routed in order to enable them to be bent into shape, thereby increasing the total area of the exposed core. It also took no account of other factors that had the potential to affect the product’s reaction to fire in cassette form, including its tendency to trap molten polyethylene and its greater propensity to deform and expose the core to the flame front because the skins are not mechanically fixed in place. 17.19 Mr Schmidt accepted that Reynobond 55 PE in cassette form never achieved a Class B classification.43 In any event, Arconic knew from early 2005 that the only available test evidence indicated that Reynobond 55 PE in cassette form had the potential to react to fire in an extremely dangerous way and had failed to obtain any classification under the European standards. Despite that, Arconic persisted in telling the market that Reynobond 55 PE had been classed B-s2, d0 regardless of the form in which it was used. 17.20 In the period leading up to the Grenfell Tower fire Arconic carried out reaction to fire tests on various forms of its Reynobond product. In none of them did the product satisfy the requirements of Class B and the results as a whole demonstrated clearly that Test 5B had been anything but “rogue”. Even if, contrary to our conclusion, Arconic had believed in early 2005 that the result of Test 5B was unrepresentative, by 2011 it knew very well that it was not. 17.21 Arconic did not disclose the results of Test 5B to any testing organisation, certification body or end user in the UK at any time before the Grenfell Tower fire. Mr Schmidt accepted that if the fire had not taken place it was likely that they would have remained secret.44 41 Wehrle {MET00053190/15} page 15, paragraph 52. 42 Wehrle {MET00053190/15} page 15, paragraphs 51, 53. 43 Schmidt {Day91/3:12}-{Day91/4:3}. 44 Schmidt {Day91/103:9-15}.

18 The Grenfell Tower Inquiry: Phase 2 Report 2003 and 2006 tests on Reynobond 55 FR (Riveted form) 17.22 In June 2003, Arconic arranged for Reynobond 55 with a fire-resistant core to be tested by Warrington Fire under BS 476-6 and BS 476-7. Taken together, the results of those tests were capable of supporting a national Class 0 classification for that product.45 Reynobond with an unmodified polyethylene core was not tested at that time. 17.23 In October 2006, Reynobond 55 FR in rivet form with a gold-coloured coating was tested by CSTB in accordance with the EN 13823 single burning item method and achieved a classification of B-s1, d0.46 Unsurprisingly, that was better than its PE equivalent. There is no evidence that Reynobond 55 FR was tested in cassette form at that time. 45 Warrington Fire Research Test Report 132317 (BS 476-6 test) {BBA00000053} and Warrington Fire Test Report 132316 (BS 476-7 test) {BBA00000050}. 46 CSTB – Reaction to Fire Classification Report RA06-0372 {BBA00008288}.

19 The application to the BBA: March to August 2006 18.1 By the mid-2000s, it had become commercially essential for Arconic to obtain a BBA certificate to enable it to sell Reynobond in this country. Arconic’s relationship with the BBA had begun in 1987, when the BBA issued a certificate for Reynolux, a solid aluminium cladding panel manufactured by the company under its former name of Alcoa Architectural Products S.A.S.47 In March 2004 Arconic approached the BBA to certify its Reynobond product,48 but it did not pursue the process for reasons of cost.49 18.2 At a meeting in Luton on 21 March 2006, Colin Southgate discussed the UK marketing strategy for various products, including Reynobond, with Didier Scheidecker, Sales Manager for Reynobond. In his report of the meeting50 Mr Scheidecker noted that an increasing number of enquiries related to public and private housing developments which he thought could represent 50% of the UK market in 2006.51 A BBA certificate was always required for such projects. He therefore asked whether Arconic could obtain BBA certification based on the approval by CSTB of its cassette version. (Since the test by CSTB of Reynobond 55 PE in cassette form had been a complete failure, that may have been a mistake for the riveted form.) 18.3 It seems clear, therefore, that Arconic had recognised that there was a significant potential market for Reynobond 55 PE in the UK and was intending to exploit it. It is also clear that its senior management appreciated that a BBA certificate was required in order to do so. 18.4 Arconic did not pursue its application to the BBA until 2 August 2006 when Mr Wehrle wrote again. He used the same form as on the previous occasion (wrongly dated 9 March 2004) and provided very similar information.52 The form invited Arconic to provide any available test data relating to the product and pointed out that such information could result in a reduction in the cost of the certificate and the “duration” of the contract (probably meaning the time required to produce it).53 18.5 When he completed the form, Mr Wehrle said that Reynobond was available with two cores, PE (unmodified polyethylene) and FR (fire retardant).54 He also referred to the tests carried out under BS 476 Parts 6 and 7 and referred to the Warrington Fire Centre reports.55 He attached to the application two test reports,56 each of which related to the fire retardant version of the product.57 Mr Wehrle also cited two CSTB 47 Initially issued in 1987, reissued in 2009 {BBA00008143}; Wehrle {MET00053190/42} page 42, paragraph 146. 48 BBA project number S3/35071 {MET00053158_P13/137-138}; {MET00053158_P13/139-140}; {MET00053158_P13/141-144}. 49 {MET00053158_P13/155}. 50 {MET00053158_P13/162-165}. 51 {MET00053158_P13/164} Item 5 under “BBA Approval”. 52 {MET00053158_P13/166}. 53 {MET00053158_P13/173}. 54 {MET00053158_P13/171} Section 2.1. 55 {MET00053158_P13/169} Section 1.3. 56 {MET00053158_P13/173} Section 3.1. 57 Warrington Fire Test Reports 132316 and 132317 {MET00053158_P13/173} Section 3.1. Chapter 18 Obtaining a BBA certificate for Reynobond 55 PE

The Grenfell Tower Inquiry: Phase 2 Report 20 Technical Assessments on Reynobond 55 PE, one in cassette form and the other in rivet form. They supported structural and system performance but were not relevant to any fire performance criteria recognised in the UK. 18.6 Mr Wehrle completed the application to the BBA about a week after he received Colin Southgate’s note of 26 July 200658 and his meeting with Gérard Sonntag the following day.59 He must therefore have known that Arconic did not have sufficient data to make claims about the reaction to fire of all variants and forms of Reynobond 55 and that the information he was providing to the BBA was incomplete and misleading insofar as it suggested that it applied equally to the product in its cassette form. Negotiations between Arconic and the BBA 18.7 On 23 August 2006 the BBA formally offered to assess Reynobond 55,60 but despite its view that that a BBA certificate was increasingly important for UK sales,61 Arconic did not immediately accept the offer. Following negotiations, the BBA agreed to reduce the cost of the certificate and to accept the Technical Assessments issued by CSTB as the basis for it. (The BBA and CSTB were both members of the European Union for Technical Approval in Construction (‘UEAtc’), a group of certification bodies whose assessments were generally carried out to a consistent set of standards, so that data produced by one member was acceptable to all others.)62 However, because the fire performance analyses in the Technical Assessments issued by CSTB were directed to the French national testing system rather than the British Standards applicable under the UK testing regime, the BBA also required test reports from Warrington Fire Research on the product’s fire performance. In his note of the meeting in November 2006 Mr Southgate recorded that the BBA would need certificates from Warrington Fire relating to the “PE Cores”. It therefore appears that the BBA had asked for fire test data relating to Reynobond with both unmodified polyethylene and fire-resistant cores.63 18.8 At a meeting between Arconic and the BBA at the latter’s premises on 2 November 2006, Colin Southgate of Arconic suggested that it might be better for the certificate to apply to Reynobond as a material rather than the rainscreen system as a whole, since (in the words of his note) that would enable a “cross connection to be put together”.64 The meaning of that part of his note is not entirely clear, but he seems to have been suggesting that the BBA should be asked to certify Reynobond 55 PE generally, without regard to the differences in fire performance between the rivet and cassette forms. By “cross- connection” we think that Mr Southgate had in mind that Arconic could use a certificate that did not refer to the method of fixing in relation to both the riveted and cassette forms without distinction, and in the event, the BBA eventually agreed to provide a certificate for Reynobond without linking it to any particular fixing system. It was envisaged that different fixing systems would simply be mentioned in the certificate.65 It is fair to point out that at that stage the BBA had yet to embark on an assessment of the product. 58 {MET00064988/19}. 59 {MET00064988/20}. 60 BBA project number S3/41014 {MET00053158_P14/100-101}; {MET00053158_P14/102-103}; {MET00053158_P14/104-105}. 61 {MET00053158_P14/115}; {MET00053158_P14/131}. 62 Gregorian {BBA00011096/2} page 2, paragraphs 8-9; Gregorian {Day105/27:6}-{Day105/28:3}. 63 {MET00053158_P14/115}. 64 {MET00053158_P14/115}. 65 {MET00053158_P14/131}.

Part 3 | Chapter 18: Obtaining a BBA certificate for Reynobond 55 PE 21 18.9 Warrington Fire Research had not tested Reynobond 55 PE panels in accordance with BS 476 Parts 6 or 7. It had tested only Reynobond FR in accordance with those methods, and those were the only British standard tests to which Arconic had referred in its application form.66 Arconic possessed no relevant European standard test data in relation to Reynobond 55 PE in cassette form, apart from Test 5B carried out in December 2004, in which the product performed so disastrously that the test had to be stopped.67 18.10 There is no indication that Arconic disclosed to the BBA that Reynobond 55 PE in cassette form had performed so badly or that it had reason to believe that the fire performance of the product in cassette form was significantly worse than in riveted form. On the contrary, Arconic succeeded in persuading the BBA that the certificate could properly relate to Reynobond as a generic product without distinguishing between the different fixing systems. In doing so, it deliberately and dishonestly concealed from the BBA the fact that, as Test 5B had shown, its reaction to fire was significantly affected by the fixing system adopted. 18.11 At that time, some of those at the BBA knew that altering the shape of a product could materially affect its fire performance. John Albon, then Section Head of a different department at the BBA, understood that particularly well,68 although he did not become responsible for the technical content of certificates until 2009.69 However, at the time of the negotiations with Arconic in 2006 the BBA agreed to assess Reynobond as a generic product in the form in which it left the factory, even though it knew that it would have to undergo fabrication to some extent before it could be used for the purpose for which it had been manufactured.70 At that stage no thought appears to have been given by the BBA to the fact that it might perform in different ways depending on the nature of the fabrication and the system of fixing adopted, even though separate test evidence was provided on the structural integrity of the cassette and rivet versions.71 Nor does anyone appear to have attached any importance to the fact that it was not possible to test the product’s reaction to fire in an unfabricated form in accordance with EN 13823, which would be necessary to obtain a European standard classification. 18.12 Mr Albon said that it was for the client to determine precisely what would be assessed as part of the certification process and that the BBA would not resist that unless it had good reason to do so.72 Hamo Gregorian, a Project Manager in the BBA’s engineering systems department who managed the initial assessment of Reynobond 55 and attended the meetings with Arconic in November 2006 and February 2007, told us that the BBA’s policy was generally to approve a product, such as a cladding panel, rather than a system, because the BBA could exercise more control over the quality of a product than a system.73 Mr Gregorian’s evidence, which we accept, was that assessment of fire performance for certification was not his area of expertise and that all such matters were checked by a fire expert or agreed in consultation with the BBA’s Technical Manager, Brian Haynes, who had 66 {MET00053158_P13/173}. See penultimate row in table of test data. 67 {ARC00000536}. 68 Albon {Day109/143:18}-{Day109/144:9}. 69 In 2006 John Albon was Section Head of the Materials department, but he came to be Technical Manager responsible for the technical content and correctness of all BBA certificates in 2009 and later Head of Approvals for Construction Products, Albon {BBA00010723/3} page 3, paragraphs 11-12. 70 Gregorian {Day105/58:3-20}. 71 {MET00053158_P13/173}; Gregorian {Day105/59:3-20}. 72 Albon {Day109/127:25}-{Day109/128:10}; {Day109/128:24-}-{Day109:129:2}; See also assessment flowchart which includes a step of “Suitability of product and use considered” {BBA00008042/17}. 73 Gregorian {Day105/48:5-18}; {Day105/57:16-23}.

The Grenfell Tower Inquiry: Phase 2 Report 22 relevant experience and knowledge.74 At all events, the potential effect of the different configurations on the fire performance of the product was overlooked by the BBA at that early stage in the certification process. Arconic’s contract with the BBA: March 2007 18.13 On 26 February 2007 Arconic submitted a fresh application to the BBA for certification of Reynobond 55 that was largely based on the form used in August 2006.75 In section 3 of the form Arconic was expected to set out all data relevant to the product and its use produced during the previous three years. In relation to fire performance it referred, as it had on the previous occasion, only to the results of the tests carried out by Warrington Fire in accordance with BS 476-6 and 476-7 on Reynobond 55 with a fire-resistant core.76 It made no mention of the results of any test on Reynobond with an unmodified polyethylene core. Nor did it refer to the results of any fire test which showed that there might be a difference in performance between the cassette and riveted forms of the product. However, the tests on Reynobond with a polyethylene core, in both riveted and cassette forms, that had been carried out in December 2004 fell within the three-year period contemplated by the form, with reports issued by CSTB in January 2005.77 Those omissions can only have been deliberate. 18.14 On 23 March 2007 the BBA entered into a contract with Arconic to provide certification for the product.78 In the final version of the contract handwritten amendments were made to the name of the product substituting “Reynobond Architecture” for the original reference to “Reynobond 55”. The description of the product was also changed from the original “Aluminium/polyethylene composite wall cladding system” to “Aluminium/polyethylene composite wall cladding panels” (our emphasis). That amendment reflected the agreement with Arconic that the certificate would refer to the product without identifying the system of fixing to be used.79 18.15 Under the BBA’s standard terms and conditions Arconic was obliged to disclose to the BBA full particulars of the product, including particulars of any test data already available and the test procedures used to obtain them.80 Arconic was also obliged to notify the BBA immediately of any change in the particulars supplied to it and any new or additional information it obtained concerning the product or its suitability for use.81 18.16 Under its standard terms the BBA had the power to withdraw or suspend any certificate if Arconic breached the contract terms, if there were any change in the technical specification of Reynobond, if any information became available that was not at the disposal of the BBA at the time the certificate was issued or if there were any change in its description, including its physical or chemical composition.82 74 Gregorian {BBA00011096/3} page 3, paragraph 10; {Day105/12:20-25}; {Day105/23:9-19}; {Day105/69:4-16}. 75 {BBA00008042/13-35}. 76 Tests numbered 132316 and 132317 {BBA00008042/29}. 77 {ARC00000535}; {ARC00000358}; {ARC00000536}. 78 BBA project number S3/41014 {BBA00008042/2-5}. 79 Gregorian {Day105/64:2-21}. 80 {BBA00008042/3} clause 7(a). 81 {BBA00008042/3} clause 7(g). 82 BBA Standard terms clause 13 (a)-(c) {BBA00008042/4}.

Part 3 | Chapter 18: Obtaining a BBA certificate for Reynobond 55 PE 23 Arconic’s further provision of test data to the BBA: May to November 2007 18.17 On 15 May 2007 Hamo Gregorian asked Claude Wehrle to provide reaction to fire data for the standard PE panel, by which he meant the version with an unmodified polyethylene core, and warned him that a French national classification (as used in the CSTB Technical Assessments) was not recognised in the UK.83 Mr Gregorian said that if such evidence was not available Arconic would need to arrange for further testing to be carried out. Mr Gregorian noted that fire test reports for the product with a fire-resistant core had been submitted with the application.84 However, Mr Gregorian did not ask for separate test evidence relating to the cassette form of the standard product and appears to have been content to accept the results of tests on the riveted form as applicable generally, without making it clear that they had been obtained only from tests on that particular form of the product. That was despite the fact that the classification report issued by CSTB stated that the European classification B-s2, d0 applied only to the riveted form.85 18.18 Mr Gregorian told us that he regarded the manner of fixing as irrelevant because the BBA was assessing only the product, by which he meant the product as it emerged from the factory.86 However, that was a fundamentally unsound approach, and not consistent with what the certificate stated. The BBA should have appreciated not only that the fire performance of the product could be tested only in one or other of the fixing configurations and might differ depending on which was adopted, but also that the proposed certificate would be making statements about fire performance which covered both fixing systems. In our view the BBA should not have been willing to give a certificate for the product in its unfabricated form because, as it was aware, that did not represent the condition in which it was designed to be used. As a result, a certificate that did not take into account the method of fixing was likely to be misleading in some, if not all, cases. The BBA should have been aware when it entered into the contract that the fire performance of the product might be affected by the method of fixing adopted, but if it did not, it should have become aware of that by the time it issued the certificate. 18.19 On 25 May 2007 Mr Wehrle sent Mr Gregorian a copy of the results of Test 5A.87 He did not provide the BBA with any test data relating to Reynobond 55 PE in cassette form, let alone the results of Test 5B. 18.20 Mr Wehrle sought to justify the decision not to provide the BBA with test data relating to Reynobond 55 PE in cassette form on the grounds that Test 5B related to a single sample and was not a valid classification report.88 However, Arconic’s contract with the BBA required it to disclose particulars of any test data available.89 Mr Wehrle also suggested that Arconic relied on the BBA to ask for any additional information it required,90 but that is no justification for ignoring the terms of the contract. In any event, we regard Mr Wehrle’s suggestion as disingenuous. First, in his email of 15 May 2007 Mr Gregorian had actually asked for reaction to fire data for the standard PE panel, without distinction between 83 Gregorian {Day105/95:5-10}. 84 Mr Gregorian’s reference to FR product tests in this correspondence is likely to be to Warrington’s BS 476-6 and BS476-7 testing reports from September 2003, numbers 132316 {BBA00008042/163-175} and 132317 {BBA00008042/177-191} which were cited in each of Arconic’s applications to the BBA and probably appended to them. 85 {ARC00000358/4}. 86 Gregorian {Day105/98:20}-{Day105/99:2}. 87 {MET00053158_P15/90}. 88 Wehrle {MET00053190/48} page 48, paragraph 177. 89 BBA Standard terms clause 7(a) {BBA00008042/3}. 90 Wehrle {MET00053190/17} page 17, paragraph 59.

The Grenfell Tower Inquiry: Phase 2 Report 24 riveted and cassette forms. Secondly, Arconic had not told the BBA that Arconic had tested Reynobond 55 PE in cassette form and it follows that the BBA was not aware that any such data existed. Mr Wehrle could not have understood Mr Gregorian’s request as limited to test data for the riveted form. Thirdly, Mr Wehrle described the results of Test 5A that he attached to the email he sent Mr Gregorian on 25 May 2007 as “the fire reaction certificate for our product Reynobond PE”, implying that there was only one test result. That was deliberately misleading. The reality is that Mr Wehrle withheld Test 5B from the BBA, despite its obvious importance both to the BBA and to the UK market, because it showed that the fire performance of the product when used in cassette form was very significantly worse than when used in the riveted form covered by Test 5A. 18.21 If Mr Wehrle had given evidence in person he would have had an opportunity to respond to the suggestion that he deliberately and dishonestly misled the BBA into thinking that Arconic held no results of any test of the product in cassette form. As it is, we have not had the benefit of hearing his response. Nonetheless, the evidence we have seen, which includes his statement, leaves us in no doubt that that is what he did. Our conclusion is reinforced by the fact that in none of its lengthy written or oral statements to the Inquiry did Arconic seek to suggest otherwise. 18.22 On 29 November 2007, Mr Gregorian asked Mr Wehrle to provide test data in respect of the fire performance of the back face of Reynobond 55 PE panels.91 In response, Mr Wehrle sent Mr Gregorian a report from CSTB classifying Reynolux (an aluminium sheet coated with a polyester finishing coat) under EN 13501 as Class A1.92 He justified that on the basis that similar coatings were applied to the front and back skins of Reynobond 55 PE.93 It is not clear why Mr Wehrle sought to support an application for a BBA certificate concerning Reynobond 55 PE, an ACM panel product, with test data relating to an entirely different product which was not ACM. It is possible that Arconic thought that, because BS 476-6 is the method for testing the fire propagation index of the surface of a product, there was a useful analogy between the test on Duragloss-coated aluminium and Reynobond 55 PE, or that it simply left it to the BBA to ask for further information. It is equally possible that that was another step in the deliberate concealment from the BBA of relevant fire performance test data with a view to obtaining a useful certificate from the BBA for Reynobond PE

1. We cannot reach a firm conclusion on that point, given the possibility of an innocent

explanation, but it is another matter on which Mr Wehrle’s assistance would have been helpful if he had chosen to give evidence. Drafting and issue of the BBA certificate: October 2007 to January 2008 18.23 By September 2007, Arconic, and Mr Wehrle himself, were well aware that many in the construction industry were seriously concerned about the fire safety of ACM with an unmodified polyethylene core. That knowledge ought to have led Arconic to ensure that the text of the BBA certificate was clear, accurate and complete. 18.24 Several drafts of the certificate were produced before it was issued. On 22 October 2007, Mr Gregorian provided Mr Wehrle with what was described as a “working draft” and invited Arconic to comment on its contents.94 He specifically asked Arconic to provide any information that was missing but would be helpful to the user and any proposed 91 {MET00053158_P16/134}. 92 {BBA00008042/139}. 93 {MET00053158_P16/136}. 94 {MET00053158_P15/188}.

Part 3 | Chapter 18: Obtaining a BBA certificate for Reynobond 55 PE 25 amendments to information that Arconic considered to be inaccurate. Claude Wehrle reviewed the certificate at least three times and asked Hamo Gregorian to include some specific wording.95 On each occasion, Mr Gregorian accepted Mr Wehrle’s proposed text.96 18.25 On 7 January 2008, shortly before the certificate was issued, Mr Wehrle also circulated a draft to Colin Southgate and Deborah French, Arconic’s UK sales representatives for Reynobond at the time.97 Mr Southgate proposed further text which was also incorporated into the certificate.98 18.26 The BBA certificate was issued on 14 January 2008. We consider its contents in detail in Chapter 19. For present purposes it is enough to note two features: first, that it declared that “the panels may be regarded as having a Class 0 surface in England and Wales”;99 secondly, that it expressly covered the product when used in both forms, riveted and cassette, without distinction or qualification.100 95 Claude Wehrle reviewed drafts of the certificate in October 2007 {BBA00008042/535}; November 2007 {BBA00008042/515-517} and December 2007 {BBA00008042/465}. 96 Hamo Gregorian accepted Arconic’s comments in November 2007 {BBA00008042/529} and {BBA00008042/511} and in December 2007 {BBA00008042/459-61}, {MET00053158_P16/149}. 97 {MET00053158_P16/167}; {MET00053158_P16/165}. 98 {MET00053158_P16/167}; {BBA00008042/463}. 99 {BBA00000047/3}. 100 {BBA00000047/2} Figure 1.

26 The Grenfell Tower Inquiry: Phase 2 Report

27 Chapter 19 The BBA certificate for Reynobond 55 PE The product 19.1 BBA certificate 08/4510 related to “Reynobond Architecture Wall Cladding Panels.”101 They were described as “ . . . two 0.5 mm thick aluminium alloy sheets . . . bonded to either side of a core of low-density polyethylene (LDPE).” The description continued as follows: “The panels are available either plain-edged (riveted system) or flanged (cassette system), to suit architectural requirements (see Figure 1). A Duragloss or PVDF coating available in various colours protects the exposed face. A polyester primer protects the unexposed face. The products are also available in a fire-retardant grade (FR).” 19.2 Figure 1 showed what were said to be typical fixing systems and depicted the riveted and cassette versions. Otherwise, however, the certificate referred to the panels without any distinction between the two forms of fixing. Any reader of the certificate would therefore naturally understand that the performance of the panels, whether FR or PE, was not affected by the fixing system adopted. 19.3 As will become clear, at the request of Arconic the product was described in the form in which it left the factory. That blurred the distinction between the fire performance of the panels once fabricated into either riveted or cassette forms. It was wrong to say that the panels were “available” plain-edged or flanged, which suggested that Arconic supplied them in both forms. That increased the potential for confusion. 19.4 It is clear from the discussions that took place in 2007 that that had been Arconic’s intention. What the BBA did not know, but Arconic did, was that the choice of fixing method made a significant difference to the fire performance of the product in use, as revealed by Tests 5A and 5B. 19.5 Arconic had chosen to withhold the results of Test 5B from the BBA and did not disclose that a separate test of the product in cassette form had taken place. Arconic was legally obliged under the terms of its contract with the BBA to provide it with the results of Test 5B. As a result of its decision not to do so, the BBA certificate was thoroughly misleading, because it failed to draw a distinction between the two fixing systems in relation to fire performance. Mr Schmidt was constrained to accept that the failure to make clear in the certificate that the B classification was obtained only in rivet form rendered the certificate wrong and such as to lead the reader into error.102 101 {BBA00000047}. 102 Schmidt {Day92/73:9}-{Day92/74:14}; {Day94/59:1}-{Day94/60:1}; {Day94/63:23}-{Day94/64:17}.

The Grenfell Tower Inquiry: Phase 2 Report 28 19.6 In both its evidence and its statements to the Inquiry, Arconic asserted that it was the responsibility of the designer in each case to ensure that Reynobond 55 PE was suitable for the use to which it was to be put and complied with any applicable regulations.103 That is obviously correct up to a point but it assumes that the information required to make the decision is available to the designer. The primary purpose of a BBA certificate is to provide the designer with confirmation that the information it contains provides a suitable basis for making that decision. In the present case Arconic’s argument ignores the fact that it withheld important information from the BBA and thereby caused the certificate to misrepresent the true position. Arconic knew that a BBA certificate was required to enable it to sell Reynobond 55 PE in this country precisely because designers considered it to contain reliable information about the characteristics of the product. It also knew that a designer reading the certificate would understand from the way it was worded that Reynobond 55 PE had been classed B-s2, d0 in European fire tests regardless of the fixing system adopted. Behaviour in relation to fire Section 6.1 19.7 The second sentence of section 6.1 of the certificate read as follows: “A fire retardant sample of the product, with a gold-coloured Duragloss finish, when tested for reaction to fire, achieved a classification B-s1, d0 in accordance with EN 13501 : 2002.”104 19.8 The statement was supported by CSTB classification report No. RA06-0372 issued on 19 October 2006 for Reynobond FR tested in riveted form.105 Claude Wehrle suggested that the BBA should specifically refer to this result in the certificate and the BBA agreed.106 However, like the classification report for Test 5A, the report stated in terms that the classification was applicable only to Reynobond FR in a riveted form. It is plain that it could never have been used to support a certificate for Reynobond PE, whether in riveted or cassette form. Sections 6.2 and 6.3: Class 0 19.9 Section 6.2 of the certificate provided as follows: “A fire retardant sample of the product, with a metallic grey PVDF finish, when tested in accordance with BS 476-6: 1989, achieved a fire propagation index (I) of 0 and, when tested in accordance with BS 476-7 : 1997, achieved a Class 1 surface spread of flame.”107 19.10 Warrington Fire’s test reports on Reynobond FR panels supported that statement.108 Taken together, they established that the FR version of the panels had achieved Class 0. However, Arconic had never provided the BBA with any reports which showed that Reynobond PE had achieved or could achieve Class 0. During the assessment process, Arconic sent the BBA product literature which claimed that both Reynobond FR and 103 Schmidt {MET00053187/29} page 29, paragraph 90-93; Wehrle {MET00053190/11} page 11, paragraphs 40‑41; Froehlich {MET00053197/9} page 9, paragraph 33; Derrendinger {MET00053191/16} page 16, paragraph 41; {ARC00000770}. 104 {BBA00000047/5}. 105 Report RA06-0372 {BBA00008042/155-162}. 106 {MET00055859}; {BBA00008042/515}. 107 {BBA00000047/5}. 108 Numbered 132316 {BBA00008042/163-175}; numbered 132317 {BBA00008042/177-191}.

Part 3 | Chapter 19: The BBA certificate for Reynobond 55 PE 29 Reynobond PE had achieved Class 0109 but Arconic had no evidence to support the claim made about the PE product. Arconic’s marketing brochure dated November 2005 headed ‘Discover New Perspectives’ also claimed that Reynobond PE had achieved Class 0 because of tests carried out by Warrington Fire Research in 1997,110 but reports of those tests were never provided to the BBA and, in any event, they had been carried out on a different product, Reynobond 160 PE. 19.11 At section 6.3 the certificate provided: “As a consequence of sections 6.1 and 6.2, the products may be regarded as having a Class 0 surface in relation to the Approved Document B of The Building Regulations 2000 (as amended) (England and Wales) …”111 19.12 Similar wording was contained on the front of the certificate. Under the heading ‘Key Factors Assessed’ the certificate stated as follows: “Behaviour in relation to fire – in relation to the Building Regulations for reaction to fire, the panels may be regarded as having a Class 0 surface in England and Wales… (see section 6).”112 19.13 This important part of the BBA certificate requires detailed consideration taking into account the evidence of the BBA, the statements of Mr Wehrle and the submissions of Arconic. The BBA’s evidence 19.14 John Albon said that the words “may be regarded as having a class 0 surface” were not intended to mean that the panels actually achieved that standard; they simply reflected the position in Diagram 40 of Approved Document B in which both Euroclass B and Class 0 materials were permitted for use on external walls of buildings over 18 metres in height. He also told us that by using those words the BBA was not intending to suggest that Euroclass B was equivalent to Class 0. It was known within the BBA that the concepts were different and could not be used interchangeably.113 Brian Haynes, who had been involved in testing and technical assessment at the BBA since 1973 and who by 2008 was the very senior head of a technical group with a broad portfolio, said something similar in his evidence.114 19.15 John Albon also told us, and the BBA argued,115 that the certificate had to be read in full, and that a reader who considered sections 6.1 and 6.2 carefully would understand that the BBA had no evidence that Reynobond PE panels had achieved Class 0 through BS 476-6 and 476-7 testing. However, he did accept that the wording was “poor”.116 We think that the wording was not merely poor but misleading and (on Arconic’s part) deliberately so for the reasons we have examined in earlier chapters. 109 Product Information brochure dated January 2005 {BBA00008042/39-81}; fire classifications {BBA00008042/43}; Discover New Perspectives marketing brochure dated November 2005 {BBA00008042/83-104}; fire classifications {BBA00008042/101}. 110 These were tests 70707 and 70708 {BBA00008042/83-104}; fire classifications {BBA00008042/101}. 111 {BBA00000047/5}. 112 {BBA00000047/1}. 113 Albon {BBA00010723/18-19} pages 18-19, paragraphs 66-77; Albon {Day110/6:6-17}; {Day110/7:3-6}. 114 Haynes {BBA00010784/6} page 6, paragraphs 26-28. 115 Albon {Day110/7:20}-{Day110/8:6}; BBA closing statement {BBA00011297/17} paragraph 52. 116 Albon {Day110/7:8-11}.

The Grenfell Tower Inquiry: Phase 2 Report 30 19.16 In the section headed “Regulations” the certificate stated that in the opinion of the BBA, the panels, if used in accordance with the provisions of the certificate, would meet or contribute to meeting functional requirement B4(1) of the Building Regulations because they were judged to meet the Class 0 requirements. Someone reading that statement and the statement on the first page of the certificate that the panels might be regarded as having a Class 0 surface might well have been led to understand that the BBA itself had considered the relevant data and had come to the opinion that Reynobond PE did achieve Class 0. 19.17 The expression “may be regarded as Class 0” appears in BBA certificates relating to other cladding panels. John Albon told us that the BBA had tried to ensure some consistency of expression between certificates for products with similar properties,117 but it is clear that the expression was not used in the same way in all cases. In some cases the phrase “may be regarded as … Class 0” was used when the BBA had evidence of testing in accordance with BS 476 Parts 6 and 7 which satisfied the definition of Class 0 in Approved Document B.118 In other cases the expression was used when test evidence satisfying the definition was not available for a panel of one particular colour but was available for the same panel in another colour.119 In yet other cases the expression was used where there was evidence of classification as Euroclass B, apparently because of the equivalence implied by Diagram 40 of Approved Document B (although that was not stated in terms).120 19.18 In our view the BBA ought to have made a greater effort to avoid giving the impression that Diagram 40 indicated an equivalence between national Class 0 and Euroclass B. We note that the certificate issued in August 2017, shortly after the Grenfell fire, did not use the expression.121 Mr Wehrle’s statements 19.19 Mr Wehrle said that he could not remember whether he had read through the BBA certificate but that he had not been aware of its contents in any detail until after the fire.122 However, the evidence shows unequivocally that he was intimately involved in the negotiations with the BBA leading to its production and must have been aware of its contents in so far as they concerned matters such as fire performance.123 19.20 However, despite his close involvement, Mr Wehrle did not comment at the time on the statement that Reynobond 55 PE might be regarded as having a Class 0 surface.124 He said that he had no specific knowledge of the UK Building Regulations, including Diagram 40 in Approved Document B,125 although he was prepared to say that the BBA and others regarded Diagram 40 as allowing European Class B to be treated as equivalent to national Class 0.126 However, there is no evidence that Mr Wehrle raised the question with the BBA. 117 Albon {Day109/111:13-22}. 118 For example, certificate 10/4746 for Alupanel XT cladding panels {BBA00000113}. 119 For example, certificate 13/5022 for Stacbond PE and Stacbond FR Cladding Systems {BBA00000067}; Albon {BBA00010723/28} page 28, paragraph 111; Albon {Day110/13:4-15}; {Day110/l14:10-14}. 120 For example, certificate 06/4367 for Bauclad External Cladding Panels {CEP00050243/5}; certificate 08/4551 for Larson and Larson FR Wall Cladding Panels {BBA00000144}; certificate 12/4901 for Vitrabond Aluminium Composite Rainscreen Cladding Panels {BBA00000074}. 121 {BBA00000046}. 122 Wehrle {MET00053190/16} page 16, paragraph 55. 123 Claude Wehrle reviewed drafts of the certificate in October 2007 {BBA00008042/535}; November 2007 {BBA00008042/515-517}; December 2007 {BBA00008042/465}. 124 {BBA00000047/1} section 6.3. 125 Wehrle {MET00053190/16} page 16, paragraph 55. 126 Wehrle {MET00053190/16} page 16, paragraphs 55 and 56.

Part 3 | Chapter 19: The BBA certificate for Reynobond 55 PE 31 19.21 Mr Wehrle also drew attention to the results of tests on another Arconic product, Reynobond 33 PE.127 Arconic submitted that they were relevant because they supported the conclusion that Reynobond PE could achieve Class 0.128 However, Reynobond 33 PE had different physical properties which makes comparison inappropriate, as is borne out by the fact that no one drew those tests to the attention of the BBA. As with most such reports, the reports of the tests on Reynobond 33 contained an explicit warning that they could not be applied to any other product.129 19.22 Arconic also submitted that it could not be blamed for the BBA’s decision in the absence of applicable test data to treat European Class B as equivalent to national Class 0 and to state that Reynobond 55 PE could be regarded as having a Class 0 surface.130 Like Mr Wehrle, Arconic suggested that Diagram 40 of ADB permitted one to extrapolate national Class 0 from the existence of European Class B,131 but that is not possible because the nature of the tests and the standards they apply are quite different.132 The note to Diagram 40 states (admittedly less clearly than it might) that Class B and Class 0 are not equivalent. In any event, Arconic knew very well that there was no relevant test data under either classification system to support such a statement in relation to Reynobond 55 PE in cassette form. 19.23 In our view the expression “may be regarded as having a Class 0 surface” should not have been used. In the absence of test data satisfying the Class 0 requirements for the PE version of the panels the BBA ought not to have proposed it and Arconic should not have allowed it to be included in the certificate. It was not appropriate for the BBA to treat Diagram 40 in Approved Document B as permitting it to treat European Class B as equivalent to Class 0, but if that was the basis of the statement, it ought to have been clearly explained. Although we consider that any reasonably competent construction professional relying on the certificate ought to have read it in full and should not have relied on the statements about Class 0 in isolation,133 the BBA and Arconic must both bear responsibility for the inclusion in the certificate of that misleading statement. Section 6.3: the unexposed face of the product 19.24 The final sentence of Section 6.3 stated: “The unexposed side of the products may also be regarded as having a class 0 surface”.134 19.25 That wording reflected a question which had arisen towards the latter stages of the assessment process and posed a significant problem for Arconic. The BBA considered that it needed reaction to fire test data for the back of the product as well as the face.135 In the event, the BBA accepted test results from Arconic’s Reynolux product as evidence that the coating on the back of Reynobond panels would perform at least as well as that on the front.136 Consequently the BBA agreed to state in the certificate that the unexposed face of Reynobond panels might “also be regarded as having a class 0 surface”.137 127 Wehrle {MET00053190/9} page 9, paragraph 34; Wehrle {MET00053190/14} page 14, paragraph 46. 128 Written closing submissions on behalf of Arconic {ARC00000770/22} paragraph 103. 129 For example {ARC00000366/7}; {EXO00001960/7}. 130 Written closing submissions on behalf of Arconic {ARC00000770/16} paragraph 76. 131 Written closing submissions on behalf of Arconic {ARC00000770/6} paragraph 29(2). 132 See Part 2, Chapter 5. 133 Hyett {Day64/149:2}-{Day64/150:7}; {Day64/151:8-15}; {Day64/160:1-6}. 134 {BBA00000047/5}. 135 {BBA00010701/5}; {BBA00010701/1}. 136 {MET00053158_P16/136-137}; {BBA00008042/525-527}; classification report RA07-0182 {BBA00008042/139-145}. 137 {BBA00000047/5}.

The Grenfell Tower Inquiry: Phase 2 Report 32 19.26 In coming to that conclusion, the BBA initially sought advice from Dr Sarah Colwell of BRE,138 but before it could be provided Mr Gregorian indicated that, following the receipt of further information from Arconic, the BBA no longer required its assistance.139 In circumstances where the BBA was dealing with claims about Reynobond’s fire performance and recognised that its own expertise was limited, it should have taken advice from a body such as BRE which had expert knowledge of testing and fire performance. We consider that it was remiss of the BBA not to seek that advice when the Reynobond certificate was first drafted. 19.27 BS 476 Part 7 requires testing to be carried out on the complete product because the performance of the surface may be affected by the underlying material. It was wrong, therefore, for the BBA to accept results obtained from testing Reynolux, which is a solid aluminium panel, as representative of Reynobond, which is a composite panel. Section 6.4: colour 19.28 Section 6.4 of the certificate drew attention to the fact that the fire performance of the products described in sections 6.1 and 6.2 might not be achieved by other colours.140 Hamo Gregorian added what had become a standard warning to the certificate on the advice of John Albon.141 It was the BBA’s policy that reaction to fire testing was colour- specific, and so a BBA certificate would cover only the colours that had actually been tested.142 John Albon said that was because he had been advised that colour might make a difference to a product’s fire performance.143 However, there is no evidence that anyone at the BBA considered whether that might be so in the case of Reynobond 55. Accordingly, the BBA considered that the certificate applied only to Reynobond with a grey/green Duragloss 5000 coating, a gold-coloured Duragloss finish, and a metallic grey PVDF finish and no others.144 All other variants of the product would need a separate test or assessment. The BBA ought to have alerted Arconic to that narrow approach during the assessment process. However, the wording is sufficiently clear to have told Arconic that the certificate only covered, or might only cover, the colours and finishes specified, and that it was not able to support the sale of the product in any other colour or finish. 19.29 For its part, Arconic did not treat the BBA certificate as applicable only to the three colours and finishes to which it referred. In the case of Grenfell Tower, for example, Ms French on behalf of the company used it to support the sale of a wide range of colours,145 including those ultimately chosen, namely, “Smoke Silver” and “Pure White”, neither of which was covered by the certificate.146 Arconic used the certificate to support the sale of all its Reynobond 55 panels in the UK without qualification as to colour. Ms French said that she had not been aware that only specific colours and finishes received the classifications stated in the BBA certificate, having never discussed the matter with Arconic.147 If that is true, then Arconic must be blamed for not ensuring that its sales representative was properly informed about the narrow scope of application of the BBA certificate. If, on the other hand, she was aware of those limitations when she provided the certificate to 138 {BBA00008042/505-507}. 139 {BRE00047592}; Colwell {Day233/67:12}-{Day233/68:3}. 140 {BBA00000047/5}. 141 {BBA00010693}. 142 Albon {BBA00010723/27} page 27, paragraphs 104-109; Albon {Day110/22:15-25}; {Day110/26:2-13}. 143 Albon {Day110/25:11-22}; {Day110/26:2-13}; {BBA00010693}. 144 BBA Closing Submissions {BBA00011297/25} paragraph 77; BBA Module 2 Closing Submissions {BBA00011296/9-10} paragraph 27-28. 145 Email from Deborah French to Mark Harris of Harley dated 23 April 2014 {RYD00003932}. 146 {ARC00000552}; {ARC00000553}. 147 French {MET00053162/4} page 4 paragraph 18; French {MET00053162/16} page 16, paragraphs 56 and 57.

Part 3 | Chapter 19: The BBA certificate for Reynobond 55 PE 33 Harley on 23 April 2014 before the colour of the panels had been chosen, she would, or at any rate should, have warned Harley that the certificate did not cover other colours, including those that she knew were being considered, such as smoke silver and white.148 She did not do so. Section 6.5: resistance to fire 19.30 Section 6.5 of the certificate warned that with regard to resistance to fire, the performance of a wall incorporating the product could be determined only by tests carried out by a suitably accredited laboratory.149 The wording, which can be found in other BBA certificates relating to cladding products,150 also appears to have been standard. 19.31 Arconic submitted that the effect of section 6.5 was that readers of the certificate were given no assurance about the product’s resistance to fire when incorporated into an external wall, the performance of which would have to be assessed by full-scale testing in accordance with BS 8414.151 By stating that the product had achieved European Class B-s2, d0 the BBA was merely identifying the standard to which Reynobond PE was capable of performing.152 19.32 We were not impressed by that argument. Resistance to fire and reaction to fire are fundamentally different concepts and therefore testing resistance to fire (as addressed by testing to BS 476-20 to 476-24) necessarily involves methods different from those used to test reaction to fire.153 Reaction to fire tests are designed to measure the ease with which a material can be ignited, surface spread of flame, the rate of heat release and the production of smoke, whereas ‘resistance to fire’ tests are designed to measure the ability of an element of construction to contain fire, including its ability to protect a frame from collapse and to restrict the spread of smoke.154 BS 8414 is an entirely different kind of test, being designed to test the reaction of an entire wall system to fire.155 19.33 Section 6.5 therefore did not qualify the statements about reaction to fire made elsewhere in the certificate, including in sections 6.1 to 6.3, and there is no support for Arconic’s submission that all construction professionals should have known that a separate large- scale test was necessary before the product could be used in an external wall. 148 {RYD00003932}. 149 {BBA00000047/5}. 150 For example, certificate 06/4367 for Bauclad External Cladding Panel {CEP00050243/5}; certificate 08/4551 for Larson and Larson FR Wall Cladding Panels {BBA00000144/5}; {BBA00000143/6}; certificate 10/4746 for Multipanel’s Alupanel XT Cladding panels {BBA00000113/5}; certificate 13/5022 for Stacbond PE and Stacbond Cladding Systems {BBA00000067/9}; certificate 15/5245 for Ash & Lacy Building systems Alucobond façade cladding systems {BBA00000120/10}. 151 Module 6 closing statement {ARC00000794/16} paragraph 51; Overarching closing statement {ARC00000797/19} paragraph 68. 152 {ARC00000797/27-28} paragraphs 99-104. 153 Namely those listed in BS 476 Part 10, Guide to Principles, Selection, Role and Application of Fire Testing and their Outputs, being BS 476 Parts 20-24 {BSI00001757/5}. 154 BS 476 Part 10, section 4 {BSI00001757/13-14}. 155 BS 476 Part 10 separates full scale tests from “resistance to fire tests” see Foreword at (b) for fire resistance tests and “Miscellaneous” for full scale testing {BSI00001757/5}; Appendix B of ADB also distinguishes between resistance to fire and reaction to fire tests; Resistance to fire is assessed by tests such as BS-476-20 and EN 13501 parts 2 to 4) {CLG00000224/119}; Reaction to fire is assessed by those tests which for example combine to make up the EN 13501-1 classification {CLG00000224/121}.

The Grenfell Tower Inquiry: Phase 2 Report 34 19.34 In any event, even if section 6.5 should be understood to mean that the fire resistance of a wall incorporating the product was outside the scope of the certificate, that was of no interest to a potential buyer of the panel who simply wanted to know whether Reynobond, as a product, complied with the guidance in Approved Document B in relation to buildings over 18 metres in height. The BBA certificate was a product certificate, and section 12.6 and Diagram 40 of Approved Document B are directed to products, not systems.

35 Chapter 20 Subsequent testing and marketing of Reynobond 55 PE The Fred-Roderick Pohl presentation: September 2007 20.1 In September 2007, while Arconic was in the process of obtaining a BBA Certificate for Reynobond 55 PE, Gérard Sonntag, Arconic’s Marketing Manager, and Didier Felder, its Area Sales Manager, attended a number of presentations organised by a metal and plastic distributor in Oslo. They included a presentation by Fred-Roderick Pohl, who had been invited by a manufacturing company, Otefal GmbH, for which he acted as a consultant. 20.2 In his report of the trip, Mr Sonntag recorded that Mr Pohl had explained the extreme danger presented by the use of ACM PE on residential buildings, comparing the combustibility of 5,000m2 of ACM PE to that of a truck containing 19,000 litres of oil, and drawing attention to the fact that even greater danger was posed by the toxic smoke emitted by burning polyethylene, which could kill in two or three minutes.156 It is quite possible that Mr Pohl was not entirely independent and was seeking to advance the benefits of pure aluminium by decrying the fire safety of ACM, but even making allowances for that, his presentation was graphic and, more importantly, was taken seriously by Mr Sonntag. Mr Sonntag had been particularly concerned by Mr Pohl’s hypothetical question of what would happen if “one building made out [of] PE core is in [a] fire and will kill 60 to 70 persons, what is the responsibility of the ACM supplier?”.157 Mr Sonntag’s own recommendation in the light of that presentation was that Arconic ought to assess the financial consequences of selling only Reynobond with an FR core and in that case introduce a program of cost reduction to enable the FR version to be manufactured at the same cost as the PE version. 20.3 We have seen the slides from the presentation given by Mr Pohl,158 which do indeed draw attention specifically to the combustibility of ACM PE159 and the toxicity of the fumes emitted by burning polyethylene.160 They also illustrate past fires in buildings covered in ACM cladding around the world, and refer specifically to the UK testing regime under BS 476.161 Mr Sonntag also mentioned that Mr Wehrle had shown him a copy of a similar presentation made by Mr Pohl some two months previously. We have been unable to identify that document but have no reason to doubt what he said. 20.4 Despite those clear warnings and Mr Sonntag’s reaction and recommendation, there is no evidence that anyone at Arconic took steps to examine the safety of Reynobond 55 PE or to ascertain the financial consequences of selling only panels with a fire-resistant core. However, shortly after Mr Sonntag made his report Arconic launched a project to reduce 156 {META00001953/2}. 157 {META00001953/3}. 158 {MET00081029}. 159 {MET00081029/4}. 160 {MET00081029/14}. 161 {MET00081029/16}.

The Grenfell Tower Inquiry: Phase 2 Report 36 the cost of Reynobond FR to that of Reynobond PE in response to increasing demand for a fire-resistant product.162 Despite various efforts over the ensuing years, however, the price of the fire-resistant version was never brought down to that of the unmodified version.163 20.5 In the light of Mr Sonntag’s report, we think it is clear that by late 2007 Arconic had become aware that there was serious concern within the industry about the safety in fire of ACM panels with an unmodified polyethylene core (ACM PE) and had itself recognised the danger they posed. However, there is no evidence that Arconic took any steps to withdraw the sale of that product in the UK in the months and years that followed. On the contrary, not only did it continue to manufacture and sell ACM PE, it also sought to exploit what it perceived to be a weak regulatory regime in the UK while withholding from the market relevant information about the product’s fire performance. That contrasts with the position in other countries, such as France, where, in 2016, Arconic insisted that its sales team specify only Reynobond 55 FR. Internal and external communications: 2009 – 2010 20.6 On 17 July 2009, Mr Wehrle wrote to Claude Schmidt, Guy Scheidecker and Robert Quattrocchi (Arconic’s plant manager) attaching some photographs of a building in Romania clad in ACM PE panels that had suffered a serious fire.164 Mr Wehrle wrote that the photographs demonstrated how dangerous ACM PE could be when it came to architecture.165 20.7 On 16 March 2010, a sales executive, Isabel Moyses, wrote to Mr Scheidecker and Mr Wehrle, amongst others, telling them that a competitor had had to recommend fire- resistant panels for use in Spain because its standard ACM PE product did not have the classification of B-s3, d2 required under Spanish law.166 She said, however, that Reynobond PE panels could still be used because they had achieved a classification of B-s2, d0. When he responded the following day, Mr Wehrle surmised that the competitor had based its view on tests of the product carried out in cassette form, which he acknowledged produced results much less favourable than those carried out on products in riveted form. He pointed out that in cassette form Reynobond PE did not meet European Class B, a matter, he said, that “we have to keep as “VERY CONFIDENTIAL!!!!”. 20.8 Mr Scheidecker’s response later the same day was much shorter: “[t]his shouldn’t even have been mentioned”.167 20.9 None of those emails were exhibited to Mr Wehrle’s statement and he did not refer to them in any way. Since he did not give evidence, we have not had the benefit of any explanation of their contents he might have been able to give, so we are left to interpret them at face value. In our view they demonstrate clearly that by March 2010 Arconic was aware that the fire performance of ACM PE panels in cassette form was generally considerably worse than in riveted form and that test data relating to panels in riveted form did not apply to panels in cassette form. They also support the conclusion that the results of Test 5B had not been “rogue” results and that Arconic knew that any suggestion that Reynobond PE 55 in cassette form had achieved, or could achieve, Euroclass B was false. Finally, we think they show that Arconic was deliberately and dishonestly concealing from 162 Schmidt {MET00053187/14} page 14, paragraph 40. 163 Schmidt {MET00053187/14-15} pages 14-15, paragraph 44. 164 {MET00053158_P10/125}. 165 {MET00053158_P10/122}. 166 {MET00064988/125}. 167 {MET00064988/125}.

Part 3 | Chapter 20: Subsequent testing and marketing of Reynobond 55 PE 37 the market the true position in relation to Reynobond PE in cassette form. We were unable to invite Mr Wehrle to respond to those inferences, but Mr Schmidt was asked to do so and agreed that that had been the case.168 20.10 In July 2010 a customer asked Ms Moyses for certification of the fire performance of Reynobond 55 PE in cassette form.169 She told him that Arconic had fire certification only for the riveted form, but that “soon” the cassette system would be better. Her message (written in English) is not entirely easy to understand, but when reporting to Mr Wehrle she said that she had told the customer that since the riveted form was the most unfavourable system, the certificate was acceptable for the cassette system. It seems, therefore, that her message had been intended to give the customer the impression that the cassette version performed better in fire than the riveted system. If so, that directly contradicted the results of Test 5B and the position as understood by Mr Wehrle. When the customer insisted on a certificate relating to the cassette form,170 Ms Moyses asked Mr Wehrle to “take care of it”.171 Mr Wehrle told her that it was hard to commit anything to writing on the subject because, as he put it, Arconic was “not clean”. 20.11 Mr Wehrle did not say in his witness statement what he had meant by the expression “not clean”, but we think he must have been referring to the fact that Arconic had no certificate for Reynobond PE in cassette form and that its use of the certificate relating to riveted panels to support the use of cassette-fixed panels was not straightforward. Mr Wehrle’s frankness with his own colleagues suggests that they knew as much as he did and that he had nothing to hide from them. 20.12 On 5 July 2010, Mr Wehrle wrote to the customer attaching what he described as “the document concerning the system we choose for the Reynobond PE fire certification”.172 It was a letter written by Mr Wehrle himself, in which he said: “Reynobond PE, is classified B-s2, d0 in accordance with the European standard EN 13501. This test was done on the riveted system, which expose the core of the material to the flame contrary to the cassette system where the core is protected by the returns. Alcoa decided to check the behaviour of its composite panels in this worst case of system (exposed fasteners on flat panels) and to use it for all the other systems.”173 20.13 The assertion that Reynobond PE in cassette form would behave better in a fire than in the riveted form tested was not only false but was known by Mr Wehrle to be false. It demonstrates his willingness to resort to deliberate dishonesty in order to support the sale of the product for use in cassette form. Mr Schmidt, who was the only person who could be asked about it, accepted that Mr Wehrle had lied to the customer.174 168 Schmidt {Day93/51:8}-{Day93/55:21}. 169 {MET00053158_P04/3}. 170 {MET00053158_P04/2}. 171 {MET00053158_P04/2}. 172 {MET00053158_P04/4}. 173 {MET00053158_P04/5}. 174 Schmidt {Day93/66:1-3}.

The Grenfell Tower Inquiry: Phase 2 Report 38 Further testing and review CSTB Testing: June 2010 20.14 CSTB performed further tests of Reynobond 55 PE in riveted form in June 2010 and reported the results in February 2011. The grey riveted specimens tested achieved a classification of B-s1, d0, which was better than the results of Test 5A in 2005.175 However, it appears that the result was unlikely to be representative of the end use of Reynobond 55 PE, because, among other things, the sample tested included a backing board of calcium silicate to simulate a 50mm air gap behind the panel.176 (Test 5A had also had an air gap of 50mm.) 20.15 In subsequent correspondence with CSTB, Mr Wehrle agreed that the panel should be tested with a 20mm air gap between it and the insulation to reflect the way it was used in practice177 and in his statement he acknowledged that variations in testing methods, such as the use of different insulation products and air gaps, were likely to influence the results.178 We do not know who was responsible for determining the test method or how the width of the air gap might have affected the outcome. However, when Reynobond 55 PE in rivet form was tested again in later years, it failed to achieve Class B. CSTB testing of Reynobond 55 PE in cassette form: 2011 20.16 In late March 2011 Mr Wehrle decided to find out what was the best classification that Reynobond 55 PE in cassette form could obtain on the basis of Test 5B. On 29 March 2011 he wrote to the CSTB enclosing Test 5B and asked whether the cassette fixing variant could be classified as European Class D. 20.17 In May 2011 Mr Wehrle arranged for CSTB to test Reynobond 55 PE in cassette form and classify it under EN13501. On 29 June 2011 CSTB wrote to Arconic and said that, as had happened in 2004, the single burning item test had been stopped early because the heat emitted by the sample had been too great.179 In response to his request for an F classification, he was told by CSTB that if the product were tested under the ISO 11925 single flame source test180 it might be granted an E classification. Arconic duly instructed CSTB to conduct a further test of the product pursuant to ISO 11925 (on a small flat sample of the panel), which, when the specimen performed adequately, necessarily led to a classification of the product as Class E.181 20.18 Mr Wehrle said that the tests enabled him to understand that cassette-fixed panels were not safer than riveted panels because molten polyethylene from the core could collect in the internal ledges of the cassette and cause a ‘flash-over’.182 He claimed to have wanted a classification report for the product in cassette form because he had a potentially different understanding of the behaviour of the cassette variant.183 As we have said, however, we think that Mr Wehrle was aware well before 2011 that the product performed worse in cassette form than in riveted form. On any view he certainly knew that by June 2011 at the very latest. 175 RA11-0032 classification report of 9 February 2011 {ARC00000383}; Test report of 9 February 2011 {ARC00000537}. 176 {ARC00000537/6}. 177 {MET00053158/184}. 178 Wehrle {MET00053190/19} page 19, paragraph 64. 179 {MET00053158/172}. 180 See Chapter 5. 181 {ARC00000538}; {ARC00000386}. 182 Wehrle {MET00053190/18} page 18, paragraph 63. 183 Wehrle {MET00053190/18} page 18, paragraph 63.

Part 3 | Chapter 20: Subsequent testing and marketing of Reynobond 55 PE 39 The first BBA review: February – July 2011 20.19 The BBA certificate was due to be reviewed at three-yearly intervals and, having been issued in 2008, its first review was therefore due in 2011. The BBA opened a review project in August 2010 under a new contract with Arconic which incorporated the original terms and conditions, including one which required Arconic immediately to notify the BBA of any new or additional information concerning Reynobond or its suitability for use.184 It was signed by Mr Schmidt for Arconic in December 2010.185 20.20 Between February and June 2011, the BBA asked Arconic for documents relevant to the review and, on 11 April 2011, Arconic provided it with a pack of documents186 precisely as requested.187 However, none of the documents that Arconic sent concerned the fire performance of Reynobond 55 PE in cassette form and no one at Arconic informed the BBA of the results of Test 5B. That was a striking omission in light of the contract terms, given that only two weeks earlier Mr Wehrle had sent the report of Test 5B to CSTB asking it to classify the product in cassette form as European Class D. 20.21 On 24 June 2011, the BBA confirmed that the certificate remained valid until 2014.188 The report was sent to Mr Wehrle on 1 July 2011,189 only two days after he had been informed that CSTB’s most recent test of Reynobond 55 PE in cassette form had been stopped early and could not produce a classification.190 20.22 Nonetheless, there is no evidence that Mr Wehrle or anyone else at Arconic took any steps to inform the BBA of those results or gave any thought to whether the reliability and accuracy of the BBA certificate might be affected by the latest information about the fire performance of Reynobond 55 PE in cassette form. Mr Wehrle sought to explain that omission by saying that it simply did not occur to him that it might be necessary to provide the BBA with that recent test data.191 That explanation is not plausible, however, given Mr Wehrle’s keenness to re-test the product in cassette form only a few days earlier in the knowledge that it could achieve at best a European Class E. We also reject his assertion that the product would have achieved Class 0 if it had been tested again under BS 476.192 In fact, the standard version of the panel had never been tested under BS 476 Parts 6 and 7 and had never achieved a national Class 0 classification. The chances of a product which could achieve no better than European Class E obtaining a Class 0 classification were slim.193 On any view, the results of CSTB’s latest tests were plainly relevant to the BBA’s review of the certificate and Mr Wehrle should have provided them to it or alerted others at Arconic of the urgent need to do so. Arconic’s failure to provide the BBA with information relating to the recent testing of the product in cassette form was entirely consistent with its deliberate failure to provide the BBA with information about Test 5B when it was preparing the 184 {BBA00008042/3} clause 7(g). 185 {BBA00008044/11}. It appears to have been signed by Claude Schmidt. 186 {BBA00008044/33}. 187 {BBA00008044/79}. 188 {MET00053158_P16/174}. 189 {MET00053158_P16/179}. 190 {MET00053158/172}. 191 Wehrle {MET00053190/17} page 17, paragraph59. 192 Wehrle {MET00053190/17} page 17, paragraph 59. 193 As is explained in Part 2 Chapter 7, the UK Government’s RADAR 2 report of 26 May 2000 {CLG00000951}, which was commissioned to find the appropriate transposition point between Euro classes and UK national classes, settled on Class B. Only one product achieved both Class E and Class 0 {CLG00000951/4}. That report was not in the public domain and not available to Claude Wehrle.

The Grenfell Tower Inquiry: Phase 2 Report 40 original certificate. It was all part of a strategy on the part of Arconic to conceal from the BBA the fact that Reynobond 55 PE in cassette form had never achieved Class B but had in fact performed significantly worse. 20.23 Some months later, in November 2011, Mr Wehrle did tell a Spanish customer that Reynobond 55 PE cassettes were certified as Class E, which the customer described as being “close to spontaneous combustion”.194 If Mr Wehrle was willing to disclose to his Spanish customer the true classification of Reynobond 55 PE in cassette form, the only reason he can have had for concealing that information from the BBA was a desire to withhold it from the UK market, a conclusion that is supported by the events described below. Concentrating on the UK market: July 2011 20.24 On 5 July 2011, a week after the disastrous test by CSTB and five days after receiving confirmation that the BBA certificate remained valid, Mr Wehrle attended a meeting in Freiburg, Germany, with Peter Froehlich of Arconic and Frank Ritter of Alucobond, one of Arconic’s competitors.195 In his report Mr Wehrle set out the results of the tests carried out on Reynobond 55 in riveted and cassette form (which in the case of Reynobond 55 PE in cassette form was Class E) and noted that Class B was the minimum requirement for a facade in Europe. He continued: “For the moment, even if we know that PE material in cassette has a bad behaviour exposed to fire, we can still work with national regulations who are not as restrictive. … Some countries (Spain …) are already working with EN 13501 standards, and the PE in cassettes is no more usable there.”196 20.25 He also acknowledged that it would be very difficult for Reynobond 55 PE in cassette form to pass a test under BS 8414.197 20.26 It is plain that by the summer of 2011 Arconic was well aware that Reynobond 55 PE when fabricated in cassette form performed much worse in a fire than in riveted form and was considerably more dangerous. Nonetheless, it was determined to exploit what it saw as weak regulatory regimes in certain countries (including the UK) to sell Reynobond 55 PE in cassette form, including for use on residential buildings. 20.27 In May 2012, Claude Wehrle attempted to discuss the European classification of Reynobond 55 PE with Claude Schmidt and Peter Froehlich with a view to deciding what information to give to the market.198 We have seen no reference to any such discussion in the documents, although in his statement Mr Wehrle said that it had been agreed that reference to Class B should be removed from marketing material as it no longer accurately reflected the position.199 He said that the sales team in each jurisdiction was to be told that Reynobond 55 PE in cassette form was Euroclass E, but there is no evidence that anyone in the UK was told that at the time. 194 {MET00053158_P04/54}. 195 {MET00053158_P04/26}. 196 {MET00053158_P04/35}. 197 {MET00053158_P04/36}. 198 {MET00053157/287}; {MET00053157/290}. 199 Wehrle {MET00053190/28} page 28, paragraph 96.

Part 3 | Chapter 20: Subsequent testing and marketing of Reynobond 55 PE 41 20.28 As far as we can see, the only step that Arconic took at that time in recognition of the true fire performance of Reynobond 55 PE in cassette form was to remove from its marketing literature the claim that Reynobond 55 PE200 was Class B.201 We think that that almost imperceptible change was designed to ensure that Arconic no longer made any positive claim for the fire performance of Reynobond 55 PE while not alerting the market to its dangers or to the fact that earlier claims that it was Class B could no longer be relied on. 20.29 Arconic claimed that CSTB openly published all test results on its website,202 but the evidence of that was limited, particularly about the time of any publication. CSTB did publish summaries of results (but not the test or rating reports which were confidential to the customer) and would always ask the manufacturer in advance of publication.203 The earliest evidence we have been able to find is that on 22 July 2013, Claude Wehrle told a colleague that she could find the technical opinion relating to Reynobond on the CSTB website.204 Having regard to that description and the link that Mr Wehrle provided, that appears to have referred to an opinion relevant to the French national classification system. The first date on which a reference to the European classifications for Reynobond PE 55 appeared on the CSTB website was 5 December 2014.205 That is consistent with Mr Wehrle’s own evidence that, in late December 2014, Arconic did not refuse CSTB’s proposal to publish the results.206 Accordingly, the earliest that European classifications were likely to have been available on the CSTB’s website was late 2014. However, that does not assist Arconic. It is entirely unclear how a UK entity would know that it should consult data published by a French testing house in order to obtain current results of reaction to fire tests. In any event, none of that explains why Arconic did not provide the information to the BBA, why it did not explicitly refer to the classifications in its marketing materials, or why it did not routinely disclose the classifications of Reynobond 55 PE to all UK purchasers. The Tamweel Tower fire: November 2012 20.30 On 18 November 2012, a fire occurred at the Tamweel Tower in Dubai, which was clad in ACM PE rainscreen panels. Senior representatives of Arconic discussed the fire in an exchange of emails on 28 November 2012. An Arconic product had not been used in that case, but Mr Wehrle pointed out that all polyethylene composites react in the same way.207 Mr Schmidt accepted that he had seen the emails at the time and that it was known within Arconic that all ACM PE products burned in the same way.208 Nonetheless, as Mr Schmidt accepted, Arconic took no action in response.209 The Al Hafeet fire and the monitoring of projects 20.31 On 22 April 2013, there was a fire at the Al Hafeet tower in Dubai, which was clad with ACM PE rainscreen panels. In response to that fire, on 9 May 2013 Alucobond, one of Arconic’s competitors, sought to allay its customers’ concerns by confirming that it offered 200 {ARC00000388/5}. 201 {ARC00000378/3}. 202 Arconic Module 2 closing submissions {ARC00000770/1} page 1, paragraph 5; Arconic Module 2 closing submissions {ARC00000770/15} page 15, paragraph 65; Arconic Module 2 closing submissions {ARC00000770/24} page 24, paragraph 119. 203 Bonhomme {METCSTB00000105/12-13} pages 12-13. 204 {MET00053158_P04/130}. 205 {MET00053158_P02/62}. 206 Wehrle {MET00053190/21} page 21, paragraph 70. 207 {MET00053157/28}. 208 Schmidt {Day94/14:13-16}. 209 Schmidt {Day94/15:4-18}.

The Grenfell Tower Inquiry: Phase 2 Report 42 ACM with a fire-resistant core as standard.210 The message was sent by Richard Geater, Alucobond’s sales agent for UK and Ireland,211 and quoted a colleague’s description of the extreme flammability of ACM panels with unmodified PE cores that were then widely used in Dubai in the interest of saving cost. 20.32 The message was sent to Deborah French, Arconic’s UK sales representative, a few minutes later. On 10 May 2013 she passed it on to Mr Froehlich, Mr Wehrle, Mr Flacon, and Mr Schmidt and asked for their comments so that she could communicate with their customers.212 The fact that she chose to include Mr Schmidt, Arconic’s president, shows how important she regarded it. Ms French said that she had discussed with Arconic’s managers whether it should make the same offer to its customers but was told that it would not do so, at least in part for commercial reasons.213 We understand that to mean that Arconic would have had to charge more for the fire-resistant panels or would have made a smaller profit if it had sold them at the price it charged for the unmodified version. Mr Schmidt did not accept that version of events214 but he offered no other explanation and we accept Ms French’s account. Arconic did not consider phasing out ACM PE in favour of the fire-resistant version then, or indeed later, because, according to Mr Schmidt, it needed time to think about it.215 Although Mr Wehrle continued to warn about the risks associated with unmodified ACM panels, Arconic’s senior management does not appear ever to have seriously considered withdrawing the product from the UK market at any time before the Grenfell Tower fire. 20.33 Indeed, Arconic decided to adopt a different course. A few days later, on 13 May 2013, Ms French wrote to a number of fabricators, including CEP.216 She referred to the recent fire at the Al Hafeet tower and offered them the following assurance: “Regarding the supply of Reynobond in the UK, as you know we supply both PE and FR core and can control and understand what core is being used in all projects due to the controlled supply route we have. By only supplying Reynobond to a very small group of Approved Fabricators and working very closely with them on all projects we are able to follow what type of project is being designed/developed and then offer the right Reynobond specification including the core. At this stage we will continue to offer both PE & FR core and continue the close working relationship we have with our Approved Fabricators to make sure the right technical support, Reynobond Specification and Materials are being used and installed on Reynobond Projects.” 20.34 In her witness statement, Deborah French said that the way in which the finished product was assembled and whether it complied with the relevant regulations were matters for the customer or designer.217 However, that was clearly not consistent with what she had said in her email of 13 May 2013, as she realistically accepted.218 Although she said that that email did not correctly reflect Arconic’s position and had been badly drafted and that we should accept what she had said in her statement,219 we think that the truth is more 210 {MET00053157/48}. 211 Richard Geater was employed by 3A Composites GmbH, the sales agent for Alucobond. 212 {MET00053157/47}. 213 French {Day89/49:22}-{Day89/53:12}. 214 Schmidt {Day94/21:19-22}. 215 Schmidt {Day94/21:17-18}. 216 {CEP00049717}. In 2014 CEP fabricated and supplied the Reynobond 55 PE cassette panels to Harley for installation on Grenfell Tower. 217 French {MET00053162/12} page 12, paragraph 44. 218 French {Day88/103:3-5}. 219 French {Day88/98:3-12}; {Day88/100:25}-{Day88/101:7}.

Part 3 | Chapter 20: Subsequent testing and marketing of Reynobond 55 PE 43 complicated. Ms French’s email, which may have reflected advice from Arconic personnel in Merxheim,220 contained clear statements that Arconic knew the details of every project on which its products were used within its controlled supply routes and would ensure that the products supplied for use on those projects were suitable for their intended purpose. It was true that Arconic often did know for which projects its Reynobond products were destined and in many cases what form they would take, since those facts were sometimes recorded on Arconic’s customer database (as the sale of Reynobond 55 PE to Harley for use on Grenfell Tower shows).221 Accordingly, Arconic was often in a good position to judge whether a particular product was suitable for a given project. Certainly, in the case of Grenfell Tower, Arconic did have a certain amount of relevant knowledge. However, it was not true that it intended to advise the fabricator, designer or customer whether the products were safe or suitable for use on any project. On the contrary, it expected the customer and designer to look after themselves. The purpose of Ms French’s message was to persuade customers to continue to buy Reynobond PE in the expectation that it would tell them if it was unsuitable for the use to which they intended to put it, although in fact it had no intention of doing so. Supply by Arconic for use at Grenfell Tower 20.35 In Part 6, Chapter 55 we have described how Reynobond 55 PE cassettes came to be supplied for the refurbishment of Grenfell Tower. The story confirms that Arconic often knew for which UK projects its products were bound, knew how they were likely to perform and whether they were safe for the intended use, but did not offer any relevant advice or warning to the designer or customer. So far as concerns Grenfell Tower, Arconic made no attempt to ensure that Harley knew about the performance of the product it supplied for the refurbishment. 20.36 Ms French was aware that Grenfell Tower was a high-rise building222 because on 24 January 2013, she was sent several drawings relating to the project that showed that it involved a tall building.223 Moreover, during the course of the project she arranged for the supply of several samples of Reynobond 55 PE panels to Grenfell Tower, including a mock-up for the RBKC planning department.224 It was also clear to her by August 2014 at the latest that ACM PE panels in cassette form were going to be used.225 She said that she did not think about the height of any building for which Arconic supplied its products,226 but in the light of her email of 13 May 2013, that seems unlikely. For her, however, it was enough that the product had a BBA certificate.227 Given that, by her own admission, that is all Ms French cared about, it was essential for Arconic, for whom she was selling Reynobond 55 PE, to ensure that the statements in the BBA certificate about fire performance and regulatory compliance were correct. That was all the more so if what she had said in her email of 13 May 2013 was to be taken at face value. 220 Froehlich {MET00053197/20} page 20, paragraph 57.1.2; French {Day88/88:23-25}; {Day88/90:14-19}. 221 See Part 6, Chapter 55; Record of customer database for Grenfell Tower, indicating the form was to be cassette: {MET00019920/31}. 222 French {Day88/66:21-23}. 223 {CEP00048962}, attaching {CEP00048966}. 224 {MET00019919}; {SEA00014518}; {SEA00014456}; {MET00053159/161}. 225 French {Day88/66:18-24}; {Day88/184:6-12}. 226 French {Day88/66:18}-{Day88/69:3}. 227 French {Day88/68:20}-{Day88/69:3}.

The Grenfell Tower Inquiry: Phase 2 Report 44 20.37 Ms French accepted that in the case of the Grenfell Tower refurbishment she had worked closely with the fabricator and the installer. It was therefore exactly the kind of project that she had described in her email.228 Despite that she said that she did not have sufficient knowledge to give advice about the risks of using the product in cassette form and did not make any recommendation about it.229 She did not seek advice about it from anyone else at Arconic because she assumed that others involved in the project would consider them.230 20.38 Arconic itself must take responsibility for the use of Reynobond 55 PE on Grenfell Tower because it knew that the sale of the product had been obtained on the basis of the BBA certificate which it was well aware gave a misleading impression of the way in which the product in cassette form reacted to fire. Further testing and classification: 2013 to 2014 20.39 By February 2013, Mr Wehrle was aware that there was potential for confusion in the market about the different fire performance classifications of Reynobond PE in cassette and riveted forms, since the former was Class E and the latter Class B.231 The FR product was also Class B. He therefore sought to obtain a lower classification for Reynobond 55 PE in riveted form in order to differentiate more clearly between the PE and FR products to assist marketing the FR product. He asked CSTB whether the PE product in both cassette and riveted form could be given a single classification.232 When testing progressed in July 2013, Claude Wehrle told CSTB that Arconic wanted both forms of Reynobond 55 PE to be classed D.233 It is not clear whether he discussed that strategy with anyone in the senior management team at Arconic. 20.40 CSTB duly tested Reynobond 55 PE again in July 2013 in both riveted and cassette forms. On that occasion, the riveted specimen achieved only Class C-s2, d0. As on both previous occasions, the test of the product in cassette form had to be stopped early because of what CSTB described as “widespread ignition”.234 Again, CSTB advised Arconic that the cassette form could be certified as achieving only Class E. The Class C result for the riveted form was not recorded in a classification report at the time. 20.41 Shortly afterwards, Arconic decided that all its Reynobond 55 PE products would be certified as Class E only and that revised classification for both cassette and riveted forms of the product was reflected in a report of CSTB dated 31 January 2014.235 That was almost exactly the time at which potential contractors were producing their final bids for the refurbishment at Grenfell Tower based on the NBS Specification which included Reynobond 55 PE as a possible rainscreen panel. All forms of Reynobond PE panel were now Class E and accordingly it was unlikely that any external wall on which they were used would comply with functional requirement B4(1) of the Building Regulations. 228 French {Day88/183:11-23}. 229 French {Day88/184:13-18}. 230 French {Day89/4:2-8}. 231 Wehrle {MET00053190/19} page 19, paragraph 65. 232 Wehrle {MET00053190/19} page 19, paragraph 65; {MET00053158/189}. 233 {MET00053158_P02/10}. 234 {MET00053158_P02/38-39}. 235 {MET00053158_P04/135}.

Part 3 | Chapter 20: Subsequent testing and marketing of Reynobond 55 PE 45 Claude Wehrle’s message of 3 February 2014 20.42 On 3 February 2014, all of Arconic’s sales staff (including Ms French) were told by Mr Wehrle that all Reynobond 55 PE products had been classified Class E, that the historic Class B classification for the riveted form could no longer be used and that all previous classification reports were immediately cancelled.236 20.43 Ms French received the email and read it,237 but did not discuss it with anyone and did not pass the information on to any of her customers.238 She plainly should have done so, as she herself accepted,239 and she was unable to explain why she had failed to do so.240 She was aware that others in the sales team at Arconic had done so,241 and she understood that the effect of Mr Wehrle’s message was that Reynobond 55 PE was not as safe as had previously been thought.242 Ms French was clearly willing and able to consider the fire performance of Arconic’s products and to discuss it with her clients or to refer any questions to Mr Wehrle’s technical sales support team. Curiously, she accepted that her failure to pass on the information had not been due to an oversight, although she insisted that it had not been deliberate.243 She said that she had not appreciated its importance because she understood that the relevant classification in the UK was Class 0 and she did not understand the relevance of European classifications to the UK market.244 Her assertion was at odds, however, with the fact that the BBA certificate contained positive statements about the product’s European classification which were plainly wrong in light of Mr Wehrle’s email. Moreover, even if the details of the different testing regimes had eluded Ms French, she must at least have understood that any information about the fire performance of Reynobond 55 PE was likely to be of interest to customers in the UK and that they ought to be given it. 20.44 We think that Deborah French took the view that the change in the European classification of Reynobond PE did not matter as far as the UK market was concerned because Class 0 was all that was required in the UK for regulatory purposes. We also think that the existence of the BBA certificate was sufficient in her eyes and that she did not consider it her responsibility to worry about whether a change in the product’s European classification might affect it. 20.45 The BBA certificate, however, remained unchanged. Arconic did not tell the BBA about the revised classification or invite it to reconsider the certificate in so far as it related to Reynobond 55 PE. Mr Schmidt sought to explain that as an oversight,245 but we think that unlikely. It must have been clear to some within Arconic, not least Mr Wehrle, that the change in classification was important information that undermined the existing certificate, which, as a result, would be likely to mislead anyone thinking of using Reynobond 55 PE in either form. Given the importance of the BBA certificate to sales in the UK and the close involvement of Mr Wehrle in its original production, we cannot accept that the failure to inform the BBA was the result of a simple oversight. 236 {MET00053158_P04/134}. 237 French {Day88/138:2-3}. 238 French {Day88/140:7-9}. 239 French {Day88/155:14-16}. 240 French {Day88/148:8-15}. 241 {MET00053159/282}. 242 French {Day88/149:5-9}. 243 French {Day88/155:18-19}. 244 French {MET00053162/13} page 13, paragraph 48.2; French {Day88/141:9}-{Day88/142:24}. 245 Schmidt {Day94/43:11-15}.

The Grenfell Tower Inquiry: Phase 2 Report 46 20.46 It remains an open question why Mr Wehrle went to the trouble of telling his sales force in different countries about the change of classification and instructed them not to represent Reynobond PE 55 as being Class B, and yet took no steps to contact the BBA to ask it to qualify or amend the certificate to reflect that fact. Whatever the explanation, however, the fact is that it was risky for Arconic to leave the BBA certificate in circulation in the UK market unamended, since designers would be very likely to continue to rely on it; and Mr Wehrle must have appreciated that risk. 20.47 Although she had been in close communication with Harley about the supply of Reynobond panels for the Grenfell Tower project since 2013, Ms French did not tell it about the revised European classification of Reynobond 55 PE or suggest that it might use the fire-resistant version instead. On the contrary, on 23 April 2014, some two months after having received Mr Wehrle’s instruction on 3 February 2014, she sent Harley a copy of the BBA certificate without comment.246 That amounted to a clear invitation to accept everything it said at face value. 20.48 Ms French told us that she had not thought that the BBA certificate might be unreliable because she had not made a connection between it and Mr Wehrle’s email.247 We do not accept that. In our view, she must, or certainly should, have recognised that a significant reduction in the European classification of Reynobond 55 PE might affect the statements made in the BBA certificate. By sending Harley a copy of the BBA certificate without any qualification she led it to think that Reynobond 55 PE was classified as European Class B and might therefore be regarded as achieving national Class 0, when that was not the case.248 20.49 Deborah French was clearly at fault in failing to pass on the substance of Mr Wehrle’s message to her customers in the UK and in using the BBA certificate without qualification to support the sale of Reynobond 55 PE. On receipt of that message, she should have told potential customers of the change of classification and should have drawn their attention to the availability of the fire-retardant version and the benefits of using it. Claude Wehrle, who was aware how dangerous the product could be in cassette form, was at greater fault in failing to ensure that the BBA was informed of the change in classification, as required by the contract, and in failing to instruct Arconic’s sales representatives in the UK not to promote Reynobond 55 PE without drawing that change of classification to the attention of customers. 20.50 Arconic had initially been reluctant to recognise that Reynobond 55 PE reacted far worse to fire in cassette form than in riveted form, and was therefore much more dangerous, and had induced the BBA to issue a certificate that masked the difference in performance. As regulatory requirements in European countries became more restrictive, it sought to take advantage of jurisdictions in which regulatory requirements were less stringent to continue selling the product with an unmodified polyethylene core for use in both cassette and riveted form without distinction relying, in the case of the UK, on the support of the BBA certificate. Its commercial strategy strongly suggests that neither the failure of Ms French to pass on important information to her customers nor the failure of Mr Wehrle to give that information to the BBA was the result of an oversight. We are satisfied that they reflected a sustained and deliberate strategy by Arconic to continue selling Reynobond 246 {CEP000000281}. 247 French {Day88/162:2-21}. 248 French {Day88/165:4-23}.

Part 3 | Chapter 20: Subsequent testing and marketing of Reynobond 55 PE 47 55 PE in the UK based on a statement about its fire performance that it knew to be false. Deborah French’s failure to pass on important information to her customers, wittingly or unwittingly, supported Arconic’s strategy. The Lacrosse Fire: November 2014 20.51 In the evening of 24 November 2014 there was a fire at the Lacrosse Building in Melbourne, Australia. A report of the fire circulated among several employees of Arconic, including Alain Flacon, Claude Wehrle and Gwenaelle Derrendinger, between April and June 2015.249 It is clear that Mr Wehrle read the report because, on 18 June 2015, he sent it to CSTB, describing it as “very interesting”.250 20.52 The report expressed a number of concerns about the use of ACM PE in high-rise buildings. It stated that the fire was directly attributable to the facade of the building and noted the “speed and intensity of the fire spread”.251 It also included descriptions of other cladding fires around the world, including those at the Mermoz Tower in France in 2012, the three other fires in the UAE in that year, and the Torch Tower fire in Dubai on 21 February 2015,252 all of which had been attributed to the use of ACM PE in the facade. 20.53 The report contained a further clear warning to Arconic of the dangers of using ACM PE in high-rise residential buildings, but although Arconic was aware that ACM with an unmodified polyethylene core was flammable, it took no action in response.253 The BBA review: 2013 – 2015 20.54 Another review of the BBA certificate began in October 2013. By January 2015 the BBA had made at least twelve attempts to contact Arconic in writing to establish whether it had any new information that might be relevant.254 On 18 July 2014 Mr Wehrle was asked to provide, amongst other things, written confirmation that there was no new information that would invalidate the certificate.255 We deal with that in more detail in Chapter 21. 20.55 As we have explained, Arconic was aware in July 2014 that Reynobond 55 PE was not classified as Class B in any form and that the BBA certificate was therefore no longer correct. However, Arconic failed to respond to the BBA’s requests for information and allowed the existing certificate to remain in circulation. Although the classification had been extended for five years and Reynobond 55 PE in rivet form had achieved Class B in 2010, Arconic knew by early 2014 that that test could not be relied on to sell Reynobond 55 PE for use in either form, hence Mr Wehrle’s message of 3 February 2014. We return to that point in more detail in Chapter 21. 249 {MET00053159/404}; {MET00053158_P10/183}. 250 {MET00053158_P11/113}. 251 {MET00053158_P11/139}. 252 {MET00053158_P12/144}. 253 Schmidt {Day93/33:1-7}; {Day94/14:13-16}; {Day94/15:19}-{Day94/16:1}; {Day94/16:11-19}. 254 {MET00053158_P17/182-186}. 255 {MET00053158_P17/182}.

The Grenfell Tower Inquiry: Phase 2 Report 48 Further testing by CSTB: October to December 2014 20.56 Further tests were carried out on Reynobond 55 PE in late 2014. On 4 December 2014 CSTB issued a report classifying the panels in riveted form as Class C256 and on the same date, at the request of Arconic, it reissued a report classifying the panels in cassette form as Class E.257 However, Arconic did not report those test results to the BBA or ask for its certificate to be revised or withdrawn. Testing of Reynobond 55 PE with a black core: 2015 20.57 In 2015, Arconic changed the colour of the core of Reynobond 55 PE from translucent to black. It then instructed CSTB to undertake a single new test of the product in riveted and cassette forms. The riveted form retained its C classification258 and the cassette form retained its E classification.259 The results of those tests were not provided to the BBA. Arconic’s involvement in the supply of Reynobond 55 PE for use at Grenfell Tower: 2015 20.58 Earlier in this chapter and elsewhere in the report260 we have covered the events by which Deborah French dealt with CEP and Harley in selling Reynobond 55 PE for use on Grenfell Tower. Ms French left Arconic at the end of 2014 and was replaced by Vince Meakins in May 2015.261 In the interim, Arconic’s sales to the UK were managed by Peter Froehlich assisted by Gwenaelle Derrendinger, an administrative sales assistant.262 20.59 On 3 March 2015, Ms Derrendinger sent a formal quotation to CEP for the supply of Reynobond 55 PE for use on Grenfell Tower.263 The order was confirmed on 18 March 2015.264 Ms Derrendinger said that, although she could not recall whether she had discussed the type of core with CEP, unless she had been asked to quote for the FR version she would have quoted for the PE version, since it was a UK project.265 Even as late as March 2015, therefore, Arconic’s marketing strategy in the UK was to sell ACM with a PE core unless an FR core was specifically requested. 20.60 At that time the panels in cassette form had a European Class E reaction to fire classification. There can be no doubt that Arconic understood that the panels it supplied for use at Grenfell Tower would be used in cassette form: Deborah French was herself aware of that fact and, in any event,266 Arconic’s client database had included that information from at least April 2014.267 Nobody at Arconic made any attempt to tell CEP, Harley or anyone else working on the Grenfell Tower project that the panels in cassette form were Class E. 256 {ARC00000397}; {MET00053158_P05/155}. 257 {MET00053158_P02/119}; {ARC00000395}. 258 {ARC00000402}. 259 {ARC00000405}. 260 See Part 6, Chapter 55. 261 French {MET00053162/3} page 3, paragraph 12; Meakins {MET00053164/2} page 2, paragraph 5. 262 Froehlich {MET00053197/11} page 11, paragraph 39. 263 {MET00053161/27}. 264 {ARC00000010}; {MET00053161/28}; {MET00053161/40}; {ARC00000149}. 265 Derrendinger {MET00053191/36} page 36, paragraph 104. See also Derrendinger {MET00053191/35} page 35, paragraph 100, in connection with orders placed by Booth Murie that also resulted in quotations for panels with PE cores. 266 French {Day88/173:5-15}; {CEP000000443}. 267 {MET00053159/86}; {MET00019920/31}.

Part 3 | Chapter 20: Subsequent testing and marketing of Reynobond 55 PE 49 20.61 Mr Froehlich attended meetings with Harley and CEP in 2014268 at which the Grenfell Tower project was discussed and was sent several emails relating to the project, including those relating to orders for Reynobond 55 PE that were placed between March and October 2015.269 Mr Froehlich acknowledged that he had been aware that the product supplied to Grenfell Tower was Reynobond 55 PE.270 20.62 Mr Meakins candidly accepted in his oral evidence that he had been aware for a year before the fire at Grenfell Tower that ACM PE should not have been used on tall buildings because it was dangerous.271 Arconic had been well aware of that from the outset, particularly in relation to panels in cassette form, but failed to disclose that information to anyone working on the refurbishment. Mr Meakins himself did not play a part in the supply of ACM PE panels for the Grenfell Tower refurbishment project. Arconic’s reaction to cladding fires overseas: 2015 and 2016 Fire at the King Fahd Medical Centre in Riyadh: October 2015 20.63 On 10 October 2015, a fire occurred at the King Fahd Medical Centre in Riyadh, a high-rise building that was clad in Alucobond FR rainscreen panels. Mr Wehrle was told about the fire on 16 October 2015, when he was sent three photographs showing the damage to the building.272 In response he expressed the view that the panels had performed very well and that the fire would have spread over the entire height of the tower if the panels had had an unmodified polyethylene core. 20.64 Mr Wehrle clearly understood that ACM PE panels were likely to contribute to the spread of flame when used on high-rise buildings and were much more dangerous than the fire-resistant version. Indeed, his comment reflects the opinion he had voiced in an internal email on 29 June 2015 that ACM PE was dangerous and that Arconic should move to selling only the FR product as a matter of urgency.273 That warning appears to have fallen on deaf ears among Arconic’s senior management. The Address, Dubai: 31 December 2015 20.65 On New Year’s Eve 2015, there was a fire at The Address, a hotel in Dubai. A news article and photograph were passed between Claude Wehrle, Guy Scheidecker and others in early January 2016.274 20.66 On 4 January 2016 Robert Campbell, the UK sales representative for Reynolux, wrote to Mr Wehrle and others at Arconic telling them that The Address had been clad in Alucobond ACM PE and suggested that architects were wondering whether ACM PE was safe to use.275 Mr Wehrle said that he hoped ACM PE would be removed from the facade cladding market because it was reflecting badly on other ACM products.276 Guy Scheidecker, a senior executive, expressed the view that ACM PE was not the only component responsible for 268 Froehlich {MET00053197/9-14} page 9 and 14, paragraphs 37 and 41. 269 {MET00053161/28}. 270 Froehlich {MET00053197/15} page 15, paragraph 45. 271 Meakins {Day88/130:6-11}. 272 {MET00053158_P10/168}. 273 {MET00053158_P05/14}. 274 {MET00053158_P10/174}. 275 {MET00053158_P10/172}. 276 {MET00053158_P10/172}.

The Grenfell Tower Inquiry: Phase 2 Report 50 such a fire.277 That may have been so, but there is no evidence that Arconic then undertook any further investigation of that possibility. Rather, the Arconic management were pleased that on this occasion, a competitor’s product was involved, not their own. Place de Hageneau: January 2016 20.67 In January 2016, a fire broke out at the Place de Hageneau in Strasbourg, France. The building that caught fire did not feature any ACM, but another building about 10 metres away was clad in Reynobond 55 PE. On 19 January 2016, Mr Wehrle wrote to Alain Flacon and Lionel Marconnet at Arconic expressing the view that Arconic had been very lucky that the wind had not changed.278 He went on to say that it was time for Arconic to stop offering ACM PE for construction purposes. It was aware of the danger and should take steps to withdraw it. 20.68 However, yet again Mr Wehrle’s warnings went unheeded internally at Arconic, and nothing appears to have been done to withdraw ACM PE from the UK market or to warn customers in the UK of the dangers of which Arconic was aware. Arconic’s French sales representatives were instructed to offer only Reynobond 55 FR, regardless of the height of the building, but no similar direction was given in respect of the UK. 20.69 There is, therefore, clear evidence that senior managers at Arconic had been aware for many years before the Grenfell Tower fire that the statements the company was making about the fire performance of Reynobond 55 PE were inaccurate and, in particular, that the fire performance of cassette-fixed panels was significantly worse than that of riveted panels. It is equally clear that, despite what they knew, they decided not to ask the BBA to withdraw or amend its certificate and did not withdraw Reynobond 55 PE from the UK market. Arconic thus promoted and sold a product knowing that it presented a significant danger to those who might use any buildings on which it was used. 277 {MET00053158_P10/176}. 278 {MET00053158_P10/179}.

51 Chapter 21 The review of the Reynobond certificate The BBA’s review processes: an overview 21.1 Once the BBA certificate of 14 January 2008 relating to Reynobond had been issued, it became subject to the scrutiny processes in the contract between Arconic and the BBA designed to ensure its continued validity.279 21.2 Although its processes changed over time, the BBA consistently monitored certificates by means of desk-based reviews carried out by Project Managers and factory inspections carried out by Technical Assessors. A desk-based review, which was carried out at least once every three years,280 involved checking that statements in the certificate continued to be valid, ensuring that the product being sold by the manufacturer continued to be the one assessed and reviewing the certificate holder’s public statements about BBA certification, including how it used the BBA logo.281 Factory inspections involved inspecting and assessing factory production against a quality plan agreed with the manufacturer which set out what should be assessed in continuing surveillance,282 usually at six month intervals.283 21.3 Typically a quality plan would require the Technical Assessor to examine the manufacturing process, including checking that the raw products, suppliers and methods of production were as had been originally described by the manufacturer and examining how it maintained quality in production.284 The process was co-ordinated with the desk-based reviews conducted by Project Managers, who agreed the quality plans with the certificate holders in advance of the inspections and considered the Technical Assessors’ reports against them.285 However, the desk-based review and factory inspection were separate and distinct activities on the BBA’s part, aimed at reviewing different aspects of certification. In particular, it was no part of a Technical Assessor’s role to review fire performance testing data or certification, which was the responsibility of the Project Manager. In turn, it was for the certificate-holder to provide any new technical performance information to the Project Manager in accordance with the contract.286 A Technical Assessor could not review the history of a product’s fire performance testing in the limited time available for an inspection and in any event could not reasonably be expected to have the skill or experience required for that task. 279 {BBA00008042/3} clause 6. 280 Albon {BBA00000158/8} page 8, paragraph 29. 281 Amoroso {BBA00010797/3} page 3, paragraphs 14-15; Amoroso {Day106/25:15}-{Day106/26:10}; Nkomo {BBA00010783/5} page 5, paragraph 12. 282 O’Neill {BBA00010789/3-4} pages 3-4 paragraphs 8-13; Albon {BBA00000158/8} page 8, paragraph 27; Amoroso {BBA00010797/11} page 11, paragraph 57. 283 Haynes {BBA00010784/7} page 7, paragraph 29. 284 {BBA00010870}. 285 O’Neill {BBA00010789/4-5} pages 4-5, paragraphs 17, 20 and 22. 286 {BBA00010790}; Amoroso {Day106/37:1-6}.

The Grenfell Tower Inquiry: Phase 2 Report 52 21.4 From time to time Arconic entered into contracts with the BBA for the review and extension of the certificate. In each case it was a term of the contract that Arconic would provide the BBA with any test data available in relation to the product and would notify it of any new information relating to Reynobond and its performance that came into its possession.287 The Agreement with CSTB 21.5 The initial assessment of Reynobond panels was based on data obtained from CSTB and the BBA therefore felt able to dispense with a quality plan and an initial factory inspection and to rely on CSTB’s continuing monitoring of Arconic’s quality standards. On 17 May 2007, Hamo Gregorian asked CSTB to confirm that it had been inspecting Arconic and, if so, whether it was satisfied that appropriate quality control had been maintained.288 He also asked CSTB to inform the BBA if it identified any major failures to comply with production processes affecting quality, or if it discontinued its visits. On 21 May 2007, Laurent Plagnol of CSTB agreed that it would identify any major failures to comply with processes affecting quality non-compliances for the BBA, although he did not directly answer Mr Gregorian’s question whether quality control had previously been satisfactorily maintained.289 Mr Gregorian recorded that agreement on 21 April 2008.290 CSTB was not asked to provide the BBA with any testing information it held relating to the Reynobond product. Review project 2011 21.6 At the end of 2010, the BBA and Arconic agreed a contract for the triennial review of the Reynobond certificate,291 which was conducted over the next few months by Project Manager Alpheo Mlotha.292 21.7 On 11 February 2011, Mr Mlotha wrote to Arconic seeking information for the purposes of the review,293 including a list of customers, current technical literature and a letter from CSTB either confirming that there were no changes in the raw materials, manufacturing process or quality control procedure, or, if there had been, stating what those changes were. 21.8 Arconic’s Quality Manager, Brigitte Gross responded on 11 April 2011 with the information requested (and no more),294 including a certificate from CSTB confirming that the technical properties of Reynobond 55 complied with the CSTB certification.295 Mr Mlotha was apparently satisfied that there had been no changes in the method of production, since he required only a few minor changes to be made to the text of the certificate at the next issue. Accordingly, the review project was closed on 24 June 2011 with the next review scheduled to commence by 15 January 2014.296 287 The 2010 review contract referred to the 2007 terms {BBA00008044/11}; the 2014 reissue contract did not alter the original terms {BBA00010889}; the 2016 technical reissue contract provided for materially the same obligations of disclosure on Arconic {MET00053158_P18/141-151} clause 10. 288 {BBA00008042/123}. 289 {BBA00008042/123}. 290 {BBA00008042/121}. 291 {BBA00008044/11}. 292 Project number S146895; Technical File: {BBA00008044}; Signed off by Review Report on 24 June 2011 {BBA00010810}. 293 {BBA00008044/35}. 294 {BBA00008044/33}. 295 {BBA00008044/79-91}. 296 {BBA00010810}.

Part 3 | Chapter 21: The review of the Reynobond certificate 53 Arconic Reynobond PE testing in 2011 21.9 On 9 February 2011, at almost exactly the same time as Mr Mlotha made his request for documents, CSTB issued a new EN 13501 classification report for grey Reynobond PE in rivet form based on the test which had been carried out in the previous June (Test RA11‑0032).297 CSTB certified the fire performance as being Bs1, d0, which was better than that reported in the BBA certificate. Arconic did not give that information to the BBA, even though it was apparently an improvement, despite the fact that it was contractually obliged to do so. 21.10 Shortly after Mr Mlotha had completed his review in 2011, CSTB conducted further testing on Reynobond PE 55 in cassette form in accordance with European methods.298 On 12 October 2011, it issued certificate RA11-0244 classifying Reynobond in cassette form as Euroclass E.299 However, Arconic did not disclose the certificate or the information it contained to the BBA. At that point, Arconic could have been in no doubt that Reynobond 55 PE in cassette form performed very badly in a fire and that the BBA certificate made no reference to that important information. Even if Arconic did not think that it was bound to disclose that information to the BBA immediately (as it was), it could have been in no doubt that it would have to disclose it at the next review in 2013. Review project: 2013-2015 21.11 After the 2011 review, the BBA decided that it would no longer rely on foreign bodies (like CSTB) to conduct inspections but would use its own Technical Assessors to carry out that task. From that time until September 2017, Technical Assessor Shaun O’Neill carried out the inspection of Arconic’s factory at Merxheim.300 Maria Barbeito’s attempts to review the certificate – October 2013-September 2014 21.12 In October 2013, BBA Project Manager Maria Barbeito began the second triennial review of the BBA certificate for Reynobond.301 On 8 October 2013 she wrote to Claude Schmidt at Arconic attaching a draft quality plan for Arconic’s agreement. That was the first quality plan proposed for the new certificate. In that letter she asked for documents relating to her review and asked Arconic for written confirmation that there had been no changes in the design, specification, context of use or other details that would invalidate the existing certificate, or if there had, to specify any changes.302 At the time it was customary for the BBA to use that form of words when making requests of that kind.303 21.13 Between 21 October 2013 and 7 May 2014 Ms Barbeito sent emails to Arconic on six occasions304 seeking a response; she also attempted to telephone Arconic at least twice, but without success.305 In an email to a colleague in July 2014, she described her frustration 297 {ARC00000537}; {ARC00000383}; See Chapter 20. 298 {ARC00000538}. 299 {ARC00000538}; {ARC00000386}; See Chapter 20. 300 O’Neill {BBA00010789/7} page 7, paragraph 29. 301 {BBA00010741}. 302 See her email dated 9 October 2013 {BBA00008089} attaching the letter {BBA00008090} and the draft quality plan {BBA00008091}. 303 Amoroso {Day106/65:11-22}; Albon {Day110/35:1-8}. 304 {BBA00008085} attaching {BBA00008086} and {BBA00008087}; forwarded to Claude Wehrle {BBA00008092/1-2}; {BBA00008075} attaching {BBA00008076} and {BBA00008077}; {BBA00008095} attaching {BBA00008096} and {BBA00008097}; {BBA00008971}. 305 {BBA00008075}; {BBA00008663}.

The Grenfell Tower Inquiry: Phase 2 Report 54 at Arconic’s lack of response, saying that Claude Wehrle was very nice on the telephone but never sent any information.306 The BBA received no substantial response whatever from anyone at Arconic during that period. 21.14 On 18 July 2014, Ms Barbeito managed to speak to Claude Wehrle on the telephone and then sent him an email in which she repeated her request for documents, including written confirmation that there had been no material changes that would invalidate the certificate.307 She and Mr Wehrle also discussed arranging a visit to Arconic’s factory at Merxheim. Shaun O’Neill carried out the BBA’s first inspection of the Merxheim factory on 10 September 2014. In his report he recorded that Claude Wehrle had told him that he had tried to communicate with the BBA several times to discuss the review but that his messages had gone unanswered and that he would like the Project Manager to contact him as soon as possible.308 However, the documentary record and recollections of other witnesses does not support Mr Wehrle’s assertion. 21.15 In the period when Ms Barbeito was attempting to obtain a satisfactory response from Arconic, several changes in the classification of Reynobond 55 PE occurred, as we have described in Chapter 20. From 31 January 2014 the product in both cassette and riveted form had been classified E,309 but by 4 December 2014, the two forms were again classified differently, with the cassette form retaining an E classification,310 and the riveted form classified as C-s2, d0.311 21.16 Each one of those changes was important to the BBA’s work on renewing the validity of the Reynobond certificate, but Arconic did not tell the BBA about them or attempt to discuss with it the amendment or withdrawal of the certificate. Valentina Amoroso’s review: September 2014-January 2015 21.17 Maria Barbeito then left the BBA, and at the end of September 2014 Valentina Amoroso joined the organisation.312 Ms Amoroso had a degree in materials engineering313 but no experience or knowledge of cladding materials or of building regulations relating to fire.314 She started working on projects relating to cladding when she was transferred to the engineering department in November 2014 and was initially assigned to the review of existing certificates, which was thought to be simpler than a full technical assessment and more suitable for a newcomer.315 One of the first projects she undertook was the resumption of work on the triennial review of Arconic’s Reynobond 55 certificate. 21.18 Ms Amoroso’s training in the skills required to assess cladding products and to understand fire performance was largely, if not completely, informal and self-directed. She read the applicable standards, asked questions of her seniors in the BBA, including those with greater expertise in fire performance, and attended some conferences and full-scale fire tests of facades.316 At one external event, she met Stephen Howard of BRE and thereafter she occasionally asked for his opinion on matters she did not understand.317 Ms Amoroso 306 {BBA00008663}. 307 {BBA00008954} attaching {BBA00008955}. 308 {BBA00010873/2}. 309 {MET00053158_P02/59}; {MET00053158_P04/135-138}. 310 {MET00053158_P02/119-124}; {ARC00000395}; See Chapter 20. 311 {MET00053158_P05/155-163}; {ARC00000397}; See Chapter 20. 312 Amoroso {BBA00010797/2} page 2, paragraph 6. 313 Amoroso {BBA00010797/2} page 2, paragraph 5. 314 Amoroso {Day106/10:15}-{Day106/11:2}. 315 Amoroso {BBA00010797/2} page 2, paragraph 7. 316 Amoroso {Day106/10:6-11}; {Day106/13:3}-{Day106/14:4}; {Day106/14:22-25}. 317 Amoroso {Day106/17:19}-{Day106/18:8}.

Part 3 | Chapter 21: The review of the Reynobond certificate 55 may have taken the initiative in learning about a new area of activity, but the BBA should not have asked her to conduct even a certificate review without any training in the knowledge and skills required for understanding cladding technology or fire performance. 21.19 One of the people to whom Ms Amoroso directed questions internally was Prayer Nkomo.318 He was a civil engineer319 who had worked at the BBA since November 2010 as a Project Manager. By the time of the 2013-2015 review he had developed some expertise in cladding technology but not in fire performance,320 and it was only on the former that he assisted Ms Amoroso. In early January 2015, shortly after Ms Amoroso had begun working on cladding products, Mr Nkomo was promoted to the role of Team Manager and Ms Amoroso reported to him.321 21.20 Between the time of the first assessment of Reynobond PE and the date of the Grenfell Tower fire no one at the BBA had expertise in the reaction of materials to fire.322 If a question about fire performance arose, Mr Nkomo might approach Jon Denyer or John Albon,323 who by 2012 had developed some experience in the field but who were not trained experts.324 Mr Nkomo was aware that if he needed external assistance, he could ask for the matter to be referred to Exova,325 with which the BBA had made formal arrangements for advice.326 However, Mr Nkomo did not routinely seek assistance and would only ask for help if he was unsure of a point relating to fire performance.327 21.21 At Ms Amoroso’s request328 Mr Nkomo contacted Claude Wehrle on 2 December 2014. Mr Nkomo was very clear in his subsequent email to Mr Wehrle that information provided to the Technical Assessor in the course of a factory visit was no substitute for responding to the Project Manager’s request.329 Shortly after, Ms Amoroso again asked Arconic to provide written confirmation that there were no changes that would invalidate the certificate.330 Mr Nkomo’s and Ms Amoroso’s emails to Mr Wehrle arrived two days before CSTB issued new classification certificates for Reynobond 55 PE, in which the riveted form was classified C, and the cassette form E. Mr Wehrle must have been aware of those classifications at the time when Mr Nkomo and Ms Amoroso were pressing him for information. 21.22 Valentina Amoroso also noticed that the Reynobond certificate files contained no regular surveillance reports from CSTB about factory visits nor any arrangements for continued monitoring,331 although it did contain a report prepared by Shaun O’Neill after his review visit in September 2014. The BBA decided that it should make arrangements for continued monitoring. 21.23 At that point the BBA had received no information about the production of Reynobond since 2007 save for a report in 2011 and Mr O’Neill’s report in September 2014. That seven-year gap in the BBA’s information was significant.332 In addition, no quality 318 Amoroso {Day106/17:4-11}. 319 Nkomo {BBA00010783/2} page 2, paragraphs 4-5. 320 Nkomo {Day107/12:15-19}; {Day107/72:5-22}; Amoroso {Day106/17:4-11}. 321 Nkomo {BBA00010783/2} page 2, paragraph 6. 322 Albon {Day109/88:22}-{Day109/89:8}; {BBA00010486} paragraph 3. 323 Nkomo {Day107/19:14-18}; {Day107/102:8-19}. 324 Albon {Day109/88:17-22}. 325 Nkomo {Day107/18:6-10}; {Day107/18:23}-{Day107/19:2}. 326 Albon {Day109/91:7-20}; {Day109/106:17}-{Day109/107:12}; {BBA00010762/4}. 327 Nkomo {Day107/20:6-10}; {Day107/20:15}-{Day107/21:14}. 328 {BBA00010550/3}. 329 {MET00053158_P18/4}. 330 {BBA00008098}. 331 Amoroso {BBA00010797/10} page 10, paragraph 51; {BBA00008112}. 332 Amoroso {Day106/67:1-7}.

The Grenfell Tower Inquiry: Phase 2 Report 56 plan had been agreed at the time of the initial assessment, so the BBA did not have a yardstick by which to measure whether production had changed or the product was the same as that initially assessed. Nonetheless, it was content to proceed with renewing the certificate, provided a quality plan and continuing monitoring could be agreed with Arconic. 21.24 On 18 December 2014, Valentina Amoroso sent a request for information to Arconic’s quality representative, Lilia Koscuk.333 In early January 2015 Ms Koscuk replied, saying that she agreed the proposed quality plan, but failed to provide the information that the BBA had requested for the purposes of the review.334 Ms Amoroso repeated her request on 7 January 2015 and again on 12 January 2015, when she imposed a deadline of 20 January 2015 for a response.335 Ms Koscuk responded by referring Ms Amoroso to various people at Arconic whom the BBA already knew, including Mr Wehrle.336 Her approach was entirely unhelpful, bordering on the obstructive. 21.25 On 22 January 2015 the BBA decided at a senior level337 to complete the review with the information Ms Amoroso already had.338 The decision is inexplicable. The BBA had said that the information it was seeking from Arconic was essential to complete the review, as indeed it was. The BBA had received no confirmation of the performance of the Reynobond product from Arconic in the previous seven years and Arconic’s failure to provide such information when asked was exceptional and extreme.339 The BBA should have realised that it was a case requiring particular attention rather than summary completion. 21.26 The BBA could and should have threatened to suspend Arconic’s BBA certificate given its lack of response340 and should have done so if the information it required was not provided.341 However, it does not appear that such a step was ever considered, despite Arconic’s wholesale lack of co-operation. Indeed, we were told that it was not the BBA’s practice at the time to suspend certificates for a failure to respond to requests for information.342 We consider that to be an unsafe and unsatisfactory position, but as a result the BBA completed the review using only publicly available information, such as the information available on Arconic’s website, published technical datasheets and marketing brochures.343 21.27 There is evidence that summaries of results were available in the CSTB’s web database344 and Ms Amoroso said that in January 2015 she would have referred to the certification available on the CTSB’s website.345 Had she looked at those summaries she would, or at least should, have noticed the Cs-2, d0 and E classifications and questioned the contents of the BBA certificate. However, for whatever reason, that did not happen. In any event, according to Mr Nkomo, BBA did not consider it part of its responsibility on a review to look for fire testing data on laboratories’ websites because the customer was obliged to provide 333 {BBA00008079/3-4}. 334 {BBA00008079/3}. 335 {BBA00008079/2-3}. 336 {BBA00008079/1-2}. 337 Nkomo {Day107/48:1-10}; Albon {Day110:39:1-7}. 338 {BBA00008079/1}. 339 Amoroso {Day106/60:2-9}; {Day106/74:8-10}; Nkomo {Day107/43:23}-{Day107/44:3}; Albon {Day110/35:25}-{Day110/36:20}. 340 See clause 13(a) of the BBA’s standard terms {BBA00008042/3} clause 13(a). 341 Albon {Day110/56:23}-{Day110/57:4}. 342 Albon {Day110/56:23}-{Day110/57:4}. 343 Amoroso {Day106/76:14-24}. 344 {MET00053158_P02/62}; Wehrle {MET00053190/21} page 21, paragraph 70. 345 Amoroso {Day160/77:14-18}.

Part 3 | Chapter 21: The review of the Reynobond certificate 57 information of that kind.346 That was not an unreasonable stance to take, but it should have been supported by a refusal to renew the certificate if the customer failed to provide information that was available to it. 21.28 The decision to close the review was made by Mr Nkomo to whom the matter was referred Ms Amoroso and probably also in discussion with their senior manager, the Head of Approvals.347 Mr Nkomo told us that it was common for reviews to be closed despite a failure by the certificate holder to provide information, although that was not BBA policy nor encapsulated in any formal instruction.348 21.29 We have seen no record of why this particular review was closed. Both Mr Nkomo and Ms Amoroso thought that it had probably been because it had become delayed,349 and Mr Nkomo agreed there had been a backlog of reviews at the time.350 A further reason appears to have been that the BBA was concentrating on agreeing a quality plan and continuing monitoring. Once that had been achieved, the BBA expected any changes in the product to be reported.351 However, neither of those was a good reason for closing the review. 21.30 The BBA was under the impression that a product’s fire performance classification would not change as long as the product itself or the manufacturing process did not change. For that reason, it thought there was no reason to check for new testing reports, but that ignored the fact that the European classification certificates said on their face that they expired five years from the date of issue. No one at the BBA working on the review of the certificate had regard to the fact that Arconic would need to have the product tested again and would or should have new fire performance information available. That would have been plain if anyone had considered the fire test data on which the initial assessment had been based.352 Ms Amoroso did not consider that data because the process did not require her to do so.353 That was an obvious flaw in the BBA’s review process. Arconic’s submissions on the review 21.31 In an attempt to avoid criticism of its failure to provide information to the BBA Arconic argued that there had been no need for it to provide the BBA with any further information after it had disclosed Test 5A because, among other things, the certificate stated only that Reynobond PE panels were capable of achieving Euroclass B, depending on the configuration of the system in which they were tested.354 It said that the potential variations in the European testing regime made it possible for a single product to have more than one classification.355 Arconic also maintained that it never claimed that the panels would achieve Euroclass B in all circumstances.356 346 Nkomo {Day107/51:7}-{Day107/52:4}. 347 Nkomo {Day107/47:13}-{Day107/48:25}; {Day107/49:12-19}; Amoroso {BBA00010797/12} page 12, paragraph 63; Amoroso {Day106/78:13}-{Day106/79:6}; Albon {Day110 /39:1-7}. 348 Nkomo {Day107/54:23}-{Day107/55:14}; Albon {Day110/45:5-25}; Moore {Day108/7:14-21}. 349 Nkomo {Day107/57:14-17}; Amoroso {Day106/86:14-16}. 350 Nkomo {Day107/57:21}-{Day107/58:9}; {BBA00008073}. 351 Amoroso {BBA00010797/12} page 12, paragraph 64; Amoroso {Day106/78:14-21}; {Day106/79:17-21}; {Day106/83:19}-{Day106 /84:16}. 352 Amoroso {Day106/99:5-8}; {Day106/99:21-25}; {Day106/100:10-18}. 353 Nkomo {Day107/66:4-5}; Albon {BBA00000158/16} page 16, paragraph 66; Albon {Day109/151:24}-{Day109/152:19}. 354 Arconic Module 2 closing submissions {ARC00000770/30} page 30, paragraph 143. 355 Arconic Module 2 closing submissions {ARC00000770/14} page 14, paragraphs 60-62; Arconic Module 6 closing submissions {ARC00000794/28} page 28, paragraph 83. 356 Arconic Module 6 closing submissions {ARC00000794/29} page 29, paragraph 88.

The Grenfell Tower Inquiry: Phase 2 Report 58 21.32 In our view Arconic’s arguments were wholly unrealistic. They ignored the terms of its contract with the BBA, which required it to provide any test data already available357 and immediately to notify the BBA of any change in the particulars supplied and of any new or additional information concerning the product or its suitability for use.358 The performance of Reynobond PE in cassette form was information available to Arconic which was highly relevant to its use, as it must have realised. If the BBA had been informed of it at any time before the completion of the review in January 2015 there can be little doubt that it would have amended the certificate to reflect such important information.359 Nor was it appropriate for Arconic to rely on CSTB giving the data to the BBA.360 Arconic’s obligation was clear. 21.33 Furthermore, Arconic’s submissions demonstrate a fundamental misunderstanding of the function of a BBA certificate. It was not, as Arconic appeared to suggest, to record the best performance that a product was capable of achieving. Its purpose was and is to provide construction professionals with independent and objective information about the nature and performance of products which can be relied on as complete and trustworthy. Those who relied on BBA certificates were entitled to expect that the description of the product concerned was complete and accurate, including any variation in performance when used in different circumstances. 21.34 Arconic also said that the Euroclass B classification was still valid at the time of the sale of Reynobond 55 PE for use on the Grenfell Tower refurbishment in March 2015361 and that therefore the BBA certificate was not incorrect.362 It argued that when at the end of 2014 Reynobond PE 55 in riveted and cassette forms returned to being separately classified (C-s2, d0 and E respectively), they ceased to be classified E.363 Arconic argued that, in effect, the classification in 2011 of Reynobond 55 PE in rivet form as Bs-1, d0 became effective once again and, being valid for 5 years, remained effective until February 2016. The effect of that argument is that there were two classifications for Reynobond 55 PE in rivet form in effect at the same time, one Euroclass B and one Euroclass C. That is unlikely, to say the least, and there is no evidence that that was its intention. 21.35 The obvious flaw in the argument is that there is no proper basis on which to read certificate RA13-0333 issue 2 dated 4 December 2014 as reinstating the result of the test carried out in 2011. The only sensible way of interpreting what occurred is that Arconic decided for a time not to rely on the Euroclass B classification and to consider all Reynobond 55 PE (whether in riveted or cassette form) to be Class E. It then decided to classify them separately again, but with the riveted form being Class C rather than B. That accords with the recollection of Mr Wehrle.364 21.36 In any event, Arconic’s argument applies only to Reynobond 55 PE in its riveted form. It is therefore completely irrelevant to the material supplied for use on Grenfell Tower in cassette form. 357 {BBA00008042/3} clause 7(a). 358 {BBA00008042/3} clause 7(g). 359 Amoroso {Day106/109:6-15}; Albon {BBA00000158/8} page 8, paragraph 27. 360 Arconic Module 2 closing submissions {ARC00000770/30} page 30, paragraph 142. 361 Derrendinger {MET00053191/37} page 37, paragraph 107. 362 Arconic Module 6 closing submissions {ARC00000794/29-30} page 29-30, paragraphs 83-87. 363 {MET00053158_P02/119-124}; {ARC00000395}; See Chapter 20. 364 Wehrle {MET00053190/20-21} pages 20-21, paragraphs 68-70.

Part 3 | Chapter 21: The review of the Reynobond certificate 59 21.37 In any event, on 23 April 2014, when it sent the BBA certificate to those involved in the refurbishment to support the sale of Reynobond 55 PE for use on Grenfell Tower,365 Arconic itself considered the correct classification of the product in either form to be Class E. On any view, the BBA certificate was at that time inaccurate. The reality is that Arconic knew that Reynobond 55 PE in cassette form was Class E and that it had been consistently classified as such since 2011. However, it did not tell the BBA, nor anyone involved in the Grenfell Tower refurbishment and it appears that only one UK supplier was ever told about the true position.366 Reissue contract 2015 21.38 The BBA’s closing report for the 2013-2015 review was issued on 10 April 2015. It stated that the certificate had to be reissued so that the text could be revised.367 The report also recommended that Arconic should check that there was no contradiction between the technical information that it published and that contained in the certificate.368 The BBA offered Arconic a contract for this work,369 which Arconic accepted,370 but for reasons which are unrecorded the BBA did not reissue the certificate. 21.39 None of the documentation closing out the review or generated when the contract for the reissue was offered referred to the fact that there had been any difficulty obtaining current information from Arconic and that a decision had been taken to rely solely on publicly available information. By the end of 2015, the BBA had introduced new documentary procedures under which information of that kind was recorded for the benefit of future reviewers. However, those procedures came too late to affect the 2015 review relating to Reynobond 55 PE.371 Review project 2016 21.40 The next triennial review of the BBA certificate for Reynobond began on 12 October 2016 and was again carried out by Valentina Amoroso.372 That was after the certificate of practical completion had been issued for Grenfell Tower and therefore too late to make any difference to that building. It is nonetheless relevant to how Arconic and the BBA continued to communicate and conduct themselves. This time, Ms Amoroso specifically asked for confirmation that no changes had been made to raw materials, manufacturing processes or quality control procedures.373 That was the standard form of request used by BBA Project Managers at the time374 and Ms Amoroso did not think it necessary to ask for a broader range of information.375 365 {CEP000000281}. 366 Gwenaelle Derrendinger provided certificates showing that Reynobond 55 PE cassettes had achieved European Class E to Taylor Maxwell, a UK supplier, on 3 February 2014 {MET00053173/91} and 9 March 2015 {MET00053173/135}. On the latter occasion the certificate was sent following a request from Deborah French who by that time had left Arconic and joined Taylor Maxwell. 367 {BBA00008135}. 368 {BBA00008135/6}. 369 {BBA00010889}; {MET00053158_P18/31}. 370 {MET00053158_P18/41}; {MET00053158_P18/38}. 371 Nkomo {Day107/67:9}-{Day107/68:3}. 372 {BBA00010742}. 373 {BBA00011051/5-6}. 374 Amoroso {Day106/134:10-12}. 375 Amoroso {Day106/137:5-24}.

The Grenfell Tower Inquiry: Phase 2 Report 60 21.41 Ms Amoroso corresponded with Nicholas Remy, Claude Wehrle’s junior colleague in Arconic’s Technical Sales Support team, who asked for clarification of precisely what documents the BBA wanted.376 On 24 October 2016, he provided the documents Ms Amoroso had asked for, namely, technical datasheets, commercial brochures, installation manuals and EU marking data.377 Before doing so, however, he wrote to Mr Wehrle on 18 October 2016 passing on part of Ms Amoroso’s request.378 He said he felt as though he was dealing with something that was not clear cut and that what the BBA was coming to review had been “completely modified without them knowing anything about it”. In response Mr Wehrle assured Mr Remy that they would talk about it to alleviate any bad impression that Mr Remy had.379 We do not know what exactly worried Mr Remy, but as far as we can tell, Arconic did not make any further information available to the BBA beyond complying strictly with Ms Amoroso’s request. 21.42 During this review, Ms Amoroso came to the firm conclusion that references to the product in cassette form should not be included in the certificate because Arconic did not manufacture cassettes or control their fabrication by others.380 However, she did not see any difficulty in retaining references to the product in riveted form, although that too required a further process of cutting to size and shape and drilling to be undertaken after the product had left the factory. She did not consider the wider implications of her conclusion so far as fire performance was concerned. 21.43 By late 2016, some at the BBA had become aware of cladding fires that had occurred abroad.381 As a result, the BBA’s newly formed Technical Excellence team decided that statements about height restrictions should be added to certificates for cladding products, particularly ACM panels.382 There was also a view at the BBA at that time that the use of the word “filler” in clause 12.7 of Approved Document B was ambiguous and that the word “etc.” potentially broadened the ambit of that clause so that the core of an ACM product needed to be of limited combustibility to fall within it.383 The BBA decided that holders of certificates for ACM products should either show that the core of the product was of limited combustibility, or that the panels achieved Euroclass A1 or A2, or that the cladding system when tested as a whole in accordance with BS 8414 could be shown to comply with the criteria in BR 135. The BBA decided that unless those statements could be included certificates for such products should state that they should not be used on buildings over 18 metres in height.384 Those statements were to be added at the next re-issue of each certificate relating to an ACM product.385 21.44 We are surprised that if the BBA had decided to add a statement to all certificates relating to cladding products for safety reasons, it did not take more urgent steps to revise those already in existence. Since the BBA did not publicise the change, a person relying on a certificate would not have known about the change in policy.386 376 {BBA00011051/1-5}. 377 {BBA00011051/1}. 378 {MET00053158_P18/61}. 379 {MET00053158_P18/61}. 380 Amoroso {Day106/150:15-19}; {Day106/151:12-15}; {Day106/153:16-20}; {BBA00011057}. 381 Nkomo {Day107/97:18-22}. 382 Nkomo {Day107/96:10-15}. 383 Albon {BBA00010723/36-37} pages 36-37, paragraphs 149-152. This is a subject examined in detail in Part 2 of this report. 384 Amoroso {BBA00010797/16-17} pages 16-17, paragraphs 88-90; Amoroso {Day106/167:4-23}. 385 Amoroso {BBA00010797/17} page 17, paragraph 91. 386 Amoroso {BBA00010797/16} page 16, paragraph 86; Amoroso {Day106/172:2-11}.

Part 3 | Chapter 21: The review of the Reynobond certificate 61 21.45 In February 2015, the BBA began using review checklists as part of the process leading to the completion of reviews.387 The review checklist relating to the 2016 review of the Reynobond certificate indicated that it needed to be reissued for technical reasons, that references to the cassette form of the product should be removed, that statements should be added restricting the height at which it was suitable for use and that the wording should be refreshed generally.388 Technical Reissue: 2016-2017 21.46 Valentina Amoroso began work on the technical reissue of the certificate in November 2016.389 The work was in progress at the time of the Grenfell Tower fire.390 21.47 Almost immediately after the fire the BBA wrote to Arconic about its Reynobond certification.391 It briefly suspended the certificate due to Arconic’s failure to respond,392 but Arconic wrote on 17 July 2017 advising that it had stopped selling Reynobond 55 PE for use on high-rise buildings and asking for the certificate to be maintained.393 The BBA was satisfied that it could continue to certify the product.394 21.48 On 21 July 2017, the BBA sent Arconic a draft of a revised certificate which stated that the panels were available in two grades, denoted “ST” and “FR”. (“ST” was formerly denoted “PE” and contained an unmodified polyethylene core.)395 It also stated in clause 1.4 that the flat panels could be formed into cassettes, but that the manufacturing and use and fixing of cassettes were not covered by the certificate. Fire performance information was presented in a table which recorded that the FR version was classed B-s1, d0 and the ST version (i.e., the version with an unmodified polyethylene core) was classed B-s2, d0.396 The latter statement was undoubtedly wrong and was particularly dangerous in view of the failure to include in clause 1.4 any indication that the fire performance of the product in cassette form was markedly worse than in riveted form. The draft also made clear that only Reynobond FR achieved national Class 0 and all statements in the previous certificate to the effect that the product could be “regarded as” Class 0 were removed. The draft included restrictions on the use of the product on buildings over 18 metres in height.397 21.49 Although the draft certificate was intended only for Arconic’s information,398 on 25 July 2017 Claude Wehrle commented on it, demonstrating that he had read it.399 He did not correct the errors in the European fire performance classification of the “ST” version, even though there was no basis on which at that stage Reynobond 55 PE could be described as Class B. Given that the certificate was being drafted by the BBA immediately after a serious fire in which many people had died involving the very product being certified, it is astonishing that it did not check that the fire performance information was correct 387 Nkomo {Day107/68:13-20}; Nkomo {BBA00010783/5} page 5, paragraph 12e. 388 {BBA00011085}. 389 {MET00053158_P18/144-151}. 390 {MET00053158_P18/157-164}. 391 {BBA00010769/6}; {MET00053158_P18/174-180}; {MET00053158_P18/181-182}. 392 {BBA00010428}; {BBA00010429}. 393 {MET00053158_P18/193-194}. 394 Moore {BBA00000159/4} page 4, paragraph 8. 395 {BBA00008221/3} clause 1.2 396 {BBA00008221/7}. 397 {BBA00008220}; {BBA00008221}. 398 {BBA00008220}. 399 {MET00053158_P19/23}.

The Grenfell Tower Inquiry: Phase 2 Report 62 but merely repeated old claims.400 Against that background it is even more astonishing that Arconic failed to say anything when presented with a draft certificate that contained materially and obviously incorrect information. 21.50 The BBA formally reissued the certificate on 4 August 2017.401 It stated, wrongly, that the standard PE panel with a grey/green Duragloss coating was classed B-s2, d0. Re-issue September 2017 21.51 On 8 September 2017 Claude Wehrle informed Shaun O’Neill that Arconic was no longer selling Reynobond 55 PE at all in the UK.402 On 22 September 2017 the certificate was amended and reissued, removing the references to Reynobond 55 PE.403 From that time the BBA certified Arconic’s Reynobond FR product only. The BBA’s discovery of the Reynobond PE and FR test reports 21.52 On 29 January 2018, BBC journalist Tom Symonds met Brian Moore, then Operations Director of the BBA. Mr Symonds said that he had information that Arconic had changed the core of Reynobond 55 PE from translucent to black404 and provided some details in writing shortly thereafter.405 On 19 February 2018 Mr Symonds sent the BBA a bundle of test reports on Reynobond 55 PE between 2013 and 2015 which showed that Reynobond 55 PE had Euroclass C and E classifications.406 21.53 Between February and April 2018 Brian Moore made extensive inquiries of Arconic and its legal representatives about the fire performance information in its possession that it had not disclosed to the BBA.407 On 27 April 2018 Arconic disclosed to the BBA six test and classification reports on Reynobond 55 FR dating from 2012 to 2016408 on the basis that the current certificate covered that product.409 Had the BBA received those reports when they were created, no doubt it would have re-evaluated the product and reissued the certificate with more accurate and complete information. Arconic refused to provide test information about Reynobond 55 PE on the basis that the certificate no longer covered that product. By that time Arconic had become a core participant in the Inquiry.410 21.54 Despite the non-disclosures and the highly material matters they revealed, the BBA did not immediately suspend or withdraw the Reynobond certificate. Mr Moore said that that was because the test reports on Reynobond PE obtained from the BBC had not come from CSTB directly and the BBA wanted to know what Arconic said about them.411 He also pointed out that at that time the certificate did not extend to Reynobond 55 PE.412 400 Amoroso {Day106/189:3-10}; {Day106/189:23}-{Day106/190:2}. 401 {BBA00000046}. 402 {BBA00010769/16}. 403 {BBA00000049}. 404 Moore {BBA00000159/4} page 4, paragraph 11. 405 {BBA00008363}. 406 {BBA00009147/2} attaching reports: RA13-0333 (Classification Report for Reynobond PE, cassette, issued 4 December 2014, Class E); RA14-0339 (Classification report for Reynobond 55 PE, riveted system, issued 4 December 2014, classification Cs2, d0); RA15-0200 (Classification Report for Reynobond 55 PE, riveted system, issued 22 September 2015, Cs2, d0); RA15-0201 (Classification Report for Reynobond 55 PE, cassette system, issued 22 September 2015, Classification E). 407 Moore {BBA00000159/5-13} pages 5-13, paragraphs 13-44; {BBA00010769}. 408 {BBA00010769/69}. 409 Albon {BBA00000158/14} page 14, paragraph 55. 410 {BBA00010769/69}. 411 Moore {Day108/83:4-16}; {Day108/84:8-15}. 412 Moore {Day108/84:22}-{Day108/85:3}.

Part 3 | Chapter 21: The review of the Reynobond certificate 63 21.55 It was only on reading Dr Lane’s report to the Inquiry in November 2018413 that the BBA became aware of the existence of Test 5B on Reynobond PE in cassette form and believed that it had the basis for taking action against Arconic.414 On 17 November 2018 it suspended the certificate for material non-disclosure in breach of contract415 and on 1 March 2019, it withdrew the certificate for Reynobond 55 in all forms.416 413 Albon {BBA00000158/11} page 11, paragraphs 38-39; {BLAS0000036}. 414 Moore {Day108/99:12-15}. 415 {MET00053158_P19/41-45}. 416 {MET00053158_P19/47}.

64 The Grenfell Tower Inquiry: Phase 2 Report

65 Chapter 22 Kingspan K15 insulation The use of K15 insulation on Grenfell Tower 22.1 Most of the insulation used on Grenfell Tower during the refurbishment was Celotex RS5000. A small amount, probably about 5% of the total, was K15 Kooltherm manufactured by Kingspan Insulation Limited and marketed for use in rainscreen cladding systems.417 22.2 K15 was a rigid phenolic foam board with a foil facer bonded to both faces. Phenolic foam is combustible, with a short time to ignition.418 How K15 came to be supplied in May419 and September420 2015 for use in the refurbishment of the tower has been described in Chapter 56 of the report. Kingspan was not aware until after the fire that K15 had been used on the tower.421 K15 – the product 22.3 K15 was first manufactured at Kingspan’s Pembridge site in Herefordshire in November 2002.422 At that time, the foam was produced with a pentane blowing agent.423 The foil facers of the product were unperforated, with a thickness of 7.6 microns.424 22.4 Following its acquisition of a Dutch company in 2003,425 Kingspan began to introduce a number of changes to its phenolic foam range. They included physical changes to the structure of the foam and the introduction of different chemical ingredients and manufacturing processes to achieve better thermal performance and rates of productivity.426 In particular, Kingspan introduced the use of a mixture of pentane and isopropyl chloride as a blowing agent427 and perforations were introduced to the aluminium foil facers.428 The new version of K15 came to be known within Kingspan as “new technology” or “Kesteren technology”429 K15 and the previous version as “old technology” K15.430 Dr Rochefort said that by September 2006 the K15 available to the market was the “new technology” version of the product.431 Ivor Meredith, who had been a Project Leader 417 Marketing literature 2001 {KIN00020720}; 2002 {KIN00009173} and {KIN00008018}; 2003 {KIN00002579}; 2006 {KIN00005071}; 2007 {KIN00002580}; 2008 {KIN00009703}; 2011{KIN00003545}; 2015 {KIN00000086}; 2016 {KIN00000070}. 418 See Phase 1 Report Volume I, paragraph 6.20 for a description of the fire properties of phenolic foam. 419 {SIG00000012}. 420 {CCF00000019}. 421 Burnley {KIN00000554/5} page 5, paragraph 4.2. 422 {KIN00022307} Tab 2, Row 2, Column C. 423 Rochefort {KIN00008838/7} page 7, paragraph 3.10; Rochefort {Day80/50:21-22}; {KIN00022307} Tab 2, Row 2, Column C. 424 Meredith {Day75/35:16-18}; Heath {Day79/13:8-10}; Rochefort {Day80/54:11}; {KIN00022307} Tab 2, Row 2, Column C. 425 Rochefort {Day80/46:15}; Rochefort {KIN00008838/6} page 6, paragraph 3.6; Heath {Day79/11:13}; Heath {KIN00020709/9} page 9, paragraph 3.4. 426 Rochefort {KIN00008838/6-7} pages 6-7, paragraphs 3.6 and paragraph 3.8. 427 Rochefort {Day80/50:25}. 428 Heath {Day79/13:4-7}; Meredith {Day75/35:16-18}; Rochefort {Day80/54:6-8}. 429 Kesteren is the name of the location in the Netherlands where Marec manufactured phenolic foam. 430 Rochefort {KIN00008838/6} page 6, paragraph 3.6. 431 Rochefort {Day80/34:23-24}; {Day80/48:22-23}; Rochefort {KIN00008838/9} page 9, paragraph 3.17.

The Grenfell Tower Inquiry: Phase 2 Report 66 in the Technical Projects team,432 and his line manager, Philip Heath, Technical Manager until 2010,433 both agreed, although they thought that production of “old technology” K15 had ceased in about August 2007.434 22.5 Phenolic foam is an organic polymer, so whatever blowing agents or methods are used to produce it, it is not a material of limited combustibility as defined in Approved Document B.435 With the exception of Dr Rochefort, who professed not to have been aware at the time of the fire performance of K15 or the existence of a definition of limited combustibility in Approved Document B,436 all the Kingspan witnesses from whom we heard confirmed that they had been aware throughout their employment at Kingspan that K15 was not, and never could be, a material of limited combustibility.437 Early marketing 22.6 From a very early stage, even before the first test in accordance with BS 8414 in 2005, Kingspan knew that, applying the guidance in Approved Document B, K15 was not suitable for use on buildings over 18 metres in height.438 However, it chose to disregard that fact when selling K15 and advising on its use. Kingspan’s principal marketing literature from 2001 onwards described K15 as suitable for use in rainscreen cladding systems generally439 and brochures published between 2002 and 2006 described it as a product designed for use behind rainscreen cladding systems without any qualification.440 None of those documents referred to the warning in Approved Document B about the use of combustible materials in tall buildings or of the guidance that insulation used on buildings over 18 metres in height should be of “limited combustibility”. That was the case even in those sections of the documents that depicted typical design details, where no distinction was drawn between use of the product on buildings of over and under 18 metres in height.441 22.7 In 2004 Ivor Meredith was a Technical Advisor in Kingspan’s Technical Projects Team; from 2005 he was a Project Leader.442 On 19 March 2004 he wrote to contacts at Tower Hamlets Borough Council and LABC inviting comments. His email was headed “Insulation above 18m”. In it he acknowledged that K15 did not meet the criteria for limited combustibility, but he expressed confidence in its fire performance and said that it had been accepted regularly for use on buildings over 18 metres in height in ventilated facade systems. He also said that K15 had been “pigeonholed” with combustible insulation, even though the char that he said would form when it was exposed to flame limited the combustibility of the product.443 432 Meredith {KIN00022312/1} page 1, paragraph 1. 433 Heath {KIN00020709/4-6} pages 4 and 6, paragraphs 2.8 and 2.18. 434 Heath {KIN00020709/13} page 13, paragraph 3.18; Meredith {Day75/124:24}-{Day75/125:3}. 435 See Chapter 5; Table A7 in all relevant editions – 2000 {INQ00014107/120}; 2002 {CLG10000740/124}; 2006 {CLG10000007/132}; 2010 {CLG00000173/132}; 2013 {CLG00000224/132}. 436 Rochefort {KIN00008838/23} page 23, paragraph 5.8; Rochefort {Day80/27:12-15}; {Day80/28:25}-{Day80/29:4}. 437 Meredith {Day75/25:17-21}; Millichap {Day81/25:4-10}; Pack {Day86/22:1-5}; Burnley {Day85/134:1-3}; Pargeter {KIN00000494/6} page 6, paragraph 3.4; Heath {Day78/181:7–12}; Mills {Day77/15:3-6}. 438 Heath {Day78/198:2}; {KIN00005054/1} where on 26 January 2004 Mr Meredith reported to Mr Heath on the work then being carried out to try to develop a K15 product “that will achieve acceptability for above 18m in facade construction by Building Regulations”. 439 {KIN00020720/1}. 440 January 2002 {KIN00009173}; November 2002 {KIN00008018}; March 2003 {KIN00002579}; June 2006 {KIN00005371}. 441 See for example {KIN00005371/2}. 442 Meredith {KIN00022312/1} page 1, paragraph 1. 443 {KIN00003685}.

Part 3 | Chapter 22: Kingspan K15 insulation 67 22.8 The language of that email was liable to mislead, because as Mr Meredith well understood,444 insulation used on buildings of 18 metres or more in height had to be of limited combustibility if it was intended to follow what was known as the “linear route to compliance” in Approved Document B and K15 did not satisfy that requirement. He said that he had borrowed the language from a set of written standard answers, possibly produced by the European Phenolic Foam Association, then in circulation within Kingspan.445 Whether that is right or not, however, the message provides some insight into the methods that Kingspan was using to sell K15 at the time and how it might have come about that, as Mr Meredith told us, K15 was being accepted for use on buildings over 18 metres in height in the period before any large-scale system test in accordance with BS 8414 had been carried out.446 Large scale testing: May 2005 22.9 Before the publication of the BS 8414-1 test standard in December 2002447 Kingspan had begun to explore the possibility that it could use successful testing to BS 8414 to promote and sell K15 for use on buildings over 18 metres in height.448 On the publication of the 2006 edition of Approved Document B in April 2007449 it encouraged and celebrated the adoption of the BS 8414 test,450 which it viewed as an opportunity to create a new category of insulation products for use on buildings over 18 metres in height, namely, products that were not materials of limited combustibility but were nonetheless suitable for use above that height. 22.10 That was the foundation of the fundamental falsehood at the heart of Kingspan’s marketing strategy in the years that followed. There was no such thing as an insulation product that was combustible and yet could be used generally on buildings above 18 metres in height while following the guidance in Approved Document B. The use of a combustible product on such a building in accordance with Approved Document B was possible only if it were incorporated in a system which had been tested in accordance with BS 8414 and had met the performance criteria in BR 135 (2003). There was therefore no “over 18 metre market” for combustible insulation products as such. Insulation materials that were not of limited combustibility could be used on buildings over 18 metres in height in accordance with the guidance in Approved Document B only on the basis of a test of the particular system it was intended to install. Nonetheless, once BS 8414 and BR 135 had become available, Kingspan treated them as a generally applicable “route to compliance” for K15 as a product, even though it could constitute only part of any such system.451 22.11 Following preliminary testing,452 in 2004 Kingspan began preparing for its first full test in accordance with BS 8414-1 of a system incorporating K15. The test was arranged by Ivor Meredith,453 under the supervision of Philip Heath.454 Mr Meredith was responsible 444 Meredith {Day75/26:14-19}. 445 Meredith {Day75/27:13-21}. 446 Meredith {Day75/28:13}-{Day75/29:3}. 447 {CEL00001205}. 448 K5, an identical phenolic foam to K15 with different foil facers, was tested to a draft version of BS 8414-1 as early as March 2002: Meredith {Day75/32:8-20}; {KIN00003685}. 449 Reference to the use of BS 8414 test data classified in accordance with the criteria in BR 135 as an alternative to the use of insulation material of limited combustibility on buildings over 18 metres in height was first included in the 2006 edition of Approved Document B published on 6 April 2007 {CLG10000007/95}. 450 Kingspan’s AD B consultation response {CLG00002607/24}; {KIN00005292/9} second paragraph. 451 Meredith {Day75/29:21-22}. 452 March 2002 test on K5 and Permarock {KIN00003685}; November or December 2004 “naked” test without cladding {KIN00022357} Row 1. See also for example {KIN00005048}; {BRE00003278}. 453 Heath {Day78/173:8-19}; Meredith {Day75/4:19}-{Day75/5:15}. 454 Technical Manager from 2001 to 2010. See Heath {KIN00020709/4-6} pages 4 and 6, paragraphs 2.8 and 2.18.

The Grenfell Tower Inquiry: Phase 2 Report 68 within Kingspan for the planning and design of the test rig and for the sourcing, purchase and delivery of the necessary materials, as well as for liaising with BRE during preparations for the test and in connection with its design.455 Both he and Philip Heath told us that the decision to test in accordance with BS 8414-1 at that time had been taken by a wider group of managers and directors at Kingspan, as had been the choice of the components of the cladding system to be tested.456 They also agreed that the purpose of the test had been to use a successful result to promote K15 as a product for use on buildings over 18 metres in height.457 22.12 The test was carried out in May 2005. Kingspan decided to test a system using “old technology” K15458 with a non-combustible cement particle or fibre cement board as the rainscreen. There was some disagreement between the witnesses about the precise nature of the rainscreen used. Philip Heath was unable to remember what it had been,459 whereas Ivor Meredith said that it had been a 6mm non-combustible cement particle board manufactured by a company called UAC,460 which is the information recorded in the test report issued by BRE in December 2005.461 Mr Meredith went on to tell us that the rainscreen had been a fibre cement board marketed in the UK as ‘Supalux’.462 Other Kingspan witnesses, notably Adrian Pargeter, the Head of Technical and Marketing,463 Adrian Brazier464 and Adam Heath,465 said they thought that the rainscreen had in fact been a non-combustible fibre cement board.466 None of the latter group had had any involvement in the test.467 Their belief that fibre cement boards had been used, which was expressed with varying degrees of confidence, was based solely on investigations carried out by Kingspan in 2016 and 2019.468 No BRE witness was able to recall the precise nature of the board beyond the description given in the test report.469 455 Meredith {Day75/42:21}-{Day75/43:16}. 456 Heath {Day78/201:14-17}; {Day78/204:19-22}; Meredith {Day75/58:9-16}. 457 Heath {Day78/202:14-15}; Meredith {Day75/58:19-20}. 458 {KIN00024104/2} paragraph 4; Meredith {Day75/88:19-24}; Pargeter {KIN00022610/52} page 52, paragraph 7.1. 459 Heath {KIN00020709/79} page 79, footnote 48. 460 Meredith {Day75/67:21}-{Day75/68:12}. 461 BRE Report (Test 220876) {BRE00002511/6} third paragraph. 462 Meredith {Day76/207:18-24}. 463 Pargeter Kingspan’s Head of Marketing from November 2014 and Head of Marketing and Technical from June 2015 {KIN00000494/4-5} pages 4-5, paragraphs 2.7 and 2.8. 464 Adrian Brazier replaced Ivor Meredith as Technical Projects Manager in September 2015, Brazier {KIN00008828/4} page 4, paragraph 2.7. 465 Adam Heath was Kingspan’s Technical Projects Leader from May 2014, with responsibility from August 2015 for large-scale fire testing. In April 2019, he moved to the role of Regulatory Affairs Manager, Heath {KIN00008834/3-5} pages 3-5, paragraphs 2.4, 2.6 and 2.9. 466 Pargeter {KIN00020824/100} page 100, paragraph 10.57; Pargeter {Day 83/175:11-19}; Heath {KIN00008834/96} page 96, paragraph 11.53; Brazier {KIN00008828/59} page 59, paragraph 11.37. 467 Pargeter {KIN00020824/100} page 100, paragraph 10.55; Heath {KIN00008834/96} page 96, paragraph 11.52; Brazier {KIN00008828/58} page 58, paragraph 11.31. 468 In 2016, while working on the development testing of a lower lambda insulation product called K115, Kingspan began preparations to replicate the test in accordance with BS 8414 carried out in May 2005, leading it in 2016 and again in 2019 to try to ascertain the precise nature of the board used as external cladding in that test. Heath {KIN00008834/96} page 96, paragraph 11.53; Pargeter {KIN00020824/100} page 100, paragraphs 10.55-10.57. 469 Clark {Day96/121:19-24}; Colwell {Day232/205:16-17}; Baker {Day100/50:6-11}.

Part 3 | Chapter 22: Kingspan K15 insulation 69 22.13 Mr Heath and Mr Meredith both told us that the components used in the 2005 test rig had been chosen in discussion with and on the advice of BRE.470 Ivor Meredith identified Dr Sarah Colwell,471 David Hoare472 and Philip Clark473 as the BRE staff who were involved in discussions with Kingspan both before and after the test.474 Philip Heath described the test as a “pilot test”, with the particular assembly suggested by BRE.475 It seems clear that the test had been intended to be the first in a series of large-scale tests.476 22.14 Mr Heath and Mr Meredith also told us that BRE had suggested that if Kingspan tested a system with a non-combustible rainscreen which met the criteria in BR 135, it could use the results to produce a report indicating that K15 could be used in other systems incorporating non-combustible rainscreens.477 Ivor Meredith described that as a “scope of application”478 or “expanded scope of application”479 report. He said that obtaining a report of that kind from BRE was the main purpose of carrying out the test. He understood that a report of that kind based on just one test might render K15 acceptable for use on buildings over 18 metres in height with all non-combustible rainscreen materials.480 In an internal activity report written on 31 May 2005, the day of the test, Mr Meredith told his managers that a successful result that afternoon would remove any limitations on selling K15 into the high-rise market.481 22.15 It was for that reason, as Ivor Meredith and Philip Heath agreed, that the boards chosen as the rainscreen for the system tested in May 2005 were not of a kind that would ever be installed in practice, either then or now. They were intended to represent a non- combustible rainscreen of any kind.482 Dr Colwell confirmed that Kingspan had given her to understand that its aim had been to test K15 with a generic rainscreen.483 We are satisfied that Kingspan’s intention in choosing cement particle or fibre cement boards for the test was simply to represent as wide a range of non-combustible rainscreen panels as possible. Since the witnesses agreed that in either case the boards used had been non-combustible, it is not necessary for us to reach a decision on precisely which kind was used in the test. 22.16 The test took place at BRE’s burn hall on 31 May 2005 and was successful in that BRE expressed the view that the system appeared to have met the criteria in BR 135.484 The test report, written by Philip Clark and approved by David Hoare, was issued on 9 December 2005.485 A separate report classifying the system in accordance with BR 135 was issued more than ten years later, on 28 September 2015.486 470 Heath {Day78/204:17-22}; {Day78/207:9-12}; {Day78/208:18}-{Day78/209:7}; Meredith {Day75/130:23-25}. 471 In 2005, Dr Sarah Colwell was the joint Business Group Manager for the BRE’s Passive Fire Team, Colwell {BRE00047571/3} page 3, paragraph 12. 472 From 2005 to September 2015, David Hoare was the BRE’s Business Group Manager in relation to cables. He also had some involvement in the testing of composite panel systems and in the approval of fire test reports, Hoare {BRE00005622/2} page 2, paragraph 5. 473 Philip Clark was the Burn Hall Manager at BRE between 2004 and 2017. Mr Clark was involved in BS 8414 testing at BRE from 1999 onwards and was part of the team that developed Parts 1 and 2 of BS 8414, Clark {BRE00005768/3-5} pages 3 and 5, paragraphs 13 and 22. 474 Meredith {Day75/59:8}; Colwell {Day75/20:24}; Clark {Day75/63:8-20}; David Hoare, the Senior Consultant who approved BRE’s test report). See BRE Report {BRE00002511/2}. 475 Heath {Day78/191:14-17}. 476 Meredith {Day75/59:21-25}; Heath {Day78/202:23}-{Day78/203:4}. 477 Heath {Day78/191:18-24}; {Day78/209:1-7}; Meredith {Day75/58:21}-{Day57/59:6}. 478 See for example, Meredith {Day75/92:24}-{Day75/93:2}. 479 Meredith {Day75/99:19-21}. 480 Meredith {Day75/59:3-6}. 481 {KIN00021738} first paragraph. 482 Meredith {Day75/69:20}-{Day75/70:24}; Heath {Day78/207:9-15}. 483 Colwell {BRE00047571/48} page 48, paragraph 299; Colwell {Day232/214:3-5}. 484 Heath {Day79/8:6-13}. 485 {BRE00002511}. 486 Report P101812-1000 {KIN00000134}.

The Grenfell Tower Inquiry: Phase 2 Report 70 22.17 In the event, no “scope of application” report was produced by BRE on the basis of the test. Mr Meredith’s evidence, which was consistent with Mr Heath’s understanding of what had happened, was that after the test had taken place, BRE had changed its position by retracting its previous suggestion that it could produce a report providing support for the use of K15 with other types of non-combustible rainscreen materials.487 In his evidence, Mr Meredith described a heated meeting with Dr Sarah Colwell and an unidentified director of Kingspan Off-Site Ltd488 at some stage after the test during which she had made it clear to him that no wider report could or would be produced by BRE.489 He recorded those events in the background section of an internal summary to his managers on 7 January 2008, describing both BRE’s initial advice and its later retraction.490 22.18 Dr Colwell denied that she had been aware of any discussions with Kingspan of the kind described by Mr Meredith either before or after the test in May 2005.491 She said she had not given any advice to Kingspan on the assembly it should use in the test492 or on how to satisfy the criteria in BR 135.493 Dr Colwell was shown an internal Kingspan document in which Mr Meredith had reported to his managers that, following a Single Burning Item test on K15 in March 2004, she had told him that K15 had a good chance of passing the BS 8414 test if the right detailing was adopted.494 In the same document Mr Meredith had recorded that in October 2004 Dr Colwell had suggested that Kingspan should carry out a preliminary “naked” test (i.e. with no rainscreen) to help it pass when it was tested in accordance with BS 8414-2.495 Dr Colwell told us that Mr Meredith was mistaken when recording those comments496 and that she thought he was putting a particular slant on their discussions.497 22.19 On 14 December 2004 Mr Meredith sent Dr Colwell an email in which he said that Kingspan had decided to follow her guidance and therefore wanted to perform a full test on K15 in accordance with BS 8414-1.498 When asked about it, she said that she could not understand what he might have meant.499 She said that her discussions with Kingspan at that time about testing K15 in accordance with BS 8414 had been of a general nature,500 and had concerned the programme of tests it was planning to carry out. They had not extended beyond exploring how BRE could meet Kingspan’s required programme.501 22.20 We did not find Dr Colwell’s evidence on these matters very convincing and have been left with the clear impression that she and other employees of BRE were doing much more to assist Kingspan than she was willing to admit. Moreover, although she initially denied that she had known anything about discussions between BRE and Kingspan during or after the May 2005 test,502 Dr Colwell was constrained to accept that, as reflected in an email 487 Meredith {KIN00022312/5} page 5, second paragraph; Meredith {Day75/130:21}-{Day75/131:4}; Heath {Day78/192:20}-{Day78/193:1}; {Day78/209:16}-{Day78/210:3}. 488 Kingspan Off-Site Ltd, previously known as Kingspan Metl-Con Ltd, was part of the Kingspan group. At the time it manufactured and sold pre-fabricated building and facade systems: Stevens {MET00080972/3} page 3, second paragraph. 489 Meredith {KIN00022312/5} page 5, first, second and third paragraphs; Meredith {Day75/130:10}-{Day75/133:24}. 490 {KIN00008847/5} page 5, first and second paragraphs. 491 Colwell {Day232/214:16}-{Day232/217:4}. 492 Colwell {Day232/205:18-21}. 493 Colwell {Day232/196:24}-{Day232/198:16}; {Day232/200:23}-{Day232/201:7}. 494 {KIN00021657} ninth paragraph. 495 {KIN00021657} twelfth paragraph. 496 Colwell {Day232/197:9-12}. 497 Colwell {Day232/198:12-16}. 498 {BRE00047572/1}. 499 Colwell {Day232/200:10-18}. 500 Colwell {Day232/198:18-22}. 501 Colwell {Day232/201:2-7}. 502 Colwell {BRE00047571/47} page 47, paragraph 295.

Part 3 | Chapter 22: Kingspan K15 insulation 71 exchange between BRE and Mr Meredith in March 2006,503 she had attended a meeting in February 2006 with him and an employee of Kingspan Off-Site, as he had described, during which they had discussed the test in May 2005. She said she could not recall any details of that discussion.504 22.21 Dr Colwell’s recollection of events during the period was poor and fragmented and tended to shift in response to the documents. In contrast, Mr Meredith’s account was detailed, clear and essentially unchanging. His recollection was also supported by a number of documents, including contemporaneous correspondence.505 We are satisfied that in the period leading up to the test in May 2005, he thought that a successful test could lead to some kind of generic approval for the use of K15 on buildings over 18 metres in height, even if limited to other systems incorporating non-combustible rainscreens. It is more likely than not that his belief was influenced to a substantial degree, if not founded upon, advice received from Dr Colwell or others at BRE. 22.22 It is not clear exactly when BRE decided that it would not produce a report on K15 that would support its use in conjunction with any non-combustible rainscreen. Philip Heath could not recall506 and Ivor Meredith could only say that it had occurred shortly after the test.507 Dr Colwell denied that any retraction had occurred. In April 2006, Kingspan was still chasing Dr Colwell for an assessment508 and was clearly still expecting it to be one that would confirm the suitability of K15 for use on buildings over 18 metres in height generally and could be sent to all its customers.509 Although we do not consider that the precise date of BRE’s change of heart is of particular importance, it is of note that by the date of his report on 7 January 2008 at the very latest (and probably considerably earlier),510 Mr Meredith had understood and had made his managers aware that any claims Kingspan made about success in the test carried out in May 2005 could apply only to external walls constructed using the same components in the same configuration.511 In his report, he informed his managers that the “BRE are adamant that approval only applies to what is tested”.512 Kingspan’s presentation of the 2005 test: 2005 and 2006 22.23 Ivor Meredith knew that a test in accordance with BS 8414 could not produce a result that would cover all possible uses of K15.513 With the exception, again, of Dr Rochefort,514 every Kingspan witness from whom we heard confirmed their understanding that BS 8414 was a system test that had no generic application, still less any application for one particular 503 {KIN00005165/2} “Further to our meeting last month”. 504 Colwell {Day232/210:16-25}. 505 See, for example, the report of January 2006 {KIN00020718/2} first bullet point under “Projects”; {KIN00004795}; {KIN00005165/1}. 506 Heath {Day78/212:20}-{Day78/213:3}. 507 Meredith {Day75/130:14}. 508 {KIN00005163}. 509 {KIN00004795}. 510 Ivor Meredith’s report of 7 January 2008 {KIN00008847/5} contained an explanation of the circumstances in which Kingspan had begun a programme of BS 8414-2 testing, the key driver being BRE’s refusal to issue a report supporting a broad scope of application. The first test in the programme had taken place on 20 December 2007 but planning for it had begun early in 2006. On 7 April 2006, Dr Malcolm Rochefort noted in his diary, “K15 – do we need another 8414 test?” {KIN00024441}. 511 {KIN00008847/5} second paragraph. 512 {KIN00008847/5} third paragraph. 513 Meredith {Day75/71:20-23}. 514 Rochefort {Day80/20:22}-{Day80/21:23}; {Day80/25:3-13}; {Day80/35:16}-{Day80/36:12}; {Day80/82:13}-{Day80/83:19}; where Dr Rochefort cited the fact that BS 8414 is a system test as the basis for his lack of action following a later unsuccessful BS 8414-2 test.

The Grenfell Tower Inquiry: Phase 2 Report 72 component of the system tested.515 Nonetheless, following the test in May 2005 Kingspan proceeded to claim precisely that in all its marketing and sales literature relating to K15, as well as in its correspondence with customers. 22.24 By October 2005, in emails advising customers about the use of K15 on buildings over 18 metres in height, Kingspan was using variations of standard wording produced by Ivor Meredith which he acknowledged to colleagues at the time was possibly “a bit heavy in some areas”.516 Kingspan always told customers that K15 had passed a test in accordance with BS 8414 and sometimes told them that any material claiming to be fire safe should have passed that test.517 The text produced by Mr Meredith included a statement that “To fall within the requirements of Approved Document B Kooltherm K15 can continue above 18 metres”518 and statements were also made to customers that K15 met “the criterion [sic] of BR 135 and thus the 18m rule”.519 Both claims were false. 22.25 In January 2006 Kingspan began sending out to customers520 a promotional document entitled “What’s lurking behind your façade?”521 which came to be referred to within Kingspan as the K15 or BS 8414 “flyer”.522 In it Kingspan stated that K15 had been tested and “awarded certification to BS 8414-1” and had been “assessed and approved in accordance with BR 135”. Both statements were false. BS 8414 is a test method which does not provide the basis for certification of any kind, much less the certification of a particular product, and a single component of a system tested in accordance with BS 8414 could not be assessed or approved in accordance with BR 135 because the performance criteria in BR 135 were applicable only to the system as a whole. 22.26 Kingspan withdrew the flyer after it came to the attention of BRE,523 who at some stage before 8 June 2006524 complained to Kingspan about the inaccuracy of its contents.525 It does not appear that there was any further complaint from BRE about Kingspan’s broader misrepresentation of BS 8414 as a product test. Although the words “certified” and “approved” were eventually removed from the flyer, avowedly to “steer clear of the BRE’s wrath”,526 the misleading assertion that K15 as a product had been tested and was acceptable for use above 18 metres “when assessed in accordance with BR 135” persisted in the revised text that Mr Meredith told Kingspan’s technical advisors to use thereafter.527 515 Pack {Day86/64:11-19}; {Day86/140:5-17}; Meredith {Day75/85:1-19}; Heath {Day78/196:14}-{Day78/197:2}; Mills {Day77/25:11-24}; Millichap {Day81/32:25}-{Day81/33:24}; Pargeter {Day83/113:21-25}-{Day83/114:1-3}; Burnley {KIN00022662/3} page 3, paragraph 1.10. 516 {KIN00003687} third paragraph. 517 {KIN00002575/2} third paragraph. 518 {KIN00003687} sixth paragraph. 519 {KIN00002577/2} While we note that Mr Meredith does refer in this email to a system, he included in that system only K15 and the particular cavity barrier product used in the May 2005 test, manufactured by Promat. He represented that those two products together met the criteria in BR 135, as part of an ultimately unsuccessful attempt to encourage Promat to make representations to the market about the compatibility of the two products. See also {KIN00005172/10} first paragraph for the claim that K15 “easily meets” the criteria in BR 135. 520 {KIN00005133}. 521 {KIN00005350}. 522 For example, see {KIN00003688}; {KIN00005179}. 523 No BRE witness was able to assist us with any details of the complaint. Despite an email copied to Dr Colwell in June 2006 in which Ivor Meredith referred to discussing the complaint with her {KIN00005180}, it was her evidence that she had no recollection of it: Colwell {Day232/223:4-15}, or indeed of ever discussing any Kingspan marketing literature with BRE colleagues {Day232/218:3-8}. 524 The date of Ivor Meredith’s internal email informing technical teams that the flyer had been withdrawn {KIN00005179}. 525 {KIN00005179}; {KIN00005180}; Meredith {Day75/121:10-12}. 526 {KIN00005206}. 527 {KIN00005179}; See draft amended text at {KIN00005194}.

Part 3 | Chapter 22: Kingspan K15 insulation 73 22.27 Meanwhile, in 2007 Kingspan began to write what Mr Meredith called “letters of suitability” for the use of K15 on high-rise projects.528 In emails and letters to customers Kingspan recommended K15 as a suitable product for use on buildings over 18 metres in height. That was done either by asserting that K15 was suitable for use in the particular system proposed by the customer or by representing that K15 was suitable for use in all systems on buildings over 18 metres in height, or both.529 22.28 Occasionally, Kingspan represented to customers not only that the use of K15 was allowed in any cladding system on a building over 18 metres in height in accordance with Approved Document B, but also that the existence of the data from the BS 8414 -1 test in May 2005 constituted an alternative route to compliance for K15 as a product.530 It was also said that choosing a product that had “passed” a test under BS 8414 might in fact be a more onerous (and, by implication, safer) “route” than choosing a product that was non-combustible or of limited combustibility.531 In other instances, Kingspan asserted that although K15 was not a non-combustible material, it had “been proved to perform the same as a non-combustible material” by testing in accordance with BS 8414.532 Again, none of those statements were true. 22.29 The text drafted by Ivor Meredith and used by Kingspan’s teams in that correspondence was checked by Philip Heath, who admitted not only that he had provided supervision and guidance but also that he had had the final say on the wording.533 False claims about K15 were therefore not being made in error or by rogue junior employees but with the knowing approval of a senior manager. 22.30 Indeed, Philip Heath told us that at that time Kingspan often found itself in the position of having to explain to customers Approved Document B’s alternative route to compliance through the BS 8414 test.534 Kingspan was keenly aware that there was a lack of detailed knowledge about BS 8414 and BR 135 among its customers, many of whom were unfamiliar with both. It relied on the fact that an unsuspecting market was itself highly likely to rely on it for advice and to accept its claims about K15’s suitability for use as reliable. Kingspan was reluctant to send out its one BS 8414 test report535 to any of its customers (it had nothing else to send), but was lucky in that they sometimes accepted its word.536 22.31 Kingspan’s strategy was to go after every job.537 Mr Meredith’s detailed report to senior managers in January 2008538 contained an important summary of the strategy at the time, namely, that Kingspan promoted the fact that K15 had “the ability to pass” (referring to the successful May 2005 test). A similar claim appeared in various Kingspan articles for industry 528 Meredith {Day76/81:15-23}; {KIN00005308}; In February 2006 Joel Clarke circulated the original BS 8414 flyer to technical staff, commenting that it would be better to send the flyer out than “write tedious letters”. He recommended that the flyer should be attached to any correspondence that was being sent to sizeable architects and designers “just in case they’ve been fooled by the lies Celotex have been spreading about how it doesn’t comply”: {KIN00005179}. 529 {KIN00008954/2}; {KIN00005203/2}; {KIN00002576}; {KIN00005216/1}; {KIN00005240}. 530 {KIN00002577/1}. 531 {KIN00002577/1}. 532 {KIN00002583/1}. 533 Heath {Day79/109:5-19}; Meredith {Day76/82:6-8}. 534 Heath {KIN00020709/31-32} pages 31-32, paragraph 4.50; Heath {Day78/182:9-11}. 535 BRE Report {BRE00002511}. 536 {KIN00005380/2}; Meredith {Day76/82:11}-{Day76/83:4}. 537 Meredith {Day76/83:3-4}. 538 {KIN00008847/5} third paragraph.

The Grenfell Tower Inquiry: Phase 2 Report 74 journals539 and in the BS 8414 flyer,540 in all of which Kingspan warned readers to question the use of any external cladding products that “do not have the ability” to pass the BS 8414 test. That was linguistic sleight of hand. It was a cynical misrepresentation of the nature and purpose of BS 8414 and BR 135 and of the provisions of Approved Document B relating to them. 22.32 Mr Meredith told us that the strategy had been agreed between him and his senior managers as offering Kingspan’s only opportunity of moving forward once it had become clear that BRE was not prepared to provide a generic report on the suitability of K15 based on the BS 8414 test in May 2005.541 The other obvious option, namely to behave honestly and with integrity by avoiding false statements, does not appear to have been considered by anyone at a senior level. Fire Performance claims for new technology K15 22.33 In the period between 2005 and 14 June 2017, two important claims were made by Kingspan in relation to the fire performance of K15. The first was that K15 had achieved a classification of Class 0 through testing to Parts 6 and 7 of BS 476. The second was that K15 had been tested to BS 8414 and had met the criteria in BR 135. Kingspan gave both claims prominence, both in its marketing literature for K15542 and in its correspondence with customers. They also appeared in the certificates relating to K15 published by the British Board of Agrément (BBA)543 and Local Authority Building Control (LABC).544 22.34 As explained above, the transition to new technology K15 involved various changes to the chemical composition and manufacturing process, as well as the introduction of perforated foil facers.545 As a result, new technology K15 had different physical properties as well as a different chemical composition. The K15 product that Kingspan sold after September 2006, although still a phenolic foam, was without question a different product from that which it had previously been selling. 22.35 Following the introduction of new technology K15 in 2006, Kingspan continued to make the two principal claims about the product’s fire performance without any reference to the changes that had been made to the product, which were not disclosed to the market. In relation to new technology K15 those claims were entirely false. The true position was that no test in accordance with BS 8414 had been carried out on a system incorporating new technology K15 or was carried out until 23 March 2015 and no classification in accordance with the criteria in BR 135 had been made or was made until June 2015.546 Moreover, new technology K15 did not achieve results when tested in accordance with BS 476 parts 539 See for example {KIN00005198/3} third paragraph; {KIN00005219/3} second paragraph; {KIN00005262/3} second paragraph. It is not known if these articles came to be published. 540 {KIN00005350} first paragraph. 541 Meredith {Day75/117:17}-{Day75/118:24}. 542 A classification to Class 0 for K15 was claimed in all K15 product literature from 2001 onwards; reference to BS 8414 was first made in K15 product literature in May 2007 and continued thereafter. March 2001 {KIN00020720}; January 2002 {KIN00009173/1}; November 2002 {KIN00008018/1}; March 2003 {KIN00002579/1}; November 2005 {KIN00022668/1}; June 2006 {KIN00005371/1}; September 2006 amended “What’s lurking behind your façade?” {KIN00000055}; May 2007 {KIN00002580/6}; November 2008 {KIN00009703/6}; March 2011 {KIN00003545/1}; July 2016 {KIN00000070/7}. 543 {BBA00000038/5}; {BBA00000037/5}; {BBA00000036/6}; {BBA00000040/5}. 544 {KIN00005705/4}; {KIN00009547/2}; {NHB00000798/1} (Class 0 claim absent from this certificate), {LABC0000997/3}; {LABC0001842/2}; {KIN00016968}; {KIN00000076}. 545 {KIN00022307} Major Changes, Row 7; Rochefort {KIN00008838/6} page 6, paragraphs 3.7-3.10; Rochefort {Day80/50:6}-{Day80/55:1}. 546 23 March 2015 BS 8414-2 test. Test report 302995 dated 14 May 2015 {BRE00002494}; BR 135 Classification Report P100769-1000 dated 8 June 2015 {BRE00002495}.

Part 3 | Chapter 22: Kingspan K15 insulation 75 6 and 7 (which was a product test but, under Approved Document B, largely irrelevant to insulation) such as to justify a rating of Class 0 at any stage before the Grenfell Tower fire.547 That came to light only as a result of our investigations. At no time did Kingspan inform the market that the particular fire tests on which it purported to rely had in fact been carried out on a product that was no longer available and had not been sold since 2007 at the latest. 22.36 For many years Kingspan marketed and sold K15 relying heavily on tests which had been carried out on a different product. That was not the result of a mistake, as Dr Rochefort claimed,548 or misunderstanding; it was done deliberately. The relevant test and classification reports were not withdrawn until October 2020, following the Inquiry’s investigations. Class 0 22.37 As has been noted, a classification of national Class 0 was claimed for K15 in all promotional literature from 2001 onwards. Some of Kingspan’s marketing brochures claimed that both the K15 product and, separately, its core, were “Class 0 fire rated”.549 That was a nonsensical assertion when considered alongside the test standards used to achieve it. Although none of its literature ever disclosed the fact, in order to substantiate its claim, Kingspan had carried out tests in accordance with BS 476 Parts 6 and 7 at various times between 2004 and 2016 not on K15 boards as supplied to the market but on the foil facer of the product alone.550 That was done by attaching the foil to a calcium silicate or other non-combustible substrate for the tests.551 Kingspan sought to justify its actions by reference to the wording of Approved Document B, which stated that Class 0 was achieved if a material or, in the case of a composite product, the surface of the product met certain criteria when tested in accordance with BS 476 Parts 6 and 7.552 22.38 Both Adrian Pargeter and Dr Rochefort told us, and Kingspan in its closing statement submitted, that that was a legitimate practice on the basis of the wording of Approved Document B.553 Mr Pargeter defended it as a technical but common-sense interpretation of the wording in Approved Document B.554 We disagree. In our view such an interpretation of Approved Document B is over-literal, artificial and has at least the potential to lead to absurd results. Kingspan’s Arron Chalmers, who was a candid, if at times lurid, internal commentator on Kingspan’s style of doing business, described it as “a bit of a cheat”.555 Neither Dr Rochefort nor Mr Pargeter had checked the test standards to ensure that it was legitimate for Kingspan to claim that K15 had achieved Class 0 by testing in that way.556 Had they done so, they would have discovered that the practice was at odds with both the purpose of BS 476-6 and its wording, both of which make clear that it is designed as a test of a product, not part of a product.557 Kingspan had sought the advice of Frans Paap at Exova on the subject. He apparently told it that the provision 547 Pargeter {Day84/72:13-16}. 548 Rochefort {Day80/68:9-16}. 549 See for example March 2011 {KIN00003545/6}. 550 {KIN00022205}. 551 See for example {KIN00000256/5}. 552 {CLG10000007/122} Appendix A, paragraph 13. 553 Pargeter {KIN00020824/8-10} pages 8-10, paragraphs 3.11-3.18; Pargeter {Day84/69:16-19}; Rochefort {Day80/89:7}-{Day80/90:1}; Kingspan Module 2 closing submissions {KIN00025944/32} page 32, paragraphs 84-87. 554 Pargeter {Day84/82:23-25}. 555 {KIN00004168}. 556 Pargeter {Day84/84:12-15}; Rochefort {Day80/89:17-21}. 557 {BRE00005557/18}.

The Grenfell Tower Inquiry: Phase 2 Report 76 could be interpreted in that way558 but said that it should test the complete product before making any claim about Class 0 because the foam behind it was likely to affect the performance of the facer.559 Adrian Pargeter accepted that the interpretation was neither conservative nor ideal but said that Kingspan was prepared to adopt a literal interpretation of Approved Document B that might be less safe but would facilitate sales of K15.560 22.39 To the extent that the tests relied on to support the claim that K15 was rated Class 0 had been carried out on the foil facer alone, that claim was false. Understandably, there was evidence of some disquiet about it even within Kingspan’s own ranks.561 Other than for one specific and limited purpose relating to the spacing of cavity barriers,562 Class 0 was not relevant to the suitability of insulation for use on buildings over 18 metres in height, as Kingspan knew. No Kingspan witness claimed otherwise. Nonetheless, in much of its correspondence Kingspan either treated Class 0 as evidence of the suitability of K15 for use on buildings over 18 metres in height or treated it as the equivalent of limited combustibility. For example, it sometimes told customers in very general terms that Class 0 was the “highest possible product fire performance classification”, using language which effectively elided the two concepts. It also made recommendations that K15 be used for projects involving buildings over 18 metres in height, immediately followed by a statement that K15 had achieved Class 0, as though the two were related.563 The fire performance of new technology K15 22.40 At the time of the change from old to new technology K15 in 2006, and for some time after, Philip Heath and Dr Rochefort considered the properties of the two products to be very similar.564 Dr Rochefort explained that the similarity between them on a chemical level was such that he had not expected their fire performance to differ significantly.565 He did not regard the introduction of perforations to the foil facers as significant,566 because the composition was the same567 and the perforations represented less than 0.5% of the surface area of the board.568 However, in an email to Philip Heath on 7 July 2005 Lamtec, the manufacturers of the foil facers, had alerted Kingspan in the clearest terms to the fact that the fire performance of the foam would be significantly different once the facers were perforated because the perforations would potentially allow gases produced by combustion to reach the atmosphere and burn.569 The warning appears to have been ignored. 558 {KIN00004168/1}. 559 {KIN00004168/2}. 560 Pargeter {Day84/118:10}-{Day84/119:6}. 561 Meredith {Day76/181:4}-{Day76/182:8}; {KIN00004168/1}. 562 Lane, Phase 1 Report Section 11 {BLAR00000006/41} paragraph 11.11.18; Millichap {Day81/42:13-16}. 563 See examples at {KIN00005363/8}; {KIN00005218/2}; {KIN00009014/1}; {KIN00002583/2}; {KIN00002882/1}. 564 Heath {KIN00020709/9} page 9, paragraph 3.4, “…basically the same chemistry but different production technology...”; Heath {Day78/227:2-4}; Heath {Day79/11:20-25}; Rochefort {KIN00008838/7} page 7, paragraph 3.10; Rochefort {Day80/54:23}-{Day80/55:1}. 565 Rochefort {KIN00008838/7} page 7, paragraph 3.10; Rochefort {KIN00008838/50} page 50, paragraph 11.22; Rochefort {Day80/67:19-22}. 566 Rochefort {KIN00008838/7} page 7, paragraph 3.10; Rochefort {Day80/54:18-25}. 567 Rochefort {Day80/53:13-17}. 568 Rochefort {Day80/54:1-5}. 569 {MET00081264}.

Part 3 | Chapter 22: Kingspan K15 insulation 77 22.41 Despite the apparent similarities between the old and the new products, Kingspan’s Product and Process Development System was engaged in order to assess any differences between various aspects of their performance.570 Following its completion new technology K15 was able to enter the market.571 22.42 Dr Rochefort had revised the Product and Process Development System at an earlier stage to ensure that the programme for the change to new technology would include fire testing.572 Responsibility for fire testing and certification fell to Philip Heath,573 who did not sign the section off as complete574 until 21 February 2008.575 He and Ivor Meredith explained that the “sign off” of any particular section of the Product and Process Development System did not in fact indicate completion but rather that something was “in hand” and confirmed that fire testing had continued for many years after the new technology had become available to the market in 2006 and the process had been signed off by Mr Heath in February 2008.576 In those circumstances, it is difficult to see what real purpose Kingspan’s Product Process and Development System served in this case. 22.43 Philip Heath was not able to explain why Kingspan had started to sell the new form of K15 years before fire testing on it had been completed.577 Dr Rochefort told us that it was difficult in practice to have everything signed off before a new product was sold and that as long as testing was still being carried out without any obvious problems that had been considered good enough.578 He assumed at the time that new technology K15 had achieved European Class C for the purposes of CE marking,579 which he had understood (wrongly) to equate to national Class 0.580 Mr Meredith thought that testing to European standards had been undertaken before new technology K15 had been made available to the market and that a Class C had been achieved,581 but he could not recollect any other testing.582 Testing in accordance with BS 476 parts 6 and 7 22.44 Neither Mr Meredith nor Dr Rochefort nor Mr Heath could recall the results of tests carried out in accordance with BS 476-6 or BS 476-7 on the new K15 product that was actually produced by Kingspan at Pembridge.583 Indeed, neither Dr Rochefort nor Mr Heath could tell us clearly what fire tests had been carried out on new technology K15 or whether any difference in fire performance between the old and the new technology products had been discovered. That was despite Mr Heath’s acknowledging that he, together with Research and Development Manager Vincent Coppock584 and Technical Processing 570 {KIN00022307} Major Changes, Row 7, Column N; Heath {Day79/16:7}-{Day79/17:14}; Rochefort {KIN00008838/9} page 9, paragraph 3.16. 571 Rochefort {KIN00008838/9} page 9, paragraph 3.16. 572 {KIN00022307} Major Changes, Row 7, Column N; Rochefort {KIN00008838/9} page 9, paragraph 3.16. 573 {KIN00022003/2}; Heath {Day79/22:21}-{Day79/23:7}. 574 {KIN00022307} Major Changes, Row 7, Column N. 575 Rochefort {KIN00008838/9} page 9, paragraph 3.16. 576 Meredith {Day75/39:3-13}; Heath {Day79/18:14-25}. 577 Heath {Day79/21:5}. 578 Rochefort {Day80/58:5-10}. 579 The letters “CE” are the abbreviation of French phrase “Conformité Européenne” which literally means “European Conformity”. It is a marking which certifies that a product has met EU health, safety, and environmental requirements. 580 Rochefort {Day80/60:13}-{Day80/61:1}. 581 Meredith {Day75/155:6-9}. 582 Meredith {Day75/40:10-16}. 583 Meredith {Day75/41:10-15}; Heath {Day79/25:12-13}; {Day79/28:21}-{Day79/29:24}; {Day79/77:12-16}; Rochefort {Day80/89:1-16}. 584 Heath {KIN00020709/15} page 15, paragraph 3.24.

The Grenfell Tower Inquiry: Phase 2 Report 78 Manager Gwyn Davies,585 had been principally responsible for the testing586 and despite Dr Rochefort’s acceptance that as Technical Director (to whom Mr Heath, Mr Coppock and Mr Davies all reported)587 responsibility for ensuring that products were fit for market, including in terms of fire safety, ultimately fell to him.588 22.45 Quite apart from that unsatisfactory evidence, we were struck by the fact that there appeared to be no composite record of the fire testing carried out on new technology K15 or of any reported difference in fire performance between the old and the new technology formulations. Although it was difficult to discern what fire testing had actually been undertaken, what did become clear was that there had been no comprehensive programme leading to a proper understanding of the fire performance of new technology K15 before it entered the market. Mr Heath admitted as much and accepted that that should have occurred.589 22.46 A detailed analysis of the contemporaneous documents, including notes from internal meetings and reports written by Mr Meredith, revealed that from 2005 onwards a number of small and medium-sized tests had been carried out on the new technology K15. That included calorimetry and single burning item tests as well as repeated testing to BS 476 Parts 6 and 7. The documents also revealed that none of that testing appears, in Kingspan’s view at the time, to have brought positive news about the fire performance of new technology K15. In particular, numerous internal documents between 2006 and early 2009 reveal discussions about Kingspan’s inability to obtain a classification to national Class 0 for the new product and details of its continuing efforts to do so over the course of many years. The documents were widely circulated among technical staff, including Dr Rochefort and Mr Heath. During the same period, however, Kingspan claimed for all external purposes that K15 had achieved that classification. 22.47 In a half-yearly report prepared for Mr Heath in July 2007, Ivor Meredith identified one of the low points of the period as a failure to verify basic properties for new technology K15, including its rating as Class 0.590 In the same report, he referred to numerous failed attempts to pass the BS 476-6 test and said that repeats of tests that had narrowly failed and the addition of fire retardants were being considered.591 22.48 In an internal report sent to Dr Rochefort and Mr Heath on 7 January 2008 that referred to the European single burning item test, Mr Meredith reported that the introduction of perforations in the foil facers of new technology K15 had led to a reduction in the European classification. He recommended the removal of the perforations and the addition of a fire retardant, noting that the latter could also help to achieve Class 0.592 22.49 Dr Rochefort told us that Kingspan’s fire focus group had done quite a lot of work to establish the effect on fire performance of the newly introduced perforations in the foil facer.593 Mr Meredith told us that the matter had been discussed at monthly technical meetings; his hypothesis was that the perforations allowed the blowing agent in the 585 Rochefort {KIN00008838/11} page 11, paragraph 3.22. 586 Heath {Day79/24:18}-{Day79/25:9}. 587 Rochefort {Day80/4:23}-{Day80/5:6}. 588 Rochefort {Day80/8:23}-{Day80/9:2}. 589 Heath {Day79/21:6-12}. 590 {KIN00005292/11} penultimate bullet point. 591 {KIN00005292/7} first paragraph. 592 {KIN00008847/3} eighth paragraph; {KIN00022466/1} paragraph 1.1, third bullet point “BS 476 Part 6 still elusive for certain formulations…”. 593 Rochefort {Day80/64:12-17}.

Part 3 | Chapter 22: Kingspan K15 insulation 79 foam to ignite more readily,594 causing a deterioration in fire performance. We note that Professor Bisby’s findings about the effect of the perforations tend to support that hypothesis.595 Dr Rochefort did not say what work had actually been carried out and we found no documents that shed light on any such assessment, other than a reference in the minutes of a meeting on 25 July 2008 to plans to perforate only one side of the facer. We note that at that meeting, which Dr Rochefort attended, someone stated that perforations had been shown to reduce fire performance considerably.596 In any event, new technology K15 was available for sale before any such assessment had been undertaken, as Dr Rochefort acknowledged.597 22.50 In a monthly technical report produced in April 2008, Mr Meredith reported indicative calorimeter tests comparing old and new technology K15 in which the latter had showed a faster time to ignition and double the heat output (or rate of heat output, as we understand it).598 Testing under BS 8414 22.51 By the end of 2005, BS 8414 Part 2 had been published, containing the large-scale test method for external cladding systems supported by steel frames rather than masonry.599 As a result, challenges began to arise in relation to Kingspan’s use of test data from its BS 8414-1 test in 2005 to support the use of K15 at height on steel-framed buildings, for which no BS 8414 test data existed.600 In an internal report in January 2008, Ivor Meredith noted that despite Kingspan’s fighting the case for each project, the absence of any BS 8414-2 test data was causing it to lose sales on a daily basis. He considered it essential to obtain such data to support the sale of K15 for use on buildings over 18 metres in height.601 22.52 In 2007 and 2008, four tests under BS 8414-2 were carried out on systems incorporating new technology K15. Two of them, on 20 December 2007602 and 24 April 2008 respectively,603 were carried out on systems using solid aluminium rainscreen panels604 and were undertaken in partnership with Sotech Ltd, a rainscreen manufacturer, and Voestalpine Metsec plc, a supplier of structural steel frame systems. The other two, on 9 April605 and 6 June 2008 respectively,606 were carried out in partnership with Kingspan Off- Site and incorporated Kingframe steel loadbearing systems607 and rendered rainscreen boards.608 All four systems failed to meet the performance criteria in BR 135.609 At all times, 594 Meredith {Day75/155:10}-{Day75/156:9}. 595 Bisby, Phase 2 Experiments Work Package 2 Report {LBYWP200000001/120} paragraph 635. 596 {KIN00022467/1} paragraph 1.2. 597 Rochefort {Day80/64:18}-{Day80/65:7}. 598 {KIN00003698} third paragraph. 599 October 2005 {BSI00000097}. 600 Heath {Day79/36:18-25}; See for example {KIN00005243/2}. 601 {KIN00008847/2} fourth paragraph; Meredith {Day75/146:3-8}. 602 Test 239825{KIN00008847/2}; {BRE00032344/1-3}; {BRE00032344/121-124}; {BRE00032344/170-171}. 603 Test reference unknown. See {BRE00032344/183}; {BRE00032344/187-190}. 604 Eggington {SOT00000029/2} page 2, paragraph 9. 605 Test 241103 {BRE00011552}. 606 Test 241105 {BRE00011552}. 607 Stevens {MET00080972/4} page 4, final paragraph. 608 {BRE00011552/1}. 609 Heath {Day79/35:7-10}; Rochefort {Day80/70:4-8}. Note that during Test 241105 on 6 June 2008 (Kingspan Off Site) the heat source was extinguished early, thereby terminating the test, due to the failure of the hearth. The rig was allowed to burn for the full duration of 60 minutes for observations to be made. See {BRE00011552} paragraph 1, lines 2-3, “... the full requirements of the standard were not however complied with...”; Wilkinson {MET00080973/6-7} pages 6-7, fourth paragraph.

The Grenfell Tower Inquiry: Phase 2 Report 80 Kingspan concealed from its three co-sponsors, including Kingspan Off-Site, the fact that its previous test in accordance with BS 8414-1 in May 2005 had been carried out on a system that incorporated the old formulation of K15.610 22.53 In January 2008, after the first test on 20 December 2007, Ivor Meredith (who had not been present at the test) sent Mr Heath, Dr Rochefort and others a report containing his detailed observations and an analysis of what had occurred.611 Describing the result as a “raging inferno”, he explained that the top fire barrier had been breached 17 minutes into the test, that the system had failed the temperature criteria in BR 135612 and that the test had been terminated early because there had been a danger that the laboratory would be set alight.613 22.54 Mr Meredith also recorded specific observations about the performance of the K15 insulation, as well as offering views (both his own and those of BRE) on the performance of the new K15 compared with the old, which had been tested in 2005. He included photographs of that earlier test in his report in order to demonstrate the differences he was describing.614 He said that the new K15 had burnt ferociously “on its own steam” and that it was, in his words, “... very different in a fire situation to the previous technology ...”.615 22.55 Mr Meredith recorded what he described in the report as “official” and “unofficial” comments from BRE.616 He thought they had been provided by Philip Clark,617 who had been present at the test together with Dr Colwell and Tony Baker618 and had been the most approachable on the subject of testing.619 The “unofficial” comments were that the insulation had been fully involved in the fire, that the foam core had continued to burn after the flame source had been extinguished, that surface spread of flame on the K15 was apparent and finally, that BRE had not remembered the product performing like that in the previous test. The “official line” was that the system as a whole had failed and that responsibility for the failure could not be attributed to any individual component.620 22.56 All three BRE witnesses denied that they had made “official” and “unofficial” comments in the way described by Mr Meredith and insisted that that was not something BRE would do.621 Dr Colwell acknowledged that it would have been wholly inappropriate for BRE to do that.622 However, Mr Clark told us that comments to that effect could have been made by Dr Colwell or Mr Baker623 and went on to say that although he could not recall making them himself, he might have commented on how bad the burning was over the surface 610 Dr Rochefort told us that he did not know whether Kingspan Off-Site had been told that the 2005 test in accordance with BS 8414-1 had been carried out on a different, old version of K15: Rochefort {Day80/118:7-11}. All the other witnesses who were involved in this testing confirm that Kingspan Off-Site had not been told: Stevens {MET00080972/12} page 12, second paragraph; Wilkinson {MET00080973/8} page 8; Heath {Day79/90:10-12}; Meredith {Day75/171:20}-{Day75/172:4}; {KIN00020917/1} penultimate paragraph. 611 {KIN00008847}. 612 {KIN00008847/2} penultimate paragraph. 613 {KIN00008847/3} first paragraph. 614 {KIN00008847/21-22}. 615 {KIN00008847/3}. 616 {KIN00008847/3}. 617 Meredith {Day75/160:3-13}. 618 “Test witnesses” {KIN00008847/2}. 619 Meredith {Day75/160:5-7}. 620 {KIN00008847/3}. 621 Clark {Day96/166:16-19}; {Day96/168:4-7}; {Day96/173:18-19}; Colwell {Day232/228:18}-{Day232/229:11}; Baker {Day100/59:8-10}; {Day100/60:4-8}. 622 Colwell {Day232/228:8-20}. 623 Clark {Day96/165:1-11}.

Part 3 | Chapter 22: Kingspan K15 insulation 81 of the K15 and that he could not rule out having made them.624 We think it unlikely that Mr Meredith had invented comments of that kind or in that detail. We prefer his evidence and are satisfied that Mr Clark did make them and that Dr Colwell was probably aware that he had done so. That is supported by Mr Meredith’s contemporaneous report and by a number of other contemporaneous documents. One particularly striking example is an email sent on 9 January 2008 by Mr Meredith to Dr Colwell in which he asked her to confirm that BRE would not deviate from the “official statement” and would not state in writing that the failure was due to the flame spread across the K15 insulation.625 22.57 Both Mr Heath and Dr Rochefort confirmed that they had read Mr Meredith’s report at the time,626 including his strongly worded observations about the performance of K15 in the test in December 2007, in which he had stated that the way in which the K15 had burned was of the “most concern”.627 Mr Heath told us that he had been concerned by the report.628 Indeed, he said that he had already been aware that Mr Meredith had concerns about the fire performance of new technology K15 and had agreed that he should write the report in order to draw the attention of more senior Kingspan personnel to them.629 Save for conveying those concerns to Dr Rochefort and offering support to Mr Meredith, however, Mr Heath did not take any action.630 Dr Rochefort told us that he too had been disturbed by the report631 and that he had understood that Mr Meredith was attempting to make him and others sit up and take notice that there was reason to be worried about the fire performance of the new K15 product.632 22.58 Nonetheless, the report was effectively ignored by Dr Rochefort, despite his claim to the contrary.633 Echoing BRE’s “official line” as recorded in Mr Meredith’s report,634 both Mr Heath and Dr Rochefort attempted to explain Kingspan’s inaction by saying that BS 8414 was a system test and that it was possible that components of the system other than the K15 might have been responsible for the failure.635 Apparently for those reasons, neither Dr Rochefort nor Mr Heath gave consideration to suspending the sale of K15.636 Dr Rochefort said that after the test in December 2007 he had considered moving back to the old technology and that he had discussed that option in a couple of internal emails,637 but his recollection was not supported by any documents we have seen. It was also inconsistent with the minutes of the many technical meetings held at that time,638 during each of which Kingspan’s plans for dealing with the fire performance of the new technology were specifically discussed, often as a “high priority” or as “urgent” business. In none of those minutes was there any mention of reverting to old technology K15.639 We think that Dr Rochefort’s memory was unreliable on that point. 624 Clark {Day96/166:2-7}. 625 {KIN00003693/1} final paragraph; {KIN00020908/1} first paragraph and penultimate paragraph. 626 Heath {Day79/38:1-7}; Rochefort {Day80/70:13-20}. 627 {KIN00008847/3}. 628 Heath {Day79/53:6-9}. 629 Heath {Day79/38:2-13}. 630 Heath {Day79/56:17}-{Day79/57:2}. 631 Rochefort {Day80/76:10-14}. 632 Rochefort {Day80/77:14-25}. 633 Rochefort {Day80/81:11-16}. 634 {KIN00008847/3}. 635 Rochefort {Day80/83:4}-{Day80/83:19}; Heath {Day79/36:14-17}. 636 Rochefort {Day80/82:2-10}; {Day80/91:17-24}; Heath {Day79/68:4-20}. 637 Rochefort {Day80/91:24}-{Day80/92:8}. 638 30 January 2008 {KIN00022466}; 21 February 2008 {KIN00023870}; 25 July 2008 {KIN00022467}; 22 August 2008 {KIN00023871}; 22 October 2008 {KIN00022468}. 639 {KIN00022467/1} paragraph 1.2; {KIN00022468/1} paragraph 1.2, fourth bullet point.

The Grenfell Tower Inquiry: Phase 2 Report 82 22.59 On 9 April 2008, a second test of a system incorporating new technology K15 was carried out in accordance with BS 8414-2 but again it failed to meet the performance criteria in BR 135, with temperatures exceeding the required levels at around 16 minutes into the test.640 That test was organised by Kingspan Off-Site, whose Project and Development Engineer, Aidan Wilkinson,641 witnessed it. He described the system as having performed “abysmally”.642 There was then a third test on 24 April 2008, which was the second test carried out in partnership with Sotech and Metsec. Various modifications had been made to the system tested in December 2007 to try to improve its performance, but again it failed to meet the performance criteria in BR 135.643 Despite that record of persistent failure, neither Dr Rochefort nor Mr Heath nor anyone else at Kingspan was moved to take any further action. 22.60 On 6 June 2008 Kingspan Off-Site carried out its second test at BRE in accordance with BS 8414-2 (the fourth in the series). After the test, Aidan Wilkinson, and Mark Stevens, his manager and Technical Team Leader,644 contacted Kingspan to share their observations about the performance of K15 during both tests and to raise questions about it. In particular, Mr Stevens and Mr Wilkinson had observed that the K15 had continued to burn for more than 30 minutes after removal of the source of ignition.645 Kingspan Off-Site questioned Kingspan several times both by email and by telephone about whether that was normal or to be expected for K15; they also asked Kingspan for help in identifying what else might have caused the prolonged burning.646 That was a pressing matter for Kingspan Off-Site, which had already arranged to carry out a series of further tests of systems incorporating K15.647 22.61 Rather than telling Kingspan Off-Site what all three by then plainly knew about the worrying fire performance of new technology K15,648 on 2 July 2008 Dr Rochefort, Mr Heath and Mr Meredith worked together to craft a carefully worded response.649 They purported to express surprise at the poor performance of the product, given what Mr Heath described as Kingspan’s previous success with BS 8414, and focused on the possibility that particular details of the test rig or inconsistencies in fire testing generally might have been the cause of the problem.650 22.62 Having responded in those terms, Mr Heath sent an email to his Kingspan colleague Gwyn Davies in which he said, “I’m spinning so much I’m dizzy”.651 Mr Heath, to his discredit, denied before us that that was effectively a boast about being less than truthful,652 but that is obviously what he meant. He later accepted that there had been gaps in the information he had provided and said that he had been trying to delay matters so that Kingspan could develop a better product for testing.653 At one stage, Mr Meredith seems to have been unsure of the account he was to give Kingspan Off-Site, asking 640 {KSO00000099/6} final paragraph; {KIN00008844/1} sixth paragraph. 641 Wilkinson {MET00080973/1} page 1, final paragraph. 642 Wilkinson {MET00080973/4} page 4, third paragraph. 643 Eggington {SOT00000029/3} page 3, paragraphs 17-18. John Eggington was the Managing Director of Sotech at the time of these tests in 2007 and 2008. 644 Wilkinson {MET00080973/1} page 1, final paragraph; Stevens {MET00080972/3} page 3, first paragraph. 645 {KIN00009031/1}; {KIN00003714/1}. 646 {KIN00003704}; {KIN00020917}. 647 Email from Mr Stevens to Mr Meredith {KIN00009031/1}. 648 Rochefort {Day80/121:15-16}; Heath {Day79/88:5-8}; {KIN00003704/1} “The question of K15s bad fire performance is no longer just an internal one”. 649 {KIN00003714/1}. 650 {KIN00020916}. 651 {KIN00009031/1}. 652 Heath {Day79/92:2}-{Day79/93:19}. 653 Heath {Day79/92:6}-{Day79/94:7}.

Part 3 | Chapter 22: Kingspan K15 insulation 83 Philip Heath by email, “Are we saying that the product supplied which failed their test is the same product that we got to pass the test?”.654 It is clear to us that both Philip Heath and Ivor Meredith were, and knew that they were, answering Kingspan Off-Site in terms that were not simply vague but actively designed to conceal and mislead. 22.63 After further questions from Kingspan Off-Site on 16 July 2008, Dr Rochefort suggested that Kingspan should say that it ought not to carry out further testing as planned while Kingspan investigated possible reasons for the failure, on the basis that the “same batch…may suffer from a similar problem”.655 As Dr Rochefort acknowledged, Kingspan well knew that the problem was not limited to any particular batch.656 22.64 The simple truth behind Mr Heath’s “spin” was that Kingspan did not have a version of K15 which it considered capable of performing well enough within a system to enable the criteria in BR 135 to be met;657 Kingspan was working to understand why, as Mr Meredith put it in an email to Mr Heath on 3 July 2008, old tech worked and new tech did not.658 Having carefully considered all the evidence, we are in no doubt that it was that fact that drove Kingspan to conceal from Kingspan Off-Site its serious reservations about the fire performance of new technology K15, rather than reasons of confidentiality, as Mr Heath suggested,659 or a desire not to cause alarm, as Dr Rochefort claimed.660 22.65 The internal correspondence from July 2008 revealed numerous discussions between the three (and others) about trials, modifications and additives which might improve the fire performance of new technology K15.661 The contemporaneous documents show that Kingspan was becoming desperate by this time to find answers to its predicament. Mr Meredith described his request for samples of a particular version of the foam for further testing as “business critical”.662 22.66 In an internal email on 9 June 2008, Dr Rochefort wrote to Mr Meredith and others saying, “Ivor, if you’re confident that old process will pass the test, we may have no choice but to provide old process K15 for Offsite until the FR [fire retardant]663 issue is sorted out”, adding, “ ... we can’t carry on providing something that we know fails a fire test”.664 Dr Rochefort told us that despite saying “for Offsite”, he meant that Kingspan might have to revert entirely to producing and supplying old technology K15 across the market.665 That is not what either Mr Heath or Mr Meredith understood him to mean, however, and neither of them thought that changing back to old technology K15 for the market generally had been considered or discussed as an option at the time.666 We saw no other document that contained a reference to any consideration of reverting to old technology K15 for general manufacture and sale and we do not believe that Dr Rochefort, or anyone else at Kingspan, gave serious consideration to stopping production of new technology K15. Instead, Kingspan simply hoped to improve the product’s fire performance while continuing to sell it and claiming compliance with Approved Document B on the basis of the 2005 test. 654 {KIN00020917/1} penultimate paragraph; See also text in red added by Mr Meredith to {KIN00008844/2-3}. 655 {KIN00003714}. 656 Rochefort {Day80/121:9-16}. 657 Heath {Day79/83:8-13}; {Day79/92:14-16}. 658 {KIN00020917/1}. 659 Heath {Day79/90:13}-{Day79/91:17}. 660 Rochefort {Day80/121:22}-{Day80/122:10}. 661 {KIN00008844}. 662 {KIN00003704/1}. 663 Rochefort {Day80/110:10-16}. 664 {KIN00003704/1}. 665 Rochefort {Day80/110:3}-{Day80/111:21}. 666 Heath {Day79/81:22}-{Day79/82:2}; Meredith {Day75/197:3-7}.

The Grenfell Tower Inquiry: Phase 2 Report 84 22.67 In July 2008, Mr Meredith reported that a fire retardant version of K15 was being sent to BRE for indicative calorimetry testing in the hope of finding a lower calorific output and slower time to ignition, characteristics that he said were required to maintain Kingspan’s position in the high rise facade market.667 He told us that this testing was being carried out in an attempt to find small scale tests in which new technology K15 demonstrated a fire performance similar to that of old technology.668 22.68 Mr Meredith said that he felt a tremendous responsibility to ensure that the product Kingspan was selling was fit for the market.669 It is clear to us from the evidence that by July 2008 he was worried about the performance in fire of the K15 then being sold. He made repeated and strongly worded attempts to make it clear to his managers how grave his worries were, but his impression at the time was that even if they were listening to him, they were neither responding to, nor acting on, what he was telling them.670 22.69 Both Dr Rochefort and Mr Heath told us that they had taken Mr Meredith’s concerns seriously.671 They each said that they had been concerned by what they had read in the report he had made in January 2008 and by the performance of K15 in the BS 8414 tests carried out in April and June 2008.672 Philip Heath accepted that he had been aware in 2008 that there was a “paper trail”673 showing considerably better performance in fire for old technology K15 than for new.674 Despite their professed concerns, however, they appear to have taken no action. In particular, no consideration was given to suspending or withdrawing sales of K15, either then or at any time.675 22.70 Mr Meredith said that Kingspan’s reaction to the problem had amounted to no more than hope and the suggestion that further testing might provide a better result.676 That is consistent with the evidence of Dr Rochefort, who said that Kingspan’s response to the concerns expressed by Mr Meredith was that a lot of work was being done to see whether the problems could be solved.677 It is also clearly borne out by the documents, in particular the records of Kingspan’s technical meetings, which show that efforts to improve the fire performance of the new technology foam continued throughout 2008 and into early 2009,678 ceasing only on the instructions of Mr Heath following the publication of the LABC Type Approval certificate for K15 in May 2009.679 Kingspan continued to sell K15 to an unsuspecting market without interruption or warning while hoping that a positive test result might turn up. 667 {KIN00008848/2}. 668 Meredith {Day75/199:7-11}. 669 Meredith {Day75/157:20-23}. 670 Meredith {Day75/157:24}-{Day75/159:1}. 671 Rochefort {Day80/130:8-14}; {Day 80/132:19-23}; Heath {Day79/56:10-16}. 672 Rochefort {Day80/76:10-14}; {Day80/109:22}-{Day80/110:2}; Heath {Day79/53:6-9}; {Day79/77:10-16}. 673 {KIN00020913/4}. 674 Heath {Day79/82:25}-{Day79/83:6}. 675 Rochefort {Day80/82:2-10}; {Day80/91:10}-{Day80/92:4}; Heath {Day79/65:25}-{Day79/66:23}. 676 Meredith {Day75/158:11-16}. 677 Rochefort {Day80/132:21-23}. 678 Minutes of meetings on 22 August 2008 {KIN00023871}; 22 October 2008 {KIN00022468/1} paragraph 1.2; 25 February 2009 {KIN00022475/1-2} paragraph 1.2. 679 {KIN00005382}.

Part 3 | Chapter 22: Kingspan K15 insulation 85 The first BBA Certificate: October 2008 22.71 The first BBA certificate for K15 was issued on 27 October 2008680 after several years of work by Kingspan in support of its application.681 Those involved from Kingspan were Senior Technical Adviser Gareth Mills682 assisted by Ivor Meredith.683 Both were supervised by Philip Heath until 2010 and thereafter by Tony Millichap, who replaced Mr Heath as Head of Technical when Mr Heath moved to another part of the business at the end of 2009.684 22.72 Kingspan was well aware of the importance of BBA certificates in achieving acceptance of construction products by architects and building control bodies.685 Mr Mills told us that he had regarded a BBA certificate as a marketing tool that would give customers greater confidence in the product;686 Mr Meredith described a BBA certificate as a “green light of acceptability”.687 We agree with that characterisation. The process of obtaining the first BBA certificate and deciding its final content involved various discussions between the BBA and Kingspan, principally Mr Mills, as well as comments on drafts being sent back and forth between the two companies. Kingspan circulated drafts internally to a team of proof readers for checking and comment. Mr Mills collated the comments and sent them back to the BBA.688 “Will not contribute to the development stages of a fire … ” 22.73 The first BBA certificate contained three important statements about the fire performance of K15. The first, which appeared on the first page under the heading “Key Factors Assessed”, was that “… the boards will not contribute to the development stages of a fire or present a smoke or toxic hazard”.689 No witness from Kingspan or from the BBA was able to offer a coherent explanation of the meaning of, or the basis for, that sentence or how it could properly be said to apply to K15, a combustible polymeric foam. Mr Mills did not know what it meant but said he had had no basis for disagreeing with it.690 Mr Meredith agreed that it was very vague but that he had believed it was a plausible statement.691 Mr Heath could not tell us what it had been based on but said that he thought it had been intended to reflect the behaviour in fire of thermoset materials.692 Christopher Hunt of the BBA, who had approved the certificate,693 told us that he was not sure what the scientific or evidential basis for the statement might have been.694 He acknowledged that it was “slightly ambiguous”695 and more confusing than helpful.696 John Albon, the BBA’s Head of Approvals from 2013 to 2019,697 told us that he had been concerned by the statement when he read 680 Certificate 08/4582 Issue 1 {BBA00000038/1}. 681 Meredith {Day75/41:7-8}. 682 Mills {KIN00022329/11} page 11, paragraph 36; Mills {Day77/5:13-24}. 683 Meredith {Day75/201:17-24}. 684 Millichap {KIN00020821/3} page 3, paragraph 2.4; Mills {Day77/4:12-19}. 685 Heath {Day79/132:12}-{Day79/133:15}. 686 Mills {KIN00022329/11} page 11, paragraph 39; Mills {Day77/33:15}-{Day77/34:20}. 687 Meredith {Day75/201:8-11}. 688 Mills {KIN00022329/15} page 15, paragraph 45(H); Mills {Day77/51:12}-{Day77/52:10}. 689 Certificate 08/4582 Issue 1{BBA00000038/1}. 690 Mills {Day77/43:1-12}. 691 Meredith {Day75/202:23}; Meredith {Day75/204:6-13}. 692 Heath {Day79/139:11-15}. 693 Christopher Hunt was Head of Approvals (Physics) at the BBA and signed the certificate: Hunt {BBA00011087/3} page 3, paragraph 7; Certificate 08/4582 Issue 1 {BBA00000038/1}. 694 Hunt {Day108/174:21-25}. 695 Hunt {Day108/170:8-13}. 696 Hunt {Day108/175:2}. 697 Albon {BBA00010723/3} page 3, paragraph 13.

The Grenfell Tower Inquiry: Phase 2 Report 86 it,698 describing it in his evidence as an opinion that could not be substantiated and was not appropriate.699 He therefore removed it.700 However, that was not until October 2015, when the fourth version of the certificate was issued.701 Class 0 22.74 The second significant statement in the BBA certificate about the fire performance of K15 was that it was classified as Class 0 and could therefore be used in accordance with the provisions of paragraphs 12.5 and 12.6 and Diagram 40 of Approved Document B.702 As we have explained, that was untrue. In October 2008 Kingspan had not been able to obtain a Class 0 classification for the product it was selling and continued, internally, to discuss and report on its attempts to do so throughout 2008 and the early part of 2009.703 22.75 Although the BBA had requested reaction to fire and surface spread of flame test data from Kingspan at an earlier stage in the preparation of the certificate in September and December 2004,704 it appears that the only data of that kind provided to the BBA related to tests undertaken between 1991 and 2003 on various products, some produced in Kesteren, rather than at Pembridge, but none of them tests on the new technology K15 that Kingspan was currently selling.705 Adrian Pargeter told us that investigation of historic records in preparation for the Inquiry had revealed that after the change to new technology in 2006, Kingspan could only have been relying on tests carried out on separate and different products706 to support its claim that K15 had achieved Class 0. (It also relied on the results of tests carried out on the foil facers alone but they were not provided to the BBA).707 Ivor Meredith and Philip Heath, as they acknowledged in their evidence, had been aware of that at the time.708 22.76 On 1 July 2008, Gareth Mills wrote to the BBA709 proposing the inclusion of the statement that K15 was classified to Class 0. He sent a document listing Kingspan’s comments710 on a BBA draft of the certificate.711 The text he proposed was an extract from a Kingspan product marketing brochure for K15.712 Mr Mills did not send the BBA any data derived from tests carried out in accordance with BS 476-6 or BS 476-7 but said that he had thought that such data existed and that it might have been sent to the BBA at some other time by someone else.713 Whether or not that was his true understanding at the time, it was not correct. In effect, by dint of Mr Mills’ efforts, the BBA did no more than recycle Kingspan’s own false marketing literature. 698 Albon {Day110/112:2-21}. 699 Albon {Day110/112:20}-{Day110/115:1}. 700 Albon {Day110/112:14-18}. 701 Certificate 14/5134 Issue 1 {BBA00000040/1}. 702 Certificate 08/4582 Issue 1{BBA00000038/5-6} paragraph 7.2. 703 {KIN00022205}; {KIN00022467/1} paragraph 1.2; {KIN00022468/1} paragraph 1.2; {KIN00022475/1-2} paragraph 1.2; {KIN00022476/1} paragraph 1.2. 704 {BBA00011093}. 705 See summary at Moore {Day107/175:5-24}. 706 Pargeter {Day84/40:13-20}. These were reports of tests carried out on Kesteren-produced products: BS 476-6 on DL 2000 {BBA00011291}; Part 7 on DL3300 {BBA00011292}; Parts 6 and 7 on DL3300 {BBA00011293}. 707 Pargeter {KIN00022610/29} page 29, paragraph 3.40; Pargeter {Day84/39:6-24}. 708 Meredith {Day75/41:10-15}; {Day79/28:21}-{Day79/29:24}; Heath {Day79/25:10-13}. 709 {BBA00000244}. 710 {BBA00000250/1} fifth row; Mills {Day77/57:16}-{Day77/59:12}. 711 {BBA00000249}. 712 Mills {Day77/58:19-24}. 713 Mills {Day77/59:7-12}; {Day77/60:1}-{Day77/61:23}.

Part 3 | Chapter 22: Kingspan K15 insulation 87 22.77 Neither at the time the first certificate was published nor at any time thereafter did the BBA have any evidence at all on which to base a statement that K15 had achieved Class 0, as its own witnesses accepted714 and as Adrian Pargeter effectively confirmed.715 Kingspan thus persuaded the BBA to state that the product being sold as K15 had achieved a Class 0 rating (just as it was itself doing in its marketing literature)716 knowing that statement to be false. The BS 8414 test in 2005 22.78 The first issue of the BBA certificate also referred to a test carried out in accordance with BS 8414-1. It provided a fairly lengthy description of the system tested but did not state the date on which the test had taken place and was imprecise about the details of key parts of it. In particular, the certificate made no mention of the masonry backing for the test rig and instead used the phrase “non-combustible substrate”. Most significantly, the description of the system ended with the words, “Within the stated test time the temperature at the level 2 thermocouples did not exceed 600°C, therefore displaying limited fire spread away from the fire source and that the product meets the criteria stated within BRE 135”.717 That assertion was fundamentally misleading, since the criteria in BR 135 relate to the performance of the system as a whole, not that of any particular component. 22.79 When asked about that wording, Mr Heath agreed that it was incorrect718 and sought to explain it away as an oversight on the part of Kingspan.719 Mr Meredith at first gave a similar explanation, suggesting that Kingspan had had only a limited time to check the accuracy of the BBA’s draft.720 In fact, however, it is clear that drafts of the certificate had been passing between the BBA and Kingspan for several months from June 2008 onwards before the certificate had been issued.721 The correspondence reveals that the statement that the product had met the criteria in BR 135 had been proposed by Gareth Mills on 3 October 2008 at a fairly late stage in the process.722 That was contrary to the evidence Mr Mills had given in his witness statement, which was that the BBA, rather than Kingspan, had suggested the wording.723 22.80 The BBA’s first draft of the certificate relating to K15 dated 4 June 2008 was sent to Kingspan for comment. It included a statement in paragraph 4.7 that K15 was combustible but that it could be used in various circumstances “… where no storey is at a height of more than 18m above ground ... ”.724 In an email of 27 June 2008 to Mr Mills and Mr Heath, Mr Meredith expressed the view that publication of that wording would be a “disaster”.725 In the same email, he urged caution over the plan to “slip the existing BS 8414 data in at the last minute so they didn’t have much time to look over it and pick holes ...”, warning 714 Albon {Day110/156:19}-{Day110/157:7}; Moore {BBA00011097/4} page 4, paragraph 15. 715 Pargeter {Day84/44:6-9}. 716 {KIN00002580/6}. 717 Certificate 08/4582 Issue 1{BBA00000038/5} paragraph 7.1. 718 Heath {KIN00020709/48} page 48, paragraph 7.35. 719 Heath {Day79/140:22}-{Day79/141:1}. 720 Meredith {Day75/205:14}-{Day75/206:13}. 721 Kingspan provided detailed comments on at least three BBA drafts: 1 July 2008 {BBA00000250}; 15 July 2008 {BBA00000211}; 3 October 2008 {BBA00002874}. 722 {BBA00002874/1}. 723 Mills {KIN00022329/14} page 14, paragraph 44(L). 724 {BBA00000249/5} paragraph 4.7. 725 {KIN00024474}.

The Grenfell Tower Inquiry: Phase 2 Report 88 that it might be foolish to think that the BBA would do anything other than go over the data with a fine-tooth comb. Mr Meredith need not have worried. The BBA did no such thing and inserted Mr Mills’ suggested text verbatim into the final version of the certificate.726 22.81 Mr Mills said that he could not remember who had proposed the change from the BBA’s original description of the system tested in accordance with BS 8414 as based on a ”blockwork” substrate727 to one with a “non combustible” substrate.728 However, correspondence within Kingspan reveals that the idea had come from Philip Heath, who suggested it on the basis that “it might allow us a little spin in the future”.729 Kingspan had been using similarly inexact language in its correspondence with customers for some time730 and went on to make use of it more widely in its K15 technical bulletins and product literature following the publication of the BBA certificate in October 2008.731 22.82 Ivor Meredith understood that the data obtained from the BS 8414-1 test in 2005 related to a system with a masonry substrate and did not apply to a system with a steel framed structure732 and had made his managers aware of that. Kingspan sought to recommend K15 for use on high-rise buildings by stating (or at any rate implying) that the 2005 test data applied equally to masonry and steel-framed structures as long as the latter were sheathed with a non-combustible board.733 As the correspondence reveals734 and as Mr Meredith and Mr Mills acknowledged,735 that wording was consciously designed to conceal the absence of any data derived from a test in accordance with BS 8414-2, which by 2008 had become a pressing problem for Kingspan.736 Kingspan’s advice to customers that K15 could be used on buildings over 18 metres in height with any non-combustible substrate was not based on any test evidence or the advice of any suitably qualified expert.737 “Advice should be sought from the certificate holder” 22.83 A few lines below the description in paragraph 7.1 of the system tested in accordance with BS 8414 the BBA certificate contained paragraph 7.3, which told the reader that, “In buildings with a floor more than 18m above ground level, advice should be sought from the certificate holder.”738 Mr Mills told us that he could not remember how that paragraph had come to be included.739 He remembered that Kingspan had asked the BBA to remove from an early draft a passage that explicitly restricted the use of K15 to buildings under 18 metres in height.740 When questioned about that, he accepted that he had proposed the removal from the summary on the front page of the certificate of the words “up to 18m” on the basis that the BS 8414 test report demonstrated that the product could be used on 726 {BBA00002874/1}; Certificate 08/4582 Issue 1{BBA00000038/5} paragraph 7.1. 727 {BBA00000219/7} paragraph 7.1. 728 {BBA00000211/7} paragraph 7.1. 729 {KIN00024476/1}. 730 {KIN00005240/2}. 731 {KIN00002607/3}; {KIN00003545/6}; {KIN00009585/2}. 732 {KIN00020913/4}; Heath {Day79/43:21}-{Day79/44:2}; {KIN00003701}. 733 {KIN00002607/3}. 734 {KIN00024476}. 735 Meredith {Day76/72:23}-{Day76/73:7}; Mills {Day77/82:10-22}. 736 {KIN00008847/2}; {KIN00020913/4}; {KIN00003701/1}; Meredith {Day75/146:3-8}. 737 Heath {Day79/47:18}-{Day79/48:6}. 738 Certificate 08/4582 Issue 1{BBA00000038/6} paragraph 7.3. 739 Mills {Day77/49:7-9}. 740 Mills {KIN00022329/13} page 13, paragraph 44(A); Mills {Day77/50:2-16}.

Part 3 | Chapter 22: Kingspan K15 insulation 89 buildings over 18 metres in height.741 He said that he had offered to provide the test report to the BBA in order to support his proposal.742 It could do no such thing, of course, for reasons of which Kingspan was well aware. 22.84 The section of the BBA certificate that advised readers to contact Kingspan when considering the use of K15 on a building over 18 metres in height was of substantial benefit to Kingspan. When potential customers sought its advice, Kingspan almost invariably advised them that K15 was suitable for such use, either in a generic sense or for a particular proposal. When doing so, it referred them to the BBA certificate, which directed them straight back to itself. Mr Meredith acknowledged that the clause was very welcome, because it meant that customers would contact Kingspan, giving it an opportunity to sell K15 for use on their projects.743 In later internal correspondence from January 2013, it was referred to as a “get-out” clause744 that Kingspan tried to avoid losing. 22.85 The self-serving nature of the provision thus allowed Kingspan to give direct advice to potential customers about whether to use K15 on any particular building. The plain and obvious conflict of interest which that created appears to have passed unnoticed by the BBA. NHBC, the largest private building control body in the country, continued to treat that advice as unremarkable until as late as the autumn of 2013, when the significance of the sheer volume of K15 on high-rise buildings began to dawn on it. What the BBA did not know 22.86 Although the BBA was not aware of the fact,745 the description in the certificate of the BS 8414 test carried out on K15 rested on a fundamental falsehood. Despite a term of the contract that obliged Kingspan to notify the BBA of any changes to the product or of any new or additional information it had acquired about its suitability for use,746 Kingspan did not tell the BBA that the test in 2005 had been carried out on a version of K15 that was by then obsolete and was no longer being manufactured.747 When asked about that, Mr Mills and Mr Heath told us that they had thought the BBA was aware of the change to new technology and the foil facers748 because of the audits and quality plans in which they had been recorded.749 22.87 We found no reference to the changes in the composition of K15 or the introduction of perforated foil facers in any BBA document. In any event, it is difficult to see how any quality plan or audit could have recorded the change to new technology. K15 had not been subject to BBA certification at the time of the changes and there would therefore have been no audit or quality plans in which to record that information.750 Moreover, it became 741 {BBA00000219/1}; {BBA00000211/1} text in red. 742 Mills {Day77/31:8-13}; {Day77/49:10}-{Day77/51:11}; {Day77/67:2}-{Day69/69:2}. 743 Meredith {Day76/6:13-19}. 744 {KIN00005572/4}. 745 Albon {Day111/28:10}-{Day111/29:7}. 746 {BBA00010745/3} paragraph 7(g). 747 Heath {Day79/137:3-7}; Millichap {Day81/194:13-17}. 748 Mills {Day77/41:4-14}; Heath {Day79/136:16}-{Day79/137:17}. 749 Heath {Day79/136:16}-{Day79/137:17}; Mills {Day77/40:3-9}; {Day77/41:4-12}. 750 Meredith {Day75/40:21}-{Day75/41:3}; Albon {Day111/28:2-7}, “Once we have accepted a report, certified the product, and then have the production under surveillance, we continue to accept that data as being representative of the performance of the product on the understanding that the formulation and specifications are, from that point onwards, unchanged”.

The Grenfell Tower Inquiry: Phase 2 Report 90 clear that no initial on-site assessment of K15 had taken place before the BBA issued the first certificate, apparently because several other Kingspan products had already obtained BBA certificates and the BBA was satisfied with its quality standards.751 22.88 Moreover, Kingspan did not tell the BBA that four tests on systems incorporating new technology K15 had failed to meet the criteria in BR 135752 or that, even in October 2008, it had misgivings about the fire performance of the product.753 Philip Heath told us that Kingspan did not consider those matters to be relevant.754 Mr Mills also told us that the four BS 8414-2 test results were not relevant to the scope of approval Kingspan was seeking from the BBA.755 We disagree. They were plainly relevant, since they were the only tests in accordance with BS 8414 that had been carried out on systems incorporating the product that was the subject of the certificate. Amendments proposed by the BBA: December 2008 22.89 On 24 December 2008, less than two months after the BBA certificate had been issued, George Lee, the Project Manager who had drafted it,756 sent an email to Kingspan in which he set out a number of proposed amendments to the part dealing with behaviour of the product in relation to fire. He explained that the BBA had received a number of comments on the clarity of the wording of that section. In particular, he proposed that the section on the first page of the certificate headed “Key Factors Assessed” should be amended by adding the following wording: “The product has been tested to BS 8414-1 for a specific construction on masonry walls”.757 22.90 Eventually, on 5 March 2009, Philip Heath responded. He expressed concern about the proposal to make changes to the wording of the certificate so soon after it had been issued and warned that there might be cost implications for Kingspan, which he would need to assess before he responded. Two minutes later, he sent the exchange to Ivor Meredith, Gareth Mills and Andrew Pack, then Technical Services Manager.758 His email said simply, “Let the file gather dust, guys”. Plainly, as Mr Pack and Meredith admitted (but Philip Heath would not),759 that was an instruction to put off responding to the BBA’s proposed amendments for as long as possible.760 Mr Meredith told us candidly that this instruction had been given because it was in Kingspan’s interests for the existing BBA certificate to remain in circulation. He said that Kingspan had not been prepared to allow the BBA to make it clear to the public that there were restrictions on the use of K15 on buildings over 18 metres in height because it could limit sales.761 Mr Mills admitted that that had possibly been the reason for the instruction to delay.762 Mr Heath denied that, stating that, although Kingspan was keen to extend the scope of the approval, he had simply been concerned about the implications of the amendments for marketing materials, which by that time had been produced.763 751 {BBA00000161/3} final three paragraphs; Albon {BBA00010751/22} page 22, paragraph 74; Albon {Day110/162:11} -{Day110/164:24}; Hunt {Day109/39:12}-{Day109/40:1}. 752 Mills {KIN00022329/13} page 13, paragraph 43(H); Heath {Day79/138:5-9}; {Day79/142:12-16}. 753 Heath {Day79/137:18}-{Day79/138:4}; {Day79/142:17-21}. 754 Heath {Day79/138:1-4}; {Day79/143:1-4}. 755 Mills {Day77/38:13}-{Day77/39:12}. 756 Lee {BBA00010794/1} page 1, paragraph 1; Albon {BBA00010751/8} page 8, paragraph 31. 757 {KIN00009103}. 758 Pack {KIN00008702/4} page 4, paragraph 2.8. 759 Heath {KIN00020709/81}, page 81 paragraph 11.47; Heath {Day79/154:20}-{Day79/155:16}. He characterised it as an instruction “not to proactively respond”. 760 Pack {Day86/147:7-11}; Meredith {Day75/211:2-12}. 761 Meredith {Day75/212:4-12}. 762 Mills {Day77/102:23}-{Day77/103:4}. 763 Heath {Day79/154:20}-{Day79/155:24}.

Part 3 | Chapter 22: Kingspan K15 insulation 91 22.91 We do not think that Mr Heath was telling the truth. The explanation given by Mr Meredith was strongly supported by the contemporaneous internal correspondence,764 which, in particular, included Kingspan’s comments on drafts of the certificate. They show that it was trying to persuade the BBA to certify that K15 was suitable for use on buildings over 18 metres in height in a general and unlimited sense and that K15 as a product met the criteria in BR 135.765 Marketing and challenges: 2008–2009 22.92 Throughout 2008, and in the early part of 2009, Kingspan continued to market K15 as a product which had met the criteria in BR 135 and was therefore suitable for use on buildings over 18 metres in height, both on masonry and metal-framed substrates. Its marketing literature included drawings of both types of construction without qualification. Kingspan’s promotional literature referred to the 2005 test without giving a date and without referring to the fact that it was applicable only to masonry substrates. It made no effort to draw the attention of the reader to the fact that BS 8414 is a method for testing a system as a whole rather than an individual component or product.766 Under the supervision of Philip Heath767 it did the same in its responses to customers who asked for advice about the use of K15 at height and continued to write “letters of suitability” representing that the 2005 test data was “directly applicable” to various proposed constructions when it plainly was not.768 Once the BBA certificate for K15 had been issued, Kingspan relied on the sections describing the BS 8414 test and the suitability of the product for use on buildings over 18 metres in height which it had shaped so carefully, sometimes referring to it as constituting the BBA’s approval of the product.769 22.93 Despite those efforts to conceal the true position about K15’s performance in fire, the period was marked by challenges from astute designers. One such was Wintech Group Ltd, a facade engineering consultancy,770 which in 2006 had begun to ask questions about the suitability of K15 for use in high-rise projects and the relevance of Kingspan’s 2005 test to steel-framed structures.771 Both Mr Heath and Mr Meredith acknowledged that the questions it raised were valid,772 but at the time Kingspan fought off the challenges as best it could. Mr Meredith told other designers that Wintech was taking a precautionary approach to following the guidance in Approved Document B.773 22.94 Wintech’s persistence led members of the technical team to seek advice from Mr Heath. On one occasion Mr Meredith asked him for a standard answer because it was becoming difficult for him to know what he could write without risking a legal confrontation. Mr Heath’s response was “Wintech can go f#ck themselves, and if they are not careful we’ll sue the a#se of them”.774 Mr Heath forwarded the exchange to a friend outside Kingspan, calling the situation a “nightmare” and writing “I’m trying to think of a way out of this one, imagine a fire running up this tower !!!!!!!!!!!!!!!!!!”.775 Even if we were to accept Mr Heath’s explanation that the emails were an attempt to make light of a situation which 764 {KIN00024474}; {KIN00024476}. 765 {BBA00000250/1-2}; {BBA00000211/1}; {BBA00000211/7}; {BBA00002874/1}. 766 {KIN00009703/6}; {KIN00002607/3}. 767 Heath {Day79/109:5-19}; {KIN00003723}; {KIN00003718}. 768 {KIN00002589/3-4}; {KIN00009042}; {KIN00002594/2}. 769 {KIN00002592/3}; {KIN00003723/1}. 770 Taylor {WIN00000002/1} page 1, paragraph 1. 771 {KIN00005243/2}. 772 Heath {Day79/115:22}-{Day79/116:9}; {Day79/120:22}-{Day79/121:7}; Meredith {Day76/86:19-24}. 773 {KIN00024478/1} penultimate paragraph. 774 {KIN00005363/1}. 775 {KIN00009066/1}.

The Grenfell Tower Inquiry: Phase 2 Report 92 was causing him “frustration”,776 we think, despite his denials,777 that they expose a casual disregard for public safety at a senior level in Kingspan, a determination to defend K15’s position in the market at all costs and a keen awareness on Kingspan’s part that it needed to find a way out of the situation it had created through its own mendacity. The LABC Certificate 2009 22.95 As has been explained elsewhere in this report,778 in May 2009 Kingspan obtained an LABC System Type Approval Certificate for K15. That certificate, obtained by Andrew Pack and Philip Heath, stated that K15 could be considered a material of limited combustibility and that it was suitable for use in all situations shown in Diagram 40 of Approved Document B, including on buildings over 18 metres in height.779 Philip Heath’s jubilation at obtaining the certificate was clear from his contemporaneous correspondence, in which he said the document could be “GOLD”.780 He celebrated the formal confirmation of its issue on 7 May 2009 with the single word “FANBLOODYTASTIC”.781 22.96 On 7 May 2009, Mr Heath circulated the “GREAT NEWS!” to various internal Kingspan mailing lists, offering special thanks to Mr Pack, summarising the benefits the certificate would bring and highlighting in bold in his quote from the certificate the words “material of limited combustibility”. In the same email, Mr Heath said that the certificate had completed the “tool kit” for K15.782 The toolkit, he explained, was the marketing information used to sell the product.783 22.97 In response to a question from Dr Rochefort asking what test results had been used to obtain the certificate, Mr Heath said that Kingspan had sent so much fire data to David Jones, the certificate’s author, that it had “probably blocked his server” and that LABC had convinced itself that K15 was the “best thing since sliced bread” without even having “to get any real ale down him”.784 Dr Rochefort never received a proper answer to his question.785 His suggestion that testing of which he had been wholly unaware might have been carried out in Australia, China or Singapore was simply not credible.786 The reality is that there was no answer. As Mr Pack accepted, Mr Heath’s claim was nonsense.787 No fire test data at all had been provided to LABC. 22.98 On 11 May 2009, in an email to Mr Meredith, Dr Rochefort and others, Mr Heath repeated that the LABC certificate satisfied the requirements for K15 to be installed on buildings over 18 metres in height and gave instructions that no further fire testing was to be carried out on K15.788 He told us that the decision to stop testing and to rely on the LABC certificate to promote the suitability of K15 for use on buildings over 18 metres in height was a collective one.789 During a meeting of Kingspan’s Fire Focus Group on 18 May 2009, attended by Dr Rochefort and Mr Meredith but not by Mr Heath, it was agreed that work would continue on the development of a K15 product that would be able to pass a BS 8414-2 test 776 Heath {Day79/118:4-25}; {Day79/124:5-19}. 777 Heath {Day79/124:11-19}. 778 Chapter 23. 779 {KIN00005705/5}. 780 {KIN00024991/1}. 781 {KIN00024993/1}. 782 {KIN00005383}. 783 Heath {Day79/189:8-12}. 784 {KIN00020714}. 785 Rochefort {Day80/146:15}-{Day80/147:7}. 786 Rochefort {Day80/144:23}-{Day80/146:14}. 787 Pack {Day86/135:5-16}. 788 {KIN00005382}. 789 Heath {Day79/193:11-13}.

Part 3 | Chapter 22: Kingspan K15 insulation 93 as a back up.790 However, Mr Heath then reversed that decision, confirming in an email to Mr Meredith on 17 June 2009 that no further facade testing involving K15 would be carried out and that the LABC certificate would be relied on “until we are challenged”.791 It is therefore clear that at that time Kingspan accepted that it had no K15 product capable of forming part of a facade system that would meet the criteria in BR 135 when tested in accordance with BS 8414-2792 and that it made a calculated decision to use the LABC certificate to gloss over the absence of relevant test evidence. 22.99 Both Mr Heath and Mr Meredith accepted that LABC’s central statement about K15’s suitability for use on buildings over 18 metres in height (described in an internal presentation to Kingspan’s sales teams as “the highlight”)793 was false and thoroughly misleading. Mr Heath accepted that he had expected it to be challenged.794 Mr Meredith, who said that at the time he had been “drowning in inquiries” about the use of K15 on buildings over 18 metres in height, told us that he was simply following suit from his line manager that, in the absence of any relevant test evidence, the LABC certificate was the solution.795 He too expected it to be challenged. Once the certificate had been obtained, the strategy was to send it out to customers and let it do the talking.796 22.100 By August 2009, that strategy appeared to be working. In an email sent that month to others in the technical and sales teams (including Mr Heath), Mr Meredith noted that questions about the use of K15 at height had died out since obtaining the LABC System Type Approval.797 Amended BBA certificates 2010-2013 22.101 Meanwhile, dust had been gathering on the amendments to the certificate relating to K15 that the BBA had proposed in December 2008.798 Although the next version of the certificate bears the date 6 April 2010,799 that was said to be the date on which it had been amended; it is clear from later correspondence that it was not the date on which it was issued.800 No Kingspan witness was able to identify the date on which it had been issued. John Albon and Jon Denyer801 thought it had been issued on 12 July 2013, although there was some uncertainty about it.802 We have seen no evidence to confirm or contradict that later date. 22.102 The amended certificate contained three significant changes to the text relating to the performance of K15 in fire. First, the section on the front page headed “Key Factors Assessed” contained the additional words that Mr Lee had suggested, namely, “The product has been tested to BS 8414-1:2002 for one specific construction on masonry walls”.803 The second change was to the description of the system tested in accordance with BS 8414 in 2005, which now stated explicitly that BS 8414-1 was a test for masonry 790 {KIN00008845/1-2}; Meredith {Day76/58:21}-{Day76/60:20}. 791 {KIN00005387}. 792 Rochefort {Day80/155:7-20}; {Day80/143:10-20}. 793 {KIN00009178/5}. 794 Heath {Day79/207:11-15}; Meredith {Day76/24:24}. 795 Meredith {Day76/35:12-24}. 796 {KIN00005385}. 797 {KIN00009135/1}. 798 {KIN00009103}. 799 Certificate 08/4582 Amended Issue 1{BBA00000037/1}. 800 {BBA00002644/7}. 801 Denyer {BBA00010780/4} page 4, paragraph 13. 802 Denyer {BBA00010780/10} page 10, paragraph 38 (publication date inserted by Jon Denyer); Albon {Day110/109:9‑25}. 803 Certificate 08/4582 Amended Issue 1{BBA00000037/1}.

The Grenfell Tower Inquiry: Phase 2 Report 94 substrates and omitted the previous assertion that “... the product meets the criteria stated within BRE135”.804 Last, in the passage immediately following the statement that K15 was rated national Class 0 (which had previously said that the product could be used in accordance with the provisions of paragraphs 12.5 and 12.6 of Approved Document B)805 the amended version said that the product could also be used in accordance with the provisions of paragraph 12.7 of the guidance.806 22.103 That proposed draft of the amended certificate was sent to Kingspan on 8 April 2010 by Mr Hunt, who explained the reason for the amendments and sought Kingspan’s agreement to them.807 In his response, which was not sent until 21 June 2010, Mr Mills effectively proposed reverting to the original, i.e. the complete removal of the amended wording on the first page (“for one specific construction on masonry walls”) and the addition at the end of the section describing the system tested in accordance with BS 8414 the words “… therefore meeting the criteria in BR 135”.808 After that, no further progress was made for many years. Kingspan failed to respond to another email from Mr Hunt on 9 July 2010 and the BBA decided that the certificate would need to be re-issued rather than amended.809 22.104 Discussions resumed in January 2013 as part of what appear to have been steps leading to the eventual issue of a new certificate in July 2013. Mr Mills, Mr Meredith and a senior technical adviser at Kingspan, Joel Clarke,810 considered how best to prevent the inclusion in the certificate of wording that would indicate any restriction on the use of K15 on buildings over 18 metres in height.811 Tony Millichap oversaw those discussions, which showed that Kingspan was now conscious of its waning influence over the BBA in relation to the contents of the certificate. Indeed, in an email sent to the other three on 9 January 2013 Mr Clarke commented that he thought Kingspan might be “pushing our luck” in seeking to restore the advice to contact the certificate holder812 and said that at a meeting the day before people had said that the BBA was “onto us”.813 That may have been right. When the amended certificate was issued Mr Mills’ comments appear to have been ignored and Kingspan’s attempts to ensure that the certificate should include wording to the effect that “the product” had met the criteria in BR 135814 had not been successful. 22.105 Despite the BBA’s evidence815 and Kingspan’s arguments to the contrary,816 we think that the BBA’s statement that K15 could be used in accordance with the provisions of paragraph 12.7 of Approved Document B was dangerously misleading because it suggested that K15 was a material of limited combustibility, which was not the case. Apart from Mr Mills, who seems to have thought that the statement was accurate,817 all the other witnesses who were asked about it, including Mr Meredith818 and Mr Millichap,819 acknowledged that 804 Certificate 08/4582 Amended Issue 1 {BBA00000037/5-6}; See previous wording {BBA00000038/5}. 805 Certificate 08/4582 Issue 1 {BBA00000038/6}. 806 Certificate 08/4582 Amended Issue 1 {BBA00000037/5}; 807 {BBA00002644/7}. 808 {BBA00002644/6}. 809 {BBA00002644/1-5}. 810 Clarke {KIN00008790/4} page 4, paragraph 2.6. 811 {KIN00009353}; {KIN00005570}. 812 {KIN00005570/2}. 813 {KIN00005570/1}. 814 Email from Gareth Mills to the BBA dated 31 May 2013 {KIN00002145/4}, “... for the section relating to BS 8414, we would want the general description of the construction tested included, i.e. similar to that is (sic) our existing certificate, along with some text stating that the result achieved met the criteria from BRE 135...”. 815 Albon {Day109/56:13}-{Day109/57:2}. 816 {KIN00025944/34-37} paragraphs 92-101. 817 Mills {Day77/109:6}-{Day77/115:4}. 818 Meredith {Day76/3:17-20}. 819 Millichap {Day81/80:8-20}.

Part 3 | Chapter 22: Kingspan K15 insulation 95 the reference to paragraph 12.7 in those terms was inaccurate and misleading. Mr Albon also acknowledged in his evidence that it was misleading.820 In its closing statement for Module 2, however, Kingspan went to some lengths to persuade us otherwise. 22.106 As we have explained in Chapter 48 of this report, the purpose of paragraph 12.7 was to restrict the use of combustible insulation materials at height. It did so by advising that only insulation materials of limited combustibility should be used on buildings over 18 metres in height, except where they form part of a cavity wall construction and are enclosed by two leaves of masonry.821 The exception for masonry cavity wall construction reflects the fact that the insulation is protected from fire on each side by a thick layer of non-combustible material. It was clearly intended to deal with a narrowly defined type of construction wholly unlike those for which the BS 8414 test and the BR 135 criteria were designed. 22.107 The passage in question has to be read and understood in the context of the certificate as a whole, which states that it relates to K15 “for use to create a warm frame wall construction or for use against masonry substrates, with a ventilated cavity and a weatherproof cladding system / protective rainscreen”. The accompanying illustration depicts its use with a steel frame construction. Other sections of the certificate, such as paragraphs 1.1, 4, 5.2, 8.2, 8.5 and 12, suggest that it was not directed to the use of the product as insulation inside an enclosed masonry cavity wall and we have seen no clear evidence to suggest that either Kingspan or the BBA had such a use in mind. However, the real vice of the statement lies in the apparently innocuous word “therefore”, which provides the link between the phrase “Class 0 or ‘low risk’” and the statement that the product may be used in accordance with the provisions of paragraph 12.7 of Approved Document B. It is clear that insulation used within a masonry cavity wall construction does not need to be Class 0 or ‘low risk’ or of limited combustibility. The causal link can therefore be relevant only to the first part of paragraph 12.7, thereby suggesting that K15 is of limited combustibility. We therefore think that the overall thrust of the certificate was clear in that respect and that it was both erroneous and misleading. 22.108 On 17 December 2013, the BBA issued a third version of the certificate for K15.822 It significantly tightened the previous language in relation to the use of K15 on buildings over 18 metres in height, in particular by explicitly stating that one specific build-up had met the criteria in BR 135 through a test in accordance with BS 8414 Part 1. In a footnote, it repeated that K15 had been tested in accordance with BS 8414 only in one specific construction and added that a separate test would be required to establish the performance of any other combination of materials. It also removed the statement containing the reference to paragraph 12.7 of Approved Document B and the section directing readers to contact Kingspan for advice on the use of K15 on buildings over 18 metres in height.823 22.109 In recognition that its continuing efforts to prevent any “restrictive” wording about the use of K15 at height were not going to be successful, Kingspan took comfort from the fact that those restrictions were printed in “the smallest possible font and buried deep in the certificate itself”. That was celebrated internally as “significant progress” from the position in a previous draft, as was the fact that the explicit restriction no longer appeared on the front page of the certificate.824 820 Albon {Day110/179:15}. 821 {CLG10000007/96}. 822 Certificate 08/4582 Issue 2{BBA00000036}. 823 {BBA00000036/6}. 824 {KIN00005870/1}.

The Grenfell Tower Inquiry: Phase 2 Report 96 22.110 Mr Meredith and Mr Mills both agreed825 that they, Mr Clarke and Mr Millichap had been working to ensure that the certificate imposed the minimum restrictions on the use of K15.826 Mr Millichap told us that his team might have been asking for more than was appropriate,827 but that they had simply been keen to ensure that K15 was presented in the most positive light and had tried to extend the scope of the certificate in a way that was accurate.828 Mr Meredith went further, however, admitting that inaccurate assertions made by Kingspan had not been due to an excess of enthusiasm but to a conscious attempt to persuade the BBA to accept claims that would maximise sales of K15, whether they were true or not.829 22.111 Again, we think that the evidence of Mr Meredith was more reliable. We are left in no doubt that Kingspan took advantage of the BBA’s initial failure properly to investigate the characteristics of K15 and thereafter did all it could to ensure that the certificates did not include wording that restricted the suitability of K15 for use on buildings over 18 metres in height, both by putting forward wording it knew to be inaccurate and by failing to correct the BBA’s own inaccurate statements. Loose language or not,830 Kingspan’s long- running internal discussions about what it could get away with831 betrayed no concern whatsoever for accuracy. LABC, NHBC and Wintech: 2012-2013 22.112 By May 2012, the LABC System Type Approval certificate issued to Kingspan in May 2009 had lapsed,832 leading to what Mr Meredith described in an email sent to Tony Millichap on 15 October 2012 as a “major headache and potentially a lot of lost work” in relation to high-rise buildings. He suggested that without the LABC certificate new data would probably be needed and that pressure should be put on the production teams to develop a form of K15 that could be expected to enable a system to meet the criteria in BR 135.833 The exchange reveals the degree of reliance that had been placed on the LABC certificate and confirms that at that time Kingspan thought that K15 was still not capable of forming part of a system that could be tested successfully in accordance with BS 8414. 22.113 In late 2012, Kingspan thought about continuing to rely on the certificate issued in May 2009, but its lapse had not escaped the notice of Wintech, which continued to raise questions about the suitability of K15 for use on buildings over 18 metres in height.834 In the event, Kingspan did obtain further LABC certificates for K15, the next being published on 28 August 2013.835 We deal with those later certificates in Chapter 23. 22.114 By 31 October 2013, Wintech’s efforts to draw attention to Kingspan’s apparent lack of test data for K15836 had culminated in a meeting between them attended by (amongst others) Dr Rochefort, Peter Wilson, the managing director of Kingspan,837 and Paul Savidge, the managing director of Wintech.838 At the meeting Dr Rochefort maintained his view 825 Meredith {Day76/14:5-9}; Mills {Day77/131:21-24}. 826 {KIN00005570/1}. 827 Millichap {Day82/13:3-10}. 828 Millichap {Day82/7:12-22}. 829 Meredith {Day76/12:16-20}. 830 Millichap {Day82/7:4}. 831 {KIN00009353/1}. 832 {KIN00005705/1} “Conditions of Certification”, second bullet point. 833 {KIN00005552/1}; Meredith {Day76/37:17}-{Day76/39:2}. 834 {KIN00005554/2-3}; Meredith {Day76/39:5}-{Day76/41:23}. 835 {LABC0001000}; {LABC0001001}. 836 {KIN00005683}. 837 {KIN00022334/17}. 838 Savidge {WIN00000004/2} page 2, paragraph 5.

Part 3 | Chapter 22: Kingspan K15 insulation 97 that K15 was suitable for use on buildings over 18 metres in height,839 but accepted that Kingspan did not have any BS 8414-2 test data and told Wintech that such tests would be undertaken and made available within six months.840 In an email sent after the meeting, Paul Savidge warned Dr Rochefort that if the data were not made available within that period Wintech would publicise its concerns about the use of K15 on high-rise buildings to the industry at large.841 22.115 The contents of the LABC certificates for K15 had also come to the attention of NHBC. In November 2014, it described the expression “K15 can be considered a material of limited combustibility”, as “all garbage” and the approval of K15 on buildings over 18 metres in height as “an accident waiting to happen”.842 In Chapter 26 of this report we describe the discussions between NHBC and Kingspan during the period from late 2013 onwards in relation to the use of K15 on buildings over 18 metres in height. Mr Meredith told us that NHBC had started to ask difficult questions in late 2013.843 Certainly, by February 2014, and following unsuccessful efforts by NHBC to obtain test evidence from Kingspan that demonstrated the suitability of K15 for use on buildings over 18 metres in height (in particular on steel frame systems), NHBC had asked Kingspan to provide written approval for every project of that kind on a job by job basis.844 The evidence that Mr Meredith had repeatedly assured NHBC he would send to support the suitability of K15 for use at height proved not to exist. Consequently, the pressure on him to resolve the situation increased.845 On 16 June 2014 NHBC wrote to Kingspan saying that unless test evidence supporting the use of K15 in any construction other than that tested to BS 8414- 1 in May 2005 had been provided by 30 June 2014 NHBC would reconsider its acceptance of K15 as suitable for use on buildings over 18 metres in height.846 In the event, however, neither occurred. BS 8414 test: 2014 22.116 In January 2014, Kingspan embarked on a programme of testing at BRE in accordance with BS 8414-2, the first since June 2008. The tests were arranged by Mr Meredith under the supervision of Mr Millichap and Dr Rochefort.847 The first test in the series, held on 7 January 2014,848 incorporated Trespa high pressure laminate rainscreen boards.849 We were not able to establish whether the test in January 2014 had incorporated K15 insulation boards of the kind that were then being sold commercially. Mr Meredith told us that he thought it had,850 but Mr Millichap thought otherwise851 and an internal Kingspan presentation from May 2015 referred to a version of K15 with an unperforated foil facer.852 (By January 2014, K15 was being manufactured and sold with perforated foil facers.) A spreadsheet produced by Kingspan for the Inquiry described the type of K15 used in 839 {KIN00003823/2}; Rochefort {Day80/172:4}-{Day80/176:21}. 840 Rochefort {Day80/181:22}-{Day80/186:4}; Savidge {WIN00000004/25} page 25, paragraphs 63-67; Taylor {WIN00000002/26} page 26, paragraphs 57-61. 841 {KIN00003823}; Meredith {Day76/139:7-21}. 842 {NHB00000810/1-3}. 843 Meredith {Day76/50:7-10}; {NHB00000645/2}. 844 {KIN00005894/1}. 845 Meredith {Day76/97:11}-{Day76/99:11}; Evans {Day219/218:25}-{Day219/219:21}. 846 {NHB00000757/3}. 847 {KIN00022334/17}. 848 Test 291718; no report produced. 849 {KIN00000673}. 850 Meredith {Day76/110:4-7}. 851 Millichap {Day82/27:1-8}. 852 {KIN00021945/17}.

The Grenfell Tower Inquiry: Phase 2 Report 98 the test as “unknown”.853 Whatever kind of K15 it contained, however, the system did not meet the criteria in BR 135, the temperature exceeding the relevant limit after just under 15 minutes, with flames breaching the top of the test rig before 30 minutes had elapsed.854 22.117 Following that test, Kingspan worked on changes in advance of the next test. It is clear that Ivor Meredith, Dr Rochefort and Tony Millichap (among others) were closely involved in the discussions about possible changes. They included a suggestion made by Mr Meredith in an email dated 13 January 2014 to produce for testing a K15 product modified with an alternative blowing agent called ‘solstice’.855 Dr Rochefort did not agree with changing to a solstice-blown foam and asked Mr Meredith to speak to him about it. Mr Meredith subsequently told Mr Millichap that he thought Dr Rochefort would be concerned about putting too much in writing.856 22.118 It is apparent from the internal correspondence in January 2014 following the first test857 that at that point Dr Rochefort, Mr Millichap and Mr Meredith all realised two important things. First, that at that time they did not think that Kingspan had a K15 product that was capable of being used in a system that, when tested in accordance with BS 8414, would meet the criteria in BR 135. That included the K15 that Kingspan was then selling. Secondly, that as a result, the next test or tests could not be carried out on the standard K15 product.858 22.119 Whatever reservations Dr Rochefort might initially have had about changing to a solstice- blown version of K15, the next test on 19 March 2014859 was carried out on a system incorporating a 15 millimetre Trespa decorative rainscreen board and a “trial” version of K15 made using solstice as the blowing agent with a 50 or 100 micron unperforated foil facer.860 Dr Rochefort, Mr Meredith and Mr Millichap were all aware at the time of the test that those were the characteristics of the insulation tested,861 although the K15 on the market in March 2014 had a 25 micron perforated foil facer and did not use solstice as the blowing agent. 22.120 Despite the use of a modified K15 product, by 31 March 2014 Kingspan had learnt from BRE that the system tested on 19 March 2014 had not met the criteria in BR 135.862 Towards the end of the test flames had breached the top of the rig and the test had therefore been effectively terminated straight away.863 Kingspan immediately set about challenging BRE’s decision, first by making a formal complaint864 and then by warning BRE that it was consulting lawyers.865 Based on its analysis of a video recording of the test, BRE stood firm and did not produce a BR 135 classification report. Mr Meredith nonetheless made good his initial promise to Dr Rochefort and others that he would get something out 853 {KIN00022357/3}. 854 {KIN00000673/1}. 855 {KIN00021095/2} fifth bullet point. 856 {KIN00021095/1}. 857 {KIN00021095}. 858 Millichap {Day81/122:12-25}; Millichap {Day82/27:16-19}. 859 Test 293940. Test report dated 26 June 2014 {BRE00002516}. 860 {KIN00022357/3}; {KIN00021945/17}. 861 Rochefort {Day80/203:5-12}; Meredith {Day76/124:23}-{Day76/125:9}; Millichap {Day82/30:23}-{Day82/31:1}. 862 {KIN00021907/2}. 863 {KIN00010461/3}; {BSI00000097/11} clause 8.5. 864 {KIN00010461/1}; {BRE00003576}. 865 {BRE00015592/2}.

Part 3 | Chapter 22: Kingspan K15 insulation 99 of the test866 by obtaining a test report.867 The resulting test report dated 26 June 2014 was later relied on in a large number of desktop assessments produced to demonstrate that systems incorporating K15 would comply with the criteria in BR 135. 22.121 Despite being aware from 31 March 2014 that the system tested on 19 March 2014 had not met the performance criteria in BR 135,868 Kingspan represented on a number of occasions,869 even as late as February 2015,870 that the test supported the suitability of K15 for use on buildings over 18 metres in height. That involved a double falsehood: the insulation tested in that system was not K15 in the form in which it was being supplied to the market and the system had not met the criteria in BR 135. 22.122 The next test took place on 7 July 2014. Dr Rochefort directed that terracotta tiles be used as the rainscreen.871 There was some discussion in late March 2014 between Mr Meredith, Mr Millichap, Dr Rochefort and others at Kingspan about the product that should be used in the next test, standard, solstice or phosphoric.872 The first was the K15 that was being sold commercially, the second was the trial version which had been tested in March 2014 and the third contained certain other chemical modifications.873 On this occasion, they decided to use a solstice-blown product with a 50 micron foil facer, perforated on one side and unperforated on the other.874 Mr Meredith told us that the decision to test that form of the product was taken by all those who had been involved in the discussions,875 who included Dr Rochefort, Mr Millichap and Peter Wilson.876 The system tested met the performance criteria in BR 135.877 22.123 There was evidence that Mr Meredith had taken steps to ensure that labels stating “trial” were removed from the insulation supplied to BRE for the test.878 He agreed that that might have been to ensure that BRE did not become aware that a trial version of K15 was being tested.879 Neither the test nor the classification report produced by BRE made any reference to the fact that the insulation was a trial version, both simply referring to it as “K15 Kooltherm insulation board”.880 As a result, the reader would not have been able to tell from the reports that the insulation was anything other than the K15 then being sold by Kingspan. 22.124 Mr Pargeter, Mr Meredith, Mr Millichap and Dr Rochefort all admitted that they had been aware at the time that the test on 7 July 2014 had been carried out on a system incorporating a trial product,881 a fact clearly borne out by the documents. Mr Millichap882 and Mr Meredith883 told us that it had been common knowledge within Kingspan. 866 {KIN00021907/2}. 867 {BRE00002516}. 868 {KIN00021907/2}. 869 {NHB00000703}; {KIN00002186}; Millichap {Day82/107:5-24}; {Day82/134:2-23}. 870 {KIN00002199/1}. 871 {KIN00021907/2}. 872 {KIN00021907/2}. 873 Millichap {Day82/54:10-13}. 874 {KIN00022357/3}; {KIN00021945/17}; Meredith {Day76/158:19-21}. 875 Meredith {Day76/130/10-19}; {KIN00021907}. 876 {KIN00021907}. 877 Test report 297099 dated 10 September 2014 {BRE00002656}; BR 135 Classification report 291642 dated 5 March 2015 {BRE00002514}. 878 {KIN00021904/3}. 879 Meredith {Day76/161:4-20}. 880 {BRE00002656/6}; {BRE00002514/6}. 881 Meredith {KIN00022312/58} page 58, paragraph 120(a); Millichap {Day82/64:9-15}; Rochefort {Day80/216:13-17}; Pargeter {Day83/191:7-16}. 882 Millichap {Day82/76:15}-{Day82/77:3}. 883 Meredith {Day76/157:16}-{Day76/158:2}.

The Grenfell Tower Inquiry: Phase 2 Report 100 22.125 The test result was immediately celebrated internally within Kingspan,884 with jubilation expressed at the effect it would have on competitors and open discussion of the pressure Kingspan had been under to achieve it.885 It does not appear to have occurred to any Kingspan employee, other than Mr Millichap, whose objections appear to have been roundly dismissed886 and must have been short-lived, to question any aspect of the “success” being celebrated. The test result was swiftly also celebrated externally. Kingspan informed NHBC, building contractors, designers and the wider market that it had carried out a successful test to BS 8414-2 as part of its “test portfolio”.887 22.126 Thereafter, in its correspondence, technical bulletins and promotional literature, Kingspan relied on the result of that test to support the use of standard K15 on buildings over 18 metres in height and that remained its position until it withdrew the test in October 2020.888 Kingspan’s witnesses were asked why it had relied on a test carried out on a different product, given that all those involved (including Mr Pargeter, who was promoted to Head of Marketing in November 2014)889 knew that the test had not been carried out on K15 of the kind being sold in the market. There was a conflict of evidence between Mr Meredith, who did not attempt to deny that Kingspan had done so knowingly and deliberately, and Dr Rochefort, Tony Millichap and Adrian Pargeter, who did. 22.127 Dr Rochefort told us that at the time he had had no idea that the test carried out in July 2014 was being used by Kingspan to support the sale of standard K15 for use on buildings over 18 metres in height. When faced with documents that tended to show that he had been aware of how the test was being used,890 he put forward various unconvincing explanations while resolutely denying that Kingspan had deliberately relied on it to promote or sell standard K15.891 In our view the evidence clearly demonstrated that he was aware that the marketing and technical departments were making use of the test in that way. 22.128 Mr Millichap agreed that it was wholly inappropriate to use the July 2014 test to support the sale of standard K15892 and said that he had not known that that was being done.893 However, having seen Mr Meredith’s email of 21 August 2014,894 he accepted that he had known that letters confirming success in the test that had been sent in response to questions from contractors895 can only have referred to the test in July 2014.896 Moreover, faced with the record of a meeting held on 15 July 2014, at which he had been instructed to produce reports and letters announcing the result of the test for use as a marketing tool,897 he admitted that he had been actively involved in using the test to support the sale of standard K15.898 He also confirmed that he had known throughout his time as Head of Technical that the product Kingspan had tested in July 2014 had never been produced or sold commercially.899 884 {KIN00010825/2}. 885 {KIN00010825/1}. 886 {KIN00010825/1}; Millichap {Day82/75:21}-{Day82/76:13}. 887 {KIN00002186/2}; Millichap {Day82/104:23}-{Day82/105:4}; {KIN00011049}. 888 {KIN00024104/1}. 889 Pargeter {KIN00000494/4-5} pages 4-5, paragraphs 2.7 and 2.8. 890 {KIN00020736/2} paragraph 6; {KIN00021904/1}. 891 Rochefort {Day80/222:9}-{Day80/224:3}; {Day80/217:9-19}; {Day80/224:17-22}. 892 Millichap {Day82/66:12-15}. 893 Millichap {Day82/64:19}-{Day83/65:6}. 894 {KIN00020736}. 895 {KIN00020736/2} paragraph 6. 896 Millichap {Day82/68:17}-{Day82/69:6}. 897 {KIN00020736/3}. 898 Millichap {Day82/72:18-24}. 899 Millichap {Day82/64:9-15}.

Part 3 | Chapter 22: Kingspan K15 insulation 101 22.129 In the summer of 2014 Adrian Pargeter was Kingspan’s Product Development Manager; he was promoted to Head of Marketing in November 2014. It is clear from the documents to which we have referred that he was closely involved in the testing of K15 and the attempts to produce a product that was capable of forming part of a system that would satisfy the criteria in BR 135 when tested in accordance with BS 8414. He could therefore be expected to have had a detailed knowledge of the differences between the various forms of K15 that were produced for testing during that period and, towards the end of 2014, of the steps being taken by the marketing department to promote and sell the product. 22.130 Mr Pargeter told us that he had not known that Kingspan had relied on the test in July 2014 in order to market and sell standard K15 until February 2019, when he had discovered it in the course of preparing to give evidence to the Inquiry,900 although he had known that a non-standard version of K15 had been tested in July 2014. In effect, his evidence amounts to saying that until early 2019 he had thought that two separate tests had been carried out in July 2014, one on the standard product and one on a trial product. 22.131 Mr Pargeter told us that he had not been involved in any discussions or decisions to use the report on the test carried out in July 2014 to support the sale of standard K15.901 However, his evidence was not consistent with a series of documents created in 2014 and 2015 that he had either written, approved or read, all of which contained statements that specifically relied on that test to support the use of K15 on buildings over 18 metres in height. One of them was a technical bulletin published in August 2015 entitled “Routes to Compliance”,902 which Mr Pargeter confirmed he had read in full (including the appendices and diagrams) thoroughly903 before he had approved it.904 The document contained pictures of the systems used for the three BS 8414 tests on which Kingspan was relying by August 2015.905 One of them was the test carried out in May 2005; another was the test carried out in July 2014. Mr Pargeter said that he had not realised at the time that it was a picture of the test carried out on development material in 2014. There was a series of other documents dating from 2015 and 2016, all of which Mr Pargeter confirmed he had read, in which the test carried out in July 2014 was described or referred to as a test carried out on K15 and was being relied on in support of the promotion, certification or sale of K15.906 22.132 Given the positions he had occupied within Kingspan, between 2014 and 2019, it would be surprising if Mr Pargeter had not been aware of the nature of the product involved in the July 2014 test or of how his department had been marketing a product as important as K15. We found his attempts to distance himself from the activities of the marketing department dishonest and entirely unconvincing. We have concluded that Mr Pargeter was fully aware, both before and after he became Head of Marketing, that Kingspan was relying on the results derived from a test incorporating a form of K15 that was not being produced commercially to sell standard K15 and that he actively condoned it at a very senior level. 900 Pargeter {KIN00022610/56-57} pages 56-57 paragraph 7.16; Pargeter {Day83/191:17}-{Day83/192:9}; {Day84/4:14-25}. 901 Pargeter {KIN00022610/28} page 28, paragraph 3.37. 902 {KIN00000086}. 903 Pargeter {Day84/15:17-24}; {Day84/17:14-15}. 904 Pargeter {Day84/12:21-25}. 905 {KIN00000086/17}. 906 {KIN00002289}; {NHB00001109/2} second bullet point; {BBA00000200/5} paragraph 8.2, {BBA00000201/5} paragraph 8.2.

The Grenfell Tower Inquiry: Phase 2 Report 102 22.133 We think it highly likely that Kingspan had always intended to rely on the first successful test it could achieve, whatever form of the product had been used in the tested system. Kingspan’s reliance after July 2014 on a test carried out using a development product was part of a carefully planned, carefully concealed and long-running deception. Conclusions 22.134 The story of the development and marketing of K15 for use on buildings of over 18 metres in height between 2006 and 2019 is one of deeply entrenched and persistent dishonesty on the part of Kingspan in pursuit of commercial gain coupled with a complete disregard for fire safety. Unfortunately, Kingspan’s dishonesty was facilitated, albeit inadvertently, by serious incompetence on the part of two bodies, the BBA and LABC, to which the industry looked for confirmation that K15 was suitable for use on buildings over 18 metres in height. Both those bodies, although supposedly independent, compromised their independence by entering into negotiations with Kingspan over the wording of their certificates and agreeing to include language that was inappropriate and in some cases misleading. They both failed to examine rigorously the material on which Kingspan’s applications were based or to require the production of test data that supported its claims. 22.135 The effect of Kingspan’s dishonest marketing of K15 was to create a spurious market for a polymeric insulation product suitable for use on high-rise buildings generally, which drew in Celotex as a competitor. Celotex found it impossible to create a similar product using polyisocyanurate foam and could not understand how Kingspan had been able to produce an organic polymeric insulation board that apparently enabled designers to follow the guidance in Approved Document B relating to buildings over 18 metres in height. It therefore embarked on its own campaign to break into the market by dishonest means. Kingspan cannot be blamed for Celotex’s dishonesty, which was the choice of Celotex itself, but it did create the conditions that encouraged it and in which it was able to flourish.

103 Chapter 23 Certification of Kingspan K15 by LABC Local Authority Building Control 23.1 Local Authority Building Control (LABC) is a membership organisation created in 2005 to support all local authority building control teams in England and Wales (all of whom are members) with training, technical matters, and to provide centralised marketing and business development for members through a single network, in part through the creation of a centralised brand that is recognisable to building control users. It also aims to provide advice and assistance to members, to promote technical consistency in the interpretation of building regulations and to provide a forum for discussion between members. LABC is governed by a Board of Directors, with a Chief Executive who until 2016 line managed the Director of Technical Policy.907 From October 2006 until March 2021, the Director of Technical Policy was Barry Turner.908 LABC’s certification schemes 23.2 By the early part of the present century the informal sharing of information between local authority building control departments about the suitability of construction products had developed into a more formal system known as the Type Approval scheme909 administered by LABC on behalf of its members. (In 2010 the name of the scheme was changed to the Registered Details scheme.)910 The purpose of the scheme was to assess and verify the compliance of construction products or systems with the Building Regulations and Approved Documents. The categories of approvals granted under the scheme included a “Product Type Approval”, which verified individual products or small components, and a “System Type Approval”, a very wide category covering modular building systems as well as individual elements forming part of a larger structure.911 The intention was to assist individual local authority building control bodies making decisions on specific projects,912 to promote technical consistency913 and to make it easier for applicants for approval in different local authority areas to demonstrate compliance with the Building Regulations.914 The Type Approval scheme was also intended to provide a means of securing long term business for and reinvestment into LABC.915 23.3 The assessment of a product or system for the purposes of granting Type Approval was carried out by the building control department of a member local authority, sometimes referred to as the “research authority”916 or “matched authority”,917 designated by LABC (if the application was made to LABC) or as a result of a direct approach by the 907 Stimpson {LABC0020158/7-11}. 908 Turner {LABC0002105/4} page 4, paragraph 14; Turner {Day216/4:9-16}. 909 Turner {LABC0011202/8} page 8, paragraph 30; {LABC0018747}. 910 Turner {LABC0011202/14} page 14, paragraph 45. 911 {HBC00000049/10-11} paragraph 2.2. 912 Turner {LABC0011202/7} page 7, paragraph 27; Turner {Day216/24:18-25}. 913 Stimpson {LABC0020158/23} page 23, paragraph 25.3. 914 Turner {LABC0011202/7} page 7, paragraph 26. 915 {HBC00000049/26} paragraph 7.3. 916 Stimpson {LABC0020158/24} page 24, paragraph 25.13. 917 {HBC00000049/5}; {LABC0002281/3}.

The Grenfell Tower Inquiry: Phase 2 Report 104 manufacturer to a particular local authority.918 However identified, it was the responsibility of that authority to undertake an objective and impartial technical assessment919 of a product or system based on information and supporting certification and test results from recognised bodies provided by the manufacturer.920 The intention was to reflect the investigation that a building control surveyor would otherwise need to carry out to determine compliance with the Building Regulations and Approved Documents,921 with the additional support of an independent second check. 23.4 LABC published various editions of a Type Approval Service Manual922 that set out the framework, process and standards for issuing certificates under the scheme. The manual was intended to act as a guide to assist member local authorities undertaking assessments.923 Although the process was based on information provided by manufacturers and therefore depended on their honesty and good faith,924 the assessment of the product or system under consideration was intended to be carried out at a high level and comprehensively checked in all respects.925 With a view to maintaining the quality of the assessment, the scheme provided for a second check that might take a variety of forms, including referral to a specialist agency, consultant or independent peer review group. 23.5 Following a successful assessment, a certificate was issued by LABC, which was intended to represent “a singular initial Building Regulation approval in respect of a standard construction matter.” As such, it was intended to confirm that the product or system complied with the Building Regulations for all uses falling within the defined scope and terms of the certificate.926 It was intended to fulfil a number of functions, including the elimination of the need for repetitive checking of compliance with the Building Regulations.927 The manual therefore contemplated that all local authorities would accept the certificate (within its terms and limits) without further checking.928 The first certificate for K15: May 2009-May 2012 23.6 From 2009 onwards, Kingspan obtained a number of LABC certificates for K15.929 The first was a System Approval certificate dated 1 May 2009 which remained valid until 30 April 2012.930 A document entitled “Summary of the System and the Main Issues Considered” accompanied and formed part of the certificate931 and made a number of important statements about the performance of K15 in fire. In particular, having stated that K15 had 918 Turner {LABC0011202/8-9} pages 8-9, paragraph 31; Stimpson {LABC0020158/23} page 23, paragraph 25.6; {LABC0020158/25} page 25, paragraphs 25.16 and 25.17; {LABC0011202/11} page 11, paragraph 39. 919 Turner {LABC0011202/5-6} pages 5-6, paragraph 23; Stimpson {LABC0020158/27} page 27, paragraph 25.25. 920 Turner {LABC0011202/6} page 6, paragraph 25; {LABC0011202/10} page 10, paragraph 35. 921 Turner {Day216/25:2}-{Day216/26:13}. 922 {HBC00000049/6-30}. 923 {HBC00000049/9} paragraph 1.1; Turner {Day216/71:6-10}. 924 Turner {LABC0011202/12} page 12, paragraph 42; Brennan {LABC0020135/15-16} pages 15-16, paragraphs 21.17 and 21.21; Stimpson {LABC0020158/25} page 25, paragraph 25.15; Ewing {LABC0020139/17} page 17, paragraph 21.18. 925 {HBC00000049/16} paragraph 3.2. 926 {HBC00000049/9} paragraph 1.2. 927 {HBC00000049/9} paragraph 1.2. 928 {HBC00000049/10} paragraph 2.1. 929 System Type Approval 1 May 2009 – 1 May 2012, Registered Details RD 165 28 August 2013-28 August 2014, Registered Details August 2014 – 30 November 2014, EWW165 Certificate 9 March 2015–9 March 2016, EWWS165 Certificate 24 March 2016-30 March 2019 {LABC0019607/2-3}; Ewing {LABC0020139/22-24} pages 22-24, paragraph 27. 930 {KIN00005705/1}. 931 {KIN00005705/3-6}.

Part 3 | Chapter 23: Certification of Kingspan K15 by LABC 105 been tested in accordance with BS 8414-1, and BS 476, parts 6 and 7,932 it said that “From the results, it can be considered as a material of limited combustibility and meets the criteria for Class 0 classification for surface spread of flame”.933 On the next page it stated that “Since K15 can be considered a material of limited combustibility, it is suitable for use in all situations shown on Diagram 40 of Approved Document B Volume 2, including those parts of a building more than 18m above the ground.”.934 23.7 Those statements were fundamentally incorrect in every respect. K15 was not, and could not be considered, a material of limited combustibility and the tests to which it was said to have been subjected were not capable of establishing whether it was a material of limited combustibility.935 Its performance in BS 476 tests did not show that it met the criteria for Class 0. Those were matters of critical importance when considering the intended use of K15, particularly on buildings over 18 metres in height. It is therefore necessary to examine how the certificate came to include statements of that kind. 23.8 The representatives of Kingspan involved in obtaining the certificate were Andrew Pack, Technical Services Manager,936 and his line manager937 Philip Heath, who until 2010 was Technical Manager.938 On 24 November 2008 Mr Pack contacted Barry Turner by telephone to discuss a Type Approval certificate for K15.939 Following that call, Mr Turner sent an email940 to LABC’s Business Development Team informing them that Kingspan had asked for information about obtaining a system type approval for K15 primarily in relation to functional requirements B and C of the Building Regulations. He expressed a preliminary view that LABC could consider granting such approval on the basis that K15 had a BBA certificate and LABC could therefore add an opinion on compliance with the Building Regulations in situations to be described by Kingspan.941 23.9 Herefordshire County Council agreed to undertake the assessment of K15 and prepare any resulting certificate. The work was given to David Jones, who was a Senior Building Control Surveyor from June 2005 until November 2011 and thereafter a Building Control Team Manager until July 2014.942 Mr Jones told us that Herefordshire was selected to undertake the assessment not for any reasons of technical expertise but due to its proximity to Kingspan’s Pembridge site.943 He had never previously been involved in the Type Approval process944 and believed that the work had been delegated to him because he had a specific role in the department for marketing activity. The Type Approval scheme was viewed as a way of raising the profile of the LABC brand.945 932 BS 8414-2:2002 (Test method for non-loadbearing external cladding systems applied to the face of a building) {CEL00001205}; BS EN 1364-1:1999 (Fire resistance tests for non-loadbearing elements – walls) {BSI00000105}; BS 476-6:1989 (Method of test for Fire propagation for products) {BRE00005557}; BS 476-7:1997 (Surface spread of flame) {CTAR00000017}. 933 {KIN00005705/4} under the heading “Requirement B – Fire Safety Considerations”. 934 {KIN00005705/5} paragraph 1. 935 {KIN00005705/4} under the heading “Requirement B – Fire Safety Considerations”. 936 Pack {KIN00008702/4} page 4, paragraph 2.8. 937 {KIN00008752}; Heath {Day79/126:12-13}; Pack {Day86/10:9-12}. 938 Heath {KIN00020709/4} page 4, paragraph 2.8. 939 {LABC0002281/4}. 940 {LABC0002281/3}. 941 {LABC0002281/3}; Turner {Day216/40:6}-{Day216/42:9}. 942 Jones {HBC00000029/3-4} pages 3-4; Jones {Day101/7:8}-{Day101/8:22}; Turner {LABC0011202/8} page 8, paragraph 31. 943 Jones {Day101/16:4-20}. 944 Jones {Day101/26:18-24}. 945 Jones {Day101/18:5}-{Day101/19:8}.

The Grenfell Tower Inquiry: Phase 2 Report 106 23.10 Mr Jones was reluctant to undertake the assessment of K15. He could see that it involved testing and certification, which he knew were not matters within his experience or within the experience of any other members of his department.946 He had not undergone any specific training on the reaction of materials to fire, the testing and certification of construction products, or on the use of materials in buildings over 18 metres in height. There were no buildings over 18 metres in height in Herefordshire, so he had not had to consider the guidance relating to them in the course of his work.947 23.11 Mr Jones spoke to someone at LABC, probably Philip Harrison,948 to explain his concern about undertaking the assessment but was told that it would be fairly limited in scope and should involve an initial meeting with the client and a review of the information provided by it. He was also told that if third party certification was considered to be reliable, it could be accepted at face value and that he need not go behind it.949 23.12 The reliability of third party certification was a matter for LABC rather than the assessing authority and the BBA was regarded as the leading organisation accredited by UKAS and therefore treated with a high degree of trust.950 Mr Jones specifically remembered being told during the call that he could rely on the existence of a BBA certificate for K15, which he regarded as significant.951 It provided him with reassurance that he was not expected to delve into complex matters of fire testing.952 He explained that he was specifically told that his assessment should be based on the BBA certificate and that because the BBA would already have examined all the test information,953 he need not verify any part of its contents.954 23.13 LABC did not accept Mr Jones’ account of the telephone call, which it said was contrary to its practice both then and now.955 However, none of its witnesses was able to tell us who had spoken to him or to provide us with any other information about the call he described. David Jones, on the other hand, was a straightforward, candid and credible witness who gave a clear and detailed account of it. We have no doubt that Mr Jones was assured by LABC that there was little to be done beyond checking the BBA certificate (which broadly reflects what a building control officer would have done) and that it was on the basis of that assurance, and the knowledge that there would be a second check,956 that he agreed to take on the task.957 946 Jones {Day101/17:4-15}. In early 2004, Mr Jones had attended a four-day training course designed for individuals new to the Building Regulations profession. Other than this, his training was “on the job” {Day101/9-23}-{Day101/10:7}; {Day101/12:2-6}; {Day101/60:5}-{Day101/61:2}. 947 Jones {Day101/12:2}-{Day101/13:7}; {Day101/32:9-15}. 948 Jones {Day101/30:12}-{Day101/31:8}. 949 Jones {Day101/31:24}-{Day101/32:11}; {Day101/36:1-7}. 950 Jones {Day101/33:18}-{Day101/34:25}. 951 Jones {Day101/32:15-22}. 952 Jones {Day101/32:9}-{Day101/33:9}. 953 Jones {Day101/32:17-18}. 954 Jones {Day101/32:15-22}; {Day101/37:5-10}; {Day101/46:1}-{Day101/47:2}, “I just remember this BBA certificate being the key factor, that, ‘No it’s okay, don’t worry, it’s got a BBA certificate’ and that was it. That was the answer really”. 955 {LABC0019740/24-25} pages 24-25, paragraph 64 (iv). 956 Jones {Day101/183:2}-{Day101/186:5}. 957 Jones {Day101/27:22}-{Day101/29:2}; {Day101/184:21}-{Day101/185:9}.

Part 3 | Chapter 23: Certification of Kingspan K15 by LABC 107 23.14 Mr Jones’ evidence about what was said during the call is consistent with the terms of LABC’s Service Manual in relation to BBA certificates958 and with Barry Turner’s evidence that when carrying out the second level review959 he would probably not have looked beyond the BBA certificate.960 That all supported Mr Jones’ understanding that in practice LABC did place complete reliance on BBA certificates and expected any authority carrying out an assessment to do the same. Mr Jones’ meeting with Kingspan in December 2008 23.15 On 5 December 2008, Mr Jones met Mr Pack and Mr Heath of Kingspan at Kingspan’s offices in order to discuss the certification of K15.961 They told him that Kingspan was keen to be associated with the LABC brand962 and was aware that an LABC certificate could ease the passage of a product through building control.963 Mr Jones recalled in particular that they had been enthusiastic about the fire testing that Kingspan had commissioned for K15 and the BR 135 criteria964 and were keen to market its suitability for use on buildings over 18 metres in height.965 They emphasised that aspect of the product as a key feature966 of what they were presenting to him. 23.16 Mr Heath could not recall being enthusiastic about Kingspan’s fire testing967 and denied having given Mr Jones the impression that K15 was suitable for use on buildings over 18 metres in height without qualification.968 He told us that, although he had overall responsibility for obtaining the LABC certificate, Mr Pack had been the person leading the project.969 23.17 Mr Pack denied that he had spoken enthusiastically about Kingspan’s BS 8414 test970 and denied that the suitability of K15 for use on buildings over 18 metres in height had been a matter of significance for him or Mr Heath.971 We found that wholly implausible, however, since the ability to sell K15 as suitable for use on buildings over 18 metres in height had been uppermost in Mr Heath’s mind for some time. In reality, Mr Pack could recall little about the meeting,972 describing his own role in obtaining the LABC certificate as merely administrative.973 In the light of Mr Pack’s later involvement in discussions with Mr Jones about the contents of the certificate that was clearly not true.974 Both Mr Pack and Mr Heath denied having claimed that K15 was or could be considered a material of limited combustibility or having given that impression.975 958 {HBC00000049/17} paragraph 3.3 under bullet points, “... the holding and submission by the customer of authoritative independent third party verification, particularly if it is from a UKAS accredited source or other method recommended in Approved Document 7, is likely to indicate an acceptable level of satisfaction for our approval purposes and eliminate the need for any additional checking within that aspect”. 959 {LABC0008171}. 960 Turner {Day216/56:11-14}; {Day216/41:18}-{Day216/42:9}; {Day216/83:13-20}. Mr Turner’s internal email in November 2008 {LABC0002281/3} “…given that the product has relevant BBA certification…”. 961 {KIN00024987}; Jones {Day101/48:24}-{Day101/49:9}. 962 Jones {Day101/41:2-7}. 963 Jones {Day101/42:5-18}. 964 Jones {Day101/56:10-15}. 965 Jones {Day101/52:20}-{Day101/53:1}; {Day101/64:2-24}; Jones {HBC00000029/20} page 20, first paragraph. 966 Jones {Day101/57:21}-{Day101/58:3}. 967 Heath {Day79/167:20-25}. 968 Heath {Day79/179:7-9}. 969 Heath {KIN00020709/59} page 59, paragraph 8.16. 970 Pack {Day86/122:15}-{Day86/123:11}. 971 Pack {Day86/126:22}-{Day86/127:25}. 972 Pack {Day86/120:20}-{Day86/121:7}; {Day86/124:6-8}; {Day86/130:13-17}; {Day86/149:24}-{Day86/150:12}; {Day86/156:22-24}. 973 Pack {Day86/100:18}-{Day86/101:20}. 974 {KIN00024989}; {KIN00024996}; {KIN00024997}; Pack {Day86/170:2}-{Day86/171:24}. 975 Pack {Day86/148:23}-{Day86/149:9}; Heath {Day79/178:25}-{Day79/179:9}.

The Grenfell Tower Inquiry: Phase 2 Report 108 23.18 We preferred the evidence of David Jones about the meeting to that of Mr Pack and Mr Heath. Mr Jones was careful to say that he could not be specific about the words they had used but he told us that he could say with “some certainty” that he had left the meeting with the clear impression that because K15 behaved like a material of limited combustibility it was, or could be considered to be, a material of limited combustibility.976 (It is unlikely to have been a coincidence that Kingspan had been making essentially the same claim in correspondence with customers for some time.)977 The impression Mr Jones had formed was that different products could be used with K15 as part of an external cladding system as long as the fire performance of those products was equal to or better than that of the products used in the tests he had been told about.978 He also left the meeting with the understanding that there was a clear business advantage to Kingspan in having a product that could be marketed for use on buildings over 18 metres in height because it was not a market that all products could enter.979 In later discussions with Mr Jones Andrew Pack proposed broadening the terms of the certificate to include a reference to K15’s suitability for use with various cladding products with which it had not been tested, but he did not tell Mr Jones that K15 could only be used at height as part of a system corresponding to that tested in accordance with BS 8414 in 2005.980 23.19 Mr Jones was given two documents during the meeting,981 Kingspan’s first BBA certificate, issued on 27 October 2008,982 and Kingspan’s principal marketing literature for K15 at the time, which was dated November 2008.983 We have considered the terms of the BBA certificate and the way in which it came to be obtained by Kingspan elsewhere in this report.984 In relation to fire, it stated on its front page under the heading “Key Factors Assessed” that K15 boards would not contribute to the development stages of a fire or present a smoke or toxic hazard.985 It also stated that K15 was classified as Class 0986 and that in a BS 8414-1 test it had displayed limited fire spread away from the source and had met the criteria in BRE 135.987 That was misleading, since the criteria in BR 135 relate to systems rather than products. 23.20 In the same vein, Kingspan’s 2008 promotional literature wrongly stated that K15 had met the criteria in BR 135 and was therefore acceptable for use on buildings over 18 metres in height in accordance with the Building Regulations. It stated definitively (again, wrongly) that K15 did not contribute to the spread of fire within a cladding system.988 The documents therefore reflected each other as well as the conversation that Mr Jones said had taken place when he met Mr Pack and Mr Heath.989 976 Jones {Day101/76:1-25}-{Day101/78:12-24}; Jones {HBC00000029/37} page 37, final paragraph; Jones {Day86/74:4-25}; {Day101/78:21-25}; {Day101/82:5-20}. 977 {KIN00002588/2}, “…it has been proved to perform the same as non combustible material via testing to the full scale BS 8414 test”. 978 Jones {Day101/70:10-17}; {Day101/71:3-9}. Mr Jones said he understood the parameters to be the non-combustible substrate referred to in the BBA certificate, a system of cavity barriers, and non-combustible cladding panels. That is what Mr Pack confirmed he had told Mr Jones. Pack {Day86/130:21}-{Day86/131:11}. 979 Jones {Day101/64:21}-{Day101/65:5}. 980 {KIN00024996}; Pack {Day86/163:12}-{Day86/169:25}. 981 Jones {Day101/55:9-13}. 982 BBA Certificate {BBA00000038}. 983 Eighth issue “Kooltherm K15 Rainscreen Board” {KIN00009703}. 984 Chapter 23. 985 BBA Certificate {BBA00000038/1}. 986 BBA Certificate {BBA00000038/5-6} paragraph 7.2. 987 BBA Certificate {BBA00000038/5} paragraph 7.1. 988 {KIN00009703/6}. 989 Jones {Day101/66:15}-{Day101/67:4}.

Part 3 | Chapter 23: Certification of Kingspan K15 by LABC 109 23.21 Mr Jones asked for no further documents and none were offered.990 The certificate he drafted was therefore based on those two documents, (principally the BBA certificate) and the information Andrew Pack and Philip Heath had provided during his meeting with them.991 Mr Jones had not read any of the test standards992 or reports of the tests993 he listed in his summary before the certificate was issued.994 He explained that there would have been little point in doing so because analysing those reports was outside his expertise and would have involved an entirely different exercise from the one he had understood he had been asked to carry out.995 He simply copied the list of tests from the BBA certificate.996 He thought that the statement that K15 could be considered a material of limited combustibility was simply a confirmation of something that was already known.997 23.22 In 2009, Mr Jones did not know that data derived from a BS 8414 test and any subsequent classification in accordance with BR 135 was valid only for the system tested998 and neither Mr Pack nor Mr Heath told him that,999 although they were both well aware of the fact.1000 Nor did he know that Class 0 was demonstrated through testing in accordance with BS 476 Parts 6 and 7, two of the tests he listed in the document accompanying the LABC certificate.1001 His understanding at the time of the term “material of limited combustibility” was that it referred to a material that had the capacity to burn but was difficult to ignite and would not allow flame to spread easily through it.1002 That was consistent both with the impression he had been given by Mr Heath and Mr Pack at their meeting that K15 had a limited capacity to burn1003 and with what he told us had been the widely held view among building control officers that Kingspan products would char slowly and stop burning when the source of ignition was removed.1004 23.23 David Jones accepted that when he did his research he had become aware of Appendix A to Approved Document B and had thus become aware of the meaning of the expression “limited combustibility”. Nonetheless, he had decided to adopt the wording in the certificate on the basis that there could be different ways of meeting the functional requirements.1005 When shown the relevant tables in Approved Document B,1006 however, he agreed that if he had looked at them at the time he would not have written that K15 could be considered a material of limited combustibility.1007 He told us that he now appreciated that, due to his lack of experience, some of the statements in the certificate should not have been made.1008 He accepted that he had not drawn a clear enough distinction between a material of limited combustibility, which has a defined meaning, and 990 Jones {Day101/108:20}-{Day101/109:5}. 991 Jones {HBC00000029/35-36} pages 35-36, paragraph 57(a)-(h); Jones {Day101/129:4}-{Day101/149:5}. 992 Jones {Day101/127:16-19}. 993 Jones {Day101/59:24}-{Day101/60:3}; {Day101/125:20}-{Day101/126:6}. 994 {KIN00005705/4} under the heading “Requirement B – Fire Safety Considerations”. 995 Jones {Day101/60:5}-{Day101/63:7}. 996 Jones {Day101/126:2-6}. 997 Jones {HBC00000029/37} page 37, first paragraph; Jones {Day101/149:20}-{Day101/150:18}. 998 Jones {Day101/104:3-19}. 999 Pack {Day86/130:21}-{Day86/131:2}; Jones {Day101/68:22}-{Day101/69:12}; Pack {Day86/73:1-6}. 1000 Pack {Day86/22:15}-{Day86/23:12}; Heath {Day78/189:21}-{Day78/190:5}; {Day78/196:16}-{Day78/194:2}. 1001 Jones {Day101/126:7-23}. 1002 Jones {HBC00000029/29} page 29, paragraph (a); Jones {Day101/96:9}-{Day101/97:5}. 1003 Jones {Day101/77:7-23}; See also Kingspan correspondence at, for example {KIN00003685/1} “Therefore it is pigeonholed with the combustible insulations even though the char that forms ‘limits the combustibility’ of the product” {KIN00005388/1} first paragraph. 1004 Jones {HBC00000029/38} page 38, first paragraph; Jones {Day101/81:13}-{Day101/83:20}. 1005 Jones {Day101/153:13}-{Day101/156:11}. 1006 Table A7 {CLG10000007/132}; Table A6 {CLG10000007/131}; Jones {Day101/158:1}-{Day101/161:14}. 1007 Jones {Day101/162:15-20}. 1008 Jones {Day101/180:10-12}.

The Grenfell Tower Inquiry: Phase 2 Report 110 a product which has a limited capacity to burn.1009 He thought his judgement might have been affected by being given the impression that K15 had already been approved for use on buildings over 18 metres in height by virtue of meeting the criteria in BR 135.1010 He also accepted that his approach might have been shaped by the commercial pressure on local authority building control officers to find innovative solutions that did not rigidly follow the Approved Documents in order to win business.1011 23.24 Mr Jones understood that after he had carried out his assessment it would be checked by LABC to ensure there were no errors.1012 In fact, however, the second check, carried out in March 2009 by a Type Approval Working Group made up of individuals from various local authorities, appears to have been cursory at best. The only question raised was why a system approval was being issued rather than a product approval, K15 plainly being a product rather than a system.1013 It appears to have gone unanswered and remained unanswered even when Barry Turner was asked about it by LABC’s Technical Administrator, Sasha Cruz, in an email sent on 21 April 2009 asking if the certificate could be issued.1014 No one noticed the fundamental errors in the summary. On 1 May 2009, Ms Cruz sent the certificate to Mr Jones to issue on behalf of LABC.1015 23.25 Barry Turner accepted that the statement that K15 could be considered a material of limited combustibility was inaccurate and misleading.1016 He could not explain how it had come to be made, telling us that he did not participate in the review process and repeatedly asserting that he was copied into various relevant emails only “as a matter of courtesy”.1017 We agree with LABC’s acknowledgment in its closing statement that Mr Turner was an unhelpful and dismissive witness.1018 We were left in no doubt that he was seeking throughout to minimise his own technical role, his involvement in the certification process and his responsibility for any aspect of it. 23.26 David Ewing, who later managed LABC’s Registered Details Approval scheme,1019 also accepted that the 2009 certificate’s wording in relation to K15’s fire performance was technically incorrect,1020 as did LABC itself in its closing statement.1021 23.27 To their discredit, neither Philip Heath nor Andrew Pack was prepared to accept that he had been aware in 2009 or thereafter that the wording of the certificate was inaccurate, that it would be likely to lead readers to believe that K15 was a material of limited combustibility or that many readers would understand from it that K15 had been approved for use on buildings over 18 metres in height. Both maintained that at the time they had understood that LABC had intended the wording to mean that K15 could be suitable for use in such circumstances as part of a system that had been tested in accordance with BS 8414 1009 Jones {Day101/150:13}-{Day101/151:23}. 1010 Jones {Day101/162:6-14}. 1011 Jones {Day101/156:7-11}; Jones {HBC00000029/40} page 40; {Day101/174:4}-{Day101/176:25}. 1012 Jones {Day101/111:17}-{Day101/112:21}; {Day101/173:12-15}. 1013 {LABC0008171/2}. 1014 {LABC0008171/1}. 1015 {LABC0001882/3}. 1016 Turner {Day216/36:19}-{Day216/37:2}. 1017 Turner {Day216/51:9}; {Day216/69:13-17}; {Day217/3:8}; {Day217/12:6-10}; {Day217/23:5}; {Day217/35:17-20}; {Day217/48:6}. 1018 {LABC0020161/34} page 34, paragraph 138. 1019 Ewing {LABC0020139/4} page 4, paragraph 7.6. 1020 Ewing {Day217/148:1-9}. 1021 LABC Phase 2 Module 2 Closing Submissions {LABC0019740/5-6} paragraph 17; LABC Phase 2 Module 6 Closing Submissions {LABC0020161/25} paragraph 101(a)-(b).

Part 3 | Chapter 23: Certification of Kingspan K15 by LABC 111 and had met the criteria in BR 135.1022 However, that was impossible, given that only a limited amount of testing had been carried out, and that on a product that had become obsolete at least two years earlier. In reality, that was neither what the certificate stated nor what Mr Jones had intended.1023 Mr Heath added that on reflection he could see that the wording had been misleading.1024 Mr Pack too told us that in hindsight, the wording could have been “slightly better”,1025 but said that Kingspan relied on LABC and on the wording chosen by Mr Jones.1026 23.28 Both Mr Pack and Mr Heath confirmed that they had understood at all times that K15 was not a material of limited combustibility.1027 Both were also aware that Approved Document B did not provide that combustible insulation could be considered a material of limited combustibility if used with non-combustible or limited combustibility substrates or outer cladding.1028 They did not need to rely on hindsight to know that the certificate was wrong in that respect and dangerously misleading. When sent a draft of the certificate and accompanying summary by Mr Jones on 27 February 2009,1029 neither Mr Pack nor Mr Heath corrected the wording. On the contrary, Mr Heath described the document as “GOLD”1030 and Mr Pack approved the draft, asking Mr Jones to proceed to issue the certificate and summary.1031 In his markedly more candid evidence, Ivor Meredith,1032 told us that he and his superiors had known at the time that the wording was misleading but that it was very advantageous for Kingspan.1033 He said that Mr Heath had been thrilled with it.1034 23.29 Kingspan’s aim from the outset (as in the case of the BBA certificate) had been to ensure that the wording of the certificate gave as much support for the use of K15 on buildings over 18 metres in height as possible, with no regard for technical accuracy or fire safety.1035 It is apparent from the triumphant tone of the emails sent by Mr Heath within Kingspan at the time1036 that his own and Mr Pack’s dogged assertions that they were ignorant of the error on the face of the certificate was untruthful. It was the very wording “...can be considered as a material of limited combustibility...”1037 that was highlighted in bold in Mr Heath’s announcement to colleagues that the certificate had been obtained and for which he heartily thanked Mr Pack.1038 That part of the certificate was also described to sales teams as the “highlight” of the document1039 and led directly to Mr Heath’s instruction to colleagues on 11 May 2009 that no further large-scale testing was to be carried out on K15.1040 Kingspan had what it needed to maintain its position in the over 18 metre market. 1022 Heath {Day79/161:5}-{Day79/164:11}; {Day79/174:1-7}; {Day79/176:21}-{Day79/177:23}; {Day79/182:6}-{Day79/183:20}; Pack {Day86/187:6}-{Day86/189:10}; {Day86/192:9}-{Day86/193:9}. 1023 Jones {HBC00000029/36} page 36; Jones {Day101/128:11-21}. 1024 Heath {Day79/176:21}-{Day79/177:23}. 1025 Pack {Day86/188:25}-{Day86/189:1}. 1026 Pack {Day86/188:15-16}; {Day86/191:21}-{Day86/192:2}. 1027 Pack {Day86/21:15}-{Day86/22:7}; {Day86/187:1-5}; Heath {Day78/181:7-20}. 1028 Pack {Day86/190:25}-{Day86/191:18}; Heath {Day79/161:5}-{Day79/162:6}. 1029 {KIN00024990}. 1030 {KIN00024991/1}. 1031 {KIN00024990}. 1032 Meredith {KIN00022312/1} page 1, paragraph 1. 1033 Meredith {Day76/30:14-23}. 1034 Meredith {Day76/33:13-15}. 1035 Chapter 22. 1036 {KIN00005383}; {KIN00024993/1}. 1037 {KIN00005705/4-5}. 1038 {KIN00005383}. 1039 {KIN00009178/5}. 1040 {KIN00005382/1} “The pressure is on other component suppliers to obtain similar statements or prove their non- combustible statements”.

The Grenfell Tower Inquiry: Phase 2 Report 112 23.30 Worse still, neither LABC nor Mr Jones knew that K15 had not achieved results when tested in accordance with BS 476-6 and BS 476-7 that enabled it to be classed as Class 01041 and that the sole test in accordance with BS 8414-1 that Kingspan had carried out which met the criteria in BR 1351042 had incorporated an obsolete form of K15 that was different from the version being produced and sold in 2009 and thereafter.1043 Those facts were concealed from LABC and from David Jones by Mr Heath, who was aware of the true position.1044 23.31 We accept both David Jones’ description of the assurances he was given by LABC about the scope of the work he was expected to carry out and his account of what he was told by Mr Pack and Mr Heath. He acted largely on trust, but was badly let down by LABC and deliberately misled by Kingspan.1045 He had expected, as had LABC,1046 that Kingspan would draw attention to any errors or inaccuracies in the draft documents because it would not wish to risk reputational damage from knowingly marketing K15 on the basis of false information.1047 In fact, however, the documents which Kingspan provided1048 in support of its application and the statements made in the course of the meeting between Mr Jones, Mr Heath and Mr Pack were intended to mislead.1049 The document Mr Jones issued was, nonetheless, an LABC approval certificate and it remains the case that LABC’s second level of checks, on which he had also relied,1050 were woefully inadequate. 23.32 Mr Jones could not remember whether he had looked at LABC’s Type Approval Service Manual,1051 but if he did, it is unlikely that he found it to be of great assistance. Although it called for a thorough and comprehensive assessment at a high level, it also said that certificates from authoritative independent third parties, particularly those accredited by UKAS such as the BBA, were likely to indicate an acceptable level of satisfaction.1052 In the event, Mr Jones did accept the BBA certificate as sufficient evidence of the statements it contained, but he had been told that that was all that was required of him and the truth is that he was neither competent nor qualified to do more.1053 It is unlikely that he would have agreed to undertake the work if he had been expected to do otherwise.1054 23.33 Although only Kingspan knew it (because it had largely drafted the text),1055 the 2008 BBA certificate on which David Jones relied so heavily had also been issued without proper checks having been made and was riddled with fundamental errors and misleading language. To that extent there was, therefore, a fatal flaw in LABC’s Type Approval scheme. As a result, Kingspan’s initial misleading of the BBA1056 combined with the failure of the BBA itself to investigate the properties of K15 with sufficient rigour led to the publication of misleading claims about K15 that were repeated and given additional credibility by the LABC certificate. 1041 Kingspan had tested to BS 476 Parts 6 and 7 the foil facer of K15 boards stapled to a non-combustible substrate {KIN00022205}; See Chapter 22. 1042 BRE Report {BRE00002511} Test 220876. 1043 See Chapter 22. 1044 Heath {Day79/179:10}-{Day79/180:6}. 1045 Jones {Day101/182:25}-{Day101/185:9}. 1046 Brennan {LABC0020135/26} page 26, paragraph 39.1. 1047 Jones {Day101/171:15-21}. 1048 BBA Certificate {BBA00000038}; Eighth issue “Kooltherm K15 Rainscreen Board” {KIN00009703}. 1049 Jones {Day101/183:2-18}. 1050 Jones {Day101/113:4-14}; {Day101/173:2-15}; {Day101/184:21}-{Day101/185:9}. 1051 Jones {HBC00000051/4} page 4, paragraph 14; Jones {Day101/166:20}-{Day101/167:10}. 1052 {HBC00000049/17} paragraph 3.3. 1053 Jones {Day101/39:11}-{Day101/40:5}. 1054 Jones {Day101/106:19}-{Day101/107:21}; {Day101/196:2-5}. 1055 See Chapter 22. 1056 See Chapter 22.

Part 3 | Chapter 23: Certification of Kingspan K15 by LABC 113 Concerns raised about the LABC Type Approval for K15 23.34 The terms of the LABC certificate appear to have caused immediate concern at BRE1057 about “misuse of data” and the broad claims that K15 was suitable for all kinds of applications in all sorts of situations,1058 though it appears that no one there mentioned those concerns to Kingspan.1059 The inclusion in the certificate of misleading statements was brought to LABC’s attention by Larry Cody, then a director of Rockwool,1060 who wrote to Barry Turner in September1061 and again in October 20091062 complaining that LABC had stated that K15 could be considered as a material of limited combustibility and pointing to life safety considerations.1063 Mr Turner did not respond until 23 February 2010,1064 following a further letter from Mr Cody on 1 February 2010 asking about LABC’s complaints policy and Mr Turner’s failure to answer his previous letter.1065 23.35 When he did respond to Mr Cody, Mr Turner wrote that he did not consider it a matter for discussion with a competitor, despite the fact that he had already corresponded with Kingspan about the matter.1066 In the same response, he comprehensively defended the terms of LABC’s claims, telling Mr Cody that the research authority that had undertaken the assessment of K15 had been satisfied that it met the relevant criteria.1067 He did so, he told us, without even checking the terms of the certificate or engaging with the substance of the complaint.1068 Bizarrely, he told Mr Cody in a further email that LABC neither accepted nor denied claims made by Kingspan about what the certificate stated.1069 Mr Turner was unable to explain why he had said that, suggesting only that he might have been trying to protect LABC’s involvement.1070 23.36 Mr Turner’s complete failure to investigate Mr Cody’s complaint was irresponsible. Although he said that if he had understood the public safety implications he would have dealt with the matter differently,1071 it is difficult to see how he can have failed to appreciate them, given the clear terms of Mr Cody’s letters. We note that Mr Turner’s immediate dismissal of the reasoned complaint as nothing but gripes from a rival manufacturer in which LABC should not become a referee1072 was in marked contrast to the tone of his emails1073 to John Garbutt, Kingspan’s Marketing Director.1074 23.37 Mr Turner had no satisfactory explanation to offer for LABC’s failure to follow its own complaints procedure, claiming that he had been unaware that Mr Cody had mentioned a formal complaint,1075 despite having been copied into the email correspondence in which 1057 {BRE00003314}. 1058 Colwell {Day233/36:8}-{Day233/38:18}. 1059 Colwell {Day233/39:2-25}; Smith {Day238/64:17}-{Day238/67:20}. 1060 Turner {LABC0011202/25} page 25, paragraph 76. Rockwool manufactured non-combustible mineral wool insulation products. 1061 {LABC0000924}. 1062 {LABC0000853}. 1063 {LABC0000853}. 1064 {LABC0019632/4}. 1065 {LABC0010318}. 1066 {LABC0019617}. 1067 {LABC0019618/1}; Turner {Day216/98:10-17}. 1068 Turner {Day216/83:4}-{Day216/84:18}; {Day216/98:18}-{Day216/99:15}. 1069 {LABC0019632/2}. 1070 Turner {Day216/102:14}-{Day216/103:2}. 1071 Turner {Day216/101:4-13}. 1072 Turner {Day216/83:13-20}. 1073 {LABC0019617}; Turner {Day216/93:15}-{Day216/95:15}. 1074 Garbutt {KIN00024388/1} page 1, paragraph 1.2. 1075 Turner {Day216/90:22}-{Day216/91:16}.

The Grenfell Tower Inquiry: Phase 2 Report 114 he had done so.1076 Mr Turner also claimed not to have been aware that a formal complaint procedure existed within LABC.1077 As LABC accepted in its closing statement, Mr Cody’s concerns were reasonable and Mr Turner’s response was inexcusable.1078 That was an important early opportunity to correct the fundamental error that had been made. It might not have been missed if Mr Turner had followed LABC’s complaints process1079 when the matter was raised by Mr Cody.1080 Later LABC Registered Details certificates for K15 23.38 Although Kingspan’s Type Approval certificate for K15 lapsed in May 2012, it was not renewed until 28 August 2013.1081 The assessment for the second certificate was also carried out by Herefordshire Building Control, on that occasion by Senior Building Control Surveyor Colin Davies1082 under the supervision of David Jones.1083 The certificate stated in the accompanying Drawings and Documents List, which was drawn up in its final form by LABC,1084 that K15 was suitable for use with a variety of outer claddings1085 and, wholly incorrectly, that K15 could be used on buildings with stories more than 18 metres above ground level provided it was used in combination with suitably non-combustible substrates and ancillary components.1086 It listed as the supporting documents on which it was based1087 the Type Approval Summary of May 2009,1088 the BBA Certificate of October 20081089 and a Kingspan marketing brochure for K15 dated March 2011.1090 The Drawings and Documents List included two diagrams, one showing K15 used on a steel frame system and the other K15 used with a terracotta rainscreen.1091 In August 2013, neither of the systems illustrated nor any similar systems had been tested in accordance with BS 8414. It remained the case that the only system incorporating any form of K15 that had been tested in accordance with BS 8414 and had met the criteria in BR 135 was the one that had been tested in May 2005 using a different formulation of K15.1092 23.39 On 1 August 2013 Gareth Mills, a Senior Technical Adviser at Kingspan,1093 had provided those diagrams to LABC’s Technical Co-ordinator, Cathal Brennan,1094 together with a description of the uses for which K15 was suitable to which we have referred.1095 Both the diagrams and the text were incorporated into the final document after the peer review process, which had taken place in June 2013.1096 At that stage the review group had been provided with an amended Type Approval Summary drafted by Mr Davies that had again stated that K15 could be considered a material of limited combustibility.1097 1076 {LABC0010318}. 1077 Turner {Day216/90:2-4}. 1078 LABC Phase 2 Module 6 Closing Submissions {LABC0020161/30} paragraphs 117-118. 1079 {HBC00000049/30} paragraph 8.2. 1080 {LABC0010318/2}. 1081 {KIN00009546}. 1082 Jones {HBC00000029/47} page 47, final paragraph. 1083 Jones {Day101/186:24}-{Day216/187:15}; {LABC0000893}. 1084 Jones {HBC00000029/48} page 48; 1085 {KIN00009547/2} Appendix A, paragraph 1. 1086 {KIN00009547/2} Appendix A, paragraph 3. 1087 {KIN00009547/1}. 1088 {KIN00005705/3-6}. 1089 {BBA00000038}. 1090 Ninth Issue {KIN00003545}. 1091 {KIN00009547/3}. 1092 See Chapter 22. 1093 Mills {Day77/4:7-10}; {Day77/7:23}-{Day77/8:2}. 1094 Brennan {LABC0020135/2-3} pages 2-3, paragraph 7.2. 1095 {LABC0000954}. 1096 {LABC0005132}; {LABC0000925}. 1097 {LABC0000894/3}.

Part 3 | Chapter 23: Certification of Kingspan K15 by LABC 115 Again, no member of the review group had noticed the mistake. David Ewing accepted that peer reviewers should have noticed that there was no test evidence to substantiate that claim.1098 23.40 Before agreeing to Mr Mills’ proposed amendments, Mr Brennan asked David Ewing and David Jones for their opinions.1099 Mr Ewing did not respond, leaving the matter to Mr Jones.1100 He told Mr Brennan that he saw no problem with the amendments and that he could not see anything in them that was not backed up by the technical data underpinning the certificate.1101 As Mr Jones accepted, that was wrong. It involved a simple perpetuation of the previous error, compounded by the fact that the amendments had not been subjected to the peer review process.1102 Mr Ewing said that it had not been considered necessary to subject the proposed amendments to the peer review process1103 but accepted, in hindsight, that the statement that K15 was suitable for use on buildings over 18 metres in height was significant and ought to have been reviewed.1104 23.41 Mr Ewing accepted that the statements made in the 2013 certificate and its accompanying documents had not been substantiated,1105 that the two diagrams ought not to have been included, since there was no test evidence to support the use of K15 in the manner shown,1106 and that the wording wrongly implied approval of the use of K15 on buildings over 18 metres in height in general.1107 He said that each of the peer reviewers should have examined the BBA certificate or the relevant technical information to see whether it supported the statements made in the certificate but accepted that they would not have been expected to go behind them and check the test results.1108 The Registered Details process,1109 according to the Registered Details Manual,1110 relied just as heavily (if not more so) on the existence and accuracy of BBA certificates1111 and was therefore as flawed as the Type Approval Scheme before it. However, Mr Ewing accepted that the statements made in the 2013 certificate went beyond those made in the 2008 BBA certificate.1112 The same was true of the statements made in the 2009 certificate. 23.42 On 2 July 2014 Brian Martin of DCLG sent NHBC what he described as a “friendly warning” about the use of K15 on buildings over 18 metres in height,1113 which Steven Evans of NHBC passed on to Barry Turner on 11 July 2014.1114 Mr Ewing understood that the revised BBA certificate for K15 was more restricted than the previous version and that LABC needed to take steps to ensure that its own certificate was consistent with the testing undertaken 1098 Ewing {Day217/119:5-20}; {Day217/120:5-8}. 1099 {LABC0002502/1}. 1100 Ewing {Day217/165:6-16}. 1101 {LABC0000936}. 1102 Brennan {LABC0020135/29} page 29, paragraph 45.1. 1103 Ewing {Day217/166:5-11}. 1104 Ewing {Day217/166:17-24}. 1105 Ewing {Day217/172:3-9}. 1106 Ewing {Day217/172:16}-{Day217/173:3}. 1107 Ewing {Day217/173:5-16}. 1108 Ewing {Day217/156:3}-{Day217/157:5}. 1109 As with the Type Approval scheme, a Registered Details certificate was intended to be recognised by all local authority building control departments across England and Wales {HBC00000023/3}; Ewing {Day217/124:4-23}. The same principles applied as had applied to the Type Approval scheme, Turner {Day216/32:22}. 1110 {HBC00000023}. 1111 {HBC00000023/19} third paragraph “... a BBA certificate does provide absolute assurance and materials should not then be interrogated further”. {LABC0002402/1} “Most of these already have BBA certification which should greatly reduce you (sic) checking time”. 1112 Ewing {Day217/177:15-20}. 1113 {LABC0000882/3}. 1114 {LABC0000882/1}.

The Grenfell Tower Inquiry: Phase 2 Report 116 by Kingspan.1115 That was not done, but by August 2014, therefore, it had become clear to LABC that people were worried by the fact that Kingspan’s test evidence did not appear to substantiate the claims being made about the suitability of K15 for use at height.1116 Mr Ewing was aware that there was a risk to buildings on which K15 had been used but had not realised that it might be significant.1117 23.43 LABC did not take any steps to correct the false impression created by the previous certificate and never asked itself whether as a result of that certificate there might be a number of tall buildings containing combustible cladding.1118 Although Mr Ewing knew that the Registered Details certificate would need to be amended following the discovery that Kingspan did not have test evidence to support the use of K15 at height, it does not appear to have occurred to him that people might have relied on the previous LABC certificate to approve its use in those situations.1119 In our view LABC should at least have drawn its members’ attention to the almost complete absence of test data supporting the use of K15 on buildings over 18 metres in height. 23.44 Similarly, LABC failed to take any action in response to an email sent on 16 July 2014 by Clive Everett of Europa Façade Consultants in which he asked how the Registered Details certificate for K15 could state that it was suitable for use on buildings over 18 metres in height with a steel frame if it had not been part of a system tested in accordance with BS 8414-2.1120 Mr Ewing acknowledged that the question was similar to others LABC had heard about through NHBC.1121 Mr Ewing did not respond to Mr Everett’s email.1122 He said that he had wanted to wait until he knew what steps LABC was going to take, but that it had then been overlooked.1123 23.45 LABC had no evidence that any system incorporating K15 had been tested in accordance with BS 8414-2 because there was none. On 6 August 2014, Doug Basen, LABC’s Head of Technical, Practice and Communications1124 sent Mr Ewing an email drawing his attention to a message that he had sent to Mr Turner in which he had said that he had spoken to Mr Evans at NHBC who did not believe that Kingspan would be able to prove that K15 was acceptable across a range of construction types. Mr Basen expressed his fear that there might be many buildings incorporating K15 which did not meet the very restrictive requirement of a masonry substrate. In response, Mr Ewing said that he had been told by Kingspan at a meeting on 25 July 2014 that “testing to BS 8414 had been undertaken in line with the requirements of BR 135 for materials of limited combustibility” but that LABC had not yet been provided with the test results. Mr Ewing also told Mr Basen that he was in the course of providing Kingspan with a quotation for certificates for up to 30 other Kingspan products and that he was keen to get its custom.1125 23.46 In spite of the continuing absence of relevant test evidence, LABC’s existing Registered Details certificate for K15 was extended throughout the autumn of 2014.1126 Mr Ewing said that although that might now appear to have been foolhardy, at the time he 1115 Ewing {Day217/181:22}-{Day217/182:7}. 1116 {LABC0000882/3} first paragraph “... it is just the fact that the testing carried out to date does not bear this out”. 1117 Ewing {Day217/183:3-22}. 1118 Ewing {Day217/190:3-9}. 1119 Ewing {Day217/187:4-10}. 1120 {LABC0000835}. 1121 Ewing {Day217/192:25}-{Day217/193:5}. 1122 Everett {CEV00000001/13} page 13, paragraph 51. 1123 Ewing {Day217/193:12-22}. 1124 Basen {LABC0020141/5} page 15, paragraphs 7.1-7.2. 1125 {LABC0002690}. 1126 {LABC0002679}; {LABC0002700}; {LABC0002701}; {LABC0001843}; {NHB00000798}.

Part 3 | Chapter 23: Certification of Kingspan K15 by LABC 117 had genuinely believed that Kingspan was seeking to co-operate with LABC by producing the relevant reports.1127 He had had no reason to think that Kingspan was being anything other than honest.1128 Mr Ewing accepted that there was a clear failure on his part to notice the inaccuracies in the certificate.1129 He could not explain why LABC had issued a certificate approving the use of a product in a configuration for which there was no supporting test evidence.1130 He accepted that by extending the certificate in that way LABC had been treating Kingspan preferentially.1131 23.47 Although from 2015 the Registered Details Certificates did not include the statement that K15 could be considered a material of limited combustibility,1132 Mr Turner was well wide of the mark when on 16 February 2015 he congratulated Mr Ewing on having scrutinised the application thoroughly.1133 The certificate issued on 9 March 2015 stated that K15 had been tested to comply with BR 135 for use in rain screen applications above 18 metres in height1134 as did the certificate issued on 24 March 2016.1135 That statement, which Mr Turner himself had drafted,1136 was another serious misrepresentation of the position. BS 8414 was a system test, not a product test and therefore no single component of a system tested in accordance with that method could “comply” with the criteria in BR 135. In the light of the messages that had been flying around over the previous year or so, LABC should have been well aware of that. Mr Turner said that it was unlikely that he had read BR 135 before drafting that wording.1137 In any event, by March 2015, much of the damage had been done given that the certificate had been in circulation since 2009. 23.48 Although we accept that many of the various internal LABC emails relating to competitive pricing, bonuses and a desire to establish and maintain strong links with Kingspan1138 contain comments that may have been made purely in jest,1139 they make it clear that raising the profile of the LABC brand was very much in the minds of various employees throughout the certification of K15. In December 2014, Mr Brennan expressed concern about losing Kingspan’s business as a result of the delay in issuing a certificate1140 after Ivor Meredith1141 of Kingspan had warned him that it might be difficult to obtain approval for the business if it were not issued soon.1142 Mr Ewing said that LABC had not responded to what he saw as a threat, but accepted that it reflected well on LABC to be asked to certify Kingspan’s products.1143 There was evidence from another LABC employee, Martin Taylor,1144 that there was some internal pressure to increase the number of registrations.1145 1127 Ewing {Day218/5:8-23}. 1128 Ewing {Day218/6:4-7}. 1129 Ewing {Day218/7:1-15}. 1130 Ewing {Day218/10:9-17}. 1131 Ewing {Day218/50:11-17}. 1132 EWW165 Certificate 9 March 2015-9 March 2016 {LABC0000855}; EWWS165 Certificate 24 March 2016-30 March 2019 {LABC0000971}. 1133 {LABC0005823/1}. 1134 {LABC0000855/1}. 1135 {LABC0000971/1}. 1136 {LABC0000863/1}; Turner {Day217/26:1}-{Day217/27:7}. 1137 Turner {Day217/28:19}-{Day217/29:14}. 1138 {LABC0002402/1}; {LABC0002021/1}; {LABC0008243/1}; {LABC0002686/1}; {LABC0008505/1}; {LABC0008506}; {LABC0002827}; {LABC0002819}. 1139 Taylor {LABC0020153/60} page 60, paragraph 47.23; Ewing {Day218/22:6}-{Day218/23:15}. 1140 {LABC0002819}; {LABC0002827}. 1141 Ball {KIN00020704/3} page 3, paragraph 2.5. Technical Projects Leader from May 2014 onwards. 1142 {LABC0002819}. 1143 Ewing {Day218/17:5-19}. 1144 Taylor {LABC0020153/5} page 5, paragraph 12.1. Registered Details Manager from April 2011 to September 2012 and Technical Development Business Director from May 2015. 1145 Taylor {LABC0020153/60} page 60, paragraph 47.23.

The Grenfell Tower Inquiry: Phase 2 Report 118 23.49 By January 2015, Cathal Brennan had come to regard with scepticism some of Kingspan’s promises about repeat business and the certification of other Kingspan products.1146 He was under the impression that Kingspan was trying to use the prospect of a larger order to persuade LABC to accept its proposed wording in the re-issued certificate for K15.1147 He regarded that as typical behaviour on the part of Kingspan.1148 1146 {LABC0002852/6-7}. 1147 Brennan {LABC0020135/48} page 48, paragraph 93.1. 1148 Brennan {LABC0020135/31} page 31, paragraph 50.2; Stimpson {LABC0020158/61} page 61, paragraph 101.2.

119 Chapter 24 Celotex RS5000 insulation Introduction 24.1 The insulation used in the cladding system at Grenfell Tower was for the most part Celotex RS5000, a polyisocyanurate (PIR) thermosetting foam product. It was not a material of limited combustibility and was therefore not capable of conforming to the guidance on the construction of external walls contained in paragraph 12.7 of Approved Document B. However, RS5000 was said by Celotex to have been tested in accordance with BS 8414‑2 in May 2014 and to have met the criteria in BR 135, thereby conforming to the guidance contained in paragraph 12.5 of Approved Document B. RS5000 was launched in August 2014. It was marketed by Celotex as “the first PIR board to successfully test to BS 8414”,1149 and as “acceptable for use in buildings above 18 metres in height”.1150 In fact, however, the test on which Celotex relied as support for that claim had been rigged by the inclusion at critical points in the construction of the system under test of fire-resistant magnesium oxide boards. Needless to say, Celotex concealed the manipulation of the test in its marketing. Moreover, BS 8414 and BR 135 did not provide for the testing and classification of individual products; they applied only to a complete system, which, if it met the criteria in BR 135, could be regarded as suitable for use in buildings over 18 metres in height. Celotex deliberately tucked that information away in the small print of its marketing literature where it was unlikely to be spotted. This part of the report describes the development and testing of RS5000 and explains what led Celotex to market its new product in a dishonest way. Background Key personnel and management 24.2 At the relevant time, the management team within Celotex was known as the management action group.1151 It was the senior day-to-day decision-making body within Celotex.1152 Paul Evans (Celotex’s head of marketing from 2013 to 2018,1153 and Jonathan Roper’s line manager) was a member of the management action group, as were Craig Chambers and Dean O’Sullivan (managing directors of Celotex from 2013 to 2016 and from 2016 respectively). Other management bodies included the product life cycle and planning meeting, whose function was to discuss new ideas for products and projects.1154 From May 2013, it was replaced by the Service Product Innovation Group.1155 24.3 The dishonest and cynical way in which RS5000 was tested and marketed reflected a culture within Celotex stretching back to at least 2009. There are a number of striking aspects of that history that deserve examination. 1149 {CEL00000012}. 1150 {CEL00000013}. 1151 O’Sullivan {CEL00010027/72-73} pages 72-73, paragraph 217. 1152 Evans {Day72/64:3-5}. 1153 Evans {CEL00010058/6} page 6, paragraph 18. 1154 Warren {CEL00010043/8} page 8, paragraph 29. 1155 Warren {CEL00010043/8} page 8,paragraph 30.

The Grenfell Tower Inquiry: Phase 2 Report 120 The acquisition by Saint-Gobain 24.4 Celotex was originally owned by AAC Capital Partners, the private equity arm of ABN Amro. In August 2012 it was acquired with effect from 31 December 2015 by BPB UK Ltd, subsequently re-named Saint-Gobain Construction Products UK Ltd.1156 The corporate culture of Celotex before its acquisition had been marked by a drive to create profits and increase the company’s share price with a view to a sale,1157 and that continued to be its focus after the sale to Saint-Gobain.1158 As a consequence of the focus on sales, budgets and the business generally were very lean.1159 Following the acquisition, Saint-Gobain set an annual budget for increasing profits, of which at least 15% was expected to come from new products.1160 Lambda values 24.5 As explained elsewhere,1161 the lambda value of a material represents its thermal conductivity expressed in watts per metre kelvin (W/mK). The lower the lambda value, the better the performance of the product as an insulator. The relevant European and national harmonised standard applicable to PIR products is the standard for rigid polyurethane foam building products, BS EN 13165.1162 It requires a manufacturer to declare the lambda value of a product as a limit value representing at least 90% of its production with a confidence value of 90%.1163 The duty of ensuring conformity with the standard rests on the manufacturer, based on tests carried out at the factory.1164 The standard requires the product to be tested at least once every 24 hours.1165 It may be tested more often, but there is nothing in the standard to suggest that if the product is tested more than once every twenty four hours it is permissible to select from among the results thus obtained. 24.6 As well as a culture of maximising profits, there had been a history within Celotex of data manipulation and dissimulation. At least as early as 2009, it had adopted a practice of taking a number of measurements each day of the lambda value of its products and selecting for the purposes of the standards (and ultimately, of course, for the purposes of marketing) the most favourable measurement without declaring the rest.1166 There was a drive within Celotex to produce products with a lower declared lambda value, both as a way of differentiating them from other PIR products on the market and as a way of competing with Kingspan in the market for insulation on buildings.1167 24.7 Even within Celotex there was an awareness at the time that the selection of data in that way1168 was questionable. An internal memorandum dated 9 December 2009 described the process as involving a high degree of data management and manipulation in order to “avoid an auditor finding evidence that thermals are selected to give [a set lambda value] rather than recording the results regardless of their value”.1169 Not only did Celotex actively seek to conceal that practice from the British Board of Agrément (BBA), its auditors for 1156 O’Sullivan {CEL00010027/3} page 3, paragraph 9. 1157 Hayes {CEL00010154/6} page 6, paragraph 17; Hayes {Day74/30:9-15}; Evans {Day72/67:20-23}. 1158 Hayes {CEL00010154/6} page 6, paragraph 17; Evans {Day72/68:1-3}. 1159 Evans {CEL00010058/5} page 5, paragraph 15. 1160 Hayes {CEL00010154/6} page 6, paragraph 17; Roper {Day70/124:11-16}. 1161 Chapter 56. 1162 {CEL00001204/10} paragraph 3.1.1. 1163 {CEL00001204/14} paragraph 4.2.1. 1164 {CEL00001204/24} paragraph 7.1. 1165 {CEL00001204/25} paragraph 7.3 read with Annex B; {CEL00001204/28}. 1166 {CEL00010498}. 1167 Hayes {Day74/34:3-24}; Evans {CEL00012233/2} page 2, paragraphs 10-11. 1168 Evans {Day72/71:7-9}. 1169 {CEL00010272/1}.

Part 3 | Chapter 24: Celotex RS5000 insulation 121 this purpose,1170 but it also appears that the practice was not disclosed to Saint-Gobain during the acquisition and was mentioned only at a management action group meeting in November 2013.1171 24.8 The lambda story is revealing. First, it is indicative of a culture in which breaking the rules and misleading external bodies was tolerated long before the advent of RS5000. It demonstrates an historic inability or unwillingness to challenge the honesty and good faith of company practices.1172 Second, it shows the malign influence of the competition with Kingspan: Paul Evans explained that the drive to create a product with an improved lambda value was a response to a similar development by Kingspan.1173 The change of polyol 24.9 A further indication of the nature of the culture at Celotex relates to FR5000 itself. FR5000 was made on two manufacturing lines, known as Hipchen and Henneke. Products manufactured on the Hipchen line were reinforced with glass fibre. Those manufactured on the Henneke line were not.1174 The products were manufactured using a polymer resin, which was mixed with a polyol and various additives before the mix was allowed to rise on the production line before being cut into shape. 24.10 In August 2012, Celotex changed the polyol used on the Hipchen line from ElastoPIR 501 to ElastoPIR 503. ElastoPIR 501 continued to be used on the Hennecke line.1175 No thought appears to have been given to whether the change in formulation might affect the fire performance. Although the BBA expressly warned Celotex that it should tell it about any change in the formulation of the product, Celotex failed to do so,1176 thereby withholding potentially material technical data.1177 The development of RS5000 Genesis of the “above 18m project”: 2008-2012 24.11 Celotex had manufactured and marketed FR5000 for some years before 2012.1178 It was not a material of limited combustibility and therefore could not be used in the construction of an external wall of a building over 18 metres in height by anyone who wished to follow the guidance in paragraph 12.7 of Approved Document B. Nor had it been incorporated in a system that had been tested in accordance with BS 8414 and had satisfied the performance criteria in BR 135. That was all well known within Celotex.1179 24.12 In November 2011, FR5000 was tested in accordance with BS 476-6 and BS 467-7 and achieved a Class 0 classification.1180 Thereafter, Celotex marketed FR5000 as having Class 0 fire performance “throughout”. The reference to Class 0 was no more than a marketing device;1181 for reasons we explain later, Class 0 had come to be understood by many in the UK construction industry as meaning that a product could be used on buildings over 1170 Evans {Day72/74:17-21}; {CEL00010456}. 1171 {CEL00010286/2}. 1172 Evans {Day72/83:3-4}; Evans {Day72/83:10-14}. 1173 Evans {CEL00012233/2} page 2, paragraphs 10-11. 1174 O’Sullivan {CEL00010027/12} page 12, paragraph 41. 1175 {CEL00009889}. 1176 {CEL00009516}. 1177 Evans {Day72/93:14-17}. 1178 {CEL00000723}. 1179 Roper {Day70/139:13-21}; Hayes {Day74/37:7-12}. 1180 {CEL00000382}. 1181 Hayes {Day74/35:10-17}.

The Grenfell Tower Inquiry: Phase 2 Report 122 18 metres in height in compliance with the Building Regulations. Kingspan was marketing its phenolic foam products in that way, and achieving Class 0 fire performance was seen as a way of demonstrating that FR5000 was as good as Kingspan’s K15.1182 The description of it as being Class 0 “throughout”’ was intended to enable it to challenge K15, which was being marketed as having a Class 0 core.1183 24.13 That was a clear abuse of the regulatory regime. The expression “Class 0 throughout” was meaningless because Class 0 is concerned with the reaction to fire of the material forming the surface of a product. It is not concerned with the underlying material, although a product which is composed entirely of a material of limited combustibility will have a Class 0 surface (see Chapter 5). To market FR5000 as “Class 0 throughout” was not only false (because the product was combustible) but can only have been designed to mislead buyers with a poor understanding of fire classification standards. Regrettably, Celotex clearly knew that many potential customers were ignorant and credulous in relation to matters of fire safety. Its marketing of FR5000 in that way laid the ground for the more fundamental mis‑selling that was to follow with RS5000. 24.14 Celotex had considered developing a product for use on buildings over 18 metres in height in 2008, but had decided not to do so because the cost of testing was thought to be too high.1184 By 2011, however, it had become aware that it was losing sales as a result of not having a product which could be used on high-rise buildings in accordance with the guidance in Approved Document B.1185 On 19 October 2011, Robert Warren (then a technical manager, but from 1 May 2013 head of technical)1186 sent a number of colleagues an email he had received from Adrian Friar, a specification manager at Celotex, asking them to track all enquiries it had received for insulation to be used on buildings over 18 metres in height.1187 24.15 By August 2012, the tracker was being maintained by Paul Evans.1188 There was concern that market share was being lost to competitors and that unless action was taken soon the market for insulation suitable for use on buildings over 18 metres in height would be controlled by other manufacturers, particularly Kingspan.1189 Mr Roper, who subsequently led the project to develop what eventually became RS5000, understood that the project was driven by a desire to compete with Kingspan in that section of the market.1190 Allocation to Jonathan Roper: 2012-2013 24.16 On 15 December 2012, Paul Evans, then a product manager at Celotex, met Tony Baker of BRE with a view to discussing the requirements for testing PIR insulation boards for use in external walls of buildings over 18 metres in height.1191 They discussed both the BS 8414-1 and BS 8414-2 test methods, as well as the fact that the results would have to be classified according to BR 135.1192 1182 Evans {Day72/108:2-5}; Hayes {Day74/34:13}-{Day74/35:17}. 1183 Hayes {Day74/36:1-8}. 1184 Warren {CEL00010043/8} page 8, paragraphs 31-32. 1185 Warren {CEL00010043/9} page 9, paragraph 33. 1186 Warren {CEL00010043/2} page 2, paragraph 8. 1187 {CEL00008564}. 1188 {CEL00008570}. 1189 {CEL00002892}. 1190 Roper {Day70/120:10-14}. 1191 Evans {Day72/96:14-16}; {CEL00002544}. 1192 {CEL00002544}.

Part 3 | Chapter 24: Celotex RS5000 insulation 123 24.17 Paul Evans then assigned the task of carrying forward the project to Jonathan Roper.1193 Mr Roper had joined Celotex in May 2012 straight from university,1194 having graduated with a degree in business management.1195 He had no previous experience of the insulation industry and had no relevant scientific qualifications.1196 Mr Roper told us that he had been closely managed by Mr Evans,1197 and that he had not done anything or said anything, at least publicly, without Mr Evans’ approval.1198 Mr Roper’s experience, as described to us, was echoed by Jamie Hayes, a colleague of Mr Roper, who said that Mr Roper had run everything past Mr Evans.1199 Mr Evans himself accepted that he had followed what Mr Roper was doing closely.1200 Given Mr Roper’s relative youth and inexperience, it would be surprising if he had not been subject to a high degree of supervision. 24.18 Despite his relative youth and inexperience, however, or perhaps because of it, Mr Roper was given the job of developing an insulation product which could be sold for use on buildings over 18 metres in height. Completion of the project was one of his formal goals for 2013.1201 Mr Roper stood to gain a financial benefit from achieving that goal, since gaining accreditation for FR5000 was worth 20% of his potential bonus.1202 However, his own understanding was that performance indicators were primarily used to create a focus on key areas for the business and we do not think that he was motivated primarily by the prospect of a bonus.1203 24.19 In an introductory briefing,1204 Paul Evans and Robert Warren told Mr Roper that since PIR foam was not a product of limited combustibility, the only way that Celotex could satisfy the criteria in paragraph 12.5 of Approved Document B was to be tested in a system that met the performance criteria of BR 135 following a BS 8414 test.1205 In March 2013, Mr Roper prepared a paper entitled “Above 18m Action Plan”,1206 in which he set out the steps required to obtain accreditation for FR5000 for use on buildings over 18 metres in height. He noted that the records showed that between August 2012 and January 2013 Celotex had lost the opportunity of selling 70,000m² of insulation as the result of not having a product that could meet that requirement. 24.20 Mr Roper embarked on a programme of research, reporting the results to Paul Evans. He was assisted by Mr Hayes, a member of the Technical Support team,1207 who did not himself have any technical expertise or qualifications.1208 As recorded in the Action Plan,1209 it involved looking at the recently published third edition of BR 135, which he obtained and sent to both Mr Warren and Mr Hayes.1210 He noted the criteria and although he did not read the whole document,1211 he understood that it applied only to complete systems.1212 1193 Evans {Day71/117:15-23}. 1194 Roper {CEL00010052/2} page 2, paragraph 2.1. 1195 Roper {Day70/110:4-10}. 1196 Roper {Day70/110:13-17}. 1197 Roper {CEL00010052/2-3} pages 2-3, paragraph 2.4. 1198 Roper {Day70/112:9-11}. 1199 Hayes {Day74/44:6-9}. 1200 Evans {Day72/120:18-25}. 1201 {CEL00002900}. 1202 Evans {Day72/123:23-25}. 1203 Roper {Day70/113:2-8}. 1204 Roper {Day70/140:20}-{Day70/141:3}. 1205 Roper {Day70/140:13-18}. 1206 {CEL00001340} 1207 Hayes {Day74/46:19-22}. 1208 Hayes {Day 74/5:10-14}. 1209 {CEL00001340/2}. 1210 {CEL00011493}. 1211 Roper {Day70/131:18}-{Day70/132:3}. 1212 Roper {Day70/143:6-14}.

The Grenfell Tower Inquiry: Phase 2 Report 124 He was also aware that any classification obtained under BR 135 applied only to the system tested.1213 As part of his research he and Mr Hayes also looked at Kingspan’s publicly available marketing material.1214 June 2013: business case 24.21 On 17 June 20131215 Mr Roper sent Mr Evans a project plan1216 and business case1217 for Celotex to undertake BS 8414 testing. The business case reiterated the point made in the earlier Action Plan that the lack of a product that was suitable for use on buildings over 18 metres in height was one of the main areas in which Celotex was unable to compete with Kingspan. Celotex’s investigations during 2013 24.22 In order to improve his understanding of testing under BS 8414 and classification in accordance with BR 135, Mr Roper obtained assistance from a number of external bodies. Some (NHBC, the BBA and BRE) were introduced to him by Mr Evans;1218 others he found for himself. Sotech and IFC: June to October 2013 24.23 Celotex sought advice on how to design a test rig in order to give it the best chance of a favourable result.1219 On 10 May 2013 Mr Roper contacted a firm of consultants, International Fire Consultants, seeking advice and explaining that Celotex wanted to design a wall incorporating FR5000 which would have the best chance of succeeding in a full-scale test.1220 24.24 Mr Roper also sought assistance from Sotech Ltd, a designer and manufacturer of cladding with previous experience of the BS 8414 test that he had come across at a RIBA event in June 2013. By that time Sotech had already been involved in two BS 8414 tests using Kingspan insulation, each of which, Mr Roper was told, had failed.1221 On 20 June 2013, Mr Roper and Mr Hayes met Sotech to discuss testing. A note of the meeting dated 24 June 2013 records that Sotech’s previous experience of testing had shown that aluminium railing systems and cladding panels melted and allowed fire to enter the cavity, and that therefore what had proved crucial was the resistance to fire of the outer surface and the performance of the fire barriers.1222 Mr Roper said that he had understood from the meeting that the success of a BS 8414 test may depend on the cladding material used.1223 They also discussed K15 and Sotech expressed surprise that K15 was used so widely based only on a single test involving the use of a cement particle board to represent a typical cladding panel.1224 Both Celotex and Sotech considered the 1213 {CEL00000584/33}; Roper {Day70/145:5-25}. 1214 Hayes {CEL00010154//12} page 12, paragraphs 36-37. 1215 {CEL00001856}. 1216 {CEL00001857}. 1217 {CEL00001858}. 1218 Roper {Day70/132:17-23}. 1219 Roper {Day71/15:17-19}. 1220 {CEL00000589}. 1221 {CEL00001851}. 1222 {CEL00001863/1}. 1223 Roper {Day71/5:2-4}. 1224 {CEL00001863/1}.

Part 3 | Chapter 24: Celotex RS5000 insulation 125 Kingspan test to be unrepresentative,1225 and thought that Kingspan had taken advantage of what they regarded as a carefully worded certificate from the BBA and cleverly designed marketing literature.1226 24.25 Mr Roper sent his note to Mr Evans on 24 June 2013.1227 In response Mr Evans indicated that his preference at that stage was to test a commonly used cladding panel rather than simply copying Kingspan’s use of a cement particle board.1228 International Fire Consultants advised that it should be possible to test with a standard cladding panel using improved fire barriers.1229 24.26 Mr Roper then arranged a meeting with Peter Jackman, the technical director of International Fire Consultants, on 22 July 2013.1230 Mr Roper could not recall what had been said at that meeting,1231 but according to the handwritten notes taken by Robert Warren he was told that Approved Document B only contains guidance and was open to “interpretation”.1232 We understand that to mean that Mr Jackman thought there were ways of interpreting Approved Document B that would render the guidance less restrictive. For his part, Jamie Hayes recalled a meeting with International Fire Consultants (specifically Peter Jackman and Dr Parina Patel), although he could not recall when it had taken place. He did remember that they had told him and Mr Roper that it might be possible to obtain a field of application report, in other words, to carry out a BS 8414 test and, using the results obtained from it, produce a report which was wider in its scope of application and cover the use of some components other than those used in the test rig.1233 That reflects the view of some in the industry at the time that “desktop” assessments based on test data were a permissible way of broadening the range of components that could be used in external walls while satisfying Approved Document B.1234 24.27 Celotex then commissioned International Fire Consultants to conduct small-scale testing with a view to giving an opinion on the likelihood of meeting the criteria in BR 135 if they were to test FR5000 under BS 8414.1235 On 4 September 2013, Mr Jackman confirmed that he had reviewed BS 476-6 and BS 476-7 test data for FR5000 and concluded that there were grounds for thinking that FR5000 would perform well in a BS 8414 test.1236 It is unclear on what basis he thought that it was possible to draw that conclusion from BS 476 data, but Celotex did not explore that question with him. On 24 September 2013 Celotex engaged International Fire Consultants to assist in the design of BS 8414 tests, having decided by that stage to test only to BS 8414-2 (i.e. a steel-framed construction).1237 On 27 September 2013 David Cooper of International Fire Consultants acknowledged the proposal, commenting that the “fire barrier” at storey levels and around the opening would be critical.1238 1225 Roper {Day71/7:2-10}. 1226 {CEL00001863/1}. 1227 {CEL00001865}. 1228 {CEL00001865}. 1229 {CEL00001864}. 1230 {CEL00000632}. 1231 Roper {Day71/16:21-23}. 1232 {CEL00002743}. 1233 Hayes {Day74/72:13-17}. 1234 See Chapter 26, and the note of the meeting on 15 November 2013 between Wintech and NHBC at {NHB00000604}. 1235 {CEL00000669}; {CEL00000670}. 1236 {CEL00000673}. 1237 {CEL00000679}. 1238 {CEL00000688}.

The Grenfell Tower Inquiry: Phase 2 Report 126 24.28 On 3 October 2013, Mr Roper and Mr Hayes met representatives of International Fire Consultants and Sotech.1239 Mr Hayes’ note of that meeting referred to tests using Kingspan insulation having failed twice with standard cavity barriers.1240 Mr Hayes also recalled (although it was not mentioned in the note) that there had been discussion of those tests.1241 Mr Hayes and Mr Roper both told us that following the meeting they had both been aware that, if tested with an aluminium panel, FR5000 was unlikely to pass a BS 8414 test.1242 24.29 On 31 October 2013 Mr Roper sent International Fire Consultants details of two European Class A2 products he had found during his researches, namely Alucobond A2 and Marley Eternit.1243 He explained that he saw three options for testing: a. test with an ACM panel and an improved cavity barrier system (e.g. with the double cavity barrier discussed at the meeting on 3 October),1244 although he was not particularly confident in that system following the meeting with International Fire Consultants and Sotech;1245 b. test with an A2 panel and standard cavity barrier, which he noted was a common system which Celotex could support if challenged; and c. test using a cement particle board as the rainscreen, as he understood Kingspan had done, which he viewed as a last resort 24.30 Mr Roper’s preference was to test using an A2 panel with standard cavity barriers, but he observed that if this failed then it would be necessary to decide whether Celotex would then want to adopt Kingspan’s method or pull out altogether.1246 What he meant by adopting Kingspan’s method can be seen from what Celotex chose to do later. Discussions with BRE: May and October 2013 24.31 In May 2013, Jonathan Roper asked Tony Baker of BRE which of the BS 8414 tests Celotex should be considering.1247 Mr Baker advised testing under BS 8414-2, adding that obtaining the classification was likely to be commercially advantageous to Celotex.1248 Mr Roper contacted Mr Baker again on 21 June 2013, asking to arrange a call with him about the purpose of testing. He said that he was sceptical of how a particular competitor of Celotex (clearly a reference to Kingspan) could have satisfied the criteria in BR 135.1249 Mr Roper went on to ask Mr Baker for advice about designing the test and whether preventing the flame from entering the cavity altogether would be acceptable,1250 but he could not recall having received any response to his message.1251 1239 {CEL00011052}. 1240 {CEL00001195}. 1241 Hayes {Day74/80:18-23}. 1242 Roper {Day70/194:2-3}; Hayes {Day74/80:24}-{Day74/81:2}. 1243 {CEL00000714}. 1244 Roper {Day71/24:12-16}. 1245 Roper {Day71/24:9-10}. 1246 {CEL00000714}. 1247 {CEL00000585/2}. 1248 {CEL00000585/2}. 1249 {CEL00000617}. 1250 {CEL00000617}. 1251 Roper {Day70/170:19-21}.

Part 3 | Chapter 24: Celotex RS5000 insulation 127 24.32 On 18 October 2014, Mr Roper asked Stephen Howard of BRE about the possibility of extending the use of FR5000 to external wall systems similar to one that had been tested successfully under BS 8414.1252 He again mentioned his concern about how the market was operating, asking how it was possible for competitors who had tested one particular system to sell its products into a variety of different systems used on buildings over 18 metres in height.1253 Mr Roper confirmed to us that he was referring to Kingspan and Xtratherm (the only other company that offered a product for use on buildings over 18 metres in height at that time).1254 He told us that the origin of his question lay in a controversy within Celotex between individuals, some of whom viewed BS 8414 as a system test and some of whom viewed it as what he called a “product in application” test.1255 He put himself, Jamie Hayes and Robert Warren in the former category, and Paul Evans, Craig Chambers and the sales team in the latter,1256 which he saw as a commercial view based on Kingspan’s approach.1257 The “commercial view” was not a tenable reading of the guidance in Approved Document B, not least since the third edition of BR 135 published earlier in 2013 had made it plain that the classification applied only to the system as tested and described in the classification report.1258 It followed that the classification could not apply to a single product forming part of the system tested when it was used in a different system. 24.33 Mr Howard responded a few days later on 21 October 2013, saying that the test report would set out exactly what had been tested, and that the way to extend it to other systems was by what he called an “assessment report”, which he described as “fairly standard practice”.1259 Mr Roper understood him to mean that if he gave BRE details of a particular system they would be able to tell him whether it might pass a BS 8414 test.1260 The Roper-Evans exchange: 1 November 2013 24.34 At the end of October and early November 2013, there was an important internal exchange between Jonathan Roper and Paul Evans. On 31 October 2013, Mr Roper sent a message to Mr Evans saying he needed to speak to him about the “Above 18m” project, and that he would send an invitation to Mr Evans, Mr Warren, Mr Hayes and Mr Chambers because they had reached a point at which a decision had to be made.1261 24.35 The following day, 1 November 2013, Mr Roper sent another message to Mr Evans setting out the matters for discussion.1262 He explained that they had originally contemplated testing what they regarded as a “worst case scenario with improved fire barrier” (i.e. using a less fire-resistant panel) that could then be supported by an assessment report which would extend the scope of application. However, he no longer thought that could be done because it was not possible, as he put it, “to find or design a suitable barrier in which we have enough confidence that it can be used behind a standard ACM panel which we know will melt and allow fire into the cavity.” His comments about how an ACM panel would perform in a full-scale test tells us much about how well known its poor fire performance was at the time, at least among manufacturers of insulation. 1252 {CEL00000708/3}. 1253 {CEL00000708/3}. 1254 Roper {Day70/174:22-25}. 1255 Roper {Day70/171:16}-{Day70/172:2}. 1256 Roper {Day70/172:13-25}. 1257 Roper {Day70/163:21-24}. 1258 {BRE00005555/28} at A2, left column and {BRE00005555/32} at B2 right column. 1259 {CEL00000708/2}. 1260 Roper {Day70/176:8-16}. 1261 {CEL00000716/2}. 1262 {CEL00000716/1}.

The Grenfell Tower Inquiry: Phase 2 Report 128 24.36 In his email Mr Roper made a number of important observations about the poor level of understanding in the market of the guidance in Approved Document B and how Kingspan had taken advantage of it. He doubted that Kingspan had a report which would support the use of K15 on buildings over 18 metres in height. His view was that it was being used in those circumstances because of widespread ignorance in the market, including among architects, about the applicable requirements1263 and a failure to think about fire performance as opposed to thermal performance.1264 He thought that the only person who might possibly challenge a product’s use on buildings over 18 metres in height was the building control officer1265 and that Kingspan had effectively neutralised that risk through the wording of their BBA and Local Authority Building Control (LABC) certificates. 24.37 The timing of his observations is uncanny. They were made exactly at the time that Kingspan was using a BBA certificate revised in July 2013 to claim that K15 complied with paragraph 12.7 of Approved Document B (i.e. that it was a material of limited combustibility), a statement that was not only self-evidently incorrect but which was causing concern at NHBC.1266 It seems that Mr Roper had tapped into a growing awareness in the cladding industry that Kingspan was taking advantage of an erroneous BBA certificate for K15, thereby mis-selling it. 24.38 Mr Roper concluded his report to Mr Evans with words that were as prescient as they were frank: “Trying to do the right thing requires a complete re-education of the market and this would require a huge campaign and probably a lawsuit”. He told us that by “doing the right thing” he had meant selling a product that had been part of a system that had met the performance criteria in BR 135 for use only in a system which was the same as that tested, and not exploiting market ignorance in a commercially more advantageous way.1267 He explained that the reason he considered re-education of the market would be necessary was because he considered it to have been distorted by Kingspan. Doing things in the right way would mean explaining to specifiers that they had been using Kingspan K15 inappropriately.1268 24.39 His report to Mr Evans then proceeded to set out various options: testing with an A2 panel, adopting Kingspan’s device of using a cement particle board, or taking the view that, as he put it, “realistically our product shouldn’t be used behind most cladding panels because in the event of a fire it will burn”. 24.40 Mr Evans responded the same day 1 November 2013. His words are, again, worth quoting: “Great summary and shows the real merit of good research and talking to the market. We are trying not to create a ‘me too’ here but if we do, it will be for the right reasons”.1269 Mr Evans was unable to recall what he had meant by “the right reasons”.1270 Mr Roper said that he had understood “the right reasons” to be commercial reasons.1271 We accept his evidence and agree that that is indeed what Mr Evans meant. Mr Evans asked Mr Roper to put the contents of his email into some slides for discussion at the meeting scheduled for 4 November 2013. 1263 Roper {Day71/35:18-24}. 1264 Roper {Day71/36:5-6}; {Day71/36:22}-{Day71/37:1}. 1265 {CEL00000716/1}. 1266 See Chapter 26. 1267 Roper {Day71/37:24}-{Day71/38:5}. 1268 Roper {Day71/38:10-19}. 1269 {CEL00000718}. 1270 Evans {Day72/166:11-15}. 1271 Roper {Day71/44:5-15}.

Part 3 | Chapter 24: Celotex RS5000 insulation 129 24.41 It is clear that by the end of 2013, Celotex had begun to come to terms with the idea that it might follow Kingspan’s lead in relation to the testing and marketing of an insulation product for use on buildings over 18 metres in height. Mr Roper’s preference was still to test a system incorporating an A2 rainscreen panel rather than a cement particle board. He understood that to reflect a preference within Celotex as a whole to test a more representative system.1272 However, the use of a cement particle board had not been entirely ruled out.1273 There remained a general desire within Celotex to enter the market for buildings over 18 metres in height in any event and if copying Kingspan was the only way of obtaining a test result that would enable it to do so, it would act accordingly.1274 In the end, Celotex did indeed adopt the same strategy as Kingspan. It neither tested a representative system nor was truthful in its marketing literature. 4 November 2013 meeting – the 5 options 24.42 On 4 November 2013, Mr Roper met Mr Evans, Mr Hayes and Mr Warren. The electronic invitation suggests that Craig Chambers, then managing director of Celotex, was also invited.1275 Mr Roper,1276 Mr Hayes1277 and Mr Evans1278 all recalled his being there and we are satisfied that he was. 24.43 Mr Roper prepared slides for the meeting.1279 The first slide set out paragraph 12.5 of Approved Document B highlighted in yellow. No one who saw it can have been under any illusion about what the guidance was or what it required.1280 24.44 Slide 14 set out the options available to Celotex.1281 The first was “Worst case scenario with field of application report”, which referred to testing a system that would enable a desktop assessment to be produced to allow FR5000 to be used in other systems.1282 Mr Roper envisaged that it would incorporate ACM rainscreen panels and improved cavity barriers,1283 but he had little confidence that he could find such a product. 24.45 The second was “System Route (Limits Scope – Requires Re-education)”, which referred to testing a representative system and making it clear that any BR 135 classification applied only to the system tested.1284 The “re-education” mentioned referred to the need to explain to the market that the industry had up to that point misunderstood the effect of full-scale testing and classification in accordance with BS 8414 and BR 135 and had wrongly allowed K15 to be used in a wider set of applications than was justified by the tests.1285 24.46 The third and fourth options were to test and launch FR5000 with, and without, certification by the BBA and LABC. 1272 Roper {Day71/25:4-7}. 1273 Roper {Day71/11:4-16}. 1274 Roper {Day71/25:20-25}. 1275 {CEL00003011}. 1276 Roper {Day71/52:15-23}. Mr Roper’s witness statement to the effect that he himself had not attended this meeting was corrected by him in oral evidence. 1277 Hayes {Day74/46:11-16}; {Day74/96:1-5}. 1278 Evans {Day72/170:6-10}. 1279 {CEL00011199}. 1280 Roper {Day71/47:5-9}. 1281 {CEL00011199/14}. 1282 Evans {Day72/172:12-21}. 1283 {CEL00000718} and see paragraph 23.29 above. 1284 Roper {Day71/49:6-10}. 1285 Evans {Day72/173:12-18}.

The Grenfell Tower Inquiry: Phase 2 Report 130 24.47 The final option was to abandon the market for insulation suitable for use on buildings over 18 metres in height altogether. It was not discussed at any length.1286 24.48 The next slide assessed the prospects of successfully testing FR5000 with various combinations of other products. A system incorporating an ACM panel and an improved cavity barrier was judged to have less than a 50% chance of success, a system incorporating an A2 rainscreen panel with a standard cavity barrier an 80% chance of success and a system incorporating a cement particle board rainscreen with a standard cavity barrier a 90% chance of success.1287 The decision to proceed 24.49 At the meeting a decision was taken to proceed with BS 8414 testing1288 using an A2 rainscreen panel and then to apply for LABC approval.1289 Mr Roper said that there had been a difference of opinion between Mr Evans and Mr Chambers on the one hand and Mr Warren on the other over what should be tested. Both Mr Roper1290 and Mr Hayes1291 recalled that Mr Warren had thought that Celotex should adopt the “systems route” or opt out, while Mr Chambers and Mr Evans were concerned that that approach would unduly limit the commercial application of the product. Mr Evans denied that that had been his view and told us that, if the product were to be taken to market, Celotex should be clear that it had tested a particular system.1292 He accepted that people might want to make use of the results to demonstrate that the product could be used in different systems, but did not believe that his and Mr Chambers’ view was entirely different from that of Mr Warren.1293 We have doubts about the reliability of Mr Evans’ evidence on this point because, in the end, we know that Celotex chose not to be clear about what it had tested. On the contrary, it deliberately concealed from end users a vital component of the system tested, namely the magnesium oxide boards, a decision which we examine below. Mr Chambers did not recall the meeting, but in his written evidence he said that he understood that an insulation material had to be either non-combustible or pass a BS 8414 test in order to achieve compliance with the Building Regulations.1294 Designing the test 24.50 On 30 October 2013 Mr Roper was introduced by a colleague at Celotex to Graham Smith of Simco External Framing Solutions Ltd (Simco), a company specialising in the production of external framing systems.1295 Simco was engaged by Celotex to help design the rig for the BS 8414 test.1296 24.51 Following the meeting on 4 November 2013, Celotex decided to use a Marley Eternit panel classed A2. Mr Roper explained that Celotex had chosen the Marley panel because Simco had suggested that it was similar to a cement particle board, although providing a decorative facade, and because Marley was a relatively well-established brand.1297 1286 Evans {Day72/174:9-11}. 1287 {CEL00011199/15}. 1288 Hayes {Day74/72:15-22}. 1289 Roper {Day71/54:17-20}. 1290 Roper {CEL00010052/10} page 10, paragraph 5.15; Roper {Day71/54:10-15}. 1291 Hayes {Day74/100:6-12}. 1292 Evans {Day72/177:20-22}. 1293 Evans {Day72/177:23}-{Day72/178:2}. 1294 Chambers {CEL00010056/4} page 4, paragraph 20. 1295 Roper {CEL00010052/8} page 8, paragraph 5.7. 1296 Roper {Day70/190:4-9}. 1297 Roper {Day71/67:9-13}.

Part 3 | Chapter 24: Celotex RS5000 insulation 131 24.52 Simco produced drawings for the test rig on 22 January 2014.1298 The system to be tested comprised a steel frame, a 12mm magnesium oxide sheathing board, 100mm Celotex FR5000, Lamatherm fire barriers and 8mm Marley Eternit cladding. The components appear to have been delivered to BRE’s testing centre at Watford. BRE was unable to produce a complete test file for the first Celotex test, but delivery notes for some of the components were found in the file relating to the second test carried out in May 2014, to which we return below.1299 The first test: 14 February 2014 24.53 The test was carried out on 14 February 2014. Mr Roper, Mr Hayes, Mr Warren and two representatives of International Fire Consultants, Dr Parina Patel and David Cooper, attended.1300 It was overseen by Philip Clark of BRE. The test was stopped after 26 minutes when flames overtopped the rig,1301 but Mr Clark allowed the rig to continue burning for a further period to enable Celotex to obtain more data.1302 BRE subsequently confirmed that the test had failed and that no classification report would be issued.1303 24.54 Mr Roper said that Mr Clark had commented favourably on the performance of the system, although he understood that it had failed the test.1304 In particular, he recalled Mr Clark’s saying that he had “seen worse fails” and suggesting that Celotex might want to strengthen the outside of the rig in order to prevent the Marley Eternit panels cracking.1305 Mr Roper said that he had suggested that the panels were available in 12mm thickness and that Mr Clark had said that he thought that might suffice.1306 Mr Roper thought that (possibly on a later occasion)1307 he had discussed with Mr Clark the possibility of using two rainscreen panels at the level of the cavity barrier to prevent cracking and allowing the fire to bypass the barrier.1308 He was unable to remember the details of the conversation, however.1309 Mr Clark denied that he had made any comments either about the performance of the system or possible changes to it.1310 24.55 Mr Roper was an exceptionally candid witness, whose recollection we generally consider to have been reliable. Moreover, a recording made by the head camera worn by Mr Clark during the test reveals that he did say that he had “seen worse”1311 and that “for a first attempt it’s not bad, actually”.1312 Mr Clark then turned off the camera. No recording was disclosed of any conversation in which Mr Clark made recommendations about the design of any future test rig,1313 but the recording that was disclosed supports that part of Mr Roper’s evidence. We therefore accept that Mr Clark did discuss possible changes to the design of the second test rig with Mr Roper, but there is no evidence to suggest that those discussions touched on the use of magnesium oxide boards. 1298 {CEL00000806}; {CEL00000807}; {CEL00000808}; {CEL00000809}. 1299 {BRE00032372/4} delivery note for 12mm magnesium oxide sheathing board used in first test; {BRE00032372/5} delivery note for FR5100 used in first test. 1300 Roper {Day71/68:18}-{Day71/69:6}. 1301 Roper {Day71/69:7-9}. 1302 {INQ00014136/3}. 1303 Hayes {CEL00010154/18} page 18, paragraph 56. 1304 Roper {Day71/77:1-3}. 1305 Roper {CEL00010052/12} page 12, paragraph 5.29. 1306 Roper {Day71/71:17-24}. 1307 Roper {Day71/74:16-20}. 1308 Roper {CEL00010052/13} page 13, paragraph 5.31. 1309 Roper {Day71/74:6-11}. 1310 Clark {BRE00005768/50} page 50, paragraphs 203-204; Clark {BRE00005768/66} page 66, paragraph 269. 1311 {INQ00014137/2}. 1312 {INQ00014137/3}. 1313 Clark {Day95/101:8}-{Day95/102:15}; {Day95/104:7-16}.

The Grenfell Tower Inquiry: Phase 2 Report 132 24.56 This episode caused us to doubt the reliability of Mr Clark’s evidence where it was not supported by the contemporaneous documents. For example, after the test Mr Roper sent Parina Patel and David Cooper of International Fire Consultants thermocouple data from the test,1314 saying that he had spoken to Mr Clark, who saw no reason why a classification report could not be issued as, in his opinion, extending the test to the full duration of 30 mins would have made little difference.1315 Mr Clark strongly denied that any such discussion had taken place, to the point of accusing Mr Roper of having invented it at the time,1316 but there was no reason for Mr Roper to have made up the conversation for the benefit of International Fire Consultants and no plausible explanation of how he had obtained the thermocouple data if not from Mr Clark. We prefer the evidence of Mr Roper. Reaction to the failed first test 24.57 Mr Roper considered that the failure of the first test demonstrated the impossibility of meeting the requirements of BR 135 with a representative system1317 and in view of the cost of the first test, he did not expect to be given an opportunity to run a second.1318 By contrast, Mr Evans said that although it had been a disappointment, he had not considered it to have been a significant problem for Celotex.1319 In the light of the importance of the project and the fact that further testing required budgetary approval,1320 we do not think that can have been correct. Without passing a BS 8414 test and meeting the BR 135 criteria Celotex could not break into the market for insulation suitable for use on high-rise buildings, and there was at that time no guarantee that further testing would be possible. In reality, the failure of the test in February 2014 was a significant setback. Decision to retest 24.58 After the test, there were further discussions between Mr Roper, Mr Hayes, Mr Evans and Mr Warren.1321 Mr Evans could not recall them but did not dispute that they had taken place.1322 Mr Mahoney (then Celotex’s Head of Research and Development) was also consulted, as he had responsibility for the development budget from which a second test would be funded.1323 Mr Evans indicated that the cost was such that it would also have required the approval of Craig Chambers, who was in any case interested in progress, given that it involved the first launch of a (supposedly) new product since the company’s acquisition by Saint-Gobain.1324 Design changes 24.59 The discussions centred on how to ensure that any further test could be designed to be successful. Mr Roper said that two main changes had been proposed: the use of thicker rainscreen panels (12mm in place of 8mm) and the use of a 6mm magnesium oxide board in the area of the level 2 thermocouples.1325 Magnesium oxide is a non-combustible material and the purpose of including it was to reduce the chance that the temperature 1314 {CEL00000843}. 1315 {CEL00000842}. 1316 Clark {Day95/120:4}-{Day95/121:25}. 1317 Roper {Day71/43:6-12}. 1318 Roper {Day71/78:18-23}. 1319 Evans {Day72/182:10-14}. 1320 Roper {Day71/82:6-22}. 1321 Roper {Day71/80:7-11}. 1322 Evans {Day72/190:12-19}. 1323 Roper {Day71/82:14-24}. 1324 Evans {CEL00010058/29} page 29, paragraph 102. 1325 Roper {Day71/81:14-19}.

Part 3 | Chapter 24: Celotex RS5000 insulation 133 at that level would exceed 600°C, thereby failing to meet the performance criteria in BR 135.1326 It was also suggested that a layer of 6mm magnesium oxide board should be used at the top of the rig to provide a firm surface against which the cavity barriers could expand to prevent flames from overtopping the rig.1327 The 6mm magnesium oxide board was to be covered with 8mm Marley Eternit, rather than the 12mm used elsewhere, in order to ensure as much continuity of the rainscreen surface as possible.1328 Celotex also decided to reduce the ventilation gaps between the rainscreen panels.1329 Mr Roper believed there were some gaps but he accepted that they were minimal and less than 10mm.1330 Taken collectively, those decisions reflected a conscious decision by Celotex to manipulate the design of the rig in order to ensure as far as possible that the performance criteria in BR 135 were met.1331 24.60 The proposal to use a 6mm magnesium oxide board was originally made by Mr Hayes;1332 Mr Roper and Mr Evans then suggested using the thinner Marley board to cover it.1333 Mr Evans told us that he could recall only the decision to revise the rig design to incorporate a thicker cladding panel.1334 He was adamant, despite repeated questioning, that at no point had he known of the presence of a 6mm magnesium oxide board until he had found a reference to it on his phone in 2017, and that the only variation in design that he had been aware of at the time was the change to the thickness of the panel.1335 He was equally adamant that he had not taken part in any meeting at which the use of a 6mm magnesium oxide board had been discussed,1336 or that he had known that it had been used in the area of the cavity barriers.1337 We did not find his evidence on those matters credible and indeed Mr Evans ultimately accepted that he had become aware of the use of the 6mm magnesium oxide boards at the latest by the time of a management action group meeting on 14 May 2014 although he maintained that he had not made the connection even by that time.1338 Given his faulty memory on this point, we regard the evidence of Mr Hayes and Mr Roper as far more reliable and we conclude that Mr Evans was indeed aware of the changes to the design of the second test. No new drawings 24.61 Celotex did not commission any drawings of the second test rig.1339 Mr Roper said that that had been in part a financial decision.1340 He had also formed the view that Simco did not particularly wish to assist further.1341 Although Mr Roper did not think that the decision not to produce revised drawings had been motivated by a desire to conceal the use of the 6mm magnesium oxide board,1342 its failure to do so was entirely consistent with Celotex’s overall desire to conceal as far as possible the introduction of that layer. The only drawings available to BRE before the test on 2 May 2014, therefore, contained the same design as 1326 Roper {Day71/97:7-12}. 1327 Roper {Day71/97:13-17}. 1328 Hayes {CEL00010154//20} page 20, paragraph 61. 1329 Roper {Day72/2:8-9}. 1330 Roper {Day72/3:10-15}. 1331 Roper {Day71/98:2-3}. 1332 Roper {Day71/86:4-16}. 1333 Hayes {Day74/127:13-22}. 1334 Evans {Day72/192:13-15}. 1335 Evans {Day72/193:9}-{Day72/195:10}; Evans {CEL00010058/31} page 31, paragraph 114. 1336 Evans {Day73/2:15}-{Day73/3:5}. 1337 Evans {Day72/199:1-13}. 1338 Evans {Day73/8:15-23}; {Day73/9:16}-{Day73/10:15}. 1339 Roper {Day71/101:1-6}. 1340 Roper {CEL00010052/13}page 13, paragraph 5.35. 1341 Roper {Day71/100:9-20}. 1342 Roper {Day71/101:20-25}.

The Grenfell Tower Inquiry: Phase 2 Report 134 had been tested in February. Moreover, although revised drawings were subsequently commissioned by Celotex at the end of June 2014,1343 they also omitted anything to indicate the use of 6mm magnesium oxide boards.1344 Source of materials 24.62 Cavity barriers were ordered from Siderise Insulation Ltd and were delivered to BRE on 7 April 2014.1345 The cladding, which was Marley Eternit in thicknesses of 12mm and 8mm, was obtained from a company called FGF Ltd and delivered to BRE on 14 April 2014.1346 The delivery note for the 8mm ruby Eternit boards that were intended to cover the 6mm magnesium oxide boards was signed by Mr Clark.1347 The FR5000 was delivered on 1 April 2014, and again was signed for by Mr Clark.1348 24.63 The 6mm magnesium oxide boards were supplied by Euroform Products Ltd, which also supplied the 12mm sheathing board.1349 Although the invoice shows the delivery as being to Celotex,1350 Mr Roper asked for it to be delivered to BRE.1351 Although BRE disclosed a delivery note for the sheathing board from the first test (addressed ‘FAO Phil Clark’, although signed for by another BRE employee),1352 no delivery note for the sheathing board used in the second test has been disclosed by BRE. We return to the significance of that below. The second test – May 2014 24.64 The second test was carried out on 2 May 2014. As set out above, the system comprised a steel-framed rig, 12mm magnesium oxide sheathing board, 100mm Celotex FR5000, Lamatherm fire barriers, 8mm Marley Eternit cladding over 6mm magnesium oxide boards over the level 2 thermocouples and 12mm Marley Eternit cladding over all other areas. The results met the criteria in BR 135. BRE’s knowledge of the design changes 24.65 As in the case of the test on 14 February 2014, the officer at BRE in charge of the test on 2 May 2014 was Phil Clark. There was a serious conflict of evidence about what, if anything, he knew about the changes in the design between the rig tested in February and the rig tested in May. Mr Clark said that he had known nothing of the changes in design other than the use of thicker external cladding,1353 but his evidence was contradicted by Mr Hayes and Mr Roper, both of whom had no doubt that he had been well aware not only of the thicker Marley panels but also of the use of the 6mm magnesium oxide boards.1354 Mr Roper told us that he remembered having referred to the additional materials in the course of a telephone conversation with Mr Clark when the second test was being planned.1355 Mr Hayes remembered a conversation with Mr Clark in the course of which 1343 {CEL00000980}. 1344 {CEL00000997}. 1345 {BRE00032372/2}. 1346 {BRE00032372/3}. 1347 Clark {Day96/3:2-23}. 1348 {BRE00032372/6}. 1349 Roper {Day71/98:4-13}. 1350 {CEL00001985}. 1351 {CEL00001981}. 1352 {BRE00032372/4}. 1353 Clark {BRE00005768/70} page 70, paragraph 287. 1354 Roper {Day71/99:11-19}; Hayes {Day74/148:11-17}. 1355 Roper {Day71/98:19-22}.

Part 3 | Chapter 24: Celotex RS5000 insulation 135 he had referred to his experiences of working during the BSE outbreak.1356 Mr Hayes said that during the conversation, Mr Clark had expressed the view in response to a question from Mr Roper that the test would have been successful even without the addition of the 6mm magnesium oxide boards. Mr Clark denied the conversation and sought to cast doubt on Mr Hayes’ recollection challenging the description he had given of his office,1357 but the description given by Mr Hayes was similar to that given by Patrick Jones of Simco, who installed the rig for both tests and we accept what he told us.1358 24.66 BRE’s standard procedures required the project officer to compare the drawings of the test rig with the structure handed over and if any discrepancy were noted to ask for revised drawings.1359 The senior member of staff who signed the test report was also expected to check the photographs and drawings.1360 BRE’s standard operating procedures dated May 2013 required all components to be checked and, if necessary, samples to be taken.1361 BRE produced forms for that purpose,1362 but no checklists were disclosed for the second test, and Mr Clark explained that they had not normally been used, otherwise, perhaps, than as an aide memoire.1363 Had the drawings been compared to the rig as it was built, or even to the components being delivered to BRE, the discrepancy between the drawings and the rig as built would have been obvious. Indeed, Mr Clark knew that the drawings had not been revised to show the thicker Marley panels and therefore knew that the Simco drawings did not accurately describe the test rig.1364 24.67 In coming to a decision about whether Mr Clark knew that the second test rig contained the additional 6mm magnesium oxide boards we have carefully considered the detailed submissions made by Celotex and BRE. Having done so, we have come to the conclusion that the evidence, taken as a whole, points strongly to the conclusion that Mr Clark was aware of the presence on the test rig of the 6mm magnesium oxide boards and the 8mm Marley Eternit boards that were used to cover them. First, it is right to say that we found Mr Roper and Mr Hayes more reliable as witnesses than Mr Clark. If the question had turned on the evidence of the witnesses alone we should have accepted their accounts of their conversations with Mr Clark. However, their evidence did not stand alone. 24.68 The delivery notes indicate that Mr Clark took delivery of the 12mm Marley panels together with the thinner 8mm ruby panels which were used to cover the 6mm magnesium oxide boards.1365 There was no rational explanation for including 8mm and 12mm Marley panels in the components unless the thinner panels were to cover the 6mm magnesium oxide boards, and Mr Clark could not explain why the different thicknesses had not been noted other than as the result of an oversight.1366 Mr Roper had arranged for the delivery of all of those materials and expected Mr Clark to sign for them because, as he understood it, he took delivery of most of the materials used on the test rigs.1367 It is inherently unlikely that Mr Roper would have openly arranged for the delivery of those materials to BRE, which had a proper system for recording deliveries, if he had been intending to conceal their presence from BRE, and unless Mr Clark was aware of the plan, 1356 Hayes {CEL00010154/22} page 22, paragraph 67. 1357 Clark {Day96/27:1-22}. 1358 Jones {Day99/129:2-20}. 1359 Clark {BRE00005768/9} page 9, paragraph 41. 1360 Clark {Day95/56:4-9}. 1361 {BRE00005773/3}. 1362 {BRE00005773/3}. 1363 Clark {Day95/156:19-25}. 1364 Clark {Day95/158:12-16}. 1365 {BRE00032372/6}. 1366 Clark {Day96/7:1-9}; {Day96/8:3-11}. 1367 Roper {Day71/98:14-18}; Hayes {Day74/145:2-4}.

The Grenfell Tower Inquiry: Phase 2 Report 136 concealment would have been essential, probably quite difficult and certainly risky. There is no reason to think that BRE’s system for recording deliveries was so inefficient that Mr Roper can have expected to get the 6mm magnesium oxide boards onto the test rig without anyone’s noticing. 24.69 The absence from BRE’s disclosure of a delivery note covering the materials supplied by Euroform has not been explained by BRE and no credible explanation for it has been provided. That it was simply lost is too much of a coincidence and does not do justice to BRE’s systems. It could have been removed or destroyed deliberately, but no one at BRE other than Mr Clark was involved in the Celotex tests in a way that would provide a motive for doing that. Mr Clark initially told us that he had not had access to either the paper or electronic versions of the test files other than documents that had been provided to him by BRE,1368 but we subsequently learnt that he had attended BRE’s offices over the course of several days when preparing his witness statement for the Inquiry and been given unsupervised access to any documents he wished to review. Mr Clark was unable to explain satisfactorily why he had failed to mention that when he made his statement.1369 24.70 The use of the ruby Eternit board meant that the rig had a distinctive red band in the area of the level 2 thermocouples and at the top of the rig. Mr Clark said he had understood that the ruby board was used because there had been a shortage of panels in the other colour,1370 but that was not very plausible and he had not asked whether it had any technical significance.1371 However, the absence of any attempt on the part of Celotex to divert attention from the use of that material and to forestall questions of that kind is inconsistent with any plan to deceive BRE. Clearly, any attempt to smuggle the ruby board past BRE would have been risky. 24.71 Patrick Jones of Simco, who constructed the test rig for Celotex, was clear that he had been given no instructions to conceal the 6mm magnesium oxide board from BRE.1372 His impression was that BRE was carrying out its normal checks.1373 The rig was assembled over several days and there was no attempt to prevent BRE from seeing the magnesium oxide boards, and no reason to think that they had not been observed.1374 He told us that there was nothing underhand going on and that BRE was fully aware of what was on the test rig.1375 Mr Jones was a patently honest witness who had no reason to be anything other than candid in his evidence. 24.72 Following the test, the rig remained standing for some 17 days until it was stripped down on 19 May 2014.1376 That provided a further opportunity for anyone at BRE to ask questions about the use of the ruby board. 24.73 On 15 May 2014, during the stripping down of the rig, which was also carried out by Mr Jones, Mr Roper asked Mr Clark by email to ensure that photographs were taken of the fire barrier at the level 2 thermocouples.1377 Again, that is wholly inconsistent with an intention on the part of Celotex to deceive BRE or to gamble on its staff’s failing to notice the presence of the 6mm magnesium oxide boards. If Mr Roper had hoped that Mr Clark 1368 Clark {Day95/182:14-21}. 1369 Clark {Day96/110:2-12}. 1370 Clark {BRE00005768/66} page 66, paragraph 269. 1371 Clark {Day95/190:18-24}. 1372 Jones {Day99/151:19}-{Day99/152:3}. 1373 Jones {Day99/155:22}-{Day99/156:5}. 1374 Jones {Day99/151:19}-{Day99/152:3}. 1375 Jones {Day99/144:8-16}; {Day99/150:23}-{Day99/152:3}; {Day99/164:9-25}. 1376 {BRE00005548/6}. 1377 {BRE00005548/6}.

Part 3 | Chapter 24: Celotex RS5000 insulation 137 might fail to notice them, it is unlikely that he would have directed his attention to the very place in which they were being used. The photographs on BRE’s files clearly show their presence.1378 24.74 The recording made by the head camera worn by Mr Clark during the second test does not of itself demonstrate conclusively that Mr Clark was aware of the presence of the magnesium oxide board, but it contains several comments made by Mr Clark that strongly suggest that he was: a. Mr Clark referred to “changing two things at the same time”.1379 His explanation that that had been a reference to the scientific principle that only one variation should be made to a system at a time was unconvincing. He was unable to explain satisfactorily why, if he thought that only one change had been made, he had referred to changing two things.1380 Celotex had in fact made two significant changes to the design: the use of an increased thickness of cladding overall (12mm Marley Eternit as opposed to 8mm); and the use of the 6mm magnesium oxide board. b. Mr Roper at one point drew Mr Clark’s attention to the ruby board, (which he described as “the rose-coloured panel”),1381 being aware, he said, that Mr Clark knew what material was behind it. c. At one point Mr Clark commented, “See how that flame seems to have ceased now that the board is there, because you’re losing a lot of the energy from behind it”.1382 Unless he was aware of the presence of the magnesium oxide board, it is difficult to understand which board he was referring to. d. In response to a comment by Mr Clark that the board at the level of the fire barrier had not deformed, Mr Roper said that it was “a shame we put calcium silicate behind it” and subsequently “like I say, it’s a shame commercially.”1383 Mr Roper said that he tended to refer to calcium silicate interchangeably with magnesium oxide, because their fire resistance properties are very similar.1384 It is likely that they were referring to the 6mm magnesium oxide board because its use in that location would not be adopted commercially. 24.75 The way in which Celotex behaved in arranging the test was wholly inconsistent with any plan to deceive BRE. It could have acted as it did only with the knowledge of Mr Clark. We are satisfied that Mr Clark was aware of the design of the rig for the second test, including the use of the 6mm magnesium boards and the 8mm ruby Eternit boards, and the reasons for it. 24.76 The question remains why Mr Clark, a senior BRE burn hall technician, was willing to lend himself to a plan to a test rig that was so obviously unrepresentative and designed only to meet the performance criteria, since there was no evidence that he had anything to gain personally from a successful test. He might have thought that a customer should be allowed to test any design of rig it liked, provided the subsequent report accurately reflected its structure and the outcome of the test, but if that was his view, it is difficult to understand why he subsequently denied any knowledge of the additional material. 1378 {BRE00030681}. 1379 {INQ00014220/2}. 1380 Clark {Day96/55:5-21}. 1381 {INQ00014220/2}. 1382 {INQ00014218/3}. 1383 {INQ00014220/2}; {BRE00035419} 1384 Roper {Day71/170:12-14}.

The Grenfell Tower Inquiry: Phase 2 Report 138 In essence, over the years leading up to 2014 BRE had by degrees lost sight of the importance of maintaining a proper distance between itself and clients and of the need for scientific rigour and independence. Its internal controls were not the subject of regular and robust training and there was no independent supervision that ensured that conflicts of interest were properly managed. It had gradually become much closer to its clients and wanted to work with them to find solutions to their problems. Scientific rigour and independence were sacrificed in favour of financial sustainability. Decisions following the second test 24.77 On 12 May 2014, Mr Roper and Mr Evans met to discuss the outcome of the test. The meeting appears to have been held in Mr Chambers’s office,1385 and Mr Roper thought it was likely the purpose of the meeting was to brief him.1386 Mr Chambers did not believe he had attended such a meeting and could not recall how or by whom he had been advised that the system had passed.1387 The slide show 24.78 At or just after that meeting Mr Roper was asked by Mr Evans to prepare a presentation which could be used to report to the management action group at their next meeting, which was scheduled for 13 and 14 May 2014. Mr Chambers, Mr Warren and Mr Evans were present on 13 May 2014;1388 Mr Chambers and Mr Evans were present on 14 May but Mr Warren probably was not. Mr Roper appears not to have attended on either day. 24.79 The slides created by Mr Roper described the requirements for use of combustible insulation on buildings over 18 metres in height, referring to the text of paragraph 12.7 of Approved Document B.1389 A further slide set out the conclusions drawn by Mr Roper from the results of his market research, namely,1390 a. that people used K15 because there was no alternative available; b. that no one understood the BS 8414 test requirements; c. that levels of understanding among building control bodies varied widely; and d. that the market would be happy to buy an alternative to K15 if one were available. 24.80 Although Mr Evans denied that the slide showed that Celotex intended to capitalise on the confusion in the market,1391 that is the only reason why it could have been relevant for the management action group to know that nobody understood the testing requirements or that building control officers had widely differing levels of understanding on the subject. Mr Evans could not explain those statements, other than by saying that the purpose of the slides was to acquaint everyone with the research that had been carried out,1392 but that hardly explains why they were thought to be of any interest to senior management. The simplest, and we think the most likely, explanation is that the slides were put before the meeting precisely to enable it to decide whether to take advantage of that confusion, and if so, how. 1385 {CEL00010627}. 1386 Roper {Day71/106:18-20}. 1387 Chambers {CEL00010056/6} page 6, paragraph 31. 1388 {CEL00009565}. 1389 {CEL00000933/2}. 1390 {CEL00000933/11}. 1391 Evans {Day72/206:9-16}. 1392 Evans {Day72/207:2-14}.

Part 3 | Chapter 24: Celotex RS5000 insulation 139 24.81 The slides also described the two BS 8414 tests that Celotex had carried out, including the systems tested. The description of the February test referred to 8mm Eternit cladding and Lamatherm cavity barriers.1393 In the case of the May test, the description listed 12mm Eternit cladding and Lamatherm cavity barriers with 6mm magnesium oxide.1394 When the slides are compared, differences are quite apparent, although there is no mention of the use of the 8mm Eternit panels that had also been used in the May test. It follows that all those present were, or should have been, aware of the presence of the 6mm magnesium oxide boards used in the May test, as well as the use of the thicker 12mm Eternit boards. Indeed, Mr Evans accepted that the presentation had provided that information.1395 Mr Evans said he did not remember whether there had been any discussion about the 6mm magnesium oxide boards at the meeting,1396 or whether anyone had asked how the test had passed in May after it had failed in February.1397 In our view it is hard to believe that no one at the meeting asked that question, if they had not been told directly, since it was critical to their decision about what to do next. The slides show that the use of the 6mm magnesium oxide boards was openly acknowledged at that meeting. 24.82 The slides were presented at the meeting on 14 May 2014, at which Mr Evans was scheduled to lead a discussion on the subject at 11.30 am.1398 There was a disagreement about who presented the slides, but it makes little difference who did so. What is clear is that they show that those attending the meeting were or should have been aware of the presence of the 6mm magnesium oxide boards and that Mr Roper did not seek to keep their use a secret from senior management. 24.83 The slides may also have been sent to Saint-Gobain. An email from Mr Evans to Mr Roper on 16 May 2014 about the project refers to a meeting with Jonathan Cheeseman of Saint- Gobain’s legal team, which appears also to have been attended by Craig Chambers.1399 In that email, Mr Evans told Mr Roper that his presentation could provide all the background needed to explain Celotex’s approach. Mr Evans was unable to recall which set of slides he had been referring to,1400 but given that this set had been used for reporting to the management action group (and that the metadata relating to the short set of slides discussed below suggests that they were not created before 30 May 2014),1401 it is likely that Mr Evans was referring to the slides shown to the meeting on 14 May 2014. Instruction to produce slides “for general business use” 24.84 Mr Roper said that after the meeting, Paul Evans had asked him1402 to create “for general business use” another version of the slides which did not refer to the February test or to the 6mm magnesium oxide boards.1403 He told us that Mr Evans had suggested that after the meeting a decision had been taken to launch the product and to say nothing further about the use of 6mm magnesium oxide boards.1404 Mr Roper subsequently produced such a presentation.1405 Mr Evans did not remember having given any such instruction, but was 1393 {CEL00000933/12}. 1394 {CEL00000933/14}. 1395 Evans {Day72/211:19-21}. 1396 Evans {Day72/214:8-10}; {Day73:4/11-16}. 1397 Evans {Day72/214:21-25}. 1398 {CEL00009566}. 1399 {CEL00003121}. 1400 Evans {Day73/121:5-8}. 1401 {CEL00000961}. 1402 Roper {Day71/113:16-19}. 1403 Roper {CEL00010052/14-15} pages 14-15, paragraph 6.3 1404 Roper {Day71/114:6-10}. 1405 {CEL00000961}.

The Grenfell Tower Inquiry: Phase 2 Report 140 unable to provide any other explanation for Mr Roper’s action.1406 He was also unable to think of any reason why anyone else on the project team might have instructed Mr Roper to do that without his knowledge.1407 We have little doubt that Mr Roper created the slides because he was asked to do so. 24.85 Mr Roper’s evidence strongly supports the conclusion that the management action group made a decision at the meeting on 13 and 14 May 2014 to market FR5000 without disclosing the fact that 6mm magnesium oxide boards had been used to improve the performance of the test rig. There was a risk that BRE might disclose the use of the 6mm magnesium oxide and the 8mm Marley Eternit panels in its test report, but it was Celotex’s general practice not to release such reports1408 and it might therefore have hoped to maintain the deception indefinitely. It was, we think, a risk that Celotex was prepared to run, having regard to the ignorance of a substantial section of its potential customers, a point to which we return in Chapter 56. BRE draft report 24.86 Mr Clark produced a first draft of the test report,1409 which he sent to Mr Roper on 19 June 2014.1410 Mr Roper was about to go into a meeting with David White and Graham Perrior of NHBC when it arrived.1411 It was dated 2 June 20141412 and described the system that had been tested as comprising 100mm RS5000 with 8mm Marley Eternit, but made no reference to the 6mm magnesium oxide boards.1413 Mr Roper denied having asked Mr Clark to omit any reference to the 6mm magnesium oxide boards; he thought it was possible that Mr Clark had done so of his own initiative because of his view that they would not have made any difference in the light of the increase in the thickness of the cladding panel.1414 Nonetheless, he said that he had been surprised by the omission.1415 Mr Clark denied having consciously decided to omit any reference to the 6mm magnesium oxide boards; he said that he had simply been unaware of them, although he was unable to explain how he had overlooked them.1416 He accepted that he must have seen the photograph at Figure 18 of the draft report showing the magnesium oxide board, as he had selected it for inclusion, but said that he had not studied it at the time.1417 24.87 It was clear from the photographs in the draft test report that at the level 2 thermocouples and at the top of the rig, exterior panels had been used that differed from the rest of the exterior of the rig. Figure 15 showed the ruby Marley Eternit panels at those levels, although it is not possible to tell from the photograph that the thickness of the ruby layer was different from that of the rest of the panels.1418 However, the fact that those boards were at least of a different colour was not mentioned anywhere in the report. The report also contained a photograph of the rig in the process of being dismantled (Figure 18), which showed the white 6mm magnesium oxide boards quite clearly.1419 The photograph 1406 Evans {Day73/13:12-19}. 1407 Evans {Day73/19:21}-{Day73/20:1}. 1408 Roome {Day70/73:17-22}; Roper {Day71/135:19-25}. 1409 Clark {Day95/171:4-7}. 1410 {CEL00003177}. 1411 Roper {Day71/120:21}-{Day71/121:3}. 1412 {CEL00003178/1}. 1413 {CEL00003178/6}. 1414 Roper {Day71/128:8-13}. 1415 Roper {Day71/131:15-24}. 1416 Clark {Day95/179:25}-{Day95/180:20}. 1417 Clark {Day96/67:23}-{Day96/68:10}. 1418 {CEL00003178/25}. 1419 {CEL00003178/28}.

Part 3 | Chapter 24: Celotex RS5000 insulation 141 shows the insulation layer, with one panel of the 6mm magnesium oxide still present at level 2 and the whole of it present at the top of the rig. Those were the levels which had been covered by the ruby cladding panels shown in Figure 15. A simple comparison between the two photographs would have alerted a careful reader to the fact that there was white material behind the ruby cladding but on top of the insulation layer, which called for an explanation. Discussion of the draft report 24.88 On 19 June 2014, following receipt by Celotex of the draft report earlier that morning and after the NHBC representatives had left, a discussion ensued between Mr Roper, Mr Evans and another colleague at Celotex, Paul Reid (although it appears that Mr Reid was not present throughout).1420 Notes were made on a whiteboard of the concerns raised by NHBC, and the conversation which had subsequently taken place about the BRE draft test report.1421 A photograph of the whiteboard was taken by Mr Evans.1422 The first five points reflected concerns that had been raised by NHBC at the meeting that morning (one of which had been that the rig had been deliberately over-engineered through the use of large 12mm cladding panels with minimal gaps)1423 and Celotex’s potential responses. Some of the proposed responses were less than frank. In relation to NHBC’s concern that the test had been over-engineered, the proposed response was to note that cladding panels were commonly available in 8mm or 12mm but that only 12mm had been available for testing, whereas in fact Celotex had deliberately chosen to use large 12 mm panels. The final entry was in different handwriting, having been added by Mr Roper.1424 It recorded a concern relating to the use of a “calcium silicate board” at level 2, although, as we noted earlier, Mr Roper did not distinguish in his own mind between calcium silicate and magnesium oxide.1425 If NHBC were to become aware of the existence of the 6mm magnesium oxide board, Celotex proposed to say that it had confidence in the fire barriers to expand. When examined about that Mr Roper admitted that it was a poor attempt to hide the fact that 6mm magnesium oxide boards had been used.1426 He said that Mr Evans and Mr Reid had suggested that they remove Figure 18 from the report.1427 Mr Reid denied having been involved in the conversation at that point or having had any knowledge of the discussion about the removal of Figure 18,1428 and we are not able to reach any firm conclusion about the extent of his involvement. Decision not to correct the report 24.89 The upshot of the discussion was that it was decided that the omission from the test report of any reference to the 6mm magnesium oxide boards would not be corrected.1429 Mr Evans did not recall any discussion with Mr Roper about that,1430 but he did accept that the white board reflected a discussion which had taken place about removing Figure 18.1431 Although he recalled its having been discussed,1432 he claimed to be unsure whether 1420 Roper {CEL00010052/16} page 16, paragraph 7.4. 1421 {CEL00002517}. 1422 Evans {Day73:36/6-12}. 1423 Roper {CEL00010052/16} page 16, paragraph 7.4 1424 Evans {Day73:37/8-17}. 1425 Roper {Day71/170:12-14}. 1426 Roper {Day71/171:22}-{Day71/172:1}. 1427 Roper {CEL00010052/18} page 18, paragraph 7.16; Roper {Day71/137:21-24}. 1428 Reid {CEL00011267/11} page 11, paragraphs 57-59. 1429 Roper {CEL00010052/18} page 18, paragraph 7.14 1430 Evans {Day73/24:18-23}. 1431 Evans {Day73:38/19-23}. 1432 Evans {Day73/29:3-10}.

The Grenfell Tower Inquiry: Phase 2 Report 142 he had looked at the photograph.1433 We do not accept that. Figure 18 clearly showed the 6mm magnesium oxide board and it could not have been discussed without Mr Evans’ having appreciated that fact. It is also not credible that he could have taken part in a discussion about the removal of a photograph from the report without having looked at the photograph in question. 24.90 Similarly, we are not convinced by Mr Evans’ assertion that he did not ask about the two orange layers shown in the photographs of the rig.1434 The test represented the second attempt to succeed in what was an important project for Celotex. We do not think that Mr Evans felt as little concern as he suggested.1435 Request to remove figure 18 24.91 On 1 July 2014, Mr Roper replied to Mr Clark’s email attaching the draft report with a number of suggested changes, including the removal of Figure 18 and its substitution by some photographs showing the condition of the insulation at the conclusion of the test.1436 The email refers to a previous discussion between Mr Roper and Mr Clark about the removal of Figure 18, but Mr Clark could not remember what had been said.1437 Mr Roper could not remember having specifically told Mr Clark that Celotex did not want any reference to be made to the areas of the rig where the 6mm magnesium oxide board had been used; the focus, as he recalled it, was simply on getting Figure 18 removed.1438 24.92 The reason Mr Roper gave for asking Mr Clark to remove Figure 18 from the test report was not the true reason, as he admitted. The truth was that Celotex wanted to ensure that a picture showing the 6mm magnesium oxide board did not appear anywhere in the report.1439 Mr Roper said that Mr Evans and Mr Reid had told him to send the false explanation,1440 but that he had thought that Mr Clark was aware of the real reason.1441 Mr Evans did not remember having asked Mr Roper to send the email,1442 and he may not have done, but he was copied into it and did not express any surprise at the request. We are satisfied that he knew about it, but cannot say whether Mr Reid also knew. 24.93 Mr Roper also sent Mr Clark some revised drawings, which showed a ventilation gap that had not existed on the rig as built but still did not show the 6mm magnesium oxide boards. Internal review and issue of the report 24.94 BRE did not reply to those requests. Internally, the final version of the report was checked by Tony Baker1443 and Stephen Howard,1444 each of whom failed to identify the discrepancy between the description of the system tested and the presence of the white layer shown in Figure 18 or the ruby Marley Eternit boards shown in Figure 15. 1433 Evans {Day73/29:17}. 1434 Evans {Day73/66:9-21}. 1435 Evans {Day73/68:2-7}. 1436 {CEL00001350/2}. 1437 Clark {Day96/65:19-24}. 1438 Roper {Day71/178:20}-{Day71/179:8}. 1439 Roper {Day71/141:22}. 1440 Roper {Day71/141:23}-{Day71/142: 4}. 1441 Roper {Day71/142:20}-{Day71/143:3}. 1442 Evans {Day73/33:4-13}. 1443 {BRE00005851}; Baker {Day100/143:4-11}. 1444 {BRE00030677}; Howard {Day99/41:2-12}.

Part 3 | Chapter 24: Celotex RS5000 insulation 143 24.95 The final test report was issued by BRE on 1 August 2014. It included the additional photographs but also Figure 18, which became Figure 19 in the final version.1445 As with earlier versions of the draft, the description of the system tested contained no mention of either the 8mm ruby Marley Eternit boards or the 6mm magnesium oxide boards.1446 Mr Roper said that he, Mr Evans and Mr Warren had discussed the report and had decided that it would be risky to press BRE to remove Figure 19, as it might result in their correcting the description of the system.1447 Mr Clark’s involvement in the BRE test report 24.96 As set out above, we are satisfied that Mr Clark was aware of the changes that had been made to the design of the rig tested on 2 May 2014, including the use of the 8mm ruby Marley Eternit boards and the 6mm magnesium oxide boards at two levels. We also think that he realised that the presence of the 6mm magnesium oxide board might have enabled the system to pass the test, although it would not be used in a commercial context. That being so, we have to ask ourselves why he failed to include them in the list of components in the test report, not least since the delivery note for the ruby 8mm Marley Eternit was available to him on the test file.1448 24.97 Mr Roper denied having specifically asked him to do so, although, as can be seen from the attempt to suppress Figure 18 in the draft report, we have little doubt that he would, if necessary, have done so. It is likely, in our view, that Mr Clark was aware of Celotex’s wish to avoid any reference to the magnesium oxide boards (and therefore the 8mm ruby Marley Eternit boards) and did not need to be asked to omit any reference to them. Mr Clark denied having deliberately omitted any reference to either of those components.1449 24.98 In view of the length of time it took to issue the draft report (just over 6 weeks), it is possible that Mr Clark simply relied on the original drawings when drafting the description of the system. That might explain why the draft referred to 8mm Marley Eternit panels as shown in the drawings for the first test.1450 It might also explain the omission of the 6mm magnesium oxide boards, which had also not been used in the first test. However, we do not think that is the most likely explanation. We think he was willing to leave out any reference to them in order to assist Celotex, though how he expected the report to escape the scrutiny of those who would need to approve it before it was issued is less clear. Perhaps he knew that the system for reviewing reports was not very rigorous. Mr Clark said he had not looked at Figure 18 again in light of the request to remove it, because BRE did not remove material in response to a request from a client.1451 We think that is probably what happened. 24.99 Although Mr Clark did not remove Figure 18 from the report, that does not mean that his omission of a reference to the 6mm magnesium oxide boards from the list of components was an oversight. He knew, or at least suspected, that the system had only met the BR 135 performance criteria at least in part because of the presence of the 6mm magnesium oxide boards, and that such boards were not representative of a system in actual use on 1445 {CEL00001109/29}. 1446 {CEL00001109/6}. 1447 Roper{CEL00010052/18} page 18, paragraph 7.16; Roper {Day71/144:25}-{Day71/145: 7}. 1448 {BRE00032372/3}. 1449 Clark {Day96/75:6-13}. 1450 {CEL00000807}. 1451 Clark {Day96/71:17}.

The Grenfell Tower Inquiry: Phase 2 Report 144 a real building. He therefore knew that referring to the presence of those boards in the report would significantly undermine the commercial viability of the product and therefore deliberately omitted any reference to them. 24.100 The test report was subsequently peer reviewed by Stephen Howard and Mr Baker, neither of whom inquired about the white layer of magnesium oxide board or the ruby Eternit boards. However, that merely suggests a lack of curiosity and a review system that was less than robust. There is no evidence that in conducting their review either of them realised that Celotex had manipulated the test by adding a layer of magnesium oxide board behind the ruby Eternit boards, still less that they realised that Mr Clark was aware of the fact. The RS5000 classification report 24.101 The classification report was issued by BRE on 4 August 2014 and reissued following typographical corrections on 11 August 2022.1452 It ran to 12 pages and described the test in the same terms as the test report, omitting any reference to the 6mm magnesium oxide boards or the 8mm Marley Eternit boards.1453 The classification report did not contain any photographs. Indeed, there is nothing in it to alert even a scrupulously careful reader to the possibility that the description of the components of the rig was incomplete. The abridged report 24.102 The classification report contained a prominent notice that it was only to be distributed in its entirety, without amendment and that any reference to the results contained in it was to be accompanied by a copy of the full report, or a link to a copy of the full report.1454 Despite that, on 11 August 2014, Mr Roper sent Paul Evans copies of the test and classification reports, asking for a discussion about which they were going to use as proof that Celotex had satisfied BR 135.1455 Although his recollection of that discussion was hazy,1456 he recalled that there was some reluctance to provide customers with any reports, and that they had decided that an abridged version of the classification report should be produced for customers to avoid having to provide them with details of the test rig.1457 Mr Roper understood that a similar approach had been adopted by Kingspan.1458 24.103 The abridged report was prepared on Mr Roper’s instructions.1459 It contained no diagrams or photographs showing the system tested, but it did contain a list of components which omitted the 6mm magnesium oxide boards and the 8mm ruby Eternit boards.1460 On 15 August 2014 a copy was sent to Jonathan Roome, again at Mr Roper’s request.1461 It was then sent by him to clients, including Harley on 27 August 2014.1462 24.104 As early as 29 August 2014, Anthony Harris of Celotex contacted Mr Roper and Mr Roome because a client to whom Celotex had provided the abridged report had complained that it was incomplete and that sections were missing.1463 Mr Roper replied the same day providing the full classification report, but not the full test report. He told Mr Harris that 1452 {CEL00002133/1}. 1453 {CEL00002133/4}. 1454 {CEL00002133/1}. 1455 {CEL00009724/1}. 1456 Roper {Day71/153:17-19}; {Day71/152:24}-{Day71/153:8}. 1457 Roper {Day71/154:3-6}. 1458 Roper {Day71/154:14-23}. 1459 Roper {Day71/155:11-18}. 1460 {CEL00011125/2}. 1461 {CEL00009725}. 1462 {CEL00011960}. 1463 {CEL00010805}.

Part 3 | Chapter 24: Celotex RS5000 insulation 145 the salient information was contained in the BR 135 classification report.1464 As Mr Roper accepted, the salient information was not in fact contained in that report, not least because it did not include the photograph of the 6mm magnesium oxide boards.1465 The marketing of RS5000 24.105 Preparatory work on marketing materials to support the launch of RS5000 started in July

1. On 1 July 2014, Jonathan Roper sent Paul Evans a marketing plan1466 which set out

the objectives for RS5000, including being presented as Celotex’s “primary rainscreen application offering to compete directly with Kingspan K15 & Rockwool Duo-Slab”.1467 It also contained a phrase that would become something of a mantra in the marketing material, “the first PIR insulation board tested and approved to BR 135 and therefore acceptable for use in buildings above 18m in height”. Mr Roper and Mr Hayes then started work preparing the marketing literature which was intended to accompany the launch of RS5000.1468 24.106 On 15 July 2014, Mr Evans replied to an email from another colleague in the marketing team, Bex Hartlebury, about a press launch for RS5000, complaining that the message that RS5000 was acceptable for use on buildings over 18 metres in height was not always prominent enough, but saying that it was necessary to exercise caution about how that message was given and how often.1469 Mr Evans accepted in evidence that there was a risk that without qualification it might mislead people into thinking that RS5000 was generally suitable for use on buildings above 18 metres in height,1470 but he denied that Celotex was trying to walk a fine line between the headline and the small print.1471 In our view, however, that is exactly what it was trying to do. The RS5000 marketing literature 24.107 Celotex launched RS5000 on 5 August 2014. A number of documents were prepared to assist in its marketing: a. a Rainscreen Cladding Compliance Guide (“the Compliance Guide”);1472 b. a Rainscreen Cladding Specification Guide (“the Specification Guide”);1473 c. a Handy Guide;1474 and d. a Data Sheet.1475 They were drafted by Mr Roper with the assistance of Mr Hayes (in relation to the Specification Guide)1476 and others in the marketing and technical teams1477 but they were reviewed and ultimately approved by Paul Evans.1478 Mr Evans told us that Celotex also sought guidance on them from Saint-Gobain, in that they had been passed to the 1464 {CEL00010805}. 1465 Roper {Day71/162:12-23}. 1466 {CEL00001213}. 1467 {CEL00001214/2}. 1468 {CEL00003179/4}; Roper {Day71/194:13-23}. 1469 {CEL00009674}. 1470 Evans {Day73/86:5-10}. 1471 Evans {Day73/86:18-24}. 1472 {CEL00000012}. 1473 {CEL00000013}. 1474 {CEL00000437}. 1475 {CEL00007961}. 1476 Hayes {Day74/173:11-20}. 1477 Evans {Day73/81:16-22}. 1478 Evans {Day73/82:1-3}.

The Grenfell Tower Inquiry: Phase 2 Report 146 legal team, but he was unsure whether they had been reviewed by anyone on the Saint- Gobain board.1479 Mr Roper also told us that Saint-Gobain’s internal lawyers had reviewed the documents and that it had been as a result of that review that the disclaimers had appeared in the documents.1480 We accept their evidence about that. 24.108 We therefore turn to examine those documents. The Compliance Guide 24.109 The front cover of the Compliance Guide stated that it was for use “when specifying Celotex RS5000 in buildings above 18m”,1481 explaining on the first inside page that it provided a step by step guide to the alternative route to compliance under Approved Document B by meeting the performance criteria in BR 135 following testing to BS 8414-1:2002 or BS 8414-2:2005.1482 That was not accurate, if only because RS5000 had not been tested in accordance with BS 8414-1:2002 (masonry wall construction).1483 Mr Evans was unable to explain that inaccuracy.1484 24.110 On page 3, it contained the following disclaimer: “The classification applies only to the system as tested and detailed in the classification report. The classification report can only cover the details of the system as tested. It cannot state what is not covered. When specifying or checking a system it is important to check that the classification documents cover the end- use application”.1485 24.111 The next page of the Compliance Guide contained a description of the system tested together with a diagram, Figure 4. The following components were listed: a. 12mm Fibre Cement Panels; b. Supporting aluminium brackets and vertical rails; c. 100mm Celotex RS5000; d. 12mm non-combustible sheathing board; e. 100mm SFS system; and f. 2 x 12.5mm plasterboard.1486 24.112 The description did not disclose either the presence of the 6mm magnesium oxide boards nor the 8mm Marley Eternit boards. Although the text goes on to warn that “the fire performance and classification report issued only relates to the components detailed and constructed in Figure 4” and that “any changes to the components listed and construction method set out in Figure 4 will need to be considered by the building designer”,1487 1479 Evans {Day73/82:3-17}. 1480 Roper {Day71/182:5}-{Day71/183: 6}. 1481 {CEL00000012/1}. 1482 {CEL00000012/2}. 1483 Evans {Day73/51:9-11}. 1484 Evans {Day73/52:13-19}. 1485 {CEL00000012/3}. 1486 {CEL00000012/4}. 1487 {CEL00000012/4}.

Part 3 | Chapter 24: Celotex RS5000 insulation 147 Figure 4 also omitted any reference to those elements. They had been omitted because, as Mr Evans admitted, any reference to them would have revealed that the system tested had been entirely unrepresentative of a commercial construction.1488 24.113 The failure to refer to the 6mm magnesium oxide boards or the 8mm Eternit boards completely undermined the disclaimers on pages 3 and 4. If the description of the system tested was materially incomplete, as it was, even the most rigorous attempt to reproduce it was bound to fail. In its statements to the Inquiry Celotex was at pains to point out that the statements that RS5000 was suitable for use on buildings over 18 metres in height should be read in the context of the disclaimer on page 3 of the Compliance Guide, but the disclaimer was effectively meaningless, as Celotex well knew. The Specification Guide 24.114 The introduction to the Specification Guide described RS5000 as “a premium performance PIR solution for use in rainscreen cladding applications and suitable for use in building (sic) above 18 metres in height”.1489 and in a section headed “Fire Performance”, it went on to describe RS5000 as having been “successfully tested to BS8414-2:2005 […], meets the criteria set out in BR 135 and is therefore acceptable for use in buildings above 18m in height”.1490 This slogan was repeated throughout Celotex’s other marketing material for RS5000. 24.115 Almost identical wording could be found in a Technical Bulletin issued by Kingspan in 2011, in which it described K15 as “successfully tested to BS8414:2002, can meet the criteria within BR 135 and is therefore acceptable for use above 18 metres”.1491 The similarity was not coincidental. As Mr Roper confirmed, Celotex took the wording directly from Kingspan’s literature.1492 Celotex had identified the device by which Kingspan had for years succeeded in selling an insulation product tested in one particular configuration for general use on buildings above 18 metres in height and had decided to adopt it. 24.116 The Specification Guide then described the system tested in the same terms as the Compliance Guide (i.e. without mentioning the 6mm magnesium oxide or 8mm Marley Eternit boards), together with the qualification that “the fire performance and classification report for Celotex RS5000 only relates to the components detailed above”.1493 Unlike the Compliance Guide, there is no diagram identifying that the listed “fibre cement panels” were in fact Marley Eternit. It did refer readers to the Compliance Guide for “full” specification details and provided a draft specification clause which said that “RS5000 has been successfully tested to BS8414-2:2005 and meets the performance criteria of BR 135”.1494 24.117 Mr Roome accepted with hindsight that the Specification Guide was a thoroughly misleading document,1495 and that a reader might have interpreted the claim that RS5000 was suitable for use on buildings over 18 metres in height as meaning it could be used 1488 Evans {Day73/62:15-22}. 1489 {CEL00000013/3}. 1490 {CEL00000013/5}. 1491 {CEL00008510}. 1492 Roper {Day71/184:16-17}. 1493 {CEL00000013/5}. 1494 {CEL00000013/8}. 1495 Roome {Day69/99:10-12}.

The Grenfell Tower Inquiry: Phase 2 Report 148 generally above that height.1496 The document was indeed thoroughly misleading and, although Mr Roome himself may not have realised it, had been deliberately crafted to mislead the reader into buying RS5000 for use on buildings over 18 metres in height without worrying about whether the external wall of which it was to form part was the same as that which had been tested. The disclaimer on page 5 that the fire performance and classification report related only to the components listed was not only buried away in the small print but was, as we have explained, itself disingenuous because the components of the system tested had not been fully described. Other marketing documents 24.118 The Handy Guide repeated the expression “the first PIR board to meet the criteria set out in BR 135 and therefore is acceptable for use in buildings above 18m in height”, without qualification, although it advised that the product should be installed in accordance with instructions supplied by Celotex.1497 24.119 The Product Datasheet contained the same claim prominently on the first page.1498 Headers on each page included, without qualification, the words “suitable for buildings above 18m in height”. Mr Roper explained that the reason for the disclaimer being placed on the third page was that certain people at Celotex wanted “to dilute that system message as much as they could”.1499 Mr Evans did not agree; his view was that it was not intended to be a free-standing statement but was to be read in conjunction with the description of the system that had been tested,1500 but the description given on the third page of the Product Datasheet did not mention the magnesium oxide boards or the use of 8mm Marley Eternit. The section did contain a warning that the fire performance and classification report related only to the components described above,1501 but that was itself misleading because the components of the system tested had not been fully described. 24.120 A press release prepared for the launch of RS5000 described it as a “new premium performing PIR solution for rainscreen cladding applications.”1502 That claim was itself false, because RS5000 was merely FR5000 under a different name. The press release repeated the claim that RS5000 was “acceptable for use in buildings above 18m in height” without qualification. 24.121 Taken in the round, the marketing literature for RS5000 contained two messages, both of which were false and deliberately misleading. The first, aimed at the designer or cladding specialist who did not read beyond the first page, was that RS5000 was suitable for use on any building over 18 metres in height, whereas it was not. The second was the warning aimed at the more conscientious reader that the fire performance and classification for RS5000 related only to the components described as making up the system tested, when in fact the components were misdescribed. 1496 Roome {Day69/100:1-9}. 1497 {CEL00000437/8}. 1498 {CEL00007961/1}. 1499 Roper {Day71/205:8-10}. 1500 Evans {Day73/70:23}-{Day73/71:2}. 1501 {CEL00007961/3}. 1502 {CEL00009599/1}.

Part 3 | Chapter 24: Celotex RS5000 insulation 149 Internal launch of RS5000 24.122 RS5000 was launched on 5 August 2014, at a regional sales meeting at which Jonathan Roper gave a presentation to the sales team about the product.1503 His slide presentation1504 included a quotation from paragraph 12.7 of Approved Document B1505 as well as the historical context provided by the fires at Knowsley Heights,1506 Garnock Court,1507 and in Dubai.1508 Although he referred to test method BS 8414 and explained in terms that BR 135 was a system classification,1509 he repeated the assertion that RS5000 was the first PIR board to meet successfully the performance criteria in BR 135 for insulated cladding systems and was therefore acceptable for use in buildings above 18 metres in height.1510 24.123 Jonathan Roome was present at the launch. Although he understood from the presentation that a BR 135 classification applied only to the system as tested,1511 he accepted that the words “therefore acceptable for use above 18 metres in height” gave the impression that RS5000 was generally suitable for use on high-rise buildings and could be read as a representation that it was suitable for use in any rainscreen system on buildings over 18 metres in height.1512 That is consistent with the evidence of Mr Roper, who said that, although he had wanted to make it clear that the test applied to a system as a whole, he had felt that the members of the management action group present at the launch had not wanted that message to be too prominent. He agreed that the combination of an early reference to the nature of the classification and the subsequent emphasis on the sales message had been a way of satisfying the technical requirements while giving a strong message to the sales teams that RS5000 was generally acceptable for use on buildings over 18 metres in height.1513 24.124 The launch presentation did not describe in any detail the system that had been tested but it did contain a diagram showing the rainscreen panel as 12mm Marley Eternit over 100mm of insulation.1514 Mr Roome confirmed that he understood that to have been the system tested because it matched the depiction in the Compliance Guide and Specification Guide.1515 That was all that he and the rest of the sales team were given by way of information about the system tested.1516 He was not aware that 6mm magnesium oxide boards had been used in the test,1517 and never became aware of it during the remainder of his time at Celotex.1518 24.125 The failure to identify the true components of the test in May 2014 was only one of a number of ways in which the presentation was misleading. It also implied that RS5000 was a completely new product and made no mention of the first, failed, test in February 2014. Mr Roome confirmed that he had not been aware of either fact. That was the result of a 1503 Roper {Day71/208:16-22}. 1504 {CEL00008668}. 1505 {CEL00008668/5}. 1506 {CEL00008668/11}. 1507 {CEL00008668/13}. 1508 {CEL00008668/14}. 1509 {CEL00008668/15-16}. 1510 {CEL00008668/26}. 1511 Roome {Day69/52:1-9}. 1512 Roome {Day69/53:2-9}. 1513 Roper {Day71/213:2-13}. 1514 {CEL00008668/27}. 1515 Roome {Day69/59:1-5}. 1516 Roome {Day69/97:2-9}. 1517 Roome {Day69/60:2-6}. 1518 Roome {Day69/60:19-23}.

The Grenfell Tower Inquiry: Phase 2 Report 150 deliberate choice by Celotex.1519 In similar vein, Mr Roome was provided with the 12-page classification report only when he requested it following a direct enquiry from Harley,1520 and during his time at Celotex he never saw the full 32 page test report.1521 Aftermath of the launch Relations with NHBC 24.126 As we have already explained, Celotex had been in contact with NHBC since November 2013, when Mr Roper sought advice from Graham Perrior about his interpretation of the requirements for use of insulation on buildings over 18 metres in height.1522 His approach was prompted by concerns about apparent inconsistencies in the approach being taken by NHBC.1523 That was again motivated by a desire to understand how Kingspan was being widely used despite having carried out only one BS 8414 test.1524 24.127 On 15 May 2015 Jonathan Roper told Graham Perrior and David White of NHBC that Celotex had passed a BS 8414 test.1525 We have already touched briefly on the meeting between Celotex and NHBC on 19 June 2014 which was held to discuss that test.1526 At that meeting NHBC raised a number of concerns which Mr Evans recorded on a white board.1527 Celotex did not tell NHBC about the test in February 2014 which had failed or about the use of the 6mm magnesium oxide boards used in the successful test in May 2014.1528 Celotex deliberately misled NHBC about the true nature of the system that had been tested in order to obtain its approval of RS5000, which was seen as critical to the success of the product.1529 24.128 On 30 July 2014, Mr Roper sent the final draft of the test report to David White and Graham Perrior,1530 possibly at the request of NHBC.1531 That involved a certain level of risk, because the report contained the photograph showing the presence of the magnesium oxide boards. Mr Roper gave NHBC the impression that the report described exactly what had been tested,1532 but that was not the case, since it omitted any reference to the magnesium oxide boards and the 8mm ruby Eternit panels. 24.129 By September 2014, NHBC was still expressing reservations about RS5000. On 5 September 2014, Jonathan Roper sent an email to Paul Evans explaining that he was aware of instances in which building control officers had refused to accept RS5000 on the basis that it had not been approved by NHBC.1533 On the same date, a Celotex area sales manager, Michael Healey, asked NHBC to explain what problems it had with the test data.1534 His request was made in response to a message from a designer on a project in which the NHBC project manager (Jon Behan) had said that there were questions about 1519 Roper {Day71/220:19}-{Day71/221: 9}. 1520 Roome {Day70/73:12-16}. 1521 Roome {Day70/73:17-22}. 1522 {CEL00000748}. 1523 Roper {Day70/198:5-15}. 1524 Roper {Day70/201:20-22}. 1525 Roper {Day71/166:9-18}. 1526 Roper {CEL00010052/15} page 15, paragraph 7.1. 1527 {CEL00002517}. 1528 Roper {CEL00010052/16} page 16, paragraph 7.4 1529 Roper {Day71/172:2-11}. 1530 {CEL00000992}. 1531 Roper {Day71/181:9-22}. 1532 {CEL00000992}. 1533 {CEL00001020}. 1534 {CEL00001022/3}.

Part 3 | Chapter 24: Celotex RS5000 insulation 151 the tests that had been carried out and that the matter had been raised with Celotex.1535 On 22 September 2014, Mr Behan replied to Mr Healey, telling him that at present Celotex had no relevant test certificate to show that RS5000 was suitable for use on buildings over 18 metres in height.1536 When Mr Healey referred to the test that Celotex had undertaken, Mr Behan said that NHBC had “issues” with it and that the Celotex technical department was well aware of them.1537 Mr Healey sent that exchange to Mr Roper who in turn sent it on to Mr Evans.1538 It was understood as an indication that NHBC would not accept the use of RS5000 on buildings over 18 metres in height.1539 24.130 The importance of NHBC approval to Celotex was reflected in its 2015 budget presented at Saint Gobain’s headquarters at Les Miroirs in Paris on 14 October 2014, which included £20,000 for “NHBC ‘buy-in’ for above 18m applications”.1540 It is unclear what the money was actually allocated for. Paul Evans thought that it might have been for additional testing but could not recall.1541 He denied, however, that it was for lobbying.1542 Despite its importance to Celotex, NHBC’s approval of RS5000 for use on buildings over 18 metres in height was not forthcoming. By 7 January 2015, Celotex had learned through an email sent by a client (Nigel Shields of Durkan) to another Celotex area sales manager (Nigel Waring) that NHBC would not accept Celotex fire test data because it did not represent a true test of the product in all its applications. Worse still, NHBC was very nervous of its use on high-rise buildings and had taken steps to consult fire and rescue services.1543 Although, as Mr Evans accepted, that was an indication that NHBC regarded RS5000 as dangerous,1544 it did not cause Celotex to reconsider its marketing strategy. Problems in the market 24.131 At the same time as NHBC was making its disquiet clear, difficult questions were being asked by clients about the breadth of application of Celotex’s BR 135 classification. On 16 January 2015, Daniel Anketell-Jones of Harley sent an email to Jonathan Roome in relation to another project,1545 in which he explained that a customer had asked exactly how RS5000 had been installed when it was tested, who had carried out the testing, how it had been fixed, what it had been covered with, what rainscreen had been used, what support structure, and, most importantly, what had been the results. Mr Anketell-Jones described the request as a headache for Celotex, which indeed it was, because it was seeking detailed information that Celotex did not wish to make public.1546 24.132 The challenges faced by Celotex from the more astute section of the market were most clearly illustrated by a complaint made by Ardmore Construction Ltd in March 2015 after NHBC had rejected the use of RS5000 that had been installed on a high-rise building at Octavius Street in Deptford, London.1547 Ardmore’s Technical Director had complained about a lack of clarity in the marketing literature and asked for evidence of the fire testing on which Celotex relied to support its claim that RS5000 was suitable for use on 1535 {CEL00001022/4}. 1536 {CEL00001022/2}. 1537 {CEL00001022/4}. 1538 {CEL00001022/1}. 1539 Evans {Day73/126:2-6}. 1540 {CEL00003342/21}. 1541 Evans {Day73/176:17-19}. 1542 Evans {Day73/176:20-23}. 1543 {CEL00003445}. 1544 Evans {Day73/127:17-25}-{Day73:128:1-3}. 1545 {CEL00000019/2}; Roome {Day70/63:14-18}. 1546 Roome {Day70/61:16-22}. 1547 {CEL00002193}.

The Grenfell Tower Inquiry: Phase 2 Report 152 buildings over 18 metres in height. Mr Evans told us that the complaint had been taken seriously at Celotex,1548 but the marketing literature remained unchanged. He was unable to explain why Celotex had not been concerned that it was not clear enough to avoid a problem with a major developer and why there had not been discussions within Celotex about improving it.1549 LABC approval 24.133 Celotex also sought to obtain an LABC certificate for RS5000. It was seen as an important form of approval,1550 in part because it would protect the use of RS5000 from the risk of challenge.1551 It was also seen as a route by which Celotex could market RS5000 as being suitable for use in systems other than that tested.1552 Before the test in February 2014 Mr Roper had been in contact with David Ewing of the LABC, who was then responsible for managing the Registered Details scheme,1553 and had been told by him that as Kingspan K15 was described as Class 0, it could be described as a material of limited combustibility.1554 Mr Roper realised that that was wrong but he did not correct the LABC’s mistake because he thought it was advantageous to Celotex not to do so.1555 24.134 The first LABC certificate for RS5000 was issued on 21 August 2014.1556 The accompanying drawing and document list stated that it was “for use in rainscreen wall construction including above 18m in height”.1557 The only test information provided was contained in the Advice Notes, which said that RS5000: “had successfully tested to BS 8414:2 2005, meets the criteria in BR 135 and is therefore acceptable for use in buildings with storeys above 18m in height (subject to the board being fixed to a non-combustible substrate) alternative compliance to ADB”.1558 That wording had been taken directly from an email Mr Roper had sent to Tim Bartlett of West Suffolk building control, the person responsible for preparing Celotex’s Registered Details certificate, even to the point of including the transposition of a typographical error.1559 However, the wording and the message it was intended to convey was untrue and misleading.1560 The certificate, together with the document and drawing list, were sent by Jonathan Roome to Daniel Anketell-Jones of Harley on 27 August 2014.1561 24.135 In early November 2014, Samantha Li of the LABC sent an email to Jonathan Roper explaining that the LABC was intending to change the form of its certificates and that the certificate for RS5000 would be reissued in the new style.1562 Mr Ewing explained that he had decided to change the form of Registered Detail certificates because he thought 1548 Evans {Day73/166:22-25}. 1549 Evans {Day73/165:3-9}; {Day73/167:8-15}. 1550 Roper {Day72/26:9-16}. 1551 Roper {Day71/35:11-16}; {Day72/44:15-22}. 1552 {CEL00000735/4}; Roper {Day72/29:24}-{Day72/30:7}. 1553 Ewing {Day217/95:18-22}. 1554 {CEL00000939/5}. 1555 Roper {Day72/34:14-23}. 1556 {CEL00000010}. 1557 {CEL00000009}. 1558 {CEL00000009}. 1559 {CEL00001995}. 1560 Roper {Day72/41:14-20}. 1561 {CEL00000006}. 1562 {CEL00002021/2}.

Part 3 | Chapter 24: Celotex RS5000 insulation 153 that the previous version did not give enough information to local authorities considering whether to approve the use of materials.1563 He had been prompted to take that course by concerns raised in relation to the certificate relating to Kingspan’s K15.1564 24.136 The new certificate was attached to Ms Li’s email. It stated that it had first been issued on 21 August 2014 and was valid until 21 August 2015.1565 It now stated on the first page that RS5000 complied with BR 135 for use in rainscreen applications on buildings over 18 metres in height, but referred the reader to the conditions of the certificate for more information. They made clear that RS5000 was acceptable for use on such buildings “subject to matching the specification criteria of the BRE fire test report 295255 carried out”. 24.137 Mr Roper, whose role as product manager of RS5000 had by this time passed to Debbie Berger, sent the email to Ms Berger on 3 November 2014, asking her to reply to the LABC with a request that it remove references to the fact RS5000 was the same product as FR5000.1566 Ms Berger replied to Samantha Li on 6 November 2014, attaching some suggested text which removed the reference to the test report and repeated the claim that RS5000 complied with BR 135 “subject to the board being fixed to a non- combustible substrate”. She also included a reference to a BBA certificate.1567 Ms Berger accepted that that her proposed text had been misleading,1568 as it suggested that the product could be used in any system with a non-combustible substrate and not merely the system that had been tested. Furthermore, it was not true that there was a BBA certificate relating to RS5000.1569 24.138 Later the same day Ms Berger sent Ms Li another email, observing again that the new certificate was available on the LABC website and asking for access to it to be restricted until they had sorted out the wording.1570 Ms Li replied, saying that she would check with her manager to see if they could prevent the page from being available to the public. The LABC appears to have treated that as a request for the registration to be withdrawn.1571 Celotex does not appear to have been told that the registration was being withdrawn, but we accept that it was removed from the LABC’s website as a result of its request. 24.139 Six months later Mr Ewing wrote to Celotex again, referring to concerns about the wording of certificates1572 and attaching a further revised certificate in draft.1573 The revised certificate was finally issued in September 2015,1574 long after the initial orders of RS5000 for Grenfell Tower had been placed. Handover to Debbie Berger 24.140 Ms Berger took over the role of product manager with responsibility for RS5000 from Mr Roper on 1 October 2014.1575 On 26 September she had a handover meeting with Mr Roper during which nothing was said about the use of 6mm magnesium oxide 1563 Ewing {Day217/122:13-25}-{Day217/123:1-3}. 1564 Ewing {Day217/123:16-20}. 1565 {LABC0000312}. 1566 {CEL00002021}. 1567 {CEL00002022}. 1568 Berger {Day78/75:2-8}. 1569 Berger {Day78/77:5-16}. 1570 {CEL00008691/2}. 1571 Phase 2 Module 2 – Written closing submission on behalf of LABC {LABC0019740/28} page 28, paragraph 73. 1572 {CEL00001286}. 1573 {CEL00003741}. 1574 {CEL00000389}. 1575 Berger {Day78/6:15-17}.

The Grenfell Tower Inquiry: Phase 2 Report 154 boards during the test in May,1576 although the concerns about the test raised by NHBC were mentioned.1577 Ms Berger discovered that the 6mm magnesium oxide boards had been used only later when she spoke to Mr Hayes on 24 October 2014 with a view to understanding the nature of the test in greater technical detail. His demeanour on that occasion led her to think that he had concerns about the test.1578 On 27 October 2014, Ms Berger obtained the full 32 page test report from Mr Roper1579 and met Mr Hayes again, either the same day or some days later, to discuss it. Mr Hayes told Ms Berger about the 6mm magnesium oxide boards and using a diagram showed her where on the rig they had been placed.1580 Ms Berger also made a note on her copy of the report, next to a diagram of the system before the test, with the expression “WTF? 6mm MgO + 8mm Marley Eternit panel”.1581 She had clearly been shocked by what she had been told.1582 Despite her shock, however, Ms Berger took no steps to alert her colleagues or anybody else to the fact that the report did not accurately describe the system tested.1583 Contact with BRE 24.141 On 8 October 2014 Jonathan Roome attended a CWCT conference,1584 at which Dr Sarah Colwell of BRE was one of the speakers. Mr Roome met her and together they arranged a meeting between her and one of her colleagues to discuss, as Mr Roome put it, how Celotex might improve its approach to marketing RS5000.1585 The meeting was planned for 4 November 2014. 24.142 A week later, on 17 October 2014, Stephen Howard of BRE sent an email to Mr Roper and Ms Berger referring to an earlier conversation about the content of the classification reports and the amount of technical detail they contained.1586 Ms Berger sent the message on to Mr Roome on 20 October 2014, saying that she would set up a meeting with Mr Howard to discuss how the report on RS5000 could be structured to provide relevant commercial information without disclosing anything sensitive.1587 24.143 In the event, Mr Roome and Ms Berger met Mr Howard on 4 November 2014. Dr Colwell did not attend. Notes of the meeting prepared by Ms Berger refer to growing uncertainty in the market, which had been “burnt by K15 approvals in the past”.1588 That was a reference to an unhappy experience which NHBC had had in the latter months of 2013 and thereafter with the BBA certificate for K15 and its widespread use above 18 metres.1589 Ms Berger noted that accreditation bodies required more information in order to give approvals and that further testing with a variety of facades was required. 1576 Berger {Day78/27:7-12}. 1577 {CEL00002555/2}. 1578 Berger {Day78/39:17-21}. 1579 {CEL00009742}. 1580 {CEL00002686}; Berger {Day78/41:23}-{Day78/42:4}. 1581 {CEL00008507/13}. 1582 Berger {Day78/52:14-19}. 1583 Berger {Day78/61:19-23}. 1584 {CEL00001255}. 1585 {CEL00001255}. 1586 {CEL00002131}. 1587 {CEL00002131}. 1588 {CEL00001260}. 1589 See Chapter 26 for the detailed analysis.

Part 3 | Chapter 24: Celotex RS5000 insulation 155 February 2015: market analysis slideshow 24.144 For the purpose of a meeting of the Service Product Innovation Group in February 2015 Mr Roome prepared a series of slides identifying three tiers of potential customers. (We have described the slides and what they depicted in Part 6, Chapter 56 dealing with the way in which Celotex RS5000 insulation came to be chosen for use in the refurbishment.) He denied that their implication was that the more ignorant a customer was of the restriction on the use of combustible insulation on buildings over 18 metres in height and the less well-equipped to ask difficult technical questions, the more likely it was that Celotex would be able to sell it RS5000,1590 but it is difficult to see how else they can be understood. 24.145 As we have said, the slides reflected a deeply cynical view that there were ignorant or reckless contractors in the market of whom advantage could be taken without any regard for the safety of occupants. 24.146 A very different approach to knowledgeable third parties can be seen in an email sent by Jamie Hayes to Paul Evans, Rob Warren and Louise Garlick on 25 March 2015 with advice on what to say where NHBC or LABC were involved and the client’s proposed construction differed from the system tested.1591 In the case of the LABC, potential customers were to be provided with a copy of the Compliance Guide and advised that, if they were using a substantially different design from the system tested, they should discuss the position with building control. If NHBC was involved, clients were to be provided with the Compliance Guide and told that Celotex did not support the use of RS5000 unless the design of the proposed system exactly matched the description given in its literature (although that did not in fact reflect the system that had been tested). Following discussions with Mr Evans, Mr Hayes subsequently promulgated an internal instruction at Celotex that in all cases where it provided a U-value calculation, and where it was asked whether a particular design complied with the Building Regulations, a copy of the Compliance Guide should be provided and customers told that it was the responsibility of building control to judge compliance.1592 Desktop study (March 2015) 24.147 In due course a meeting took place on 20 February 2015 between Frans Paap and Andrew Evans of Exova and Debbie Berger and Rob Warren of Celotex.1593 The notes of the meeting record that Exova needed to see the full test report and the Class 0 reports and refer to the need for a “case by case basis assessment”.1594 Ms Berger said that she had not understood that to mean that a separate desktop assessment would have to be made for each project.1595 24.148 On 18 March 2015 Ms Berger sent Mr Paap the full 32 page RS5000 test report. Her covering email set out four systems which she said were commonly presented to Celotex at the design stage and which she wanted Exova to assess: brickwork, a ventilated cavity with terracotta cladding, a ventilated cavity with A1 cladding and a ventilated cavity with a 1590 Roome {Day 69/81:23}-{Day69/82:4}. 1591 {CEL00003597} 1592 {CEL00003604}. 1593 Berger {CEL00010055/57} page 57, paragraph 213. 1594 {CEL00002691}. 1595 Berger {Day78/144:21-25}.

The Grenfell Tower Inquiry: Phase 2 Report 156 Class 0 aluminium rainscreen.1596 However, as she ought to have realised, any desktop study based on the test report was bound to be misleading and dangerous because the report did not correctly describe the system tested.1597 Exova’s draft report 24.149 Exova produced a draft report dated 7 May 2015.1598 It set out the test evidence relied on, which had been taken from the full 32-page BRE Report.1599 It did not refer to the 6mm magnesium oxide boards or the 8mm Marley Eternit boards because they did not appear in the report and Mr Paap had not been told about them.1600 24.150 The report concluded that all the designs set out in Ms Berger’s email would pass, save for the ventilated cavity system with aluminium Class 0 cladding. In respect of any such system, Exova concluded that it could not be judged with certainty to meet the performance requirements in BR 135.1601 The report was formally issued on 26 May 2015.1602 NHBC’s reaction 24.151 The draft report was presented to NHBC at a meeting on 19 May 2015 attended by Debbie Berger, Paul Evans and Rob Warren for Celotex and Graham Perrior, Steve Evans, David White and John Lewis for NHBC.1603 It was not well received by NHBC, which considered that its generic nature indicated a failure by Celotex to understand the purpose of desktop studies.1604 The monthly report to the management action group described the meeting as “quite heated”.1605 24.152 NHBC’s objections were set out in greater detail in an email sent by Mr Perrior to Mr Evans on 8 June 2015, which was sent on by Mr Evans to Ms Berger and Mr Warren. In it Mr Perrior identified a number of shortcomings and concluded that it appeared that the basis of Exova’s analysis did not reflect a true model of a ventilated facade or take fully into account the fact that a large part of the Marley rainscreen had caught fire.1606 NHBC did not, of course, know that the description of the system in the Exova report contained material omissions; its concern was whether a system such as that described would ever be built in practice. Mr Evans told us that he had been concerned by the fact NHBC thought Celotex’s position was untenable and that nothing, in effect, had changed in the year since their meeting on 19 June 2014. However, he intended to work with NHBC to understand what needed to be done to gain its acceptance.1607 The report to the management action group acknowledged that at some point it would be necessary to consider another test to broaden the scope of use of RS5000.1608 However, Celotex kept selling RS5000 and no further testing was undertaken before the fire at Grenfell Tower. 1596 {CEL00003589}. 1597 Evans {Day73/154:21}-{Day73/155:1}. 1598 {CEL00002040}. 1599 {CEL00002040/5}. 1600 Berger {Day78/149:13-24}. 1601 {CEL00002040/9}. 1602 {CEL00001116}. 1603 Berger {CEL00010055/61} page 61, paragraph 230; {CEL00003682}. 1604 Berger {Day78/156:22}-{Day78/157:6}. 1605 {CEL00003710/8}. 1606 {CEL00001122/2}. 1607 Evans {Day73/195:19-25}. 1608 {CEL00003710/8}.

157 Chapter 25 Certification of Celotex RS5000 by LABC Initial contact with LABC 25.1 On 29 October 2013, Jonathan Roper, Celotex’s Product Manager, spoke to Cathal Brennan, LABC’s Technical Co-ordinator about the possibility of obtaining an LABC certificate for RS5000. Mr Brennan informed his colleague David Ewing, the manager of LABC’s Registered Details Approval scheme,1609 of the conversation by email, telling him that Mr Roper had asked a number of questions about a competitor (by which he subsequently confirmed he meant Kingspan) and LABC’s relationship with it.1610 25.2 Celotex saw obtaining an LABC Registered Details Certificate as an important step in promoting RS5000,1611 in part because it would protect its use from the risk of challenge by building control officers.1612 Indeed, marketing material sent by LABC to Celotex included the claim that it could be considered a “fast track” through building control because, once it had been approved, local authority building control departments would not have to repeat the process.1613 25.3 Mr Roper subsequently met Mr Ewing on 18 November 2013 at Celotex’s offices to discuss the process of obtaining an LABC certificate. Mr Ewing understood that Celotex wanted a certificate to enable the product to compete with Kingspan K15.1614 He was not aware at that stage that RS5000 was the same as FR5000; he had believed that Celotex had been developing a new product.1615 25.4 At the meeting, Mr Roper questioned whether Kingspan K15 could be described as a material of limited combustibility (as it was in the LABC certificate then in force).1616 Mr Ewing was not able to answer that question, given his lack of knowledge at the time, so he asked David Jones, who had carried out the research leading to the issue of the certificate relating to K15.1617 25.5 On 19 December 2013 Mr Ewing sent Mr Jones an email seeking his assistance with Celotex’s question.1618 On 20 December 2013 Mr Jones responded, referring Mr Ewing to section 7 of the BBA certificate relating to K15, an extract from Kingspan’s technical literature and LABC’s internal assessment. Mr Jones told him that as K15 was described as Class 0, it could be termed a material of limited combustibility and so was suitable for use on buildings over 18 metres in height in accordance with Approved Document B. That was a fundamental misunderstanding on his part1619 and none of the material Mr Jones relied on supported that conclusion. Mr Ewing told us that he had not been sure that that answered his question, but he assumed that that was due to his own lack of 1609 Ewing {LABC0020139/4} page 4, paragraph 7.6. 1610 {LABC0008417}. 1611 Roper {Day72/26:9-16}. 1612 Roper {Day71/35:11-16}; {Day72/44:15-22}. 1613 {CEL00010021/1}. 1614 Ewing {Day218/143:1-11}. 1615 Ewing {Day218/143:12-20}. 1616 Ewing {Day218/147:18-20}. 1617 Ewing {Day218/147:22}-{Day218/148:4}. 1618 {LABC0005339}. 1619 Chapter 5.

The Grenfell Tower Inquiry: Phase 2 Report 158 understanding.1620 Nevertheless, he did not seek help from anyone else in attempting to understand it.1621 Mr Ewing passed the substance of Mr Jones’s response on to Mr Roper on 2 January 2014.1622 Mr Roper replied on 3 January 2014, stating that Celotex was confident that it could also prove that RS5000 was classified as Class 0.1623 He realised that LABC had made a fundamental mistake but thought that it was viewed as advantageous to Celotex and therefore did not correct Mr Ewing.1624 Registered Detail 491 25.6 Following the test in accordance with BS 8414-2:2005, on 2 May 2014, Mr Roper contacted Mr Ewing again on 15 May 2014 to confirm that Celotex wanted to pursue an application for an LABC Registered Details Certificate.1625 Tim Bartlett of West Suffolk District Council had been identified by LABC as a suitable person to assess the product because he was on LABC’s registration and partnerships group and regularly involved in peer reviews, but no steps had been taken to ascertain his level of understanding of Approved Document B.1626 25.7 Mr Bartlett visited Celotex’s office1627 during the week of 9 June 2014 to discuss the application. Following his visit, Mr Roper provided what he called the “first batch” of information to support the application and set out the wording that Celotex was seeking to have included in the certificate.1628 It read as follows: “ – Celotex RS5000 can be used with a variety of cladding systems (including masonry or rainscreen systems) and can be fixed back to a structural steel frame with a sheathing board or direct back to masonry. … – Celotex RS5000 has successfully tested to BS 8414:2 2005, meets the criteria set out in BR 135 and therefore is acceptable for use in buildings with storeys above 18m in height (subject to the board being fixed to a non-combustible substrate) alternative compliance to AD B. – The product has Class 0 fire performance.” 25.8 That description of RS5000’s fire performance had been taken almost directly from Appendix A to the Registered Details certificate for K15.1629 Mr Ewing thought he had realised at the time that Celotex was effectively seeking the same broad statements that had been made in respect of Kingspan K15.1630 25.9 Mr Roper sent a further email to Mr Bartlett on 17 June 2014 providing a copy of a letter from BRE confirming that a system incorporating RS5000 had been tested in accordance with BS 8414-2 and that a test report and classification document under BR 135 was being issued.1631 The letter did not give any details about the system that had been tested, nor did it say what conclusions BRE had drawn when classifying it.1632 1620 Ewing {Day218/150:11-24}. 1621 Ewing {Day218/151:5-11}. 1622 {LABC0001706}. 1623 {LABC0001706}. 1624 Roper {Day72/32:15}-{Day72/33:23}. 1625 {LABC0001706}. 1626 Ewing {Day218/153:16}-{Day218/154:10}. 1627 {LABC0000279}. 1628 {LABC0000279}. 1629 {LABC0001001/2}; Roper {Day72/41:4-24}. 1630 Ewing {Day218/155:11-25}. 1631 {LABC0000329/3}. 1632 {LABC0000285}.

Part 3 | Chapter 25: Certification of Celotex RS5000 by LABC 159 25.10 Notwithstanding that, on 30 June 2014 Mr Bartlett sent an email to Mr Brennan telling him that that was his last day at West Suffolk and that although he had not been able to finalise Celotex’s certificate pending provision of further information, once that information was available he expected it to satisfy the requirements.1633 Among the information that was yet to be received was the BR 135 classification report from BRE.1634 Mr Bartlett attached to his email a draft Compliance Declaration form, Drawing and Documents List and a briefing note which stated: “Celotex RS5000 has been successfully tested to BS 8414:2 2005, meets the criteria set out in BR135 and therefore is acceptable for use in buildings with storeys above 18m in height (subject to the board being fixed to a non- combustible substrate) alternative to compliance to AD B.”1635 That was the very wording that had been requested by Jonathan Roper and was used by Celotex as a central plank of its marketing strategy. By suggesting, and then relying on, untrue and misleading statements of that kind it hoped to avoid challenge by building control officers.1636 However, a statement that Celotex RS5000 had been successfully tested to BS 8414 and met the criteria set out in BR 135 could never properly be made, since such claims could be made only in relation to the system as a whole and not in relation to individual components. It is remarkable that LABC saw fit to prepare a draft of that kind without having seen the classification report itself. Its approach was fundamentally flawed.1637 However, at the time no one at LABC challenged Mr Bartlett’s approach or the claims made about the product’s performance. Mr Ewing accepted that he might have been under the misapprehension at the time that if a product had formed part of a system which had obtained a classification report in accordance with BR 135, it could be used on any buildings above 18 metres in height.1638 25.11 In the event, despite having left West Suffolk, Mr Bartlett continued to be involved in the assessment process for RS5000. On 24 July 2014, he sent an email to Mr Brennan (with a copy to Mr Ewing) attaching further documents for the RS5000 certificate and indicating that it was ready for peer review.1639 Among the attachments to that email were BRE’s letter of 17 June 20141640 and a Class 0 classification report for RS5000 dated 14 July 2014.1641 No BR 135 classification report was attached, not least since LABC had not received one. Further, none of the attachments described the system that had been tested or how it had performed against the criteria in BR 135. Mr Bartlett told Mr Ewing that Celotex was still waiting for the test report but had provided the letter from BRE in the hope that LABC would accept it as sufficient proof of compliance.1642 25.12 On the same day, Mr Brennan circulated the Compliance Declaration, Drawings and Document List and details of RS5000 to the peer review group.1643 Mr Bartlett responded the same day, attaching a draft certificate,1644 the wording of which stated that RS5000 was suitable for use on buildings over 18 metres in height.1645 1633 {LABC0000306}. 1634 Ewing {Day218/158:3-11}. 1635 {LABC0000345/2}. 1636 Roper {Day72/44:15}-{Day72/45:6}; {Day72/46:15-18}. 1637 Ewing {Day218/158:12-16}. 1638 Ewing {Day218/158:17-21}. 1639 {LABC0000339}. 1640 {LABC0000342}. 1641 {LABC0000344}. 1642 {LABC0005566}. 1643 {LABC0005564}. 1644 {LABC0000369}. 1645 {LABC0000370}.

The Grenfell Tower Inquiry: Phase 2 Report 160 25.13 On 8 August 2014, Mr Ewing sent an email to Cathal Brennan and Sam Li Muller noting that Celotex had still not provided a BR 135 classification report.1646 He observed that that was an important document as LABC was under scrutiny from NHBC regarding its certification of Kingspan K15.1647 He said that the certificate for RS5000 should not be issued until the report had been received.1648 25.14 Later that day, an LABC employee, Robert Adungo, sent an email to Mr Brennan noting that Celotex’s publicity for the launch of RS5000 included the claim that it was “supported by LABC approval”. That was not correct, because LABC had not issued a certificate. Nonetheless, Mr Brennan told Celotex that it could refer to LABC at the product launch, presumably in a way that implied that LABC had approved, or was going to approve, the product.1649 Mr Brennan said that he had acted on the basis of a misunderstanding of BRE’s letter of the 17 June 2014 and on the fact that RS5000 had received four votes at the peer review stage.1650 However, the holding letter from BRE did not provide any basis for a claim of that kind and those who carried out the peer review had not themselves been provided with a classification report and so had no basis for reaching any final view about the product’s compliance with the statutory guidance.1651 That was plainly not an acceptable approach.1652 25.15 Mr Ewing sent an email to Mr Roper shortly after, asking for the classification report.1653 Mr Roper responded, attaching a copy of the BR 135 classification report.1654 Mr Ewing sent it on to Mr Brennan, with the comment that it contained everything needed to satisfy the criteria in paragraphs 12.5 and 12.6 of Approved Document B. However, in saying that Mr Ewing was still labouring under the misapprehension that the classification report provided some form of general support for the use of RS5000 on buildings over 18 metres in height, which was not the case.1655 25.16 Despite having been alerted to the fact that Celotex’s marketing and promotional materials included a claim that RS5000 had its approval, notwithstanding that it had not issued a certificate for the product, LABC did not attempt to make Celotex correct that statement or remonstrate with it for making a misleading claim.1656 25.17 On 11 August 2014, Mr Bartlett confirmed that, having seen the classification report, everything appeared to be in order, although he noted that it related to the particular system tested rather than the use of RS5000 on buildings over 18 metres in height generally. He therefore questioned whether the certificate should be limited to the specific system tested.1657 In response, Mr Ewing confirmed that the certificate should relate to what had been tested,1658 but then expressed the view that the rainscreen construction was relatively standard, a comment for which, as he accepted, there had been no basis.1659 Despite that fact, the LABC issued a certificate which implied generic 1646 {LABC0005598}. 1647 As to that, see Chapter 23. 1648 {LABC0005598}. 1649 {LABC0005601}. 1650 {LABC0005601}. 1651 Ewing {Day218/175:18}-{Day218/176:9}. 1652 Ewing {Day218/172:18-23}. 1653 {LABC0000288/2}. 1654 {LABC0000288}; {LABC0000289}. 1655 Ewing {Day218/178:15-17}. The question put to Mr Ewing referred to K15 but was clearly intended to refer to RS5000. 1656 Ewing {Day218/180:4-11}. 1657 {LABC0005608}. 1658 {LABC0005608}. 1659 Ewing {Day218/181:21-24}.

Part 3 | Chapter 25: Certification of Celotex RS5000 by LABC 161 approval for the use of RS5000 on buildings over 18 metres in height.1660 The certificate was effective from 21 August 2014 until 21 August 2015.1661 It was accompanied by a Drawing and Document List. The contents of the certificate are set out in detail in Chapter 24. We reiterate that it gave an untrue and misleading impression that RS5000 was suitable for use on buildings over 18 metres in height generally. Withdrawal and reissue of registered detail certificates for RS5000 25.18 In early November 2014, Sam Li Muller, a Consult and Technical Administrator at LABC, sent an email to Jonathan Roper explaining that LABC had changed the format of its certificates and attaching the certificate for RS5000 in the new style.1662 The new certificate stated that it had first been issued on 21 August 2014 and was valid until 21 August 2015.1663 It now stated on the first page that RS5000 “complies with BR 135 for use in rainscreen applications above 18 metres in height”, but referred the reader to the conditions of the certificate for more information. The conditions made clear that RS5000 was acceptable for use on buildings above 18 metres in height, “subject to matching the specification criteria of the BRE fire test report 295255 carried out”.1664 25.19 Mr Roper forwarded that email to Ms Berger at Celotex,1665 who was by then the product manager for RS5000. She responded to Ms Li Muller seeking changes to the wording and attaching suggested text that removed the reference to the test report and repeated the claim that RS5000 complied with BR 135 “subject to the board being fixed to a non-combustible substrate”, referring to a BBA certificate that in fact related to FR5000.1666 25.20 Discussions about the suggested changes took place between Ms Li Muller, Mr Brennan and Mr Ewing throughout November 2014.1667 Meanwhile, Ms Berger had noticed on 6 November 2014 that the new-style certificate was available on the LABC website and asked the LABC to limit access to it until the wording had been sorted out.1668 Ms Li Muller said she would check with her manager to see if they could prevent the page from being visible to the public and as a result access to it was withdrawn. 25.21 On 12 May 2015 Mr Ewing sent Ms Berger an email to which he attached a revised certificate.1669 He explained there had been concern that earlier LABC certificates implied general approval for the use of thermosetting insulation materials on buildings over 18 metres in height, which he said had never been the intention.1670 The attached document was watermarked “Draft”.1671 25.22 The revised certificate, under the heading “Description of Product”, stated that RS5000 had been assessed by BRE and “complies with BR135 for use in rainscreen applications above 18 metres in height subject to the board being fixed to a non-combustible substrate *see condition of certificate for more information”.1672 The first line under the heading “Conditions of Certificate” read “For use in rainscreen wall constructions including 1660 {LABC0000360}, {LABC0000361} and {LABC0000362}. 1661 {LABC0000358} and {LABC0000359}. 1662 {CEL00002021/2}. 1663 {LABC0000312}. 1664 {LABC0000312/2} 1665 {CEL00002021}. 1666 {CEL00002022}. 1667 {LABC0002803}; {LABC0001780}. 1668 {CEL00008691/2} 1669 {LABC0000332}. 1670 {LABC0000332}. 1671 {LABC0000333}. 1672 {LABC0000321}.

The Grenfell Tower Inquiry: Phase 2 Report 162 above 18m in height”. Further down and within a different sub-paragraph it read “This classification is only valid for the system specification and detailing outlined in section 2 of the BRE classification report 295255…”.1673 No one could explain why that information had not been given greater prominence. Mr Ewing accepted that the certificate could have been drafted in a much clearer way to avoid confusion.1674 25.23 The new-style LABC certificate was eventually published on 10 September 2015.1675 A further (and final) LABC certificate was issued on 19 August 2016 in very similar terms to that which had been issued on 10 September 2015, save that it included details of the system which had been tested.1676 That certificate was withdrawn on 16 June 2017 in the aftermath of the Grenfell Tower fire.1677 25.24 It was Mr Ewing’s understanding that there had been no certificate for RS5000 in place or available on LABC’s website between November 2014 and July 2015, but he could not be sure whether Celotex had been told that or that it had been told that it should not use the certificate that had been issued.1678 He was unable to recall why he had sent an email to Ms Li Muller on 1 July 2015 asking her to check which certificate was publicly available.1679 He could not state categorically that the certificate had been removed.1680 In its written closing statement for Module 2, LABC referred to Ms Berger’s email of 6 November 2014 as a request for the registration to be withdrawn,1681 to which the LABC had acceded. However, the correspondence was not expressed in that way and we have seen no evidence to suggest that Celotex was told that the certificate had been withdrawn. 25.25 Even if the certificate had been removed, Celotex could not reasonably have understood that to have been the case from the messages they received from LABC. Although Mr Ewing sent the ‘new style’ certificate to Celotex, the version held by LABC was still marked as a draft as late as May 2015. At no stage did LABC clearly state that the certificate issued in August 2014 for RS5000 was no longer valid and there was no formal process through which information of that kind could be expected to be communicated.1682 25.26 In those circumstances, Mr Ewing’s assumption that Celotex realised that a new certificate had been issued and would act with integrity by not relying on the old certificate, knowing it had been changed,1683 was naïve. Yet again, LABC failed to communicate properly with Celotex and failed to take proper steps to ensure that it understood that the previous certificate (which stated on its face that it was valid until August 2015) should not be used. There is no evidence that LABC took any steps to inform local authority building control departments or approved inspectors (in particular NHBC) that the old certificate could no longer be relied on. Plainly, it should have done so. 1673 {LABC0000321}. 1674 Ewing {Day218/201:1-6}. 1675 {LABC0000321}; Ewing {Day218/201:7-10}. 1676 {LABC0000337}. 1677 {LABC0020139/48} 1678 Ewing {Day218/194:21}-{Day218/195:17}. 1679 {LABC0000330}. 1680 Ewing {Day218/203:16}-{Day218/204:5}. 1681 Phase 2 Module 2 Closing Submissions {LABC0019740/28} page 28, paragraph 73. 1682 Ewing {Day218/205:2}-{Day218/206:8}. 1683 Ewing {Day218/195:11-17}.

163 NHBC and associated organisations 26.1 The National House Building Council (NHBC) is the largest provider of warranties for newly built properties in the UK and (through its subsidiary) the largest private building control body in England and Wales.1684 NHBC did not provide building control or warranty services for the Grenfell Tower refurbishment, but it had (and retains) a major influence over standards in the housebuilding industry.1685 Its dealings with Kingspan and DCLG (“the department”), in particular Brian Martin, in the period 2010 to 2016 are revealing. 26.2 NHBC was established in 1936 in order to respond to what was seen as the poor quality of construction provided by the housebuilding industry.1686 At the time of the Grenfell Tower refurbishment it provided warranties of the quality of construction in the form of its “Buildmark” warranty and building control services as an approved inspector under the Building Act 1984. In both contexts it occupied a dominant position in the private sector market, supplying over 80% of warranties on newly built properties1687 and about 60% of the services provided to the residential market by approved inspectors.1688 26.3 NHBC is a private company limited by guarantee,1689 meaning that it retains any profits it makes rather than distributing them to shareholders.1690 Warranties are issued by the company itself, whereas building control services are provided by NHBC Building Control Services Ltd (NHBC BCS), a profit-making company of which NHBC is the sole shareholder.1691 26.4 The “Buildmark” warranty is a policy of insurance. Although the standards required for a property to be eligible for a “Buildmark” warranty were set by the Standards department of NHBC, the wording of the policy and its underwriting were handled by a different department.1692 The issue of warranties was carried out separately from the provision of building control services.1693 26.5 Oversight of both warranty and building control operations was provided by NHBC’s Technical Services Department; Steve Evans was the Building Control Manager and John Lewis one of the specialist surveyors.1694 John Lewis reported to Steve Evans who in turn reported to Diane Marshall in her role as Head of Technical Services. She in her turn 1684 Evans {Day219/17:5}-{Day219/18:17}. 1685 Evans {NHB00003020/13} page 13, paragraph 36(c). 1686 Evans {NHB00003020/4} page 4, paragraph 15. 1687 {NHB00003501}. 1688 Evans {Day219/18:4-17}. 1689 Evans {NHB00003020/4} page 4, paragraph 15. 1690 Evans {Day219/19:5-25}. 1691 Evans {Day219/19:5-25}. 1692 Evans {Day225/82:9}-{Day225/83:4}. 1693 Evans {NHB00003020/5} page 5, paragraph 18 (b). 1694 Evans {NHB00003020/6} page 6, paragraph 18 (c). Chapter 26 The National House Building Council

The Grenfell Tower Inquiry: Phase 2 Report 164 reported to Ian Davis, the Operations Director, who was a member of NHBC’s board of directors.1695 Ms Marshall occasionally reported directly to the board in respect of technical matters and the financial affairs of NHBC BCS.1696 26.6 The Technical Services Department contained a group set up specifically to deal with projects over eight storeys in height. It was called the Major Projects Team.1697 NHBC did not, however, employ any specialist fire engineers after 2008 and it was not until John Lewis completed a Masters’ degree in fire and explosion engineering in 2013 that the teams had access to any internal fire safety expertise.1698 Even during that period, Mr Lewis’s work was never reviewed by anyone with equivalent qualifications.1699 Mr Lewis was joined by another fire engineer, Maulik Katkoria, in 2016.1700 The Building Control Alliance 26.7 The Building Control Alliance (BCA) was formed in 2008 with five member organisations, the Association of Consultant Approved Inspectors (ACAI), Local Authority Building Control (LABC), the Royal Institution of Chartered Surveyors (RICS), the Chartered Institute of Building (CIB) and the Chartered Association of Building Engineers (CABE).1701 The alliance was established to promote the role of building control bodies, respond to government proposals, provide mediation services and provide a unified view on areas of uncertainty in the Building Regulations. It was, at least in part, a response to a government review of building control and opposition from building control bodies to a proposed relaxation of building control requirements.1702 It was later incorporated as a limited company.1703 Although the BCA published guidance for the construction industry, it had no statutory standing and was an unregulated, voluntary, professional body.1704 26.8 NHBC was not itself a member of the BCA, but it was a member of the ACAI, through which it was actively involved in the BCA.1705 Steve Evans was a founding member of the BCA executive board and was chair of the Technical Group from 2010 until 2019.1706 He was involved in publishing guidance notes, including Technical Guidance Note 18 first published in June 2014.1707 Diane Marshall was a member of the BCA’s executive committee from its inception in 2007.1708 NHBC’s knowledge of Kingspan K15: 2010 26.9 By 2010 at the latest, NHBC was aware that combustible insulation was commonly being used in the external walls of buildings over 18 metres in height. In April of that year BRE published a report entitled Fire performance of highly insulated residential buildings and modern methods of construction: A literature review1709 that had been commissioned by NHBC Foundation, a body established and funded by NHBC to carry out research and 1695 Lewis {NHB00003433/5} page 5, paragraph 18 (c) and {NHB00002769}; Marshall {Day225/79:9-18}. 1696 Marshall {Day225/79:9-18}. 1697 Lewis {Day223/7:9-14}. 1698 Lewis {Day223/5:24}-{Day23/6:20}. 1699 Lewis {Day223/7:5-8}. 1700 Lewis {Day223/6:21}-{Day223/7:1}. 1701 Evans {NHB00003020/59} page 59, paragraph 164 (b). 1702 Evans {Day219/38:15}-{Day219/40:5}; Turner {LABC0011202/28} page 28, paragraph 92. 1703 Evans {NHB00003020/59} page 59, paragraph 164 (f). 1704 Evans {Day219/53:14}-{Day219/55:4}. 1705 Evans {Day219/41:22}-{Day219/42:12}. 1706 Evans {NHB00003020/60} page 60, paragraph 166-167. 1707 Evans {NHB00003020/61} page 61, paragraph 168. 1708 Marshall {NHB00003434/4} page 4, paragraph 16; Marshall {Day225/86:4-7}. 1709 {NHB00000452}.

Part 3 | Chapter 26: The National House Building Council 165 provide guidance to the house-building industry. During the preparation of the report, BRE consulted a group of industry professionals that included two representatives of NHBC, John Lewis and Dave White.1710 Mr Lewis confirmed that he had read the report at around the time of its publication.1711 26.10 The report contained a detailed explanation of the principal regulatory requirements applicable to residential buildings and the materials that were commonly used to construct them. It warned that the growing prevalence of modern insulation products meant that the fire load within dwellings had increased leading to a greater risk of fire spreading through the fabric of the building.1712 It concluded that the materials being used in the construction of modern buildings appeared to be resulting in increasingly large fire losses.1713 26.11 Mr Lewis accepted that by April 2010 at the latest he had been aware that combustible insulation was being used much more commonly in the external walls of buildings over 18 metres in height1714 and that the most commonly used product was Kingspan K15.1715 He said that Kingspan K15 was commonly accepted by fire engineers on the basis of its BBA certificate and that NHBC relied heavily on Kingspan’s own assurances concerning the way in which its products could be used.1716 For her part, Diane Marshall said that it had been NHBC’s practice until 2015 to allow the use of Kingspan K15 on buildings over 18 metres in height, again on the basis of the BBA certificate.1717 The BBA certificate 26.12 The first BBA certificate for Kingspan K15 was issued on 27 October 2008. It referred to one successful test in accordance with BS 8414 Part 1 in 2005.1718 It stated that Kingspan K15 might be used in accordance with paragraphs 12.5 and 12.6 of Approved Document B,1719 but warned that advice should be sought from the certificate holder if the product were being considered for use on buildings over 18 metres in height.1720 That statement remained in the version of the BBA certificate that was amended in April 2010 and published in July 2013.1721 26.13 Seeking advice from the manufacturer in that way was not a route to compliance with the functional requirement of the Building Regulations indicated by Approved Document B. Kingspan could never have given any advice sufficient to satisfy the guidance in Approved Document B or the requirements of the Building Regulations other than that the system proposed for use was or was not the same as that which had been the subject of the 2005 test.1722 It should have been obvious to any properly informed reader of the BBA certificate that Kingspan’s own advice could not safely be relied upon. 26.14 Nonetheless, NHBC did exactly that. Steve Evans told us that NHBC had been satisfied with a letter from Kingspan’s technical department stating that the proposed system was acceptable without knowing anything about the knowledge or experience of the writer and 1710 {NHB00000452/6}. 1711 Lewis {Day223/17:8}. 1712 {NHB00000452/5}. 1713 {NHB00000452/9}. 1714 Lewis {Day223/19:5-7}. 1715 Lewis {NHB00003433/7} page 7, paragraph 26. 1716 Lewis {NHB00003433/7} page 7, paragraph 26; Lewis {Day223/22:21}-{Day223/23:20}. 1717 Marshall {NHB00003434/17} page 17, paragraph 72. 1718 {BBA00000038/5}. 1719 {BBA00000038/5-6}. 1720 {BBA00000038/6}. 1721 {BBA00000037/5}. 1722 Lewis {Day223/152:1-19}.

The Grenfell Tower Inquiry: Phase 2 Report 166 without any guidance from NHBC about what technical information it should contain.1723 He told us that it was for the NHBC surveyor receiving the letter to decide whether it contained enough information to enable him to approve the use of K15 on a building over 18 metres in height.1724 26.15 Diane Marshall sought to justify NHBC’s reliance on assurances by Kingspan by referring back to the BBA certificate itself.1725 She appeared to think that the effect of the recommendation that advice should be sought from the certificate holder was effectively to enable Kingspan to certify that its products could be used in applications which bore no relation to that on which the BBA certificate was based. 26.16 If that was her belief it overlooked two matters of fundamental importance: first, that reliance on the advice of the manufacturer of a product could never have been a proper way of ensuring compliance with the Building Regulations, and secondly, as Ms Marshall accepted, the advice Kingspan provided was generally no more than a bald assertion that K15 was suitable for the project, without any technical assessment or analysis.1726 Paragraph 12.7 of Approved Document B 26.17 When it was revised in July 2013, the BBA certificate included a new statement that Kingspan K15 could be used in accordance with paragraph 12.7 of Approved Document B, which required insulation products used in buildings over 18 metres in height to be materials of limited combustibility.1727 K15 was not a material of limited combustibility and the reference to paragraph 12.7 was therefore clearly wrong. That mistake should have been obvious to all at NHBC who knew, or should have known, that it was a phenolic foam and therefore combustible.1728 26.18 Despite that, no one at NHBC said anything to the BBA about the error in the certificate until July 2015. The witnesses from whom we heard sought to justify that omission by relying on the Approved Document providing guidance on regulation 7 of the Building Regulations 2010.1729 Paragraph 1.15 of that document stated that an independent product certification scheme might indicate that a material is suitable for its intended purpose and use, but the operative word there is “might”.1730 Paragraph 1.18 stated that past experience, such as use in an existing building might show that a product could perform the function for which it was intended, but again, the operative word is “might”.1731 Neither of those paragraphs detracts from the clear requirements of functional requirement B4(1) and the guidance in Approved Document B. If those at NHBC thought they did, they were wrong. Diane Marshall ultimately accepted that the guidance in the Approved Document on regulation 7 could have no bearing on paragraph 12.7 of Approved Document B but she insisted that it provided an alternative route to compliance with functional requirement B4(1).1732 1723 Evans {Day219/126:19}-{Day219/135:5}. 1724 Evans {Day219/133:12}-{Day219/134:1}. 1725 Marshall {Day225/155:3}-{Day225/158:22}. 1726 See for example the Kingspan letter of 13 January 2014 to Mount Anvil in respect of its Eagle House project {KIN00002663}; Marshall {Day225/155:3-6}. 1727 {BBA00000037/5}. 1728 Marshall {Day225/115:15}-{Day225/116:11}; Evans {Day219/66:1-4}; Lewis {Day223/37:1-4}. 1729 {INQ00014930}. 1730 {INQ00014930/13}. 1731 {INQ00014930/14}. 1732 Marshall {Day225/101:4-7}.

Part 3 | Chapter 26: The National House Building Council 167 26.19 In support of that position, Ms Marshall appeared to rely on a section in Approved Document B entitled “Use of Guidance”, which stated that building control bodies might accept the certification of products under approved product certification schemes as evidence that they complied with a relevant standard.1733 She appeared to think that a building control body need look no further than, for example, a BBA certificate, nor examine its contents critically, when deciding whether a product was suitable for use, even when some of the statements in it were obviously wrong.1734 We cannot agree. It should have been clear to everyone at NHBC that there was nothing in regulation 7 or Approved Document B that could justify such a perverse outcome. We read regulation 7 and that paragraph in Approved Document B as saying no more than that ordinarily a building control body should be able to rely on statements in certificates issued by certification bodies accredited by UKAS, but not that they are entitled to do so in the face of ambiguity or obvious error. Internal discussions about K15: August to November 2013 26.20 On 28 August 2013, Steve Cook (NHBC’s Area Technical Manager for London) wrote to Steve Evans saying that the question of using what he referred to as “non-combustible cavity insulation” in buildings with a storey over 18 metres in height was causing a lot of concern to customers.1735 He asked whether NHBC was in possession of any guidance on the issue or whether it might be able to encourage Kingspan to test its K15 and K12 products to achieve certification as non-combustible. Steve Evans replied that NHBC had no involvement in the testing carried out by Kingspan, but that he would discuss with John Lewis whether NHBC might be able to draft some guidance.1736 26.21 Mr Cook may have used the phrase “non-combustible” as shorthand for having limited combustibility, or perhaps he did not understand the difference. Either way, Mr Lewis and Mr Evans both told us that they knew at the time those emails were exchanged that Kingspan K15 was combustible and should not be used in the external walls of buildings above 18 metres in height.1737 However, neither of them could recall having discussed the matter or reaching any consensus on NHBC’s approach to Kingspan K15 at that time.1738 Certainly, no new guidance was issued. 26.22 On 16 October 2013, John Lewis and Steve Cook received an email from a project surveyor in NHBC’s Technical Services department. The surveyor said, in summary, that he did not think that Kingspan K15 was a material of limited combustibility but had become aware of a colleague in NHBC who believed that it was and had consequently been accepting its use on buildings above 18 metres in height.1739 Mr Cook responded the following day, saying that any insulation used on high-rise buildings was required to be a material of limited combustibility but that Kingspan did not have test evidence to show that K15 met that requirement.1740 26.23 Although John Lewis claimed that those emails indicated confusion about whether Kingspan K15 was acceptable for use on high-rise buildings, both he and Steve Evans conceded that they had known that paragraph 12.7 of Approved Document B advised 1733 {CLG00000224/7}. 1734 Marshall {Day225/114:1}-{Day225/120:13}. 1735 {NHB00000583}. 1736 {NHB00000583}. 1737 Evans {Day219/65:1-4}; Lewis {Day223/36:15}-{Day223/37:4}. 1738 Evans {Day219/71:15}-{Day219/72:3}; Lewis {Day223/40:20}-{Day223/41:5}. 1739 {NHB00000587}. 1740 {NHB00000587}.

The Grenfell Tower Inquiry: Phase 2 Report 168 that insulation materials should be of limited combustibility and that Kingspan K15 did not meet that guidance.1741 Nonetheless, NHBC was routinely accepting it for use on high-rise buildings.1742 John Lewis sought to justify that approach, again by reference to regulation 7 of the Building Regulations. He conceded, however, that he had never checked whether regulation 7 supported NHBC’s approach and could not recall anyone else at NHBC having done so.1743 Had he done so, we think he would have reached the clear conclusion that it did not. 26.24 John Lewis was shown an email sent by Chris Macey of Wintech, the façade engineering consultants, to Dave White of NHBC on 4 October 2013 in which Mr Macey said that Kingspan K15 was not a material of limited combustibility.1744 Mr Macey noted that K15 was widely used and said that Kingspan’s marketing material wrongly implied that it was suitable for all applications. He expressed the view, which he said was shared by BRE, that it should not be used without supporting documentation or test data to confirm its acceptability. Mr Lewis rightly accepted that what Mr Macey had said was correct.1745 26.25 In his email, Chris Macey offered to meet NHBC in order to explain Wintech’s concerns, and Dave White began to make arrangements for a meeting.1746 We return to that meeting below. 26.26 Meanwhile, on 31 October 2013, Brian Stevenson, Steve Cook and Paul Williams, three Area Technical Managers employed by NHBC in its Technical Services department, exchanged emails concerning Kingspan K15. Mr Williams said that he had been told that NHBC was no longer accepting K15 on the basis that it was combustible and asked whether NHBC’s surveyors had been advised accordingly. Mr Cook said that most surveyors were aware of that view. Mr Stevenson responded that he was certainly not aware that it was NHBC’s policy not to accept K15,1747 which it had previously accepted on the basis that it held a BBA certificate.1748 Mr Lewis told us that he was surprised by Mr Stevenson’s ignorance of that matter.1749 26.27 On 4 November 2013, Paul Williams wrote to NHBC’s south-west area technical team saying that John Lewis and Steve Evans were reviewing whether K15 could be accepted for use on high-rise buildings, as NHBC had doubts about its combustibility.1750 In reality, as we have said above, neither Steve Evans nor John Lewis had any such doubts: they both knew perfectly well that K15 was combustible and thus did not meet the guidance in paragraph 12.7 of Approved Document B for use in the external walls of buildings over 18 metres in height. 26.28 Chris Cooley, a Project Surveyor in the Technical Services Department, responded to Mr Stevenson on 8 November 2013 asking how long the promised review would take. He also asked what the alternatives were to using K15 and pointed out that there were no other foam insulation boards that were of limited combustibility and therefore mineral wool was the only material that could be used on high-rise buildings. He stressed that surveyors needed to communicate their requirements at the outset of any design process 1741 Lewis {Day223/45:4-9}; Evans {Day219/81:2-13}. 1742 {NHB00000587/2}; Evans {Day219/78:1}-{Day219/82:12}; Lewis {Day223/46:14}-{Day223/47:7} 1743 Lewis {Day223/47:8}-{Day223/48:15}. 1744 {NHB00000585}. 1745 Lewis {Day223/50:20}. 1746 {NHB00000585/1}. 1747 {NHB00000589}. 1748 Stevenson {NHB00003524/2} paragraphs 10-11. 1749 Lewis {Day223/53:6-9}. 1750 {NHB00000594/3}.

Part 3 | Chapter 26: The National House Building Council 169 and warned that a refusal by NHBC to accept K15 would give rise to a major problem with customers who relied on foam board insulation to achieve required U-values.1751 Mr Cooley warned that Mr Evans should be prepared to receive a barrage of enquiries. That message worked its way up to Steve Evans the same day.1752 Mr Evans could have been in no doubt, by that point, therefore, about the serious consequences of NHBC’s building control officers’ having routinely accepted the use of K15 on high-rise buildings in the past and continuing to do so. However, NHBC did not immediately act on what it now knew. 26.29 Although Mr Lewis candidly accepted that a change in NHBC’s position on K15 would have resulted in a lot of angry customers, he denied that its failure to act was motivated by commercial considerations.1753 Likewise, Ms Marshall denied that the likely reaction of customers was a factor in its continued acceptance of K15; she said it had not been taken into consideration.1754 In our view, however, in the light of Chris Cooley’s email that was not credible. 26.30 Ultimately, Mr Evans came to accept that the NHBC’s failure to adopt a tougher stance on K15 had indeed been motivated by the likely reaction of its customers. He said that what he characterised as a “knee-jerk” reaction would have caused a lot of disruption to NHBC, which wished to get hold of all the facts before it made a decision.1755 He claimed that NHBC continued to permit the use of K15 because it had no information that it was not safe,1756 but K15 could not be regarded as safe for use on buildings over 18 metres in height since it was not a material of limited combustibility and its use did not comply with paragraph 12.7 of Approved Document B, as NHBC well knew. Furthermore, NHBC also knew that K15 had been and was still being approved for use in the external walls of high- rise buildings which were not constructed in the same way and with the same components as the system that Kingspan had tested in 2005.1757 In those circumstances, NHBC had no reason to think that K15 was generally safe for use on high-rise buildings and every reason to challenge the claim in Kingspan’s marketing literature that it was. NHBC’s continued endorsement of its use from then on was unjustifiable and amounted to an abdication of its responsibility. Meeting with Wintech: 15 November 2013 26.31 The meeting between Wintech and NHBC took place on the morning of 15 November

1. John Lewis, Dave White and Graham Perrior represented NHBC; Stuart Taylor and

David Watakabi represented Wintech. John Lewis said that meeting had been responsible for bringing concerns about K15 to the forefront of his mind.1758 26.32 In the hours following that meeting, Mr Lewis compiled a note of the discussions, together with a draft of what he described as an internal guidance note, which he circulated at 14.45 the same day.1759 The second paragraph of Mr Lewis’ note is of particular importance. It described how Wintech had outlined the route to compliance, as recommended in Approved Document B, and set out in bullet points three ways of following it, which formed 1751 {NHB00000594/3}. 1752 {NHB00000594/1}. 1753 Lewis {Day223/60:17-22}. 1754 Marshall {Day225/161:10-19}. 1755 Evans {Day219/222:3-20} 1756 Evans {Day219/223:2-17; {Day219/174:11}-{Day219/175:21}. 1757 John Lewis’s email of 19 November 2013 {NHB00000604/1}. 1758 Lewis {NHB00003433} page 12, paragraph 47. 1759 {NHB00000604/4}; {NHB00000605}.

The Grenfell Tower Inquiry: Phase 2 Report 170 the basis of his internal guidance note. Although it was described as “internal” at that time, the guidance note eventually became (with only minor amendments) Technical Guidance Note 18, published by the BCA in June 2014.1760 26.33 One important element in the discussion was Wintech’s view, apparently shared by Mr Lewis, that after the 2006 amendments paragraph 12.7 of Approved Document B required all elements of a cladding system to be of limited combustibility, including the external facing material, not only the insulation. The alternative route to compliance was to test the entire proposed system in accordance with BS 8414 and satisfy the performance criteria in BR 135. As a further alternative, a “desktop” opinion from BRE, based on test data, that the performance criteria in BR 135 would be met by the system, would also suffice. 26.34 When Mr Lewis was asked why he felt that he needed to recite the guidance in Approved Document B in such detail to his colleagues, he said that, although NHBC already knew it, it had not really digested it.1761 He explained that the guidance in Approved Document B was not second nature to NHBC and that it had not previously understood properly the restrictions on the use of combustible insulation in high-rise buildings.1762 For NHBC as an institution to have had such a poor grasp of the statutory guidance on a matter affecting the safety of life significantly detracted from its ability to discharge its function as an approved inspector. 26.35 Although Mr Lewis’s notes referred to the use of desktop studies, he candidly admitted that he had never heard of them being provided but said that the representatives of Wintech had told him that other building control bodies had accepted them as demonstrating compliance with the Building Regulations.1763 The basis of that part of the guidance was, therefore, purely anecdotal, although in principle a desktop assessment was an acceptable method of demonstrating compliance, provided it was performed competently using appropriate data. However, it was unwise, in our view, to produce draft guidance of that kind, even in its most rudimentary form, without finding out whether BRE, Exova, or other testing houses were capable of producing reliable desktop studies and how widespread was the practice of building control officers’ accepting them. 26.36 Mr Lewis’s notes referred to the Class 0 classification, which it described as “solely a measure of the spread of a flame across the surface”.1764 In fact that was incorrect, because Class 0 refers to both the spread of flame and fire propagation. Mr Lewis said that there was a lot of misunderstanding and confusion within NHBC about Class 0 and that he was not fully aware at the time of the way in which the classification was achieved.1765 That confusion about the meaning of Class 0 was not limited to NHBC but was shared by industry generally, and had been for many years. 26.37 In the following days, NHBC discussed the guidance note internally. On 19 November 2013 Mr Lewis agreed to put it into a form that would enable it to be presented for consideration at a forthcoming meeting of the BCA.1766 He also told Steve Evans in terms that Kingspan had tested K15 only once on a masonry wall construction, that K15 was acceptable only if incorporated into an identical system, and that since most 1760 Lewis {Day223/74:16-20}. 1761 Lewis {Day223/63:20-25}. 1762 Lewis {Day223/64:13-15}. 1763 Lewis {Day223/66:15}-{Day223/67:3}. 1764 {NHB00000604/5}. 1765 Lewis {Day223/68:19}-{Day223/69:25}. 1766 {NHB00000604}.

Part 3 | Chapter 26: The National House Building Council 171 of the schemes being approved by NHBC involved steel-framed constructions it should not be accepting K15, if it intended to follow the guidance in Approved Document B and BR 135.1767 Mr Lewis told us that none of his colleagues at NHBC disagreed with that view.1768 26.38 Nonetheless, NHBC continued to accept K15 for use on high-rise buildings. In an email sent on 2 December 2013 Steve Evans asked John Lewis for his comments on a draft message he was proposing to send to all NHBC technical staff saying that there was some confusion about whether K15 could be treated as a material of limited combustibility but that until NHBC was in a position to say otherwise, its policy was to continue to accept the use of K15 in rainscreen and masonry construction on buildings over 18 metres in height.1769 Mr Lewis responded by saying that there was no confusion and that K15 was not a material of limited combustibility. He advised in his email that staff should be told to check with Kingspan first, but that NHBC was obliged in principle to accept the statement in the BBA certificate that K15 could be used in accordance with paragraph 12.7 of Approved Document B (i.e. that it was a material of limited combustibility).1770 26.39 Mr Evans’ draft and Mr Lewis’s response betray serious flaws in NHBC’s thinking. First, the language of these communications strongly suggests that Mr Evans was anxious to play down the potential threat to safety by requiring Kingspan to justify the use of K15 in each individual case and in the meantime to continue to accept it for use on buildings over 18 metres in height generally. NHBC knew that K15 could not be used in a system other than one that was identical to the system tested in 2005, which was very different from any of the systems being passed by its building control officers. Secondly, they were both quite wrong to think that NHBC was obliged to endorse the use of K15. On the contrary, as Mr Lewis clearly knew, paragraph 12.7 of Approved Document B did not apply to the product because it was not a material of limited combustibility. Mr Lewis sought to justify his statement by saying that the statement in the BBA certificate that advice should be sought from Kingspan if K15 was proposed for use on high-rise buildings indicated a route to compliance.1771 However, as he ultimately accepted, it did no such thing; the “route” it suggested was, at best, a way of circumventing the guidance in Approved Document B, rather than following it. 26.40 At that point, rather than issue a flimsy warning to its staff, NHBC ought to have told them to stop accepting K15 for use in the external wall of any building over 18 metres in height immediately unless and until they had evidence that that system had met the performance criteria in BR 135 following a test under BS 8414. The failure of NHBC to do so reflects a desire at the time to placate customers and manufacturers at the expense of safety. 26.41 The BBA certificate was subsequently amended to remove the advice to contact the manufacturer,1772 but NHBC’s policy in late 2013 was conceived before it had any knowledge of that change and cannot therefore be justified by reference to the amended certificate. As Mr Lewis explained, NHBC foresaw that a refusal to accept K15 would have a massive effect across the industry.1773 It also believed that any change in its position on K15 would have isolated it from the rest of the industry, as the use of K15 was endorsed by the 1767 {NHB00000604}. 1768 Lewis {Day223/75:20}. 1769 {NHB00000615/2}. 1770 {NHB00000615/1}. Lewis {Day223/161:14-22}. 1771 Lewis {Day223/161:14-22}. 1772 {BBA00000036/6}. 1773 Lewis {Day223/165:16}-{Day223/166:12}.

The Grenfell Tower Inquiry: Phase 2 Report 172 LABC. As Mr Lewis put it, that led NHBC to ask whether there was any point in rejecting K15 when it was likely to be approved by local authority building control departments.1774 In our opinion, that was an unacceptable approach for NHBC to take. Dealings with Kingspan: November 2013 to April 2014 26.42 On 26 November 2013, Mr Lewis sent an email to Kingspan asking for advice about the use of K15 on a project involving a building over 18 metres in height.1775 He noted that K15 was not a material of limited combustibility and therefore asked how the alternative route to compliance in Approved Document B, namely, testing in accordance with BS-8414 and classification in accordance with BR 135, could be achieved. Kingspan’s initial response came on 12 December 2013 and merely referred Mr Lewis to the BBA certificate as the basis for the use of K15 on high-rise buildings.1776 26.43 Mr Lewis was, unsurprisingly, not satisfied with that response and repeated his request the same day.1777 He explained that his original question had been prompted by the BBA certificate’s suggestion that NHBC should seek advice from Kingspan about the suitability of K15 rather than simply reading the product literature. Mr Lewis pointed out that K15 was not a material of limited combustibility and that there had been only one test under BS-8414-1 involving K15 for which results were available. He questioned how K15 could be used as part of a differently constructed external wall or on any system attached to a structural steel frame (which required testing under BS 8414-2). 26.44 Mr Lewis had not received any substantive response by the following day and therefore wrote again, with copies to Steve Evans, Dave White and Graham Perrior.1778 He said that he and his managers at NHBC wished to raise the matter with Kingspan’s management team and requested a meeting in early 2014. He noted that, given the number of affected projects that it was dealing with, NHBC wished to start to advise its customers that K15 did not comply with the Building Regulations or the BBA certificate when used on a building over 18 metres in height. 26.45 It is clear from Mr Lewis’s email that, despite what its witnesses repeatedly told us, NHBC did not in fact consider that the BBA certificate provided conclusive evidence that K15 was safe or acceptable for use in accordance with the Building Regulations. Indeed, the import of Mr Lewis’s message to Kingspan of 13 December 2013 was plainly that the BBA certificate did not support the use of K15 on buildings over 18 metres in height, despite what it said. In our view, NHBC correctly thought that the BBA certificate was wrong in stating that K15 could be used in accordance with paragraph 12.7 of Approved Document B and was free to reject it as proof that K15 was suitable for use under those circumstances. However, it chose not to act on what it knew, pending receipt of an explanation from Kingspan, in order to avoid provoking protests from customers and Kingspan alike. As to that, Mr Lewis had told Mr Evans on 2 December 2013 that he doubted that Kingspan would be able to provide the evidence required to justify the use of K15 on high-rise buildings1779 but admitted he feared the massive effect across the industry that a change in NHBC’s position would cause.1780 1774 Lewis {Day224/19:10-24}. 1775 {NHB00000644/5}. 1776 {NHB00000644/3}. 1777 {NHB00000644/2}. 1778 {NHB00000644}. 1779 {NHB00000615/2}. 1780 Lewis {Day223/165:2}-{Day223/166:12}.

Part 3 | Chapter 26: The National House Building Council 173 26.46 As Mr Lewis conceded, his threat to advise NHBC’s customers that K15 was not suitable for use on high-rise buildings was intended to prompt a response from Kingspan.1781 It achieved its aim and Steve Evans, John Lewis, Graham Perrior and Dave White of NHBC met Richard Bromwich, Kingspan’s National Business Development Director, and Ivor Meredith, its Technical Project Manager, in January 2014.1782 Mr Lewis told us that at the meeting Kingspan had not contradicted his understanding of Approved Document B1783 and had confirmed that there was currently only one successful BS 8414 test of a system incorporating K15.1784 26.47 At that meeting, Kingspan produced a video showing the flame from a blowlamp being applied to a sample of K15 and suggested that, in Mr Lewis’ words, “it doesn’t burn particularly”,1785 notwithstanding the absence of any test data to justify that conclusion. Mr Lewis said he did not think that that was an acceptable, independent or robust way of verifying the suitability of K15,1786 but NHBC continued to accept the use of the product on high-rise buildings on the basis of an assertion that it was accepted for use on many tall buildings around the world.1787 26.48 John Lewis accepted that he had been aware that Appendices A and B to BR 135 provided that the results of a BS 8414 test could be used to justify the use of a combustible material only in an external wall system that was identical to that which had been tested.1788 He also accepted that it had been clear to him that there were simply no test results available to support the use of K15 in the many external wall systems in which it had already been used.1789 However nobody at NHBC accepted, as they should have done, that the only advice that Kingspan could properly give to its customers was that K15 could not be used at all on buildings over 18 metres in height except as part of a system exactly the same as that tested in 2005. 26.49 At that point, NHBC should immediately have stopped approving the use of K15 on buildings above 18 metres in height. However, it did not. It continued to endorse the use of K15, despite the guidance in Approved Document B, because Kingspan was willing to confirm that it was suitable.1790 That approach made no sense, as Mr Lewis accepted in hindsight, but it was adopted because NHBC felt at the time that Kingspan was the only party with detailed knowledge of K15’s fire performance.1791 Mr Lewis told us that he had raised concerns with his superiors in NHBC that the justification for approving the use of K15 was becoming ever flimsier but that no change had been made.1792 NHBC’s approach of relying uncritically on what Kingspan itself claimed for K15, given that it cannot have been in any doubt that Kingspan was selling K15 on the basis of a self-evidently misleading BBA certificate, demonstrated weakness and a failure to live up to its responsibilities. It was all the more serious for the fact that NHBC was an institution responsible for providing building control services in respect of a large number of new buildings and for ensuring their compliance with the Building Regulations. 1781 Lewis {Day223/125:5-13}. 1782 {NHB00000652}. 1783 Lewis {Day223/125:23}-{Day223/126:5}. 1784 {NHB00000652/1}. 1785 Lewis {Day223/131:3-10}. 1786 Lewis {Day223/131:14}. 1787 Lewis {Day223/131:3-10}. 1788 Lewis {Day223/155:17}-{Day223/157:8}. 1789 Lewis {Day223/157:8}. 1790 Lewis {Day223/126:21-22}. 1791 Lewis {Day223/127:2-14}. 1792 Lewis {Day223/131:15-24}.

The Grenfell Tower Inquiry: Phase 2 Report 174 26.50 Although NHBC realised that the BBA certificate was flawed, no one thought to ask the BBA on what basis it had been issued,1793 even though Mr Lewis was not aware of any other BBA certificates which advised the reader to refer to the manufacturer for advice in the same way.1794 26.51 NHBC held a further meeting with Kingspan on 2 April 2014, attended by John Lewis and Dave White. Mr White reported the results of that meeting to NHBC’s technical services managers the same day. He said that for external walls of buildings over 18 metres in height, the only system incorporating K15 for which there was full proof of fire performance was one with a masonry backing wall.1795 His message was unequivocal. However, even at that point, NHBC did not stop endorsing the use of K15 on high-rise buildings. John Lewis sought to justify that failure by referring to the fact that the BBA certificate for K15 had been revised in January 2014.1796 That certificate removed the reference to paragraph 12.7 of Approved Document B and the advice to consult the manufacturer, leaving the 2005 test in accordance with BS 8414 as the sole means of achieving compliance. 26.52 NHBC discovered the change on or around 25 February 2014.1797 Thereafter, all projects for which an initial notice had been served before January 2014 were accepted on the basis of Kingspan’s historic assurances.1798 NHBC intended those projects for which the initial notice had been served in or after January 2014 to be the subject of a more rigorous assessment of whether K15 could be used.1799 It was likely to be several months at least until any new projects reached the stage of completion, during which Kingspan might produce proof that K15 was acceptable for use on buildings over 18 metres in height before NHBC had to take a final position.1800 In our view, that was not a responsible approach for NHBC to adopt. It was well aware that there could be no proof of the kind envisaged because no BS 8414 test results could be applied to high-rise buildings generally, and Kingspan had not produced any desktop assessments from BRE to support such an approach. 26.53 On 3 April 2014, Phil Pettinger, a Special Risk Projects Manager employed by NHBC, responded to Mr White’s email.1801 He said that every job involving a building over 18 metres in height that Special Risk Project Managers dealt with proposed or had used K15. He made plain that K15 was being widely accepted by both NHBC and other building control bodies.1802 John Lewis accepted that it had been clear to him at the time that there was an industry-wide problem with the acceptance of K15 and that Mr Pettinger’s email had come as no surprise.1803 However, he said that NHBC had not raised the matter with other building control bodies or investigated whether any of them had any other understanding of how K15 could safely be used on buildings over 18 metres in height because of the pressure of time.1804 However, given that NHBC had gained time by waiting for Kingspan to justify the use of K15 on high-rise buildings, we do not understand what the pressure of time was. A simple enquiry of the LABC or the BCA was all that was required. 1793 Lewis {Day223/129:6}; {Day223/153:24}-{Day223/155:11}; {Day223/163:5-17}. 1794 Lewis {Day223/129:17}. 1795 {NHB00000688/2}. 1796 {NHB00000853/11}. 1797 {NHB00000689/3-4}. 1798 Lewis {Day223/131:3-10}; {Day223/178:20}. 1799 Lewis {Day223/134:23}-{Day223/135:5}. 1800 Lewis {Day223/135:20-24}. 1801 {NHB00000688/1}. 1802 {NHB00000688/1}. 1803 Lewis {Day223/141:1}-{Day223/142:11}. 1804 Lewis {Day223/143:1-10}.

Part 3 | Chapter 26: The National House Building Council 175 26.54 On 25 February 2014, Steve Evans asked Mr Lewis to study the new version of the certificate and make an assessment,1805 but it took him until 9 May 2014 to respond.1806 In the event, his conclusion was that there was no justification for NHBC to continue accepting K15.1807 Mr Lewis said that NHBC had been hoping that Kingspan would produce a justification for the use of K15 on high-rise buildings but it never materialised. He said that in the meantime, a practice had developed of asking for desktop studies to justify the use of K15 on high-rise buildings,1808 but we have not seen any evidence of that. TGN 18 (Issue 0): draft 26.55 The guidance note that Mr Lewis had drafted within hours of NHBC’s meeting with Wintech on 15 November 2013 was presented materially unamended as a formal document by Steve Evans to the Technical Working Group of the BCA on 9 December 2013. He proposed that it should be adopted as BCA policy guidance.1809 It was indeed adopted without material change and became the BCA’s Technical Guidance Note 18 (TGN 18), Use of Combustible Cladding Materials on Residential Buildings Issue 0, dated June 2014. It was published in July or August 2014.1810 26.56 Like Mr Lewis’s guidance note, the proposed guidance put before the BCA in December 2013 referred to three potential routes to compliance with functional requirement B4(1) for the external walls of buildings over 18 metres in height. The first was that all the elements should be materials of limited combustibility, in accordance with paragraph 12.7 of approved Document B. That included the insulation, internal lining board and the external facing material.1811 That represented Mr Lewis’s understanding of the position based on a discussion he had had with Tony Baker of BRE by email in November 2013.1812 In that exchange Mr Lewis had said that he thought that the provisions of paragraph 12.7 of Approved Document B extended to external cladding panels because it seemed to him logical to expect them to perform as well as the insulation in a fire.1813 Mr Baker had responded by saying that all significant elements of the cladding system should be included in any analysis.1814 26.57 That approach appears to have reflected BRE’s view, at least according to what Dr Sarah Colwell told NHBC in a meeting on 27 November 2014.1815 It did not come as a surprise to John Lewis.1816 However, as the evidence from David Metcalfe of CWCT shows, that was by no means the general view of the industry at the time.1817 In fact, as Mr Lewis accepted, Approved Document B advised in paragraph 12.7 that insulation materials should be of limited combustibility and in diagram 40 that external surfaces should have a Class 0 or Euroclass B or better classification.1818 Accordingly, by suggesting that “all elements” 1805 {NHB00000689/3} 1806 {NHB00000689/1}. 1807 {NHB00000689/1}. 1808 Lewis {Day223/176:25}-{Day223/178:14}. 1809 {NHB00000604/2}; {NHB00000605}; Evans {Day219/104:7-9}. 1810 {NHB00000760}. 1811 {NHB00000760/2}. 1812 {NHB00002971}. 1813 {NHB00002971/2}. 1814 {NHB00002971}. 1815 {NHB00000829}. 1816 Lewis {Day223/100:12}. 1817 Metcalfe {CWCT0000115} page 10, paragraph 36. 1818 Lewis {Day223/92:21}-{Day223/94:4}.

The Grenfell Tower Inquiry: Phase 2 Report 176 of the external wall should be composed of materials of limited combustibility, TGN 18 presented a restrictive and conservative view of Approved Document B that was not widely shared in the industry. 26.58 The second option in TGN 18 was for the client to submit evidence that the complete cladding system had been tested in accordance with BS 8414 and classified in accordance with BR 135. TGN 18 did not refer to classifications; instead it stated that the results of a test in accordance with BS 8414 would need to be supported by proof that the acceptance criteria in BR 135 had been met.1819 Mr Lewis told us that that was simply intended to mean that full test data should be supplied, because NHBC had not realised that BRE would also produce classification reports with any test data.1820 26.59 The third option in TGN 18 was the production of a desktop study of the kind that Wintech had told NHBC had been accepted by other building control bodies. However, that was the first time that Mr Lewis had encountered such an approach being adopted in relation to an external wall.1821 Wintech had not provided NHBC with any details of how the process would work in practice or any examples.1822 That proposed third route to compliance was entirely theoretical, in as much as it was not based on experience of any such assessments and neither BRE nor any of the other testing houses had been asked whether they could provide desktop assessments and if so how they went about doing so. 26.60 Mr Lewis maintained that Appendix A of Approved Document B endorsed the use of desktop studies but he could not recall whether they had been discussed at the meeting with Wintech and there is no evidence to suggest that they had been.1823 He said that he had examined the provisions of Appendix A before drafting the guidance note,1824 but any examination he did carry out can only have been cursory because the guidance note (and accompanying email) had been produced in a matter of hours. 26.61 In any event, we do not think that Appendix A of Approved Document B did endorse the use of desktop studies. Paragraph 1 of the introduction, which set the context for what followed, referred to the fact that much of the guidance in the document was given in terms of performance in relation to British or European Standards for products or methods of test or design or in terms of European Technical Approvals. In such cases the guidance required the material product or structure under consideration to have been assessed from test evidence against appropriate standards or by using relevant design guides as meeting the performance required by the tests.1825 In our view, that provision was clearly referring to the results of tests on the relevant material, product or structure and not to the extrapolation of data from tests on a different material, product or structure. 26.62 Moreover, even if it were thought that that passage supported the use of desktop assessments, that reasoning could not sensibly be applied to a complex structure such as the entire external wall of a building. Such an interpretation would undermine the express routes to compliance given in Approved Document B, which required either compliance with the “linear route” or a full-scale test in accordance with BS 8414. It would make no sense for Appendix A to permit the use of combustible materials in circumstances where the proposed structure had not been tested at all. 1819 {NHB00000760/2}. 1820 Lewis {Day223/105:4}-{Day223/106:12}. 1821 Lewis {Day223/106:5}-{Day223/108:1}. 1822 Lewis {Day223/204:7-20}. 1823 Lewis {Day223/109:5-11}. 1824 Lewis {Day223/109:16-21}. 1825 {CLG00000224/119}.

Part 3 | Chapter 26: The National House Building Council 177 26.63 That is not to say, however, that a desktop assessment is never acceptable as a means of demonstrating compliance with one of the functional requirements, but it must be based on sufficient accurate test evidence.1826 NHBC had no basis for promoting desktop assessments as an alternative way of showing compliance with functional requirement B4(1) without identifying the test data that should be used, the method that should be employed or the qualifications that were required on the part of those who were to conduct them. 26.64 When Mr Lewis had spoken of the available test data for K15 in his email of 15 November 2013 setting out his draft internal guidance, he had rightly pointed out that any difference between a proposed external wall system and the system that had been tested by Kingspan would prevent any direct reliance on the test result, and that the limited test data available would make it difficult to draw any reliable conclusions about the fire performance of the proposed system.1827 However, when it came to drafting TGN 18, it appears that NHBC did not consider either of those matters or make any enquiries of BRE about how desktop studies could safely be performed. Mr Lewis told us that NHBC was doing whatever it could to put a guidance note together and simply did not think about consulting BRE.1828 Nor did it give any thought to who might be responsible for conducting the desktop studies it was supporting or the qualifications they might need to hold, beyond the rather vague reference to a suitable independent testing body accredited by UKAS.1829 26.65 In his witness statement, Mr Lewis said that the third option had been included because he and Mr Evans had wanted to include a route to compliance for those developers who were unable to comply with the two routes described in Approved Document B.1830 In his oral evidence, however, he said that they were considering all the options and that it had made sense to include it. We do not agree. It was wholly unnecessary and indeed dangerous for NHBC to strive to find a way to help developers who wished to use non-compliant cladding products to do so, having applied little or no thought to that suggested route. The “desktop study” route should not have been suggested by NHBC or the BCA because NHBC had no grounds for thinking that anyone in the industry understood what data was required for a reliable desktop assessment or had the competence necessary to produce one. 26.66 In our view, NHBC’s desire for a third route to compliance was rooted in three things. First, it had formed a view that the requirements of the “linear route” were particularly onerous. However, that view does not appear to have been shared by the industry at large and, in any event, however onerous, it was not for NHBC to seek to ameliorate the requirements of the guidance. 26.67 Secondly, NHBC considered that the tests required by the second option were time- consuming and expensive and were in any event of limited application because they were irrelevant if any element of the system differed from that which had been tested.1831 Again, however, it was not appropriate for NHBC to seek to circumvent or dilute the effectiveness of the guidance by suggesting another route to compliance. 1826 Torero {Day292/92:6}-{Day292/95:16}. 1827 {NHB00000604/4}. 1828 Lewis {Day223/111:1}-{Day223/112:19}. 1829 Evans {Day220/:47-13}-{Day220/50:19}. 1830 Lewis {NHB00003433/35} page 35, paragraph 133; Lewis {Day223/189:24-25}. 1831 Lewis {Day223/190:8-15}.

The Grenfell Tower Inquiry: Phase 2 Report 178 26.68 Finally, Mr Lewis explained that NHBC did not want to prevent the industry from achieving the high degrees of insulation performance that combustible insulation products provided.1832 However, as a provider of building control services, it was precisely NHBC’s role to ensure that unsafe products that were frequently being proposed for use were not approved by its building control officers. Its evident desire to assist the industry was wholly inappropriate. As Mr Lewis was constrained to accept, the practice of building control bodies and approved inspectors “working with” the industry rather than holding it to proper standards was corrupting, because it tended to undermine the independence of building control officers and approved inspectors.1833 26.69 Mr Lewis denied that the third route to compliance proposed by TGN 18 had been devised as a means of legitimising schemes using K15 that he knew had been wrongly approved by NHBC in the past.1834 Although we accept his evidence that it arose directly from the suggestion made by Wintech at the meeting on 15 November 2013, that was all it was, a suggestion based on hearsay and anecdote. The evidence shows that NHBC clearly understood that the use of K15 could not be justified by any other means and that refusing to approve the use of K15 on high-rise buildings would have significant commercial repercussions. TGN 18 (Issue 0): June 2014 26.70 TGN 18 was formally issued in June 2014.1835 The three alternative routes to compliance were identical to those included in John Lewis’s initial draft prepared on 15 November 2013, save that a sentence had been added to the second route to identify some of the requirements of BR 135. There is no evidence that the BCA itself took any steps to verify or investigate the validity and safety of the three options, in particular to examine the basis for option 3, and we infer that it did not. 26.71 In the result, the BCA promulgated the third route to compliance on the basis of extremely limited information, namely the second-hand assurances of Wintech, and without any independent verification or indication of how it could operate in practice. Moreover, although each of the NHBC witnesses sought to justify its inclusion by reference to Appendix A of Approved Document B, there is no evidence that it had received any consideration within NHBC or the BCA. 26.72 In the circumstances, the inclusion of the third option in TGN 18 was irresponsible. It was not motivated by a desire for rigour in the application of Approved Document B, nor by a desire to improve fire safety standards in high-rise buildings, but by NHBC’s desire to assist developers to find a way to justify the use of non-compliant products. Discussions with the government and industry: 2014 – 2015 26.73 On 2 July 2014 Brian Martin of the department sent an unprompted email to Neil Smith of NHBC to provide a “friendly warning” that PIR insulation was being used in cladding systems. He did so because, as he put it, people were under the impression that PIR was a material of limited combustibility (which was not the case) and he thought that NHBC 1832 Lewis {Day223/193:13} 1833 Lewis {Day223/194:1}-{Day223/196:3}. 1834 Lewis {Day223/196:4-11}. 1835 {NHB00000760}.

Part 3 | Chapter 26: The National House Building Council 179 ought to ensure that its surveyors were aware of that.1836 Mr Martin’s email was sent at 11.42, shortly before a meeting of the CWCT at 14.00 that day. Mr Martin attended that meeting but did not stay until the end.1837 26.74 Mr Martin’s email came as no surprise to NHBC, as it had been endorsing the use of PIR insulation since at least November 2013 in the full knowledge that it was not a material of limited combustibility.1838 It took NHBC until 11 July 2014 to respond and when the response came, it came from Steve Evans, to whom Mr Smith had passed Mr Martin’s email. Mr Evans drafted a response and discussed it with Diane Marshall before it was amended and sent.1839 He said that there was no reason to suspect that buildings which had been built with Kingspan K15 were at risk; it was just the fact that testing carried out to date did not bear that out. Kingspan, he said, was confident that the testing currently being carried out would prove the suitability of the material for use on buildings over 18 metres in height.1840 26.75 The first sentence was clearly misconceived.1841 Although Mr Evans did not accept it,1842 the fact that there was no available test evidence to indicate that K15 was compliant was itself a reason to suspect that buildings on which it had been installed were at risk. The statement amounted to a suggestion that any untested combustible insulation material was safe for use on buildings over 18 metres in height unless testing proved otherwise. That was obviously not the case. For her part, Ms Marshall sought to explain that sentence by saying that the high-rise buildings containing K15 which NHBC had approved in the past had been accepted on the basis of the BBA certificate.1843 However, the sentence does not say that NHBC had relied on the BBA certificate and, for reasons already given, the BBA certificate for K15 was plainly unreliable. She also told us that she had placed confidence in the fact that Kingspan had told NHBC that it was going to conduct more tests,1844 but that was not a sound basis for the assertion that tall buildings with K15 in their external walls were not at risk. 26.76 The second sentence of Mr Evans’ email merely perpetuated the falsehood, disseminated by Kingspan with the assistance of NHBC and with the inadvertent support of the LABC and the BBA, that a single successful BS 8414 test could support the generic use of K15 in external walls of buildings over 18 metres in height generally, irrespective of the construction of the system. It could only have made sense if Steve Evans had been suggesting that Kingspan would subject every external wall system in which K15 had been used (of which there were very many) to a BS 8414 test, but that was clearly not his intention. As John Lewis accepted, that would require a vast number of tests (as many as there were different external wall systems containing K15), occupying BRE for months.1845 26.77 The correspondence was not sent to John Lewis until 15 August 2014 and he was not consulted on its contents.1846 Mr Lewis said that NHBC did not see Mr Martin’s email as a reason to change anything it was doing because it was already aware of the historic legacy 1836 {NHB00000732/3}. 1837 Lewis {Day224/5:4-22}. 1838 Evans {Day220/67:3}-{Day220:68:5}. 1839 {NHB00000732/1}. 1840 {NHB00000732/2} 1841 Evans {Day220/90:2-25} 1842 Evans {Day220/91:1}-{Day220/93:11} 1843 Marshall {Day226/16:1}-{Day226/18:4}. 1844 Marshall {Day226/17:25}-{Day226/18:4}. 1845 Lewis {Day224/14:6-22}. 1846 Lewis {Day224/4:15}-{Day224/5:25}; {Day224/11:11-16}

The Grenfell Tower Inquiry: Phase 2 Report 180 of buildings containing combustible insulation, was continuing to press Kingspan for the results of tests on K15 (thus far without success), and in any event had already drafted TGN 18 as a response to the problem.1847 26.78 Steve Evans’ response to Brian Martin contrasted starkly with the position he had taken in correspondence with Kingspan the previous month. On 16 June 2014, he had told Richard Bromwich of Kingspan that the change in the BBA certificate for K15 meant that NHBC had no remaining basis for accepting its use on buildings over 18 metres in height.1848 He warned that unless Kingspan could produce additional test evidence supporting the use of K15 in constructions which differed from the BS 8414-1 test referred to in the BBA certificate by 30 June 2014, NHBC would need to reconsider its acceptance of K15 on such buildings. That was some six months after its meeting with Kingspan in January

1. NHBC must have realised by that point, if not earlier, that it was being deceived by

Kingspan. Mr Evans’ message of 16 June 2014 simply gave Kingspan a further opportunity to keep selling K15 for use on buildings over 18 metres in height in the UK market safe in the knowledge that NHBC had not instructed its surveyors to reject it. 26.79 In the event, Mr Evans’ deadline of 30 June 2014 came and went without any action being taken by NHBC. Instead, it continued to give Kingspan further time to produce the results of tests that it must have known could not provide a satisfactory resolution. Mr Lewis said that had been because a change in NHBC’s position would have created a storm within the industry and would in any event have been futile because local authority building control officers would have accepted the use of K15 based on the LABC certificate, which stated that it could be considered a material of limited combustibility.1849 That was not a responsible position for NHBC to take. 26.80 By August 2014, NHBC was clearly becoming increasingly uncomfortable with Kingspan’s failure to provide convincing evidence that K15 was suitable for use on high-rise buildings. On 15 August 2014, Steve Evans wrote to Ivor Meredith of Kingspan requesting a letter of comfort from BRE pending receipt of further promised test results in order to protect everyone’s position in circumstances where it could be months before the further information was received and there were many designers currently using or planning to use K15.1850 26.81 That was itself a telling request for a number of reasons. First, it is wholly unclear what comfort Kingspan could give in relation to the use of K15 on buildings over 18 metres in height. Secondly, it revealed that NHBC knew that it was open to criticism and possibly claims for accepting K15 for use on high-rise buildings when it knew that it did not comply with the guidance in Approved Document B and could therefore not demonstrate compliance with the Building Regulations by the linear route. Thirdly, it treated Kingspan and NHBC as if they had a common interest in Kingspan’s continuing to market K15 for use on high-rise buildings. That was a fundamental misconception. It was NHBC’s responsibility as an approved inspector to ensure that its surveyors and building control officers applied the Building Regulations correctly and rejected the use of any materials or products that would prevent the building from complying with them. The action of NHBC provides a vivid example of a large body with substantial influence over building control officers nationwide 1847 Lewis {Day224/9:18-25}. 1848 {NHB00000757/3}. 1849 Lewis {Day224/18:3} – {Day224/19:24}. 1850 {NHB00000757/1}.

Part 3 | Chapter 26: The National House Building Council 181 electing to co-operate with manufacturers rather than robustly enforce regulations designed to protect life. The attitude of NHBC, as revealed by Mr Evans’ message, deserves criticism in the strongest terms. Meeting with Arup and BRE: autumn 2014 26.82 On 30 October 2014, Steve Evans wrote to Dr Barbara Lane of Arup Fire seeking a meeting to discuss technical issues relating to the use of combustible materials in the external facades of high-rise buildings.1851 In her response Dr Lane said that Arup believed that the use of combustible materials in residential buildings was an accident waiting to happen.1852 A meeting then took place between Arup and NHBC on 25 November 2014.1853 Despite Arup’s clear concerns, NHBC did not think to tell Brian Martin that, contrary to the previous assurances given by Steve Evans in his letter of 11 July 2014, there was indeed a real risk to existing buildings.1854 Nor did NHBC, even at that late stage, a year after the Wintech meeting, start refusing to accept K15 for use on high-rise buildings.1855 26.83 On 27 November 2014, Steve Evans, John Lewis, Graham Perrior and Dave White of NHBC met Dr Sarah Colwell, Steve Manchester and Stephen Howard of BRE. At that meeting, NHBC was told that the time between a BS 8414 test and the consequent BR 135 classification was usually short and learned that no classification report had been issued in relation to K15.1856 Therefore, despite BRE’s unwillingness for reasons of client confidentiality to answer specific questions about Kingspan’s latest tests, it was clear to NHBC that at least one of them had failed.1857 26.84 Dr Sarah Colwell also confirmed that BRE had agreed with NHBC’s view that the provisions in paragraph 12.7 of Approved Document B applied to all major components of a cladding system, including the external finish.1858 John Lewis specifically asked Sarah Colwell about that because of the resistance to that view that NHBC was receiving from customers. He wanted BRE to confirm that in its view Option 1 in TGN 18 issue 0 interpreted that paragraph correctly.1859 However, Dr Colwell did not explain how she derived that meaning from the language of paragraph 12.7.1860 Contact with the BBA: January 2015 26.85 NHBC did not contact the BBA about its certification of Kingspan K15 until January 2015, some seven years after the BBA certificate had first been published and a year after the certificate had been amended to remove the instruction to seek advice from Kingspan.1861 On 27 January 2015, Graham Perrior asked John Albon of the BBA to explain why the certificate had been changed, which he said had seriously affected the situations in which K15 was acceptable.1862 1851 {NHB00000811/4}. 1852 {NHB00000811/3}. 1853 {NHB00000829/1}. 1854 Evans {Day220/154:15}-{Day220/158:3}. 1855 Evans {Day220/157:1-11}. 1856 {NHB00000829/2}. 1857 Lewis {Day224/89:20}-{Day224/90:14}. 1858 {NHB00000829/2}. 1859 Lewis {Day224/69:8-12}. 1860 Lewis {Day224/69:1-7}. 1861 {NHB00000895/3}. 1862 {NHB00000895/3}.

The Grenfell Tower Inquiry: Phase 2 Report 182 26.86 The BBA provided a comprehensive response the following day, the essence of which was that the change to the certificate was a matter of emphasis and there had been no change in the assessment criteria or scope of approval.1863 When he saw that response, Graham Perrior was unimpressed. He passed it on to Dave White and Steve Evans that day saying that the BBA’s position was not correct.1864 Regrettably, no one at NHBC had asked the BBA to explain its statement that K15 could be used in accordance with paragraph 12.7 of Approved Document B and Mr Evans could not explain why it had not done so.1865 Mr Evans maintained before us that even at that stage NHBC could continue to rely on the BBA certificate to approve the use of K15 on high-rise buildings because it said that it could be used in accordance with paragraph 12.7 of Approved Document B, but we find it difficult to understand that position, given that K15 was known not to be a material of limited combustibility.1866 Reliance on TGN 18 26.87 On 5 February 2015 NHBC told Kingspan that it would no longer approve the use of K15 on high-rise buildings unless evidence of compliance with the Building Regulations was provided in accordance with TGN 18.1867 Kingspan’s response was to instruct its lawyers to allege that it was being treated unfairly and to threaten legal action against NHBC.1868 26.88 NHBC’s new policy applied to all projects using K15 from 1 January 2014.1869 However, NHBC continued to accept confirmation from Kingspan that K15 was suitable for any project for which the initial notice had been given before that date.1870 John Lewis accepted that K15 was no less combustible on 31 December 2013 than it had been on 1 January 2014, and could not explain why NHBC had not changed its approach.1871 In our view, the policy adopted by NHBC in early 2015 towards the continued acceptance of Kingspan K15, despite what it knew, could not reasonably be justified. The 2015 policy review 26.89 Following the adoption of its new policy towards K15, NHBC launched what it termed the “Combustible Cladding Review”.1872 In accordance with the instructions of the board,1873 the review was limited to buildings over 18 metres in height currently under construction or about to start.1874 The board also decided not to tell its previous customers that NHBC had approved external cladding systems on high-rise buildings that contained combustible insulation.1875 That decision was apparently based, at least in part, on the fact that at the time NHBC had held what it regarded as a valid BBA certificate.1876 We have no reason to doubt that that was in fact in part the basis of its decision. However, we do not accept Ms Marshall’s assertion that the BBA certificate for K15 ever justified such an approach, certainly not after NHBC had become aware that it was erroneous and unreliable. 1863 {NHB00000898/2}. 1864 {NHB00000899}. 1865 Evans {Day221/52:15-18}. 1866 Evans {Day221/53:18-24}. 1867 {NHB00000922/1}. 1868 {KIN00008283}. 1869 {NHB00000934}. 1870 As per Steve Evans’s instructions on 2 December 2013 at {NHB00000935} as set out in {NHB00000934}. 1871 Lewis {Day223/157:25}-{Day223/158:17}. 1872 Lewis {NHB00003433/32} page 32, paragraph 115. 1873 Marshall {Day226/32:7-15}. 1874 Lewis {Day224/158:22}-{Day224/159:5}; Marshall {Day226/5:14-19}. 1875 Marshall {Day226/33:25}-{Day226/34:7}. 1876 Marshall {Day226/33:15}-{Day226/34:19}.

Part 3 | Chapter 26: The National House Building Council 183 The board’s decision not to tell previous customers of the fact that its building control officers had approved cladding systems that were at least at serious risk of preventing the building from complying with one of the principal functional requirements of the Building Regulations, and so a potential danger to life, was irresponsible.1877 As we shall see, the scale of the problem was huge. 26.90 The review categorised buildings as being either high, medium or low risk according to the materials used in their construction.1878 Those categories had been suggested by John Lewis based on his knowledge of combustible materials and were accepted by Steve Evans.1879 Mr Lewis described the review as a screening exercise, although he conceded that some projects with ACM PE had slipped through the net.1880 26.91 The results of the review were subsequently put into a table that identified in detail the projects in which NHBC had been involved that included the use of combustible materials.1881 All the buildings in the review were ultimately accepted by NHBC, despite containing combustible materials,1882 although many required remedial work to be carried out before they could be finally approved.1883 NHBC’s approval was ultimately given by Steve Evans and Diane Marshall, neither of whom had any fire engineering qualifications, based on the advice and expertise of John Lewis or Maulik Katkoria as fire engineers.1884 Revision of TGN 18: June 2015 TGN 18 (Issue 1): June 2015 26.92 Issue 1 of TGN 18 was published by the BCA in June 2015. That revision had been drafted by John Lewis at the request of Steve Evans1885 and contained two major changes. First, the pool of people who could produce desktop studies was widened to include any suitably qualified fire specialist. Secondly, a holistic fire engineering solution was included as a fourth alternative route to compliance. 26.93 John Lewis1886 and Steve Evans1887 said that the first change had been prompted by responses from the three testing houses which said that they were struggling to keep up with the number of requests for desktop studies. However, we have not seen any contemporaneous documents to suggest that that was the case and it was certainly not mentioned in the minutes of the meeting between BRE and NHBC in November 2014.1888 We think that if BRE had been inundated with requests for desktop reviews, Dr Colwell would probably have raised the matter at the meeting with NHBC on 25 November 2014, but there is no evidence that she did. Although Mr Evans recalled a discussion about it, Mr Lewis did not.1889 We prefer Mr Lewis’ recollection, given the total absence of any reference to the matter in the contemporaneous documents. In our view, it is more likely that the change was motivated by a desire on the part of NHBC to make it easier for developers to obtain timely building control approval. 1877 Marshall {Day226/33:25}-{Day226/34:19}. 1878 Lewis {NHB00003433/32} page 32, paragraph 118. 1879 Lewis {Day224/164:13-19}. 1880 Lewis {Day224/164:20}-{Day224/165:14}. 1881 {NHB00003038}. 1882 Evans {Day221/19:3-18}. 1883 Lewis {Day224/168:7-10}. 1884 Evans {Day221/41:18}-{Day221/43:21}. 1885 Lewis {Day224/91:1}-{Day224/92:4}; {Day224/99:21-23}. 1886 Lewis {NHB00003433/38} page 38, paragraph 148; Lewis {Day224/99:13}-{Day224/100:19}. 1887 Evans {NHB00003020/77} page 77, paragraph 200 (a). 1888 {NHB00000829/2-3}. 1889 Lewis {Day224/111:16}-{Day224/112:18}.

The Grenfell Tower Inquiry: Phase 2 Report 184 26.94 The second change was the inclusion of a holistic fire-engineered solution. That had always been an alternative way of demonstrating compliance with functional requirement B4(1), as clearly provided by Approved Document B.1890 It was included simply for completeness.1891 Option 3 and desktop studies 26.95 As NHBC’s only qualified fire engineer, John Lewis was responsible for examining the desktop studies that it received.1892 He found them to be of variable quality, those from BRE and Exova being the most comprehensive.1893 Initially he found few problems with the studies he received, but after the publication of Issue 1 of Technical Guidance Note 18 in June 2015 the standard began to drop.1894 He did not accept, however, that those who were permitted to produce reports were not qualified to do so.1895 26.96 John Lewis reported his concerns to Diane Marshall,1896 who was aware that some desktop studies submitted to NHBC often lacked proper references to relevant test data and that others applied only the requirements of diagram 40 of Approved Document B as opposed to the guidance in paragraph 12.7.1897 She nonetheless claimed to believe that desktop studies worked well so long as they were done correctly.1898 However, there was no established method for assessing whether they had been done correctly. 26.97 In his report Professor Luke Bisby expressed the view that the change to TGN 18 in relation to desktop studies further eroded the already weak oversight of competence in this part of the industry.1899 We agree. It is clear that in 2015 the practice of producing desktop assessments was fraught with dangerous shortcomings. Further discussions with industry: 2015–2016 Paragraph 12.7 of Approved Document B and “filler” 26.98 On 15 June 2015, Steve Evans wrote to Brian Martin, whom he regarded as the “guardian of Approved Document B”,1900 to seek clarification of the meaning of “filler material etc” in paragraph 12.7 of Approved Document B.1901 He was keen to know what the department understood “filler” to mean and whether the suggested restriction to materials of limited combustibility extended to the external surface of a cladding panel. Given that NHBC had taken the view when drafting TGN 18 that all elements of the external wall construction should be materials of limited combustibility (a view shared by BRE), it is surprising that Mr Evans felt that he had to ask those questions. However, he told us that many of NHBC’s customers had been challenging its view that paragraph 12.7 required cladding panels to be composed of materials of limited combustibility rather than simply being classified Class 0.1902 The key point was that contained in the last paragraph of the email. NHBC was of the view that there was little point in ensuring that insulation products were materials 1890 {CLG00000224/15}, at paragraph 0.30. 1891 Lewis {Day224/95:6-23}. 1892 Lewis {Day224/115:21-25}. 1893 Lewis Second Statement {NHB00003433/48} page 48, paragraph 182 (b). 1894 Lewis {Day224/123:23}-{Day224/124:19}. 1895 Lewis {Day224/124:20}-{Day224/125:7}. 1896 Marshall {Day226/59:2-10}. 1897 Marshall {Day226/60:11-22}. 1898 Marshall {Day226/61:6-13}. 1899 Bisby, Phase 2 Report - BR 135 Desktop Assessment Report {LBYP20000004/37} paragraph 277. 1900 Evans {Day221/68:15-17}; {NHB00002792/3}. 1901 {NHB00002792}. 1902 Evans {Day221/55:16}-{Day221/56:15}.

Part 3 | Chapter 26: The National House Building Council 185 of limited combustibility if they could be faced with a cladding finish which, although Class 0, could contribute to the spread of fire, but there was a difference of opinion within the industry. For that reason, he was seeking clarification from the department. 26.99 Despite NHBC’s plea for help, Mr Martin’s response was that he could not offer a formal view, because the interpretation of Approved Document B as it applied to specific projects was a matter for the relevant building control body.1903 As Mr Evans said at the time, that was not an answer at all.1904 Nonetheless, Mr Evans did not press Mr Martin for a clearer statement and Mr Lewis thought that his existing response might be enough to justify the position taken by NHBC in its discussions with one particular developer.1905 Although NHBC had confidence in its own view that all components of the external wall of a high- rise building should be materials of limited combustibility, large swathes of the industry disagreed. Given NHBC’s powerful influence in the industry, it is regrettable that it did not press Mr Martin to adopt a clear position. BRE and Siderise Conference: January 2016 26.100 On 13 January 2016, Steve Evans attended a conference on external facades organised by BRE and Siderise. He gave a presentation entitled Facades to Tall Buildings: Routes to Compliance and took questions from the audience. Among those present was Nick Jenkins of Booth Muirie, a supplier of rainscreen materials, including aluminium composite panels.1906 During the question and answer session, Mr Jenkins explained that combustible ACM panels were commonly being used on high-rise residential buildings and expressed his grave concern that they did not meet the requirements of the Building Regulations.1907 Mr Evans’ response was that an ACM panel with a Class 0 classification was considered to comply with Approved Document B.1908 He referred to what he described as an anomaly in Approved Document B created by the different requirements of paragraph 12.7 and Diagram 40. Although he acknowledged that ACM panels could technically be compliant if they met the requirements of Diagram 40, he said that that was not an approach he agreed with.1909 26.101 Mr Evans’s own position was that NHBC could not demand higher standards than those required by the Building Regulations.1910 That may be so, but it begs the question what the Building Regulations actually required. Mr Evans confirmed that NHBC’s position as expressed in Option 1 of TGN 18 (both Issues 0 and 1), namely, that all elements of the external wall of a high-rise building had to be of limited combustibility, had not altered between June 2014 and January 2016.1911 There was therefore an obvious inconsistency between what he told the conference and NHBC’s approach at the time, which he sought to explain away by saying that his answer at the conference had been badly worded.1912 He said that his claim to have discussed with the department what he called the anomaly in Approved Document B was a reference to NHBC’s email exchange with Brian Martin in June 2015, although, as NHBC recognised at the time, those perfunctory discussions had not advanced matters at all.1913 1903 {NHB00002792/4}. 1904 {NHB00002792/2}. 1905 {NHB00002792}; Evans {Day221/72:4-23}. 1906 Murden {BLM00000004/1} page 1, paragraph 7. 1907 {INQ00014949/10-11}. 1908 {INQ00014949/12}. 1909 {INQ00014949/12 -13}. The video clip is at {SIL00010066}, played at {Day 221/79:4-15}. 1910 Evans {Day220/167:7}-{Day220/170:24} and {Day221/37:6-23}; Lewis {Day224/188:13}-{Day224/189:8}. 1911 Evans {Day221/89:5-7}. 1912 Evans {Day221/87:14}-{Day221/88:6}. 1913 Evans {Day221/90:1}-{Day221/91:9}.

The Grenfell Tower Inquiry: Phase 2 Report 186 26.102 The significance of the conference in January 2016 was twofold. First, Mr Evans did not adopt the position set out in TGN 18, and thus publicly adopt a clear position, even though it might, on one reading of Approved Document B, be over-strict. Secondly, the discussion brought home to NHBC (if it had not realised it earlier) that there was a significant number of high-rise buildings in the UK which its building control surveyors (and others) had approved as compliant with the Building Regulations but which contained combustible materials in the external wall systems that should not have been accepted. 26.103 On 19 January 2016, after the conference, Mr Jenkins took the matter up with Steve Evans in email correspondence, picking up the ambiguities in some of the responses given by the panel at the conference. He asked whether the entire external wall of a high-rise building had to be of limited combustibility or whether, where ACM cladding panels were used, it was sufficient that they be classified Class 0.1914 Steve Evans responded on 29 January 2016 saying that Approved Document B advised that all materials used in the external wall should comply with both paragraph 12.7 and Diagram 40, thereby contradicting the view he had expressed at the conference.1915 Mr Evans fairly acknowledged before us that his position was indeed directly inconsistent with what he had said at the conference but insisted that it was what he had been trying to express.1916 We are not convinced by that answer, not least because Mr Evans took ten days to respond to Mr Jenkins, during which time he had had plenty of time to think about the point carefully. 26.104 Although Steve Evans told us that NHBC would not have approved any buildings clad in ACM panels with unmodified polyethylene cores,1917 we do not accept that. John Lewis conceded that the 2015 review had revealed a number of such buildings that had been approved by NHBC.1918 By early 2016 at the latest NHBC knew at the highest levels of its management that there were a substantial number of high-rise buildings in the UK on which ACM panels with unmodified polyethylene cores had been installed and which had been passed as compliant by NHBC’s building control surveyors.1919 The July 2016 guidance note 26.105 After NHBC changed its policy in February 2015 to require proof of compliance with the Building Regulations in accordance with TGN 18, it noticed that it was frequently being provided with the same desktop study amended in insubstantial ways to cater for differences between projects.1920 As no further test data had been forthcoming from Kingspan, despite a string of promises stretching back to January 2014, NHBC realised that it was likely to continue to receive desktop studies based on the same data. It therefore decided that it could dispense with the requirement for such studies altogether for certain façade systems.1921 26.106 Accordingly, in July 2016, NHBC published a guidance note entitled Acceptability of Common Wall Construction Containing Combustible Materials in High Rise Buildings.1922 The note was drafted by John Lewis and approved by Steve Evans, Diane Marshall, Ian Davis and the NHBC Executive Committee.1923 The new guidance set out functional requirement 1914 {BLM00000211/4}. 1915 {BLM00000211/2}. 1916 Evans {Day221/100:22-23}. 1917 Evans {Day221/120:4}-{Day221/121:7}. 1918 Lewis {Day225/42:17}-{Day225/45:25}. 1919 Lewis {Day225/42:17}-{Day225/45:25}. 1920 Lewis {NHB00003433/53} page 53, paragraph 194. 1921 Lewis {NHB00003433/54} page 54, paragraph 195. 1922 {NHB00001293}. 1923 Lewis {NHB00003433/55-56} pages 55-56, paragraphs 204-205.

Part 3 | Chapter 26: The National House Building Council 187 B4(1) and the four options contained in Issue 1 of TGN 18, which it described as alternative ways of demonstrating compliance with the Building Regulations. It went on to say that the new guidance had been produced to provide advice to builders on some of the most common wall types in relation to which NHBC would no longer require a desktop assessment in accordance with Option 3 in TGN 18 in order to demonstrate compliance. In the appendices it described three common wall and façade types that were acceptable to NHBC without the need to provide a desktop assessment provided that the design specification and installation met the minimum requirements set out in the appendices. 26.107 Appendix 3 covered aluminium composite panels. The requirements for automatic approval included the use of panels with a minimum Euroclass B classification and a Class 0 classification for surface spread of flame. Also acceptable as part of the system were Kingspan K15 and Celotex RS5000 insulation boards. 26.108 Diane Marshall told us that NHBC had been prompted to issue the guidance partly by the poor quality of the desktop studies submitted to it and partly by the administrative burden of reviewing many assessments relating to similar systems,1924 but clearly neither of those was a good reason for NHBC to abdicate its responsibility for examining carefully the proposed structure of an external wall. Ms Marshall sought to justify NHBC’s approach by reference to regulation 7 of the Building Regulations and said that it was common knowledge that past experience could be used to inform future decisions.1925 However, no one at NHBC had ever examined Approved Document B to see whether that was a permissible approach.1926 We do not think it was. 26.109 Paragraph 1.18 of the Approved Document supporting regulation 7 states that past experience, such as the use of a material in an existing building, may show that it can perform the function for which it is intended.1927 Ms Marshall conceded that a cladding system would need to comply with functional requirement B4(1) in order to demonstrate that the same system, if installed on another building, could perform the function for which it was intended as contemplated by regulation 7. However, she appeared not to grasp the important point that a previous desktop assessment could never demonstrate compliance in the absence of relevant test data relating to the particular system being used as the exemplar.1928 26.110 Both Diane Marshall and Steve Evans agreed that the guidance note published by NHBC involved drawing an inference from underlying assessments that were themselves based on inferences from some underlying data.1929 However, NHBC was not concerned by the fact that there had been no large-scale testing of any systems incorporating ACM panels,1930 and the guidance note was published without any contribution from organisations such as BRE or Exova.1931 That was particularly surprising given that NHBC was aware of the international cladding fires involving ACM panels in 2015 and early 2016.1932 1924 Marshall {Day226/62:14-18}. 1925 Marshall {Day226/73:9-21}. 1926 Marshall {Day226/74:18-23}. 1927 {INQ00014930/14}. 1928 Marshall {Day225/73:9}-{Day225/74:10}. 1929 Marshall {Day226/70:14-23}. 1930 Evans {Day221/138:11}-{Day221/139:25}. 1931 Evans {Day221/147:24}-{Day221/148:7}. 1932 Evans {Day220/19:14-17}; {Day220/21:20-23}; Lewis {Day225/8:18-22}.

The Grenfell Tower Inquiry: Phase 2 Report 188 26.111 Appendix 3 did contain a warning that the use of aluminium composite panels with polythene or polythene and mineral cores which did not achieve a Euroclass B classification fell outside the scope of the guidance.1933 Diane Marshall said that that had been intended to mean that all panels with polyethylene cores were prohibited in addition to those with fire retardant cores that had not achieved Class B.1934 In other words, she suggested that the clause “which do not achieve a minimum Class B combustibility classification” was to be read as if in parenthesis, so that all ACM panels with unmodified or modified polyethylene cores fell outside the guidance.1935 We are unable to accept that interpretation. First, no one at NHBC suggested that the passage was intended to have that meaning until Ms Marshall proposed it in the course of her evidence. Secondly, and more importantly, some ACM panels with fire retardant polyethylene cores can be classified Class 0 and Euroclass B. Indeed, some of Arconic’s Reynobond FR core panels were. No-one at NHBC had done any research before the note was published on the fire-retardant versions of ACM panels and their corresponding Euroclass classifications, and there was therefore no basis on which to ban all panels with polyethylene cores regardless of their mineral content.1936 Thirdly, if that had been intended, it would have been easy simply to say that all ACM panels with polyethylene cores fell outside the scope of the guidance note, without referring to any classification. 26.112 We think it clear that the sentence meant what it says, namely, that only ACM panels with polyethylene cores that were classified Class 0 or Euroclass B were covered by the guidance, without regard to the nature of the core. Mr Lewis, who drafted the note, told us that he thought that it would effectively exclude ACM panels with unmodified polyethylene cores, but he could not explain why he had not said so plainly.1937 26.113 The guidance note was silent on the size and orientation of the cladding panels, the spacing between them, the fixing method (cassette or riveted) and the width of the drained and vented cavity, all of which were capable of affecting the fire performance of the system as a whole. Steve Evans said that the guidance note was intended to apply to external wall systems that were practically identical to those in the numerous desktop studies submitted to NHBC,1938 but he was unable to explain what that meant.1939 26.114 Diane Marshall conceded that the guidance note permitted the use of external wall systems containing insulation and cladding that were not materials of limited combustibility and was therefore inconsistent with her understanding of paragraph 12.7 of Approved Document B.1940 Although the witnesses denied it,1941 the 2016 guidance note was clearly inconsistent with the policy NHBC had adopted in 2015 and, as Kingspan said in an internal email of 8 July 2016, eased the passage of compliance for K15.1942 Given the trouble that NHBC had had with Kingspan since early 2014, the sudden blanket approval of the use of K15 in the external walls of buildings over 18 metres in height was, to say the least, surprising. 1933 {NHB00000065/4}. 1934 Marshall {Day226/79:4-16}. 1935 Marshall {Day226/83:1-24}. 1936 Lewis {Day225/35:22}-{Day225/37:4}. 1937 Lewis {Day225/33:24}-{Day225/35:21}. 1938 Evans {NHB00003020/102} page 102, paragraph 251 a. 1939 Evans {Day221/147:12-22}. 1940 Marshall {Day226/90:22}-{Day226/91:7}. At least if, as she thought, all elements of the cladding system had to be material of limited combustibility, as Option 1 in TGN 18 provided. 1941 Lewis {Day225/51:18}-{Day225/52:5}. 1942 {KIN00002297/1}.

Part 3 | Chapter 26: The National House Building Council 189 26.115 The guidance note was presented to an NHBC conference in London on 7 July 2016. It is a tragic irony that that was the same date as the issue by RBKC’s building control officer of the certificate of practical completion for the Grenfell Tower refurbishment, the new cladding on which was composed of Celotex RS5000, a small amount of Kingspan K15 and ACM panels with unmodified polyethylene cores that purported to hold a Euroclass B classification. 26.116 For NHBC building control officers the guidance note was effectively a substitute for Approved Document B. For them to accept an external wall as complying with functional requirement B4(1), it was no longer necessary for the insulation (let alone all the elements) to be of limited combustibility, or, as an alternative, to have a full system test meeting the criteria in BR 135, or a desktop assessment, or a holistic fire-engineered solution. It was sufficient for the external wall to be composed of the common products listed. It drove a coach and horses through the guidance in Approved Document B and rendered TGN 18 completely irrelevant. There is no evidence that the BCA was ever consulted about it. We agree with Mr Lewis when he said that the guidance note should never have been produced.1943 Events after the fire at Grenfell Tower Approach from Brian Martin 26.117 On 16 June 2017, two days after the fire at Grenfell Tower, Brian Martin wrote to Diane Marshall attaching a script written to rebut a newspaper article which had stated that ACM panels with polyethylene cores complied with the guidance in Approved Document B.1944 He asked whether she would be prepared to make a public statement to that effect as an independent expert. Ms Marshall told us that she did not know why Brian Martin had approached her and had not given any thought at the time to whether it was appropriate for him to do so.1945 26.118 In contrast to the guidance note published by NHBC in July 2016, the script stated that only materials of limited combustibility could be used in the external walls of buildings over 18 metres in height.1946 Nonetheless, Diane Marshall told Brian Martin that she fully agreed with the proposed text.1947 She did not, however, agree to act as the required independent expert and instead suggested he approach the chairman of the BCA.1948 She said that her decision had not been motivated by the obvious inconsistency between the position of NHBC and that of the department but by the fact that she did not consider NHBC’s views to be representative of the industry.1949 We find that an unconvincing explanation given the influence of NHBC nationally, its role in the production of TGN 18 and the issue of its guidance note. 1943 Lewis {Day225/60:1-9}. 1944 {NHB00001460/2}; {NHB00001458}. 1945 Marshall {Day226/103:1}-{Day226/104:9}. 1946 Marshall {NHB00003434/43} page 43, paragraph 201. 1947 {NHB00001460/1}. 1948 {NHB00001460/1}. 1949 Marshall {Day226/105:16}-{Day226/109:18}.

The Grenfell Tower Inquiry: Phase 2 Report 190 Withdrawal of the guidance note 26.119 On 26 June 2017, Brian Martin wrote to Diane Marshall again to say that NHBC’s 2016 guidance note had been raised in response to the Grenfell Tower tragedy, but he offered no further explanation. He questioned its evidential basis and asked for the test results from any BS 8414 testing which had taken place using Class B ACM panels.1950 26.120 On 28 June 2017, NHBC withdrew the 2016 guidance note on the basis of commercial considerations rather than any consultation with fire specialists.1951 Diane Marshall told us that the guidance relating to ACM panels with polyethylene cores was open to being misread.1952 We do not accept that and we do not accept that the guidance note was a distraction from the tragedy at Grenfell Tower. On the contrary, it is of direct relevance to the attitudes of industry and NHBC at the time. 26.121 Diane Marshall responded to Mr Martin on 29 June 2017,1953 the day after the guidance note had been withdrawn.1954 She was aware it had been receiving media attention but disputed that she was concerned about the department’s request for evidence.1955 We do not accept that the timing was coincidental. Enquiries from government were clearly instrumental in NHBC’s decision to review its policy and withdraw the note. Indeed, Ms Marshall conceded that she was aware that no relevant ACM panels had ever been part of a successful test in accordance with BS 8414.1956 1950 {NHB00001465/2}. 1951 Marshall {Day226/96:25}-{Day226/97:24}. 1952 Marshall {Day226/81:22}-{Day226/84:7}. 1953 {NHB00001465/1}. 1954 Marshall {NHB00003434/43} page 43, paragraph 201. 1955 Marshall {Day226/110:8}-{Day226/112:13}. 1956 Marshall {Day226/119:9}-{Day226/120:12}.

191 Chapter 27 Siderise cavity barriers Background 27.1 Siderise Insulation Limited (‘Siderise’) designs and manufactures fire, thermal and acoustic insulation products for use in curtain walling and cladding. It also supplies associated products, such as brackets, sealants and tapes for use with its products.1957 It sells direct to customers or through distributors.1958 It is a member of various industry bodies, including the Centre for Window and Cladding Technology and the Association for Specialist Fire Protection.1959 It has contributed to the development of publications and guidance relating to external walls1960 and has hosted industry conferences on facades in collaboration with the Building Research Establishment (BRE).1961 27.2 As well as manufacturing cavity barriers, Siderise provided additional services to its customers,1962 including advice on the suitability of its products for particular applications1963 and guidance on installation.1964 Product Development and Testing 27.3 A cavity barrier is defined in Appendix E of Approved Document B as “a construction, other than a smoke curtain, provided to close a concealed space against penetration of smoke or flame, or provided to restrict the movement of smoke or flame within such a space.”1965 The guidance in Approved Document B is that cavity barriers should provide 30 minutes’ integrity and 15 minutes’ insulation when tested to the relevant part of BS 476.1966 27.4 According to Siderise’s witnesses, cavity barriers were traditionally tested in accordance with the general principles set out in BS 476 Part 20,1967 which is the British Standard containing general principles governing the method of determining the fire resistance of elements of construction.1968 Part 20 was accompanied by supplementary standards for testing specific elements of construction, namely, Part 21 for loadbearing elements, Part 22 for non-loadbearing elements, Part 23 for fire-protecting suspended ceilings and Part 24 for ventilation ducts.1969 Those supplemental parts did not apply to cavity barriers, which had to be tested in accordance with the general fire resistance principles outlined in BS 476-20.1970 1957 Swales {SIL00000306/3} page 3, paragraphs 11 and 13. 1958 Swales {SIL00000306/3} page 3, paragraph 11. 1959 Swales {SIL00000306/4} page 4, paragraph 14. 1960 Including the ASFP Red Book chapter “Firestopping: Linear Joint seals, penetrations & cavity barriers”, Swales {SIL00000306/4} page 4, paragraph 14. 1961 Swales {SIL00000306/4-5} pages 4-5, paragraph 16. The first was on 1 November 2012 and the second on 13 January 2016. 1962 Siderise Site Services dated January 2016 {SIL00002589}. 1963 Swales {SIL00000306/7} page 7, paragraph 28. 1964 Siderise Site Services dated January 2016 {SIL00002589}. 1965 Approved Document B 2013 {CLG00000224/143}. 1966 Approved Document B 2013 {CLG00000224/125} Table A1, Item 15. 1967 Mort {SIL00000298/10} page 10, paragraph 38; {BSI00001748}. 1968 {BSI00001748/1}. 1969 Part 21 {BSI00001745}; Part 22 {BSI00001743}; Part 23 {BSI00000074}; Part 24 {BSI00000075}. 1970 Mort {Day102/16:23}-{Day102/18:1}.

The Grenfell Tower Inquiry: Phase 2 Report 192 27.5 The cavity barriers installed at Grenfell Tower were vertical “full-fill” barriers and horizontal “open-state” barriers. A full-fill barrier consisted of a solid piece of material spanning the entire cavity, thus forming a permanent vertical barrier against the horizontal spread of fire. An open-state barrier had a gap between the face of the barrier and the rainscreen panels to allow the passage of air and moisture. It had an intumescent strip on the outside edge that was designed to expand to fill the gap when exposed to heat in order to restrict the passage of fire vertically.1971 The intumescent strip could be effective in sealing the cavity only if the surface against which it expanded remained in place.1972 The effectiveness of a “full-fill” cavity barrier also depended on the integrity of the surfaces it abutted, in particular the rainscreen. 27.6 Stephen Swales, Chief Commercial Officer at Siderise, explained that from the late 1990s onwards Siderise had begun to develop open-state cavity barriers in response to demands from industry for a product that would leave a gap to allow for ventilation and the passage of moisture behind the rainscreen but which would close the gap in the event of fire.1973 From around 2002 Siderise began to evaluate a number of different intumescent materials through a programme of testing carried out with the company that later became Exova.1974 27.7 Christopher Mort, the Sales and Technical Engineer for Siderise (and from 2011 their Technical Officer for Fire), was responsible for ensuring that the new product complied with the relevant statutory and regulatory requirements.1975 At a product development meeting in July 2006 it was agreed that the aim was for the product to meet the requirements of a modified BS 476 Part 20 test.1976 Mr Mort told us that it had been accepted within Siderise that testing to the general principles of BS 476 Part 20 was not ideal, as the standard could not be applied directly to open-state cavity barriers.1977 (There was no precedent for testing open-state cavity barriers and Siderise was the only company embarking on such testing at the time.)1978 The standard test procedure in BS 476 Part 20 was therefore modified following discussions with Exova, in particular to dispense with the requirement that there be no gaps present at the start of the test.1979 The standard test procedure involved pushing a metal rod into the test specimen. If it was possible to penetrate the full width, the product failed the test.1980 All open-state cavity barriers automatically failed that requirement because of the gap that was present in the cold state. Instead, Siderise agreed with Exova that it would monitor and record the closure of the gap and test the integrity of the product at that stage.1981 27.8 At no stage did Siderise or Exova ask any other industry bodies or anyone in government whether such a test method was appropriate. Siderise relied entirely on the advice it received from Exova.1982 1971 Mort {Day102/21:3-16}. 1972 Mort {Day102/22:13-24}. 1973 Swales {SIL00000306/11-12} pages 11-12, paragraphs 44-46. 1974 Swales {SIL00000306/12} page 12, paragraph 45. 1975 {SIL00002586}, {SIL00002587} and Mort {Day102/27:4-13}. 1976 {SIL00002587}. 1977 Mort {SIL00000298/10} page 10, paragraph 38. 1978 Swales {SIL00000306/10} page 10, paragraph 39 and Mort {Day102/43:23}-{Day102/44:8}. 1979 Mort {Day102/28:24}-{Day102/29:7}. 1980 Mort {Day102/29:8-13}. 1981 Mort {Day102/29:18}-{Day102/30:12}. 1982 Mort {Day102/44:24}-{Day102/45:13}.

Part 3 | Chapter 27: Siderise cavity barriers 193 27.9 Between 2007 and 2011 Exova carried out four tests on open-state cavity barriers on which it produced reports.1983 During each of the tests the product was held between two concrete lintels.1984 Insulation and integrity were measured only after the intumescent strip had closed the gap.1985 All the reports contained important qualifications about the procedure that had been adopted. They stated that the results related only to the behaviour of the specimens under the particular conditions of the test, were not intended to be the sole criteria for assessing the potential performance of the products in use and did not reflect their behaviour in an actual fire. In addition, they stated that the results of the tests might not be applicable to situations in which the width of joints, orientation or supporting construction varied from those of the test. Since no movement was induced during the tests it was not possible to evaluate the products’ performance where movement was induced under actual fire conditions.1986 They were important qualifications, because they set out clear limits on the testing that Exova had undertaken.1987 Anyone reading the test reports should have appreciated that they could not be relied on to predict with any accuracy how the products would perform in a fire or, in particular, how they would perform as part of a ventilated rainscreen system. That was made particularly clear in the test report issued in 2011, which included the following paragraph drawing attention to the risk of failure of the rainscreen: “This report does not consider the fire resistance performance of the rainscreen element or whether fire spread may occur as a consequence of collapse or failure of the rainscreen. The approving authority or regulator should decide whether it is necessary for the rainscreen to be ‘fire rated’, whether it is of an appropriate construction and whether separate test or assessment evidence is necessary.”1988 27.10 In the test report dated 20 September 20111989 Exova combined favourable integrity test results from tests carried out in 20101990 with favourable insulation results from tests carried out in 20071991 and concluded that Siderise open-state cavity barriers would achieve 60 minutes’ integrity and 30 minutes’ insulation respectively,1992 although no one specimen had produced both results.1993 Nonetheless, there is no reason to think that the product did not in fact meet those standards. 27.11 Siderise considered that successful testing to some, but not all, of the requirements of BS 476 Part 20 would evidence compliance with the guidance in Approved Document B, as it would demonstrate that the open-state cavity barriers met the requirement for 30 minutes’ insulation and 15 minutes’ integrity.1994 1983 February 2007 {SIL00000290}; January 2009 {SIL00000223}; August 2010 {SIL00000224}; September 2011 {SIL00000211}. 1984 Mort {Day102/63:7-10}; {Day102/65:14-18}; {SIL00000290/12}; {SIL00000223/4}; {SIL00000224/12}; {SIL00000211/5}. 1985 Mort {Day102/63:21}-{Day102/64:4}; {SIL00000290/28}; {SIL00000223/3}; {SIL00000224/23}; {SIL00000211/8}. 1986 {SIL00000290/28}; {SIL00000223/7}; {SIL00000224/24}; {SIL00000211/7}. 1987 Mort {Day102/68:17-21} and {Day102/69:2-4}. 1988 {SIL00000211/4}. 1989 {SIL00000211/7}. 1990 {SIL00000224/3}. 1991 {SIL00000290/4}. 1992 Mort {Day102/77:25}-{Day102/78:12}. 1993 Mort {Day102/78:13-16}. 1994 Mort {Day102/32:2-7}.

The Grenfell Tower Inquiry: Phase 2 Report 194 Testing in accordance with BS 8414 27.12 According to Mr Swales, before the Grenfell Tower fire there had been a general reluctance to conduct large-scale tests in accordance with BS 8414 as they were considered too costly.1995 However some guidance relating to the use of cavity barriers suggested that it was nevertheless important to consider whether full-scale testing for reaction to fire (as opposed to resistance to fire) might provide important information on whether they could perform effectively as part of a ventilated rainscreen system. For example, Technical Report 31 of the European Organisation for Technical Approvals on “Fire Resistance Tests for Cavity Barriers” dated October 20081996 stated that the method of testing it described was not applicable to horizontal cavity barriers in rainscreen cladding systems because it was difficult, if not impossible, to model the correct thermal exposure and boundary conditions in a test for resistance to fire. It therefore recommended that the fire resistance of horizontal cavity barriers be assessed in the context of a full-scale facade test.1997 According to Mr Swales, Siderise was a strong advocate of BS 8414 testing and was keen to test its cavity barriers in that way, having actively sought out partners for such tests in the period before 2017.1998 27.13 At the time Siderise cavity barriers were specified for use on Grenfell Tower, Mr Mort was not aware of any testing that had been undertaken by Siderise, or by anyone else using its products, that demonstrated how they would perform in conjunction with metal composite rainscreen panels.1999 However, it had taken part in six BS 8414 tests between 2012 and May 2015.2000 The cladding used for those tests had been rainscreen boards or terracotta tiles but not aluminium composite material;2001 the insulation had been either PIR or phenolic foam boards or mineral wool.2002 Not all of the systems tested met the criteria in BR 135. In particular, a test undertaken in conjunction with Celotex RS5000 insulation in February 2014 failed to do so.2003 Mr Mort was aware that during the test the Marley Eternit panels had pulled away from the rig and distorted, thereby rendering the cavity barriers ineffective because they had nothing against which they could form a seal.2004 Siderise was aware that the effectiveness of its cavity barriers, whether full-fill or open-state, in creating and maintaining a seal depended on the integrity of the rainscreen.2005 Industry Testing 27.14 Since it was not possible to test open-state cavity barriers in accordance with BS 476 Part 20,2006 Siderise worked with the Association for Specialist Fire Protection, laboratories, certification engineers, manufacturers,2007 members of the Comité Européen de Normalisation and the British Standards Institution to develop a new method of testing entitled “Technical Guidance Document 19” (“TG19”).2008 The test, which was published by 1995 Swales {SIL00000306/17} page 17, paragraph 64. 1996 {INQ00014544}. 1997 {INQ00014544/7} section 1, paragraph 4. 1998 Swales {SIL00000306/17} page 17, paragraph 64. 1999 Mort {Day102/122:10-22}. 2000 Swales {SIL00000306/17} page 17, paragraph 63. 2001 Mort {Day102/136:14-19}. 2002 Swales {SIL00000306/17} page 17, paragraph 63. 2003 {Day102/135:19}-{Day102/136:2}. For our factual findings in relation to these Celotex tests see Chapter 24. 2004 Mort {Day102/144:8-12}. 2005 Mort {Day102/145:8-17}. 2006 Swales {SIL00000306/13} page 13, paragraph 49 and Mort {Day102/80:25}-{Day102/81:3}. 2007 Including Siderise, Hilti, Rockwool, Firetherm, Firestopit and Promat. 2008 Swales {SIL00000306/13} page 13, paragraph 49.

Part 3 | Chapter 27: Siderise cavity barriers 195 the Association in 2014, required an open-state cavity barrier to close within five minutes of the beginning of the test.2009 Any failure of integrity before that was to be disregarded unless any part of the surface exhibited sustained flaming above the seal.2010 In other words, the test standard permitted the response of the product during the first five minutes to be ignored, save in the event of extreme flaming.2011 27.15 TG19 was specifically designed for small-scale furnace testing of open-state cavity barriers.2012 Small-scale furnace testing was considered appropriate because it demonstrated the performance of the product in isolation.2013 The test did not, therefore, extend to assessing the performance of open-state cavity barriers as part of a ventilated rainscreen system.2014 TG19 expressly recommended that to evaluate the performance of open-state cavity barriers as part of a cladding system, a large-scale test, such as a BS 8414 test, should be considered.2015 It also referred to a warning in the second edition of BR 135 that small-scale tests had been found not to reflect the fire hazard associated with full‑scale cladding systems.2016 Siderise appreciated the importance of that warning before it became involved in the Grenfell Tower refurbishment.2017 27.16 Technical Note 17 published by the Centre for Window and Cladding Technology in March 20112018 also contained a warning that cavity barriers could be tested in accordance with the principles contained in BS 476-20 (and other similar standards), but that their performance in conjunction with rainscreen panels might be different.2019 Mr Mort confirmed that he had been aware of that guidance from 2011.2020 27.17 The recommendation that any proposed system be tested in accordance with BS 8414 was included in TG19 because the two tests served different purposes. The test described in TG19 measured the properties of a cavity barrier, in particular the duration of insulation and integrity, in isolation but, unlike a BS 8414 test, did not measure the performance of an external wall system as a whole.2021 On the other hand, a BS 8414 test did not measure the performance of individual components.2022 Siderise was aware before the Grenfell Tower fire that if cavity barriers were used as part of a ventilated rainscreen system, the rainscreen panels might distort or become detached and thus compromise the effectiveness of the cavity barriers.2023 27.18 On 15 May 2013,2024 Siderise tested an open-state cavity barrier between two concrete lintels2025 in accordance with a draft version of TG19.2026 Exova produced a report on 23 July 20132027 which contained warnings similar to those in the reports mentioned 2009 {SIL00001540/14}. 2010 {SIL00001540/15}. 2011 Mort {Day102/123:17}-{Day102/124:1}. 2012 Mort {SIL00000298/11} page 11, paragraph 40. 2013 Mort {Day102/91:14-24}. 2014 Mort {Day102/101:9-21}. 2015 {SIL00001540/3}. 2016 {SIL00001540/17}. 2017 Mort {Day102/128:1-13}. 2018 {CWCT0000019}. 2019 {CWCT0000019/5}. 2020 Mort {Day102/131:7}-{Day102/132:5}. 2021 Mort {Day102/117:19}-{Day102/118:4}. 2022 {SIL00001540/16}; Mort {Day102/120:3-10}. 2023 Mort {Day102/120:11}-{Day102/121:20}. 2024 Swales {SIL00000306/13} page 13, paragraph 50 and {SIL00000212/3}. Siderise again tested open state cavity barriers on 24 April 2014 with Chiltern International {SIL00000288}. 2025 {SIL00000212/2}; Mort {Day102/92:6-16}. 2026 Entitled “ASFP TG 3 N64, fourth draft February 2013”. 2027 {SIL00000212}.

The Grenfell Tower Inquiry: Phase 2 Report 196 above. In particular, it made it clear that the test results were not to be used as the sole basis for assessing the fire performance of the cavity barriers and that the results were not applicable to situations in which the width of the joints or the depth, orientation or supporting construction was different. It also drew attention to the fact that the test did not induce movement and therefore might not represent conditions that would be encountered in a fire.2028 The report also made it clear that the results were applicable only to a void of the size tested.2029 Siderise staff understood those limitations, including the staff in its sales and marketing teams.2030 27.19 As far as Mr Mort was aware, there were no discussions with DCLG about adding a reference to TG19 to Approved Document B.2031 Extended Application Assessments 27.20 Siderise also carried out extended application assessments for cavity barriers of the kind that were used at Grenfell Tower. For that purpose, it used data from previous tests to calculate whether the products could be used in situations other than those in which they had been tested.2032 That enabled it to assess the ability of its open-state cavity barriers to seal voids of greater width than those that had been used for the tests.2033 27.21 All the extended application assessments for the products as used on Grenfell Tower were signed by Christopher Mort and dated 23 June 2017;2034 in other words, they post- dated the fire by a few days.2035 No formal assessment had been carried out before that date, or at any rate no reference to one appeared in any document.2036 Mr Mort said that informal assessments had been carried out, but he accepted that there was nothing in the documents provided to us to support that.2037 At Grenfell Tower, Siderise supplied cavity barriers for voids of between 326 and 425mm without having tested its products in voids of that width and without having undertaken any formal extended application assessments.2038 27.22 Even when Siderise did undertake formal extended application assessments in June 2017, it did not seek any external verification for its conclusions.2039 Mr Mort’s explanation was that external validation was not required by Siderise or by Approved Document B.2040 It did not occur to him that it might be inappropriate for Siderise to certify its own products for use in extended applications without the support of an independent expert.2041 2028 {SIL00000212/32}. 2029 {SIL00000212/34}. 2030 Mort {Day102/100:7-20}. 2031 Mort {Day102/134:16-23}. 2032 Mort {Day102/174:10-16}. 2033 Swales {SIL00000306/14} page 14, paragraph 52. 2034 {SIL00000204/22}; {SIL00000204/29}; {SIL00000204/35-6}; and {SIL00000204/42-43}. 2035 Mort {Day102/175:2-18}. 2036 Mort {Day102/178:21}-{Day102/179:13}. 2037 Mort {Day102/180:13}-{Day102/181:5}. 2038 Mort {Day102/180:13-21}. 2039 Mort {Day102/177:8-16}. 2040 Mort {Day102/177:20-23}. 2041 Mort {Day102/178:4-8}.

Part 3 | Chapter 27: Siderise cavity barriers 197 Marketing material Datasheet 2110 27.23 In mid-2012 Siderise produced datasheet 2110 relating to Lamatherm cavity barriers for rainscreen cladding.2042 It gave copies of it to Harley in August 2013 in connection with two projects which required rainscreen cavity fire barriers.2043 The title of the datasheet was “Cavity Barriers for Rainscreen Cladding”. In the introduction it stated that rainscreen cladding systems typically incorporated a ventilated air space to allow the drainage of rainwater and that, to accommodate that design feature, Siderise had developed a purpose-made solution, namely, a horizontal cavity barrier with an integral intumescent strip along the edge which “fully closes the ventilated air gap in the event of a fire”. 27.24 The datasheet referred to the four Exova reports2044 and said that the product had been tested by Exova and in its opinion represented a practical solution for a particularly demanding condition.2045 However, nowhere in any of the reports had Exova expressed that opinion.2046 Mr Mort told us that he had reviewed the data sheet to ensure that it was accurate,2047 but he was unable to explain how it had included Exova’s apparent endorsement.2048 He suggested that there might have been conversations with Exova, of which he had been unaware at the time, during which Exova had expressed that opinion,2049 but we think that unlikely, since as Sales and Technical Engineer, he had a leading role in arranging and attending the testing with Exova.2050 Plainly, Siderise should not have relied in its marketing material on an endorsement that was not genuine. 27.25 Under the heading “Advantages”, the datasheet set out the results achieved in tests conducted by Exova using the principles of BS 476-20 & BS EN 1366-4:2006.2051 It stated that a technical failure of integrity and insulation was deemed to have occurred at the start of the test due to the passage of flame through the open void, but went on to state that following the rapid expansion of the intumescent strip, the gap had become fully sealed and that the product had achieved the required standards for integrity and insulation.2052 27.26 The datasheet did not describe the nature of the test in detail, nor did it reflect any of the qualifications set out in the test reports, including the warning that the results might not apply to situations in which the supporting construction differed from that of the test. The datasheet also failed to warn the reader that it was not possible to evaluate the product’s performance in circumstances where movement of the supporting construction was induced by exposure to fire. Finally, the datasheet did not draw attention to the fact that cavity barriers might be rendered ineffective if the rainscreen became distorted or dislodged in a fire. 2042 {SIL00004672}. 2043 Richard Kay (Siderise) emailed it to Mark Harris (Harley) in relation to the Wayland House project on 19 August 2013 {SIL00000325/2}. Richard Kay also sent it to Tim Lovell (Harley) in relation to the 10 Trinity Square project on 5 August 2013 {SIL00000327}. 2044 As discussed above, February 2007 {SIL00000290}; January 2009 {SIL00000223}; August 2010 {SIL00000224}; September 2011 {SIL00000211}. 2045 {SIL00004672} section ‘Introduction’, second column final paragraph. 2046 Mort {Day102/197:4-12}. 2047 Mort {Day102/193:4-6}. 2048 Mort {Day102/199:11-16}. 2049 Mort {Day102/196:16-20}; {Day102/197:10-21}. 2050 Mort {SIL00000298/2} page 2, paragraph 7(b); Mort {Day102/69:6-17}. 2051 {SIL00004672/1}. 2052 {SIL00004672/1} section “Fire Performance”.

The Grenfell Tower Inquiry: Phase 2 Report 198 27.27 If the construction industry is to function effectively and safely it requires products that do the job expected of them and are marketed honestly. Although there is no evidence to suggest that, unlike Arconic, Kingspan and Celotex, Siderise set out in its marketing literature deliberately to mislead, it was suggested that its datasheet was in fact misleading because it suggested that its cavity barriers were effective when used in rainscreen cladding systems of all kinds, when the tests it had carried out did not support that claim.2053 We think that the datasheet should have described more fully the nature of the tests it had carried out. The unqualified statement that the horizontal cavity barrier “fully closes the ventilated air gap in the event of a fire” tended to suggest that it would do so regardless of the nature of the rainscreen panel against which it was to form a seal. On the face of it, that was misleading, because no test had been carried out in conjunction with any recognised form of rainscreen panel. However, it is unlikely that any competent designer reading the datasheet would have been misled about the suitability of the product for particular rainscreen applications. 27.28 The title of the datasheet, “Cavity Barriers for Rainscreen Cladding”, indicated no more than that the product had been designed for use in rainscreen cladding systems, which was indeed the case. Any competent fire engineer should have been aware of the warning in the second edition of BR 135 that small-scale tests on individual products had been found not to reflect the fire hazard associated with full-scale cladding systems2054 and would have realised that the effectiveness of cavity barriers in any ventilated rainscreen system depends not only on the quality of the product itself but on whether the rainscreen panels remain in place during a fire. A competent fire engineer would also have asked for the underlying fire test data2055 to obtain a proper understanding of the tests that had been carried out on the product. 27.29 We recognise, however, that this kind of marketing literature would also have been read and relied on by a wide range of construction professionals, including architects, cladding designers2056 and building control officers, some of whom might not have been familiar with test method BS 476-20. Although Siderise argued that anyone familiar with BS 476 Part 20 or BS EN 1366-4 would have been aware that tests on cavity barriers are carried out on the product held between concrete lintels,2057 its marketing literature stated only that the tests had been carried out “using the principles” of those methods.2058 We do not think that some professionals, for example, reasonably competent cladding contractors, could be expected to be familiar with those fire resistance tests, although they should have appreciated that tests on cavity barriers are generally conducted with the product held between walls of fire resisting construction and that their performance in conjunction with rainscreen panels might be different.2059 However, anyone with even a basic understanding of the principles underlying the use of cavity barriers who gave the matter a moment’s thought would have realised that, if the rainscreen became distorted or dislodged for whatever reason, no cavity barrier of any kind could continue to be effective. 27.30 Although the datasheet was intended to, and did, tell the reader that the intumescent strip would expand effectively to close the gap in a rainscreen system in the event of a fire, the description of the way in which it worked made it clear that the claim was based on 2053 {BSR00000070/31} page 31, paragraph 9.1. 2054 {SIL00001540/17}. 2055 Siderise made those available only on request: Mort {Day102/73:8-24}. 2056 Jonathan Sakula’s evidence was that specialist cladding designers would normally have referred to the manufacturer’s technical literature Sakula, Façade Expert Report {JOS00000001/49} paragraph 12.1. 2057 {SIL00010048/12}. 2058 {SIL00004672/1}. 2059 Sakula {Day125/80:5}-{Day125/81:8}.

Part 3 | Chapter 27: Siderise cavity barriers 199 an assumption that the rainscreen would retain its integrity and provide a stable surface against which the intumescent strip could expand. It may not have been clear to some readers of the datasheet that the product had been tested between two concrete lintels, but any competent designer should have appreciated that the stability of the rainscreen was essential to its effective operation, as it was to the effectiveness of the vertical full-fill cavity barriers. 27.31 It has been suggested that Siderise ought to have postponed marketing its products for use in rainscreen applications until there was a body of data from BS 8414 tests which demonstrated that they were effective when used in conjunction with particular rainscreen panels, and then only for use in systems of those kinds. In our view that is unrealistic. The BS 8414 test is not designed to test individual products and the behaviour of the rainscreen in response to an actual fire may depend on many factors. It may not accurately reflect its behaviour in a test. The fact is that the cavity barriers sold by Siderise, both full-fill and open-state, met the claims made for them in relation to integrity and insulation and the open-state barriers functioned effectively when tested in accordance with the principles of BS 476-20. Design professionals must take responsibility for ensuring that the choice of rainscreen panel will not render the cavity barriers ineffective. No competent design professional could reasonably have understood the datasheet to mean that the cavity barrier would remain effective even if the rainscreen became seriously distorted or detached and no one claimed to have understood it in that way. 27.32 The statement that the ventilated air gap would be fully closed in the event of a fire was therefore subject to the implicit qualification that the rainscreen remained in place and retained its rigidity and integrity. That qualification would have been obvious to a competent designer or cladding contractor but not necessarily to others. Siderise could not assume that everyone who read the datasheet would be competent and would be aware of the implicit qualification. It should therefore have made the qualification explicit. Sending the datasheet to Harley 27.33 When Siderise sent datasheet 2110 to Harley in August 2013 it did not provide Harley with any information about the suitability in general of cavity barriers for use in rainscreen systems or the potential limits on their effectiveness. Nor did it refer to the nature of the tests that it had carried out on its own product. However, it was for Harley and others to determine whether the combination of materials it was using on a particular project, including the external wall at Grenfell Tower, would satisfy the Building Regulations. Siderise was not asked for general advice about the suitability of its products for use at Grenfell Tower nor is there any evidence that Harley relied on datasheet 2110 for the purposes of the design of the external wall. Siderise cannot reasonably be criticised for failing to point out to Harley that if a rainscreen failed, the cavity barriers would cease to be effective. Postscript 27.34 Functional requirement B3(4) of the Building Regulations requires a building to be designed and constructed so that the unseen spread of fire and smoke within concealed spaces in its structure and fabric is inhibited. Functional requirement B4(1) requires that the external wall shall adequately resist the spread of fire over the walls having regard to the height, use and position of the building. Section 9 of the 2013 revision of Approved Document B

The Grenfell Tower Inquiry: Phase 2 Report 200 provided guidance on the use of cavity barriers. It included advice in paragraph 9.15.d2060 that they should be fixed so that their performance is unlikely to be made ineffective by the failure in a fire of any material or construction which they abut. The risk that cavity barriers in the external wall construction of a building with ventilated rainscreen cladding might become ineffective if the rainscreen failed appears therefore to have been foreseen. Despite that, none of those involved in the design of the refurbishment of Grenfell Tower appears to have considered how the rainscreen was likely to react if exposed to fire or whether its behaviour might undermine the effectiveness of the cavity barriers. In our view, designers should give much more thought to the behaviour in fire of rainscreen panels intended for use in conjunction with cavity barriers in order to comply with functional requirements B3(4) and B4(1). 2060 {CLG00000224/86}.

201 Role and function 28.1 The United Kingdom Accreditation Service (UKAS) assesses, against nationally and internationally accepted standards of accreditation, those organisations which provide conformity assessment services, such as certification, testing, inspection, calibration and verification.2061 28.2 UKAS was established in 1995 as a company limited by guarantee.2062 Throughout its existence it has operated under a memorandum of understanding with the government.2063 In 2009 it was appointed the national accreditation body for the purposes of article 4(1) of Regulation (EC) No 765/2008 under the Accreditation Regulations 2009.2064 It was, and as at June 2017 remained, the only body exercising that function in the UK.2065 It is a not- for-profit organisation2066 funded primarily by the fees it charges under contracts entered into on its standard terms2067 with the organisations it accredits.2068 Our findings about its policies and operations are to a large extent based on the evidence of Lorraine Turner, its Accreditation Director. 28.3 Since the early 2000s, UKAS has accredited the BBA to certify products and systems under its Agrément certification schemes.2069 As an accredited organisation the BBA issued a certificate for Arconic’s Reynobond ACM panels.2070 UKAS also accredited BRE. It had done so for several years before April 2002, when it first accredited BRE to perform large-scale fire tests in accordance with what became BS 8414.2071 As an accredited organisation BRE carried out BS 8414 tests on systems incorporating Kingspan K15 and Celotex RS5000. Policies and procedures 28.4 UKAS accredited organisations to various national and international standards, in particular, a. ISO/IEC 17065, Conformity assessment – Requirements for bodies certifying products, processes and services,2072 which was the standard by which it assessed the BBA’s Agrément certification schemes,2073 and 2061 See Ukas.com/about-us/about-ukas. 2062 Turner {UKAS0011242/4} page 4, paragraph 7(a). 2063 UKAS Memorandum of Understanding (MOU) 2006 {UKAS0011258}; UKAS Memorandum of Understanding (MOU) 2007 {UKAS0011259}; UKAS Memorandum of Understanding (MOU) 2009 {UKAS0011260}; UKAS Memorandum of Understanding (MOU) 2009 {UKAS0011261}; UKAS Memorandum of Understanding (MOU) 2013 {UKAS0011262}; UKAS Memorandum of Understanding (MOU) 2014 {UKAS0011263}; UKAS Memorandum of Understanding (MOU) 2017 {UKAS0011264}; UKAS Memorandum of Understanding (MOU) 2021 {UKAS0011251}. 2064 Turner {UKAS0011242/8-9} pages 8-9, paragraph 7(g); UKAS was appointed pursuant to The Accreditation Regulations 2009 {UKAS0011250}. 2065 UKAS Closing Submissions for Module 6 {UKAS0011447/5} page 5, paragraph 17. 2066 Turner {UKAS0011242/8-9} pages 8-9 paragraph 7(g). 2067 Turner {Day226/174:5-7}; {UKAS0011300}; {UKAS0011301}; {UKAS0011302}. 2068 Turner {Day 226/147:5-17}. The MOUs allowed for sponsoring government departments to provide financial assistance in defined circumstances. Those circumstances were not relevant to any matters before this Inquiry. 2069 {BSI00001920}. 2070 {BBA00000047}. 2071 {BSI00001726}; {BSI00001924}. 2072 {BSI00001920}. 2073 Albon {BBA00010723/7} page 7, paragraphs 19-20. Chapter 28 United Kingdom Accreditation Service

The Grenfell Tower Inquiry: Phase 2 Report 202 b. ISO/IEC2074 17025, General requirements for the competence of testing and calibration laboratories2075 which was the standard by which it assessed BRE’s performance of BS 8414 tests.2076 28.5 For both of those standards the process adopted by UKAS for accrediting an organisation involved checking both the technical requirements of each accredited activity as well as that organisation’s processes and safeguards, such as its management systems, internal auditing, environmental conditions and the training of its personnel.2077 28.6 In addition, its internal policies provided for a rolling programme of annual assessment visits,2078 examining each of the organisation’s accredited activities at least once over a four-year period.2079 If it found that improvement was needed, by identifying a failure or “non-conformity” with a relevant standard, UKAS required the organisation to propose steps known as “improvement actions” to address the deficiencies. UKAS assessed whether those improvement actions met the problem and had been performed satisfactorily and then decided whether the body had met the accreditation standard. In addition, UKAS could make extra visits, including unannounced visits, outside the rolling programme and did make extra visits to some bodies as a result of the Grenfell Tower fire. However, it rarely made unannounced visits,2080 so the organisation in question almost always knew when a visit was about to take place. 28.7 It was not possible for UKAS to review all the activities of an organisation being considered for accreditation. Each organisation subject to accreditation was therefore required to keep detailed management records, to audit its own performance and to record its more serious non-conformities. Accredited organisations were required to report any significant non-conformities to UKAS,2081 but if they failed to do so, UKAS had access to the records when carrying out the next assessment and could see how the organisation had dealt with them.2082 However, that meant that the effectiveness of its oversight depended to a significant extent on the honesty and integrity of the organisation in question 2083 and its ability and willingness to examine its own behaviour and respond comprehensively to rigorous self-evaluation as well as criticism by UKAS. 28.8 UKAS formed committees to advise on technical matters.2084 Members were drawn from professional bodies, regulators, customers of accredited organisations and the government.2085 The only committee within UKAS that considered matters relating to construction was the Construction Industry Technical Advisory Committee.2086 However, for 2074 ISO/IEC stands for International Organization for Standardization/International Electrotechnical Commission. 2075 {BSI00001726}; {BSI00001924}. 2076 Howard {BRE00005771/4} page 4, paragraph 18. 2077 Turner {Day226/174:11}-{Day226/175:16}; {BSI00001920}; {BSI00001726}. 2078 General Principles of Assessment of Conformity Assessment Bodies by the United Kingdom Accreditation Service (GEN-1) {UKAS0011246/13} figure 1; The Accreditation Process – Policy and Associated Requirements (ACC 1000) {UKAS0011247/22-23} section 6.8.2. 2079 The Accreditation Process – Policy and Associated Requirements (ACC 1000) {UKAS0011247/32-39}; Turner {Day 226/181:1-10}. 2080 Turner {Day226/188:21}-{Day226/189:11}. 2081 General Principles of Assessment of Conformity Assessment Bodies by the United Kingdom Accreditation Service (GEN-1) {UKAS0011246/18} section 4.5.2; Turner {UKAS0011422/11} page 11, paragraphs 8.1-9.1. 2082 Turner {UKAS0011422/12} page 12, paragraph 11.1. 2083 Turner {Day226/195:25}-{Day226/197:14}. 2084 Turner {UKAS0011242/13} page 13, paragraph 10(b). 2085 Turner {UKAS0011242/13} page 13, paragraph 10(c). 2086 Turner {UKAS0011242/14} page 14, paragraph 11.

Part 3 | Chapter 28: United Kingdom Accreditation Service 203 years before the fire that committee’s work focussed on topics relating to infrastructure, for example, building roads and bridges.2087 It rarely considered matters relating to fire testing or the fire safety of products used in construction and did not do so at all after 2000.2088 28.9 UKAS published accreditation schedules that listed all the activities that a particular organisation was accredited to perform. That was the principal way in which the construction industry could find out what functions a particular organisation was accredited to carry out at any time. If UKAS was satisfied that an accredited organisation was failing to meet the standards required for accreditation, it had the power to suspend or withdraw accreditation, either partially or fully.2089 If it had proof of fraudulent behaviour or an accredited organisation deliberately provided false information or deliberately violated accreditation rules, UKAS was obliged to initiate the process for withdrawal of accreditation.2090 If UKAS suspended or withdrew an organisation’s accreditation, it did not publish the reasons for doing so because it considered itself bound by the confidentiality undertaking in its standard terms.2091 In cases of fraud or where there were serious concerns about safety UKAS would consider who needed to know about such matters. That might involve notifying the regulator or, if there were no regulator, might involve putting the information into the public domain.2092 Since the fire UKAS has changed its standard terms to make clear that it is not bound by confidentiality in cases of fraud or a risk to the safety or health of individuals.2093 UKAS had no regulatory or enforcement powers. Accreditation of the BBA 28.10 UKAS accredited the BBA to issue Agrément certificates for certain products. A schedule2094 was agreed with the BBA, known as “BBA Document 001”, setting out thirteen “Technical Specifications”, each of which contained short descriptions of categories of products in respect of which UKAS agreed that the BBA could assess and, if appropriate, issue Agrément certificates. For example, Technical Specification 0012 was for “Wall and cladding products and systems”, within which both cladding products and built-in cavity wall insulation products were briefly and broadly described.2095 28.11 The Technical Specifications listed core certificates for each product category, known as “Leader” certificates.2096 When a product falling within one of the categories came to be assessed, the BBA’s project manager was required to follow the process that had been used to produce the Leader certificate. Those processes were not recorded in any 2087 Turner {UKAS0011242/14} page 14, paragraph 11(b). 2088 {UKAS0010843/4} item 4.5; {UKAS0010844/2} item 4.2; {UKAS0010845/2} item 3.2. 2089 General Principles of Assessment of Conformity Assessment Bodies by the United Kingdom Accreditation Service (GEN-1) {UKAS0011246/30} section 6; The Accreditation Process – Policy and Associated Requirements (ACC 1000) {UKAS0011247/24-25} section 7.2. 2090 The Accreditation Process – Policy and Associated Requirements (ACC 1000) {UKAS0010905/19} section 7.2.11; General Principles of Assessment of Conformity Assessment Bodies by the United Kingdom Accreditation Service (GEN-1) {UKAS0011246/30} section 6.5; Turner {UKAS0011422/14} page 14, paragraph 15.1. 2091 Turner {Day226/206:21}-{Day226/207:9}. 2092 Turner {Day226/210:7}-{Day226/211:10}. 2093 Turner {Day226/211:11-16}; UKAS closing submissions for Module 6 {UKAS0011447/13-14} pages 13-14, paragraphs 40-42. 2094 Albon {BBA00010723/8-9} pages 8-9, paragraphs 23-29; {BBA00010722}; Randall {UKAS0011424/11} page 11, paragraphs 14.1-14.2. 2095 {BBA00010722/6-7}. 2096 Haynes {BBA00010784/5} page 5, paragraphs 20-21; Randall {UKAS0011424/11-12} pages 11-12, paragraph 14.4.

The Grenfell Tower Inquiry: Phase 2 Report 204 separate document; instead, the project manager was expected to follow the steps taken to produce the Leader certificate, as set out in the contract between the BBA and the relevant manufacturer.2097 28.12 We have not seen any evidence that when it assessed the BBA’s competence to issue Agrément certificates UKAS carried out a critical examination of the process by which individual Leader certificates had been produced. Instead, it appears that it considered whether the BBA had followed the steps set out in the contracts with its customers. However, that did not enable it to understand what the BBA was doing to follow those steps. The appendix to the contract made in 2006 between the BBA and Arconic for the certification of Reynobond, for example, consisted merely of short and rather uninformative summaries of the aspects to be considered, such as “behaviour under fire”.2098 It contained no description of the steps the project manager was expected to take to assess and record the product’s properties. Accordingly, when it came to assess the work of the BBA, UKAS could not tell what the project manager was supposed to have done and therefore whether it had been done properly or at all. That led to a tendency on the part of UKAS to look only at the BBA’s generic documentary processes rather than examine its technical assessment of performance for each type of product to see whether it was sound. In that respect there seems to have been a gap in its assessment of the BBA’s Agrément certification scheme. 28.13 UKAS’s policy relating to the assessment of conformity to ISO/IEC 17065 was to conduct a technical review of all schemes at least once every four years.2099 It regarded each category of products (for example, wall and cladding products and systems) as a separate scheme2100 and accredited the BBA on that basis. Accordingly, although UKAS assessed the Agrément process as a whole, because it was similar for every scheme, it should have assessed the scheme for each of the thirteen Agrément product types separately every four years. 28.14 In practice, however, it failed to do so. The BBA’s Agrément certification relating to “Wall and cladding products and systems” was assessed just once between 2008 and 2016, in 2009.2101 UKAS thus failed to meet its own requirements for assessment of the BBA during that period. It is possible that UKAS treated an assessment of one scheme as being sufficient to accredit the BBA for all thirteen Technical Specifications, but there is no evidence that it did and if that was its reasoning, it was unsatisfactory, given the very significant differences between the products and systems covered by the Technical Specifications. Overall, as Ms Turner accepted, UKAS did not pay sufficient attention to the BBA’s activities for Agrément certification.2102 28.15 For its part, the BBA did not comply with its obligation to keep UKAS informed of important developments as part of the continuing accreditation of its certification activities. Despite becoming aware in 2014 that there had been a very serious misstatement about fire performance in the certificate relating to K15,2103 the BBA neither reported it to UKAS as significant non-conforming work nor recorded it as such in its own records so that UKAS could discover it on the next assessment.2104 It should have been clear to the BBA that 2097 Randall {UKAS0011424/11} page 11, paragraph 14.2. 2098 {BBA00008042/11}. 2099 {UKAS0011247/35}. 2100 Turner {Day227/81:16}-{Day227/82:1}. 2101 {UKAS0000586/5-6}; Randall {UKAS0011424/13} page 13, paragraph 17.2. 2102 Turner {Day227/93:10-17}. 2103 The certificate provided that K15 could be used in accordance with Approved Document B paragraph 12.7, see Chapter 22; {BBA00000178}. 2104 {UKAS0000977}; There was no mention of this significant non-conforming work in UKAS’s subsequent management review: {UKAS0000977/4-5}.

Part 3 | Chapter 28: United Kingdom Accreditation Service 205 the information was relevant to its accreditation and needed to be shared with UKAS in accordance with its publicly available principles of assessment and standard terms of contract.2105 We note that UKAS has now put the matter beyond any doubt by amending its standard terms.2106 28.16 The steps taken by UKAS after the Grenfell Tower fire to review its assessment of the BBA shed significant light on the efficacy of its previous practices. On 12 July 2017, UKAS made an extra visit to the BBA to consider the Reynobond certificate.2107 That visit prompted a further visit2108 on 15 August 2017 which examined the Reynobond certificate in greater depth and considered the BBA’s work in reissuing several certificates relating to ACM material after the fire.2109 28.17 At around the same time, UKAS received correspondence from a person who alleged that the Reynobond certificate was not up to date, that the BBA lacked competence, that it had failed to heed previous cladding fires and that it did not attach sufficient importance to fire performance generally.2110 The UKAS assessors who attended the BBA had known of those allegations before the visits in July and August 2017.2111 28.18 When they visited the BBA in July 2017, the UKAS assessors identified only two respects in which remedial action in relation to the Reynobond certificate was considered mandatory: changes to statements concerning the use of the material on buildings over 18 metres in height (including the removal of the picture of a tall building on the front of the certificate) and a change in the name of the holder from “Alcoa” to “Arconic”.2112 The BBA had already identified those errors and at the time of the visit had made arrangements to correct them in the forthcoming reissue of the certificate. 28.19 The assessors also examined the BBA’s conformity with ISO/IEC 17065, not only at the date of the visit but also over the period since the certificate relating to Reynobond had been first issued in January 2008. However, despite declaring in their report that the statements made in the certificate were supported by appropriate test data,2113 they failed to notice that the fire performance certificates provided by Arconic at the time of the initial assessment related only to the product in rivetted form, not in cassette form. They also failed to notice that the description of the product blurred the distinction between the form in which it left the factory (flat sheets) and the form it would take in use, which required that it be cut to shape and drilled for rivets or fabricated into cassettes. Those were significant failings, because in these particular assessments UKAS’s specific role was to consider whether statements made by the BBA about the performance of the product were complete and accurate. The assessors noted that Arconic had failed to respond to the BBA’s requests for information when the certificate was reviewed between 2013 and 2015, even though the BBA’s own processes required responses,2114 but failed to take any further steps to understand whether there were any problems or risks with continuing 2105 General Principles of Assessment of Conformity Assessment Bodies by the United Kingdom Accreditation Service (GEN-1) {UKAS0011246/18} section 4.5.2; {UKAS0011300/3-4} section 2.7; Turner {Day226/193:12}-{Day226/194:6}. 2106 UKAS Closing Submissions for Module 6 {UKAS0011447/12-15} paragraphs 39-46; UKAS Phase 2 statement {UKAS0011448/8} paragraphs 34-36. 2107 Randall {UKAS0011424/14-15} pages 14-15, paragraph 18.1. 2108 {UKAS0001077/4}. 2109 {UKAS0001083}. 2110 {UKAS0001382}. 2111 Randall {UKAS0011424/15} page 15, paragraph 18.2. 2112 {UKAS0001077/4-8}; {UKAS0001077/7}; {UKAS0001077/8}. 2113 {UKAS0001077/4}. 2114 Randall {UKAS0011424/20} page 20, paragraph 28.1; {UKAS0001083/6}.

The Grenfell Tower Inquiry: Phase 2 Report 206 certification. Ms Turner admitted that Arconic’s failure to respond should have prompted UKAS to examine more fully the merits and robustness of the BBA’s decision to continue to certify Reynobond. 2115 28.20 The file that UKAS reviewed in the course of those assessments contained correspondence from which UKAS could have seen that the BBA was prepared to negotiate with Arconic about the wording of the certificate. For instance, it contained correspondence in November 2007 in which Claude Wehrle of Arconic negotiated the additions to the draft BBA certificate for Reynobond with Hamo Gregorian.2116 It should have been plain to UKAS that, if manufacturers were allowed to influence statements made in certificates, the quality of certificates might be undermined. We consider that UKAS should have identified the willingness of the BBA to discuss the wording of its certificates with manufacturers and at least have questioned whether it affected the independence, quality and accuracy of the certificates it issued. 28.21 UKAS also considered the technical competence of Valentina Amoroso2117 and Prayer Nkomo, both of whom had been involved in the reviews of the Reynobond certificate. However, it did not record any assessment of the competence of Hamo Gregorian and Brian Haynes, who had worked on the original Reynobond certificate.2118 That was a significant oversight, because one purpose of the visits was to assess the validity of the certificate for the whole of the period from its initial issue in 2008. That required a more thorough investigation into whether those involved in the initial certification had the necessary skills and had properly assessed the product’s performance at the outset. 28.22 The Lead Assessor for UKAS on the visits to the BBA in both July and August 2017 was Cary Randall, who had previously been employed by the BBA on Agrément certification until 2012.2119 Indeed, his own work on the BBA’s certification of a cladding product had been assessed by UKAS in 2009, the only assessment of the “Wall and cladding products and systems” scheme it had carried out.2120 Mr Randall had also worked for a time for Geoffrey Gurney, who had provided technical approval for the Reynobond certificate.2121 His appointment created a potential conflict of interest, as UKAS was aware. However, it decided that it was not inconsistent with its policy for Mr Randall to assess the BBA because five years had passed since his employment by it and its policy required only a two-year interval.2122 28.23 Although the potential for bias was to some extent mitigated by the fact that Mr Randall was assisted by individuals who had no connection with the BBA,2123 we consider that the decision to use him was unwise. He was not merely assessing the BBA’s current performance; his task included the assessment of previous work, some of which had been done while he was still an employee of the BBA. Although Mr Randall had no involvement in the BBA’s original certification of Reynobond or in its reviews of the certificate, his involvement in similar work for the BBA and his employment by it during the period under consideration would have made it difficult for him to examine its work critically. 2115 Turner {Day227/117:11}-{Day227/118:1-5}; {Day227/128:13-20}; {Day227/131:18}-{Day227/132:2}. 2116 {MET00055859}; {BBA00008042/515-517}. 2117 {UKAS0001077/8}. 2118 Randall {UKAS0011424/18} page 18, paragraph 23.1. 2119 Randall {UKAS0011424/3} page 3, paragraph 5.1 2120 {UKAS0000586/5-6}. 2121 {UKAS0001077/3-5}; Albon {BBA00010723/6} page 6. 2122 Turner {UKAS0011242/18} page 18, paragraph 12(a). 2123 Mr Randall was assisted by Technical Assessor Dan Patterson (for the July review) and observed by Sam Giles (for both): Randall {UKAS0011424/15} page 15, paragraphs 19.1-19.2; {UKAS0001077}; {UKAS0001083}.

Part 3 | Chapter 28: United Kingdom Accreditation Service 207 28.24 The assessments of the BBA carried out by UKAS in 2017 resulted in almost no significant criticism. In our view UKAS should have examined the history of the BBA’s work on the Reynobond certificate more critically and, given that the assessment specifically considered the entire history of the certificate from 2008 onwards, should have considered whether the BBA’s work was sufficiently robust for the whole of the period from that date until the Grenfell Tower fire. That was all the more so in the light of the fact that the fire had involved a product that had been certified by the BBA and that it had received highly critical allegations about the BBA’s past performance. Having noticed that the certificate had failed to state that the product was not suitable for use on buildings over 18 metres in height, the BBA should have been required as part of the assessment process to ascertain why the certificate had been wrong and why the error had been allowed to persist for so many years. UKAS should have made critical findings and should have considered suspending the BBA’s accreditation until it had done so.2124 The fact that UKAS failed to scrutinise the BBA’s processes in that way and does not appear to have considered imposing any sanction of that kind indicates to us that its assessment of the BBA was too lenient. Accreditation of BRE 28.25 UKAS accredited BRE to perform BS 8414 tests in accordance with ISO/IEC 17025. The tests of systems incorporating Kingspan K15 and Celotex RS5000 were carried out under that accreditation. It also accredited BRE under ISO/IEC 17025 to perform many other activities and each assessment generated lengthy and detailed reports covering a variety of subjects.2125 Any weaknesses identified by UKAS in BRE’s systems must therefore be understood in the context of the full report.2126 However, there were some weaknesses that should have been of particular concern to UKAS but which it failed to identify and its failure to do so indicates defects in its assessment process. 28.26 To meet the requirements of ISO/IEC 17025, BRE was required to conduct internal audits which assessed its own performance and recorded failures and corrective action.2127 That was particularly important, because assessments by UKAS could only involve a sample of BRE’s work. 28.27 Between 2012 and 2016, assessors repeatedly raised concerns about the quality of BRE’s auditing. In 2012, it made several criticisms of BRE processes, principally, that its audit procedures were not recorded, that there was no comprehensive management of audits for the entire year, that the few audits of testing that had been carried out had not been reported to the Quality Manager and that no corrective action had been recorded.2128 In its report of 24 July 2012 UKAS told BRE that it would not renew its accreditation unless it was able to demonstrate at a further visit that management control was being exercised and that the management system was being implemented.2129 At the next visit BRE was able to satisfy UKAS about those matters2130 and in 2013 it demonstrated some improvement,2131 but in its assessments in 2014 and 2015 UKAS recorded delays in carrying out and responding to audits.2132 In 2015, in particular, UKAS reported that BRE had failed 2124 Turner {Day227/133:9}-{Day227/134:10}. 2125 Turner {Day226/176:11-14}. 2126 Turner {Day227/19:24}-{Day227/20:10}; {Day227/21:25}-{Day227/21:1-7}. 2127 {BSI00001726/19-20} section 4.14.1-4. 2128 {UKAS0004239/4}; {UKAS0004239/11}. 2129 {UKAS0004239/6}. 2130 {UKAS0004253}. 2131 {UKAS0004269/8}. 2132 {UKAS0004315/3}; {UKAS0004315/11}; {UKAS0004339/3}.

The Grenfell Tower Inquiry: Phase 2 Report 208 to record as non-conforming work certain deficiencies that had been noted in audits.2133 UKAS assessors noted that the BRE had not investigated the scale and effect of that non- conforming work, so it was not possible to understand whether it was necessary to take immediate action, for example, by halting work.2134 28.28 It is clear from the assessments made by UKAS that throughout the period BRE’s internal auditing processes were inadequate and UKAS should have been aware of that.2135 Although it is now not possible to determine whether there was a single root cause of that underperformance,2136 UKAS should have identified the problem and required BRE to investigate it. Assessment of BS 8414 testing 28.29 In the four years between 2012 and 2016, UKAS witnessed only one test in 2016 as part of its assessment of BRE’s competence to conduct BS 8414 tests2137 and there are no records of its having witnessed any such tests during the period between 2008 and 2011. UKAS planned to witness BS 8414 testing every year from 2011 to 20162138 and although we accept that there might have been difficulties in arranging to observe a full-scale test, nonetheless UKAS failed to meet its own policy2139 of witnessing a live test once every four-years.2140 28.30 In its assessment in 2016, UKAS recorded the following findings and requirements for improvement in relation to BS 8414 testing: a. that BRE did not maintain a formal record of the procedure for carrying out BS 8414 tests, but relied on informal documents that did not form part of the quality assurance system;2141 b. that the test area and control rooms in the burn hall used for BS 8414 tests were untidy and disorganised, with equipment and test materials not being stored appropriately.2142 BRE was therefore not meeting the ISO/IEC 17025 standard in those respects and improvements were required if BRE was to maintain accreditation. 28.31 In failing to witness BS 8414 tests for many years UKAS was depriving itself of the ability to monitor BRE’s performance effectively and was unable to say if BRE was conducting the tests accurately and consistently. 2133 {UKAS0004339/3}; {UKAS0004339/7}. 2134 {UKAS0004339/7}; {UKAS0004353}. 2135 Turner {Day227/20:11}-{Day227/21:15}. 2136 Turner {Day227/21:15-23}. 2137 UKAS Assessment Report 2012 {UKAS0004239}; UKAS Assessment Report 2013 {UKAS0004269}; UKAS Assessment Report 2014 {UKAS0004315}, where BS 8414 was assessed by checks on equipment and discussion only (see {UKAS0004315/28-29}); UKAS Assessment Report 2016 {UKAS0004364}. 2138 Visit Plan 2011 {UKAS0004200/5}; Visit Plan 2012 {UKAS0004230/3} which planned to assess all reaction to fire tests; Visit Plan 2013 {UKAS0004265/12}; Visit Plan 2014 {UKAS0004313/7}; Visit Plan 2015 {UKAS0004329/3}. 2139 {UKAS0011247/39}. 2140 Turner {Day227/8:8-9}. 2141 {UKAS0004364/21}. 2142 {UKAS0004364/21}.

Part 3 | Chapter 28: United Kingdom Accreditation Service 209 Subsequent assessments of BRE 28.32 As in the case of the BBA, certain events that occurred after the fire show that longstanding defects in the assessments by UKAS of BRE continued in the years after the Grenfell Tower fire and proved stubbornly resistant to correction. 28.33 In September 2017, Sam Giles, Head of Construction and Physics in the Operations Department, reported to his seniors on the three bodies accredited by UKAS that had been connected with the refurbishment of Grenfell Tower, the BBA, BRE and Exova.2143 The report described the additional visits and other investigations that had been conducted by UKAS by that time. In the case of BRE, they included reviewing the records of the BS 8414 tests that DCLG had commissioned in July 2017, including the tests on systems which reproduced the external wall of the tower.2144 Although its review was based only on the records, UKAS identified a number of deficiencies, including inadequate staff training records, the absence of any formal contract between DCLG and BRE and inconsistencies in the recording of technical findings.2145 Mr Giles suggested that in the light of what it had discovered UKAS needed to take a tougher approach to BRE, particularly with regard to implementing required improvements.2146 28.34 However, it appears that there was no change in the existing state of affairs. On 23 October 2020, Kingspan wrote to BRE to tell it that it had withdrawn several BS 8414 test reports on K15 because the material used in the tests had not been representative of the product it was selling.2147 Despite the fact that the letter was reported in the specialist construction press shortly afterwards,2148 UKAS became aware of it only on 17 March 2021 when Sam Giles noticed the article and circulated it within the organisation.2149 28.35 UKAS immediately arranged an extraordinary assessment of BRE, which was conducted in May 2021 by John Leadbeater, Senior Assessment Manager and Technical Focus Person for fire testing,2150 with responsibility for leading on fire testing.2151 He found no evidence that the tests had been performed incorrectly, but he did find evidence of weakness in complying with documentary requirements and internal audit procedures.2152 He recommended that if similar non-compliances were noted on the next routine assessment, there might be grounds for partial or full suspension of the BRE’s accreditation for those activities.2153 28.36 BRE objected to various aspects of the report2154 and as a result UKAS withdrew it and replaced it with a less critical version that made it clear that the findings had no bearing on the current performance of BRE.2155 That was done without consulting Mr Leadbeater, who was not made aware of the decision to withdraw the original report.2156 2143 {UKAS0010859}; {UKAS0010860}. 2144 {UKAS0004456}. 2145 {UKAS0004456/3-4}. 2146 {UKAS0010860/2}. 2147 {KIN00024104}. 2148 On 5 November 2020, Inside Housing magazine published an article about this letter: https://www.insidehousing. co.uk/news/kingspan-withdraws-insulation-fire-test-admitting-it-is-not-representative-of-product-on-market-for- 15-years-68461. 2149 {UKAS0011430}. 2150 Leadbeater {UKAS0011426/4-5} pages 4-5, paragraphs 3.2-3.3. 2151 Turner {Day227/33:6-13}; Leadbeater {UKAS0011426/5} page 5, paragraph 3.3. 2152 {UKAS0004773}. 2153 {UKAS0004773/7}. 2154 {UKAS0004774}. 2155 {UKAS0004778}; {UKAS0011435}; Leadbeater {UKAS0011426/20} page 20, paragraph 18.1. 2156 Mr Leadbeater’s annotated comments: {UKAS0011435/3}; Turner {Day227/56:13}-{Day227/57:11}.

The Grenfell Tower Inquiry: Phase 2 Report 210 28.37 In the end UKAS decided to avoid any potential conflict by withdrawing the revised report and leaving all potential criticisms until the next assessment of BRE, which was imminent.2157 It was conducted by Mr Leadbeater over several days in July and August 2021, as a result of which he made numerous adverse findings and identified a number of areas for improvement.2158 28.38 One consequence of withdrawing Mr Leadbeater’s first report was that his observations about the historical deficiencies of BRE were subsumed in an assessment of how BRE was performing in July 2021.2159 Similarly, after that assessment discussions about BRE’s performance turned on how UKAS could prevent a recurrence of the failures, a matter that UKAS proposed to make the subject of requirements for improvement.2160 Although an organisation’s current competence is, rightly, the main question for UKAS, a process that fails to take account of historic performance risks overlooking significant trends. An organisation could, and on the evidence before us did, propose measures to deal with problems as though they were of an isolated nature when they were symptomatic of more general shortcomings. BRE should have conducted a searching analysis of both the root cause of the deficiencies and their effects, and if it did not, UKAS should have required it to do so. Conclusions 28.39 UKAS accepted in its closing statement that its dealings with the BBA and BRE showed that its systems were in need of improvement.2161 It also told us that it had introduced a number of changes to its policies and procedures that were intended to rectify the defects that had been identified.2162 In October 2022, we received further documents from UKAS indicating that it was continuing to make efforts to address weaknesses.2163 We take account of those matters when we come to make our recommendations. Nonetheless, the evidence of the way in which UKAS handled the accreditation of BRE and the BBA in the period before the Grenfell Tower fire has led us to the following conclusions: a. UKAS did not follow its own policies in relation to the frequency of assessing activities. Its assessment of the BRE’s performance of BS 8414 tests between 2008 and 2016 was inadequate, with just one test being witnessed in 2016.2164 It also failed to carry out a proper assessment of the BBA’s Agrément schemes, assessing the certification of only a few categories of products sporadically between 2008 and 2015. b. It failed to identify a consistent failure on the part of BRE to audit its work adequately in the years 2012-2016. UKAS should have required BRE to examine the underlying cause or causes of those repeated auditing failures. Similarly, when other failures were identified, it failed to require the BBA or BRE to complete a comprehensive investigation into their cause and possible wider effects. c. When assessing the BBA after the fire it failed to identify important errors in the issuing and review of the Reynobond certificate, which resulted from a failure to examine the information available in the assessments with sufficient rigour. It was also 2157 Leadbeater {UKAS0011426/20} page 20, paragraph 18.1; Turner {Day277/57:24}-{Day227/58:8}. 2158 {UKAS0011327/35-45}; {UKAS0011314} rows 107-120. 2159 {UKAS0011327}. 2160 {UKAS0011331}. 2161 UKAS Closing Submissions for Module 6 {UKAS0011447/18} page 18, paragraph 56. 2162 UKAS Closing Submissions for Module 6 {UKAS0011447/8-17} pages 8-17, paragraphs 25-53. 2163 {UKAS0011454}; {UKAS0011455}; {UKAS0011456}; {UKAS0011457}. 2164 Turner {Day 227/7:5-18}.

Part 3 | Chapter 28: United Kingdom Accreditation Service 211 unwise of UKAS, after the Grenfell Tower fire, to allow a former employee to assess the BBA’s Agrément Scheme. The relationship between UKAS and accredited bodies 28.40 Although we accept that UKAS took its role as national accreditation body seriously, the reliability of its assessments depended on the honesty and co-operation of the organisations it was accrediting. It was therefore left to the organisations themselves to identify weaknesses, to report them to UKAS and to implement improvements in good faith. UKAS left a great deal to trust. Although a degree of trust was essential, UKAS should have taken a more searching, even sceptical, attitude to the bodies it accredited. 28.41 Sam Giles identified that as a potential problem in 2017 after the Grenfell Tower fire. After an assessment of the BRE, the BBA and Exova (conducted in July and August 2017), Mr Giles concluded in September 2017 that some organisations might be displaying a degree of arrogance in dismissing findings made by UKAS.2165 However, despite Mr Giles’ observations, his comments did not appear to prompt a reconsideration of the relationships between UKAS and some of its accredited bodies, at least at that time. For example, UKAS assessors might have been instructed to adopt a less trusting view of the organisations subjected to routine assessment and to push them to consider in greater detail the cause and effect of any critical findings that UKAS made. 28.42 UKAS was sometimes too willing to accept the competence of an organisation without having reviewed all the relevant documents2166 and sometimes too quick to minimise or ignore its deficiencies or to accept superficial improvements as adequate. That was demonstrated by events both before and after the fire. The effect of failing to require more thorough investigations into the causes and effects of shortcomings was that opportunities to improve the work of organisations engaged in testing and certifying products were lost. 28.43 UKAS’s powers in the face of recalcitrant or defective bodies are surprisingly limited. The most it can do in the face of unsatisfactory conduct on the part of an accredited organisation is to suspend or withdraw accreditation. It has no legal powers or role in enforcement. Moreover, the fact that accreditation is voluntary presents a particular challenge, in that, subject to market pressures, a certification body can simply decline to be accredited by UKAS at all. 28.44 That seems to us to be a thoroughly unsatisfactory state of affairs. A voluntary system of accreditation, where the accrediting body has no power of enforcement other than suspension or withdrawal of accreditation, in the end simply leaves the designer and building owner having to trust the certificate or test report and classification. It deprives them of the confidence that the relevant body has itself adopted rigorous methods which are wholly free from the commercial pressures inherent in relationships with manufacturers. 2165 {UKAS0010859}; {UKAS0010860/3}. 2166 {Day227/144:25}-{Day227/145:5}.

The Grenfell Tower Inquiry: Phase 2 Report 212

213 29.1 Our examination of the role played by the government and other bodies that had important parts to play in the testing and certification of construction products enable us to identify a number of respects in which the systems designed to ensure the safety of buildings in general and of high-rise buildings in particular failed to achieve the purposes for which they were established. The government 29.2 As the organisation with primary responsibility for establishing and maintaining a system for the regulation of construction work in the interests of public safety the government should ensure that as far as reasonably possible regulations and guidance keep pace with developments in construction materials and techniques. It should also take reasonable steps to ensure that regulations are enforced and that any guidance it publishes is clear and easily accessible to all those in the industry. 29.3 In our view between 1991 and 2017 the government failed to discharge those responsibilities in a number of ways. That was primarily due to its failure to ensure that the department responsible for the Building Regulations and statutory guidance was expected to monitor the performance of the system as a whole (including the effectiveness of building control) and inform itself of developments in the methods and materials being used in the construction industry with a view to ensuring that the regulations and guidance were understood and followed and, where necessary, clarified or amended. We have criticised officials for failing to take steps of that kind, but officials can act only in accordance with the way in which the department is organised. If, as appears to have been the case, the department was not expected to ensure that the regulations were being properly followed, officials cannot be blamed for failing to make enquiries or taking active steps to discover what is going on. 29.4 In the period between the fire at Knowsley Heights in 1991 and the fire at Grenfell Tower in 2017 there were numerous opportunities for the department to identify the risks posed by the use of combustible insulation and cladding panels, particularly on high-rise buildings, and take action in relation to them. Of particular significance is the failure by the government to implement the recommendations of the Select Committee in December 1999, or at least keep them under review, and its failure to pay due regard to the striking results of the test in 2001 involving aluminium composite panels with unmodified polyethylene cores. 29.5 The report of the Select Committee warned the government in unambiguous terms that it should not take a serious fire in which people were killed before steps were taken to minimise the risks posed by some external cladding systems. Unfortunately, that warning was ignored and although a large-scale system test (which became BS 8414) was introduced as an alternative way of assessing risk, national Class 0, which was based on small-scale testing, was allowed to remain in the statutory guidance as the primary standard for external wall coverings, notwithstanding its clear and well-known limitations. On numerous occasions the department was made aware that national Class 0 was wholly inadequate as a measure of the propensity of composite panels to promote the spread Chapter 29 Failures in the system

The Grenfell Tower Inquiry: Phase 2 Report 214 of fire across an external wall but it allowed it to remain in the statutory guidance as an acceptable standard until after the Grenfell Tower fire. As soon as the obvious inadequacy of Class 0 for that purpose was demonstrated by the fire, the Building Regulations and guidance were changed. The need for that change could and should have been identified and acted upon years earlier. 29.6 The failure of the government following the large-scale test in 2001 of a system incorporating aluminium composite panels with unmodified polyethylene cores to take any steps to ascertain the extent to which panels of that kind were in use or to warn the construction industry about the risks they posed represents a significant failure of the system, as was the department’s failure to publish the results of the test. 29.7 The review of Approved Document B between 2005 and 2006 provided the department with another opportunity to clarify the guidance on compliance with functional requirement B4(1). Changes were made to paragraph 12.7 of Approved Document B but the choice of language was vague and ill thought out and the changes were slipped in at a late stage in the process with no proper consultation. The failure to follow established procedures appears to have been driven by a desire to achieve a quick solution to a previously unforeseen problem, but an absence of proper consultation and time for thought resulted in an unsatisfactory amendment that was responsible for confusion and uncertainty. Once again, there was a failure of sound policy-making and the systems designed to ensure an effective outcome. 29.8 In the period between 2012 and 2017 the department received warnings about the risks posed by polymeric insulation products and aluminium composite cladding products with polyethylene cores. It also became aware of several major cladding fires abroad. They should have alerted it to the dangers posed by those materials and should have led it to investigate the extent to which such materials were being used by the construction industry in this country. The department appears to have proceeded on the assumption that, because a serious high-rise cladding fire had not occurred in this country, the regulatory regime was sufficient to prevent one from occurring. That was a mistaken assumption for which there was no basis. 29.9 Despite those warnings, the department failed to amend or clarify the guidance in Approved Document B on the construction of external walls, which, by 2013 at the latest, it knew was unclear and not properly understood by a significant proportion of those engaged in the UK construction industry. By February 2016 it was aware that some in the industry were worried that combustible insulation and ACM PE panels were routinely being used on high-rise buildings in breach of functional requirement B4. The failure to act on that knowledge represented a serious failure on the part of the government to take seriously its responsibility for the safety of those living in such buildings. 29.10 If systems of government are to work well it is necessary that those who are employed to operate them are carefully appointed. It is not clear how Brian Martin was chosen to be the official with day-to-day responsibility for the Building Regulations and Approved Document B, why he was allowed to remain in that position for so long or why he was allowed to wield so much influence over the department’s response to developments. His repeated failures to bring to the attention of more senior officials serious risks of which he became aware suggest that he was given a much greater degree of responsibility than was justified without suitable oversight.

Part 3 | Chapter 29: Failures in the system 215 29.11 More senior officials must also take responsibility for what were systemic failures. Anthony Burd, Mr Martin’s line manager, was directly involved in the introduction into paragraph 12.7 of the expression “filler material” and appears to have been solely responsible for the further addition at the last minute of the reference to gaskets and sealants. He should have ensured that more senior officials were told about it. 29.12 It was a serious weakness in the organisation of the department that Mr Martin was given too much independence in deciding how it should respond to information reaching it from the industry and elsewhere. As his Deputy Director for a significant part of the relevant period, Bob Ledsome must bear some of the responsibility for that because he did not exercise the degree of oversight that matters of such importance required. He could and should have done more to understand the potential risks involved in the use of certain products, particularly when he became aware in late 2015 of various international cladding fires. Given the extent to which matters affecting the safety of people’s lives depended on Mr Martin’s recognition of a serious danger and the soundness and thoroughness of his decision-making, Mr Ledsome, Mr Burd and later Mr Harral should have exercised a greater degree of supervision over him, if only to ensure that his response to events was appropriate. It was a serious failure of the system to allow an area of activity that directly affected the safety of people’s lives to depend on the judgment of one relatively junior official. 29.13 The effective working of the system was not enhanced by the privatisation of BRE. In our view its relationship with the department became less beneficial after it was required to operate in a commercial environment. The transition from adviser to contractor meant that it did not regard itself as being under a duty to provide robust and independent advice to the government. Indeed, the department made it clear that it should not volunteer policy advice but should confine itself to providing the services described in its contracts. The flaws in the relationship between BRE and the department were epitomised by the Investigation of Real Fires contracts2167 under which BRE’s contribution to discussions was restricted. 29.14 Once the relationship between BRE and the department had been put on a purely commercial footing, it was for the department to decide what it wanted BRE to provide. If it did not want BRE to provide policy or any other advice it was free to make that clear. However, for the relationship to work to best advantage it was desirable that the department should have the benefit of BRE’s advice and experience. Unfortunately, that did not always occur. BRE’s investigation into the Lakanal House fire was curtailed by the department prematurely and at every stage, including the inquests, officials displayed a short-sighted attitude towards learning the wider lessons of the fire. Lessons could and should have been learnt that might have improved the robustness and clarity of the regulatory regime before the refurbishment of Grenfell Tower was carried out. 29.15 The department’s response to the coroner’s recommendations was inadequate. No-one treated them with any sense of urgency; officials did not explain clearly to the Secretary of State the steps that were required to comply with them and at least one junior official appeared to treat the coroner with disdain. There was a lack of clarity about which of them had been accepted and which rejected and there was no system for monitoring or tracking them. 2167 See Chapter 8.

The Grenfell Tower Inquiry: Phase 2 Report 216 29.16 The picture of a department struggling under significant pressure was reinforced by the response of ministers and officials to other external bodies. Legitimate concerns repeatedly raised by the All-Party Parliamentary Group on Fire Safety were met with a defensive and dismissive attitude by officials, reflected in the responses of ministers to correspondence. They ought to have considered whether the concerns were well-founded, and if so, what action was required. 29.17 In the years that followed the receipt of the coroner’s recommendations the government’s deregulatory agenda, enthusiastically supported by some junior ministers and the Secretary of State, dominated the department’s thinking to such an extent that even matters affecting the safety of life were ignored, delayed or disregarded. Senior officials and ministers alike appeared to be almost completely unaware of the day-to-day effect of those policies on junior officials who were charged with matters of that kind. Mr Ledsome made no attempt to bring to the attention of any more senior official the negative effect on his team of the pressure to deregulate and no senior official or minister appears to have given any real thought to whether it was appropriate that the policy of deregulation should apply to the Building Regulations and statutory guidance. 29.18 Building control was a regulatory activity in which the department played no direct role, but senior officials and ministers ought to have ensured that arrangements were in place to monitor the system and ensure that it was working properly. From 2013 onwards there were warnings about systemic failings and risks to public safety that junior officials should have brought to the attention of those in more senior positions, but no formal process for doing so existed. 29.19 The effectiveness of the Building Regulations division was undermined by a failure to include among its responsibilities monitoring the effectiveness of the Building Regulations and statutory guidance and the development of new methods of construction and the use of new materials and by a lack of sufficient resources to enable it to identify and record risks to public safety arising from the use of unsuitable materials. Nor did it have sufficient resources to ensure that the guidance in Approved Document B was kept up to date and fit for its purpose. The division was not afforded the priority it deserved and was not given the resources and expertise it needed to carry out the demands on it. 29.20 There were serious and longstanding failings of leadership at the highest levels. Senior officials should have taken a closer interest in the working of a small, but important, part of the department that was responsible for significant matters affecting the safety of people’s lives. The fact that the Building Regulations division was not expected to monitor the way in which the regulations and guidance were understood and applied created a dangerous situation, given the low levels of competence in the construction industry, the introduction of new construction materials, such as polymeric insulation and ACM panels with combustible cores, and the extent to which many in the industry regarded Approved Document B as prescribing the circumstances in which combustible materials could be used in the construction of external walls without regard to the functional requirements. Most importantly, there was a failure to create a climate in which concerns reaching the department about matters affecting the safety of life were expected to be raised with more senior officials and frank advice given. 29.21 In conclusion, we have come to the view that over a period of many years the department failed to recognise the importance of the Building Regulations and the accompanying statutory guidance as a system of regulation whose purpose was to ensure public safety, including the safety of those who live and work in high-rise buildings. For that reason it failed to put in place arrangements to ensure that the working of the system was properly

Part 3 | Chapter 29: Failures in the system 217 monitored and that steps were taken as and when necessary to ensure that it remained capable of achieving its purposes. Those were systemic failings of a kind for which ministers and the senior officials responsible for the organisation of the department must take responsibility. Despite the warning from the Select Committee in 1999 that action needed to be taken on the use of combustible materials in the construction of external walls, inertia combined in later years with a drive to avoid regulation made it likely that only a major fire in a high-rise building leading to a large number of casualties would prompt it to take the necessary action. The government must take responsibility for the systemic failures that played a significant part in enabling the Grenfell Tower fire to occur. 29.22 Regrettably, there was a similar failure on the part of the government to ensure that the provisions of the Fire Safety Order relating to the carrying out of fire risk assessments were capable of being implemented as effectively as the nature of the activity required. The problem lay in the competence of those who held themselves out as capable of carrying out such assessments, particularly in relation to high-risk buildings, and the government’s apparent determination not to respond to repeated calls for the regulation of the industry. The need for regulation to ensure the competence of those practising as fire risk assessors was drawn to the department’s attention by the Chief Fire and Rescue Adviser in 2009 and over the following years calls came from various quarters for the industry to be regulated. 29.23 When the matter next came before the relevant minister (then Brandon Lewis MP) in 2013, reluctance to introduce new regulations appears to have trumped the need to put the industry on a sound footing. The determination to pursue a solution based on the creation of voluntary schemes of accreditation of a kind that had not previously proved effective resulted in stalemate. Unfortunately, the government failed to pay proper attention to the voice of the fire sector whose various bodies were largely in agreement about what was needed. That may have reflected the degree of importance ministers attached to fire risk assessments, but whatever the reason, its refusal to act was in our view a serious error and a failure of the system designed to keep people safe from the effects of fire. 29.24 Much the same can be said of the department’s response to requests for clarification of the Fire Safety Order. As early as 2012 the London Fire Commissioner asked the minister (again, Brandon Lewis MP) to provide guidance on the meaning of the expression “[parts] used in common”. His call for clarification was echoed by the coroner at the Lakanal House inquests but once again, the policy of deregulation appears to have stood in the way of amending the Order to provide the necessary clarity. Despite a further request for clarification from the London Fire Commissioner, the government shelved the matter and no action was taken until the passing of the Fire Safety Act 2021, some years after the Grenfell Tower fire. The Building Research Establishment 29.25 BRE held a trusted position within the construction industry and more widely. Having begun life as a government agency it was privatised in 1997, after which it was engaged to advise the department from time to time on a broad range of matters relating to fire safety under contracts for research, investigations, reports and experimental work. Senior staff, including Dr Debbie Smith and Dr Sarah Colwell, were members of a range of committees working on fire safety standards at both European and national level, sometimes acting on behalf of the government. BRE was responsible for managing public consultations on, and drafting amendments to, Approved Document B and for advising working groups formed by the department on the introduction of new classifications such as Euroclass standards in 2002. Informally, BRE staff corresponded with the department, principally Mr Martin,

The Grenfell Tower Inquiry: Phase 2 Report 218 on inquiries relating to fire safety received both by the department and by BRE itself. Their correspondence covered a range of matters, including the interpretation of parts of Approved Document B and international cladding fires. 29.26 BRE was widely recognised both nationally and internationally as a leader in fire safety. For many years before the fire at Grenfell Tower it was the only organisation in the UK capable of carrying out large-scale testing in accordance with BS 8414. BRE developed that test and published all three versions of BR 135, which set out the criteria against which data from tests carried out in accordance with BS 8414 should be assessed. 29.27 However, as our findings in earlier chapters demonstrate, much of the work carried out by BRE was marred by unprofessional conduct, inadequate practices, a lack of effective oversight, poor reporting and a lack of scientific rigour. In some cases we saw evidence of a desire to accommodate existing customers at the expense of maintaining the rigour of its processes. Despite its close association with the department over a long period of time and the opportunities that association provided for the informal exchange of views, BRE appears to have been reluctant to alert the department to developments of potential importance in the construction industry of which it became aware. Testing in accordance with BS 8414 29.28 There were weaknesses in the way BRE carried out tests in accordance with BS 8414. It did not identify carefully the materials delivered to the burn hall for individual tests, it did not ensure that they corresponded to the drawings of the system to be tested and did not ensure that the rig as constructed and tested accurately reflected the drawings that had been provided. The periodic checks that Dr Smith told us BRE staff were expected to make on systems under construction were vague and did not contain any clear direction in relation to frequency, timing or purpose. She told us that BRE staff in the burn hall were not trained to understand architectural drawings,2168 so it is difficult to see why BRE required drawings to be provided or why its staff were expected to check systems under construction against them. Mr Clark, who managed the BRE burn hall between 2005 and 2015 and was responsible for compiling BRE’s standards and procedures for testing in accordance with BS 8414 in 2013,2169 told us that he thought the drawings submitted by test sponsors were not intended to represent the system tested but the system as it was intended to be constructed as part of a building.2170 He also told us that drawings had sometimes not been provided until after the test had taken place,2171 as happened with the second test carried out for Celotex in May 2014. In that case Mr Clark prepared a draft report using drawings from the previous test in February 2014.2172 As a result of those defects in the system, reports of tests did not always correctly describe the system tested. 29.29 BRE took the position, repeated in all test reports, that the configuration of the system to be tested was entirely a matter for the sponsor of the test, but that did not prevent it from carrying out proper checks to ensure that the system tested matched the description in the test reports and that the components were correctly identified and accurately recorded. We see no reason why BRE could not have kept comprehensive records of all materials delivered to the burn hall for every test, examined the drawings in advance and decided at what stage of construction checks should be made by BRE staff. Since the description of the system tested was fundamental to any subsequent report, close monitoring of the 2168 Smith {Day237/167:17-25}. 2169 {BRE00005769/295-305}; Clark {Day95/60:20-21}. 2170 Clark {Day97/72:14-18}. 2171 Clark {BRE00005768/9} page 9, paragraph 41. 2172 Clark {Day96/81:3-13}.

Part 3 | Chapter 29: Failures in the system 219 system in the course of construction was essential to ensure that the report was accurate. Nothing in BS EN ISO EIC 17025 prevented BRE from doing that. The absence of such arrangements represented a serious failure in its systems. 29.30 Shortcomings of that kind enabled Celotex to manipulate the testing process by introducing materials other than those described in the report. Moreover, although BRE was aware that commercial organisations were liable to manipulate their relationship with it to gain commercial advantage,2173 it did not take adequate steps to ensure that those of its employees who came into direct contact with clients in the course of carrying out tests understood the need to maintain their distance and avoid undue familiarity. As a result, its employees were liable to be drawn into relationships with customers that undermined the independence, objectivity and rigour of their work. 29.31 In 2004 Dr Colwell discussed testing with Kingspan in a way that went some way beyond providing general information about the process and amounted to giving advice on the best way to satisfy the criteria in BR 135.2174 In December 2007, BRE staff offered unofficial comments and observations to Kingspan about the performance of K15 following the disastrous result of a test on a system of which it had formed part.2175 In keeping with Kingspan’s strongly expressed wishes,2176 BRE agreed to say no more in its report than that the system as a whole had not met the criteria in BR 135, despite having commented privately to Kingspan that the insulation had been fully involved and had continued to burn even after the flame source had been extinguished. 29.32 Despite his denials, we have found that Mr Clark advised Celotex on more than one occasion on ways in which it could improve its system for a second test after a failed test in February 2014. We have also found that he was aware of the inclusion of additional magnesium oxide boards during the second Celotex test that were not referred to in the test report or the classification report. We also saw for ourselves a recording of Mr Clark engaging in discussions with Mr Meredith during the test of a system incorporating Kingspan K15 in March 2014 in the course of which he gave advice on the performance of the system and how to argue about what the results showed.2177 29.33 The unprofessional behaviour of some of BRE’s staff was in part the result of a failure to provide them with adequate training in the performance of their responsibilities. We have been critical of Mr Clark for advising Celotex on ways in which it might improve its system following the test in February 2014, for failing to draw attention to the use by Celotex of magnesium oxide boards in the system tested in May 2014 and for giving advice to Kingspan during the test conducted for it in March 2014. However, he had received no training from BRE of any kind on what was required by way of independence and impartiality,2178 nor had he had any discussion at any time with any of his managers about what might constitute impermissible advice and consultancy services.2179 There was no mandatory training2180 or centralised record of training within BRE and its staff were 2173 {BRE00014770/6}; {BRE00041887/12}; Smith {Day235/67:8-24}; {Day236/155:18}-{Day236/156:23}; {Day238/44:21-23}. 2174 {KIN00021657} ninth and twelfth paragraphs; {BRE00047572/1}; Meredith {Day75/20:14}-{Day75/21:1}; Heath {Day78/204:17-22}; {Day78/207:9-12}; {Day78/208:18}-{Day78/209:7}; Meredith {Day75/130:23-25}. See Chapter 22. 2175 {KIN00008847/3}; Meredith {Day75/160:3-13}. See Chapter 22. 2176 {KIN00003693/1} 2177 {BRE00035418}. 2178 Clark {Day97/88:23}-{Day97/89:3}. 2179 Clark {Day97/89:19}-{Day97/90:2}. 2180 Smith {Day237/153:11-16}.

The Grenfell Tower Inquiry: Phase 2 Report 220 responsible for their own training records.2181 Quite simply, Mr Clark did not know where to draw the line and he crossed it on various occasions. The failure to provide training of that kind represents a failure to establish proper management systems. Commercial interests 29.34 When invited to a meeting of the CWCT’s Fire Group in July 2014 to discuss fire and facades, including the use of combustible insulation on high-rise residential buildings, Dr Smith’s alarm at what she saw as a potential threat to BRE’s pre-eminent position as an adviser on such matters betrayed a desire to put BRE’s status in the industry and commercial position ahead of considerations of public safety.2182 Investigation of Real Fires project 29.35 We recognise that BRE’s fire investigations for the department were constrained by limited resources and time and also by the restrictive terms of its contracts, particularly after

1. Nonetheless, the investigations it carried out for the department were characterised

by a lack of analysis and were at best superficial.2183 Most reports revealed very little that would enable one to discern patterns or trends or even understand what had caused or contributed to any particular fire. The reports repeatedly confirmed the overall effectiveness of the regulations and guidance without any proper basis for that conclusion. As a result they gave false comfort to the department for many years and served only to increase the danger that important matters would be missed. BRE’s reports into the major fires at Knowsley Heights (1991), Garnock Court (1999) and The Edge (2005) and its preliminary report into the fire at Lakanal House (2009) were far from comprehensive and in each case failed to identify or assess important contributory factors. Most significantly, although each of those fires was often referred to as providing important lessons for the future, no one at BRE was able to describe what those lessons actually were. Relationship with the government 29.36 The status of BRE, its origins and historical links with the department, as well as the fact that for many years Brian Martin, while employed by BRE, had been seconded to the department might reasonably have been expected to foster a relationship under which BRE would alert the department to significant developments in matters affecting the safety of life that might call for amendments to the Building Regulations or statutory guidance. However, the relationship did not work in that way, to the detriment of the department and the public at large. Although BRE recognised from as early as 1991 following the fire at Knowsley Heights that small-scale testing, in particular of the kind that provided the basis for national Class 0, was inadequate to enable a proper assessment to be made of the reaction of external cladding systems to fire, we found nothing to indicate that BRE had drawn that to the department’s attention, formally or informally. 29.37 Similarly, following its large-scale test of a system incorporating aluminium composite panels with polyethylene cores in 2001 under contract cc1924, BRE failed to draw the department’s attention in clear terms, either in its report or informally, to the way in which the material had behaved and the dangers it presented, particularly if used on high-rise buildings. The department did not have access to its own scientific advice on 2181 Smith {Day237/154:19-25}. 2182 {BRE00047459/1}; Smith {Day237/59:2-8}; Smith {Day237/61:25}-{Day237/62:8}; Smith {Day237/62:24}-{Day237/63:6}. See Chapter 11. 2183 See Chapter 8.

Part 3 | Chapter 29: Failures in the system 221 matters affecting fire safety, as we think BRE must have been aware, and so depended to a significant extent on information of the kind that BRE was able to provide. The failure of that relationship represented a significant gap in the arrangements intended to protect the safety of the public. The quality of BRE’s work 29.38 BRE was engaged regularly by the department to carry out research and provide reports, but the quality of the work it produced was in many cases poor. For example, reports produced under the cc1924 project conflated Class 0 and limited combustibility when describing the regulatory requirements and guidance.2184 That was a fundamental error that was repeated by BRE when reporting on the fire at Lakanal House2185 and in the work done for the department by the BRE on external fire spread in 2015.2186 That particular piece of work, which involved experimental testing and a background research paper, was seriously inadequate. It was deeply flawed in almost every respect, lacked any scientific value and purported to draw positive conclusions about the effectiveness of the regulations and guidance that could not sensibly have been reached on the basis of the work that had been carried out.2187 Certification bodies 29.39 Our investigations also uncovered serious weaknesses in two important certification bodies, the British Board of Agrément (BBA) and Local Authority Building Control (LABC). The British Board of Agrément 29.40 As an organisation claiming to be one of the leading certification bodies the British Board of Agrément should have ensured that its procedures for investigating the claims made by manufacturers for their products were by nature both wholly independent and rigorous and that they were followed with equal independence and rigour. In fact, however, as our investigation of the circumstances surrounding the issue of its certificates in respect of Reynobond and Kingspan K15 have shown, there were failings of a kind which undermined their value and rendered them misleading. Moreover, we have no reason to think that the shortcomings we discovered in those certificates and the way in which they had been issued were confined to those particular cases. 29.41 In the case of the BBA the root of the problem lay in the conflict between the need to act as a commercial organisation, and therefore to attract customers in order to generate profits, and the need to maintain a high degree of independence and rigorous investigation in order to satisfy those who might be considering using the products in question that the contents of their certificates could safely be relied on. The BBA failed to manage effectively the conflict between the commercial and (for want of a better word) regulatory aspects of its operations in the two cases we investigated and, because that conflict was inherent in its operations, we think it likely that it failed to manage it appropriately in other cases too. 29.42 The BBA’s scrutiny of the evidence relating to the fire performance of Reynobond was superficial. Although some within the BBA knew that the performance in a fire of a product of that kind might be affected by its configuration and method of fixing, the BBA failed to ask for any test evidence relating to the product when used in cassette form. It also 2184 {BRE00001353/14} first paragraph; See Chapter 10. 2185 {BRE00005881/14} fourth paragraph. See Chapter 9. 2186 {CLG00019445/3} fifth paragraph; Crowder {Day230/160:22}-{Day230/162:21}. See Chapter 10. 2187 Chapter 10.

The Grenfell Tower Inquiry: Phase 2 Report 222 failed to obtain any evidence to support the claim that the version of the product with an unmodified polyethylene core had satisfied the requirements of Class 0. Despite those important omissions, it issued a certificate for Reynobond which stated that the panels “could be regarded as having a Class 0 surface” and failed to draw any distinction between the way in which different methods of fixing affected the way in which it reacted to fire. 29.43 The lack of rigour in the BBA’s investigations was also exemplified by its approach to the certification of Kingspan’s K15 in October 2008. No aspect of the product’s manufacture, testing or fire performance was assessed by the BBA before it issued the certificate. It did not obtain any test data relating to K15 before it issued a certificate that contained a statement that the product had been classified as national Class 0, since none existed. In July 2013 the BBA issued a revised certificate stating that K15 met the requirements of paragraph 12.7 of Approved Document B, although it ought to have known that that claim was false because K15, as a phenolic product, was not a material of limited combustibility. It is clear that for some years no-one at the BBA had any real expertise in assessing the fire performance of materials or understood the need for it. Until 2016, any recourse to outside expert bodies (such as BRE) was haphazard at best.2188 29.44 Until December 2013, when it issued its third certificate for K15, the BBA effectively allowed the contents of the certificates relating to the fire performance of K15 to be dictated by Kingspan itself, accepting the text it put forward without checking its accuracy. At the suggestion of Kingspan, the first and second versions of the certificate advised designers to consult Kingspan if they were considering its use on buildings over 18 metres in height. That was a singularly foolish thing to include, as should have been obvious, because it effectively allowed Kingspan to approve the use of the product itself and bypass the certificate as independent verification of the product’s compliance with the guidance in Approved Document B. 29.45 We accept that in the case of Arconic and Kingspan the BBA was the victim of dishonest behaviour on the part of unscrupulous manufacturers, but if it had maintained robust processes that could not have happened. 29.46 In these different ways the BBA demonstrated an inappropriate desire to please its customers and in order to do so accepted forms of wording proposed by them for inclusion in certificates that were wrong and misleading. It failed to recognise that the way in which Arconic described the product deliberately blurred the distinction between the form in which the product left the factory and the two forms in which it would inevitably be used. Moreover, despite imposing on customers terms of contract that required them to provide information when called upon to do so, the BBA failed to enforce them and allowed Arconic to ignore them without any sanction.2189 In our view all those failures reflected an ingrained willingness to cultivate customers, certainly those of any commercial value, rather than insist on high standards and compliance with a contract that was intended to maintain them. The first two certificates issued by the BBA in relation to K15 lent substantial support to Kingspan’s efforts to create a market for combustible insulation material for use on high- rise buildings. 2188 Amoroso {Day106/17:19}-{Day106/18:8}; Albon {Day109/92:18-23}; {Day109/110:7}-{Day109/111:22}; Gregorian {Day105/25:12}-{Day105/27:2}; {Day105/157:19}-{Day105/160:4}. 2189 Chapter 21.

Part 3 | Chapter 29: Failures in the system 223 Local Authority Building Control 29.47 Over a period of some years the LABC’s certificates relating to Kingspan K15 and Celotex RS5000 contained misleading statements about the fire performance and suitability of both products for use in the external walls of buildings over 18 metres in height. They also misrepresented the nature of the BS 8414 test and classification in accordance with BR 135. 29.48 The LABC had received, and effectively ignored, several warnings from various organisations and individuals about the contents of the certificates it had issued for K15. In the case of K15 and RS5000, it failed to scrutinise properly the claims made for the products by the manufacturers; instead, it adopted uncritically the language they suggested. In short, it was willing to accommodate the customer at the expense of those who relied on the certificates. 29.49 Drafts were prepared for the certificate relating to RS5000 without sight of important documents. For much of the time those involved in producing the draft certificates did not understand the nature or purpose of the BS 8414 test or classification by reference to the criteria in BR 135. Nor did they understand the difference between a material with a Class 0 surface and a material of limited combustibility, which was an important distinction for the purposes of Approved Document B. As a result, they were under the misapprehension that if an external wall system containing a particular material or product satisfied the criteria in BR 135 when tested in accordance with BS 8414, that material or product was suitable for use in the external walls of buildings over 18 metres in height generally.2190 29.50 Although the LABC was not a testing house and did not ultimately determine whether a product could be used safely on any particular development, and although local authority building control officers were not obliged to accept its certificates, it remains the case that one of the main purposes of an LABC certificate was to enable the product or system in question to gain approval from building control easily and quickly. As a body that issued certificates, the LABC was necessarily aware that its certificates were relied on by manufacturers to demonstrate that their products complied with the Building Regulations2191 and by building control officers to satisfy themselves that they were suitable for the use to which it was proposed to put them. It should therefore have been aware that it was of the utmost importance that its processes were robust and the technical contents of its certificates accurate. 29.51 Like the BBA, the LABC was the victim of dishonest behaviour on the part of unscrupulous manufacturers. Kingspan and Celotex outmanoeuvred and took advantage of the LABC throughout the process of certification. Each of them set out to mislead those who were responsible for assessing the claims made in respect of their products. Like the BBA, however, the LABC should have been aware of the risk that manufacturers eager to obtain certificates for their products might be tempted to present them in an unduly favourable light, if not worse, but it did little to ensure that its processes were sufficiently rigorous to avoid its being misled, so far as that was possible. 29.52 The LABC was vulnerable to deception because its processes were not rigorous enough and those who were responsible for the process of certification, including those who carried out the peer review, did not take them as seriously as was required. The task of producing the initial assessment should not have been given to building control officers 2190 Ewing {Day218/165:23-25}-{Day218/166:1-7}. 2191 Brennan {LABC0020135/12} page 12, paragraph 21.3; Turner {Day216/23:16-20}.

The Grenfell Tower Inquiry: Phase 2 Report 224 who did not have the degree of knowledge and experience required to make an informed assessment of the product in question. It should have been given to someone who, at the very least, was capable of understanding the properties of the product and the nature of any tests to which the certificate was expected to refer. Its procedures should have ensured that appropriate test evidence existed to support the use of the products described in its certificates. 29.53 The LABC accepted that in the case of Kingspan K15 and Celotex RS5000 the approval scheme had, at least at first, failed in all respects.2192 We agree but would go further. The LABC failed to scrutinise rigorously the information provided by Kingspan or Celotex at any stage and initial errors were repeated in later certificates. The fact that the original assessments were carried out by LABC member authorities rather than by the LABC itself does not excuse the absence of proper reviews, robust second checks or, in the case of K15, the failure to respond to warnings given by reputable organisations about the inaccurate terms of a previous certificate. 29.54 In the final analysis, there was a complete failure on the part of the LABC over a number of years to take basic steps to ensure that the certificates it issued for K15 and RS5000 were technically accurate. We have not examined its certification of any other products and therefore cannot tell whether those were exceptions to an otherwise satisfactory process, but having seen evidence of the system in operation, we think that unlikely. We are therefore concerned by the serious deficiencies in the operation of the certification scheme that have come to light in the course of our investigations. The way in which the Type Approval and Registered Details schemes were operated in the two cases we have examined rendered them incapable of providing the construction industry, including local authority building control departments, with the objective and reliable information they required. United Kingdom Accreditation Service 29.55 The role of UKAS was to assess organisations providing testing and certification services. It accredited both the BBA and BRE for many years before the Grenfell Tower fire. However, as we have concluded in Chapter 28, it did not always follow its own policies and its assessment processes were lacking in rigour and comprehensiveness. Even when failings were identified they were not properly explored and opportunities to improve were not always taken. The assessment process relied too much on the candour and co-operation of the bodies it was assessing and too much was left to trust. UKAS should have taken a more searching, even sceptical, attitude to the bodies it accredited. The powers it had to address concerns were surprisingly limited, with no powers of enforcement; the most it could do to address unsatisfactory conduct was suspend or withdraw accreditation. That was an unsatisfactory state of affairs. The National House Building Council 29.56 In this chapter we have sought to identify shortcomings that had a wider significance because of their systemic nature. NHBC, whose involvement in the approval of Kingspan K15 and the publication of guidance to the construction industry on the construction of the external walls of high-rise buildings we have described in Chapter 26, played no direct part in the refurbishment of Grenfell Tower. However, as an organisation employing a large number of Approved Inspectors through whom it provided building control services 2192 {LABC0019740/4} paragraph 11.

Part 3 | Chapter 29: Failures in the system 225 to a large part of the housing market, it was very influential. It also wielded considerable influence on the housebuilding industry through its membership of the Building Control Alliance and its publication of guidance notes. It was therefore well-placed to ensure that the requirements of the Building Regulations and Approved Document B were known about and acted upon. 29.57 As we have observed elsewhere, building control is essentially a regulatory function exercised in the public interest free of commercial pressure. However, as we have described in Chapter 26, there were repeated occasions on which NHBC failed to demonstrate sufficient independence and showed itself willing to accommodate the wishes of Kingspan for commercial reasons. It also showed itself unwilling to upset its own customers and the wider construction industry by revealing the scale of the problem caused by the use of combustible insulation in the external walls of high-rise buildings and the likelihood that they did therefore not comply with the Building Regulations. Those failures struck at the heart of the system of building control. The incentive to act in that way had been created by the introduction of Approved Inspectors, who were able to operate as commercial providers of building control services. In our view there is an irreconcilable tension between the requirements of regulation and the pressures of commerce that prevents a system of that kind from effectively serving the public interest. An overall view 29.58 In this chapter we have sought to look beyond the individual shortcomings to identify failings of a more systemic nature in various organisations responsible in one way or another for protecting public safety. Each of them had a part to play in a larger system that was intended to achieve that end. Unfortunately, that system lacked the degree of integration required to ensure that it operated as effectively as it should. The government made the regulations and provided the guidance but was not actively involved in monitoring their effectiveness or developments in the construction industry. BRE and other similar organisations provided information and advice to the government, but only as and when it asked for it. Certification bodies provided assurance to the market that products had certain properties and were suitable for use in certain ways but were subject to conflicting interests which in some cases they failed to manage properly. Building control was meant to exercise an important regulatory function, but local authority building control departments did not have adequate resources and the competence of their employees was variable. Moreover, following the introduction of approved inspectors, building control was exposed to the conflict between commercial interests and the regulatory function. The government did not see it as part of its function to oversee its activities in a way that would ensure that the system was discharging its intended purpose of protecting the public. 29.59 In our view, there was a lack of effective co-ordination between what were in substance different aspects of a single system, the purpose of which was to ensure that the built environment was safe for those who lived and worked in it and for those who might be affected by it as visitors or just passers-by. That is a task that only the government can undertake. The department responsible for making the Building Regulations and publishing guidance should also be responsible for ensuring that there is effective monitoring of the working of the system as a whole. Only if there is a greater degree of integration of the different parts of the system will the public obtain the benefits that the system as a whole is intended to provide.

The Grenfell Tower Inquiry: Phase 2 Report 226

ISBN 978-1-5286-5080-9 (Volume 2 of 7) 7 volumes not available separately

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Volume 3 Part 4 - The Tenant Management Organisation Part 5 - The management of fire safety at Grenfell Tower HC 19–III GRENFELL TOWER INQUIRY: PHASE 2 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 The Panel: Chairman: The Rt Hon Sir Martin Moore-Bick Ali Akbor OBE Thouria Istephan September 2024

Volume 3 Part 4 - The Tenant Management Organisation Part 5 - The management of fire safety at Grenfell Tower HC 19–III GRENFELL TOWER INQUIRY: PHASE 2 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 The Panel: Chairman: The Rt Hon Sir Martin Moore-Bick Ali Akbor OBE Thouria Istephan September 2024 Presented to Parliament pursuant to section 26 of the Inquiries Act 2005 Ordered by the House of Commons to be printed 4 September 2024

© Crown copyright 2024 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. This publication is available at www.gov.uk/official-documents. Any enquiries regarding this publication should be sent to us at contact@grenfelltowerinquiry.org.uk. ISBN 978-1-5286-5080-9 (Volume 3 of 7) 7 volumes not available separately E03165832 09/2024 Printed on paper containing 40% recycled fibre content minimum. Printed in the UK by HH Associates Ltd. on behalf of the Controller of His Majesty’s Stationery Office. This report contains content which some may find distressing.

5 Part 4 The Tenant Management Organisation

6

7 30.1 The Tenant Management Organisation occupies a central position in the matters we have investigated. As the body appointed by RBKC to manage the whole of its housing stock it was responsible for all aspects of the management of Grenfell Tower in the years leading up to the fire, including responsibility for repairs and maintenance and, most importantly, matters affecting fire safety. Although RBKC provided the funds for the refurbishment, the TMO was responsible for organising and managing it and was the client under the design and build contract with the principal contractor, Rydon. In carrying out its operations it was allowed a large measure of autonomy under the overall supervision of the council. 30.2 In order to provide a context for what follows, we begin this Part of our report by describing the history and structure of the TMO and the agreement with RBKC under which it managed the council’s residential properties. We also describe its internal organisation and processes and their effectiveness. At the same time, we identify those responsible for some important aspects of its operations. 30.3 The arrangements made by RBKC for supervising the TMO’s operations were of considerable importance, both as to their structure and their implementation, so we have described them and expressed our conclusions on their effectiveness. 30.4 Managing a large housing stock inevitably gives rise to a considerable amount of interaction between managers and tenants and it is difficult to avoid a certain amount of friction from time to time. However, it was accepted by all concerned that for some years before the fire many tenants, including some of those who lived in Grenfell Tower, had expressed considerable dissatisfaction with the way in which they were treated by the TMO and that relationships had deteriorated to the point at which they could be described as hostile. 30.5 We describe the history of the relationship between the residents of the Lancaster West Estate (of which Grenfell Tower formed part) and the TMO in the years leading up to the fire, including the various local residents’ associations that were formed in an effort to pursue their members’ interests, because it is an important part of the context in which the refurbishment of the tower took place. Chapter 30 Introduction to Part 4

8 The Grenfell Tower Inquiry: Phase 2 Report

9 Background 31.1 In 1991 the government pledged to increase opportunities for tenants of social housing to assume greater powers of management of the properties in which they lived, independent of the local authorities which owned the buildings. That was done by amending the Housing Act 1985 to create a right to manage, so that local authorities would be obliged to transfer their housing management functions to a tenant management organisation, provided that a majority of tenants were in favour of such a transfer and certain other conditions were met. Following a study carried out by RBKC of the feasibility of transferring its housing management functions to a tenant management organisation, a ballot of RBKC tenants was held. The necessary majority voted in favour of the proposal and following preliminary government approval the Kensington and Chelsea Tenant Management Organisation (the TMO) was incorporated on 19 April 1995. 31.2 Following a further ballot in which the majority of tenants again voted in favour of the transfer, the first formal management agreement came into force on 28 February 1996,1 under which RBKC appointed the TMO as its agent to carry out some (but not all) of its housing management functions.2 Those functions were formally delegated on 1 April 1996 when the TMO became operational3 and 250 officers employed in RBKC’s Housing Services Department transferred to the TMO. Constitution 31.3 The TMO was set up as a company limited by guarantee and was owned by its members, all of whom were tenants or leaseholders of premises owned by RBKC. In April 1996, members of the TMO elected the first tenant and leaseholder members of the board. 31.4 The TMO board had 15 members consisting of eight residents (tenants and leaseholders, in which the former were in the majority), up to four members appointed by the council and three members appointed by the board itself.4 31.5 Throughout its life, the TMO’s board comprised tenant, leaseholder, council-appointed and independent board members. Its articles of association were designed to ensure that residents’ representatives made up the majority of the board’s members.5 In particular, the chair and the two vice-chairs were required to be residents’ representatives.6 1 {RBK00018516}. 2 The TMO’s management functions under this first Management Agreement {RBK00018516} included repairs, maintenance and services provision (Chapter 2), the collection of rent and levying of service charges (Chapter 3), the granting and management of tenancies (Chapter 5). 3 RBKC’s note on the chronology and history of the TMO {RBK00058262/4} paragraph 14. 4 Amended Memorandum of Association of KCTMO Constitution {RBK00050806/16} Article 15, clause 15.1. 5 Amended Memorandum of Association of KCTMO Constitution {RBK00050806/16} Article 15, clause 15.1. 6 Amended Memorandum of Association of KCTMO Constitution {RBK00050806/21} Article 23, clause 23.2. Chapter 31 Structure and governance

The Grenfell Tower Inquiry: Phase 2 Report 10 31.6 The TMO’s board was responsible for ensuring that the TMO’s objectives were carried out and for ensuring its proper day-to-day management.7 In particular, the board was responsible for the appointment and dismissal of the chief executive and other senior managers.8 31.7 The TMO board operated independently of RBKC except on matters relating to the Housing Revenue Account.9 31.8 The TMO’s principal object was to manage and maintain RBKC’s housing stock and ancillary properties on its behalf10 and on behalf of its 5,600 members, who were either residents or leaseholders of RBKC properties.11 31.9 In 1996 a Management Agreement was entered into with RBKC, under which the TMO agreed to manage the residential properties owned by RBKC. Arm’s Length Management Organisations 31.10 Arm’s Length Management Organisations (ALMOs) were introduced by the government in its 2000 Housing Green Paper Quality and Choice: A decent home for all.12 31.11 In 2002, RBKC applied to the government to allow the TMO to become an ALMO. The application was granted, with the result that strategic control of RBKC’s housing capital programme was delegated to the TMO.13 31.12 In April 2002, an extraordinary general meeting of the TMO was held at which the members voted unanimously to amend its constitution to allow it to operate as an ALMO and in September 2002, the Secretary of State formally consented to the delegation of additional responsibilities to it.14 31.13 To give effect to the TMO’s change of status, the 1996 Management Agreement was varied by a deed executed by RBKC and the TMO which came into effect on 7 November 2002. The deed appointed the TMO as an ALMO and, in particular, made the TMO responsible for developing and undertaking all major work schemes as defined in the Management Agreement as well as for the management of the capital programme. 31.14 In 2006, the 1996 Management Agreement and the 2002 deed were replaced by a Modular Management Agreement with effect from 1 April 2006 (the 2006 Agreement), under which the TMO continued to manage residential properties for RBKC as its managing agent. The text of the 2006 Agreement was based on a template approved by the government for agreements between local authorities and tenant management organisations. It was based on a standardised form with a chapter on each of the relevant subject areas, such as repairs and payment of rent. 7 Amended Memorandum of Association of KCTMO Constitution {RBK00050806/20} Article 22, clause 22.1. 8 Amended Memorandum of Association of KCTMO Constitution {RBK00050806/20} Article 22, clause 22.4. 9 Black {TMO00000888/4} page 4, paragraph 23. 10 Amended Memorandum of Association of KCTMO Constitution {RBK00050806/2} Article 4, clause 4.1. 11 Black {TMO00000888/4} page 4, paragraph 21. 12 RBKC’s note on the chronology and history of the TMO {RBK00058262/8} paragraph 36. 13 RBKC’s note on the chronology and history of the TMO {RBK00058262/8} paragraph 39. 14 RBKC’s note on the chronology and history of the TMO {RBK00058262/8} paragraph 39.

Part 4 | Chapter 31: Structure and governance 11 31.15 Over the next decade there were further minor changes to the 2006 Agreement before it was superseded by a new Modular Management Agreement in 2015 which reflected the structure and content of a revised template.15 Thus, in the period leading up to the fire, the contractual relationship between the TMO and RBKC was contained in the 2006 and 2015 Agreements.16 31.16 The effect of the two Agreements was essentially the same. Neither agreement transferred any ownership or rights in RBKC’s housing stock to the TMO, except the right to manage and maintain that stock, and neither agreement affected RBKC’s legal relationship with its tenants or leaseholders. In particular, RBKC retained its statutory, contractual and common law obligations to its leaseholders and tenants. The TMO undertook to carry out management functions in accordance with RBKC’s legal obligations.17 In particular, the TMO was responsible for maintenance and repairs18 and for proposing major works.19 If the TMO decided that major works were necessary, it was obliged to prepare and approve works within the level of financial resources made available to it by RBKC.20 The board and its committees 31.17 There were three committees of the TMO board: the Operations Committee, the Finance, Audit and Risk Committee and the Appointments and Remuneration Committee. Only the first two are relevant for present purposes. 31.18 The Finance, Audit and Risk Committee was responsible for health and safety (including fire safety). Every March, a Health and Safety report was presented to the Finance, Audit and Risk Committee. The report was also presented to the board and to RBKC’s Housing and Property Scrutiny Committee (the Scrutiny Committee) as one means by which the TMO and RBKC monitored compliance with fire safety policies.21 The Finance, Audit and Risk committee also monitored the scope and effectiveness of the systems used to identify and assess all material financial and non-financial risks to the TMO.22 The executive team 31.19 The TMO’s day-to-day operations were carried on by an executive team that reported to the chief executive. From May 2009, that was Robert Black. There were three executive directors at the time of the fire, Sacha Jevans (Operations), Barbara Matthews (Finance and ICT) and Yvonne Birch (People, Performance and Governance). 31.20 Each executive director led a senior management team responsible for the TMO’s management functions. In June 2017, the team that reported to Sacha Jevans consisted of Peter Maddison, Director of Assets and Regeneration, Teresa Brown, Director of Housing, 15 For example, the 2006 Modular Management Agreement was varied in July 2008 to provide for implementation of an improvement plan {RBK00050380} and again in April 2010 to transfer responsibility for allocation of housing from the TMO to RBKC; RBKC’s Note on the Chronology and History of the TMO {RBK00058262/11} paragraph 45. 16 Tenant Management Organisation Modular Management Agreement Volume 1, Chapter 1 {RBK00018796/13} clause 5. 17 Tenant Management Organisation Modular Management Agreement Volume 1, Chapter 1 {RBK00018796/13} clause 6.2. 18 Tenant Management Organisation Modular Management Agreement Volume 1, Chapter 2 {RBK00018796/33} clause 1.1. 19 Tenant Management Organisation Modular Management Agreement Volume 1, Chapter 2, {RBK00018796/34-35} clause 4.1. 20 Tenant Management Organisation Modular Management Agreement Volume 1, Chapter 2 {RBK00018796/35} clause 4.3. 21 Matthews {TMO00873380/6} page 6, paragraph 20. 22 TMO Annual Health and Safety Report 2015/16 {TMO00843882/1}.

The Grenfell Tower Inquiry: Phase 2 Report 12 Hash Chamchoun, Director of Housing Support Services and Graham Webb, managing director of Repairs Direct Ltd, a subsidiary of the TMO which was responsible for carrying out repairs. For present purposes, it is sufficient to note that Janice Wray, who had been the Health and Safety and Facilities Manager since 2011, reported to Barbara Matthews.23 The management of health and safety 31.21 The Director of Finance and ICT was responsible for ensuring the health and safety of all TMO residents, employees and contractors.24 That included responsibility for putting in place arrangements to manage the risk of fire.25 An important element of her role was to monitor the TMO’s health and safety performance at a strategic level.26 Anthony Parkes was the Director of Finance and ICT between August 2009 and June 201527 when he was succeeded by Barbara Matthews. 31.22 Before joining the TMO, Barbara Matthews had not held responsibility at any organisation for health and safety or fire safety management. She had received no training in, or experience of, managing health and safety28 or fire safety management. She received no training on the requirements of the Fire Safety Order, either before or during her time with the TMO,29 and was not familiar with its details.30 She was not aware of the concept of the responsible person under the Fire Safety Order or of the substance of that person’s duties,31 nor did she take any steps to satisfy herself of the adequacy of the TMO’s arrangements to discharge its duty to take general fire precautions under Article 8 of the Fire Safety Order.32 31.23 Anthony Parkes, Barbara Matthews and the wider executive team relied heavily on Janice Wray for all aspects of health and safety. Although she was not part of the TMO’s senior management team, the degree of reliance placed on her by Barbara Matthews and the broad autonomy she was given within her area of operations, meant that Janice Wray was effectively acting at senior management level in relation to health and safety.33 31.24 The TMO’s Health and Safety Committee, chaired by Barbara Matthews, was the TMO’s primary forum for discussion of health and safety matters.34 It was the body which oversaw health and safety performance and challenged managers of services on their compliance with health and safety duties.35 The health and safety committee was a critical element in the management of fire safety.36 23 Wray {Day140/6:16-17}. 24 Matthews {Day147/103:21-25}. 25 Matthews {Day147/113:8}-{Day147/114:5}. 26 Matthews {TMO10049987/2} page 2, paragraph 7. 27 Parkes {TMO00873400/1} page 1, paragraph 3. 28 Wray {Day147/99:19}-{Day147/100:14}. 29 Wray {Day147/100:25}-{Day147/101:3}. 30 Matthews {Day147/107:23}-{Day147/108:3}. 31 Matthews {Day147/108:23}-{Day147/109:1}. 32 Matthews {Day147/110:24}-{Day147/111:2}. 33 Matthews {Day147/104:15}-{Day147/105:1}. 34 Matthews {TMO00873380/2} page 2, paragraph 8. 35 Matthews {TMO00873380/2} page 2, paragraph 8. 36 TMO Health and Safety Committee Terms of Reference dated September 2015 {TMO00873368/1}.

Part 4 | Chapter 31: Structure and governance 13 31.25 Between them Barbara Matthews and Janice Wray identified the matters that they considered should be put forward for discussion at executive team meetings and included in the annual health and safety report.37 They typically arose out of meetings of the health and safety committee, discussions in the broader housing sector or publications brought to the TMO’s attention.38 31.26 The TMO maintained a “corporate risk map” that identified the various risks to its operations, the harm that might arise if they occurred and the measures that could be employed to mitigate them.39 It had identified health and safety as a strategic risk and was aware that the consequences of a failure to manage health and safety duties properly could result in serious injury or death.40 Health and safety committee meetings, involving executive and senior management teams, were held at regular intervals. At those meetings fire risk assessments and any measures required by them were discussed and remedial work monitored and audited.41 Janice Wray 31.27 Janice Wray played a fundamental role in the TMO’s performance of its health and safety obligations, including its obligations in relation to fire safety. Although she saw her role as essentially advisory,42 it is plain from the various versions of the TMO’s health and safety policy that it was broader, more substantive and covered a range of matters, including those of the Competent Person for the purposes of the Fire Safety Order that we have set out in Chapter 35.43 The responsibilities she was given were probably too much for one person to discharge properly without substantial assistance and effective oversight and unfortunately she had neither. Senior managers either did not realise that there was simply too much for her to do, or, if they did, they were nonetheless willing for her just to get on and do her best. Annual health and safety reports 31.28 The principal means by which the TMO executive committee reported to the board and to RBKC on health and safety matters was its annual health and safety report. The document was prepared by Janice Wray and reviewed by Barbara Matthews and the executive team before it was submitted to the board.44 The matters reported to the board were those set out in the annual health and safety report and any exceptional events, such as the Adair Tower fire.45 The TMO itself reported to RBKC’s scrutiny committee46 and to RBKC at quarterly joint management meetings, principally through Robert Black.47 31.29 From time to time Janice Wray met members of RBKC’s housing team, such as Amanda Johnson and Celia Caliskan, and in the course of those meetings reported informally on what the TMO was doing. 37 Matthews {TMO10049987/2} page 2, paragraph 8. 38 Matthews {Day147/105:7-17}. 39 Matthews {Day147/132:8-14}; Example of Corporate Risk Map {TMO00899699}. 40 Matthews {Day147/135:13-25}; Corporate Risk Map dated 16 March 2016 {TMO00899699/1} Risk 5. 41 Matthews {Day147/136:5-25}. 42 Wray {Day140/7:22-25}. 43 At paragraph 18. See also TMO Health and Safety Policy 2012 {TMO10031076/3}. This list was reproduced in the 2016 version of the policy {TMO10024402/3}. The 2010 version of the policy {TMO10031078/3} does not include the references at (i) and (j) to the Fire Safety Order. 44 Matthews {TMO10049987/3} page 3, paragraph 15. 45 Matthews {Day147/105:18-25}. 46 Matthews {TMO00873380/6} page 6, paragraph 20. 47 Matthews {TMO00873380/9} page 9, paragraph 31.

The Grenfell Tower Inquiry: Phase 2 Report 14 31.30 Robert Black told us that Barbara Matthews and Janice Wray raised health and safety matters with him which might then be included in the annual health and safety report.48 Although other TMO employees contributed to the report, it was substantially the work of Barbara Matthews and Janice Wray.49 As a result, Mr Black was entirely reliant on their judgement to determine whether a matter concerning fire safety or fire safety management should be drawn to the attention of the board.50 Funding health and safety management 31.31 The TMO was funded by RBKC. It maintained three separate accounts: a management account, which covered its costs under the agreement with RBKC, a “Repairs Direct” account, which related to the cost of maintenance and repairs, and a Housing Revenue account into which rents were paid,51 which it maintained on behalf of RBKC.52 31.32 The TMO’s annual management fee was paid by RBKC into the TMO’s management account. Robert Black thought that the TMO board’s decision-making was not independent of RBKC because it depended on RBKC for its income.53 31.33 The cost of employing and running the health and safety team, including that of the fire risk assessment programme, was borne by the health and safety team budget, which was one of the departmental budgets within the Financial Services and ICT directorate.54 That budget did not include the cost of carrying out works required as a result of a fire risk assessment, which was borne by whichever team was responsible for the work in question. Reporting to the Board and RBKC 31.34 The board of the TMO was the body ultimately responsible for its affairs, including strategic decisions relating to matters affecting fire safety in the buildings it managed. It was therefore important that it be kept informed of developments as they occurred, but regrettably there were many instances in which important information was not drawn to its attention. RBKC was responsible for the oversight of the TMO which reported to its scrutiny committees. Reports to the scrutiny committees did not always contain the information that might reasonably have been expected. 31.35 From the start of Robert Black’s tenure as chief executive in May 2009, fire safety and the adequacy of the TMO’s fire safety measures were regular subjects of discussion, primarily because of the LFB’s concern about the TMO’s approach to fire risk assessments.55 The substance of those matters is discussed in Part 5, Chapter 37. At the outset the LFB was concerned that the TMO was producing its own fire risk assessments and that they were inadequate.56 The LFB was so troubled that it indicated that it would serve an enforcement notice on both the TMO and RBKC.57 As a result, the TMO entered into a contract with Salvus Consulting Ltd to carry out fire risk assessments in respect of all its high‑risk properties.58 48 Black {Day149/56:14-25}. 49 Black {Day149/57:10-19}. 50 Black {Day149/57:2-8}. 51 Black {Day149/21:6-7}. 52 Matthews {TMO00873380/10} page 10, paragraph 33. 53 Black {Day149/23:23}-{Day149/24:2}. 54 Matthews {TMO00873380/10} page 10, paragraph 35. 55 Black {Day149/217:3-8}. 56 {RBK00052528/3}. 57 {RBK00052528/3}. 58 Black {Day149/212:1-4}.

Part 4 | Chapter 31: Structure and governance 15 31.36 The first fire risk assessments produced by Salvus in 2009 identified a number of risks that Janice Wray wanted to discuss with Robert Black. One concerned flat entrance doors.59 Mr Black was aware from at least October 2009 that defects in flat entrance doors (in particular, a lack of effective self-closing devices, intumescent strips and cold smoke seals) resulting in ineffective compartmentation had been identified by the fire risk assessments as a problem that required attention across the TMO’s estate.60 Mr Black was also aware of the Fire Safety Management report dated 22 September 2009 produced by Salvus for the TMO,61 which drew attention to 19 respects in which Salvus considered the TMO to be in breach of the Fire Safety Order.62 31.37 In December 2009, Janice Wray prepared a report for a meeting of the TMO board on 10 December 2009.63 It is likely that a copy was provided to Mr Black.64 In relation to the Salvus Fire Safety Management report it simply said that a management report had been received from the consultant which set out the fire safety framework within which the TMO and its contractors should be working.65 It said nothing about the 19 breaches of the Fire Safety Order that had been identified and gave the board no information about the serious defects that Salvus had found in the TMO’s management of fire safety across its estate. There is no evidence that Mr Black presented the report to the board and no recorded explanation or discussion of its contents. We can only conclude that he and the executive team failed to make even the most basic disclosure to the board of the widespread systemic failings in the TMO’s management of fire safety that Salvus had found. Janice Wray was seriously at fault in not writing a candid report for the board; Mr Black was equally at fault in failing to inform the board about the deficiencies in fire safety management. 31.38 Following the board meeting, Mr Black, Laura Johnson and Jean Daintith produced a report for the meeting of RBKC’s Housing, Environmental Health and Adult Social Care Scrutiny Committee on 15 March 2010, which included an item on the TMO’s fire risk assessment programme.66 Paragraph 3 of the report said that the increasingly stringent requirements of the LFB had led the TMO and RBKC to agree a new approach to fire risk assessments and carrying out any remedial work required as a result. The report did not mention that the LFB had been so concerned about the adequacy of the fire risk assessments carried out by the TMO itself that it had considered issuing an enforcement notice.67 Mr Black could not account for that omission,68 nor could he recall whether the scrutiny committee had been told of Salvus’s recommendations or the TMO’s response to them.69 Robert Black’s failure to disclose those matters was part of an emerging pattern of withholding from those to whom he reported the fact that there were serious problems with the management of fire safety by the TMO. 59 {TMO10037375}. 60 Black {Day150/3:18-25}. 61 Fire Risk Assessment for Fire Safety Policy and Procedures prepared by Salvus Consulting Ltd {SAL00000013}. 62 Black {Day150/4:15-19}. 63 {TMO00873623}. 64 Cover Letter to Board Member dated 4 September 2009 {TMO00881999}; Enclosure 16 {TMO00888764}; Board Action Sheet {TMO00882005/20}. 65 {TMO00873623/2} paragraph 4.5. 66 {RBK00030060}. 67 Black {Day150/9:8-14}. 68 Black {Day150/9:21-22}. 69 Black {Day150/9:24}-{Day150/10:5}.

The Grenfell Tower Inquiry: Phase 2 Report 16 A fire at Grenfell Tower: 30 April 2010 31.39 On 30 April 2010, a fire broke out in the lift lobby on floor 6 of Grenfell Tower. On 5 May 2010 Janice Wray sent an email to Collette O’Hara of the LFB (with a copy to Robert Black) giving her report on it.70 She said there had been a leakage of smoke from the extraction system into the lobbies of floors 7, 12, 13, 15, 17, 18, 19 and 20 that had led a number of residents to believe that their lobbies were smoke-logged and that they were trapped in their homes. They had therefore telephoned the LFB asking for help. 31.40 When Janice Wray reported the incident to the TMO board in her report of 17 June 2010,71 she did not say that smoke had leaked into the lobbies on eight floors (as described in the email to Collette O’Hara) nor did she mention the residents’ belief that they had been trapped in their flats and had called the LFB. The report gave the impression that the smoke ventilation system had operated substantially as intended, but with some relatively minor leakage.72 It grossly understated the extent to which smoke had spread within the tower and was seriously misleading. Mr Black accepted that it did not give the board proper information about the operation of the smoke ventilation system or, importantly, the residents’ fear that they were trapped. Again, Mr Black could not explain why the board had been given a materially incomplete account.73 He had seen Janice Wray’s original report to Collette O’Hara and should have corrected the false impression that Ms Wray’s report gave. 31.41 In March 2014 the LFB issued a deficiency notice to the TMO because of its failure to maintain the smoke ventilation system at Grenfell Tower.74 The system was finally replaced in 2016 as part of the refurbishment, but between 2010 and 2016 there was no fully functioning smoke ventilation system.75 We return to this episode later in Chapter 43 because it seems that, as Mr Black accepted, the absence of a functioning smoke ventilation system was the subject of repeated complaints by the Grenfell Tower Leaseholders’ Association. 31.42 The next TMO board meeting took place on 22 May 2014. Robert Black prepared a report for that meeting which was circulated in advance.76 It made no mention of the deficiency notice. Although he accepted that it was essential information for the board to receive, Mr Black could not explain why it had not been placed before it.77 The omission can only have been deliberate. Yet again, Mr Black’s failure to provide the board with important information relating to fire safety in the TMO’s housing stock deprived it of the ability to take corrective action. Adair Tower Deficiency Notice 31.43 On 12 October 2015, the LFB issued a deficiency notice in respect of Adair Tower.78 Some of the contraventions of the Fire Safety Order identified by the LFB resulted from failures to carry out remedial works called for in fire risk assessments.79 Janice Wray received the 70 {TMO10048221/4}. 71 {TMO10037437/96-97} paragraphs 8.2 and 8.3. 72 {TMO10037437/97} paragraph 8.3. 73 Black {Day150/31:11}-{Day150/32:4}. 74 {LFB00032101}. 75 Black {Day150/45:5-8}. 76 TMO Board document pack {RBK00051017}; Chief Executive’s report {RBK00051017/27-28}. 77 Black {Day150/101:2-24}. 78 {TMO00842271}. 79 Black {Day150/138:6-14}.

Part 4 | Chapter 31: Structure and governance 17 notice on 22 October 2015,80 but she did not bring it to Robert Black’s attention until the morning of 31 October 2015, when a fire occurred at Adair Tower.81 Mr Black accepted that that had been a serious failing on her part,82 but it was consistent with a culture of concealment that had started at the top and filtered down to lower layers of management. 31.44 In the evening of 31 October 2015, Robert Black sent an email to the members of the TMO board to tell them about the fire.83 Although he emphasised the LFB’s success in tackling it, he made no mention of the deficiency notice. The issue of such a notice was an obviously important piece of information, given that a fire had broken out only two weeks later in that very building. Yet again, Mr Black was unable to explain why he had not told the board about it.84 We can only conclude that his failure to do so was deliberate. 31.45 On 4 November 2015, Rebecca Burton of the LFB sent an email to Janice Wray containing a list of questions relating to the Adair Tower fire.85 The email chain had originated with Janice Wray on 22 October 2015 because she had been told that the LFB was about to issue five more deficiency notices relating to other properties managed by the TMO.86 Some of them were based on the absence of effective self-closing devices on doors in buildings that had been inspected.87 31.46 Janice Wray forwarded the correspondence between herself and Rebecca Burton to Robert Black and others the same day. Mr Black could not remember whether he had read it or had been made aware that the LFB was about to issue more deficiency notices, but he accepted that it was likely that he had.88 31.47 On 5 November 2015, Mr Black attended a meeting of RBKC’s Housing and Property Scrutiny Committee. The minutes of that meeting record that he provided a report on the fire at Adair Tower, in which he said that the fire doors had worked well.89 He did not mention the deficiency notice that had been issued 19 days before the fire. Mr Black could not recall why the committee had not been told about the deficiency notice,90 but the omission cannot have been accidental. 31.48 The fact that a deficiency notice had been issued, not to mention its contents, was clearly a matter of some importance and should have been drawn to the attention of the scrutiny committee.91 Robert Black’s failure to report those matters to the committee was a serious dereliction of duty on his part, but entirely consistent with the pattern of concealment he had established in relation to fire safety matters. 31.49 On 4 December 2015, Barbara Matthews sent an email to the members of the TMO board (including Mr Black) telling them that the LFB intended to serve enforcement notices in relation to Adair Tower and Hazelwood Tower.92 Again, the email is instructive as much for what is not said as for what is. She did not mention the deficiency notice issued on 12 October 2015, nor did she mention the various enforcement measures available to the 80 {LFB00001645}. 81 Black {Day150/139:25}-{Day150/140:5}. 82 Black {Day150/140:6-8}. 83 {TMO00866480/2}. 84 Black {Day150/143:3-7}. 85 {TMO00869184/3}. 86 {LFB00003440}. 87 {TMO00869184/6}. 88 Black {Day150/147:10-17}. 89 {RBK00048049/6}. 90 Black {Day150/143:3-7}. 91 Marshall {Day133/137:5-15}. 92 {TMO00902920}.

The Grenfell Tower Inquiry: Phase 2 Report 18 LFB, although in a draft message to the board composed only two days earlier Robert Black had identified them.93 Neither Barbara Matthews94 nor Robert Black95 could explain why the fact that a deficiency notice issued on 12 October 2015 had again not been mentioned. Again, the omission can only have been deliberate. 31.50 An enforcement notice dated 23 December 2015 was served by the LFB on the TMO in relation to breaches of the Fire Safety Order identified following the fire at Adair Tower.96 The enforcement notice required the TMO to take steps to remedy the failures specified in the schedule to the notice by 23 June 2016.97 31.51 On 6 July 2016, Janice Wray spoke to Ben Dewis of the LFB. During that call he told her about the current status of the LFB’s investigation into the Adair Tower fire and the possibility of enforcement action. Janice Wray sent a note of the call by email to Laura Johnson, Robert Black and Barbara Matthews.98 In it she said that she was concerned to hear that investigations were continuing.99 Mr Black accepted that he must have seen and read the note100 which made it clear that the LFB were considering taking legal action against the TMO in respect of breaches of the Fire Safety Order, including possible criminal proceedings, although, as the note recorded, Mr Dewis felt that was unlikely. 31.52 Robert Black reported to the TMO board on 20 July 2016. His report, which was circulated to the members before the meeting,101 did not mention the possibility that criminal proceedings might be taken against the TMO. Once more, he was unable to explain why he had not told the board about a potential prosecution for failing to comply with the Fire Safety Order, which was obviously a serious matter.102 It was his responsibility, as he accepted, to keep the board informed about anything that might affect its legal position,103 but although he denied that he had deliberately withheld the information from the board, we are unable to accept that it was the result of a mere oversight.104 31.53 On 17 November 2016, the LFB issued a deficiency notice to the TMO in respect of Grenfell Tower.105 It was based on the absence of self-closing devices on some doors in the building, which was a potential breach of the Fire Safety Order. The notice required remedial action to be taken by 18 May 2017. 31.54 The events we have described lead us to conclude that although there was a satisfactory system in place within the TMO for reporting through senior management to the board and the scrutiny committee, it failed to operate effectively because of an entrenched reluctance on the part of Robert Black to inform the board and RBKC’s scrutiny committees of matters that affected fire safety. It was his decision whether to report to the board what he knew about problems with fire safety at the TMO and he consistently chose not to do so. Robert Black consistently failed to tell either the board or RBKC of the LFB’s concerns about the TMO’s compliance with the Fire Safety Order or the various steps taken by the LFB to 93 {TMO00902919}. 94 Matthews {Day148/81:16}-{Day148/82:5}. 95 Black {Day150/164:18}-{Day150/165:22}. 96 {TMO00840703}. 97 {TMO00840703/1-2}. 98 {RBK00001865}. 99 {RBK00001863}. 100 Black {Day150/206:5-7}. 101 {TMO10014037/68}. 102 Black {Day150/209:19}-{Day150/210:18}. 103 Black {Day150/142:24}-{Day150/143:2}. 104 Black {Day150/201:2-18}. 105 {TMO10017254}.

Part 4 | Chapter 31: Structure and governance 19 enforce it. His persistent failure to provide them with important information denied both the board and RBKC of the ability to exercise effective oversight of the TMO’s performance of its obligations under the Fire Safety Order.

The Grenfell Tower Inquiry: Phase 2 Report 20

21 Introduction 32.1 This chapter considers the arrangements under which RBKC exercised oversight of the TMO in relation to health and safety matters generally and fire safety in particular. RBKC’s constitutional arrangements 32.2 RBKC carried on its operations partly through executive members of the council, partly through committees, including the scrutiny committees, and partly through the full council made up of 50 elected councillors. The executive 32.3 The executive was composed of individual councillors each responsible for a particular area of the council’s functions. It was referred to as “the cabinet” when it met collectively and individual councillors were known as “cabinet members”.106 The cabinet could comprise up to ten councillors, including the leader, who appointed the members and decided which portfolio each would hold.107 The executive carried out all those functions that were not reserved to the full council or otherwise delegated to committees, sub‑committees or officers.108 32.4 In 2013, Councillor Paget-Brown, the leader of the council, appointed Councillor Feilding‑Mellen as the cabinet member for housing, property and regeneration. He served in that role until after the Grenfell Tower fire.109 32.5 The leader of the council was responsible for all portfolios and could make any decision that may have been delegated to an individual cabinet member or to the cabinet.110 Councillor Paget-Brown said that, as leader, his responsibilities included decisions relating to housing, but not to projects such as the refurbishment of Grenfell Tower.111 However, he accepted that he had been responsible for ensuring that Councillor Feilding-Mellen was properly discharging his responsibilities as the cabinet member for housing, property and regeneration,112 which included the oversight of fire safety within the TMO’s buildings,113 communicating with the LFB,114 social housing projects and the proper management of the TMO115 and the welfare of those who lived in RBKC’s properties.116 106 Part two, article 7 of the RBKC constitution {RBK00035010/1} paragraph 7.01(a). 107 Paget-Brown {Day132/134:22}-{Day132/135:2}. 108 Part two, article 7 of the RBKC constitution {RBK00035010/1} paragraph 7.01(a). 109 Paget-Brown {Day132/135:3-10}; Feilding-Mellen {Day131/82:23-24}. 110 Part three, article 1 of the RBKC constitution {RBK00035007/4} paragraph 1.7. 111 Paget-Brown {Day132/144:3-20}. 112 Paget-Brown {Day132/145:3-16}. 113 Paget-Brown {Day132/148:3-16}. 114 Paget-Brown {Day132/145:3-16}. 115 Paget-Brown {Day132/149:1-5}. 116 Paget-Brown {Day132/149:6-9}. Chapter 32 RBKC’s oversight of the TMO

The Grenfell Tower Inquiry: Phase 2 Report 22 32.6 The responsibilities of the cabinet member for housing, property and regeneration were set out in paragraph 1.8 of part 3A of RBKC’s constitution. In relation to housing matters, they included responsibility for leadership, strategic planning and decision-making in respect of all social housing regeneration projects, policies on maintenance of the social housing stock and the TMO management agreement.117 The scrutiny committee 32.7 RBKC had a number of scrutiny committees, but for our purposes only the Housing and Property Scrutiny Committee (the scrutiny committee) is relevant. It had 11 members, whose function was to scrutinise the provision, planning, management and performance of all housing services, social housing regeneration, the TMO, housing strategy and the financing and development of the council’s housing stock,118 based on the information provided to it.119 32.8 Between 13 October 2010 and 11 May 2016, Councillor Quentin Marshall was chairman of the scrutiny committee.120 He was succeeded by Councillor Sam Mackover, who chaired his first scrutiny committee meeting on 13 July 2016.121 Scrutiny of fire safety matters 32.9 Fire safety fell within the scope of responsibility of both the scrutiny committee and the Cabinet and Corporate Services Scrutiny Committee. The scrutiny committee had a responsibility for it because residents of the council’s housing stock were affected by arrangements relating to fire safety.122 The Cabinet and Corporate Services Scrutiny Committee also had a responsibility for it because fire safety was an aspect of community safety and emergency planning.123 The scrutiny committee received reports from RBKC’s Housing department on fire safety across the council’s estate, including the buildings managed by the TMO.124 RBKC’s fire safety policy 32.10 RBKC’s fire safety policy dated January 2014125 was produced in conjunction with the London Borough of Hammersmith and Fulham. It set out the strategy and organisational arrangements for the management of fire safety within RBKC126 and described how RBKC could manage fire safety effectively.127 32.11 The fire safety policy applied to any premises in respect of which other parties were the responsible persons by virtue of a contract or tenancy agreement, but in respect of which RBKC retained responsibilities as landlord.128 Accordingly, the policy applied to the premises managed by the TMO.129 It required RBKC’s health and safety team to have appropriate 117 Part three, article 1 of the RBKC constitution {RBK00035007/5} paragraph 1.8. 118 Part two, article 6 of the RBKC constitution {RBK00035012/3-4} paragraph 6.03(a) and (b). 119 Feilding-Mellen {Day131/91:21-24}. 120 Marshall {RBK00033744/2} page 2, paragraph 9; Marshall {RBK00033744/28} page 28, paragraph 118. 121 Mackover {RBK00029923/5} page 5, paragraph 20. 122 Mackover {Day134/3:13-17}. 123 Mackover {RBK00029923/9} page 9, paragraph 40. 124 Feilding-Mellen {Day131/97:8-15}; {Day131/95:10-13}; Mackover {Day133/95:11-16}; Marshall {Day133/95:11-16}. 125 {RBK00001655}. 126 {RBK00001655/2} final paragraph. 127 {RBK00001655/3}. 128 {RBK00001655/4} paragraph 2.2. 129 Paget-Brown {Day133/7:4-9}.

Part 4 | Chapter 32: RBKC’s oversight of the TMO 23 processes in place to ensure that suitable and sufficient fire safety management systems had been established and that suitable protocols had been devised to ensure that compliance with fire safety requirements was assured.130 RBKC’s arrangements for monitoring the TMO 32.12 Celia Caliskan was the general needs housing commissioning manager in RBKC’s Housing Commissioning Team.131 From 2005, she was directly responsible for managing the agreement between RBKC and the TMO.132 Between 2011 and 2017 she reported to Amanda Johnson.133 32.13 Until 2016 Celia Caliskan was one of two officers in RBKC’s housing commissioning team who reported to Ms Johnson on matters relating to general needs commissioning, which had been delegated to the TMO.134 In 2016, she became the only officer dedicated to that task, because the second officer was made redundant and was not replaced in order to save costs.135 Much of the work involved in overseeing the agreement was thereafter left to Celia Caliskan.136 32.14 Amanda Johnson became the permanent head of the housing commissioning team at around the end of 2010 and was then involved in overseeing the TMO.137 As Celia Caliskan’s line manager, she was responsible for monitoring the performance of the TMO.138 Annual performance reviews and performance agreements 32.15 Every July reports on the performance of the TMO were prepared for the scrutiny committee.139 They incorporated as appendix 1140 a review of the TMO’s performance and (as appendix 2) the performance agreement for the coming year.141 The annual performance agreement was drawn up in consultation with the TMO. It contained key performance indicators and “actions” for the TMO to take during the coming year. It also set out the annual cycle of auditing of the TMO to be carried out by RBKC.142 32.16 The stated purpose of the annual performance agreement was to set out how the performance of the TMO would be monitored by the council over the coming year in accordance with its priorities and national and local requirements.143 The stated purpose of the annual review was to allow the council to assess the TMO’s performance over the past year and to comment on various aspects of its activity in the borough that contributed to the council’s strategic priorities.144 130 {RBK00001655/5} fifth paragraph. 131 RBKC organograms contained within {RBK00000278}. 132 Amanda Johnson {Day130/136:16-18}; {Day130/144:4-6}; Caliskan {RBK00035166/3} page 3, paragraph 11. 133 Amanda Johnson {Day130/137:2}-{Day130/140:7}; RBKC organograms contained within {RBK00000278}. 134 Amanda Johnson {Day130/143:25}-{Day130/144:3}. 135 Amanda Johnson {Day130/144:12-19}. 136 Amanda Johnson {Day130/149:2-4}. 137 Amanda Johnson {Day130/133:10-12}. 138 Amanda Johnson {Day130/139:16-19}. 139 For example {RBK00032466}. 140 {RBK00032466/4}. 141 {RBK00032466/18}. 142 Amanda Johnson {RBK00033719/7} page 7, paragraph 38. 143 {RBK00032466/18}. 144 {RBK00032466/4}.

The Grenfell Tower Inquiry: Phase 2 Report 24 Absence of fire safety as a key performance indicator 32.17 Although the key performance indicators evolved over the years,145 none related to fire safety or fire safety management, fire risk assessments, or performance by the TMO of its duties under the Fire Safety Order. Although both RBKC and the TMO were aware of the delay in completing work identified in fire risk assessments, none of the annual performance agreements contained a performance indicator based on their full and prompt completion. Although Laura Johnson conceded that fact, she said that the contents of mid-year and annual reports to the scrutiny committee did provide current information about fire risk assessments.146 She also made the point that the focus of key performance indicators was on the “big six” matters147 and that the details of compliance were monitored by the TMO’s health and safety committee.148 RBKC’s oversight 32.18 RBKC’s function was to exercise strategic oversight of the TMO’s activities, not to monitor its operations on a day-to-day basis.149 It had monitored fire safety in the same way as it had monitored other areas of activity requiring compliance with its legislative and regulatory obligations, and the TMO reported on its performance in respect of fire safety in the six-monthly and annual reviews.150 Laura Johnson also discussed matters relating to fire safety at her monthly meetings with Robert Black.151 32.19 Janice Wray’s understanding was that the management of health and safety at the TMO was monitored primarily by RBKC’s Corporate Health and Safety Advisor and its main Health and Safety Co-ordinating Committee.152 Laura Johnson’s understanding was that RBKC’s Housing department had not monitored health and safety at the TMO. She admitted that she had not been aware that the annual health and safety report had been presented to the RBKC corporate health and safety manager. She conceded that, in hindsight, that had been a weakness in RBKC’s governance arrangements.153 32.20 The annual performance agreement required reports on discrete areas, one of which was always health and safety. The health and safety reports were drafted by Janice Wray. The broad purpose of their inclusion was to draw attention to any relevant developments.154 32.21 Celia Caliskan said that she received information from Janice Wray, which she used for drafting the performance review.155 The division of labour between Celia Caliskan and Janice Wray is usefully demonstrated by a draft version of the 2016-17 annual performance review, in which the person responsible for drafting each section appears to be marked in red.156 The health and safety section of the report is marked “TMO” and ‘’Janice’’157 Janice Wray confirmed that she had drafted the health and safety sections of 145 Caliskan {RBK00035166/5} page 5, paragraph 24. 146 Laura Johnson {Day128/220:3-11}. 147 Fire safety, legionella, asbestos, gas, electricity and lifts. 148 Laura Johnson {Day128/220:16-25}. 149 Laura Johnson {Day129/38:3-16}. 150 Laura Johnson {Day129/39:15-21}. 151 Laura Johnson {Day129/59:11}-{Day129/60:19}. 152 Wray {TMO00000890/37} page 37, paragraph 164. 153 Laura Johnson {Day129/67:1}-{Day129/68:14}. 154 For example {RBK00032466/23-24}. 155 Caliskan {RBK00054409/5} page 5, paragraph 13. 156 {RBK00002395/15}. 157 {RBK00002395/15}.

Part 4 | Chapter 32: RBKC’s oversight of the TMO 25 the performance reviews.158 Amanda Johnson said that Celia Caliskan relied heavily on Janice Wray for the information contained in the report.159 Although Amanda Johnson said that she would scrutinise the contents of Janice Wray’s reports, she accepted that they contained no independently verified information about the TMO’s performance.160 32.22 Laura Johnson also confirmed that the health and safety sections of the annual performance review had been drafted by Janice Wray and Celia Caliskan.161 Some of them, such as the health and safety section of the annual performance review for 2013/14, contained judgments and assessments that reflected well on how fire safety was being managed by the TMO.162 In practice, Janice Wray was effectively writing her own reference. RBKC’s audits of the TMO 32.23 The purpose of RBKC’s audits on behalf of the TMO was to provide senior management and members of the TMO with assurance about the adequacy and effectiveness of the internal controls in the area being audited. The audits considered each service area and gave an assurance assessment rating ranging from “substantial” to “limited”. Where the rating was “limited”, a further exercise was usually undertaken within six to nine months to assess the effect of remedial measures.163 32.24 RBKC produced an audit plan for the TMO every three to five years in order to ensure that the areas of interest were audited at least once every five years.164 The plan was approved by the TMO’s Finance, Audit and Risk Committee at the beginning of each year.165 RBKC allocated a maximum of 100 audit days to the TMO a year.166 32.25 A list of audits was provided for in the annual performance agreement between the TMO and RBKC.167 They were carried out by RBKC’s internal audit department as part of its corporate function rather than the housing department.168 At the conclusion of an audit, the auditors would provide the TMO officers in charge of the relevant departments with a draft of their report which would be reviewed by TMO before it was formally issued. The TMO was given two weeks to provide its responses to the report’s recommendations together with an indication of the time within which any necessary steps would be implemented.169 32.26 The annual performance agreement forming part of the report to the scrutiny committee in July 2012 identified that an audit in relation to fire risk assessments by the TMO was due to take place in 2012.170 There is no evidence that it did in fact take place.171 32.27 RBKC carried out three separate audits of health and safety management at the TMO between 2013 and 2016. The first was undertaken in 2013.172 Its purpose was to examine how health and safety policies and procedures were being implemented. The TMO 158 Wray {Day140/84:10-14}. 159 Amanda Johnson {Day130/209:21}. 160 Amanda Johnson {Day130/210:3}-{Day130/211:4}. 161 Laura Johnson {Day129/145:24-25}. 162 {RBK00032466/15-16} paragraph 3.9. 163 Patel {RBK00029884/2} page 2, paragraph 5. 164 Patel {RBK00029884/3} page 3, paragraph 9. 165 Patel {RBK00029884/2} page 2, paragraph 7. 166 Patel {RBK00029884/3} page 3, paragraph 10. 167 {RBK00030149/22}. 168 Amanda Johnson {RBK00033719/9} page 9, paragraph 50. 169 Patel {RBK00029884/3} page 3, paragraph 10. 170 {RBK00030149/22}. 171 Amanda Johnson {Day131/32:17-25}. 172 {RBK00000313}.

The Grenfell Tower Inquiry: Phase 2 Report 26 received a “limited” assurance rating in respect of that audit.173 A follow-up audit was carried out in December 2013 when the TMO was given a “satisfactory” rating.174 The final audit took place in March 2016.175 It was a high-level audit with a budget of 10 audit days. The TMO received a “substantial” assurance rating. 32.28 Two other significant reviews of the TMO specifically in respect of the management of fire safety were carried out by external parties at the request of the TMO. The first was carried out by Salvus Consulting Ltd in September 2009, which specifically considered fire safety policy and procedures.176 The second was a safety management review carried out by Matt Hodgson in July 2013.177 We address these in detail in Chapter 37. 173 Amanda Johnson {Day131/33:3-16}. 174 {RBK00000320}. 175 {RBK00000531}. 176 {SAL00000013}. 177 {TMO10040497}.

27 Complaints 33.1 In the first part of this chapter, we consider the various mechanisms by which the residents of Grenfell Tower were able to express their views about the quality of the services provided by the TMO. Those mechanisms were not confined to personal representations; they included membership of the various groups that the TMO recognised as representing residents and membership of unofficial organisations set up by residents who were concerned that their views were not being heard, or at least not being heeded, by their landlord. The Memoli and the Butler reports 33.2 In July 2008, RBKC asked Maria Memoli, a retired solicitor, to investigate longstanding complaints made against the TMO by residents of its properties and to establish whether there were any common themes that could inform a plan for improvement.178 Her initial report, dated 10 April 2009 (the Memoli report), made serious criticisms of the TMO’s relationship with its tenants, leaseholders and some freeholders, particularly as it affected repairs, major works, management charges, service charges, customer care, probity and ethics, communications, performance and monitoring, and trust and confidence. Complaints had not been resolved, it was felt, for some years.179 The report concluded that the TMO’s board should understand better its constitutional and legal role and take collective responsibility to lead the work required by the TMO’s improvement plan.180 It made 34 recommendations. 33.3 Robert Black, who had become the TMO’s chief executive officer in May 2009, said that, although he had been made aware of the Memoli report, he could not remember having been given a copy of it.181 He recalled a report that had made serious criticisms of the TMO’s governance and its relationship with its tenants,182 but his impression had been that RBKC had not been particularly impressed by it.183 33.4 A final report, dated 22 September 2009, was produced by John Butler (the Butler report), also commissioned by RBKC, which made a number of recommendations echoing Maria Memoli’s proposals, such as requiring that every complaint be investigated as appropriate.184 Most importantly for our purposes, the Butler report made a number of observations that are relevant to the difficulties affecting the TMO’s relationship with its residents throughout the time with which we are concerned. Although the Butler report 178 {TMO00888711/2} paragraph 1.1. 179 {IWS00001462}. 180 {IWS00001462/3}. 181 Black {Day151/55:2}-{Day151/56:5}. 182 Black {Day151/61:16-22}. 183 Black {Day151/58:16-24}. 184 {TMO00888711/2} paragraph 1.4. Chapter 33 The TMO’s relationship with its residents

The Grenfell Tower Inquiry: Phase 2 Report 28 noted that governance, customer service, staff attitudes and a poor repairs service were constant themes of the investigation, it is noteworthy that it considered that the residents’ lack of trust in the TMO lay at the heart of the troubled relationship.185 33.5 RBKC and the TMO responded to the 34 recommendations of the Memoli report and their responses were included in appendix 2 to the Butler report.186 In the light of how the relationship between the TMO and the Grenfell community evolved in the years between 2010 and 2017, the following recommendations and responses are particularly relevant: a. In response to the recommendation that there be a process of mediation or conciliation to rebuild relationships with residents of the TMO, RBKC replied that the approach to resident consultation was under review and that it would consider the results.187 b. In response to the recommendation that TMO staff should take a more active approach and that the TMO’s contractors should share information with residents about prospective work schedules, planned maintenance and emergency works on estates, the response was that the TMO had recently published a five-year capital works programme to residents,188 one purpose of which was to give leaseholders a chance to plan for their share of the cost.189 c. In response to the recommendation that the TMO should be conscious of the diversity of its residents, the response was that it had devised an equality and diversity action plan which was intended to inform all aspects of service improvement plans.190 Although Robert Black told us that he thought that the plan actively identified those with mental or physical disabilities or disadvantages, he did not appear to know whether in fact it did so.191 d. In response to the recommendation that RBKC and the TMO should re-examine their relationship with each other to ensure openness, transparency and trust and to address an historic “them and us” culture,192 it was said that the problem had been resolved by changes at executive level within RBKC and the TMO. Robert Black explained that it had involved increasing engagement between various people in RBKC and the TMO, as well as other organisational changes within the TMO.193 e. In response to the recommendation that RBKC should be more robust in making sure that the TMO’s technical services were capable of delivering an effective major works programme and cyclical repairs,194 RBKC and the TMO said that the TMO had arrangements in place for managing contracts effectively. Laura Johnson told us that Robert Black acted on that recommendation before the Grenfell Tower refurbishment project began.195 185 {TMO00888711/5-6} paragraphs 4.2 and 4.4. 186 {TMO00894426}. 187 {TMO00894426/2}. 188 {TMO00894426/3}. 189 Black {Day151/67:14}-{Day151/68:10}. 190 {TMO00894426/3}. 191 Black {Day151/70:16-24}. 192 {TMO00894426/4}. 193 Black {Day151/71:3}-{Day151/73:15}. 194 {IWS00001462/4}. 195 Johnson {Day128/190:1-17}.

Part 4 | Chapter 33: The TMO’s relationship with its residents 29 33.6 Those recommendations are striking, both in their prescience and as a measure of the TMO’s failure thereafter. They could just as well have been contained in this report, given what we have found. It says much about the TMO’s character as an organisation that, despite those penetrating reports, eight years later it showed little sign of any change and appeared to have learnt nothing about how to treat, or relate to, its residents. Complaints procedures and management systems from 2009 33.7 The TMO had a complaints policy that set out the procedure to be followed when a resident made a formal complaint.196 It was intended to be reviewed every three years and was communicated to residents through leaflets, posters in the housing offices and on the TMO’s website.197 In the event, however, the policy published in 2010 was reviewed only in 2015, when it was revised by broadening the definition of a complaint and by the introduction of a procedural hierarchy for different forms of communication from residents.198 33.8 Yvonne Birch was responsible for managing the complaints procedure from 2012. She received reports from Janet Seward, the TMO’s policy and improvement manager, who oversaw the administration of the complaints team’s work.199 Residents’ Associations 33.9 Between 2010 and 2017, there were, at various times, four groups and associations representing the residents of Grenfell Tower. They were the Lancaster West Residents’ Association, the Grenfell Action Group, the Grenfell Tower Leaseholders’ Association and the Grenfell Tower Compact. Lancaster West Residents’ Association 33.10 The Lancaster West Residents’ Association was founded in 1977.200 Before 2015, it was a vehicle for raising residents’ concerns with the TMO and providing support to members of the community more generally.201 33.11 In September 2015, the TMO called a meeting of the Association which led to the formation of a new committee and a new constitution.202 The aim was to strengthen the Association, increase active participation in its work and provide a more cohesive community by putting on social events and activities.203 33.12 Over the next few years, although the Association appears to have had some communication with residents’ groups associated with Grenfell Tower, it had little involvement in the disputes that later arose between them and the TMO. 196 An earlier version dated May 2010 {TMO00831399} and a revised version dated July 2015 {TMO00879692}. 197 Birch {TMO00879690/2} page 2, paragraphs 8- 9. 198 {TMO10026197/2}. 199 Birch {TMO00879690/1} page 1, paragraph 5. 200 Burke {IWS00001544/2} page 2, paragraph 9. 201 Richer {IWS00002345/2-3} pages 2-3, paragraph 9. 202 {MET00049167}. 203 Blanchflower {IWS00002072/4} page 4, paragraph 12.

The Grenfell Tower Inquiry: Phase 2 Report 30 Grenfell Tower Leaseholders’ Association 33.13 The Grenfell Tower Leaseholders’ Association was founded by Shahid Ahmed in 2010204 to give Grenfell Tower’s leaseholders one voice.205 By 2010, the leaseholders believed that the heating system was poor and that the building in general was poorly maintained. Mr Ahmed used the Leaseholders’ Association to try to improve the management of the building.206 33.14 The constitution of the Leaseholders’ Association provided that its aims were to look after the leaseholders’ interests and to work with RBKC and others to do so.207 The Association had 12 members. Mr Ahmed was the chairman and Tunde Awoderu the vice-chairman. Keith Mott was secretary and treasurer.208 33.15 Mr Ahmed said that he had done almost all the work for the Association after Mr Mott moved away in 2013. Mr Ahmed was worried that raising concerns would lead to reprisals from the TMO, and even the forfeiture of his lease. For that reason, although letters and emails were drafted by Mr Ahmed, they were signed in Tunde Awoderu’s name with his permission.209 Although Mr Awoderu was a leaseholder, he did not live in the tower. He rented his flat to tenants and so, presumably, was thought to be less exposed to any risk of reprisal. 33.16 The Leaseholders’ Association held meetings from time to time to which all members were invited. At around the time proposals for the refurbishment were being made there were more frequent meetings which all members attended. 33.17 When problems arose, Mr Ahmed sent emails directly to individuals at RBKC or the TMO; he did not make use of the complaints procedure, in which he said he had no faith.210 He frequently sent emails first to the local ward councillors and often to Councillor Judith Blakeman. He would also copy his correspondence to many, if not all, of the other councillors and officers of RBKC and the TMO. 33.18 Although the concerns of the Leaseholders’ Association were initially directed to the reasonableness of the service charge and the quality of services, over time they developed to encompass a broad range of matters affecting the tower, one of which was fire safety. On 30 April 2010, there was a fire on floor 6 of the tower, as a result of which smoke leaked from the smoke ventilation system into the lobbies on a number of floors, in some cases a long way from the seat of the fire.211 After that, some residents complained about the efficiency of the smoke ventilation system212 and Mr Ahmed raised concerns about the TMO’s attitude to fire safety generally.213 He said he had never received a proper response from the TMO despite repeating his concerns for several years after the fire.214 Mr Ahmed said that he had felt that the TMO had misrepresented the seriousness of the fire by, among other things, understating the number of people who had been injured, among whom had been his wife.215 204 Ahmed {IWS00001335/4} page 4, paragraph 13. 205 Ahmed {IWS00001335/4} page 4, paragraph 13. 206 Ahmed {IWS00001335/4} page 4, paragraph 13. 207 {IWS00001386}. 208 Ahmed {IWS00001335/4-5} pages 4-5, paragraph 13. 209 Ahmed {IWS00001335/5} page 5, paragraph 14. 210 Ahmed {IWS00001335/6-7} pages 6-7, paragraph 16. 211 {TMO00847309/1}. 212 Blakeman {RBK00054461/15} page 15, paragraph 76. 213 Burton {IWS00001661/2} page 2, paragraph 8. 214 Ahmed {IWS00002369/3} page 3, paragraph 8. 215 Ahmed {IWS00002369/4} page 4, paragraph 10 c.

Part 4 | Chapter 33: The TMO’s relationship with its residents 31 Grenfell Action Group 33.19 Grenfell Action Group was set up in 2010 by Edward Daffarn and Francis O’Connor, both of whom lived in the tower.216 Mr Daffarn said that he founded the group by putting up a poster in the tower in June 2010.217 He later met Francis O’Connor and Teresa Miles, whose husband, Keith Miles, was the chair of the Lancaster West Residents’ Association. Mr Daffarn told us that the Grenfell Action Group had four members: Francis O’Connor, Teresa Miles, Peter Martindale and himself.218 Rob Regan had also possibly been a member.219 33.20 According to Mr Daffarn, the Group was formed because of dissatisfaction with the Lancaster West Residents’ Association and the moribund Estate Management Board.220 (The Estate Management Board had been created in or about 1993221 and was the precursor of the TMO, to which it later delegated most of its functions.222 In 2010, RBKC became concerned about its effectiveness and its ability properly to oversee the TMO. Eventually, in 2014 or thereabouts, the Estate Management Board ceased to function.)223 Mr Daffarn said that the Group intended to speak on behalf of all Lancaster West residents whose lives were to be affected by the KALC project.224 Indeed, the first poster that Mr Daffarn put up in 2010 concerned information that residents had received from Councillor Blakeman about the KALC project.225 33.21 From 2012 onwards, both Mr O’Connor and Mr Daffarn tried to obtain recognition by both RBKC and the TMO of a residents’ association called “Grenfell Action Group”. In September 2012, Mr Daffarn applied successfully to RBKC for the Group to be added to its list of recognised tenants’ and residents’ associations.226 Attempts were also made to register the Group as a residents’ association with the TMO, but the TMO refused to give it official recognition. In August 2012, Edward Daffarn told Janet Edwards of the TMO that the Group was in the process of being registered with RBKC as a residents’ association and he asked her for the form to apply for similar recognition by the TMO.227 For some reason it was not forthcoming. 33.22 On 20 August 2012, there was a meeting between Mr Daffarn, Janet Edwards and Teresa Miles,228 at which the TMO refused to recognise the Group. Following the meeting, Mr Daffarn asked the TMO to give written reasons for its decision. In reply Ms Edwards told him that a residents’ association already existed on the Lancaster West Estate and that the TMO could not recognise another one. She then suggested that Grenfell Action Group consider becoming a sub-group of the Lancaster West Residents’ Association. Ms Edwards told him that she had sought advice from the Tenancy Participation Advisory Service, which discouraged landlords from supporting and recognising two residents’ associations in relation to the same estate because of the risk of conflict.229 216 Daffarn {IWS00000169/7} page 7, paragraph 18. 217 Daffarn {Day118/12:13-20}. 218 Daffarn {Day118/12:1-6}. 219 Daffarn {Day118/12:3-6}. 220 Daffarn {IWS00002109/49} page 49, paragraph 124. 221 Caliskan {RBK00035166/4} page 4, paragraph 19. 222 Johnson {RBK00033719/23-24} pages 23-24, paragraph 115. 223 Johnson {RBK00033719/24} page 24, paragraphs 116-119. 224 Daffarn {IWS00002109/49} page 49, paragraph 126. 225 Daffarn {Day118/12:13-25}. 226 {IWS00002154}. 227 {TMO00845472}. 228 {TMO00845472}. 229 {TMO00846422}.

The Grenfell Tower Inquiry: Phase 2 Report 32 33.23 On 3 September 2012, Jon Warnock of the Tenancy Participation Advisory Service sent an email to Janet Edwards suggesting that she should seek to find a way to support the Grenfell Action Group and establish a harmonious relationship between it and the Lancaster West Residents’ Association. It was suggested that the TMO consider a tripartite agreement between the two of them and the TMO which set out their respective roles and responsibilities. However, on 8 October 2012 Yvonne Birch confirmed that, having considered that advice, the TMO still would not recognise the Grenfell Action Group.230 Her principal reason for doing so was that the suggested agreement would require a dispute resolution process which she considered to be unworkable. In an email of 23 October 2012, Yvonne Birch repeated the objection that the Group could not be recognised because there was already a recognised residents’ association for the estate as well as an elected estate management board which the TMO had a duty to involve in the estate’s management.231 33.24 In late June 2012, Mr Daffarn and Francis O’Connor began publishing the Grenfell Action Group blog. Mr Daffarn said that it was intended to publicise issues that had not been picked up by the media and to document what was happening to the community.232 He told us that at the start he felt that the blog was a means of communicating directly with the TMO, rather than writing to it or using the established processes, and that it gave the community on the Lancaster West estate a voice to express its views about the effect on it of the KALC project.233 He considered it a necessary response to the TMO’s overbearing treatment of the tower’s residents.234 33.25 Another purpose of the blog was to raise concerns about fire safety.235 The posts that were concerned with fire safety are discussed more fully in Chapter 42, but one particular incident discussed in the blog usefully illustrates the nature of the concerns expressed by residents about fire safety and their belief that the TMO paid insufficient regard to the risk of fire in its buildings. 33.26 In 2013, power surges occurred at the tower which caused damage to electrical equipment in some residents’ flats. The Grenfell Action Group and the Leaseholders’ Association were concerned about the incident and communicated their concerns to the TMO by emails and in a petition.236 They were also the subject of a blog post in September 2013,237 the thrust of which was that the TMO had played down the seriousness of the surges. Edward Daffarn told us that the residents had asked RBKC’s Housing and Property Scrutiny Committee to consider the problems surrounding the power surges, but he felt that the matter had been covered over,238 with the result that the residents lost trust in the TMO’s ability to take appropriate action in respect of fire safety.239 Councillor Blakeman told a meeting of the Scrutiny Committee in July 2013 that the TMO would find it difficult to regain residents’ trust, since many believed that the TMO had failed to take the power surges seriously.240 230 {TMO00845579}. 231 {TMO00845856}. 232 Daffarn {IWS00000169/7} page 7, paragraph 18. 233 Daffarn {Day118/150:8}-{Day118/151:2}. 234 Daffarn {Day118/26:1-4}. 235 Daffarn {IWS00000169/8} page 8, paragraph 20. 236 Ahmed {IWS00002369/15} page 15, paragraphs 52 and 54. 237 {IWS00002180}. 238 Edward Daffarn’s formal complaint {TMO00838788}. 239 Daffarn {Day118/118:23}-{Day118/120:3}. 240 {TMOH00004598/3}.

Part 4 | Chapter 33: The TMO’s relationship with its residents 33 The Grenfell Compact 33.27 The Grenfell Compact was a residents’ group set up during the refurbishment of Grenfell Tower specifically to represent residents’ interests. The efforts taken by the residents to obtain recognition are worthy of being recorded as an illustration of the difficulties they faced. 33.28 Mr Daffarn explained that the Grenfell Action Group’s early efforts to form an association for the broader community changed over time to an organisation designed specifically for the residents of Grenfell Tower. When the refurbishment works were under way there were around 100 people in the tower who had expressed support for such an initiative. There was a perception that the Lancaster West Residents’ Association was ineffective241 and Mr Daffarn hoped that an association specifically for residents of the tower would counteract the TMO’s perception that the Grenfell Action Group was a small, disgruntled minority.242 33.29 On 22 January 2014, Mr Daffarn sent an email to Claire Williams which he copied to the Leaseholders’ Association and other residents. He asked for recognition, funds and support so that a Grenfell Tower residents’ group could be set up to help tenants during the refurbishment. He explained that such a group would allow leaseholders and tenants to make their views known and ensure that the TMO carried out the refurbishment in co-operation with the residents rather than simply imposing it on them. Mr Daffarn said he had spoken to both the Lancaster West Residents’ Association and the Leaseholders’ Association, both of which supported the request.243 The TMO’s position, however, was unchanged. It declined to recognise the proposed group because a residents’ association covering the area already existed.244 33.30 On 10 September 2014, Mr Daffarn sent an email to Fola Kafidiya, the TMO’s Head of Governance, to complain that residents of Grenfell Tower were being denied the opportunity to form a representative group to speak on their behalf about matters affecting the refurbishment of the tower. He said that the Lancaster West Residents’ Association was moribund and that residents were therefore effectively unrepresented.245 33.31 On 17 September 2014, Janet Edwards made it clear that the TMO did not object to the tenants and leaseholders of Grenfell Tower forming a group for the purposes of consultation on matters relating to the building work. She also confirmed that the group would be consulted by the TMO on matters relating to the refurbishment.246 That ought to have provided an opportunity for matters to be put on a better footing. 33.32 On 17 March 2015, Mr Daffarn and others organised a meeting of Grenfell Tower residents which was attended by over 100 people from more than 55 households.247 On 26 March 2015, residents from about 20 households held another meeting and agreed to form a group which they called Grenfell Community Unite.248 They agreed to ask the TMO and Rydon to meet them to discuss their concerns. 241 Daffarn {IWS00002109/50-51} pages 50-51, paragraph 131. 242 Daffarn {IWS00002109/51} page 51, paragraph 134. 243 {TMO00845842}. 244 {TMO00832280}. 245 {TMOH00004881/3}. 246 {TMOH00004881/1}. 247 Collins {IWS00002334/6} page 6, paragraph 27. 248 GAG Blog, “A collective voice for residents as ‘Grenfell Community Unite’ is formed!” {IWS00002239}.

The Grenfell Tower Inquiry: Phase 2 Report 34 33.33 The meetings on 17 March and 26 March 2015 were both reported on the Grenfell Action Group blog in forthright terms.249 On 1 April 2015, Peter Maddison sent an email to Fola Kafidiya at RBKC, saying that Mr Daffarn was continuing to agitate, attaching the blog posts and asking Ms Kafidiya to advise at what point his comments would become libellous. Mr Maddison noted that there had been no direct contact from the group and said that the TMO would continue its approach of concentrating on consulting residents individually.250 33.34 On 6 April 2015, David Collins asked Claire Williams to arrange a meeting between the group and the TMO, Rydon, Studio E and Max Fordham.251 He also asked for confirmation that the TMO would acknowledge Grenfell Community Unite as a residents’ group. 33.35 Before responding, Claire Williams consulted other TMO officers.252 In her response, she deflected the request and suggested that discussion with individual households was more appropriate and that a survey had indicated that residents preferred to receive information by letters, newsletters and notices rather than at public meetings.253 Siobhan Rumble suggested that the TMO should agree to meet Mr Daffarn and Mr Collins, but make it clear that it would not tolerate abusive language or threatening behaviour.254 33.36 On 13 April 2015, Claire Williams sent David Collins’ request for a meeting to Peter Maddison with a draft response declining to meet residents.255 She noted that she had spoken to Robert Black and explained that TMO people preferred not to meet Grenfell Community Unite, since such a meeting would provide a platform for Mr Daffarn.256 In our view, that internal message is revealing. It suggests that one reason for the TMO’s reluctance to recognise the Grenfell Action Group or any new group to speak for residents about the refurbishment was because of a grave mistrust of Mr Daffarn. 33.37 Edward Daffarn is an intelligent, articulate and motivated individual, who was an impressive witness. Whether he ever spoke for the wider community is debatable and his language and approach in his dealings with the TMO caused resentment among its staff. One thing is clear, however: those in the TMO who were responsible for managing the refurbishment were nervous of him and allowed him to become a barrier to proper communication with the rest of the community. 33.38 Councillor Blakeman also took an interest in the request for a meeting with residents and asked the TMO to copy her and other ward councillors into the response.257 After receiving Peter Maddison’s comments, Claire Williams responded to David Collins and Edward Daffarn on 17 April 2015 refusing their request to recognise the Group or organise a meeting with residents.258 She referred to the survey citing the residents’ preference to be consulted by letter, but she offered Mr Daffarn an opportunity to meet Rydon to discuss the work in his flat. 249 GAG Blog “Minutes from the Grenfell Tower Emergency Residents Meeting (17/03/15)” {IWS00002209}; GAG Blog “A collective voice for residents as ‘Grenfell Community Unite’ is formed!” {IWS00002239}. 250 Email from Peter Maddison to Fola Kafidiya dated 1 April 2015 {TMO00845965}. 251 {TMO10043300}. 252 Email from Claire Williams regarding ‘’DRAFT Grenfell Community - meeting with TMO/Rydon’’ dated 8 April 2015 {TMO10043313} and Draft response to David Collins {TMO10043314}. 253 Response to David Collins {TMO00846124}. 254 Email from Siobhan Rumble to Claire Williams dated 8 April 2015 {TMO10043321}. 255 {TMO00846102}. 256 {TMO00846102}. 257 {TMO00845970}. 258 {TMO00846124}; {TMO00846121}.

Part 4 | Chapter 33: The TMO’s relationship with its residents 35 33.39 Following the involvement of Councillor Blakeman, on 11 July 2015, representatives of the TMO and Rydon met residents in Flat 145259 and on 17 July 2015 there was a meeting with the local Member of Parliament, Victoria Borwick, at which the TMO agreed to her suggestion that it should recognise the Grenfell Compact as a representative group for the purposes of the refurbishment.260 33.40 It had taken the best part of three years and the intervention of the local MP to get to that point, but by July 2015 the refurbishment was only a year from completion. The residents of Grenfell Tower had never before that been given any collective say in relation to it, as required by the agreement between the TMO and RBKC. 33.41 The Grenfell Compact was formally constituted on 23 September 2015.261 An information sheet sent by the TMO to residents following its formation explained that a residents’ compact was an agreement between representatives of a block or estate and the TMO which sets out how residents will be involved in decisions affecting their homes.262 It also stated that the compact was a means of influencing decision-making.263 The signatories to the compact were William Thompson, Edward Daffarn, David Collins, Hanan Wahabi and Marcio Gomes.264 Consultation with residents 33.42 We can now examine the extent to which the TMO consulted residents during the course of the refurbishment, its response to residents’ complaints and its broader attitude to its relationship with the residents of the buildings it managed. Consultation between the TMO and residents: 2011 to 2014 33.43 In September 2011, Edward Daffarn had complained to Laura Johnson that the residents of Grenfell Tower had not been consulted about the selection of Studio E as architect for the KALC project. He had felt that the KALC presentation on 13 September 2011, which had been attended by an architect from Studio E, had been a charade because Studio E had already been appointed without consulting residents.265 33.44 At a KALC forum meeting on 28 March 2012, Mr Daffarn asked why Studio E had been selected to undertake the initial work on the refurbishment of Grenfell Tower. He was told by Councillor Coleridge that it was difficult to have two architects undertaking separate projects on a single site and that there was a need for synergy between the KALC and Grenfell Tower projects.266 33.45 At a meeting of the TMO’s Lancaster West Estate Management Board on 15 May 2012, Edward Daffarn asked if Studio E had experience of tower blocks and, if not, why it had been retained for the refurbishment.267 He never received an answer to that question.268 259 Daffarn {IWS00002109/57} page 57, paragraph 153. 260 {IWS00002194}; Daffarn {IWS00002109/58-59} pages 58-59, paragraphs 156-158; {TMO00846146}. 261 {TMO00846191}. 262 {TMO10009741}. 263 {TMO10009741}. 264 {IWS00001711}. 265 {RBK00030110}. 266 {LBI00000129/3}. 267 {TMO00848807/4}. 268 Daffarn {Day118/21:24}-{Day118/22:1}. See also Part 6 Chapter 66. The Tenant Management Organisation

The Grenfell Tower Inquiry: Phase 2 Report 36 33.46 Most TMO officers knew little or nothing about schedule 3 to the Modular Management Agreement, which contained detailed provisions about resident engagement in respect of refurbishments such as that of Grenfell Tower. Nevertheless, the TMO did make efforts to consult the residents of Grenfell Tower about its refurbishment. Consultation began in February 2012 and covered numerous topics, including cladding, heating, gas and the windows.269 It took a variety of forms, including drop-in sessions, newsletters, telephone communications270 and two major questionnaires in February and May 2012.271 The TMO consultation strategy was set out in the Grenfell Tower engagement statement dated 22 August 2012,272 which contained the responses to the wide range of questions that the residents had been asked in the questionnaires. One of the questions in the May 2012 questionnaire was “Do you wish to be involved in the development proposals for Grenfell Tower?” The responses were “Yes” 13 and “No” 1, but despite that request for involvement, no proposals were developed. 33.47 In July 2012, the TMO’s project team for the refurbishment called for a resident focus group to be established by the TMO,273 but a group was never established. There is also no evidence that the residents, who in May 2012 had indicated that they wanted to be involved in the development proposals for the tower,274 were ever invited to join a focus group.275 Indeed the creation of a residents’ focus group was not part of the consultation strategy. 33.48 In December 2013, the TMO decided that it would no longer hold public consultations with residents about Grenfell Tower. Councillor Blakeman told Councillor Feilding-Mellen that Edward Daffarn had become too disruptive to continue holding public consultations.276 Peter Maddison agreed that that had been one of the reasons, but said that poor attendance had been another.277 At a drop-in session on 12 December 2013, a survey was undertaken and residents were asked to indicate how they would prefer the TMO to consult them.278 Most people did not want formal meetings. 33.49 The decision to discontinue public meetings was regrettable. Mr Daffarn perhaps should have stood back and questioned whether his preferred methods were the only, or even the most effective, way in which the voice of the community could be heard. A more conciliatory approach on his part might have been reciprocated. On the other hand, for its part the TMO ought to have reacted less defensively and, instead of retreating, should have made a greater effort to engage with Mr Daffarn, both on a personal and public level. It allowed its fear and personal mistrust of him and his methods to influence the way in which it engaged with the residents more generally. As custodian of the safety and security of its residents, it must take responsibility for the breakdown in trust. 269 Dunkerton {TMO00000885/11} page 11, paragraph 60. 270 Dunkerton {Day51/94:11-17}. 271 Dunkerton {Day51/95:19-25}. 272 {TMO10001401/4}. 273 {ART00000169/4}. 274 {TMO10001401/10}. 275 See, for example, Anderson {Day51/99:16}-{Day51/100:2}. 276 {RBK00003386}. 277 Maddison {Day124/22:1-15}. 278 Williams {TMO00840364/30} page 30, paragraph 170.

Part 4 | Chapter 33: The TMO’s relationship with its residents 37 33.50 Some 65 households were recorded as attending the drop-in on 12 December 2013, at which people were asked to identify their preferred methods of consultation and 55 forms were returned.279 Six methods to choose from were listed but they did not include consultation through a residents’ group. They were all directed at giving information to residents, not hearing from them. 33.51 The residents of Grenfell Tower were consulted in respect of the various cladding options for the tower. In August 2012, the preference was said to be for a zinc cladding system280 but the decision eventually conveyed to residents in the newsletter circulated in October 2014 was that RBKC had approved a smoke silver metallic (grey) colour for the cladding.281 Claire Williams said that she did not think the residents had ever been told that there had been a change from zinc to aluminium composite material or the reasons for the change. She thought that had been because the decision had not been made until after the project had begun.282 The petition 33.52 In December 2015, at Councillor Blakeman’s suggestion,283 some 60 residents of Grenfell Tower signed a petition to the Housing and Property Scrutiny Committee of RBKC asserting that residents’ views had been ignored or minimised, that their day-to-day concerns had been belittled and brushed aside and that they had been forced to endure intolerable living conditions while the work on the tower was going on.284 It had been prompted by the frustration felt by residents that their concerns about the refurbishment had been ignored by the TMO.285 They asked the committee to consider their views and experiences and include them in its report. 33.53 The petition was presented by Councillor Blakeman to RBKC on 2 December 2015 and was then referred to Councillor Marshall and the Housing and Property Scrutiny Committee for its consideration.286 On the same day, RBKC and the TMO held a joint management meeting, at which Peter Maddison is recorded as having said that Councillor Blakeman and Mr Daffarn were a negative force at Grenfell and that residents were going to them with problems rather than the TMO.287 The minutes also record Amanda Johnson as having said that she felt that Councillor Blakeman had a conflict of interest since she was a TMO board member appointed by the council.288 It is striking that senior officers of the TMO and RBKC appear to have been more interested in silencing Councillor Blakeman than in resolving the residents’ grievances. 33.54 In response to the petition, the TMO’s board suggested that it conduct an internal review of the refurbishment works. Laura Johnson supported the proposal while emphasising that RBKC had no desire to be involved in it. She said she would relay the proposal to Councillor Mackover so that it was supported by the Scrutiny Committee.289 Clearly, the TMO hoped by that means to avoid external scrutiny of the way in which the refurbishment had been conducted. 279 {TMO00828516}. 280 {TMO00838191}; {TMO10049897/3}. 281 {TMO00837599/2}. 282 Williams {Day121/90:3-25}. 283 Blakeman {RBK00054461/17} page 17, paragraph 91. 284 {RBK00000110}. 285 Blakeman {RBK00054461/17} paragraph 91. 286 {RBK00033519}. 287 {TMO10011523/2}. 288 {TMO10011523/2-3}. 289 {TMO00852704/3}.

The Grenfell Tower Inquiry: Phase 2 Report 38 33.55 A meeting of the Scrutiny Committee was held on 6 January 2016.290 Edward Daffarn was given an opportunity to address the committee and the request set out in the petition for a review of the TMO’s management of the refurbishment was then discussed. Councillors Mackover, Berrill-Cox, Blakeman and Press proposed that a working group should be set up to investigate the management of the refurbishment and Councillors Blakeman and Press said that the reviewers should be independent of the TMO.291 However, the Chairman, Councillor Marshall, was reluctant to establish a working group at that time.292 He suggested that the establishment of a working group should await the conclusion of existing working groups as well as the TMO’s suggested review.293 33.56 Between January and March 2016 the TMO’s board carried out a review of the refurbishment. Robert Black did not know why an independent review had not been suggested rather than one led by the board, but it was never envisaged that the review would fully address the request made in the residents’ petition for an independent investigation of the TMO’s management of the refurbishment, as opposed to responding to the particular complaints that had been made.294 33.57 In January 2016, members of the TMO board were invited to express an interest in joining the review group. No residents of Grenfell Tower joined the group and there is no evidence that any of them were even invited to do so. At an initial meeting in February 2016 it was decided that the review would include, among other things, consultation and engagement with residents and responses to complaints. In March 2016, there was a presentation and a tour of Grenfell Tower and the review group was given a pack of information covering each area of the investigation.295 33.58 Although the review did not collect residents’ views about how the refurbishment had been carried out, the TMO was required under the Modular Management Agreement to gather them after the work had been completed.296 Robert Black accepted that, although the plan had been to include their opinions as part of the review,297 he might have overlooked the need to do so.298 Whether that was deliberate or not, ignoring residents’ views was entirely consistent with the TMO’s approach to engagement with its residents from at least February 2012, and indeed, on the basis of Maria Memoli’s report, from far earlier than that. The working group’s report 33.59 The working group’s review culminated in a report dated 31 March 2016.299 The group found that engagement with and consultation of residents had been comprehensive and had used various methods to obtain their views. It recommended that in future details of those attending public meetings should be recorded, that minutes should be taken and that resident profile surveys should be repeated every six months when projects lasted for longer than 12 months.300 290 {RBK00032130}. 291 Blakeman {Day135/135:1-14}. 292 {RBK00032130/5}; Blakeman {Day135/136:1-5}. 293 {RBK00032130/5}. 294 Black {Day151/127:18-19}. 295 {RBK00003513/2}. 296 Tenant Management Organisation Modular Management Agreement Volume 2 {RBK00019006/177} Clause 22.1. 297 Black {Day151/146:19-24}. 298 Black {Day151/148:14-21}. 299 {RBK00003513}. 300 {RBK00003513/3} section 3.

Part 4 | Chapter 33: The TMO’s relationship with its residents 39 33.60 In response to the allegations that the contractor and the TMO had used threats, lies and intimidation, the group noted that the only detailed information was a complaint that had not been upheld at Stage 3 of the complaints procedure. A new procedure was proposed for gaining access to flats to carry out work internally which could be sent to unco‑operative residents in future to avoid any misunderstanding.301 33.61 The group reviewed seven formal complaints and other enquiries received from ward councillors and was satisfied that the TMO had responded adequately to them.302 33.62 The report’s conclusion acknowledged the disruption and inconvenience caused by the works over an extended period of time,303 but commended Rydon, Peter Maddison and his team on completing the refurbishment works. 33.63 In our view, the review was flawed in its origins, its process and its conclusions. Given the history of the matter and the lack of trust between the residents of Grenfell Tower and the TMO, the board should have realised that only an independent review of the management of the project with particular reference to the residents’ complaints could fairly satisfy the requirements of the moment. As it was, the review was superficial and the group conducting it failed to carry out its investigation in a sufficiently thorough and robust manner. The report lacked balance. It gave the impression that very little, if anything, had gone wrong and that there was no substance in any of the complaints made in the petition. The Scrutiny Committee in its turn failed in its task of ensuring that the relationship between the TMO and its residents was rigorously investigated. 33.64 On 4 July 2016, David Collins wrote to Councillor Feilding-Mellen on behalf of Grenfell Compact to express his view that the report failed to address how the refurbishment work and resident consultation had been carried out by the TMO.304 He thought that the report was not sufficiently critical about the lessons to be learned from the refurbishment and he set out 15 recommendations for the conduct of future refurbishment works. 33.65 Councillor Feilding-Mellen responded on 7 July 2016. He told Mr Collins that, although he was happy to review his recommendations, he considered that many of them had already been addressed in the TMO board’s review. He went on to say that he would not advise officers to investigate new allegations which were not submitted in writing and supported by evidence.305 Councillor Feilding-Mellen met David Collins later in July 2016,306 but their meeting took matters little further forward. 33.66 On 6 September 2016, David Collins wrote to Councillor Feilding-Mellen again to thank him for attending the meeting in July and to ask him whether he was minded to reconsider RBKC’s approach to regeneration projects or the TMO’s operations.307 Councillor Feilding‑Mellen sent the email on to Laura Johnson and asked her if she could think of any “small concession” he could offer David Collins. Although he told us that only a small concession was needed because the differences between them were not great,308 what he really meant, we think, was that he was looking for something trivial he could give away. 301 {RBK00003513/4} section 5. 302 {RBK00003513/4} section 6. 303 {RBK00032438}. 304 {RBK00003501/1-2}. 305 {RBK00003466}. See also {RBK00000136} for further emails in the same chain. 306 {RBK00030865/2}. 307 {RBK00030865/2}. 308 Feilding-Mellen {Day132/95:14}-{Day132/96:7}.

The Grenfell Tower Inquiry: Phase 2 Report 40 Conclusion 33.67 The overwhelming impression we have gained from the evidence, both that of the witnesses and that contained in the contemporaneous documents, is that between 2011 and 2017 relations between the TMO and many of the residents of the tower were increasingly characterised by distrust, dislike, personal antagonism and anger. Some, perhaps many, occupants of Grenfell Tower regarded the TMO as an uncaring and bullying overlord, which belittled and marginalised them, regarded them as a nuisance or worse, and simply failed to take their concerns seriously. For its part, the TMO regarded some of the residents as militant troublemakers led on by a handful of vocal activists, principally Edward Daffarn, whose style they found offensive. The result was a toxic atmosphere fuelled by mistrust on both sides. 33.68 In the end, however, responsibility for the maintenance of the relationship between the TMO and the Grenfell community fell not on the members of that community, who had a right to be treated with respect, but on the TMO as a public body exercising control over the building which contained their homes. The TMO lost sight of the fact that the residents were people who depended on it for a safe and decent home and the privacy and dignity that a home should provide. That dependence created an unequal relationship and a corresponding need for the TMO to ensure that, whatever the difficulties, the residents were treated with understanding and respect. We regret to say the TMO failed to recognise that need and therefore failed to take the steps necessary to ensure that it was met. 33.69 However irritating and inconvenient it may at times have found the complaints and demands of some of the residents of Grenfell Tower, for the TMO to have allowed the relationship to deteriorate to such an extent reflects a serious failure on its part to observe its basic responsibilities.

41 Part 5 The management of fire safety at Grenfell Tower

42

43 34.1 One of the TMO’s most important functions as manager of Grenfell Tower was to take appropriate steps in relation to fire safety. In this Part of our report we examine the nature of the obligations imposed by law on those who manage residential buildings and the steps taken by the TMO to comply with them in the years leading up to the fire. 34.2 The Fire Safety Order prescribes the duties imposed on the person who has control of premises such as Grenfell Tower, known as the “responsible person”, and on every other person who has, to any extent, control of the premises so far as the requirements relate to matters within his control. In the case of Grenfell Tower it was accepted that both the TMO and RBKC were subject to those duties but for practical purposes we decided to concentrate on the TMO and examine the way in which it went about discharging its duties and the extent to which it did so effectively. 34.3 In this Part we have therefore considered the systems adopted by the TMO to discharge its obligations, its discussions with the LFB as the enforcing authority, the steps it took to identify the risks to which the properties it managed were subject and its response to the findings that emerged. RBKC had an important part to play because it was responsible for overseeing all the TMO’s arrangements for protecting health and safety. We have therefore also examined the extent to which RBKC fulfilled its responsibility in that respect. 34.4 Fire risk assessments play an important part in ensuring fire safety. We therefore examined the steps taken by the TMO to obtain suitable and sufficient fire risk assessments as required by the Fire Safety Order and the way in which it responded to them. 34.5 Maintenance of fire protections within buildings are an important element in managing fire safety effectively. One of the most important, but often least regarded, protections against the spread of fire within a residential building is the provision and effective maintenance of fire doors at the entrance to individual flats with working self-closing devices. We have therefore examined the steps taken by the TMO to ensure that the flats in Grenfell Tower were fitted with modern fire doors and the measures put in place to ensure regular inspection and maintenance of the doors and self-closing devices. 34.6 When Grenfell Tower was built it included a smoke ventilation system designed to operate in the event of a fire to clear smoke from the lobby of the floor on which the flat affected by the fire was situated. Such systems require regular maintenance as part of managing fire protection, so we examined the extent to which the TMO had maintained the system and whether it was capable of operating effectively. Regrettably, by the time of the refurbishment it was not in working order and could not be renovated. We describe how that situation had come about and, in the next Part, the steps that were taken to replace it as part of the refurbishment. 34.7 Finally, we identify certain other matters relating to fire safety that we consider to be important to comment on, including emergency planning, the provision of fire safety information in public parts of the building and arrangements for safeguarding vulnerable residents. Chapter 34 Introduction to Part 5

44 The Grenfell Tower Inquiry: Phase 2 Report

45 Introduction 35.1 Part of our terms of reference is to investigate the fire prevention and fire safety measures in place at Grenfell Tower on 14 June 2017.309 The starting point for any investigation of that kind is to understand the obligations of those who were in law responsible for fire safety. Article 8 of the Regulatory Reform (Fire Safety) Order 2005 (the Fire Safety Order) imposes on “the responsible person” an obligation to take such general fire precautions as will ensure, so far as is reasonably practicable, that the premises are safe.310 The first question we consider, therefore, is who was, for the purposes of article 8 of the Fire Safety Order, the responsible person in relation to Grenfell Tower. The responsible person 35.2 Under article 3 of the Fire Safety Order, the responsible person in relation to premises that are not a workplace is the person who has control of the premises in connection with the carrying on of an undertaking of some kind or, where the person in control of the premises does not have control in connection with the carrying on of an undertaking of some kind, the owner of the premises. By article 5(2) the responsible person must ensure that any duty imposed by articles 8 to 22 or by regulations made under article 24 is complied with in respect of those premises, so far as the requirements relate to matters within his control. Article 5(3) imposes on anyone other than the responsible person who has control of the premises the same duties as those imposed on the responsible person, so far as they relate to matters within his control. 35.3 In addition to the duty under article 8 to take general fire precautions, the responsible person and anyone to whom article 5(3) applies are subject to certain specific duties. The most relevant are: a. to carry out a suitable and sufficient risk assessment for the purpose of identifying what general fire precautions are necessary;311 b. to make and give effect to appropriate arrangements for the effective planning, organisation, control, monitoring and review of preventive and protective measures;312 c. to ensure, where necessary to safeguard the safety of relevant persons, that the premises are appropriately equipped with fire-fighting equipment and fire detectors and alarms and that any non-automatic fire-fighting equipment is easily accessible, simple to use and indicated by signs;313 d. to take measures for fire-fighting, nominate competent persons to implement them and ensure that their training and the equipment available to them are adequate;314 309 Terms of reference, paragraph (i)(f). 310 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/8} Article 8(1). 311 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/8} Article 9(1). 312 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/9} Article 11(1). 313 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/9} Article 13(1). 314 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/10} Article 13(3). Chapter 35 The Fire Safety Order

The Grenfell Tower Inquiry: Phase 2 Report 46 e. to ensure that routes to emergency exits from premises and the exits themselves are kept clear at all times;315 f. to establish and, where necessary, give effect to appropriate procedures, including fire safety drills, to be followed in the event of serious and imminent danger;316 g. to ensure that the premises are subject to a suitable system of maintenance and are maintained in an efficient state, in efficient working order and in good repair;317 h. to appoint one or more competent persons to assist him in undertaking the necessary preventive and protective measures;318 i. to ensure that his employees are provided with adequate safety training.319 RBKC as the responsible person 35.4 RBKC contended that, between 1 April 2005 (when the Fire Safety Order came into force) and June 2017, the responsible person in relation to Grenfell Tower (outside the period of the refurbishment and excluding the non-residential units) had been the TMO, although it accepted that it had itself fallen within the scope of article 5(3) during that period.320 It argued that under the Modular Management Agreement (the Agreement) it had delegated to the TMO the vast majority of its housing management functions and that the TMO had been responsible for health and safety arrangements (including arrangements relating to fire safety) for the housing stock which it managed on behalf of the council. RBKC’s position was based on the proposition that, as a matter of law, the Fire Safety Order seeks to identify a single responsible person for each premises.321 We do not need to resolve that question, however, because RBKC was either the responsible person in relation to Grenfell Tower or was a person to whom article 5(3) applied, as it recognised in its opening statement, and was therefore subject to the same duties. 35.5 Before the fire, the identity of the responsible person appeared to be uncontroversial. For example, officers of the TMO thought that both bodies were responsible persons322 in relation to Grenfell Tower. Moreover, on 20 February 2012, a joint protocol was agreed between LFEPA and RBKC323 under which RBKC undertook to discharge certain duties under the Fire Safety Order. The correspondence about the joint protocol between Kevin Thompson, Laura Johnson and Janice Wray demonstrates that there was a mutual understanding between the TMO and RBKC that they both had responsibilities under the Fire Safety Order.324 35.6 That understanding was reflected in the TMO’s Fire Safety Strategy of November 2013, which expressly stated that both RBKC and the TMO were to be considered responsible persons for the purposes of the Fire Safety Order.325 There is no evidence that that statement was challenged by anyone. 315 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/10} Article 14(1). 316 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/10} Article 15(a). 317 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/12} Article 17(1). 318 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/12} Article 18(1). 319 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/14} Article 21(1). 320 RBKC Module 1 Opening Statement {RBK00055479/8} paragraph 33. This submission is maintained in RBKC Module 3 Opening Statement {RBK00063631/9} paragraph 31. 321 RBKC Module 3 Opening Statement {RBK00063631/10} paragraph 34. 322 Black {Day149/37:22}-{Day149/38:1}; Wray {TMO00000890/37} page 37, paragraph 166; TMO Fire Safety Strategy November 2013 {TMO00830598/1}. 323 {LFB00032248}. 324 {RBK00001176}. 325 {TMO00830598/1}.

Part 5 | Chapter 35: The Fire Safety Order 47 35.7 On the other hand, Laura Johnson thought that the TMO was the only responsible person in relation to RBKC’s housing stock but she could not explain why and speculated (incorrectly) that the TMO’s responsibility had been set out in the Agreement. She said that, because RBKC took the view that it was not the responsible person, it had not put in place any arrangements to discharge any of the duties of the responsible person under the Fire Safety Order.326 As far as she knew, nobody in RBKC oversaw the TMO’s performance on health and safety matters beyond receiving an annual health and safety report.327 35.8 We found Laura Johnson’s evidence on this point unconvincing. The evidence shows that while she was RBKC’s Director of Housing she took an active interest in matters relating to fire safety. At no time did she say that RBKC was not the responsible person in relation to the housing managed by the TMO. We conclude that, before the fire, Laura Johnson understood that RBKC, together with the TMO, was the responsible person for the premises managed by the TMO. The TMO as the responsible person 35.9 The TMO set out its understanding of the division of responsibilities under the Fire Safety Order in its annual health and safety reports to the TMO Board and to RBKC. As set out in the Annual Health and Safety Report for the year 2009-2010328 it was: a. that operational compliance with the Fire Safety Order had been delegated to the TMO; b. that RBKC was liable for any breach of the Fire Safety Order and subject to enforcement notices or prosecution or both; c. that RBKC would monitor the TMO’s actions on health and safety matters to ensure compliance with relevant statutory responsibilities and adherence to best practice; d. that RBKC’s corporate health and safety adviser and the health and safety adviser for housing, health and adult social care would receive minutes of the meetings of the TMO’s health and safety committee and copies of the TMO’s annual report on health and safety; e. that the TMO’s health and safety adviser would attend RBKC’s six-weekly meetings of its Main Co-ordinating Committee dealing with health and safety matters; and f. that it would notify RBKC of major incidents, accidents, significant near-misses and any current investigations. 35.10 Robert Black understood that RBKC shared the TMO’s understanding of their respective responsibilities.329 He understood that, as a responsible person under the Fire Safety Order, the TMO was responsible for appointing competent people to ensure safety. He understood the distinction, which we explain below, between the responsible person and the competent person under the Fire Safety Order.330 326 Johnson {Day129/57:21-25}. 327 Johnson {Day129/64:16-20}. 328 {TMO00879745/1}. 329 Black {Day149/37:22}-{Day149/38:1}. 330 Black {Day149/38:23-25}.

The Grenfell Tower Inquiry: Phase 2 Report 48 35.11 In mid-2015, Barbara Matthews succeeded Anthony Parkes as the TMO’s Director of Financial Services and ICT. Although she was unaware of the duties imposed on the responsible person,331 she believed that RBKC and the TMO were both responsible persons for the premises owned by RBKC but managed by the TMO.332 She relied on the fact that fire risk assessments and internal audits were carried out to satisfy herself that the TMO was discharging its obligations under the Fire Safety Order.333 She was unaware of RBKC’s arrangements for discharging its own duties as a responsible person under the Fire Safety Order.334 The competent person 35.12 Article 18(1) of the Fire Safety Order requires the responsible person to appoint one or more competent persons to assist him in undertaking the preventive and protective measures. In particular, article 18(3) obliges the responsible person to ensure that the number of competent persons appointed, the time available for them to fulfil their functions and the means at their disposal are adequate having regard to the size of the premises, the risks to which relevant persons are exposed and the distribution of those risks throughout the premises. 35.13 Article 18(5) provides that a person is to be regarded as competent if he has sufficient training and experience or knowledge and other qualities to enable him properly to assist in undertaking the preventive and protective measures. Janice Wray, the TMO’s health and safety manager, was familiar with the concept of the competent person and undertook that role for the TMO.335 Janice Wray’s responsibilities 35.14 Although Ms Wray saw her role as essentially advisory,336 it is plain from the various versions of the TMO’s health and safety policy that it was broader, more substantive and included the following:337 a. providing competent advice on health and safety matters as required by the Management of Health & Safety at Work Regulations; b. formulating health & safety policy and strategy; c. producing health & safety policy, procedures and guidelines and ensuring that they were regularly reviewed and kept up to date; d. providing managers and employees with specialist health and safety advice; e. organising and administering the health & safety committee and communicating with and consulting safety representatives through it; f. identifying the need for health and safety training; g. monitoring, reviewing and auditing compliance with the policy; 331 Matthews {Day147/108:23}-{Day147/109:1}. 332 Matthews {Day147/109:2-9}. 333 Matthews {Day147/110:24}-{Day147/111:2}. 334 Matthews {Day147/112:14-17}. 335 Wray {Day140/43:10-13}. 336 Wray {Day140/7:22-25}. 337 TMO Health and Safety Policy 2012 {TMO10031076/3}. This list was reproduced in the 2016 version of the policy {TMO10024402/3}. The 2010 version of the policy {TMO10031078/3} does not include the references at i and j to the Fire Safety Order.

Part 5 | Chapter 35: The Fire Safety Order 49 h. producing an annual Health & Safety Report for presentation to the TMO board and RBKC; i. advising on compliance with the Fire Safety Order; and j. attending meetings and committees as necessary to provide information on the TMO’s performance in relation to specific areas of health & safety, including compliance with the Fire Safety Order. 35.15 Janice Wray accepted that that was an accurate description of her responsibilities.338 When asked whether she had primary operational responsibility for the TMO’s compliance with the Fire Safety Order, she denied having overall responsibility for it but accepted that she was responsible for overseeing and monitoring the performance by the TMO of its fire safety obligations.339 35.16 Although Janice Wray may have had responsibility for monitoring the performance by the TMO of its obligations in relation to fire safety, from mid-2015 primary operational responsibility lay with Barbara Matthews. An important part of her responsibilities was to monitor the TMO’s health and safety performance at a strategic level,340 which encompassed ensuring the health and safety of all the TMO’s residents, employees and contractors.341 35.17 In his safety management review produced in September 2013 Matt Hodgson342 identified Janice Wray as the competent person at the TMO343 and considered that her qualifications were more than adequate for that role.344 He noted that the TMO Health and Safety Policy named Adrian Bowman, Janice Wray’s assistant, as the competent person and recommended that it be amended to name her.345 35.18 In undertaking the responsibilities of a competent person Janice Wray considered that she had access to a fire safety specialist and, if she needed further advice, was able to ask for it.346 She had regular meetings with the LFB and access to various people to whom she could go for advice.347 She felt that she had had sufficient training, experience and knowledge to carry out the role of competent person for the TMO.348 35.19 Janice Wray did not think that a shortage of funds or other resources had hindered her ability to discharge her responsibilities as the competent person.349 Although she felt that she was often spread very thinly,350 she felt able to discharge her fire safety responsibilities satisfactorily.351 338 Wray {Day140/39:18-22}. 339 Wray {Day140/42:11-25}. 340 Matthews {TMO10049987/2} page 2, paragraph 7. 341 Matthews {Day147/103:21-25}. 342 An independent consultant who was instructed by the TMO to prepare a safety management review in 2013 {RBK00055531}. 343 {RBK00055531/23}. 344 {RBK00055531/23}. 345 {RBK00055531/23-24}. 346 Wray {Day140/44:5-10}. 347 Wray {Day140/44:15-18}. 348 Wray {Day140/45:9-12}. 349 Wray {Day140/47:16-25}. 350 Wray {Day140/48:10-20}. 351 Wray {Day140/49:23}-{Day140/50:13}.

The Grenfell Tower Inquiry: Phase 2 Report 50

51 Health and safety policies 36.1 The TMO maintained a policy which described the way in which it sought to comply with its obligations under health and safety legislation. We saw various versions of the policy but the witnesses were asked principally about the versions dated July 2010352 and February 2016.353 36.2 The TMO’s senior staff were familiar with the policy. Teresa Brown was familiar with the general principles in the policy, but had no reason to refer to the details.354 Barbara Matthews helped to review the policy in February 2016355 and Janice Wray also contributed to it.356 The policy provided that Robert Black was ultimately responsible for health and safety at the TMO.357 36.3 According to the policy, the TMO was required to make sure that staff with key roles in the management of health and safety were competent and adequately trained.358 However, Barbara Matthews told us that there was no document that described standards of competence or the training required for those members of staff.359 The TMO’s fire safety strategies 36.4 On 18 January 2013, Janice Wray sent Carl Stokes360 a document entitled “Fire Safety Policy”,361 which she had drafted to address one of the failings identified by Salvus in a report dated September 2009.362 It was intended to replace the fire safety policy approved by Robert Black in 2009.363 When drafting the document Janice Wray had consulted her colleagues, Cyril Morris and Adrian Bowman, and the operations division of the TMO. She may also have consulted the LFB with the intention of adopting its standards.364 On 1 February 2013, Carl Stokes provided some comments.365 36.5 The draft policy was discussed at a meeting of the TMO’s Assets & Regeneration and Repairs, Health & Safety Group on 18 April 2013.366 It was discussed again at a meeting of the Operational Health and Safety Committee on 15 November 2013. The intention was for it to be circulated by Janice Wray in draft for comments before sending it to the LFB by mid-December.367 352 {TMO10031078}. 353 {TMO10024402}. 354 Brown {Day126/9:14-22}. 355 Matthews {Day147/140:5-16}. 356 Wray {Day142/152:14-16}. 357 Matthews {Day147/141:3-5}; {TMO10024402} paragraph 1.2. 358 {TMO10024402/1} paragraph 1.4. 359 Matthews {Day147/142:11-25}. 360 {CST00001187}. 361 {CST00002046}. 362 Wray {Day140/141:20-25}. 363 Wray {Day140/142:2-11}. 364 Wray {Day140/142:25}-{Day140/143:13}. 365 {CST00030180}. 366 Item 7.1 “Fire Safety Policy” {TMO10002648}. 367 TMO Operational Health & Safety Minutes {TMO10004726/6}. Chapter 36 Fire safety management at the TMO

The Grenfell Tower Inquiry: Phase 2 Report 52 36.6 The version of the document produced in November 2013368 (entitled “TMO Fire Safety Strategy”) was given to the LFB at the bi-monthly meeting in December 2013. Janice Wray said that the LFB had not commented on it.369 The draft was discussed again at the meeting of the Operational Health and Safety Committee on 17 January 2014, when it was noted that it had already been given to the LFB and that the final version could be approved at the next committee meeting.370 In fact, there is no record of the document’s having been approved at the next or any subsequent Operational Health and Safety Committee meeting. Despite that, it was in its final form, as far as Janice Wray was concerned.371 36.7 The minutes of the meeting on 17 January 2014 recorded that Janice Wray and Michael Lyons (the Health and Safety manager of Repairs Direct) were to meet to discuss any changes to the strategy. In the event, Michael Lyons, who had been sent a copy of the draft, sent back a different document described as a fire safety policy dated January 2014.372 Janice Wray said that that document had not been adopted, however, as it did not reflect the TMO’s working practices.373 36.8 There were various versions of that document, the earliest being dated January 2014374 and the latest May 2014.375 The former, apparently written solely by Michael Lyons, contemplated the appointment of a fire safety manager,376 who would be responsible for the strategic management of fire precautions, including the formulation and revision of the TMO’s fire safety plan and oversight of the process for obtaining fire risk assessments.377 When she received that document from Michael Lyons Janice Wray noted the different structure for managing fire safety, including the introduction of a fire safety manager. She sent a copy of the policy to Anthony Parkes, her then line manager, who confirmed that the TMO did not intend to implement the arrangements described in the draft.378 36.9 The draft dated May 2014, jointly written by Janice Wray and (apparently) Michael Lyons, did not contain any reference to a fire safety manager and made it clear that responsibility for fire safety policy lay with the Health & Safety Manager. In any event, it appears that neither the January 2014 nor May 2014 draft was taken any further.379 36.10 Another version of a fire safety policy was identified by the RBKC auditor, Alpesh Patel, who carried out an audit of the TMO’s health and safety arrangements in March 2016. Janice Wray had provided him with examples of the latest internal policies and procedures, which included a Fire Safety Policy and Strategy.380 That document was presented in the same way as the January and May 2014 drafts and was in substance a revised version of the fire safety strategy dated November 2013.381 It was not adopted by the TMO’s health 368 {TMO00830598}. 369 Wray {Day140/151:2-3}. 370 TMO Operational Health & Safety Meeting {TMO00840384}. 371 Wray {Day140/155:17-19}. 372 {TMO10040770/1}. 373 Wray {Day140/151:25}-{Day140/152:12}. 374 See Fire Safety Policy, Issue 01, January 2014 {TMO10040770}. 375 {TMO00856458}. 376 {TMO10040770/6}. 377 {TMO10040770/6}. 378 Wray {Day140/154:13}-{Day140/155:5}. 379 Wray {Day140/157:13-15}. 380 Patel {RBK00058245/11-12} pages 11-12, paragraph 32; Exhibit AP2/38 - TMO fire safety policy and strategy {RBK00058236}. 381 Wray {Day140/162:9-14}.

Part 5 | Chapter 36: Fire safety management at the TMO 53 and safety committee.382 Janice Wray did not know why that document had been given to the auditor.383 The current fire safety strategy remained the one that had been approved in November 2013. 36.11 A review of the 2013 strategy began in April 2016.384 Janice Wray presented a paper385 at a meeting of the TMO Health and Safety Committee that took place on 12 April 2016.386 The document was entitled “Review of Fire Safety Strategy” and set out initial points to consider as part of the review. The review is likely to have been prompted by the Adair Tower fire, which had occurred on 31 October 2015.387 36.12 The process of reviewing the strategy continued well into 2017. The TMO Health and Safety Committee considered a draft dated June 2017388 at its meeting on 13 June 2017, the day before the fire. Janice Wray said that the revision had taken so long to complete because the TMO wanted to review many aspects of the draft and make many minor changes and because there were many aspects on which she needed to obtain responses from others.389 That may be so, but on any view, the delay speaks to an absence of proper expedition to make sure that a policy, which touched on the health and safety of residents, was completed expeditiously and kept up to date to reflect any changes in circumstances or regulatory requirements. 382 Wray {Day140/162:19}-{Day140/163:2}. 383 Wray {Day140/163:6-22}. 384 Wray {Day140/164:4-13}. 385 {TMO10024351}. 386 {TMO10012811}. 387 Wray {Day140/167:24}-{Day140/168:10}. 388 {TMO10017036}. 389 Wray {Day140/171:7-20}.

The Grenfell Tower Inquiry: Phase 2 Report 54

55 37.1 Before 2008 the TMO’s health and safety team comprising Adrian Bowman and Janice Wray carried out fire risk assessments itself in order to save money, rather than using external fire risk assessors.390 In May 2008, however, Collette O’Hara, a fire safety inspecting officer in the LFB’s Kensington & Chelsea fire safety team (the LFB fire safety team), identified certain deficiencies in the TMO’s fire risk assessments.391 37.2 In January 2009, the LFB fire safety team was not satisfied that the TMO’s fire risk assessments had improved. It therefore sent a series of letters to the TMO, each in relation to a property in respect of which it did not consider the fire risk assessment to be suitable and sufficient as required by article 9(1) of the Fire Safety Order. That precipitated a number of meetings and discussions between Angus Sangster, the team leader, Collette O’Hara and Janice Wray about the standard expected of fire risk assessments.392 37.3 Following a site visit to one of the TMO’s properties with Janice Wray on 17 June 2009, Mr Sangster and Ms O’Hara concluded that the TMO was not competent to carry out fire risk assessments itself. Accordingly, Mr Sangster advised Janice Wray that the LFB would issue an enforcement notice against RBKC and the TMO requiring fire risk assessments to be carried out by a competent person.393 37.4 Later that day, Janice Wray told Laura Johnson and Jean Daintith, RBKC Executive Director of Housing, what the LFB intended to do.394 Jean Daintith immediately sought advice from RBKC’s building control department, which said that the TMO’s fire risk assessments were not sufficiently robust and that a specialist should be engaged to carry them out.395 37.5 As a result, on 18 June 2009, Alexis Correa, RBKC’s health and safety advisor for the Housing, Health and Adult Social Care department, contacted Angus Sangster to explain that RBKC would provide funds to allow the TMO to appoint an external fire risk assessor and to carry out all necessary works. He sought an assurance that in those circumstances the LFB would not issue an enforcement notice. Mr Sangster agreed not to do so, subject to receiving from RBKC and the TMO a schedule for the completion of fire risk assessments.396 390 Wray {Day140/85:17-19}; Briefing Note on Fire Safety dated 27 July 2009 by Janice Wray {TMO10037317/1} item 3; Email from Janice Wray to Robert Black and Liam Good copying in various others on 17 June 2009 about the LFB’s intention to issue an enforcement notice {RBK00052535/4}. 391 LFEPA (LFB) Report Form on the TMO by Collette O’Hara dated 16 November 2009 {LFB00031977/22}. 392 LFEPA (LFB) Report Form on the TMO by Collette O’Hara dated 16 November 2009 {LFB00031977/22}; Wray {Day140/85:10}-{Day140/86:8}. 393 LFEPA (LFB) Report Form on the TMO by Collette O’Hara dated 16 November 2009 {LFB00031977/22}. 394 Email from Janice Wray to Jean Daintith and Laura Johnson copying in others on 17 June 2009 about the LFB’s intention to issue an enforcement notice {RBK00052535/3}. 395 Email from Jean Daintith to Derek Myers cc David Prout on 17 June 2009 about the LFB’s intention to issue an enforcement notice {RBK00052535/3}; Email from Jean Daintith to Derek Myers and Robert Black cc others on 18 June 2009 about the TMO’s fire risk assessments {RBK00052528/1}. 396 LFEPA (LFB) Report Form on the TMO by Collette O’Hara dated 16 November 2009 {LFB00031977/23}. Chapter 37 Development of fire safety strategies and policies

The Grenfell Tower Inquiry: Phase 2 Report 56 37.6 On 9 July 2009, Janice Wray sent Mr Sangster a schedule of work397 that had been agreed between RBKC and the TMO,398 but he did not consider it acceptable and suggested a further meeting to discuss the way forward.399 The meeting took place on 6 August 2009400 and was attended by representatives of the LFB fire safety team, RBKC and the TMO. During the meeting Keith Holloway, the TMO’s Director of Strategic, Planning, Performance and Compliance, confirmed that fire risk assessments would be carried out by an external consultant. He and Jean Daintith also agreed that RBKC and the TMO would complete fire risk assessments for all their properties within three years, starting with high-risk properties, and carry out any work identified in them within five years.401 37.7 Although RBKC and the TMO felt that, in requiring that approach to fire risk assessments, the LFB was treating them unduly harshly, they agreed to comply with its requirements.402 37.8 On 7 September 2009, a fire risk consultant, Salvus Consulting Ltd (Salvus), was appointed by the TMO to carry out the first phase of fire risk assessments. It covered 110 properties that were considered to pose a high risk, including Grenfell Tower. Work was due to start on 24 September 2009.403 There were meetings between Salvus, the LFB fire safety team, the TMO and RBKC on 16 September 2009 and 23 November 2009 to discuss the scope of the fire risk assessment programme and the method to be adopted.404 37.9 On 27 January 2010, Robert Black and Laura Johnson wrote to Angus Sangster confirming the joint commitment of RBKC and the TMO to achieving compliance with the Fire Safety Order. In their letter they described what had been agreed in their meetings with the LFB fire safety team in relation to the fire risk assessment programme, which by that time was already under way. The LFB was evidently satisfied with their proposal.405 397 LFEPA (LFB) Report Form on the TMO by Collette O’Hara dated 16 November 2009 {LFB00031977/23}. 398 Email from Alexis Correa to Pam Sedgwick cc others on 7 July 2009 about providing a schedule of works for fire risk assessments {TMO00866049/2}; Email from Alexis Correa to Janice Wray and others on 8 July 2009 describing the outcome of a meeting that day with Janice Wray, Liam Good and Ann Muchmore about fire risk assessments {TMO00865069/1}. 399 LFEPA (LFB) Report Form on the TMO by Collette O’Hara dated 16 November 2009 {LFB00031977/23}; Briefing Note on Fire Safety dated 27 July 2009 by Janice Wray {TMO10037317/3} item 5. 400 Minutes of meeting between RBKC, TMO and LFB on 6 August 2009 {RBK00018535/1}. 401 Minutes of meeting between RBKC, TMO and LFB on 6 August 2009 {RBK00018535/2} item 5. 402 Minutes of TMO Executive Team meeting dated 29 July 2009 {TMO00903017/5} item 9; Minutes of TMO Executive Team meeting dated 3 August 2009 {TMO00903019/3} item 2.4; Emails between Laura Johnson and Janice Wray cc Keith Holloway dated 4-5 August 2009 about fire safety {TMO10037329}; Minutes of meeting between RBKC, TMO and LFB on 6 August 2009 {RBK00018535/1} item 1; Minutes of meeting between RBKC, TMO and LFB on 6 August 2009 {RBK00018535/4} item 10. 403 Wray {TMO00842341/2} page 2, paragraph 9; Agreement between TMO and Salvus to appoint Salvus to carry out fire risk assessments on high-risk properties dated 7 September 2009 {TMO10037438/42}; TMO spreadsheet of potentially high-risk properties dated 1 July 2009 {TMO00842374}. 404 Minutes of the meeting between Salvus, LFB fire safety team and TMO on 16 September 2009 {SAL00000039}; Minutes of the meeting between Salvus, LFB fire safety team, TMO and RBKC on 23 November 2009 {SAL00000043}. 405 Minutes of meeting between RBKC, TMO and LFB on 6 August 2009 {RBK00018535}; Minutes of the meeting between Salvus, LFB and TMO on 16 September 2009 {SAL00000039}; Minutes of the meeting between Salvus, LFB, RBKC and TMO on 23 November 2009 {SAL00000043}.

Part 5 | Chapter 37: Development of fire safety strategies and policies 57 The Salvus Management Report 37.10 On 22 September 2009, Steve Wain, a Salvus fire risk assessor, carried out a detailed assessment of the TMO’s fire safety management systems at the request of Russell Thompson, the TMO’s Head of Assets Strategy and Investment.406 Steve Wain set out his findings in a report of the same date entitled “Fire Risk Assessment for Fire Safety Policy and Procedures” (known as the Salvus Management Report).407 37.11 The Salvus Management Report was divided into two parts. Part 1 identified 25 deficiencies in the TMO’s fire safety management arrangements that created hazards. It also identified where there were inadequate control measures in place in relation to those hazards and the level of risk the hazards presented.408 It based risk on both the likelihood of harm occurring and the likely severity of harm. A high-risk event, for example, was defined as one that was very likely or almost certain to occur and cause major injury or death and a medium-risk event as one that could occur in time and was likely to cause injury and ill health.409 All but two of the deficiencies were assessed as presenting a high or medium to high level of fire risk.410 Hazards included the absence of an overall fire safety policy setting out the TMO's strategic fire safety objectives, which was assessed as a high risk, the lack of policy and supporting arrangements to explain how the TMO would meet its fire safety objectives (for example, in relation to fire risk assessments and the maintenance of fire safety measures), which was also assessed as high risk and the lack of senior managerial audit of the fire safety arrangements to ensure that they were being satisfactorily implemented, which was assessed as medium to high risk.411 37.12 Although Janice Wray did not agree with all of Salvus’s conclusions, she did accept that the TMO had not adequately recorded its fire safety arrangements.412 Indeed, the TMO’s Health and Safety Policy dated May 2009 was the only policy relevant to fire safety in existence at the time of the Salvus Management Report.413 It was not, however, a fire safety policy. It referred only briefly to fire safety and emergency procedures and made no mention at all of the Fire Safety Order, which had come into force in October 2006 some two and half years earlier.414 37.13 Part 2 of the Salvus Management Report was an action plan which set out 49 steps required to reduce the risks that had been identified.415 Salvus considered that 19 of them were required to remedy statutory breaches.416 According to the priority ratings, Salvus 406 Salvus report entitled “Fire Risk Assessment for Fire Safety Policy and Procedures” dated 22 September 2009 {SAL00000013/2}. 407 Salvus report entitled “Fire Risk Assessment for Fire Safety Policy and Procedures” dated 22 September 2009 {SAL00000013/1}. 408 Salvus report entitled “Fire Risk Assessment for Fire Safety Policy and Procedures” dated 22 September 2009 {SAL00000013/2}. 409 Salvus report entitled “Fire Risk Assessment for Fire Safety Policy and Procedures” dated 22 September 2009 {SAL00000013/2}. 410 Salvus report entitled “Fire Risk Assessment for Fire Safety Policy and Procedures” dated 22 September 2009 {SAL00000013/5-12}. 411 Salvus report entitled “Fire Risk Assessment for Fire Safety Policy and Procedures” dated 22 September 2009 {SAL00000013/5}. 412 Wray {Day140/108:18-21}. 413 TMO’s Health and Safety Policy dated May 2009 {TMO00870519}. 414 TMO’s Health and Safety Policy dated May 2009 {TMO00870519/5}. 415 Salvus report entitled “Fire Risk Assessment for Fire Safety Policy and Procedures” dated 22 September 2009 {SAL00000013/13-19}. 416 Salvus report entitled “Fire Risk Assessment for Fire Safety Policy and Procedures” dated 22 September 2009 {SAL00000013/13-19}. The key to colour coding on page 19 shows that red signifies a statutory breach. The statute and statutory instruments Steve Wain probably had in mind are set out in the “Reference Material” on page 4.

The Grenfell Tower Inquiry: Phase 2 Report 58 required that the majority be completed within one or three months or, if a plan had been agreed, within six months.417 There was, therefore, some urgency attached to the recommendations. 37.14 Salvus strongly recommended that the TMO develop an overall fire safety policy within one month setting out its strategic fire safety objectives. It also strongly advised that the TMO introduce policy and supporting arrangements to show how it would meet its strategic fire safety objectives (for example, in relation to fire risk assessments and the maintenance of fire safety measures) within three months or, if a plan had been agreed, within six months.418 37.15 Although we do not know exactly who received the Salvus Management Report, Janice Wray believed that copies had been sent to all those in the TMO who regularly dealt with Salvus. She mentioned Russell Thompson, Janet Rhymes, the TMO’s Consultancy Services Manager, and also Ann Muchmore, RBKC’s Performance and Contracts Monitoring Officer.419 37.16 Janice Wray did not receive the Salvus Management Report until 20 November 2009.420 We do not know why there was a delay of two months in her receiving it; on the face of it, it should have reached her much sooner. The delay may explain why she did not mention the report in her fire risk assessment report to the TMO board on 8 October 2009,421 but it does not explain why, according to her report, Salvus had said at its meeting with the TMO on 24 September 2009 that generally the TMO had good fire safety policies and procedures in place, although they had not been consistently documented.422 That statement is difficult to reconcile with the deficiencies in fire safety policy and arrangements that Salvus had identified in the report it had made only two days before that meeting. Regrettably, we have not seen any minutes of that meeting. 37.17 When Janice Wray received the Salvus Management Report she should have communicated at least the substance of its findings to the executive team, which in turn should have communicated them to the board and to RBKC. We have seen no evidence that that was done and we conclude that she did not do so. That would at least have set the record straight and would have corrected the false impression that Ms Wray had given the board on 8 October 2009. 37.18 Janice Wray may have discussed the report with Lornette Pemberton, the TMO’s Head of Human Resources and Organisational Development and her line manager at the time and if so, she probably assumed that Ms Pemberton would report the deficiencies to the executive team.423 Robert Black said that he could not recall the report but was sure that he had seen it.424 417 Salvus report entitled “Fire Risk Assessment for Fire Safety Policy and Procedures” dated 22 September 2009 {SAL00000013/13-19}. The “key to priority rating” on page 19 shows that “3” means “Undertake action within 1 month” and “4” means “Action within 3 months or agree plan within 6 months”. 418 Salvus report entitled “Fire Risk Assessment for Fire Safety Policy and Procedures” dated 22 September 2009 {SAL00000013/13}. 419 Wray {Day140/105:7-11}. 420 Minutes of the meeting between Salvus, LFB, RBKC and TMO on 23 November 2009 {SAL00000043/4}. At item 5.4 it is recorded that Janice Wray received the email “late Thursday” which would have been 20 November 2009. See also Wray {Day140/118:4-12}; Wray {Day140/119:7-25}. 421 Janice Wray’s report to the TMO Board entitled “Further Update on Fire Risk Assessments” dated 8 October 2009 {RBK00053571/1}. 422 Janice Wray’s report to the TMO Board entitled “Further Update on Fire Risk Assessments” dated 8 October 2009 {RBK00053571/2} item 3.4. 423 Wray {Day140/122:16}-{Day140/123:12}; Wray {Day140/127:12-17}. 424 Black {Day149/63:9}-{Day149/67:11}; Wray {Day140/133:6-10}.

Part 5 | Chapter 37: Development of fire safety strategies and policies 59 37.19 In her fire risk assessment report on 10 December 2009, Janice Wray told the board that the TMO had received a report from the consultant that set out the fire safety framework within which it and any contractors should be working.425 However, she did not mention any of the critical findings or urgent measures that needed to be taken by the TMO in relation to the management of fire safety. She could not explain that omission,426 nor could she remember having told the executive team or the board about them. We have seen no evidence that she or anyone else did so and are forced to the conclusion that they were not drawn to the attention of either the executive team or the board.427 37.20 The report and its findings were, however, discussed by Salvus, the TMO and RBKC at a progress meeting on 26 January 2010. That meeting was attended by Janice Wray, Russell Thompson, Abigail Acosta (a TMO project manager) and Ann Muchmore.428 It is clear from the minutes of the discussion of the report that Ann Muchmore was aware of its existence, even if she had not been provided with a copy. However, we have seen no evidence that she ever shared the report more widely within RBKC. Laura Johnson had no recollection of having seen it.429 Implementation of the recommendations 37.21 At the meeting on 26 January 2010, Janice Wray raised a number of questions about the Salvus Management Report.430 It is clear from the minutes of that meeting that many of Salvus’s recommendations had yet to be implemented and indeed Janice Wray accepted that some had not been. For example, she said she had not had an opportunity to put in place policy and supporting arrangements to explain how the TMO would meet its strategic fire safety objectives.431 That was despite a recommendation that it be done within three months.432 37.22 It appears that Janice Wray had started to implement that particular recommendation within the required time but had stopped work before it was complete. There is a document headed “TMO Fire Safety Policy”, apparently signed by Robert Black and dated December 2009,433 which appears to be an early draft of the fire safety policy. Although she had little recollection of it, Janice Wray thought she had probably started drafting it in response to Salvus’s recommendation and had put it aside because of other work.434 As it was, the TMO did not produce a fire safety policy in response to that recommendation until November 2013.435 37.23 On any view, the pace at which the recommendations were implemented was glacial. Given a high or medium to high assessment of the danger posed by a recommendation’s remaining incomplete, the TMO failed to act with the degree of urgency that the subject demanded. It is not clear whether the problem flowed from Janice Wray’s failure to 425 Janice Wray’s report to the TMO Board entitled “Further Update on Fire Risk Assessments” dated 10 December 2009 {TMO00873623/2} item 4.5. 426 Wray {Day140/123:7-12}. 427 Wray {Day140/122:24}-{Day140/123:12}. 428 Minutes of the meeting between Salvus, RBKC and TMO on 26 January 2010 {RBK00052572/3-4} item 4. 429 Johnson {Day129/100:25}. 430 Minutes of the meeting between Salvus, RBKC and TMO on 26 January 2010 {RBK00052572/3-4} item 4. 431 Wray {Day140/125:3-20}. 432 Salvus report entitled “Fire Risk Assessment for Fire Safety Policy and Procedures” dated 22 September 2009 {SAL00000013/13} item 1.2. 433 Draft TMO Fire Safety Policy dated December 2009 {TMO00870171}. 434 Wray {Day140/131:5-25}; Wray {Day140/142:6-11}. 435 TMO Fire Safety Strategy dated November 2013 {TMO00830598}.

The Grenfell Tower Inquiry: Phase 2 Report 60 prioritise the work or whether she did not have the capacity to undertake it and failed to ask for more resources. Whatever the cause, given their importance, the TMO should have made sure that the recommendations were promptly implemented and it failed to do so. 37.24 One of the other recommendations made by Salvus was that within three months (or six months if a plan had by then been produced) the TMO should introduce a senior managerial audit of fire safety arrangements. There was also a recommendation that it be reviewed as part of the TMO’s Business Plan.436 We have seen no evidence that the TMO had introduced such an audit before the Grenfell Tower fire on 14 June 2017 and no explanation has been given for its failure to do so. 37.25 The TMO Performance Agreement for 2012/13 contained a draft audit programme for the following year that included a full review of fire risk assessments by Lornette Pemberton.437 It is evident, however, that the audit was intended to relate to fire risk assessments rather than the fire safety management system as a whole. It would not, therefore, have fully met Salvus’s recommendation. In any event, we have seen no evidence that Lornette Pemberton, or anyone else, carried out an audit of that kind and we conclude that no one did. Robert Black could not explain why it had not been carried out.438 An audit of fire risk assessments did not appear again in the TMO audit programme before 14 June 2017.439 37.26 In June 2013, PAS 7:2013, a publicly available specification concerning fire risk management systems, was published by the British Standards Institution.440 Paragraph 7.4.3 stated that an organisation should audit the fire risk assessment programme after the delivery of the fire risk assessments and hold review meetings at planned intervals to discuss the results of the audits of fire risk assessments and the efforts made to respond to the findings.441 37.27 At paragraph 8.3.1, it provided that senior management should review the organisation’s fire risk management system at planned intervals to ensure its continuing suitability, adequacy and effectiveness.442 That specification bears a striking resemblance to the recommendation made by Salvus in September 2009 for a senior managerial audit of fire safety arrangements. 37.28 Janice Wray was aware of PAS 7:2013.443 Despite that, she made no provision in the TMO fire safety strategy that she prepared in November 2013 for an audit of the fire risk assessment programme or for a review of the fire risk management system.444 37.29 We have seen no evidence that RBKC or the TMO incorporated a specific audit of the fire risk assessment programme or a review by senior management of the fire risk management system into its policy. Nor have we seen any evidence that the management of the TMO ever implemented such an audit or review in practice. No explanation has been given for those chronic failings. 436 Salvus report entitled “Fire Risk Assessment for Fire Safety Policy and Procedures” dated 22 September 2009 {SAL00000013/14} item 1.4. 437 TMO Performance Agreement 2012/13 {TMO00883568/42} paragraph 3.4. 438 Black {Day149/211:14-22}. 439 TMO Performance Agreement 2013/14 {TMO10002878/22} item 3.2; TMO Performance Agreement 2014/15 Mid-Year Review {TMO10042117/5-6} item 2; TMO Performance Agreement 2015/16 {TMO10043715/20-21} item 3.2; TMO Performance Agreement 2016/17 {RBK00000589/24-25} item 3.2. 440 BSI Standards Publication PAS 7:2013 “Fire Risk Management System - Specification” {LFB00116924/2}. 441 BSI Standards Publication PAS 7:2013 “Fire Risk Management System” {LFB00116924/23} paragraph 7.4.3. 442 BSI Standards Publication PAS 7:2013 “Fire Risk Management System” {LFB00116924/25} paragraph 8.3.1. 443 Wray {Day145/11:12}-{Day145/12:17}. 444 TMO Fire Safety Strategy dated November 2013 {TMO00830598}.

Part 5 | Chapter 37: Development of fire safety strategies and policies 61 RBKC audit of the TMO’s health and safety arrangements 37.30 The TMO, in conjunction with RBKC, set annual audit plans, the results of which allowed senior management to assess the adequacy and effectiveness of the internal controls in any particular year.445 Audits were carried out by RBKC’s audit department, whose reports gave an overview of the area of service being audited. They also provided an assurance assessment rating, which ranged from “substantial” to “limited”, based on the findings and the number of recommendations made in the report. If a “limited” assurance rating was given, there was usually a review within six to nine months to assess the implementation of any recommendations.446 37.31 For TMO health and safety audits, each recommendation was given a high, medium or low priority and the overall audit would be given a “limited”, “satisfactory” or “substantial” assurance rating. “Limited” assurance meant that there were weaknesses that put the objectives of the system at risk of failure. “Satisfactory” assurance meant that there were some weaknesses or omissions that put the objectives of the system at risk of failure. “Substantial” assurance meant that there was a sound system of control designed to achieve its objectives with few errors of weaknesses found.447 RBKC’s audit team provided an independent audit service for the TMO.448 37.32 An audit of the TMO’s Health and Safety department was carried out by RBKC in April 2013.449 The report was circulated, initially in draft, to Sacha Jevans, Janice Wray, Peter Maddison and Anthony Parkes. When completed, copies of the report were sent to Robert Black and Laura Johnson.450 The audit provided only limited assurance that the TMO had adequate controls and processes in place in relation to health and safety.451 The report made two relevant recommendations, first, that all high priority remedial work identified in the annual health and safety inspection should be reviewed by the Health and Safety Team to ensure that it was undertaken promptly; and secondly, that appropriate performance indicators relating to health and safety inspections should be developed by management. 37.33 The TMO accepted that some performance indicators would be useful, including indicators relating to fire risk assessments and reviews, the service of enforcement and deficiency notices and the number of fires.452 Matt Hodgson’s review 37.34 Following the audit in April 2013 and the finding of “limited assurance”,453 the TMO instructed Matt Hodgson, a health and safety professional, to complete a safety management review. 445 Patel {RBK00029884/2} page 2, paragraph 5. 446 Patel {RBK00029884/2} page 2, paragraph 5. 447 Patel {RBK00029884/4} page 4, paragraph 12. 448 Patel {RBK00029884/4} page 4, paragraph 14. 449 {RBK00000313}. 450 {RBK00000313/1}. 451 {RBK00000313/4}. 452 {RBK00000313/21}. 453 Black {Day149/135:19}-{Day149/136:13}.

The Grenfell Tower Inquiry: Phase 2 Report 62 37.35 Mr Hodgson prepared two reports, dated 19 July 2013454 and September 2013 respectively,455 both of which were marked for the attention of Robert Black. The reports set out to provide an independent assessment of the implementation of the TMO’s health and safety policy and its supporting arrangements.456 37.36 In his first report Mr Hodgson identified 39 matters that required attention across the broad range of the TMO’s health and safety responsibilities.457 For example, he recommended a review of the section of the corporate policy dealing with roles and responsibilities to make sure that the management of health and safety was appropriate to the TMO. He also concluded that the designation of RBKC’s chief executive as the responsible person for the purposes of the Fire Safety Order was not appropriate. He advised that someone within the TMO should be designated as the responsible person and should receive the training and resources necessary to allow the role to be performed effectively.458 37.37 More fundamentally, Mr Hodgson found that the health and safety policy did not identify the risks to which the TMO was exposed and failed to explain in sufficient detail what arrangements were necessary to satisfy, among other matters, its obligations in relation to fire safety.459 He observed that many of the fire safety arrangements had been grouped together in a way that lacked the detail required to produce an effective planned preventative maintenance process. 37.38 Matt Hodgson’s analysis echoed the criticism made by Salvus in 2009. The maintenance process remained reactive, which defeated the object of effective policy arrangements, namely, the clear definition of planned preventative maintenance arrangements that ensured compliance with the TMO’s health and safety obligations.460 Mr Hodgson therefore recommended a full review of the policy arrangements to ensure that there was a section for each property risk in order to achieve compliance.461 Robert Black was asked whether any new policies had been introduced or any existing policies revised following that recommendation. He could not remember.462 37.39 Matt Hodgson also considered the position in relation to fire risk assessments.463 He found that the TMO’s records of fire risk assessments were not up-to-date and that it was therefore not possible to see whether and, if so, to what extent the TMO had complied with its duties. It was clear, however, that there were between 900 and 1,000 outstanding matters arising from previous fire risk assessments. 37.40 Following receipt of the report, Robert Black prepared a report for the meeting of the TMO’s board on 5 September 2013. In it he referred to Mr Hodgson’s initial report and said that an action plan was being prepared for incorporation into the final report, but he did not mention any of the shortcomings identified by Mr Hodgson, not least the fact that the TMO itself and the members of the board could be exposed to liability if some of the deficiencies that had been identified were not remedied. Nor did he mention the lack of a co-ordinated approach to risk management or a lack of leadership from the executive 454 Safety management review, July 2013 {TMO10003124}. 455 Safety management review, September 2013{TMO00873398} paragraph 2. 456 Safety management review, September 2013 {TMO00873398/4}. 457 Safety management review, July 2013 {TMO10003124/9}. 458 Safety management review, July 2013 {TMO10003124/34} paragraph 1. 459 Safety management review {TMO00873398/19} paragraph 5. 460 Safety management review {TMO00873398/19}. 461 Safety management review {TMO00873398/20} item 4. 462 Black {Day149/141:13-16}. 463 Safety management review July 2013 {TMO10003124/33}.

Part 5 | Chapter 37: Development of fire safety strategies and policies 63 team. In evidence, Mr Black agreed that they were all important matters for the TMO board to know.464 He suggested that the reason he had not revealed those findings to the board was that at that stage the report was still in draft.465 The fact is that the Hodgson report contained a powerful criticism of the TMO’s health and safety arrangements and was all the more serious for the fact that four years had passed since the Salvus report and not all of the recommendations had been carried out. If Mr Black had disclosed those matters to the board he would no doubt have been asked some very difficult questions. We can only infer that he chose not to face up to them and hoped instead to keep Mr Hodgson’s conclusions away from the board and thereby avoid embarrassment. 37.41 Yet again, Mr Black’s decision not to inform the board about those important matters prevented it from exercising effective supervision and control over the development of adequate fire safety management policies and arrangements. That was a very serious failing on his part. 37.42 The result was that by the end of 2013, the TMO’s executive team had received two independent reports, four years apart, on its fire safety management arrangements, each of which had made far-reaching criticisms and recommendations. Those reports went to the chief executive but not to the board. They were not acted on in any material way by the TMO, not least because Mr Black’s failure to bring them to the attention of the board meant that there was no pressure on him to take action. His own failure to take responsibility for implementing the recommendations and put in place a strategy for solving the myriad of deficiencies in the management system was a further serious failing on his part. It was also a serious failing on the part of Janice Wray, who knew as much as he did and on whom he relied. Clearly neither of them regarded fire safety as a high priority, even though the TMO had gone to the trouble and expense of commissioning the reports. Further audits 37.43 In December 2013, RBKC carried out a further audit of the TMO’s Health and Safety department.466 The report was circulated in draft to Peter Maddison, Alex Bosman and Janice Wray before the final version was sent to Sacha Jevans and Anthony Parkes. Robert Black also received it.467 The level of assurance had risen from “limited” to “satisfactory” because of the steps that the TMO said had been taken.468 37.44 The action said to have been taken on key performance indicators is set out on page 9 of the report.469 Notwithstanding the clear terms of the TMO’s response to the report produced in April 2013, no indicators had been prepared for fire risk assessments or reviews, the service of enforcement or deficiency notices or the number of fires. The TMO did not set up a system to monitor each indicator until January 2016.470 No explanation was given for that delay.471 The TMO did not inform RBKC of the contents of the two Hodgson reports, much less provide it with copies. 37.45 Another audit of the TMO’s health and safety arrangements was undertaken as part of the 2015/16 audit plan. The final report, dated March 2016, was a “high level audit review”. It did not identify any shortcomings in the TMO’s management of fire safety. It found 464 Black {Day150/87:13-23}. 465 Black {Day150/88:24}. 466 Exhibit AP/3 - RBKC, TMO Health and Safety Follow up Audit Report {RBK00000320}. 467 Black {Day150/64:20}-{Day150/65:1}. 468 Exhibit AP/3 - RBKC, TMO Health and Safety Follow up Audit Report {RBK00000320/2}. 469 Exhibit AP/3 - RBKC, TMO Health and Safety Follow up Audit Report {RBK00000320/9}. 470 Black {Day150/63:3-6}. 471 Black {Day150/63:18}-{Day150/64:11}.

The Grenfell Tower Inquiry: Phase 2 Report 64 that appropriate procedure and guidance documents existed covering fire safety policy and had recently been revised.472 It said that fire risk assessments were carried out by a specialist consultant and were reviewed by the TMO Assistant Safety Advisor during routine inspections to ensure that any significant findings and recommendations were pursued in a timely manner and in accordance with their stated priority. Checks on the electronic database relating to ten estates had confirmed that they were up to date and that all fire equipment had been inspected within the past twelve months.473 37.46 That finding failed to take account of the serious backlog of remedial work required by previous fire risk assessments that existed in the months before the final audit report.474 The TMO failed to correct the auditor’s mistake in thinking that all remedial work had been carried out in a timely manner and in accordance with their stated priority. None of the witnesses from the TMO could explain that failure. As a consequence, the audit report gave the misleading impression that there were no deficiencies in the TMO’s management of fire safety. Nor, once again, did the TMO take the opportunity to tell RBKC about the contents of Matt Hodgson’s reports or the systemic failings in its fire safety management he had identified. 472 Exhibit AP/4 - RBKC, TMO Final Internal Audit Report {RBK00000531/6}. 473 Exhibit AP/4 - RBKC, TMO Final Internal Audit Report {RBK00000531/6-7}. 474 See for example minutes from the 11 November 2015 TMO Executive Committee meeting, item 3 “Adair Tower - Responses” {TMO00843593/2}.

65 Chapter 38 Fire risk assessments Introduction 38.1 Fire risk assessments lie at the heart of the arrangements by which the responsible person discharges its obligations under the Fire Safety Order. In this chapter, starting with the engagement of Salvus by the TMO in 2009, we consider how the TMO carried out fire risk assessments of the high-rise residential buildings within its housing stock, principally in relation to Grenfell Tower. In particular, we concentrate on the appointment of Carl Stokes as the TMO’s preferred fire risk assessor, his qualifications and competence, the adequacy of his fire risk assessments and concerns that emerged about the quality of his work. Fire risk assessments – background 38.2 Between 24 September 2009 and March 2010, Salvus carried out fire risk assessments of high-risk TMO properties for the TMO and RBKC.475 The programme was a joint initiative between the RBKC and the TMO for which they had joint responsibility.476 Janice Wray took responsibility for identifying which blocks should take priority, the procurement, commissioning the fire risk assessments and ensuring that progress met the LFB’s requirements.477 Valerie Sharples, and for a brief period Abigail Acosta, were the TMO’s project managers.478 Ann Muchmore, RBKC’s performance and contracts monitoring officer, had responsibility for overseeing the contract.479 38.3 At the start of the contract, Angus Sangster and Steve Reade of the LFB’s Fire Safety team met Janice Wray, Adrian Bowman and Abigail Acosta and Andrew Furness and Steve Wain of Salvus.480 Angus Sangster repeated the LFB’s requirements for the fire risk assessment programme, namely to have the entire property portfolio assessed within three years and to have the remedial work required for properties to be fully compliant with the Fire Safety Order completed within five years.481 38.4 Salvus employed four fire risk assessors, including Carl Stokes.482 Carl Stokes started working for Salvus on 24 September 2009 on a six-month contract as a sub-contractor.483 475 Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/3}. 476 Wray {Day140/101:16-19}; Amanda Johnson {Day130/6:2-14}. 477 Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/1}; Amanda Johnson {Day130/6:2-14}. 478 Minutes of Fire Risk Assessments in high rise blocks, introductory meeting between Consultant and Fire Brigade dated 16 September 2009 {TMO00842368/1}. 479 Wray {Day140/101:20}-{Day140/102:9}. 480 Minutes of Fire Risk Assessments in high rise blocks, introductory meeting between Consultant and Fire Brigade dated 16 September 2009 {TMO00842368/1}. 481 Minutes of Fire Risk Assessments in high rise blocks, introductory meeting between Consultant and Fire Brigade dated 16 September 2009 {TMO00842368/1}. 482 Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/1}. 483 Stokes {Day136/6:5-8}; {Day136/7:19-21}; {Day136/58:6-18}.

The Grenfell Tower Inquiry: Phase 2 Report 66 Carl Stokes 38.5 Before he started working for Salvus, Carl Stokes had been an operational firefighter.484 In 1986, he joined the Royal Berkshire Fire and Rescue Service.485 During that time, he was seconded to the Fire Safety department and carried out familiarisation visits to high-rise buildings.486 In 1994, Mr Stokes transferred to the Oxfordshire Fire and Rescue Service where he spent most of his time in the Fire Safety department.487 Following the introduction of the Fire Safety Order, he received training on it and spent a significant amount of time auditing the findings made by fire risk assessors on behalf of responsible persons pursuant to the Fire Safety Order.488 However, none of these included residential blocks of flats over 18 metres in height.489 38.6 On 12 December 2007, Mr Stokes was awarded a Fire Risk Assessment Certificate by the Northern Ireland Fire Safety Panel, which enabled him to carry out fire risk assessments.490 He set up C S Stokes and Associates Ltd in February 2009 and retired from the Oxfordshire Fire and Rescue Service in September 2009.491 Carl Stokes was the sole director of C S Stokes and Associates Ltd and employed no-one else. He was therefore always a “one man band”.492 When he started working for Salvus, he had no experience of carrying out fire risk assessments on highrise residential blocks of flats.493 He had less than two years’ experience as a certified fire risk assessor.494 Salvus’s fire risk assessment programme 38.7 Salvus operated a quality control process under which all fire risk assessments were reviewed and discussed by email, when required, before being approved by the managing director, Andrew Furness.495 Mr Furness attended sites periodically to ensure consistency of assessments.496 Steve Wain oversaw the team of fire risk assessors.497 38.8 In the case of the TMO, Andrew Furness held regular monthly meetings with Valerie Sharples and Janice Wray.498 Ann Muchmore of RBKC and officers of the LFB Fire Safety Team often attended those meetings.499 484 Stokes {CST00003063/4} page 4, paragraph 7. 485 Stokes {CST00003063/4} page 4, paragraph 7. 486 Stokes {CST00003063/5} page 5, paragraph 8; Stokes {Day136/4:22}-{Day136/5:5}. 487 Stokes {CST00003063/5} page 5, paragraph 9. 488 Stokes {CST00003063/5} page 5, paragraph 10; Stokes {Day136/10:14-17}. 489 Stokes {Day136/15:24}-{Day136/16:9}. 490 Stokes {CST00003063/5} page 5, paragraph 11; {TMO00880581/12}. 491 Stokes {CST00003063/6} page 6, paragraph 13. 492 Stokes {CST00003063/1} page 1, paragraph 1; Stokes {Day136/5:20}-{Day136/6:3}. 493 Stokes {Day136/19:7-13}. 494 Stokes {Day136/19:25}-{Day136/20:7}. 495 ‘Background re Carl Stokes employment with Salvus Consulting Limited’ dated August 2019 {SAL00000002}. 496 Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/1}. 497 Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/1}. 498 Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/3}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 16 September 2009 {TMO00842368/1}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 19 October 2009 {SAL00000044}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 23 November 2009 {SAL00000043}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 26 January 2010 {RBK00052572}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 23 February 2010 {SAL00000042}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 1 April 2010 {SAL00000041}. 499 Minutes of Fire Risk Assessments in high rise blocks meeting dated 19 October 2009 {SAL00000044/1}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 23 November 2009 {SAL00000043/1}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 26 January 2010 {RBK00052572/1}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 1 April 2010 {SAL00000041/1}.

Part 5 | Chapter 38: Fire risk assessments 67 38.9 Over the course of the six months between September 2009 and March 2010 the team at Salvus carried out fire risk assessments in relation to about 110 high-risk properties managed by the TMO, including Grenfell Tower.500 Carl Stokes believed he had carried out between 20 and 30 of those assessments.501 38.10 The fire risk assessment in relation to Grenfell Tower was completed on 30 September 2009 by Carl Stokes under the supervision of Andrew Furness.502 It identified the chief executive of RBKC and the TMO503 as the responsible persons for the purposes of the Fire Safety Order, which reflected Carl Stokes’s view504 and presumably also that of Salvus. Janice Wray was consulted during the assessment.505 The fire risk assessment was subject to a quality control process and was reviewed by Andrew Furness on at least two occasions.506 It rated the overall risk for the building as “normal”, but identified 51 defects requiring remedial measures to reduce the risk.507 Of those 51 defects, 19 were categorised as involving statutory breaches and were marked in red. Each defect was given a “priority rating” which identified the length of time within which it was recommended that action be taken to remedy it.508 Some of the measures required to remedy red defects, such as reviewing the evacuation procedure and confirming the policy and procedures for the operation of the smoke ventilation system, required action to be taken within one week.509 Other defects requiring remedial measures marked in red required the TMO to take action within three months or to agree a plan within six months.510 They included recommending that the TMO introduce and implement a system of formal checks on flat front doors to ensure that compartmentation remained fit for purpose.511 The assessment also recommended that the TMO engage competent engineers to test the smoke ventilation system and the lifts, if testing was not being carried out in accordance with current industry best practice.512 38.11 The programme ended in March 2010.513 In February 2010, Janice Wray and Ann Muchmore evaluated the performance of Salvus in accordance with a commitment they had made to the LFB.514 Although, as she explained to us, they were not unhappy with Salvus’s work, on 11 February 2010 Janice Wray told Ann Muchmore that she had some concerns that Salvus were “very rule-bound” and that they had shown some reluctance to challenge the LFB on behalf of the TMO.515 She noted that Salvus was not as robust as she had hoped and that Carl Stokes, who had done most of the inspections as a sub-contractor, might be willing to tender for the work in future.516 Janice Wray felt that Salvus had not 500 Minutes of Fire Risk Assessments in high rise blocks meeting dated 16 September 2009 {TMO00842368/1}; Wray {TMO00842341/2} page 2, paragraph 9; {TMO00842374}; Minutes of the meeting between LFB, RBKC and TMO dated 20 April 2010 {TMO00873670/1}. 501 Stokes {Day136/61:17-25}. 502 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128}; Stokes {Day136/70:2-16}. 503 Under General Information the Chief Executive of the Royal Borough of Kensington and Chelsea is listed as a Responsible Person. The Tenant Management Organisation Warden is listed as a Responsible Person/contact on site: Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/5}. 504 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/5}; Stokes {Day136/69:7-10}. 505 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/5}. 506 Stokes {Day136/70:2-16}. 507 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/6}; Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/15-19}. 508 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/15-19}. 509 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/16-19}. 510 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/19}. 511 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/16}. 512 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/18-19}. 513 Wray {TMO00842341/2} page 2, paragraph 10; Minutes of Fire Risk Assessments in high rise blocks meeting dated 1 April 2010 {SAL00000041/1}. 514 Wray {TMO00000890/30} page 30, paragraph 135; Wray {Day140/172:7}-{Day140/173:14}. 515 {RBK00053588/3}. 516 {RBK00053588/1}.

The Grenfell Tower Inquiry: Phase 2 Report 68 given her a clear indication on fire safety issues raised by the LFB and she wanted to know whether the course of action suggested by the LFB was required before she committed the budget.517 They decided to invite tenders for carrying out fire risk assessments in relation to the medium – and low-risk phases of the programme.518 38.12 Janice Wray’s message reveals that the TMO wanted a fire risk assessor that would take its side against the LFB when debating its fire safety requirements instead of taking them entirely at face value. Given that the LFB was the enforcing authority under the Fire Safety Order, that was a mistake. It also explains why Carl Stokes, who was ill-qualified to carry out fire risk assessments of buildings on this scale, let alone to hold the entire TMO portfolio, was selected by the TMO as the sole fire risk assessor and allowed to retain that role for the best part of seven years. Appointment of fire risk assessor for medium- and low-risk properties 38.13 Once the fire risk assessment programme for high-risk buildings had been completed, on 18 October 2010 the TMO started a six-month fire risk assessment programme of its medium risk properties.519 The fire risk assessment programme for the low-risk properties started later, on 17 August 2011.520 Carl Stokes was appointed as the sole fire risk assessor for both programmes.521 He began the reviews of the fire risk assessments for the high-risk properties in about December 2010.522 Once the medium- and low-risk programmes had been completed, Carl Stokes was retained as the TMO’s sole fire risk assessor indefinitely until his contract was terminated in about November 2017.523 38.14 RBKC and TMO made a commitment to the LFB to evaluate the performance of the fire risk assessor at the end of the medium- and low-risk programmes, resources permitting, and to appoint a competent fire risk assessor to complete the assessments.524 The TMO, with the agreement of RBKC, conducted a procurement process for a fire risk assessor for the medium-risk properties in 2010.525 It did not carry out a further procurement exercise for the review of the assessments relating to the high-risk properties or for the programme relating to the low-risk properties.526 38.15 The procurement process that was carried out in 2010 and the decision to appoint Carl Stokes bears further examination. 517 Wray {Day140/175:24}-{Day140/177:5}. 518 Wray {TMO00000890/30} page 30, paragraph 135; Wray {Day140/174:1-5}. 519 {TMO00842327}; {CST00030040}. 520 {CST00030041}. 521 {CST00030041}; {CST00030040}; Wray {TMO00842341/3-4} pages 3-4, paragraphs 12-14. 522 Stokes {CST00003063/9-10} pages 9-10, paragraphs 25 and 26; Stokes {Day136/89:7-15}; Wray {Day140/216:14-20}; {CST00001926}. 523 Wray {TMO00842341/4} page 4, paragraph 15; Stokes {Day136/89:3-6}; {Day136/8:14-17}. 524 {LFB00031977/30-31}. 525 {TMO00842327}; Stokes {Day136/88:10-18}. 526 Wray {Day144/220:12-15}; Stokes {CST00003063/9-10} pages 9-10, paragraphs 25 and 26; Stokes {Day136/89:7-15}; Wray {Day140/216:14-20}.

Part 5 | Chapter 38: Fire risk assessments 69 The decision to appoint Carl Stokes 38.16 On 11 February 2010, Janice Wray sought funding and approval from Ann Muchmore to invite tenders for carrying out fire risk assessments in relation to the medium-risk properties.527 In May 2010, the TMO Operations Committee was told that it had been agreed between the TMO and RBKC that a new fire risk assessor should be appointed for the medium-risk programme by July 2010.528 38.17 On or around 6 August 2010, C S Stokes and Associates Ltd, Salvus, and three other companies were invited to tender for the medium-risk programme.529 The invitation included a consultants’ brief, which set out the proposed terms of the contract.530 It provided at paragraph 1.10 that the consultant’s appointment would be for a one year period with an option for the TMO to extend for a further year, subject to the consultant’s satisfactory performance.531 38.18 There was evidence to suggest that, even before the tender process had begun, Carl Stokes was undertaking fire risk assessments for the TMO. Invoices show that he had been carrying out fire risk assessments of areas of the TMO’s offices from as early as 22 June 2010 and 2 July 2010.532 There was no evidence to show that he had formally applied for that work or had taken part in any formal procurement process. Janice Wray could not explain why he had been conducting fire risk assessments for buildings in the TMO stock before the procurement process had started.533 She was adamant that she had not already decided to appoint him as the fire risk assessor534 and that it was to be a joint decision with RBKC.535 That may be so, but the episode does suggest that in some way Carl Stokes had an advantage in the procurement process. 38.19 On 22 June 2010, Carl Stokes met Janice Wray.536 He sent her a letter the following day setting out the matters they had discussed, including employee fire training, personal emergency evacuation plans (PEEPs) and the lift maintenance policy for buildings over 18 metres in height.537 When he gave evidence he said that they had discussed the nature of the information that he would include in his fire risk assessments and their discussions were reflected in the assessments he subsequently produced.538 Carl Stokes could not explain the reason for that meeting.539 Janice Wray suggested that he had only been seeking more information about the organisation and its policies and procedures.540 She thought he had been trying to create a good impression.541 Ms Wray did not meet any of the other applicants, nor did she tell any of them that she had provided Carl Stokes with the information set out in the letter.542 527 {RBK00053588/3}. 528 {TMO10037422/2}. 529 Wray {TMO00842341/2-3} pages 2-3, paragraphs 10 and 11. 530 Wray {TMO00842341/2-3} pages 2-3, paragraph 10; {TMO00842371}. 531 {TMO00842371/3}. 532 {CST00030111}; {CST00030077}. 533 Wray {Day141/15:19}-{Day141/17:8}. 534 Wray {Day141/17:9-21}. 535 Wray {Day141/17:9-21}. 536 {CST00001887}. 537 {CST00001887}. 538 Stokes {Day136/118:3-17}; {Day136/122:7-11}; Fire Risk Assessment for Grenfell Tower dated 29 December 2010 {CST00003181}. 539 Stokes {Day136/119:12-15}. 540 Wray {Day141/9:16}-{Day141/10:5}. 541 Wray {Day141/9:16}-{Day141/10:5}. 542 Wray {Day141/10:6-18}.

The Grenfell Tower Inquiry: Phase 2 Report 70 38.20 On the face of it, it appears that Carl Stokes was the favoured applicant because he had already carried out work for the TMO under its contract with Salvus and had continued to carry out work for it. 38.21 Carl Stokes submitted his tender on 24 August 2010.543 Thereafter, interviews were held with a panel of two officers of the TMO, Janice Wray and either Janet Rhymes or Valerie Sharples, and one officer of RBKC.544 38.22 Clause 1.5 of the consultants’ brief required the consultant to hold a current fire risk assessment qualification.545 Carl Stokes held a qualification from the Northern Ireland Fire Safety Panel, having gained a Fire Risk Assessment certificate on 12 December 2007.546 The consultants’ brief also required applicants to submit documentary evidence of their competence to undertake the appointment, in particular, their experience in assessing residential blocks.547 Carl Stokes submitted a pack of certifications but he did not provide any other details of his qualifications and experience.548 The only document that demonstrated his qualifications and experience was a statement in a pro forma fire risk assessment he submitted549 that read as follows: “Assessment completed by: Mr C Stokes, ACIArb, FPA Dip FP (Europe), Fire Eng (FPA), NEBOSH, FIA BS 5839 System Designer, Competent Engineer BS 5266, IFE Assessor/Auditor (FSO). 19 years Fire Safety experience with local Fire Authority, in enforcement and auditing roles, 3 years as an independent fire risk assessor. Member of the construction industry CPD certification Service. Professional Indemnity insurance cover provided by Hiscox. Enhanced C R B checked.” 38.23 Mr Stokes accepted in evidence that he had included that statement to lead the reader to think that he possessed the formal qualifications and professional body memberships set out in it.550 The purpose of including it was to advance his application to become the TMO’s fire risk assessor.551 38.24 The statement was false in a number of respects. All but one of the qualifications referred to either did not exist or were irrelevant or meaningless.552 The only one that was valid and correctly stated was “ACIArb”, indicating he was an associate of the Chartered Institute of Arbitrators, which had no bearing on fire safety.553 Carl Stokes also claimed to hold an “FPA Dip FP (Europe)”, which, although incorrect in abbreviation,554 was intended to convey that he had completed the Diploma in Fire Prevention awarded by the Confederation of Fire Protection Association, as indeed he had.555 Carl Stokes was neither registered nor certificated by any professional or certification body as competent to carry out fire risk assessments.556 He suggested that the post-nominals were meant to evidence 543 {CST00002368}. 544 {TMO00842327/1}; Wray {Day140/189:5-22}; Carl Stokes’s interview was held on 6 September 2010 {CST00003159}. 545 {TMO00842371/3} paragraph 1.5. 546 Stokes {CST00003063/5} page 5, paragraph 11; {TMO00880581/12}. 547 {TMO00842371/3} paragraph 1.4. 548 Stokes {Day 136/72:21}-{Day136/73:14}; {TMO00880581}. 549 Stokes {Day136/73:18}-{Day136/74:21}; Stokes {CST00003063/17} page 17, paragraph 50; {CST00003071}. 550 Stokes {Day136/75:5-21}. 551 Stokes {Day136/74:17-21}. 552 Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/55-58} paragraphs 6.45 and 6.46. 553 Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/55-56} paragraph 6.46. 554 The correct abbreviation is “CFPA(EU) Dip”. 555 Todd {Day167/66:24}-{Day167/67:7}; Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/51} paragraph 6.16; {CTA00000011/56} paragraph 6.46. 556 {CTA00000011/58} paragraph 6.47.

Part 5 | Chapter 38: Fire risk assessments 71 qualifications, training and experience required by the Fire Safety Order,557 but the fire safety training he had completed did not entitle him to invent qualifications and use them as he did in that statement.558 Mr Stokes accepted that he had known at the time that the statement was thoroughly misleading.559 38.25 His claim that at the time he had carried out the fire risk assessment on 21 August 2010 he had been an independent fire risk assessor for three years was also false. In fact, he had begun work as an independent fire risk assessor only 11 months earlier on 24 September 2009.560 He accepted that the statement about the extent of his experience had been misleading.561 38.26 Each of the fire risk assessments produced by Carl Stokes stated that he was “a member of the construction industry CPD certification service”, which, he explained, meant that he had attended “formal CPD designated training 2 or 3 times a year”, usually lasting for one day.562 As Mr Stokes was not registered or accredited by any professional body, he was under no requirement to undergo continuing professional development, but both Dr Lane and Mr Todd considered that even an unregistered fire risk assessor would be expected to undergo a certain amount of regular training.563 Mr Todd considered it necessary in order to keep up with new developments and to ensure that competence was maintained.564 As Dr Lane observed, some regular training is necessary to ensure that a fire risk assessor has sufficient skill and knowledge to do his job.565 38.27 There was evidence that Mr Stokes did undertake a mixture of formal and informal training which complemented his practice as a fire risk assessor, such as attending training days and lectures held by fire industry bodies, such as the Fire Industry Association.566 He did not keep a training log or any other written record of the training he had undertaken and was not required to do so.567 We saw no evidence that Carl Stokes consistently undertook any formal training on an annual basis during the years he was employed as the TMO’s fire risk assessor and we conclude that he did not.568 38.28 Janice Wray knew that Carl Stokes had elected not to join any professional bodies.569 When she raised it with him, he told her that he did not feel that he would gain anything from such memberships.570 On 1 February 2013, the Fire Risk Assessment Competency Council published A Guide to Choosing a Competent Fire Risk Assessor (the FRACC Guide) which recommended using fire risk assessment companies, including sole traders, who were “third party certificated to appropriate schemes operated by Certification Bodies which have been UKAS accredited to certificate against such schemes.”571 but it could not make registration or certification mandatory. The FRACC Guide listed the holders of registers, such as the British Standards Institution, the Institute of Fire Prevention 557 Stokes {Day136/77:11-15}. 558 Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/55-58} paragraph 6.46. 559 Stokes {Day136/81:24}-{Day136/82:6}. 560 Stokes {Day136/83:9}-{Day136/84:12}. 561 Stokes {Day136/84:13-15}. 562 Stokes {CST00030186/7} page 7, paragraph 25(iii). 563 Lane {Day171/27:20}-{Day171/28:9}; Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/46} paragraph 5.37. 564 {CTA00000011/46} paragraph 5.37. 565 Lane {Day171/27:20}-{Day171/28:9}. 566 Stokes {CST00030186/7-8} pages 7-8, paragraphs 25-27; Stokes {CST00030186/45-49} pages 45-49, Appendix 1. 567 Stokes {CST00030186/8} page 8, paragraph 26. 568 Stokes {CST00030186/7-8} pages 7-8, paragraphs 25-27; Stokes {CST00030186/45-49} pages 45-49; {CST00030191}. 569 Wray {TMO00000890/31} page 31, paragraph 139; Wray {Day140/197:17-19}. 570 Wray {TMO00000890/31} page 31, paragraph 139. 571 {HOM00025548/4}.

The Grenfell Tower Inquiry: Phase 2 Report 72 Officers (IFPO), the Institute of Fire Safety Managers, the Institution of Fire Engineers and Warrington Certificated Ltd.572 Carl Stokes was never registered with or certificated by any of those bodies. Janice Wray was aware of the FRACC Guide and was aware that Mr Stokes had chosen not to join any professional register,573 but she was not concerned.574 She thought that, as he had already demonstrated his competence in the work he had done for the TMO, the FRACC Guide did not demand that he be certificated.575 However, she thought it would apply to the appointment of any future fire risk assessor.576 38.29 Ms Wray said that she did not think that the interviewing panel (of which she had been a member) had considered Carl Stokes’s statements about his qualifications, but she thought they might have looked at a copy of his curriculum vitae,577 in which he had claimed to be a fire risk auditor and assessor accredited by the Institute of Fire Engineers, even though he had not been a member of the institute.578 She knew at the time that Carl Stokes used post-nominals to describe his qualifications, even though they were not genuine, but she was surprised to be told that some of the qualifications which he claimed to hold did not exist.579 His deliberately misleading description of his experience and qualifications demonstrate a lack of integrity and reliability on Mr Stokes’s part, but it is the failure of the TMO and RBKC to pay any serious attention to his supposed qualifications that represent the more serious failing, since it betrays a fundamental carelessness about fire safety matters in the housing stock for which they were responsible. 38.30 When the TMO evaluated the competing tenders Carl Stokes’s was rated first for quality; he also submitted the lowest price for a six-month programme.580 Overall his tender was just over £2,000 cheaper than that of his nearest competitor.581 He was thought to have the knowledge, competence, experience and enthusiasm to be a good partner.582 The fact that he was already known to the TMO because of his work with Salvus also weighed in his favour.583 38.31 The consultants’ brief required applicants to demonstrate that they were able to satisfy the provisions of a quality management system in accordance with BS EN ISO 9001,584 but Carl Stokes was not required to satisfy that provision.585 He ought to have been. He was to all intents and purposes a sole trader who had no quality management system or arrangements in place for peer reviewing his work.586 Janice Wray was not concerned about that or about the fact that his work for the TMO would not be supervised.587 She said that the LFB had still been heavily involved in scrutinising the TMO’s fire risk assessments and that she had expected it to raise any problems quickly.588 Moreover, she claimed to have challenged Mr Stokes’s fire risk assessments when she did not agree with them,589 572 {HOM00025548/5}. 573 Wray {TMO00000890/31} page 31, paragraph 139; Wray {Day140/197:17-19}. 574 Wray {Day140/199:7-14}. 575 Wray {Day140/200:2-15}. 576 Wray {Day140/197:22}-{Day140/200:16}. 577 Wray {Day140/190:17}-{Day140/193:22}; {CST00001895}. 578 {CST00001895}; Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/57} paragraph 6.46. 579 Wray {Day140/196:3-9}. 580 {TMO00842327/2}. 581 {TMO00842327/3}. 582 Wray {TMO00000890/31} page 31, paragraph 137. 583 Wray {TMO00000890/31} page 31, paragraph 137. 584 {TMO00842371/5} paragraph 3.2. 585 Stokes {Day136/86:2-21}. 586 Stokes {Day136/86:2-21}; {Day136/61:9-16}. 587 Wray {Day140/201:10-13}. 588 Wray {Day140/203:11-23}. 589 Wray {Day140/203:11-23}.

Part 5 | Chapter 38: Fire risk assessments 73 but that is of little significance, since she had no relevant expertise and was certainly not independent. In the end she was reassured by the fact that he had been recruited by Salvus and that he had been one of the principal assessors it had used to produce fire risk assessments on its high-risk buildings.590 She knew that he was familiar with many of the TMO’s buildings. She said he appeared to be extremely knowledgeable and she understood that everything he had done appeared to meet the requirements of the LFB.591 38.32 Ms Wray’s approach was not in itself contrary to the Fire Safety Order, given that there is no requirement under article 9 for the responsible person to commission an independent fire risk assessment, nor for the person carrying out a fire risk assessment to be qualified or competent,592 but it did create a risk that the resulting fire risk assessment would not meet the statutory requirement of being suitable and sufficient. No good reason was given to justify the failure of the TMO and RBKC to require Mr Stokes to show that he could satisfy the provisions of an appropriate quality management system in accordance with the consultants’ brief. 38.33 By the end of September 2010, Amanda Johnson had approved the appointment and confirmed the funding of the medium-risk programme.593 On 28 October 2010, Robert Black approved the appointment,594 although Carl Stokes had signed the contract seven days earlier.595 Laura Johnson was aware that the TMO obtained fire risk assessments because it was required to do so,596 but neither she nor anyone else in the RBKC Housing department received copies of them.597 Indeed, no one in the Housing department had the experience needed to analyse them or to challenge the TMO on their contents.598 38.34 On 25 November 2010, Janice Wray reported to the Operations Committee the completion of the high-risk programme and the appointment of Carl Stokes as fire risk assessor for the TMO’s medium risk properties.599 She explained that he was willing to challenge the LFB if he considered its requirements to go beyond what it could reasonably require.600 Clearly, Mr Stokes’s willingness to be an advocate for the TMO in disagreements with the LFB was a material factor in the decision to appoint him. The expansion of Carl Stokes’s retainer in December 2010 38.35 From December 2010 onwards, Carl Stokes carried out fire risk assessments for the TMO on its high-risk buildings.601 The TMO did not invite tenders for that work.602 Janice Wray believed she had taken advice from colleagues dealing with procurement, her line manager (Lornette Pemberton) and possibly RBKC before appointing Carl Stokes to review the fire risk assessments carried out the year before on high-risk buildings, but we have seen no evidence to support that.603 It had not originally been intended to appoint Carl Stokes to 590 Wray {Day140/201:10-25}. 591 Wray {Day140/202:12-15}; {Day140/202:20-25}. 592 See Chapter 12 for the examination of the role of government in regulating standards of competence in this area. 593 {TMO00842327/2}. 594 {TMO00842327/2}. 595 {CST00030040}. 596 Laura Johnson {Day129/79:16-19}. 597 Laura Johnson {Day129/70:16-22}. 598 Laura Johnson {Day129/71:4-15}. 599 Minutes of TMO Operations Committee meeting dated 25 November 2010 {RBK00052563/8}. 600 Minutes of TMO Operations Committee meeting dated 25 November 2010 {RBK00052563/8}. 601 Stokes {CST00003063/9-10} pages 9-10, paragraphs 25 and 26; Stokes {Day136/89:7-15}; Wray {Day140/216:14-20}; {CST00001926}. 602 Wray {Day140/216:14-16}. 603 Wray {Day140/215:7-15}; {Day140/216:14-20}; {Day140/217:15}-{Day140/218:14}.

The Grenfell Tower Inquiry: Phase 2 Report 74 carry out that work604 but the need to review the assessments of the high-risk properties and the pressure of time led to a decision not to invite fresh tenders.605 Neither the TMO nor RBKC had established a programme for the regular review of the fire risk assessments on high-risk buildings at the conclusion of the first programme in March 2010. As a result, the need for the reviews had been overlooked and there was no proper recruitment or selection process.606 No written contract was entered into with Carl Stokes, who took over the work on an informal basis.607 Janice Wray could not recall whether the appointment had been approved by the TMO executive team or RBKC or how the funding for it had been obtained.608 The TMO simply drifted unthinkingly into a broader retainer of Carl Stokes without any formalities. 38.36 When the programme of fire risk assessments on medium-risk buildings had been completed, the low-risk programme began. Carl Stokes was appointed to carry it out.609 Sacha Jevans approved his appointment610 and Mr Stokes signed the contract on 24 August 2011.611 The programme was completed in May 2012, well before the LFB’s deadline of July 2012.612 38.37 Once the programmes covering the medium and low-risk buildings had been completed, the TMO continued to retain Carl Stokes as its fire risk assessor but did not enter into any new contracts with him.613 He became responsible for carrying out fire risk assessments on all 650 properties managed by the TMO.614 He did not work exclusively for the TMO but it was his biggest client, having more buildings under its management than any other.615 Robert Black was aware that Carl Stokes had been retained but he did not know that his continued appointment had not been subject to a further procurement process.616 He had assumed that a formal procurement process of some kind had taken place and accepted that the failure to keep him informed pointed to a defect in the reporting processes and governance of the TMO.617 38.38 Carl Stokes was allowed, therefore, to drift into his role as the sole fire risk assessor for 650 properties, many of which were high-rise buildings, without any regard to formal selection or contracting processes. That was not a proper or safe way for either the TMO or RBKC to seek to discharge their duties under the Fire Safety Order and it created a risk that the standard of the fire risk assessments produced as a result might not meet the statutory requirement. 604 Wray {Day140/218:15-20}. 605 Wray {Day140/216:21}-{Day140/217:15}. 606 Wray {Day140/217:8-18}. 607 Wray {Day140/219:7-10}; Stokes {CST00003063/10} page 10, paragraph 26. 608 Wray {Day140/218:21}-{Day140/219:5}. 609 {TMO00842318}. 610 Wray {TMO00842341/3} page 3, paragraph 14; {TMO00842378}. 611 {CST00030041}. 612 {TMO10031056/2} paragraph 3.2. 613 Stokes {CST00003063/10} page 10, paragraph 26. 614 Wray {Day140/207:20}-{Day140/208:8}. 615 Stokes {Day136/9:8-9}. 616 Black {Day150/17:2-17}. 617 Black {Day150/18:3-16}.

Part 5 | Chapter 38: Fire risk assessments 75 Carl Stokes’s work as the TMO’s fire risk assessor 38.39 Part 2 of the consultants’ brief set out the scope of the work in relation to fire risk assessments that Carl Stokes had undertaken to carry out. Paragraph 1.1 of Part 2 required fire risk assessments to be undertaken and reviewed as regularly as the degree of risk dictated. It also required fire risk assessments to include an examination of each communal fire door.618 38.40 Paragraph 1.3 of Part 2 of the brief instructed the fire risk assessor to focus on a building’s compartmentation (and any possible shortcomings), the operation and adequacy of fire doors, firefighting equipment and automatic detection and other systems, the means of escape, fire safety management systems and the overall fitness for purpose of the building in relation to fire safety.619 38.41 Janice Wray and Carl Stokes operated on the understanding that his work was always governed by the terms of the original contract, including the consultant’s brief, even after his formal contracts for the programmes of fire risk assessments in relation to medium and low-risk buildings had come to an end.620 38.42 The LGA Guide described four kinds of fire risk assessment: Type 1 – Common parts only (non-destructive); Type 2 – Common parts only (destructive); Type 3 – Common parts and flats (non-destructive); and Type 4 – Common parts and flats (destructive).621 Mr Stokes told us that he had carried out ‘Type 1’ assessments with elements of ‘Type 3’.622 (He had carried out that hybrid type of fire risk assessment before the LGA Guide was published in July 2011.)623 The LGA Guide stated that unless there was reason to expect serious deficiencies in structural fire protection, such as inadequate compartmentation, or poor fire stopping, a Type 1 inspection would normally be sufficient for most purpose-built blocks of flats.624 38.43 On one reading of the Fire Safety Order, Carl Stokes was required to consider only the common parts of the building when carrying out a fire risk assessment.625 In the case of purpose-built blocks of flats, like Grenfell Tower, that meant inspecting the lift-lobby areas of each floor, the refuse chute rooms, the staircase enclosure and both sides of the entrance doors to the flats, but not the interiors of individual flats.626 It was his practice also to report any problems with access to properties.627 He was not expressly instructed to consider the external walls of the properties he inspected628 and there was nothing in the LGA Guide to suggest that he should do so, unless there was reason to think that they might affect the compartmentation of the building. 618 {TMO00842371/6} paragraph 1.1. 619 {TMO00842371/6} paragraph 1.3. 620 Stokes {CST00003063/10} page 10, paragraph 26; Stokes {Day136/89:25}-{Day136/90:8}; Wray {Day140/220:1-25}. 621 {HOM00045964/44-46} paragraph 35.1. 622 Stokes {CST00003063/16} page 16, paragraph 47. 623 Stokes {CST00003063/16} page 16, paragraph 47. 624 {HOM00045964/45} paragraph 35.1. 625 Stokes {CST00003063/13} page 13 paragraph 36; Wray {TMO00000890/31} page 31, paragraph 140. 626 Stokes {CST00003063/15-16} pages 15-16, paragraphs 43 and 44; {HOM00045964/44} paragraph 34.1; Stokes {Day136/94:2-18}. 627 Wray {Day140/236:20-25}. 628 Wray {Day141/1:18-22}.

The Grenfell Tower Inquiry: Phase 2 Report 76 38.44 Carl Stokes’s practice in relation to Grenfell Tower was to carry out a primarily visual inspection. He also carried out some additional inspection of the inside of front doors where he could gain access.629 In those circumstances, he checked the self-closer and whether a domestic fire alarm system was fitted.630 In 2015, he was also asked to check the heat interface units.631 38.45 Mr Stokes agreed that for the purposes of making a Type 1 fire risk assessment he had to gain access to some flats in order to inspect the entirety of the entrance door, including the strips and smoke seals and self-closing device, if fitted.632 38.46 PAS 79:2012, published by the British Standards Institution, contained the standards for carrying out fire risk assessments as they existed at the time of the Grenfell Tower fire. Paragraph (i) of the commentary on clause 16 says that fire safety management should be regarded as of equal importance to fire protection measures.633 Clause 16 of PAS 79 required that, among other matters, any shortcomings in evacuation procedures should be identified.634 Carl Stokes was familiar with those provisions. 38.47 Mr Stokes assessed the TMO’s fire safety management systems as part of his fire risk assessments on a continuing basis and expected Janice Wray to tell him if the TMO had changed its policies or procedures.635 He was aware of the need to consider the arrangements for maintaining all the fire prevention measures required under the Fire Safety Order.636 38.48 Carl Stokes frequently gave the TMO advice about matters relating to fire safety. For example, he might be asked whether matters he had raised in his fire risk assessment and action plans had been remedied or to provide comments or advice on discrete issues.637 He gave advice on matters such as the TMO’s programme for the replacement of flat doors, potentially non-compliant entrance doors to leaseholder’s flats and work on the gas supply and was asked to inspect and assess the front doors of particular flats.638 In December 2016 and July 2017 he provided training to the Estate Service Assistants.639 38.49 Carl Stokes was never appointed to advise on the refurbishment of Grenfell Tower, although he occasionally provided advice to the TMO and Rydon about matters relating to the refurbishment.640 When Janice Wray wanted his advice on a particular matter she usually asked him to produce a report, which she then provided to the Asset Management team.641 Sometimes Claire Williams instructed him directly,642 for example, if she wanted a second opinion on a matter or if the project team wanted him to produce a report.643 629 Stokes {CST00003063/16} page 16, paragraph 48. 630 Stokes {CST00003063/16} page 16, paragraph 48. 631 Stokes {CST00003063/16} page 16, paragraph 48. 632 Stokes {Day136/94:2-25}. 633 {CTA00000003/50} clause 16, commentary, paragraph (i). 634 {CTA00000003/54} clause 16.3. 635 Stokes {Day136/164:3-15}. 636 {HOM00045964/44} paragraph 34.5; Stokes {Day136/101:25}-{Day136/102:10}. 637 Stokes {CST00003063/10} page 10, paragraph 28. 638 Stokes {CST00003063/29-33} pages 29-33, paragraphs 87-94; Stokes {CST00003063/47-48} pages 47-48, paragraphs 137-141; Wray{Day140/223:5-6}; {CST00000932}. 639 Stokes {CST00030186/9} page 9, paragraphs 28-32. 640 Stokes {CST00003063/11} page 11, paragraph 30(iv); Minutes of Grenfell Tower Progress Meeting No.22 dated 19 April 2016 {TMO10045055/2} Item 2.6. 641 Wray {TMO00000890/9} page 9, paragraph 44. 642 Wray {Day141/2:24}-{Day141/3:6}. 643 Wray {Day141/2:12-20}.

Part 5 | Chapter 38: Fire risk assessments 77 During the course of the refurbishment he provided advice in relation to the smoke vents and lifts, rights of way to Grenfell Tower, the heating interface units, floor numbering and premises information boxes.644 Frequency of fire risk assessments 38.50 Carl Stokes carried out fire risk assessments on the properties managed by the TMO as instructed by Janice Wray.645 Initially, she sent him a list of the properties requiring inspection in November each year and he assessed the buildings during the course of the following year.646 38.51 The TMO’s fire safety strategy acknowledged that fire risk assessments could not remain valid indefinitely.647 It required fire risk assessments to be reviewed periodically in various circumstances.648 In the case of high-risk buildings, reviews were required annually and a new assessment every three years.649 In the case of medium or low-risk buildings, the intention was to carry out reviews on a two-yearly basis with a new assessment every four years.650 In practice, new fire risk assessments of Grenfell Tower, which was a potentially high-risk block, were made at least every two years. Two were carried out in 2016.651 38.52 The reviews of the fire risk assessments were carried out by the TMO Health and Safety team, primarily by Adrian Bowman.652 Their purpose was to monitor whether the measures recommended by Carl Stokes had been completed and to check for obvious changes to the building. That included anything that would cause an increased level of risk, such as anti-social behaviour or work being carried out on site, of which the TMO was unaware.653 Adrian Bowman used the Significant Findings and Action Plans that Carl Stokes had submitted with the fire risk assessments to record whether remedial measures had been completed.654 Meetings with Carl Stokes 38.53 Before he started work Carl Stokes met Janice Wray on two occasions to obtain information, once on 22 June 2010 and once on 24 September 2010. 38.54 In a letter to Janice Wray following their meeting on 22 June 2010, Carl Stokes asked her to send him a copy of the fire safety report produced by Salvus655 “to back up any fire related issues that may be raised in some of the reports”.656 On 28 September 2010 Ms Wray sent Mr Stokes a copy of the report and action plan.657 He told us that he assumed that he had 644 Wray {TMO00000890/10-14} pages 10-14, paragraphs 45-64; {CST00000894}; Stokes {CST00030186/43-44} paragraphs 167-172; Stokes {Day136/140:5}-{Day136/162:14}; {CST00003088}; {CST00003173}; {CST00001258}; {TMO10043487}. 645 Stokes {Day136/129:5-9}. 646 Stokes {CST00003063/17} page 17, paragraph 51. 647 {TMO00830598/9} paragraph 14.3.1. 648 {TMO00830598/9} paragraph 14.3.1. 649 {TMO00830598/10} paragraph 14.3.4. 650 {TMO00830598/10} paragraph 14.3.5. 651 Fire Risk Assessment of Grenfell Tower dated 29 December 2010 {CST00003181}; Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084}; Fire Risk Assessment of Grenfell Tower dated 26 April 2016 {CST00003161}; Fire Risk Assessment of Grenfell Tower dated 20 June 2016 {CST00003145}. 652 {TMO00830598/10} paragraph 14.3.3; Wray {Day140/233:6-16}. Janice Wray’s “colleague” in the TMO Health and Safety team was Adrian Bowman: Wray {Day140/212:24}-{Day140/213:2}. 653 Wray {Day140/232:14-23}. 654 Wray {Day140/212:18}-{Day140/213:2}; Wray {Day140/233:6-15}. 655 {CST00001887/2}. 656 {CST00001887/2}. 657 {CST00004383}; {SAL00000013}.

The Grenfell Tower Inquiry: Phase 2 Report 78 read it, but could not remember having done so.658 If he did read it, however, it appears to have made very little impression on him. He did not recall having become aware of the weaknesses in the TMO’s fire safety management system or the 19 statutory breaches that had been identified in the Salvus report.659 Janice Wray, for her part, expected him to read the report and to ask her about any outstanding items and when they would be completed. However, she could not recall any such conversation with him660 and there is no evidence one ever took place. Carl Stokes does not appear to have taken any steps to find out whether the TMO had resolved, or planned to resolve, the statutory breaches identified in the report. We find that very surprising, given the widespread and significant failings identified by Salvus and the effect they must have had on the risk to the TMO’s properties.661 38.55 A number of matters were discussed between Carl Stokes and Janice Wray at their meeting on 24 September 2010, some of which had already been covered in the meeting on 22 June 2010.662 The information Mr Stokes obtained on that occasion did not relate to any particular building,663 but he used it to fill out the fire risk assessments relating to various buildings.664 Not once during the seven years that he subsequently acted as the TMO’s only fire risk assessor did he seek or obtain current information about the matters covered in the letters of 23 and 27 September 2010. Carl Stokes’s methods 38.56 The method adopted by Carl Stokes for carrying out fire risk assessments reflected the Health and Safety Executive’s five steps for managing risks and PAS 79665 He explained that in his fire risk assessments for 2009 and 2010 he had kept in mind the guidance in the government’s publication Fire Safety Risk Assessment – Sleeping Accommodation and, following its publication in July 2011, LGA Guide.666 38.57 When Carl Stokes undertook a fire risk assessment, he obtained information from Janice Wray about the nature of the common parts and the active and passive fire safety measures they contained.667 He asked for any reports of the testing of dry risers or any other services in the building.668 He obtained maintenance and servicing records from the TMO’s management system, Keystone, or by asking the maintenance department for them.669 If he could not obtain the information he needed, he drew attention to its absence in the action plan.670 658 Stokes {Day136/176:1}-{Day136/178:18}. 659 Stokes {Day136/176:1}-{Day136/178:18}. 660 Wray {Day140/127:18}-{Day140/129:5}. 661 Stokes {Day136/177:11}-{Day136/179:6}. 662 {CST00003061}; {CST00001887}. 663 Stokes {Day136/220:21-25}. 664 Stokes {Day136/125:14-20}. 665 Stokes {CST00003063/13} page 13, paragraph 35; {CTA00000003}; {RBK00036722/13}; https://www.hse.gov.uk/simple-health-safety/risk/steps-needed-to-manage-risk.htm. 666 Stokes {CST00003063/13} page 13, paragraph 35; {RBK00036722}; {HOM00045964}. He would apply the HM Government Guide for Offices and Shops to the office part of Grenfell Tower: Stokes {CST00003063/13} page 13, paragraph 35(iii). 667 Stokes {CST00003063/18} page 18, paragraph 55(i). 668 Stokes {Day136/129:12-20}. 669 Stokes {CST00003063/22} page 22, paragraph 67; {TMO00859318}; Stokes {Day136/131:15}-{Day136/133:19}; Parsons {TMO00870938/2} page 2, paragraph 10. 670 Stokes {Day136/133:21-24}.

Part 5 | Chapter 38: Fire risk assessments 79 38.58 If Mr Stokes had completed a fire risk assessment for a building previously, he usually reviewed the last Action Plan and checked whether the remedial measures had been completed.671 The check did not go much beyond a tour of the building and a look at the TMO’s records (including what he described as “tick sheets”) which showed what had been done since his last assessment.672 Janice Wray did not recall his ever asking her for completed action plans or sending him the action plan sheets and she could not recall a tick sheet at all.673 We saw no health and safety tick sheets nor any evidence that he was sent completed action plan sheets. We have concluded that when drawing up the latest fire risk assessment he had little information before him about which of the remedial measures he had recommended in his previous fire risk assessment had been completed and which had not and why. 38.59 When he visited a building for a fire risk assessment, Mr Stokes inspected it and spoke to anyone he met, such as residents or contractors.674 In the assessment he set out the names of those he had consulted, which would often be Janice Wray, one of the Estate Service Assistants or Claire Williams.675 He asked for certificates and records when the opportunity to do so arose.676 If work had been carried out by third parties, he would rely on their records.677 He thought that the first fire risk assessment of a building took about four hours to complete and four hours to write up; it would take him less time to carry out a review of an existing assessment.678 He then prepared his fire risk assessment and a document entitled “Significant Findings and Action Plan”.679 After his inspection he could request additional information but often he would draw attention to any missing information in the Action Plan.680 38.60 If he was concerned about a particular matter, Carl Stokes included it in his Action Plan, which identified the risk or hazard and the remedial action to be taken.681 He categorised the item of the significant findings as of high, medium or low priority. The Action Plan was set up as a checklist for the use of the TMO.682 38.61 Carl Stokes set out his findings in a fire risk assessment that followed a standard template approved by the TMO, RBKC and the LFB before the start of work on the medium-risk properties.683 At the time he entered into the contract on 21 October 2010 to carry out fire risk assessments on the medium risk properties Mr Stokes understood that copies would be provided to the LFB.684 671 Stokes {CST00003063/23} page 23, paragraph 68; Stokes {Day136/145:7}-{Day136/146:5}; For an example see: Record of Significant Findings and Action Plan for Grenfell Tower dated 26 April 2016 with handwritten notes {CST00000003}. 672 Stokes {Day136/129:12-20}; {Day136/147:21}-{Day136/148:16}. 673 Wray {Day140/232:25}-{Day140/233:23}. 674 Stokes {CST00003063/18} page 18, paragraph 55(ii); Stokes {Day136/202:16-24}. 675 For example, see Fire Risk Assessment of Grenfell Tower dated 29 December 2010 {CST00003181/3}; Fire Risk Assessment of Grenfell Tower dated 26 April 2016 {CST00003161/3}. 676 Stokes {Day136/69:11-16}. 677 Stokes {CST00003063/22} page 22, paragraph 67(iii). 678 Stokes {Day136/66:19-20}; {Day136/185:7-15}; {Day136/186:7-10}. 679 Stokes {CST00003063/19} page 19, paragraph 55(iv); Stokes {Day136/143:8-16}. 680 Stokes {CST00003063/18} page 18, paragraph 55(iii); Stokes {Day136/143:8-16}. 681 Stokes {CST00003063/23} page 23, paragraph 68. 682 Stokes {CST00003063/23} page 23, paragraph 68. See for example, Record of Significant Findings and Action Plan for Grenfell Tower dated 17 October 2014 {CST00003177}. 683 Stokes {CST00003063/16} page 16, paragraph 45; Stokes {CST00003063/9} page 9, paragraph 24(iii); Stokes {CST00003063/17} page 17, paragraph 50; {TMO00842371/6} section 1.4; {RBK00029052/2}. 684 Stokes {CST00003063/17} page 17, paragraph 50.

The Grenfell Tower Inquiry: Phase 2 Report 80 Carl Stokes’s fire risk assessments for Grenfell Tower 38.62 Carl Stokes carried out fire risk assessments of Grenfell Tower on 29 December 2010,685 20 November 2012,686 17 October 2014,687 26 April 2016688 and 20 June 2016.689 In each case he identified the chief executive of RBKC as the responsible person,690 although he did not provide any of his assessments directly to RBKC.691 In fact, he had no contact with anyone at RBKC.692 38.63 Provided nothing had changed, Mr Stokes’s practice was to copy text from one fire risk assessment of Grenfell Tower to the next.693 He also copied text from fire risk assessments of other buildings. For example, in the fire risk assessment for Grenfell Tower dated 17 October 2014, he included some text referring to balconies taken from the assessment of another building, even though there were no balconies at Grenfell Tower.694 The passage was then repeated in his fire risk assessment dated 26 April 2016.695 Similarly, in section 11 of his fire risk assessments, he always included a passage headed “Pest control”. In the fire risk assessment for Grenfell Tower dated 17 October 2014 he reported on the condition of pigeon netting on the balconies,696 although there were no balconies on Grenfell Tower. That was simply lazy and careless and undermined the authority and quality of the fire risk assessment. Thoughtless drafting of that kind was bad enough, but it was aggravated by the fact that the same inapposite information was repeated in the fire risk assessments dated 26 April 2016 and 20 June 2016.697 Carl Stokes explained that the information had been repeated in those assessments because he knew that nothing had changed in relation to pest control and had not read the section again.698 He did not read through those fire risk assessments before sending them to the TMO,699 which Mr Todd described as very bad practice.700 We agree. 38.64 What is worse, nobody at the TMO noticed those inapposite observations that had clearly been transposed from fire risk assessments on other buildings. That strongly suggests that Janice Wray did not read the fire risk assessments with any degree of care. If she had too many things on her desk to read and digest, she ought to have asked for help. In her own words, she was “spread very thinly”, as she had responsibility for 650 buildings across the whole of the borough.701 Failing to read such important documents with due care reflected the TMO’s casual approach to fire safety. 685 Fire Risk Assessment of Grenfell Tower dated 29 December 2010 {CST00003181}; Significant Findings and Action Plan dated 29 December 2010 {CST00003165}. 686 Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084}; Significant Findings and Action Plan dated 20 November 2012 {CST00003083}. 687 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157}; Significant Findings and Action Plan dated 17 October 2014 {CST00003177}. 688 Fire Risk Assessment of Grenfell Tower dated 26 April 2016 {CST00003161}; Significant Findings and Action Plan dated 26 April 2016 {CST00003098}. 689 Fire Risk Assessment of Grenfell Tower dated 20 June 2016 {CST00003145}; Significant Findings and Action Plan dated 20 June 2016 {CST00003069}. 690 See for example, Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/3}. 691 Stokes {Day136/191:10}-{Day136/193:9}. 692 Stokes {Day136/193:10-13}. 693 Stokes {Day136/187:4-17}. 694 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/1}. 695 Fire Risk Assessment of Grenfell Tower dated 26 April 2016 {CST00003161/1}. 696 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/18}. 697 Fire Risk Assessment of Grenfell Tower dated 26 April 2016 {CST00003161/19}; Fire Risk Assessment of Grenfell Tower dated 20 June 2016 {CST00003145/20}. 698 Stokes {Day136/190:23}-{Day136/191:4}. 699 Stokes {Day136/191:5-7}. 700 Todd {Day167/78:21-24}. 701 Wray {Day140/48:12-20}.

Part 5 | Chapter 38: Fire risk assessments 81 38.65 Carl Stokes included a section headed “Legal statement” in every fire risk assessment for Grenfell Tower. In it he told the recipient (in this case the TMO), among other things, that it did not have to give a copy to anybody, not even the fire authority, and that, if it did so, the document could be used against it at a later date.702 38.66 Mr Stokes explained that he included that statement in his fire risk assessments because it was his understanding that the Fire Safety Order required the responsible person only to record the significant findings and make them available for inspection.703 As there was no requirement to record the risk assessment itself, he considered that there was no obligation to produce it to the fire service.704 He considered that a fire risk assessment that was critical of the fire safety arrangements could be used against the responsible person at a later date.705 Colin Todd thought that the statement was unnecessary, confrontational and wrong in law, given that the local fire and rescue service as the enforcing authority has extensive powers under article 27 of the Fire Safety Order to obtain information and documents relating to compliance with the Order.706 Again, we agree. Quality management and auditing 38.67 Carl Stokes did not operate a quality management system or peer review process. A one‑man company can implement a quality management system and can also be certificated under BS EN ISO 9001.707 The absence of a quality management system was a structural weakness in Carl Stokes’s business and the absence of such a system in relation to a company that was the only fire risk assessor for the TMO’s entire portfolio of 650 buildings was a structural weakness in the TMO’s fire risk management system.708 38.68 Janice Wray placed an undue amount of trust and confidence in Mr Stokes’s ability to carry out sufficient and suitable fire risk assessments. Although she claimed to have read every fire risk assessment and action plan (which, for reasons explained above, we doubt she did with any care) and although she sometimes challenged Carl Stokes when she did not agree with him, she did not monitor the technical quality of his documents709 and could not have done so, since she had neither the necessary technical expertise nor the time to do it. As we have already mentioned, she was overworked as it was.710 However, it was a significant failure on the part of the TMO not to monitor the quality of the work done by Mr Stokes as the sole provider of fire risk assessments for its portfolio of buildings.711 38.69 The Publicly Available Specification “PAS 7:2013 entitled Fire risk management system – Specification” (PAS 7), published by the British Standards Institution in June 2013, contained guidance on the requirements for establishing a fire risk management system by which an organisation can put in place the practical steps required to carry out its fire 702 See for example, the Fire Risk Assessment of Grenfell Tower dated 20 June 2016 {CST00003145/2}. 703 Stokes {Day136/199:5-10}; Stokes {CST00003063/24} page 24, paragraph 70. 704 Stokes {CST00003063/24} page 24, paragraph 70(ii). 705 Stokes {CST00003063/24} page 24, paragraph 70(iii). 706 Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/76} paragraph 8.15. 707 Todd {Day167/72:2-10}; Lane {Day171/32:8}-{Day171/33:2}. 708 Todd {Day167/73:16}-{Day167/74:20}. 709 Wray {Day140/47:10-15}; {Day140/203:11-23}; Lane, Fire Safety Investigation Module 3 Report {BLARP20000027/145} paragraph 8.4.5. 710 Wray {Day140/48:12-20}. 711 Lane, Fire Safety Investigation Module 3 Report {BLARP20000027/145} paragraphs 8.4.5 and 8.4.6.

The Grenfell Tower Inquiry: Phase 2 Report 82 safety policy.712 It suggested that an organisation should audit its fire risk assessment programme after fire risk assessments had been delivered and conduct review meetings at planned intervals to discuss the results of the audits.713 38.70 Janice Wray was familiar with the provisions of PAS 7 but she did not arrange for the fire risk assessment programme to be audited.714 Her excuse was that she could not find the time to do it and that she had received a degree of reassurance from the fact that the LFB had been asking questions about some of the fire risk assessments that had led her to understand that they were of a suitable and sufficient standard.715 She accepted, however, that she should have arranged an audit and that she could not rely on the enforcement authority to act as an auditor.716 Ms Wray could not recall ever having raised the question of auditing the fire risk assessment programme with Barbara Matthews, although she admitted that she should have done so.717 Again, we agree. 38.71 Robert Black never gave any thought to whether a sole trader could properly act as the fire risk assessor for 650 buildings.718 Nor did he ever consider specifically whether Janice Wray had sufficient resources to carry out her fire safety responsibilities properly.719 He simply never brought his mind to bear on how the TMO, as the responsible person with statutory obligations, was actually setting out to discharge them. That indicates a lack of interest in matters of fire safety and explains his failure to exercise sufficient control over such matters. It also goes a long way to explain the casual approach to fire safety of the TMO as an organisation. External concerns 38.72 In her first witness statement Janice Wray said that, as far as she could remember, the LFB had never commented on fire risk assessments produced by Carl Stokes in such a way as to give the TMO any reason to doubt his competence or the quality of the assessments themselves.720 In fact, however, that was not the case. There were many occasions when both Mr Stokes’s competence and the quality of his fire risk assessments were called into question, not only by the LFB but also by others. In the end, Janice Wray was not only constrained to admit that her statement was incorrect, but was unable to provide any credible explanation of how she had come to make it.721 On this aspect of our investigations, therefore, we have been able to place little weight on her evidence. Concerns expressed by the LFB 38.73 During the last quarter of 2015, two of the LFB’s fire safety inspecting officers, Julie-Anne Steppings and Michelle McHugh, told Rebecca Burton, the leader of the LFB’s Fire Safety Team for Hammersmith, Fulham, Kensington and Chelsea, of the concerns they had about the approach taken in fire risk assessments produced by Carl Stokes for the TMO.722 As a result, between November 2015 and September 2016, she raised the matter with the TMO on a number of occasions. 712 {LFB00116924/1-7}. 713 {LFB00116924/23} paragraphs 7.4.3 and 7.4.4. 714 Wray {Day145/12:6-21}. 715 Wray {Day145/14:9}-{Day145/15:25}. 716 Wray {Day145/14:9}-{Day145/16:6}. 717 Wray {Day145/13:15-20}. 718 Black {Day150/19:9-12}. 719 Black {Day150/19:13}-{Day150/21:12}. 720 Wray {TMO00000890/36} page 26, paragraph 158. 721 Wray {Day144/200:3}-{Day144/201:2}. 722 Burton {Day145/119:1-4}; Burton {LFB00084098/12-13} pages 12-13, paragraph 24.

Part 5 | Chapter 38: Fire risk assessments 83 38.74 Among the concerns identified by Rebecca Burton were that Carl Stokes would rely on inspections by the LFB and undocumented discussions and agreements with LFB personnel as support for his assessments.723 She did not think that he was providing the TMO with suitable and sufficient fire risk assessments and considered that the matter needed to be addressed.724 She also highlighted a tendency on his part when carrying out a fire risk assessment to select the most convenient parts of different documents rather than identify the most suitable guide and apply it in full to the premises in question.725 Meeting between Janice Wray and Rebecca Burton on 13 November 2015 38.75 On 13 November 2015, a meeting took place between Janice Wray and Rebecca Burton following the fire that had occurred at Adair Tower on 31 October 2015. Neither of them kept a contemporaneous note of their discussions, but at different times each of them described the substance of them in emails to their respective superiors. 38.76 On 13 November 2015, Janice Wray sent a long email to Robert Black, Barbara Matthews and Sacha Jevans, in which she described the review being carried out by the LFB for the purposes of deciding whether to issue an enforcement notice. She referred to a number of questions that had been raised by Ms Burton, none of which had been critical of the fire risk assessment. She did not mention agreeing to raise any concerns with Carl Stokes.726 38.77 On 5 May 2016, Rebecca Burton reported what had transpired in an email to her superior, Spencer Sutcliff, when discussing the review. She said that various areas of concern about fire risk assessments had been discussed with Janice Wray, including the assessor’s approach to self-closing devices on flat entrance doors generally, his claim that the LFB had agreed that self-closing devices were not required on flat entrance doors and the failure of his fire risk assessment to reflect an understanding of the strategy for the building and how occupants were to be kept safe in the event of fire.727 Although he is not mentioned by name, it is obvious that when she referred to the fire risk assessor she was referring to Carl Stokes. She went on to record that Janice Wray had agreed to consider each of those points and discuss with Mr Stokes what improvements could be made.728 38.78 The difference between the two accounts no doubt reflects the authors’ different interests but is striking, nonetheless. However, any difficulty we might otherwise have had in deciding whether Ms Burton did in fact voice criticisms of the fire risk assessment was resolved by Ms Wray’s admission that during the meeting Ms Burton had indeed raised the matters to which she had referred in her email.729 Ms Wray said that she had raised them with Carl Stokes, but we cannot be confident that she did, since there is no record of any such discussion.730 That itself is a matter for criticism, since, if the LFB had serious concerns about Carl Stokes, she ought to have made a record of when and how she had raised those matters with him. 723 Burton {LFB00032331/4-5} pages 4-5, paragraph 11. 724 Burton {LFB00032331/5} page 5, paragraph 11. 725 Burton {LFB00084098/7-8} pages 7-8, paragraph 11; {LFB00003439/1}. 726 {TMO10011001}. 727 {LFB00003445/1}. 728 {LFB00003445/1}. 729 Wray {Day144/204:2-4}. 730 Wray {Day144/204:9-16}.

The Grenfell Tower Inquiry: Phase 2 Report 84 38.79 Barbara Matthews was also well aware of the LFB’s views about Carl Stokes’s fire risk assessments.731 On 30 November 2015, Barbara Matthews had a telephone conversation with Rebecca Burton, during which they discussed the proposed enforcement notices for Adair and Hazlewood Towers. According to her note of the call, Barbara Matthews was told by Rebecca Burton that the fire risk assessments for Adair and Hazelwood Towers were not suitable and sufficient, that Carl Stokes had not considered the question of smoke ventilation and that his risk assessments were not comprehensive.732 Barbara Matthews told us that she had thought that Rebecca Burton was criticising only the particular fire risk assessments under discussion and not his overall performance733 but she had no reason to believe that the defects that the LFB had highlighted were limited to those assessments and certainly should not have assumed that that was the case without further investigation. 38.80 On 4 December 2015, Barbara Matthews wrote to the TMO board to provide a report on the Adair Tower fire.734 She said that the LFB had confirmed that it would serve enforcement notices in respect of Adair and Hazlewood Towers.735 She explained that the LFB had advised the TMO of what she called “key matters of concern”, specifically smoke ventilation and the absence of self-closing devices on flat entrance doors, but she made no reference to the direct criticism of Carl Stokes’s fire risk assessments that Rebecca Burton had made during their conversation on 30 November 2015, less than a week earlier.736 Nor, strikingly, did she refer to the service of the deficiency notice in relation to Adair Tower on 12 October 2015, a point which is considered elsewhere in this report. 38.81 Barbara Matthews could not explain why she had failed to include in her report any reference to the criticism of Carl Stokes’s fire risk assessments, but in hindsight she accepted that she should have drawn it to the board’s attention.737 Her failure to do so was consistent with the desire of Robert Black and the executive team as a whole to keep any bad news about fire safety away from the board. 38.82 Rebecca Burton again raised her concern about Carl Stokes with the TMO at their bi‑monthly meeting on 5 January 2016. The minutes record that she told the meeting that Carl Stokes was prone to making statements that were not justified or supported and that he needed to provide support for what he said. If he referred to discussions with the LFB he needed to identify with precision in each case when they had taken place, who had been parties to them and what had been the outcomes.738 Janice Wray agreed to raise the issues identified by Rebecca Burton with Carl Stokes. Janice Wray told us that she did speak to him,739 but the outcome is not clear and there is certainly no evidence that Carl Stokes’s approach improved or that he absorbed the LFB’s criticisms. 38.83 On 31 March 2016 there was a meeting of the TMO board at which Barbara Matthews described the progress of the enforcement notices relating to Adair and Hazlewood Towers.740 At the meeting, Jeff Zitron, a board member nominated by the council, asked why enforcement notices had been issued, given that at the time of the fire 731 Wray {Day144/206:4-17}. 732 Barbara Matthews’ notebook, entry date 30 November 2015 {TMO00880324/31}. Rebecca Burton confirmed the note as an accurate record of the discussion: Burton {Day145/126:10-14}. 733 Matthews {Day148/75:23}-{Day148/76:4}. 734 {TMO00902920}. 735 {TMO00902920/1}. 736 {TMO00902920/1}; {TMO00880324/31}. 737 Matthews {Day148/81:23}-{Day18/83:2}. 738 Minutes of bi-monthly meeting between LFB and TMO dated 5 January 2016 {LFB00032330/3} item 8. 739 Wray {Day144/208:9-11}. 740 Minutes of meeting of the TMO Board dated 31 March 2016 {TMO10045103/4} item 9.1.

Part 5 | Chapter 38: Fire risk assessments 85 the TMO had valid fire risk assessments.741 Sacha Jevans responded, telling the board that enforcement notices had been served despite the fact that Carl Stokes had not identified any problems when carrying out his fire risk assessment, and that the LFB had identified none either when it carried out its fire audit.742 That was wrong and misleading. In fact, the LFB had served a deficiency notice relating to Adair Tower on 12 October 2015, about 2 weeks before the Adair Tower fire, which had identified contraventions of Articles 11, 17(1) and 8 of the Fire Safety Order.743 38.84 We have already commented on this and other examples of the TMO’s executive officers misleading the board or failing to disclose to it material matters relating to fire safety. The result in this particular case was that Mr Zitron did not get a straight answer to his question but it was a question that the TMO ought to have asked itself instead of resorting to deflection and concealment. By this point, however, it seems that the TMO had become so heavily reliant on Carl Stokes that any challenge to his work was disregarded, even in the wake of a serious fire. The TMO Health & Safety Report 2015/2016 38.85 In June 2016, Janice Wray and Barbara Matthews produced the TMO’s Health & Safety Report for the period 1 April 2015 to 31 March 2016.744 In the section relating to fire risk assessments, it said that suitable and sufficient fire risk assessments were in place which had been produced in accordance with best practice as set out in PAS 79.745 No mention was made of the concerns raised by Rebecca Burton in November 2015 and January 2016. Janice Wray was unable to explain that omission,746 but she accepted that unless she included those criticisms in the report, or the matter had been raised by Barbara Matthews, neither the TMO’s executive team nor the board nor RBKC would have been aware of them.747 Yet again, the board of the TMO was kept in the dark about concerns expressed by the enforcing authority about the quality of the TMO’s fire risk assessments. That was a particularly important matter for the board to know because it put the TMO, and indirectly the members of the board, at risk of incurring liability for breach of the Fire Safety Order, which carried serious sanctions. 38.86 The report referred to the TMO’s intention to procure a new contract for fire consultancy and fire risk assessment services.748 Janice Wray and Barbara Matthews both denied that that had been prompted by criticisms of Carl Stokes’s work.749 In the event, the procurement manager apparently did not think that a new contract was required at that time and no steps were taken to obtain one. The subject was not discussed further by the TMO’s Health and Safety Committee, the executive team or the board.750 741 Minutes of meeting of the TMO Board dated 31 March 2016 {TMO10045103/4-5} item 9.2. 742 Minutes of meeting of the TMO Board dated 31 March 2016 {TMO10045103/5} item 9.2. 743 {LFB00084110/3-4}. The contravention of Article 17(1) identified referred expressly to an absence of a self-closing device on a flat entrance door, in contradiction to the statement in the fire risk assessment that flat entrance doors were fitted with a self-closing device: {LFB00084110/4}. 744 {TMO10024405/1-22}. 745 {TMO10024405/7} paragraph 7.9. 746 Wray {Day144/217:20-25}. 747 Wray {Day144/219:4-12}. 748 {TMO10024405/18} paragraph 15.2. 749 Wray {Day144/220:17}-{Day144/221:11}; Matthews {Day148/79:23}-{Day148/80:2}. 750 {TMO10047034/19}.

The Grenfell Tower Inquiry: Phase 2 Report 86

87 Chapter 39 Response to fire risk assessments The duty to record significant findings 39.1 Article 9(6) of the Fire Safety Order requires the responsible person to record certain information, including the significant findings of the assessment and the measures which have been or will be taken by that person pursuant to the order.751 39.2 Guidance on carrying out fire risk assessments was published by the British Standards Institution in the form of Publicly Available Specification 79 (PAS 79). It represented current best practice in the industry. The edition of PAS 79 relevant to the fire risk assessments carried out in relation to Grenfell Tower by Carl Stokes (other than that carried out in December 2010) was PAS 79:2012. We therefore refer mainly to that edition in this section of the report. 39.3 Clause 19 of PAS 79:2012 provided guidance on the formulation of an action plan.752 It recommended that every documented fire risk assessment should incorporate an action plan such as to ensure that, if implemented, it would reduce the fire risk to, or maintain it at, a tolerable level.753 The commentary on Clause 19 stated that it was normally appropriate to allocate a priority to each measure recommended and gave an example of a scheme of prioritisation.754 39.4 In addition to the guidance, the annexes to PAS 79:2012 contained model documents available for use by fire risk assessors.755 Annex B contained a template that could be used for an initial fire risk assessment and Annex E provided a shorter template for a review of an existing fire risk assessment.756 It included prompts for the assessor to record any significant changes in the management of fire safety since the previous fire risk assessment.757 At the end of each template PAS 79:2012 included a basic pro forma action plan.758 Both of the PAS 79:2012 action plan templates provided space for recording the actions to be taken by the responsible person in a table that contained columns for priority, the identity of the person by whom action was to be taken and the date on which it was taken. They also contained sections for the assessor to indicate the overall level of fire risk that would be achieved once all the actions identified had been completed. In addition, 751 Fire Safety Order {BEI00001545/8} Article 9(7). 752 PAS 79:2012 {CTA00000003/59-60} clause 19; Similar guidance is provided in PAS 79:2007 {CTA00000001/55-56} clause 18. 753 PAS 79:2012 {CTA00000003/60} clauses 19.1 and 19.2; PAS 79:2007 {CTA00000001/56} contains identical provisions at clauses 18.1 and 18.2. 754 PAS 79:2012 {CTA00000003/59-60} paragraphs (vii) to (xiv); PAS 79:2007 {CTA00000001/56-57} contains similar provisions. 755 PAS 79:2012 {CTA00000003/77-99}; PAS 79:2012 {CTA00000003/106-113}; Similar templates were included in PAS 79:2007 {CTA00000001/59-80} Annex A; PAS 79:2007 {CTA00000001/85-94} Annex D. 756 PAS 79:2012 {CTA00000003/77-99} Annex B; PAS 79:2012 {CTA00000003/106-113} Annex E; PAS 79:2007 {CTA00000001/59-80} Annex A; PAS 79:2007 {CTA00000001/85-94} Annex D. 757 PAS 79:2012 {CTA00000003/111} Annex E. 758 PAS 79:2012 {CTA00000003/98-99}; PAS 79:2012 {CTA00000003/112-113}; PAS 79:2007 {CTA00000001/80}; PAS 79:2007 {CTA00000001/93-94}.

The Grenfell Tower Inquiry: Phase 2 Report 88 the template for a fire risk assessment review included a section prompting the assessor to enter details of any actions identified on a previous occasion that had not been carried out by the time of the review.759 39.5 The TMO’s fire safety strategy in force from November 2013 recorded that the LFB’s Fire Safety team had been told that the assessment to be produced by the TMO’s consultant would be based upon the pro forma in PAS 79.760 39.6 In their fire risk assessments produced for the TMO, Salvus and Carl Stokes both included a schedule setting out their significant findings and providing a plan for any necessary remedial work. However, although the purposes of the schedules were the same, the contents and approaches differed. 39.7 Salvus’s action plan was incorporated in the risk assessment as part of a single document.761 That was necessary, because the action plan did not repeat the findings in the assessment that required remedial action. Instead, it referred to them using the item number in the assessment. In addition to setting out the action which needed to be taken, Salvus identified the time within which it should be taken. Space was provided to record the name of the person responsible for carrying it out and the date by which it should be completed. A colour-coded column indicated whether the action related to a statutory breach, was required to conform to best practice or guidance, or was simply recommended by the assessor. A column was available to record the name of the person carrying out a re-assessment. Finally there was a column to record any change in the level of risk.762 However, the form did not make provision for recording the overall risk to the premises once all the actions had been completed, as suggested by the template in PAS 79:2012. It also did not include a section relating to actions outstanding from previous assessments. 39.8 The format in which Carl Stokes produced his fire risk assessments was different. The schedule of significant findings did not form part of the assessment itself but was contained in a separate document described as a “Record of Significant Findings and Action Plan”.763 His form differed from that used by Salvus in that, as well as cross-referring to the section of the assessment which identified necessary remedial action, it also repeated the description of the risk or hazard that had been identified. It indicated the priority to be given to each action, whether high, medium, or low, with colour-coding, although without a key to explain the classification. At the head of the document there was an indication of the time within which each category of remedial measures needed to be completed. The form also provided sections in which the identity of the person or department responsible for carrying out the work and the date by which it needed to be completed could be recorded. 39.9 In contrast to the pro forma at Annex E of PAS 79:2012, Carl Stokes’s form did not contain a section for the assessor to record any actions that had not been completed since the last inspection, nor did it contain an indication of the level of risk to the premises once the actions identified had been completed. 39.10 Carl Stokes understood that his form of risk assessment and Record of Significant Findings and Action Plan had been shown to and approved by the LFB.764 759 PAS 79:2012 {CTA00000003/113}; PAS 79:2007 {CTA00000001/93}. 760 TMO Fire Safety Strategy dated November 2013 {TMO00830598/9} paragraph 14.1.3. 761 Salvus FRA and Action Plan for Grenfell Tower dated 30 September 2009 {CST00003128}. 762 Salvus FRA and Action Plan for Grenfell Tower dated 30 September 2009 {CST00003128/15-19}. 763 Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 {CST00003165}. 764 Stokes {Day137/36:11-13}; Specimen FRA and Action Plan {CST00003071}; {CST00003089}.

Part 5 | Chapter 39: Response to fire risk assessments 89 Carl Stokes’s practice 39.11 Carl Stokes said that when he identified concerns in the course of a fire risk assessment, he recorded them in the schedule of significant findings and assigned a priority for their completion.765 He said that the document had been set out in that way to allow the TMO to use it as a checklist to ensure that all the points raised had been dealt with.766 Subsequent inspection of premises 39.12 In his written statement Mr Stokes said that when he made subsequent visits to premises in order to conduct a fire risk assessment he would take with him the schedule of significant findings produced following his previous visit, which he would use as a starting point to ensure that all the points raised had been dealt with.767 That approach, had he actually adopted it, would have been in accordance with the guidance in clause 20 of PAS 79:2012, which advises that when a fire risk assessment is reviewed, consideration should be given to the extent to which the original action plan has been implemented and work that has not been completed identified.768 39.13 However, we doubt that he did in fact adopt that approach. Although the annotated copies of his significant findings and action plans for Grenfell Tower made in October 2014 and April 2016 contain his manuscript annotations,769 there is no reference in any of his fire risk assessments or action plans to any outstanding (or indeed, completed) work that he had identified as necessary during a previous assessment. 39.14 When he gave evidence Carl Stokes said that it was his practice to ask Janice Wray to provide him with a printed copy of the previous fire risk assessment from which to work.770 He said that by comparing the state of the premises during his inspection with the records of his previous inspection, he could see that recommendations he had made on a previous visit had not always been completed, but he did not have any idea of the total number of recommendations outstanding at any time.771 Mr Stokes told us that he had raised the importance of completing actions during meetings with Janice Wray, but there is no record of any of those meetings.772 The TMO therefore had no reliable or comprehensive record of what remedial work Mr Stokes thought it particularly important to complete. The involvement of the TMO’s Health and Safety team 39.15 Once the information had been put on to the relevant TMO system, it could be distributed to the teams whose responsibility it was to carry out the work. It was primarily Janice Wray’s responsibility to allocate the remedial work to the appropriate team in the TMO.773 765 Stokes {CST00003063/19} page 19, paragraph 55(iv); Stokes {CST00003063/23} page 23, paragraph 68. 766 Stokes {CST00003063/23} page 23, paragraph 68. 767 Stokes {CST00003063/23} page 23, paragraph 68. 768 PAS 79:2012 {CTA00000003/61} paragraph 20(v). Carl Stokes confirmed that he was aware of this advice, Stokes {Day137/55:20-23}. 769 Handwritten notes on 2014 FRA Significant Findings Schedule {CST00003151}; Handwritten notes on April 2016 FRA Significant Findings Schedule {CST00000003}. 770 Stokes {Day139/103:22}-{Day139/104:4}. 771 Stokes {Day139/103:16-21}. 772 Stokes {Day139/104:5-21}. 773 Wray {Day141/33:20}-{Day141/34:8}.

The Grenfell Tower Inquiry: Phase 2 Report 90 39.16 The way in which the information was recorded and processed by the TMO changed over time. From October 2010, the work was recorded in electronic spreadsheets and documents.774 The documents contained information which appeared to have been copied from various different Action Plans and pasted into the document.775 From August 2013, the TMO began to use a computerised system for logging recommendations. This system, known as “W2”, was a database in which recommendations were recorded and by which work could be assigned to the appropriate team for completion within a given time.776 When a job was assigned to a team, it would appear in that team’s general “inbox” on the W2 system, along with any other tasks assigned to it.777 When a team had completed the work assigned to it, it could mark the tasks as complete and Janice Wray or one of her assistants would then close them.778 When the W2 system was first introduced, it ran in parallel to Janice Wray’s spreadsheet tracker until all the actions recorded in the spreadsheet had been completed. At that point the spreadsheet was closed.779 On 25 May 2016, the TMO launched a new system, which took over the electronic processes for recording and monitoring remedial work. However, the TMO Health and Safety team did not use that system to record remedial work until about a week before the Grenfell Tower fire.780 39.17 Where remedial work was assigned to the TMO Health and Safety team, Janice Wray could give instructions herself to Repairs Direct or the relevant contractor to carry it out. Instructions of that kind were given through the Capita Housing Management System.781 39.18 The methods of recording and monitoring we have described related only to actions recorded in the schedules of Significant Findings and Action Plan produced in the course of fire risk assessments. Any necessary remedial work identified by other means, for example by the LFB in a deficiency notice, was not recorded in or monitored using the electronic systems. We describe below how they were handled.782 Access to data 39.19 Throughout his time as fire risk assessor Carl Stokes was not given full access to relevant fire safety information by the TMO, despite his asking for it. In particular, many of the actions identified in the Significant Findings and Action Plans referred to the need for the TMO to confirm the maintenance of certain items of equipment. For example, in the Significant Findings and Action Plan for Grenfell Tower produced in November 2012, Mr Stokes sought confirmation that the smoke ventilation system was being serviced and maintained in accordance with the manufacturer’s instructions.783 39.20 Between 2010, when he began his assessments for the TMO, and October 2015, Carl Stokes had to rely for information about the maintenance and servicing of equipment on records printed out for him by the TMO Maintenance Department or Janice Wray.784 774 Wray {Day141/25:10-18}. 775 See Composite FRA (High Risk) Action Plan Items for response repairs for Grenfell and other TMO stock {TMO10002330}. 776 Wray {TMO00000890/33-34} pages 33-34, paragraph 148. 777 Wray {TMO00873629/17} page 17, paragraph 71. 778 Wray {TMO00000890/33-34} pages 33-34, paragraph 148; Wray {TMO00873629/16} page 16, paragraph 65. 779 Wray {Day141/27:10-20}. 780 Wray {TMO00873629/17} paragraph 70. 781 Wray {Day143/197:6-15}; Bowman {TMO00842308/1-2} pages 1-2, paragraph 2. 782 Wray {Day141/222:21}-{Day141/224:11}. 783 Record of Significant Findings and Action Plan for Grenfell Tower dated 20 November 2012 {CST00003083/5} item 23c. 784 Stokes {Day136/131:15-25}.

Part 5 | Chapter 39: Response to fire risk assessments 91 39.21 From 2010, the TMO recorded information on servicing and inspection of plant and machinery on a computer programme known as “Keystone”.785 Although he had been providing fire risk assessments for the TMO since 2010, Carl Stokes did not have access to the data held on Keystone until October 2015. He was eventually given remote access to Keystone in the hope that he could check for himself that servicing had been carried out and thus reduce the number of recommendations he made in the future.786 In any event, Carl Stokes had access to the Keystone system by the time he carried out the fire risk assessment in April 2016, as he recorded in that assessment that he had checked the Keystone records in relation to certain items.787 39.22 Even with access to Keystone, Carl Stokes was reliant upon TMO staff for some information because Keystone did not contain maintenance and servicing records for some equipment that was critical to fire safety. In particular, it did not contain maintenance and servicing records for the fire control system, dry rising fire main or emergency lighting system at Grenfell Tower.788 Carl Stokes told us that if he could not obtain information for himself, he asked the TMO for the information he needed.789 If he was still unable to obtain the information, he would record in the Significant Findings and Action Plan that he did not have it.790 39.23 However, we doubt that he was consistently conscientious in doing so and his requests for information were patchy. Paul Steadman, who was the estates services assistant (ESA) for Grenfell Tower at the relevant time, had no recollection of having been consulted by Carl Stokes in relation to a fire risk assessment,791 despite the fact that Mr Stokes recorded having consulted him by name in connection with the fire risk assessments for Grenfell Tower carried out in 2010, 2012, and 2014.792 Moreover, Mr Stokes was never given access to the W2 system and was therefore unable to check for himself whether actions which had been identified during his previous visit to a property had been completed. He said that he had been forced to rely on documents printed out by Janice Wray,793 but if that was so, it is surprising that they were not mentioned in his fire risk assessments. The TMO’s management of remedial work 39.24 Within its sections on formulating an action plan, PAS 79 provides guidance on prioritising actions and the time to be allowed for their completion. PAS 79:2007 provided a scheme comprising three priorities: “immediate”, “short term” (within three months), and “long term” (to be carried out as and when the opportunity arose).794 PAS 79:2012 also provided a scheme comprising four priorities, which broadly replicated the 2007 scheme publication with the addition of a “medium term” category for implementation within three to six 785 Parsons {TMO00870938/1-2} pages 1-2, paragraphs 5-6. 786 TMO Health & Safety Committee Minutes dated 16 April 2015 {TMO10009485/2} item 4.1. 787 Record of Significant Findings and Action Plan for Grenfell Tower dated 26 April 2016 {CST00003098/7-8} item 23a and item 23e. 788 Lane, The Management and Maintanance of Grenfell Tower, Chapter 7, Module 3 Report {BLARP20000033/220} paragraph 11.2.56. 789 Stokes {Day136/133:3-19}. 790 Stokes {Day136/133:21-24}. 791 Steadman {Day146/84:9-25}. 792 Fire Risk Assessment of Grenfell Tower dated 29 December 2010 {CST00003181/3}; Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084/3}; Fire Risk Assessment of Grenfell Tower dated 10 October 2014 {CST00003157/3}. 793 Stokes {Day138/121:5-22}; Wray {Day141/153:9}-{Day141/154:5}. Janice Wray was unable to recall whether she had provided Carl Stokes with spreadsheets from W2. She thought that she had probably done so for blocks in respect of which he had been requesting information, Wray {Day141/153:24}-{Day141/154:5}. 794 PAS 79:2007 {CTA00000001/55-56} clause 18.

The Grenfell Tower Inquiry: Phase 2 Report 92 months.795 It is clear from the text of both editions of PAS 79 that the intention of the document was that actions were to be completed within the timescales indicated. Both the 2007 and 2012 versions of PAS 79 recognise that other systems of prioritisation could be adopted, including a system which distinguished between items which breach legislation and those which do not.796 39.25 There were five categories of priority for implementing the remedial measures identified in the action plan produced by Salvus for Grenfell Tower.797 The highest three priorities required action within a short time, ranging from 24 hours to one month. Salvus also included a colour-coded designation, indicating whether an action represented a breach of statute (red), compliance with best practice or guidance (amber) or simply a recommendation (green).798 As such, the colour-coding was not directly related to the priority rating or the time for completion, but it gave a useful indication of the basis of the advice. The risk presented by each item was assessed separately and the action plan included a column for a revised level of risk once the remedial work had been completed. 39.26 The Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 resulted from Carl Stokes’s first fire risk assessment of the tower.799 He identified 23 separate risks or hazards, each of which was given a priority rating for completion on the scale “High” (2 – 3 weeks), “Medium” (1 – 2 months) and “Low” (3 – 6 months). He thought that those periods had been agreed between the TMO and the LFB, but Janice Wray could not confirm that and did not believe that a detailed discussion of that kind had taken place.800 Mr Stokes confirmed that the document required actions to be completed within the periods indicated.801 39.27 Carl Stokes also included a colour-coded designation of priority in his action plans. The TMO’s fire safety strategy of November 2013 referred to that colour-coding as a guide to the priority to be accorded to different actions and explained that, like the Salvus colour‑coding system, red referred to measures required to comply with legal requirements under the Fire Safety Order and any significant risk to life, amber to recommendations relating to good practice and green to actions that would enhance fire safety based on good practice, but of a lower priority.802 The fire safety strategy also confirmed that remedial work would be carried out in order of risk, with priority given to items with a red or amber rating.803 Unlike the Salvus document, in which the colour-coding indicated the basis of the action and a separate system was incorporated to indicate priority, Carl Stokes’s system effectively dealt with both aspects together.804 By taking such an approach he conflated the gravity of the risk and the urgency of the work. We agree with Colin Todd that it is generally better to deal separately with the degree of risk and the time for completion of remedial measures, because, for example, it may be possible to eliminate a low risk quickly.805 795 PAS 79:2012 {CTA00000003/59-60} clause 19(ix). 796 PAS 79:2007 {CTA00000001/56} clause 18; PAS 79:2012 {CTA00000003/60} clause 19(x). 797 Salvus FRA and Action Plan for Grenfell Tower dated 30 September 2009 {CST00003128/19}. 798 Salvus FRA and Action Plan for Grenfell Tower dated 30 September 2009 {CST00003128/19}. 799 Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 {CST00003165}. 800 Stokes {Day137/36:11-13}; Wray {Day141/53:8-13}. 801 Stokes {Day137/35:19-25}. 802 TMO Fire Safety Strategy dated November 2013 {TMO00830598/9} paragraph 14.1.3. 803 TMO Fire Safety Strategy dated November 2013 {TMO00830598/9} paragraph 14.1.3. 804 Under a system of that kind an item identified as a breach of legislation would always be categorised red and be prioritised, regardless of the actual risk it posed. 805 Todd {Day167/26:21-24}; Todd {Day167/27:9-12}.

Part 5 | Chapter 39: Response to fire risk assessments 93 39.28 Carl Stokes’s form did not include a section for an overall assessment of the risk level once all remedial measures had been carried out, as suggested in Annex E to PAS 79, nor did it include a column for a revised level of risk, as did the Salvus template. 39.29 The next Record of Significant Findings and Action Plan for Grenfell Tower is dated 20 November 2012, reflecting Carl Stokes’s fire risk assessment of that date. In that document the time within which high priority items were to be completed remained the same as in the 2010 schedule, but the time allowed to complete medium and low priority actions were both increased. In the case of medium priority actions the period of 1 – 2 months was increased to 2 – 3 months; for low priority actions it was increased from 3 – 6 months to 6 – 12 months.806 39.30 Carl Stokes thought that he had extended the periods for medium and low priority actions because of relevant guidance, but he was unable to identify it when he gave evidence807 and none has come to light in any document we have seen. His extended periods did not accord with either the 2007 or 2012 versions of PAS 79. When pressed during his evidence for the specific source of guidance he had relied on to support the change, he suggested that he had taken them from the LGA Guide,808 but that document contained no reference to the extended periods he adopted and provides guidance on the prioritisation of remedial measures only in the broadest of terms.809 No other support for his decision has been identified. 39.31 The time allowed for completing remedial measures was changed again in the Action Plan for Grenfell Tower dated 17 October 2014.810 Although the periods allowed for each category remained the same, there was added in parenthesis after the period of 6 – 12 months relating to low priority work the words “to start to action any works”. Carl Stokes confirmed that he intended the qualification to apply to all three priority ratings.811 The effect of that amendment was that whereas previously the TMO had been required to complete the work within the prescribed periods, it was now required only to have started it within that period. No date for completion was prescribed. 39.32 The TMO had not asked for the action plan to be altered in that way.812 Carl Stokes’s explanation was that “companies” had told him that they were encountering difficulties in completing work identified in action plans where they required capital investment which could not be provided at short notice.813 His reference to “companies” suggests that he understood it to be a problem that had either been raised by a number of clients or was widespread and well-known within the industry. However, neither of the experts who considered the matter thought that the change he had made reflected a standard approach in the industry. Colin Todd considered that without any reference to specific examples of major capital works, it was too broad and was unusual.814 Dr Lane considered it to be entirely incorrect.815 806 Record of Significant Findings and Action Plan for Grenfell Tower dated 20 November 2012 {CST00003083/1}. 807 Stokes {Day137/37:19-25}. 808 Referred to elsewhere in this report as the LGA Guide. 809 Local Government Association Guide “Fire safety in purpose-built blocks of flats” {HOM00045964/47} paragraph 37.1. 810 Record of Significant Findings and Action Plan for Grenfell Tower dated 17 October 2014 {CST00003177/1}. 811 Stokes {Day137/41:1-5}. 812 Stokes {Day137/41:14-15}; Wray {Day141/61:20-23}. 813 Stokes {Day137/39:12-23}. 814 Todd {Day167/31:19-25}. 815 Lane {Day171/2:19}-{Day171/4:6}.

The Grenfell Tower Inquiry: Phase 2 Report 94 39.33 The main problem created by the change was that it meant that in theory a responsible person could allow remedial measures to remain incomplete indefinitely, provided they had been started within the required time.816 In practice, however, Janice Wray understood the change to mean that in situations where it was not feasible to complete the work with the prescribed time, for example, because it was necessary to undertake a procurement exercise, the TMO needed to be able to demonstrate only that the necessary process had been put in hand.817 She explained that the teams to which work was assigned did not see the schedule in its original form, because they received their instructions only after the action had been put onto the W2 system for completion.818 In those circumstances we think that Carl Stokes’s unusual and potentially dangerous approach to the completion of remedial work from 2014 onwards probably had little or no effect on how the TMO dealt with the work in practice. The TMO’s approach 39.34 Although Carl Stokes included priority ratings for the risks identified in his action plans, the TMO did not always accept them uncritically. On the contrary, on occasions, the management team even went so far as to challenge his professional judgement and seek to persuade him to change his findings. That was despite the fact that they had far less experience in matters of fire safety than he did. Other than Janice Wray, senior managers at the TMO were not experienced in matters relating to fire safety management and had not received training on it during their time at the TMO. Barbara Matthews, the director responsible for health and safety had no previous experience in that field and had received no fire safety training before or during her time at the TMO.819 Similarly, Peter Maddison, the TMO’s Director of Assets and Regeneration, had no qualifications or experience in the management of fire safety.820 Although Robert Black had had some practical experience of health and safety, he had no relevant qualifications821 and had received no fire safety training.822 Re-categorising actions – discussions between Janice Wray and Peter Maddison 39.35 On at least two occasions in 2014 and 2015, Peter Maddison and Janice Wray discussed the categorisation of deficiencies identified in fire risk assessments. The common factor in their discussions was his wish to divide the remedial measures into categories or sub-categories of priority actions. The June 2014 intervention 39.36 The minutes of the TMO’s Health and Safety Operational Meeting on 20 June 2014 record that during a discussion of statistics relating to fire risk assessments Peter Maddison asked Janice Wray which of the actions could be defined as absolute requirements and which were best practice.823 Janice Wray’s view was that there was nothing to clarify, 816 Stokes {Day137/41:10-13}. 817 Wray {Day141/62:7-13}. 818 Wray {Day141/63:17-22}. 819 Matthews {TMO10049987/1-2} pages 1-2, paragraphs 4 and 8; Matthews {Day147/103:15-20}; {Day147/100:6}-{Day147/102:23}. 820 Maddison {TMO00000892/14} page 14, paragraph 79. 821 Black {Day149/7:4-17}. 822 Black {Day149/7:18-20}. 823 TMO Health and Safety Operational Meeting Minutes dated 20 June 2014 {TMO10009784/2}.

Part 5 | Chapter 39: Response to fire risk assessments 95 other than the number of actions and which ones were “red”, that is to say, urgent.824 She was clear that she would not adjust the priorities but she said that she had not thought that Peter Maddison was seeking to treat some red items as having a slightly lower importance.825 The upshot on that occasion was that she resisted his request. However, he did not give up. Peter Maddison’s next request 39.37 The minutes of the TMO’s Health and Safety Operational Meeting on 23 February 2015 record a discussion between Janice Wray and Peter Maddison in which he suggested that it would be useful to have more information about priority levels and the nature of each outstanding action.826 Janice Wray agreed to “split the outstanding actions into high, medium and low categories with targets”.827 39.38 Initially Peter Maddison told us that he had been seeking more information about what the different categories of action entailed.828 He said that his intention had been to get a better means of understanding what the actions were, the risk they presented and the urgency of remedying them.829 He thought that was the information he had asked for in June 2014 but had not received.830 However, he later conceded that by February 2015 his team did have access to spreadsheets setting out the actions and suggested that he was looking for a summary overview.831 We are not sure what Mr Maddison wanted and we are unable to place much reliance on his evidence of his intentions at the time, as it was rather confused. Janice Wray also thought that Peter Maddison, or members of his team, already had the information he wanted, but she nevertheless ran reports and produced high‑level information.832 39.39 It is unclear why Peter Maddison felt it necessary to ask Janice Wray for information his team already held. He was emphatic that he was not seeking to change the priorities assigned by Carl Stokes, but was seeking to address the backlog of actions as effectively as possible, although he accepted he might have been seeking to understand which of the high priority work was the most urgent.833 The Adair Tower fire risk assessment 39.40 The clearest example of the TMO’s seeking to challenge Carl Stokes’s risk assessments occurred after the fire at Adair Tower on 31 October 2015. Following that fire, Carl Stokes reviewed the fire risk assessment and action plan for Adair Tower which were discussed at a meeting between him and the TMO on 19 November 2015.834 The draft Record of Significant Findings and Action Plan included at item 12e a high priority recommendation that self-closing devices be fitted to all flat entrance doors that did not already have them.835 Carl Stokes told us that during that meeting he had advised the TMO to undertake 824 Wray {Day141/141:17-21}. 825 Wray {Day141/142:16-19}; {Day141/142:20}-{Day141/143:3}. 826 Health and Safety Operational Meeting Minutes dated 23 February 2015 {TMO00869479/1-2}. 827 Health and Safety Operational Meeting Minutes dated 23 February 2015 {TMO00869479/2}. 828 Maddison {Day122/206:1-3}. 829 Maddison {Day122/206:4-15}. 830 Maddison {Day122/207:9-23}. 831 Maddison {Day123/20:7-18}. 832 Wray {Day141/146:18}-{Day141/147:4}. 833 Maddison {Day123/24:24}-{Day 123/25:6}; {Day123/16:8-14}. 834 Stokes {Day138/190:3-12}. 835 Record of Significant Findings and Action Plan for Adair Tower dated 11 November 2015 {CST00026368/3}.

The Grenfell Tower Inquiry: Phase 2 Report 96 the work set out in the action plan.836 His recollection of the meeting was that, although the TMO had suggested that there was no legal or regulatory requirement to fit self-closing devices, he had told it to fit them.837 39.41 The next day, 20 November 2015, Peter Maddison sent an email to Sacha Jevans, Janice Wray, Robert Black, Alex Bosman and Daniel Wood at 07:45 in which he questioned Carl Stokes’s assignment of a high priority rating to the recommendation that self-closing devices be fitted.838 He explained that he did not consider that to be justified because it was not a statutory requirement to install self-closing devices retrospectively and because the entrance doors of the leasehold flats were demised to the leaseholders. The proposed action plan would therefore require the TMO to carry out work that it could not require the leaseholders to undertake.839 Peter Maddison could not remember how he had gained the understanding that there was no statutory requirement to fit self-closing devices.840 In his email he went on to express his concern that committing itself to carrying out work that it did not have the power to undertake would leave the TMO exposed. He suggested that the priority be reduced to “low” or “advice” and that a note be added that the TMO could not enforce the requirement in relation to leasehold properties.841 39.42 Peter Maddison’s view was supported by Barbara Matthews and Robert Black.842 In her response, Barbara Matthews said that Janice Wray had been instructed to raise the matter with Carl Stokes and that a revised Record of Significant Findings and Action Plan would be provided to the LFB.843 She later confirmed that Carl Stokes had changed his categorisation to “strong advice” (as he had), which, she said, had “no regulatory requirement or defined timescale” but was “advisory only”.844 39.43 It is surprising that Barbara Matthews supported Peter Maddison’s view, given that she was aware that the LFB was keeping a close eye on this matter. Only a week before those email exchanges, Janice Wray had attended a meeting with Rebecca Burton to seek clarification on its response to the fire at Adair Tower.845 Following that meeting, she told Barbara Matthews that the LFB was focusing specifically on self-closing devices and smoke ventilation systems and that she thought the LFB might take a kinder view of smoke ventilation if the revised fire risk assessment recognised the need to fit self-closing devices and it was programmed to be completed swiftly.846 Barbara Matthews therefore decided to support Peter Maddison’s suggestion that Carl Stokes be asked to downgrade 836 Stokes {Day138/190:16-21}. 837 Stokes {Day138/190:22-24}. 838 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/3-4}. 839 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/4}. 840 Maddison {Day123/135:16}-{Day123/136:17}. 841 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/4}. Peter Maddison was unable to explain exactly what he was concerned the TMO would be exposed to, other than possible criticism Maddison {Day123/134:9-13}. 842 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/1-3}. 843 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/3}. 844 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/1}. 845 Correspondence between Janice Wray, Robert Black, Barbara Matthews, and Sacha Jevans, regarding Adair Tower meeting with LFB Fire Safety Team Leader dated 13 November 2015 {TMO00840415}. 846 Correspondence between Janice Wray, Robert Black, Barbara Matthews, and Sacha Jevans, regarding Adair Tower meeting with LFB Fire Safety Team Leader dated 13 November 2015 {TMO00840415/2}.

Part 5 | Chapter 39: Response to fire risk assessments 97 the urgency of the action on self-closers despite knowing very well that the LFB was considering taking action against the TMO with a particular focus on self-closing devices on flat entrance doors. Carl Stokes’s response to pressure from the TMO to amend his findings 39.44 Carl Stokes had not been included in the email conversation discussed in the previous section. On 20 November 2015, he sent an email to Janice Wray advising that the item in the action plan concerning fitting self-closing devices should continue to be rated high priority,847 but agreed to alter that to “strong advice”, partly to appease the LFB. However, he reiterated that the fitting of self-closing devices to the front doors of flats should be given a high priority.848 As a result, that item was downgraded to “strong advice” and was not colour-coded.849 39.45 When Carl Stokes was asked about his decision to alter the action plan, he said he felt able to make the change as the work was in hand.850 He also said that his reference to “appeasing” the LFB meant helping them, as it was better to be on the right side of the enforcing authority.851 Perhaps surprisingly, given his email of 20 November 2015 at 09.48, he said he thought it had been appropriate for the TMO to challenge his professional judgement and suggested that he had decided not to oppose it as the work was being undertaken in any event.852 However, when pressed he accepted that the change appeared to have been the result of pressure put on him by the TMO.853 That is exactly what had happened. The TMO, in full knowledge of risks involved, persuaded him to downgrade an important aspect of his assessment in relation to a building in which a serious fire had already occurred and in respect of which the LFB was already considering enforcement action. 39.46 Dr Lane and Mr Todd agreed that altering a recommendation in that way in response to pressure from a client was not consistent with the standards to be expected of a reasonably competent fire risk assessor854 and we have no hesitation in saying that in doing so Mr Stokes was not acting professionally or in accordance with those standards. 39.47 We have analysed this episode at length not because it had any direct impact on what occurred at Grenfell Tower 20 months later but because it illuminates so well the TMO’s general approach to fire safety. Its behaviour in seeking to challenge and dilute Mr Stokes’s risk assessment, not for the first time, suggests that the TMO treated the demands of managing fire safety as an inconvenience rather than an essential aspect of its care for those living in the buildings under its management. It was a betrayal of its statutory obligations to its tenants. 847 Email correspondence between Carl Stokes, Barbara Matthews and Janice Wray regarding FRA for Adair Tower dated 20 November 2015 {CST00026445/2-3}. 848 Email correspondence between Carl Stokes, Barbara Matthews and Janice Wray regarding FRA for Adair Tower dated 20 November 2015 {CST00026445/3}. 849 Record of Significant Findings and Action Plan for Adair Tower dated 11 November 2015 {CST00009046/5} item 12i. 850 Stokes {Day138/200:17}-{Day138/201:9}. 851 Stokes {Day138/199:4-21}. 852 Stokes {Day138/201:15-25}. 853 Stokes {Day138/201:10-14}. 854 Lane {Day171/9:21}-{Day 171/10:5}; Todd {Day167/40:17-24}.

The Grenfell Tower Inquiry: Phase 2 Report 98 Remedial work 39.48 When she entered remedial work on the W2 system Janice Wray included a time for completion, which she took from the Record of Findings and Significant Actions. The time was treated as running from the date that she received the action plan and entered the work on the system.855 She understood that the work was to be completed within the time indicated.856 Janice Wray explained that she treated any work that had not been completed as “outstanding”, not merely those items which had not been completed when the time allowed expired.857 Over time, the number of outstanding items of work increased, but they were broadly unrelated to any particular kind of risk and do not appear to have been taken into account in assessing the overall risk affecting the TMO’s properties. 39.49 From early 2012, various committees and groups within the TMO began to identify problems in dealing with the outstanding work. The minutes of a meeting of the TMO Health and Safety Committee on 26 January 2012 recorded that Janice Wray was continuing to chase up work arising from the assessments in relation to high-risk buildings carried out by Salvus in May 2010.858 By January 2012, therefore, the TMO was at least 12 months behind in completing some of the remedial work. Although Ms Wray was very concerned about the backlog and took steps to discover its cause,859 she did not know what it was, other than that there were problems with contractors.860 39.50 The arrears of remedial works were discussed at a meeting of the TMO Assets, Investment and Engineering Health and Safety Group on 15 March 2012. The minutes recorded that some work to put right some high – and medium-risk defects had been outstanding for as long as two years.861 By December 2012 a significant amount of work was outstanding, which was causing concern.862 The Hodgson Report (July 2013) 39.51 In July 2013, Matt Hodgson produced the report on his review of the TMO’s safety management to which we referred in Chapter 37.863 In a section of the report dealing with fire risk assessments he recorded that there were between 900 and 1,000 outstanding items of remedial work waiting to be completed.864 The figure is significant, first, because Matt Hodgson clearly thought it large enough to justify specific mention and secondly, because it is the earliest record of the amount of outstanding remedial work presented in that form to the TMO’s executive team. 39.52 Although Mr Hodgson had drawn attention to the existence of that huge number of outstanding items of remedial work, Robert Black had little recollection of that part of the report and did not remember what he had done about it.865 He did not take any steps to find out why a backlog of that size had been allowed to accrue, because he regarded 855 Wray {Day141/59:21-25}. 856 Wray {Day141/60:1-3}. 857 Wray {Day141/86:4-17}. 858 TMO Health & Safety Committee Minutes dated 26 January 2012 {TMO10001026/3} item 8. 859 Wray {Day141/88:6-22}. 860 Wray {Day141/91:3-8} 861 TMO Assets, Investment and Engineering Health & Safety Group Minutes dated 15 March 2012 {TMO00869800/2} item 5.2. 862 TMO Assets, Investment and Engineering Health & Safety Group Minutes dated 13 December 2012 {TMO10001903/3} item 6.2. 863 TMO Safety Management Review by Matt Hodgson dated 19 July 2013 {TMO10003124}. 864 TMO Safety Management Review by Matt Hodgson dated 19 July 2013 {TMO10003124/33}. 865 Black {Day150/81:10-22}.

Part 5 | Chapter 39: Response to fire risk assessments 99 that as the responsibility of Anthony Parkes. He could not recall any discussions about it following the receipt of the report.866 As a result, there was no direction from the top and nothing to indicate that it was a serious problem that needed to be resolved urgently. 39.53 Matt Hodgson’s report was discussed by the TMO’s executive team on 7 August 2013.867 The minutes of that meeting do not record a detailed discussion about the number of outstanding items of work as such, but do reflect concern that the Assets and Regeneration department was being bogged down with recommendations addressing the situation.868 There is nothing to suggest that the number of outstanding items was regarded as a shocking statistic that demanded to be treated as an urgent priority. 39.54 Matt Hodgson produced a further report on 13 September 2013.869 The reference to the number of remedial items outstanding had been removed from that version of the report, which instead referred only to the number of high priority items completed between 28 February and 17 July 2013.870 The arrears were now presented as a percentage of the total number of high priority items completed within a six-month period. It is unclear why that measure was chosen because, although the figures identified relatively low percentages of completions, for example, 34% by Assets and Regeneration Building Services and 34% by Response Repairs, the overall number of outstanding actions, and thus the scale of the backlog, was missing from the report. 39.55 Recommendation 16 of Mr Hodgson’s report was to take steps to eliminate the backlog of remedial work.871 Janice Wray was quite glad that he had made that recommendation, because she thought it would force the TMO to take the necessary action.872 That was a telling admission because it suggested that her efforts to persuade the TMO’s senior management to take the backlog seriously had thus far been in vain. 39.56 The final report also stated that the lack of sufficient information provided to the executive team relating to compliance with statutory duties had resulted in a want of leadership in making important changes or decisions needed to manage risk effectively.873 The completion of outstanding remedial work identified in fire risk assessments was given as a specific example. 39.57 In his original report Matt Hodgson had also referred to a breakdown in communication between the Health and Safety department and other departments in relation to remedial work.874 Janice Wray denied there had been a breakdown in communications, although she accepted that there had been some frustration,875 but the fact is that Mr Hodgson’s view was near enough the mark. It was on any view a clear warning that remedial work and the associated risks were not being effectively managed by the TMO and that one reason for that was structural. 866 Black {Day150/81:10-15}; Black {Day150/81:20-22}. 867 TMO Executive Team Minutes dated 7 August 2013 {TMO00899807/1-2} item 1.4. 868 TMO Executive team Minutes dated 7 August 2013 {TMO00899807/2} item 1.4. 869 TMO Safety Management Review by Matt Hodgson dated 13 September 2013 {TMO00873398} and Chapter 4A more generally. 870 TMO Safety Management Review by Matt Hodgson dated 13 September 2013 {TMO00873398/31-32}. 871 TMO Safety Management Review by Matt Hodgson dated 13 September 2013 {TMO00873398/12}, recommendation 16. 872 Wray {Day141/118:24}-{Day141/119:3}. 873 TMO Safety Management Review by Matt Hodgson dated 13 September 2013 {TMO00873398/8}. 874 TMO Safety Management Review by Matt Hodgson dated 19 July 2013 {TMO10003124/8}. 875 Wray {Day141/111:19}-{Day141/112:15}.

The Grenfell Tower Inquiry: Phase 2 Report 100 39.58 Between March 2012 and June 2017, the need to clear the arrears of remedial work was a constant topic of discussion by the Health and Safety Committee, but it did not consider detailed statistics until July 2015. Despite Matt Hodgson’s reports in 2013 and the discussions in the various committees from 2012, the TMO was unable to keep up with the flow of remedial work. Janice Wray prepared a paper (“Paper 2”) for a meeting of the TMO Health and Safety Committee on 31 July 2015 which showed the number of items of remedial work completed, partly completed and outstanding. Of the 1,850 items recorded, only 941, or about 50 percent, had been completed, leaving 909 outstanding or only partly completed.876 That was similar to the position in July 2013 when Matt Hodgson produced his first report. At no time does the TMO Health and Safety Committee or the executive team appear to have considered the risk to life presented by the arrears. 39.59 Following the presentation of Janice Wray’s paper in July 2015, Barbara Matthews, who had recently taken over executive responsibility for health and safety, asked her to produce a more informative breakdown of outstanding actions so that the committee could see the details better and understand what programme of work would be required to clear them.877 For the meeting on 29 September 2015, Janice Wray produced statistics which included a breakdown of work by priority for the contract management team and a breakdown of contract management work by category, showing how long they had been outstanding (by year).878 A further paper including the breakdown of actions by priority and type was produced in November 2015.879 However, when statistics were produced for the January 2016 meeting, far less detail was included (only two pages of the document related to fire risk assessment actions) and the paper no longer included information about the priority of actions, although an age profile was included.880 Janice Wray was unable to explain why some of the detail had been removed, beyond saying that she thought she may have run out of time to prepare the document.881 Subsequent papers containing statistics on remedial work did not provide the same level of detail as the papers produced in September and November 2015.882 39.60 Despite those efforts to monitor the number of items of remedial work and the progress in completing them, the TMO had not been able to bring the arrears under control by the time of the fire at Grenfell Tower. At the meeting of the TMO Health and Safety Committee on 19 January 2017, Barbara Matthews raised concern about the number of items of work that had been outstanding for more than 12 months. She required the various teams to whom the work had been assigned to explain their plans to complete it,883 but explanations were provided by only two of the five teams.884 The progress made following the meeting of the Health and Safety Committee in March 2017 was evidently insufficient and Barbara Matthews again expressed her concern at the number of outstanding actions at the next meeting of the committee on 13 June 2017, the day before the fire at Grenfell Tower.885 876 TMO Health & Safety Committee FRA Action Statistics Paper dated 31 July 2015 {TMO10009662/1}. 877 TMO Health & Safety Committee Minutes dated 31 July 2015 {TMO10010039/3} item 4.1. 878 TMO Health & Safety Committee FRA Action Statistics Paper dated 28 September 2015 {TMO10010066/4-6}. 879 TMO Health & Safety Committee FRA Action Statistics Paper dated 23 November 2015 {TMO10011191}. 880 TMO Health & Safety Committee FRA Action Statistics Paper dated 9 January 2016 {TMO10011910}. 881 Wray {Day141/171:14-18}. 882 See TMO Health & Safety Committee FRA Action Statistics Paper dated 6 April 2016 {TMO10012642}; TMO Health & Safety Committee FRA Action Statistics Paper dated 10 March 2017 {TMO10016217}. 883 TMO Health & Safety Committee Minutes dated 19 January 2017 {TMO10016020/2} paragraph 4.1. 884 TMO Health & Safety Committee FRA Action Statistics Paper dated 16 March 2017 {TMO10016217/3}. Explanations received from Health & Safety Team and Neighbourhood Management South. Peter Maddison suggested that only teams with actions older than 12 months needed to provide a report, Maddison {Day123/98:14-17} however this was not Janice Wray’s understanding, Wray {Day141/189:22}-{Day141/190:3}. 885 TMO Health & Safety Committee Minutes dated 13 June 2017 {TMO10021548/3} item 3.1.

Part 5 | Chapter 39: Response to fire risk assessments 101 Interim measures: paragraph 14.4.2 of the fire safety strategy 39.61 The TMO’s fire safety strategy made specific provision for instances where it was not possible to complete remedial work within the required time. Paragraph 14.4.2 provided that if high-priority work could not be completed within the time indicated, interim measures would be implemented to reduce the risk in the short term.886 That was a sound attempt, in theory at least, to render the risk as low as reasonably practicable, but the TMO failed to create suitable plans to ensure that necessary interim measures were identified, documented or completed.887 39.62 Janice Wray said that paragraph 14.4.2 had not been intended to apply in all cases in which remedial work had not been completed within the time allowed but only in those where significant delay was expected, such as where a lengthy procurement process was needed.888 However, whenever it was thought that it might not be possible to complete high-priority remedial work within times indicated in the action plan, consideration should have been given to adopting interim measures, if appropriate.889 In reality, however, that was only ever an aspiration. Although Ms Wray thought that over the years a number of interim measures had been implemented by the TMO,890 she could not identify any, other than those relating to the smoke control system at Grenfell Tower.891 39.63 We have not been able to identify any occasion on which the TMO implemented interim measures. The TMO did not record such measures and although Janice Wray said that she would have put the details into the W2 system if she had known of them,892 there was in fact no field in which information of that kind could be recorded. Although interim measures were said to have been recorded as an “update”, there was no evidence from W2 of that having been done.893 Indeed, Janice Wray admitted that there had been no system to record the fact that interim measures had been considered in relation to any particular high priority item or that a decision had been taken about it one way or the other.894 She accepted that it would probably not be possible to find out whether in any particular case interim measures had been considered.895 There was no formal system for notifying Carl Stokes of any decision to implement interim measures, although it is likely that Janice Wray discussed the matter with him first.896 Reporting on the progress of remedial measures 39.64 Remedial work was monitored by the TMO’s Health and Safety Committee and also, before July 2015, by the TMO’s Health and Safety Operational Committee.897 The minutes of the TMO’s Health and Safety Committee were circulated for the consideration of the executive team.898 886 TMO Fire Safety Strategy dated November 2013 {TMO00830598/10} paragraph 14.4.2. 887 PAS 79:2012 {CTA00000003/59} Clause 19 (ix); Lane, The Management and Maintenance of Grenfell Tower, Module 3 Report, Chapter 8 {BLARP20000027/141} paragraphs 8.2.37 - 8.2.39. 888 Wray {Day141/75:6-10}; {Day141/76:5-10}. 889 Wray {Day141/77:4-12}. 890 Wray {141/78:21-24}. 891 Wray {Day141/78:25}-{Day141/79:8}. 892 Wray {Day141/79:13-16}. 893 Wray {Day141/79:17-24}. 894 Wray {Day141/81:1-8}. 895 Wray {Day141/80:16-19}. 896 Wray {Day141/81:15}-{Day141/82:7}. 897 TMO Health & Safety Committee Meeting Minutes dated 31 July 2015 {TMO00880645/3} item 4.1. At the TMO Health and Safety Committee Meeting on 31 July 2015, Barbara Matthews is recorded in the minutes as stating that she hoped the committee would become the only Health and Safety Committee {TMO00880645/2} item 2.1. 898 See the distribution list at the foot of the minutes of the TMO Health and Safety Committee {TMO00880645/8}.

The Grenfell Tower Inquiry: Phase 2 Report 102 39.65 Janice Wray prepared reports on safety performance which were presented to the executive team and to TMO board meetings by members of the executive team.899 Anthony Parkes and his successor, Barbara Matthews, reported to the executive team and, to the best of Janice Wray’s knowledge, presented her reports to the executive team.900 39.66 It appears that the TMO executive team never reported to the board on the need for remedial work or the extent of the delay in carrying it out. That is consistent with its failure to report to the board other matters of importance to fire safety. Barbara Matthews said that the only health and safety matters referred to the TMO board were those which had been included in the annual health and safety report or exceptional items, such as matters to do with the enforcement notice served following the fire at Adair Tower.901 As a result, the board lacked the information it needed to perform its function. It did not know whether the TMO was complying with its statutory duties and did not have the information it needed to make decisions that might enable its management to eradicate the arrears of remedial work. 39.67 The TMO’s executive team itself does not appear to have been regularly and reliably provided with information about the arrears of remedial work, which, as was plain from the content of the minutes, was a chronic problem. If it had been given that information and had reported properly to the board, the board might have realised that the TMO had long- term difficulty completing remedial work. Auditing the fire risk assessment programme 39.68 Although Janice Wray and the other members of the Health and Safety Committee gave frequent consideration to the question of remedial work, they never attempted to identify trends and failings in the delivery and implementation of the fire risk assessment programme. Such an audit was advised by clause 7.4 of PAS 7:2013.902 The failure to undertake such an exercise contributed to the TMO’s lack of understanding of the underlying causes of the problem and its inability to overcome the arrears. Resources 39.69 At many points in her evidence Janice Wray blamed a lack of money for her failure to act in a more efficient and effective way, but the evidence does not enable us to reach any firm conclusion on that question. 39.70 Robert Black was unsure whether the TMO had a specific budget or sub-budget line item for health and safety, and agreed that the TMO “probably” did not have a line item within the general budget to cover remedial work identified in fire risk assessments.903 However, he said that, if Barbara Matthews had asked for additional funds to eliminate the arrears of remedial work, he was sure that he would have been able to provide them, although he noted that as finance director she knew where all the money was.904 899 Wray {TMO00000890/37} page 37, paragraph 168. 900 Wray {Day140/38:24}-{Day140/39:6}. During his evidence, Robert Black explained that the TMO’s budget was not big enough to have someone with Health and Safety expertise on the executive team, Black {Day149/27:5-9}. 901 Matthews {Day147/105:18}-{Day147/106:4}. 902 {LFB00116924/23} paragraphs 7.4.3 and 7.4.4. 903 Black {Day150/14:18}-{Day150/15:3}. 904 Black {Day150/120:2-10}.

Part 5 | Chapter 39: Response to fire risk assessments 103 39.71 Barbara Matthews told us that there had been a specific budget to enable the TMO to meet its health and safety obligations. Although the budget was restricted,905 if there had been specific demands which could not be managed within the existing budget, it would have approached RBKC for additional funds.906 She could not recall any occasion on which RBKC had refused a request for additional funds.907 However, it had not occurred to her to approach RBKC to obtain funding for additional staff to support Janice Wray because she had felt that she might not have been able to make a strong enough case.908 She thus appears to have adopted a degree of self-restraint when considering whether to ask RBKC for more funds. By contrast, Janice Wray was under the impression that no additional funding was available. 39.72 It is difficult to tell why Janice Wray and Barbara Matthews had such divergent understandings of the position, given their shared responsibility to deliver the fire risk assessment programme. Throughout her evidence Janice Wray referred to many instances in the years 2009 until 2017 when she thought that the absence of funds was the reason why work had not been undertaken or why additional resources or assistance had not been sought. An early example of this was when she was asked about emergency plans and the recommendation by Salvus to ensure that all emergency plans were in accordance with government guidance.909 When asked why the TMO had not followed Salvus’s advice, she said that she suspected that resources had not been available, but she could not recall asking for additional resources to enable her to do so.910 It is interesting to note that neither the minutes of the TMO Health and Safety committee nor those of the regular meetings between the LFB and the TMO in those years contain any reference to difficulties caused by a lack of funds for fire safety matters. That suggests that lack of resources was not a real constraint, but in the end we do not consider that we have enough information about the TMO’s finances or the extent to which RBKC was willing to make additional funds available to it to be able to reach a reliable conclusion on that question. Failure to assess the risk posed by the arrears 39.73 None of Carl Stokes’s fire risk assessments considered the risk posed to residents by the TMO’s longstanding failure to carry out remedial work in a timely manner. As a result, he did not consider the extent to which the risk to the occupants of the building was enhanced by remedial measures not being carried out within the time required. Secondly, he failed properly to assess the effectiveness of the fire safety management system. 39.74 Clause 20.2 of PAS 79:2012 advised that when a fire risk assessment was reviewed, the assessor should confirm whether work previously recommended has been carried out911 and the template in Annex E relating to a review assessment included a section headed “Action on Previous Action Plan”.912 It thus prompted the assessor to record whether remedial work required by the previous assessment had been carried out. 905 Matthews {Day147/144:2-12}. 906 Matthews {Day147/144:13-24}. 907 Matthews {Day147/144:25}-{Day147/145:9}. 908 Matthews {Day148/136:5-16}. 909 Salvus Fire Risk Assessment of TMO Fire Safety Policy and Procedures dated 22 September 2009 {SAL00000013/18} row 9.1. 910 Wray {Day142/30:1-13}. 911 PAS 79:2012 {CTA00000003/62} clause 20.2. 912 PAS 79:2012 {CTA00000003/112}.

The Grenfell Tower Inquiry: Phase 2 Report 104 39.75 Dr Lane considered that a fire risk assessor could not make a suitable and sufficient assessment of the risks affecting a building without identifying whether previous recommendations had been satisfactorily addressed,913 and that a failure to include in a fire risk assessment information about whether previously identified remedial work had been carried out fell below the standard of a reasonably competent fire risk assessor.914 Colin Todd agreed that it was important for a fire risk assessor to document in the assessment or action plan any items from previous assessments that had not been completed.915 His preference was to identify deficiencies that had been found on the previous occasion and had not been rectified rather than simply treat them as new items,916 but he said approaches varied and a failure to deal with them in that way did not of itself fall below the standard to be expected of a reasonably competent fire risk assessor.917 However, we are not sure why, given the standards set by PAS 79 and the self-evident risks arising from not keeping a track on the progress of previous fire risk assessments. 39.76 Carl Stokes’s fire risk assessments and significant findings and action plans did not contain a section recording the completion or otherwise of recommendations made during a previous assessment. There is some evidence that during his inspections he looked at the previous Schedule of Significant Findings and Action Plan in order to see whether the TMO had complied with his recommendations, but even if he did so, it did not contribute to his overall assessment of the fire risk and he did not record his findings in the documents provided to the TMO. As a result, he could not tell how long individual deficiencies had remained outstanding. That was particularly important when assessing the extent to which the risk to residents was affected by arrears of remedial work. 39.77 However, Carl Stokes was aware that the TMO was not completing remedial work within the recommended times. a. In each of the Schedules of Significant Findings and Action Plans produced in 2010, 2012 and 2014, he asked for confirmation that the caretakers were checking and testing the installed fire protection systems and emergency lighting.918 He said that he had been challenging the absence of a record of that work, but it must have been apparent to him by 2014 that, regardless of whether the checks and tests were in fact being carried out, the TMO had not established a proper system of keeping records over that 4-year period. Mr Stokes believed that he had taken that issue up with Janice Wray but was unable to recall the outcome.919 b. On 13 November 2015, Alex Bosman sent Carl Stokes a consolidated spreadsheet containing a number of questions about recommendations that he wanted him to answer.920 The spreadsheet contained recommendations relating to a range of buildings managed by the TMO drawn from assessments made in 2013, 2014, and

1. They included recommendations classified as “high priority” which had been

913 Lane {Day171/14:8-13}. 914 Lane {Day171/14:17}-{Day171/15:2}. 915 Todd {Day167/41:20}-{Day167/42:9}. 916 Todd {Day 167/42:6-10}. 917 Todd {Day167/43:4-23}. 918 Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 {CST00003165/4-5} items 20, 23b & 23e; Record of Significant Findings and Action Plan for Grenfell Tower dated 20 November 2012 {CST00003083/5-6} items 23b & 23e; Record of Significant Findings and Action Plan for Grenfell Tower dated 17 October 2014 {CST00003177/9} items 23b & 23d. 919 Stokes {Day136/210:18}-{Day136/211:10}. 920 Alex Bosman’s FRA Queries Spreadsheet {CST00002213}. This document also contains entries where Alex Bosman asked Carl Stokes to “justify” the fire risk and classification of the action as “high risk” (Row 9).

Part 5 | Chapter 39: Response to fire risk assessments 105 outstanding for 20 months.921 Mr Stokes responded a few days later attaching a revised spreadsheet containing his own annotations. It is clear from that document that by 16 November 2015 at the latest he had been aware that the TMO had been routinely and systematically failing to complete remedial work within the recommended times.922 c. In October 2016, Carl Stokes was instructed by Janice Wray to inspect Grenfell Tower before an audit scheduled to be undertaken by the LFB.923 The outcome of that inspection, as recorded in his letter of 19 October 2016, was that he found that 23 of the 46 recommendations he had made following the fire risk assessment on 20 June 2016, 43 of which had been described as being of “high priority”, were still outstanding.924 Indeed, the majority of the recommendations in the June 2016 action plan were themselves outstanding from an earlier assessment made in April 2016.925 Further, 14 of the recommendations described by Carl Stokes in his letter of 19 October 2016 as outstanding appear in both the April and October 2016 action plans and were unresolved, despite having been brought to the TMO’s attention six months earlier. 39.78 Accordingly, by October 2016 at the latest, Carl Stokes was aware that the TMO was not carrying out remedial work promptly. He expressed his frustration with the failure to complete work that ought to have been carried out within two or three weeks.926 He suggested that he had contacted Janice Wray to ask her why the work had not been undertaken but he could not remember what her response had been.927 He did not record his advice and there is no other evidence to show that he gave it. 921 Alex Bosman’s FRA Queries Spreadsheet {CST00002213}, see in particular Row 9. 922 Email from Carl Stokes to Janice Wray dated 16 November 2015 {CST00002482}; Annotated spreadsheet {CST00002483}. 923 Letter from Carl Stokes to Janice Wray dated 19 October 2016 {CST00003137}. 924 Letter from Carl Stokes to Janice Wray dated 19 October 2016 {CST00003137}; Record of Significant Findings and Action Plan for Grenfell Tower dated 20 June 2016 {CST00003069}. 925 The Record of Significant Findings and Action Plan for Grenfell Tower dated 26 April 2016 {CST00003098} contained 42 entries; Record of Significant Findings and Action Plan for Grenfell Tower dated 20 June 2016 {CST00003069} contained 46 entries of which 31 were identical or in close terms to a corresponding entry from the April 2016 document. 926 Stokes {Day138/139:25}-{Day138/140:6}. 927 Stokes {Day138/140:18-25}.

The Grenfell Tower Inquiry: Phase 2 Report 106

107 Chapter 40 The replacement of entrance doors 40.1 On the night of the fire, 13 of the entrance doors to the flats had been fitted when the tower was built, 104 had had been installed by Manse Masterdor Limited between 2011 and 2012 as part of a comprehensive replacement programme implemented by the TMO, three had been replaced since 2014, either by the leaseholder or by the TMO, and nine had been fitted to new flats on the lower floors of the building. The doors installed by Manse Masterdor were Suredor GPR fire doors. 40.2 Fire risk assessments of high-risk properties carried out in 2009 and 2010 had drawn the TMO’s attention to the need to introduce regular inspections of entrance doors to flats to ensure that they complied with regulatory requirements. They had also drawn attention to the fact that many doors did not meet current standards and needed to be modernised or replaced. A survey of fire safety features of entrance doors conducted by Rand Associates across the whole of the TMO’s housing stock completed in October 2010928 found that a significant proportion of entrance doors did not have fire safety features and in particular did not have the necessary 30 minute fire resistance.929 They could not, therefore, be modernised.930 The TMO therefore embarked on a programme of replacing entrance doors to flats in many of its buildings. Funding for the replacement programme was agreed with RBKC and various properties were selected for inclusion in it, including all tenanted properties at Grenfell Tower. 40.3 Abigail Acosta was project manager for the replacement programme until her departure from the TMO early in 2012.931 In the initial phase of the programme, Simon Throp, the TMO’s assistant director of the Assets Investment and Engineering team, was also involved. 40.4 The TMO procured replacement doors through the London Housing Consortium,932 a social housing procurement company with a framework agreement for external doorsets.933 Following a competition, Manse Masterdor’s tender was accepted by the TMO’s Operations Committee on 22 February 2011.934 40.5 A pilot door was fitted by Manse Masterdor at Flat 16, Grenfell Tower on 11 May 2011 and the rest of the work appears to have started soon after. The final doors were installed by February 2012 or thereabouts. Regulatory requirements 40.6 The standard of performance required of a door in a compartment wall separating a flat from a space in common use, such as the entrance doors to the flats in Grenfell Tower, was set out in Appendix B to Approved Document B. It called for 30 minutes’ integrity when tested in accordance with BS 476-22 and an ability to meet the requirements 928 {TMO00866665}; Wray {TMO00847305/1-2} pages 1-2, paragraphs 5 and 7. 929 {TMO00847327}. 930 KCTMO Health and Safety Annual Report 2010-2011 {TMO00854890/7} paragraph 8.1.9. 931 Wray {TMO00000890/3} page 3, paragraph 13; Acosta {TMO00862539/1} page 1, paragraph 1. 932 Wray {TMO00847305/2-3} pages 2-3, paragraph 9. 933 External Doorsets Specifiers’ Guide {LHC00000006/1}. 934 Minutes of the Operations Committee meeting on 22 February 2011 {TMO00866724/2} item 3.

The Grenfell Tower Inquiry: Phase 2 Report 108 of BS 476‑31.1 or BS EN 1634:2004 for cold smoke leakage. It also had to meet those standards when exposed to fire on each side of the door separately as part of the complete assembly of the doorset.935 If it met those requirements, it was denoted FD30S. 40.7 The Inquiry has seen two fire resistance test certificates for Suredor GPR fire doors, both of which confirm 30 minutes’ integrity when tested in accordance with BS 476-22.936 However, it appears that no fire resistance tests were carried out937 in accordance with the standard because the test certificates show that the doorset was tested on one side only and not, as required, on both sides.938 There is no evidence that the door was tested for smoke leakage as required by BS 476-31.1. 40.8 Dr Lane and her team examined many of the entrance doors to the flats in Grenfell Tower after the fire for the purposes of Phase 1 of the Inquiry and in Annex I of her report she identified numerous discrepancies between the construction of the doors fitted to the flats and the construction of the door that had been subjected to testing.939 We accept her evidence, from which it follows that in many, if not all, cases the doors installed under the replacement programme did not satisfy the requirements of Approved Document B for that reason also. The specification 40.9 Simon Throp drafted the specification for the doors to be used for the replacement programme.940 Carl Stokes and Janice Wray941 were either consulted or provided general advice about the relevant regulatory requirements.942 40.10 The tender documents required that the doors be “Security/30 min fire doors”,943 but despite the clear requirements of Approved Document B, they did not specify that the doorsets should be rated FD30S, nor did they expressly require the inclusion of cold smoke seals or confirmation that cold smoke leakage testing had been carried out. The documents did require fire test certification to be provided on request, but there was no similar requirement in relation to cold smoke leakage.944 40.11 In its letter of 22 February 2011 conditionally accepting the bid, the TMO said that the schedule of individual door prices provided by Manse Masterdor in the tender documents would be incorporated in the contract.945 The schedule referred to the doors as being rated FD30S but no further details were provided.946 That was the only reference to the FD30S rating in the tender documents or product literature seen by Carl Stokes or others at the TMO. 935 Dr Lane Phase 1 Report – Appendix I – Flat Entrance and Stair Fire Doors – requirements and provisions {BLAR00000024/30-31} sections I4.3.39 – I4.3.46 and {BLAR00000024/53} section I4.7.4. 936 Building Test Centre Report on fire resistance test on single leaf composite door BS 476 {MAS00000001}; Chiltern International Fire test report {MAS00000002}. 937 Duncan {MAS00000356/2-4} pages 2-4, paragraphs 8, 9, 11, 14 and 15; Duncan {MET00040071/2}. 938 Building Test Centre Report on fire resistance test on single leaf composite door BS 476 {MAS00000001}; Chiltern International Fire test report {MAS00000002}. 939 Dr Lane Phase 1 Report – Appendix I – Flat Entrance and Stair Fire Doors – requirements and provisions {BLAR00000024/30} sections I4.3.42, {BLAR00000024/40-53} I4.5.29 – I4.5.88 and I4.7.4. 940 Acosta {Day166/7:6-18}; {Day166/16:6-12}; {Day166/18:9-18}; Letter from Carl Stokes to Janice Wray dated 7 March 2011 updated on 10 March 2011 {CST00013074/2}; Wray {Day143/42:8-19}. 941 Stokes {Day138/39:1-5}; {Day138/40:4-15}; Wray {Day143/40:13-15}; Acosta {Day166/17:6-18}; Wray {Day143/39:9-25}. 942 Acosta {Day166/21:13-24}. 943 Manse Masterdor Ltd Tender Documents 2011 {MAS00000035/3}; {MAS00000035/90-91}. 944 Manse Masterdor Ltd Tender Documents 2011 {MAS00000035/93}. 945 Letter from the TMO to Manse Masterdor Ltd dated 10 February 2011 {MAS00000016/1}. 946 Manse Masterdor Ltd Tender Documents 2011{MAS00000035/7}.

Part 5 | Chapter 40: The replacement of entrance doors 109 40.12 Carl Stokes referred to three documents which he said had given him some assurance that the doors were available as 30-minute fire doors:947 the Manse Masterdor “Suredor” brochure,948 a style guide949 and a specification sheet.950 It is true that the style guide indicated that some doors were available as 30-minute fire doors, but none of them was said to be available with an FD30S rating or with appropriate testing for cold smoke leakage. It seems clear to us that the Suredor GPR door was being marketed primarily as an entrance door for ordinary domestic use, for which a fire and smoke rating was not required. 40.13 Although it is unclear whether the TMO received copies of the certificates relating to tests carried out in accordance with BS 476-22, no one took any steps to check whether the doors supplied corresponded to the test certificates available.951 Carl Stokes’s advice 40.14 Carl Stokes was asked to advise the TMO on the requirements for fire doors in the relevant guidance952 and gave the TMO written advice on 7 March 2011953, 23 May 2011954 and 24 June 2011955. Although he correctly identified the test standard for fire resistance, BS 476-22, he made no reference to the requirement for doors to be tested for cold smoke leakage. However, he was consistently clear that self-closing devices and smoke seals were required. He understood that the entrance doors to flats were required to be FD30 doors with the addition of smoke seals956 and believed that “S” indicated that a cold smoke seal was fitted.957 He was clearly unaware of the requirement for entrance doors to flats on protected corridors to have been tested for cold smoke leakage to the standard set out in BS 476-31.1. 40.15 Following a meeting with Simon Throp and Janice Wray on 10 March 2011, Carl Stokes wrote to Janice Wray958 asking her to obtain documentation from Manse Masterdor to confirm that the doors to be supplied would be the FD30 version and complied in all respects with the Building Regulations and the “Sleeping Guide”. At the same time he pointed out the absence from the information he had seen of any references to self-closing devices or intumescent seals. 40.16 Carl Stokes had originally drafted the letter on 7 March 2011, three days before his meeting with Mr Throp and Ms Wray. In a note added after the meeting he recorded that Mr Throp had confirmed that the doors would have self-closing devices and cold smoke seals. 40.17 Carl Stokes attended the pilot installation of a Suredor GPR fire door by Manse Masterdor on 11 May 2011. He said that he had checked the sticker on the door to confirm that it was rated FD30.959 947 Stokes {CST00030186/15} page 15, paragraph 59. 948 {CST00000116}. 949 {CST00002070}. 950 Manse Masterdor specification sheet {CST00002306}. 951 Wray {Day143/57:13}-{Day143/58:3}; Stokes {Day138/66:8-22}, {Day138/67:3-13}; Acosta {Day166/31:15}-{Day166/32:18}; Pollard {MAS00000341/3} page 3, paragraphs 14 and 17 (certificates were provided to the TMO on two occasions). 952 Stokes {CST00030186/15} page 15, paragraph 57. 953 Letter from Carl Stokes to Janice Wray dated 7 March 2011 updated on 10 March 2011 {CST00013074}. 954 Letter from Carl Stokes to Janice Wray dated 23 May 2011 {CST00000991}. 955 Letter from Carl Stokes to Abigail Acosta dated 24 June 2011 {CST00003149}. 956 Stokes {Day138/39:25}-{Day138/40:3}; {Day138/52:12-17}; {Day138/55:7-19}; {Day138/56:3-19}; {Day138/61:5-8}. 957 Stokes {Day138/65:18-19}. 958 Letter from Carl Stokes to Janice Wray dated 7 March 2011 updated on 10 March 2011 {CST00013074}. 959 Stokes {Day138/52:11-14}.

The Grenfell Tower Inquiry: Phase 2 Report 110 40.18 Following the pilot installation, Carl Stokes wrote to Janice Wray on 23 May 2011 telling her that on the basis of technical sheets she had given him and information provided by the installation team, the door was a fire-rated (FD30) version of the Suredor GRP fire door.960 It is clear that he had not seen the fire resistance test certificates for himself and that he made his assessment of the doors on the basis of the limited information provided to him961 and what he saw during the pilot installation. He said that having seen smoke seals fitted to the door frame he was satisfied that the doors were indeed rated FD30S.962 From his letter of 23 May 2011, it appears that he was satisfied that the doorset met the regulatory requirements.963 Colin Todd thought it was reasonable to infer from the presence of a seal that a door was rated FD30S.964 40.19 On 24 June 2011, Carl Stokes wrote to Abigail Acosta about the standards required for entrance doors to residential flats. He said that the doors should have a minimum of 30 minutes’ integrity when tested in accordance with BS 476-22, be fitted with a self‑closing device and intumescent strips and a cold smoke seal, in other words that they should bear the suffix “S”.965 40.20 Carl Stokes did not tell the TMO that entrance doors to flats should be tested for cold smoke leakage and his advice led Janice Wray to understand that, if doors had been tested for fire resistance for 30 minutes and had self-closing devices and smoke seals, they were FD30S doors. 40.21 The TMO’s invitation to tender did not specify, as it should have done, that FD30S doors were required.966 Responsibility for that omission lies squarely with the TMO, which should have taken effective steps to make sure that it was procuring entrance doors that met the required standards. However, conditions on the night of 14 June 2017 were such that even a door rated FD30S would have provided little protection to the lobbies or the occupants of any of the flats. 960 Letter from Carl Stokes to Janice Wray dated 23 May 2011 {CST00000991/1}. 961 Stokes {Day138/62:10-15}. 962 Stokes {Day138/64:9-25}. 963 Letter from Carl Stokes to Janice Wray dated 23 May 2011 {CST00000991}. 964 Todd {Day167/220:1-9}; {Day167/221:24}-{Day167/222:20}. 965 Letter from Carl Stokes to Abigail Acosta dated 24 June 2011 {CST00001388/1}. 966 Manse Masterdor Ltd Tender Documents 2011 {MAS00000035}.

111 41.1 On the night of the Grenfell Tower fire many of the self-closing devices on the front doors of flats in the block failed to work effectively and some were entirely missing. As a result, many doors remained open when the occupants left, allowing smoke to enter the lobbies, which quickly became smoke-logged. The absence of effective self-closing devices was therefore an important cause of the inability of many occupants to escape the tower at a time when the stairs were relatively free of smoke. It represents a serious defect in the management of the building in relation to fire safety. Legislation and guidance 41.2 Under article 17(1) of the Fire Safety Order the responsible person must ensure that any equipment or devices provided in respect of the premises under the order are subject to a suitable system of maintenance and are maintained in efficient working order and good repair where necessary in order to protect the safety of relevant persons. 41.3 Among the equipment and devices that fall within article 17(1) are fire-resisting doors and self-closing devices. Part G of the LGA Guide, which is entitled “Managing fire risk – ongoing control”, indicates that arrangements for managing fire safety in a block of flats should include putting in place programmes for routine inspection, testing, servicing and maintenance of fire safety systems, such as fire-resisting doors and monitoring the common parts, both through formal inspections and informally as part of day-to-day activities by staff.967 It also recognises that whatever safety equipment is provided, its effectiveness will depend on proper inspection and maintenance.968 41.4 Section 82.3 of the LGA Guide advised that it was good practice to inspect timber fire‑resisting doorsets every six months with a view to identifying defects, such as missing or ineffective self-closing devices and doors which had been replaced with non-fire- resisting products. 41.5 The Guide also said that entrance doors to flats should be fitted with effective self-closing devices that should be replaced as a matter of urgency when found to be missing or damaged. It also warned of the dangers of residents’ removing or disconnecting them.969 41.6 Before the LGA Guide was published, on 30 April 2011 Carl Stokes wrote to Janice Wray about a draft version dated 18 April 2011970 quoting certain paragraphs which he considered could affect the programme for the replacement of entrance doors.971 Janice Wray was therefore aware by 30 April 2011, if not before, that entrance doors needed to be fitted with self-closing devices and that residents might remove or disconnect them.972 967 {HOM00045964/112}. 968 {HOM00045964/113}. 969 {HOM00045964/99}; {HOM00045964/105}. 970 {TMO00847318/1}; {CST00012483}. 971 {TMO00847318/1}. Paragraph 68.2 in the draft LGA Guide was materially the same as that in the published version. 972 Wray {Day143/68:7}-{Day143/69:5}. Chapter 41 Inspection and maintenance of entrance doors

The Grenfell Tower Inquiry: Phase 2 Report 112 Problems with self-closing devices 41.7 Shortly after Manse Masterdor began installing new entrance doors in March 2011, two problems began to emerge with the concealed self-closing devices fitted to them. One was a mechanical fault in the self-closing device which prevented the door from closing or which caused it to become stuck in the closed position. That appears to have been caused by a defect in the fixings connecting the self-closing device to the door and the doorframe. The other was that the self-closing devices were too strong for some residents, particularly those who were elderly or frail, who had difficulty opening and closing their doors. The evidence suggests that both problems were inherent in the design or manufacture of the doorsets rather than the result of defective installation. However, whether the problem was one of design, manufacture or installation, doors were proving difficult to open easily and the solution adopted by many, including the TMO’s repair staff, was to remove the self‑closing devices, even though they were an important fire safety measure. 41.8 Our conclusions about the extent to which one or other of those problems affected the self-closing devices at Grenfell Tower and the extent to which they were remedied before 14 June 2017 depend to a significant extent on evidence provided by residents about their entrance doors and the requests for repairs sent to Manse Masterdor and the TMO. That evidence has its limitations, however. For example, there are many references to doors’ not opening or closing properly that do not identify any more clearly the nature of the problem. Moreover, the lapse of six years between the start of the door replacement programme and the fire means that other factors, such as wear and tear, may have contributed to the condition of some of the self-closing devices on 14 June 2017. We have made findings about the condition of self-closing devices on 14 June 2017 where the evidence gives us sufficient confidence to do so, but it is important to acknowledge at the outset the limited nature of the information available to us. Early discovery of failings: 2011 41.9 On 17 May 2011, Andy Webster, a project manager for Manse Masterdor, sent an email to fellow employees Paul Birkett and Richard Moore about the entrance doors being installed for the TMO in which he referred to a defect in concealed self-closing devices that prevented doors from closing. He recognised that the doors should not have left the factory in that state.973 41.10 It is unclear from Mr Webster’s email what the precise nature of the fault was, except that it prevented the doors from shutting. It appears to have arisen during the design or manufacturing process, but it is unclear how. It is not clear what steps Manse Masterdor took to cure the problem, either in relation to doors that were yet to be installed or in relation to doors that had already been fitted. (At Grenfell Tower 17 entrance doors had been fitted by that date.)974 It is clear, however, that Manse Masterdor did not tell the TMO about the problem.975 973 {MAS00000187/82}. 974 {MAS00000003}. 975 Acosta {Day166/86:3-5}. There is no record of the problem being raised and discussed in the progress meetings for the entrance door replacement programme.

Part 5 | Chapter 41: Inspection and maintenance of entrance doors 113 41.11 On 24 June 2011, Carl Stokes sent an email to Abigail Acosta about problems with two newly installed entrance doors that he had identified during an inspection of King Charles House.976 He had found that the self-closing device had come out of the door of Flat 13. Abigail Acosta told Natasha Brown, resident liaison officer at Manse Masterdor, about the problem and she arranged for a fitter to repair it.977 41.12 On 21 July 2011, Carl Stokes sent another email to Abigail Acosta about the same problem affecting newly installed entrance doors at Grenfell Tower. He said that he had been told that three self-closing devices had been dislodged from the doors. He did not say which flats were affected but he suggested that the screws securing the closer inside the door were too short.978 41.13 Abigail Acosta sent the message on to Andy Webster on 26 July 2011.979 He said that he was aware of the problem and explained that although the factory had used the screws recommended by the manufacturers, they had turned out not to be long enough. As a precautionary measure the size of the screws had been increased.980 Apparently Mr Webster told Ms Acosta which other properties had also been affected, but she could not remember which ones they were.981 41.14 It is clear that from the outset inadequate screws and fixings presented a systemic problem in relation to self-closing devices on the new entrance doors throughout the TMO stock, as the TMO knew. It is also clear that as a result there was a real possibility that self-closing devices would become dislodged from the doors unless the screws and fixings were changed. It is less clear whether the problem was the same as, or related to, the problem with doors not shutting that Mr Webster had referred to in his email of 17 May 2011. 41.15 In his response to Abigail Acosta of 26 July 2011 Mr Webster said that Manse Masterdor had started changing the fixings as necessary,982 but it changed the screws and fixings only of the doors that were affected, not of all doors.983 41.16 At Grenfell Tower, the vast majority of the new entrance doors had been installed by the end of June 2011.984 Unless Manse Masterdor returned to change them, therefore, they retained the original fixings and did not have the larger screws and fixings that the factory apparently used from July 2011 onwards. There is in fact no evidence that Manse Masterdor replaced the fixings of the self-closing devices on any of the new entrance doors. 41.17 We have seen no evidence that Abigail Acosta ever received confirmation that any remedial work had been carried out by Manse Masterdor at either King Charles House or Grenfell Tower. Further, there is no evidence that she, as project manager, carried out any checks herself or that she had a system to record any remedial work that needed to be carried out. She appears to have assumed that Manse Masterdor carried out any necessary remedial work and that the problem had been resolved.985 976 {TMO00867377/2}. 977 {TMO00867377/1-2}. 978 {TMO00867783/2-3}. 979 {TMO00867783/2}. 980 {TMO00867783/1-2}. 981 Acosta {Day166/87:14-18}. 982 {TMO00867783/1-2}. 983 Acosta {Day166/88:1-6}. 984 {MAS00000003}. 985 Acosta {Day166/87:14}-{Day166/89:5}.

The Grenfell Tower Inquiry: Phase 2 Report 114 41.18 Carl Stokes also assumed that the problem had been cured.986 He did not carry out any checks at the time or investigate whether the problem had been satisfactorily resolved when he carried out his next fire risk assessment at Grenfell Tower in November 2012.987 41.19 Whatever steps Manse Masterdor took to cure the problem, it is reasonably clear that it persisted, at least at Grenfell Tower, which may explain why so many self-closing devices were defective or missing on 14 June 2017.988 41.20 There was evidence that during the period from 2011 to 2013 the self-closing devices on the entrance doors of a number of flats at Grenfell Tower had become dislodged or that the doors would either not close at all or else become stuck in the closed position. It is likely that those problems were caused by inadequate screws and fixings, but it is possible that in some cases there were other faults. It is also evident that various repairers, including employees of Manse Masterdor, Morrisons989 and Repairs Direct,990 as well as Seamus Dunlea (the Lancaster West Estate handyman) and residents themselves removed self-closing devices so that doors could be opened and closed freely. Self- closing devices were removed from the doors of Flat 11,991 Flat 12,992 Flat 25,993 Flat 32,994 Flat 41,995 Flat 54,996 Flat 66,997 Flat 76,998 Flat 82,999 Flat 115,1000 Flat 133,1001 Flat 134,1002 Flat 1521003 and Flat 205.1004 41.21 A common feature of all the flats listed above is that the self-closing device on the entrance door was missing on 14 June 2017.1005 We have seen no evidence that Manse Masterdor, the TMO or anyone else replaced the self-closing devices on those doors before 14 June 2017, except for Flat 32. In the case of that flat there is evidence that Manse Masterdor replaced the self-closing device. 41.22 There is positive evidence that the self-closing devices on the entrance doors of some of the flats listed above had not been replaced by June 2014. On 14 June 2014 Leon Taylor, a fire risk assessor for PSC London Ltd, carried out a fire risk assessment of Grenfell Tower on instructions from Michael Lyons, a health and safety manager employed by 986 Stokes {Day138/75:24}-{Day138/76:3}; {Day138/83:5-21}. 987 {CST00003084}; Record of Significant Findings and Action Plan {CST00003083}. 988 {MET00039807/76-80}. 989 Morrisons Facilities Services Ltd provided reactive repair services for the TMO until the termination of their contract in June 2012 when Willmott Dixon was appointed by the TMO to provide those services. 990 Repairs Direct Ltd was a wholly owned subsidiary of the TMO which was established in 2013 to provide reactive repair services for the TMO in place of Willmott Dixon. 991 Alison Moses {IWS00001281/4-5} pages 4-5, paragraphs 21-25 992 Dainton {IWS00000806/6} page 6, paragraph 33; Dainton {IWS00001974/5} page 5, paragraph 25; {RBK00053524} row 3709. 993 Rasoul {IWS00001768/7-8} pages 7-8, paragraphs 34-35; {RBK00053524} rows 3555 and 3052. 994 {MET00045733} row 5303. The flat was identified in that document by cross-checking the factory reference with the document showing the doors installed at Grenfell Tower {MAS00000003} row 15. 995 Kasote {IWS00000768/5} page 5, paragraph 19; Kasote {IWS00001775/7} page 7, paragraph 23; Kasote {Day117/63:17-20}. 996 Rawda Said {IWS00001729/2-3} pages 2-3, paragraph 4(b); Salma Said {IWS00001727/4-5} pages 4-5, paragraph 4(b). 997 Hanan Wahabi {IWS00000074/5} page 5, paragraph 16; {TMO00899663}; {TMO00899664}. 998 Quang {IWS00000080/3} page 3, paragraph 11; Quang {IWS00001821/8-9} pages 8-9, paragraphs 40-42; {RBK00053524} row 2851. 999 {TMO00868337/1}; {RBK00053524} row 3745. 1000 {MET00045733} row 5110. The flat was identified in that document by cross-checking the factory reference with the document showing the doors installed at Grenfell Tower {MAS00000003} row 62. 1001 Hanife Macit {IWS00000904/5} page 5, paragraph 32; Sener Macit {IWS00000069/7} page 7, paragraphs 39 and 40. 1002 Daffarn {IWS00000169/15} page 15, paragraph 47. 1003 Yahya {IWS00000498/3} page 3, paragraph 10; El-Guenuni {IWS00002034/2-3} pages 2-3, paragraph 7. 1004 Neda {IWS00000886/22} page 22, paragraph 132. 1005 {MET00039807/76-80}.

Part 5 | Chapter 41: Inspection and maintenance of entrance doors 115 Repairs Direct.1006 Mr Taylor inspected some of the new doors and found that their self- closing mechanisms had been disconnected; he also found that some of the old fire doors did not have self‑closing devices.1007 He took photographs of missing self-closing devices on at least three entrance doors, including Flats 25 and 76.1008 He recommended that the entrance doors to all flats should have fully functioning, positive-action, working, self- closing devices fitted.1009 We have seen no evidence that Repairs Direct or the TMO took any action in response to that recommendation. 41.23 On 17 December 2015, Janice Wray sent an email to Siobhan Rumble to report Carl Stokes’s concern that some residents of Grenfell Tower had told him that Seamus Dunlea had disconnected the self-closers on their entrance doors. Janice Wray asked Ms Rumble to tell him to stop disconnecting or removing self-closing devices, which apparently she did.1010 On the face of it, that is consistent with Seamus Dunlea’s own evidence.1011 It is not clear when he disconnected self-closing devices or on which doors, but it does indicate that by December 2015 some of the self-closing devices he had removed had not been replaced. There is no evidence that they were replaced at that point or that any investigation was carried out to determine from which flats they had been removed.1012 Moreover, the TMO did not have a system for the regular inspection and maintenance of entrance doors that might have revealed that self-closing devices at Grenfell Tower were missing or defective and prompted their replacement before the fire. 41.24 In those circumstances, the only plausible explanation for the absence of self-closing devices from the entrance doors of the flats on the night of the fire (except Flats 32 and 53) is that they had been removed as a result of problems that had arisen shortly after the doors had been installed and not replaced before the fire. It is unclear how the self-closing devices on the doors of Flats 32 and 53 came to be missing at the time of the fire.1013 Excessive strength of the self-closing device 41.25 During the summer of 2011 there were various reports that the strength of the self- closing devices on new doors caused difficulties for residents when opening and closing them. There is evidence that the self-closing devices to Flats 43,1014 72,1015 1831016 and 1221017 were removed or disabled as a result. We have seen no evidence that they had been repaired or replaced before 14 June 2017, but they were all missing on 14 June 2017 except one (Flat 43), which was present but not working.1018 Again, it is likely that the 1006 Emails between Michael Lyons and Amelia Sales on 26-31 March 2014 {TMO00856436/1-2}; Taylor {PSC00000002/1} page 1, paragraph 2; Leon Taylor’s fire risk assessment of Grenfell Tower dated 14 June 2014 {TMO10001286}. 1007 Leon Taylor’s fire risk assessment of Grenfell Tower dated 14 June 2014 {TMO10001286} “FRA” sheet, Reference L6, rows 231-233. 1008 Photographs taken by Leon Taylor on 15 June 2014 of missing self-closing device at Flat 76 {PSC00000072}; Flat 25 {PSC00000082}; another flat entrance door where the number is not visible {PSC00000087}. 1009 Leon Taylor’s fire risk assessment of Grenfell Tower dated 14 June 2014 {TMO10001286} “Action Plan” sheet, row 9. 1010 {TMO00859693/1}. 1011 Dunlea {MET00019959/6} page 6. 1012 Janice Wray could not remember, but said she would have asked Siobhan Rumble to ask for repairs, Wray {Day143/189:5-15}-{Day143/190:6-12}. Siobhan Rumble said she took no action beyond asking Seamus Dunlea to stop disconnecting and removing the self-closing devices, Rumble {Day120/43:1-5}. Carl Stokes did not investigate whether the issue had been addressed in his subsequent fire risk assessment of Grenfell Tower in April 2016 {CST00003161}. 1013 {MET00039807/76-80}. 1014 Sobieszczak {IWS00001539/4} page 4, paragraphs 16 and 17. 1015 Roncolato {IWS00001774/2} page 2, paragraph 8. 1016 Gomes {IWS00001078/12} page 12, paragraphs 59 and 60. 1017 Beadle {IWS00001872/7} page 7, paragraphs 30 and 31. 1018 {MET00039807/76-80}.

The Grenfell Tower Inquiry: Phase 2 Report 116 reason for their absence is because they had been removed or disabled as a result of the problems that had arisen shortly after the doors were installed and were not subsequently repaired or replaced. Inspection and maintenance of entrance doors 41.26 The TMO was repeatedly advised, both before and after the LGA Guide was published in July 2011, that it needed to put in place a system of regular inspection and maintenance of fire-resisting doors, including the entrance doors to flats. 41.27 The Salvus Management Report, dated 22 September 2009,1019 identified the absence of adequate inspection and monitoring of premises and facilities as a hazard. It specifically identified that the monthly safety inspection did not include any formal checks on fire doors1020 and contained a strong recommendation that the inspection sheet be revised to include formal checks on fire doors. Salvus advised that that needed to be done within a month to remedy what it considered to be a breach of the TMO’s statutory obligations.1021 41.28 In his fire risk assessment of Grenfell Tower dated 30 September 2009 on behalf of Salvus Carl Stokes recommended that a system of formal checks on the entrance doors to flats and all other fire compartmentation doors be introduced by the TMO to ensure that fire compartments remained fit for their purpose. He made it clear that checks should be made on all fire doors within the building and recommended that a system of inspection be put in place within three months or that a plan for doing so be agreed within six months.1022 41.29 Salvus repeated that recommendation in, at least, 12 other fire risk assessments on TMO properties which it carried out between September 2009 and January 2010 under the high‑risk programme. In each case, it recommended that a system of inspection be put in place within three months or that a plan for doing so be agreed within six months.1023 41.30 On 4 November 2010, Carl Stokes advised Janice Wray that when carrying out the programme of replacing the entrance doors to flats, the TMO ought to consider introducing an inspection system to ensure that the residents did not disconnect or disable the self‑closing devices.1024 41.31 On 8 November 2012, representatives of the LFB, the TMO, RBKC and the London Borough of Hammersmith and Fulham met to discuss responsibility for enforcing the law against leaseholders whose entrance doors were not adequately fire-resisting.1025 Andy Jack, the Head of Fire Safety Enforcement at the LFB, Nicolas Comery, team leader of the LFB fire safety team, and Matthew Ramsey, a LFB fire safety inspecting officer, attended on behalf of the LFB. Janice Wray attended on behalf of the TMO. Carl Stokes also attended.1026 No minutes were made of that meeting. 1019 See Chapter 37. 1020 {SAL00000013/7} item 4.1. 1021 {SAL00000013/15} item 4.1. 1022 {CST00003128/16}. 1023 9 Colville Square dated 25 September 2008 {CST00003736/12}; 11 and 12 Colville Square dated 25 September 2008 {CST00003737/12}; Gillray House dated 14 October 2009 {TMO00873667/19}; Salvus fire risk assessments of Dixon House dated 16 November 2009 {CST00002006/21}; Clydesdale House dated 16 November 2009 {CST00003596/15}; Elm Park House dated 9 December 2009 {CST00003744/15}; Whitstable House dated 25 January 2010 {CST00002008/20}; Frinstead House dated 25 January 2010 {CST00003214/22}; Markland House dated 15 January 2010 {CST00003215/22}; Adair Tower dated 28 January 2010 {CST00002623/17}; Hazelwood Tower dated 28 January 2010 {CST00002626/15}. 1024 {CST00001156/1}; {CST00001155}. 1025 Jack {MET00040001/6} page 6, last paragraph; {LFB00004623}. 1026 Jack {MET00040001/6-7} pages 6-7; Comery {LFB00032144/15} page 15, paragraph 50; Ramsey {LFB00032092/13} page 13, paragraphs 47 and 48.

Part 5 | Chapter 41: Inspection and maintenance of entrance doors 117 41.32 A further conversation took place immediately after that meeting involving, at least, Andy Jack, Carl Stokes and Nicolas Comery about the monitoring and maintenance requirements for entrance doors to flats and self-closing devices.1027 Janice Wray did not stay for the discussion but Carl Stokes told her afterwards what had been said.1028 Andy Jack made the point that there was a need to maintain doors and self-closing devices in good working order and to carry out sufficient checks of their effectiveness.1029 He also drew attention to the possibility of carrying out checks on self-closing devices during gas safety inspections.1030 It appears, however, that no agreement was reached about what form the TMO maintenance system should take.1031 The TMO’s policy on inspection and maintenance of flat entrance doors 41.33 From late 2012 to November 2013 Janice Wray drafted the TMO’s fire safety strategy with help from Carl Stokes.1032 As it was the TMO’s overarching policy in relation to fire safety, we should have expected it to contain the arrangements for complying with important aspects of the Fire Safety Order, including the inspection and maintenance of entrance doors to flats and self-closing devices. That is particularly so in view of the specific advice which had been given to the TMO between 2009 and 2012 on the need for a system of regular inspection and maintenance of entrance doors and the recommendations in the LGA Guide that had been published in July 2011. Despite that, however, the TMO’s fire safety strategy, which was completed in November 2013, did not provide for such a system. 41.34 Section 5 of the fire safety strategy covered management arrangements for fire safety. Paragraph 5.1 provided for a programme of regular estate inspections, risk assessments and monitoring by neighbourhood and health and safety staff. It said that inspections ensured that fire doors were operating effectively. It also said that repairs to fire doors and self-closing devices were given priority.1033 However, the inspection checklist covered only communal fire doors and chute room doors, not the entrance doors to flats.1034 41.35 The fire safety strategy also provided for the inspection, testing and maintenance of all fire safety systems and equipment in accordance with the requirements of the relevant British Standard,1035 but did not include the entrance doors to flats or other fire doors.1036 41.36 Section 17 specifically dealt with the entrance doors to flats, but although it clearly envisaged that the TMO’s fire risk assessor would inspect some entrance doors as part of his fire risk assessments, it made no provision for a system of regular inspection and maintenance of entrance doors and self-closing devices.1037 41.37 We have seen no evidence that before the TMO completed its fire safety strategy it gave any consideration to Mr Jack’s suggestion at the meeting on 8 November 2012 that regular inspections of self-closing devices might be combined with the annual gas safety check. 1027 Jack {MET00040001/15} page 15. 1028 Wray {Day143/116:24}-{Day143/117:1-7}; Stokes {Day138/167:16-25}. 1029 Jack {MET00040001/19} page 19; Jack {Day147/68:19}-{Day147/69:24}. 1030 Jack {MET00040001/19} page 19. 1031 Jack {Day147/75:1-7}. 1032 {CST00001188}; {CST00001187}; {CST00001159}; {CST00002046}; {TMO00830598}. 1033 {TMO00830598/2-3} paragraph 5.1, first bullet point. 1034 {TMO00830598/18}. 1035 {TMO00830598/3} paragraph 5.1, second bullet point. 1036 {TMO00830598/4-7} paragraphs 5.1, 6.2, 9.1.3, 9.2, 9.4 and 10. 1037 {TMO00830598/11} paragraph 17.

The Grenfell Tower Inquiry: Phase 2 Report 118 Janice Wray’s email to Matthew Ramsey, 18 December 2013 41.38 On 18 December 2013, Janice Wray sent an email to Matthew Ramsey about various fire safety matters affecting Elm Park House.1038 In response to a concern he had raised about self-closing devices there, Janice Wray described the TMO’s approach to entrance doors as follows: first, when replacement doors were fitted they were fire-rated and fitted with self-closing devices; secondly, when properties became vacant self-closing devices were reinstated or installed as necessary; thirdly, at other times when major work was to be undertaken in a dwelling the self-closing device would be reinstated if it had been removed or disconnected. 41.39 We have seen no evidence that Matthew Ramsey or anyone else in the LFB fire safety team replied to that email or otherwise commented on the approach it described. Mr Ramsey said that neither he nor Nicolas Comery had approved it.1039 Andy Jack said that he had not approved it either.1040 Janice Wray accepted that the LFB had not approved it in the past.1041 None of that is surprising. The TMO’s approach inevitably led to irregular and infrequent inspections of the entrance doors to flats and so was inconsistent with both the LGA Guide’s recommendation for six-monthly inspections and the advice given by Andy Jack in November 2012, which Janice Wray had already accepted.1042 41.40 The TMO’s approach to inspecting self-closing devices, as described by Janice Wray to the LFB, did not appear in the fire safety strategy. It was also absent from the document used by the TMO and Repairs Direct that described the condition that vacant properties were required to attain in order to be ready for letting (known as the “relettable standard”) and was not included in the forms for recording inspections of vacant properties.1043 However, a requirement to carry out a fire risk assessment inspection was added to a new version of the “relettable standard” that was produced in November 2014.1044 In addition, there is some evidence that the TMO and Repairs Direct were, in practice, inspecting the entrance doors to flats and their self-closing devices when vacant properties were inspected.1045 41.41 Quite apart from that, however, the policy was inadequate because it did not ensure that entrance doors were inspected on a regular and systematic basis. It could be many years before a property changed hands and was inspected. Records of repairs show that work was carried out on only 17 of the 120 flats in Grenfell Tower between the end of 2013, when the policy apparently came into existence, and 14 June 2017.1046 That means that the vast majority of entrance doors in Grenfell Tower had not been inspected before the fire. 41.42 The policy of inspecting the entrance door to a flat when major work was carried out was similarly inadequate, because it did not ensure regular inspection. It was only by coincidence that the flats in Grenfell Tower all underwent major work relatively shortly before 14 June 2017 as result of the refurbishment. Janice Wray conceded that the refurbishment provided a suitable occasion on which to visit the flats and inspect the self‑closing devices on the entrance doors,1047 but in the event, that did not happen. 1038 {LFB00003534}. 1039 Ramsey {Day147/15:12-17}. 1040 Jack {Day147/78:1-8}. 1041 Wray {Day143/123:13-25}. 1042 Wray {Day143/123:24}-{Day143/124:4}. 1043 {TMO00905397}; {TMO00905501}; {TMOH00000805/1}; {TMO00861934}. 1044 {TMO00905400/2}; {TMO00905535/2}. 1045 Brunning {TMO00880533/7} page 7, paragraph 34. 1046 {RBK00053524}; {RBK00053297}. 1047 Wray {Day143/123:3-11}.

Part 5 | Chapter 41: Inspection and maintenance of entrance doors 119 Other situations in which the TMO inspected entrance doors 41.43 According to Janice Wray there were three other ways in which the TMO monitored entrance doors to ensure that they remained in good condition once the new doors had been installed.1048 First, Carl Stokes inspected a proportion of doors as part of the fire risk assessment programme. Secondly, flat entrance doors were to an extent monitored by caretakers, known as Estate Services Assistants, during their weekly and monthly inspections of the communal areas. Thirdly, the TMO expected tenants to report any problems with doors to their flats. However, that did not amount to a reliable system of regular inspection. Carl Stokes’s inspections during fire risk assessments did not constitute a systematic and regular inspection of all or even a majority of entrance doors. He was required to carry out fire risk assessments at properties deemed to be high-risk only every two or three years and even less frequently at lower-risk properties.1049 Moreover, he was expected to look at only a sample of entrance doors as part of his fire risk assessments.1050 Accordingly, in a building as large as Grenfell Tower, there were likely to be many doors he had not checked even after several cycles of fire risk assessments. Moreover, it is not part of a fire risk assessor’s task to inspect the entrance doors to flats as part of the responsible person’s system of inspection and maintenance. His job is to assess whether that person has an effective system of inspection and maintenance in place.1051 41.44 The inspection of entrance doors to flats was not formally one of the duties of the Estate Services Assistants and was not included in their daily, weekly or monthly inspection checklists.1052 To the extent, therefore, that they did carry out such inspections, they did so irregularly and there was no means for them formally to record any defects that they found. Their inspections were also limited to reporting visible damage on the outside of an entrance door.1053 41.45 Paul Steadman, the Estate Services Assistant who carried out the inspections of the communal areas at Grenfell Tower, did not inspect entrance doors to flats otherwise than by making a visual check when passing.1054 His inspections, therefore, were not systematic nor did they include the internal aspects of the doors, including, critically, the self-closing devices. The TMO’s records show that he did not identify the need for a single repair to an entrance door or any other fire door as a result of his inspections of Grenfell Tower between 1 January 2016, when the records for those inspections began, and 14 June 2017.1055 1048 Wray {TMO00000890/7} page 7, paragraph 31; Wray {TMO00847305/16-17} pages 16-17, paragraphs 53 and 54. 1049 Wray {Day143/95:2-6}; {CST00030042}. 1050 These matters are addressed in detail in Chapter 38. {HOM00045964/43-45} paragraphs 33.2, 34.1 and 35.1; The TMO Consultant’s Brief dated July 2009 for fire risk assessments in high-risk blocks, which became the instructions to which Salvus worked, stated at Part 2, section 1.1 that the “FRA and FRA reviews will include an individual examination of each fire door including whether it operates correctly”: {TMO00865175/6}; However, at the meeting on 7 September 2009 between Salvus and TMO, Janice Wray agreed that only a random sample of doors needed to be inspected {SAL00000040/1} item 2.1; Wray {TMO00873629/2} page 2, paragraph 9. 1051 Todd {Day168/17:21}-{Day168/18:3}; Lane {Day171/197:14}-{Day171/198:6}. 1052 Daily Estate Staff Inspection Checklist for daily routines appended to TMO Fire Safety Strategy dated November 2013 {TMO00830598/16-19}; Daily Inspections Routine Checklist contained in Estate Staff Quick Reference Handbook {TMO10028449/83-88}; Record of weekly health and safety checks carried out by Estate Service Assistants between 1 January 2016 and 14 June 2017 {CST00000068}; Record of monthly health and safety checks carried out by Estate Service Assistants between 1 January 2016 and 14 June 2017 {CST00000069}. 1053 Rumble {TMO10050001/2-3} pages 2-3, paragraph 9; Wray {TMO00000890/7} page 7, paragraph 32; Wray {Day143/98:14}-{Day143/106:12}. 1054 Steadman {TMO10049875/3} page 3, paragraph 13; Steadman {Day146/8:20}-{Day146/9:18}. 1055 TMO spreadsheet entitled “ESA002D_Fault Report Repairs” which shows “results for all fault report (repairs) forms completed” by Estate Services Assistants between 1 January 2016 and 14 June 2017 {CST00000067} sheet 2, filter for Paul Steadman in column E and Grenfell Tower in column H.

The Grenfell Tower Inquiry: Phase 2 Report 120 41.46 Relying on tenants to report problems with their entrance doors did not amount to a system of inspection at all,1056 but in any case to be effective would depend heavily on the extent to which residents were aware of the importance of their entrance doors, particularly the self-closing device, to fire safety in the building and of the need to report any defects. Residents who had disconnected self-closing devices themselves could not be expected to report the fact. Although the residents received some information about the purpose of fire-resistant entrance doors, they were not specifically told about the purpose and importance of self-closing devices and the need to report defects in them.1057 The number of self-closing devices found to have been defective or missing on 14 June 2017 (77 out of 120), for which no request for repair had been made, demonstrates the folly of relying on residents to identify and report defects.1058 41.47 The TMO’s arrangements for the inspection of entrance doors therefore fell far short of the six-monthly inspections recommended by the LGA Guide and the advice received from the LFB in November 2012. By any measure they fell far below acceptable standards. The TMO’s reasons for not implementing a programme of regular inspections 41.48 Janice Wray was familiar with the recommendation in the LGA Guide that entrance doors be inspected every six months as part of a programme of planned preventative maintenance.1059 She put the failure to implement such a programme down to a lack of resources and difficulties in obtaining access to flats.1060 However, she accepted that the TMO might have been able to fund the programme, but only at the expense of something else.1061 She was confident that she had discussed resourcing a programme of regular inspections with her line managers, Anthony Parkes and (from June 2015) Barbara Matthews, but could not recall when.1062 We have seen no evidence of any such discussions until after the Adair Tower fire on 31 October 2015. We consider that her frequent references to budget restrictions as a reason for not taking necessary action across the TMO estate in relation to fire safety were based on an assumption that any request for further funds would be refused. Neither she nor anyone else appears to have made any serious effort to obtain additional resources. Adair Tower and the LFB’s stance on self-closing devices 41.49 Both before and after the fire at Adair Tower on 31 October 2015 the LFB fire safety team raised concerns with the TMO about its approach and that of Carl Stokes to ensuring that self-closing devices were fitted on entrance doors to flats. 41.50 In early September 2015, the LFB fire safety team identified during an inspection that the entrance door to Flat 41 at Adair Tower, which had not been replaced as part of the replacement programme, did not have a self-closing device.1063 They also discovered that in his fire risk assessment of Adair Tower dated 20 February 2014 Carl Stokes had advised that self-closing devices were “not applicable” and that, although entrance doors to flats were not fitted with self-closing devices, he had not identified their absence as a concern and 1056 Wray {Day143/107:1-18}. 1057 Wray {Day143/107:20}-{Day143/110:23}. 1058 {MET00039807/76-80}. 1059 Wray {Day143/91:20-23}. 1060 Wray {Day143/92:8-15}; {Day143/143:16-25}. 1061 Wray {Day143/93:24}-{Day143/94:2}. 1062 Wray {Day143/94:5-13}. 1063 {LFB00003385/1-2}; {LFB00001613}.

Part 5 | Chapter 41: Inspection and maintenance of entrance doors 121 had not assessed the consequent risk or recommended remedial action.1064 On 12 October 2015, the LFB issued a deficiency notice to the TMO in respect of Adair Tower based on the absence of self-closing devices.1065 41.51 On 14 September and 22 October 2015, Janice Wray sent emails to Julie-Anne Steppings, the LFB fire safety inspecting officer who had conducted the inspection, and Rebecca Burton, the LFB fire safety team leader, respectively. She told them that the TMO’s approach to self-closing devices on existing entrance doors reflected advice from Carl Stokes who had himself received clarification of the position from Andy Jack at the meeting on 8 November 2012.1066 The LGA Guide had introduced the concept of a “nominal” or “notional” fire door to describe an existing door that does not meet current standards for fire-resistance but satisfied the previous standard and therefore did not necessarily need to be replaced.1067 For the TMO, the concept applied to the doors that had not been replaced under the replacement programme, such as those at Adair Tower. 41.52 Although she did not say so explicitly, Janice Wray suggested that she had understood from Carl Stokes that the LFB accepted that self-closing devices were not required on “nominal” doors, despite the fact that the LGA Guide said that all entrance doors to flats and any doors leading onto a protected escape route needed to have a self-closing device.1068 Janice Wray suggested that the LFB had changed its position in that respect.1069 On 22 October 2015 Rebecca Burton replied to Janice Wray, telling her that she was unaware of any guidance that allowed fire doors not to be self-closing, especially those leading to the means of escape.1070 We do not think that the LFB had changed its position, not least because the LGA Guide is clear on the point.1071 LFB advice and enforcement action 41.53 After the fire at Adair Tower, Rebecca Burton sent an email to Andy Jack, Nicholas Coombe and Nicolas Comery on 1 November 2015 asking what had been agreed at the meeting with the TMO on 8 November 2012.1072 Although none of them could recall the precise details of what had been discussed, each of them effectively denied that they had agreed that entrance doors did not need to be self-closing.1073 Andy Jack said in evidence that he had been shocked by the suggestion. He was also shocked that Carl Stokes, as a former fire safety officer, should have thought that entrance doors did not need to be self-closing.1074 Nicolas Comery was similarly clear that there had been no such agreement.1075 We accept their evidence about that. 41.54 On 13 November 2015, Rebecca Burton met Janice Wray to discuss the LFB’s concerns about Adair Tower.1076 They included the suitability and sufficiency of fire risk assessments, especially in relation to self-closing devices, and the claim that the LFB had agreed that 1064 Burton {LFB00084098/5-6} pages 5 and 6, paragraph 10; {LFB00024281/19}; {LFB00084107/1}. 1065 {LFB00001613/4}. 1066 {LFB00003385/1-2}. The meeting with Andy Jack is incorrectly referred to in that email as having taken place in November 2015. Email from Janice Wray to Rebecca Burton on 22 October 2015 {LFB00003440/1}. 1067 {HOM00045964/98} paragraph 62.17. 1068 {HOM00045964/99} paragraph 62.19. 1069 {LFB00003440/1}. 1070 {LFB00003440/1}. 1071 Burton {Day145/90:4-7}; {HOM00045964/99} paragraph 62.19. 1072 {LFB00003385/1}. 1073 {LFB00001610}; {LFB00003463/1}. 1074 Jack {Day147/80:7-21}. 1075 Comery {Day145/181:6-10}. 1076 {TMO00869184/3-4}; {TMO00840415}; {LFB00003445}; Burton {Day145/96:13-25}; Burton {LFB00084098/9} page 9, paragraph 16.

The Grenfell Tower Inquiry: Phase 2 Report 122 entrance doors to flats did not need to be self-closing.1077 She told Janice Wray that Andy Jack, Nicholas Coombes and Nicolas Comery all denied that they had agreed to that and she told Janice Wray that self-closing devices were required on all entrance doors.1078 Janice Wray accepted that they had discussed the need for self-closing devices to be checked regularly.1079 41.55 On 23 December 2015, the LFB fire safety team served an enforcement notice on the TMO in respect of Adair Tower and sent a copy to RBKC.1080 It described a number of matters that the LFB fire safety team considered to involve breaches of the Fire Safety Order. They included a failure to carry out a suitable and sufficient fire risk assessment for the purposes of Article 9 because the assessment carried out by Carl Stokes did not give adequate consideration to existing and required standards for self-closing devices. They also included a failure to maintain the fire resistance of the protected route because none of the doors that opened onto it were fitted with positive-action self-closing devices.1081 The LFB issued another enforcement notice on 18 January 2016 in respect of Hazlewood Tower (Adair Tower’s sister block) which included essentially the same alleged breaches in relation to self-closing devices.1082 41.56 Rebecca Burton and Janice Wray discussed the LFB’s stance on self-closing devices at their regular meeting on 5 January 2016.1083 The minutes recorded the LFB’s view that landlords should ensure that self-closing devices were fitted and that effective procedures were introduced to ensure that the devices remained operational and were not disconnected or removed by residents.1084 That was, we consider, a clear and unambiguous warning to the TMO. 41.57 Janice Wray’s response was that it would be difficult to establish any other sort of maintenance regime due to problems of access and that she would need to speak to her line management to devise a programme.1085 They discussed ways in which the TMO could maintain self-closing devices, including by using caretakers, Estate Services Assistants and incorporating a check of self-closing devices into the TMO’s annual electricity and gas safety checks.1086 Rebecca Burton in effect said that, rather than pressing for entrance doors to be inspected every six months the LFB thought that it was better that inspections actually be carried out at less frequent intervals than to be scheduled at more frequent intervals that could not be achieved.1087 The response of the TMO and RBKC 41.58 After her meeting with Rebecca Burton on 5 January 2016, Janice Wray told Robert Black and Barbara Matthews that Rebecca Burton had stressed that the entrance doors to all flats in the TMO’s housing stock needed to be fitted with self-closing devices and that the policy of checking self-closing devices only in vacant properties was insufficient.1088 She also reported the LFB’s view that the TMO should have a procedure in place for carrying out 1077 {LFB00003445}. 1078 Burton {Day145/97:1-7}; {Day145/97:17}-{Day145/98:2}. 1079 Wray {Day143/139:4-11}. 1080 {LFB00003383}. 1081 {LFB00003383/4-5}. 1082 {RBK00001020}. 1083 {LFB00032330}. 1084 {LFB00032330/3} item 7; {LFB00032331/4} page 4, paragraph 10. 1085 Burton {Day145/101:23}-{Day145/102:3}. 1086 Burton {LFB00032331/4} page 4, paragraph 10; Burton {Day145/102:8-24}. 1087 Burton {Day145/103:5-19}. 1088 {TMO00840451}.

Part 5 | Chapter 41: Inspection and maintenance of entrance doors 123 and recording regular checking of the devices as well as her own opinion that that would be virtually impossible to achieve. In response, Barbara Matthews asked Janice Wray whether it was possible to find out what approach other housing providers, including the London Borough of Hammersmith and Fulham, were taking to self-closing devices.1089 41.59 Accordingly, later the same day Janice Wray sent an email to a number of housing providers to ask whether they required all entrance doors to flats to be self-closing and, if so, how they achieved it, what procedures they adopted to ensure that self-closing devices were not removed or disconnected, and what approach the relevant fire and rescue service took to them.1090 All those who replied said that it was their policy to ensure that entrance doors were fitted with self-closing devices. None of them said that they had a formal system of inspection of self-closing devices, but three of the five who replied had informal approaches to checking self-closing devices, although the methods varied.1091 None of those who replied had encountered a challenge to their approach by the fire and rescue service, except one that had also received a number of deficiency notices and an enforcement notice.1092 41.60 On 8 April 2016, Janice Wray circulated papers for the TMO Health and Safety Committee meeting on 12 April 2016.1093 They included a paper dated 4 April 2016 entitled “Review of the Fire Safety Strategy”,1094 in which she said that it was time to review the strategy to make sure that the TMO’s policies complied with the relevant legislation and the LFB’s advice, guidance and requirements.1095 However, for reasons which are not apparent, she did not invite the committee to consider the matters she had discussed with Rebecca Burton on 5 January 2016, namely, the need to install self-closing devices on all entrance doors and to put in place a system for the regular inspection and maintenance of self-closing devices. James Swindells’ email to Janice Wray of 1 August 2016 41.61 On 27 July 2016, James Swindells, an LFB fire safety inspecting officer, reported to Janice Wray, copying in Rebecca Burton, on his inspection of Lonsdale House.1096 He had found that a number of self-closing devices had been broken or removed by residents. Janice Wray replied on 1 August 2016 saying that the doors had been replaced as part of the entrance door replacement programme in 2012-2013 and had operational self-closing devices at that time. She said that the TMO could not control the action of residents and pointed out that, even if the self-closing devices were repaired or replaced, they could soon be removed or disabled again.1097 41.62 In response Mr Swindells emphasised the obligation imposed on the responsible person by Articles 11 and 17 of the Fire Safety Order to monitor and maintain fire safety systems and suggested that residents should be reminded that the device was there to protect both them and their neighbours.1098 1089 {TMO00902946/1}. 1090 {TMO00865995/2-3}. 1091 {CST00007708/1-2}; {CST00006634/1}; {TMO00865995/1}; {CST00002902/1}; {CST00002302/1-2}. 1092 {CST00002902/1}. 1093 {TMO10012661}. 1094 {TMO10024351}; {TMO10012811/5} item 6.3. 1095 {TMO10024351}. 1096 {CST00009704/2}. 1097 {CST00009704/1-2}. 1098 {CST00009704/1}.

The Grenfell Tower Inquiry: Phase 2 Report 124 Review of the TMO fire safety strategy: September 2016 41.63 On 9 September 2016, Janice Wray circulated papers for a meeting of the TMO Health and Safety Committee on 13 September 2016.1099 She again included a paper entitled “Review of the Fire Safety Strategy”, in which she invited the committee to comment on various fire safety matters.1100 On that occasion they included for the first time the need to install and inspect self-closing devices on entrance doors to flats as had been discussed with Rebecca Burton on 5 January 2016. Janice Wray could not explain the delay other than by saying that complying with the enforcement notices for Adair Tower and Hazlewood Tower had been time-consuming work.1101 Given the obvious importance of the matter, that is scarcely a sufficient explanation. 41.64 Janice Wray invited the committee to consider the requirement for self-closing devices, the LFB’s interpretation of the Fire Safety Order and what the TMO could do to advance the installation of self-closers.1102 She suggested that one option was to create, and give priority to, a programme for installing self-closing devices, which would need approval and financial support from RBKC. She also asked the committee to consider how the TMO might implement a system of regular inspection and maintenance of self-closing devices, asking a number of questions relating to practical matters, such as the extent to which the TMO’s caretakers could assist, when checks might best be carried out and whether the importance of self-closing devices could be emphasised in communications to residents.1103 41.65 At its meeting on 13 September 2016 the committee acknowledged the need to have a more active policy on the installation of self-closing devices in order to meet the LFB’s requirements. Someone suggested that the work could be included in cyclical redecoration projects but it was decided that further work needed to be done to obtain approval and funding from RBKC.1104 We have seen no evidence that the ways in which self-closing devices might be inspected were discussed, either at the meeting or subsequently.1105 41.66 The possibility of inspecting self-closing devices when carrying out annual gas safety checks had been raised by Andy Jack in November 2012. Janice Wray said that she had instructed Alex Bosman to discuss that with the TMO’s gas safety contractors, but that they had refused to do it.1106 She was not able to say when that discussion had taken place, only that it had probably occurred before her meeting with Rebecca Burton on 5 January 2016.1107 However, that is not easy to reconcile with the matter being raised for discussion for the first time in September 2016. We have seen no other evidence that discussions of that kind took place and on balance we do not think that they did. The involvement of RBKC 41.67 The fitting of self-closing devices was discussed at a meeting of the TMO executive team on 5 October 2016 attended by Robert Black, Sacha Jevans, Barbara Matthews and Yvonne Birch. The meeting was told that the LFB was putting pressure on the TMO to fit self-closing devices to all entrance doors to flats but that that had been resisted by 1099 {TMO00840649}. 1100 {TMO00840660/1-2}. 1101 Wray {Day143/152:17}-{Day143/153:19}. 1102 {TMO00840660/2}. 1103 {TMO00840660/2}. 1104 {TMO00840753/5} item 6.1. 1105 {TMO00905766}. 1106 Wray {Day143/85:20}-{Day143/86:5}; {Day143/120:2}-{Day143/121:16}. 1107 Wray {Day143/120:2}-{Day143/121:16}; {Day143/141:22}-{Day143/142:7}.

Part 5 | Chapter 41: Inspection and maintenance of entrance doors 125 Laura Johnson.1108 It was also told that the fire strategy was being revised to contain a programme for the work be done over a period of five years, although it was thought likely that the LFB would expect it to be done within a shorter period. It was agreed that it would be necessary to discuss the matter with RBKC, which would need to provide the necessary funding.1109 41.68 Robert Black’s view was that RBKC (in particular, Laura Johnson) was in a position to decide whether or not the TMO took the steps required by the LFB because it controlled the budget.1110 Laura Johnson said that she had suggested that any programme for installing self-closing devices should be spread over five rather than three years for financial and practical reasons.1111 She said that she had understood that it would probably have to be carried out within a shorter period, but that she had not wanted to set the TMO up to fail.1112 41.69 It is clear that Laura Johnson was not persuaded of the need to install self-closing devices over a three-year period. The minutes make that clear. Although she was right to have in mind the need to balance the expense of the proposed programme against the risks involved, her decision failed to give sufficient weight to the advice of the LFB and the nature of the risk that self-closing devices were intended to mitigate. The deficiency notice for Grenfell Tower: 17 November 2016 41.70 On 17 November 2016, the LFB issued a deficiency notice to the TMO in respect of Grenfell Tower1113 on the grounds that the protected escape route (corridors, lobbies and stairs) was compromised by doors that did not have self-closing devices. It also identified the doors to Flats 44 and 153 as having failed to close themselves when inspected.1114 It recommended that the deficiencies be remedied by 18 May 2017. The deficiency notice thus informed the TMO of its obligations in respect of the installation and maintenance of self-closing devices and the urgency with which they needed to be discharged. RBKC’s decision 41.71 On 28 February 2017, Barbara Matthews sent a report on self-closing devices to members of the RBKC and TMO Joint Management Committee in advance of its meeting on 1 March 2017.1115 It had been drafted by Janice Wray.1116 It set out the LFB fire safety team’s requirements in relation to the installation and inspection of self-closing devices, which were based on its view of articles 11 and 17 of the Fire Safety Order. The report drew attention to the TMO’s concern that even regular inspections and maintenance would not ensure that self-closing devices remained effective. It referred to the email sent by James Swindells on 1 August 2016 voicing that concern, in which he said that the TMO only needed to put in place a reasonable system of inspection to discharge its duty.1117 The report included an estimate prepared by Graham Webb, the managing director of Repairs Direct, of the cost of carrying out a programme of installation and inspection and 1108 {TMO00843861/2} item 3.2. 1109 Jevans {Day127/97:25}-{Day127/98:5}. 1110 Black {Day150/211:17-20}. 1111 Johnson {Day129/200:2}-{Day129/202:7}; Jevans {Day127/96:15}-{Day127/97:5}; Matthews {Day148/108:7-10}. 1112 Johnson {Day129/200:2}-{Day129/202:7}; Jevans {Day127/96:15}-{Day127/97:5}. 1113 {TMO10017254}. 1114 {TMO10017254/4-5}. 1115 {RBK00000987}. 1116 {RBK00000988}. 1117 {TMO00869692}.

The Grenfell Tower Inquiry: Phase 2 Report 126 the assumptions underlying.1118 It did not, however, mention the recommendation in the LGA Guide that inspections be carried out every six months. Although it was estimated that 50% of the TMO’s properties did not have self-closing devices fitted to the entrance doors and that 40% of those that were present needed to be repaired or replaced, the report did not touch on the effect that self-closing devices have on the safety of residents.1119 41.72 At the meeting of the Joint Management Committee concern was expressed at the fact that no other housing provider had a programme for the regular inspection of self-closing devices.1120 There appears to have been no reference to the recommendation in the LGA Guide for six-monthly inspections, the available means of carrying out inspections or the risk to the safety of residents if a programme of installation or regular inspection was delayed or not implemented. 41.73 On 3 March 2017, Barbara Matthews sought to confirm with Laura Johnson and Robert Black what she understood had been agreed at that meeting, namely, that the installation of self-closing devices would be carried out over a period of between three and five years but that regular inspection would not be introduced until legal advice had been obtained about the TMO’s right to obtain access if tenants or leaseholders refused it.1121 Laura Johnson said that she wanted to spread the installation programme over five years because it would make funding more manageable. In respect of the proposed inspection programme, she took an uncompromisingly negative line, saying that it would impose a continuing burden on the Housing Revenue Account without any evidence that it would affect the safety of residents and that she did not think it was necessary.1122 41.74 Laura Johnson accepted that her message amounted to, or at least was interpreted by the TMO as, a direction to extend the period over which the installation programme was to be carried out and to not establish an inspection regime.1123 The TMO did not resist.1124 In effect, therefore, she alone decided that the installation programme should be extended.1125 She did so without having taken any advice about the consequences for the safety of residents.1126 She effectively accepted that financial considerations were the principal, if not sole, basis for her decision.1127 41.75 Laura Johnson admitted that she had not taken any steps to understand the risk to safety of not inspecting and maintaining self-closing devices1128 and she accepted that her decision not to establish an inspection system had been wrong.1129 She could not recall what her views had been on the LFB’s clear advice about the need to inspect and maintain self closing devices, except that she had wanted to understand whether there was a statutory requirement to do so.1130 She said that she had not been aware of the recommendation in the LGA Guide that landlords should establish a system of inspection 1118 {RBK00000988/3}; {TMO00905766}. 1119 {RBK00000988/3}. 1120 {RBK00014072/2} item 5. 1121 {RBK00014053/4}. 1122 {RBK00014053/4}. 1123 Johnson {Day129/225:1-5}. 1124 {RBK00014053/3}; {TMO00842281/1} item 3; {TMO00847312/5} item 4.2. 1125 Johnson {Day129/221:20-23}. 1126 Johnson {Day129/221:24}-{Day129/222:2}. 1127 Johnson {Day129/224:4-17}. 1128 Johnson {Day129/225:17-20}. 1129 Johnson {Day129/225:6-16}. 1130 Johnson {Day129/225:6-16}.

Part 5 | Chapter 41: Inspection and maintenance of entrance doors 127 and maintenance of self-closing devices.1131 It is evident from the email she sent to Barbara Matthews on 6 March 2017 that money again was the driving force behind her refusal to introduce a system of inspection and maintenance.1132 Revision of the fire safety strategy: June 2017 41.76 Janice Wray revised the TMO’s fire safety strategy in June 2017.1133 In paragraph 18.1.1 there was a reference to the agreement with RBKC to carry out a programme of fitting self-closing devices to the entrance doors of all flats over a period of five years.1134 In the same paragraph it said that the TMO had a variety of methods of ensuring that self-closing devices remained in place and operational. They included inspections when properties were vacant and sample inspections during fire risk assessments.1135 In short, little, if anything, in the TMO’s approach had changed. Oversight by RBKC Housing Property and Scrutiny Committee 41.77 The evidence indicates that neither RBKC nor the TMO fully informed the Housing Property and Scrutiny Committee (“the scrutiny committee”) about the position in respect of the installation and inspection of self-closing devices after the Adair Tower fire and before the Grenfell Tower fire. The evidence also indicates that, to the extent that the scrutiny committee was made aware of the LFB’s concerns about self-closing devices, it did not take adequate steps to investigate why those concerns had arisen or to ensure that RBKC and the TMO had adequately addressed them. 41.78 In her report for the scrutiny committee meeting on 6 January 2016, Laura Johnson warned that the LFB intended to serve enforcement notices in respect of Adair Tower and Hazlewood Tower, in part because of the lack of self-closing devices on entrance doors to flats.1136 Robert Black reported orally to the meeting that the LFB’s requirement to install self-closing devices applied not only to Adair and Hazlewood Towers, but to all the council’s properties.1137 However, he did not mention that the LFB also required a system of regular inspection to be put in place. We have seen no evidence that the scrutiny committee took steps at that point to find out how the problems with self-closing devices had arisen, particularly in the light of the replacement of entrance doors only a few years earlier and the continuing programme of fire risk assessments. We find that lack of curiosity surprising. 41.79 In her report for the meeting of the scrutiny committee on 13 July 2016 Laura Johnson provided further information about the enforcement notices relating to Adair and Hazlewood Towers.1138 She said that the TMO and RBKC had agreed to ensure that all entrance doors to flats in both blocks were adequately fire-rated and fitted with self-closing devices.1139 At the meeting, Councillor Nicholls asked whether RBKC complied at other locations. Ms Johnson told him that self-closing devices were fitted at all properties,1140 although at that time the TMO was still discussing internally how to remedy the lack of 1131 Johnson {Day129/226:24}-{Day129/227:3}. 1132 {RBK00014053/4}. 1133 {TMO10017036}. 1134 {TMO10017036/12} section 18.1.1. 1135 {TMO10017036/12} section 18.1.1. 1136 {RBK00032439/5-6} paragraphs 4.6-4.7. 1137 {RBK00014534/11}. 1138 {RBK00032476/1-2} paragraphs 1.3 and 1.4. 1139 {RBK00032476/1-2} paragraphs 1.3 and 1.4. 1140 {RBK00032473/5} paragraph A9.

The Grenfell Tower Inquiry: Phase 2 Report 128 self-closing devices across its properties. There is no record of Robert Black, who was in attendance, correcting her. The scrutiny committee did not take any further action to satisfy itself that RBKC and TMO had fully addressed the LFB’s concerns in that respect. 41.80 In her report for the scrutiny committee meeting on 16 November 2016, Laura Johnson said that the works required by the Adair Tower and Hazlewood Tower enforcement notices had been completed.1141 However, she did not refer to the need to install and inspect regularly self-closing devices across the whole of the housing stock, although by that point she had begun discussing that with the TMO.1142 Nor were they mentioned in the TMO’s Mid Year Review of Performance which had been prepared for that meeting.1143 Laura Johnson and Barbara Matthews attended the meeting. There is no record of any fire safety matters having been raised by either of them.1144 41.81 As we have already said,1145 we have also seen no evidence that the scrutiny committee were ever informed about the deficiency notice the LFB issued in respect of Grenfell Tower dated 17 November 2016 and the concerns it identified in relation to the maintenance of self-closing devices before the Grenfell Tower fire. 41.82 At the scrutiny committee meeting on 4 May 2017, following the fire at Trellick Tower on 19 April 2017, Councillor Mackover and Councillor Pascall expressed concern about the TMO’s approach to the installation of fire doors on properties owned by leaseholders.1146 The scrutiny committee had not been briefed about the decision only a month or so earlier to spread the installation of self-closing devices over a period of five rather than three years and not to introduce a system of regular inspection and Laura Johnson did not draw it to their attention. 41.83 The minutes of a TMO executive team meeting on 17 May 2017 recorded that at the meeting of the scrutiny committee on 4 May 2017 Councillor Mackover had criticised the TMO’s approach to fire doors but that Laura Johnson had made it clear that RBKC did not want the TMO to inspect the front doors of flats.1147 41.84 Laura Johnson sent an email to Robert Black the following day in response to a question he had asked about the nature of Councillor Mackover’s concern and whether he should contact him.1148 She said that it related to the entrance doors of leaseholders’ flats and that there was nothing in it. She recommended not contacting him. She thought that a section in the annual report would be sufficient. Robert Black agreed.1149 41.85 It is evident, therefore, that the scrutiny committee was not told about the decisions that had been made, principally by Laura Johnson, about the installation and inspection of self‑closing devices before the Grenfell Tower fire. 1141 {RBK00032461/1} paragraphs 1.1-1.3. 1142 {TMO00843861/2} item 3.2. 1143 {RBK00000731}; {RBK00032475/8} paragraph A16. 1144 Minutes of the meeting of the scrutiny committee meeting on 16 November 2016 {RBK00032475}. 1145 See Chapter 31. 1146 Mackover {RBK00029923/18} page 18, paragraph 67; {RBK00052464/7} paragraph A8; {RBK00002340/1-2}. 1147 Minutes of the TMO executive team meeting on 17 May 2017 {TMO00894337/1-2} item 2.6. 1148 Emails between Laura Johnson and Robert Black on 17-18 May 2017 {RBK00002340/1-2}. 1149 Email from Robert Black to Laura Johnson on 18 May 2017 {RBK00002340/1}.

Part 5 | Chapter 41: Inspection and maintenance of entrance doors 129 The TMO’s approach to the repair of entrance doors 41.86 Section 5.1 of the TMO’s fire safety strategy dated November 2013 said that repairs to fire doors and self-closing devices were given priority.1150 Beyond that, the TMO had no policy or procedure for responding to requests for repairs to fire doors, including entrance doors to flats. For example, they were not included in the TMO’s Fire Protections Systems Policy & Procedure drafted in 2017, which set out the procedure for repairing faults in a number of fire protection systems, including sprinklers, fire alarms, fire extinguishers, hose reels and automatic opening vents.1151 41.87 Despite the terms of section 5.1, the TMO’s repair records for Grenfell Tower reveal no discernible system for giving repairs to fire doors priority over other matters.1152 Where a need to repair a fire door was identified by Carl Stokes in the course of a fire risk assessment, it was marked as “FRA”, or something similar, but we saw nothing to suggest that it was given priority.1153 The repair records suggest that defects of that kind were dealt with in the same way as any other kind of repair. That is consistent with a finding of a “Health Check” audit carried out on Repairs Direct after the Grenfell Tower fire that there was no structured approach to categorising repairs, which made them difficult to manage effectively.1154 41.88 Those sent to carry out repairs to self-closing devices at Grenfell Tower between 2011-2013 often simply removed them, so that doors could be opened and closed freely, but did not replace them. In the period up to 14 June 2017 Repairs Direct staff continued on occasions to remove, or offer to remove, self-closing devices or failed to identify the need to replace them when carrying out repairs to entrance doors. That occurred at Flat 26,1155 Flat 45,1156 Flat 126,1157 Flat 1311158 and Flat 135.1159 41.89 At each of those flats the self-closing device was found to be missing on 14 June 2017, apart from Flat 26 where the resident had refused the Repair Direct workman’s offer to remove it.1160 In our view that is indicative of a broader failure by the TMO to ensure that those carrying out repairs fully understood the importance of effective self-closing devices and ensured that repairs did not undermine the protection offered by the doors. Fire risk assessment and flat entrance doors 41.90 Paragraph 33.2 of the LGA Guide drew attention to the importance of ensuring that the fire resistance between flats and the common parts was considered as part of a fire risk assessment by examining at least a sample of the entrance doors to flats to 1150 TMO fire safety strategy dated November 2013 {TMO00830598/3}. 1151 TMO Fire Protections Systems Policy & Procedure Version 8 dated 10 January 2017 {TMO00899324/2}. 1152 {RBK00053524}; {RBK00053297}. 1153 {RBK00053524}; {RBK00053297}. 1154 {TMO00862541/11}. 1155 Dagnachew {IWS00001742/4} page 4, paragraph 4b; {RBK00053297} row 467. 1156 Email from Glen Duggan to Janice Jones on 22 July 2015 {CST00000989/2}; Carl Stokes’s letter to Janice Wray on 28 July 2015 {CST00001448}; Capita repair spreadsheet {RBK00053524} rows 686 and 1227; West {IWS00000021/3} page 3, paragraph 14; Paramasivan {IWS00001003/3} page 3, paragraph 9. 1157 Repair records {RBK00053524} rows 30 and 163. 1158 Gashaw {IWS00001738/2-3} pages 2-3, paragraph 4b; Fletcher {IWS00001797/3} page 3, paragraph 5b; Repair record {RBK00053524} row 847. 1159 Daniels {IWS00000608/6} page 6, paragraph 40; Daniels {IWS00002065/3} page 3, paragraphs 13-15; Open Contractor spreadsheet {RBK00053297} row 82; Repair records {RBK00053297} row 82. 1160 {MET00039807/76-80}.

The Grenfell Tower Inquiry: Phase 2 Report 130 ensure that they were fire-resisting and self-closing.1161 In a similar vein, Annex D to PAS 79:2012 stated that a fire risk assessor must consider whether all fire-resisting doors are properly self-closing.1162 The approach to flat entrance doors to be expected of a fire risk assessor 41.91 We have no doubt that a fire risk assessor considering any building containing a large number of flats should inspect a representative sample of entrance doors.1163 Although they expressed themselves in slightly different terms the experts agreed that the number of doors that should be expected will be a matter of judgment in each case and depend on the nature and size of the building and the assessor’s familiarity with it.1164 There appears to have been a general understanding at the time among fire risk assessors that 10% of the total number with a minimum of two doors was sufficient.1165 41.92 The experts also agreed that a fire risk assessor should inspect both sides of the door, check whether the self-closing device was working effectively,1166 keep a record of the doors inspected,1167 record any defects in the fire risk assessment1168 and assess the adequacy of the arrangements for the inspection and maintenance of entrance doors.1169 41.93 Salvus and the TMO had agreed in late 2009 at the start of programme of assessing high-risk buildings that its fire risk assessors would inspect a sample of the entrance doors to flats during each of their assessments, although they did not agree a specific number or percentage of doors to be inspected.1170 When Carl Stokes was engaged by the TMO to assess medium-risk buildings in September 2010, it does not appear that he and Janice Wray discussed the need to inspect a sample of doors but they both clearly proceeded on understanding that he would.1171 That expectation was ultimately recorded in the TMO’s fire safety strategy dated June 2017.1172 Carl Stokes’s inspection of entrance doors at Grenfell Tower 41.94 In section 12 of his fire risk assessment template referring to the means of escape Carl Stokes included the questions whether fire doors were fitted with self-closing devices and whether they functioned correctly.1173 It was his own addition to the model template contained in PAS 79:2012.1174 1161 The LGA Guide {HOM00045964/43} paragraph 33.2. 1162 PAS 79:2012 {CTA00000003/104}. 1163 Lane {Day171/177:22}-{Day171/178:11}; Todd {Day168/6:5-11}. 1164 Lane {Day171/178:20}-{Day171/179:11}; {Day171/186:19}-{Day171/187:20}. 1165 Todd {Day168/6:12-20}. 1166 Lane {Day171/178:6-11}; {Day171/184:3-9}; Todd {Day168/6:7-11}. 1167 Lane {Day171/180:7}-{Day171/182:16}; Todd {Day168/9:9-23}; Todd {Day168/14:20}-{Day168/15:20}. 1168 Lane {Day171/175:19}-{Day171/176:23}; {Day171/188:13}-{Day171/189:11}; Todd {Day168/20:10}-{Day168/24:1}. 1169 Lane {Day171/197:3-12}; Todd {Day168/17:8-19}. 1170 The TMO Consultant’s Brief dated July 2009 for fire risk assessments in high-risk blocks, which was the brief for Salvus, states at Part 2 section 1.1 that the “FRA and FRA reviews will include an individual examination of each fire door including whether it operates correctly”: {TMO00865175/6}; However, at a meeting on 7 September 2009 between Salvus and TMO, Janice Wray agreed that only a random sample of doors needed to be inspected {SAL00000040/1} item 2.1; Wray {TMO00873629/2} page 2, paragraph 9. 1171 Janice Wray said Carl Stokes continued to inspect flat entrance doors as part of his fire risk assessments, Wray {TMO00000890/7} page 7, paragraph 31; Stokes {Day138/84:5-7}; Stokes {Day138/149:11-15}; {CST00002861}. 1172 {TMO10017036/12} section 18.1. 1173 For example, Carl Stokes’s fire risk assessment of Grenfell Tower dated 26 April 2016 {CST00003084/18}. 1174 PAS 79:2012, Annex B model proforma fire risk assessment template {LFB00034866/77}.

Part 5 | Chapter 41: Inspection and maintenance of entrance doors 131 41.95 Carl Stokes said that he did not make appointments to inspect doors but knocked on doors and asked residents whether he could inspect them and, in particular, whether self-closers were fitted.1175 He said that tried to inspect at least a handful, or about 5%, of entrance doors1176 and that if the doors in a building were of the same kind, he aimed to inspect a sample. If they differed, he aimed to inspect at least one of each kind.1177 However, even when the doors in a building were all of the same kind, inspecting only 5% of them was barely enough.1178 41.96 Notwithstanding what he said about his approach to sample inspections, the evidence suggests that at Grenfell Tower Carl Stokes did not carry out sample inspections of entrance doors which extended to both the external and internal faces of the doors, including self-closing devices. The evidence tends to support the conclusion that he looked only at the outside of doors and that he noted only such damage as he happened to see rather than visiting a number of flats as part of an organised plan. In the course of four fire risk assessments he carried out at Grenfell Tower between November 2012 and June 2016 Carl Stokes identified defects in only four entrance doors.1179 Only one of them was a defect that affected the inside face of the door: a self-closing device missing from the door to Flat 112. As it happened, the door to Flat 112 was being replaced in June 2016 and had been open at the time he was carrying out his fire risk assessment. His ability to inspect the inside of the door had therefore been fortuitous rather than planned.1180 41.97 Carl Stokes’s failure to identify defects on the inside of doors, particularly defective and missing self-closing devices, is in stark contrast with what others who carried out sample inspections of entrance doors at Grenfell Tower found. Leon Taylor, who carried out a sample inspection of entrance doors in the course of a fire risk assessment on 14 June 2014 found at least three self-closing devices missing,1181 whereas Carl Stokes, who carried out a fire risk assessment on 17 October 2014, did not find any self-closing devices missing. Michelle McHugh, of the LFB fire safety team, carried out an inspection of a sample of entrance doors during her audit of Grenfell Tower on 26 October 2016 and found that three self-closing devices were defective,1182 but Carl Stokes did not find any devices missing during his fire risk assessments in April and June 2016 or during an inspection he carried out on 18 October 2016, only a week or so before Ms McHugh.1183 41.98 Given the number of self-closing devices that were found to be missing or broken after the fire (some 77 out of 120), and in the light of Leon Taylor and Michelle McHugh’s findings, we think it likely that, if Carl Stokes had inspected both the inside and outside of a representative sample of entrance doors during his fire risk assessments, he would have discovered a significant number of missing or defective self-closing devices.1184 Accordingly, we think it unlikely that he did routinely inspect the inside of doors. 1175 Stokes {CST00003063/20} page 20, paragraphs 58 and 59. 1176 Stokes {Day136/96:3-12}. 1177 Stokes {Day136/95:21}-{Day136/96:2}. 1178 Lane {Day171/179:14}-{Day171/180:6}; Todd {Day168/8:24}-{Day168/9:8}. 1179 Carl Stokes identified holes in the flat entrance doors of flats 166 and 202 in his Record of Significant Findings and Action Plan for Grenfell Tower dated 20 November 2012 {CST00003083/3} item 12b. Carl Stokes identified that the flat entrance door of Flat 24 was damaged and that the door to Flat 112 was being replaced, was not marked as fire rated and did not have a self-closing device, Record of Significant Findings and Action Plan dated 20 June 2016 {CST00003069/4-5} items 12g and 12h. 1180 Stokes {Day138/130:17}-{Day138/131:1}. 1181 {TMO10001286} ‘FRA’ sheet, ref L6, row 232; Taylor {PSC00000002/2} page 2, paragraph 2.d. 1182 {LFB00105489/6} penultimate paragraph under ‘Observations’. 1183 {CST00003098}; {CST00003069}; {CST00003137}. 1184 {MET00039807/76-80}.

The Grenfell Tower Inquiry: Phase 2 Report 132 41.99 Carl Stokes kept no record of which flats he had visited or tried to visit as part of his fire risk assessments or of the results of any such inspections, except in relation to the four defects he identified in his action plans.1185 41.100 In each of his fire risk assessments Carl Stokes stated that the entrance doors to the flats had recently been replaced with new self-closing 30-minute fire doors but he did not say that he had inspected a sample of entrance doors.1186 Further, in his contemporaneous notes of the fire risk assessment he carried out on 20 June 2016, he recorded only the defects that he had identified on the outside of the door to Flat 24 and on the open door to Flat 112.1187 He did not include a note of any other flats he had sought to enter, nor what he had found. That has left us in some doubt whether he did, in fact, inspect a representative sample of entrance doors during any of his fire risk assessments. 41.101 Gaining access to flats clearly posed a problem for Carl Stokes from time to time. In his fire risk assessment of Grenfell Tower dated 30 September 2009 (when he was working for Salvus), he recorded that the entrance to each flat appeared to be a rated fire door to FR30 standard but that without being able to obtain access to all the flats he could not confirm that every door was fitted with an intumescent strip, cold smoke seals and a self- closing device.1188 He confirmed when he gave evidence that he had not always been able to gain access to flats because, for example, the residents were out at work.1189 However, he did not tell the TMO that he was having difficulty in inspecting the inside of entrance doors to flats because people were not at home to let him in,1190 and except for the fire risk assessments he produced in 2009, he did not record that as a problem. If he could not gain access to enough flats to inspect a representative sample of doors, he ought to have told Janice Wray so that she could arrange access for him.1191 41.102 Carl Stokes also failed to record in his fire risk assessments for Grenfell Tower problems that he knew existed in relation to self-closing devices. For example, in the assessment he carried out in November 2012, he did not mention the recurring problem of people disconnecting self-closing devices that he had identified in July 2011.1192 Similarly, in the assessment he carried out in April 2016, he did not mention the missing self-closing device at Flat 45 that he had identified in July 2015, nor the fact that Seamus Dunlea had been removing self-closing devices on entrance doors, something he had discovered in December 2015.1193 There is nothing to suggest that he had been told that those problems had been satisfactorily resolved and he ought, therefore, to have taken steps as part of his next fire risk assessment to find out. If they had not, or if he did not get a satisfactory response, he should have taken that into account in assessing the risk. 41.103 We have seen no evidence that Carl Stokes ever considered the TMO’s arrangements for the inspection and maintenance of entrance doors to flats, whether as part of his fire risk assessments or otherwise, much less that he advised it that they were inadequate. When he was asked to comment on the draft strategy in early 2013, he did not tell Janice Wray that it needed to include arrangements for the inspection and maintenance 1185 For example, {CST00003084/19}. 1186 {CST00003157/19}; {CST00003161/21}; {CST00003145/20}. 1187 {CST00000003/10}. 1188 Carl Stokes’s fire risk assessment of Grenfell Tower dated 30 September 2009 {CST00003128/9} item 3.4. 1189 Stokes {CST00003063/20} page 20, paragraphs 58 and 59; Stokes {Day138/149:11-15}. 1190 Carl Stokes said that he considered the sample inspections he carried out to be sufficient and that he did not tell the TMO that he had been unable to obtain access to a sufficient number of doors because he was happy with the process that he had adopted. Stokes {Day138/150:11}-{Day138/151:11}. 1191 Lane {Day171/181:19-24}. 1192 {TMO00867783}; {CST00003084/19}. 1193 {CST00001448}; {TMO00859693}; {CST00003161}.

Part 5 | Chapter 41: Inspection and maintenance of entrance doors 133 of entrance doors, although the LGA Guide recommended inspections every six months and Andy Jack had referred to the need for regular inspection in the course of their conversation on 8 November 2012.1194 41.104 We have seen no evidence that Carl Stokes ever drew Janice Wray’s attention to the recommendation in the LGA Guide, although she said she had been aware of it.1195 Nor did he mention it in his letter of 30 April 2011 when he drew her attention to other provisions of the draft LGA Guide which could adversely affect the replacement of doors, including the risk of residents’ removing self-closing devices.1196 He also failed to draw it to her attention after the Adair Tower fire when there were discussions about the approach the TMO should take to self-closing devices, of which he appears to have been aware.1197 41.105 In the fire risk assessment of Grenfell Tower he produced in April 2016, Carl Stokes referred to the TMO’s policy of inspecting self-closing devices in vacant properties1198 but he did not comment on its adequacy. It is not clear what prompted him to refer to the policy for the first time in April 2016. 1194 {CST00002046}. 1195 Wray {Day143/71:20}-{Day143/72:14}; {Day143/91:20-23}. 1196 Note the letter from Carl Stokes to Janice Wray is wrongly dated as 30 April 2010 {TMO00847318/1}. 1197 For example, {CST00007708/1-2}; {CST00006634/1}; {CST00002902/1}; {CST00002302/1-2}. 1198 {CST00003161/21}.

The Grenfell Tower Inquiry: Phase 2 Report 134

135 42.1 Under the Fire Safety Order the TMO had a duty to take such general fire precautions as would ensure, so far as was reasonably practicable, that Grenfell Tower was safe for those who lived there, their visitors and its own employees.1199 General fire precautions include measures in relation to the means of escape and the arrangements for action to be taken if a fire occurs.1200 It also had a duty to establish procedures to be followed in the event of serious and imminent danger to persons present in the parts of the tower to which the Fire Safety Order related.1201 As part of our investigation into the fire that occurred on 14 June 2017, therefore, we have considered it appropriate to examine the steps taken by the TMO to comply with those duties. In earlier chapters we have examined the steps taken by the TMO to carry out fire risk assessments as required by the Fire Safety Order and we have described the problems that affected the smoke ventilation system. In this chapter we consider the information given to residents relating to fire safety. 42.2 Before the refurbishment Grenfell Tower had been constructed entirely of concrete, apart from some internal structures and the usual internal fittings. The structure was therefore not combustible. The front door of each flat was a fire door and had originally been fitted with a self-closing device. Although a fire could spread from one flat to another up the outside of the building or through the lift lobby, that was likely to happen relatively slowly, giving time for the occupants to escape and the fire brigade to gain control before many people were affected. That was the design principle behind the “stay put” strategy for responding to fires in individual flats which had proved effective in the past. 42.3 The existence of a “stay put” strategy was reflected in the advice the TMO gave residents about how to respond to a fire in the building. It also affected the way in which it approached the question of evacuation. 42.4 The TMO provided fire safety advice to residents in letters to new tenants, in magazines distributed to residents (Link magazine and Homeowner newsletter), through fire action notices and in roadshows held by the TMO Resident Engagement team.1202 Written materials were produced in the seven major languages identified as being most likely to meet the needs of the residents. 42.5 Before moving into a property, new residents were given a handbook that included some fire safety advice, including instructions not to store items in communal areas or obstruct the means of escape. The TMO did not display fire safety action notices in residential buildings because it considered that it had provided the relevant information in other ways.1203 1199 Article 8. 1200 Article 4(1). 1201 Article 15(1). 1202 Wray {TMO00000890/53-55} pages 53-54, paragraphs 245-250. 1203 Letter from Carl Stokes to Janice Wray dated 27 September 2010 {CST00001979}; Stokes {Day136/217: 2}-{Day136/219:8}; Stokes {Day136/220:15-22}. Chapter 42 Fire safety information

The Grenfell Tower Inquiry: Phase 2 Report 136 The resident’s handbook 42.6 Historically, the resident’s handbook had contained some fire safety advice,1204 such as how to prevent a fire and how to make sure that a smoke detector was installed, but no advice on how to respond to a fire.1205 The original stock of handbooks ran out in 2008 or

1. There were no plans to publish any more at that time, but later on a decision was

made to produce a new version.1206 By January 2010 a first draft was said to be ready for consideration,1207 but in the event it had not been published by the time the coroner made her recommendations following the Lakanal House inquests in March 2013, four years later. They included a recommendation that information and guidance should be provided to residents about fire procedures. 42.7 In June 2013, Janice Wray told the Health and Safety Committee that residents received fire safety information on the TMO’s website, in the resident’s handbook, through articles in Link and in letters and LFB leaflets to new tenants. She asked the committee to consider what other opportunities there were to promote fire safety and fire procedures to residents. No one appears to have pointed out that the new resident’s handbook had not been finished and so could not be distributed to residents. It is not clear why Janice Wray told the committee that information was given in the handbook. Although she may not have had direct knowledge of the matter, she told us that she had thought that by March 2013 it had been finalised.1208 However, that seems unlikely. 42.8 When the TMO’s Fire Safety Strategy was completed in November 2013, it referred to the resident’s handbook as one means by which information about fire safety was communicated to residents.1209 Although the strategy was submitted to the Health and Safety Committee for its views in November 2013, no one mentioned that the resident’s handbook had still not been finished.1210 In 2017, when the Health and Safety Committee’s views were sought on the revised fire safety strategy, yet again no one raised the fact that the handbook had not been produced,1211 even though it was one of the ways of communicating with residents referred to in the fire safety strategy.1212 42.9 The delay in the production of the resident’s handbook illustrates many aspects of the TMO’s attitude to its fire safety obligations. Having rightly identified the need for a revised handbook in 2010, nothing had been produced by June 2017. Although the handbook had been repeatedly relied upon as a way of communicating information to residents about how to respond to a fire, no one at the TMO had noticed that supplies of the old handbook had been exhausted in 2008 or 2009 and that the new edition had never been produced. The effectiveness of the TMO’s Emergency Plan depended to a great extent on residents being aware of what to do in an emergency, but the TMO’s failure over such a long period of time to make it available denied residents one useful means of receiving that information. No reasonable explanation was offered for that failure. 1204 Tenant’s Handbook {IWS00001762} and Rasoul {IWS00001768/3} page 3, paragraph 13. 1205 Tenant’s Handbook {IWS00001762} and Rasoul {IWS00001768/3} page 3, paragraph 13. 1206 Jones {TMO00900052/3} page 3, paragraph 9; “Tenant’s Handbook” was used interchangeably with “Resident’s Handbook”. The TMO also produced a “Homeowner’s Handbook” which was intended for leaseholders and contained information which was different from that provided to tenants. 1207 {TMO10000641/2}. 1208 Wray {Day142/185:17-23}. 1209 Fire safety policy dated November 2013 {TMO00830598}. 1210 The meeting was attended by, among others, Sacha Jevans, Janice Wray, Peter Maddison, and Alex Bosman. Minutes of TMO Operational Health & Safety Meeting dated 15 November 2013 {TMO10004726/6}. 1211 The meeting was attended, among others, by Barbara Matthews, Janice Wray, Peter Maddison and Teresa Brown. Minutes of Health and Safety Committee Meeting dated 13 June 2017 {TMO10021549/4}. 1212 Fire safety strategy dated June 2017 {TMO00847324/3}.

Part 5 | Chapter 42: Fire safety information 137 Letters to new residents 42.10 We have seen three draft letters to new residents containing fire safety advice. The first appears to date from December 2010.1213 It advised new residents, among other things, that: a. there was a “stay put” strategy in place; b. they should not prop open fire doors; c. they must not disconnect the self-closing device on the entrance door to the flat; d. they should fit a smoke alarm, if one was not already installed; e. they should not use a lift in the event of a fire; f. they should refer to the resident’s handbook for additional fire safety information; and g. they would be provided with a personal emergency evacuation plan (PEEP) if they had difficulty hearing or responding to a smoke alarm or had special requirements. The letter we were shown was a draft and we do not know whether it was sent to any new residents. 42.11 The letter was substantially revised in May 2013.1214 In its new form it advised residents: a. to ensure that an operational smoke alarm was installed in their flats; b. that if there was a fire elsewhere in the building, residents were safe to stay in their flats unless they were affected by heat, flames, smoke or the LFB or the TMO instructed them to leave; and c. that the front door should be self-closing and should not be propped open. Residents were encouraged to report defective doors to the TMO. Again, it is not clear whether that letter was ever used. 42.12 Some minor changes were made to the letter in September 2016, but the contents remained essentially the same.1215 We do not know why the reference to PEEPs was removed from the 2013 and 2016 drafts.1216 Janice Wray thought that the housing officers who met residents took them through the induction pack and, if there were any concerns about vulnerability, came back to her so that appropriate action could be taken.1217 42.13 The letter was provided to residents as part of an induction pack by Moira MacDonald, the TMO officer who arranged viewings for prospective tenants.1218 They could ask for a translation, but there is no evidence that they were routinely told that a translation could be provided. There was no system to record whether residents received the letter during the induction process.1219 1213 {TMO00870665}. 1214 {TMO00865707}. 1215 {TMO00865991}. 1216 Wray {Day142/187:13-25}. 1217 Wray {Day142/187:17-25}. 1218 Wray {Day142/187:4-11}. 1219 Wray {Day142/187:1}.

The Grenfell Tower Inquiry: Phase 2 Report 138 42.14 Daniel Lewis, a TMO Neighbourhood Co-ordinator, said that fire safety advice for new residents had not been included in the documents that formed part of the “Welcome Pack” that he had compiled and that the Neighbourhood Officer provided to new residents.1220 Janice Jones agreed that the fire safety letter had not been included in the pack, but said that Moira MacDonald took her own paperwork to viewings, including a fire safety letter signed by Janice Wray.1221 42.15 We have been left with the impression that it was largely a matter of chance whether new tenants, at whom the fire safety letter in its various versions was directed, saw it at their viewings. The point of the letter was to bring home to tenants in clear terms the fire safety arrangements in their buildings. That was important, but the TMO simply failed to ensure that the message always reached its intended recipients. ‘Link’ magazine 42.16 Link was a quarterly publication for TMO tenants. Originally it was produced only in English, but from 2012 it contained information about how it could be translated into other languages.1222 TMO leaseholders received the Homeowner newsletter instead of Link. 42.17 Some issues of Link and Homeowner contained fire safety advice. In the Winter 2009 issue of Link the TMO announced that a fire safety consultant would carry out fire risk assessments in the communal areas and would require access to the front doors of some flats. Residents were reminded not to smoke in communal areas and to keep those areas free of items.1223 42.18 Fire safety advice was also included in the June 2013, Summer 2014 and Autumn/Winter 2015 issues.1224 Only the latter, published after the Adair Tower fire, gave advice about evacuation and what to do if there was a fire.1225 42.19 Some editions of Homeowner also contained information about fire safety, including advice about compliance with the requirements relating to flat entrance doors and smoke alarms.1226 However, only the Summer 2016 issue contained advice about what to do in the event of a fire.1227 It is clear that, as Janice Wray accepted, there had been no regular programme for the distribution of fire safety advice; it was included as and when it seemed appropriate.1228 Contrary to the statements made in the fire safety strategies of November 2013 and June 2017, Link and Homeowner did not regularly contain fire safety information or information about the evacuation strategy in properties managed by the TMO.1229 In any event, they were distributed to tenants in a wide range of buildings, so it was not possible to include in them advice which related to specific buildings. 1220 Lewis {TMO00899762/3} page 3, paragraph 10. 1221 Jones {TMO00900052/6} page 6, paragraph 24. 1222 See, for example, Link Magazine dated Winter 2012 {TMO00873414}; Link magazines from 2009 did not include information about how to translate the newsletter; see, for example, Link Magazine dated Winter 2009 {TMO10048206}. 1223 Link Magazine Winter 2009 {TMO10048206/5}. 1224 Link Magazine Autumn/Winter 2015 {TMO00873549}; Link Magazine Summer 2014 {TMO10031098}; Link Magazine June 2013 {TMO00873438}; Link Magazine Winter 2009 {TMO10048206}. 1225 Link Magazine Autumn/Winter 2015 {TMO00873549/25}. 1226 Homeowner Newsletter December 2013 {TMO00873466}; Homeowner Newsletter June 2015 {TMO00873520}; Homeowner Newsletter Winter 2015 {TMO00873536}. 1227 Homeowner Newsletter Summer 2016 {TMO00873556/4}. 1228 Wray {Day142/189:2-23}. 1229 Fire safety strategy dated September 2013 {TMO00830598/3}; fire safety strategy dated June 2017 {TMO00847324/3}.

Part 5 | Chapter 42: Fire safety information 139 Fire safety advice leaflets 42.20 Carl Stokes delivered leaflets on fire safety produced by the LFB to residents of smaller TMO premises.1230 He did not do that in the larger blocks, as he thought the caretakers would leave them with the concierge instead. Carl Stokes did not deliver any leaflets to the residents of Grenfell Tower because there was a caretaker or handyman who did that.1231 Roadshows 42.21 The TMO organised regular “Roadshows” which were used informally to consult or communicate with residents. On one occasion, on 14 May 2016, Janice Wray invited the LFB to attend a roadshow in Lancaster West Green to speak to residents about fire safety.1232 However, that was no substitute for consistent, clear and regular communication of fire safety advice to residents. Website 42.22 The TMO maintained a website, which included a page containing fire safety advice. A page headed “Fire and smoke alarms” provided advice on fire safety measures. It first appeared on the website on 13 February 2012.1233 The website set out detailed advice on fire safety, including advice on the evacuation strategy for residential blocks with purpose-built self‑contained dwellings.1234 42.23 Apart from a minor change to its contents, the “Fire and smoke alarms” page remained available on the TMO’s website until 14 June 2017.1235 Again, it was not a comprehensive statement of the fire safety advice to all residents and its efficacy depended on residents’ accessing, and being able to access, the website to find information for themselves. Engagement, therefore, depended on the curiosity or sensitivity to risk of the individual tenant. The disadvantages of the website as a means of communicating fire safety information are obvious. Fire Safety Advice during the refurbishment 42.24 From September 2013 to May 2016, the TMO and Rydon distributed newsletters almost monthly to the residents of Grenfell Tower. Two newsletters published in July 20141236 and May 2016 respectively1237 contained fire safety advice. 42.25 The July 2014 newsletter was prompted by complaints made by Edward Daffarn to the LFB that Rydon was occupying a designated evacuation meeting point for Grenfell Tower.1238 Janice Wray proposed that the TMO write to residents to reiterate that the “stay put” strategy was still in place. The same day she also responded to Ben Dewis of the LFB saying that the “stay put” strategy was still in place and that the July newsletter included confirmation of that.1239 In relation to communication of fire safety information, that was as far as it went. The May 2016 newsletter included fire safety advice after the LFB had asked 1230 Stokes {Day139/ 99:2}-{Day139/100: 20}; Carl Stokes confirmed he distributed the leaflet {CST00017272}. 1231 Stokes {Day139/ 101:9-14}. 1232 Wray {TMO00000890/54} page 54, paragraph 250; Email from Janice Wray to LFB dated 13 April 2016 {LFB00001085}. 1233 {TMO00899658/18}. 1234 {TMO00899658}. 1235 {TMO00899658/17}. 1236 {CST00001919/2}. 1237 {JRP00000028/4}. 1238 Williams {TMO00840364/38} page 38, paragraph 210. 1239 {TMO10007353/5}.

The Grenfell Tower Inquiry: Phase 2 Report 140 how the “stay put” policy was advertised to residents.1240 On both occasions, fire safety advice to residents was included in the newsletter only as a response to concerns raised with the TMO by the LFB. But for those expressions of concern, it is doubtful whether the TMO would have done anything. Fire action notices 42.26 In September 2009, Salvus identified a number of deficiencies in the TMO’s management of fire safety across its housing stock, one of which was that adequate information and instruction on fire safety was not provided to employees. It also said that fire action notices were not displayed in properties where there was no fire alarm system and that residents did not receive specific individual emergency plans based upon the layout of their buildings.1241 It recommended that fire action notices should be displayed in all properties managed by the TMO setting out the fire action procedure for the particular property.1242 42.27 On 26 January 2010, fire action notices were considered at a progress meeting with Salvus on fire risk assessments in high-risk blocks.1243 There was a long discussion about whether to install a notice in the main entrance of each block setting out the emergency procedure in relation to that block. It was agreed that fire action notices should be put up in each block and that letters should be sent to residents describing the evacuation procedure.1244 42.28 On 13 May 2010, the TMO’s Operations Committee agreed to put fire action notices in each block,1245 but the matter was not raised again at any subsequent meetings and in September 2010 Janice Wray presented a report on fire risk assessments which said nothing about fire action notices.1246 Instead, she reported that the TMO would write to the residents in each block explaining the relevant evacuation procedure and summarising the fire risk assessment’s findings. The decision to post fire action notices was seemingly forgotten. 42.29 On 27 September 2010, Carl Stokes wrote to Janice Wray, at her request, about fire safety signage in the TMO’s residential buildings.1247 He told her that, as the TMO provided fire safety information to residents in other ways, fire action notices were not required. Janice Wray accepted that advice, but she did not tell the Operations Committee or the executive team that the decision to put up fire action notices would not be carried out, though she believed that she had told her line manager.1248 42.30 Janice Wray was of the view that the LGA Guide (which was published after Carl Stokes’s advice of 27 September 2010) supported her understanding that fire action notices were not required in high-rise residential blocks.1249 She told us that she had thought that the passage in which it is stated that it is not always necessary to display fire action notices in blocks of flats with simple layouts was consistent with Carl Stokes’s previous advice.1250 1240 {TMO00860222/1}. 1241 {SAL00000013/10} section 7.2. 1242 {SAL00000013/17} section 7.2. 1243 {RBK00052572/1} paragraph 2.2. 1244 {RBK00052572/1} paragraph 2.4. 1245 {TMO10037437/89}; Wray {Day142/211:11-18}. 1246 {TMO00899839/4}; {TMO00888971/1}. 1247 {CST00002701}. 1248 Wray {Day142/212:15}-{Day142/213:20}. 1249 Wray {Day142/212:22}-{Day142/213:4}; {Day142/214:11-25}. The LGA Guide suggested that there would rarely be a need for a more elaborate emergency plan than a simple fire action notice. It also said that it was not universally necessary to display a fire action notice and that it was common to convey the emergency plan to tenants in other ways, for example, through residents’ handbooks {HOM00045964}. 1250 {HOM00045964/118}.

Part 5 | Chapter 42: Fire safety information 141 Nonetheless, neither she nor Carl Stokes assessed each block to decide whether a fire action notice was required. On the contrary, the same generic approach was taken by the TMO to all its high-rise residential buildings.1251 However, the LGA Guide did not say that fire action notices are never required in a purpose-built block; on the contrary, paragraph 79.1 provided in terms that a fire action notice would usually be all that would be needed by way of emergency plan for most purpose-built blocks.1252 If Janice Wray and Carl Stokes thought that it supported a blanket decision not to put up fire action notices in any of the buildings managed by the TMO, they were mistaken. 42.31 The question of fire safety advice for residents was considered by the TMO again after the coroner published her recommendations following the Lakanal House inquests. The inquests had identified the need to find ways to advise residents about the fire procedure other than by the website, leaflets, magazines and letters. However, no effective alternative had yet been identified and fire action notices do not appear to have been discussed. On 2 May 2013, Janice Wray wrote a report for the Operations Committee about the TMO’s fire risk assessments which summarised the coroner’s recommendations following both the Lakanal House and Shirley Towers inquests, particularly as they touched upon the “stay put” strategy.1253 The Lakanal House coroner’s recommendations were discussed at a meeting between the LFB Fire Safety team and the TMO Health & Safety team at a meeting on 15 May 2013.1254 42.32 A further briefing note was circulated to the Health and Safety Committee about the recommendations and the implications for the TMO1255 which included a reference to the need to provide information and guidance to residents about fire procedures. The coroner’s recommendations were discussed again at a meeting of the TMO’s Health and Safety Committee on 20 June 2013.1256 Janice Wray asked the committee to consider other opportunities for promoting fire safety and bringing fire procedures to the attention of residents.1257 There was no mention of the coroner’s recommendation to put up fire action notices, however, and the committee did not identify any new ways of providing fire safety information to residents. Nor was there any discussion at the meeting of the agreement that had been reached by the committee in May 2010 to install fire action notices in each block or why that had not been done. There was no discussion either about whether the coroner’s recommendations should lead the committee to reconsider the assumption that it was not necessary to put up fire action notices in any of the buildings managed by the TMO. 42.33 On 23 December 2015, following the Adair Tower fire on 31 October 2015, the LFB issued enforcement notices against the TMO and RBKC.1258 One breach of the Fire Safety Order they identified was that the TMO’s procedures in the event of serious and imminent danger were inadequate. That was because no instructions about action to be taken in the event of a fire had been displayed in the common parts of the premises where they might be seen by visitors and other relevant persons.1259 1251 Wray {Day142/217:6}-{Day142/219:19}. 1252 {HOM00045964/118}. 1253 {TMO10031056/5}. 1254 {TMO00844568/2-3}. 1255 {TMO10039112}. 1256 {TMO00880630/4}. 1257 {TMO00880630/4}. 1258 {RBK00029298/4}. 1259 {RBK00029298/6}.

The Grenfell Tower Inquiry: Phase 2 Report 142 42.34 Janice Wray and Rebecca Burton discussed the enforcement notice at their next regular meeting on 5 January 2016.1260 Rebecca Burton confirmed that the LFB required work to be completed within six months from the date the notice had been posted, i.e. by 23 June 2016. She told Janice Wray that, although the notice related to Adair Tower, the LFB expected that the standards required in one block would be applied in others.1261 Janice Wray told her that the TMO had not put up fire action notices because the buildings were not complex and a “stay put” strategy was in place. Rebecca Burton indicated that notices were required, but that it was not a priority.1262 In the light of that Janice Wray did not think the requirement was pressing.1263 42.35 Rebecca Burton told us that in her view fire action notices were of limited use.1264 When shown the wording of the enforcement order which proposed an adequate fire action notice in the common parts, she said that the LFB would suggest action but that it was for the responsible person to decide how to comply with the notice. 42.36 If the TMO had provided its residents with fire safety information, we can see why fire action notices might not have been required, but it did not provide them with such information. The tenancy pack included no fire safety information and had not done so for many years, and the newsletters contained no advice about what to do in the event of a fire until the Autumn/Winter 2015 issue of Link which was published after the Adair Tower fire. There was no resident’s handbook.1265 Nothing said by Rebecca Burton could fairly have led Janice Wray to think that it was acceptable to have no fire action notices in buildings managed by the TMO, let alone that that would be consistent with the LGA Guide. Janice Wray can fairly be criticised for seeking to justify doing the minimum in the face of the enforcement notice. 42.37 Shortly afterwards, on 8 January 2016, Councillor Pat Mason sent an email to Councillor Marshall expressing concern about the advice given to residents on fire procedures. The email followed a meeting of the Cabinet and Corporate Services Scrutiny Committee, which had discussed the Adair Tower fire.1266 On 9 January 2016, Councillor Marshall asked Robert Black to set out the advice that was normally given to residents of high-rise residential buildings.1267 Robert Black responded on 15 January 2016,1268 saying that “stay put” advice was given to residents of high-rise buildings and was available on the website, in regular fire safety articles in Link and in LFB leaflets distributed by the fire risk assessor to some dwellings.1269 In relation to procedures to respond to a major fire breaking out at the weekend when offices were closed, he said that Pinnacle, the out-of-hours call handling service, would activate the emergency plan. Janice Wray and Hash Chamchoun were the principal contacts and other staff were available. Estate services staff would also be called out to visit and assess the situation.1270 1260 {RBK00013997/1}. 1261 {RBK00013997/2}. 1262 {RBK00013997/2}. 1263 Wray {Day142/222:10}-{Day142/223:20}. 1264 Burton {Day145/134:3-11}. 1265 {TMO00873549/25}. 1266 {RBK00053869/5}. 1267 {RBK00053869}. 1268 {RBK00053869/3}. 1269 {RBK00053869/3-4}. 1270 {RBK00053869/4}.

Part 5 | Chapter 42: Fire safety information 143 42.38 On 14 April 2016, Councillor Pat Mason wrote to Robert Black asking whether fire safety information was provided to residents otherwise than on the TMO’s website. He was concerned that not all residents might have access to the internet.1271 Janice Wray responded on 15 April 2016 saying that such information was provided to residents on the TMO website, in the letter to new tenants and by regular articles in Link and Homeowner.1272 However, her response tended to gloss over the defects we described earlier in the quality of the information provided by the TMO and its delivery to residents. 42.39 It was not until 13 September 2016 that the Health and Safety Committee considered putting up fire action notices in all buildings managed by the TMO.1273 The committee expected the LFB to require notices to be placed in all buildings, having seen the position it had taken in the Adair Tower enforcement notice. The TMO therefore decided to adopt a risk-based approach and to start placing fire action notices in high-risk buildings.1274 That was a far cry from what Janice Wray had understood to be required as a result of her meeting in early January 2016 with Rebecca Burton, but it was the correct approach. On 13 October 2016, Barbara Matthews asked Janice Wray to develop a programme for putting up fire action notices in all the TMO’s buildings and to provide costings. 42.40 A month later, on 17 November 2016, the LFB issued a deficiency notice in relation to Grenfell Tower because there were no fire action notices in the common parts (among other reasons).1275 The deficiency notice was issued a year after the Adair Tower fire, 11 months after the enforcement notice relating to Adair Tower and two months after Janice Wray had told the Health and Safety Committee that fire action notices would be installed in all properties managed by the TMO. Janice Wray was not able to say why there had been a delay in putting up the fire action notices; she thought they had been on order by that time.1276 However, the evidence we have seen suggests that a quotation for fire action notices for Grenfell Tower had been requested on 23 November 2016 after Edward Daffarn and Councillor Blakeman had complained about the lack of notices.1277 The Grenfell Action Group blog - “KCTMO - Playing with fire” 42.41 On 20 November 2016, Edward Daffarn posted an article on the Grenfell Action Group blog entitled “KCTMO – Playing with fire”. In it he criticised the TMO for failing to take fire safety seriously. He said that the Grenfell Action Group firmly believed that only a catastrophic event would expose what he described as the “ineptitude and incompetence” of the TMO.1278 The post contained links to previous blogs on fire safety and referred to the Adair Tower fire in October 2015, saying that the LFB had found that the TMO had not looked after the safety of residents properly and had issued an enforcement notice compelling it to improve fire safety. He said that the residents of Grenfell Tower had received no proper fire safety instructions from the TMO. Residents, he said, had been informed by a temporary notice in a lift and one announcement in a recent regeneration newsletter that they should remain in their flats in the event of fire.1279 1271 {TMO00865782/3}. 1272 {TMO00865782/1}. 1273 {TMO00840753/5}. 1274 {TMO00840753/5}. 1275 {TMO10017254}. 1276 Wray {Day143/3:7-14}; {Day143/6:24}-{Day143/7:8}. 1277 {TMO00861289/2}. 1278 {TMO00845987}. 1279 {TMO00845987/2}.

The Grenfell Tower Inquiry: Phase 2 Report 144 42.42 The post has since gained a degree of notoriety for its apparent prescience, but it did not in fact predict the fire at Grenfell Tower, much less what turned out to be its cause. Nonetheless, based on his own experience as a resident of Grenfell Tower, Mr Daffarn was able to put his finger on something very wrong with the TMO’s management of fire safety and used his forthright style to make his point. Shorn of the rhetoric, it was a message that the TMO could not afford to ignore. 42.43 On 23 November 2016, Councillor Blakeman saw the blog post and raised its contents with Robert Black. She agreed with Mr Daffarn’s point that instructions were not permanently available on noticeboards or in letters to residents (or in appropriate languages, where required) and asked whether that could be rectified.1280 42.44 Robert Black asked Janice Wray to prepare a response.1281 She told him that advice on fire procedures was included in newsletters, on the website, in regular articles in Link and provided to all new tenants. She said the Health and Safety Committee had been considering putting up fire action notices in all the buildings and that, although the LFB had issued a deficiency notice relating to the absence of fire action notices, its attitude to the need for them had been inconsistent. Janice Wray asked for permission to order notices for Grenfell Tower to address Mr Daffarn’s concerns.1282 She also said that although Mr Daffarn was challenging the “stay put” strategy, none of the professionals with whom she had discussed Grenfell Tower had suggested that there was a need to change it. 42.45 A quotation for the cost of obtaining fire action notices was provided on 23 November 2016, presumably in response to the issue of the deficiency notice, Mr Daffarn’s blog post and Councillor Blakeman’s concerns.1283 On 14 December 2016, Janice Wray confirmed that 30 fire action notices had been put up in Grenfell Tower the previous day.1284 They cost £328.32.1285 42.46 In the response that she prepared for Mr Black to send to Councillor Blakeman, Janice Wray failed to mention that on 17 November 2016 the TMO had received a deficiency notice in relation to Grenfell Tower and that one of the deficiencies identified had been the absence of fire action notices. There is no doubt that Councillor Blakeman should have been told about the notice and its substance. She was a member of the TMO board who had specifically asked about fire safety advice in response to a resident’s concerns and she should have been given the full picture. Janice Wray’s failure to mention the deficiency notice to Councillor Blakeman mirrored Robert Black’s own failure to bring the notice to the attention of the TMO Board, a matter to which we have referred in Chapter 31. 42.47 On 2 December 2016, Peter Maddison asked if any of the allegations in the blog post could be considered libellous.1286 Barbara Matthews responded indicating that she had spoken to Robert Black and that they agreed to take no action in response to it.1287 Peter Maddison’s reaction, to seek advice about whether Mr Daffarn had libelled the TMO rather than to get to the bottom of the complaint, was telling. By this point, the TMO’s defensiveness and hostility towards the Grenfell community, at least as represented by Mr Daffarn, had sunk to a new low. 1280 {TMO10015228/2}. 1281 {TMO10015214/1}. 1282 {TMO10015214/1}. 1283 {TMO00829191}. 1284 {TMO00861381}. 1285 Quote for fire action notices for Grenfell Tower {TMO00829191}. 1286 {TMO00865831/3}. 1287 {TMO00865831/1}.

Part 5 | Chapter 42: Fire safety information 145 42.48 The history of fire safety notices illustrates a reluctance on the part of the TMO to take active steps to promote fire safety. Although the need for fire action notices was first raised in 2009 by Salvus, they were not provided until the end of 2016 after the LFB had issued a deficiency notice and Councillor Blakeman had questioned the position having read Mr Daffarn’s blog post. In the end, fire action notices proved a relatively inexpensive means of providing fire safety advice. Their timely installation following Salvus’s advice in 2009, or even immediately after the Adair Tower fire in 2015, would have ensured that consistent advice was available to residents. That might have gone some way to reassuring them that fire safety was taken seriously by the TMO. The delay in installing fire action notices should also be understood in the context of enquiries and complaints from residents of Grenfell Tower about the evacuation strategy. Residents’ complaints about fire safety advice 42.49 Mr Daffarn’s was not a lone voice. The blog post of 20 November 2016 was the culmination of a long history going back to 2010 of complaints about fire safety by residents of Grenfell Tower. 42.50 On 3 September 2010, the Leaseholders’ Association wrote to Robert Black setting out 11 areas of concern that had arisen as a result of the fire on 30 April 2010.1288 The letter said that no one in the block had been aware of the evacuation procedure and that they had not been given information about what to do in the event of a fire in the previous 36 years.1289 42.51 Anthony Parkes responded on Robert Black’s behalf on 21 September 2010,1290 saying that the fire alarm was functioning and the smoke ventilation system had been working at the time (although in fact it had not).1291 He did not address the complaint that residents had not been informed of the evacuation procedure. 42.52 On 6 October 2010, the Leaseholders’ Association sent another letter to the TMO making a number of complaints again.1292 Anthony Parkes responded on 27 October 2010. Among other things, he said there was a “stay put” strategy in place, which he explained. He also said that information about fire safety was regularly published in Link and that the TMO planned to write to the residents of each block to advise on the action to be taken in response to a fire in that block.1293 He also expressed the TMO’s commitment to working with the Association and invited it to provide some dates when they could meet for a discussion. 42.53 In 2012, the Association made further complaints about the management of fire safety. On 14 November 2012, it sent an email to David Ward, the TMO’s Home Ownership Manager, about the plan to replace the entrance doors to tenants’ flats,1294 asking why leaseholders had not been included in the programme if the replacement related to fire safety and complaining about their omission. They also complained about the lack of health and safety training or drills in case of an emergency.1295 Paul Dunkerton responded on 20 November 2012 reminding the leaseholders that a “stay put” strategy was in place at Grenfell Tower, meaning that if a fire were to break out anywhere other than in their own 1288 {TMO10037439}. 1289 {TMO10037439/5}. 1290 {TMO00846320}. 1291 {TMO00846320/4}. 1292 {IWS00001310}. 1293 {TMO00836390}. 1294 {TMO00833837}. 1295 {TMO00833837/1}.

The Grenfell Tower Inquiry: Phase 2 Report 146 flats they were safe to remain in their homes.1296 The existence of the “stay put” strategy was repeated in several subsequent letters responding to various points raised by the Leaseholders’ Association. 42.54 On 29 September 2016, the Association sent an email to Councillor Blakeman raising a number of complaints, including the failure of the TMO to organise any fire drill at Grenfell Tower since 2012. They referred to the recent fire at Shepherd’s Bush and asked her to investigate their various concerns.1297 42.55 Robert Black circulated the email within the TMO and asked for responses.1298 Janice Wray told him that fire drills were not required in blocks with a “stay put” fire strategy.1299 The purpose of fire drills, she said, was to test the procedure to be followed in the event of a fire and if that was to stay put, a fire drill would conflict with the way residents were expected to respond.1300 Peter Maddison prepared a draft response in which he explained that Grenfell Tower maintained a “stay put” fire strategy1301 and that, if the LFB decided that an evacuation was necessary in response to a particular incident, it would organise it.1302 It is not clear whether that response was sent to the Leaseholders’ Association. 42.56 Grenfell Compact was formed in 2015 to voice residents’ concerns during the refurbishment. Councillor Blakeman responded briefly to the Leaseholders’ Association’s email on 4 October 2016 attaching a list of complaints that had been prepared by Grenfell Compact in May 2016 together with the TMO’s responses to them.1303 They did not include a complaint about the absence of fire action notices, but as mentioned earlier, fire action notices were put up in Grenfell Tower on 13 December 2016. 42.57 The repeated complaints by the Leaseholders’ Association about fire safety advice and procedures over the years prompted responses from the TMO but not a review of the fire safety advice provided to residents. Instead, the TMO simply repeated the “stay put” advice in correspondence with the Association and took no further action. It is difficult to know, even with the benefit of hindsight, whether the earlier installation of fire action notices would have made any difference, but it might have addressed some of the concerns of the Association to have had the advice set out in accessible and publicly available notices. 1296 {TMOH00027332/2}. 1297 {TMO00846025/35}. 1298 {TMO00847231}. 1299 {TMO10033125}. 1300 {TMO10033125}. 1301 {RBK00000142}. 1302 {RBK00000142}. 1303 {TMO00846745}; {TMO00846746}.

147 Chapter 43 The smoke ventilation system The system 43.1 Grenfell Tower was equipped with a ventilation system designed to allow the passage of air through the building for ventilation and the extraction of smoke in the event of a fire. Ventilation depended entirely on natural airflow. The extraction of smoke depended on the natural convection of hot smoke but could be boosted by mechanical means. The booster fans were designed to be operated manually by the fire and rescue service. 43.2 The system comprised two pairs of shafts running the full height of the building with openings into each lift lobby controlled by louvred dampers. In the event of a fire the dampers were designed to open on the floor affected by the fire and close on all other floors, thereby allowing smoke to flow up the shaft to the opening at roof level without escaping into lobbies on other floors. The fire at Grenfell Tower on 30 April 2010 43.3 On 30 April 2010, a fire was started deliberately outside Flat 64 at Grenfell Tower.1304 During the fire, the smoke ventilation system (sometimes referred to as the automatic opening vent system or AOV) failed to operate properly.1305 Smoke leaked into the lobbies of eight other floors, which led a number of residents to believe they were trapped and call the LFB.1306 43.4 On 5 May 2010, Janice Wray sent the results of her investigation into the fire to Collette O’Hara, an LFB fire safety inspecting officer.1307 She explained that the system was subject to quarterly inspections by RGE Services (RGE)1308 and said that the most recent inspection had identified “incomplete sealing” of a number of dampers.1309 She said that the remedial work had been delayed and had therefore not been carried out by the time of the fire.1310 Janice Wray accepted, in retrospect, that the TMO should have implemented interim measures while the system was being repaired.1311 43.5 When he replied to Janice Wray on 6 May 2010,1312 Spencer Sutcliff, the leader of the LFB Fire Safety team, agreed that the TMO should implement interim measures in future.1313 He also recommended that the TMO introduce a procedure to assess faults in fire safety systems to ensure that any high-priority remedial work was completed to a strict time 1304 Wray {TMO00000890/43} page 43, paragraphs 195-196; LFB notifiable fire report into the fire {LFB00000201/1-2}; LFB report into the fire dated 22 December 2010 {IWS00001463/3}. 1305 Wray {TMO00000890/43} page 43, paragraphs 195-196; LFB notifiable fire report into the fire {LFB00000201/2}; LFB report into the fire dated 22 December 2010 {IWS00001463/3}. 1306 Email from Janice Wray to Collette O’Hara on 5 May 2010 {TMO10048221/4} item 2; TMO spreadsheet of previous fires {TMO00873387} “fires” sheet, row 6; LFB notifiable fire report into the fire {LFB00000201/1-2}; LFB report into the fire dated 22 December 2010 {IWS00001463/3}. 1307 Email from Janice Wray to Collette O’Hara on 5 May 2010 {TMO10048221/4-5}. 1308 Email from Janice Wray to Collette O’Hara on 5 May 2010 {TMO10048221/4} item 3. 1309 Email from Janice Wray to Collette O’Hara on 5 May 2010 {TMO10048221/4} item 3. 1310 Email from Janice Wray to Collette O’Hara on 5 May 2010 {TMO10048221/4} item 3. 1311 Email from Janice Wray to Collette O’Hara on 5 May 2010 {TMO10048221/4-5} items 3-4; TMO spreadsheet of previous fires {TMO00873387} “fires” sheet, row 6. 1312 Email from Spencer Sutcliff to Janice Wray on 6 May 2010 {TMO10048221/2}. 1313 Email from Spencer Sutcliff to Janice Wray on 6 May 2010 {TMO10048221/2}.

The Grenfell Tower Inquiry: Phase 2 Report 148 scale.1314 He expressed surprise about the amount of smoke leakage caused by defective sealing of the vents1315 and recommended that the entire system be tested by an engineer because of what he described as a “catastrophic failure of the system”.1316 43.6 Janice Wray replied to Spencer Sutcliff on 12 May 2010.1317 She included an earlier response from the TMO’s senior electrical engineer, Keith Fifield,1318 who had explained that the remedial work, which had been agreed before the fire, included a complete overhaul of the system1319 and that, when the work had been done, the system would be fully operational.1320 Mr Fifield did not agree that the failure had been catastrophic.1321 He said that, except for the incomplete sealing, the system was working properly, but that there had been a failure to activate the mechanical extract system manually during the fire.1322 He said that he had arranged for smoke tests to be carried out on completion of the work.1323 43.7 On 7 May 2010, Janice Wray told Spencer Sutcliff that the remedial work had been completed and a smoke test had been successfully undertaken.1324 RGE’s inspections of the system 2009 – 2010 43.8 On 28 July 2009, the TMO appointed RGE to carry out maintenance work on the fire safety equipment and systems.1325 At some time after, but before the fire at Grenfell Tower on 30 April 2010, RGE had carried out its first test on the system.1326 There is an undated maintenance report that refers to fire damage, suggesting that it was completed after the fire on 30 April 2010,1327 but it also refers to a “first visit” to test the system, which RGE apparently carried out before the fire. In that report RGE said that all fresh air inlet dampers were in the open position and had been for some years. As a result, most of them were seized open or so contaminated that they were impossible to close and reset.1328 43.9 If the dampers were open and unable to close, smoke could spread between lobbies through the system in the event of a fire.1329 It is a matter of concern that the situation had apparently existed for a number of years before RGE’s inspection. Although it is not clear precisely when that first visit took place, there are records of RGE having been instructed to carry out repairs on the system on 4 January 2010 and 20 April 2010, so it was probably before then.1330 A quotation from RGE dated 20 April 2010 refers to stripping down, cleaning and lubricating each vent, which, on the face of it, relates to the problems 1314 Email from Spencer Sutcliff to Janice Wray on 6 May 2010 {TMO10048221/2}. 1315 Email from Spencer Sutcliff to Janice Wray on 6 May 2010 {TMO10048221/3}. 1316 Email from Spencer Sutcliff to Janice Wray on 6 May 2010 {TMO10048221/3}. 1317 Email from Janice Wray to Spencer Sutcliff on 12 May 2010 {TMO10048221/1}. 1318 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. 1319 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. 1320 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. 1321 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. 1322 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. 1323 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. 1324 Email from Janice Wray to Spencer Sutcliff on 12 May 2010 {TMO10048221/1}. 1325 Letter from Keith Fifield to RGE dated 28 July 2009 {RGE00000003}. 1326 Undated RGE maintenance report on AOV system at Grenfell Tower {MAX00001414/3}. 1327 Undated RGE maintenance report on AOV system at Grenfell Tower {MAX00001414/5}. 1328 Undated RGE maintenance report on AOV system at Grenfell Tower {MAX00001414/5}. 1329 As explained by Dr Lane in her Module 3 report, The Management and Maintenance of Grenfell Tower – Chapter 7 {BLARP20000033/355} paragraph 15.4.14. 1330 Capita Repair Spreadsheet {RBK00053524} row 4870 and row 4701; Repair order raised with RGE on 20 April 2010 {RBK00046981}.

Part 5 | Chapter 43: The smoke ventilation system 149 identified during the “first visit”.1331 They appear to have been the repairs Janice Wray had referred to in her emails to the LFB fire safety team following the fire at Grenfell Tower on 30 April 2010, which she said had been completed on 7 May 2010.1332 43.10 RGE produced another maintenance report dated 12 May 2010 that set out the results of its tests on the system after the fire on 30 April 2010.1333 It concluded that due to the spring force on the inlet dampers the actuators were not reliable and might not operate on every activation, but that the system was otherwise generally in good operational order and capable of being maintained for the next 5 years.1334 The report included a quotation of £27,280 for work to the inlet dampers to ensure that they automatically opened and closed without manual intervention.1335 43.11 Janice Wray said that she had not been made aware of that report, either before she replied to Spencer Sutcliff on 12 May 2010 or after.1336 She said that the TMO’s Contract Management team dealt with RGE,1337 but that she would have expected Keith Fifield to provide the report to her.1338 We have not seen any evidence that the remedial work identified by RGE in its report dated 12 May 2010 was ever carried out.1339 43.12 An RGE engineer carried out a further test on the smoke ventilation system at Grenfell Tower on 4 June 2010.1340 The service sheet says that the purpose was to test the fire dampers following the recent fire and remedial works.1341 It is likely that the sheet refers to the remedial works for which instructions were given on 20 April 2010 and which were completed on 7 May 2010, given that there is no evidence that the remedial works identified in the report dated 12 May 2010 were carried out. Despite that, the engineer stated that following the test he had left the site in full working order as witnessed by Keith Fifield and others.1342 43.13 In about August 2010, the TMO started to consider the need to modernise or replace the smoke ventilation system at Grenfell Tower.1343 The minutes of the meeting of the Asset Investment and Engineering Health and Safety Group on 26 August 2010 recorded that the feasibility of modernising the smoke extraction system was being examined.1344 Janice Wray suggested that the need for that had been brought to the TMO’s attention by the fire on 30 April 2010, which had brought to light the age of the system, rather than by RGE’s report in May 2010 or the failure of the system to operate properly.1345 1331 Quote from RGE for £2,257.05 to carry out repair work to the system at Grenfell Tower {RBK00013641}. 1332 Email from Janice Wray to Collette O’Hara on 5 May 2010 {TMO10048221/4} item 3; Email from Janice Wray to Spencer Sutcliff on 12 May 2010 {TMO10048221/1}. 1333 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637}. 1334 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637/7}. 1335 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637/8}. 1336 Wray {Day144/22:14-21}. 1337 Wray {Day144/23:2-20}. 1338 Wray {Day144/24:1-13}. 1339 There is, for example, no record of a repair corresponding with this quote in the Capita Repair Spreadsheet, whereas there are records of the repairs raised on 4 January 2010 and 20 April 2010 {RBK00053524}. 1340 RGE service/maintenance sheet for smoke test to smoke ventilation system at Grenfell Tower dated 4 June 2010 {RBK00046980}. 1341 RGE service/maintenance sheet for smoke test to AOV system at Grenfell Tower dated 4 June 2010 {RBK00046980}. 1342 RGE service/maintenance sheet for smoke test to smoke ventilation system at Grenfell Tower dated 4 June 2010 {RBK00046980}; Email from Janice Wray to Collette O’Hara on 7 June 2010 about the smoke test {LFB00000767}. 1343 Minutes of the Asset Investment and Engineering Health and Safety Group meeting on 26 August 2010 {TMO10000725/3} item 2. 1344 Minutes of the Asset Investment and Engineering Health and Safety Group meeting on 26 August 2010 {TMO10000725/3} item 2. 1345 Wray {Day144/26:23}-{Day144/27:11}.

The Grenfell Tower Inquiry: Phase 2 Report 150 The Leaseholders’ Association’s complaint 43.14 In July 2010, the Grenfell Tower Leaseholders’ Association made a complaint about fire safety which included a specific concern about the operation of the smoke ventilation system. The evidence suggests that the TMO was less than full and frank in its response. In particular, it did not tell the leaseholders or other residents of the tower about the defects in the system which had been found by RGE or the heightened risk to their safety. 43.15 On 28 July 2010, the Leaseholders’ Association wrote to Geoff Payne, the TMO’s Head of Housing, making various complaints including a complaint that during the fire on 30 April 2010 smoke had entered lobbies on other floors of the tower.1346 It asked what defects had been found in the system and what action had been taken in response.1347 Daniel Wood, the TMO’s Head of Home Ownership, responded on 20 August 2010,1348 saying that there had been a “minor fault” in the system that had been identified during the service visit before the fire.1349 He said that repairs had been put in hand and that, when completed, the system would be fully operational.1350 He said that the problem with leaking vents had been put right.1351 43.16 On 3 September 2010, the Leaseholders’ Association wrote to Robert Black about their complaints.1352 Among other matters it asserted that the recent fire had raised so many health and safety questions that it demanded an independent investigation into the safety of the building.1353 Later, when dealing with the fire, it said that if the smoke ventilation system was not working it should be considered a major rather than a minor fault as Mr Wood had described it.1354 43.17 Anthony Parkes replied on 21 September 2010.1355 He acknowledged that the seals on some of the vents had leaked, but said that otherwise they had been working at the time of the fire.1356 He said that the effects of the fire would not have been so serious if the LFB fire fighters had activated the smoke extract fan manually, but that they had not known how to do so.1357 He also said that the system was being upgraded so that it would work automatically when the fire alarm sounded.1358 Mr Parkes gave an assurance that the system was regularly checked and test reports completed.1359 43.18 Neither Daniel Wood nor Anthony Parkes referred to RGE’s report of 12 May 2010, which had advised that the inlet dampers might not operate on every activation and recommended significant remedial work.1360 As set out above, we have seen no evidence that that remedial work was carried out. 1346 Letter from GTLA to Geoff Payne on 28 July 2010 {IWS00001497/2}. 1347 Letter from GTLA to Geoff Payne on 28 July 2010 {IWS00001497/2}. 1348 Letter from Daniel Wood to GTLA on 20 August 2010 {TMO00846311}. 1349 Letter from Daniel Wood to GTLA on 20 August 2010 {TMO00846311/4}. 1350 Letter from Daniel Wood to GTLA on 20 August 2010 {TMO00846311/4}. 1351 Letter from Daniel Wood to GTLA on 20 August 2010 {TMO00846311/4}. 1352 Letter from GTLA to Robert Black on 30 September 2010 {TMO10037439}. 1353 Letter from GTLA to Robert Black on 30 September 2010 {TMO10037439/2}. 1354 Letter from GTLA to Robert Black on 30 September 2010 {TMO10037439/5}. 1355 Letter from Anthony Parkes to GTLA dated 21 September 2010 {TMO00846320}. 1356 Letter from Anthony Parkes to GTLA dated 21 September 2010 {TMO00846320/4}. 1357 Letter from Anthony Parkes to GTLA dated 21 September 2010 {TMO00846320/4}. 1358 Letter from Anthony Parkes to GTLA dated 21 September 2010 {TMO00846320/4}. 1359 Letter from Anthony Parkes to GTLA dated 21 September 2010 {TMO00846320/4}. 1360 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637/7-8}.

Part 5 | Chapter 43: The smoke ventilation system 151 RGE’s inspection of the system in 2011 43.19 On 9 August 2011, RGE produced a further test report on the system at Grenfell Tower.1361 In section 3, under the heading “Test Results / Urgent Recommendation”, it said that, having maintained the system for over 12 months, it could not guarantee that it would operate as required or that it met the requirements of the fire regulations. In particular, it reported that the systems for actuating the vents in the lobbies were no longer reliable and were found to have opened at random between maintenance visits. They were no longer fit for purpose and needed to be replaced.1362 43.20 Janice Wray said that she had not been made aware of that report either.1363 Keith Fifield, however, was certainly aware of it. He discussed it at a meeting with RGE on 7 September 2011.1364 The minutes of that meeting record that he had seen the report and was aware that RGE could not guarantee that the system would work in the event of an emergency.1365 They also recorded that he had said that the matter was being looked into by the TMO and that RGE and other contractors would be invited to submit tenders for the necessary work.1366 43.21 The required improvements to the system at Grenfell Tower were discussed at a meeting of the TMO Asset Investment and Engineering Health and Safety Group on 15 September 2011 attended by Keith Fifield and Janice Wray.1367 The minutes of the discussion do not refer to RGE’s recent report,1368 but in our view, given Keith Fifield’s knowledge of that report, it is unlikely that the modernisation or replacement of the system was discussed without mentioning the significant findings it contained. 43.22 Despite the reports made by RGE in May 2010 and August 2011, we have seen no evidence that the TMO gave any consideration at that time to implementing measures to mitigate the risk presented by the potential failure of the smoke ventilation system to operate in the event of a fire. That was despite the assurance Janice Wray had given the LFB Fire Safety team after the fire on 30 April 2010 that it would do so.1369 Modernisation of the system 43.23 Even if Janice Wray was not aware of the findings made by RGE in August 2011, it is reasonably clear that she was aware of at least some of the concerns about the system that had been identified in the course of the feasibility study for its modernisation. 43.24 In October 2011, AECOM, a construction industry consultancy, produced a tender for the modernisation of the system.1370 In a description of the existing system it noted that some of the dampers leaked, making it possible for smoke from a fire on a lower floor to leak through the closed dampers on an upper floor into the lift lobby. It was also possible that more than one set of dampers would open at any one time, since there was no way 1361 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 9 August 2011 {TMO00894311}. 1362 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 9 August 2011 {TMO00894311/5}. 1363 Wray {Day144/25:3-11}. 1364 Minutes of RGE Contract Review meeting with the TMO on 7 September 2011 {TMO00848054/1} item 1.7. 1365 Minutes of RGE Contract Review meeting with the TMO on 7 September 2011 {TMO00848054/1} item 1.7. 1366 Minutes of RGE Contract Review meeting with the TMO on 7 September 2011 {TMO00848054/1} item 1.7. 1367 Minutes of Asset Investment and Engineering Health and Safety Group meeting on 15 September 2011 {TMO00869798/1-2} item 2.2(e). 1368 Minutes of Asset Investment and Engineering Health and Safety Group meeting on 15 September 2011 {TMO00869798/1-2} item 2.2(e). 1369 Email from Janice Wray to Collette O’Hara on 5 May 2010 {TMO10048221/4-5}. 1370 AECOM tender for upgrade to fire alarm and smoke extract system dated October 2011 {MAX00017497}.

The Grenfell Tower Inquiry: Phase 2 Report 152 of establishing whether dampers were open other than by visual inspection. Although the extractor fans would overcome those problems, they had to be started manually by the fire brigade.1371 43.25 Apart from the installation of an autodialler to monitor the system remotely when staff were not on site, we have seen no evidence that Janice Wray or anyone else at the TMO considered measures to mitigate the risk caused by the defects in the system pending its modernisation. Further, although the tender document was produced in October 2011, no work had been carried out by late 2013 when it was included in the refurbishment, and it was not completed until April 2016, some four and a half years later.1372 Janice Wray told us that the work had been put back so that it could form part of the refurbishment.1373 The fire risk assessments 2009-2012 43.26 Having heard the evidence of Dr Lane and Mr Todd, we are satisfied that a fire risk assessor should assess the risk that the means of escape might be compromised by a failure of a smoke ventilation system to work.1374 He could not reasonably be expected to test the system, but should satisfy himself that the system had been effectively tested and maintained in efficient working order, either by checking the records or by making reasonable enquiries of the competent person.1375 If the necessary information is not immediately available, the fire risk assessor should make a further effort to acquire it.1376 There may be occasions when a fire risk assessor might ask to see the equipment tested,1377 but that would not be normal.1378 In the absence of satisfactory information about testing and maintenance he should increase the assessment of risk until provided with information to justify reducing it.1379 We agree that the absence of available information about the testing and maintenance of a system of that kind indicates a shortcoming in the responsible person’s management of fire safety in relation to the building in question.1380 PAS 79:2012 43.27 The approach of Dr Lane and Colin Todd was, in essence, the same as that set out in PAS 79:2007 and PAS 79:2012.1381 The guidance in relation to smoke ventilation systems is materially the same in the two versions. Clause 15 of PAS 79:2012, entitled “Assessment of Fire Protection Measures”, states that among the systems that should be taken into account are smoke control systems, which, in some premises can be essential for the protection of the means of escape. It is often vital to ensure that there are adequate arrangements for control, testing and maintenance of such systems.1382 1371 AECOM tender for upgrade to fire alarm and smoke extract system dated October 2011 {MAX00017497/6-7}. 1372 See, for example, email from Bruce Sounes to John Allen and Paul Hanson (RBKC Building Control) copying in Terry Ashton and Duncan Campbell on 23 October 2013 {TMO10040556}. It was commissioned in April 2016: PSB Above Ground Commissioning Report dated 28 April 2016 {PSB00000224/7}. 1373 Wray {Day144/46:14}-{Day144/47:4}. 1374 Todd {Day168/24:18-22}; Lane {Day172/3:4-11}. 1375 Todd {Day168/24:14}-{Day168/26:14}; {Day172/3:12}-{Day172/4:5}; {Day172/5:4}-{Day172/6:17}; Lane Module 3 Report, The Management and Maintenance of Grenfell Tower, Chapter 8 {BLARP20000027/267} s.12.3.14-15. 1376 Todd {Day168/26:16}-{Day168/27:10}; Lane {Day172/14:14}-{Day172/15:7}; {Day172/15:15}-{Day172/16:1}. 1377 Lane {Day172/6:25}-{Day172/7:20}. 1378 Todd {Day168/26:12-14}. 1379 Lane {Day172/15:8}-{Day172/16:1}. 1380 Todd {Day168/29:1-7}; Lane {Day172/16:2}-{Day172/17:1}. 1381 PAS 79:2007 {CTA00000001}; PAS 79:2012 {CTA00000003}. 1382 PAS 79:2012 {CTA00000003/45-48}; See Clause 14 in PAS 79:2007 for the equivalent paragraphs {CTA00000001/42-45}.

Part 5 | Chapter 43: The smoke ventilation system 153 43.28 Clause 16 says that fire safety management, which includes the testing and maintenance of fire protection systems, and fire protection measures should be regarded as of equal importance.1383 The approach of Carl Stokes 43.29 Carl Stokes told us that he never tested or witnessed the testing of the smoke ventilation system at Grenfell Tower during his fire risk assessments.1384 He said that in order reliably to verify that the system was functioning correctly he used the contractor’s service sheets and made certain that he had one that was in date.1385 He preferred to use that information rather than ask Janice Wray about the condition and operation of the system, because she would have had to go to the same source material.1386 The fire risk assessment in September 2009 43.30 In the fire risk assessment of Grenfell Tower he carried out on behalf of Salvus in September 2009, Carl Stokes reported that he could not confirm that the smoke ventilation system had been maintained and tested in accordance with current guidance and British Standards.1387 He advised that that presented a medium to high risk and recommended that the TMO confirm within a month whether the system had been tested and, if not, that it engage a competent engineer to do so within three months.1388 43.31 The action plan based on that assessment, which was revised by the TMO in October 2009, stated that regular maintenance was being carried out.1389 It is not clear precisely when RGE carried out its first test of the system.1390 If it had taken place by the time of Carl Stokes’s fire risk assessment, it is not clear why the test results, which had identified defects in the dampers which had existed for possibly five years, were not provided to him or why he was otherwise unable to obtain them.1391 The fire risk assessment in December 2010 43.32 Carl Stokes completed his next fire risk assessment of Grenfell Tower on 29 December 2010.1392 In it he referred to the fire on 30 April 2010 (although he incorrectly dated it as July 2010), but he did not mention that the system had not operated as intended.1393 He told us that he had not been aware that there had been a leakage of smoke during the fire.1394 He said he would have expected Janice Wray to give him that kind of information or for it to be included in the service reports for the system.1395 Janice Wray, for her part, could not remember having given him that information.1396 1383 PAS 79:2012 {CTA00000003/50-53}; See Clause 15 in PAS 79:2007 for the equivalent paragraphs {CTA00000001/46-47}. 1384 Stokes {Day139/4:14-17}. 1385 Stokes {Day139/4:18-21}. 1386 Stokes {Day139/4:22}-{Day139/5:12}. 1387 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/14}. 1388 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/18} item 9.2. 1389 Fire Risk Assessment Action Plan for Grenfell Tower updated in October 2009 {CST00000019} rows 52-54. 1390 Undated RGE maintenance report on AOV system at Grenfell Tower {MAX00001414/5}. 1391 Undated RGE maintenance report on AOV system at Grenfell Tower {MAX00001414/5}. 1392 Fire Risk Assessment for Grenfell Tower dated 29 December 2010 {CST00003181}. 1393 Fire Risk Assessment for Grenfell Tower dated 29 December 2010 {CST00003181/5}. 1394 Stokes {Day139/7:3-9}. 1395 Stokes {Day139/7:3-13}. 1396 Wray {Day144/7:1-21}; {Day144/9:11-21}.

The Grenfell Tower Inquiry: Phase 2 Report 154 43.33 In the Record of Significant Findings and Action Plan dated 29 December 2010, Mr Stokes noted that there were automatic opening vents in each lobby area, but that he did not know whether the system had been serviced and maintained.1397 He sought confirmation of that as a matter of high priority.1398 That essentially repeated the request he had made in the fire risk assessment carried out in 2009.1399 However, we have seen no evidence either that he sought, or that the TMO provided, the confirmation he had asked for before he completed the assessment. Carl Stokes could not remember whether he had asked for it.1400 43.34 The failure to obtain that information as part of the fire risk assessment was significant because, by that stage, RGE had identified defects in the inlet dampers in their maintenance report dated 12 May 2010 and the TMO had begun to consider the need to modernise or replace the system.1401 Carl Stokes said that he had not been aware of RGE’s concerns about the inlet dampers,1402 and as he did not have that information, he could not take it into account when making his assessment of the risk at Grenfell Tower. Nor could he advise on the need for measures to mitigate the risk presented by the defects in the system pending its renovation or improvement. The fire risk assessment in November 2012 43.35 Carl Stokes completed his next fire risk assessment of Grenfell Tower on 20 November 2012.1403 In section 23, he ticked the box to indicate that there was no record of monthly testing or annual servicing of the smoke ventilation system1404 but did not provide any comment or observation.1405 In his Record of Significant Findings and Action Plan, he referred to the presence of automatic opening vents in each lobby and asked for confirmation that they were serviced and maintained. He rated that a matter of high priority.1406 43.36 That was the third time that Mr Stokes had said that he did not know whether the system had been routinely tested and maintained, but we have seen no evidence that he tried to obtain the maintenance records before he completed his assessments.1407 Moreover, he made no comment about what had become a persistent and, in our view, worrying problem. Nor did he vary his assessment of the fire risk at Grenfell Tower, which he considered “tolerable”, to account for the possibility that the system might not have been maintained in efficient working order.1408 1397 Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 {CST00003165/5} item 23c. 1398 Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 {CST00003165/5} item 23c. 1399 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/18} item 9.2. 1400 Stokes {Day139/11:15-19}. 1401 RGE maintenance report for the smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637/7}; Minutes of the Asset Investment and Engineering Health and Safety Group meeting on 26 August 2010 {TMO10000725/3} item 2. 1402 Stokes {Day139/8:1-15}. 1403 Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084}. 1404 Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084/28}. 1405 Colin Todd explained that, where “no” was ticked in the fire risk assessment to a proforma question, the fire risk assessor should include commentary explaining the “no” in the fire risk assessment, then there should be a corresponding action in the action plan: Todd {Day168/34:5}-{Day168/36:3}. 1406 Record of Significant Findings and Action Plan dated 20 November 2012 {CST00003083/5} item 23c. 1407 Carl Stokes said it would have been covered in meetings with Janice Wray, but the Inquiry has seen no evidence in support of that assertion, Stokes {Day139/16:1-12}. 1408 Carl Stokes’s Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084/10}.

Part 5 | Chapter 43: The smoke ventilation system 155 43.37 Carl Stokes’s failure to request that information before he completed his assessment, and the TMO’s failure to provide it, was especially significant in November 2012. By that stage, RGE had stated in explicit terms in its report dated 9 August 2011 that it could not guarantee that the system would work.1409 The AECOM tender of 19 October 2011 also referred to serious defects in the system.1410 That information should have been taken into account in assessing the risk and measures should have been put in place to mitigate it, pending the completion of remedial work. However, Mr Stokes did no more than renew his request for confirmation that the system had been tested and maintained. The Leaseholders’ Association’s complaints in 2012 43.38 On 14 November 2012, the Leaseholders’ Association wrote a further letter to David Ward about the concerns felt by its members about being excluded from the programme to replace flat entrance doors in 2011 to 2012.1411 It complained that leaseholders had not been told after the fire on 30 April 2010 that their entrance doors might not comply with safety regulations and questioned whether other health and safety equipment was in working condition and fit for its purpose.1412 It therefore asked for copies of all reports, conclusions or recommendations relating to any investigation into the fire.1413 43.39 On 22 November 2012, in preparing a response to that complaint, Janice Wray sent an email to Paul Dunkerton containing information about the fire on 30 April 2010.1414 She said it would be inappropriate to provide the leaseholders with a copy of the email she had sent to the LFB Fire Safety team after the fire.1415 Instead, she proposed telling them that the smoke ventilation system had removed the smoke from the lift lobby, but had not worked as effectively as it should have because of a need for remedial works that were then pending. All those works had been completed and the system continued to operate effectively.1416 43.40 Paul Dunkerton included that information in his reply to the Leaseholders’ Association on 14 December 2012.1417 By that time, however, the TMO had for a long time been in possession of RGE’s report dated 9 August 2011, which stated explicitly that it could not guarantee that the system would work, and AECOM’s tender, which described its defects.1418 Even if Janice Wray had not seen those documents, she should have asked Keith Fifield for information about the maintenance of the system before responding to Paul Dunkerton.1419 There is no evidence that she did so. 43.41 By omitting that information from its reply, the TMO failed to give the leaseholders a full and accurate account of the investigation carried out into the fire, failed to inform them, and indeed other residents, of the operational status of the system and provided them with false assurances about the protection the system would provide in the event of a fire. 1409 RGE maintenance report on the smoke ventilation system at Grenfell Tower dated 9 August 2011 {TMO00894311/5}. 1410 AECOM tender for upgrade to fire alarm and smoke extract system dated October 2011 {MAX00017497/6-7}. 1411 Letter/email from GTLA to David Ward on 18 November 2012 {TMO00842270}. 1412 Letter/email from GTLA to David Ward on 18 November 2012 {TMO00842270/2}. 1413 Letter/email from GTLA to David Ward on 18 November 2012 {TMO00842270/2}. 1414 Email from Janice Wray to Paul Dunkerton on 22 November 2012 {TMO00848792}. 1415 Email from Janice Wray to Paul Dunkerton on 22 November 2012 {TMO00848792}. 1416 Email from Janice Wray to Paul Dunkerton on 22 November 2012 {TMO00848792}. 1417 Letter from Paul Dunkerton to Tunde Awoderu, GTLA, on 14 December 2012 {TMOH00027328/2}. 1418 AECOM tender for upgrade to fire alarm and smoke extract system dated October 2011 {MAX00017497/6-7}. 1419 Wray {Day144/36:1-7}; {Day144/39:15-18}.

The Grenfell Tower Inquiry: Phase 2 Report 156 The TMO’s review of the action plan dated 20 November 2012 43.42 In April 2013, after receiving the leaseholders’ complaint, the TMO reviewed Carl Stokes’s Record of Significant Findings and Action Plan dated 20 November 2012.1420 A version of the Action Plan was produced with an additional column containing comments following a review in April 2013.1421 In response to his request for confirmation that the smoke ventilation system had been regularly tested and maintained, there is a comment that the TMO had been informed that the vent needed changing and that RGE had said that it could not guarantee that in the event of an emergency the system would work.1422 A report was said to have been sent to someone and additional copies were to be provided to Alex Bowman. The action was marked as completed by Ricki Sams.1423 43.43 Janice Wray accepted that she had seen that action plan and the findings of the review.1424 She accepted, therefore, that from at least April 2013 she had known that the system was not sure to work1425 but she took no steps at that stage to put in place any measures to mitigate the risk it presented.1426 She accepted that it had been her job to make sure that the relevant department was aware of its responsibility to carry out repairs, but she did not accept that she had been responsible for ensuring that the work was in fact carried out, or that she had had the ability to do so.1427 That responsibility lay with the contracts management team, which had the expertise needed to determine what was required.1428 We disagree. Janice Wray, as the competent person, was responsible for overseeing the TMO’s compliance with the Fire Safety Order. In particular, she had a responsibility to make sure that the smoke ventilation system was either repaired or, if that was not viable, replaced and mitigating measures put in place pending its replacement. RGE’s inspection of the system in October 2013 43.44 RGE carried out a further test of the system on 11 October 2013, which identified the same problems as had been described in its report dated 9 August 2011.1429 The test report stated that the dampers were still not functioning correctly and could not be guaranteed to work correctly in an emergency.1430 RGE had provided a quotation for remedial work in May 2010, but the work was evidently still outstanding.1431 It seems that no immediate action was taken to remedy the defects because of the plan to modernise the system as part of the refurbishment. No measures were put in place to mitigate the increased risk presented by those defects pending the completion of that work. 1420 TMO review in April 2013 of Carl Stokes’s Record of Significant Findings and Action Plan dated 20 November 2012 {MAX00001426}. 1421 TMO review in April 2013 of Carl Stokes’s Record of Significant Findings and Action Plan dated 20 November 2012 {MAX00001426/1}. 1422 TMO review in April 2013 of Carl Stokes’s Record of Significant Findings and Action Plan dated 20 November 2012 {MAX00001426/7} item 23c. 1423 TMO review in April 2013 of Carl Stokes’s Record of Significant Findings and Action Plan dated 20 November 2012 {MAX00001426/7} item 23c. 1424 Wray {Day144/65:13-17}. The document metadata for the TMO’s review of the action plan also states that it was last modified on 4 June 2013 by Janice Wray: {MAX00001426/1}. 1425 Wray {Day144/67:4-19}. 1426 Wray {Day144/67:20-25}. 1427 Wray {Day144/68:1-25}. 1428 Wray {Day144/68:1-25}. 1429 RGE engineers’ service/maintenance report dated 11 October 2013 {TMO00879757}. 1430 RGE engineers’ service/maintenance report dated 11 October 2013 {TMO00879757/3}. 1431 RGE maintenance report on the smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637/8}.

Part 5 | Chapter 43: The smoke ventilation system 157 Maintenance records 43.45 On 23 January 2014, Matt Smith of Max Fordham sent an email to Simon Coleman of RGE asking for the test and maintenance records for the smoke ventilation system to assist in formulating a submission to building control on the designs for the proposed new system.1432 Later that day, Dil Singh of RGE sent him a maintenance report for the system, which, although undated, was the same as the inspection report dated 12 May 2010.1433 Dil Singh told Mr Smith that RGE had told the TMO following every service visit that it could not guarantee that the system would work.1434 43.46 It is not clear why Dil Singh did not give Max Fordham the test reports dated 9 August 2011 and 11 October 2013, given the more serious and recent concerns that they raised about the operation of the system.1435 Despite a number of further requests from Matt Smith and Claire Williams between January and March 2014 for the test and maintenance records and for clarity about the current condition of the system, RGE did not provide either.1436 It is not clear why, but there is evidence that the TMO had previously experienced problems obtaining documents from RGE.1437 As it was, RGE’s contract came to an end on 31 March 2014.1438 LFB visit to Grenfell Tower on 12 March 2014 43.47 On 12 March 2014, Matthew Ramsey and Ben Dewis, LFB fire safety inspecting officers, and Daniel Hallisey, the local fire station manager, visited Grenfell Tower with Claire Williams and Bruce Sounes.1439 During the visit, consistent with RGE’s previous findings, Matthew Ramsey identified that about 25-30 percent of the vents on the smoke ventilation system were not in the correct position.1440 He was sufficiently concerned about the state of the system to turn his visit into a formal audit and threatened to issue an enforcement notice requiring the TMO to demonstrate within four to six weeks that the system was fully operational.1441 43.48 After the visit Claire Williams sent an email to Janice Wray, with a copy to Carl Stokes, telling her of the outcome and suggesting that Ms Wray chase up RGE for the servicing records.1442 1432 Email from Matt Smith to Simon Coleman on 23 January 2014 {MAX00004262/3}. 1433 Email from Dil Singh to Matt Smith on 23 January 2014 {MAX00004262/1}; Undated RGE maintenance report for the smoke ventilation system at Grenfell Tower {MAX00018264}. 1434 Email from Dil Singh to Matt Smith on 23 January 2014 {MAX00004262/1}. 1435 RGE maintenance report on AOV system at Grenfell Tower dated 9 August 2011 {TMO00894311/5}; RGE engineers service/maintenance report dated 11 October 2013 {TMO00879757/3}. 1436 Email from Matt Smith to Dil Singh on 24 January 2014 {MAX00004266/1}; Email from Matt Smith to Claire Williams on 3 February 2014 {MAX00004281/1}; Email from Dil Singh to Claire Williams on 6 February 2014 {MAX00004293}; Email from Duncan Campbell to Claire Williams on 13 February 2014 {MAX00004306}; Email from Duncan Campbell to Claire Williams on 28 February 2014 {MAX00004329}; Email from Claire Williams to Duncan Campbell on 3 March 2014 {EXO00000644}; Email from Claire Williams to Dil Singh on 3 March 2014 {MAX00004330}. 1437 See, for example, email from Gary Mitchell to Peter Maddison on 21 February 2013 {TMO10002270/1}; Emails between Roger Greene and Gary Mitchell on 14 March 2013 {CST00004790}. 1438 Craig {RGE00000010/1} page 1, paragraph 1; RGE Maintenance Contract {RGE00000004/3} paragraph 3.2. 1439 Email from Bruce Sounes to Claire Williams and Janice Wray on 13 March 2014 {TMO10005515/3}. 1440 Email from Claire Williams to Janice Wray on 12 March 2014 {TMO10005515/4-5}; Ramsey {LFB00032092/6-7} pages 6-7, paragraphs 19 and 23.2. 1441 Ramsey {MET00071003/4} page 4; Ramsey {LFB00032092/6} page 6, paragraphs 19-20; Email from Claire Williams to Janice Wray on 12 March 2014 {TMO10005515/5}; Email from Bruce Sounes to Claire Williams and Janice Wray on 13 March 2014 {TMO10005515/3}. 1442 Email from Claire Williams to Janice Wray on 12 March 2014 {TMO10005515/4-5}.

The Grenfell Tower Inquiry: Phase 2 Report 158 43.49 Carl Stokes replied to Claire Williams’ email later that day with a copy to Janice Wray. In relation to Matthew Ramsey’s concern about the system, he said that the matter had been raised on numerous occasions, but that RGE had failed to provide servicing and maintenance information. He suggested that if the LFB issued an enforcement notice, it would be challenged and that the LFB should be asked to serve it on RGE as the maintenance contractor.1443 43.50 On 17 March 2014, Carl Stokes visited the tower at the request of Claire Williams to investigate the LFB’s concerns.1444 He set out his findings in a letter to her dated 18 March 2014.1445 His inspection of the smoke ventilation system appears to have been limited to what he described as the “smoke extract panel”, which he said was “showing healthy”, and RGE’s maintenance logbook, which he appended to his letter.1446 For reasons which are not clear, the logbook did not contain entries for the tests carried out on 9 August 2011 and 11 October 2013, which Carl Stokes had not seen.1447 As a result, he concluded that the logbook showed that RGE had found the system to be generally in working order at the last service.1448 43.51 Carl Stokes said that he had also inspected those parts of the system that were visible, but he did not refer to that in his letter.1449 Nor did he refer to Matthew Ramsey’s finding that 25-30 percent of the vents were not working, although he said that he thought he had done so.1450 He recommended that the contractor be asked to service the system sooner rather than later.1451 Neither Claire Williams nor Janice Wray raised with him the fact that he had not recorded Matthew Ramsey’s findings or the fact that his assessment was, on the face of it, at odds with them. Janice Wray did not tell him that RGE had said that it could not guarantee the system would work in the event of the fire, a matter of which she had been aware from at least April 2013.1452 Notice of deficiencies 43.52 On 24 March 2014, the LFB served a deficiency notice on the TMO.1453 In summary, it stated that about a quarter of the dampers in the smoke ventilation system were not working, which indicated that it had not been maintained in effective working order.1454 It stated that 1443 Carl Stokes email to Claire Williams on 12 March 2014 {CST00001426/1}. 1444 Wray {TMO00000890/10} page 10, paragraph 46. 1445 Letter from Carl Stokes to Claire Williams on 18 March 2014 {CST00003100}. 1446 Letter from Carl Stokes to Claire Williams on 18 March 2014 {CST00003100/2}. 1447 The logbook contained only two entries one dated 11/5/2010, which possibly relates to the test report on 12 May 2010, and the other incorrectly dated “15/15/2013”, which identified a faulty relay on 15th floor: {CST00003100/14-15}. Carl Stokes interpreted that to mean “15/12/2013” so that the inspection was in date: {CST00003100/2}. There is, however, a separate record of a test to the fire alarm system associated with the smoke ventilation system on 15/05/2013 so, in our view, that is the more likely date: {RGE00000005}. Carl Stokes stated that “the previous loose page in the logbook” was full, but he did not append it: {CST00003100/2}. 1448 Letter from Carl Stokes to Claire Williams on 18 March 2014 {CST00003100/11}; Carl Stokes said that he understood from RGE’s servicing records that the system was functional, notwithstanding Matthew Ramsey’s findings, Stokes {Day139/22:19}-{Day139/23:8}. 1449 Stokes {Day139/24:18}-{Day139/25:10}. 1450 Stokes {Day139/26:23}-{Day139/27:1}. 1451 Letter from Carl Stokes to Claire Williams on 18 March 2014 {CST00003100/11}. 1452 As discussed earlier in this section, see the TMO’s review in April 2013 of the Record of Significant Findings and Action Plan dated 20 November 2012 {MAX00001426/7} item 23c. 1453 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/1}. 1454 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}.

Part 5 | Chapter 43: The smoke ventilation system 159 that was a breach of Articles 11(1) and 17(1) of the Fire Safety Order1455 and that effective monitoring and maintenance of the system was required to remedy the breach.1456 It said those steps should be taken by 5 May 2014.1457 43.53 Matthew Ramsey decided to issue a deficiency notice rather than an enforcement notice because in his experience the TMO, as a responsible person, generally acted on the LFB’s advice and could be trusted to take remedial action within the time allowed and because the imminent refurbishment of the building was subject to the oversight of building control.1458 When they had spoken after the visit, Janice Wray had satisfied him that there was a plan to replace the system during the refurbishment.1459 However, he expected the TMO to ensure that the existing system was working by 5 May 2014, which was necessary to protect both residents and firefighters.1460 43.54 In the event, that did not happen. Claire Williams said that it had not been possible to produce a temporary solution to the problem in advance of the refurbishment.1461 There is evidence that she thought about that following the receipt of the deficiency notice. For example, in an email to Matt Smith and Bruce Sounes on the 25 March 2014, she said that she was looking at the possibility of fixing the dampers in the open position,1462 but Matt Smith advised against that because it would simply allow smoke to spread from floor to floor.1463 Claire Williams subsequently sent an email to Janice Wray and Alex Bosman on 17 April 2014 suggesting they discuss the options open to the TMO before the time for remedial work allowed by the deficiency notice expired on 5 May 2014. She had already been advised by Max Fordham that the only option available was to carry out the full modernisation work.1464 It is not clear whether that discussion ever took place. 43.55 Despite the developing recognition that it was not possible to find a temporary solution to the problem, the TMO had the system serviced again, presumably in response to Carl Stokes’s recommendation and the deficiency notice.1465 On 17 March 2014, after the LFB had visited Grenfell Tower, Alex Bosman had instructed Colt International Ltd, a company specialising in the design, supply and maintenance of smoke control systems, which serviced smoke ventilation systems in some of the TMO’s other properties, to quote for servicing the system.1466 However, the proposal for servicing that Colt produced on 28 March 2014 does not appear to have been pursued, possibly because the inspection on which it had been based had not identified any of the defects noted by the LFB.1467 1455 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. 1456 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. 1457 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/1}. 1458 Ramsey {LFB00083855/7} page 7, paragraph 19. 1459 Ramsey {LFB00032092/7} page 7, paragraph 23.2; Ramsey {Day147/38:16}-{Day147/39:3}. 1460 Ramsey {Day147/38:1-4}; Ramsey {MET00071003/5} page 5. 1461 Williams {Day121/127:15}-{Day121/128:8}. 1462 Email from Claire Williams to Matt Smith on 25 March 2014 {MAX00004366/3-4}. 1463 Email from Matt Smith to Claire Williams on 25 March 2014 {MAX00004366/3}. Claire Williams had also emailed Michael Lyons on 3 April 2014 about a “temporary option” for the smoke ventilation system: {TMO00856447}. 1464 Email from Claire Williams to Alex Bosman copying in Janice Wray on 22 April 2014 {TMO00856473}. 1465 Letter from Carl Stokes to Claire Williams on 18 March 2014 {CST00003100/11}; LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. 1466 Email from Alex Bosman to Debbie Sanderson on 17 March 2014 {TMO00856389/3}. 1467 Colt service proposal for the smoke ventilation system at Grenfell Tower dated 28 March 2014 {TMO10005654}.

The Grenfell Tower Inquiry: Phase 2 Report 160 43.56 On 11 September 2014, Simon Lawrence sent an email to Claire Williams asking whether the LFB had returned to check the system after the time allowed in the deficiency notice had expired.1468 The answer was that it had not. It is evident from that correspondence that almost six months after the deficiency notice, the smoke ventilation system had still not been properly inspected and serviced. Meeting with Rydon to discuss interim measures 43.57 Also on 11 September 2014, Claire Williams sent an email to Janice Wray inviting her to a discussion about the smoke ventilation system on 16 September 2014.1469 She explained that Rydon had been working with JS Wright to find an interim solution to the problem. Janice Wray forwarded the email to Carl Stokes and invited him to the meeting as well.1470 That appears to have been the first time the TMO had given any consideration to implementing measures to mitigate the risk presented by the defects in the existing system pending the completion of the refurbishment and the installation of a new system. However, we have not seen any minutes of the proposed meeting and neither Carl Stokes1471 nor Claire Williams1472 had any recollection of it. It is not clear, therefore, whether the meeting actually took place. Meeting with the LFB fire safety team on 18 September 2014 43.58 A progress meeting for the Grenfell Tower project, attended by Claire Williams, was held on 16 September 2014.1473 The minutes of the meeting record that the smoke ventilation system was currently not working. Rydon was asked to try to bring it up to contracted specification as soon as possible. If that was not possible, the system would be returned to the original specification.1474 The minutes recorded that Claire Williams would keep the LFB informed about the work,1475 but she said that Janice Wray was the main point of contact with the LFB.1476 Janice Wray thought that Claire Williams and the project team were responsible for keeping the LFB informed about the work to the smoke ventilation system.1477 Neither of them had a clear understanding of their responsibilities in that respect, but they agreed that the bi-monthly meetings, which they both attended, were the time for informing the LFB fire safety team about the refurbishment. Apart from that, Rydon spoke to the local fire crews when they visited the site.1478 1468 Email from Simon Lawrence to Claire Williams on 11 September 2014 {TMO00856902/1-2}. 1469 Email from Claire Williams to Janice Wray on 11 September 2014 {CST00003178/1}. 1470 Email from Janice Wray to Carl Stokes on 12 September 2014 {CST00003178/1}. 1471 Stokes {Day139/29:24}-{Day139/30:21}. He also did not mention it in his letter to Janice Wray dated 17 September 2014 {CST00030043/9} item 27-28. 1472 Williams {Day121/138:18}-{Day121/139:8}. 1473 Grenfell Tower project progress meeting no.3 on 16 September 2014 {TMO00830089}. 1474 Grenfell Tower project progress meeting no.3 on 16 September 2014 {TMO00830089/4} item 9.2. 1475 Grenfell Tower project progress meeting no.3 on 16 September {TMO00830089/4} item 9.3. 1476 Williams {Day121/136:3-23}; Williams {Day121/144:9-19}. Claire Williams said that she kept Janice Wray updated as to the progress of the works to the AOV system: Williams {Day121/140:25}-{Day121/141:3}. 1477 Wray {Day144/54:22}-{Day144/55:10}; {Day144/56:1-7}. 1478 Williams {Day121/141:4-20}; {Day121/144:20}-{Day121/145:8}; Wray {Day144/55:2-10}; {Day144/58:21}-{Day144/59:5}.

Part 5 | Chapter 43: The smoke ventilation system 161 43.59 On 18 September 2014, Claire Williams and Janice Wray attended one of the regular meetings with the LFB fire safety team.1479 Ms Williams told them that the smoke ventilation system was to be modernised as a priority. She also drew attention to the fact that while the work was going on the system would not be working at full capacity. That had also been brought to Carl Stokes’s attention.1480 43.60 According to the minutes of the meeting, neither Claire Williams nor Janice Wray told the LFB that the existing system was not working.1481 Claire Williams said that the statement that the system “would not be working at full capacity” while the work was going on did not do justice to the state of the existing system, but that the LFB should have known that it was not working because it had issued the deficiency notice.1482 The minutes also suggest that the TMO thought about putting in place interim measures only during the modernisation work and did not consider taking steps to mitigate the immediate risk presented by the defects in the existing system.1483 43.61 Later that day Claire Williams sent an email to Simon Lawrence telling him that the smoke ventilation system would not be fully operational until after Christmas.1484 It is evident from that email that at the meeting the LFB had also made a specific request, which was not reflected in the minutes, that the unavailability of the system during the period of the work should be taken into account in Rydon’s and the TMO’s fire risk assessments. 43.62 On 6 October 2014, Claire Williams told Janice Wray that although the ventilation system would be “in some sort of order” by Christmas, the new extractor fans in the roof plant room would probably not have been fitted, as they would be waiting for building control approval.1485 In her response Janice Wray asked whether any steps could be taken to reinstate the ventilation and extraction system, even partially, before it was refurbished.1486 We have not seen a direct response to that email, but it is evident from the subsequent correspondence that it was not considered possible to carry out temporary repairs to the system. Chubb’s inspection 43.63 On 29 September 2014, Alex Bosman instructed Chubb Fire and Security to service the smoke ventilation system at Grenfell Tower, which was said to be “out of target”.1487 He also instructed Chubb to contact Carl Stokes, who wished to meet their engineer.1488 Mr Stokes met Chubb’s engineer at Grenfell Tower on 6 October 2014 to examine the 1479 Minutes of bi-monthly meeting between TMO and LFB fire safety team on 18 September 2014 {TMO10023364}. 1480 Minutes of bi-monthly meeting between TMO and LFB fire safety team on 18 September 2014 {TMO10023364/3} item 6. 1481 Minutes of bi-monthly meeting between TMO and LFB fire safety team on 18 September 2014 {TMO10023364/2-3} item 6. 1482 Williams {Day121/149:23}-{Day121/150:7}. 1483 Minutes of bi-monthly meeting between TMO and LFB fire safety team on 18 September 2014 {TMO10023364/3} item 6. 1484 Email from Claire Williams to Simon Lawrence on 18 September 2014 {TMO00851824/1}. 1485 Email from Claire Williams to Janice Wray on 6 October 2014 {TMO00851844/1-2}. 1486 Email from Janice Wray to Claire Williams on 6 October 2014 {TMO00851844/1}. 1487 Email from Alex Bosman to Steve Plumridge and Adria Frith copying in Janice Wray and Siobhan Rumble on 29 September 2014 {CST00001451/3}. 1488 Email from Alex Bosman to Adrian Frith copying in Carl Stokes on 29 September 2014 {CST00001451/1}.

The Grenfell Tower Inquiry: Phase 2 Report 162 smoke ventilation system, but it seems that he was unable to test it because a fault was showing on the fire alarm panel.1489 The service certificate, therefore, recorded that further investigation of the system was required.1490 43.64 On 9 October 2014, Alex Bosman sent on to Claire Williams, Janice Wray and Carl Stokes an email that he had sent to Chubb that day, in which he had said that the system had been confirmed as beyond repair and scheduled for replacement shortly.1491 It is not clear whether the description of the system as “beyond repair” came from Chubb’s inspection or from Rydon’s investigations or something else, but, in any case, in our view, it should have been clear to the recipients of that email that the existing system could neither be temporarily repaired nor maintained pending its modernisation. 43.65 Nonetheless, neither Claire Williams nor Janice Wray told the LFB that the existing system was beyond repair, nor did they pass on the information that the completion of the work was likely to be delayed beyond Christmas.1492 When it became clear that the work would not be completed by that time, neither of them sought to implement mitigating measures or to inform the residents that the system was not operating.1493 Claire Williams had suggested that her concern about the risk to residents had been allayed by the plan to have the system in some kind of working order by Christmas.1494 If it was not possible, as had by then become apparent, further measures were required. The fire risk assessment in October 2014 43.66 Carl Stokes carried out a fire risk assessment of Grenfell Tower on 17 October 2014.1495 In the section headed “Any other relevant information on this premises” he summarised the three requirements of the deficiency notice and stated that they had been covered in the assessment and accompanying Record of Significant Findings.1496 In respect of the smoke ventilation system, he referred to the LFB’s requirement that a system of monitoring should be implemented in relation to the equipment in the lobbies and a maintenance schedule put in place so that the system was kept in good working order.1497 43.67 Carl Stokes did not refer to the fact that the deficiency notice stated that about a quarter of the dampers were not working and that the system had not been maintained in effective working order.1498 Although he did state where the notice could be found, the omission of that information meant that his summary failed to convey the seriousness of the LFB’s findings.1499 43.68 In section 19 of his fire risk assessment, headed “Fixed Fire Systems and Equipment”, he described the smoke ventilation system and recorded that it had been serviced by RGE Services on the 11 October 2013. He also recorded that it was being modernised as part of the refurbishment. However, he did not mention that RGE had said in its service report that 1489 Email from Janice Wray to Alex Bosman copying in Carl Stokes on 6 October 2014 {TMO10007591}; Email from Carl Stokes to Alex Bosman on 7 October 2014 {CST00001451/1}. 1490 Email from Janice Wray to Alex Bosman copying in Carl Stokes on 6 October 2014 {TMO10007591}. The Inquiry has not been provided with a copy of Chubb’s service certificate. 1491 Email from Alex Bosman to Claire Williams, Janice Wray and Carl Stokes on 9 October 2014 {CST00001244/1}. 1492 Williams {Day121/156:6-18}. 1493 Williams {Day121/139:10}-{Day121/140:1}; {Day121/156:19}-{Day121/159:18}. 1494 Williams {Day121/139:10}-{Day121/140:1}; {Day121/142:2-14}. 1495 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157}. 1496 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/7-8}. 1497 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/8}. 1498 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. 1499 Carl Stokes disputed in his oral evidence that he had downplayed the seriousness of the situation: Stokes {Day139/42:2-6}.

Part 5 | Chapter 43: The smoke ventilation system 163 it could not guarantee that the system would work; nor did he refer to Matthew Ramsey’s findings on 12 March 2014 that 25-30% of the dampers were not working.1500 He did not refer either to the fact that Chubb had been unable to carry out a service of the system on 6 October 2014, or to Alex Bosman’s email of 9 October 2014 in which he had described the system as “beyond repair”.1501 In short, he failed to address any of the information before him which showed that the system was not working. Despite knowing that, he maintained his assessment that the fire risk at Grenfell Tower was tolerable.1502 In those respects, his fire risk assessment gave the misleading impression that the system was operational, at least to the extent that it did not affect the overall risk rating for the building. 43.69 Mr Stokes should have recorded in his fire risk assessment that the smoke ventilation system was not working and should have taken account of that in his assessment of the risk.1503 He said that he had not referred to the fact that the system was considered to be beyond repair because it was being modernised as part of the refurbishment,1504 but that did not justify ignoring the fact that it was not then working.1505 He also said that, because there was a “stay put” strategy in place, the fact that the system was defective would increase the risk to residents only slightly.1506 Whatever the merits of that suggestion, however, he did not deal with it in his fire risk assessment. 43.70 In his accompanying Record of Significant Findings and Action Plan, Carl Stokes stated that Rydon was going to upgrade the existing smoke ventilation system in the lobbies and the refuse chute rooms.1507 He asked what compensatory measures, if any were being put in place whilst the work was being done, but he did not ask whether any measures had been put in place to mitigate the immediate risk presented by the defects in the existing system, nor did he recommend any. He did not include any assessment of the extent to which there were any measures which might adequately mitigate that risk. 43.71 Neither Janice Wray nor Claire Williams pointed out to Carl Stokes that he had not dealt in his risk assessment with the failure of the existing system. That was despite the fact that Matthew Ramsey had specifically asked Ms Wray to ensure that Carl Stokes addressed his concerns about the system,1508 and despite the LFB’s request at the meeting on 18 September 2014 to ensure that the unavailability of the system during the modernisation work was covered in its fire risk assessment.1509 43.72 In section 23 of his fire risk assessment, headed “Testing and maintenance”, Carl Stokes responded to the question “Is there a monthly testing and annual servicing and maintenance of any automatic opening vents along with any associated equipment/ devices, with records kept?” with the answer “No”.1510 He did not include any comment by way of explanation, even though good practice requires that in such circumstances the fire risk assessor should explain the answer and make a corresponding entry in the 1500 Email from Claire Williams to Janice Wray on 12 March 2014 {TMO10005515/4}; Email from Bruce Sounes to Claire Williams and Janice Wray on 13 March 2014 {TMO10005515/3}. 1501 Email from Alex Bosman to Claire Williams, Janice Wray and Carl Stokes on 9 October 2014 {CST00001244/1}. 1502 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/10}. 1503 Todd {Day168/31:7}-{Day168/32:23}; Lane {Day172/19:7-12}. 1504 Stokes {Day139/35:3-16}. 1505 Lane {Day172/19:14}-{Day172/20:17}. 1506 Stokes {Day139/35:17}-{Day139/37:23}. 1507 Record of Significant Findings and Action Plan dated 17 October 2014 {CST00003177/8} item 19d. 1508 Email from Matthew Ramsey to Janice Wray on 14 March 2014 {CST00003115/1}. 1509 Email from Claire Williams to Simon Lawrence on 18 September 2014 {TMO00851824/1}. 1510 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/29}.

The Grenfell Tower Inquiry: Phase 2 Report 164 action plan.1511 Nor did he record that Chubb had been unable to service the system on 6 October 2014,1512 but he did record that he did not know whether the occupier’s tests and inspections of the fire systems within the building were being undertaken.1513 In his accompanying action plan he recommended that the occupier should carry out weekly tests of the system and record the results.1514 43.73 That was the fourth time in as many fire risk assessments that Carl Stokes had said that he did not have any information about the maintenance of the smoke ventilation system and had asked for it to be provided. In our view, even though the system was considered to be beyond repair, that was simply not good enough. He ought to have insisted on being given that information before he completed his assessment.1515 If in October 2014 he had asked directly what had been done in response to his previous recommendations, he might have discovered the chronic nature of the failure to maintain the system and taken account of it in his assessment. The meeting with the LFB on 13 November 2014 43.74 On 12 November 2014, in advance of Janice Wray’s meeting with the LFB fire safety team the following day, Claire Williams sent an email to Simon O’Connor asking what it was currently thought could be done to put the smoke ventilation system at Grenfell Tower into working order.1516 Simon Lawrence replied the next day saying that the design team had been trying to find a solution which did not involve carrying out work that would later have to be discarded, but that one was unlikely to be available before Christmas.1517 43.75 Claire Williams did not pass that information to Janice Wray until after her meeting with the LFB that morning,1518 but apparently the subject of the smoke ventilation system had not been raised.1519 However, Ms Wray had been aware from early October that the existing system was beyond repair and that it would, at best, only be partly operational by Christmas, but she did not share that information with the LFB .1520 Nor did she or Claire Williams pass on the information she had been given by Simon Lawrence to the LFB.1521 There was evidence that the project team was keeping the local LFB operational crew informed, but Janice Wray accepted that she and Claire Williams should have kept the LFB Fire Safety team informed.1522 The Leaseholders’ Association complaint, January 2015 43.76 On 2 January 2015, the Leaseholders’ Association sent an email to Councillor Blakeman and Councillor Dent-Coad seeking confirmation that the smoke ventilation system at Grenfell Tower was going to be replaced as part of the refurbishment.1523 Later that day, 1511 Todd {Day168/34:5}-{Day168/36:3}. 1512 Email from Carl Stokes to Alex Bosman on 7 October 2014 {CST00001451/1}. 1513 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/30}. 1514 Record of Significant Findings and Action Plan dated 17 October 2014 {CST00003177/9} item 23c. 1515 Todd {Day168/26:24}-{Day168/27:10}; Lane {Day172/14:14}-{Day172/15:7}; Carl Stokes’s Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/8}. 1516 Email from Claire Williams to Simon O’Connor on 12 November 2014 {TMO00852028/3}. 1517 Email from Simon Lawrence to Simon O’Connor and Claire Williams on 13 November 2014 at 08:50 {TMO00852028/1-2}. 1518 Email from Claire Williams to Janice Wray on 13 November 2014 at 13:59 {TMO00852028/1}. 1519 Email from Janice Wray to Claire Williams on 13 November 2014 {TMO00852028/1}. 1520 Email from Claire Williams to Janice Wray on 6 October 2014 {TMO00851844}; Email from Alex Bosman to Claire Williams, Janice Wray and Carl Stokes on 9 October 2014 {CST00001244/1}. 1521 Wray {Day144/54:15-20}. 1522 Wray {Day144/55:2}-{Day144/57:9}. 1523 Email from Claire Williams to Janice Wray on 5 January 2015 {TMO00846731}.

Part 5 | Chapter 43: The smoke ventilation system 165 Mr Maddison sent a draft response to Councillor Blakeman, in which he said that the system was currently beyond economic repair and that the TMO was working with building control to agree a design for a system that would meet current standards.1524 Meeting with the LFB, 20 January 2015 43.77 On 13 January 2015, in preparation for a meeting with the LFB on 20 January 2015 Claire Williams asked Matt Smith whether building control had approved the plans for replacing the smoke ventilation system and whether any steps were being taken in the meantime to produce an effective system.1525 Matt Smith said in reply that a technical submission had been prepared comprising a two-stage scheme under which natural ventilation would be reinstated as an interim measure before new pressure differential controls and fans were added later. However, he was unable to say when the work was likely to begin.1526 43.78 The minutes of the meeting on 20 January 2015 suggest that the information obtained from Max Fordham was not passed on to the LFB.1527 In the event, only Janice Wray attended the meeting on behalf of the TMO1528 and although Claire Williams thought it likely that she had sent Matt Smith’s email on to Janice Wray, she could not remember having done so.1529 We are satisfied that she did not send it to the LFB herself.1530 However, even if Janice Wray had not received the email, she was already aware that the work had not been completed and should have drawn that to the attention of the LFB. 43.79 On 21 January 2015, Claire Williams told Janice Wray that the first phase of the work, involving the creation of a passive system, was programmed to start on 16 March 2015 and be completed by 1 May 2015 and that the second phase, involving the installation of fans and controls, was programmed to start on 5 May 2015 and be completed by 19 June 2015.1531 It does not appear that either Janice Wray or Claire Williams passed that information on to the LFB at the time.1532 Rydon Fire Risk Assessment, 20 February 2015 43.80 On 20 February 2015, Simon Camps and Simon O’Connor of Rydon carried out a project fire risk assessment in relation to Grenfell Tower.1533 43.81 They identified as a hazard that the detection and alarm systems and the smoke ventilation system did not work.1534 Each of them was marked as high risk.1535 Among their recommendations were that the TMO obtain a fire risk assessment that took into account current circumstances.1536 1524 Email from Peter Maddison to Councillor Blakeman on 5 January 2015 {TMO10008422}. 1525 Email from Claire Williams to Matt Smith on 13 January 2015 {TMO10042871/2}. 1526 Email from Matt Smith to Claire Williams on 13 January 2015 {TMO10042871/1}. 1527 Minutes of the bi-monthly meeting between the TMO and LFB fire safety team on 20 January 2015 {TMO00844037}. 1528 Minutes of the bi-monthly meeting between the TMO and LFB fire safety team on 20 January 2015 {TMO00844037}. 1529 Williams {Day121/190:3-8}. 1530 Williams {Day121/190:3-8}. 1531 Email from Claire Williams to Janice Wray on 21 January 2015 {TMO10042915/2}. 1532 It was provided at the meeting on 23 March 2015: {RBK00013999/3} item 9. 1533 Rydon Project Fire Risk Assessment dated 20 February 2015 {RYD00035553/1}. 1534 Rydon Project Fire Risk Assessment dated 20 February 2015 {RYD00035553/10}. 1535 Rydon Project Fire Risk Assessment dated 20 February 2015 {RYD00035553/10}. 1536 Rydon Project Fire Risk Assessment dated 20 February 2015 {RYD00035553/10}.

The Grenfell Tower Inquiry: Phase 2 Report 166 43.82 On 18 March 2015, Simon O’Connor sent the fire risk assessment to Claire Williams.1537 She did not notice that Carl Stokes had not addressed those defects in the system in his own risk assessment, nor did she notice the criticism that was made of his assessment.1538 Accordingly, she did not ask Carl Stokes to review his assessment to take account of the fact that the smoke ventilation system did not work properly, nor did she ask Janice Wray to do so.1539 Indeed, she could not recall having given the document to Janice Wray at all.1540 Further updates to the LFB and delays to the upgrade work 43.83 The work to modernise the system did not begin until April 20151541 and the new system was not fully commissioned until 28 April 2016.1542 Janice Wray and Claire Williams kept the LFB informed of the progress of the work during that period.1543 The TMO also implemented measures during that period intended to mitigate the risk caused by the absence of a smoke ventilation system while it was being installed. That took the form of familiarisation visits by local fire crews, increased and enhanced inspections by estate staff, health and safety visits, additional inspections by Carl Stokes and preventing contractors from carrying out hot work.1544 1537 Email from Simon O’Connor to Claire Williams on 18 March 2015 {RYD00035549}. 1538 Williams {Day122/10:3}-{Day122/12:21}. 1539 Williams {Day122/12:22}-{Day122/13:4}; {Day122/14:11}-{Day122/15:2}. 1540 Williams {Day122/15:3-4}. 1541 Emails between Simon O’Connor, Claire Williams and Matt Rawlings on 22-23 April 2015 {TMO00858424}. 1542 PSB Above Ground Commissioning Report dated 28 April 2016 {PSB00000224/7}. 1543 Minutes of the bi-monthly meetings between the TMO and LFB fire safety team on 23 March 2015, 19 August 2015 and 4 March 2016: {RBK00013999/3} item 9; {LFB00000063/4} item 9.1; {TMO10014736/3} item 10.1. 1544 Record of Significant Findings and Action Plan dated 17 October 2014 {TMO10017386/9} row 41; Minutes of the bi‑monthly meeting between the TMO and LFB fire safety team on 19 August 2015: {LFB00000063/4} item 9.1.

167 Chapter 44 Lifts Introduction 44.1 During Phase 1 there was evidence that in the early stages of the fire the firefighters had been unable to secure control over the lifts in Grenfell Tower. That meant that the they had been unable to use the lifts in their firefighting and search and rescue operations; it also meant that some occupants of the tower were able to use the lifts in an attempt to escape.1545 The inability of the firefighters to bring the lifts under their control is therefore relevant to the circumstances in which some residents died1546 and it is therefore necessary to consider why the firefighters were not able to bring the lifts under their control on the night of the fire. Background 44.2 In 2005, the lifts serving Grenfell Tower were substantially refurbished and many of their components were replaced. At that time the lifts served only the ground floor, the walkway floor (floor 2) and what became floors 4 to 23.1547 As part of the refurbishment new flats were created on what became floors 1, 2 and 3. To accommodate those new flats it was necessary to extend service of the lifts to floors 1 and 3.1548 The extent of that work, which was carried out between 2014 and 2015, seems to have been limited to creating two new lift openings and landing entrances and associated work, such as reprogramming of the software. 44.3 Over the course of time there have been developments in the specifications of lifts installed in high-rise buildings. A fireman’s lift is one that is designed to enable firefighters to take control of it when responding to a fire in the building. A firefighting lift has a higher specification and is designed to transport firefighters and their equipment to the scene of a fire with the minimum amount of time and effort. It is fitted with a higher level of equipment and structural protection, a communication system and a secondary back-up power supply. Much evidence was heard about whether the lifts at Grenfell Tower were fireman’s lifts or firefighting lifts and, if they were fireman’s lifts, whether they could or should have been upgraded to firefighting lifts. For present purposes, however, only two points need to be made: first, at no stage were the lifts firefighting lifts, as they did not possess all the features of firefighting lifts required by the relevant contemporaneous standards;1549 secondly, there is not enough evidence to enable us to determine whether it was reasonably practicable at any stage to upgrade the lifts so that they had at least those features of firefighting lifts that the physical constraints of the building would allow. 1545 Phase 1 Report Volume IV paragraph 33.13. 1546 Phase 1 Report Volume IV paragraph 28.11. 1547 {TMO00853783/16}. 1548 Phase 1 Report Volume I paragraphs 6.38-6.39. 1549 BS 5588-5: 1991, BS EN 81-72: 2003 and BS 5588-5: 2004. The lifts did not have many of the important features of a firefighting lift including, for example, a secondary power supply, water protection or a trap door.

The Grenfell Tower Inquiry: Phase 2 Report 168 The fire control switch 44.4 There were two fire control switches at Grenfell Tower, one on the ground floor and one on floor 2 (the Walkway floor). The switch on the ground floor appeared older and at the time of the fire was connected, whereas the switch on floor 2 appeared newer but was not connected.1550 44.5 Email correspondence between Janice Wray and Claire Williams on 18 August 2014 showed that the entrance to the tower had been moved temporarily from the ground floor to the Walkway level.1551 44.6 In his Record of Significant Findings dated 17 October 2014 Carl Stokes noted that the entrance to the building had been moved to the Walkway level and asked whether the fire service override controls for the lifts had been moved.1552 In his Record of Significant Findings dated 26 April 2016 he asked whether the controls for the lifts had been moved back down to street level.1553 A spreadsheet that appears to be dated October 2016 states that he had received confirmation the controls had been moved back down to street level.1554 44.7 It is likely, therefore, that a new fire control switch was installed temporarily on floor 2 during the refurbishment in about August 2014. The switch on floor 2 was subsequently disconnected and the switch on the ground floor reconnected when the entrance was moved back to the ground floor. It is likely that that took place after April 2016, but it is difficult to be any more precise. Maintenance and testing of the lifts 44.8 In the years before the fire the TMO produced various policies relating to lift safety, lift breakdowns and lift trap-ins.1555 Those published after 2011 required a lift engineer to carry out periodic visual checks of safety gear and other equipment, such as emergency alarms, emergency car lighting and lift machine room emergency lighting, in accordance with statutory regulations. The policies also required all lifts, hoists, disabled people’s hoists and stairlifts to be inspected periodically by a competent engineer as required by statutory regulations, British Standards and manufacturers’ instructions, and inspections to be recorded.1556 44.9 The policies also required checks to be carried out by staff, including the TMO’s senior lift engineer. He was directed to carry out checks on safety gear, emergency alarms, emergency car lighting and lift machine room emergency lighting in accordance with regulations. Monthly checks of all fireman’s switches were required.1557 Responsibility for those checks passed to the TMO’s lift maintenance contractor in January 2014.1558 44.10 The TMO also published a “Lift Safety (Passenger, Goods, and Fireman’s) Policy and Procedure” dated 23 September 2013.1559 It stated that lifts should be thoroughly examined by a competent person, usually an insurance engineer, every six months and that a lift 1550 {MET00019973/19-21}. 1551 {CST00001858}. 1552 {CST00001734/7}. 1553 {CST00002206/6}. 1554 {CST00000196/25-27}. 1555 {TMO00899279}; {TMO00899287}; {TMO00880413}; {TMO00880416}; {TMO00880418}; {TMO00880419}. 1556 See, for example, clause 10.0 in {TMO00880416/6}. 1557 {TMO00880421/30}; {TMO00880422/30}; {TMO00880423/30}; {TMO00880430}; {TMO00880430/30}. 1558 {TMO00880432/26}; {TMO00880430}. 1559 {TMO00880431}.

Part 5 | Chapter 44: Lifts 169 maintenance contract should be established with a competent lift maintenance company. The policy also required lifts to be checked weekly or monthly to ensure that they were operating correctly.1560 44.11 The TMO also produced a “Lift Safety Policy and Procedure” dated February 20141561 which dealt with statutory inspections and maintenance. Section 4.1, relating to planned preventative maintenance, stated that the TMO should appoint a competent lift contractor to carry out monthly maintenance checks on all lifts, to record maintenance on the lift log card and to carry out maintenance identified by inspections as soon as practicable. The policy also noted that that was to be supplemented by regular inspections of the lift cars by the estate staff and health and safety staff. Section 4.2 provided that the lifts should be thoroughly examined every 6 months.1562 Subject to various minor changes, the substance of the policy remained in place until the fire. The PDERS maintenance contract 44.12 PDERS (an unincorporated trading division of Otis Ltd) was the TMO’s planned preventative maintenance provider from 3 February 2014.1563 44.13 Based on the Description of the Works contained in paragraph 2.0 of the document entitled “Service Information and Preambles for the Lift Preventative Planned Maintenance and Repair Contract”,1564 PDERS was expected to provide fully comprehensive servicing of the lifts throughout RBKC’s estate, including routine inspection, maintenance and repairs. Breakdown response repairs due to vandalism or misuse were not included. The contract required maintenance visits to take place monthly with a minimum period between visits of not less than 21 days.1565 44.14 The contract identified the maintenance tasks and how often they should be carried out. Codes designated the frequency of a task, so, for example, “M1” indicated that a task should be carried out monthly, “M2” that it should be carried out every two months, and so on.1566 Under the heading of “Landing Entrances” the contract expressly provided that fireman’s control switches should be checked monthly. 44.15 The contract listed the lifts at Grenfell Tower (H090 and H091) and provided that a minimum of two hours should be spent each month on the maintenance of each of them.1567 The evidence of Mark Wallis, a maintenance engineer at PDERS, was that a maintenance visit normally took about two hours for each lift.1568 Maintenance by PDERS 44.16 The service visit reports for lift H090 covering the period from February 2014 until the fire1569 suggest that it suffered no significant defects. The repair visit reports1570 also reveal no noteworthy problems with it. 1560 TMO Lift Safety (Passenger, Goods and Fireman’s) Policy Procedure Clause 3.23 {TMO00880431/3}. 1561 {TMO00880433}. 1562 {TMO00880433/3-4}. 1563 Fallis-Taylor {PDR00000050/2} page 2, paragraph 9. 1564 {PDR00000049/43} paragraph 2.0. 1565 {PDR00000049/44} paragraph 2.1.1. 1566 {PDR00000049/45} paragrapgh 2.1.9. 1567 {PDR00000049/82}. 1568 Wallis {Day163/86:21-25}. 1569 {PDR00000047}. 1570 {PDR00000048}.

The Grenfell Tower Inquiry: Phase 2 Report 170 44.17 Similarly, the service visit reports for lift H091 covering the period between February 2014 and June 20171571 show no significant faults. The repair visit reports for lift H0911572 also disclose no significant problems. Testing by Bureau Veritas 44.18 Bureau Veritas is a testing, inspection and certification organisation which tests equipment, including lifting equipment, to assess whether it meets required technical standards.1573 44.19 Bureau Veritas was engaged by RBKC from January 2013 to carry out “thorough examinations” of all the lifts in the borough every six months, including those at Grenfell Tower.1574 A thorough examination is a detailed examination of a lift and its associated equipment. It does not include maintenance or repairs.1575 44.20 The reports of the inspections carried out by Bureau Veritas in 2016 and 2017 were available to us. They identified some category A defects (defects that are or could become a danger to users), some category B defects (defects that do not affect safety but usually require some maintenance) and some category C defects (defects that call for observations or recommendations only).1576 44.21 On 7 January 2016, a Bureau Veritas engineer examined lifts H0901577 and H091.1578 He found no category A defects but several category B and C defects. On 2 June 2016, Bureau Veritas examined lift H0901579 and lift H091 again.1580 Again, no category A defects were found but several category B and C defects were identified. 44.22 On 2 November 2016, Isiaka Lasisi of Bureau Veritas examined lifts H0901581 and H091.1582 Although a category A defect was found in the latter, it did not relate to its fire safety features.1583 The evidence shows that on 2 November 2016 the TMO raised the category A defects with PDERS and on 3 November 2016 an engineer examined the lifts and rectified them.1584 44.23 Michael Arnold of Bureau Veritas examined lifts H090 and H091 on 10 April 2017.1585 Although he identified some category B defects, he found no category A defects. As no category A defects had been identified during the visit on 10 April 2017 and there is nothing to suggest that the inspection was anything other than diligent, we conclude that there were no significant defects in the lifts at the time of the fire. 1571 {PDR00000041}. 1572 {PDR00000045}. 1573 Veitch {BVL00000006/1} page 1, paragraph 2. 1574 Veitch {BVL00000006/8} page 8, paragraph 29. 1575 Veitch {BVL00000006/2-3} pages 2-3, paragraph 5. 1576 Lasisi {BVL00000015/2-3} pages 2-3, paragraphs 7-10. 1577 {MET00036488}. 1578 {MET00036489}. 1579 {MET00035852}. 1580 {MET00035853}. 1581 {BVL00000014}. 1582 {BVL00000016}. 1583 Lasisi {BVL00000015/5} page 5, paragraph 19. 1584 {MET00036245} 1585 {BVL00000008}.

Part 5 | Chapter 44: Lifts 171 Maintenance and testing of the fire control switch 44.24 Although until January 2014 the TMO’s policies (in draft from August 2011 and approved in June 2012) provided that its own lift engineer would test the fireman’s switch each month,1586 there is no evidence that the TMO did carry out any testing or maintenance of the fire control switch itself. PDERS said that the switch had been tested monthly from 2014 onwards, as the contract required. Although before that date the TMO’s policies required it to be tested by its own lift engineer, it was not done regularly or, it seems, at all.1587 The lift maintenance contractor - PDERS 44.25 Not all the lifts maintained by PDERS had fire control switches and it was therefore decided not to include the fire control switch in the report forms.1588 As a result, none of the service visit reports produced by PDERS1589 records testing of the fire control switch and there is no other written record of its having tested the switch. 44.26 From September 2016, Dave Smalley was the PDERS lift maintenance engineer for the North Kensington area, which included Grenfell Tower. He said that the fire control switch had been tested on each of his service visits in November and December 2016 and January and March 2017. He did not recall any problems with it.1590 44.27 From April 2017, Mark Wallis was the lift maintenance engineer for Grenfell Tower. He carried out service visits on 12 April 20171591 and 9 May 2017.1592 He said he specifically remembered checking that the fire control switch had been in good working order on both occasions.1593 However, after he had given evidence, a CCTV recording made on 9 May 2017 was obtained which covered his maintenance visit. It showed clearly that, contrary to his evidence, he had not tested the fire control switch on that occasion. In the light of that recording Mr Wallis accepted that he had not tested the switch on that day.1594 No CCTV recording of his visit on 12 April 2017 or, if he attended, of any previous visit was available, so we cannot be confident that he tested the control switch on that occasion or on any previous visit. 44.28 In the circumstances, there is no reliable evidence of when the fire control switch was last tested by PDERS before the fire. In fact, the weight of the evidence suggests that the fire control switch was not regularly tested before 14 June 2017. The insurance inspections - Bureau Veritas 44.29 The Bureau Veritas reports from 2016 and 20171595 record only defects affecting the lifts, not the testing of the fire control switch.1596 1586 {TMO00880421/30}; {TMO00880430/30}. 1587 Cahalarn {Day164/68:12-19}; {Day164/69:1}; {Day164/70:3}. 1588 Fallis-Taylor {PDR00000050/6-7} pages 6-7, paragraph 25; Wallis {PDR00000036/3} page 3, paragraph 12. 1589 {PDR00000047}; {PDR00000041}. 1590 Smalley {PDR00000029/5} page 5, paragraphs 25-28. 1591 {PDR00000047/34}; {PDR00000041/36}. 1592 {PDR00000047/35}; {PDR00000041/37}. 1593 Wallis {PDR00000036/3} page 3, paragraph 12; {PDR00000036/5-6} pages 5-6, paragraphs 22-23; Wallis {Day163/115:9}-{Day163/116:5}. 1594 Wallis {PDR00000056/1} page 1, paragraph 2. 1595 {MET00036488}; {MET00036489}; {MET00035852}; {MET00035853}; {BVL00000014}; {BVL00000016}; {BVL00000008}. 1596 Lane, The Management and Maintenance of Grenfell Tower - Chapter 7 - KCTMO’s duty to provide a suitable system of maintenance for fire protection measures {BLARP20000033/463} paragraph 19.5.47.

The Grenfell Tower Inquiry: Phase 2 Report 172 44.30 Michael Arnold, the engineer who tested the lifts on 10 April 2017, confirmed that he had tested the fire control switch at Grenfell Tower. The outcome of the test was not separately documented, but we were told that if the switch had been defective, that would have been recorded in the Report of Thorough Examination.1597 There is no such record. Accordingly, the insurance inspections found nothing to suggest that the fire control switch was not working effectively. The London Fire Brigade 44.31 For the sake of completeness, we note that the LFB made a number of visits to Grenfell Tower.1598 The last took place on 27 March 2017 and was carried out by Dean Ricketts and a crew from North Kensington fire station.1599 He recalled that he had been told by one of his crew that the lifts had “fireman’s lifts” controls but due to the number of people using the lifts they were unable to test them.1600 Automatic fire alarm recall 44.32 An automatic fire recall function was installed in about March 2006. Although there is evidence that the system was tested in 2013 and early 2014,1601 correspondence from September 2015 suggests that by then it had been disconnected. We do not know when that happened or who disconnected it.1602 Investigations carried out after the fire also showed that there was no connection between the fire alarm, the smoke detection system and the lifts.1603 The failure of the fire control switch 44.33 As set out in the Phase 1 report, the firefighters who attended Grenfell Tower on the night of the fire were not able to operate the ground floor fire control switch. 44.34 The first person to attempt to use the switch was CM Christopher Secrett. A CCTV recording shows him inserting a drop key into the switch at 01.01.1604 He put the drop key into the fire control switch and felt the end of it drop down and engage but it did not work. He felt that the key was hitting some sort of stop. He turned the key several times in both directions but it did not operate the switch. He tried to turn it with more force but it made no difference. Eventually he tried to take the key out of the box but it was stuck. He left the key in place and tried to use the lifts in the normal way.1605 44.35 CM Secrett had bought a new drop key on 27 April 2017 on eBay. He kept it in a pocket of his tunic. He wore the tunic on the night of the fire but he could not be sure that the key he had bought on eBay was the key he had used on the night of the fire as the keys all look alike to the naked eye and it is common for keys to be switched and replaced.1606 1597 Arnold {BVL00000017/5} page 5, paragraph 6c; Arnold {BVL00000019/2-3} pages 2-3. 1598 {TMO00855611}; Ramsey {LFB00083855/3} page 3, paragraph 9; Ramsey {MET00071003/10} page 10; Ramsey {Day147/31:7}-{Day147/32:1}; Stokes {Day138/5:20}-{Day138/6:12}; McHugh {LFB00091787/12} page 12, paragraph 28. 1599 Ricketts {LFB00004825/4} page 4. 1600 Ricketts {LFB00004825/5} page 5. 1601 Howkins, Supplementary Report concerning the lifts at Grenfell Tower {RHO00000005/35-36} paragraphs 92-94. 1602 Howkins, Report concerning the lifts at Grenfell Tower {RHO00000003/177-179} paragraphs 437-449. 1603 {MET00018469/11}; {MET00065879/34-35}; {MET00072161/12}; {MET00072161/26}. 1604 {INQ00000138}. 1605 Secrett {MET00039598/3} page 3; Secrett Phase 1 {Day16/192:23}-{Day16/193:6}. 1606 Secrett {MET00056990/2} page 2.

Part 5 | Chapter 44: Lifts 173 44.36 A CCTV recording shows that at 01.33 CM Ben Gallagher tried to use the fire control switch. A key was already in the box which CM Gallagher tried to use to take control of the lift. However, he was unable to activate the switch and left the key in place.1607 Evidence recovered after the fire 44.37 Another CCTV recording showed FF Nuttall removing the drop key from the fire control switch. He was unable to remember doing so and explained that, some two years after the fire, he had been called by a member of the LFB’s investigation team and asked if he had any drop keys. FF Nuttall said that he had posted to them the one drop key that he had been able to find, although he had thought he had two. He was not able to say that the key that he had provided to the investigation team was the one that he had removed from the tower.1608 44.38 It is not possible to say whether the key sent in by FF Nuttall had been used on the night of the fire. The period between the fire and the posting of the key was very long and FF Nuttall accepted that he might have swapped the key with another firefighter.1609 44.39 The Metropolitan Police instructed an engineering consultant, WSP, to visit Grenfell Tower on 15 March 2018 to conduct a visual inspection of the fire control switch on the ground floor. The engineer who attended noted that it had not been damaged by fire or water and therefore recommended that it be removed for examination.1610 The fire control switch therefore remained in place from the date of the fire until about March 2018. Why did the switch fail to operate? Presence of debris 44.40 The first possibility is that the switch was jammed with debris. It was first tested on 18 April 2018 in the presence of professional engineers from WSP, Elan Lifts, the Metropolitan Police, the LFB and an independent lift test engineer.1611 The report of the test made by WSP recorded that the switch was difficult to operate. The faceplate was removed to determine the reason why the switch could not be operated and the mechanism was found to be seized and deformed.1612 44.41 The report also concluded that, as the mechanism of the switch was defective, it had not been examined by the lift service company at regular intervals.1613 44.42 The switch was tested again on 15 February 2019 at the Building Research Establishment (BRE). The test is described in two reports: the first written by Arup,1614 the second by André Horne, an independent expert instructed by the Metropolitan Police.1615 In both reports the switch is described as Exhibit BJG/74. 44.43 There is no evidence that the switch was cleaned between the test on 18 April 2018 and that on 15 February 2019. However, it had been moved between locations, so it is possible that any debris that had originally been inside it had moved or had been dislodged. 1607 Gallagher {MET00040215}. 1608 Nuttall {MET00056991/1} page 1. 1609 Nuttall {MET00056991/2} page 2. 1610 {MET00019973/12} paragraph 6.1. 1611 {MET00019973}. 1612 {MET00019973/21}. 1613 {MET00019973/43} paragraph 10.1. 1614 {RHO00000001}. 1615 {MET00056700}.

The Grenfell Tower Inquiry: Phase 2 Report 174 44.44 Arup’s report is dated 1 March 2019. It stated that a visual examination of the switch disclosed a build-up of builders’ material on the casing and that the micro-switch was jammed. The author’s impression was that the debris was wall plaster. On examination, the micro-switch became free and worked. The cause of the jamming could not be identified, but there were plaster grains on the work bench. The author’s view was that the presence of builders’ material had not been the result of disturbance when the switch was extracted but from the original works.1616 44.45 André Horne’s report was based on the same test. He said that the switch frame arms were jammed because of debris on the frame which appeared to be dirt, mortar or sand, possibly from the construction of the building. Mr Horne could not say whether some of the debris had been dislodged during the removal, transportation and storage of the switch, thereby causing the jam, or if it had been jammed before its removal. After some gentle manipulation by hand, it moved freely. In Mr Horne’s view, forceful manipulation of a correctly fitting key would have moved the switch frame arms.1617 44.46 Mr Howkins was also present at the test on 15 February 2019. He provided a diagram which showed where the debris had been observed.1618 He originally estimated the quantity of debris removed as about a quarter of a teaspoonful,1619 but in his evidence he said that it had been half to three-quarters of a teaspoonful.1620 There was no way of knowing if the switch had become jammed with debris while it was still in place, during its removal, while it had been stored or in the course of transportation before testing. 44.47 During the test a drop key was inserted into the switch. The switch did not immediately operate but after the key had been turned left and right a few times the debris on the micro switch cleared and it was possible to operate the switch.1621 Mr Howkins and Mr Horne agreed that the use of a reasonable amount of force would probably have cleared the debris.1622 44.48 Both Mr Horne and Mr Howkins noted another abnormality in the switch, unrelated to the debris, namely that the side wards were bent out of shape. That was not specifically noted in WSP’s report, but the reference to the mechanism being “deformed” may have been a reference to the bent side wards.1623 44.49 The Arup briefing note also noted the deformation of the side wards and photo 13 in the report showed the damage.1624 The author concluded (and Mr Horne agreed)1625 that the damage to the side wards had been caused either by the use of an incorrect drop key, which deformed the side wards, or by a drop key being inserted too far into the barrel with the result that a high twisting force damaged the side wards.1626 Use of an incorrect key 44.50 The second possibility is that the drop key used was not the right one for the fire control switch. 1616 Howkins, Grenfell Tower Lifts Briefing Note regarding fire control switches {RHO00000001/13}. 1617 {MET00056700/3}. 1618 Howkins, Supplementary Report concerning the lifts at Grenfell Tower {RHO00000005/48}. 1619 Howkins, Supplementary Report concerning the lifts at Grenfell Tower {RHO00000005/48} paragraph 161. 1620 Howkins {Day165/103:5-10}. 1621 Howkins, Supplementary Report concerning the lifts at Grenfell Tower {RHO00000005/48} paragraph 159. 1622 Howkins, Supplementary Report concerning the lifts at Grenfell Tower {RHO00000005/49} paragraph 163. 1623 {MET00019973} page 21. 1624 Howkins, Grenfell Tower Lifts Briefing Note regarding fire control switches {RHO00000001/8-9}. 1625 {MET00056700/3}. 1626 Howkins, Grenfell Tower Lifts Briefing Note regarding fire control switches {RHO00000001/13}.

Part 5 | Chapter 44: Lifts 175 44.51 The LFB purchased drop keys for fire stations which were made available through its internal supply system. The LFB has used the same supplier of lift keys since at least 2011.1627 44.52 Drop keys are not issued to individuals but are kept on the pumps with many other keys and are used by all crew members as necessary. If a key is lost and a replacement needs to be ordered using the LFB’s internal system, it can take up to four weeks to arrive. For that reason, firefighters often buy their own drop keys from suppliers such as Amazon or through eBay.1628 44.53 The drop key obtained from FF Nuttall was labelled LJH/67 by the police. It is not possible to know whether it was the one used on 14 June 2017.1629 It was tested on 29 July 2019 at BRE Watford. In his subsequent report Andre Horne noted that because of its dimensions it could not be used in the fire control panel at the tower or in the example panel provided by the Metropolitan Police for the purposes of the examination.1630 The key could be inserted into the opening of the switch but could not be turned and therefore could not have caused the damage to the side wards. 44.54 A key supplied by Jeff Turner, a forensic locksmith, fitted the switch taken from the tower correctly. An example key provided for the purposes of the examination was also tested but did not fit correctly.1631 44.55 Further testing took place on 7 February 2020.1632 For that purpose two more keys were compared. Key DER/22 was one of a set of keys provided by the LFB that had been assembled from keys left over from various appliances no longer in use and included a drop key.1633 It did not fit very well in the switch taken from the tower and Mr Horne noted that, even if the side wards had been straight, it would still not have fitted correctly. However, Key DER/22 did fit normally in the example panel and could operate the panel taken from the tower if sufficient force was applied.1634 44.56 Key SJG/01 had been bought on eBay. It fitted both the switch taken from the tower and the example switch.1635 44.57 By contrast, the key obtained from FF Nuttall could not be used to operate either switch. The only keys that functioned normally in the switch taken from the tower were the key bought on eBay (SJG/01) and the key provided by Jeff Turner. Neither the example key nor the key provided by the LFB (DER/22) fitted the switch taken from the tower correctly, but, if sufficient force had been applied, they could both have operated it. All the keys other than LJH/67 worked properly in the example fire control panel. An unidentified fault 44.58 It is possible that some other unidentified cause was responsible for the failure of the fire control switch to work on the night of the fire, but there is no evidence that the switch had been damaged by smoke or fire and no other defects in it were identified. 1627 Atkinson {LFB00083885/2} page 2, paragraph 6; Atkinson {LFB00083885/8} page 8, paragraph 11. 1628 Secrett {MET00056990}; Secrett {LFB00091726/2-3} pages 2-3, paragraphs 7-8. 1629 Nuttall {MET00056991}. 1630 {MET00056700/4}. 1631 {MET00056700/3}. 1632 {MET00071006/1}. 1633 Wilson {MET00077769/2}. 1634 {MET00071006/3}. 1635 {MET00071006/4}.

The Grenfell Tower Inquiry: Phase 2 Report 176 44.59 We think that the use of the wrong size of drop key is the most likely reason for the failure of the fire control switch to operate properly on the night of the fire.1636 Conclusions 44.60 Two important matters emerge from this aspect of our investigations. The first is the need for regular maintenance of fire control switches. Whether debris in the switch box interfered to any significant extent with the operation of the switch on the night of the fire, the likelihood is that more foreign material was present than should have been allowed to accumulate in a piece of equipment that was supposed to be checked at regular intervals. We cannot say that a failure of regular maintenance was the cause of the switch becoming inoperable, but we can say that the evidence strongly suggests that it was not given the attention it deserved. 44.61 The second concerns the significant variation in the dimensions of the drop keys tested and their compatibility with different fire control switches. One might have expected fire control switches to conform to a specified pattern and that drop keys would likewise conform to a pattern known to be capable of operating the standard switch. That appears not to have been the case. As a result, it appears to have been largely a matter of chance whether the key carried by the first firefighter who tried to take control of a lift enabled the switch to be operated. That is a recipe for disaster. Part of the reason for that unsatisfactory state of affairs lies in the practice of firefighters’ obtaining drop keys from various sources without appropriate guarantees of their suitability. Standardisation and control of equipment by fire and rescue services are necessary to avoid incompatibility. On 8 August 2019, the LFB notified all watch managers and crew managers that keys purchased from external sources were in circulation and instructed them to carry out an immediate physical check of all drop keys to ensure that keys of the correct pattern were stowed on all firefighting appliances at all stations.1637 We hope that as a result the substantial variation in the keys used by firefighters has now been eliminated. 1636 Howkins {Day165/112:5-7}. 1637 Atkinson {LFB00083885}; also see {LFB00083895}.

177 Chapter 45 Emergency planning Legislative framework and guidance 45.1 Save for the purposes of article 30 (which is not relevant for present purposes), the Fire Safety Order does not apply to domestic premises. Each flat in Grenfell Tower was occupied under a separate lease or tenancy agreement and so constituted domestic premises for the purposes of the Order. Accordingly, as far as the residents were concerned, the duties imposed by articles 8 to 22 applied only in relation to the common parts of the building, namely, the lobbies, lifts and staircase. 45.2 Article 14 imposes a duty to ensure that routes to emergency exits and the exits themselves are kept clear at all times; emergency routes and exits must be indicated by signs and be adequately lit (including, where necessary, by emergency lighting). Article 15(1)(a) requires the responsible person to establish, and where necessary give effect to, appropriate procedures to be followed in the event of serious and imminent danger from fire and to nominate a sufficient number of competent persons to implement those procedures in so far as they relate to the evacuation of relevant persons from the premises. The procedures must, so far as is practicable, require any relevant persons exposed to a serious and imminent danger to be informed of the nature of the hazard and of the steps taken or to be taken to protect them from it (article 15(2)(a)). 45.3 In practical terms the Fire Safety Order required the TMO to ensure that the lift lobbies, the lifts themselves and the staircase were kept free of obstructions, were properly lit (including by emergency lighting when necessary) and displayed appropriate signs to indicate the escape route. It appears to assume that the occupants of any flat in which a fire occurred, or which was affected by heat or smoke from a fire in a neighbouring flat, could escape into the lobby and from there make their way to safety using the stairs. It did not, however, impose a duty on either of them to devise a plan to evacuate residents from within their flats, much less a plan to evacuate the building as a whole. A “stay put” or “defend in place” strategy for responding to a fire is better viewed as a response strategy rather than an evacuation plan. 45.4 Publicly available guidance, in particular the guidance published by the Local Government Association specifically in relation to purpose-built blocks of flats (the LGA Guide), emphasised the need to ensure that that information about the procedure to be followed in the event of a fire should be disseminated to all residents.1638 45.5 Section 79 of the LGA Guide, under the heading “Preparing for emergencies”, advised that there must be a suitable emergency plan for the premises, but that, in the case of purpose‑built blocks of flats, that would rarely require more than a fire action notice, which in most cases would be sufficient as an emergency plan. It also recognised that it was common to communicate the emergency plan to tenants in other ways, so that it was not always necessary to display a fire action notice in the building.1639 1638 {HOM00045964/115-117} paragraphs 77.1 to 77.6; {HOM00045964/133} Appendix 1. 1639 LGA Guide {HOM00045964/118} paragraph 79.1.

The Grenfell Tower Inquiry: Phase 2 Report 178 45.6 With the approval of the LFB, both before and after the refurbishment Grenfell Tower was subject to a “stay put” strategy, under which residents were encouraged to remain in their flats unless they were directly affected by fire or smoke because that was considered to be the safest course for them to take. Any more general evacuation of the building was expected to be directed and supervised by the fire and rescue service. There was therefore no need for the responsible person to create an evacuation plan for the building as a whole. We consider below the steps taken by the TMO to inform residents of the steps to be taken in the event of a fire in the building. The TMO Emergency Plan 45.7 The TMO maintained an Emergency Plan. It had been drafted in August 2004 and revised in October 2006, May 2009, November 2009 and February 2016.1640 Adrian Bowman was responsible for maintaining, and when necessary revising, it under the general supervision of Janice Wray.1641 She was unable to say what had given rise to the various revisions, but accepted that there had been no system for reviewing it at regular intervals and making any necessary changes.1642 That, of itself, was a serious failing, because, if a plan is not reviewed regularly, it may not be fully effective when an emergency occurs. 45.8 The chairman considered the TMO Emergency Plan in the Phase 1 report and found that it was far from adequate.1643 The evidence we have heard at Phase 2 only reinforces that conclusion. The TMO Emergency Plan was in two parts: the first was the generic plan; the second contained separate sections relating to the various properties managed by the TMO, each containing a description of a particular property. 45.9 The section relating to Grenfell Tower was dated 25 February 2002.1644 It contained estimates of the number of residents and vulnerable persons; it identified places where the emergency services could gather and identified a nearby place of shelter. There was information about the electricity, gas and water supplies and the dry riser. The location of the keys was also recorded and the means of escape. The “stay put” strategy was recorded as was the existence of automatic fire alarm and smoke extract systems, but no further information was provided about them.1645 45.10 The version of the Emergency Plan dated February 2016 was current at the date of the fire. The sub-section relating to Grenfell Tower was largely the same as that which had been created on 25 February 2002, 15 years earlier. Janice Wray was unable to explain why that was the case. The number of dwellings had not been changed to reflect the new flats created in the lower floors as a result of the refurbishment, but the place of shelter had been changed to North Kensington Resource Centre. The means of escape were still described as through the stairs and onto the walkway level, which did not reflect the fact that the door to the walkway had been blocked up during the refurbishment. The section containing “other information” had only partly been brought up to date. Information about the reception desk, the creche and the boxing club had been removed as well as information about the hydraulic lift to social services on the first floor. A description of the 1640 TMO Emergency Plan – Version 1 August 2004 {TMO10013898}; TMO Emergency Plan – Revised October 2006 {TMO10048195}; TMO Emergency Plan – Revised November 2009 {TMO00841015}; TMO Emergency Plan – Revised 2016 {TMO10013898}. The 2016 version referred to revisions in May 2009 and May 2015, but these have not been disclosed to the Inquiry. 1641 Wray {Day142/34:23-25}. 1642 Wray {Day142/36:20}-{Day142/38:3}. 1643 Phase 1 Report, Volume IV, paragraph 30.93. 1644 November 2009 TMO Emergency Plan {TMO00841015/147}. 1645 November 2009 TMO Emergency Plan {TMO00841015/147-148}.

Part 5 | Chapter 45: Emergency planning 179 bin stores was included and a note recorded about a fire that had affected them in 1997. However, the plan still recorded that there was an automatic fire alarm and smoke extract system, even though the former no longer existed. The plan noted that in case of fire residents were advised to remain in their homes unless affected by heat or smoke.1646 45.11 The piecemeal and inconsistent revision of the information in the Emergency Plan meant that that part of the plan could not safely be relied on in an emergency at Grenfell Tower. 45.12 Janice Wray told us that the Emergency Plan had been intended to deal with only minor emergencies, such as a fire, a power failure, a leak or a flood.1647 That was because the TMO lacked the resources to respond to a major emergency. RBKC had a more comprehensive emergency plan and greater resources. The plan itself, however, said that it set out the roles and responsibilities of the TMO in the event of a major incident, which it defined as an incident or natural disaster resulting in death, injury or serious disruption to normal life of a magnitude that would acutely stretch the TMO’s resources.1648 45.13 Ms Wray said that the section on Grenfell Tower had been intended to collate information that the emergency services or anybody else might require for the purposes of emergency planning,1649 but she appears not to have given any thought to whether it contained all the information recommended by the guidance. They referred only to the requirement to communicate the emergency plan (that is, the “stay put” strategy) which they did through the residents’ handbook, Link magazine and in documents provided to residents when they signed the tenancy agreement with the TMO.1650 The fire safety strategy 45.14 The TMO’s fire safety strategies of 2013 and 2016 did not refer to the Emergency Plan,1651 but that may have been because it was understood that the Emergency Plan was intended as a response to a wide range of emergencies. 45.15 The 2013 fire safety strategy asserted that a “stay put” or “defend in place” strategy was “overwhelmingly” appropriate for the TMO’s housing blocks. That was because compartmentation, both between flats and also between flats and the common parts, was considered to be sufficient to withstand fire for long enough to enable the fire and rescue service to attend and extinguish it. That message was said to have been communicated to residents in various ways, including in the resident’s handbook, on the TMO’s website and in Link magazine.1652 Evacuation planning in the fire risk assessments 45.16 A fire risk assessment should set out in detail the fire management procedures required to respond to a fire so that they can provide the basis of an appropriate response plan.1653 Clause 16 of PAS 79:2012 also required a fire risk assessor to undertake an assessment of fire safety management, which included procedures for people to follow in the event of fire, including people with special responsibilities, the nomination of people to respond to 1646 February 2016 TMO Emergency Plan {TMO10013898/145-146}. 1647 Wray {Day142/38:5-19}; {Day142/40:22}-{Day142/41:19}. 1648 February 2016 TMO Emergency Plan {TMO10013898/13}. 1649 Wray {Day142/43:22}-{Day142/44:2}. 1650 Wray {Day142/45:5}-{Day142/46:1}. 1651 2013 TMO Fire Safety Strategy {TMO00830598}; 2017 TMO Fire Safety Strategy {TMO00847324}. 1652 {TMO00830598/10-11}, paragraph 15.1; {TMO00847324/10}, paragraph 15.2. 1653 Lane, Chapter 8 – The adequacy of the advice provided by the fire risk assessor Carl Stokes of CS Stokes & Associates Ltd to KCTMO Report {BLARP20000027/373}.

The Grenfell Tower Inquiry: Phase 2 Report 180 fire and, where appropriate, to assist with evacuation and arrangements for liaison with the fire and rescue service, both in respect of planning for fire and at the time of any fire.1654 The commentary to clause 16 said that in making a fire risk assessment there was a need to ensure that there were formal, documented procedures of an adequate kind for people to follow in the event of fire. A list of procedures considered to be adequate was included.1655 45.17 Carl Stokes did, in the main, take PAS 79:2012 as his guide for making fire risk assessments, although his adherence to it was patchy and inconsistent. Each of his fire risk assessments for Grenfell Tower had a section headed “The Evacuation Strategy for this building” in which he noted that there was a “stay put” strategy in place and that the fire and rescue service or the TMO would organise a general evacuation of the building, if appropriate. He also noted that the TMO had provided information to all residents in a tenant’s handbook, letters and briefing sheets and in articles in Link.1656 Once the refurbishment of the tower was under way, he recorded that the contractors had an evacuation policy and procedure relating to areas under their control and that the nursery and boxing club had their own fire risk assessments and evacuation procedures. He did not record whether there was an emergency plan specifically for Grenfell Tower that described how the TMO would contact the LFB, residents or the nursery or boxing club in the event of a fire. Nor did he record whether there was a plan which contained relevant information specific to the tower. That part of the fire risk assessment remained substantially the same between 2010 and 2016 with minor and immaterial variations.1657 45.18 Carl Stokes told us that in the case of Grenfell Tower the evacuation plan had been a “stay put” strategy,1658 information that he admitted he had obtained at a meeting with Janice Wray on 24 September 2010.1659 In his view, that explained why his fire risk assessments for many other high-rise residential blocks contained similar language. He had been responsible for the inclusion in his fire risk assessments of the statement that the Fire and Rescue Service or the TMO would organise a general evacuation of the building. He had not been told by Janice Wray that the TMO (either alone or in conjunction with the Fire and Rescue Service) would organise a general evacuation.1660 He had based it on the knowledge that under GRA 3.2 it was something for which the fire and rescue service should have contingency plans and that the TMO was aware of the needs of individual residents.1661 He thought that it was always possible that a situation might arise in which the fire and rescue service would have to evacuate the building. He said that he had not contemplated that the TMO would organise an evacuation in response to an emergency; in such cases it would act under the direction of the Fire and Rescue Service.1662 It would do so only in cases where it had other reasons for evacuating the building and could do so in its own time.1663 However, those qualifications were not recorded in the fire risk assessment itself, nor were they readily apparent to anyone reading the document, which gives a quite different impression.1664 1654 PAS 79:2012 {CTA00000003/50}, paragraph ii.c-e. 1655 PAS 79:2012 {CTA00000003/51}, paragraph viii. 1656 Grenfell Tower Fire Risk Assessment – 20 June 2016 {CST00003145/6}. 1657 Lane, Chapter 8 – The adequacy of the advice provided by the fire risk assessor Carl Stokes of CS Stokes & Associates Ltd to KCTMO Report {BLARP20000027/376}. 1658 Stokes {Day136/223:3-6}; Letter from Carl Stokes to Janice Wray of 27 September 2010 {CST00003061}. 1659 Stokes {Day137/16:6-11}. 1660 Stokes {Day136/221:15}-{Day136/222:3}; {Day137/4:3}-{Day137/5:18}; Wray {Day142/54:10}-{Day142/55:4}; {Day142/59:2-7}. 1661 Stokes {CST00003063/51} page 51, paragraph 150 (i). 1662 Stokes {Day137/9:19-23}. 1663 Stokes {Day137/6:1-7}. 1664 Stokes {Day137/9:24}-{Day137/10:4}.

Part 5 | Chapter 45: Emergency planning 181 45.19 It was the TMO’s responsibility to check the accuracy of the statements in Mr Stokes’s fire risk assessments, since, under article 9 of the Fire Safety Order, they were its own assessments. We therefore find it difficult to understand why no one at the TMO took issue with an erroneous statement on a matter of such importance, particularly since it was repeated in fire risk assessments made in respect of other high-rise buildings, including Adair Tower, Gillray House, Hazlewood Tower and Markland House. However, as we have noted elsewhere, at no point during the seven years in which Carl Stokes carried out fire risk assessments for the TMO did Janice Wray seek to question any of his assessments whether in relation to Grenfell Tower or any other building.1665 She was clear in her own mind that the TMO had no formal role in organising an evacuation in the event of a fire, but she did not make that clear to Carl Stokes.1666 The fires at Adair Tower and Trellick Tower 45.20 In the two years before the Grenfell Tower fire there were two fires in high-rise residential buildings managed by the TMO. On 31 October 2015, a fire occurred in Adair Tower and on 27 April 2017 there was a fire in Trellick Tower.1667 On both occasions, the LFB carried out a partial evacuation of the building.1668 45.21 Janice Wray was aware that on each occasion part of the building had been evacuated and knew that the “stay put” strategy had sometimes been departed from.1669 On 23 November 2015, she drafted a note to the Health and Safety team about the Adair Tower fire in which she reported that there was a “stay put” strategy at Adair Tower, in common with most of the TMO’s high-rise residential blocks. She said that the LFB would decide whether an evacuation was required and, if so, would carry it out. She also said that the LFB would be assisted by any TMO staff who were present.1670 She described that as merely an observation on the response at Adair Tower rather than a plan.1671 The response of senior management to the fires 45.22 After the fire at Adair Tower on 31 October 2015, Robert Black asked Janice Wray and Sacha Jevans to explain the building’s fire procedures and processes.1672 In response Janice Wray described the “stay put” strategy and explained that, if a fire occurred, the LFB would decide whether an evacuation was necessary and, if so, whether it should be partial or total.1673 45.23 On 1 November 2015, Robert Black sent Peter Griffiths, Teresa Brown, Sacha Jevans and Yvonne Birch some complaints that Councillor Mason had received from the press and residents. They included the absence of an evacuation plan.1674 1665 Apart from a disagreement about whether the lifts at Grenfell Tower were fire-fighting lifts (see Chapter 44); and on his grading of remedial actions (see Chapter 39). 1666 Wray {Day142/63:8-16}. 1667 LFB FSR Post Fire Review Report {LFB00054910}; LFB Senior Fire Safety Officers Report {LFB00001626}; Paper 3 – Adair Tower fire – 31 October (2015) dated 23 November 2015 {TMO00840431}. 1668 Paper 3 – Adair Tower fire – 31 October (2015) dated 23 November 2015 {TMO00840431}. 1669 Wray {Day142/52:2-19}; {Day142/53:2-7}. 1670 Paper 3 – Adair Tower fire – 31 October (2015) dated 23 November 2015 {TMO00840431}. 1671 Wray {Day142/63:2-7}. 1672 Email from Robert Black “re Fire Adair Tower” dated 31 October 2015 {TMO00869147}. 1673 Email from Janice Wray to Robert Black dated 31 October 2015 {TMO00869159}. 1674 Email from Robert Black dated 1 November 2015 {TMO00866475}.

The Grenfell Tower Inquiry: Phase 2 Report 182 45.24 On 2 November 2015, Robert Black told the board that the TMO had responded to the fire rapidly,1675 and following an inspection of Adair Tower on 3 November 2015 Carl Stokes expressed the view that the TMO’s management procedures had worked well.1676 Robert Black told the Housing and Property Scrutiny Committee on 5 November 2015 that the emergency planning had worked and that the fire doors had also worked well,1677 but that was not quite the message that was conveyed in internal meetings of the TMO that followed. The incident was discussed at an executive meeting on 11 November 2015.1678 Barbara Matthews, who was co-ordinating the response to the fire, said that although RBKC had been supportive, the TMO should be more involved in RBKC’s emergency planning strategy so that everyone was aware of contact numbers and roles and responsibilities. The TMO’s own Emergency Plan was discussed and it was agreed that the executive team should meet Janice Wray and Hash Chamchoun to gain a better understanding of who was responsible for keeping it up to date and for applying any lessons learnt from the fire at Adair Tower.1679 45.25 As a result of the Adair Tower fire, it had become apparent to the TMO that its role in an emergency was unclear and that its Emergency Plan should be reviewed in conjunction with RBKC’s emergency plan and revised as necessary.1680 Barbara Matthews may have looked at the plan,1681 but she did not take any steps herself to make sure that it was brought up to date; instead, she relied on Janice Wray to do that.1682 1675 Email from Robert Black dated 2 November 2015 {TMO00866480}; {TMO10050075}. 1676 Initial views of the fire risk assessor following his inspection of Adair Tower on 3 November 2015 {CST00025017}. 1677 Minutes of the Housing and Property Scrutiny Committee, 5 November 2015 {RBK00048049/6}. 1678 TMO executive team meeting {TMO00843593/2}. 1679 TMO executive team meeting {TMO00843593/2}. 1680 Matthews {Day148/122:9-15}. 1681 Matthews {Day148/122:16-18}. 1682 Matthews {Day148/122:9}-{Day148/123:5}.

183 Chapter 46 Vulnerable residents The Fire Safety Order 46.1 Articles 14 and 15 of the Fire Safety Order set out the duties of the responsible person to ensure that there are effective emergency exits and to establish and give effect to procedures to be followed in the event of serious and imminent danger. We need not set them out in detail here. However, we make two general observations at the outset. First, the expression “relevant persons” includes anyone who is lawfully on the premises.1683 That clearly includes all occupants of the building and any visitors, regardless of their physical or mental capabilities, who are in those parts of the building to which the Fire Safety Order applies. The Order extends to the common parts but not to individual flats. Secondly, whatever the origins of the Fire Safety Order, it cannot be read as applying only to premises where there are employees of the responsible person present at all times to provide assistance with evacuation. 46.2 Between 2005 and 2017 there was much guidance available to assist those who had responsibility under the Fire Safety Order for managing fire safety to understand their duties to those with disabilities. DCLG Guidance Note No. 1: Enforcement 46.3 DCLG Guidance Note No.1 published in October 2007 gave general guidance to enforcing authorities on the need to ensure that the means of escape were suitable and sufficient to allow safe escape from the premises. In relation to the duties under article 14, paragraph 77 of the guidance advised that all emergency routes and exits should lead as directly as possible to a place of safety and be adequate for everyone to escape quickly and safely. It also advised that the risk assessment should identify any person for whom special evacuation arrangements might need to be made because of their age, state of health, physical or mental abilities or, in some circumstances, their location on the premises.1684 However, no specific guidance was available in relation to different types of premises, such as high-rise residential buildings, and no distinction was made between residential and commercial premises. The Sleeping Guide (2007) 46.4 The guidance entitled Fire Safety Risk Assessments: Sleeping Accommodation, commonly known as the “Sleeping Guide”, published by the government in 2007, was intended to assist in carrying out fire risk assessments in relation to the common parts of buildings containing flats and maisonettes, as well as premises of other kinds.1685 It was not intended to apply to domestic premises occupied as a single private dwelling, including private flats or rooms. It recommended that when carrying out a fire risk assessment steps should be taken to identify people who may be particularly at risk, such as children and people 1683 DCLG regulatory reform (fire safety) order 2005 {CLG00000094/12}, Article 2 1684 DCLG regulatory reform (fire safety) order 2005 {CLG00000094/20}. 1685 HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015 {RBK00036722/6}. 12 bullet points which state that the guide will address the common areas of flats and maisonettes.

The Grenfell Tower Inquiry: Phase 2 Report 184 with disabilities or with a sensory impairment.1686 In particular, it advised that the means of escape should be assessed to make sure that they are suitable for the evacuation of everyone from the premises, including vulnerable residents. It suggested that, in evaluating the risk to people with disabilities, the responsible person might need to discuss their individual needs with them. 46.5 The Sleeping Guide drew attention to the Disability Discrimination Act 1995 and advised that if a disabled person could realistically be expected to use the premises, the responsible person must make any reasonable adjustments that will make it easier for that person to use and, if necessary, escape from the premises.1687 In particular, it advised that the concept of “reasonable adjustments” applied equally to fire safety, although its precise application would depend on the circumstances of each case.1688 As in other aspects, the Sleeping Guide also advised that if people with special needs used the premises, their needs should so far as practicable be discussed with them.1689 It recommended that effective management arrangements be put in place for those who need help to escape.1690 DCLG supplementary guide “Means of Escape for Disabled People” 46.6 In 2007, DCLG published a supplementary guide which considered accessibility and the means of escape for disabled people.1691 It was intended to be read with its other guides on fire risk assessment. The supplementary guide contains a “Legal Overview” in paragraph 1.1, in which it states that there should be adequate means of escape for all people, including disabled people, which do not depend on the fire and rescue service. It also points out that if an employer or a service provider does not make provision for the safe evacuation of disabled people, that may be discriminatory and a breach of the Fire Safety Order.1692 46.7 The guide draws attention to the disability equality duty which, since 2006, had required all public bodies to promote the equality of disabled people.1693 It also sets out guidance on preparing emergency evacuation plans for disabled people who are likely to be in the building or visiting it. The LGA Guide 2011 46.8 The LGA Guide was drafted following the Lakanal House fire in July 2009 specifically to provide guidance on fire safety in purpose-built blocks of flats.1694 It recognises that there is likely to be a diverse range of physical and mental capabilities among the occupants of a general needs block. The needs of vulnerable occupants are addressed in paragraphs 16.11-16.13 which recognise that older people and people with certain disabilities may have particular needs in responding to a fire. The guide also recognises, however, that in many circumstances it will be impracticable in existing blocks of flats to make special provision for such occupants.1695 1686 HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015 {RBK00036722/16-17}. 1687 HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015 {RBK00036722/54}, paragraph 1.15. 1688 HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015 {RBK00036722/54}. 1689 HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015 {RBK00036722/54}. 1690 HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015{RBK00036722/69}. 1691 Fire Safety Risk Assessment Supplementary Guide, Means of escape for disabled people {INQ00014732}. 1692 Fire Safety Risk Assessment Supplementary Guide, Means of escape for disabled people {INQ00014732/6}. 1693 Fire Safety Risk Assessment Supplementary Guide, Means of escape for disabled people {INQ00014732/6}. 1694 LGA Guide, Fire safety in purpose-built blocks of flats {HOM00045964/11} paragraph 2.1. 1695 LGA Guide, Fire safety in purpose-built blocks of flats {HOM00045964/25}.

Part 5 | Chapter 46: Vulnerable residents 185 46.9 Section 79 is concerned with “Preparing for Emergencies”. Paragraph 79.9 provides that in “general needs” blocks of flats the physical and mental abilities of the residents are likely to vary but suggests that it is usually unrealistic to expect the responsible person to plan for that or to have in place special arrangements, such as personal emergency evacuation plans. We assume that is intended to reflect the fact that the responsible person’s duty under the Fire Safety Order is circumscribed by what is reasonably practicable. In our view, those whose ability to evacuate the building without assistance should be provided with personal emergency evacuation plans (see the chairman’s recommendations in paragraph 33.22 of the Phase 1 report), although the content of such a plan will depend in each case on what is practicable. It is difficult to see what additional measures the TMO could have taken to assist the evacuation of disabled residents once they had entered the common parts of Grenfell Tower. 46.10 Paragraph 79.11, on the other hand, states that the case of a “general needs” block it is not realistic to expect the responsible person to hold information relating to residents with mobility or other conditions affecting their ability to escape in a way that enables it to be made available to the fire and rescue services, for example, in a premises information box. The justification offered is the difficulty of keeping that information up to date and the risk that inaccurate information could be more harmful than no information. However, although we understand the risks involved, we do not think it is impracticable for the responsible person to make available to the fire and rescue services by digital or other means reliable information about those with chronic disabilities whose ability to evacuate the building without assistance in an emergency is known to be compromised. Again, that was the subject of a recommendation in the chairman’s Phase 1 report. In our view, therefore, this paragraph of the Guide should be reconsidered. PAS 79:2012 46.11 We have considered some of the provisions of PAS 79:2012 in Chapter 39. For present purposes we note that it contained very detailed guidance on how to go about ensuring that a fire risk assessment took due account of the specific needs of vulnerable persons in the relevant building. It stated in terms that it applied to blocks of flats,1696 and indeed Carl Stokes himself rightly considered that it applied to his work for the TMO generally and to Grenfell Tower in particular. Although Colin Todd, who played an important part in drafting PAS 79 in 2005, and its revisions in 2007 and 2012, said that its focus was on commercial premises, he was constrained to accept that it (or at least the 2012 edition) applied to purpose-built blocks of flats.1697 He also told us that in his view a fire risk assessor would have sufficient training and experience to know that some parts of PAS 79:2012 were not intended to apply to high-rise blocks of flats and other parts were.1698 We see no overt support in PAS 79 2012 itself for that view, but in any event it was not an approach actually adopted by Carl Stokes, who did, albeit idiosyncratically and unevenly, follow the guidance it contained. 46.12 PAS 79:2012 recommended that a fire risk assessment should consider factors that have a major effect on the risk of fire.1699 They included the approximate number of occupants of the premises, the maximum number of members of the public likely to be present (unless small in number), the nature of the occupants (e.g. young or old, disabled or able-bodied), the familiarity of the occupants with the premises (e.g. fully familiar, slightly familiar or 1696 {CTAR00000003/9}. 1697 Todd {Day166/132:23}-{Day166/133:5}; {Day166/133:24}-{Day166/134:19}. 1698 Todd {Day167/106:5-10}. 1699 {CTA00000003/19}.

The Grenfell Tower Inquiry: Phase 2 Report 186 totally unfamiliar) and the state (or likely state) of the occupants (e.g. awake or asleep, alert or under the influence of alcohol or drugs). It recommended a 9-step approach to fire risk assessments. Step 1 was to obtain relevant information about the premises and their occupants, including those particularly at risk in the event of fire.1700 Step 6 was to make an assessment of the likely consequences to the occupants of a fire. Step 8 was to formulate a plan, if necessary, to address shortcomings in the fire precautions.1701 46.13 The commentary on clauses 12 and 15 contains guidance about assessing the risks to vulnerable persons in order to ensure that the fire risk assessment is suitable and sufficient. We draw particular attention to paragraphs viii, ix, xi, xiv and xv of the commentary on clause 12, and to paragraphs xx and xxviii of the commentary on clause 15.1702 Tellingly, paragraph xxix of the commentary on clause 15 provides that “Disabled evacuation strategy should not rely on rescue of disabled people by the fire and rescue service”,1703 but then goes on to say that “assistance with their evacuation is provided by persons within the premises”. 46.14 Standing back from the detail, PAS 79:2012 envisages that the fire risk assessment will first assess whether there are persons particularly at risk because of their personal characteristics and consider whether adequate provisions are or can be put in place to ensure their safety. That approach is necessary to ensure that as far as is reasonably practicable those who are vulnerable have a means of escape which is as good as that available to those who do not share their particular vulnerability. BS 9991:2015 Fire Safety Code of Practice 46.15 The Code of Practice BS 9991:2015 considered the means of escape for disabled occupants at various points. It advised on the need to be aware of the types of people in the building (such as disabled people, elderly people, children, pregnant women, etc) and any special risks or needs they might have.1704 Paragraphs 4.6 and 54, and Annex E, in particular, advised that fire safety management of a residential building needed to take account of the needs of disabled persons with permanent or temporary impairment. High-rise residential premises and premises with a “stay put” strategy in place are not excluded. The TMO’s fire safety planning for vulnerable residents 46.16 The TMO had a duty in relation to each building in respect of which it was a responsible person to identify and record the presence of residents with disabilities and the nature of those disabilities. That was necessary both for the purposes of carrying out a suitable and sufficient fire risk assessment and to enable it to take all such steps as were reasonably practicable to ensure their safety in the event of a fire. The “stay put” strategy assumed that residents would leave their flats only if they were affected by fire, heat or smoke but that in those circumstances they would escape into the lobby from where they could reach the stairs, which were in a protected area. Any resident who needed help to negotiate the stairs could telephone for assistance but ultimately would have to rely on another resident or the fire and rescue service to escape from the building. The TMO was entitled to assume that if a total or partial evacuation of the building was required it would be carried out under the direction and control of the LFB. 1700 {CTA00000003/34} paragraph i.1. 1701 {CTA00000003/34} paragraphs i.6 and i.8. 1702 {CTA00000003/36-44}. 1703 {CTA00000003/44}. 1704 {BSI00000059/20} paragraph d.

Part 5 | Chapter 46: Vulnerable residents 187 46.17 With that in mind we consider what steps the TMO took to discharge its duty to vulnerable residents. Concern about vulnerable residents: June 2009 46.18 By June 2009 the LFB had become concerned about the failure of the TMO to make adequate provision for disabled people to escape from some of its buildings. On 17 June 2009, it told Janice Wray that it intended to serve an enforcement notice on the TMO and RBKC due to their failure to make suitable and sufficient fire risk assessments of the communal areas of some of their blocks.1705 In particular, the LFB considered that the fire risk assessment for Gillray House was not suitable and sufficient because there were no procedures to enable occupants with reduced mobility to escape. 46.19 Janice Wray sent an email to Robert Black advising him of the LFB’s intention and at his request she sent it to Jean Daintith and Laura Johnson at RBKC.1706 It eventually reached Alexis Correa, Health and Safety Advisor in RBKC’s Housing, Health and Adult Social Care Services department, and Claire Wise (then a member of the Housing Policy Team). 46.20 On 18 June 2009 Claire Wise sent an email to Janice Wray in which she said that there was little information on the application of the Fire Safety Order to dwellings, but that there might be duties under the Disability Discrimination Act 1995 not to treat disabled people less favourably than people without a disability. She advised Ms Wray that if an evacuation plan was in place that was unsuitable for a person with a disability, alternative provision for disabled people should be provided.1707 She went on to say that she thought that provision for disabled people in domestic premises and communal areas had slipped through the net in legislation and guidance.1708 She asked Janice Wray for a meeting to discuss progress and an action plan. She also suggested it would be an opportunity for collaborative working with the fire brigade to develop a model to be applied across the remaining TMO buildings. 46.21 Jean Daintith forwarded that exchange to Robert Black later that day. She told him that Alexis Correa had confirmed that the fire risk assessments were not robust enough and that a specialist would need to be engaged.1709 46.22 Janice Wray accepted that the LFB had recommended there should be a procedure in place to enable residents with reduced mobility to escape,1710 but admitted that she had not sought advice about the TMO’s duties under the Fire Safety Order or the Disability Discrimination Act 1995.1711 46.23 Two points emerge from this exchange. First, that the TMO at the highest level was aware from as early as 2009 of the need to consider the arrangements for the safe evacuation of disabled people and, secondly, that RBKC was itself fully aware of the fact. 1705 {RBK00053539}. 1706 {TMO00901459}. 1707 {RBK00052528/1-2}. 1708 {RBK00052528/2}. 1709 {RBK00052528/1}. 1710 Wray {Day142/82:6-9}. 1711 Wray {Day142/84:15}-{Day 142/85:24}.

The Grenfell Tower Inquiry: Phase 2 Report 188 Salvus’s Advice: September 2009 46.24 In its report entitled “Fire Risk Assessment for Fire Safety policy and procedures” dated 22 September 2009, Salvus identified a need for the TMO to establish procedures to ensure the safety of disabled or vulnerable persons in the event of a fire.1712 The absence of such procedures was described as constituting a breach of the statutory requirements. In the enclosed action plan, it recommended that as a high priority the TMO consider developing formal procedures to deal effectively with fire safety concerns associated with disabled or vulnerable tenants and leaseholders and also any employees.1713 It marked the item as needing to be completed within three months or a plan to be agreed within six months. 46.25 Following receipt of the report, a progress meeting was held on 19 October 2009 attended by Salvus, the TMO and RBKC.1714 Paragraph 4.3 of the minutes records that Salvus had been unable to confirm whether any residents had sensory impairments at the time of the fire risk assessment and the TMO was advised to tell tenants to contact it if they had a disability affecting their ability to react to an alarm.1715 The minutes also record that the TMO had attempted to identify and record vulnerable residents. Andrew Furness of Salvus said that if the fire risk assessor had been informed about the location of vulnerable residents and the nature of their vulnerabilities in advance, the assessment would have been more comprehensive. It was agreed that an attempt would be made to obtain that information in relation to one of the TMO properties, the World’s End Estate.1716 46.26 It seems that the effort was to some extent successful. On 19 October 2009 (the same day as the meeting), two spreadsheets were produced containing data about vulnerable persons.1717 That is the only documentary evidence we have seen of TMO officials’ attempting to gather information about vulnerable residents for the purposes of a fire risk assessment. Janice Wray confirmed that as a result of that meeting, she was aware of the need to provide fire risk assessors with information about vulnerable residents.1718 46.27 On 5 January 2010, Andrew Furness complained to Nicholas Coombe of the LFB that the TMO and RBKC had little or no knowledge of the occupiers of their premises and that Salvus had advised them to gather better information about their residents in order to take appropriate steps in respect of disabled or vulnerable people and, specifically, to help them prepare PEEPs.1719 46.28 It is not clear what Mr Furness based his report on. Janice Wray told us that he had not spoken to the Housing team at the TMO, but she did not take any steps herself to obtain information about vulnerable residents. She regarded that as a matter for the Housing team.1720 46.29 On 21 January 2010, there was another progress meeting attended by Salvus, the TMO and RBKC to discuss fire risk assessments for high-rise buildings at which procedures for vulnerable residents were again discussed. Andrew Furness said that a formal documented 1712 {SAL00000013}. 1713 {SAL00000013/18}. 1714 Minutes of Progress Meeting dated 19 October 2009 {RBK00047771/1}. 1715 Minutes of Progress Meeting dated 19 October 2009 {RBK00047771/2}. 1716 Minutes of Progress Meeting dated 19 October 2009 {RBK00047771/2-3}. 1717 {TMO00866618}. 1718 Wray {Day142/87:1}-{Day142/88:10}. 1719 {SAL00000047/2}. 1720 Wray {Day142/89:3}-{Day142/90:22}.

Part 5 | Chapter 46: Vulnerable residents 189 system needed to be implemented to address the needs of disabled and vulnerable people in the event of a fire.1721 Although the recommendation was clear and well made, it was not implemented by the TMO in relation to its general needs housing stock.1722 Carl Stokes’s advice to the TMO: 2010 onwards 46.30 Carl Stokes met Janice Wray on 22 June 2010 and on 23 June 2010 he sent her a letter confirming his advice.1723 He told her that the PEEPs she had shown him accorded with those described as best practice in the government’s guidance on risk assessments. She confirmed that the intention had been to use the PEEPs documents annexed to DCLG’s 2007 guide entitled “Means of Escape for Disabled People”1724 for TMO residents as well as staff.1725 46.31 Carl Stokes and Janice Wray had a further meeting on 24 September 2010, the substance of which was reflected in a letter he wrote to her on 27 September 2010.1726 In it he noted that the TMO had recently introduced a comprehensive programme to gather information about residents, including any disabilities or restrictions on their ability to respond to an emergency. The information would be held on the “TP Tracker system” and used to assess whether residents required any additional devices to provide them with early warning of smoke or fire in their homes. It would also be used to inform the development of a personal emergency evacuation plan.1727 46.32 Carl Stokes did not check the TMO’s systems for recording vulnerable residents as he thought that was beyond what was expected of him as a fire risk assessor.1728 He did say, however, that Janice Wray had agreed that when carrying out fire risk assessments she would provide him with information about residents who were especially at risk.1729 She, on the other hand, could not recall whether she had agreed to provide him with that information. At all events, given that he had noted that they had discussed the identification of vulnerable residents for the purposes of preparing PEEPs and that Salvus had advised her of the need to provide fire risk assessors with information about individuals especially at risk, we think it likely that Janice Wray did agree to provide that information to him. However, there is no evidence that she did so. 46.33 Janice Wray thought that Carl Stokes’s reference in his fire risk assessments to the residents’ newsletters was a reference to the Link magazine, but no edition of Link between 2009 to 2017 made any reference to PEEPs. Janice Wray explained that she was reluctant to use the term “PEEP” because it was not generally understood; she invited those with concerns about being able to leave their homes in the event of fire to contact her or the 1721 Minutes of Progress Meeting dated 26 January 2010 {RBK00052572/5}. 1722 In 2012, TMO prepared a paper on fire safety and housing which addressed fire safety in sheltered housing. This was limited to sheltered housing only and had no application to general housing {CST00005799}. 1723 {CST00001887}. 1724 HM Government Fire safety risk assessment supplementary guide, means of escape for disabled people {INQ00014732/46-49}. 1725 Wray {Day142/91:23}-{Day142/93:11}. 1726 {CST00003061/1}. 1727 {CST00003061/3}. 1728 Stokes {Day137/81:10}-{Day137/85:20}. 1729 Stokes {Day137/70:19}-{Day137/74:18}.

The Grenfell Tower Inquiry: Phase 2 Report 190 fire brigade.1730 No editions of Link from Autumn 2009 to Spring 2017 carried any article inviting residents who were worried about their ability to evacuate their homes in an emergency to contact the TMO.1731 RBKC’s oversight of the TMO’s preparation of PEEPs 46.34 On 28 September 2010, Jean Daintith sent Robert Black a copy of an article written by Claire Wise about fire safety and the requirements of housing legislation relating to people living in flats in tall buildings. She invited Robert Black to respond with his observations about what lessons could be learnt.1732 His response on 30 September 2010 was to reassure her that the TMO had completed fire risk assessments for all its high-risk buildings, including high-rise blocks, and that the evacuation strategy was “stay put – defend in place”. He told her that the TMO intended to produce PEEPs for disabled residents but had so far done so only in a small number of cases with advice from the LFB. However, fire risk assessments had identified the need to extend the work to residents known to have disabilities and that the TMO planned to work with Carl Stokes to produce generic PEEPs for larger blocks which could then be adapted to individual needs. 46.35 Robert Black’s assurances were, however, misleading. The first of only two PEEPs to be prepared for TMO residents was still in preparation and was not completed until 18 October 2010, nearly three weeks later.1733 Plans to produce generic and individual PEEPs were not fulfilled. Even so, at a joint meeting of RBKC, TMO executives and the LFB on 20 July 2011, Janice Wray gave similar assurances that the TMO intended to identify vulnerable and disabled residents who required PEEPs.1734 46.36 Despite having been made aware in late 2010 and July 2011 of the TMO’s supposed plans, neither Laura Johnson nor Amanda Johnson asked Robert Black whether any PEEPs had been prepared.1735 Indeed, nobody from RBKC asked whether the TMO had completed any PEEPs. In its written submissions, RBKC rightly acknowledged that fact and admitted that it had been a failure of oversight on its part.1736 46.37 Contrary to what had been said by Robert Black and Janice Wray, the TMO did not regularly identify vulnerable residents. Only two residents were assessed for PEEPs between 2010 to 2017,1737 one in Markland House and one in Gillray house.1738 Although Janice Wray said that the Health and Safety team were prepared to receive requests for PEEPs from residents in general needs housing,1739 as far as we can see, none was ever prepared by Janice Wray or her team. 1730 Wray {Day142/98:11-22}. 1731 None of the Link or Homeowner magazines disclosed to the Inquiry invited residents to contact the TMO to be evaluated for a PEEP. Fire safety advice was contained in the following Link Magazines: Autumn 2009 {TMO00901358}; Winter 2009 {TMO10048206}; June 2013 {TMO00873438}; Summer 2014 {TMO10031098}; Autumn/Winter 2015 {TMO00873549}. 1732 {RBK00026862}; {RBK00030073}. 1733 {CST00005610}. 1734 Minutes of RBKC, KCTMO and LFB Meeting dated 20 July 2011 {RBK00053638/6}; Wray {Day142/119:4}-{Day142/120:3}. 1735 Laura Johnson {Day129/117:5-17}; Amanda Johnson {Day131/44:25}-{Day131/45:12}. 1736 RBKC Module 3 Closing submissions {RBK00068069/29-30} pages 29-30, paragraph 103; Laura Johnson {Day129/117:5-17}; Amanda Johnson {Day131/44:25}-{Day131/45:12}. 1737 Stokes {CST00030186/38} page 38, paragraph142. 1738 {CST00005610}; {CST00020896}. 1739 Stokes {CST00030186/38} page 38, paragraph 143; Wray {TMO00862589/2} page 2, paragraphs 6-7.

Part 5 | Chapter 46: Vulnerable residents 191 The TMO’s assurances to the LFB 46.38 The LFB, like RBKC, received assurances from the TMO about the identification and treatment of vulnerable people. At a meeting on 20 July 2011, Janice Wray told the LFB that the TMO was gathering information about vulnerable and disabled residents in the council’s properties with the intention of preparing PEEPs for those who needed them.1740 46.39 On 26 September 2012, Nicolas Comery, Nick Coombe and Andy Jack of the LFB met Janice Wray and Claire Wise.1741 The LFB team asked the TMO to prepare a list of residents with additional needs to be kept close to the fire alarm control panel. They told Janice Wray and Claire Wise that the LFB’s view was that the person or organisation managing a building had a duty to develop a plan to be followed in the event of a fire and to collect information on residents with additional needs. A risk assessment would also need to be reviewed if a resident’s needs changed significantly or became permanent. Although the discussion was focused on sheltered housing, the LFB’s advice related to general needs accommodation as well.1742 The LFB’s views were passed to RBKC’s Housing department.1743 46.40 Notwithstanding that prompt from the LFB, the TMO did not create a system to collect information about residents with additional needs that could be made available to the LFB in the event of a fire. According to Janice Wray, that was because it was concerned about its ability to keep documents held in a premises information box up to date. It was not discussed with the LFB again.1744 Critically, it does not appear that the TMO told the LFB why it was difficult to comply with its request. Correspondence with the LFB 46.41 On 30 November 2012, Nick Comery asked Janice Wray for help in identifying vulnerable persons in local authority premises who might be suitable for an LFB initiative promoting sprinklers. Janice Wray passed the request to Carl Stokes who advised her to say that she was not aware of anyone. He did so in order to avoid any questions being asked about why anyone who might qualify had not been identified in the fire risk assessments or received a PEEP.1745 46.42 Carl Stokes thought he had spoken to Janice Wray before responding to her email, although he could not be sure about that.1746 He said that he had not been suggesting that there were no vulnerable residents in the properties managed by the TMO, but that there were no heavy smokers. His evidence was that he had thought that the LFB were asking for people who were vulnerable because they were heavy smokers. Although automatic fire suppression systems may have been particularly suitable for use by those who were heavy smokers, we do not accept that explanation. Carl Stokes had no information about the smoking habits of TMO residents and had never sought any. The truth is that he knew that PEEPs were required for vulnerable residents, that the TMO had produced only two, and that his fire risk assessments had not recommended any additional fire safety measures for vulnerable people. His advice amounted to a suggestion that she should lie to the LFB. 1740 Minutes of RBKC, KCTMO and LFB Meeting dated 20 July 2011 {RBK00053638/6}; Wray {Day142/119:4}-{Day142/120:3}. 1741 {TMO00863422}. 1742 Wray {Day142/119:4}-{Day142/120:3}. 1743 {TMO00863422}. 1744 Wray {Day142/122:16}-{Day142/123:8}. 1745 {CST00016416}. 1746 Stokes {Day137/128:10}-{Day137/129:4}.

The Grenfell Tower Inquiry: Phase 2 Report 192 46.43 Janice Wray agreed that it was not possible to say that there were no vulnerable residents in the properties managed by the TMO,1747 but although she said she would not lie to the LFB, she does not appear to have been unduly concerned about Mr Stokes’s suggestion that she should.1748 46.44 Carl Stokes’s reaction to the LFB’s request for information about vulnerable people ought to have acted as a spur to him and Janice Wray to correct the position quickly. The TMO should have initiated a process of collecting information and should have asked him to carry out a proper risk assessment, taking into account the vulnerable people in each building. 46.45 Neither Carl Stokes nor Janice Wray was able to provide a clear explanation for their failure to ascertain the number of vulnerable people living in properties managed by the TMO. Janice Wray had been aware of the need to collect and maintain that information since receiving the advice from Salvus in 2009 and 2010. However, she did not take any steps to review the fire risk assessments or take any action to check whether any of them should contain any reference to vulnerable residents. She said she had had no concerns about Mr Stokes’s response, and that if she had, she would have done something about it.1749 Carl Stokes’s fire risk assessments of Grenfell Tower 46.46 As we have said in Chapter 38, Carl Stokes carried out six fire risk assessments in relation to Grenfell Tower between 30 September 2009 and 20 June 2016.1750 The first, dated 30 September 2009, was carried out as a sub-contractor of Salvus and follows the Salvus template.1751 46.47 In section 5 on page 11 of that fire risk assessment, Carl Stokes described the measures in place to counter the risk that people on the premises might not be aware of the fire. In section 5.4 he identified as a hazard the possibility that if tenants and others within the building suffered from a hearing impairment they might not receive adequate warning. In relation to control measures he recorded that there was no evidence that any resident or member of staff on the premises suffered from a sensory impairment that would prevent them from hearing a shouted warning of fire. However, he also recorded that he could not confirm that that was the case or whether the TMO had any personal emergency evacuation plans available or policies in place if they were needed. 46.48 Mr Stokes said that he had focused on hearing impairments to the exclusion of other disabilities, including mobility and visual impairments, because there had been no communal fire alarm in Grenfell tower so residents would be affected if they could not hear someone trying to warn them of a fire.1752 However, he failed to consider the full range of impairments that could affect residents who might be required to evacuate. 1747 Wray {Day142/128:14-23}. 1748 Wray {Day142/128:24}-{Day142/130:1}. 1749 Wray {Day142/131:5-9}. 1750 Fire risk assessment for Grenfell Tower dated 30 September 2009 {CST00003128}; Fire risk assessment for Grenfell Tower dated 29 December 2010 {CST00003181}; Fire risk assessment for Grenfell Tower dated 20 November 2012 {CST00003084}; Fire risk assessment and schedule of significant findings for Grenfell Tower dated 17 October 2014 {CST00003177}; Fire risk assessment for Grenfell Tower dated 26 April 2016 {CST00003161}; Fire risk assessment for Grenfell Tower dated 20 June 2016 {CST00003145}. 1751 Fire risk assessment for Grenfell Tower dated 30 September 2009 {CST00003128/11}. 1752 Stokes {Day137/94:7-20}.

Part 5 | Chapter 46: Vulnerable residents 193 Fire risk assessments: 29 December 2010 and later 46.49 After Carl Stokes had been appointed by the TMO to carry out its fire risk assessments he used his own templates that were partly, but not consistently, based on PAS 79. Section 13 of his form referred to “Disabled People”. 46.50 The 2010 fire risk assessment for Grenfell Tower stated that there was no evidence that any residents suffered from a hearing impairment that would prevent them hearing a shouted warning of fire or a warning in the form of a loud knocking.1753 It also recorded that the TMO had introduced a programme to gather information about tenants, including any disabilities and their ability to respond to emergency situations. The information was to be recorded in the TP Tracker system and used to decide whether any residents required additional devices or PEEPs.1754 46.51 Aside from minor variations, the text remained substantively the same between 2010 and 2016.1755 Janice Wray could not recall speaking to Carl Stokes about the variations in the text. She admitted that she had probably noticed that he had repeatedly used the same information in section 13 of his fire risk assessments, but she never asked him why. She did not remember being concerned that the information in section 13 might have become out of date, but she admitted that she should have been.1756 46.52 Although the TP Tracker was discontinued in 2013, the fire risk assessments in relation to Grenfell Tower continued to refer to its being used to identify residents in need.1757 Janice Wray could not say why Carl Stokes had not been told that it had been discontinued in 2013. She accepted that it had been part of her responsibility to identify vulnerable residents, but she said that she had not been aware of how the Housing department was recording them. She failed to ask Carl Stokes whether he had that information when he was preparing the fire risk assessments, but she did try to clarify what information was held by the TMO when she reviewed the fire strategy in December 2016.1758 We return to her attempt to do so below. Leon Taylor’s fire risk assessment: June 2014 46.53 Leon Taylor, an independent fire risk assessor, carried out a fire risk assessment in respect of Grenfell Tower on 14 June 2014. He noted that the vulnerabilities of the occupants were unknown, but that as the building was designated as “general needs” he assumed that the occupants were typical of the general population.1759 46.54 In section K13 of his fire risk assessment Mr Taylor noted that the TMO Housing department should have a record of all those who had special needs in relation to evacuation and should make arrangements in accordance with the Housing Act 2004 for evacuation plans and any PEEPs that might be required. No action appears to have been taken by the TMO in response to that fire risk assessment. 1753 Fire risk assessment for Grenfell Tower dated 29 December 2010 {CST00003181/16}. 1754 Fire risk assessment for Grenfell Tower dated 29 December 2010 {CST00003181/16}. 1755 Fire risk assessment for Grenfell Tower dated 29 December 2010 {CST00003181/16}; Fire risk assessment dated for Grenfell tower dated 20 November 2012 {CST00003084/20-21}; Fire risk assessment for Grenfell Tower dated 17 October 2014 {CST00003157/21}; Fire risk assessment for Grenfell Tower dated 26 April 2016 {CST00003161/22}. 1756 Wray {Day142/133:7-20}. 1757 {RBK00057527}. 1758 Wray {Day142/135:24}-{Day142/137:13}; {TMO00865834/2}. 1759 {TMO10001286}, Cell E39.

The Grenfell Tower Inquiry: Phase 2 Report 194 Carl Stokes’s fire risk assessments relating to other TMO properties 46.55 A sample of Carl Stokes’s fire risk assessments for other high-rise buildings managed by the TMO revealed that it was his practice not to identify vulnerable residents.1760 Only the fire risk assessment carried out in relation to Gillray House in 2010 recorded that there was a resident with impaired mobility.1761 Moreover, as he accepted, the first three paragraphs of the text in section 13 of each of his fire risk assessments for Adair Tower (2011), Gillray House (2012), Hazlewood Tower (2014), Markland House (2016) and Trellick Tower (2017) were identical to each other and to that section of the assessment carried out in relation to Grenfell Tower in 2010. 46.56 Carl Stokes drew up a PEEP for a resident of Gillray House on 18 October 2010.1762 The same resident asked for a copy of the PEEP in November 2013, indicating that she was still living in the property.1763 Her presence in Gillray House was reflected in the 2010 fire risk assessment but not in the assessment prepared in 2012. He also drew up a PEEP for a resident of Markland House on 8 March 2014,1764 but it was not noted in the 2016 fire risk assessment.1765 He was unable to explain why those two fire risk assessments did not record that PEEPs had been produced for residents of those properties.1766 46.57 Janice Wray did sometimes comment on fire risk assessments,1767 but she does not appear to have questioned the inclusion of identical text in section 13 of the fire risk assessments relating to those five different buildings at different times over the course of some six years. It is difficult to believe that she failed to notice the fact or the fact that he continued to refer to the system used to record information on vulnerable residents years after it had been discontinued. 46.58 We are bound to conclude that the fire risk assessments carried out by Mr Stokes that we examined, including those relating to Grenfell Tower, were inaccurate and out of date in relation to the presence of vulnerable persons and were not suitable and sufficient for the purposes of Article 9 of the Fire Safety Order. 1760 Fire risk assessment for Adair Tower dated 28 October 2010 {CST00004307}; Fire risk assessment for Adair Tower dated 20 February dated 2014 {LFB00027631}; Fire risk assessment for Adair Tower dated 11 November 2015 {CST00025478}; Fire risk assessment for Adair Tower dated 28 September 2016 {TMO00843943}; Fire risk assessment for Gillray House dated 19 November 2012 {TMO00854930}; Fire risk assessment for Gillray House dated 28 January 2016 {CST00025186}; Fire risk assessment for Hazlewood Tower dated 20 February 2014 {TMO10043804}; Fire risk assessment for Hazlewood Tower dated 25 November 2015 {TMO10044598}; Fire risk assessment for Hazlewood Tower dated 3 October 2016 {TMO10048023}; Fire risk assessment for Markland House dated 16 November 2010 {CST00009754}; Fire risk assessment for Markland House dated 29 November 2012 {CST00017016}; Fire risk assessment for Markland House dated 21 January 2016 {TMO10047159}; Fire risk assessment for Trellick Tower dated 11 June 2012 {CST00017807}; Fire risk assessment for Trellick Tower dated 6 March 2014 {TMO00842081}; Fire risk assessment for Trellick Tower dated 26 April 2017 {TMO00842255}. 1761 Fire risk assessment for Gillray House dated 8 October 2010 {CST00012048/15}. 1762 {CST00005610}. 1763 {CST00005609}. 1764 {CST00020896}. 1765 Fire risk assessment for Markland House dated 21 January 2016 {TMO10047159/21}. 1766 Stokes {Day137/117:3}-{Day137/122:5}. 1767 On 2 December 2015, Janice Wray asked Carl Stokes to correct a sentence on page 5 of the Hazlewood fire risk assessment: email from Janice Wray to Carl Stokes dated 2 December 2015 {CST00006647}.

Part 5 | Chapter 46: Vulnerable residents 195 TMO Policies relevant to vulnerable persons The TMO fire safety strategy 46.59 The TMO had no formal fire safety strategy at all until November 2013. The strategy was later reviewed in 2016 and approved in June 2017.1768 46.60 Although the original fire safety strategy made express provision for PEEPs for the TMO’s staff,1769 it contained no reference to PEEPs for vulnerable residents. Similarly, the TMO’s Health and Safety Policy (dated February 2016 and in force in June 2017) referred to PEEPs only in relation to staff.1770 46.61 The 2017 version of the fire safety strategy also referred to PEEPs in relation to staff, but not in relation to residents.1771 A new section (paragraph 28) was added, to cover both hoarders and vulnerable residents. Paragraph 28.3 stated that efforts were made to collect information about a resident’s vulnerability when the tenancy was signed and thereafter as part of the TMO’s continuing contact with residents. The purpose of the exercise was said to be providing a service which better met the resident’s needs, including fire safety. The new paragraph therefore acknowledged to some extent the TMO’s obligation to identify vulnerable residents in order to meet their needs in respect of fire safety, but it did not extend to the provision of PEEPs. 46.62 Janice Wray was unable to explain why the 2013 and 2017 fire safety strategies did not refer to PEEPs being produced for residents and accepted that they should have done so.1772 Robert Black could not remember why there had been no reference in the fire safety strategies or the Health and Safety policy to producing PEEPs for residents, but thought the TMO had probably decided not to follow Salvus’s advice about that.1773 We agree that that is the most likely explanation. 46.63 Given Salvus’s clear advice in 2009 about the need for procedures to ensure the safety of disabled or vulnerable persons in the event of a fire it is difficult to understand why none were ever included by the TMO in any of its policies.1774 The “Supporting Residents” policy and procedure 46.64 The TMO recognised the need to identify vulnerable residents living in its properties and to make them known to the appropriate support services. David Noble and Teresa Brown started preparing a policy for vulnerable residents in December 2014.1775 The first draft of the Vulnerability Policy adopted the definitions of vulnerable persons already used by the TMO. It recorded that the process for identifying residents who required PEEPs depended on chance or a request from the relevant resident.1776 In that regard, the document reflects Janice Wray’s evidence, but the position was not recorded in any of the later drafts of the Vulnerability Policy or the “Supporting Residents”’ policy. None of the draft policies relating to vulnerable residents dealt with fire safety. 1768 {TMO10004485}; {TMO00832724}. 1769 {TMO10004485/14} section 24.1 (“Fire Procedures”). 1770 {TMO10024402/6} sections 7-10. 1771 {TMO00832724/15} section 25.1. 1772 Wray {Day142/149:23}-{Day142/152:1}. 1773 Black {Day149/169:22}-{Day149/170:1-14}. 1774 {SAL00000013/18}. 1775 {TMO00880460}; {TMO00880458}; {TMO00880463}. 1776 {TMO00880461/2}.

The Grenfell Tower Inquiry: Phase 2 Report 196 46.65 The final version of the “Supporting Residents” policy was drafted by David Noble and dated April 2016 .1777 Neither he nor Teresa Brown was able to explain why it had taken nearly two years to complete.1778 The purpose of the policy was to provide an agreed approach to recognising vulnerable residents and referring them to the neighbourhood teams who could provide them with support.1779 It was accompanied by the “Supporting Residents” procedure dated April 2016.1780 The policy and procedure described certain potential indicators of vulnerability and identified steps that might be taken to provide assistance to those who required it. There was no mention of fire safety in either the policy or the procedure. 46.66 The senior management team discussed the “Supporting Residents” policy at a team meeting on 18 February 2016.1781 Teresa Brown did not recall having discussed it with the Health and Safety team, but she noted that Barbara Matthews, who had overall responsibility for health and safety, had been present at the meeting and had not raised any concerns.1782 Apparently, no one asked how fire safety procedures might apply to vulnerable residents. Although the revised policy was presented to the senior management team on 17 March 2016,1783 it was not presented to the executive team for approval. 46.67 In December 2016, before the final version of the policy had been circulated to the senior management team, Janice Wray asked David Noble how the TMO obtained and stored information on vulnerability, as she was reviewing the fire safety strategy.1784 Although the review of the fire safety strategy (which culminated in the 2017 version) took place when the “Supporting Residents” policy was being completed, neither the TMO’s senior management team nor Janice Wray nor David Noble thought that there were matters, such as fire safety, that ought to be covered in both documents. Gathering information about vulnerable residents 46.68 The TMO’s regular means of gathering information about residents’ vulnerability was by talking to them at the time of granting a tenancy and during a tenancy audit. When registering a new tenant, the TMO recorded whether that person or anyone in the household suffered from any disability. Any disabilities were recorded in the tenancy agreement, Tenancy Information forms and in a data entry form that all new tenants were required to complete. The forms were all stored on the W2 system. The way in which the information was recorded was not consistent and in most cases the Neighbourhood Officers that helped to complete the forms recorded that no support was required, even if a vulnerability of some kind was recorded.1785 46.69 On 29 April 2014, David Noble and Teresa Brown told the executive team that there were gaps in some of the information held on tenants, particularly relating to disabilities.1786 They suggested that the collection of information could be improved by the use of a detailed questionnaire.1787 The proposal was approved; a new tenancy questionnaire was introduced and a programme of tenancy audits was put in place. 1777 {TMO00880481}. 1778 Noble {Day119/69:12}-{Day119/70:4}; Brown {Day126/89:25}-{Day126/91:22}. 1779 Brown {Day126/77:5-13}. 1780 {TMO00880482}. 1781 Minutes of Senior Management Team Meeting dated 18 February 2016 {TMO00866011}. 1782 Brown {Day126/94:12}-{Day126/95:1}. 1783 Minutes of Senior Management Team Meeting on 17 March 2016 {TMO00880549/1}. 1784 {TMO00865834}. 1785 Lane, Module 3 Report {BLARP20000034/173} Table 10-1. 1786 Noble {Day119/51:11-23}. 1787 Minutes of Executive Team Meeting dated 29 April 2014 {TMO00851128/1}.

Part 5 | Chapter 46: Vulnerable residents 197 46.70 From 2015 onwards, housing officers were required to carry out about 30 tenancy audits a month.1788 Janice Jones carried out tenancy audits at Grenfell Tower.1789 She collected information about residents, such as their names, contact details, ethnicity, vulnerabilities or disabilities, support needs and whether any repairs needed to be carried out to their properties.1790 Information gathered in tenancy audits was entered on the W2 system.1791 A spreadsheet dated 13 April 2016 recorded that 547 audits of TMO properties had been completed between 1 April 2015 and 1 April 2016.1792 46.71 The TMO gathered information on vulnerable residents in Grenfell Tower during the refurbishment. Rydon spoke to tenants to ask them, among other things, whether any member of the household had any health problems. The information was recorded in a report dated November 20141793 which identified 57 residents as having a sensory, cognitive or mobility impairment.1794 46.72 The report was discussed with Rydon at Housing Management Liaison Meetings and there is some evidence that it was sent to Siobhan Rumble at the TMO.1795 There is no evidence, however, that it was used to revise any of the TMO’s records. Most importantly, the information was not included in the spreadsheet from which attempts were made on the night of the fire to extract information about vulnerable residents. Premises information box 46.73 During a visit to Grenfell Tower on 12 March 2014, representatives of the LFB fire safety team and a local fire station crew asked for a premises information box to be installed.1796 The intention was that it should contain fire safety information specific to Grenfell Tower, such as floor plans, that would assist the LFB in the event of a fire.1797 46.74 On 18 March 2014, Carl Stokes strongly advised Claire Williams against installing a premises information box, in essence, because he thought that the onus was on the LFB to gather the information themselves during section 7(2)d and familiarisation visits.1798 According to Colin Todd, it was not common at the time for premises information boxes to be installed in general needs blocks of flats, but both he1799 and Dr Lane1800 thought that they could be of assistance to fire and rescue services.1801 We agree. In the face of a request from the LFB we can see no good reason for Carl Stokes to oppose the suggestion. 46.75 Following a demonstration of the smoke ventilation system at Grenfell Tower on 28 April 2016, the LFB renewed its request for a premises information box or other secure information box to be installed in the foyer of the tower,1802 but on 4 May 2016 Carl Stokes 1788 Jones {TMO00873924/3} page 3, paragraph 11. 1789 Jones {TMO00873924/3} page 3, paragraph 11. 1790 Jones {TMO00873924/3-4} pages 3-4, paragraphs 13-15. 1791 Jones {TMO00873924/3} page 3, paragraph 13. 1792 {TMO00860130}. 1793 {RYD00024466}. 1794 Lane, Module 3 Report {BLARP20000034/177} paragraph 10.6.10. 1795 Minutes of Housing Management Liaison Meeting with Rydon dated 28 January 2015 {TMO00852169}. 1796 {CST00000178/2-3}. 1797 {CST00000178/2-3}; {TMO10013186/1}. 1798 {CST00003100/4}; Stokes {CST00030186/42} page 42, paragraph 160. 1799 Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/102-103} paragraph 10.3. 1800 Lane, Module 3 Report {BLARP20000027/346-347} paragraphs 15.2.31-15.2.42. 1801 Lane, Module 3 Report {BLARP20000027/347} paragraphs 15.2.39-15.2.41; LGA Guide, Fire safety in purpose-built blocks of flats {HOM00045964/120} paragraph 79.12. 1802 {CST00001131/2}.

The Grenfell Tower Inquiry: Phase 2 Report 198 again told Janice Wray that the TMO had no obligation to provide an information box.1803 He may have been right, but there was no obvious reason to refuse the LFB’s request and in our view his advice was foolish.1804 46.76 At the regular meeting between the TMO and the LFB fire safety team on 5 May 2016, Nick Davis, the local station manager, asked Janice Wray again for a premises information box to be installed at Grenfell Tower. He agreed to confirm what information the LFB wanted to have stored in it but said that it would include at least information about the operation of the smoke ventilation system.1805 On 6 May 2016, he sent her a list of the information that he wanted to see made available.1806 46.77 At the next meeting on 13 July 2016, which was attended by Janice Wray and Rebecca Burton, the TMO told the LFB that arrangements had been made to store the documents to which the LFB needed access in a secure box in the lobby, the key to which would held in a key safe secured by a padlock in the bin room.1807 Despite that assurance, however, by the time of the fire no premises information box or any other secure box containing the relevant fire safety information had been installed at Grenfell Tower. Janice Wray thought that was because Claire Williams had made arrangements for the information to be kept in an existing secure box in the lobby, as contemplated by the minutes of the meeting on 13 July 2016,1808 but she did not check whether the box did in fact exist or, if it did, what information it contained.1809 Claire Williams said that there had been a “fire panel” at Grenfell Tower which described how to operate the smoke ventilation system, but she could not identify anything else.1810 There was nothing else. The TMO simply never complied with the LFB’s request for a secure box containing information about the building. There was no good reason for its failure to do so. TMO’s systems for recording data about vulnerable residents 46.78 Between 2010 and 2017 Carl Stokes’s fire risk assessments for Grenfell Tower stated that the TMO used the TP Tracker for recording information about vulnerable residents. An entry dated 8 June 2013 recorded that one resident of Grenfell Tower had visual and hearing impairments, three had impaired mobility and one had a mental health illness, but none of those residents was recorded in the fire risk assessment made in October 2014.1811 That tends to show that, although Carl Stokes was aware of the TP Tracker, he did not take into account the information it contained when making his assessments. 46.79 In 2013, there were proposals for replacing the TP Tracker with the Civica W2 electronic document management system1812 that held electronic copies of documents relating to residents. The information could then be entered manually into Capita, the housing management system maintained by the TMO.1813 In 2016 the Customer Relationship Management platform (CRM) was introduced with the intention of replacing W2. By 1803 {CST00001131/1-2}. 1804 Wray {Day144/198:19-22}. 1805 Minutes of the Bi-Monthly Meeting dated 5 May 2016 {TMO10013185/3} item 8. 1806 {TMO10013186/1}. 1807 Minutes of the Bi-Monthly Meeting dated 13 July 2016 {LFB00032335/3} item 7. 1808 Wray {TMO00000890/13} page 13, paragraph 60; Wray {Day144/195:20}-{Day144/198:1}. 1809 Wray {Day144/195:20}-{Day144/198:1}. 1810 Williams {Day122/33:13-21}. 1811 Fire Risk Assessment for Grenfell tower dated 17 October 2014 {CST00003157}. 1812 {TMO00862586}. 1813 Noble {Day119/54:11-18}.

Part 5 | Chapter 46: Vulnerable residents 199 14 June 2017, therefore, information about vulnerable residents was recorded in three different places: on documents held in W2, on the Capita housing management system and on the CRM database.1814 46.80 There was some confusion about how information recorded on Capita was transferred to CRM. However, it appears that, although some of the information was transferred to CRM, most of it was not.1815 That turned out to be significant, because on the night of the fire there was some uncertainty about the reliability of the information held by the TMO about the number of vulnerable residents in the tower. 46.81 Of the 297 people present in Grenfell Tower on the night of the fire, 67 were children and 37 were adults with sensory, mobility or cognitive impairments.1816 There were a further 17 residents who had a sensory, mobility or cognitive impairment that was not recorded in the tenancy records, tenancy audit documents or David Noble’s spreadsheet. The TMO ought to have had a readily accessible system for collecting and maintaining information about its residents’ vulnerabilities which would not only have enabled it to decide whether in any case a PEEP was necessary but would also have assisted in responding to emergencies. PEEPs for Vulnerable Residents 46.82 Janice Wray said that the Health and Safety team would prepare PEEPs for residents in general needs housing if it were asked to do so, but that there was no established procedure for identifying circumstances that would result in consideration of the need for a PEEP and residents were not told that they could ask for one.1817 For its part, the members of the Housing team did not know that they could refer a resident to the Health and Safety team to be assessed for a PEEP.1818 46.83 Neither Siobhan Rumble nor Nicola Bartholomew was aware that she could ask for residents to be given PEEPs. Janice Wray said that was because she did not use the expression “PEEP” with the Housing team. She told them that if residents were concerned about fire safety generally, they could be referred to the Health and Safety team.1819 If the Health and Safety team expected to have residents referred to them by the Housing team for assessment for a PEEP, even if described in other terms, the Housing team should have been aware of that and it should have been covered in one of the policies, such as the fire safety strategy or the “Supporting Residents” policy. 46.84 Residents were not told that they could ask to be assessed for a PEEP and the possibility was not drawn to their attention in any of the literature they were given. Janice Wray could not say why that was and we cannot see any reasonable explanation for it. The first draft version of the fire safety letter to new tenants dated December 2010 did include the offer of a personal emergency evacuation plan for those who were not able-bodied or had special requirements,1820 but it is unclear whether the letter was ever finished and distributed to residents between 2010 and 2013. 1814 Noble {TMO00899669/1} page 1, paragraph 2 (a) and (b). 1815 Noble {Day119/54:19}-{Day119/55:8}; {TMO00899673}. 1816 Lane, Module 3 Report {BLARP20000034/237} paragraph 14.2.3. 1817 Wray {TMO00862589/2} page 2, paragraph 6; Wray {Day142/32:4-21}; {Day142/66:5}-{Day142/67:4}; {Day142/69:1}-{Day142/71:11}; {Day142/71:12-18}. 1818 Brown {Day126/65:9}-{Day126/67:3}; Rumble {Day120/70:8-24}; Bartholomew {Day120/163:3-10}; Williams {TMO00879804/11} page 11, paragraphs 79-80; Jones {TMO00873924/6} page 6, paragraph 27. 1819 Wray {Day142/72:7-17}. 1820 {TMO00870665}.

The Grenfell Tower Inquiry: Phase 2 Report 200 46.85 Janice Wray did not prepare a PEEP for any resident while working at the TMO,1821 perhaps because no one in the Housing team knew that a resident could be referred to the Health and Safety team for a PEEP. Nonetheless, there is evidence that even when Janice Wray was made aware of a resident in Grenfell Tower with a particular vulnerability, she took no steps to ascertain whether that resident needed a PEEP. That was Elpidio Bonifacio in Flat 83. 46.86 On 4 February 2016, Charles Batterbee of the LFB and Janice Wray exchanged emails about a resident of Flat 83, Elpidio Bonifacio, whom the LFB had met during a home fire safety visit and believed to be blind.1822 Janice Wray said that she should have asked whether he needed a PEEP or some other form of assistance in the event of a fire and could not explain why she had not done so.1823 Moreover, Mr Bonifacio’s disabilities were not recorded on the spreadsheet produced by David Noble on 14 June 2017.1824 46.87 Elpidio Bonifacio was the last person to escape from Grenfell Tower at 08.07 on 14 June 2017. Although he had been encouraged by his family to leave his flat from about 02.00, he had had to wait for more than six hours to be rescued by firefighters because he was blind, elderly and unable to escape without help.1825 There is no reason to think that he was an isolated example or that Grenfell Tower was different from the other buildings managed by the TMO, given the deficiencies in the TMO’s system of creating and maintaining accurate records of vulnerable residents. Vulnerable residents in Grenfell Tower on 14 June 2017 46.88 The list of residents that David Noble produced on 14 June 2017 identified only ten residents of Grenfell Tower as having mental or physical impairments. That was only half the number recorded as vulnerable by the TMO in the tenancy creation and tenancy audit documents.1826 A result of its failure to maintain an adequate record of residents’ vulnerabilities was that the TMO was unable to provide the LFB with an accurate list of vulnerable residents,1827 although by the time the list reached the LFB all those who died in the tower had already lost their lives.1828 46.89 Of the ten residents recorded in the spreadsheet as vulnerable, three, Sakina Afrasehabi, Majorie Vital and Alexandra Atala, died in the fire.1829 They lived on the top floors of the tower. The remaining seven lived on floors 2 and 3. They were able to escape as their flats were below the fire line. It is impossible to say what effect an accurate list of vulnerable residents would have had on the outcome of the tragedy, but it might have provided the LFB with valuable information about the locations and numbers of vulnerable residents when considering the deployment of crews. 46.90 On any view, the Grenfell Tower fire revealed the importance of ensuring that the responsible person collects sufficient information about any vulnerable occupants to enable PEEPs to be prepared, when appropriate, and, in the event of a fire, appropriate measures to be taken to assist their escape. The TMO’s failure to collect such information illustrates a basic neglect of its obligations in relation to fire safety. 1821 Wray {Day142/72:18-24}. 1822 {LFB00001057}. 1823 Wray {Day142/163:4}-{Day142/165:24}. 1824 {TMO00866002}. 1825 Bonifacio {IWS00001085/5-6} pages 5-6, paragraphs 31-32. 1826 Lane, Module 3 Report {BLARP20000034/188-189} paragraphs 10.8.32-10.8.34. 1827 Phase 1 Report Volume III paragraphs 20.65-20.66. 1828 Phase 1 Report Volume III paragraphs 20.67-20.68. 1829 {TMO00866002}.

ISBN 978-1-5286-5080-9 (Volume 3 of 7) 7 volumes not available separately

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分类：06_境外及港澳台调查报告 ｜ 年份：2017 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Volume 4 Part 6 – The refurbishment of Grenfell Tower HC 19–IV GRENFELL TOWER INQUIRY: PHASE 2 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 The Panel: Chairman: The Rt Hon Sir Martin Moore-Bick Ali Akbor OBE Thouria Istephan September 2024

Volume 4 Part 6 - The refurbishment of Grenfell Tower HC 19–IV GRENFELL TOWER INQUIRY: PHASE 2 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 The Panel: Chairman: The Rt Hon Sir Martin Moore-Bick Ali Akbor OBE Thouria Istephan September 2024 Presented to Parliament pursuant to section 26 of the Inquiries Act 2005 Ordered by the House of Commons to be printed 4 September 2024

© Crown copyright 2024 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. This publication is available at www.gov.uk/official-documents. Any enquiries regarding this publication should be sent to us at contact@grenfelltowerinquiry.org.uk. ISBN 978-1-5286-5080-9 (Volume 4 of 7) 7 volumes not available separately E03165832 09/2024 Printed on paper containing 40% recycled fibre content minimum. Printed in the UK by HH Associates Ltd. on behalf of the Controller of His Majesty’s Stationery Office. This report contains content which some may find distressing.

5 Part 6 The refurbishment of Grenfell Tower

6

7 47.1 The refurbishment of Grenfell Tower between 2012 and 2016 lies at the heart of our investigations. We have therefore examined in some detail the course of the project from its original inception to completion. In order to provide the context in which the important decisions were made we begin with a description of the regulations and guidance relating to the construction of external walls of high-rise buildings which ought to have been uppermost in the minds of those making decisions about the nature of the work to be undertaken and the choice of materials. 47.2 That is followed by a brief description of the people and organisations involved in the work, which we have included to give the reader an overall understanding of the way in which individuals and organisations that appear frequently in the following chapters fit into the overall picture. 47.3 The story of how the refurbishment was planned and the important roles filled is of interest and importance, not only because decisions were made at that stage that affected the subsequent course of the work, but also because it sheds light on the way in which the TMO, as the client for the refurbishment, went about managing its own responsibilities. 47.4 Expert advice on fire safety was sought in the form of a fire safety strategy for the building, both in its existing form and following its intended refurbishment, but for reasons we describe, the latter was never completed, leaving a significant gap in the advice that should have been received by the TMO and the design team. A failure to understand the characteristics of the materials proposed for use in the refurbishment turned out to have disastrous consequences. 47.5 There follow several chapters in which we describe how the various materials and products used in the work came to be selected. It is a subject that calls for detailed examination because it was the decision to use aluminium composite panels with unmodified polyethylene cores in what was known as “cassette” form as the rainscreen that was primarily responsible for the rapid spread of the fire. Other products made a contribution, however, in particular the Celotex and Kingspan insulation boards, neither of which complied with the guidance on the use of combustible materials on high-rise buildings. 47.6 The requirement to obtain building control approval for the refurbishment should have ensured that any errors in design or the choice of materials were identified and put right before the work started. Regrettably, however, that did not happen. Given the importance of building control for the protection of the public, we have examined in some depth the reasons why the system failed to achieve the purpose for which it was designed. 47.7 Our investigations have disclosed that errors were made by many of those involved in the refurbishment and at many points during its course. As a result, we have found it convenient to collect our criticisms of each of the organisations principally responsible for the work in a number of individual chapters at the end of this Part. Chapter 47 Introduction to Part 6

8 The Grenfell Tower Inquiry: Phase 2 Report

9 Chapter 48 The legislative background 48.1 Chapter 5 of the Phase 1 report contains a brief summary of the main legislative provisions and associated guidance that applied to the refurbishment of Grenfell Tower. However, in order to give a true picture of the context in which important decisions were taken in connection with the work, it is necessary at this stage to describe those provisions more fully and in greater detail. Given the important role played by the cladding system in the fire at Grenfell Tower, we concentrate on the statutory framework, including the statutory guidance relating to the construction of external walls, applicable during the period in which the refurbishment was carried out. In this chapter we also examine briefly the regulatory framework governing building control and the duties applicable under the CDM Regulations. The Building Act 1984 48.2 The Building Act 1984 (“the Act”)1 is the principal primary legislation governing building and buildings and related matters. Section 1(1) of the Act gives the Secretary of State the power to make regulations with respect (among other things) to the design and construction of buildings for a number of purposes, including securing the health, safety and welfare of persons in or about buildings. Regulations made under section 1(1) of the Act are known as “building regulations” and were made by way of statutory instrument. The regulations in force at the time of the refurbishment were the Building Regulations 2010 (“the Regulations”).2 48.3 Section 6 of the Act provides that the Secretary of State, or a designated body, may approve and issue documents for the purpose of providing practical guidance with respect to the requirements of any provision of the Regulations. At the time of the refurbishment that practical guidance was contained in a series of Approved Documents. The provisions of the Approved Documents are not mandatory; their purpose is merely to describe one or more ways in which the requirements of the Regulations can be met. Failure to comply with an Approved Document does not in itself render a person liable to any civil or criminal proceedings, but it may be relied upon in any proceedings as “tending to establish liability”. Likewise, compliance with the provisions of an Approved Document, although not proof of compliance with the Regulations, may be relied on in any proceedings as “tending to negative liability”.3 It is important to note, however, that compliance with the Approved Documents does not ensure compliance with the Regulations. 48.4 Schedule 1 of the Act sets out further matters which building regulations may provide for. Paragraph 7 of Schedule 1 provides that they may make provision for (among other things) fire precautions.4 1 The Building Act 1984 {HOM00035068}. 2 The Building Regulations 2010 {INQ00015098}. 3 See Section 7 of the Building Act 1984 {HOM00035068/13}. 4 Paragraph 7(iv) of Schedule 1 of the Building Act 1984 {HOM00035068/109} states “Fire precautions including (a) structural measures to resist the outbreak and spread of fire and to mitigate its effects, (b) services, fittings and equipment designed to mitigate the effects of fire or to facilitate fire-fighting, and (c) means of escape in case of fire and means for securing that such means of escape can be safely and effectively used at all material times.”

The Grenfell Tower Inquiry: Phase 2 Report 10 48.5 Part 3 of the Regulations contains requirements for local authorities to be notified of building work. In particular, regulation 12(3) obliges a person intending to carry out building work in relation to a building to which the Regulatory Reform (Fire Safety) Order 2005 (the Fire Safety Order) applies to deposit full plans with the local authority in accordance with regulation 14. (The refurbishment of Grenfell Tower involved work on a building to which the Fire Safety Order applied and a deposit of full plans was therefore required.) By virtue of regulation 14, full plans are to consist of a description of the proposed work together with plans describing the work and demonstrating that it would comply with the Regulations. 48.6 The Act itself provides for the local authority’s response to the deposit of full plans. Section 16 provides that, where plans for proposed work are deposited with a local authority, it is their duty to pass the plans unless a provision elsewhere in the Act requires them to be refused, or the plans are defective, or they show that the proposed work would contravene any of the Regulations. If the plans are defective or show that the work would contravene the Regulations, the local authority may reject them or (with the consent of the person by whom they were deposited) pass them subject to conditions. Within 5 weeks from the deposit of plans the local authority must give notice to the depositor stating whether they have been passed or rejected.5 48.7 Failure to comply with the Regulations is punishable by a fine (section 35), but in addition local authorities have the power to require the owner of the building to pull down or remove any work that contravenes the Regulations or make such alterations to it as are necessary to make it comply with them (section 36). The Building Regulations 2010 48.8 The Regulations prescribe the standards that building work must meet and impose on the person proposing to carry it out a requirement to obtain approval from a local authority or approved inspector. The requirements for building work are set out in regulation 4, which provides that building work shall be carried out so that it complies with the requirements contained in Schedule 1. The Regulations apply to building work as defined in regulation 3, which includes, among other things, the material alteration of an existing building. An alteration is material for these purposes if the work, or any part of it, would at any stage result in the building’s ceasing to comply with any one of a number of listed requirements of the Regulations or (if it did not comply with such a requirement before the work commenced) becoming more unsatisfactory than it previously had been, but there is no requirement when work is done to an existing building to bring it up to current standards. This is sometimes known as the “non-worsening principle”. The listed requirements include functional requirements B1, B3, B4 and B5 relating to fire safety.6 It is not disputed that the cladding work to Grenfell Tower, including the addition of insulation, and the renovation of the smoke control system constituted material alterations and that the Regulations therefore applied to them. 48.9 Paragraph 8(1)(e) of Schedule 1 to the Act gives the Secretary of State power to make building regulations with respect to buildings that are subject to a material change of use. A material change of use is defined in regulation 5. It occurs when, among other things, a building which contains dwellings is altered to contain a greater or lesser number of 5 Section 16(4) of the Building Act 1984 {HOM00035068/20}. The five-week limit is subject to any agreed extensions up to a maximum of two months (section 16(12) {HOM00035068/22-23}. 6 Section 3(3) of the Building Regulations 2010 {INQ00015098/7}.

Part 6 | Chapter 48: The legislative background 11 dwellings than it did previously. In the case of Grenfell Tower refurbishment, the addition of new flats in those parts of the building that had previously been put to other uses constituted a material change of use. 48.10 The prescribed standards for building work are expressed in schedule 1 to the Regulations in terms of functional requirements. Although the refurbishment was required to comply with all the requirements, for the purposes of this report we concentrate on Part B. 48.11 Part B is concerned with fire safety and is divided into five sections: B1 Means of warning and escape. B2 Internal fire spread (linings). B3 Internal fire spread (structure). B4 External fire spread. B5 Access and facilities for the fire service. 48.12 Requirements B1, B3(4) and B4 are of particular relevance to the fire at Grenfell Tower and deserve to be quoted in full: Means of warning and escape B1. The building shall be designed and constructed so that there are appropriate provisions for the early warning of fire, and appropriate means of escape in case of fire from the building to a place of safety outside the building capable of being safely and effectively used at all material times. Internal fire spread (structure) B3. (4) The building shall be designed and constructed so that the unseen spread of fire and smoke within concealed spaces in its structure and fabric is inhibited. External fire spread B4. (1) The external walls of the building shall adequately resist the spread of fire over the walls and from one building to another, having regard to the height, use and position of the building.

(2) The roof of the building shall adequately resist the spread of fire over the roof and from one building to another, having regard to the use and position of the building. 48.13 The Regulations also contain certain energy efficiency requirements. In particular, regulation 23 provides that where renovation of a thermal element (which would include an external wall) constitutes a major renovation or amounts to the renovation of more than 50% of the element’s surface area, the renovation must be carried out so as to comply with paragraph L1(a) of schedule 1 in so far as that is technically, functionally and economically feasible. Requirement L of schedule 1 is headed “Conservation of Fuel and Power” and paragraph L1(a) provides that reasonable provision shall be made for the conservation of fuel and power in buildings by limiting heat gains and losses through thermal elements and other parts of the building fabric. 48.14 The supervision of the proposed work by the local authority is intended to culminate in the issue of a completion certificate evidencing compliance with certain requirements of the Regulations. Those requirements include the applicable requirements of regulation 38

The Grenfell Tower Inquiry: Phase 2 Report 12 (discussed below) and schedule 1 of the Regulations. Once issued, a certificate is evidence (but not conclusive evidence) that the requirements specified in the certificate have been complied with. 48.15 Regulation 38 is concerned with the provision of fire safety information. It applies where building work consists of or includes the erection or extension of a relevant building or is carried out in connection with a relevant change of use and when Part B of Schedule 1 imposes a requirement in relation to the work. In those circumstances the regulation obliges the person carrying out the work to give the responsible person under the Fire Safety Order not later than the date of completion of the work or the date of occupation of the building or extension, whichever is the earlier, information relating to the design and construction of the building and the services, fittings and equipment provided in or in connection with it that will assist that person to operate and maintain the building with reasonable safety. 48.16 The Fire Safety Order is considered in greater detail in Part 2 of this report. For the purposes of the Regulations, however, it is important to note that article 45 requires a local authority in receipt of a full plans application in relation to a building to which the order applies to consult the enforcing authority (in this case the London Fire and Emergency Planning Authority (“LFEPA”) before passing the plans.7 The Construction (Design and Management) Regulations 2007 and 2015 48.17 The Construction (Design and Management) Regulations were made by the Secretary of State under powers in the Health and Safety at Work Act 1974. They seek to protect persons against risks to health and safety arising from construction work through the establishment of a systematic framework for the assessment and management of those risks. The definition of construction work includes the construction, alteration, conversion, fitting out, commissioning, renovation, repair, upkeep, redecoration or other maintenance of any building.8 The first regulations were made in 1994 and came into force in March

1. They were replaced in 2007 and again 2015. The 2007 Regulations remained in force

until 5 April 2015 when the 2015 Regulations came into force. 48.18 The CDM Regulations 1994 and 2007 were each supported by guidance in the form of Approved Codes of Practice (ACOPs) published by the Health and Safety Executive, which provided practical guidance on how to comply with the law.9 48.19 When the CDM Regulations 2007 were superseded by the CDM Regulations 2015, a transition period from 6 April to 6 October 2015 was introduced to enable all those affected to put in place alternative arrangements. 48.20 The CDM Regulations 2007 are relevant to our investigation of the refurbishment because they imposed various duties on clients, designers (defined as including anyone preparing or modifying a design or instructing others to do so)10 and contractors relating to health and 7 For more detailed consideration of this provision see Menzies Module 1 Report {BMER0000004/139-140}. In practice, save for the highest risk or most complex projects, the consultation expected by building control and the LFEPA related to the B1 (means of escape) and B5 (access and facilities for the fire service) functional requirements only. 8 See regulations 2 and 3 of the Construction (Design and Management) Regulations 2007 {INQ00011315/1-4}. 9 See the 2007 Code “Managing health and safety in construction” at {INQ00013936}. The CDM Regulations 2015 {INQ00011316} were not supported by an ACOP. Instead, the HSE published guidance in the form of a document entitled “Managing health and safety in construction” {HSE00000003}. 10 See Regulation 2 of the 2007 Regulations {INQ00011315/2}.

Part 6 | Chapter 48: The legislative background 13 safety or reinforced existing duties under health and safety legislation. We refer to these in more detail where relevant in the following chapters describing the refurbishment work at Grenfell Tower. The 2015 Regulations also imposed an obligation on the principal designer to prepare a health and safety file, keep it under review and deliver it to the client at the end of the project.11 Statutory guidance: Approved Documents 48.21 As we have set out above, section 6 of the Building Act 1984 Act provides for the publication by the Secretary of State of documents providing practical guidance with respect to the requirements of the Building Regulations. At the time of the refurbishment that practical guidance was contained in a series of Approved Documents, which themselves referred to British Standards and other guidance. Approved Document B dealt with fire safety. Before the Grenfell Tower fire, it was divided into two volumes: volume 1 dealt with dwelling houses; volume 2 dealt with all other buildings, including blocks of flats and buildings containing flats. Approved Document B 48.22 As we have set out in Chapters 4 and 6, Approved Document B was first published in 1985 and was amended on numerous occasions thereafter. In this section of the report we have referred to the 2006 version incorporating the 2007, 2010 and 2013 amendments.12 48.23 Section 12 of Approved Document B provided guidance on the construction of external walls.13 Our attention has focused most closely on paragraphs 12.5–12.8 of that guidance, which are worth setting out in full: “12.5 The external envelope of a building should not provide a medium for fire spread if it is likely to be a risk to health or safety. The use of combustible materials in the cladding system and extensive cavities may present such a risk in tall buildings. External walls should either meet the guidance given in paragraphs 12.6 to 12.9 or meet the performance criteria given in the BRE Report Fire performance of external thermal insulation for walls of multi storey buildings (BR 135) for cladding systems using full scale test data from BS 8414-1:2002 or BS 8414-2:2005. 12.6 The external surfaces of walls should meet the provisions in Diagram 40… 12.7 In a building with a storey 18m or more above ground level any insulation product, filler material (not including gaskets, sealants and similar) etc. used in the external wall construction should be of limited combustibility (see Appendix A). This restriction does not apply to masonry cavity wall construction which complies with Diagram 34 in Section 9.14 12.8 Cavity barriers should be provided in accordance with Section 9.” 48.24 Paragraph 12.5 thus provided two potential routes to compliance with the Regulations: following the guidance in paragraphs 12.6 to 12.9 (sometimes referred to as the “linear route”) or meeting the performance criteria in BR 135 following testing in accordance with BS 8414. However, Approved Document B provided no more than guidance and in addition to the two routes it set out, there could be other ways of demonstrating compliance with 11 Regulations 12(5) and 12(10) of the 2015 Regulations {INQ00011316/12}. 12 {CLG00000224}. 13 {CLG00000224/95}. 14 {CLG00000224/95-96}.

The Grenfell Tower Inquiry: Phase 2 Report 14 the functional requirements of the Regulations to which we refer below. We note in passing that the majority of witnesses who gave evidence about the design of the Grenfell Tower refurbishment either thought that the “linear route” had been adopted or were not aware which route had been adopted.15 48.25 Paragraph 12.6 of Approved Document B provided that the external surfaces of walls should meet the provisions in Diagram 40.16 Figure 48.1 – Diagram 40 15 Sounes {Day7/138:2-16}; Crawford {Day9/177:3}-{Day179:23}; Ashton {Day17/138:2-3}; Lawrence {Day22/77:1-16}; Bailey {Day33/27:10-24}; Anketell-Jones {Day35/170:21}-{Day172:25}; Anketell-Jones {Day35/173:15-19}; Lamb {Day37/141:19}-{Day37/142:14}; Hoban {Day45/37:21}-{Day45/40:16}; Allen {Day47/25:22-25} {Day47/116:22-25}. 16 {CLG00000224/95-97}.

Part 6 | Chapter 48: The legislative background 15 48.26 The heading of Diagram 40 (in particular the use of the words “or walls”) might suggest that a distinction is being drawn between “external surfaces” and “walls” but the label in the key to Diagram 40 is concerned solely with “external wall surface classification”. We think it is clear that it was intended to apply to the wall’s external surface and thus to the material or product that makes up the outer surface of the wall.17 That is certainly consistent with the language of paragraph 12.6 of the guidance which introduces Diagram 40 and which refers to the “external surfaces of walls”. 48.27 Diagram 40e applied to Grenfell Tower and required that above 18 metres from the ground the external surface of the walls had to satisfy national class 0 or European class B-s3, d2 or better. We have described in Chapter 5 the tests which supported those classifications. 48.28 In our view the wording of paragraph 12.6 suggests that it applies to the external surface of a wall and does not include any product, such as insulation, that may have been fitted behind it. Similarly, when considering a composite product, such as an ACM panel, the paragraph naturally refers to its surface rather than to its core. 48.29 Paragraph 12.7 is headed “Insulation Materials/Products”. It provided that in a building with a storey 18 metres or more above ground level any insulation used in the external wall construction should be of limited combustibility.18 Limited combustibility is defined in Appendix A of Approved Document B (see Chapter 6).19 48.30 It has been argued that paragraph 12.7 should be understood as applying to the core of ACM cladding panels of the kind installed at Grenfell Tower.20 The argument was put in two ways. The first relied on the use of the word “filler” in paragraph 12.7, which was said to be apt to refer to the core of a composite cladding panel. We do not agree with that. The word “filler” forms part of the expression “insulation product, filler material (not including gaskets, sealants and similar) etc. used in the external wall construction”. In that context the word “filler” naturally means a material, such as compressible fibre or expanding foam, used to fill gaps of an unplanned or occasional kind rather than small apertures that are intended to be closed off by gaskets or sealants. It is not apt to refer to the core of a composite cladding panel which is an integral part of the finished product. We derive further support for our conclusion from the fact that we have not seen any evidence that the core of a composite panel was described as “filler” by anyone in the building industry before the Grenfell Tower fire. 48.31 The second argument was that the provisions relating to external surfaces in paragraph 12.6 and Diagram 40 were additional to the basic requirement that the external walls of a building over 18 metres in height should be composed only of materials of limited combustibility in the facade and do not override the functional requirement that they adequately resist the spread of fire.21 That interpretation was supported by Beryl Menzies22 and support can also be found for it in industry guidance published by the Building Control Alliance in its Technical Guidance Note 18, which we discuss in Chapter 49.23 However, in neither case was any reason given for adopting that interpretation, beyond saying that it would give effect to functional requirement B4(1). 17 Hyett {PHYR0000029/34} section 4.2.42. 18 Throughout the external wall, not just at heights above 18 metres. 19 {CLG00000224/132}. 20 Team 1 Module 1 Opening Statement {BSR00000061/30} paragraph 13.16(2). 21 BSR Team 1 Module 1 Opening Submissions {BSR00000061/30} paragraph 13.16 (2). 22 Menzies {BMER0000004/126} paragraph 417. 23 BCA Technical Guidance Note 18, Issue 0 {CEP00057294}.

The Grenfell Tower Inquiry: Phase 2 Report 16 48.32 We do not agree that paragraph 12.7 of Approved Document B can be read in that way. Functional requirement B4(1) sets out the standard with which external walls must comply. The purpose of Approved Document B was to provide guidance on ways in which that standard might be met, which it did by identifying certain elements of the wall and suggesting the kinds of materials that were likely to ensure compliance. There is nothing in the language of paragraphs 12.5–12.9 (including paragraph 12.7) to support the conclusion that all elements of the external wall, including the core of any composite panel, should be of limited combustibility. The only reference to “limited combustibility” is found in paragraph 12.7 which referred only to insulation products. That would naturally have been understood as referring to materials and products used for the purposes of insulation, not as referring to materials chosen for other purposes but which happen to have insulating properties. 48.33 Section 9 of Approved Document B provided guidance on the provision of cavity barriers to inhibit the spread of smoke and flame through concealed spaces or cavities in the construction of a building as required by functional requirement B3.24 Paragraph 9.1 draws attention to the risks of fire spread within cavities and warns that “as any spread is concealed, it presents a greater danger than would a more obvious weakness in the fabric of the building.”25 Paragraph 9.3 makes it clear that cavity barriers should be provided to close the edges of cavities, “including around openings”. Diagram 33 (reproduced below) shows where cavity barriers are required in external walls, namely, at the lines of compartment floors and compartment walls, at the top of any cavities in the walls and around openings such as those provided for doors and windows. 24 {CLG00000224/82}. 25 {CLG00000224/82}.

Part 6 | Chapter 48: The legislative background 17 Figure 48.2 – Diagram 33 48.34 Paragraph 9.13 gives guidance on the construction and fitting of cavity barriers and states that they should provide at least 30 minutes’ fire resistance.26 Cavity barriers should be distinguished from fire stopping, which is a seal provided to close an imperfection of fit or design tolerance between elements or components, to restrict the passage of fire and smoke.27 26 {CLG00000224/86}. 27 Approved Document B, Appendix E, definition of “Fire stop” {CLG00000224/144}.

The Grenfell Tower Inquiry: Phase 2 Report 18 Comments on Approved Document B 48.35 Our investigations have revealed two particular problems relating to Approved Document B to which we think we should draw attention. The first relates to the guidance itself. Paragraph 2.3c on the means of escape from flats assumes that compliance with functional requirement B3 will provide a high degree of compartmentation and a low probability of fire spreading beyond the flat of origin, so that simultaneous evacuation of the building is unlikely to be necessary. In other words, it assumes that there would be no need for a partial or total evacuation of the building in the unlikely event that the fire spread beyond the compartment of origin and that a stay put strategy is therefore appropriate. That assumption holds good, however, only as long as the external wall of the building does not itself support the spread of fire. 48.36 Some uncertainty has arisen from the fact that functional requirement B4(1), which section 12 of Approved Document B was intended to support, requires only that the external walls should “adequately” resist the spread of fire, having regard to the height, use and position of the building. However, we assume that the word “adequately” was chosen to accommodate the full range of buildings to which the functional requirement applies. What is adequate will vary from case to case having regard to a number of matters, including the characteristics of the building. 48.37 It has been known for a long time that, even in the case of a fully compartmented residential building constructed entirely of non-combustible materials such as concrete (as Grenfell Tower was before the refurbishment), a fire in one compartment may spread to the compartment above as a result of the “coanda” effect. A limited degree of fire spread of that kind is not considered to undermine a stay put strategy because the extent of the evacuation required is very limited. Thus a limited degree of fire spread is acceptable, even where the building has a stay put strategy, because the ability of the external walls to resist the spread of fire is adequate. 48.38 However, the assumption underlying the guidance ceased to hold good when it became the practice to overclad high-rise residential buildings using materials that would support the spread of fire and to construct new buildings with steel frames with external walls composed in whole or in part of materials that would support the spread of fire. Unless all the materials used in the external wall are non-combustible, the effect in either case is to destroy the isolation of individual compartments by installing a continuous layer of combustible material on the outside of the building that would support the spread of fire across the outside of many compartments. 48.39 The failure to appreciate the effect of those developments introduced a fundamental flaw into the statutory guidance, which was not amended to draw the attention of designers to the need to consider the nature of the materials proposed to be used and other factors, such as access for the fire and rescue service, the nature of the occupants, the measures provided for alerting them to a fire and the means of escape if that should that become necessary, all of which have a bearing on whether the ability of the external wall to resist the spread of fire is adequate. If the external walls of a high-rise residential building support the spread of fire to any significant degree they are unlikely adequately to resist the spread of fire unless arrangements have been made to enable all those occupants who may be threatened by the fire to escape quickly and safely; but in any event it is not possible to operate a stay put strategy safely in relation to such a building.

Part 6 | Chapter 48: The legislative background 19 48.40 The effect of the introduction of new materials and methods of construction does not appear to have been recognised by any of the witnesses (other than the experts), including those from DCLG or BRE.28 There appears to have been a widely held view in the construction industry that if the surface of an external wall panel was classified Class 0, it was safe to use it on a building of any kind. There was also a widespread but erroneous understanding that if, following a test in accordance with BS 8414, an external wall system satisfied the criteria in BR 135, the building when completed would inevitably satisfy functional requirement B4(1) of the Building Regulations. Moreover, many in the industry failed to appreciate that the BS 8414 test applies only to a wall system as a whole and tells one nothing about its individual components. It is a matter of concern that no one appears to have considered whether the extent of flame spread that could occur while still satisfying the performance criteria in BR 135 was consistent with the adoption of a stay put strategy. We return to this matter in the context of our recommendations. 48.41 The second problem relates to the relationship between the regulations and the statutory guidance and the way in which Approved Document B is understood and applied by many in the construction industry. One striking feature of the evidence was the extent to which many construction professionals have routinely regarded the statutory guidance as containing a definitive statement of the requirements of the Building Regulations. In the absence of a clear statement to the contrary, we think that is an inevitable consequence of couching the guidance in prescriptive terms. Many construction professionals appear to be uncomfortable with the broad language of functional requirements B1 to B4 and want to be told what is expected of them and in any event many are not competent to translate the general language of the functional requirements into decisions about the choice of materials or methods of construction. That presents a particular problem for those who frame the statutory guidance, but while the functional requirements continue to set the standard which the law requires, it must be made clear in the guidance that following its provisions will not necessarily result in compliance with the regulations. 48.42 For reasons given elsewhere, Class 0 was never an appropriate standard for rainscreen panels, particularly panels with highly combustible polyethylene cores. In our view the guidance should explicitly have drawn the attention of those responsible for designing the cladding to the fact that Class 0 panels might not satisfy the requirements of functional requirement B4(1). 48.43 More generally, we think that Approved Document B requires a complete overhaul. It is out of date in many respects, not helpfully worded and does not contain the guidance that designers need. In a constantly changing environment it needs to be kept under review and revised annually or more often if circumstances demand. It should be drafted conservatively, so that those who follow the guidance can have a high degree of confidence that, if it is followed, the functional requirements will be met. Again, we return to this matter in the context of our recommendations. 28 See the examination of Dr Colwell at {Day231/175:11-24}; Debbie Smith {Day236/114:4}-{Day236/115:4}; Martin {Day251/96:19}-{Day251/98:19}; Burd {Day238/214:10}-{Day238/215:6}.

20 The Grenfell Tower Inquiry: Phase 2 Report

21 Chapter 49 Industry guidance on the construction of external walls 49.1 In this chapter we describe the industry guidance relevant to the refurbishment of the external wall of Grenfell Tower that was publicly available from reputable sources at and around the time of the refurbishment. In addition to the guidance contained in Approved Document B, certain bodies within the construction industry published guidance on the various aspects of the construction of external walls, particularly the walls of high-rise buildings. There were important developments in that guidance, particularly between 2012 and 2017, as more became known about the performance of certain products and materials in response to fire. In some respects the guidance contained in Approved Document B was overtaken by guidance published by the industry which suggested more rigorous requirements for the fire performance of each element of any external wall. According to Dr Lane29 and Mr Sakula,30 knowledge of the dangers posed by the use of combustible materials was developing rapidly during that time, partly as the result of a series of fires in high-rise buildings in various countries whose external walls contained insulation made from organic materials and aluminium composite material rainscreen panels with a polyethylene core (“ACM PE panels”). Those fires and the information readily available about them are discussed in more detail in Chapter 11 of this report. Building Research Establishment: BR 135 49.2 In 1988 the Building Research Establishment (BRE) published guidance entitled Fire performance of external thermal insulation for walls of multi-storey buildings.31 It is generally known as “BR 135”. The document was revised in 1999 and a second edition was published in 2003 following the fire at Garnock Court, Irvine in 1999.32 A third edition was published in 2013.33 The second and third editions are relevant to the refurbishment of Grenfell Tower. BR 135 is expressly referred to in paragraph 12.5 of Approved Document B, which adopts its performance criteria using full scale test data derived from a BS 8414 test as providing one way of demonstrating compliance with functional requirement B4(1) of the Building Regulations.34 The history of BR 135 and the test methods contained in BS 8414‑1 (2002) and 2 (2005) are described in Chapter 5 of this report. 49.3 The second edition of BR 135 (2003) contained a series of important warnings about the risks posed by combustible external cladding systems. For example, Figure 2 illustrated the way in which fire may spread rapidly up through the building envelope itself to create secondary fires in compartments at many levels.35 29 Lane {Day61/195:1}-{Day61/197:19}.}. 30 Jonathan Sakula, Report of Facade Expert {JOS00000001/34} paragraphs 8.1.1-8.1.2; {JOS00000001/35-37} paragraphs 9.2-9.4; {JOS00000001/60-61} paragraphs 17.6-17.12, Sakula {Day125/29:13-20}; {Day125/94:15}-{Day125/96:12}; {Day125/101:25}-{Day125/102:22}; {Day125/108:1-5}. 31 See introduction to BR 135, 3rd Edition {CEL00003364/4}. 32 {BRE00005554/7}. 33 {CEL00003364/4}. 34 {CLG00000224/95}. 35 {BRE00005554/9}.

The Grenfell Tower Inquiry: Phase 2 Report 22 49.4 The guidance contained further warnings about the risks posed by external cladding systems, in particular, the risk that the existence of cavities may cause flames to become elongated and drawn up the building, possibly unseen,36 to affect several stories simultaneously and how fire can spread unseen through cavities,37 thus making firefighting more difficult.38 The guidance also referred to the fact that non-combustible materials were typically used in such systems as it was difficult to prevent fire entering the cavity and spreading through the insulating material.39 It also warned that, if exposed directly to the sustained flame envelope, metal panels, such as aluminium, might melt, generating molten debris.40 49.5 The third edition of BR 135 (2013) repeated the warnings given in the second edition41 and contained further warnings about external fire spread and the use of certain materials in cladding systems. In particular, it drew attention to the rapid development of the market for cladding systems, driven by the need to construct more energy-efficient and sustainable buildings, which had resulted in increased volumes of potentially combustible materials being used in external cladding applications.42 There were further important warnings about the proper use of cavity barriers and fire-stopping. The warnings about insulation and cladding panels were also more detailed. In particular, on the subject of cladding panels it said: “These products generally have good surface spread of flame characteristics to prevent rapid fire spread across the surface of the system, but once the panels become involved in the fire, they have the potential to generate falling debris, add to the overall fire load, and provide a route for fire to propagate up the outside of the building”43 Building Control Alliance 49.6 The Building Control Alliance (‘BCA’) was formed in 2008 to represent the interests of those involved in carrying out building control functions, both local authorities and approved inspectors, and to promote consistency in the interpretation of the Building Regulations and statutory guidance. From time to time its Technical Group published guidance notes intended to assist building control officers in carrying out their functions. 49.7 In June 2014 BCA produced version 0 of its Technical Guidance Note 18 entitled Use of Combustible Cladding Materials on Residential Buildings (TGN 18).44 The introduction to TGN 18 stated that the note outlined the procedures referred to in paragraph 12.5 of Approved Document B for demonstrating compliance with functional requirement B4(1) and set out to address common misconceptions relating to combustibility and surface spread of flame ratings.45 36 {BRE00005554/10}. 37 {BRE00005554/17}. 38 {BRE00005554/10}. 39 {BRE00005554/17}. 40 {BRE00005554/17-18}. 41 {CEL00003364} see e.g. paragraphs 3.3.2 and 3.5. 42 {CEL00003364/11} paragraph 2.1. 43 {CEL00003364/22} paragraph 6.4.1. 44 {CEP00057294} The purpose of the note is described as follows: “BCA technical guidance notes are for the benefits of its members and the construction industry, to provide information, promote good practice and encourage consistency of interpretation for the benefit of our clients. They are advisory in nature, and in all cases the responsibility for determining compliance with the Building Regulations remains with the building control body concerned.” 45 {CEP00057294/1}.

Part 6 | Chapter 49: Industry guidance on the construction of external walls 23 49.8 Under the heading “Key Issues”, TGN 18 stated that the spread of fire by way of the external wall is exacerbated by the use of combustible materials and extensive cavities. It warned that within the confines of a cavity, flames can elongate up to ten times in search of oxygen, meaning that there is a need for robust cavity barriers, restricted combustibility of key components and the use of materials with a low spread of flame rating.46 49.9 Importantly, TGN18 made it clear that a surface spread of flame classification does not indicate that the material is not combustible. It went on to state that: “Thermosetting insulants (rigid polyurethane foam boards) do not meet the limited combustibility requirements of AD B2 Table A7 and so should not be accepted as meeting AD B2 paragraph 12.7. However, if they are included as part of a cladding system being tested to BR135 & BS8414, the complete assembly may ultimately prove to be acceptable. The BR135 / BS8414 tests deal solely with the spread of fire once it has entered the cavity. Hence, the requirements for cavity barriers in accordance with Section 9 of AD B2 are required in all cases including around openings in the façade.”47 49.10 TGN 18 went on to recommend three options for demonstrating compliance with paragraph 12.7 of Approved Document B.48 Option 1 was the use of materials of limited combustibility for all elements of the cladding system both above and below 18 metres. Option 2 was to demonstrate that the entire system met the performance criteria in BR 135 when tested in accordance with BS 8414. Option 3 was to submit a desktop study report from “a suitable independent UKAS accredited testing body” based on test data already in its possession stating whether, in its opinion, the proposed system would meet the criteria in BR 135. As far as we are aware, that was the first occasion on which it had been formally suggested that a desktop study could provide a means of demonstrating compliance with functional requirement B4(1). It was not referred to in Approved Document B and was not the method adopted in connection with the refurbishment of Grenfell Tower. 49.11 A further edition of TGN 18 (version 1) published in July 2015 contained similar warnings about external fire spread.49 This revised guidance made it clear that a wider group of thermosetting insulants did not meet the limited combustibility requirements of Approved Document B Table A7, including polyisocyanurate and polystyrene foam boards. When dealing with desktop study reports the guidance now said that a report from a “suitably qualified fire specialist” based on test data from a suitable independent UKAS accredited testing body was acceptable, without indicating what qualifications might be required for the purpose. The effect of that change was to increase the number of persons who might be considered suitable to carry out such a study. This version also introduced a fourth option in the form of a “holistic fire-engineered approach” taking into account “the building geometry, ignition risk and factors restricting fire spread etc.”50 That method was not adopted in connection with the refurbishment of Grenfell Tower. 46 {CEP00057294/1}. 47 {CEP00057294/1}. 48 {CEP00057294/2}. 49 {CEL00002347}. 50 {CEL00002347/2}.

The Grenfell Tower Inquiry: Phase 2 Report 24 Centre for Windows and Cladding Technology 49.12 The Centre for Windows and Cladding Technology (CWCT) is an industry body comprising a broad spectrum of clients, architects, consultants, contractors, manufacturers and researchers which exists to assist its members in the construction of building envelopes and glazing.51 From time to time it publishes recommended standards and guidance for the benefit of its members and hosts meetings to discuss matters of interest to the industry. In the period 1996 to 2018, CWCT produced five documents of relevance to the Inquiry’s investigations: Guide to Good Practice for Facades, 1996;52 Standard for Walls with Ventilated Rainscreens, 1998;53 Standard for Systematised Building Envelopes, 2008 (“the CWCT Standard”);54 Technical Note 73, Fire performance of curtain walls and rainscreens, March 2011;55 and Technical Note 98, Fire performance of facades – Guide to the requirements of UK Building Regulations, 2017.56 49.13 The CWCT’s Guide to Good Practice for Facades (1996) stated that thermal insulation should be inert and drew attention to the fire performance of some insulating materials.57 The Standard for Walls with Ventilated Rainscreens (1998) made clear that any cavity behind rainscreens should not include materials which could significantly promote flame spread within the unseen cavity and therefore recommended non-combustible insulation.58 It warned that the use of any combustible material for the cladding framework and insulation needed to be carefully considered as the height of the building increased.59 Both of those CWCT standards were referred to in the structural performance specification for Grenfell Tower.60 49.14 The CWCT Standard (2008) gave guidance on a range of aspects of the construction of the external envelopes of buildings61, with part 6 focusing on fire performance.62 Within part 6 the standard provided that the building envelope should not be composed of materials which readily support combustion, add significantly to the fire load, or give off toxic fumes.63 It emphasised the importance of test evidence supporting fire performance requirements, as follows: “In all cases, products or elements of construction requiring a fire resistance or spread of flame performance should have the appropriate evidence of performance test based on test information. The final installation should follow the applicable test evidence in all respects.”64 51 https://www.cwct.co.uk/pages/about-us. 52 {CWCT0000055}. 53 {CWCT0000053}. 54 {CWCT0000046}. 55 {CWCT0000019}. 56 {CWCT0000024}. 57 {CWCT0000055/13} paragraph 4.10.1. 58 {CWCT0000053/45} paragraph 2.20.4; {CWCT0000053/46} paragraph 2.20.8. 59 {CWCT0000053/45} in the notes to the right of paragraph 2.20.4. 60 Curtins Consulting, the structural engineer appointed by the TMO, wrote a specification entitled ‘Structural Performance Specification for the Design, Supply and Application of Overcladding Systems to Grenfell Tower’ dated March 2013 {CCL00002347}, in which section 7.0 addressed ‘Overcladding’ and included reference to these standards. 61 {CWCT0000046/10}. Including, but not limited to, rainscreen cladding. 62 {CWCT0000046/10-16}. 63 {CWCT0000046/11} section 6.2. 64 {CWCT0000046/11} section 6.2. It also stated in blue italic text: “The suitability of materials should be judged in relation to their conditions of use. For example, combustible insulation may give acceptable performance when used with a metal facing…” The black text in the CWCT Standard was prescriptive, while the blue italic text gave background information or guidance on interpretation of the clause which it followed, see {CWCT0000046/6}.

Part 6 | Chapter 49: Industry guidance on the construction of external walls 25 49.15 The CWCT Standard stated that aluminium envelope systems do not normally have significant resistance to fire and that most unmodified aluminium building envelopes would provide only 10–20 minutes stability and integrity resistance.65 Under the heading “Insulation materials” it contained the same guidance as in paragraph 12.7 of Approved Document B, namely, that insulation in walls of buildings with a storey more than 18 metres above ground level should be of limited combustibility.66 It also made clear that cavity barriers needed to be provided to close any cavity around penetrations through the rainscreen for windows.67 The standard also expressly addressed “Composite components”, providing: “When one of the cladding elements is a composite of two or more materials (mechanically jointed, bonded or fused together) the elements as a whole must demonstrate the appropriate fire performance. Similarly it must be demonstrated that the composite will remain reasonably whole and not become prematurely separated from the building or framework.”68 49.16 The CWCT Standard (2008) was expressly referred to in the NBS specification for the refurbishment works at Grenfell Tower (see Chapter 56).69 49.17 Technical Note 73, Fire performance of curtain walls and rainscreens, was published by CWCT in March 2011.70 It contained warnings about fire and smoke spread within cavities and out of the top of cavities and highlighted the importance of cavity barriers to close the edges of cavities, including around window openings.71 Under the heading “Use of combustible material” it made it clear that “the only commonly used insulation material that will satisfy the definition of limited combustibility is mineral wool”.72 It also emphasised that where testing was carried out in accordance with BS 8414, the test applied to the complete cladding system including insulation, rainscreen and cavity barriers73 and that changing any of those components might affect the ability of the walls to resist the spread of fire.74 49.18 Technical Note 98 Fire performance of facades – Guide to the requirements of UK Building Regulations was published in April 2017. Although it was published too late to be taken into account in the design and construction of the refurbishment of Grenfell Tower, it provides a useful picture of the state of knowledge in the industry in the months before the fire. In particular, in the introductory section the note warnsː “Strict compliance with ADB does not necessarily guarantee adequate performance of a given façade in a fire. It is incumbent on the building designer to ensure that the guidance given in ADB is relevant to their building and what additional measures (if any) are required to ensure the façade achieves the required performance standard.”75 65 {CWCT0000046/11} section 6.3. 66 {CWCT0000046/15} section 6.6.2. 67 {CWCT0000046/14} section 6.4.4.2 (ii) under the heading “Cavities in rainscreen walls”. 68 {CWCT0000046/16} section 6.6.3. 69 NBS Specification prepared by Studio E {SEA00000169/68-69} NBS Specification clauses 220/310. 70 {CWCT0000019}. 71 {CWCT0000019/4-5}. 72 {CWCT0000019/6}. 73 {CWCT0000019/6} under the heading “Alternative approaches”. 74 {CWCT0000019/6}. 75 {CWCT0000024/1}.

26 The Grenfell Tower Inquiry: Phase 2 Report 49.19 Technical Note 98 also stated that combustible materials may have non-combustible facings which restrict the spread of flame over the surface. It warned that combustible materials with non-combustible facings rely on the facings remaining intact and that the materials should be checked for damage.76 Appendix C of Technical Note 98 dealt with the combustibility of materials and paragraph 12.7 of Approved Document B. It stated: “Clause 12.7 specifically refers to insulation materials and filler materials but is now being interpreted more generally (see BCA Guidance note 18). Therefore, where a building has a storey 18m or more above ground level all significant materials should be of limited combustibility (Class A2 in accordance with EN 13501). This includes but is not limited toː Rainscreen panels • Standard ACM panels do not meet these requirements. Limited combustibility ACM panels are available. Insulation materials • The only commonly used insulation material that will satisfy the definition of limited combustibility is mineral wool. …”77 Booth Muirie Technical Guidance Note 1 49.20 Booth Muirie Ltd is a company which provides specialist architectural cladding services, including design, manufacturing and distribution. In March 2016 it published a guide to designing multi-layered walls using ACM rainscreen panels.78 Like the BCA Technical Guidance Notes it set out various options for complying with the fire safety requirements for external walls of buildings over 18 metres in height. Option 1, which was described as “the most straightforward” was to restrict all the significant elements of each layer to non-combustible materials or materials of limited combustibility. Options 2, 3 and 4 were the same as those contained in Issue 1 of the BCA’s TGN 18. Reynobond ACM with a polyethylene core, Celotex RS5000 and Kingspan K15 were all identified as being neither non-combustible nor of limited combustibility. 76 {CWCT0000024/3}. 77 {CWCT0000024/13}. 78 {ARC00000559}.

27 Chapter 50 Organisations involved in the refurbishment 50.1 In this chapter we describe the organisations principally involved in the refurbishment of Grenfell Tower and the people who acted on their behalf. The purpose of doing so is to provide a brief introduction to those engaged on the project and the nature of their involvement. A number of other organisations, not referred to here, played minor and uncontroversial roles of a kind that do not call for discussion at this stage. Their involvement will be described in later chapters as we come to discuss particular aspects of the work. 50.2 The refurbishment of a major building is a complex undertaking which requires the co‑operation of many different bodies, some with specialised skills and experience. In addition to the client, who ultimately controls the budget and determines the scope of the work, they usually include (and in this case did include) an architect, quantity surveyor, the principal building contractor and several sub-contractors. In this case other consultants were employed at different times and for different purposes. They included a mechanical and electrical services (“M & E”) consultant, a fire engineering consultant, an employer’s agent and a CDM co-ordinator. Others, such as the local authority building control office, were also directly involved in the project, although in a different way. Building control, in particular, had a responsibility to the public to ensure that those involved in the project complied with the requirements of the Building Regulations. The client: Kensington and Chelsea Tenant Management Organisation 50.3 Although Grenfell Tower was owned by the Royal Borough of Kensington and Chelsea (RBKC), it was managed by the Kensington and Chelsea Tenant Management Organisation (TMO) under a modular management agreement. Although the decision to refurbish the tower was taken by RBKC, which provided the funds required for that purpose, the TMO acted as the client and in that capacity procured the services needed to carry out the project and oversaw its execution. The circumstances in which the TMO procured the services of the architect and the main contractor are discussed in Chapters 51, 52 and 53. 50.4 As client the TMO also incurred certain obligations under the CDM Regulations 2007 and 2015. They included ensuring that all designers were competent and adequately resourced.79 79 CDM Regulations 2007{INQ00011315/4-5}Regulations 4 and 9; Approved Code of Practice to Construction (Design and Management) Regulations 2007, Managing Health and Safety in Construction (HSE) {INQ00013936/15-17} paragraphs 43 and 49-52; CDM Regulations 2015{INQ00011316/5-6} Regulation 4; Approved Code of Practice to Construction (Design and Management) Regulations 2015 {HSE00000003/16-18} paragraphs 29-36.

The Grenfell Tower Inquiry: Phase 2 Report 28 50.5 The people principally involved in negotiating the contracts for the refurbishment on behalf of the TMO and overseeing the project were: Mark Anderson Peter Maddison Paul Dunkerton David Gibson Claire Williams. 50.6 Mark Anderson was an architect by profession with experience of private practice before he became involved with social housing.80 He was appointed by the TMO as interim Director of Asset Investment and Engineering in March 2011 and following a redesignation of his role served as interim Director of Assets and Regeneration from April 2012 until January 2013.81 He was responsible for the early stages of the refurbishment project which he later handed over to Peter Maddison when the latter was appointed to succeed him. 50.7 Peter Maddison was appointed by the TMO to the post of Director of Assets and Regeneration from January 2013.82 In that role he took over primary responsibility for organising the refurbishment project at a strategic level for the TMO, including overseeing the engagement of consultants and the selection of the main contractor. 50.8 Paul Dunkerton was a freelance project manager for the TMO between late 2010 and early July 2013.83 He initially reported to Mark Anderson and later to Peter Maddison, taking on a more active role when he had no senior manager to whom to report.84 50.9 David Gibson was Head of Capital Investment at the TMO from February 2013 until the end of June 2016, reporting to Peter Maddison.85 As such he was responsible for assisting Mr Maddison in the development and delivery of the refurbishment project. Mr Gibson had been a registered architect between 1987 and 1991 and had had some previous experience of regeneration projects in the social housing sector.86 50.10 Claire Williams joined the TMO in September 2013 as project manager for the Grenfell Tower refurbishment. Once the work began, she became the primary point of contact with the main contractor. One of her tasks was to communicate with the residents of Grenfell Tower,87 having been appointed for her particular skill and experience in resident relations.88 She considered herself to be the TMO’s project manager for the refurbishment,89 although there was some confusion about who, if anyone, was formally acting in that capacity. 80 Anderson {TMO10048968/1} page 1, paragraph 6. 81 Anderson {TMO10048968/1} page 1, paragraph 5. Mr Anderson was not employed as an architect by the TMO. 82 Maddison {TMO00000892/1} page 1, paragraph 2. 83 Dunkerton {TMO00000885/1} page 1, paragraph 5. 84 Dunkerton {Day51/11:4-15}. 85 Gibson {TMO00000887/1-2} pages 1-2, paragraphs 2 and 8. 86 Gibson {Day53/11:15-23}; Gibson {TMO00000887/1-2} pages 1-2, paragraphs 5-7; Gibson {TMO00879742/1} page 1, paragraph 3. 87 Williams {TMO00840364/4} page 4, paragraphs 18-19. 88 Williams {TMO00840364/2} page 2, paragraph 11; Williams {Day54/87:12}-{Day54/88:1}. 89 Williams {Day54/80:23}-{Day54/81:9}; {Day54/101:7-12}.

Part 6 | Chapter 50: Organisations involved in the refurbishment 29 The architect: Studio E 50.11 The architectural practice known as “Studio E” was appointed by the TMO for the Grenfell Tower refurbishment and provided professional services in respect of the project from about February 2012 to July 2016.90 In Chapter 52 we describe the circumstances in which it came to be appointed, but for present purposes it is necessary to refer in a little more detail to the origin and structure of the practice. 50.12 Studio E Architects Limited (“SEAL”) was founded in 1994 by Andrzej Kuszell and two others. A separate body in the form of a limited partnership, Studio E LLP (“SELLP”), was established by Mr Kuszell and his partners in 2007 but did not start trading until 2011.91 Thereafter, between 2011 and 2014, SEAL was effectively dormant92 but it was revived in 2014 when SELLP became insolvent and ceased trading. Throughout this report we refer to the practice simply as “Studio E”, except when it is necessary to identify the particular legal entity involved. 50.13 After the principal contractor had been appointed Studio E’s services were transferred to it under a separate agreement between them. We discuss the circumstances under which that occurred and the terms of the resulting contractual arrangements in Chapter 63. 50.14 Studio E was represented in relation to its work on the Grenfell Tower refurbishment principally by the following persons:93 Andrzej Kuszell Bruce Sounes Neil Crawford Tomas Rek. 50.15 Andrzej Kuszell is a registered architect and a founding director of SEAL.94 During his career he worked in various sectors, including defence, commercial development and education work with an emphasis on education, sports and leisure centres.95 Mr Kuszell did not have day-to-day involvement with the Grenfell Tower project,96 although he oversaw the provision of resources and took part in design reviews. He did not have any personal experience of overcladding an occupied residential building and no personal experience of refurbishing a high-rise building.97 50.16 Bruce Sounes studied architecture at the University of Natal at Durban in South Africa between 1989 and 1994. He completed the RIBA Part 3 examination and became a registered architect in 2000.98 Before 2000, his experience had been predominantly in education, sports, and leisure projects.99 He joined Studio E in the role of architect in 2000 and was promoted to the role of associate in 2005.100 Mr Kuszell said that it was not 90 Kuszell {SEA00014271/9-10} page 9-10, paragraph 35; Sounes {SEA00014273/30} page 30, paragraph 58; Studio E {SEA00014232/2} page 2, paragraph 3.1. 91 Kuszell {Day6/16:7-16}. 92 Kuszell {Day6/18:15-18}. 93 Others at Studio E were also involved in the Grenfell Tower refurbishment from time to time. 94 Kuszell {Day6/10:17} – {Day6/11:2}; Kuszell {SEA00014271/2} page 2, paragraph 3. 95 Kuszell {Day6/11:3-18}. 96 Kuszell {SEA00014271/2} page 2, paragraph 4. 97 Sounes {Day6/173:14-16}; {Day6/11:19-22}. 98 Sounes {Day6/169:2-3}; He commenced work in the UK as an Architectural Assistant in 1998 at KSR Architects: Sounes {Day6/167:17}-{Day6/169:1}. 99 Sounes {Day6/166:13-23}. 100 Sounes {Day6/170:3-19}; Kuszell (Day6/104:21-24}.

The Grenfell Tower Inquiry: Phase 2 Report 30 unusual for an associate to lead a project and that for a commission with a construction value of £1 million or more either a partner or an associate would do so.101 From July 2014, Neil Crawford took over day-to-day responsibility for the project from Mr Sounes, although Mr Sounes remained responsible for it and for supervising Mr Crawford’s work.102 Mr Sounes did not have any experience of overcladding an occupied residential building, although he had gained some experience of an overcladding project when working on the Watford Woodside Leisure Centre.103 50.17 Neil Crawford had a degree and a post-graduate diploma in architecture104 but was not a registered architect because he had not completed the Royal Institute of British Architects Part 3 examination.105 Between 1997 and 2009 he had worked at Foster + Partners, initially as a Part 2 graduate and later as an associate.106 He joined Studio E in 2009 and soon became an associate.107 From July 2014, he took over day-to-day responsibility for the project from Mr Sounes, although Mr Sounes continued to lead it.108 50.18 Mr Crawford worked on the Grenfell Tower refurbishment on a day-to-day basis.109 By October 2015, he had been made the project architect.110 He had some limited experience of commercial projects involving cladding and curtain walling but had not previously been involved in the overcladding of a high-rise residential building.111 50.19 Tomas Rek was a registered architect who was employed by Studio E between December 2011 and December 2013.112 Before joining Studio E he had worked mainly in the education sector.113 He started work on the Grenfell Tower refurbishment project on 18 September 2013.114 Under the supervision of Mr Sounes, he developed the National Building Specification (NBS) specification for the project and the architectural drawings intended to form part of the tender documents.115 (The NBS is a computerised system designed to assist architects and other building professionals in describing the materials, standards and workmanship required on a construction project.) Studio E drafted three versions of the NBS Specification dated 21 November 2013116, 29 November 2013117 and 30 January 2014.118 The second and third of those were sent to tenderers. The quantity surveyor, employer’s agent and CDM co‑ordinator: Artelia 50.20 Appleyards Ltd had been appointed by the TMO as a consultant on the KALC project and as a result the TMO appointed it as quantity surveyor, employer’s agent and CDM co‑ordinator for the Grenfell Tower project. In March 2012, Artelia Ltd bought Appleyards 101 Kuszell {Day6/105:5}-{Day6/107:13}. 102 {SEA00014276}; Kuszell {Day6/124:5-10}; Crawford {Day9/22:15-20}. 103 Sounes {Day6/174:21-25}. 104 Crawford {Day9/4:9-15}. Neil Crawford studied at the Mackintosh School of Architecture between 1991 and 1997. 105 He had studied towards the RIBA Part 3 examination in London in 2007 but had not completed it: Crawford {Day9/5:19-22}. 106 Crawford {Day9/10:2-11}. 107 Crawford {Day9/21:19-22}. 108 {SEA00014276/7}; Kuszell {Day6/124:5-10}; Crawford {Day9/22:15-20}. 109 Crawford {Day9/23:25}-{Day9/24:8}. } 110 {SEA00013508}. 111 Crawford {SEA00014275/9} page 9, paragraph 21; Crawford {Day9/19:20}-{Day9/20:5}. 112 Rek {Day12/5:5-9}. 113 Rek {Day12/8:18-20}. 114 Rek {SEA00014278/4} page 4, paragraph 9. 115 Rek {SEA00014278/5} page 5, paragraph 14; Rek {Day12/11:17-20}. 116 {SEA00000152}. 117 {RYD00001712}. 118 {SEA00000169}.

Part 6 | Chapter 50: Organisations involved in the refurbishment 31 and thereafter Appleyards traded in the name of Artelia until 30 June 2015, when its business was formally transferred to Artelia.119 In this report we refer to both entities as Artelia, unless the context requires otherwise. 50.21 A quantity surveyor is a surveyor trained in the particular skill of calculating the quantity and cost of materials required to carry out, or that have been used in carrying out, the whole or a particular part of a construction project. They may be used to estimate the cost of work, help manage costs during the course of the work and participate in agreeing the final account.120 Artelia agreed to provide quantity surveying services, including preparing an initial budget to test feasibility, preparing regular monthly cost reports as the project progressed and advising the TMO of any decisions required.121 Simon Cash was its project director and had overall responsibility for the whole of Artelia’s involvement in the refurbishment.122 He was a trained quantity surveyor and a Fellow of the Royal Institution of Chartered Surveyors.123 50.22 The function of an employer’s agent is to perform on behalf of the client various administrative tasks that have to be undertaken by it in relation to a project.124 Philip Booth acted as employer’s agent from about April 2013 until June 2015.125 He left Artelia in April 2016.126 Neil Reed succeeded Philip Booth as employer’s agent in March 2015.127 In July 2015, Neil Reed left Artelia to start his own business, Re Sol Group Limited (Re Sol), but continued to provide the services of employer’s agent under a subcontract with Artelia.128 50.23 CDM co-ordinator (CDM-C) is a statutory role under the Construction (Design and Management) Regulations 2007 (“CDM Regulations 2007”).129 The regulations required the TMO to appoint a CDM co-ordinator (CDM-C) for the Grenfell Tower project because of its size.130 The CDM-C is required to assist and advise the client on the appointment of competent contractors, ensure that health and safety matters are properly co-ordinated during the design process, help communication and co-operation between project team members and prepare the health and safety file.131 Keith Bushell of Artelia was appointed to that role. Following the introduction of the Construction (Design and Management) Regulations 2015 (CDM Regulations 2015), Artelia’s appointment as CDM-C terminated on 6 October 2015. On 8 October 2015, Simon Cash wrote to Peter Maddison to confirm that Artelia’s appointment as CDM-C had terminated.132 119 Artelia {ART00005764/2} page 2, paragraph 4. 120 Cash {Day48/2:9-13}. 121 Artelia Agreement 2014 {ART00005742/55-58}. 122 Save for a brief period at the end of 2015 to early 2016; Cash {ART00006544/2} page 2, paragraph 4. 123 Cash {ART00006544/2} page 2, paragraph 5. 124 The Building Contract between Rydon and the TMO envisaged that an employer’s agent would be appointed {RYD00094235/22} Articles (conformed copy). 125 Booth {ART00008527/3} page 3, paragraph 12; Booth {ART00008527/5} page 5, paragraph 22. 126 Booth {Day49/113:7-8}. 127 Reed {ART00006663/2} page 2, paragraph 8. 128 Reed {ART00006663/2} page 2, paragraph 6; On 10 July 20215, Neil Reed for Re Sol proposed to perform the services of employer’s agent, as set out in the 2015 Agreement {ART00007552}. On 28 July 2015, Artelia appointed Re Sol on the basis of that proposal to start from 1 August 2015 and continue to the issue of the certificate of Practical Completion {ART00006674}. In effect, Neil Reed left his employment at Artelia but continued working the same capacity on the refurbishment through his own consultancy business. 129 {INQ00011315}. 130 CDM Regulations 2007, Regulation 2(3) {INQ00011315/4}; CDM Regulations 2007, Regulation 14(1) {INQ00011315/8}. 131 Approved Code of Practice to the CDM Regulations 2007{INQ00013936/24} paragraph 84; CDM Regulations 2007 {INQ00011315/10} Regulation 20(1)(a); reflected in 2014 Agreement: {ART00005742/61} clause 3; CDM Regulations 2007{INQ00011315/11} Regulation 20(2)(e); reflected in 2014 Agreement: {ART00005742/62} clause 11. 132 {ART00006244}.

The Grenfell Tower Inquiry: Phase 2 Report 32 M & E consultant: Max Fordham 50.24 The TMO appointed Max Fordham LLP as building services engineers with effect from the summer of 2012. Andrew McQuatt was the lead project engineer.133 Matt Cross Smith was a building services engineer who worked on the Grenfell Tower project as a graduate engineer.134 Structural engineer: Curtins Consulting Ltd 50.25 Curtins Consulting Limited (Curtins) was the consultant structural engineer for the Grenfell Tower project. Its contract was novated to Rydon by an agreement dated 25 April 2016 following that company’s appointment as principal contractor.135 Fire engineer: Exova (UK) Ltd 50.26 Exova (UK) Ltd, trading as Exova Warringtonfire (Exova), is a company specialising in fire safety, fire engineering and related matters. It had been employed as a consultant by Studio E in connection with the KALC project,136 and as a result, it was approached by the TMO to advise on the Grenfell Tower refurbishment.137 Although it was retained by the TMO, it continued to send reports to Studio E.138 There was no fresh tender or procurement exercise for fire engineering services for the Grenfell Tower project. Exova was used because it was known and trusted as a result of its work on the KALC project. 50.27 The TMO appointed Exova to produce a fire safety strategy for Grenfell Tower in its existing state (the “Existing Fire Safety Strategy”)139 and a fire safety strategy for the building in its refurbished condition (the “Outline Fire Safety Strategy”).140 Its appointment was not novated to Rydon after that company had been appointed as principal contractor and it therefore continued as a consultant to the TMO.141 However, as discussed in Chapter 54, there was a confusion in some people’s minds about Exova’s position following Rydon’s appointment that was never properly clarified. 50.28 In relation to its work on the Grenfell Tower refurbishment Exova was represented principally by the following persons: James Lee Cate Cooney Dr Clare Barker Terence Ashton Dr Tony Pearson. 133 McQuatt {MAX00017292} page 5, paragraph 19. 134 Cross Smith {MAX00017304} pages 1-2, paragraph 4. 135 {TMO10013954}. 136 Sounes {SEA00014273/36} page 36, paragraph 73. 137 TMO’s procurement of Exova’s services in respect of the Grenfell Tower refurbishment is explored in Chapter 54. 138 Ashton {Day17/20:1-13}. 139 See fee proposal dated 11 June 2012 {TMO10003884}. 140 See fee proposal dated 9 May 2012 {ART00000026}. 141 {ART00002255/4}; Ashton {EXO00001621/14} page 14, paragraphs 5.9 – 5.10; Ashton {Day16/117:2-10}; {Day17/185:2-3}; {Day16/117:2-10}; {Day17/187:7-10}.

Part 6 | Chapter 50: Organisations involved in the refurbishment 33 50.29 For a brief period, James Lee was involved with the project until he left the company in late July 2012. He attended a design team meeting on 19 April 2012142 and visited the tower briefly on 29 May 2012.143 He provided Studio E with a series of marked-up drawings and comments in respect of the proposed refurbishment works144 and prepared a fee proposal for Studio E for the production of the Existing Fire Safety Strategy.145 50.30 At the time Exova was appointed Dr Clare Barker was a principal fire engineer in Exova’s Warrington office and a member of the Institute of Fire Engineers.146 She attended a project meeting on 26 July 2012,147 shortly before Exova was instructed to provide the Existing Fire Safety Strategy. She asked another employee, Cate Cooney, to prepare a first draft,148 which she later reviewed.149 50.31 Cate Cooney had joined Exova in 2011 after spending eight years working in building control. By 2012 she had reached the position of senior consultant. At the request of Dr Barker, she prepared the first draft of the Existing Fire Safety Strategy. She also provided some advice to Bruce Sounes of Studio E in relation to the refurbishment proposals.150 50.32 Terence Ashton had joined Exova in 1989 as a principal consultant after 25 years in building control. He was based at Exova’s London office, where he was an associate in the fire engineering department151 and acted as office manager.152 He had no formal qualifications in fire engineering. He had worked on high-rise residential buildings but had no experience of overcladding projects.153 He did not have the expertise to carry out highly technical fire engineering analyses, such as determining how particular materials are likely to behave in a fire, and would have called on his colleagues in Warrington for assistance if had he been asked to do one.154 He saw his primary role as being to ensure compliance with the Building Regulations.155 Following James Lee’s departure from the company in July 2012, Terence Ashton assumed overall responsibility for Exova’s work on the Grenfell Tower refurbishment. 50.33 In 2013, Mr Ashton was aware that Approved Document B contained an express warning that the use of combustible materials in cladding systems and the existence of extensive cavities might present a risk to health and safety in tall buildings.156 Although he was aware of the existence of BR 135, he had not read it from cover to cover and it did not occur to him to read it before starting work on the Grenfell Tower project.157 Mr Ashton was aware that serious fires had occurred both in the UK and overseas as a result of the use of inappropriate materials (although he was not aware of the fire at the Lacrosse Building in Melbourne) and was therefore aware that combustible cladding should not be used on 142 {TMO10001143}; {EXO00001740/2} page 2, paragraph 3.3. 143 Lee {EXO00001740/3} page 3, paragraph 3.6; {EXO00000802}. 144 Lee {EXO00001740/3}; page 3, paragraph 3.7; {EXO00001750}. 145 Lee {EXO00001740/3}; page 3, paragraph 3.10; {TMO10037721}. 146 Barker {Day15/7:1-5}. 147 Barker {EXO00001603/2} page 2, paragraph 3.4; {EXO00000242}; {EXO00001620} 148 {EXO00001620/4}; Barker {EXO00001603/3} page 3, paragraph 3.10; Cooney {EXO00001590/2} page 2, paragraph 3.3; Cooney {Day14/27:15-21}; Barker {Day15/9:20-24}; {Day15/41:20-25}. 149 Barker {EXO00001603/3} page 3, paragraphs 3.13-3.14; Cooney {EXO00001590/3} page 3, paragraph 3.9. 150 {EXO00000655}. 151 Ashton {Day16/23:23-25}; {Day16/24:1-2}; {Day16/24:6-8}; Ashton {EXO00001621/2} page 2, paragraph 2.3. 152 Pearson {Day19/4:5-10}. 153 Ashton {Day16/29:1-8}. 154 Ashton {EXO00001621/3} page 3, paragraph 3.4; Ashton {Day17/94:7-20}. He said he would also have called on his testing colleagues within Exova if he needed further advice, for example, on a new type of insulation coming on to the market. 155 Ashton {Day16/64:7-13}. 156 Ashton {Day17/87:3-8}; {CLG00000224/95} page 95, paragraph 12.5. 157 Ashton {Day17/77:14-19}.

The Grenfell Tower Inquiry: Phase 2 Report 34 high-rise buildings.158 He had not encountered the use of composite metal panels, apart from one particular composite panel with a polyethylene core.159 However, he did not envisage that material of that kind would be used on high-rise buildings. He knew that polyethylene was a highly combustible substance and was aware, at least subconsciously, that panels containing polyethylene could exacerbate the spread of fire over the exterior wall of a building.160 50.34 Dr Tony Pearson joined Exova in 2008 as a graduate. In 2013 he was promoted to senior consultant161 and remained in that role until he left the company in January 2016.162 Before he started working on the Grenfell Tower project Dr Pearson had had no experience of refurbishing high-rise residential buildings and very little experience of overcladding projects.163 Clerk of works: John Rowan & Partners 50.35 The TMO engaged John Rowan & Partners to provide a limited range of clerk of works services during the refurbishment. John Rowan is a construction consultancy offering a variety of services to the construction industry, including site monitoring and supervision or clerk of works services.164 Those principally involved were Gurpal Virdee, the managing partner since August 2016,165 and Jonathan (“Jon”) White, who was an experienced clerk of works. 50.36 The functions that John Rowan were required to perform were more limited than those that would be performed by a traditional clerk of works.166 In effect, they were employed to act as site inspectors or site monitors167 and were expected to focus a lot of attention on the residents.168 The principal contractor: Rydon 50.37 The TMO appointed Rydon Maintenance Ltd (“Rydon”) as principal contractor under a contract on the JCT Design and Build Contract form 2011 with amendments.169 As principal contractor, Rydon was responsible for all aspects of the refurbishment project, including its design, compliance with the Building Regulations and other statutory requirements. The refurbishment division of Rydon, led by its Refurbishment Director, Stephen Blake, was responsible for the project. We describe the circumstances in which Rydon came to be appointed in Chapter 53. 158 Ashton {Day18/82:1-10}. 159 Ashton {Day17/88:1-7}. 160 Ashton {Day17/89:2-7}. 161 Pearson {Day19/3:2-5}; Pearson {EXO00001753/2} page 2, paragraph 2.2. 162 Pearson {EXO00001753/2} page 2, paragraph 2.2. 163 Pearson {Day19/7:17-25}. 164 Virdee {JRP00000333/2} page 2, paragraphs 7-8; Virdee {Day43/4:14-21}. 165 Virdee {Day43/3:2-8}. 166 Virdee {JRP00000333/2} page 2, paragraphs 11-12; Virdee {JRP00000333/3} page 3, paragraph 17; Virdee {JRP00000333/5} page 5, paragraph 24; Virdee {JRP00000333/7} page 7, paragraph 28; Virdee {JRP00000333/8} page 8, paragraph 32; Virdee {JRP00000333/12-13} pages 12-13, paragraph 51; White {JRP00000330/2-3} pages 2-3, paragraphs 13-17; White {JRP00000330/5} page 5, paragraph 43. See also oral evidence, Virdee {Day43/19:7}-{Day43/20:1}; with which Claire Williams agreed, Williams {Day55/202:5-22}. 167 White {JRP00000330/2} page 2, paragraph 13. 168 White {Day42/173:7-10}; Williams {Day56/35:9}-{Day56/37:14}; {Day56/45:16}-{Day56/47:9}. 169 {RYD00094235} (conformed copy).

Part 6 | Chapter 50: Organisations involved in the refurbishment 35 50.38 Those principally involved in the refurbishment on behalf of Rydon were: Stephen Blake, the Refurbishment Director Simon Lawrence, one of the contract managers Simon O’Connor, a project manager David Hughes, a site manager Gary Martin, a site manager Daniel Osgood, a site manager Zak Maynard, the commercial manager. 50.39 Stephen Blake was Refurbishment Director throughout the project.170 He assumed the role of contract manager in October 2015 following the departure of Simon Lawrence to see the project through to completion and was the most senior Rydon employee to be directly involved in the Grenfell Tower refurbishment.171 50.40 Simon Lawrence was the contracts manager responsible for the refurbishment from its inception until October 2015. As such he was the most senior Rydon employee with day- to-day involvement in and responsibility for the project.172 When he left Rydon in 2015 Stephen Blake took over his role. 50.41 Simon O’Connor was project manager for the refurbishment until September 2015.173 He had worked for Rydon since September 2002, progressing from foreman to site manager and then to project manager.174 The Grenfell Tower refurbishment was the first project for which he had taken on the role of project manager.175 It was his task to manage the day-to- day running of the project on site.176 50.42 David Hughes was employed by Rydon as a site manager for the Grenfell Tower project from October 2015 until its completion.177 He had worked for Rydon since November 2001, after graduating with a degree in civil engineering from Plymouth University.178 50.43 Gary Martin was employed by Rydon as a site manager on the Grenfell Tower project from May 2014 until its completion. Before joining Rydon he had worked for another company as a site manager on residential refurbishment projects.179 50.44 Daniel Osgood had joined Rydon in March 2014, starting in the role of temporary site manager.180 He was employed by Rydon as a site manager on the Grenfell Tower refurbishment from April 2015 until July 2015, when he was moved to work on a different project.181 At the time of the Grenfell Tower project, he had worked as a site manager for over 10 years.182 170 Blake {Day28/4:10-11}. 171 Blake {RYD00094225/7} page 7, paragraph 4.8. 172 Lawrence {Day22/16:3-9}. 173 O’Connor {RYD00094221/1-2} pages 1-2, paragraph 3. 174 O’Connor {Day26/3:19} 175 Blake {Day28/29:19-22}. 176 O’Connor {RYD00094221/1-2} pages 1-2, paragraph 3. 177 Hughes {RYD00094213/5} page 5, paragraph 22. 178 Hughes {Day27/3:19-22}. 179 Martin {Day30/4:4}. 180 Osgood {RYD00094212/1} page 1, paragraph 3. 181 Osgood {RYD00094212/1} page 1, paragraph 3; Osgood {Day30/100:3-5}. 182 Osgood {Day30/94:14-16}.

The Grenfell Tower Inquiry: Phase 2 Report 36 50.45 Zak Maynard was Rydon’s commercial manager, responsible for all financial aspects of the project,183 including the management of a team of several surveyors, the allocation of work packages to subcontractors, controlling budgets, assessing the financial implications of changes to the works and liaison with the employer’s agent.184 50.46 Although it took responsibility for all aspects of the design and execution of the works, Rydon did not employ within its organisation people with all the skills and expertise required to discharge its contractual obligations. As is common in the construction industry, it preferred to delegate the discharge of its responsibilities to a host of subcontractors, regarding itself as little more than the conductor of a large and varied orchestra of players. Later in the report we shall refer to the following subcontractors who were employed by Rydon on the refurbishment: Harley Curtain Wall and Harley Facades J S Wright & Co Ltd S D Plastering Ltd S D Carpentry Ltd. The facade sub-contractor: Harley 50.47 Harley Curtain Wall (“Harley CW”) was established in 1996 by Ray Bailey to carry on the business of designing and installing facades of buildings under construction. By 2013, Harley employed about 16 people,185 but none of them had any formal qualifications in facade engineering.186 Mr Bailey had been involved in several projects on high-rise residential buildings which had used ACM rainscreen panels before Harley undertook the work on Grenfell Tower.187 It was Harley’s practice to subcontract much of the work it undertook, including design, manufacture and the installation of the facade itself.188 50.48 Harley Facades was established in 2000, also by Ray Bailey. He had originally intended to use the two Harley companies on separate projects,189 but in the event Harley Facades remained dormant until 2015 when Harley CW went into administration. At that point it took over the work on the Grenfell Tower project.190 In Chapter 65 we describe how Harley came to be appointed and the key terms of its contract with Rydon. For present purposes it is sufficient to say that Harley was contractually responsible to Rydon for all aspects of the design and construction of the facade of Grenfell Tower, including the cladding, insulation, window frames, window infill panels, glazing and cavity barriers. 50.49 The people principally involved in the project on behalf of Harley were: Ray Bailey Mark Harris Mike Albiston 183 Maynard {Day31/7:9-14}. 184 Maynard {RYD00094346/1} page 1, paragraphs 4-6; Maynard {Day31/7:7}-{Day31/18:11}. 185 Ray Bailey {HAR00010184/3} page 3, paragraph 9. 186 Ray Bailey {Day32/11:16-20}. 187 Ray Bailey {HAR00010184/3} page 3, paragraph 10 and Ray Bailey {Day32/13:20}-{Day32/14:12}. Premier House, Castlemaine Tower, Clements Court, Ferrier Point, Chalcots Estate and Little Venice. 188 Ray Bailey {Day32/12:11}-{Day32/13:5}. 189 Ray Bailey {HAR00010184/2} page 2, paragraph 7. 190 Ray Bailey {HAR00010184/2} page 2, paragraph 7.

Part 6 | Chapter 50: Organisations involved in the refurbishment 37 Daniel Anketell-Jones Ben Bailey. 50.50 Ray Bailey was the founder of the Harley companies and was in overall control of the business. Mr Bailey graduated with a degree in civil engineering from Salford University in 1981 following which he worked for a number of companies in which he gained experience of all aspects of building envelopes, including design, manufacturing and installation.191 He had no formal qualifications in facade engineering.192 50.51 Mark Harris was a self-employed consultant in the field of commercial glazing and cladding appointed by Harley to assist with the Grenfell Tower project.193 He had been working exclusively for Harley since about 2011 and his experience lay mainly in the field of sales and developing business connections.194 By the time he became involved in the refurbishment of Grenfell Tower Mark Harris had been involved in several projects on which ACM panels had been used.195 50.52 Mike Albiston was Harley’s senior estimator for the Grenfell Tower project. His main contribution was assisting in the production of Harley’s tender for the work of designing and constructing the facade, which began in December 2013.196 50.53 Daniel Anketell-Jones had been engaged by Harley as a project engineer in November 2006197 and had been promoted to the role of design manager by the time Harley began work on the Grenfell Tower project.198 His main duties were to appoint a designer and monitor the progress of the design work until a project manager had been appointed. Between 2014 and 2017, while employed by Harley, he obtained an MSc in structural engineering and began studying for an MSc in facade engineering,199 but he had not received any instruction in the fire performance of facades until after he had left Harley and his involvement in the Grenfell project had come to an end.200 During his time at Harley Daniel Anketell-Jones had been involved in a design capacity in two previous high- rise overcladding projects.201 While working on the Grenfell Tower refurbishment he also worked on two other Harley projects.202 50.54 Ben Bailey is the son of Ray Bailey. He was employed by Harley as project manager for the Grenfell Tower refurbishment but had not been involved in that capacity on any previous project.203 He had worked for Harley from time to time while at school and university and had been taken on as a site manager following his graduation in 2013.204 Until about May 2017, Ben Bailey continued to be involved intermittently in the Grenfell Tower project 191 Ray Bailey {HAR00010184/1-2} pages 1-2, paragraph 4. 192 Ray Bailey {HAR00010184/2} page 2, paragraph 5. 193 Harris {HAR00010159/2} page 2, paragraph 7. 194 Harris {Day43/9:16-20}; Harris {HAR00010159/2} page 2, paragraph 8. 195 Harris {HAR00010159/2} page 2, paragraph 9; Harris {Day34/34:23}-{Day34/35:19}. Mr Harris told Bruce Sounes at Studio E in an email: “Over-cladding tower blocks is very much what we do…”. He attached project information sheets for Castlemaine Tower, Chalcots Estate and Clements Court {SEA00007603} dated 25 April 2013. 196 Albiston {HAR00010151/3} page 3, paragraph 9. 197 Anketell-Jones {Day35/114:4-11}. 198 Anketell-Jones {Day35/114:4-11}. 199 Anketell-Jones {HAR00010149/2} page 2, paragraph 7. 200 Anketell-Jones {Day35/116:6-18}. 201 Anketell-Jones {Day35/143:16}-{Day35/144:3} Ferrier Point and Little Venice. 202 Anketell-Jones {Day35/125:12-14}; Anketell-Jones {HAR00010149/2} page 2, paragraph 9. Trinity Square and Compass House. 203 Ben Bailey {HAR00010060/3} page 3, paragraph 9. 204 Ben Bailey {Day39/3:25}-{Day39/4:6}.

The Grenfell Tower Inquiry: Phase 2 Report 38 when maintenance requests or problems with snagging required attention.205 When he started work on the Grenfell Tower project Ben Bailey had no previous experience of managing the refurbishment of a high-rise residential building.206 Harley’s subcontractors 50.55 Harley engaged the following as sub-contractors: Kevin Lamb, to produce designs and construction drawings CEP Architectural Facades Ltd, to fabricate and supply ACM rainscreen cassette panels Osborne Berry Installations Ltd, to install the cladding. 50.56 Kevin Lamb was a self-employed designer of curtain walling and cladding, including glazing and rainscreen systems. He was engaged by Harley for the Grenfell Tower project in August 2014,207 having previously worked for it on one other project as a freelance draftsman.208 Mr Lamb had previously produced preliminary schematic drawings for the Chalcots Estate refurbishment undertaken by Harley.209 50.57 CEP Architectural Facades Ltd (CEP) was appointed by Harley as a subcontractor to fabricate and supply the rainscreen panels and glazing units for the Grenfell Tower refurbishment. Geof Blades was a director from 2004 until 2013, when CEP was sold.210 After that, he remained with the company as national glazing manager until 2016, when he became commercial projects manager. He retired in 2018. 50.58 CEP entered into six contracts with Harley between October 2014 and November 2015 for the fabrication and supply of rainscreen cladding panels and window units for Grenfell Tower.211 In addition, after Harley Curtain Wall had gone into administration, in September 2015 CEP entered into a contract with Rydon for the supply of Reynobond PE 55 panels.212 50.59 Osborne Berry Installations Ltd was established by Mark Osborne and Grahame Berry in 2002 as a corporate vehicle for their business of installing windows and cladding on buildings under construction or in the course of refurbishment.213 Osborne Berry had worked for Harley on many previous occasions and was engaged by Harley to install the facade, including the windows, cavity barriers, cavity wall insulation and the rainscreen panels.214 The company engaged self-employed fitters to carry out the work. 205 Ben Bailey {HAR00010060/3} page 3, paragraph 8. 206 Ben Bailey {Day39/12:4-9}. 207 Lamb {HAR00010419/3} page 3, paragraphs 12-15. 208 Lamb {HAR00010419/3} page 3, paragraph 12. 209 Lamb {Day37/67:6-14}; Lamb {HAR00010419/3} page 3, paragraph 12. 210 Blades {Day41/5:12}. 211 {CEP000000447}; {CEP000000469}; attaching {CEP000000470}; {CEP000000471}; {CEP000000472}; {CEP000000492}; {CEP000000512}; attaching {CEP000000513}; {CEP000000527}; {CEP000000528}; attaching {CEP000000529}; {CEP00053848}; {CEP000005833}; {RYD00040435}; {CEP000000616}; {CEP000000617}; {CEP000007550}; {CEP000001124}; {CEP000001168}. 212 {CEP000000693}. 213 Berry {OSB000000084/1} page 1, paragraph 1. 214 Berry {OSB000000084/1} page 1, paragraph 3; Ray Bailey {HAR00010184/24} page 24, paragraph 97; Berry {OSB000000084/2} page 2, paragraph 9; Berry {OSB000000084/3} page 3, paragraph 12; Berry {OSB00000091/9} page 9, paragraph 15; Osborne {OSB00000090/8} page 8, paragraph 15. Osborne Berry’s package of work did not include refurbishment of the internal window reveals/internal window trimming. That work was undertaken by SD Plastering. Osborne Berry was also instructed by Harley to undertake some measurements of Grenfell Tower – see Osborne {Day43/88:14-21}; Osborne {Day43/89:1}-{Day43/90:3}; Osborne {Day43/92:11}-{Day43/93:1}; Berry {MET00019985/1-2}; Osborne {OSB00000090/4} page 4, paragraph 7.

Part 6 | Chapter 50: Organisations involved in the refurbishment 39 50.60 There was no written contract between Harley and Osborne Berry215 and no document exists which sets out the terms on which Osborne Berry was engaged to carry out the work, the scope and content of that work, the standard to be applied or any programme for the works. Grahame Berry said that there may have been some conversations with Ray Bailey about a programme of works, but not about the quality or the standard of workmanship.216 Ray Bailey said that it was not uncommon for Harley to appoint subcontractors without any written contract.217 Other sub-contractors of Rydon 50.61 SD Plastering Limited (SDP) was incorporated in 2002. It was a company that mainly provided dry-lining services.218 Rydon sub-contracted a package of work to SDP, most of which comprised dry-lining, plastering, remodelling and ceiling works to the lower floors of the tower.219 In about February 2015, Rydon asked SDP to assist in designing the internal window linings and to carry out the work on the refurbishment of the internal window reveals.220 Rydon subsequently sub-contracted the work on the internal window reveals of the newly refurbished windows to SDP.221 50.62 Rydon employed J S Wright & Co Ltd to carry out the mechanical and electrical works which included the design and supply of a new smoke control and ventilation system for Grenfell Tower. J S Wright employed PSB UK Limited to design and install the smoke control and ventilation system. Building Control 50.63 Building control functions were carried out by RBKC’s building control department. John Allen had joined RBKC as an assistant district surveyor in 1996. By the time he became involved in the refurbishment in 2012, he was Head of Special Projects and was subsequently promoted to Building Control Manager in September 2013.222 He was directly involved in giving advice on the refurbishment in 2012 and 2013 before any application had been submitted. John Hoban took over responsibility for Grenfell Tower in about December 2013.223 Between 2014 and 2016 as Mr Hoban’s manager Mr Allen continued to be involved in the refurbishment and in due course the completion certificate for the refurbishment was issued in his name as Head of Building Control.224 50.64 John Hoban was a senior surveyor in RBKC’s building control department between 1986 and March 2017, when he retired.225 He holds BTEC ordinary and higher certificates in building studies. He worked as a junior technical officer in the Building Regulations division and from 1979 to 1986 as a technical assistant in the District Surveyor’s office 215 Berry {OSB000000084/3} page 3, paragraph 12; Ray Bailey {Day33/178:22-25}. Osborne Berry had never had any standard terms in the past that ever formed the basis of Osborne Berry’s contracts with Harley, Berry {Day44/15:6‑13}. 216 Berry {Day44/13:4-19}; {Day 44/14:1-3}. 217 Ray Bailey {Day33/179:2-4}. 218 Dixon {SDP00000196/2} page 2, paragraphs 6-7; Dixon {Day44/94:14-18}; Dixon {Day44/129:3-11}. 219 Dixon {MET00056695}; Dixon {Day44/100:10-14}. 220 {RYD00032519}. 221 Dixon {SDP00000196/4-5} pages 4-5, paragraphs 19- 20; Dixon {SDP00000196/5}; {SDP00000189}; Cole {SDP00000220/3} page 3, paragraphs 15-16. 222 Allen {RBK00033930/1} page 1, paragraphs 2-3; He took voluntary redundancy in early June 2017 but was asked to carry on his role after the fire before leaving RBKC 2018, Allen {Day47/4:24}-{Day47/5:13}. 223 {SEA00010232}. 224 Completion Certificate {RBK00018811}; Allen {Day47/187:10}-{Day47/188:2}. 225 {RBK00050415}.

The Grenfell Tower Inquiry: Phase 2 Report 40 of the Greater London Council.226 At the time of the refurbishment he was an associate member of the Chartered Association of Building Engineers.227 The refurbishment was the first project on which he had to deal with the overcladding of an occupied high-rise residential building.228 50.65 Paul Hanson was a senior building control surveyor (Fire Regulations) who acted as a consultant to the building control surveyors. 50.66 Jose Anon joined the building control department as a surveyor in 1989.229 In 2013 he was promoted to Deputy Building Control Manager.230 He was not involved in the refurbishment, save for one site visit on 17 April 2015.231 226 {RBK00050415}; Hoban {Day45/10:7-24}. 227 Hoban {Day45/12/24}-{Day45/13:9}. 228 Hoban {Day45/91/3-7}. 229 Anon {RBK00029897/2} page 2, paragraph 6. 230 Anon {RBK00029897/2} page 2, paragraph 6. 231 Anon {RBK00029897/8-9} pages 8-9, paragraphs 37-44.

41 Introduction 51.1 In this chapter we describe the background to the Grenfell Tower refurbishment project, including its origins and reasons, the establishment of the project team and the appointment of Studio E as architect. The Kensington Aldridge Academy and Kensington Leisure Centre (“KALC”) project 51.2 In 2009, the Royal Borough of Kensington and Chelsea (RBKC) instructed a design and planning consultant, Urban Initiatives Limited, to produce a report into options for the transformation of Notting Barns in North Kensington.232 The report proposed the demolition of Grenfell Tower due to the appearance of the building and the blight on its surroundings resulting from the way in which it met the ground and affected the area east of Latimer Road Station.233 The report envisaged a new academy for the area and a new leisure centre.234 51.3 The report was presented to an RBKC cabinet working group in September 2009.235 Rock Feilding-Mellen was then a backbench councillor who sat on the Public Realm Scrutiny Committee and was familiar with that report.236 Later, in 2012, when he held the portfolio for Civil Society,237 he became aware through a conversation with Cllr Timothy Coleridge of the proposal to refurbish Grenfell Tower and was concerned to know whether it would hinder or obstruct any future potential regeneration of the Lancaster West estate.238 Cllr Feilding-Mellen attended a meeting on 25 April 2012239 with Cllr Coleridge and Laura Johnson, RBKC’s director of housing, during which the refurbishment of Grenfell Tower and the effect of wider regeneration were discussed. Ms Johnson told Cllr Feilding-Mellen that there was an immediate need to decide whether to invest in Grenfell Tower and reassured him that such investment would not preclude the possibility of regenerating the wider estate in the future.240 51.4 In 2010 RBKC began work on the Kensington Aldridge Academy and Kensington Leisure Centre.241 The borough needed a new secondary school, for which RBKC had received a government grant. The school was to be located on the site of an existing leisure centre 232 Notting Barns South, Draft Final Masterplan Report, {IWS00002090/5}. 233 {IWS00002090/19}. 234 {IWS00002090/17}. 235 {RBK00057224}. 236 Feilding-Mellen {RBK00033403/5} page 5, paragraph 18. 237 Feilding-Mellen {RBK00033403/5} page 5, paragraph 20. 238 Feilding-Mellen {RBK00054433/2} page 2, paragraph 5. 239 {RBK00028392}. 240 Feilding-Mellen {Day131/138:15}-{Day131/139:16}. 241 Laura Johnson {RBK00034943/10} page 10, paragraph 44. Chapter 51 The origins of the Grenfell Tower Project

The Grenfell Tower Inquiry: Phase 2 Report 42 that was to be demolished and rebuilt as part of the same project. Together the work was known as the “KALC” project.242 A certificate of practical completion was issued on 13 November 2014.243 51.5 Laura Johnson was the senior responsible officer for the project and oversaw the project managers in RBKC’s property services team who managed it on a day-to-day basis.244 51.6 In September 2011, Studio E won the commission advertised by RBKC in the Official Journal of the European Union (“OJEU”) for the design of the KALC project.245 Studio E retained the services of specialist fire engineers Exova as sub-consultant.246 The reasons for the refurbishment of Grenfell Tower 51.7 RBKC recognised that the KALC project would be disruptive to residents of Grenfell Tower and consequently a KALC Residents Forum was set up, chaired by the RBKC Cabinet Member for Housing and Property, Cllr Timothy Coleridge. It first met on 18 July 2011247 and was usually attended by Cllr Coleridge, Laura Johnson, local residents and, on occasions, the KALC architects or contractors.248 The local residents who attended included some living in Grenfell Tower who were unhappy that KALC was being built while Grenfell Tower and the wider Lancaster West Estate was in need of refurbishment.249 51.8 In December 2011 Cllr Coleridge was invited to visit the flat of a resident of the tower, Edward Daffarn.250 He saw that the windows were very poor and single-glazed. Mr Daffarn told him that because the hot water was on all the time the flat was very hot in the summer but that it was very cold in the winter due to the lack of good insulation. Cllr Coleridge felt that something should be done for the residents of the tower and hoped that the rest of the Lancaster West estate could be refurbished in the long term.251 Grenfell Tower had seen no significant investment for 30 years.252 51.9 At about the time the KALC project was being undertaken, RBKC developed and sold basement space at Elm Park Gardens in Chelsea. The sale resulted in surplus capital receipts initially to the value of about £6 million.253 In late 2011, when RBKC knew that that money would become available, Cllr Coleridge raised with Laura Johnson the possibility that the funds might be used to improve Grenfell Tower.254 51.10 A meeting took place on 1 November 2011 between Jane Trethewey, RBKC’s Housing Strategy and Regeneration Manager, and representatives of the TMO, including Mark Anderson, the TMO’s Interim Director of Asset Investment and Engineering. At that meeting the effect of the KALC project on Grenfell Tower and the Lancaster West estate was discussed. In an email sent by Jane Trethewey of RBKC to Laura Johnson the following day, Ms Trethewey said that the TMO was keen to investigate the opportunity to overclad Grenfell Tower and replace its windows, which would have the advantage of improving one of its worst properties and preventing it looking like a poor cousin to the new facility 242 Coleridge {RBK00033737/4} page 4, paragraph 21. 243 {RBK00068791}. 244 Laura Johnson {RBK00034943/10} page 10, paragraph 44. 245 Kuszell {Day6/31:10-23}. This was a competitive procurement exercise. 246 Kuszell {Day6/36:3-16}. 247 Coleridge {RBK00064251/2} page 2, paragraph 5. 248 Coleridge {RBK00033737/4} page 4, paragraph 22. 249 Coleridge {RBK00033737/4-5} pages 4-5, paragraph 22. 250 Coleridge {RBK00064251/2} page 2, paragraph 4. 251 Coleridge {RBK00033737/5} page 5, paragraph 23. 252 Coleridge {RBK00064251/3} page 3, paragraph 7. 253 Coleridge {RBK00033737/4} page 4, paragraph 20. 254 Coleridge {RBK00064251/3} page 3, paragraph 8.

Part 6 | Chapter 51: The origins of the Grenfell Tower Project 43 being developed next door.255 It was also suggested that a cladding design might be chosen which corresponded to the design of KALC, thereby improving the overall visual appearance of the area.256 51.11 That is the first record we have found of any discussion of the possibility of cladding Grenfell Tower. In his evidence Mark Anderson said that the thermal efficiency of the building had been discussed at that time but not cladding as such,257 but the emails recording the discussion258 and Laura Johnson’s evidence suggest otherwise. She said that the primary motivation at that time for considering cladding had been the building’s appearance259 and accepted that RBKC had no reason to think that the thermal efficiency of the tower was poor enough to justify the cost of cladding.260 Laura Johnson said that she was probably the person who first mentioned the idea of cladding Grenfell Tower to the KALC project architects, Studio E.261 51.12 On 12 December 2011 Mr Anderson sent Ms Johnson an email containing indicative costings for cladding the tower.262 The costings came from Hunters & Partners Ltd, a firm of architects, quantity surveyors and building consultants who had been recommended to the TMO by RBKC, and were intended by Mr Anderson to give an indicative budget for the overall cost of the project.263 The assumptions behind the costings included using a rainscreen cladding incorporating an insulated panel. According to Mr Anderson, that assumption originated from Hunters.264 51.13 Mr Anderson prepared a report265 for the meeting of the TMO’s Operations Committee on 31 January 2012,266 the purpose of which was to advise the committee that RBKC might make funding available for significant regeneration. In that report Mr Anderson advised the committee that cladding Grenfell Tower and providing it with new windows would address the TMO’s need for investment in the building; he also told it that the KALC and Grenfell Tower projects would be procured jointly.267 51.14 On 9 February 2012 a housing digest meeting took place between RBKC and TMO. The purpose of such meetings was to provide an opportunity for the member of the RBKC cabinet holding the housing portfolio, at that time Cllr Coleridge, to meet the TMO and discuss important aspects of its delivery of the council’s housing strategy and investment.268 At that meeting there was detailed discussion about the proposed work to Grenfell Tower and it was noted that any new windows and cladding should reflect or complement KALC. Officers were planning to appoint Studio E to draw up a detailed design plan which was intended to provide the benefit of economies of scale and ensure that the two projects complemented each other.269 255 See the email from Jane Trethewey to Laura Johnson on 2 November 2011, containing a summary of the discussion – {TMO10000965/3-4}. 256 As above. 257 Anderson {Day52/44:22}-{Day52/45:2}. 258 {TMO10000965/3}. 259 Johnson {Day128/34:23}-{Day128/35:1}. 260 Johnson {Day128/35:3-8}. 261 Johnson {Day128/47:15-18}. 262 {RBK00002335}. 263 Anderson {Day52/46:21}-{Day52 47:7}. 264 Anderson {Day52/48:1-6}. 265 {TMO10001001/110-112}. 266 {TMO10001001}. 267 {TMO10001001/112}. 268 Anderson {Day52/49:5-14}. 269 {RBK00033739}.

The Grenfell Tower Inquiry: Phase 2 Report 44 51.15 Mark Anderson said that by that stage a decision had been made that cladding Grenfell Tower was also the route to achieving greater thermal efficiency. He said that the repeated use of the words “reflect” and “complement” in relation to the KALC project indicated a genuine desire on the part of RBKC not only to improve the Lancaster West estate in general and Grenfell Tower in particular, but also to ensure there was synergy between the two projects.270 He said that there had been a desire to give a good feeling about the Grenfell Tower refurbishment project and convey a message that North Kensington was receiving some very serious investment.271 Mr Coleridge also said that it had been clear that any insulation for the building would require a rainscreen of some sort, which would change the look of the building and could only improve its general appearance. It had been his view that, if it were decided that Grenfell Tower needed to be insulated, a fresh look at the exterior would be welcome.272 He had thought it a reasonable assumption that metal sheeting would be used as a rainscreen, which would result in a clean and contemporary look.273 51.16 In the light of that evidence, we are satisfied that the initial motive for cladding Grenfell Tower was to improve its visual appearance and to prevent its looking like a poor relation to the KALC development next door. RBKC in particular wished to ensure that the significant investment involved in the refurbishment resulted in a visible legacy. The desire to improve the thermal efficiency of the building was a later consideration, driven in part by Cllr Coleridge’s meeting with Mr Daffarn in late 2011. As Laura Johnson admitted, other than residents’ complaints about the windows, RBKC did not have any independent evidence that the thermal efficiency of Grenfell Tower was so poor that it needed overcladding.274 Funding the Grenfell project 51.17 Mr Anderson prepared a further report on the tower for a meeting of the TMO board on 29 March 2012.275 In it he recommended that the board approve the submission of a Housing Revenue Account (HRA)276 Regeneration Bid for Grenfell Tower in the sum of £6 million (excluding VAT) together with the appointment of the members of the existing KALC design team to undertake the detailed development of the project.277 He informed the board that RBKC had already appointed professionals for the KALC project and proposed that, subject to due diligence and legal compliance, they also be appointed to undertake the work on the Grenfell Tower project, subject to a dispensation from the full TMO Contract Regulations.278 His recommendation was accepted by the TMO board, 270 Anderson {Day52/50:21}-{Day52/51:4}. 271 Coleridge {RBK00064251/10} page 10, paragraph 27. 272 Coleridge {RBK00064251/10} page 10, paragraph 27. 273 Coleridge {RBK00064251/6} page 6, paragraph 17. 274 Johnson {Day128/32:15} – {Day128/33:6}. 275 {TMO10001095}. 276 The Housing Revenue Account (HRA) was used by RBKC and the TMO to account for housing income and expenditure. It was used for day-to-day repairs, planned and major works and all other costs relating to RBKC properties managed by the TMO. See, for example, Johnson {RBK00034943/3} page 3, paragraph 10 and Matthews {TMO00873380/10} page 10, paragraph 36. 277 {TMO10001095/4}. 278 See paragraphs 5.2 and 5.3 {TMO10001095/3}. The Royal Borough of Kensington and Chelsea Tenant Management Organisation Ltd Contract Regulations were approved by the TMO board on 26 May 2011 {RBK00000762}. Those Regulations provided the framework for the procurement by the TMO of goods, works and services. They were intended to ensure propriety, compliance with statutory and other regulatory frameworks, and the proper use of financial resources. They required a competitive tendering process in accordance with the regulations for any contract with a value in excess of £25,000, see {RBK00000762/7} paragraph 6.04.

Part 6 | Chapter 51: The origins of the Grenfell Tower Project 45 which unanimously agreed to the submission of the bid and the appointment of the KALC consultant team for the project. The board also agreed to dispense with the TMO Contract Regulations guidelines for that appointment.279 51.18 Following that approval, the RBKC cabinet met on 2 May 2012 to consider a report prepared by Laura Johnson on the use of the funds derived from the sale of basements at Elm Park Gardens.280 The report recommended that they be set aside for investment in renovation, regeneration and conversion works to Grenfell Tower.281 The cabinet accepted that recommendation.282 Consequently, RBKC funded the Grenfell Tower project and had oversight of how it was undertaken.283 279 {TMO00847333}. 280 {RBK00029027}. 281 {RBK00029027/8} paragraph 6.3.3. 282 {RBK00047482}. 283 Laura Johnson {Day128/9:5-12}.

The Grenfell Tower Inquiry: Phase 2 Report 46

47 52.1 Although the TMO appointed other professionals engaged on the KALC project to act on the Grenfell Tower project (Artelia, Curtins, Max Fordham and Exova), at this stage we concentrate on Studio E’s appointment because it provides some context in which to judge its performance. It also illustrates the TMO’s general approach to the appointment of its professional team, which was to prioritise saving cost over other considerations. 52.2 Peter Wright284 met Andrzej Kuszell, one of the founding directors of Studio E and lead partner on the KALC project, on 9 December 2011 at RBKC Town Hall to discuss the Grenfell Tower refurbishment.285 The agenda for that meeting included a review of the scope of the works to be carried out,286 although Mr Kuszell told us that it was not certain that the works to the tower would be commissioned and that he had understood it to be merely an exploratory meeting.287 52.3 Mark Anderson’s recollection was that the TMO had formally engaged Studio E in February 2012.288 He said that RBKC had expressed a strong desire for the TMO to make use of the original KALC professional team, which included Studio E and Artelia.289 He said that the drive to use the KALC team had come from the portfolio holder, who at that time was Cllr Coleridge, and also from all the RBKC officers with whom he had had dealings.290 Mr Anderson said that he had not been told that the TMO was required to use that team, but there had been a very strong message that that was RBKC’s earnest wish.291 Mr Anderson said that he thought the TMO would have been challenged by RBKC if it had not instructed them.292 52.4 Laura Johnson said that she was aware that such a wish might have been expressed by RBKC293 and that the dominant reason for using the same professional team had been to harmonise the appearance of the two projects and co-ordinate them so that there was an understanding of how they were to work together.294 Like Mr Anderson, she accepted that the TMO would have been challenged by RBKC if it had decided not to use the KALC team.295 52.5 Grenfell Tower was Studio E’s first residential high-rise cladding project and yet Mr Anderson told us that no steps had been taken before it was appointed to find out whether it had any experience of a project of that kind.296 He accepted that that was an obvious question and could not explain why no one had asked it.297 284 Project Manager for Capital Projects in RBKC’s Corporate Property Department. 285 Kuszell {SEA00014271/9} page 9, paragraph 34; {TMO10000965/4}. 286 {SEA00003557} at Item 2. 287 Kuszell {Day6/43:18-25}. 288 Anderson {Day52/59:16-19}. 289 Anderson {Day52/60:2-7} Artelia was previously known as Appleyards. 290 Anderson {Day52/60:17-22}. 291 Anderson {Day52/61:16-22}. 292 Anderson {Day52/61:1-4}. 293 Johnson {Day128/59:2-14}. 294 Johnson {Day128/60:6-14}. 295 Johnson {Day128/63:10-14} 296 Anderson {Day52/64:5-9}; Kuszell {Day6/63:16-20}. 297 Anderson {Day52/64:10-11}. Chapter 52 The appointment of Studio E

The Grenfell Tower Inquiry: Phase 2 Report 48 52.6 The first formal communication from the TMO to Studio E, which set out the TMO’s requirements for Grenfell Tower, was sent by Mark Anderson to Andrzej Kuszell on 29 February 2012.298 Mr Anderson identified the principal objectives of the project and stated that the work would be separate from, but complementary to, the KALC project. He also said that it must not in any way compromise the KALC project, by which he meant that RBKC did not want the Grenfell project to impede the KALC project.299 52.7 Mr Anderson went on to state that all commissions on the project would be paid by the TMO and were subject to OJEU limits. He accepted that his intention in saying that was to direct Studio E to produce a fee estimate that would fall below the financial threshold for services contracts300 in order to avoid a public procurement process.301 Mr Anderson said that no discussion had taken place at that time with Studio E regarding the OJEU limit or the effect it would have on Studio E’s fees.302 He recalled a discussion about OJEU limits with Bruce Sounes on 6 March 2012 and agreed that they effectively capped Studio E’s fees, but he also said that there had been no indication from Studio E or from any other members of the professional team that they saw it as a cap or that their fees were likely to approach it.303 52.8 The Studio E witnesses, on the other hand, told us that they had been concerned about the capping of their fees at the OJEU limit.304 Mr Anderson sent his email of 29 February 2012 to Bruce Sounes305 as well as Andrzej Kuszell, which prompted a discussion within Studio E about the challenge which the limit on the level of fees would present for the project. Mr Sounes replied directly to Mr Kuszell that evening saying that he was concerned about the emphasis of working at risk (i.e. pending a formal agreement) while also being subject to OJEU limits.306 On 7 March 2012 Mr Sounes mentioned to Mr Kuszell that he (mistakenly) thought the OJEU limit was £99,000, which Mr Kuszell said in his reply would be “problematic”.307 Mr Kuszell told the Inquiry that he had thought that even a limit of £174,000 would result in Studio E doing more work than the fee would cover.308 Mr Sounes also thought the overall fee to deliver the project would be more than £174,000,309 but there is no evidence that either he or Mr Kuszell raised their concerns with the TMO.310 52.9 On 12 June 2012 Bruce Sounes sent Mr Anderson a fee proposal and draft letter of appointment.311 The proposal was for Studio E to provide architectural services under the Standard Conditions of Appointment for a Consultant (2010) published by the Royal Institute of British Architects (RIBA). (We refer to these as the RIBA Standard Terms.) However, no agreement was signed at that stage and in the event discussions about the terms on which Studio E was to be appointed continued until November 2013.312 298 {SEA00000007/1-2}. 299 Anderson {Day52/91:20-25}. 300 See Regulation 8 of the Public Contracts Regulations 2006 (as amended). 301 Anderson {Day52/92:20}-{Day 52/93:4}. 302 Anderson {Day52/93:21}-{Day 52/94:8}. 303 Anderson {Day52/96:1-8}. 304 Kuszell {Day6/71:4-24}; {SEA00003567}. 305 {SEA00000007}. 306 {SEA00003567}. 307 Kuszell {SEA00014271/12} page 12, paragraph 44; {SEA00014272/2}. 308 Kuszell {Day6/87:13-19}. 309 Sounes {SEA00014273/32} page 32, paragraph 63. 310 Sounes {Day7/38:23}-{Day7/39:7}. 311 {SEA00004561}; Bruce Sounes chose to put forward the RIBA standard form contract terms. Sounes {Day7/56:7}-{Day7/57:4}; The covering letter {SEA00004562} attached: The RIBA Standard Conditions of Appointment for a Consultant (2010) {SEA00004571}, The Standard Conditions of Appointment for an Architect Amendment 1 (1 October 2011) {SEA00004564}, A Memorandum of Agreement {SEA00004570} and appendices A-E {SEA00004565}, {SEA00004566}, {SEA00004563}, {SEA00004567}, {SEA00004568}, {SEA00009827}. 312 Sounes {Day7/57:8-25}; {SEA00009820}.

Part 6 | Chapter 52: The appointment of Studio E 49 Both parties contemplated that the refurbishment would be carried out under a design and build contract and that if Studio E were appointed by the TMO as architect its services would in due course be transferred to the principal contractor by what is known as a “novation”. 52.10 The proposal was for a fee of £323,000 for all stages of the work (including work to be done after the novation) but only £161,000 for the work to be done before the novation that the TMO had said should be subject to OJEU limits.313 Although Mr Sounes attempted to persuade us that it was a fairly typical breakdown of fees314, Artelia advised the TMO in a meeting on 18 July 2012, attended by Mr Sounes, that working to OJEU limits would probably involve deferring some of Studio E’s fees to the period after novation, when the contractor would become liable for them.315 52.11 In the event, that is exactly what happened. Studio E produced a further fee proposal on 27 July 2012 which showed the fees for the pre-novation design work as £190,000.316 However, in his covering email to the TMO Mr Sounes proposed deferring 50% of all Stage D fees to keep the total Stage D fee below £174,000.317 52.12 The TMO board met on 15 November 2012. In advance of that meeting Mr Anderson prepared a report on the Grenfell Tower project,318 in which he advised the board that the design team had been engaged by the TMO under its own contract regulations. He also told the board that the fees had been capped at the EU procurement threshold of £174,000 because the procurement process for the design team on KALC did not cover the Grenfell Tower Regeneration project.319 That represented a change from the position he had reported to the board in March 2012.320 The report went on to state that the novation of the Grenfell Tower design team to Leadbitter (the principal contractor for KALC and at that time the proposed principal contractor for the Grenfell Tower project) after the planning stage would be compliant with EU procurement rules because the Grenfell Tower project had been included in the OJEU notice relating to the KALC project.321 However, that statement was wrong, as no mention of the Grenfell Tower project had been made in the OJEU Notice relating to the KALC project.322 52.13 By December 2012, Studio E had already issued invoices totalling £174,000 and had stopped invoicing the TMO because it had, in Bruce Sounes’ words, “reached the OJEU threshold”.323 It follows that Studio E’s fees were always going to exceed the OJEU limit and the capping of its fees by the TMO was a way of avoiding a competitive procurement exercise for design services on the project. 52.14 The appointment of Studio E as architect for the project involved no element of competitive procurement whatsoever.324 No member of the firm was interviewed as part of a competitive procurement and there was no design competition.325 Mr Anderson said he had thought that, because the OJEU notice published for the KALC project had included 313 {ART00000148}. 314 Sounes {Day7/42:7}-{Day7/43:17}. 315 {ART00000168}; Sounes {Day7/44:14-18}. 316 {SEA00007386} under the Studio E tab of the spreadsheet. 317 {ART00000981}. 318 {TMO10001766/90}. 319 {TMO10001766/91} paragraph 5.2. 320 {TMO10001095/3} paragraph 5.2. 321 {TMO10001766/91} paragraph 5.3. 322 {TMO10005215}; {RBK00068762}. 323 Sounes {SEA00014273/78} page 78, paragraph 162. 324 Anderson {Day52/73:22-25}; Kuszell {Day6/64:22-25}. 325 Kuszell {Day6/65:1-6}.

The Grenfell Tower Inquiry: Phase 2 Report 50 the term “housing regeneration”, the TMO could rely on the outcome of that exercise to appoint Studio E for the Grenfell Tower project, even though that project had not been mentioned in the notice.326 He also told us that he had asked the council’s legal department and those responsible for procurement whether he could rely on the procurement process for the KALC project to appoint the same professional team for the Grenfell Tower project and was told that he could.327 However, he did not receive confirmation of that advice in writing and in due course it changed.328 It is hard to see how Mr Anderson could possibly have thought that it was permissible for the TMO to rely on the procurement process undertaken by RBKC for the KALC project to justify its appointment of Studio E on the Grenfell Tower refurbishment, but if he did, he was obviously mistaken. 52.15 On 11 November 2013, Bruce Sounes sent Peter Maddison by email a revised set of contractual documents.329 The RIBA Standard Terms were not included in the attachments, but Mr Sounes confirmed that they were the terms on which he was proposing that Studio E be engaged and we are satisfied that that is how the proposal was understood by Mr Maddison. 52.16 By 20 November 2013 the terms of Studio E’s appointment appear to have been agreed in principle330 but Mr Sounes could not recall whether a letter of appointment had ever been signed and Studio E was unable to find a copy of an agreement.331 Given the inability of either party to produce a signed copy of the terms of appointment, we think it very unlikely that a formal written agreement between Studio E and the TMO was ever signed. That does not matter for present purposes, because both parties accept that a contract came into existence between them incorporating the RIBA Standard Terms.332 However, it demonstrates a casual approach to the establishment of contractual relations which we have found to exist in relation to other aspects of the refurbishment and which appears to be widespread in the construction industry. In our view a more rigorous and careful approach at all levels would significantly reduce the risks of disagreement about where responsibility for important matters lies. 52.17 In the Schedule of Services in Appendix B to the contract documents, Studio E was designated as lead consultant and lead designer for RIBA Stages A to L of the project,333 a position that was confirmed by Mr Sounes in a letter to the TMO in November 2013.334 In the light of the documents and Mr Sounes’ evidence, it is clear to us that Studio E was appointed as lead consultant. As such, it had a duty to advise on the need for, and the scope of services to be provided by, consultants, specialists, sub-contractors or suppliers and to monitor the work of other consultants.335 326 Anderson {Day52/70:15-23}. 327 Anderson {Day52/78:25}-{Day 52/79:9}. 328 Anderson {Day52/79:10-16}. 329 {SEA00009820}; The family of updated contract documents are {SEA00009821}; {SEA00009822}; {SEA00009823}; {SEA00009824}; {SEA00009825}; {SEA00009826}; {SEA00009827}; {SEA00009828}; {SEA00009829}; {SEA00009830}; and {SEA00009831}. 330 {SEA00009993}; Sounes {Day7/58:3-12}. 331 Sounes {Day7/58:3}-{Day7/59:4}; {Day7/60:18-21}; Sounes {SEA00014273/11} page 11, paragraph 26. 332 Sounes {Day7/61:16}-{Day7/62:19}; {Day7/79:2}-{Day7/80:5}; {Day7/80:9-19}. 333 {SEA00009824/2}. 334 See letter {SEA00009821} and attached contract documents {SEA00009822} and {SEA00009824/2}. 335 See Appendix B: Schedule of Services {SEA00009824/5} sent by Bruce Sounes to Peter Maddison on 11 November

1. The version sent to Mark Anderson on 12 June 2012 also says the same thing {SEA00004566/5}. Bruce Sounes

agreed that these services were part of Studio E’s role as Lead Consultant. Sounes {Day7/80:9-19}.

Part 6 | Chapter 52: The appointment of Studio E 51 52.18 The RIBA Standard Conditions obliged Studio E to exercise reasonable skill, care and diligence in accordance with the normal standards of the architectural profession when performing its services.336 52.19 Studio E did not have any previous experience of providing architectural services in respect of the refurbishment and cladding of an existing residential high-rise building.337 The process of appointing Studio E as architect for the Grenfell Tower project did not require it to demonstrate that it had the relevant skills, knowledge or experience for such a project.338 Mr Sounes said that Studio E had not held itself out as having any such experience,339 but neither Mr Kuszell nor Mr Sounes could remember ever having informed the TMO or Artelia that it did not have experience of high-rise projects or cladding. Thus, by failing for purely financial reasons to follow the proper procurement process, the TMO deprived itself of the opportunity to appoint a firm of architects with relevant skills, knowledge and experience. 52.20 In his email to Mr Kuszell dated 29 February 2012 Mr Sounes described Studio E as a “little green on process and technicality”. He therefore suggested “some rapid CPD” (i.e. continuing professional development).340 Mr Sounes said that by “green on process” he had meant to refer to the logistics of undertaking work on an occupied building.341 He had noted that overcladding the building formed part of the work, which had struck him as a challenge. He said the challenge lay in the fact that the building was to remain occupied during the work, rather than in the cladding work itself.342 By “rapid CPD”, Mr Sounes said that he had meant nothing more than a consultation to understand the feasibility of how the work could be done, which he said he had undertaken with an employee of Max Fordham, the mechanical and electrical engineers engaged on KALC.343 Mr Sounes said that his initial concerns about taking on the project had been allayed344 and that despite his initial uncertainty he had been satisfied that Studio E had the experience and expertise necessary to take on the work being discussed at that stage.345 He agreed that he had decided that it was possible for him to learn on the job as the project proceeded.346 52.21 Mr Kuszell accepted that it was necessary for Studio E to carry out some continuing professional development and to conduct research to identify the various challenges the project might throw up,347 but he said he had had no reason to believe that the firm was not competent and adequately resourced to do that.348 He said that Studio E had experience of undertaking complex projects for the first time and that he had no reason to doubt that it would do the research necessary to do the project properly.349 336 {SEA00004571/4}. See Condition 2.1 under the subheading ‘Duty of Care’. Bruce Sounes confirmed that this condition was consistent with the standard of service required by Studio E’s professional indemnity insurance. Sounes {Day7/61:16} – {Day7/62:7}; {Day7/79:24}-{Day7/80:5}; {Day7/80:9-19}. 337 Kuszell {MET00019989/3} page 3; Kuszell {SEA00014271/4-5} pages 4-5, paragraph 17; Sounes {SEA00014273/32} page 32, paragraph 64; Kuszell {Day6/80:5-15}. 338 Kuszell {Day6/64:14-21}. 339 Sounes {Day6/194:6-20}. 340 {SEA00003567/1}; Sounes {SEA00014273/32} page 32, paragraph 64. 341 Sounes {Day6/185:24}-{Day6/186:4-5}. 342 Sounes {Day6/186:22-25}; {Day6/187:1-7}; {Day6/192:12-14}. 343 Sounes {Day6/188:5-8}; {Day6/189:10-12}; {Day6/190:2}-{Day6/191:9}; {Day6/192:18-25}; Sounes {SEA00014273/32} page 32, paragraph 64. 344 Sounes {Day6/192:15-16}. 345 Sounes {SEA00014273/32} at paragraph 64. 346 Sounes {Day6/194:3-5}. 347 Kuszell {Day6/74:15-17}; {Day6/77:21-23}. 348 Kuszell {Day6/76:17-23}. 349 Kuszell {Day6.75:15-21}; {Day6/76:2-6}; {Day6/80:21-24}.

52 The Grenfell Tower Inquiry: Phase 2 Report 52.22 Both Mr Kuszell and Mr Sounes accepted that, given Studio E’s lack of relevant experience, if a competitive procurement process for architectural services had been undertaken in relation to the Grenfell Tower project, it was unlikely that Studio E would have qualified for appointment.350 350 Kuszell {Day6/70:10-16}; Sounes {SEA00014273/32} page 32 paragraph 63; Sounes {Day6/196:13}-{Day6:197:23}.

53 Initial design team meeting: April 2012 53.1 The Grenfell Tower refurbishment began life as an independent project on 19 April 2012 with an initial design team meeting attended by Studio E, Max Fordham and Leadbitter.351 Artelia was also present as a potential consultant for the TMO, having acted as employer’s agent and quantity surveyor for the KALC project.352 Simon Cash was designated project director for the refurbishment, the most senior position with overall responsibility for the delivery of Artelia’s services.353 The purpose of the meeting was to introduce the project, to set out in broad terms its scope and objectives and to discuss costs and funding. The TMO indicated that it would request a budget of £6m from RBKC for the full cost of the works.354 53.2 On 2 May 2012 Simon Cash wrote to Mark Anderson of the TMO offering to perform quantity surveying, employer’s agent and CDM co-ordinator (CDM-C) services for the refurbishment.355 The letter appended RICS standard forms of contract for employer’s agent and quantity surveying services356 and a list of CDM-C services.357 53.3 On 21 August 2012 Mark Anderson confirmed that the TMO wished to appoint Artelia to carry out those functions on the terms outlined in its proposal of 2 May 2012 under the standard RICS standard terms. Although the parties did not sign a contract at that time,358 both appear to have acted on the basis that they were contractually bound on the terms set out in Artelia’s proposal. Eventually, on 23 June 2014, Artelia and the TMO executed a formal deed of appointment incorporating the RICS standard terms.359 The Schedule of Services stated that Artelia would perform the roles of quantity surveyor, employer’s agent and CDM co-ordinator.360 Artelia’s cost budget estimates in 2012 53.4 A second design team meeting was held on 24 May 2012.361 At that meeting Chweechen Lim, a quantity surveyor employed by Artelia, was instructed to prepare a cost budget estimate for the project. 351 {ART00000013}. 352 Cash {ART00006544/5-6} pages 5-6, paragraph 16. 353 Cash {Day47/210:21-23}. 354 {ART00000013/4} item 5.0. 355 {ART00000301}. This letter attached documents including: the RICS standard form of Quantity Surveyor Services; the RICS standard from of Employer’s Agent Services and a printed list of services stated to be a summary of the duties of a CDM-C under the CDM Regulations 2007. 356 {ART00000301/7}; {ART00000301/17}. These documents listed specific functions which Artelia selected by marking tick boxes. 357 {ART00000301/24} stated to be a summary of the statutory duties of CDM-C. 358 Cash {Day47/213:24}-{Day47/214:2}. 359 {ART00005742}. 360 {ART00005742/23}. 361 {ART00000038}. Chapter 53 Planning the refurbishment

The Grenfell Tower Inquiry: Phase 2 Report 54 53.5 Between June and December 2012 Chweechen Lim prepared several cost budgets for the TMO under the supervision of Simon Cash.362 The estimates were based on information provided by the primary designers of the project, Studio E, Curtins Consulting and Max Fordham363 and ranged from £7,803,000 to £9,645,000. 53.6 The first estimate in 2012, which costed the project at £7,803,000, was presented at the third design team meeting on 7 June 2012.364 At that meeting Mark Anderson, then interim Director of Asset Investment and Engineering at the TMO, indicated that he was content with the projected cost. He confirmed that RBKC’s funding was £6 million, but that he expected further funds to be made available from the TMO’s capital programme.365 53.7 During 2012 the estimated total cost of the project changed several times, increasing by December 2012 to £9,645,000. The changes were attributable to a number of factors, including changes to the scope of the works and corrections of errors in measurements. 53.8 After June 2012, none of Artelia’s estimates were within the budget available to the TMO, a fact not lost on those involved in the project. In mid-September 2012, after Ms Lim had costed the project at £9,280,000,366 both Artelia and Studio E told the TMO that either the budget must increase, or savings must be achieved, whether by reducing the scope of the project or through “value engineering”.367 In theory, “value engineering” involves making changes to the design or specification that reduce cost without sacrificing performance,368 but in our view it is in practice little more than a euphemism for reducing cost, because substituting a cheaper product for a more expensive one or altering the design or scope of the work in a way that reduces cost almost invariably involves a compromise of some kind, whether in content, performance or appearance. Certainly, in the present case the expression was being used by the parties simply to mean changes that would lead to a reduction in cost. Leadbitter’s proposed appointment 53.9 At the outset of the Grenfell refurbishment project, and throughout 2012, the TMO had planned to engage Leadbitter Group (“Leadbitter”), the principal contractor for the KALC project, using the IESE (“Improvement and Efficiency in the South East”) framework agreement, which was a legitimate alternative to a full procurement exercise.369 Accordingly, representatives of Leadbitter were present at most of the Grenfell project meetings in 2012 and were on the distribution list for the minutes. Leadbitter became involved in some activities, including preparing a programme of works370 and conducting site inspections.371 However, retaining Leadbitter was not uncontroversial within the TMO and the minutes of a meeting of the TMO board on 24 May 2012 record that it needed to be persuaded that using Leadbitter was in the TMO’s best interests.372 Efforts by Mark Anderson to persuade the TMO board to appoint Leadbitter continued until at least 362 Lim {ART00005817/5} page 5, paragraph 15; Cash {Day48/2:5-6}. 363 Cash {Day48/130:24}-{Day48/131:1}. 364 {ART00000079}. 365 {ART00000079/1} The TMO Capital Programme was an RBKC-funded investment programme for works to improve residences. 366 In Estimate 3 Rev 1 {ART00005913}. 367 {ART00005879}; {ART00005783}; {ART00006081}. 368 Hyett, Specialist Report {PHYR0000028/13} section 3.3.21 quoting the definition of value engineering in the RIBA Stage Guide 2015. 369 Anderson {Day52/73:13-21}; Anderson {TMO00847334/2} page 2, paragraph 8. 370 Minutes of meeting 5 {ART00000169}, item: “Programme”. 371 Minutes of meeting 10 {ART00000489}, item: “Contractor”. 372 {ART00000038/1} item 1.00.

Part 6 | Chapter 53: Planning the refurbishment 55 November 2012,373 but although it authorised the TMO to enter into a pre-construction agreement with Leadbitter,374 the TMO failed to do so, probably because RBKC and Leadbitter had been unable to agree a final cost for the KALC project, as explained below. 53.10 At the beginning of 2013, RBKC and Leadbitter were negotiating the final account for the KALC project, but they were finding it difficult to reach agreement.375 On 3 January 2013, Laura Johnson sent an email to Cliff Thomas of Leadbitter telling him that in view of the continuing failure to agree the final account for KALC, RBKC would no longer be recommending that the TMO appoint Leadbitter on the Grenfell Tower project and would advise it to invite tenders from a list of contractors that did not include Leadbitter.376 53.11 Although Ms Johnson was the senior responsible officer for the KALC project, she was not the senior responsible officer for the Grenfell Tower refurbishment. Nor was anyone else at RBKC, because the refurbishment was a TMO project and RBKC had no power to decide which contractors the TMO should appoint to deliver its projects.377 Nevertheless, that did not stop her trying to use Leadbitter’s interest in the Grenfell Tower project as a means of putting pressure on it to agree the final account for the KALC project.378 Ms Johnson took the precaution of sending a copy of her email to Mark Anderson of the TMO so that he would see that RBKC, as the TMO’s funder, was seeking to apply pressure to Leadbitter in that way. Although Artelia had also received a copy of Ms Johnson’s email to Leadbitter, it nonetheless continued to hold discussions with Leadbitter about the cost of the refurbishment because the TMO was Artelia’s client and the TMO wanted Artelia to carry on negotiating with Leadbitter.379 53.12 Despite the advice from Artelia and Studio E to increase the budget or achieve savings, the estimated cost of the project continued to rise. The TMO had wanted to enter into a contract with a principal contractor for the refurbishment works by 8 January 2013380 and therefore by December 2012 there was a pressing need to agree a fixed sum for the project with Leadbitter, which at that time was still expected to be the principal contractor.381 Discussions between Leadbitter and Artelia: January–April 2013 53.13 The IESE framework provided for a two-stage mini-tender procurement process for use by public bodies in the south-east of London. The first stage of the process was the selection of a contractor from eight on the framework list; the second was negotiating with that contractor to agree a price.382 As Leadbitter had already been selected at the outset of the Grenfell Tower project, the IESE process effectively began with negotiating the contract price. 53.14 However, even before discussions had started, Leadbitter indicated that it considered Artelia’s cost estimate for the project to be £2 million too low.383 In January 2013, one of its quantity surveyors, Mohit Kotecha, estimated the cost at £12.6m.384 Between January and April 2013, Ms Lim and Mr Kotecha exchanged assessments of the cost of the project, 373 TMO Board meeting minutes, 15 November 2012, {TMO10001766/90-93}. 374 TMO Board meeting minutes, 15 November 2012 Part B {TMO00883922/2-3} item 2. 375 Laura Johnson {Day128/116:3-16}. 376 {ART00000637}. 377 Anderson {Day52/28:11-22}. 378 Laura Johnson {Day128/118:25}-{Day128/119:1-2}. 379 Cash {Day48/152:9-19}. 380 As recorded in the minutes of the 22 November 2012 meeting {ART00006750} item 2.2. 381 {ART00000633/4}. 382 Lim {ART00009428/10} page 10, paragraph 27. 383 {ART00008469} item 3. 384 Kotecha {LBI00003938/3} page 3, paragraph 9.

The Grenfell Tower Inquiry: Phase 2 Report 56 commenting on each other’s calculations in detail. They also met in person several times.385 Both Artelia and Leadbitter adjusted their assessments as a result, having taken into account a number of factors, including some value engineering options.386 53.15 Artelia attempted to test its cost assessments by approaching various contractors who had procurement framework agreements with RBKC.387 At the suggestion of Peter Maddison, Director of Assets and Regeneration at the TMO,388 in April 2013 Artelia also approached Rydon, even though it was not included in any available framework agreements.389 Although it was not unusual for potential competitors to be asked to provide information for the purpose of checking costs,390 none of the contractors approached for that purpose did so. 53.16 Leadbitter’s costings drew attention once again to the main difficulty facing the TMO, namely, the inadequacy of its budget. Both Ms Lim and Mr Kotecha, the professional quantity surveyors in the best position to assess the costs, agreed that they exceeded the funds available by a significant margin.391 Although they worked to understand the differences between their analyses, others in the design team and the TMO tried to find ways to bring the project within budget.392 53.17 The cladding was a focal point of the discussions about savings, being described by Bruce Sounes as an obvious target.393 The TMO also asked for information on the savings that could be made, including specifically on cladding.394 By April 2013, the cladding, together with the crown and the construction of the new windows, was assumed by all involved in the project to be a prime area in which costs could be reduced and it featured prominently in budget discussions from that point onwards. A new procurement process considered: February 2013–April 2013 53.18 Peter Maddison joined the TMO in January 2013 as Director of Assets and Regeneration. Like his predecessors, he was attuned to the relationship between RBKC and the TMO and regarded RBKC effectively as TMO’s client.395 He and Laura Johnson had several meetings about the Grenfell Tower refurbishment in the first quarter of 2013.396 Ms Johnson accepted that in early 2013 she had discussed the relationship between RBKC and Leadbitter with Mr Maddison and had mentioned the difficulties she was having with Leadbitter on the KALC project.397 53.19 By late February 2013, Peter Maddison and Paul Dunkerton, who was working as a freelance project manager for the TMO, had become frustrated with what they perceived to be the slow progress of the negotiations with Leadbitter on the Grenfell Tower project. On 27 February 2013, Mr Dunkerton asked Alun Dawson of Artelia to produce a 385 For example: 17 January 2013 {ART00006072/2}; Lim {ART00005817/14} page 14, paragraph 52; and 25 March 2013 {ART00006018}; {ART00006074}. 386 {ART00006072}. 387 {ART00001005}; {ART00009101/18}. 388 Maddison {Day58/178:19}-{Day58/179:1-4}; {RYD00001115}. 389 {ART00008995}; {ART00008434}; {ART00009105}. 390 Lim {ART00009428/17} page 17, paragraph 49. 391 Cloke {MET00070907/5} page 5. 392 {ART00006129/2}; {ART00005911}. 393 {ART00005911/1-2}. 394 On 27 February 2013 {ART00005807}; 22 March 2013 {ART00006017}. 395 Maddison {Day57/80:19-25}-{Day57/81: 12}. 396 See Maddison’s notebook for January – May 2013 {TMO00879771} for example, at page 26 (for 13 February 2013). 397 Laura Johnson {Day128/119:21-24}.

Part 6 | Chapter 53: Planning the refurbishment 57 programme based on running a fresh procurement process for a principal contractor398 and from about that time work on a new procurement exercise ran in tandem with the attempt to agree a price with Leadbitter for the refurbishment. The TMO Programme Board discussed running a new procurement exercise at a meeting on 25 March 2013.399 At that meeting Peter Maddison recommended that it should do so but noted that it might be difficult to explain that change of heart to the TMO board, which had been persuaded to use Leadbitter in the interests of efficiency.400 53.20 As incoming employer’s agent from March 2013, Robert Powell took over the task of considering a fresh procurement exercise.401 On 10 April 2013 he proposed that Artelia produce a full report, without which he considered that the TMO could find itself in a worse situation.402 On 19 April 2013, Mr Dunkerton confirmed the TMO’s instruction to Artelia to provide formal advice on how to proceed with the Grenfell Tower project.403 That was exactly a year after the first project team meeting. Artelia’s Status Report: April 2013 53.21 Artelia produced a Status Report dated 23 April 2013,404 the executive summary of which identified a number of factors which had contributed to the slow progress and excessive cost of the scheme. Artelia did not consider re-procurement a viable option and recommended that the TMO should retain Leadbitter as principal contractor.405 It warned the TMO that if the project were not stopped and the scope, programme and cost fundamentally reviewed, it would fail.406 It therefore recommended that the scheme in its existing guise be stopped immediately, pending a design team review.407 53.22 The trenchant terms in which Artelia couched its opinion was matched by the strength of feeling of those working on the project. Philip Booth, who became involved in it in April 2013,408 recalled that the project had been in a state of distress at that time.409 53.23 Simon Cash repeated Artelia’s advice to the TMO in a meeting on 26 April 2013.410 On the same day, Peter Maddison confirmed that a budget of £8.5m for construction costs would be available for the project.411 53.24 On 2 May 2013, perhaps in a bid to save a project in trouble, Robert Powell sent Paul Dunkerton a Draft Revised Project Brief,412 in which he proposed that Artelia should take on the roles of project manager and employer’s agent in addition to its responsibilities 398 {ART00008989/4}; see also 15 March 2013 {ART00006556/2}. 399 {TMO10038870}. 400 {TMO10038870/2}. 401 Powell {ART00008984/11} page 11, paragraph 43. 402 {ART00001083}. 403 {ART00001116}. 404 {ART00009101}. 405 {ART00009101/18-19}. 406 {ART00009101/25}. 407 {ART00009101/25}. 408 Booth {ART00008527/3} page 3, paragraph 12. Philip Booth assumed the role of EA in July 2013 when Robert Powell left Artelia. 409 Booth {Day49/128:24}-{Day49/129:15}; {Day50/113:19-21}. 410 {TMO00830537/2} Section “Procurement” Item 8. 411 {ART00009081} item 3. Confirmed in Powell’s Draft project Brief of May 2013 {ART00006475} under header “Budget”. 412 {ART00006475}; {ART00006383}; Powell{ART00008984/25} page 25, paragraph 77.

The Grenfell Tower Inquiry: Phase 2 Report 58 as quantity surveyor. He also suggested that Artelia should become the lead consultant.413 In the event, however, when a formal contract was eventually signed in July 2014 Artelia was engaged to act only as employer’s agent, quantity surveyor and CDM co-ordinator. A change of priorities: value for money rather than maintaining programme 53.25 On 21 May 2013, Robert Powell sent an email to Philip Booth and Simon Cash describing a meeting he had attended with RBKC and the TMO earlier that day. He told them that Peter Maddison had been overruled by Laura Johnson, that Mr Maddison was no longer keen to appoint Leadbitter as principal contractor and that value for money was more important to RBKC and the TMO than preserving the programme. He said that it was likely, therefore, that the TMO would decide to hold a new procurement process in accordance with EU regulations.414 53.26 From that moment, the TMO’s attention was increasingly directed towards a new procurement exercise, either by inviting tenders through the Official Journal of the European Union (OJEU) or by making use of an existing framework agreement. Neither Laura Johnson nor Peter Maddison accepted there had been any overruling,415 but, even allowing for some flamboyance in Robert Powell’s turn of phrase among colleagues,416 it is clear to us that Laura Johnson had exercised a decisive influence in favour of re‑procurement.417 Mr Maddison told us that he had changed his mind as a result of what he had been told by Laura Johnson about problems which RBKC had encountered with Leadbitter on the KALC project, although that is not supported by any of the documents we have seen.418 Ms Johnson, for her part, accepted that her view of Leadbitter had influenced the TMO’s decision to put the contract for the Grenfell Tower refurbishment out to tender again.419 We think that when they gave evidence both Ms Johnson and Mr Maddison independently sought to downplay her influence over the direction of the Grenfell Tower project in order to preserve an appearance of independence from RBKC on the part of the TMO not wholly borne out by the contemporaneous evidence. 53.27 In his email Robert Powell said that the emphasis of the TMO’s approach had changed from “programme” to “value for money”. Even though the scope of works was still evolving,420 the project was constrained by an inadequate budget. In the context of the developments that had by then taken place, it is clear to us that the email was recording the change of emphasis on the part of the TMO from one of maintaining the original programme to one of saving cost, and that what the TMO really meant by achieving value for money was finding a contractor who would do the work at a cost lower than that suggested by Leadbitter. 413 {ART00006475/2} under “Contract and Procurement”. 414 {ART00006252}. 415 Maddison {Day58/100:20}-{Day58/101:13}; Laura Johnson {Day128/145:2-11}. 416 Booth {Day50/16:8-11}. 417 Powell {ART00008984/27-28} pages 27-28, paragraph 85; Cash {Day48/164:10-16}. 418 Maddison {Day58/103:2-19}. 419 Laura Johnson {Day128/120:6}-{Day128/121:1}. 420 As can be seen by Laura Johnson’s email on not progressing kitchens / bathrooms {ART00006252}; Booth {Day50/11:2-25}; {Day50/12:5-8}.

Part 6 | Chapter 53: Planning the refurbishment 59 Artelia reports: May–June 2013 53.28 On 24 May 2013, Artelia produced an Addendum to its Status Report.421 That short document stated that the TMO had made it clear that value for money was to be regarded as the key driver for the project and that it remained to be convinced that the existing arrangements with Leadbitter could provide that. It therefore believed that a new procurement process would provide best value. In the light of those observations Artelia recognised that it was necessary to reconsider its original recommendation and accept that value for money might be enhanced by seeking a principal contractor through a new procurement process.422 53.29 When Robert Powell sent the Addendum to Peter Maddison, he commented that he hoped it gave him the support he had been looking for to proceed with a new procurement exercise for a principal contractor, in contrast with the earlier recommendation which had been based on information that had become obsolete.423 At the time, Robert Powell described the Addendum to Simon Cash as “political lubrication” to give the TMO justification for going against its original recommendation to keep Leadbitter involved in the project.424 It is apparent that the TMO had decided to start the project again from scratch, which required it to climb down from its position that there was a benefit to using the contractor it had employed on the KALC project. The TMO needed a professional opinion to support its change of position and Artelia, under pressure from its client, duly obliged. In our view, Artelia, as a professional consultant, should not have allowed itself to be influenced to that degree by its client. 53.30 That change of approach was reflected in a revised version of Robert Powell’s Project Brief425 that was circulated by Philip Booth on 3 June 2013.426 According to that version, the primary driver was “Cost (Value for money)”. The Project Brief was presented at a meeting on 6 June 2013 and was approved by the TMO, with some adjustments.427 53.31 In a meeting on 6 June 2013 Peter Maddison asked Artelia to change the Addendum to demonstrate that a fresh procurement exercise would deliver better value for money,428 and in a further meeting on 11 June 2013, he asked Artelia to reword it.429 Accordingly, Simon Cash sent Mr Maddison a revised status report dated 18 June 2013,430 the contents of which had been materially altered. Simon Cash noted in his covering email that he had reworded sections to “read in a better light”.431 Having already changed its original advice in favour of support for a new procurement process, in this latest version of the addendum Artelia, having analysed the options, now more firmly recommended that using the EU procedure, rather than a framework agreement, would be more likely to give value for money.432 In addition, criticisms of the TMO were largely removed or watered down and replaced with criticisms of Leadbitter.433 421 {ART00006232}. 422 {ART00006232/6}. 423 {ART00009020/2}. 424 {ART00006418}. 425 {ART00009032}. 426 Booth {ART00008527/13} page 13, paragraph 55; {ART00008529}. 427 {TMO00833043} item 1.1.; Philip Booth made the amendments and reissued on 10 June 2013: {ART00008641}; {ART00008825}. 428 {TMO00833043} item 2.1. 429 {ART00006473}. 430 {TMO10048492}; {ART00001241}. 431 {ART00001241}. 432 {TMO10048492/28}; Booth {Day50/19:9-18}. 433 Cash {Day48/191:5}-{Day48/194:7}.

The Grenfell Tower Inquiry: Phase 2 Report 60 53.32 Simon Cash was reluctant to amend the criticisms of the TMO because they did not reflect Artelia’s assessment of what had happened on the project,434 but he was put under pressure to do so by Peter Maddison in the course of what he described as a “particularly strong”435 conversation. Mr Maddison did not accept that description of the conversation, but he did accept that a “frank” conversation436 had taken place between them. Later, in an email sent on 17 September 2013 to Claire Williams, the project manager in the TMO Assets and Regeneration Department, David Gibson, TMO’s Head of Capital Investment, said that the TMO had had to “twist [Artelia’s] arms quite hard” to obtain the revised report.437 Mr Gibson’s evidence was that he meant that the report had not been in the clear form he had wanted,438 nor had it been as positive and forward-looking as he had expected,439 but the clear meaning of the words used in that email is that Mr Gibson was aware that Artelia had been reluctant to amend its earlier report and had required some considerable persuasion to do so. In our view the evidence shows that the TMO put significant pressure on Artelia to make changes which it would not otherwise have made. 53.33 Peter Maddison relied on the advice expressed by Artelia in the Addendum to support his presentation to the TMO board on 20 June 2013.440 The board agreed to hold a new procurement process, noting the then estimated cost of £9,780,000 for the project.441 In her Budget Monitoring Report for the first quarter of 2013/2014, prepared for RBKC’s Management Board, Leaders Group and Cabinet, Laura Johnson reported that the estimated cost of the Grenfell Tower refurbishment was around £9,700,000, but that that was to be confirmed after the procurement process had been completed.442 She recommended that the cabinet increase the total budget accordingly.443 That increase was approved by RBKC’s Cabinet on 18 July 2013.444 The OJEU procurement 53.34 One effect of the decision to hold a new procurement process for the selection of a principal contractor under the OJEU process was to force the TMO to decide the scope of the project and the materials to be used. The details were set out in the NBS Specification, which was included in the tender packs. 53.35 The tender process was led by Jenny Jackson, a procurement specialist engaged directly by the TMO, with the assistance of Artelia. The TMO published a notice of its intention to award the contract on 20 August 2013.445 Despite the notice receiving 22 expressions of interest, only five potential bidders returned responses to the Pre-Qualification Questionnaire by the deadline of 20 September 2012.446 All five, namely, Mulalley & Co Limited, Keepmoat Regeneration Limited, Durkan Limited, Rydon Maintenance Limited and Wates Construction Limited, passed the 434 Cash {Day48/194:18-20}. 435 Cash {Day 48/194:15-16}. 436 Maddison {Day58/143:3-8}. 437 {TMO10048490}. 438 Gibson {Day53/139:7-19}. 439 Gibson {Day53/140:1-5}. 440 Maddison {Day58/143:16-22}; {Day58/148:13-24}; {TMO10002849}. 441 {TMO10049945} item 1. 442 {RBK00013783/6} paragraph 3.15. 443 {RBK00013783/7} paragraph 4.1; Laura Johnson {RBK00034943/14} page 14, paragraph 58. 444 {RBK00059321/2} paragraph A5(iv). 445 {ART00008871}. 446 {ART00008876}.

Part 6 | Chapter 53: Planning the refurbishment 61 Pre-Qualification Questionnaire evaluation, which was scored by Artelia and the TMO,447 and were invited to tender.448 Although Leadbitter had been informed about the process in July 2013,449 it did not tender for the project. 53.36 In the end, only three of the five companies which had satisfied the Pre-Qualification Questionnaire eventually submitted tenders, Wates having pulled out on 18 December 2013450 and Keepmoat on 15 January 2014.451 The tenders were opened on 14 February 2014 and it was immediately apparent that Rydon’s was significantly lower than those of the other two companies, Durkan and Mulalley.452 Manipulation of the procurement process 53.37 Following their formal evaluation, Rydon’s bid was confirmed as being the lowest price; it also achieved the highest score on quality.453 All the prices for the external facade were substantially higher than Artelia’s estimate. The basis of evaluating tenders was 40% for price, and 60% for quality, of which 55% was attributed to written submissions and 5% to interview. Weighting the scoring in that way meant that the tender process slightly favoured the bidder with the highest quality rather than the lowest price. After the scores for the written submissions had been collated, Rydon’s bid was identified as the most competitive.454 53.38 Residents had some limited participation in the process.455 At the stage of the Pre‑Qualification Questionnaire in October 2013, and at the stage of the Invitation to Tender in February 2014, they contributed their assessments of the quality of the tenderers’ communication and liaison with residents.456 They were not invited to contribute questions about programming or quality, even though those were matters which affected them and on which they might have had valuable insights.457 On 21 February 2014, Cllr Judith Blakeman suggested to Peter Maddison that some residents should attend the interviews with those who had submitted tenders.458 That required Claire Williams to find a leaseholder and a tenant at short notice.459 We do not know which residents attended the interviews or what contributions they made, although Ms Williams thought that Pily Burton and Fahed Barakat had been involved when no one else had come forward.460 On any view, only very few residents were involved in the process. They marked a limited range of questions, their scores were averaged with those of the professionals and the TMO,461 which diluted their contribution, and, when it came to the interviews, their attendance 447 {ART00008544}. 448 {ART00001972}; {ART00008841}; {ART00008584}. 449 {ART00008603}. 450 {ART00008690}; {ART00008642}. 451 {ART00008949}. 452 {ART00005886}; {ART00008976}. 453 {ART00002167/23}. 454 {ART00002167/23}. 455 Williams {TMO00840364/8} page 8, paragraph 39; {TMO00840364/27} page 27, paragraph 149; Booth {ART00008527/23} page 23, paragraph 89. 456 Booth {ART00008527/23} page 23, paragraph 89; {ART00008693}; {ART00008909/3} question 10.3 only; {TMO00847721} question 7.1 only. 457 Williams {Day54/176:12}-{Day54/177:22}. 458 {TMO10005313/4}. 459 {TMO10005313/3}; Residents apparently attended {ART00008870}; {ART00008969}. 460 Williams {TMO00840364/8} page 8, paragraph 39. 461 Booth {ART00008527/23} page 23, paragraph 89; Booth {Day50/43:14}-{Day50/44:14}.

The Grenfell Tower Inquiry: Phase 2 Report 62 appeared to be an afterthought. Despite the TMO’s saying that it had every intention of involving residents in the process,462 we think that their involvement was largely symbolic, having been hastily arranged and entirely undocumented. 53.39 In its final tender report, dated 12 March 2014, Artelia confirmed its view that the prices of all three bidders were “at a sustainable level”.463 Even so, as was made clear in Artelia’s Draft Tender Report, even Rydon’s tender sum (the lowest) exceeded the budget then available and in those circumstances Artelia sought the TMO’s permission to undertake a value engineering exercise with Rydon.464 By that point, however, Rydon (but no other bidder) had been told by the TMO that it was “in pole position” and would be awarded the contract if it could indicate that it could make significant reductions in its price through value engineering. 53.40 There then followed some days of discussions about potential areas of savings and specific amounts, in order to arrive at an agreed figure.465 The discussions culminated in a meeting on 18 March 2014, at which the TMO and Rydon agreed that if Rydon were awarded the contract it would reduce its price.466 The TMO considered internally that a reduction could be achieved through the “value engineering” clauses in the proposed building contract,467 but that was really just a euphemism for reducing the cost to enable an acceptable price to be achieved.468 53.41 The discussions between the TMO and Rydon, which took place at a time when the procurement process had not been completed, were not contemplated by the legislation relating to procurement. The meeting of 18 March 2014 was particularly significant, because Rydon was given an opportunity to amend its price in advance of the award of the contract, an arrangement for which the TMO could provide no reasonable justification. Those involved in the meeting knew or should have known that what they were doing was improper. The meeting was described in correspondence as taking place “offline”,469 the TMO did not invite its professional advisors, and no minutes were taken. Moreover, it had received advice from its solicitors that a meeting of that kind was not permissible. 53.42 Simon Lawrence explained to Mike Albiston of Harley that Rydon was alive to the risk that other prospective main contractors might challenge the procurement process on the grounds that they had not been given a similar opportunity to engage in the value engineering process.470 Stephen Blake said that he never considered the potential for challenge by other contractors471 and denied having any knowledge of Mr Lawrence’s concerns,472 but we do not accept that evidence. As we explain in Chapter 55,473 the meeting of 18 March 2014 was organised through Mr Blake and he was the driving force at Rydon behind the early value engineering process. Mr Blake himself asserted that the TMO had been changing the basis of the tender474 and it would be surprising if he had not considered the concerns articulated by Mr Lawrence as a result. 462 Williams {Day54/166:3-6}; Williams {Day54/168:5-8}. 463 {ART00002167/13}. 464 {ART00002167/23}. 465 See Chapter 55 466 See Chapter 55 467 Gibson {Day54/13:9-12}; {Day54/17:12-19}. 468 Per Gibson email to Rydon {RYD00003302/1-2}. 469 Chapter 55 470 {HAR00010160/6}. 471 Blake {Day28/187:1}. 472 Blake {Day28/188:6-24}. 473 Chapter 55 474 Blake {Day28/185:24} – {Day 28/186:5}.

Part 6 | Chapter 53: Planning the refurbishment 63 53.43 The steps that were taken to reduce the price of the works are described in Chapter 55 However, it is striking that the TMO appears to have given no thought at any stage to asking RBKC to increase the budget to meet Rydon’s tender price, rather than seeking to drive down the costs to bring them within the budget. Given that in July 2013 RBKC had been amenable to an increase in the budget by about a third (from £6,000,000 to £9,700,000),475 it is possible, to put it no higher, that RBKC would have agreed. Indeed, in July 2014, it agreed to increase the budget to £10,300,000, without any apparent reluctance or obvious opposition from within the cabinet.476 The contract with Rydon and confirmation of the budget 53.44 On 18 March 2014 Rydon was told that it had won the contract. On 27 March 2014, Peter Maddison presented a paper477 to the TMO board478 in which he recommended that the TMO should enter into what he called a “pre-contract arrangement” with Rydon so that the project could make progress while the possibility of reducing the price was investigated, in particular by changing the cladding material and securing government funding for improving the building’s energy efficiency.479 According to the minutes of that meeting, the board asked Mr Maddison whether Rydon might have submitted a low tender in order to obtain the contract, but he confirmed that he had confidence in Rydon’s pricing480 and that any problems with the budget would be addressed during the pre- contract period.481 In reality, the primary focus of attention during the pre-contract period was clearly on achieving a reduction in Rydon’s price; at any rate, there is no evidence that the TMO board took any steps to find out whether it was realistic. Peter Maddison conceded that that had not been the purpose of the pre-contract period and said that the minutes were incorrect to the extent that they stated otherwise.482 However, the minutes of the meeting are detailed and we consider that they probably are accurate. We think that Mr Maddison did reassure the board that the budget was sustainable and told it that any concerns that Rydon might have submitted an artificially low tender would be addressed during the pre-contract period. 53.45 Having received that assurance, the TMO board agreed to appoint Rydon as principal contractor for the Grenfell Tower refurbishment. Accordingly, it authorised an immediate agreement to cover preliminary work up to the value of £350,000 and thereafter a design and build contract for the works as a whole at a total price of £9,700,000, inclusive of fees.483 53.46 On 19 June 2014, Laura Johnson presented a paper to the RBKC cabinet484 recommending an increase in the budget for the refurbishment from £9,700,000 to £10,300,000 to include a contingency.485 The cabinet agreed the increase,486 which was noted in an executive decision issued by Cllr Feilding-Mellen in August 2014.487 475 {RBK00003316/3}; Feilding-Mellen {Day131/153:6} – {Day131/155:18}. 476 Feilding-Mellen {RBK00054433/4} page 4, paragraph 11; {Day131/161:16}-{Day131/162:18}. 477 {TMO10005583}. 478 {TMO10031040}. 479 {TMO10031040/2}. 480 {TMO10031040/3} item 3. 481 {TMO10031040/3} item 2. 482 Maddison {Day59/71:3-21}. 483 {TMO10031040/3}; {RYD00086702}; {RYD00094236/91} paragraph 215. 484 {RBK00000409}. 485 {RBK00000409/5-6} Item 3.2; {RBK00000409/8} item 6.2. 486 {RBK00018808}; Laura Johnson {RBK00034943/14-15} pages 14-15, paragraph 58; {RBK00034943/16} page 16, paragraphs 65-66. 487 {RBK00003309}.

The Grenfell Tower Inquiry: Phase 2 Report 64 The influence of cost in the selection of materials 53.47 In response to a suggestion that it had been concerned above all things to reduce costs the TMO argued that its choice of the more expensive cassette version of the panels for the rainscreen showed that cost had not been the sole or overriding consideration in the selection of materials.488 However, the evidence does not support that conclusion. Peter Maddison denied that the TMO had been looking for the cheapest option; he said that it had been looking for a material that would, in his words, “achieve planning permission and ... meet the regulations”.489 As Mr Maddison’s evidence makes clear, the need to obtain planning permission was a critical factor in the decision about which version of the product to use. Emails passing between Simon Lawrence and Claire Williams in May 2014 refer to the TMO’s discussions with the planning committee about the different forms of fixing and the adverse cost implications if it were to prefer cassettes.490 Simon Lawrence asked Ms Williams whether showing the committee examples of the panels in cassette form would be a risk.491 He hoped to persuade it to accept riveted fixing by showing it a mock‑up.492 Mr Maddison was informed of the efforts being made to persuade the planning committee to accept riveted fixing493 and had a meeting with Councillor Feilding-Mellen at which the difference in cost was discussed.494 It is clear to us that Rydon and the TMO were seeking to persuade the planning committee to accept riveted fixing for cost reasons. In the event, however, the committee insisted on the cassette version. Client design adviser 53.48 On 28 February 2014, Artelia had offered to act as client design adviser for the TMO, to review and advise on decisions made by the principal contractor in developing the design of the project. Following the appointment of a principal contractor under a design and build contract, the services of those engaged by the client to carry out the initial design work may be transferred to the contractor by a legal process known as novation to enable it to continue developing the design. The creation of new contractual relationships between the designers and the principal contractor creates a risk that the contractor may wish to adopt lower quality design solutions than those originally contemplated. The designers, whose client is now the contractor, are not able to advise the employer on matters of that kind. As a result, there is a risk that a design agreed with the employer before the appointment of the contractor may be watered down as a result of commercial pressures. 53.49 In early February 2014, Artelia and the TMO (represented by Jenny Jackson) were negotiating amendments to the terms of Artelia’s appointment. The discussions eventually concluded with a variation to the contract agreed in July 2014. In the context of those discussions Philip Booth reviewed the scope of the services to be provided by Artelia as employer’s agent and concluded that they would not overlap with the services that would be provided as client design adviser. Artelia proposed that Richmal Hardinge, an architect, be appointed in that capacity. She had acted as client design adviser to RBKC on the KALC project and had drafted the proposal for the Grenfell Tower project, which offered to set and safeguard design quality. She proposed that she should provide a “Design Compliance Report” before the contract was awarded, after reviewing the contractor’s proposals to 488 Phase 2, Modules 1 and 2 Closing TMO submissions for TMO {TMO00903690/13} paragraph 52. 489 Maddison {Day59/90:9-23}; TMO submissions {TMO00903690/13} paragraph 53. 490 Emails 6 May 2014 {TMO00851142}; 23 May 2014 {RYD00005374/1-2}. 491 Email 23 May 2014 {RYD00005374/2}. 492 Email 29 May 2014 {RYD00005374/1}. 493 Emails 6 May 2014 {TMO00851142}; 2 June 2014 {SEA00011069}. 494 Diary of Peter Maddison {TMO00879770/46}; {TMO00879770_T}/60}.

Part 6 | Chapter 53: Planning the refurbishment 65 ensure that they were consistent with the Employer’s Requirements, the NBS Specification and British, European and other statutory standards. Ms Hardinge also proposed that, once the contract had been awarded, she would review the contractor’s drawings to ensure they continued to meet the Employer’s Requirements and provide advice on matters of design as required by the TMO. The proposal excluded any aspects of the mechanical and electrical (“M&E”) services. 53.50 At a progress meeting on 15 July 2014, attended by Peter Maddison, David Gibson and Claire Williams on behalf of the TMO, it was agreed that the TMO would appoint a client design adviser. However, a few weeks later, on 29 August 2014, the TMO decided to perform the role itself. Claire Williams set out the TMO’s reasons for that decision in an email sent to Peter Blythe and Philip Booth on 29 August 2014. They included the fact that the cladding and M&E elements were under guarantee, which she thought obviated the need for such an appointment. A note was later added to the minutes of the progress meeting confirming that the TMO would perform the role of client design adviser itself and stating that it would need to approve all design decisions. 53.51 Claire Williams told us that the TMO had come to the view that the services that would have been provided by a client design adviser role fell within the scope of the services Artelia had already agreed to provide and that she had not wanted responsibility for design to be complicated. However those are not the reasons she gave at the time, which suggest that she was more concerned about the value that a client design adviser would provide. In those circumstances we think that the TMO’s decision not to appoint Artelia as client design adviser was driven by a combination of commercial considerations and an unrealistic view of the expertise available within the TMO. The TMO’s rejection of that offer meant that it was unable to review effectively any of the design work carried out following the appointment of Rydon as the principal contractor. In reaching its decision the TMO significantly overestimated its ability to scrutinise the design work and chose to overlook the fact that no one within the organisation had experience of a project involving the overcladding of a high-rise residential building. 53.52 The TMO’s decision not to appoint a client design adviser does not, of course, make it responsible for the quality of subsequent decisions affecting the design of the refurbishment or their compliance with the Building Regulations. That rested with Rydon and its contractors, including Studio E and Harley. However, the TMO’s decision not to appoint a client design adviser at modest expense was foolish and reflected an over- confidence in its ability to manage the design aspects of the project itself.

66 The Grenfell Tower Inquiry: Phase 2 Report

67 Chapter 54 Fire safety strategies; the contribution of Exova Introduction 54.1 This chapter examines the work done by the fire engineer, Exova, in producing fire safety strategies for Grenfell Tower in connection with the refurbishment. 54.2 Exova had been working in the field of fire safety since 1965 and described itself as having established a worldwide reputation for excellence in fire safety.495 In the UK it had offices and facilities in London, Manchester and Warrington and it maintained a presence in other countries around the world.496 Exova had won numerous prestigious awards for its work.497 Due to its access to international experts in the behaviour of materials, fire testing and reaction to fire, Exova described itself (at least to Studio E) as “unique among its peers”.498 54.3 Before the refurbishment, Exova had been instructed by Studio E as a consultant on the Kensington Academy and Leisure Centre project.499 As a result, it was instructed by the TMO500 to work on the Grenfell Tower refurbishment,501 but it reported (or at least sent its reports) to Studio E.502 There was no fresh tender or selection exercise for fire engineering services for the project. Exova was used on the Grenfell Tower refurbishment because it was known and trusted as a result of its work on the KALC project, despite certain misgivings that had been expressed by Neil Crawford of Studio E about the quality and timeliness of that work.503 54.4 After Rydon became the principal contractor for the project in April 2014 Exova’s existing relationship with the TMO continued. Its services were not transferred to Rydon504 and the TMO continued to pay its fees,505 although the precise scope of its retainer became somewhat unclear and was never clarified by Exova, the TMO or Studio E. In this chapter we set out our findings and conclusions about the work that Exova carried out in relation to the refurbishment. 54.5 Before going any further, however, we think it necessary to say something about the evidence given by Dr Barbara Lane, one of the experts instructed by the Inquiry. It was not disputed that Dr Lane is a highly qualified and very experienced fire engineer with a long and distinguished career. She provided a lengthy report for the Inquiry506 and gave evidence in person over two days.507 While recognising her expertise, Exova argued in its closing statement on Modules 1 and 2 that she had failed to deal with the evidence accurately, 495 {TMO10037721/1}; {TMO10003885/1}. 496 {TMO10037721/1}; {TMO10003885/1}. 497 {TMO10037721/1}; {TMO10003885/1}. 498 {TMO10037721/2}; {TMO10003885/3}. 499 Sounes {SEA00014273/36} page 36, paragraph 73. 500 {SEA00004789}; {EXO00000543}; Ashton {Day17/19:4-6}. 501 TMO’s procurement of Exova’s services in respect of the Grenfell Tower refurbishment is explored in Chapter 50. 502 Ashton {Day17/20:1-13}. 503 {SEA00004051}; Sounes, {Day7/176:1-25}; Crawford, {Day10/8:15-16}. 504 {ART00002255/4}; Ashton {EXO00001621/14}; Ashton {Day16/117:2-10}; {Day17/185:2-3}; {Day17/187:7-10}. 505 {EXO00001204}; {EXO00001205}. 506 Lane, Phase 2 Report {BLARP20000017}; Appendix A {BLARP20000018}. A document outlining corrections and addenda {BLARP20000014}. 507 Lane {Day61/1-224}-{Day62/1-213}.

The Grenfell Tower Inquiry: Phase 2 Report 68 fairly or in a balanced way. It said that some of her criticisms were demonstrably wrong and that some of the evidence in her report fell outside the scope of her expertise.508 It urged the Panel to treat her report with great caution and rely on it only insofar as it was necessary to do so and if the evidence was not contentious.509 54.6 As we have said, Dr Lane’s expertise as a fire engineer was not in dispute. Her work is characterised by meticulous attention to detail and reflects a constant awareness that the responsibility of a fire engineer, particularly in relation to the design of a residential building, is the protection of human life. Her standards are high, but in our view they reflect those that can reasonably be expected of any competent fire engineer. Her evidence may not be beyond criticism, but in general we found her to be a thorough and reliable witness who was careful in her criticisms of Exova and was willing to modify the opinions expressed in her report after she had heard the evidence of the factual witnesses. It is also important to note that Exova did not ask us to hear evidence from a fire engineer expressing opinions that differed from those of Dr Lane. Most of the major criticisms of Exova’s work relate to significant omissions from the various documents it produced in the course of its work and its conduct in relation to them. In the main they do not involve minor details but matters of real substance on which Dr Lane was well qualified to express an opinion but on which we have been able to reach our own conclusions. Although we have considered carefully Exova’s criticisms of Dr Lane’s evidence, we do not consider that we would be justified in rejecting her evidence about the standards to be expected of a reasonably competent fire engineer in relation to the work that Exova was asked to carry out. Fire Engineering and the purpose of Fire Safety Strategies 54.7 Before considering Exova’s work on the project we think it may be helpful to explain the role of a fire engineer and the nature and purpose of a fire safety strategy. Dr Lane referred us to recognised definitions of fire engineering and fire engineers. According to the Institution of Fire Engineers (IFE), fire engineering is “the application of scientific and engineering principles, rules, and expert judgment, based on an understanding of the phenomena and effects of fire and the reaction and behaviour of people to fire, to protect people, property and the environment from the destructive effects of fire”.510 Further, the IFE defines a “fire engineer” as a person who “through education, training and experience” understands, amongst other things, the “nature, characteristics and mechanisms of fire, the spread and control of fire” and “the likely behaviour of materials, structures, machines, apparatus and processes as related to the protection of life, property and the environment from fire”.511 Dr Lane was of the opinion that any reasonably competent fire engineer ought as a minimum to have a sound understanding of all those matters.512 54.8 In the context of a residential building fire safety is primarily concerned with the protection and preservation of life. The creation of an effective fire safety strategy therefore calls for high standards of skill, knowledge and professional experience. The fire safety strategy for a building is intended to fulfil a number of purposes. In particular: a. It should address each of the five functional requirements of the Building Regulations in relation to fire (i.e. Functional Requirements B1-B5). 508 Exova Closing Submissions {EXO00002124/34} page 34, paragraph 20.2. 509 Exova Closing Submissions {EXO00002124/52} page 52, paragraph 27.1. 510 Lane, Fire Safety Engineer Report {BLARP20000017/17} paragraph 2.6.1; The Institute of Fire Engineers, Frequently Asked Questions Website Page, “What is Fire Engineering?” {INQ00011261}. 511 The Institute of Fire Engineers, Frequently Asked Questions Website Page, “What is Fire Engineering?” {INQ00011261}. 512 Lane {Day61/9:1}-{Day61/10:7}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 69 b. It should provide a narrative description of the fire safety objectives for the building and how those objectives are to be met, including by means of the active and passive fire safety systems in the building.513 c. It should describe the characteristics of the building and the people who use it, including the details of its construction, the systems provided for use in the event of fire and the reasons for providing them.514 d. It should explain how the building is to be managed in order to protect persons using it from fire515 and identify any fire risks which have either been mitigated or which it is not possible to mitigate.516 e. It should be written in a way that enables those managing and occupying the building to have a clear understanding about what fire protection and prevention measures are present, how they need to maintain them and how they need to educate people on what to do in the event of fire. It should also be capable of being easily understood by the Fire and Rescue Service so that firefighters are aware of the measures that have been provided for them and why.517 f. It should identify the fire safety performance requirements on which those responsible for the design of the building can rely. As Mr Ashton accepted,518 the fire safety strategy is the founding source of the required performance criteria for the architect’s fire drawing information and for other parties responsible for the design of fire safety systems.519 54.9 Dr Lane drew attention to the Fire Industry Association (FIA) Guidance Note “Scope of Works for the Fire Engineer”,520 dated May 2015, which she considered reflected good industry practice and had done so for many years before its publication.521 It makes clear that any fire safety strategy should address all relevant design questions relating to fire safety, including “surface spread of flame requirements for surface materials”,522 “fire compartmentation requirements, including fire-stopping and cavity barriers”523 and “external fire spread”.524 Again, Mr Ashton accepted that those were matters that ought to be included in any fire strategy.525 54.10 The FIA Guidance Note also makes it clear that the work of a fire engineer will often be linked to the RIBA Stages of Work. Dr Lane explained that a fire engineer has an important role before each of the RIBA stage reports are produced, so that the fire safety strategy, the architect’s reports and the mechanical and electrical services reports at the end of each RIBA stage are aligned.526 It followed, in her opinion, that the RIBA stage reports produced 513 Lane {Day61/14:17}-{Day61/15:5}. 514 Lane {Day61/15:10-14}. 515 Lane {Day61/19:6-23}. 516 Lane {Day61/15:25}-{Day61/16:3}. Published Document 7974:2002 also states: “The fire safety strategy for the building will be based on the successful trial design and is likely to comprise a range of physical fire safety measures and management procedures. A description of these measures should be provided, together with performance specifications and any recommended deviations from the relevant system codes.” 517 Lane {Day61/15:16-24}; {Day61/44:25}-{Day61/45:17}. 518 Ashton {Day16/49:12-16}. 519 Lane, Phase 2 Report {BLARP20000017/48} paragraph 3.6.8; Lane {Day 61/23:10}-{Day61/24:2}. 520 {INQ00011219}. 521 Lane {Day61/24:12}-{Day61/25:12}. 522 {INQ00011219/4}. 523 {INQ00011219/4}. 524 {INQ00011219/4}. 525 Ashton {Day16/44:9-{Day16/47:3}. 526 Lane {Day61/131:21}-{Day61/132:25}.

The Grenfell Tower Inquiry: Phase 2 Report 70 by the architect on any project were “significant milestone documents” for a fire engineer and that any reasonably competent fire engineer would know that it was necessary to read them in full,527 or at least to review them and digest all aspects that were relevant to fire safety.528 54.11 In the view of Dr Lane, a fire safety strategy for an existing building is a particularly important document and preparing it is a more demanding piece of work than working on a new project.529 At the time in question guidance on how to create a fire safety strategy for an existing building was to be found in PAS 911:2007,530 which contained a step-by-step guide, including guidance on the research and site activities required and on the need for discussion with stakeholders before the document is finally approved.531 54.12 The fire safety strategy is also an important document for the purposes of carrying out a suitable and sufficient fire risk assessment under the Fire Safety Order.532 Conversely, any fire risk assessment of that kind is an important source of information for a fire engineer preparing a fire safety strategy for an existing building, since it should contain information about the characteristics of the building and the people using it.533 The results of investigations undertaken to produce an existing fire safety strategy will also provide significant information for the purpose of a fire risk assessment.534 54.13 Having regard to the nature of a fire safety strategy, we accept Dr Lane’s evidence that any reasonably competent fire engineer instructed to produce such a strategy for the Grenfell Tower refurbishment would have appreciated that they were a “designer” within the meaning of the CDM Regulations 2007. Preparation of a fire safety strategy is part of the design process which routinely includes the production of drawings, design details and specifications, including fire performance specifications.535 As a designer preparing a fire safety strategy, a fire engineer is under a duty to take reasonable steps to avoid foreseeable risks to the health and safety of any person liable to be affected by the construction work, including the residents of any occupied building undergoing refurbishment work.536 Exova’s early involvement in the Grenfell project 54.14 In early April 2012 Studio E began to send Exova information about the Grenfell Tower refurbishment project, including architectural drawings. At that stage it was seeking an initial assessment of the proposed fire escape strategies for the layout proposals contained in the drawings.537 527 Lane {Day61/131:8}-{Day61/133:11}. 528 Lane {Day61/177:7-19}. 529 Lane {Day61/28:5}-{Day61/35:13}; Lane, Phase 2 Report {BLARP20000017/49-50} paragraphs 3.6.20-3.6.23. 530 {BSI00000066}; PAS stands for Publicly Available Specification. 531 Lane {Day61/30:15}-{Day61/35:10}. 532 Lane {Day61/21:15-17}; See PAS 911:2007 {BSI00000066/37-38} paragraph 7.1.3; Lane, Phase 2 Report {BLARP20000017/338} paragraph 14.1.38; Lane {Day61/36:12}-{Day61/39:7}. 533 Lane {Day61/39:8-21}. 534 Lane, Phase 2 Report {BLARP200000017/117} paragraph 5.4.19; Lane {Day61/40:4-15}. 535 Lane {Day62/80:25}-{Day62/82:18}; Lane, Phase 2 Report {BLARP200000017/249} paragraphs 14.1.16-14.1.10; See Regulation 2 of the CDM Regulations 2007 and the definitions of “design” and “designer”. 536 CDM Regulations 2007, Regulation 11(2)-(3). 537 {EXO00001743}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 71 54.15 On 19 April 2012 James Lee attended a design team meeting at which Bruce Sounes made it clear that the refurbishment would include the overcladding of the entire building.538 There was some discussion about the budget for the cladding.539 At that point, therefore, Exova ought to have understood, at least in general terms, what the refurbishment involved. 54.16 On 3 May 2012 Mr Sounes sent an email540 to Terence Ashton and James Lee attaching some site photographs and setting out the likely scope of the project. As well as various works to the lower levels of the tower, the scope of works included overcladding. Mr Sounes asked for a fee proposal from Exova for the works, broken down into RIBA Stages C, D, E, F “and beyond (if required)” and a summary of what Exova would be doing at each stage. 54.17 On 9 May 2012 Mr Ashton responded with a fee proposal for the provision of consultancy services which included the creation of an outline fire safety strategy for the refurbishment.541 The proposal quoted a fee of £3,300 for RIBA Stage C and £5,300 for RIBA Stages D-E. It was eventually accepted by Artelia on behalf of the TMO on 1 November 2012.542 54.18 On 21 May 2012 Bruce Sounes asked Exova for some advice about the feasibility of certain proposals for the works for the purposes of RIBA Stage C.543 Mr Ashton responded on 22 May 2012 with some initial comments. He explained that the proposed alterations “must not adversely affect [the building] in relation to compliance with the requirements of Part B (fire safety)”. He also said that a site visit would be very helpful in understanding the existing condition of the building.544 Mr Sounes found Mr Ashton’s comments “difficult to follow”,545 and replied attaching some photographs, inviting Mr Ashton to a design team meeting and suggesting that a site visit was essential.546 54.19 Mr Lee visited the tower on 29 May 2012 and took a number of photographs.547 Thereafter there were exchanges between Studio E and Exova focusing on the lower levels of the tower where there was a proposed change of use.548 Following his visit, Mr Lee sent Studio E a series of marked-up drawings with comments on the proposed refurbishment works.549 54.20 On 11 June 2012, Mr Lee sent Mr Sounes a fee proposal for the production of an Existing Fire Safety Strategy that would relate to the building in its existing state. It set out a detailed scope of work and proposed a fixed lump sum fee of £2,865.550 538 {EXO00001744/4} sections 5 and 6. 539 {EXO00001744/4} sections 5 and 6. 540 {EXO00001745}. 541 {EXO00000164}. 542 Email from David Hale to Margaret Treanor (Exova) on 1 November 2012 {EXO00000540} attaching approval of the Fee Proposal in the form of an email from Paul Dunkerton (TMO) {EXO00000541} together with invoicing instructions {EXO00000542}. Confirmation of approval of this fee proposal was sent to Terry Ashton on 18 July 2012 {ART00006294} and also sent to Dr Clare Barker on 24 July 2012 {ART00000184}. 543 {EXO00001748}. 544 {EXO00001748}. 545 Sounes {Day7/201:3-6}. 546 {EXO00000685}. 547 {EXO00001749}. 548 {EXO00001750}; {EXO00001751}; Lee {EXO00001740/3} page 3, paragraph 3.9. 549 {SEA00000022}; {SEA00004324}. 550 {TMO10037721/2}.

The Grenfell Tower Inquiry: Phase 2 Report 72 54.21 Mr Lee left Exova on 20 July 2012 before the proposal had been accepted. He was not involved in the preparation of the Existing Fire Safety Strategy and had no further involvement in the refurbishment project.551 The Existing Fire Safety Strategy 54.22 On 26 July 2012 Dr Clare Barker, a Principal Consultant at Exova, attended a Grenfell project meeting at the invitation of Bruce Sounes.552 Dr Barker had had no previous involvement with Grenfell Tower and Exova’s emails at the time recorded that she had “drawn the short straw” in having to attend. She explained that she was based in the Warrington office and had to cover the work because others within Exova were too busy.553 At the meeting there were references to the overcladding. Attention was drawn to the absence of an existing fire safety strategy for the building.554 There was no discussion of the scope of work required to produce one, but the minutes show that Exova was instructed to proceed with it. 54.23 In subsequent exchanges with Mr Sounes in late July 2012 Dr Barker indicated that she aimed to get the Existing Fire Safety Strategy to Studio E by 16 August 2012.555 (Mr Ashton was off sick at that point, as he had been for some four weeks.)556 However, it was not until 7 August 2012 that she instructed Cate Cooney to produce a first draft. Ms Cooney had produced existing fire safety strategies for only a small number of buildings since joining Exova and was not sure how many of those had been for high-rise residential blocks.557 54.24 On 7 August 2012, as part of her initial instructions, Dr Barker sent Ms Cooney Mr Sounes’ email of 30 July 2012, together with some drawings.558 Her email simply said “See below.” Since they sat close to each other in the Warrington office, there were frequent, informal and unrecorded conversations between them and Dr Barker’s email probably followed an informal instruction to start the process of preparing a draft strategy.559 54.25 Ms Cooney said that the information she had initially been given was limited.560 At that stage she had not known the identity of the ultimate client; she knew only that she was producing a report for Studio E.561 She could not recall having seen the fee proposal at any time before she had begun preparing her evidence for the Inquiry.562 54.26 As well as the drawings that Dr Barker had sent her, Ms Cooney obtained copies of the original plans of Grenfell Tower on microfiche from Studio E.563 On 9 August 2012 she also asked Mr Sounes about certain features of the building, including whether there was a fire-fighting lift.564 He told her that there was not.565 However, three or four days later she received from the TMO a copy of the fire risk assessment dated 29 December 2010 prepared by Carl Stokes (“the 2010 fire risk assessment”),566 which wrongly described 551 Lee {EXO00001740/4} page 4, paragraph 3.15-3.16. 552 {EXO00000242}. 553 Barker {Day15/19:24}-{Day15/20:23}. 554 See Minutes of Project Meeting (Number 5) on 26 July 2012 page 4, where the following appears (under the heading Quantity Surveyor), “There is no existing fire strategy for the building. Exova to proceed.” {EXO00001620/4}. 555 Barker {EXO00001603/2-3} pages 2-3, paragraph 3.7. 556 Ashton {Day16/66:17-22}. 557 Cooney {Day14/37:15}-{Day14/38:4}. 558 {EXO00001613}. 559 Cooney {Day14/30:3-9}. 560 Cooney {EXO00001590/3} page 3, paragraph 3.6; Cooney {Day14/30:20-22}; {Day14/80:24}-{Day14/87:18}. 561 Cooney {Day14/34:6-17}. 562 Cooney {EXO00001590/2} page 2, paragraph 3.4; Cooney {Day14/52:4-13}. 563 Cooney {EXO00001590/3} page 3, paragraph 3.6; Cooney {Day14/80:2-16}. 564 {EXO00001592}. 565 {EXO00001593/3} and {EXO00001593/2}; Lane, Fire Safety Engineer Report (Version 2) {BLARP20000017/140}. 566 {TMO10037743}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 73 the lifts as “fire-fighting lifts”.567 Ms Cooney noticed the inconsistency in the information before her but did not seek to resolve it,568 choosing instead to prefer what was said in the fire risk assessment because it was what she described as a “regulatory document” (i.e. prepared to enable the TMO to comply with its obligations under the Fire Safety Order) and, therefore, a more reliable source of information.569 In our view that was a mistake. The distinction between a fire lift and a firefighting lift570 is important and a reasonably competent fire engineer would have taken steps to clarify the matter by obtaining some independent authoritative information.571 She denied that she had failed to do so because she was in a hurry to get the document finished before the 16 August deadline,572 but we think that the short deadline for the work is likely to have played at least some part in it. 54.27 For some reason Cate Cooney was not sent the Significant Findings and Action Plan referred to at the foot of page 1 of the 2010 fire risk assessment, nor did she ask to see them.573 She did not visit the building, despite the fact that the fee proposal provided for a site visit and that she had difficulty understanding its layout from the drawings alone. As a result, there were numerous gaps in the information available to her which led her to make a wide variety of assumptions about its state. Ms Cooney did not even have a copy of the Fee Proposal, which, although a largely standard document, would have acted as an aide memoire for what she was to do. If she had obtained a copy, as required by internal Exova guidance,574 she could have used it as a checklist. 54.28 Ms Cooney had available to her the photographs taken by James Lee when he had visited the building in May 2012575 and she discussed the layout of the building and other matters (including the smoke control system) with him following his visit.576 However, when he left Exova James Lee left behind no notes of his site visit and it seems likely that he had intended to visit the tower again, because he provided for a half-day site survey in the fee proposal. Although Ms Cooney said that she took notes of her discussion with him, she was unable to produce any577 and there is no reference in the contemporaneous documents to a discussion of that kind. We think it unlikely, therefore, that any detailed discussion about the building took place between Ms Cooney and Mr Lee for the purposes of preparing the Existing Fire Safety Strategy. Dr Barker confirmed that she had not spoken to Mr Lee about his visit to the tower, he having left Exova before her involvement in the project.578 54.29 In its fee proposal Exova had described itself as having a worldwide reputation for excellence in fire safety579 and as being unique among its peers in its access to international experts in the behaviour of materials, fire testing and reaction to fire.580 By appointing Exova, therefore, the TMO and Studio E could reasonably have expected to have access to high-quality fire engineering advice from leaders in the field. In Dr Lane’s opinion, any company holding itself out as providing the highest quality of fire engineering services ought to ensure that its work has the approval of a qualified Chartered Fire Engineer who 567 {TMO10037743/4}. 568 Lane {Day61/84:15}-{Day61/86:6}. 569 Cooney {Day14/189:22}-{Day14/192:7}, especially at {Day14/190:5-13}. 570 Phase 1 Report, paragraph 34.11. 571 Lane {Day61/85:9-25}. 572 Cooney {Day14/191:2-7}. 573 {CST00000091}. 574 {EXO00001224/1-2} section 4. 575 Cooney {Day14/90:20}-{Day14/91:12}. 576 Cooney {Day14/67:3-5}; Cooney {EXO00001590/3} page 3, at paragraph 3.7. 577 Cooney {Day14/87:14}-{Day14/89:5}. 578 Barker {Day15/37:19-22}. 579 {TMO10037721/1}; {TMO10003885/1}. 580 {TMO10037721/2}; {TMO10003885/3}.

The Grenfell Tower Inquiry: Phase 2 Report 74 has undergone the minimum training required by the Engineering Council.581 In the event, Dr Barker was the only member of Exova’s staff engaged on the Grenfell Tower project who was qualified as a Chartered Engineer,582 and her involvement was limited to a cursory review of the draft Existing Fire Safety Strategy produced by Ms Cooney. 54.30 On 15 August 2012 Ms Cooney sent the draft Existing Fire Safety Strategy by email to Dr Barker for review, saying that she had printed off drawings for her assistance.583 She did not send Dr Barker either the 2010 fire risk assessment or copies of her email correspondence with Mr Sounes but she may have printed them off and left them on Dr Barker’s desk, because Dr Barker said that she thought she had seen the fire risk assessment when she reviewed Ms Cooney’s draft.584 54.31 There is reason to think that Ms Cooney may not have devoted as much time to the task as might normally have been expected. She was working under pressure because she had told Studio E that the document would be ready by 16 August 2012 and was due to go on holiday on 17 August 2012. She said that she would normally expect to take between a few days and a week to complete a task of that kind, but in this case the records show that it occupied no more than 15 chargeable hours of her time. Even allowing for the fact that she may have spent more time on it than the records show, they suggest that she completed the work rather more hurriedly than one would have expected.585 54.32 On 16 August 2012, almost exactly 24 hours later, Dr Barker replied to Ms Cooney’s email in the following terms: “I have reviewed it and it is fine.”586 Dr Barker said that she had reviewed the draft together with the drawings, but she could not remember in how much detail she had considered the drawings themselves, nor whether she had reviewed all of them, nor even whether she had checked the measurements.587 Nor could Dr Barker remember how long she had spent reviewing the report, although she thought that it must have been a couple of hours.588 She said that she would usually give a more detailed response and could not remember why she had not done so on that occasion.589 54.33 Dr Barker accepted that 16 August was her last day in the office before she went on holiday and that she had a number of other matters to finish before she left.590 It is hard to know exactly how long she spent considering the document, but the fact that the Exova summary of timesheets for the project do not record any time spent by Dr Barker on a peer review suggests that it was very little. If, as she hinted, she had deliberately posted the time she spent on it to another project for a different client,591 that would have been a serious failing in the billing system and quite improper, and even an inadvertent failure to post the time to the correct account would have been surprising. There is no reliable evidence 581 Lane {Day61/66:10-25}. 582 A Chartered Engineer is a person who has been registered as a professional engineer in accordance with the requirements of the Engineering Council. The Fire Engineering Council of the Fire Industry Association is the only body that currently has a process for assessing the competence of fire engineers. It confers the qualification of Chartered Fire Safety Engineer through the chartership process overseen by the Engineering Council. See Lane {Day61/46:6}-{Day61/49:23}. 583 {EXO00000175}; Cooney {EXO00001590/3} page 3, paragraph 3.8. 584 Barker {Day15/72:4-10}. 585 {EXO00001353}; Cooney {Day14/194:3}-{Day14/195:7}. 586 {EXO00000175}. 587 Barker {Day15/71:2-15}. 588 Barker {Day15/73:10-13}. 589 Barker {Day15/80:11-14}. 590 Barker {Day15/73:20-22}; {Day15/128:10-16}. 591 Barker {Day15/78:8-10}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 75 to suggest that either of those events occurred and, viewing the evidence as a whole, we think it most likely that in fact Dr Barker spent too little time considering the draft to justify billing the client. 54.34 At that stage the document created by Ms Cooney was a first draft; indeed, throughout her evidence she made it clear that she had only been instructed to produce a draft,592 which was one of the explanations she gave for the many assumptions and qualifications it contained. Ms Cooney sent the document to Mr Sounes by email later on 16 August 2012.593 54.35 On 17 August 2012, Cate Cooney and Bruce Sounes had a telephone conversation594 but it is likely that their conversation related to aspects of the refurbishment other than the draft Existing Fire Safety Strategy.595 On 30 August 2012, Mr Sounes sent an email to Mr Ashton, with a copy to Dr Barker saying that he needed to go through the draft Existing Fire Safety Strategy,596 but in the event no discussion ever took place. Why it did not remains unclear. Exova operated a Project Completion Procedure under which the project manager was required to make a careful note of the scope of services described in the contract documentation597 and check that all elements of the project had been completed satisfactorily. Dr Barker did not have a good recollection of the procedure,598 although she appears to have been aware of its existence. However, she said that it did not apply at that stage because at that time the document was still no more than a draft.599 54.36 After the draft Existing Fire Safety Strategy had been sent to Studio E it was still not clear who within Exova was responsible for it. Dr Barker thought that Mr Ashton had assumed responsibility for it; Mr Ashton assumed that Ms Cooney and Dr Barker were dealing with it. Ms Cooney said that it had been handed back to colleagues who were dealing with the project overall.600 Mr Ashton admitted that there had been a misunderstanding between the Exova employees,601 but said that he “didn’t think it was that important”, given that there were other strands to Exova’s work on the building at the time.602 Somewhat surprisingly, Mr Ashton was not aware that the Existing Fire Safety Strategy was meant to provide the basis on which a fire safety strategy for the refurbishment was to be constructed.603 The draft Existing Fire Safety Strategy sent to Bruce Sounes on 16 August 2012 was never finalised and the review intended to verify the assumptions it contained and provide the missing information did not take place. 592 Cooney {Day14/30:3-9}. 593 {EXO00001396}. On 16 August 2012, only a few minutes after Dr Barker had approved the draft, Ms Cooney sent it to the Exova administration team to format before being circulated. She asked Dr Barker to authorise her signature on it. Cooney {EXO00001590/3} page 3, paragraph 3.10; {EXO00000577}. Dr Barker did so straight away {EXO00000158}, and Ms Cooney immediately sent it to Mr Sounes. She told him that she was going on holiday the next day and that if he wanted to discuss it he should telephone her before then. She thus gave him at most 24 hours to discuss it. The document remained watermarked “DRAFT” throughout. 594 {EXO00001279}. 595 {SEA00000043}. 596 {SEA00000048}. 597 {EXO00001224}. 598 Barker {Day15/83:9}. 599 Barker {Day15/85:1-15}. 600 Barker {Day15/94:11-15}; Ashton, {Day16/139:20-23}; {Day16/145:3-7}; {Day16/145:11-14}; {Day16/146:5-18}; {Day16/145:3-7}; Cooney {Day14/205:18-23}. 601 Ashton {Day16/152:13-18}. 602 Ashton {Day18/10:10}-{Day18/11:3}. 603 Ashton {Day18/11:4-7}.

The Grenfell Tower Inquiry: Phase 2 Report 76 54.37 At a project meeting on 6 September 2012 attended by Mr Ashton and Mr Sounes it was agreed that the draft Existing Fire Safety Strategy required “detailed interrogation”604 but when they met on 10 September 2012 they did not consider it in any detail,605 since Mr Ashton did not see the meeting as part of the process of getting the draft to the final stage.606 He did not view the completion of the Existing Fire Safety Strategy as his responsibility and regarded it simply as a record of what was there.607 54.38 Fortified by the opinion of Dr Lane, we are satisfied that the draft Existing Fire Safety Strategy was based on an extremely brief (two-hour) site visit, was completed without the benefit of detailed site inspection notes, was based on unsubstantiated assumptions,608 and failed to identify the relevant regulatory guidance.609 The fee quoted (£2,865 plus VAT) represented about three-and-a-half days’ work, which was insufficient for a task of that magnitude.610 Dr Lane considered that four to six weeks’ work would have been more appropriate.611 A site visit lasting only two hours was in her view wholly insufficient to make a meaningful appraisal of the fire safety features of a building of the scale and condition of Grenfell tower.612 She would have expected two people to spend at least a day on site.613 While she thought that it would have been reasonable for Ms Cooney to have relied on Mr Lee’s site visit if it been well documented,614 that was not the case; there were no site notes or marked-up drawings, and the photographs,615 according to Dr Lane, were difficult to interpret since they were not accompanied by any information or explanation.616 There is no evidence that Mr Lee inspected the fire compartmentation during his visit, an omission which Dr Lane considered to be of crucial significance, given that the “stay put” strategy at Grenfell Tower was wholly reliant on a high degree of compartmentation.617 54.39 Dr Lane considered that the information available to Ms Cooney had been too limited to enable her to draft an effective fire safety strategy for the existing building.618 In her opinion Ms Cooney ought to have listed all the information that was not available to her and set out clearly what was needed in order to analyse the building properly.619 That would have included relevant fire safety policies, fire safety management policies and maintenance records.620 In addition, Dr Lane pointed out that Exova had not identified within the draft Existing Fire Safety Strategy any of the shortcomings or assumptions in the 604 {ART00000404}. 605 Ashton {Day 16/151:21-25}. 606 Ashton {Day16/152:4-6}. 607 Ashton {Day16/145:3-7}. 608 Lane {Day61/72:3-18}; {Day61/77:18}-{Day61/78-13}; {Day61/78:6-8}; {Day61/80:6-9}; {Day61/91:3-24}; {Day61/95:7-18}; {Day61/99:8}-{Day61/104-4}. 609 Lane, Phase 2 Report {BLARP20000017/157} paragraph 5.7.1(e). See also {BLARP20000017/127} in relation to Cate Cooney’s paragraph 3.2.1; Exova provided incorrect guidance on the spread of fire across internal linings (copying incomplete guidance from Approved Document B) and distance from the main fire outlet. Lane, Phase 2 Report {BLARP20000017/158} Table 5-10; {BLARP20000017/158} paragraph 5.7.1(q)). 610 Lane, Phase 2 Report {BLARP20000017/61} paragraph 4.3.46; Lane {Day61/72:1-18}. 611 Lane {Day61/74:23-25}. 612 Lane, Phase 2 Report {BLARP20000017/88} paragraph 4.7.14; See also Lane, Phase 2 Report {BLARP20000017/336} paragraph 14.1.21. 613 Lane {Day61/78:17-19}. 614 Lane {Day61/79:3-8}. 615 {EXO00001749}. These photographs are not acknowledged or used as part of the existing building fire safety strategy report. 616 Lane {Day61/80:14-21}; Lane, Phase 2 Report {BLARP20000017/255} paragraph 8.3.1; Lane {Day61/81:17-24}. See also Lane, Phase 2 Report {BLARP20000017/336} paragraph 14.1.19. 617 Lane, Phase 2 Report {BLARP20000017/146} paragraphs 5.4.28-5.4.29. 618 Lane {Day61/83:24-25}. 619 Lane {Day61/84:6-13}; {Day61/121:1-7}. 620 Lane {Day61/84:15}-{Day61/85:7}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 77 2010 fire risk assessment made by Carl Stokes. She was critical of Ms Cooney’s failure to ask for the Significant Findings which formed part of Mr Stokes’ 2010 fire risk assessment and of her decision to go ahead without them. Nor had Exova explained the steps it had taken to satisfy itself that the contents of that 2010 fire risk assessment were based on an accurate assessment of the condition of Grenfell Tower, something which Dr Lane would have expected a competent fire engineer to have done.621 In her view, the proposed Existing Fire Safety Strategy was akin to an independent audit of the existing building and any differences between the strategy and the fire risk assessment, such as the status of the lifts, were important matters to identify.622 54.40 In Dr Lane’s opinion, Ms Cooney’s failure to carry out that step meant that, even as a draft, the document was wholly inadequate. It did not constitute a record of the condition of the existing building, could not be used as the basis of a fire risk assessment for the purposes of the Fire Safety Order, and could not inform the necessary mitigation measures in the refurbishment strategy.623 The document did not adequately identify what further investigation was needed, nor did it provide an explanation of how Exova had taken the missing information into account in its overall assessment of the risk.624 It did not warn the reader that until that information had been obtained it was unsafe to rely on the document. 54.41 Among the salient omissions identified by Dr Lane were the following: a. The document did not state whether the means of escape were sufficient to satisfy the requirements of Article 14 of the Fire Safety Order625 and therefore did not provide the responsible person with practical guidance on that topic.626 b. It did not tell the TMO what action needed to be taken under the Fire Safety Order in response to the existing condition of the building,627 in particular, in relation to the condition of the doors, the inoperability of the smoke control system and the status of the lifts.628 c. It contained no assessment of the width of the stairs or of the performance of the front doors to the flats, the doors to the stair or the lift doors. (Ms Cooney did not understand that to fall within the scope of her instructions.)629 d. No sketches or drawings were provided to enable the reader to understand how the text related to the building.630 e. The document contained no consideration of the characteristics of the people who occupied the building and no evaluation of the needs of those who required assistance to evacuate in the event of a fire.631 621 Lane, Phase 2 Report {BLARP20000017/147} paragraphs 5.4.39-5.4.40. 622 Lane {Day61/120:8-14}. 623 Lane, Phase 2 Report contains a list of defects in the Existing Fire Safety Strategy and their effect {BLARP20000017/157} paragraphs 5.7.1-5.7.6. Dr Lane confirmed that the evidence of Ms Cooney and Dr Barker had not caused her to change her opinions: Lane {Day61/130:23}-{Day61/131:2}. 624 Lane, Phase 2 Report {BLARP20000017/157}. 625 Which deals with emergency routes and exits from a building. 626 Lane, Phase 2 Report {BLARP20000017/129}. 627 Lane, Phase 2 Report {BLARP20000017/336} paragraphs 14.1.22-14.1.23; Lane {Day61/115:14}-{Day61/116:17}. 628 Lane {Day61/116:6-10}. 629 Cooney {Day14/171:20}. 630 Lane, Phase 2 Report {BLARP20000017/158} paragraph 5.7.1(p). 631 Lane {Day62/83:13}-{Day62/96:1}; See the relevant provisions of ADB {CLG00000173/14} section 0.19 and {CLG00000173/18} paragraph B1.v, including the Note.

The Grenfell Tower Inquiry: Phase 2 Report 78 54.42 We have already explained why we accept the evidence of Dr Lane both in relation to the standard of work to be expected of a reasonably competent fire engineer and in relation to the shortcomings of the draft Existing Fire Safety Strategy. We recognise that the document produced by Ms Cooney was no more than a draft, but even a draft can be expected to cover the necessary ground, identify missing information and provide a basis for the eventual completion of the finished document. Moreover, the document contained a number of material errors and omissions that should never have been made by a competent fire engineer undertaking this sort of work, such as the assumption that there was a firefighting and evacuation lift.632 Errors of that kind should have been identified by any competently conducted peer review, but in this case they were not. 54.43 We accept Dr Lane’s opinion that the information available to Ms Cooney was so limited that she should either have refused to produce a draft until further information had become available or have included an express warning that no reliance could be placed upon the document until further work had been done.633 Much of the missing information could have been obtained and many of her assumptions tested by the simple expedient of carrying out the site visit which had been provided for in the fee proposal. In our view those were very significant omissions, not least because they deprived Exova of a proper understanding of the means of escape from the tower. 54.44 Given the shortcomings in the draft Existing Fire Safety Strategy, we doubt whether Ms Cooney properly understood the full extent of her task. Although the fee proposal stated that the purpose of the Existing Fire Safety Strategy was to inform the fire safety risk assessment and the fire risk management plan, her understanding was that it was only one of a number of documents that would be used for that purpose.634 Although it is certainly reasonable to have expected the TMO to look at the current fire risk assessment when compiling its fire risk management plan, a fire safety strategy which provided nothing more than a checklist for statutory compliance would be of little use. The TMO required at least some guidance about the condition of the existing building, but the draft Existing Fire Safety Strategy failed to give clear advice of a kind that could affect or influence the management plan, e.g. by drawing attention to respects in which there was a failure to comply with existing requirements (as in the case of the emergency lighting) or where standards that formerly applied had become outdated (as in the location of the dry rising main outlets). Ms Cooney appeared to think that her role was simply to state whether the design of the building as it stood complied with the Building Regulations, not to provide information that would inform the management of fire safety. 54.45 Dr Barker’s review of the draft was rushed, cursory and superficial and little better than a rubber stamp. She did not follow Exova’s peer review system, or if she did, she did not do so thoroughly and with proper care. It was therefore all the more important for her to ensure that someone took the necessary steps to complete the production of the Existing Fire Safety Strategy, but she failed to do so. On 8 August 2012, following his return to work after a period of illness, Mr Ashton asked Dr Barker in terms whether she was taking over the project.635 He received no reply to his question, but Dr Barker seems to have thought that he had assumed responsibility for the work from early September. However, he failed to take any steps to complete the document, apparently in the understanding that she had retained responsibility for it. The confusion thus engendered meant that there was no effective transfer of responsibility for the work, which as a result fell between 632 As summarised in Lane, Phase 2 Report {BLARP20000017/157} section 5.7. 633 Lane {Day61/83:24}-{Day61/85:7}. 634 Cooney {Day14/60:10}-{Day14/62:2}. 635 {EXO00000668/1}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 79 the cracks and was allowed to remain uncompleted. It amounted to a serious failure in Exova’s management processes. That explains why Mr Ashton did not discuss the draft with Mr Sounes, but it does not excuse his failure to carry the work forward. Surprisingly, neither Exova, Studio E or the TMO appears to have asked why the document was no more than a draft or when the completed version would be available. Why that was so remains a mystery. 54.46 In our view Exova’s work on the Existing Fire Safety Strategy fell well below the standards to be expected of a reasonably competent fire engineer. The Existing Fire Safety Strategy ought to have provided a precise record of the baseline condition of fire safety at Grenfell Tower which could inform the refurbishment fire safety strategy.636 The document should have been a critical building block in the establishment of that strategy, since, without understanding the existing condition of the building, it was impossible to understand the full effect of the refurbishment on fire safety.637 However, Exova’s work on the Existing Fire Safety Strategy was poor and incomplete. The document failed to record the condition of the building in its existing state and did not provide a reliable baseline for the creation of a fire safety strategy for the refurbishment. Cate Cooney’s email of 17 August 2012 54.47 In addition to producing the Existing Fire Safety Strategy Cate Cooney was also involved in some of the other fire safety aspects of the refurbishment. On 16 August 2012, having received her email attaching the draft Existing Fire Safety Strategy, Bruce Sounes asked her to advise on the introduction of residential units on the mezzanine floor of the building for the purposes of a submission to RBKC’s planning department the following week.638 Later that morning Ms Cooney sent Andrew Martyn, a senior consultant at Exova,639 an email to which she attached plans showing the layout of the new flats. Having mentioned that she had spoken to Bruce Sounes, she said: “We have just sent through the existing fire strategy for it, basically 1970s 24 storey residential tower with non-residential use to first 4 floors. They are now adding additional levels which merges uses around a single stair. Not great. Basically I have told him we can massage the proposal to something acceptable, with separation, lobbies etc but that there are approval risks to the project on the ff shaft / MOE front. James has been to site and given some advice, but I don’t know what he’s said, but it would appear not much. They are making an existing crap condition worse so it’s a matter of working the worse bits out and making the new stuff work. No sprinklers wanted. LABC building control Kensington and Chelsea – do we have any contacts there?”640 54.48 This email gained some prominence during the hearings because of its blunt and colourful language. However, the message speaks for itself: first, the existing condition of the building raised concerns about fire safety; second, the proposed refurbishment would increase those concerns; and third, the proposals could be altered to make them satisfactory from the perspective of building control but there would remain a risk that approval would be refused because of dissatisfaction with the fire-fighting shaft and the means of escape. 636 Cooney {Day14/71:1-19}; {Day14/92:1-10}; Barker {Day15/170:1-25}. 637 Lane, Phase 2 Report {BLARP20000017/49-50} paragraphs 5.7.3 - 5.7.6. 638 {SEA00000043}. 639 Martyn {EXO00001577/2} page 2, paragraph 3.2. 640 {EXO00001279}.

The Grenfell Tower Inquiry: Phase 2 Report 80 54.49 Ms Cooney denied that her use of the word “massage” had been intended to mean anything more than “change”. She emphatically denied any suggestion that she had used the word in the sense of manipulation or sleight of hand in order to get the designs past building control.641 She said that her intention was to propose substantive changes to the design to make it more acceptable to building control in accordance with the Building Regulations.642 We accept her evidence about that. 54.50 The key to understanding the substantive points being made in the message is the reference to adding additional levels which merge uses around a single stair. That is what Ms Cooney was referring to when she used the expression “making an existing crap condition worse”. The existing arrangements, under which the occupants from areas in different uses were required to use the same stair as an escape route, was not considered to be consistent with modern guidance (in her words “not ideally something we would be looking for”) and would be made worse by the addition of additional flats at the lower levels. Her proposal was to introduce “new measures” to reduce the risk of building control’s refusing approval.643 54.51 Ms Cooney did not recall her conversation with Mr Sounes about this email.644 Although he did recall a discussion with Ms Cooney about different escape routes, he was clear that the email reflected a level of concern within Exova of which he had previously been unaware and which had not been disclosed in Exova’s subsequent report to him.645 We accept Mr Sounes’ evidence on this point and we doubt that Ms Cooney ever conveyed to him the full extent of her concerns, including her view that the refurbishment was “making a crap condition worse”. There is no record of those concerns having been expressed by Ms Cooney to Studio E in the plain terms in which they were couched in her email to Mr Martyn (or indeed at all). Nor do they appear to have been communicated to Dr Barker. Perhaps most importantly, there is no record of their having been expressed to Exova’s client, the TMO. Given the seriousness of the concerns we would have expected Exova to have communicated them directly to the TMO and in our view, in failing to do so it fell short of the standard to be expected of a reasonably competent fire engineer. 54.52 Although Ms Cooney’s message concerned the refurbishment, which was Mr Ashton’s responsibility rather than hers, it was not copied to Mr Ashton, who did not see it at the time. However, he said that even if he had seen it, it would not have caused him any particular concern.646 He told us that he had told the design team fairly forcefully at his first meeting with them (possibly on 6 September 2012) that Studio E’s proposals would not receive building control approval and that serious work was required to ensure that the scheme was accepted.647 Although Mr Sounes could not recall what Mr Ashton had said, he accepted that he might well have said something to that effect, since it was consistent with what they had understood to be the problem in a building with a single stair and limited smoke exhaust to the lobbies.648 641 Cooney {Day14/207:25}-{Day14/209:16}. 642 Cooney {EXO00001590/7} page 7, paragraph 5.3; Cooney {Day14/208:17}-{Day14/209:6}. 643 Cooney {Day14/209:18}-{Day14/211:8}; {Day14/225:9-17}. 644 Cooney {Day14/206:14-18}. 645 Sounes {Day8/5:17}-{Day8/7-17}. 646 Ashton {Day17/8:17-19}. 647 Ashton {Day17/5:17}-{Day17/9:12}. 648 Sounes {Day21/124:10}-{Day21/125:20}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 81 54.53 Dr Lane criticised Ms Cooney for failing to draw her concerns to the attention of those responsible for the building.649 In her view the casual tone of the message demonstrated a failure to recognise that the primary goal of a fire engineer is to protect people’s lives by means of the fire safety design solutions for which they are responsible650 and in her oral evidence, she emphasised the “massive responsibility” that fire engineers have to protect people. Dr Lane thought that this email indicated a culture within the Exova team of “making things work and getting things through”,651 similar to that which she had experienced elsewhere in the construction industry. It is an approach which concentrates more on obtaining building control approval than on ensuring people’s safety.652 We agree and have noticed many examples of that attitude displayed by others involved in the refurbishment. Ms Cooney’s email of 10 September 2012 54.54 On 10 September 2012, following her return from holiday, Ms Cooney sent Mr Ashton an email in which she gave him her thoughts on the problems associated with the additional flats proposed for Grenfell Tower. After setting out how the design could be changed to make the building safer, she said: “The existing ventilation system is questionable and the overall scheme theoretically makes the existing conditions worse by adding the additional risk of 2 No extra residential floors to the building. It is proposed to upgrade the ventilation system, but the standard it will achieve is unknown.”653 Ms Cooney finished by stating again that she saw a “significant approvals risk with the current proposals”. 54.55 This message was a more detailed version of her email to Andrew Martyn of 17 August

1. It does not appear that Mr Ashton responded in substance to it, although he did

acknowledge receipt.654 Mr Ashton said that it had not been necessary for him to discuss the message with Ms Cooney because it “was pretty comprehensive”.655 It did not prompt him to discuss the draft Existing Fire Safety Strategy with her or to ask her to complete it.656 Ms Cooney could not recall ever having discussed the draft Existing Fire Safety Strategy with Mr Ashton in detail so that he could use it as a baseline for the Outline Fire Safety Strategy.657 The Design Note 54.56 While Exova was working on the draft Existing Fire Safety Strategy communications about the Outline Fire Safety Strategy for the refurbishment had continued. On 7 August 2012 Mr Sounes contacted Dr Barker to tell her that he would be submitting a 649 Lane {Day61/125:18-24}; Lane, Phase 2 Report {BLARP20000017/337} paragraph 14.1.30. 650 Lane, Phase 2 Report {BLARP20000017/337} paragraph 14.1.29. 651 Lane, Phase 2 Report {BLARP20000017/337} paragraph 14.1.27. 652 Lane {Day61/126:1-23}. 653 {EXO00000388}. 654 {EXO00000667}. 655 Ashton {Day17/6:11-14}. 656 Ashton {Day18/16:7-25}. 657 Cooney {Day14/218:19}-{Day14/219:1}.

The Grenfell Tower Inquiry: Phase 2 Report 82 Stage C type document to the client by the end of the week or during the following week. He wanted to know whether she had any comments or reservations about the scheme and whether the strategy for fire safety was achievable.658 54.57 Two weeks later, on 28 August 2012, Mr Sounes chased Ms Cooney for a mark-up of the plans and expressed his concern that the fire safety strategy for the proposed design was still embryonic.659 Later, on 12 September 2012, a document describing itself as a Design Note660 was prepared by Mr Ashton and reviewed by Sean McEleney. It was produced two days after a meeting between Mr Ashton and Mr Sounes on 10 September 2012 and purported to provide an outline fire safety strategy for the refurbishment. Mr Ashton explained that it was intended to be a series of “headlines”661 for achieving a satisfactory fire safety strategy for the refurbished building to assist Studio E in developing the design662 and also to put in writing what had been discussed at the meeting. Although not intended to be a RIBA Stage C report, the Design Note was issued for Stage C663 and was included in the formal reporting package for Stage C on 31 October 2012.664 54.58 Mr Ashton did not visit the tower, either before drafting the Design Note or afterwards, despite having been told by Bruce Sounes in May 2012 that a site visit was probably essential665 and despite the view that he had himself expressed at the time that it would be better to visit the building before giving the necessary advice.666 When he gave evidence he conceded that a visit would have been desirable,667 explaining that he failed to make one because he had “other priorities.”668 He therefore became familiar with the tower only from the drawings provided by Studio E.669 However, he did not have any notes from James Lee’s visit and did not look at Mr Lee’s photographs.670 He had no conversations with Mr Lee about the layout of the building671 or about the plans to overclad it.672 There appears to have been no formal handover of the work from Mr Lee to Mr Ashton and Mr Ashton made no enquiries of the TMO building maintenance team before carrying out his work.673 If he had done so, he might have gained some important information, for example, that the smoke control system had ceased to function and that the lifts were not in fact fire- fighting lifts. He might also have obtained a better overall understanding of the condition of the building. 658 {SEA00005595/1}. He also said that he wanted “… any implications of the layout and external works is understood by the rest of the design team…” Mr Sounes, Dr Barker and Mr Ashton understood the phrase “external works” to relate to the landscaping. See Sounes {Day7/213:10-11}; Ashton {Day17/14:10}-{Day17/15:2}; Barker {Day15/58:2-30}. 659 {SEA00000058}. See also Sounes {Day8/12:22-25}-{Day8/13:1-2}. 660 {TMO10001562}. 661 Ashton {Day16/164:20}-{Day16/165:5}. 662 Ashton {EXO00001621/7} page 7, paragraph 4.2. 663 {Day16/165:7-12}. 664 {SEA00006429}. 665 {EXO00000685}. 666 {EXO00000685}. 667 Ashton {Day16/169:7}. 668 Ashton {Day16/168:8-25}. 669 Ashton {Day16/168:25}-{Day16/169:1-2}. 670 Ashton {Day16/170:7-14}. 671 Ashton {Day16/171:2-5}. 672 Ashton {Day16/172:3-7}. 673 Ashton {Day16/172:16-18}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 83 54.59 The Design Note itself did not identify the information that Mr Ashton had relied on for its production, but we know that he had access to the draft Existing Fire Safety Strategy,674 some marked up General Arrangement plans675 and the 2010 fire risk assessment,676 which he considered to be enough for his purposes.677 He also had access to the planning drawings available on a File Transfer Protocol (FTP) site to which Mr Sounes had sent him a link,678 but he did not make use of them.679 54.60 Of the five functional requirements relating to fire safety in Schedule 1 of the Building Regulations 2010, the Design Note dealt only with Requirements B1 (Means of Warning and Escape) and B5 (Access and Facilities for the Fire Service). Mr Ashton explained that he concentrated on those two requirements because the design team wanted answers on them immediately and the other requirements were not as pressing.680 54.61 The Design Note contained no analysis of Requirement B4 and no reference to the cladding. Mr Ashton explained that, although he had seen a reference in Mr Sounes’ email of 3 May 2012 to overcladding the tower,681 he had not at that stage seen any specific proposals that he could comment on,682 nor had he discussed the cladding build- up with any of the design team. Although cladding is mentioned in very general terms in the minutes of a Project Meeting on 6 September 2012 which he attended,683 Mr Ashton did not remember anything of the discussion, suggesting that he might have left early.684 Mr Sounes thought that, during his meeting with Mr Ashton on 10 September 2012, there had been elevation drawings on the table showing the proposed cladding and was almost sure they had discussed it,685 but Mr Ashton did not recall having seen any drawings and said that they had certainly not discussed any. His recollection was that their discussions focused on the means of escape.686 On balance, given that the design of the cladding system was in its infancy at that stage, we think it unlikely that Mr Sounes and Mr Ashton discussed it in any detail before the Design Note was produced. That is consistent with Mr Sounes’ evidence that the contents of the Design Note reflected his conversations with Exova.687 54.62 The absence of an analysis of Requirement B4 did not trouble Mr Sounes, because at that stage his priority was understanding the scope of the proposed changes to the structure of the building and ensuring that the contents of the planning application were both feasible and complied with the Building Regulations.688 He also said that the Design Note had given him reason to believe that means of escape (Requirement B1) and access facilities for the 674 {EXO00000413}. 675 Attached to the email of 10 April 12 {EXO00000468} were the following drawings: SK003-Rev00 - Existing Sections

• Elevations {TMO00830016} (10.4.12); SK001-Rev01 - Existing Floor Plans (10.4.12) {TMO00831044}; SK002-Rev00

Deck 0 & Deck 1 Layout Proposals 10.4.12 {TMO00831044}. 676 {TMO10017402}. 677 Ashton {Day16/173:4-6}. 678 {EXO00000716}. 679 Email from Terence Ashton to Adrian Jess dated 19 November 2012{EXO00000601/3} “I haven’t logged on to this FTP site before…”; Ashton {Day17/65:6} “I didn’t access the FTP site anyway.” 680 Ashton {Day16/174:13-21}. 681 {EXO00000474}. 682 Ashton {EXO00001621/7} page 7, paragraph 4.3. 683 {ART00000404/4}. 684 Ashton {Day16/178:4-8}. 685 Sounes {Day 8/48:23}-{Day8/49:6}. 686 Ashton {Day16/154:8-14}. 687 Sounes {SEA00014273/61} page 61, paragraph 128.5. 688 Sounes {Day8/21:6-19}.

The Grenfell Tower Inquiry: Phase 2 Report 84 fire service (Requirement B5) were the most significant matters that needed to be dealt with at that point.689 His discussions with Exova and the contents of the Design Note had given him a degree of confidence.690 54.63 The Design Note indicated that the existing smoke control system serving the lobbies did not comply with current guidance and therefore needed to be refurbished or modified,691 but it did not describe the condition of the system. That is surprising, given that the day before the document was produced Mr Ashton had been told that it was not working properly.692 His bland description of the state of the smoke control system can be contrasted with the more strongly worded email he received from Cate Cooney on 10 September 2012.693 Nowhere in the Design Note did he spell out that there was a significant risk that the proposals would not receive building control approval. 54.64 The Design Note also pointed out that, as stairs serving residential accommodation should not also serve non-residential accommodation, it might be necessary to provide sprinkler or water mist systems to the boxing club and office suite.694 Yet in no version of the Outline Fire Safety Strategy did Mr Ashton advise that sprinklers might be necessary and there is no record of sprinklers having been discussed in design team meetings.695 54.65 Dr Lane was critical of the Design Note on the grounds that it did not provide the necessary information in sufficient detail to enable the design to be developed to RIBA Stage C with respect to fire safety.696 It appeared to have been produced in haste in order to meet a project deadline697 and dealt only with functional requirements B1 and B5. It therefore failed to provide adequate guidance to the design team on all those aspects of fire safety that needed to be considered in connection with the refurbishment. In our view all those criticisms are well founded. Issue 1 of the Outline Fire Safety Strategy: 31 October 2012 54.66 Issue 1 of the Outline Fire Safety Strategy698 was prepared by Mr Ashton and reviewed by Mr McEleney. It was addressed to Studio E. Although it does not identify the RIBA Stage for which it had been prepared, Mr Ashton said that it was appropriate for Stage C.699 It was issued on 31 October 2012, too late to be incorporated into the formal reporting package for that stage of the works.700 Mr Ashton said that he had not been aware that the report needed to be issued at the same time as the other RIBA Stage C reports.701 689 Sounes {Day8/21:20}-{Day8/23:5}; Sounes {SEA00014273/61} page 61, paragraph 128.5. 690 Sounes {Day8/24:14-15}. 691 {TMO10001562/2} under Existing Parts. 692 Email from Paul Dunkerton (KCTMO) to Terence Ashton, forwarding an email from Janice Wray {EXO00000220} which attaches KCTMO’s investigation into a fire that occurred at Grenfell Tower on 30 April 2010 {TMO10001785}. 693 {EXO00000388}. 694 {TMO10001562/2}; Ashton {EXO00001621/8} page 8, paragraph 4.4. It is also listed as a potential solution to the mixing of non-residential stairs with the open base to the firefighting stair in Cate Cooney’s email of 10 September 2012 {EXO00000388}. 695 Ashton {Day18/143:13-15}; Lane, Phase 2 Report {BLARP20000017/171} paragraph 6.3.16. 696 Lane, Phase 2 Report {BLARP20000017/170} paragraph 6.3.9. 697 Lane, Phase 2 Report {BLARP20000017/174} paragraph 6.3.27. 698 {EXO00000519}. 699 Ashton {Day17/23:4-16}. 700 Studio E’s Stage C Report was issued on 31 October 2012 {ART00008396}; Max Fordham’s Stage C report was issued on 10 October 2012 {MAX00000636}. 701 Ashton {Day17/24:4-19}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 85 54.67 Nowhere in Issue 1 of the Outline Fire Safety Strategy did Exova state that the refurbishment included overcladding of the building.702 That was consistent with the description of the refurbishment in the introduction to the report, which omitted any reference to the overcladding, despite the fact that Mr Ashton was well aware by that time that it constituted an important feature of the works. Although he sought to justify that omission by saying that there had been nothing in the report relating to overcladding (as indeed was the case), he accepted that something of that significance ought to have been included in the description of the refurbishment.703 54.68 The only reference in the document to functional requirement B4 was in section 3.1.4,704 which read: “Compliance with B4 (External fire spread) It is considered that the proposed changes will have no adverse effect on the building in relation to external fire spread but this will be confirmed by an analysis in a future issue of this report.” 54.69 Moreover, although section 3.1.3 dealt with functional requirement B3 (unseen spread of fire in concealed spaces), it was confined to the internal structure and compartmentation generally. It did not deal with compartmentation and concealed spaces within the external wall.705 The document contained no reference to the application of requirement B3 to the external wall, such as could be found in section 9 of the current edition of Approved Document B in relation to the requirement for cavity barriers. 54.70 Mr Ashton said that the documents on which the report had been based had not provided any information about the cladding706 and that he had not been given any details on which he could comment.707 He had expected that information to be provided by Studio E and had assumed that matters relating to requirement B4 would be discussed at a meeting.708 When asked why he had not made it clear in the report that he had insufficient information to make an assessment in relation to requirement B4, he said simply, “That’s not the way we chose to do it. The truth of the matter is that we didn’t have any details that we could comment on.”709 54.71 That was not entirely correct. Although the general arrangement drawings listed in the introduction to the Outline Fire Safety Strategy710 contain no sections or elevations of the tower (and therefore no details of the external wall arrangements), Mr Ashton already had some information about the external wall build-up, having received a draft of potential work packages711 from Adrian Jess of Studio E on 23 October 2012712 for the purposes of a design team workshop to be held on Thursday 25 October 2012. The section 702 The report states that it is based on discussions with the design team and drawings (numbers 1279 RE 110 05, 1279 RE112 04, 1279 RE113 04 and 1279 RE114 03) produced by Studio E LLP {EXO00000856}; {EXO00000858}; {EXO00000860}; {EXO00000861}. 703 Ashton {Day17/101:3-20}. 704 {EXO00000519/8}. 705 {EXO00000519/7-8}. 706 Ashton {EXO00001621/10} page 10, paragraph 4.9 (D). 707 Ashton {EXO00001621/9} page 9, paragraph 4.9; Ashton {Day17/39:17}-{Day17/41:8}. 708 Ashton {Day17/49:8-22}. 709 Ashton {Day17/41:4}. 710 {EXO00000519/4}. The drawings can be found at: Proposed Floor Plans {EXO00000856}; Proposed Mezz Plan {EXO00000858}; Proposed Walkway Plan {EXO00000860}; Proposed Walkway+1 Plan {EXO00000861}. 711 {SEA00006395}. 712 {SEA00006394}.

The Grenfell Tower Inquiry: Phase 2 Report 86 entitled “Architectural Strategy” referred to overcladding comprising insulation with zinc rainscreen,713 but it is unlikely that Mr Ashton looked at that document, since it did not have any obvious relevance to fire safety and he had not been asked to do so.714 54.72 The statement in Issue 1 of the Outline Fire Safety Strategy relating to compliance with functional requirement B4 led Mr Sounes to understand that it was too soon for Exova to comment on the structure of the external wall, but he took it as confirmation that Exova had no immediate concern about the proposals.715 Mr Ashton, however, did not realise that.716 54.73 Studio E produced its RIBA Stage C report on 31 October 2012. It was sent to the TMO by a link in an email sent at 11.37 which was copied to the design professionals, including Mr Ashton.717 Just under five hours later, at 16.21, Margaret Treanor, an administrative assistant at Exova, sent Issue 1 of the Outline Fire Safety Strategy to Adrian Jess at Studio E.718 There may have been a brief interlude, therefore, in which Mr Ashton could have read the Stage C report before he released the Outline Fire Safety Strategy, but he did not read it then or later, because the email to which it had been attached had not been addressed to him and he had not specifically been asked to read it. It was not his practice to look at Stage C or Stage D reports unless specifically asked to do so.719 54.74 If Mr Ashton had read the Stage C report carefully, he would have seen that the tower was to be overclad,720 with various options being considered for the rainscreen, including zinc721 and aluminium.722 He would also have seen that Celotex FR5000 was proposed as insulation in the external wall.723 Mr Ashton repeatedly said that he had not been told what insulation or rainscreen was being used on the tower.724 Further information provided to Mr Ashton in November 2012 54.75 On 16 November 2012 Adrian Jess of Studio E sent Mr Ashton a link to Studio E’s then current drawings on an FTP site.725 Mr Ashton had not previously used the site and asked for assistance.726 However, although Mr Jess sent him a new link to the site, he did not visit it and so did not see the drawings it contained. Nor did he ask to be given the drawings in some other way.727 Mr Ashton’s lack of interest in the information being made available to him is regrettable to say the least, but it is not clear which drawings were available on the FTP site at that time or whether they contained any information about the external wall.728 713 {SEA00006395}. 714 Ashton {Day17/30:1}-{Day17/32:9}. 715 Sounes {Day8/52:9-11}; See also Sounes {SEA00014273/73} page 73, paragraph 149. 716 Ashton {Day17/47:25}-{Day17/48:4}. 717 {ART00008396}. 718 {EXO00000518}. 719 Ashton {Day17/97:8}-{Day17/98:4}, {Day17/98:17-19}. Dr Pearson’s evidence was also that architects would usually provide them with Stage C or Stage D reports voluntarily. Pearson {Day19/110:16-25}. 720 {SEA00006429/27}. 721 {SEA00006429/28}; {SEA00006429/31}; {SEA00006429/32}. 722 {SEA00006429/32}. 723 {SEA00006429/82-83}. 724 Ashton {Day17/92:2-14}; {Day17/95:19-20}. 725 {SEA00006666}. 726 {EXO00000601/3}. 727 Ashton {Day17/63:17-19}; {Day17/64:15-25}. 728 Proposed Walkway +1 Floor Plan, annotated {SEA00006728}; Proposed Mezzanine Floor Plans, annotated {SEA00006727}, attached to email {SEA00006726}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 87 54.76 In both her written and oral evidence Dr Lane was critical of Issue 1 of the Outline Fire Safety Strategy, not just for failing to record the fact that the project included the overcladding of the entire building but for expressing the view, albeit subject to confirmation in due course, that the work would have no adverse effect on the building in relation to external fire spread.729 The purpose of obtaining an Outline Fire Safety Strategy was to provide the design team with the information they needed to ensure that when the refurbishment had been completed the building would be safe for occupation. Dr Lane said that in a document of this kind she would expect a reasonably competent fire engineer to set out, as a bare minimum, the statutory guidance relating to insulation, cavity barriers, and the external surface, with references to the relevant sections of Approved Document B.730 That would involve making clear the performance required of each of the separate elements of the external wall.731 She agreed that Exova could properly have made it clear that it had no information about the proposed cladding and would consider that at a later stage, but considered that to express even a provisional opinion without the benefit of any information about the cladding was unacceptable.732 54.77 Neither Mr Ashton nor anyone else at Exova had any information about the proposed cladding and no attempt had therefore been made to analyse the proposals for the external wall of the building. Exova therefore had no basis for expressing an opinion, even of a provisional nature, that the proposed work would have no adverse effect on the building in relation to external fire spread. Such a statement was bound to lead Studio E and the TMO to assume that, unless it was later withdrawn or modified, they could be confident that the building would comply with functional requirement B4 and be safe for occupation. Dr Lane considered that the inclusion of that statement fell short of the standards to be expected of a competent fire engineer, a view with which we agree. Liaison with building control 2012–2013 54.78 Following the production of Issue 1 of the Outline Fire Safety Strategy in October 2012, Mr Ashton took the lead in dealing with building control in relation to fire safety aspects of the Grenfell Tower refurbishment. He sent Issue 1 of the Outline Fire Safety Strategy directly to John Allen on 31 October 2012.733 He also organised a meeting at Kensington Town Hall on 6 November 2012 with Mr Jess and John Allen and Dave Gammon, both of RBKC building control, to introduce the scheme to them, to gauge their response and to discuss the fire strategy.734 He said that RBKC building control could be difficult to deal with, particularly when presented with something that did not comply exactly with official guidance.735 He told Bruce Sounes that they set their own standards, by which he meant that they were sticklers for compliance.736 54.79 Mr Ashton said that neither functional requirement B4 nor the overcladding of the tower was discussed during the meeting because its purpose had been to discuss Issue 1 of the Outline Fire Safety Strategy report.737 He said he would have expected Studio E to have put overcladding on the agenda if it had needed to be discussed; he did not think it his 729 Lane {Day61/168:16-21}; Lane, Phase 2 Report {BLARP20000017/188}, paragraph 6.5.10. 730 Lane {Day61/168:16-21}; {Day61/169:18-25}; {Day61/170:5-8}; {Day61/170:18-20}. 731 Lane {Day61/169:18}-{Day61/170:20}. 732 Lane, Phase 2 Report {BLARP20000017/187-188} paragraphs 6.5.9-6.5.12. 733 {SEA00006443}. 734 Terence Ashton’s notes of this meeting are at {EXO00001371}; Adrian Jess’s notes of the meeting are at {SEA00006526}. 735 Ashton {Day17/66:9}-{Day17/67:19}. 736 {ART00000385}. 737 Ashton {Day17/70:7-18}. John Allen said that he did not believe that cladding had been referred to during the meeting, although he could not recall the meeting at all. Allen {Day47/175:4-11}.

The Grenfell Tower Inquiry: Phase 2 Report 88 responsibility to do that.738 According to Mr Sounes, a meeting of that kind would normally begin with a brief description of the project, which would inevitably have included a description of the cladding. However, given the absence from Mr Jess’s detailed notes of any reference to the overcladding,739 we think it unlikely that it was discussed or even mentioned in a way that could have been expected to lodge in Mr Ashton’s mind. 54.80 Mr Ashton met building control again for the last time on 17 September 2013 to discuss the fire strategy.740 He agreed that he would normally have expected to have had more meetings with them741 and indeed the Fee Proposal allowed for one meeting at Stage C and two meetings at Stage D or E,742 but he had expected them to be arranged only if Studio E asked for them.743 Again, there is no evidence that the overcladding of the tower was discussed at that meeting.744 Mr Ashton said that he had never discussed with anyone from building control whether the cladding proposals complied with the guidance in Approved Document B745 and there is no written record of any such discussion having taken place. Issue 2 of the Outline Fire Safety Strategy: 24 October 2013 54.81 Issue 2 of the Outline Fire Safety Strategy was dated 24 October 2013.746 It was written by Mr Ashton and reviewed by Dr Tony Pearson, a senior consultant747 although junior to Mr Ashton at Exova. It was produced following the meeting with building control on 17 September 2013, after which alterations had been made to some of the drawings on which the previous report had been based.748 Issue 2 of the Outline Fire Safety Strategy did not identify the RIBA Stage for which it had been written. According to Mr Ashton, it could have been intended for use at Stage D, although unknown to him Studio E had already produced its Stage D report in August 2013.749 54.82 Studio E’s Stage D report had included Issue One of Exova’s Outline Fire Safety Strategy at Appendix D,750 a fact of which Mr Ashton was also unaware.751 Since he had not read the Stage D report, (or, for that matter, the Stage C report),752 it is no surprise that neither of the reports was referred to in Issue 2 of the Outline Fire Safety Strategy. If Mr Ashton had read the Stage D report, he would have seen the reference to the zinc composite rainscreen proposed for the upper levels,753 images of cladding754 and references to Celotex 738 Ashton {Day17/70:14}-{Day17/71:7}; {Day17/73:13-16}. 739 {SEA00006526}. 740 {EXO00000693/5}. 741 Ashton {Day17/182:13-19}. 742 {EXO00001349/2}; {EXO00001349/3}. It was also envisaged that at Stage F work would include, when appropriate, discussion with “the regulatory approvers”, including attendance at up to one meeting in London. 743 Ashton {Day17/182:20-24}. 744 Sounes {Day21/135:1}-{Day21/136:9}. 745 Ashton {Day17/181:9-12}. 746 {EXO00000430}. 747 According to Dr Pearson a senior consultant was the minimum grade for reviewing other people’s work, for managing a more complicated project or for leading negotiations with building control. Pearson {Day19/3:16-19}. 748 Ashton {Day17/116:11-18}; {EXO00000390}. The altered drawings can be found at {EXO00000961}, {EXO00000962}, {EXO00000980}. 749 Ashton {Day17/99:17-18}. 750 {SEA00008054/78}. 751 Ashton {Day17/97:8-11}. 752 Ashton {Day17/100:25}; Stage C report {SEA00006429}. 753 {SEA00008054/22}; {SEA00008054/29}. 754 {SEA00008054/26}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 89 FR5000 as the proposed insulation.755 By that time, however, Studio E was working to the Employer’s Requirements – Stage E,756 so Mr Ashton was once again out of step with the other design professionals on the project. 54.83 When reviewing Issue 2 of the Outline Fire Safety Strategy, Dr Pearson had seen only the general arrangement floor plans and the mark-ups on the drawings produced by colleagues at Exova.757 It would have been useful for him to have seen the minutes of the discussions with building control, but they had not been made available to him.758 He had not seen the draft Existing Fire Safety Strategy which ordinarily he would have wanted to see when conducting a review of that kind.759 Dr Pearson did not know what stage of the RIBA process the report was being written for, nor did he know that Studio E had issued its Stage C report in October 2012 and its Stage D report in August 2013.760 We think that he should have known both of those things when carrying out a peer review of the fire safety strategy so that he properly understood the context in which the report was being prepared. 54.84 In the introductory section of Issue 2 the description of the refurbishment had been amended,761 but it still omitted any reference to the overcladding of the tower. According to Mr Ashton, that was because Exova had still not given any consideration to the cladding.762 The drawings identified at the end of the introduction were general arrangement drawings and did not show any details of the external wall construction.763 Dr Pearson was not aware at the time that the refurbishment included overcladding,764 nor did he have any knowledge of the arrangements proposed at the top of the tower,765 all of which may explain why he had no concern about the treatment in the report of functional requirement B4. He assumed that Mr Ashton would carry out an analysis when further information had become available. 54.85 In Issue 2 of the report the section dealing with functional requirement B4 (external fire spread) was unchanged and therefore the single sentence at para 3.1.4 remained the only reference to that requirement of the Building Regulations.766 Nor did the report contain any express reference to the performance requirements for an external wall. It seems that that was not something which Exova routinely included in a document of that kind.767 Dr Pearson explained that at the time there had been an assumption within Exova that designers knew what the requirements were,768 but with the benefit of hindsight he recognised that that assumption had been misplaced. Similarly, they had assumed that the designers would choose appropriate materials.769 755 {SEA00008054/29}. 756 Sounes {Day8/67:25}; Sounes {SEA00014273/105} page 105, paragraph 241. 757 Pearson {Day19/109:5-16}. 758 Pearson {Day19/105:13-19}; {Day19/126:21-24}. 759 Pearson {Day19/107:3-4}. 760 Pearson {Day19/106:9-24}; {Day19/107:21-25}. 761 {EXO00000430/4} Two additional features were added: “…a new stair providing access to the boxing club at ground storey level;” and “…office accommodation in the mezzanine over the ground storey (mezzanine level).” 762 Ashton {Day17/100:19-21}. 763 {EXO00000430/4}. The drawings were: 1279 SEA (08) 100, “Fire Access”, 24.10.13 {TMO00828152}; and 1279 SEA (08) 101, “Fire Strategy”, 24.10.13 {TMO10040859}. 764 Pearson {Day19/105:6}; {Day19/122:12-17}. 765 Pearson {Day19/123:4-14}. 766 “It is considered that the proposed changes will have no adverse effect on the building in relation to external fire spread but this will be confirmed by an analysis in a future issue of this report.” 767 Ashton {Day17/104:5-7}. 768 Pearson {Day19/160:8-17}. 769 Pearson {Day19/171:10-14}.

The Grenfell Tower Inquiry: Phase 2 Report 90 54.86 Mr Ashton said that at the time he had been slightly nonplussed by the fact that the overcladding had not been the subject of any discussion by that late stage in the development of the design,770 yet he also said that he had not thought that there had been a general awareness in the construction industry before the Grenfell Tower fire of the need to look critically at the construction of external walls.771 That suggests, however, that Mr Ashton was aware that he needed to ensure that this aspect of the project had been, or would be, properly addressed. 54.87 Dr Pearson did not discuss section 3.1.4 of the document or requirement B4 with Mr Ashton at the time;772 he had absolute faith in Mr Ashton and believed that he would provide all the necessary advice on B4 when appropriate.773 However, he was unaware at that time that Mr Ashton had no experience of advising on cladding work on high-rise residential buildings.774 54.88 No changes were made to the section covering functional requirement B3 (internal fire spread)775 and therefore there was still no guidance on compliance with Section 9 of Approved Document B and the provision of cavity barriers. Dr Pearson was not concerned that the second issue of the Outline Fire Safety Strategy failed to identify the locations of concealed spaces or places where cavity barriers would be needed because the document was described as an outline rather than a detailed strategy.776 He also failed to notice that the document incorrectly stated that the floors should provide at least 60 minutes’ fire resistance, as he took it on trust that that was correct.777 54.89 In the process of conducting his peer review Dr Pearson added a new paragraph to the report drawing attention to the fact that, although the sharing of a means of escape between residential and non-residential accommodation was not endorsed by current statutory guidance, the proposals complied with the Building Regulations because they represented a continuation of the existing principles.778 Mr Ashton said that amendments would usually be discussed before a document was sent out, but that there had been no discussion in this case because they had been under pressure of time.779 Mr Ashton had asked for the document to be sent out without having read Dr Pearson’s amendment and was irritated by it when he did read it,780 because he thought that it unnecessarily drew attention to a failure to comply with Approved Document B.781 He had noted the fact that the proposal to share the means of escape did not comply with Approved Document B in the Design Note782 and he knew that Ms Cooney had previously expressed concern about merging the stairs serving the boxing club and office with those serving the residential units.783 He said that he had already established with building control that there was a mixture of uses and that he was addressing it with appropriate fire safety measures,784 770 Ashton {Day17/104:13-16}. 771 Ashton {Day 17/104:17}-{Day17/105:7}. 772 Pearson {Day19/117:14}. 773 Pearson {Day19/130:2-21}; {Day19/171:20-22}; {Day19/110:3-9}; {Day19/121:6-13}. 774 Pearson {Day19/125:18-22}. 775 {EXO00000430/8} section 3.1.3. 776 Pearson {Day19/114:16-23}. 777 Pearson {Day19/111:7-25}. 778 {EXO00000430/6} Section 3.1.1. 779 Ashton, {Day17/175:1-13}. 780 Ashton {Day17/113:14-20}; {EXO00001444}. Dr Tony Pearson had given Terence Ashton two opportunities to comment on the amendment (at 16.13 and at 16.52) before it was sent out. 781 {EXO00001444}. 782 {EXO00000142/2}. 783 {EXO00000388}; Ashton {Day17/114:14-24}. 784 Ashton {Day17/114:14-24}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 91 but he did not want to draw attention to it in case they said it was not acceptable.785 Mr Ashton’s view was that it was a matter of emphasis and suggested that he had overreacted to what Dr Pearson had written.786 54.90 Dr Lane considered that the problem to which Dr Pearson’s amendment drew attention involved a fundamental breach of the Building Regulations and she considered that Mr Ashton’s attitude in hoping that building control would not notice it fell below the standards to be expected of a reasonably competent fire engineer.787 In her view, it was important when drafting a fire safety strategy to identify any deviations from the statutory guidance so that the different readers could take account of them when making decisions about the project.788 We agree and return to this at a later stage when we consider broader questions about Exova’s work on this project. 54.91 When Mr Ashton produced Issue 3 of the Outline Fire Safety Strategy in November 2013, he retained the statement that “sharing means of escape between residential and non-residential accommodation is not endorsed by current statutory guidance”,789 but deleted from section 3.1.1 the statement that the proposals represented “a continuation of the existing principles for means of escape in the building and therefore do not create a non-compliance with the requirements of the Building Regulations”.790 Mr Ashton did not seek to discuss that amendment with Dr Pearson791 and Dr Pearson appears not to have realised at the time that the words in question had been removed.792 54.92 Studio E sent Issue 2 of the Outline Fire Safety Strategy to building control by email on 25 October 2013.793 John Allen responded on 11 November 2013,794 saying that the information submitted was not adequate to enable an effective consultation to be had with the fire authority. Mr Ashton thought that building control’s concerns related to Max Fordham’s work in designing the smoke control system,795 and that it was therefore Max Fordham’s responsibility to provide whatever additional information was required.796 There is nothing in the email to suggest that building control considered the proposals to be unacceptable because they failed to address functional requirements B3 and B4. 54.93 The very fact that Issue 2 of the Outline Fire Safety Strategy was in substance almost identical to Issue 1 produced a year earlier is itself a ground of criticism. Max Fordham and Studio E had produced their RIBA Stage D reports in August 2013.797 Dr Lane said that she would have expected a reasonably competent fire engineer about to produce a fire safety strategy for RIBA Stage E to have asked for the Stage D report for use as a reference guide and to check the sections that were relevant to its work.798 In her opinion Mr Ashton’s failure to obtain the latest information at that stage of the design process fell short of what could be expected of a reasonably competent fire engineer who could be expected to obtain any information needed to complete its work.799 We agree. 785 Ashton {Day17/110:25}-{Day17/111:5}; See also Ashton {EXO00001621/11} page 11, paragraph 4.17. 786 Ashton {Day17/112:19-20}. 787 Lane, Phase 2 Report {BLARP20000017/99}, paragraphs 4.7.81-4.7.82. 788 Lane {Day61/207:7-13}. 789 {EXO00001107/6}. 790 {EXO00001107/6}. 791 Pearson {Day19/91:11-15}. 792 Pearson {Day19/93:7-23}. 793 {SEA00000121}. 794 {RBK00002985}. 795 Ashton {Day17/195:18-20}; See also Ashton {EXO00001621/12} paragraph 5.3. 796 Ashton {Day17/200:1-4}. 797 {SEA00008054}; {TMO00834924}. 798 Lane {Day61/188:7-13}. 799 Lane {Day61/188:1-23}.

The Grenfell Tower Inquiry: Phase 2 Report 92 54.94 Exova’s failure to review the statement in relation to functional requirement B4 was again the subject of criticism by Dr Lane, who was critical of its failure to provide the guidance that in her view should have been included in Issue 1. We find it very surprising that no one at Exova recognised that the statement relating to functional requirement B4 had not been properly resolved. Mr Ashton’s explanation that he had not been provided with the information he needed in order to deal with it was in our view a poor excuse. We consider that a reasonably competent fire engineer would have realised that the report remained incomplete in an important respect, would have drawn the matter to the attention of its client and would have sought the information needed to complete the report. In failing to do so Exova in the person of Mr Ashton fell below the standards to be expected of a reasonably competent fire engineer. Correspondence with Studio E before Issue 3 54.95 After the production of Issue 2 of the Outline Fire Safety Strategy on 24 October 2013, but before the production of Issue 3 on 7 November 2013, a question was raised by the design team about the performance of the external wall. On 1 November 2013, Tomas Rek of Studio E sent an email to Mr Ashton asking him to confirm that the rainscreen cavity barriers were to have 60 minutes’ fire resistance to match that of the compartmentation.800 Mr Ashton’s response on 4 November 2013 was brief, stating simply that cavity barriers needed to have only 30 minutes’ fire resistance.801 Mr Ashton did not check Approved Document B before giving that advice because, he claimed, he had known the answer off the top of his head.802 Nor did he consider it necessary to advise Mr Rek of the performance requirements set out in Approved Document B for the external wall or the required locations of cavity barriers.803 Although he did not have any details of the rainscreen to which Mr Rek had referred, he did not ask for further information since he assumed that it might be forthcoming in the not too distant future.804 Regrettably, Mr Rek’s email did not prompt Mr Ashton, as it should have done,805 to address the external wall requirements in Issue 3 of the Outline Fire Safety Strategy which was produced within a week of this correspondence.806 Issue 3 of the Outline Fire Safety Strategy: 7 November 2013 54.96 Issue 3 of the Outline Fire Safety Strategy was produced on 7 November 2013,807 less than two weeks after Issue 2. It had been prepared by Mr Ashton and reviewed by Mr McEleney. The stated reason for the revision was to take into account comments from the design team.808 The document was said to be based upon discussions held with the design team and building control and on unidentified fire access and fire strategy drawings produced by Studio E.809 Exova did not provide a set of fire strategy drawings to accompany Issue 3. 800 {EXO00000586}. 801 {EXO00000586}; Ashton {Day17/124:21}-{Day17/125:3}. 802 Ashton {Day17/123:25}-{Day17/124:1-2}. 803 Ashton {Day17/124:8-10}; {Day17/126:21-23}. 804 Ashton {Day17/120:22-25}. 805 {EXO00000586}; Lane {Day61/212:7}-{Day61/213:7}. 806 Ashton {Day17/121:6}-{Day17/122:23}. 807 {EXO00001107}. 808 {EXO00001107/2}. See also exchanges between Terence Ashton and the Studio E design team {EXO00001408} and changes to the Fire Strategy marked up in yellow on {EXO00001501}. 809 {EXO00001107/4}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 93 Dr Lane was critical of that omission, and explained that anyone reading the report would need both the detailed information on the drawings and the narrative in the report in order to understand the basis for the fire safety design.810 54.97 Again, Exova failed to specify for which RIBA stage the document had been written. Mr Ashton thought that it was another version of one intended for Stage D, but Mr Sounes said it had related to Stage E.811 Mr Ashton had still not seen either the Stage C or Stage D report.812 54.98 The introduction to Issue 3 described the refurbishment works and, as in the case of Issues 1 and 2, made no mention of the overcladding.813 The wording of the section covering B4 (external fire spread) also remained the same.814 Mr Ashton explained that nothing had changed since the previous issue because he still had not been given the details of the external wall.815 He said that Exova had been disengaged from the design team for a number of months between Issues 1 and 2 and that the project had “gone a bit cold”.816 He had been expecting a discussion, but none had taken place by the time the document had been produced.817 By contrast, Mr Sounes said he had expected Mr Ashton to ask if he needed any further information to enable him to provide the advice covered by Exova’s Fee Proposal, including any necessary drawings, details or specifications.818 In oral evidence, Mr Ashton accepted that Exova should have pursued Studio E more vigorously for information about the external walls, but he rejected the suggestion that retaining the original wording without any clarification was an abdication of its responsibilities as fire strategy consultant for the project.819 54.99 In common with Issue 2, Issue 3 did not describe the fire performance materials needed to comply with functional requirement B4, nor did it set out the fire safety standards for the construction of external walls, which, according to Dr Lane, was the minimum Exova should have provided by way of advice.820 Accordingly, it did not make it clear that the guidance in paragraph 12.7 of Approved Document B required any insulation product used in the external wall to be of limited combustibility. Mr Ashton explained that omission by saying that he did not include performance requirements as a matter of course in every report.821 He accepted that he had taken no steps before the production of Issue 3 to ascertain whether the cladding would or would not be likely to have an adverse effect on the building in relation to fire spread.822 810 Lane {Day61/221:10-15}. 811 Sounes {Day12/147:19-23}. 812 Ashton {Day17/128:9-18}. 813 {EXO00001107/4}. 814 {EXO00001107/9} paragraph 3.1.4. 815 Ashton {EXO00001621/12} page 12, paragraph 4.20, “Again, I had still seen no proposals in relation to any cladding, and so the report contains the same statement as before.” See also Ashton {Day17/130:7-16}. 816 Ashton {Day17/131:6}-{Day17/132:6}. 817 Ashton {Day17/131:6-13}. 818 Sounes {Day12/150:15-20}. 819 Ashton {Day17/135:8-22}. 820 Lane, Phase 2 Report {BLARP20000017/214} paragraphs 6.9.12-6.9.13. See also Lane {Day62/25:22-24}; {Day62/26:12-14}. 821 Ashton {Day17/137:8-18}; {Day17/48:13-17}-{Day17/49:11-14}. 822 Ashton {Day17/130:25}-{Day17/131:5}.

The Grenfell Tower Inquiry: Phase 2 Report 94 54.100 Similarly, Issue 3 contained no guidance on the need for cavity barriers823 nor any reference to the performance requirements for cavity barriers within external walls as set out in section 9 and paragraph 12.8 of Approved Document B, despite the fact that Tomas Rek had sought guidance on that very matter only days earlier.824 54.101 Issue 3 of the Outline Fire Safety Strategy also omitted any reference to the crown, but that was because Mr Ashton had never been asked to advise on that part of the structure. He had not seen any drawings of the crown and did not know anything about the arrangements at the top of the building.825 Nor did it contain any reference to the draft Existing Fire Safety Strategy. Dr Pearson said that if he had been the author of the report he would have included a lengthy summary of the existing strategy,826 but Mr Ashton was not aware that the Existing Fire Safety Strategy (even though only in draft form) was intended to be the baseline from which the Outline Fire Safety Strategy was to be developed.827 54.102 When addressing the means of escape and functional requirement B1, Mr Ashton advised that the design of the smoke control system would be covered in a separate report by Max Fordham.828 No performance requirements for the new smoke control system were set out, nor was the role of the system specified. Mr Ashton told us that the performance requirements for smoke ventilation systems serving a common lobby were well known in the industry and certainly would have been well known to Max Fordham, so he did not think it necessary to spell them out.829 54.103 Issue 3 of the Outline Fire Safety Strategy did state that for the walkway, mezzanine and ground floor levels and in the lobby to the boxing club and community room, automatic opening vents of 0.4m² in area would be provided.830 As Mr Ashton accepted, that did not comply with the guidance in Approved Document B, because the size of the opening vents did not comply with BS5588-5:2004,831 but it was the best that could be achieved. He did not expressly refer to that shortcoming in the strategy because he had discussed it with building control, which appeared to be happy with it on that basis.832 54.104 Similarly, there was no reference in the section dealing with functional requirement B1 to the fact that the width of the stairs at 1040mm was 60mm less than the 1100mm stated in Approved Document B,833 although Mr Ashton had been aware of the fact, having advised on the question by email in October 2013.834 He accepted that it could have been added to the narrative discussion in the report, but did not consider that to be necessary, since it was not practicable to alter the stairs, which in his view were perfectly adequate.835 823 {EXO00001107/8} paragraph 3.1.3. 824 {EXO00000586}. 825 Ashton {Day17/139:16}-{Day17/140:3}. 826 Pearson {Day19/108:1-9}. 827 Ashton {Day18/11:4-7}. 828 Note under the heading “SMOKE VENTILATION OF LOBBIES”, “(this supply and extract system will be overhauled as part of the improvement to the building services. This is covered in a separate report from Max Fordham.)” {EXO00001107/7} and see also Ashton {Day17/143:12-16}. 829 Ashton {Day17/143:17}-{Day17/144:3}. 830 {EXO00001107/7}. 831 Referred to in Diagram 52 of Approved Document B, Note 2 {CLG00000224/116}; See also Lane, Phase 2 Report {BLARP20000017/299}. 832 Ashton {Day17/146:5-19}. 833 Approved Document B {CLG00000224/32} section 2.33. 834 {EXO00000739/1}. In response to a question about the width of the stair, Mr Ashton replied, “If the stair were to be used as access for fire-fighters it would have to be 1100mm between walls.” See also Ashton {Day17/147:16-20}. 835 Ashton {Day17/147:9}-{Day17/149:14}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 95 54.105 The strategy contained no advice that might have assisted the TMO in discharging its duties under the Fire Safety Order or any information about how the active and passive fire safety systems would need to be maintained in order to ensure compliance with the legislation. Nor did it contain any acknowledgement of the fact that the mixed-use nature of the building might result in there being more than one responsible person. Mr Ashton considered that that would be more appropriately addressed in a fire safety management plan.836 54.106 Similarly, there was no consideration in the strategy of the means of escape for those in the tower with disabilities because Mr Ashton did not think that the law required designers to consider their position.837 He had therefore not asked for information about who was living in the building or who might be living there in the future.838 He said that he would not have expected to be given that information by the TMO unless there had been some particular reason to consider it, for example, if the building had been purpose-built for people with disabilities.839 54.107 Mr Ashton did not review the Fee Proposal before putting the finishing touches to Issue 3 to remind himself of the scope of Exova’s instructions; it was not something he did as a matter of routine.840 54.108 Issue 3 was the last version of the Outline Fire Safety Strategy produced by Exova for the Grenfell project841 and represented the culmination of its work on the refurbishment up to and including RIBA Stages D and E.842 Exova produced nothing commensurate with RIBA Stages E or F.843 According to Mr Ashton, that was because Exova had not been novated to Rydon.844 Mr Ashton said that the relatively minor nature of the differences between the three versions of the report reflected changes to the design of the lower four floors.845 54.109 In the event, Exova never did produce a final version of the fire strategy. Mr Ashton did not consider Issue 3 to be the final version846 and accepted that a detailed fire strategy would have dealt with all the functional requirements from B1 to B5.847 He acknowledged that Issue 3 did not deal with a number of subjects, including an analysis of the external wall in relation to functional requirement B4.848 He said that his intention at the time had been to produce the final version once he had received the necessary information from the design team;849 but he never asked Studio E for that information850 and allowed the matter to drift in the absence of any request from Studio E for a complete analysis.851 He did not regard completion of the fire safety strategy as a priority and he had a lot of other work on his hands at the time.852 836 Ashton {Day17/155:16-22}. 837 Ashton {Day17/150:1-11}. 838 Ashton {Day17/153:13-24}. 839 Ashton {Day17/158:24}-{Day17/159:4}. 840 Ashton {Day17/131:20-25}. 841 Ashton {EXO00001621/12} page 12, paragraph 4.18. 842 Ashton {Day18/165:6-9}. 843 Lane, Phase 2 Report {BLARP20000017/101} paragraph 4.7.104. 844 Ashton {Day18/166:10-14}. 845 Ashton {Day18/166:4-9}. 846 Ashton {Day 17/133:1-3}. 847 Ashton {Day16/101:1-4}. 848 Ashton {Day17/132:16-18}; {Day18/165:18-20}; {Day18/166:1-3}. 849 Ashton {Day17/133:1-6}. 850 Ashton {Day17/133:22-25}. 851 Ashton {Day17/48:5-17}. 852 Ashton {Day17/133:11-15}.

The Grenfell Tower Inquiry: Phase 2 Report 96 54.110 Mr Ashton said that building control had never asked for a more detailed fire safety strategy and that Exova had not received any instructions from the TMO to review it.853 In retrospect he thought it surprising that he had had no contact with Studio E to discuss a compliance check of the design for the external wall, but he did not consider that it would have been appropriate for him to tell the TMO that further work was required.854 In the event, Exova never told Studio E or Rydon that further work needed to be done on the Outline Fire Safety Strategy. 54.111 Issue 3 of the Outline Fire Safety Strategy was expressly incorporated into the Design & Build Contract between the TMO and Rydon.855 Although Mr Ashton was aware that a document of that kind would usually be provided to the main contractor for information at the tender stage, he was not specifically aware that in this case it had been incorporated into the building contract.856 54.112 Studio E also included Issue 3 of the Outline Fire Safety Strategy in the full plans application that was submitted to building control on 29 September 2014.857 Mr Ashton was not aware of that at the time, but he knew that it was standard practice to do so.858 He also knew that it was unusual, when the work to a building was to include overcladding, for a fire safety strategy which did not deal with functional requirement B4 to be included in a full plans application.859 He said that it would have been “nice” if the final version had contained such an analysis, but it had not been included because it had not been considered.860 54.113 Issue 3 of the Outline Fire Safety Strategy was produced at RIBA Stage E. According to Dr Lane, that was the time for the production of the final fire safety strategy which should have recorded the detailed proposals for the development, together with the promised analysis.861 However, Issue 3 did not represent any material advance on Issue 2 and Exova failed to produce any detailed and comprehensive fire safety strategy at any stage during the project.862 In Dr Lane’s opinion Issue 3 wholly failed to provide the fire safety design guidance required by the design team, the client and the contractor.863 54.114 Despite having undertaken to provide a fire safety strategy for the refurbishment, Exova failed to complete the work in fundamental respects. Issue 3 represented nothing more than a stepping stone on the way to the production of the final document, as the paragraph dealing with functional requirement B4 made clear, and as a result, Exova failed to provide any guidance on the performance standards for the external wall. Dr Lane described that as a serious omission,864 but in truth it was more than that; it represented a fundamental failure by Exova to provide the services for which it had contracted. The fact that the reports were provided to the architect rather than the lay client does not excuse that failure. Although Studio E was at fault in failing to ask questions about the Outline Fire Safety Strategy in any of its forms, and particularly in failing to ask Exova to provide a 853 Ashton {Day18/168:4-8}; {Day18/169:5-12}. 854 Ashton {Day18/171:8-25}. 855 Contract Documents for Enhancements and Improvements to Grenfell Tower, Schedule of Contract Information {TMO10041791/267} item 115. 856 Ashton {Day18/172:6-14}. 857 {SEA00000215}. 858 Ashton {Day18/172:15-22}. 859 Ashton {Day18/173:5-9}. 860 Ashton {Day18/173:11-14}. 861 Lane {Day61/210:25}-{Day61/211:9}. 862 Lane, Phase 2 Report {BLARP20000017/225}, paragraph 6.12.12. 863 Lane {Day61/222:3-7}; Lane, Phase 2 Report {BLARP20000017/224} paragraph 6.12.2. 864 Lane {Day61/174:1-12}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 97 concluded opinion on functional requirement B4(1), that does not excuse Exova for failing to seek the information needed to complete its work or make it clear that without it an essential part of the strategy was missing.865 54.115 It was also of importance for Exova to draw attention to the fact that any insulation materials in the external wall should be of limited combustibility if the designers were following the guidance in paragraph 12.7 of Approved Document B. If that had been expressly stated, others engaged on the project, including Rydon and the TMO, might have thought twice about their choice of insulation. Again, the fact that others were unaware of that requirement does not exonerate Exova. 54.116 Mr Ashton sought to justify his failure to provide final advice in relation to functional requirement B4 by relying on Studio E’s failure to provide him with detailed information about the overcladding. However, that does not excuse Exova’s complete failure to deal with the requirements for the external wall. The project had been introduced to Mr Ashton as one which would include overcladding,866 he had attended at least one project team meeting (on 6 September 2012) at which the cladding had been discussed,867 he had been sent minutes of other project team meetings referring to it868 and he had been sent a number of work packages containing information about it.869 At no stage, however, did he address his mind to the build-up of the external wall. Given his acknowledgement that the overcladding was, in his own words, “a fairly significant part of the design”,870 his failure to include it in the description of the project and his subsequent failure to consider that aspect of the refurbishment fell below the standards to be expected of a reasonably competent fire engineer. Something should have been included in the document to alert the designers to the need for careful consideration of functional requirement B4 in relation to the external wall and the peer reviews carried out before the production of all three issues of the strategy were defective in failing to identify that deficiency. That is so, even if each of them was understood at the time to be no more than an interim document. 54.117 None of the issues of the Outline Fire Safety Strategy contained any reference to the need for cavity barriers. When Mr Ashton prepared Issue 3 in November 2013 he had had his attention specifically drawn to the fact that there was to be a rainscreen cladding system in an email from Tomas Rek on 1 November 2013.871 That email ought to have alerted Mr Ashton to the need to address cavity barriers in the fire safety strategy, since it should have been clear to him that the design team needed his help in understanding the basic performance requirements for the external wall.872 In those circumstances we consider that Mr Ashton’s failure to address cavity barriers and their locations fell below the standard of a reasonably competent fire engineer.873 865 Lane {Day61/198:14}-{Day61/202:15}. 866 {EXO00000474}. 867 {ART00000404}. 868 Meeting minutes dated 18 July 2012 {EXO00000753}, sent via email on 24 July 2012 {EXO00000751}. 869 {SEA00006394}; {SEA00006395}; Ashton {Day17/30:1-25}. 870 Ashton {Day17/49:2-14}. 871 {EXO00000586}. 872 {EXO00000586}; Lane {Day61/212:7}-{Day61/213:7}; Ashton {Day17/119:12}-{Day17/126:23}. 873 Lane {Day61/211:14}-{Day61/213:25}; Lane, Phase 2 Report {BLARP20000017/213} paragraph 6.9. Her views were unchanged after hearing the evidence of Exova’s witnesses. Lane {Day61/222:22}-{Day61/223:1}.

The Grenfell Tower Inquiry: Phase 2 Report 98 Failure by Artelia to identify the omission 54.118 As employer’s agent, Artelia was responsible for monitoring the performance of the contractor, Rydon, and reporting to the TMO.874 It also had responsibility for establishing the roles and responsibilities of Rydon and specialist design subcontractors, confirming the scope of the building contract to the TMO and advising on additional works required by third parties.875 It was not obliged to advise the TMO about specialist services required in connection with the project or about the design services needed under the building contract.876 However, as administrator of the building contract it had an obligation to be aware of the appointment of specialist advisers and ensure that any work they had undertaken to perform was completed. Philip Booth accepted that Artelia’s role as employer’s agent included identifying any gaps in the completion of work.877 54.119 It was apparent from the language of Issue 3 of the draft Outline Fire Safety Strategy that further work was required to complete it. Not only was it described as a draft, but it stated in terms that the effect of the proposed changes to the building in relation to the spread of fire over the external walls would be covered in a future issue. Philip Booth told us that he had read the tender documents in November 2013 and had recognised that there was more work to be done on the fire safety strategy, which he assumed would be carried out by Rydon.878 Of itself, that was not remarkable and we accept that at the tender stage of a design and build contract, the fire safety strategy may not be fully developed.879 However, having recognised that there was further work to be done on it, the minutes of the contractor introduction meeting of 1 April 2014 taken by Artelia and checked by Mr Booth should not have recorded that Exova had completed the fire strategy at the tender stage.880 Regardless of whether it had mentioned the matter to Rydon, Artelia should have drawn the attention of the TMO to the fact that Exova’s work had not been completed but failed to do so. At no time did Mr Booth or anyone else at Artelia alert the TMO to the need to ensure that the fire safety strategy had been completed by a suitably qualified fire engineer. The safety of the cladding was therefore never considered by a fire engineer. Subsequent advice 54.120 During numerous meetings on the project between April and October 2014 Rydon expressed an intention to engage Exova as consultant fire engineer, as is formally recorded in the minutes of those meetings,881 but no one on behalf of Rydon contacted Exova for that purpose.882 In the event, Rydon did not appoint Exova as a consultant and there is no evidence that anyone from Exova attended any design team meetings after 6 September

1. However, between 1 April 2014, when Rydon was proposed as principal contractor,

874 {ART00005742/47} clause 1.1.4. 875 {ART00005742/48} clause 1.3.3 and clause 1.3.5. 876 {ART00005742/47} clause 1.2.5 and clause 1.2.8. 877 Booth {Day49/151:3-7}; {Day50/83:18}-{Day50/84:21}. 878 Booth {Day 50/84:25}-{Day50/87:7}. 879 Booth {Day50/86:18}-{Day50/87:7}. 880 {ART00002256/4} item 5.3. 881 Minutes of Contractor Induction Meeting of 1 April 2014 {ART00002255/4}. Simon Lawrence said that he thought his understanding at the time had been that Rydon would engage Exova as a subcontractor. Lawrence {Day23/52:16}-{Day23/53:3}; The Pre-Start Meeting of 13 June 2014 {ART00002495/3}; Progress Meeting No. 1 held on 15 July 2014 {ART00002614/2}; Progress Meeting No. 3 held on 16 September 2014 {RYD00018299/2}; Progress Meeting No.2 held on 19 August 2014 {RYD00017870}. 882 Lawrence {Day23/58:18-25}; Ashton {Day17/191:3-15}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 99 and 24 March 2016,883 Exova continued to provide advice to Studio E, Rydon and its subcontractors884 on aspects of fire safety and Mr Ashton was sent or copied in to at least 40 emails. 54.121 Rydon’s attitude towards advice from Exova is evident from an email sent by Simon Lawrence to Neil Crawford on 19 September 2014. Mr Lawrence had noticed Exova’s inclusion in an e-mail chain and had questioned its continued involvement in the project. He wrote: “I know that they provided information in the tender for KCTMO but I don’t know if they are still working for them. I know that we haven’t employed them. So if you are getting some free advice then great otherwise we will need to look at this.”885 At this point, according to Simon Lawrence, Rydon had not decided whether a fire consultant was needed. It wanted to understand the strategy relating to the lower four floors before making a decision about the services they needed and wanted to obtain the views of building control, which it regarded as a “resource.”886 During Progress Meeting No. 4 on 21 October 2014 Rydon again indicated that it would appoint a fire consultant887 and the item remained on the agenda because Artelia retained it as a matter calling for decision by Rydon.888 54.122 By the time of Progress Meeting No. 5 on 18 November 2014, however, the reference to Rydon’s intention to appoint a fire consultant had disappeared from the minutes.889 Claire Williams did not notice that890 and said she would have expected Artelia, as Employer’s Agent, to pick it up.891 Philip Booth said that the usual practice was for an item to remain on the minutes until it had been completed or resolved and that he could not recall how that particular item had been allowed to disappear.892 54.123 Bruce Sounes recalled a conversation with Simon Lawrence in March or April 2014 during which Mr Lawrence had said that Rydon typically did not engage fire consultants on the basis that the fire safety strategy had been established by the client’s team.893 Mr Lawrence did not recall that conversation,894 but agreed that it was a fair description of how Rydon typically dealt with such matters and did not quarrel with the substance of Mr Sounes’ evidence, which we accept.895 He explained that Rydon did not normally engage fire consultants because it was building control’s responsibility to raise any concerns over matters of that kind.896 54.124 Mr Lawrence told us that Rydon had been looking for advice from a fire safety consultant only in relation to the lower four floors of the tower, but he accepted that there was nothing in the documents to suggest that it had drawn any distinction for that purpose between the restructuring of the lower four floors and the installation of the cladding. We therefore think it unlikely that that distinction was present to Mr Lawrence’s mind 883 {MAX00006093}. 884 For example, advice to Neil Crawford on 18 September 2014 {EXO00000714} and {HAR00012077} and advice to David Hughes (Rydon) on 24 March 2016 {MAX00006094}. 885 {SEA00011754/1}. 886 Lawrence {Day23/67:18}-{Day23/74:20}. 887 {RYD00022280}. 888 Booth, {Day50/94:20-25}. 889 {ART00003150}. 890 Williams {Day55/83:9}. 891 Williams {Day55/79:10-14}; {Day55/80:4-10}; {Day55/81:1-11}. 892 Booth {Day50/95:20-23}. 893 Sounes {SEA00014273/152} page 152, paragraph 372; Sounes {Day12/168:20}. 894 Lawrence {Day23/62:24}. 895 Lawrence {Day23/62:3-11}. 896 Lawrence {Day23/65:17-24}; {Day23/74:8-12}: he considered that Rydon “had a resource with building control.”

The Grenfell Tower Inquiry: Phase 2 Report 100 in 2014.897 He said that Rydon had made a positive decision not to appoint a fire safety consultant when it became clear that the lower four floors were not going to present a significant problem,898 but there was no evidence of when or how that decision was made or by whom. Stephen Blake told us that he and Simon Lawrence had decided not to appoint Exova as a consultant because it had already produced a fire safety strategy and because it was the responsibility of Studio E to make sure that it contained all the necessary information.899 We think it likely that Rydon decided not to engage Exova, or any other fire safety consultant because it did not think that it needed to do so in its own interests. Rydon did not tell the TMO or Studio E that it had decided not to appoint a fire consultant900 and it seems that the matter then disappeared from sight. Artelia and the TMO should both have been aware that Rydon had not appointed a fire consultant and Artelia should have obtained a formal decision from Rydon and recorded it, together with the reasons for it, pursuant to its obligation to monitor Rydon’s performance. 54.125 The failure to ensure the effective involvement of a fire engineer in the project following the appointment of Rydon as principal contractor was in our view one of the most serious flaws in the design and execution of the refurbishment. When Rydon was appointed as principal contractor the TMO continued to retain Exova, but neither the TMO nor Artelia appears to have understood clearly what services it was expected to provide or to whom. Artelia’s duties included understanding where additional works by third parties were required. Artelia ought to have made it clear to the TMO that Exova’s work had not been completed, that Rydon had not appointed anyone to finish it and that the TMO itself would therefore have to ensure that it was completed. For its part, the TMO, ought to have clarified Exova’s position and ensured that the fire safety strategy was completed. 54.126 Mr Ashton understood that Exova’s retainer had ended when Rydon was appointed as principal contractor and neither Rydon nor anyone else had asked it to continue acting.901 Exova received no formal confirmation from the TMO that its services were no longer required, but Mr Ashton said that in his experience it was not unusual for Exova’s services not to be retained in that situation.902 We are surprised that Exova allowed client relations to be managed in such a casual manner, but the fact is that Mr Ashton never thought to ask for clarification of Exova’s position, even though he was still being asked for advice on various matters from time to time on an ad hoc basis.903 He thought that some members of the design team had assumed that Exova was still instructed; he certainly had taken no steps to disabuse them.904 54.127 Exova did not make a separate charge for their ad hoc advice but treated it as covered by the fee agreed with the TMO for RIBA Stages D and E.905 Despite approving the invoices which Exova submitted to the TMO, it did not dawn on Claire Williams that Rydon had not appointed a fire consultant.906 Mr Ashton said that in his view the advice had not been provided under Exova’s contract with the TMO, but was supplementary advice given on an ad hoc basis,907 but that is not reflected in the billing procedures. 897 Lawrence {Day23/79:13}-{Day23/80:7}. 898 Lawrence {Day23/80:8-16}. 899 Blake {Day29/67:11-19}. 900 Williams {Day55/84:2-10}. 901 Ashton {Day18/61:11-25}. 902 Ashton {EXO00001621/14} page 14, paragraph 5.9, 903 Ashton {Day18/64:3-7}. 904 Ashton {Day18/141:9}-{Day18/142:6}. 905 {EXO00001204}; {EXO00001205}. 906 Williams {Day55/85:12-15}. 907 Ashton {Day17/184:16-25}. See also Ashton {EXO00001621/14} page 14, paragraph 5.10.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 101 54.128 Exova gave significant ad hoc advice on two occasions: once in September 2014 and again in March 2015. Advice in September 2014 (design of the cladding) 54.129 On 18 September 2014 Neil Crawford asked Mr Ashton for his comments on a request for information908 he had received from Harley about the location of horizontal fire breaks within the cladding.909 Harley thought that horizontal firebreaks might not be required between windows, because there was no “chimney effect” there. Mr Ashton replied that he had not seen details of what Studio E was doing to the external walls and asking for cross section or elevation drawings.910 At that stage he had not given any substantive consideration to the cladding or its implications for external fire spread.911 54.130 Later that day, in response to Mr Ashton’s request, Mr Crawford sent him a number of drawings, including drawing number 1279 SEA (06) 120 which showed zinc outer cladding and contained a reference to thermal insulation alongside the code H92/776.912 That was the first time Mr Ashton had seen the design and specification for the cladding system.913 54.131 The code H92/776 referred to a paragraph in the NBS Specification914 which specified Celotex FR5000 insulation. Mr Ashton had not seen the Employer’s Requirements or the NBS Specification915 and did not ask to see them.916 The code meant nothing to him917 and he did not understand that the drawings included references to the materials to be used for insulation.918 Drawing number 1279 SEA (06) 120 also referred to “aluminium composite TBC”, but, despite not being familiar with composite materials, Mr Ashton did not ask what that meant. He said that he had not looked at the drawings in any detail because Exova was no longer part of the design team.919 In those circumstances he was not spending a lot of time on the project, although, as he accepted, he had not made that clear to Studio E.920 54.132 Having received the drawings from Studio E, Mr Ashton responded by saying that if the insulation in the cavities behind the rainscreen was combustible it would be necessary to provide cavity barriers as shown in drawing number 1279 (06) 120 in order to prevent fire from spreading from a flat to the one above, even if there was not a continuous cavity from the top of the building to the bottom.921 That advice was wrong insofar as it suggested that cavity barriers were required only if the insulation were combustible.922 In order to comply with Approved Document B cavity barriers were required around the windows and at the top of the walls, regardless of the type of insulation used.923 He also failed to point out that in a building of over 18 metres in height the insulation should be of limited combustibility 908 {HAR00003616}; Email attaching the RFI {SEA00011703}. 909 {SEA00011705}. 910 {RYD00018154}. 911 Ashton {Day18/25:17-19}. 912 {EXO00000710}, {EXO00000709}. 913 Ashton {Day18/31:15-22}. 914 {SEA00000169/73}. 915 Ashton {Day18/127:7-8}. 916 Ashton {Day18/31:1-14}. 917 Ashton {Day18/29:11-22}. 918 Ashton {EXO00001621/15} page 15, paragraph 5.17; Ashton {Day18/29:16-22}. 919 Ashton {Day18/30:1-10}. 920 Ashton {Day18/30:1-15}; {Day18/33:1-7}. 921 {EXO00000708}. 922 Lane {Day62/44:16-25}. 923 Lane {Day62/45:7-15}.

The Grenfell Tower Inquiry: Phase 2 Report 102 in order to comply with paragraph 12.7 of Approved Document B. Mr Ashton accepted that his response could have been more clearly worded924 but in our view that suggests that he had not understood the significance of the nature of the insulation. 54.133 The drawings provided to Mr Ashton by Studio E925 also showed horizontal cavity barriers only between the windows and not around the window frames. He did not notice that omission, despite his understanding that Approved Document B contained clear guidance on the importance of cavity barriers around windows.926 He said that that was not the question he was being asked and that he had just wanted to know in broad terms what they were doing.927 He said he had not asked for full details of the construction in order to do hours of work for which he would not be paid.928 He had not seen that as part of his responsibility.929 54.134 Later the same day Neil Crawford sent another email to Mr Ashton930 attaching a datasheet for Celotex RS5000.931 He asked whether Daniel Anketell-Jones was right in thinking that, because the insulation was rated Class 0, cavity barriers were not required around the windows. Mr Ashton did not open the attachment and therefore did not read the datasheet.932 That was a serious error on his part. A reasonably competent fire engineer would have done so and, having read the datasheet, would have explained to Mr Anketell- Jones that Class 0 did not denote limited combustibility.933 Mr Ashton said that he had not seen any need to open the attachment, since he had just been dealing with an exchange of emails about whether using a Class 0 material meant that cavity barriers were not required. If it had been necessary for him to look at it, he would have expected Mr Crawford to make some express reference to it.934 Mr Ashton was aware of the Celotex insulation product in general and, although he had never had cause to investigate it, he knew that it was a PIR foam and therefore combustible935, even if he did not know how exactly it reacted to fire.936 Despite having been sent the datasheet, however, at no stage did he ask himself whether Celotex RS5000 was suitable for use on the tower; indeed he maintained in evidence that he had not known that it was being used.937 He said that, if he had been told that Celotex was to be used, he would have said that it was not acceptable for use on the building without test evidence.938 It did not occur to him to ask Mr Crawford what type of rainscreen cladding panel was being proposed939 or to tell him that the Outline Fire Safety Strategy needed to be revised.940 54.135 Mr Ashton’s response to the question posed to him was therefore directed solely to whether the use of Class 0 insulation obviated the need for cavity barriers in certain locations. He said: 924 Ashton {Day18/39:1-18}. 925 In particular, drawing 1279 (06) 120{EXO00000710}. 926 Ashton {Day18/42:4-18}. 927 Ashton {Day18/41:10-25}. 928 Ashton {Day18/40:10-13}; {Day18/41:16-25}-{Day18/42:1-3}; {Day18/42:19-24}; {Day18/43:15-21}. 929 Ashton {Day18/42:19}-{Day18/43:5}. 930 {SEA00011724}. 931 {RYD00018155}. 932 Ashton {Day18/46:15-23}; {Day18/47:3-19}; {Day18/49:1-8}; {Day18/55:6-8}. 933 Lane, Phase 2 Report {BLARP20000017/279}; Lane, {Day62/49:11}-{Day62/50:8}. 934 Ashton {Day18/46:17}-{Day/47:11}. 935 Ashton {Day18/67:11-15}. 936 Ashton {Day18/48:1-17}; {Day18/56:12-17}. 937 Ashton {Day18/53:21-25}-{Day18/54:1-5}. 938 Ashton, {Day17/96:1-3}; {EXO00001775/2} page 2, paragraph 2.3; See also Ashton {Day18/135:4-10} Mr Ashton said he would have carried out investigations if he had known that Celotex insulation was being used in the external walls. 939 Ashton {Day18/69:2}. 940 Ashton {Day18/69:11-18}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 103 “A material which has a Class 0 rating is not necessarily non-combustible although the reverse is invariably true. Some Class 0 products will burn when exposed to a fully developed fire. In any case, you need to prevent fire spread from one flat to the flat above as I stated in my earlier email. What isn’t clear from the information to hand is whether or not there is a continuous cavity from top to bottom in any part of the cladding (apart from around the column casings) irrespective of the type of insulation.”941 No one responded to his comment about the extent of the external wall cavity and he did not press for further information.942 54.136 According to Dr Lane, industry awareness of the dangers presented by combustible materials was evolving rapidly at that time and by September 2014 Exova ought to have been aware of the third edition of BR 135 published in 2013 and BCA Technical Guidance Note 18 Issue 0 dated June 2014 (and published in August 2014), including the warnings they contained about the use of combustible insulation.943 It ought also to have been aware by that time of a number of cladding fires that had occurred in other countries, demonstrating the dangers posed by the use of combustible materials.944 Mr Ashton had already received indications from a number of sources that Celotex RS5000 was being proposed for use on the tower945 but had apparently failed to absorb the information. If he had opened the datasheet and obtained advice from colleagues in Warrington with specialist knowledge of materials946 and their reaction to fire, it is likely that he would have alerted the design team to the risks involved. 54.137 Although at that time the drawings still specified zinc rainscreen panels, Dr Lane was clear that Mr Ashton should have known that the insulation did not comply with the guidance contained in Approved Document B and that cavity barriers were missing.947 She said that they were “red flags” which should have prompted him to consider how the external wall was being assessed and how it could comply with functional requirement B4.948 54.138 Mr Crawford said that he had spoken to someone from Exova on 17 or 18 September 2014 to confirm the compliance of the Celotex insulation.949 Mr Ashton did not recall any such conversation at about that time, nor could he recall ever having discussed with Mr Crawford Celotex insulation or its compliance.950 Mr Crawford said that Exova had been emphatic that it was appropriate to use Celotex,951 an assertion which Mr Ashton equally unequivocally denied.952 Mr Crawford also told us that at about the same time he had told Mr Ashton that ACM panels were to be used on the building.953 Again, Mr Ashton denied that. He did not recall ever having discussed with Mr Crawford the use of ACM panels 941 {EXO00001430}. 942 Ashton {Day18/59:5-22}. 943 Lane {Day62/53:12}-{Day62/56:6}; {Day61/203:6-11}. 944 Lane {Day61/202:21}-{Day61/203:5}. 945 In the Stage C Report, the link sent to him on 31 October 2012 {ART00008396}, and the datasheet sent to him for RS5000 {SEA00011724}. 946 Ashton {Day17/93:9-14}. 947 Lane {Day62/56:15-19}. 948 Lane {Day62/52:16-22}; {Day62/56:15-19}. 949 Crawford {Day9/176:23}-{Day9/177:11}. 950 Ashton {Day18/71:3-19}; Ashton {EXO00001775/2-5} page 2-5, paragraphs 2.2-2.3 and paragraphs 3.8-3.9}; Ashton {Day18/72:13}-{Day18/74:17}. 951 Crawford {Day10/58:1}-{Day10/59:1}. 952 Ashton {Day18/72:14}-{Day18/74:14}; Ashton {EXO00001775/2} pages 2, paragraphs 3.3-3.5. 953 Crawford {Day10/91:16}-{Day10/92:11}.

The Grenfell Tower Inquiry: Phase 2 Report 104 generally or Reynobond 55 PE panels in particular.954 Neil Crawford said that Mr Ashton had understood the wall build-up955 and had discussed with him the suitability of the cavity barrier strategy.956 Mr Ashton also denied that.957 54.139 Mr Crawford said that his understanding of the basis on which the cladding system was considered to be compliant with Approved Document B had been derived from conversations he had had with Exova sometime around 18 September 2014.958 Mr Ashton did not recall any such conversation.959 Mr Crawford also said that he recalled Mr Ashton’s mentioning that the fire safety strategy would need to be revisited and completed,960 which again Mr Ashton denied.961 Mr Crawford went on to say that at about the end of March 2015 Exova had given him the impression that the proposed cladding system was acceptable and created no risk of external fire spread and that therefore there was no need for a further report.962 Mr Ashton also denied that.963 54.140 There was, therefore, in these respects a direct conflict between the evidence of Mr Ashton and that of Mr Crawford, both in relation to Exova’s acceptance of the use of Celotex insulation and in relation to its recognition of the need for the work on the Outline Fire Safety Strategy to be completed in relation to functional requirement B4. Having considered their evidence carefully, we think that the evidence of Mr Ashton is the more reliable. The discussions, if they had occurred, would have been of considerable significance and would have merited confirmation by email, if not more formally. However, there is no reference to them in any of the contemporaneous documents, nor did Mr Crawford refer to them in the very full statement he made in November 2018.964 Mr Ashton may have adopted a casual approach to the Outline Fire Safety Strategy, but his failure to complete the section dealing with functional requirement B4 reflected a lack of positive instructions from Studio E. He was aware of the importance that would inevitably be attached to any opinion expressed by Exova on matters of that kind and could be expected to have put in writing any advice of that kind. Whatever may have passed between them, we are unable to accept that Mr Ashton gave the assurances described by Mr Crawford in what could only have been the most informal manner. If Mr Crawford had thought that that was his intention, he would surely have confirmed the conversation in an email to ensure that there had been no misunderstanding. 54.141 The exchanges that took place in September 2014 between Studio E and Exova occurred at a critical moment in the life of the project. The design team was asking important questions relating to the safety of the external wall and its compliance with the statutory guidance that were not answered in the current version of the Outline Fire Safety Strategy.965 All those involved in the exchanges, including Exova, should have realised that the sections of the strategy relating to functional requirements B3 and B4 needed to be completed and that detailed and definitive guidance was required. Even if Mr Ashton could not complete that work without further information, at the very least he should have warned the project 954 Ashton {Day18/76:1-14}; Ashton {EXO00001775/2} page 2-4, paragraphs 2.5-2.6 and paragraphs 3.6-3.7. 955 Crawford {Day10/94:1-22}; Ashton {Day18/77:5-21}. 956 Crawford {Day10/94:1-22}. 957 Ashton {Day18/74:18}-{Day18/77:24}, {Day18/124:11}-{Day18/125:6}; Ashton {EXO00001775/3} page 3, paragraphs 3.1-3.2. 958 Crawford {Day9/179:5-7}. 959 Ashton {Day18/78:7-9}. 960 Crawford {Day10/95:22}-{Day10/96:10}; {Day11/169:23}-{Day11/170:5}. 961 Ashton {Day18/78:10-20}. 962 Crawford {Day11/181:20}-{Day11/183:15}. 963 Ashton {Day18/79:3-5}. 964 Crawford {SEA00014275}. 965 Lane, {Day62/49:11-19}; {Day62/60:4}-{Day62:61:20}; {Day62/52:16-22}; {Day62/56:15-19}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 105 team and the TMO, his client, that important work was outstanding and that the current version of the strategy was materially incomplete. We can see no good reason why he did not do so and are satisfied that in failing to do so he fell short of the standard required of a reasonably competent fire engineer. Advice in March 2015 (cavity barriers and fire stopping) 54.142 On 3 March 2015 Mr Crawford asked Mr Ashton for advice on “fire breaks” at Grenfell Tower,966 attaching Harley’s Specification Notes967 which referred to Reynobond rainscreen cassettes. Mr Ashton did not respond to that email and is unlikely to have read it at the time.968 He said that if he had read the Specification Notes, he would have drawn Studio E’s attention to the fact that the use of Styrofoam in the window infill panels would not be acceptable to building control because it was combustible.969 54.143 On 27 March 2015 Mr Crawford sent an email to John Hoban of RBKC building control, with a copy to Mr Ashton,970 asking for confirmation that a proposal for cavity barriers put forward by Ricky Kay of Siderise was acceptable. That appears to have been the first time that Mr Ashton had been copied in to an e-mail about the cladding sent to building control.971 He was not concerned by the reference to rainscreen aluminium cassettes, as he was aware that aluminium was used in a variety of applications, and did not understand the term “cassettes”.972 He did not take in the fact that aluminium rather than zinc was now being proposed.973 In Dr Lane’s view, this correspondence should have prompted Mr Ashton to ask for the information he needed to complete the Outline Fire Safety Strategy,974 but regrettably it did not do so.975 54.144 Earlier that month a disagreement had broken out within the design team over whether fire stopping or cavity barriers were required in the cladding at the level of compartment floors between the internal structure and the rainscreen panels. On 30 March 2015 Mr Ashton was copied in to an email from Mr Hoban to various employees of Siderise, Harley and Rydon,976 in which he said that he interpreted Diagram 33 of Approved Document B as requiring fire stopping of the same fire resistance as the compartment floor (in this case 120 minutes) rather than a cavity barrier. On 31 March 2015 Mr Crawford sought Mr Ashton’s advice, saying that he could not see any reference to that element of the design in the fire safety strategy.977 Mr Ashton responded the same day,978 saying that it was not something that would necessarily form part of a fire safety strategy for a building (although when he gave evidence he accepted that that had been wrong, because advice on the provision of cavity barriers would normally be part of any fire 966 {EXO00001315}. 967 {EXO00001319}. 968 Ashton {Day18/83:16-23}; Ashton {EXO00001621/17} page 17, paragraph 5.25. 969 Ashton {EXO00001621/17} page 17, paragraph 5.27(c). 970 {EXO00001434}. 971 Ashton {Day18/92:10-17}. 972 Ashton {Day18/92:21-22}. 973 Ashton {Day18/93:3-6}. 974 Lane, {Day62/52:4-12}; {Day62/61:5-11}; {Day62/62:20-24}. 975 Ashton {Day18/93:7-11}. 976 {EXO00000715/2}. 977 {EXO00000715}. 978 {EXO00000715}.

The Grenfell Tower Inquiry: Phase 2 Report 106 strategy for a building that was to be overclad).979 He also expressed the view that only a cavity barrier was required in that location, since fire stopping would not stay in place in a fire, which would cause the zinc cladding to fail.980 54.145 Mr Ashton’s cursory reading of the email chain was remarkably casual, given that he had been specifically asked to comment on the history of the discussion and to look at the correspondence in the chain below.981 His failure to read down the short chain also meant that he failed to notice the reference to aluminium cladding cassettes and continued to labour under the misapprehension that the rainscreen panels would be composed of zinc.982 If he had included in the Outline Fire Safety Strategy the minimum requirements in Approved Document B for satisfying functional requirement B4, those questions might not have arisen. Moreover, the design team might have been alerted to the need to analyse in more depth the choice of materials for use in the external wall of the tower. 54.146 In Dr Lane’s opinion, this correspondence demonstrated exactly the problem caused by a failure on the part of a fire engineer to express minimum performance requirements in clear terms.983 In her view, the sections of the detailed fire safety strategy relating to functional requirements B3 and B4 should have answered those questions, given that there was clearly confusion within the design team about the difference between fire stops and cavity barriers. In this case there was a need for the fire engineer to explain what they were, what they were for, and where they needed to be incorporated into the building.984 She considered that those and some later exchanges with the design team in September 2014985 should again have led Mr Ashton to realise that the fire safety strategy needed to be revised.986 As an absolute minimum he should have drawn attention to the fact that it was incomplete and asked for confirmation that he could complete it.987 54.147 At the time Mr Ashton did not know what type of cavity barrier had been proposed for use in the refurbishment. He did not ask the design team, since he thought that the information would be provided as part of the description of the cladding, which in the event Exova did not receive.988 His reference to zinc cladding is surprising, given that he had been sent information only a few days earlier which had included reference to the fact that aluminium rainscreen cassettes were to be used,989 but he appears to have thought from start to finish that the rainscreen would be zinc. Mr Crawford said that he had told Mr Ashton in an email that the panels would be made of ACM,990 but no such email has come to light and Mr Crawford’s response to Mr Ashton did not refer to the nature of the rainscreen material. 979 Ashton {Day18/95:20-25}-{Day18/96:1-9}; {Day18/96:21-25}; {Day18/99:4-9}; Ashton {EXO00001621/19} page 19, paragraph 5.29 (F). 980 {EXO00000715}. 981 {EXO00001434/2}. 982 Lane {Day62/63:24}-{Day62/64:8}. 983 Lane {Day62/60:3-10}. 984 Lane {Day62/60:23}-{Day62/61:4}. 985 Lane {Day62/73:4-23}. 986 Lane, Phase 2 Report {BLARP20000017/255} paragraph 8.2.10. In relation to additional correspondence in October 2014 {EXO00001441} Dr Lane said that it would have been perfectly normal professional practice to have suggested updating the fire safety strategy. Lane {Day62/77:5-14}. 987 Lane, {Day62/61:6-11}. 988 Ashton {Day18/100:19-21}. 989 {EXO00000715/4}. 990 Crawford {Day10/159:22}-{Day10/162:4}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 107 54.148 Throughout the exchange Mr Ashton was careful to confine himself to the questions asked of him,991 focusing solely on the individual components of the external wall rather than on the wall as a whole.992 He did not notice that the drawing993 attached to Mr Crawford’s email of 31 March 2015994 showed cavity barriers only at the head of the window, because he did not look at it at the time.995 He did not identify the locations where cavity barriers were required in the external wall and he did not identify the performance criteria for the external wall set out in section 12 of ADB. 54.149 Mr Ashton said that his reference to the failure of the rainscreen in the event of a fire reflected his understanding that, although debris would fall from the building, the fire would not spread externally through the cladding as zinc is non-combustible.996 In his written statement997 he said that producing a fire safety strategy does not normally involve advising on whether the use of a specific product would be satisfactory, but when giving evidence he agreed that, if the fire strategy consultant knew what kind of rainscreen panel the designer proposed to use, it would be essential to consider its flammability.998 54.150 Mr Ashton said that it did not occur to him in late March 2015 to revise the Outline Fire Safety Strategy because nothing he had seen had given him any cause for concern. He had not realised that the designers had been planning to use unsuitable materials.999 In any event, although it had been in his mind that he might need to revise it in due course,1000 he still did not have enough information from Studio E to enable him to do that.1001 He accepted however that a reasonably competent fire engineer should have informed his client that the outstanding work on the Outline Fire Safety Strategy needed to be completed now that further information had become available about the design of the external wall and the choice of materials.1002 He said he had not done that because he had been concentrating on the specific question raised in the email, which had been concerned with individual components of the external wall rather than with the wall as a whole.1003 Overall we were unimpressed by Mr Ashton’s narrow approach. 54.151 On 31 March 2015, two minutes after Mr Ashton had sent his email to Mr Crawford, he received an email from Dr Pearson on the same point.1004 Mr Ashton did not recall having received it1005 and Dr Pearson could not recall why he had been sent it, but thought it might have been in response to a request for advice from Mr Ashton.1006 Mr Ashton thought that it had probably been sent because he had asked Dr Pearson for his opinion on the question that had been put to him.1007 991 Ashton {Day18/111:4}; {Day18/118:21}-{Day18/119:2}. 992 Ashton {Day18/131:2-4}. 993 {SEA00002499}. 994 {SEA00013044}. 995 Ashton {Day18/123:7-15}. 996 Ashton {Day18/104:10-14}. See also Ashton {EXO00001621/19} page 19, paragraph 5.30: “My email was trying to explain that if a fire were to occur with external flaming, it would take some of the cladding panel with it, and this might cause the fire stop to fall away with it (this would of course depend on precisely how the fire stop was fixed).” 997 Ashton {EXO00001621/3} page 3, paragraph 3.6. 998 Ashton {Day17/91:8-13}. 999 Ashton {Day18/109:16-23}. 1000 Ashton {Day18/120:1-3}. 1001 Ashton {Day18/119:24-25}. 1002 Ashton {Day18/130:16-23}. 1003 Ashton {Day18/131:1-4}. 1004 {EXO00001347}. 1005 Ashton {EXO00001621/20} page 20, paragraph 5.32. 1006 Pearson {Day19/146:14-19}; {Day19/147:11-16}. 1007 Ashton {Day18/116:1-6}.

The Grenfell Tower Inquiry: Phase 2 Report 108 54.152 Dr Pearson’s email read as follows: “We note that the barrier against fire spread between floors is provided through the connection of the structural floors to the existing external walls. The existing external walls are expected to provide sufficient fire resistance to prevent fire from entering the cavities at or near floor or ceiling level. We would not rule out that fire could enter the cavity if there is flaming through the windows. However, if significant flames are ejected from the windows, this would lead to failure of the cladding system, with the external surface falling away and exposing the cavity, eliminating the potential for unseen fire spread. A standard cavity barrier should be sufficient to prevent fire spread between floors while there remains a cavity. In view of the above, we do not feel that there should be a need for a 2-hour rated fire break in the cavities along the lines of the compartment floors or walls.” 54.153 The message thus drew more explicit attention to the risks posed to the cladding by fire than Mr Ashton had done in his response. 54.154 When he drafted that email Dr Pearson had still not been given any detailed information about the construction of the external wall.1008 He did not know what stage had been reached in the design process,1009 did not look back to the Outline Fire Safety Strategy,1010 did not check what materials it was proposed to use1011 and directed his mind only to the specific question asked of him.1012 Dr Pearson accepted that, generally speaking, any fire safety strategy should have been updated to include an analysis of the factors affecting external fire spread1013 and that someone should have considered the materials being used in the external wall.1014 54.155 The correspondence illustrates the confusion within the design team between cavity barriers and fire stops. It also demonstrates the failure of Mr Ashton and Exova to provide clear, coherent advice on the minimum relevant performance requirements for the external wall as a whole, including the identification of cavity barriers and the locations at which they should be fitted. Subsequent emails 54.156 On 19 October 2015, Claire Williams and Terence Ashton exchanged a series of emails relating to the changes that had been made to the layout of the lower floors of the tower1015 and on 21 December 2015 Andrew Bridges of R J Electrics also sent an email to Mr Ashton and Dr Pearson referring to major changes to the lower four floors.1016 54.157 Those messages should have prompted Mr Ashton to review the Outline Fire Safety Strategy, but unfortunately it did not occur to him to do so.1017 1008 Pearson {Day19/156:16}. 1009 Pearson {Day19/157:3}. 1010 Pearson {Day19/166:5-8}; {Day19/169:1-4}. 1011 Pearson {Day19/170:2-8}. 1012 Pearson {Day19/158:16-23}; {Day19/164:15-18}. 1013 Pearson {Day19/169:15-17}. 1014 Pearson {Day19/159:6-19}. 1015 {ART00004926}. 1016 {MAX00006084/6}: “I’m not sure if you’ve been made aware but there have been some fairly major changes to the lower levels since you issued your last Fire Strategy document, Iss 03.” 1017 Ashton {Day18/138:5-6}; {Day18/139:7-10}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 109 Completing the Outline Fire Safety Strategy 54.158 We find it surprising that neither the TMO, nor Studio E nor Rydon ever pressed Exova to revise its drafts or produce a final version of either the Existing Fire Safety Strategy or the Outline Fire Safety Strategy. As a result of that, and as a result of Mr Ashton’s failure to ensure that he obtained the information required to enable him to complete the task, Exova never did complete either of the two pieces of work on Grenfell Tower for which it had been retained. 54.159 In January 2016 the minutes of a Clerk of Works meeting recorded1018 that the fire strategy needed to be brought up to date in accordance with discussions on site. It was duly recorded as an action point for Rydon’s site manager, David Hughes. Mr Ashton said that Mr Hughes had never asked for the fire strategy to be brought up to date.1019 Mr Hughes’ said1020 that the minutes had not been referring to Issue 3 of the Outline Fire Safety Strategy but to the fire safety strategy drawings, which in due course had been updated.1021 That is not how the note reads, but Mr Hughes was at the meeting and must have been aware of the nature of the discussions. CDM Regulations 54.160 It did not occur to Mr Ashton that a completed fire safety strategy for the building was needed for the purposes of the health and safety file required by the CDM Regulations.1022 54.161 Dr Pearson thought that in 2013 Exova was a “designer” within the meaning of the CDM Regulations,1023 although he could not remember how advanced his understanding of the regulations was at that particular time. Mr Ashton, on the other hand, told us that Exova generally took the view that when it was producing a fire safety strategy it was not a designer for the purpose of the CDM Regulations because it was simply applying regulations and guidance available in the public domain rather than creating something unique or original. For that reason the Fee Proposals did not refer to the CDM Regulations.1024 As explained earlier in this chapter, Exova’s work on the fire safety strategies made it a “designer” under the CDM Regulations. It therefore had a duty to avoid foreseeable risks to the health and safety of any person liable to be affected by the refurbishment work.1025 Mr Ashton should have appreciated that. Overview 54.162 Exova’s work on the Grenfell Tower project fell a long way short of the standard to be expected of a reasonably competent fire engineer. Its work was poorly resourced, casual and both incomplete and inaccurate in a number of important respects, all of which in our assessment contributed to the lack of proper attention to fire safety matters throughout the refurbishment project. Its unprofessional approach was characterised by Cate Cooney’s email of 17 September 2012, in which she described how the proposals would make 1018 {ART00006688/5}. 1019 Ashton {Day18/140:20}. 1020 Hughes {Day27/183:4-17}. 1021 {TMO10013339}; See also email from David Hughes to Neil Crawford requesting that the fire strategy drawing be updated. {RYD00082268}. 1022 Ashton {Day18/139:11-15}. 1023 Pearson {Day19/55:20-24}. 1024 Terence Ashton did say that this view is changing “… in light of the fact that we sometimes design smoke extract systems and so possibly we need to look at that.” Ashton, {Day16/120:1-25}. 1025 CDM Regulations 2007, regulation 11.

The Grenfell Tower Inquiry: Phase 2 Report 110 “a crap condition worse,”1026 and by Mr Ashton’s response to Dr Pearson’s identification of a “rather fundamental”1027 non-compliance with statutory guidance, in which he expressed the hope that building control would not identify the problem.1028 The latter comment revealed an approach to fire safety that we consider irresponsible. 54.163 We entirely accept that Exova was badly briefed on the project and that others, particularly Studio E, Rydon, and the TMO, failed to take a proper interest in its work. Studio E failed to provide it with important information in a timely manner, particularly information about the overcladding of the tower. Rydon demonstrated a worrying lack of concern for fire safety, in particular, in failing to obtain a completed fire safety strategy for the project. It misguidedly assumed that it could rely on others (including building control) to identify any problems and failed to appoint a fire engineer, despite having said repeatedly over many months after its appointment as principal contractor that it intended to do so. Artelia and the TMO also overlooked the fact that the fire safety strategy was incomplete and that no fire engineer had been appointed to complete it. The TMO displayed a regrettable lack of interest in fire safety and a casual attitude to its responsibilities in that regard. Those are all matters which contributed to the unsatisfactory way in which Exova carried out its work. It is, in particular, astonishing that none of the other professionals appears to have realised or warned Rydon or the TMO that Exova’s work on the Outline Fire Safety Strategy was incomplete in relation to the compliance of the external wall with functional requirement B4. 54.164 However, none of that can exonerate Exova. The very fact of its involvement in the project gave the design team and the TMO as the client a false sense of security and led some to believe that fire safety matters had been properly and comprehensively addressed.1029 54.165 By far the most serious criticism of Exova is that a final version of the much-needed Outline Fire Safety Strategy was never produced and that it failed either to draw that fact to the attention of the design team or to warn it about the potential consequences, despite having numerous opportunities to do so. Exova’s approach was to do the minimum required at the time and, when asked for advice, to adopt a narrow and blinkered approach to the questions it was asked. Consistently with that, Mr Ashton repeatedly failed to take action when he saw, or should have seen, that action was required. Dr Barker and Ms Cooney approached their work in a casual manner not consistent with its importance. None of the authors or reviewers of documents ever attended the site1030 and the only site visit carried out by James Lee lasted a mere two hours, which was far too short for a building of the size and condition of Grenfell Tower.1031 Insufficient time was spent drafting the reports,1032 fewer than three working days being spent on RIBA Stage C, less than a week on Stage D/E and no time at all recorded for work on Stage F.1033 Exova’s attitude was wholly inconsistent with the careful approach to matters affecting life-safety that was 1026 {EXO00001279}. 1027 Lane, Phase 2 Report {BLARP20000017/99} paragraph 4.7.81; Lane, {Day61/205:15}-{Day61/207:1}. 1028 {EXO00001444}. 1029 For example, John Hoban of RBKC building control relied on the fact that Exova was working on the project when failing to scrutinise properly the external wall materials. Hoban {Day46/27:16-21}; {Day45/202:6}-{Day45/204:10}. 1030 Cooney, {Day14/72:24}-{Day14/73:1}; Dr Barker did not have time to carry out a site visit herself. Barker {Day15/119:17-24}; Terence Ashton did not visit the site “possibly because [he] had other priorities”. Ashton {Day16/168:8-25}. 1031 Lane {Day61/77:18}-{Day61/78:13}; Lane, Phase 2 Report {BLARP20000017/88} paragraph 4.7.14. 1032 For example, 15 hours was spent by Cate Cooney on the Existing Building fire strategy of August 2012. Phase 2 Report {BLARP20000017/87} paragraph 4.7.11; There is no evidence that Ms Cooney attended the site. Phase 2 Report {BLARP20000017/336} paragraph 14.1.19; For the Primary Refurbishment Project, 53 hours were invoiced for Primary Refurbishment project, 51.5 were Mr Ashton’s. Phase 2 Report {BLARP20000017/90} at paragraph 4.7.23. 1033 {EXO00001353}.

Part 6 | Chapter 54: Fire safety strategies; the contribution of Exova 111 required on a project of this kind. One sees a similar attitude displayed in Mr Ashton’s repeated failure to take the initiative, for example, by asking for missing information, obtaining and reading the RIBA Stage C and D reports and by regularly failing to open attachments to emails. 54.166 Exova’s casual approach is also demonstrated in the operation of its peer review process. Dr Barker’s review of the Existing Fire Safety Strategy drafted by Ms Cooney was cursory, to say the least, and reviews which should have been undertaken by someone of an equal or greater seniority than the author1034 were in the case of the documents produced by Mr Ashton in fact undertaken by a more junior employee. We agree with Dr Lane that this was unacceptable and that the unsatisfactory nature of the process was demonstrated by the failure of any of Exova’s reviewers to notice the inadequacies of paragraph 3.4.1 in relation to functional requirement B4.1035 Exova’s peer review procedure also applied to emails containing technical advice,1036 but there again it was not always followed. Dr Pearson said that Mr Ashton usually led by example,1037 but he does not appear to have followed the policy in the case of the Grenfell Tower project. One notable example is the email he sent to Mr Crawford on 31 March 2015,1038 which was sent before he had received Dr Pearson’s advice. There is nothing to suggest that the emails Mr Ashton sent on 18 September 2014 had been checked by anyone of equal or greater seniority. 54.167 Mr Ashton’s cavalier approach to formal procedures was demonstrated in other ways. Exova purported to operate in accordance with the requirements of ISO 9001 and had produced a code of procedure called its “Overall Procedure Review”,1039 which was designed to help staff meet the relevant standards. Mr Ashton was familiar with it1040 but he did not routinely follow it and did not do so in relation to the Grenfell Tower project. Instead he chose to follow procedures he had adopted on previous projects.1041 He said that he had not followed the procedure described in the “Overall Procedure Review” because the project had not proceeded in the usual way.1042 That was unfortunate, because if he had followed the prescribed procedure, he would have had to check that all elements of the project had been completed satisfactorily.1043 He did not do that, however, as he was still waiting for further information about the external wall. He did not contact either the TMO or Studio E to ask them whether the services Exova had provided matched their expectations.1044 54.168 Mr Ashton himself had no formal training in fire engineering,1045 no previous experience of overcladding high-rise buildings,1046 and very little knowledge of cladding materials.1047 In those circumstances it is perhaps unsurprising that he failed to grasp the importance of ensuring that a thorough analysis was made of the proposals in so far as they affected functional requirement B4, but that in turn makes it difficult to understand why he was 1034 Ashton {Day17/171:4-6}, Ashton {EXO00001621/9} page 9, paragraph 4.7; Cooney {EXO00001590/3} page 3, paragraph 3.8; Ashton {Day17/174:8-11}. 1035 Lane {Day61/209:24}-{Day61/210:7}. 1036 Pearson {EXO00001753/3} page 3, paragraph 3.7; Pearson {EXO00001753/6} page 6, paragraph 4.5; Ashton {Day17/177:1-9}. 1037 Pearson {Day19/41:2-13}. 1038 {EXO00000715}. 1039 {EXO00001209}. Issue 2 was issued on 18 December 2014 and became effective from 1 January 2015. 1040 Ashton {Day17/161:6-19}. 1041 Ashton {Day17/163:3-25}. 1042 Ashton {Day17/165:1-3}. 1043 {EXO00001209/4} paragraph 9. 1044 Ashton {Day17/168:25}-{Day17/169:13}. 1045 Lane Phase 2 Report {BLARP20000017/85} paragraphs 4.6.18-4.6.19. 1046 Ashton {Day16/28:18}-{Day16/29:8}. 1047 Ashton {Day17/76:20}-{Day17/77:6}; Ashton {Day18/86:5}-{Day18/89:25}.

112 The Grenfell Tower Inquiry: Phase 2 Report assigned to lead the project in the first place. In our view that was itself a fundamental mistake. If Exova had asked a fire engineer with experience of overcladding high-rise residential buildings to manage the project, the critical importance to fire safety of the components of the external wall might have been recognised. Mr Ashton was effectively unsupervised in this work. The only Chartered Fire Engineer involved in the project at Exova was Dr Barker, whose contribution to the work was negligible.1048 54.169 Neither Mr Ashton, Dr Barker, nor Dr Pearson thought that when drafting a fire safety strategy for a general needs block of flats they were required to consider means of escape for those with disabilities,1049 despite the fact that Mr Ashton had been involved in the drafting of Part 8 of BS 5588-8:1999, Fire precautions in the design, construction and use of buildings – Part 8: Code of practice for means of escape for disabled people.1050 Accordingly, neither the Existing Fire Safety Strategy, nor the Outline Fire Safety Strategy contained any reference to the characteristics of those who lived in the tower or the possibility of providing additional measures for those who needed help in evacuating. In that respect Exova again fell below the standard to be expected of a reasonably competent fire engineer as it overlooked the inclusive design guidance in Approved Document B on identifying additional measures which may be required to accommodate the needs of all persons with access to the building.1051 54.170 Exova’s failure to identify the significant fire safety risks introduced by the refurbishment was not only inadequate but positively dangerous. In order to complete its work it should have identified the nature of the proposed rainscreen, and as a result its combustible nature, and also the unsuitability of the combustible insulation and window infill panels, as well as the absence of cavity barriers in key locations. We have therefore come to the view that Exova bears considerable responsibility for the fact that Grenfell Tower was in a dangerous condition on completion of the refurbishment. 1048 Lane Phase 2 Report {BLARP20000017/82} paragraph 4.6; Lane {Day61/51:1-25}. 1049 Lane {Day62/85:22}-{Day62/88:23}; Pearson {Day19/133:2}-{Day19/138:25}. 1050 Ashton {Day18/2:19}-{Day18/3:12}; {BSI00000018}. 1051 Lane {Day62/84:11}-{Day62/96:1}.

113 Chapter 55 The choice of ACM PE rainscreen panels Initial proposals 55.1 Although the initial motive for overcladding Grenfell Tower was to improve its appearance, it was soon recognised that doing so could also provide a significant improvement in the energy efficiency of the building. Adding insulation to the outside, protected by a rainscreen, was proposed by Studio E as a solution.1052 Discussions with RBKC’s Planning Department resulted in a proposal to use zinc panels as a rainscreen, but from the early part of 2012 Bruce Sounes began to think of aluminium as an alternative because it was light, presented a limited risk of corrosion and was available in a variety of colours.1053 55.2 At the beginning of April 2012 Mr Sounes carried out some internet searches from which he identified CEP Architectural Facades Ltd (“CEP”) as a potential supplier of the rainscreen.1054 He then contacted Geof Blades of CEP seeking information about cladding systems and prices1055 and provided him with drawings and photographs of the tower.1056 In response Mr Blades sent Studio E details of a high-rise cladding project on which an ACM rainscreen had been used in rivet fix.1057 Mr Sounes met Mr Blades on 11 April 2012 to discuss potential cladding options, but they did not talk about the fire performance of any of the elements of the cladding.1058 55.3 Later that month Mr Sounes suggested Alucobond ACM panels as a possible option for the rainscreen, although he knew that at that stage RBKC’s Planning Department did not care for aluminium on aesthetic grounds.1059 55.4 On 28 May 2012, Mr Sounes indicated to Chweechen Lim of Artelia that both zinc rainscreen and render were being considered for the external facade of the building1060 and in her first budget estimate Ms Lim priced those two options.1061 During July 2012 Studio E continued to look into various options for the cladding,1062 but zinc rainscreen appeared to be gaining preference on aesthetic grounds.1063 In July 2012, Studio E sent Paul Dunkerton at the TMO a technical data sheet on a VM Zinc composite panel with a fire retardant core,1064 although Bruce Sounes had not considered whether it complied with the Building Regulations or the guidance contained in Approved Document B.1065 1052 {SEA00000007}. 1053 Sounes {SEA00014273/88} paragraphs 206 – 207; Sounes {Day20/108:11}-{Day20/113:8} 1054 Sounes {Day20/77:4-11}. 1055 {CEP00048112/1}; Sounes {SEA00014273/35} page 35, paragraph 71; {SEA00003965}. 1056 {CEP000000043}. 1057 {SEA00003941} The project involved Rockwool insulation {SEA00003942}-{SEA00003956}. 1058 Sounes {Day20/83:8-12}. Geof Blades did not recall the content of the conversation – see Blades {Day41/85:3-7}. 1059 {SEA00004051}; {TMO10001143/4-5}; Sounes {Day20/83:20}-{Day20/85:15}. 1060 {ART00006104}. 1061 {ART00005838}. Render is a plastered finish for external walls that provides a smooth surface and protects the underlying material against the elements. 1062 Sounes First Witness Statement {SEA00014273/52} paragraph 111; Sounes {Day20/89:25}. 1063 {EXO00000753/2}. 1064 {SEA00005320} and {SEA00005330}. This panel was not ultimately selected for inclusion in the NBS Specification. 1065 Sounes {Day20/89:20-25}.

The Grenfell Tower Inquiry: Phase 2 Report 114 55.5 On 7 August 2012 at a pre-application meeting with the Planning Department, Mr Sounes suggested zinc cladding,1066 which was considered by the planning officer present to be acceptable.1067 The move towards Reynobond ACM PE 55.6 On 16 October 2012, Mr Blades arranged an introductory meeting between himself, Mr Sounes and Deborah French of Arconic.1068 Mr Sounes thought that they had discussed the fact that Grenfell Tower was a high-rise residential block,1069 but the others did not remember that. Ms French said she did not remember ever having thought about the height of the building.1070 She presented the rainscreen products that Arconic offered, including a metal composite with zinc outer skins (called “ZCM”) and an ACM composite which could be painted to resemble solid zinc.1071 Neither Mr Sounes nor Ms French could remember having discussed the composition of the cores or their reaction to fire.1072 55.7 On 31 October 2012 Studio E issued its Stage C report,1073 which included options for rainscreen materials, including zinc composite1074 and aluminium.1075 Although the Stage C Report addressed Approved Document L (Conservation of fuel and power) in detail,1076 no detailed analysis of a similar kind was included in relation to Approved Document B. 55.8 Mr Blades remained in contact with Studio E. On 16 November 2012, he told Ms French that Studio E was inclined towards zinc but that there was still a chance for her to promote the sale of Reynobond panels.1077 He encouraged her in her efforts because if Reynobond ACM panels were chosen for the refurbishment, there would be a chance for CEP to be engaged as fabricator.1078 Studio E continued to consider other cladding options1079 and on 7 December 2012 Mr Sounes suggested that aluminium might be a better choice than zinc on aesthetic grounds.1080 55.9 In January 2013, Mohit Kotecha of Leadbitter emailed documents to Geof Blades for cost estimation purposes.1081 They included an outline specification showing VMZ composite zinc panels as the rainscreen.1082 Despite that specification, Mr Blades provided a quotation1083 pricing only Reynobond Zinc Patina finish ACM and not the specified VMZ composite zinc panels. Although the price quoted included a full facade design service,1084 Mr Blades did not consider whether the panels were suitable for use on a building over 18 metres in height.1085 1066 {SEA00005602}. 1067 Sounes {SEA00014273/53} page 53, paragraph 114; {SEA00005597/1}; Sounes {Day20/92:2-8}. 1068 Sounes {SEA00014273/65} page 65, paragraph 136.6; {CEP000003961}. 1069 Sounes {Day20/96:14-17}. 1070 French {MET00053162} page 21, paragraphs 72-73; French {Day88/67:1}-{Day88/69:3}. 1071 Sounes {Day20/93:19}-{Day20/98:7}; Sounes {SEA00014273/65} page 65, paragraph 136.6; Blades {Day41/85:12}-{Day41/92:20}. 1072 Sounes {Day20/98:3-7}; French {Day88/52:2-11}. 1073 {SEA00006429}. 1074 {SEA00006429/28}; {SEA00006429/31}; {SEA00006429/32}. 1075 {SEA00006429/32}. 1076 {SEA00006429/81}. 1077 {CEP00048712}; Blades {Day41/92:21}-{Day41/93:12}. 1078 Blades {Day41/93:24}-{Day41/94:3}. 1079 {SEA00007446}; {SEA00007448}, Sounes {SEA00014273/86} page 86, paragraph 192. 1080 {ART00000584/2-3}. 1081 {CEP00048886}. 1082 {CEP00048887/6}. 1083 {CEP000000138}; {CEP000000148}. 1084 Blades {Day41/96:3-6}. 1085 Blades {Day41/101:12-17}.

Part 6 | Chapter 55: The choice of ACM PE rainscreen panels 115 55.10 Geof Blades immediately sent the documents received from Leadbitter to Arconic.1086 They included an outline specification with drawings showing the height and dimensions of the tower,1087 images of the tower, which showed it to be a tall building,1088 and a scope of works which included a specification for Celotex FR5000 insulation.1089 Although Ms French said that she did not remember whether she had looked at those documents,1090 she accepted that she had become aware that the tower was a high-rise building.1091 At that stage CEP was promoting Reynobond because it had a commercial interest in doing so. Mr Blades did not give any thought to whether the PE version was suitable for use on a high-rise building, but at that stage the distinction between a PE and FR core had not really come to the fore. In Mr Blades’ mind “Reynobond” was synonymous with Reynobond PE. 55.11 In January 2013 the RBKC Planning Department rejected a proposal for green and yellow panels.1092 In discussions between Artelia and Leadbitter later that month it became clear that Leadbitter’s proposed costs were substantially higher than Artelia’s Stage D cost budget estimate. In a costs workshop on 18 January 2013, Leadbitter made various value engineering proposals, including substituting aluminium panels for zinc, resulting in a potential saving of £250,000.1093 On 1 February 2013, Leadbitter costed the saving to be made by using aluminium panels at £300,000.1094 55.12 In February 2013 Artelia asked Studio E, Curtins and Max Fordham to take a radical look at the specification to identify potential opportunities for value engineering.1095 In the view of Studio E, one obvious possibility was to change the rainscreen from zinc to a cheaper material.1096 Studio E had long held a preference for a Proteus Honeycomb zinc product,1097 but it was under significant pressure from the TMO to specify a cheaper alternative to zinc. 55.13 Throughout February and March 2013 CEP continued to promote Reynobond ACM panels for use on the tower.1098 Pursuant to the request to consider opportunities for value engineering, on 4 March 2013 CEP and Studio E met to discuss substituting ACM panels for zinc.1099 In advance of the meeting CEP told Arconic that it would propose the Reynobond range of products.1100 Mr Blades said that he did so out of professional loyalty to Arconic, having already introduced them to the project, and during the meeting he supported the use of Arconic’s Reynobond panels.1101 In doing so, he reinforced the impression held by Studio E that Reynobond PE was a suitable material for use on Grenfell Tower, although he had only limited knowledge of the regulatory regime governing the use of such products and, at that stage, only a limited understanding of the way in which Reynobond PE reacted to fire. 1086 {CEP00048962}. 1087 {CEP000000075/7}; {CEP00048966}. 1088 {CEP000000076}. 1089 {CEP00048971/5}. 1090 French {Day88/64:5-11}. 1091 French {Day88/66:18-23}. 1092 TMO Position Statement {TMO00837466/7}; {SEA00007275}; Sounes {SEA00014273/78} page 78, paragraph 164. 1093 {ART00006072}. 1094 {ART00006045}; {ART00005812/7}; {SEA00007298}; {TMO00879771/10}; Maddison {Day59/84:17}-{Day59/85:13}. 1095 {SEA00007413}. 1096 {SEA00007415}; Sounes {Day20/102:6}-{Day20/104:7}; {SEA00007414} Studio E also identified other potential cost savings, including scaling back the crown and changing the windows. 1097 The core of this product was an aluminium honeycomb structurally bonded between two thin sheets of metal – see {SIG00000248/9}. 1098 Blades {Day41/117:20-24}. 1099 Sounes {SEA00014273/85} page 85, paragraph 190. 1100 {CEP000000150}; Blades {Day41/104:14}-{Day41/108:25}. 1101 Blades {Day41/116:6-12}; Blades {CEP000008838/11} page 11, paragraph 7.42; Blades {Day41/117:8-19}.

The Grenfell Tower Inquiry: Phase 2 Report 116 55.14 In our view CEP should have taken steps to ensure that a person in the position of Mr Blades understood the behaviour, particularly in response to fire, of the products it supplied and had a general understanding of the regulatory regime that applied to them. In fact, he believed, quite wrongly, that “Class 0” was synonymous with “limited combustibility”.1102 Both he and Neil Wilson, the general manager, were under the impression that Reynobond PE had achieved Class 0,1103 which was not the case, although it is fair to say that BBA Certificate 08/4510 relating to Reynobond ACM panels, of which he was aware,1104 stated (wrongly) that the panels might be regarded as having a Class 0 surface. 55.15 Following the meeting, Mr Sounes felt that it might be possible to switch from zinc to ACM1105 and reported to Alun Dawson of Artelia that other options included insulated render and Marley “Natura” fibre cement panels.1106 At the request of Mr Blades, Ms French sent samples of various Reynobond panels directly to Adrian Jess at Studio E between 22 March and 8 April 2013.1107 Further samples were sent between the beginning of March and the end of June 2014.1108 55.16 In April 2013, CGL Systems Ltd, a facade designer and manufacturer who had been visiting Studio E’s offices in connection with another project,1109 provided Studio E with the names of cladding contractors, including Harley.1110 Harley had already become aware of the project through commercial sources and on being told by CGL that its name had been given to Studio E,1111 it contacted Studio E by email to express its interest in the project.1112 Harley’s email included details of its previous projects, all of which involved ACM rainscreen.1113 Studio E did not make any enquiries about Harley,1114 nor did it investigate the construction of the external walls of the buildings involved in any of those projects. 55.17 On 17 April 2013, Studio E gave the TMO details of a number of alternative materials to zinc that could be used as a rainscreen, most of which were ACM.1115 By that time the project had effectively stalled while the TMO made decisions about costs and procurement. Bruce Sounes said that it had been necessary to look at the cheapest options because that was what the TMO needed.1116 1102 Blades {CEP00064247/14} page 14, paragraph 67; Blades {Day41/58:13-24}. 1103 Wilson {CEP00064249/5} page 5, paragraph 21; {CEP00064249/6} page 6, paragraph 24; Blades {CEP00064247/5} page 5, paragraph 22; Blades {Day41/192:18}-{Day41/193:5}. 1104 Blades {Day41/57:14-19}. 1105 {SEA00007442}. 1106 {SEA00007442} see also {SEA00000547/26}; {SEA00000909}; {SEA00007563/2}; Sounes {Day20/107:11}; Blades {Day41/8:16-19}. 1107 {CEP000000151}. 1108 Exhibit French DF/4 List of samples provided for the refurbishment project {MET00019919}. 1109 Sounes {SEA00014273/89} page 89, paragraph 209. 1110 Sounes {SEA00014273/89} page 89, paragraph 209. 1111 {HAR00005352}; Ray Bailey {Day32/131:1-6}. 1112 {SEA00007603}. 1113 {SEA00007604}; {SEA00007605}; {SEA00007606}; Ray Bailey {Day32/134:23}-{Day32/135:2}. 1114 Sounes {Day20/118:23-25}. 1115 {SEA00007563}. 1116 Sounes {Day20/111:21}-{Day20/112:9}.

Part 6 | Chapter 55: The choice of ACM PE rainscreen panels 117 55.18 By June 2013 Mr Blades had become aware that an ACM panel with a fire resistant (“FR”) core was available1117 and realised that it would perform better in a fire.1118 However, he consistently promoted Reynobond 55 PE and accepted in evidence that he had relied on its Class 0 classification in the BBA certificate without having a working knowledge of the Building Regulations.1119 55.19 In June 2013, Studio E was given a copy of Artelia’s Draft Revised Project Brief, which stated that the primary driver of the project was value for money.1120 However, despite the fact that ACM was likely to be a cheaper option, Studio E still preferred zinc.1121 55.20 In July 2013, following a meeting with Councillor Rock Feilding-Mellen, Bruce Sounes prepared a document describing a range of materials and fixing methods that could be used to provide a rainscreen for insulated cladding. Both zinc and ACM panels were illustrated,1122 but the document did not mention fire safety. Studio E submitted a revised planning application to RBKC in July 2013 in which the proposed zinc composite rainscreen remained unchanged.1123 55.21 On 20 August 2013, Studio E completed a revised Stage D report which included Rheinzink panels for the rainscreen with ACM panels as an alternative.1124 The Rheinzink panel was not combustible.1125 The Hays Galleria meeting 55.22 On 27 September 2013, Bruce Sounes and Tomas Rek of Studio E met Ray Bailey and Mark Harris of Harley at a coffee shop in Hays Galleria near London Bridge to discuss options, costs and technical details for the cladding of Grenfell Tower.1126 During the meeting Harley showed Studio E photographs of some of their previous projects, including Ferrier Point, a high-rise overcladding project in East London, where Harley had installed face-fixed ACM panels over mineral wool insulation.1127 Studio E and Harley discussed cladding options, including Zinc Proteus HR with a honeycomb core and ACM.1128 Mark Harris said1129 that Harley had indicated to Studio E that Harley’s clients were frequently forced to use ACM because it was the cheapest product available and that Harley had used ACM on tower blocks more than any other product. Ray Bailey claimed not to have expressed a preference for ACM1130 and Tomas Rek did not recall any particular preference being expressed by Harley.1131 1117 Blades {Day41/43:17-23}. 1118 Blades {Day41/44:11-13}. 1119 Blades {Day41/57:5}-{Day41/59:7}. 1120 {SEA00007722}; {SEA00007721}. 1121 Sounes {Day20/120:2-11}. 1122 {SEA00002067}. 1123 Sounes {SEA00014273/25} page 25, paragraph 48. The changes related predominantly to the lower 4 floors. {SEA00002077}. 1124 {SEA00008052}; {TMO10003310}; {TMO10003310/21-26}; {SEA00014616/37}. 1125 SEA00014616/41} at paragraph 1.2; {SEA00014616/37}. 1126 {SEA00008375}; Sounes {Day20/129:15-25}; Harris {HAR00010159/4} page 4, paragraph 15; Harris {Day34/48:13}-{Day34/52:14}. 1127 SEA00003497}; {SEA00003516}. Before the meeting, Harley sent an email to Studio E attaching information sheets for three projects: Castlemaine, Clements Court and Chalcots Estate, all of which used ACM as the rainscreen material {SEA00007603}. 1128 Ray Bailey Witness Statement {HAR00010184/6} page 6, paragraph 22; Ray Bailey {Day32/139:4-23}. 1129 Harris {Day34/51:12}-{Day34/52:16}. 1130 Ray Bailey {Day32/146:14-18}. 1131 Rek {Day12/68:2-15}.

The Grenfell Tower Inquiry: Phase 2 Report 118 55.23 Throughout the discussions between Studio E and Harley, price and aesthetics were the dominant considerations;1132 the fire safety of the panels was not discussed at all.1133 Mark Harris accepted that Studio E had been relying on Harley to suggest materials that were suitable for use on the tower,1134 but the individuals involved at Harley and Studio E did not turn their minds to the risks involved in using ACM, particularly on a building over 18 metres in height. They simply assumed that it was safe because it had been used on a number of other projects involving tower blocks.1135 55.24 Despite the discussions about ACM at the meeting, Mr Sounes still preferred zinc or a zinc composite material. He told Harley that Studio E was looking seriously at Nedzink (a zinc composite panel)1136 but, when he reported back to the TMO with Harley’s rough estimate of £3 million based on zinc rainscreen cassettes,1137 he pointed out that in Harley’s experience budgets often forced clients to adopt face-fixed ACM.1138 Peter Maddison responded asking whether Harley had given a similar cost estimate for aluminium rainscreen.1139 55.25 On 18 October 2013 Harley provided budget costs to Studio E1140 omitting the requested quotation for Nedzink1141 and listing three alternative options for the rainscreen, including Reynobond ACM panels and Reynobond zinc-faced panels. Mr Sounes, who was still pursuing zinc,1142 replied asking for an indication of what the cost would be for Nedzink1143 and explaining that the Reynobond Natural Zinc (also referred to as VM Zinc “Quartz”) was not an option for aesthetic reasons.1144 55.26 Harley provided further costs information to Studio E in November 2013, including a quotation for Proteus HR Composite, but expressed a clear preference for ACM because it had used it on many previous projects and was confident about the costs involved.1145 However, Mr Sounes remained adamant that Studio E had set out to use zinc and that if the budget allowed it the result would be excellent.1146 In the same email he explained that the TMO would also want ACM options in the tender, despite the fact that the planners did not like the standard finish.1147 On 7 November 2013, Mr Sounes forwarded his email exchange with Harley about the cost of different cladding options to Chweechen Lim of Artelia. At that stage Artelia was preparing the OJEU tender documentation and on 11 November 2013, Ms Lim told Mr Sounes that she would include ACM in the tender contract sum analysis and ask contractors to provide an optional cost for zinc panels to ensure that tenderers provided costs for both types.1148 Ms Lim noted that Harley’s quoted costs were higher than Artelia’s cost plan and were also higher than the TMO’s budget.1149 1132 Ray Bailey {Day32/174:8-11}. 1133 Bailey {Day32/142:17-19}; Rek {SEA00014278/10} page 10, paragraph 30; Rek, {Day12/133:7-9}. 1134 Harris {Day34/52:20}-{Day34/53:1}. 1135 Ray Bailey {Day32/145:2}-{Day32/146:4}; {Day32/173:18}-{Day32/174:4}; Harris {Day34/53:7-17}. 1136 Email from Bruce Sounes to Ray Bailey and Mark Harris dated 27 September 2013, {SEA00008809} in which he states, “we are looking seriously at Nedzinc’s composite panel. The small sample we have in the office looks like Alucobond but is apparently zinc.” See also Sounes {Day20/138:18-25}; {SEA00008985}. 1137 {SEA00008809}. 1138 {SEA00008790}. 1139 {SEA00008836}. 1140 {HAR00005515}; budget attached at {SEA00002275}. 1141 {SEA00008985}. 1142 {SEA00009240}. 1143 {SEA00009237}. 1144 {Day20/145:19-25}. 1145 {SEA00009736}; Ray Bailey {Day32/173:18}-{Day32/174:11}. 1146 {ART00001895}. 1147 {ART00001895}. 1148 {ART00001895}. 1149 {ART00001895}.

Part 6 | Chapter 55: The choice of ACM PE rainscreen panels 119 55.27 Mark Harris responded to Bruce Sounes some two weeks later on 21 November 2013. He failed to answer Mr Sounes’ question about the rate for Nedzink, but he gave standard rates for ACM cassette and face-fixed panels. The email makes clear the close business relationship between Harley and Arconic,1150 which led Harley to press for Reynobond panels to be used.1151 By December 2013 Harley was seeking prices for Arconic’s Reynobond ACM panels1152 and by the spring of 2014 it had become committed to their use on the project.1153 55.28 Planning permission for the refurbishment was granted on 10 January 2014,1154 subject to conditions, including a requirement that the materials to be used on the external face of the building be approved in writing by RBKC.1155 On 15 January 2014 Arconic provided a quotation to CEP for Reynobond 55.1156 Although silent about the composition of the core, Deborah French accepted that as a standard product it would have been polyethylene.1157 55.29 CEP, the only fabricator which Harley approached for the supply and fabrication of the rainscreen,1158 sent two formal quotations on 21 January 2014. These differed only in respect of the window system proposed: Metal Technology,1159 or Wicona.1160 In relation to the rainscreen, the only quotation was for panels manufactured using 4mm Reynobond ACM with rivet fixings. Mr Blades confirmed that Harley had asked him to quote only for Reynobond.1161 Following the receipt of the quotation, Harley sent its own quotation to Rydon on 29 January 2014, which did not include VM Zinc as an option.1162 The NBS Specification 55.30 The final version of the NBS Specification produced by Tomas Rek at Studio E was dated 30 January 2014.1163 It specified Celotex FR5000 insulation1164 and Proteus HR zinc honeycomb rainscreen panels.1165 It also asked bidders to provide alternative prices for ACM rainscreen panels, including Reynobond Duragloss 5000.1166 The TMO agreed to the inclusion of ACM options in the NBS Specification for two reasons: first, because it wanted priced options, as RBKC’s Planning Department had not yet granted consent for any specific type of rainscreen;1167 second, because it had in mind that it might consider options that were less expensive than zinc in order to reduce the cost.1168 Peter Maddison denied that the inclusion of ACM had been driven by the TMO; he said that the TMO had included the ACM options on the advice of its professional design team and in the understanding that it was compliant with all the regulations.1169 We accept his evidence about that. 1150 {HAR00005509}; Harris {Day34/95:22}-{Day34/100:6}. 1151 Harris {Day34/68:4}-{Day34/85:12}. 1152 {CEP000000267/3}; Ray Bailey {Day32/183:10-15}. 1153 Albiston {Day35/76:17}-{Day35/77:4}. 1154 {ART00001999}. 1155 See condition 3 {ART00001999/2}. 1156 {ARC00000083}. 1157 French, {Day88/128:22-25}. 1158 Albiston {Day35/46:11-16}. 1159 {CEP000000268}. 1160 {CEP000000270}. 1161 Blades {Day41/137:8}-{Day41/141:2}. 1162 {RYD00002606}; {RYD00002607}. 1163 {SEA00000169}. 1164 {SEA00000169/73}. 1165 {SEA00000169/65}. See section 3 for further details of the CWCT Standard 2008; Rek {Day12/75:23}-{Day12/76:11}. 1166 {SEA00000169/64}. 1167 Maddison {Day59/88:3-10}; {Day59/92:5-10}. 1168 Maddison {Day59/93:1-12}. 1169 Maddison {Day59/91:4-18}; {Day59/92:17-24}.

The Grenfell Tower Inquiry: Phase 2 Report 120 55.31 Studio E, which had drafted the NBS Specification, had not checked whether the materials specified for use in the cladding complied with the requirements of the Building Regulations or reflected the guidance given in Approved Document B.1170 It appears simply to have assumed that they did because they had been used on other projects.1171 Appearance clearly played a central part in the choice of rainscreen,1172 which was entirely reasonable, but Studio E did not ask Exova, or any other fire engineer, to review the NBS,1173 nor did it ask itself whether ACM was an appropriate material to use.1174 It was not common practice at Studio E to carry out a full assessment of materials for compliance at RIBA Stage D or E.1175 55.32 Studio E did not investigate the fire performance of any of the proposed rainscreen panels. In his witness statement, Mr Sounes claimed that research and consultations, including with Exova, had not revealed any particular concerns or fire risks associated with the proposals or the materials,1176 but he was unable to identify any specific research that he had done or persons he had consulted.1177 At all events, we are satisfied that Studio E did not consult Exova on the use of ACM rainscreen panels. Until the night of the fire Mr Sounes was unaware that ACM panels could be produced with different cores, some fire retardant and some not.1178 Indeed, he was unaware that any of the materials referred to in Harley’s quotation might be available in fire-rated versions1179 and simply did not think about the fire performance of the ACM panels.1180 None of those involved in the refurbishment at Studio E or Harley scrutinised the BBA certificate relating to Reynobond 55 PE properly.1181 55.33 Following the production of the NBS Specification and throughout the discussions in early 2014 between Studio E, Harley and Rydon, everyone involved concentrated on the appearance of the rainscreen panels to the complete exclusion of their fire performance.1182 Previous projects on which ACM panels had been used 55.34 Between 2006 and 2011 Rydon had carried out two substantial overcladding projects on high-rise residential buildings in London, the Chalcots Estate and Ferrier Point, using Harley as sub-contractor. Chalcots Estate comprised five tower blocks, four of which were 23 storeys in height and the fifth 19 stories.1183 Ferrier Point was a 23-storey tower block. In both cases a company in the Rydon group was appointed as principal contractor under a design and build contract for the refurbishment of the building1184 and in both cases Rydon installed ACM rainscreen panels over mineral wool insulation.1185 Although in each case the core of the panels was unmodified polyethylene, there was one difference: the panels 1170 Sounes {Day20/173:12-24}; Rek {Day12/23:2}; {Day12/20:15-20}; {Day12/24:16-21}; {Day12/27:7-21}. 1171 Sounes {Day7/170:2-5}; Sounes {SEA00014273/140} page 140, paragraph 343; Sounes {Day20/93:12}{Day20:95:14}. 1172 Sounes {Day20/135:1-7}. 1173 Sounes {Day20/51:2-10}. 1174 Sounes {Day 20/105:12-15}; {Day20/72:1-4}. 1175 Sounes {Day20/64:13}-{Day20/65:3}. 1176 Sounes {SEA00014273/140} page 140, paragraph 343.2. 1177 Sounes {Day8/57:2}-{Day8/58:6}. 1178 Sounes {Day20/176:17-24}. 1179 Sounes {Day20/144:12-18}; {RYD00003953}. 1180 Sounes {Day20/135:4-7}. 1181 Sounes {Day21/16:18-21}; {Day21/19:3-24}; {Day21/23:8-15}; Ray Bailey {Day33/36:11}-{Day33/37:3}; Lamb {Day38/23:17-24}; Anketell Jones {Day37/6:10}-{Day37/7:23}; Albiston {Day35/43:6-24}: Harris {Day34/178:1-5}. 1182 Harris {Day34/115:12-25}. 1183 {RYD00094236/25} page 25 paragraph 44-47. 1184 {RYD00094236/26} page 26, paragraph 48-50. 1185 {RYD00094236/51} page 51, paragraph 103.

Part 6 | Chapter 55: The choice of ACM PE rainscreen panels 121 used were face-fixed (i.e. riveted to the supporting rails), whereas the Reynobond panels installed at Grenfell Tower were cassette-fixed.1186 For reasons that will become clear, that was an important distinction. 55.35 Rydon and Harley remained in close contact throughout the procurement process relating to the Grenfell Tower project and it is clear that they approached it as a team, so much so that Rydon’s tender included notes on the background and experience of three of Harley’s employees, Daniel Anketell-Jones, Mark Stapley and Robert Maxwell.1187 55.36 CEP had worked with Harley on ten previous projects, including the Chalcots Estate and Ferrier Point projects,1188 but the Grenfell Tower refurbishment was the only project it had undertaken with Harley using ACM panels in cassette form.1189 CEP had supplied ACM panels for many other high-rise residential overcladding projects in the years leading up to the Grenfell Tower refurbishment, including both panels with unmodified polyethylene cores and fire-resistant polyethylene cores.1190 Early discussions about value engineering 55.37 At the time of the formal procurement process Rydon also had an existing relationship with the TMO and there had been at least some discussion within Rydon of the project and its connection with Peter Maddison before 5 April 2013.1191 55.38 Stephen Blake, Rydon’s Refurbishment Director, had known Peter Maddison and Sacha Jevans of the TMO since about 2000, having met them at various conferences.1192 Although he had not seen either of them regularly, they had kept up a direct line of contact, as Simon Cash of Artelia recorded in an email in October 20151193 and as was broadly confirmed by both Mr Maddison and Ms Jevans.1194 55.39 On 6 March 2014, during the OJEU tender process, Mr Blake sent an email to Tim Shutler of Rydon, copied to Jeff Henton, Rydon’s chief executive, in which he said that at a recent housing conference he had met senior representatives from the TMO and had been given to understand that Rydon was the leading contender to obtain the contract for the refurbishment.1195 The housing conference to which Mr Blake referred took place between 4 and 6 March 2014 in Brighton. According to Mr Blake, the “senior representatives” of the TMO were either Mr Maddison or Ms Jevans,1196 but both of them denied having spoken to Rydon about the tender.1197 The tender interviews for the project were due to take place on 7 March 2014 and in our view the email speaks for itself. However it came about, it is clear to us that Rydon was given an indication of the likely outcome of the tender process while it was still going on. No other contractor was afforded the same benefit.1198 1186 The distinction is important for the purposes of understanding the BBA certificate governing Reynobond PE 55. See in particular Chapter 19. 1187 {RYD00094244/44}. 1188 Blades {MET00040323/4} page 4, paragraph 3.3; {CEP000003010}. 1189 Blades {Day41/24:6-8}. 1190 {CEP000003010}; Blades {Day41/21:5} – Blades {Day41/25:7}. 1191 Email from Steve Blake to Jeff Henton of 5 April 2013: “This is the Peter Maddison scheme which is right up our street.” {RYD00001115}. 1192 Blake {Day28/92:8} – {Day28/93:15}. 1193 {ART00006206}. 1194 Maddison {Day58/161:18}-{Day58/162:1}; {Day127/172:10-19}. 1195 {RYD00086648}. 1196 Blake {Day28/100:7-11}. 1197 Maddison {Day58/184:11}-{Day58/187:9}; Jevans {Day127/174:17-21}. 1198 Maddison {Day58/202:7-13}.

The Grenfell Tower Inquiry: Phase 2 Report 122 55.40 When he gave evidence Mr Maddison accepted that he had telephoned Mr Henton on 10 March 2014, after the TMO had interviewed all the potential contractors, to tell him that Rydon was in first position.1199 The next day Mr Henton sent an email to Alan Sharrocks and Simon Lawrence telling them that, subject to a small amount of value engineering, he expected Mr Maddison to recommend to the TMO board the following week that Rydon be appointed as principal contractor for the refurbishment.1200 55.41 Mr Blake had not been included in Mr Henton’s email and he was unable to say why that was,1201 or how the conversation between Mr Henton and Mr Maddison had come about.1202 He was asked whether at that time (11 March 2014) he had understood that Rydon’s appointment would be conditional on its willingness to accommodate the TMO’s desire for value engineering and initially told us that he had not known that at the time.1203 However, he had in fact been sent a draft of the email on 10 March 2014 by Sandra Guest, Mr Henton’s assistant, who had asked him to give her the names of the Rydon employees who had been involved in the bid.1204 Despite his prevarication, it is clear that Mr Blake had been in direct contact with Mr Maddison on or before 10 March 2014 about the results of the tender, because at 7.10pm on 10 March 2014 he had written to Mr Henton to tell him as much.1205 Having been shown the contemporaneous documents, Mr Blake ultimately accepted that he had been aware by 10 March 2014 at the latest that the TMO required significant reductions in the cost of the project by way of “value engineering” if it was to go ahead.1206 On 12 March 2014 Mr Blake sent an email to various Rydon employees telling them that Rydon would be asked by the TMO to find some savings in addition to those identified in the tender.1207 Mr Maddison said that he had spoken to Mr Blake to establish that Rydon was prepared to work with TMO to value engineer the project once the contract had been awarded.1208 55.42 When asked about that exchange Mr Blake originally denied having spoken to Mr Maddison on 12 March 2014, but having been shown the contemporaneous documents he was forced to accept that his previous evidence had been untrue,1209 though he said he had had no recollection of the emails. He also accepted that he and Mr Henton had had personal and private access to the top decision-makers on the project at the TMO.1210 Mr Blake insisted that their relationship with Mr Maddison and Ms Jevans had not influenced the tender process.1211 Peter Maddison did not score the tenders; that was done by Artelia, Jenny Jackson and the TMO, each of whom provided their own independent scoring, and Rydon came top. However, we are satisfied that Mr Maddison and Ms Jevans played an important part in ensuring Rydon’s appointment, both in providing information to Rydon about the tender and in negotiating with it so that its appointment would proceed. 1199 Maddison {Day58/195:6-23}; {Day58/197:2-12}. 1200 {RYD00003279}. 1201 Blake {Day28/148:16}. 1202 Blake {Day28/149:8}. 1203 Blake {Day28/152:14}. 1204 {RYD00086650}. 1205 {RYD00094368}. 1206 Blake {Day29/10:11-16}. 1207 {RYD00003295}. 1208 Maddison {Day58/203:12}-{Day58/204:4}; {TMO00879770/28}. 1209 Blake {Day29/15:3}. 1210 Blake {Day29/16:15}. 1211 Blake {Day28/120:19-20}.

Part 6 | Chapter 55: The choice of ACM PE rainscreen panels 123 Rydon’s costing error 55.43 While those discussions were going on with the TMO, Rydon was also attempting to make good a mistake in the preparation of its tender that had led to a shortfall of approximately £212,000 in its costing. On 11 March 2014, Katie Bachellier, one of Rydon’s estimators, had written to Mr Blake to tell him of the error. Mr Blake’s response was to look for a way to claw back the loss that would otherwise be made.1212 That had significant repercussions, which we describe below. Value engineering before Rydon’s appointment 55.44 On 13 March 2014, Peter Maddison sent an email to David Gibson of the TMO1213 with copies to Claire Williams and Jenny Jackson, the TMO’s procurement consultant, telling him that Mr Blake was confident that a gap in the budget of £270,000 could be closed. Mr Maddison intended to include Rydon’s proposals for achieving that reduction in the submission he was about to make to the TMO’s board seeking its approval of Rydon as principal contractor. 55.45 Later the same day Mr Gibson sent an email to Mr Blake attaching a spreadsheet which indicated that the TMO was looking to achieve a saving in cost of around £800,000 in total.1214 The spreadsheet identified the cladding as offering a saving of £243,000, that being the saving that Rydon had included in its tender submission in respect of new aluminium cladding.1215 The combined result of the TMO’s request for Rydon to reduce its price by about £800,000 and Rydon’s own estimating error meant that Rydon needed to achieve a saving in cost of just over £1 million even before it had formally been awarded the contract.1216 55.46 Mr Blake responded to Mr Gibson a little over five hours later, saying that he could see no reason why the reduction in cost that Mr Gibson had asked for could not be achieved. At that stage, however, he had not taken any steps to satisfy himself that such a reduction was in fact achievable.1217 Mr Blake clearly understood that if Rydon could provide savings to match the TMO’s budget, it would be awarded the contract.1218 55.47 On receipt of Mr Gibson’s email, Mr Blake contacted Harley more or less immediately. A log entitled “Sales/tender progress report” kept by Mark Harris recorded that he had received a call from Mr Blake who had told him that Rydon had been informed “off the record” that they were in “pole position”, but that the job was over budget. Rydon had asked Harley to confirm potential cost savings for them to table in discussions with the TMO.1219 Private discussions between Mr Blake and Mr Maddison revealed by Mr Maddison’s diary entries for 12 and 13 March 2014 are likely to have been the occasions when Rydon was given that “off the record” indication.1220 1212 {RYD00086654}. 1213 Initially the email was wrongly sent to David Burns but was then forwarded to David Gibson: {TMO00850707}. 1214 {RYD00003302}; {RYD00003301}. 1215 {RYD00094244/15}. 1216 Lawrence {Day23/135:1}. 1217 Blake {Day28/169:13-25}. 1218 {RYD00003302}. 1219 {HAR00010160/5}. 1220 {TMO00879770/28}.

The Grenfell Tower Inquiry: Phase 2 Report 124 55.48 On 14 March 2014 Mark Harris sent Rydon an email giving Harley’s analysis of the savings that could be achieved by changing the materials used in the construction of the facade of the tower.1221 He attached a document entitled “Grenfell Tower, London proposed VE cost savings”, which set out the cost of Harley’s “compliant bid” (i.e. its bid for provision of the facade system specified in the NBS Specification) in the sum of £3,736,595, together with two alternative window systems and four alternative cladding systems, each with an associated saving.1222 Harley indicated savings that could be achieved by using zinc and ACM rainscreen panels as follows: Zinc (cassette-fixed): £157,385 Zinc (riveted):

£279,764 Cassette-fixed ACM: £419,627 Riveted ACM:

£576,973 55.49 Stephen Blake and Simon Lawrence both said that by that time it had been accepted by Harley and Rydon that ACM panels would be used if planning permission could be obtained.1223 55.50 A meeting took place during the evening of Tuesday 18 March 2014, attended by Mr Lawrence, Mr Blake and Ms Bachellier on behalf of Rydon and Mr Gibson, Mr Maddison and Claire Williams on behalf of the TMO, at which they discussed how the project could be brought within the TMO’s revised budget.1224 Mr Blake said that he could not recall the meeting in any detail, but he did remember that Rydon and the TMO had discussed the need to find a significant amount of savings to enable the scheme to meet the TMO’s budget.1225 55.51 We do not know exactly what was discussed at the meeting because no record was kept of it. Mr Maddison described it as an “offline conversation” that was not part of the formal process, but specifically denied that it had been a secret meeting.1226 However, the TMO had been advised by its solicitors in February or early March that it was bound to assess all the tenders received for the project on the basis of the price and quality criteria set out in the tender documents and that the regulations did not allow it to enter into negotiations with individual tenderers before the contract had been awarded or even to invite all tenderers to submit revised offers. It was advised that it could run value engineering exercises with its selected tenderer only after it had entered into the contract. Ms Jackson therefore suggested that the TMO enter into the contract with Rydon at its tender price and then embark on value engineering, but she noted that there would need to be some informal discussion with the preferred contractor before they entered into a contract to ensure that it understood the TMO’s approach.1227 55.52 Simon Cash of Artelia agreed with Ms Jackson that the TMO could have an “offline discussion” with the preferred contractor and that the TMO was entitled to look for savings and seek Rydon’s agreement in principle to work with it later to achieve them. He added that some savings had been identified and others might be put forward during that 1221 {RYD00003315}. 1222 {RYD00003316}. 1223 Lawrence {Day23/151:20}; Blake {Day28/182:14-17}. 1224 Lawrence {RYD00094220/5} page 5, paragraph 22. 1225 Blake {Day28/171:10}. 1226 Maddison {Day59/13:11-20}; {Day59/14:24}. 1227 {ART00006433}.

Part 6 | Chapter 55: The choice of ACM PE rainscreen panels 125 conversation.1228 He told us that he had not been comfortable about the TMO’s meeting Rydon in that way but had felt under pressure from the TMO to agree.1229 In oral evidence, Mr Cash said he had meant that the TMO could tell Rydon what its approach to value engineering would be once the contract had been awarded,1230 without indicating that Rydon was the preferred bidder.1231 If that was so, however, we do not understand why Mr Cash said that suggestions for savings might be put forward before the contract had been awarded. Nor do we think that is the plain meaning of his message. As employer’s agent he should not have lent his support to discussions which, in the light of the advice that he knew had been given by the TMO’s solicitors, he had every reason to think might not be consistent with the procurement rules. 55.53 On 23 March 2014, after the “offline” meeting had taken place, the TMO received further advice from its solicitors.1232 They said that the procurement process could be open to challenge if a contracting authority sought to vary a price after receiving tenders or entered into negotiations with its preferred contractor. In an email sent to Sacha Jevans, David Gibson and Claire Williams on 26 March 2014 Peter Maddison summarised that advice as “Low risk of challenge and low risk of success.”1233 55.54 Peter Maddison said that the “offline” meeting on the 18 March 2014 and the conversations which had preceded it were in accordance with the solicitors’ advice,1234 being solely to seek agreement to value engineering in principle, and to agree a process for doing so.1235 David Gibson, however, conceded that no record had been made of the meeting because the TMO had wanted to achieve a secret understanding with Rydon.1236 He was aware that holding it had been contrary to the legal advice given to the TMO and that there was a risk that the procurement process would be challenged if other contractors found out about it. He ultimately conceded that one purpose of the meeting had been to identify changes to the specification that would reduce the overall cost of the project.1237 55.55 We do not accept Peter Maddison’s characterisation of the discussions. Their clear purpose, which was understood by both the TMO and Rydon, was to achieve a reduction in the cost of the project that would be reflected in the contract price. Specific areas of savings were identified and figures were discussed. Peter Maddison said that there had been a commercial risk of challenge,1238 but that the discussions had not been improper.1239 No doubt the TMO was in a difficult position: only three tenders had been received and all exceeded the budget as it then stood.1240 Repeating the procurement process would have caused considerable delay, which would have disappointed residents who had been waiting a long time for the refurbishment, and there was no guarantee that any of the contractors would bid again, or would bid again at a lower price.1241 However, we do not accept that Peter Maddison thought at the time that the “offline” discussions were consistent with 1228 {ART00008594}. 1229 Cash {Day48/233:7-19}. 1230 Cash {Day48/225:24-25}; {Day48/226:1-4}. 1231 Cash {Day48/224/16-17}. 1232 {TMO10005632}. 1233 {TMO10005632}. 1234 Maddison {Day59/12:21}-{Day59/13:3}. 1235 Maddison {Day58/198:6}-{Day58/199:19}. 1236 Gibson {Day54/34:21-25}. 1237 Gibson {Day54/30:7}-{Day54/31:18}; Gibson {Day54/43:3-11}. 1238 Maddison {Day59/15:11}-{Day59/17:3}. 1239 Maddison {Day58/202:19}-{Day58/203: 6}. 1240 {ART00002197}. 1241 Maddison {Day59/16:1-24}.

The Grenfell Tower Inquiry: Phase 2 Report 126 the rules governing the procurement process; indeed, in answer to a question from the Chairman he accepted that they “did not strictly comply with the letter of the process.”1242 That, of course, explains why the meeting was described as “offline”, i.e. secret. Secrecy was essential so far as both the TMO and Rydon were concerned because transparency might defeat its object. 55.56 On 17 March 2014, Philip Booth of Artelia had drafted a letter to Rydon formally notifying it of its status as the preferred bidder.1243 Substantial amendments were made to the wording by Ms Jackson later that evening.1244 The amended version, dated 18 March 2014,1245 was sent to Rydon at 5.55pm, some time after the “offline” meeting had ended.1246 Although Artelia had been aware of the process that the TMO proposed to adopt, there is no evidence that Artelia had been aware of the meeting itself and it is likely that it sent the letter on the instructions of Mr Gibson or Mr Maddison.1247 The letter referred to certain conditions, but said nothing about value engineering or the need to find substantial (or indeed any) cost savings. Unsurprisingly, the letters sent to the unsuccessful bidders the same day did not refer to the contact between the TMO and Rydon.1248 55.57 Simon Lawrence reported to Mark Harris on 19 March 2014 that Rydon had been confirmed as the preferred contractor for the refurbishment, although the decision was yet to be formally approved. Mr Harris recorded in his log that Rydon was “keen to push this job down the face-fixed ACM route with standard colour finish”.1249 He immediately contacted Deborah French of Arconic to procure samples of ACM rainscreen that would appear similar to zinc but at a lower cost.1250 In the weeks and months that followed, there were extensive discussions between Harley, Arconic, Studio E, Rydon and CEP about the use of ACM rainscreen cladding, but they related only to its cost and appearance;1251 certainly, there were no discussions about its reaction to fire. Peter Maddison’s diary entry for 19 March 2014 suggests that he had been advised by the TMO’s solicitors to agree with Rydon that the negotiations and the contract price should both be kept confidential.1252 55.58 On 20 March 2014, Katie Bachellier sent Peter Maddison and others at the TMO a summary of Rydon’s value engineering proposals1253 in the form of two documents entitled “VE Options 18.03.14”1254 and “Cladding VE Options 18.03.14”,1255 which set out the cost savings that Rydon had presented to the TMO at the “offline” meeting on 18 March 2014. The first of those documents showed a possible saving of £862,041 (enough to meet the TMO’s objective) if all the suggestions were adopted.1256 The second indicated the savings that could be achieved by the use of different rainscreen materials as follows: Zinc (cassette-fixed): £100,406 Zinc (riveted):

£202,372 1242 Maddison {Day59/23:5-18}. 1243 {TMO10005474}. 1244 {ART00002210}. 1245 {ART00008632}. 1246 {ART00008755}. 1247 Williams {Day54/192:7 – {Day54/193:3}. 1248 {ART00002224}; {ART00002219}. 1249 {HAR00006044} and {HAR00010160}. 1250 {HAR00006044}; {CEP00051117}; {RYD00003525}; {RYD00003508}; {RYD00003524}. 1251 {ARC00000089}; {RYD00003890}; {HAR00000931}; {HAR00005692}; {HAR00000933}; {SEA00010775}; {RYD00003964}; {CEP00051309}; {HAR00005737}. 1252 {TMO00879778/4}. 1253 {RYD00003489}. 1254 {RYD00003490}. 1255 {RYD00003491}. 1256 Lawrence {Day23/159:4}; Blake {Day28/190:15}.

Part 6 | Chapter 55: The choice of ACM PE rainscreen panels 127 Cassette-fixed ACM: £293,368 Riveted ACM:

£376,175 55.59 Those figures were all lower than those that Harley had given Rydon on 14 March 2014. Stephen Blake, Simon Lawrence and Zak Maynard were all asked to explain why Rydon had not disclosed to the TMO the true extent of the savings that could be achieved by changing the rainscreen. Both Mr Lawrence and Mr Maynard accepted (though not in so many words) that the purpose was to enable Rydon to retain the difference in order to make up the shortfall caused by the £212,000 error in costing.1257 Mr Blake conceded that Rydon had seen the change of rainscreen as an opportunity to generate additional profit for itself1258 and ultimately accepted that Rydon was showing the TMO significantly less by way of savings than it was obtaining from Harley.1259 55.60 At all events, it is self-evident that Rydon stood to make a greater profit from the refurbishment if the rainscreen were changed to ACM, particularly if a face-fixed (riveted) system was chosen rather than a cassette system. It was therefore in Rydon’s interest to promote the selection of ACM panels, which goes some way to explaining its enthusiasm for choosing that material and method of fixing. The TMO was kept entirely in the dark about Rydon’s financial interest in recommending ACM. The BBA certificate 55.61 Arconic held a certificate issued by the BBA in respect of Reynobond Architecture Wall Cladding Panels, the most recent version of which, at the time of the refurbishment, was dated 14 January 2008.1260 Astonishingly, at no stage of the project did anyone at Rydon, Harley or Studio E examine the certificate with any care with a view to understanding how ACM panels with unmodified polyethylene cores might react to fire. 55.62 Deborah French gave Mr Harris a copy of the BBA certificate on 23 April 2014 and he passed it straight on to Simon Lawrence,1261 apparently without giving it any consideration. Simon Lawrence sent a copy to Mr Sounes the same day and also arranged for a copy to be provided to Mr Blake on or around 6 May 2014 as part of a pack of documents relating to a meeting with RBKC’s Planning Department.1262 55.63 Mr Sounes did not spend long looking at the certificate; indeed he said that it had not been his practice to read the whole of a BBA certificate for any product that he was planning to recommend for a project.1263 He admitted that he had never read section 6 of the Reynobond certificate, which related to the fire performance of the panels, and said that investigating their fire performance had not been a concern at that stage.1264 In his view Rydon had by that time taken over responsibility for the design of the project which included responsibility for assessing the suitability of any materials that might be used. Mr Sounes was not aware of the distinction between the fire retardant (FR) and unmodified polyethene (PE) versions of the product and he never discussed the matter with Harley or CEP.1265 For his part, Neil Crawford could not remember having looked at the 1257 Lawrence {Day23/163:18}; Maynard {Day31/91:15}-{Day31/92:2}. 1258 Blake {Day28/193:6-8}. 1259 Blake {Day28/193:12}. 1260 {ARC00000678}. 1261 {RYD00003932}. 1262 {RYD00003932}; {RYD00004142}. 1263 Sounes {Day21/12:5-7}; {Day21/13:3}. 1264 Sounes {Day21/19:24}; {Day21/16:20}; {Day21/17:8}; Sounes {SEA00014273/154} page 154, paragraph 381. 1265 Sounes {Day21/24:7-13}.

The Grenfell Tower Inquiry: Phase 2 Report 128 BBA certificate before the fire and we think it unlikely that he did so.1266 No one at Studio E sought any guidance on the meaning or effect of the BBA certificate from Exova, Rydon, Harley, Arconic or anyone else.1267 55.64 Although Simon Lawrence may have looked at the BBA certificate generally, he did not study it in any detail and did not pay any attention at all to the section relating to fire performance.1268 He did not ask Harley to check the test evidence on which the certificate was based, nor did he ask it whether the panels being proposed for use on the tower were in all respects the same as those described in it. Rather, he appears simply to have assumed that ACM panels generally were suitable for use on the tower because Rydon and Harley had previously worked together to install similar panels on the Chalcots Estate and Ferrier Point projects.1269 55.65 Mr Lawrence could not recall having discussed the BBA certificate with Bruce Sounes or anyone else and he did not discuss the fire performance of ACM panels with anyone at any stage of the project.1270 When he sent the certificate to Mr Blake on 6 May 2014 he specifically drew attention to the fact that it stated that the panels were rated Class 0, which might suggest that he had addressed his mind to the question of the fire performance, at least to a limited extent.1271 However, when he was asked about that email, he said that he had merely been trying to provide Mr Blake with as much information as possible and that he had not considered that the fire performance of panels to be relevant to the meeting.1272 Mr Blake said that there had been no discussions at all within Rydon about which, if any, of the routes to compliance for external walls in Approved Document B had been adopted.1273 Furthermore, none of those who gave evidence on behalf of Rydon was aware that Reynobond 55 panels were available with a fire retardant core, despite that being clear from the wording of the BBA certificate.1274 In the circumstances, we are satisfied that no one at Rydon gave any meaningful consideration at any stage to the part of the certificate that dealt with the fire performance of the ACM panels used on Grenfell Tower. 55.66 As for Harley, Ray Bailey had read the BBA certificate in 2008 at the time of the Chalcots Estate project and did not read it in detail again.1275 He accepted that Harley was obliged to examine certificates such as the BBA certificate in order to satisfy itself that the products that were being used on the tower were appropriate,1276 but he said he had only been concerned to ensure that the BBA certificate confirmed that the panels had a Class 0 rating.1277 He was not aware that that classification did not extend to the smoke silver polyethylene cored panels that had been selected for use. 55.67 Despite Mr Bailey’s evidence, it is difficult to resist the conclusion that no one from Harley gave any serious consideration at all to the current BBA certificate. Daniel Anketell-Jones did not read it1278 and, despite having received a copy of the email from Ms French to 1266 Crawford {Day10/149:22}-{Day10/150:14}. 1267 Sounes {Day21/29:11-21}. 1268 Lawrence {Day24/4:11-14}; {Day24/6:5-14}. 1269 Lawrence {Day24/18:14}-{Day24/19:21}. 1270 Lawrence {Day23/179:2-7}; {Day24/21:4} – {Day24/22:6}. 1271 {RYD00004142}. 1272 Lawrence {Day24/35:19}-{Day24/37:9}. 1273 Blake {Day28/86:8-12}. 1274 Lawrence {Day24/14:1-14}; Blake {Day28/48:20-23}; O’Connor {Day26/27:18-24}; Hughes {Day27/53:24}-{Day27/54:1}; Martin {Day30/116:4-7}. 1275 Ray Bailey {Day32/15:11-20}. 1276 Ray Bailey {Day33/37:4-11}; {HAR00000120}; {HAR00000391/2} at clause 4.2. 1277 Ray Bailey {Day32/124:16-18}; {Day33/33:14-15}. 1278 Anketell-Jones {Day37/7:22}.

Part 6 | Chapter 55: The choice of ACM PE rainscreen panels 129 Mr Harris attaching it, nor did Mike Albiston.1279 Harley’s designer, Kevin Lamb, did not consider it to be part of his job to read the certificate; indeed, it had never crossed his mind that there might be one.1280 55.68 We think it is clear that none of those responsible for the design of the overcladding of Grenfell Tower asked themselves whether the BBA certificate could be relied upon as evidence that the ACM panels which they proposed to use, whether in face-fixed or cassette form, would result in the creation of an external wall which complied with the Building Regulations. In her evidence to the Inquiry, Ms French, who sold the cladding for Arconic, said that this fundamental lack of curiosity in the reaction of the panels to fire was more normal than otherwise.1281 55.69 The approach of RBKC’s Building Control Department was much the same. Mr Allen accepted1282 scrutinising certificates such as the BBA certificate and the test data referred to within them was a core function of a Building Control officer, but Mr Hoban did not look beyond the first page of the BBA certificate with its reference to Class 0.1283 The reliability of a BBA certificate was accepted without question by RBKC’s Building Control Department, but it was not Mr Hoban’s practice to read BBA certificates in any detail.1284 55.70 Geof Blades was aware of the existence of the BBA certificate and thought (wrongly) that it stated that Reynobond 55 PE panels had achieved a Class 0 fire rating, having failed to notice that only the FR version was said to have passed both the BS476-6 and BS476-7 tests.1285 He did not appreciate that the certificate did not in that respect cover panels with an unmodified polyethylene core. He also thought, quite wrongly, that Class 0 was synonymous with limited combustibility1286 and failed to consider whether the nature of the core might affect its compliance with the Building Regulations. He had no understanding of the ways in which cladding systems could be shown to comply with the Building Regulations and Approved Document B.1287 Negotiations with the Planning Department 55.71 From March 2014 onwards, the attention of Studio E, Rydon, Harley and the TMO turned to obtaining approval from the RBKC Planning Department for the material to be used on the external walls of the tower. From that time, the only product that was proposed for use was Reynobond 55 PE ACM panels, i.e. with unmodified polyethylene cores.1288 The only remaining questions were about colour and whether the fixing system should be cassette or rivet. 55.72 On 1 April 2014, a meeting was held to introduce the TMO to Rydon, as the main contractor for the project. The minutes of that meeting record that the TMO was told that there was a potential saving of up to £376,175 to be made if the material used for the rainscreen were changed from zinc to ACM and if rivet fixings were used.1289 Rydon did not tell the TMO that Harley was willing to reduce the cost of the rainscreen by as much as 1279 Albiston {Day35/43:24}. 1280 Lamb {Day38/23:19}. 1281 French {Day88/187:21-25}. 1282 Allen {Day47/80:3-13}; {Day47/77:4-12}. 1283 Hoban {Day46/23:14-16}; Allen {Day47/80:3-24}; Menzies {Day60/97:14}-{Day60/98:6}; {Day60/99:2-16}. 1284 Hoban {Day46/15:20}-{Day46/16:45}. 1285 Blades {Day41/60:4-25}. 1286 {CEP00064247/14} page 14, paragraph 67; Blades {Day41/58:11-12}; {Day41/60:19-24}; {Day41/131:10-12}. 1287 Blades {Day41/64:7-12}. 1288 Williams {Day55/20:9-15}. 1289 {ART00002256}; Peter Blythe asked that the minutes of this meeting be kept confidential {RYD00003682}.

The Grenfell Tower Inquiry: Phase 2 Report 130 £576,000 for face-fixed ACM and if, as the minutes tend to suggest, the TMO was given to understand that the sum of £376,175 reflected the full amount of the reduction available from Harley, that was clearly false and was known by Rydon to be false.1290 55.73 Artelia immediately began to discuss with Rydon, Studio E, Harley, the TMO and IBI Taylor Young, an independent planning consultant appointed by the TMO, the best strategy for obtaining planning permission for the change in design.1291 On 8 May 2014, Stephen Blake attended a meeting with the Planning Department, together with (among others) Bruce Sounes, to discuss the proposed changes to the design of the facade. In an email to Claire Williams before the meeting, Simon Lawrence listed what he described as “agenda points” for the meeting, including, in particular, a proposal for changing the rainscreen from zinc to ACM. He intended to argue that ACM was not inferior to zinc.1292 Mr Lawrence saw Rydon as an advocate for ACM against a reluctant planning committee because it had used ACM successfully on previous occasions. He thought it was in everyone’s interests for ACM to be accepted, because there was a risk that, if it were not, the project might not go ahead at all.1293 As we have already noted, Rydon also had a powerful financial interest in the choice of ACM. 55.74 When Mr Lawrence briefed Mr Blake before the meeting, he told him that the ACM panels they proposed to use had a Class 0 rating, but there was no discussion about their fire performance at the meeting. Indeed, he could not remember any discussion about the fire safety of the panels at all.1294 Mr Blake said that he had not been aware of any consideration having been given to the fire performance of ACM panels at any time between May and October 2014, when final planning permission was obtained.1295 The appearance and cost of the cladding, together with concerns about the programme, were the only matters considered by the council, either in its internal discussions or those it held with Studio E.1296 55.75 RBKC’s Planning Department was principally concerned with two matters: the colour of the panels and the method of fixing. There is no evidence that the TMO, Rydon or Harley was aware that the method of fixing might affect the reaction of the panels to fire, but it did affect the appearance of the facade and was therefore regarded as an important aesthetic consideration.1297 Bruce Sounes said that his own examination of the technical documents provided by Arconic concentrated on the colour charts because the focus at that time had been on the building’s appearance.1298 When one of the councillors, Rock Feilding-Mellen, intervened in the debate in July 2014, the only issues on which he commented were fixing method and colour,1299 with a heavy emphasis on the latter. 1290 Lawrence {Day23/174:1-9}; Blake {Day28/193:9-12}. 1291 {RYD00003898}; {SEA00010720}; {SEA00010767}; {RYD00004155}. 1292 {RYD00086654}. 1293 Lawrence {Day24/32:2-6}. 1294 Blake {Day29/40:8-16}. 1295 Blake {Day29/43:18}-{Day29/44:21}. 1296 Feilding-Mellen {Day131/188:15}-{Day131/189:22}; {Day131/191:15}-{Day131/193:14}; {Day131/195:2-17}; {Day131/199:3-6}. 1297 RBKC Planning also considered whether the face-fixing could rust: {SEA00011359}. 1298 Sounes {Day21/11:9-20}; Sounes {SEA00014273/154} page 154, paragraph 381. 1299 {RBK00033430}; {RBK00003508}.

Part 6 | Chapter 55: The choice of ACM PE rainscreen panels 131 55.76 The Planning Department had a clear preference for a cassette rather than a riveted system. On 23 May 2014, Simon Lawrence sent an email to Stephen Blake and Zak Maynard, in which he expressed his concern that the planners would accept only cassette-fixed panels on aesthetic grounds.1300 His concern stemmed from the fact that Rydon stood to gain far less from the use of a cassette system than a riveted system.1301 55.77 On 17 July 2014, representatives of the planning committee visited Grenfell Tower to view a mock-up of the cladding.1302 Arconic supplied Reynobond ACM rainscreen for the purpose free of charge to CEP, which fabricated it. On 31 July 2014 the TMO informed Rydon that the planning department had approved ACM rainscreen cladding using cassette fixings and formal planning permission was granted for those panels in “smoke silver” on 25 September 2014.1303 Fabrication by CEP 55.78 Once Reynobond 55 PE ACM panels had been approved, attention turned to their fabrication by CEP. Harley placed four orders with CEP for ACM panels to be used on the facade and crown of the tower, on 13 March 2015, 6 July 2015, 8 July 2015 and 9 November 2015.1304 Harley placed separate orders for the fabrication of the windows, in October 2014 and February and May 2015.1305 Contemporaneous knowledge of the combustibility of ACM panels 55.79 Although it appears that neither Harley, nor Rydon nor Studio E gave detailed consideration to whether ACM rainscreen panels complied with the requirements of the Building Regulations, many of those involved in the decision to use them had some general awareness of their combustibility, in some cases as a result of personal experience. The most significant event, in our view, was the fire which occurred on the night of 16 January 2012 at Taplow House on the Chalcots Estate. Employees of Rydon and Harley, including Stephen Blake, attended Taplow House on 17 January 2012 to inspect the damage, including the damage to the ACM panels.1306 A report produced by Harley on 17 January 2012 found that the fire had melted the windows of the flat in which it had started and had damaged the cladding, but had been prevented from spreading more widely into the cladding system (and in turn to other flats) by the cavity barriers around the windows.1307 Mr Blake was pictured in the report pointing to the cavity barrier system around the damaged window.1308 55.80 After the initial inspection on 17 January 2012, Harley and Rydon agreed that an abseil survey should be conducted. It took place on 18 January 2012 and a further report was produced by Harley on 23 January 2012.1309 The report stated that the purpose of the inspection had been to examine the external facade of the building to ensure that the 1300 {RYD00005064}. 1301 Lawrence {Day24/69:10}. 1302 {RYD00012461}; {RYD00012459}. 1303 {RYD00003932} attaching {HAR00000934}; {IBI00001802}; {RYD00014150}. 1304 {CEP000000512}, attaching {CEP000000513}; {CEP000000527}; {CEP000000528}, attaching {CEP000000529}; {CEP000000616}; {CEP000000617}; {CEP000007550}; {CEP000001124}; {CEP000001168}. 1305 {CEP000000447}; {CEP000000469}, attaching {CEP000000470}; {CEP000000471}; {CEP000000472}; {CEP000000492}; {CEP00053848}; {CEP000005833}; {RYD00040435}. 1306 {HAR00010169}. 1307 {HAR00010169/3}. 1308 {HAR00010169/3}; Blake {Day29/121:21-23}. 1309 {CEP000003223}.

The Grenfell Tower Inquiry: Phase 2 Report 132 cladding panels were safe, as the fire had caused extensive damage.1310 The inspection revealed that the ACM panels had distorted as a result of being exposed to heat and smoke, and the report contained photographs showing that they had been seriously damaged, having melted and warped.1311 The abseil report was circulated to, amongst others, Mr Blake, Ray Bailey and Daniel Anketell-Jones.1312 Despite the contents of the report, Mr Blake appears to have told David Hughes (of Rydon) that he had no concerns about the safety of ACM panels arising from the Taplow House fire.1313 Ray Bailey told us that the fire at Taplow House had demonstrated to Harley that ACM would burn1314 and he accepted that Harley’s failure to implement the lessons it had learnt from Taplow House in the designs of the windows at Grenfell Tower had been an error.1315 55.81 There were other events which should have made those responsible for the cladding at Grenfell Tower aware of the dangers posed by the combustible nature of ACM panels. On 13 May 2013, Deborah French of Arconic wrote to Geof Blades, Neil Wilson and Roy Fewster of CEP to alert them to press reports of a fire in a building in the United Arab Emirates that had been overclad with ACM rainscreen panels.1316 Mr Blades knew as a result of those exchanges that ACM panels with unmodified polyethylene cores were combustible.1317 Ms French’s email followed a message to CEP a few days earlier from Richard Geater, the UK sales representative of Alucobond’s, another producer of ACM panels, which referred to the Tamweel Tower fire in Dubai and described the problems that had been encountered there with the use of cheap ACM panels with polyethylene cores.1318 Those messages ought to have prompted Mr Blades to reconsider whether it was safe to use Reynobond PE on any high-rise building in the UK, including Grenfell Tower, but regrettably he did not do so. 55.82 On 7 October 2014, Daniel Anketell-Jones attended the Annual General Meeting and Members’ Meeting of the Centre for Window and Cladding Technology (CWCT), at which a presentation was given by Sarah Colwell discussing the regulatory requirements and testing regimes for the construction of facades.1319 It is clear from the slides used at that presentation that the combustibility of rainscreen facades was discussed, including the large number of cladding fires that had affected high-rise buildings in other countries.1320 Daniel Anketell-Jones said that he had no specific recollection of being at that presentation; he thought he had been there but that he had not been concentrating.1321 55.83 It is unlikely to be a coincidence that on 8 October 2014, the day after that meeting, Samuel Anketell-Jones, a junior design engineer at Harley and Daniel Anketell-Jones’s brother, sent Deborah French of Arconic an email asking for information about Reynobond ACM panels with a fire-resistant mineral core.1322 Daniel Anketell-Jones told us that when he had proposed the cladding for Grenfell Tower he had not realised that Reynobond ACM panels were available with a fire-resistant core.1323 (Ray Bailey said that he had been aware 1310 {CEP000003223}. 1311 {CEP000003223/5-14}. 1312 {CEP000003223/2}. 1313 Hughes {Day27/42:1-18}. 1314 Ray Bailey {Day33/143:4-5}. 1315 Ray Bailey {Day33/146:11-16}. 1316 {CEP00049719}. 1317 Blades {Day41/123:14-15}. 1318 {MET00053158_P10/157}; Blades {Day41/122:15-25}. 1319 {CEL00001037}. 1320 {CEL00001038/3}. 1321 Anketell-Jones {Day36/5:16-18}. 1322 {MET00081175}. This email was disclosed to the Inquiry by the MPS in 2022 after the conclusion of the hearings and was disclosed to core participants in April 2023. 1323 Anketell-Jones {Day37/8:13-18}; {Day36/212:21}-{Day36/213:8}.

Part 6 | Chapter 55: The choice of ACM PE rainscreen panels 133 that two kinds of panel were available as a result of reading the BBA certificate but had assumed that they performed in similar ways and that neither he nor anyone else at Harley had ever asked Deborah French about it.)1324 Although it is not clear to which of Harley’s projects the email related, it suggests quite strongly, particularly when viewed together with the information shared at the CWCT meeting, that Harley knew more than it was willing to admit about the availability of a fire-resistant version of the Reynobond panel and the dangers of using ACM with an unmodified PE core. 55.84 In March 2015, discussions took place between Siderise, Harley and Rydon about the cavity barrier requirements for Grenfell Tower. For present purposes it is not necessary to refer to the details of the debate but it is worth drawing attention to some of the things said in the course of it by Exova, Studio E, Rydon and Harley. In an email of 27 March 2015, Daniel Anketell-Jones wrote to Ray Bailey saying, “There is no point in ‘fire stopping’, as we all know; the ACM will be gone rather quickly in a fire!”1325 On 31 March 2015, Terence Ashton wrote to Neil Crawford saying, amongst other things, that it was difficult to see how a fire-stop would stay in place in a fire involving external flaming as it would cause the zinc cladding to fail.1326 Mr Crawford agreed, expressing the view that “metal cladding always burns and falls off.”1327 Later the same day, he relayed Mr Ashton’s opinion to Simon Lawrence.1328 It is clear that Mr Lawrence read Mr Ashton’s comments because he responded, “Excellent. That looks positive.”1329 55.85 None of the witnesses was prepared to accept that those messages showed that those concerned were aware that ACM panels were combustible. Mr Ashton said that he had meant to say that metal rainscreen would not burn, but that if windows connected to metal cladding failed, the panels themselves would fall off the building in that area,1330 not that they would actually burn.1331 We do not accept that evidence. In our view he was aware that ACM panels would burn, but at the time he was still under the impression that the panels were to be zinc.1332 Similar explanations were offered by Mr Crawford and Mr Anketell‑Jones. Mr Anketell-Jones said that he had been referring to the fact that ACM panels and their fixings were made of aluminium, which would melt at a lower temperature than steel, and was not referring to the combustibility of the panel itself or to the fact that its core was made of polyethylene.1333 He told us that at the time nobody had been aware that any of the materials were combustible,1334 and went on to explain that he had meant to say that metal cladding would melt, fail and fall off.1335 He denied that he had been aware that composite panels with a polyethylene core could contribute to the spread of flame.1336 For his part, Simon Lawrence simply said that he did not give any thought to what would happen if the rainscreen were exposed to flames.1337 He said that if he had been aware that ACM would quickly fail in a fire, he would have checked with Building Control that it complied with the regulations and would then have looked into it 1324 Ray Bailey {Day33/44:4-25}. 1325 {HAR00006585}. 1326 {EXO00001434}. 1327 {EXO00001434}. 1328 {SEA00013051}. 1329 {SEA00013051}. 1330 Ashton {Day18/103:4-10}. 1331 Ashton {Day18/104:10-14}. 1332 See Chapter 54 and our findings about Exova’s work. 1333 Anketell-Jones {Day37/20:4}-{Day37/21:24}. 1334 Anketell-Jones {Day37/27:6-8}. 1335 Crawford {Day10/154:6-7}. 1336 Crawford {Day10/156:2-16}. 1337 Lawrence {Day25/11:17}.

The Grenfell Tower Inquiry: Phase 2 Report 134 further.1338 In the event, it is clear that he did neither of those things. We agree with the view expressed by Deborah French in a witness statement given to the Metropolitan Police that it would have been obvious to anyone that polyethylene was plastic and flammable.1339 We are satisfied that Mr Crawford and Mr Anketell-Jones knew that ACM was combustible; Mr Lawrence may not have known, but ought to have taken the trouble to find out after he had been asked about the reaction of the panels to fire by Claire Williams in her email of 12 November 2014. 55.86 However, even if none of them gave any real thought to the implications of using ACM panels with polyethylene cores, those representatives of Exova, Studio E, Rydon and Harley were aware that an external wall incorporating the rainscreen panels that were to be used on Grenfell Tower would not adequately resist the spread of fire across the surface of the building. That much is clear from the exchange of emails mentioned above.1340 The “Lacknall moment” 55.87 On 12 November 2014, Claire Williams wrote to Philip Booth and Nick Valente of Artelia asking, amongst other things, whether in the light of the fire at Lakanal House there was any requirement for materials to be flame retardant.1341 Later the same day she sent an email to Simon Lawrence referring to Lakanal House and asking him to clarify the fire retardance of the new cladding.1342 She was familiar with the Lakanal House fire principally because she had attended a presentation by Dr David Crowder of the BRE on 10 January 2014,1343 but could not recall any specific aspect of the presentation that had caused her to make a connection between that fire and the fire performance of the cladding chosen for use on Grenfell Tower. She also included in her email extracts from the NBS Specification for the project, which Philip Booth had sent her as a reminder of what had been specified.1344 He had suggested that she seek clarification from Rydon about the fire performance of the cladding. Mr Lawrence accepted that it had been part of Rydon’s task as principal contractor to answer questions of that kind from the TMO and that, within Rydon, he was the person to do so.1345 55.88 Mr Lawrence told us that when he read Ms Williams email he had understood her to be referring to the glass reinforced concrete (“GRC”) cladding that was to be installed on the lower levels of tower,1346 but that was not what she had said in her email and, although the information she included had referred to GRC products, it had also referred to the CWCT standard for systemised building envelopes, which applied to the whole of the tower’s facade. We are unable to accept that Mr Lawrence understood that message to refer only to the GRC element of the cladding installed at Grenfell Tower. 55.89 Mr Lawrence said that he would not have expected to respond to an email of that kind himself but would have sent it to the project’s design team for a response.1347 However, there is no record of his having done so, or indeed of any response to it, and Ms Williams could not recall having received any response.1348 We think that Simon Lawrence simply 1338 Lawrence {Day25/12:23}-{Day25/24:1}. 1339 {MET00053162/7} page 7, paragraph 28. 1340 {HAR00006585}; {SEA00013051}. 1341 {ART00003042}. 1342 {RYD00023468}. 1343 {TMO10040126}; Williams {Day55/126:21}-{Day55/130:20}. 1344 {ART00008527/52} page 52, paragraph 173; Booth {Day50/62:9-15}; Booth {Day50/64:15}-{Day50/65:6}. 1345 Lawrence {Day24/166:18-23}. 1346 Lawrence {Day24/161:12}-{Day24/168:8}. 1347 Lawrence {Day24/164:1}-{Day24/166:23}. 1348 Williams {Day55/145:25}.

Part 6 | Chapter 55: The choice of ACM PE rainscreen panels 135 failed to take any action at all in response to the email, possibly because he did not understand its significance, that Ms Williams did not pursue it, and that no one in the design team gave any consideration to the question she had raised, despite the fact that it was of real importance. 55.90 In both his written and oral evidence David Gibson told the Inquiry that he had raised concerns about the fire performance of the rainscreen system during a meeting chaired by Philip Booth of Artelia in March or April 2015.1349 He said that he had become concerned when he learnt that there was to be an air gap between the insulation and the rainscreen, as he had understood that a cavity of that kind had contributed to spread of fire at Lakanal House.1350 He said that Mr Lawrence had assured him that the rainscreen was completely inert and would not burn at all.1351 Claire Williams supported Mr Gibson’s recollection.1352 Both Mr Gibson and Ms Williams said they recalled being given hard copies of the minutes of the meeting drafted by Artelia which recorded Simon Lawrence’s advice, although their accounts of how they received them were not consistent. Mr Gibson believed he received a copy at the next scheduled meeting1353 and said he had noted that “Lakanal” had been misspelled.1354 Ms Williams did not think that Mr Gibson had been at the subsequent meeting; she said she had been given a hard copy which she had brought back to the office and read to him.1355 55.91 Neither Simon Lawrence nor Philip Booth recalled any such conversation nor any such minutes.1356 In particular, Mr Booth said that compliance with the fire safety requirements of the regulations had not been discussed with him, because it was an absolute requirement, not a matter for debate.1357 None of those who could be expected to have received copies of the minutes disclosed them, either in electronic or paper form, and there is no reference in any of the contemporaneous documents to an assurance of that kind. In those circumstances we are unable to regard the evidence of Mr Gibson and Ms Williams on this matter as reliable. We find the evidence of Mr Booth persuasive: as employer’s agent, he was required to ensure that meetings were properly and fully recorded for the benefit of the TMO. If such an important assurance had been given at the meeting, he would have noted it. We consider it very unlikely that a paper document was produced and distributed at a meeting if no paper or electronic copy of it could be found, either on Artelia’s systems or among the records or documents of any other party. Contrary to the assertions of Ms Williams that there is a gap in the minutes for February 2015,1358 there is none.1359 1349 Gibson {TMO00000887/19} page 19, paragraph 99. 1350 Gibson {TMO00000887/18} page 18, paragraphs 94-98; {TMO00842310/8} page 8, paragraph 23; Gibson {Day53/177:9-22}. 1351 Gibson {TMO00842310/8} page 8, paragraph 23. 1352 Williams {TMO00842312/15} page 15, paragraph 64; Williams {Day55/159:18}-{Day55/160:6}. 1353 Gibson {TMO00000887/19} page 19, paragraphs 101 and 103; Gibson {Day53/190:5-14}. 1354 Gibson {TMO00842310/8} page 8, paragraph 22; Gibson {Day53/180:15-18}. 1355 Williams {Day55/163:20}-{Day55/164:6}. 1356 Booth {ART00008527/52} page 52, paragraph 173; Lawrence {Day24/170:6-10}; {Day24/171:15-18}; Booth {Day50/77:4-11}. 1357 Booth {Day50/60:8-14}. 1358 Williams {Day55/175:6-8}. 1359 {ART00006769}, It is clear in the footer that Progress Meeting 8 was held on 13 February 2015. The body of the minutes erroneously record this as having been held on 20 January 2014, the date of Progress Meeting 7 {ART00006766}.

136 The Grenfell Tower Inquiry: Phase 2 Report 55.92 The matter does not end there, however. Ms Williams made no reference at all to any such assurance in her first statement; it was not until she made her second statement, produced after she had seen Mr Gibson’s statement,1360 that she first mentioned it.1361 Ms Williams said that she simply had not remembered the conversation with Mr Lawrence when she made her first statement,1362 but it is difficult to understand how such an important matter could have escaped her mind. Moreover, she said that she had not recalled Mr Lawrence’s assurance when she became aware of the fire on 14 June 2017.1363 Again, that is difficult to understand. If she had been told that ACM panels were inert and would not burn, that assurance would surely have come to mind as soon as she became aware of the disaster. 55.93 Finally, it is worth bearing in mind that Ms Williams sought an assurance of a similar kind in two emails sent on 12 November 2014. In the first,1364 she told Mr Booth that she wanted to ensure that the flame retardance of the ACM panels was raised. In the second, her “Lacknall moment” email to Mr Lawrence, she said that she was writing to get clarification on the fire retardance of the new cladding. If Mr Lawrence had already given her a clear assurance before 12 November 2014, we think it unlikely that either of those messages would have been sent, or, if sent for other reasons, that she would not have referred to it. If the assurance was given after 12 November 2014 (as Ms Williams and Mr Gibson suggested), we think that she would have recalled telling Simon Lawrence that she had asked for the same information some months before but had not received a response. In the light of all the evidence we do not accept that Mr Lawrence gave Mr Gibson and Ms Williams any assurance of the kind they described. 1360 Gibson {TMO00000887/19} page 19, paragraphs 99-103. 1361 Williams {TMO00842312/15} page 15, paragraphs 64-65; Williams {Day55/154:1-{Day55/155:8}; {Day55/163:13-15}. 1362 Williams {Day55/154:5-19}. 1363 Williams {Day55/155:9-17}. 1364 {ART00003042}.

137 Chapter 56 The choice of insulation 56.1 The purpose of adding insulation to a building is to keep it warmer in winter and cooler in summer. Laura Johnson, Head of RBKC’s Housing Department, accepted that at the end of 2011 there was no evidence that the thermal efficiency of Grenfell Tower was sufficiently poor to justify the investment in cladding; she thought, at least at the outset, that the primary rationale for cladding it was to improve its appearance.1365 Bruce Sounes thought that the modernisation of the heating system, the replacement of the windows and the addition of insulation were all integral to the refurbishment of the building, but he had not been involved in RBKC’s original decision.1366 56.2 Two insulating products were ultimately used in the construction of the external wall of Grenfell Tower, Celotex RS5000 (“RS5000”) and Kingspan Kooltherm K15 (“K15”).1367 RS5000 was a polyisocyanurate (“PIR”) rigid foam board insulation. K15 was a phenolic (“PUR”) rigid foam board insulation. Both were combustible, with a short time to ignition.1368 Neither RS5000 nor K15 met the limited combustibility guidance in paragraph 12.7 and table A7 of Approved Document B; and neither of them had been tested in accordance with BS 8414 in combination with the other materials intended for use on the tower. It follows that the system had not been shown to meet the criteria set out in BR 135. No alternative way of establishing compliance with the Building Regulations, e.g. by way of a desktop report or a holistic fire-engineered solution, had been followed. The use of those products was therefore contrary to official and industry1369 guidance and, as the Chairman found in his Phase 1 report, the external wall of the building as a whole, including the insulation, was combustible and did not adequately resist the spread of fire over the walls. The use of those materials was therefore a clear breach of functional requirement B4(1) of the Building Regulations. In this chapter we seek to explain how the insulation came to be chosen for use on the tower. The initial selection of Celotex FR5000: 2012–2014 56.3 Celotex FR5000 was the insulation product specified in the contract between the TMO and Rydon. It was specified by Studio E in the NBS Specification in November 2013,1370 which formed part of the Employer’s Requirements. However, the origins of that decision can be traced back to early in the previous year. 56.4 On 24 May 2012, there had been a design team meeting at which insulation was discussed, but only in very general terms.1371 Some consideration was given to installing insulation internally, rather than on the outside of the building,1372 but that option had 1365 Johnson {Day128/32:15}-{Day128/35:1}. 1366 Sounes {Day12/190:9-12}. 1367 See Grenfell Tower Inquiry Phase 1 Report, Volume I, Chapter 6 for a description of the construction of the external facade. 1368 Grenfell Tower Phase 1 Report, Volume I, Chapter 6, paragraph 6.20. 1369 For example, CWCT’s Technical Note 73, Fire Performance of curtain walls and rainscreens, dated March 2011 at {CWCT0000019/6}. 1370 {SEA00000169/73} final version of 30 January 2014: thermal insulation was specified at item 776. 1371 Minutes at {ART00000037}. In attendance at this meeting were various representatives of the TMO, Bill Watts of Max Fordham, and Bruce Sounes of Studio E. The minutes were circulated to James Lee of Exova. 1372 {ART00000037/2}.

The Grenfell Tower Inquiry: Phase 2 Report 138 been quickly rejected because it would have caused too much disruption to residents.1373 At that meeting Max Fordham was instructed to assist the design team in establishing environmental design criteria, including U-values, ventilation openings and other matters, in order to advance the design of the cladding.1374 U-value is a measure of the rate of heat transfer through a material or structure, measured in watts per square metre kelvin (W/m2K). The lower the U-value, the better the material or structure’s thermal efficiency; that is, the more it prevents heat loss in winter and heat gain in summer. Lambda value is a measurement of thermal conductivity of a material, measured in watts per metre kelvin (W/mK). The lower the lambda value of a material, the less is needed to achieve the desired U-value. Following the meeting, Bruce Sounes understood that Max Fordham was to provide the environmental design criteria, including the U-values.1375 56.5 On 18 June 2012, Matt Smith of Max Fordham sent an email to Bruce Sounes asking what U-value Studio E was seeking to achieve.1376 Andrew McQuatt of Max Fordham understood that Mr Smith had written that email to prompt Studio E to suggest its own U-value, assuming that Studio E as architect was designing the whole system and that Max Fordham did not have the power to specify any of the elements of the cladding. The email was intended to stimulate a dialogue with Studio E about the overall design, including the U-value.1377 In response, Mr Sounes instructed a colleague to send Max Fordham drawings of the likely build-up of the cladding system.1378 56.6 At a design team meeting on 25 June 2012,1379 Bill Watts of Max Fordham suggested a target U-value of 0.15 W/m2K for the walls of the tower.1380 That was ambitious. It was to become the target U-value for walls of new buildings in the Approved Documents published in 2013,1381 but in 2012 the Approved Documents required a U-value of 0.30 W/m2K only for walls of existing buildings with external insulation,1382 as was recorded in the minutes of the meeting.1383 Even greater latitude was provided in the Approved Documents, which stated that where a U-value of 0.30 W/m2K could not be achieved, the external wall should reach the best standard that was technically and functionally possible.1384 56.7 Max Fordham’s suggestion that the designers seek to achieve a U-value of 0.15 W/m2K was therefore twice the efficiency required by the statutory guidance for existing buildings. The purpose of doing so was, in summary, to ensure that the building would continue to perform well by future standards.1385 In addition, Max Fordham considered that, in principle, overcladding an existing high-rise building did not differ in principle from constructing a new one.1386 Another consideration was that the London Plan recommended reducing energy use by improving the fabric of the building first1387 and there was also 1373 McQuatt {Day42/35:17-21}. 1374 {ART00000037/2}. 1375 Sounes {Day12/192:21-24}; {Day12/193:4-6}; Sounes {SEA00014273/39} page 39, paragraph 81. 1376 {SEA00004737}. 1377 McQuatt {Day42/44:10}-{Day42/46:3}. 1378 {SEA00004737}. 1379 {ART00000096}. Attended by the TMO, Studio E and Max Fordham, among others. 1380 {ART00000096/2}. Another U-value was suggested for the windows. McQuatt {Day42/38:3-11}. 1381 {INQ00015203/39}. 1382 See Approved Document L 1B at {INQ00011283/20}, Table 3 and also Approved Document L 2B {INQ00015204/25} at Table 5. 1383 {ART00000096/2}. 1384 See Document L1B at {INQ00011283/20}, Section 5.9 and Document L2B at {INQ00015204/24} section 5.10. 1385 McQuatt {Day42/39:10-16}; {Day42/41:9-19}. See also {MAX00000412/6}. at table 2.1. 1386 McQuatt {Day42/38:12-21}; {Day42/39:6-16}. 1387 McQuatt {Day42/39:17-25}.

Part 6 | Chapter 56: The choice of insulation 139 a widespread recognition in the industry of the importance of improving the fabric of buildings. Accordingly, it was environmental considerations, including energy efficiency, that lay at the heart of the U-value that was chosen.1388 56.8 When he came to work on the project, Andrew McQuatt checked that the U-values suggested by Max Fordham were consistent with Approved Document L. He understood that if the target was not achievable, it was permissible to depart from it to a U-value that was technically and functionally feasible.1389 Max Fordham did not think that the U-value it had suggested was unduly ambitious.1390 Bruce Sounes also shared that view,1391 and realised that Max Fordham was seeking to match the statutory guidance relating to new buildings.1392 Neither Max Fordham nor Studio E checked the proposed U-value against the fire safety guidance in Approved Document B to see whether a higher U-value would have to be accepted in order to comply with the guidance on insulation contained in paragraph 12.7.1393 56.9 Following Max Fordham’s suggestion, Bruce Sounes carried out some research into insulation products. On 5 July 2012, he asked Rockwool1394 to advise which mineral wool insulation product it would be appropriate to use within an external cladding system and what thickness would be required to achieve a U-value of 0.15 W/m2K.1395 Mr Sounes sent an email to Andrew McQuatt and Matt Smith telling them that he had sent enquiries about insulation to both Rockwool and Kingspan,1396 attaching a spreadsheet with some calculations. At that point, neither Studio E nor Max Fordham had given any consideration to using a Celotex product, or indeed any polymeric material. 56.10 The spreadsheet contained an analysis of the thickness of mineral wool that would be required to achieve a U-value of 0.15 W/m2K.1397 Mr Sounes had carried out that analysis himself using various thicknesses of one of Rockwool’s products, “Rainscreen Duo Slab”. For each thickness of the product, he derived the corresponding U-value by extrapolation from the information in the datasheet. He calculated that 325mm of Duo Slab would achieve a U-value of only 0.20 W/m2K.1398 He concluded that to achieve a U-value of 0.15 W/m2K about 450mm of Duo Slab would be required.1399 It was on that basis that he said in his email to Max Fordham that the target U-value of 0.15 W/m2K looked to him “a bit aspirational” and he questioned whether it would be feasible to use Rockwool, given the thicknesses apparently required to achieve it.1400 Mr Sounes did not ask Max Fordham or anyone else to check his calculations1401 and he did not check Approved Document L to see what U-value the guidance required.1402 1388 McQuatt {Day42/40:1-9}. 1389 McQuatt {Day42/8:4-8}; {Day42/10:15-20}; {INQ00011283/20}; Bruce Sounes was not aware that Approved Document L provided that flexibility. Sounes {Day20/10:18}-{Day20/11:3}. 1390 McQuatt {Day42/40:12-21}. 1391 Sounes {Day20/33:13-15}. 1392 Sounes {Day20/9:21}-{Day20/10:17}; {Day20/18:4-9}. 1393 McQuatt {Day42/47:21}-{Day41/48:7}. 1394 Rockwool is a company manufacturing a range of mineral or stone wool insulation products for use in external cladding systems, among other applications. According to the CWCT in Technical Guidance Note 73 dated March 2011, mineral wool was the only insulation product which would satisfy the definition of “limited combustibility” in Approved Document B (see Chapter 49). 1395 {SEA00004967}. 1396 {SEA00004973}. 1397 {SEA00001334}. 1398 Sounes {Day20/15:17-22}. 1399 {SEA00004973}; {SEA00004974}. 1400 {SEA00004973}. 1401 Sounes {Day20/25:4-9} and McQuatt {Day42/65:9-14}. 1402 Sounes {Day20/9:11-20}.

The Grenfell Tower Inquiry: Phase 2 Report 140 56.11 In the light of his calculations Mr Sounes might have been expected to consider whether he should abandon the proposed U-value 0.15 W/m2K in favour of a higher value that might be easier to achieve, but he does not appear to have done so. He did not think that “aspirational” meant irresponsible; it just meant trying to do the best you can.1403 He said that Max Fordham had prided itself on being an aspirational engineer and that Studio E had followed it. He had seen no reason to abandon a U-value of 0.15 W/m2K and thought that it had been in the project’s interest to try to achieve it.1404 56.12 In his email of 5 July 2012, Bruce Sounes had referred to Max Fordham’s having “asked for” a target U-value of 0.15 W/m2K. Mr Sounes said in evidence that in the past Studio E had looked to Max Fordham to propose U-values and he was doing the same in connection with the Grenfell Tower project.1405 It was part of Max Fordham’s role, as set out in its fee proposal, to help the architect to comply with the energy efficiency requirements in Part L of the Building Regulations.1406 56.13 In our view, although Max Fordham did first suggest a target U-value of 0.15 W/m2K for the external walls in its capacity as the building services engineer,1407 it was Studio E’s responsibility, as lead consultant and lead designer, to assess the feasibility of that U-value in the context of its initial design of the cladding system. Max Fordham did not “ask for” that U-value or specify it in such a way as to oblige the design team, including Studio E, to accept it without question. A reasonably competent lead consultant and lead designer would not have considered itself limited in any way in its selection of materials or the design of the cladding system by suggestions made by the M & E consultant. Mr Sounes accepted as much,1408 and rightly so. The services to be provided by Studio E included co-ordinating the design of all constructional elements, including work by consultants, specialists or suppliers, and determining materials, elements and components, standards of workmanship, type of construction and performance in use.1409 It was Studio E’s responsibility as architect and lead designer to decide what U-value was feasible and appropriate. 56.14 Matt Smith replied to Bruce Sounes on 5 July 2012, probably after having discussed the matter with Andrew McQuatt.1410 He had done a quick calculation using the lambda value for the Rockwool product and the thicknesses proposed by Mr Sounes. It was his view that the thicknesses of Rockwool calculated by Mr Sounes were too great and he questioned whether Mr Sounes had taken thermal bridging1411 into account.1412 Matt Smith’s calculation did not include any thermal bridging considerations, because Max Fordham did not have any more specific details of the design of the cladding to enable him to do so.1413 It was Andrew McQuatt’s own view that Mr Sounes’ analysis may have been based on rather pessimistic assumptions.1414 1403 Sounes {Day20/17:24}-{Day20/18:1}. 1404 Sounes {Day20/27:9-23}. The target U-value was never rejected by Studio E as being unachievable. Sounes {Day20/4:20-21}; {Day20/16:24-25}. 1405 Sounes {Day20/3:23}-{Day20/4:1}; {Day20/17:20-22}. 1406 {MAX00000075}. 1407 McQuatt {Day42/44:4-9}. 1408 Sounes {Day20/17:15-18}. 1409 Appendix B: Schedule of Services {SEA00009824/7}. 1410 McQuatt {Day42/66:3-8}; {SEA00004978}. 1411 A thermal bridge is an area or component of an object which has higher thermal conductivity than the surrounding materials, creating a path of least resistance for the transfer of heat. 1412 {SEA00004978}. 1413 McQuatt {Day42/68:22}-{Day42/69:6}. 1414 McQuatt {Day42/69:15}-{Day42/70:7}.

Part 6 | Chapter 56: The choice of insulation 141 56.15 In the same email Matt Smith referred to a “glass fibre slab” product.1415 It is not clear whether that was a mistake,1416 but in any event, Andrew McQuatt said that both the mineral wool and glass fibre products were flexible and had similar lambda values, so the calculation he provided was reasonable despite any potential confusion between the two products.1417 56.16 Andrew McQuatt thought at this point that the U-value might need to be changed, given that Studio E considered that the necessary thickness of mineral wool could not be accommodated. However, he knew that the Kingspan rigid insulation board would be a thinner product and thought that it would be appropriate to wait to see what Kingspan said in response to Bruce Sounes’ email of 5 July 2012 before commenting further.1418 56.17 On 6 July 2012 Bruce Sounes sent an email to Matt Smith to tell him that Kingspan had recommended 200mm of its phenolic foam product to achieve the required U-value.1419 He also attached to his email a product datasheet for a mineral wool insulation manufactured by Superglass Insulation Ltd called “Cladding Mat 37”,1420 but that was rejected because it was thought that too great a thickness would be required.1421 56.18 On 24 July 2012, Ian Pritchard of Rockwool responded to Bruce Sounes’ email of 5 July 2012. He said that they would normally recommend the use of Rainscreen Duo Slab for the type of construction that Mr Sounes had in mind, but that due to the low U-value required the thickness needed would be exceptionally high, probably beyond the point of sensible building practice.1422 Bruce Sounes forwarded Rockwool’s email to Matt Smith and Andrew McQuatt, drawing attention to his concerns about buildability and appearance if mineral wool were used.1423 He did not ask Max Fordham to obtain from Rockwool a formal calculation of the thickness of material required, so apart from Matt Smith’s “quick calculation” no attempt was made at any stage to determine precisely what thickness of mineral wool would be required to achieve a U-value of 0.15 W/m2K. 56.19 Andrew McQuatt understood the email from Mr Sounes to mean that he had decided that the maximum thickness for the insulation should be 200mm.1424 He thought that Mr Sounes’ calculations formed part of a bigger picture; he did not question it because he assumed that Studio E had chosen it as the best thickness for a wide range of reasons.1425 56.20 There was never any serious discussion about increasing the U-value to something greater than 0.15 W/m2K,1426 and Studio E did not raise the possibility of doing so with Max Fordham.1427 According to Andrew McQuatt, the design team remained confident that a reasonable technical solution to the problem could be found, so there was never any resistance to adopting the ambitious U-value.1428 1415 {SEA00004978}. 1416 McQuatt {Day42/67:4-6}. 1417 McQuatt {Day42/67:11-23}. 1418 McQuatt {Day42/49:15}-{Day42/50:9}. 1419 {SEA00004986}. The calculations by Kingspan can be found at {MAX00000104}. 1420 {SEA00001337}. Cladding Mat 37 is a form of mineral wool insulation, marketed as an A1 non-combustible product. 1421 McQuatt {Day42/80:10-20}. Bruce Sounes did not consider the fire performance of that product. Sounes {Day20/36:2-6}. 1422 {SEA00005276/2}. 1423 {SEA00005276}. Neil Crawford could not recall any discussion about the use of a mineral wool product in the external wall facade but had understood that the thickness of the product required would have been impractical. He thought he got that understanding from Bruce Sounes. Crawford {Day10/67:12-21}. 1424 McQuatt {Day42/60:17-20}. 1425 McQuatt {Day42/61:5-9}. 1426 McQuatt {Day42/43:6}-{Day42/44:3}. 1427 Sounes {Day20/33:17-25}. 1428 McQuatt {Day42/43:19-23}.

The Grenfell Tower Inquiry: Phase 2 Report 142 56.21 Bruce Sounes sent another email to Andrew McQuatt on 15 August 2012 asking for his help in calculating the thickness of insulation required to achieve the target U-value.1429 He attached to his email a further calculation of the thickness of mineral wool insulation required.1430 The exchange occurred just before a report was to be made to the Planning Department in which the proposed U-value would be disclosed, so it was important to make sure the external wall could be built to produce that U-value. Mr Sounes was concerned whether the proposed U-value could be achieved over all the different elements of the wall.1431 56.22 On either 15 or 16 August 2012, there was a telephone conversation between Andrew McQuatt and Bruce Sounes during which Mr McQuatt attempted to answer Mr Sounes’ concern. He undertook to do some calculations based on the different areas of the building in order to determine whether the target U-value could be achieved on average across the building as a whole and to establish the thickness of insulation required to achieve the target U-value overall.1432 56.23 On 16 August 2012 Andrew McQuatt sent Mr Sounes his calculations1433 and attached the product datasheet for Celotex FR5000.1434 In order to do his U-value calculation, Mr McQuatt had needed to use the lambda value of an insulation product. In his mind there was little difference between the rigid board insulation products marketed by Kingspan and those sold by Celotex, so he went to the Celotex website and looked at a datasheet for a solid insulation board, FR5000. He obtained the lambda value from the datasheet and sent it to Mr Sounes so that he could see the source of the information he had used.1435 He thought that Celotex FR5000 was the only type of product that would provide the required thermal performance at a thickness that could realistically be accommodated.1436 56.24 Celotex FR5000 was a polyisocyanurate (PIR) product. The datasheet1437 made no reference to its being suitable for use as part of a cladding system nor did it state that it was suitable for use on buildings with a storey above 18 metres in height. It did not say that FR5000 was a product of limited combustibility, but it did say that it had Class 0 fire performance throughout the entire product in accordance with BS 476. 56.25 Andrew McQuatt did not give any thought to the fire performance of Celotex FR5000 before he sent his email to Bruce Sounes on 16 August 2012.1438 Mr Sounes had suggested both the Rockwool product and the Kingspan product and Mr McQuatt thought that the use of Kingspan had already been established.1439 Since Studio E had proposed a Kingspan product as an option from the outset, he had thought there was nothing wrong with using 1429 {SEA00005818}. 1430 {MAX00000214}. 1431 McQuatt {Day42/53:7-22}. 1432 McQuatt {Day42/81:21}-{Day42/82:12}. 1433 {SEA00005840}. 1434 {SEA00005841}. Issue 2, January 2012. 1435 McQuatt {Day42/82:13}-{Day42/82:17}. 1436 {SEA00005840}. When Andrew McQuatt said in this email of 16 August 2012 that Celotex FR5000 was “the only type of product that will give us the required performance”, he had in mind the lambda value of the product and that, at least in his mind, FR5000 was interchangeable with a rigid insulation board marketed by Kingspan. McQuatt {Day42/85:3-9}. 1437 {SEA00005841} Issue 2, January 2012. 1438 McQuatt {Day42/86:20}-{Day42/87:18}. 1439 McQuatt {Day42/85:3-9}.

Part 6 | Chapter 56: The choice of insulation 143 it or, by extension, Celotex FR5000.1440 He accepted that he would have been just as likely to put forward the Kingspan product if he had obtained the lambda value of one of their foam boards instead of a Celotex product.1441 56.26 At the time, Andrew McQuatt was not aware of the guidance given in Approved Document B about insulation materials and their combustibility, nor could he recall with any certainty having heard the expression Class 0.1442 He was not aware of industry guidance on the construction of external walls and insulation materials and had never had cause to look at the guidance published by the Centre for Window and Cladding Technology (CWCT).1443 He was aware that there were different types of insulation and he knew that Kingspan produced a solid board rather than a mineral wool product, but that was really the extent of his knowledge.1444 No one had suggested to him that phenolic or PIR foam insulation boards were not appropriate for use in the external walls of buildings above 18 metres in height.1445 56.27 The suggestion made by Andrew McQuatt in his email of 16 August 2012 that a PIR insulation product might be used did not give Bruce Sounes any cause for concern. He told us that PIR and phenolic insulation boards had become all but standard by that time1446 and that PIR products were widely used in the industry, which reassured him about their suitability.1447 Mr Sounes thought that Celotex FR5000 was suitable for use as part of the cladding system partly because it had been used in the past by Max Fordham in what he had understood to be similar circumstances, but he took no steps to find out whether Max Fordham had ever used FR5000 in the past in the external wall of a building over 18 metres in height. He could not recall having read the datasheet for Celotex FR5000 when he was working on the project, nor did he recall noting at the time that it was rated Class 0,1448 but if he had been aware of that it would have served only to increase his confidence in its use, because he understood that if a product was rated Class 0 it was, as he put it, “not hazardous”.1449 Mr McQuatt did not realise that Studio E had understood his email of 16 August 2012 as a tacit endorsement of the safety of FR5000 for use on the building,1450 but there is no reason why he should have done so, given that his expertise did not extend to fire safety and he had not been consulted about that. 56.28 Mr McQuatt wrote a Sustainability and Energy Statement in respect of the project dated 17 August 2012,1451 which made it clear that the recommended U-value far exceeded that required by the Building Regulations.1452 At Tables 2.2 and 2.3 of the report, Celotex FR5000 was identified as the insulation for the spandrels and columns.1453 When he received it, Bruce Sounes did not pause to consider whether mineral wool could be used to produce a U-value which, although higher, still complied with the regulations. 1440 McQuatt {Day42/61:18-22}. 1441 McQuatt {Day42/86:2-7}. 1442 McQuatt {Day42/18:8}-{Day42/19:12}. 1443 McQuatt {Day42/21:20}-{Day42/22:4}. 1444 McQuatt {Day42/51:9-16}. 1445 McQuatt {Day42/91:25}-{Day42/92:4}. 1446 Sounes {Day20/39:2-3}. 1447 Sounes {Day20/40:8-15}. Bruce Sounes said that every project that he had worked on involved some form of foam board in the facade, but he confirmed that those other projects had involved low-rise buildings. Sounes {Day20/39:6-14}. He said he thought he had been aware that PIR insulation had been used on high-rise buildings. Sounes {Day20/50:11-15}. 1448 Sounes {Day12/178:4-7}; {Day12/183:14-17}. 1449 Sounes {Day12/183:6-13}. 1450 McQuatt {Day42/84:19-23}; {Day12/181:12-23}. 1451 {MAX00000412/6}. 1452 {MAX00000412/6} at Table 2.1. 1453 {MAX00000412/6}.

The Grenfell Tower Inquiry: Phase 2 Report 144 56.29 On 10 October 2012, Max Fordham issued its RIBA Stage C report.1454 Andrew McQuatt drafted most of it, with a contribution from Matt Smith.1455 The information contained in the Sustainability and Energy Statement was repeated on page 12 of the report.1456 Mr McQuatt explained that FR5000 had been referred to in the Stage C report solely because it delivered the U-value required at the thickness sought.1457 He said that detailed information had been included in the report so that readers could see how the thermal conductivity value had been achieved for the insulation. If for any reason FR5000 had not been used, the technical details were available to enable a substitution to be made.1458 He did not see it as his role to influence the design team’s decision about the materials to be selected.1459 Max Fordham’s Stage C report makes no reference to fire safety because its practice was to advise on questions of fire safety only to the extent that they affected the work that the building services engineer was specifying.1460 We therefore infer that, as Max Fordham was not responsible for choosing the insulation, it did not regard itself as responsible for giving advice in the Stage C report about its use, whether in relation to fire safety or otherwise. 56.30 Studio E issued its own RIBA Stage C report on 31 October 2012.1461 It incorporated Max Fordham’s Stage C report and referred to Celotex FR5000 as the chosen insulation.1462 Before issuing the report, Bruce Sounes did not ask Exova or Max Fordham or any other specialists to advise on the suitability of using Celotex FR5000 in the cladding system or whether its use would comply with the Building Regulations. 56.31 In January 2013, Adrian Jess1463 sent a draft of Studio E’s Stage D report to Leadbitter, which at that stage was expected to become the principal contractor for the project. It showed EPS (expanded polystyrene) insulation at the lower levels of the tower behind rainscreen panels.1464 On 21 January 2013 Juan Medina, Framework Design manager for Leadbitter, sent Mr Jess an email asking whether Studio E had checked with building control whether EPS insulation could be used on a tower of that kind. Mr Medina understood that EPS was a combustible material and was not allowed as part of a rainscreen cladding system. He suggested that phenolic insulation should be used instead.1465 The email was copied to Studio E and is therefore likely to have been seen by those at Studio E who were working on the project, including Bruce Sounes. Although the discussion concerned the lower levels of the tower, it shows that Studio E was on notice from January 2013 that building control might not allow combustible insulation to be used in a rainscreen cladding system. That warning by Leadbitter ought to have prompted Studio E to pay close attention to the fire performance of the insulation materials that it had proposed for the project. However, from the documents available to the Inquiry, it does not appear that the warning resulted in any discussion of that kind within Studio E. 1454 {MAX00000636}. 1455 McQuatt {Day42/92:5-12}. 1456 {MAX00000636/12}. 1457 McQuatt {Day42/95:10-17}. 1458 McQuatt {Day41/92:18}-{Day41/93:11}. 1459 McQuatt {Day42/93:13}-{Day42/94:1}. Andrew McQuatt could not recall whether a final decision had been taken to use FR5000. 1460 McQuatt {Day42/94:16-25}. 1461 {ART00008396}; {MAX00000445}. 1462 {MAX00000445/82}. 1463 Sounes {SEA00014273/59} page 59, paragraph 124. 1464 {MET00081283/11} under Item P10. 1465 {MET00081282}.

Part 6 | Chapter 56: The choice of insulation 145 56.32 Studio E issued its final Stage D report on 20 August 2013,1466 which proposed the use of Celotex FR5000.1467 Between issue of its Stage C and Stage D reports there were no communications between Studio E, Max Fordham, Exova, or any other specialist about the safety of using FR5000 product or how it reacted to fire.1468 56.33 On 25 October 2013, Tomas Rek commented in an internal email to Bruce Sounes that Max Fordham’s U-values were “OTT”, i.e. excessive.1469 Tomas Rek thought he had had a discussion with Mr Sounes about it, but he could not recall what Mr Sounes had said.1470 Bruce Sounes did not remember any discussion of that kind.1471 In any event, no further attempts were taken by Mr Rek to address his concerns.1472 Mr Sounes thus missed the opportunity properly to understand Mr Rek’s concerns about the U-values and to check with Max Fordham whether they needed to be quite so ambitious. The Hays Galleria meeting: insulation 56.34 As we have found when describing the discussions about the choice of cladding material, on 27 September 2013 Bruce Sounes and Tomas Rek met Ray Bailey and Mark Harris of Harley at a coffee shop in Hays Galleria in south London.1473 As well as discussing the rainscreen, they also discussed the insulation for Grenfell Tower. What was said on that matter was the subject of differing recollections and the evidence about it requires detailed consideration. 56.35 Ray Bailey said that Studio E had given Harley calculations relating to U-values in advance of the meeting, from which he had seen that it intended to specify a PIR insulation product.1474 In his witness statement, Bruce Sounes said that at the time of the meeting he had had a lingering uncertainty about the fire safety of PIR because he was dealing with a high-rise building and had not worked on one before. He thought he had asked Ray Bailey about the acceptability of using a rigid foam insulation on such a building, but did not remember having received a clear response.1475 56.36 Bruce Sounes said that insulation had been discussed in general as part of the assembly of the facade1476 and that he might not have mentioned that he had Celotex in mind.1477 Mr Sounes said that his doubt about the acceptability of a rigid foam insulation product was an afterthought and that he had not had a serious concern.1478 Indeed, he said that he had not raised the question with Exova because it was not a genuine concern.1479 56.37 Bruce Sounes recalled that during the meeting he had looked at photographs of Ferrier Point under construction, in which the mineral wool insulation used in the external wall was visible. It was that, as he recalled it, which prompted him to question the use of 1466 {MAX00000757}. 1467 {MAX00000757/29}. 1468 Bruce Sounes could not recall whether he had asked building control about the acceptability of using a PIR product in a high-rise building. Sounes {Day20/51:1-18}. 1469 {SEA00014346/2}; {SEA00014346/2}; Rek {Day12/137:2-17}. 1470 Rek {Day12/138:24}-{Day12/140:7}. 1471 Sounes {Day20/33:3-10}. 1472 Andrew McQuatt said in his evidence that no one had ever referred to the target U-value as “over the top” to him. McQuatt {Day42/57:22}-{Day42/58:16}. 1473 Near London Bridge station. The purpose of the meeting was to discuss the lay concept design drawings for the refurbishment. Ray Bailey {HAR00010184/20} page 20, paragraph 77. 1474 Ray Bailey {Day32/149:21-25}; {Day32/150:1-22}. 1475 Sounes {SEA00014273/114} page 114, paragraph 271. Repeated in his oral evidence Sounes {Day20/49:9-12}. 1476 Sounes {Day20/47:3-9}. 1477 Sounes {Day20/46:24-25}; {Day20/47:1-5}. 1478 Sounes {Day20/50:3-4}. 1479 Sounes {Day20/50:17-22}.

The Grenfell Tower Inquiry: Phase 2 Report 146 rigid foam board insulation.1480 Ray Bailey said that before the meeting Mark Harris had sent Studio E some photographs of buildings that Harley had previously worked on1481 and agreed that it was possible that those or some similar photographs had been discussed at the meeting.1482 However, he could not recall discussing whether the insulation proposed for use on Grenfell Tower was mineral wool or rigid foam, in contrast to that used on Ferrier Point.1483 Mark Harris said that he did not recall having shown photographs at the meeting, but that it would not be unusual to do so and might have happened.1484 56.38 There is nothing in the documents to indicate that Bruce Sounes questioned the use of PIR insulation during the meeting.1485 Tomas Rek did not recall Bruce Sounes raising the matter with him1486 and he could not recall whether the suitability of PIR or rigid foam insulation had been discussed during the meeting.1487 Mr Rek could not recall any discussions about fire safety or performance of the insulation during the meeting.1488 56.39 Neither Ray Bailey nor Mark Harris had any recollection of Bruce Sounes asking about the acceptability of using rigid foam products on high-rise buildings.1489, 1490 Ray Bailey said that the question would have struck him as odd, because PIR was a product Harley had not used on a high-rise building at that stage.1491 It was Ray Bailey’s impression at the time that there was no flexibility in the choice of insulation and that FR5000 had already been selected.1492 Ray Bailey said that no one at Studio E or Harley had asked him about the suitability of the Celotex insulation or whether its use complied with the Building Regulations.1493 56.40 There is little doubt that photographs of Ferrier Point were shown and discussed at the meeting and it is likely that there was some comment about the use of a mineral wool insulation on that building. We think it unlikely, however, that Bruce Sounes asked whether rigid foam insulation was acceptable for use on Grenfell Tower. If it had been sufficiently important in his mind for him to have done so, it is likely that Ray Bailey would have made some response and that he would have remembered what it was. It is also likely that there would have been some reference to it in the contemporaneous documents. Asking about the safety of PIR would not have been consistent with Mr Sounes’ understanding of its suitability in general or with his lack of curiosity about the fire safety of the products he proposed to use in the cladding system. 1480 Sounes {Day20/47:10-15}; {Day20/50:22}-{Day20/51:1}. The photographs at {SEA00003497} and {SEA00003516} are similar to those shown by Ray Bailey to Bruce Sounes at the Hays Galleria meeting, although Bruce Sounes could not be sure that he was shown those particular photographs. Sounes {Day20/51:12-25}. 1481 Ray Bailey {Day32/152:2-6}. 1482 Ray Bailey {Day32/152:10-18}. 1483 Ray Bailey {Day32/152:23}-{Day32/153:1}. 1484 Harris {Day34/56:8-21}. 1485 {ART00001487}. Mr Sounes emailed various parties at Artelia, TMO and Max Fordham with a summary of the matters discussed at the Hays Galleria meeting. Mr Sounes’ remarks that Harley “pointed to Ferrier Point as being very similar to Grenfell, although it is triple glazed and super insulated”. Aside from this there is no reference to any discussion regarding the insulation. 1486 Rek {Day12/135:14-16}. 1487 Rek {SEA00014278/10} page 10, paragraph 29. 1488 Rek {Day12/133:7-18}. 1489 Ray Bailey {Day32/149:14-17}; {Day32/151:23}-{Day32/152:6}. 1490 Harris {Day34/54:14-17}; {Day34/55:5-7}; {Day34/56:4-7}. 1491 Ray Bailey {Day32/149:19}-{Day32/150:22}; Ray Bailey {Day32/153:7-16}. 1492 Ray Bailey {Day32/153:7-16}. 1493 Ray Bailey {Day32/153:2-6}.

Part 6 | Chapter 56: The choice of insulation 147 Celotex FR5000 in the NBS Specification 56.41 Studio E produced three versions of the NBS Specification for the project dated 21 November 2013,1494 29 November 20131495 and 30 January 2014 respectively.1496 56.42 Studio E started work on the Employer’s Requirements, including the proposed NBS Specification, early in 2013.1497 The NBS Specification was prepared largely by Tomas Rek at Bruce Sounes’ direction and subject to his oversight, Adrian Jess having already done some initial work1498 before he was made redundant in March 2013. By September 2013 the project had been developed to Stage D (the Stage D report was dated 20 August 2013). Tomas Rek was told to use Studio E’s Stage D report and drawings to draw up the NBS specification and Mr Sounes gave him additional information as required.1499 56.43 In the case of the insulation to be applied to the external concrete walls Studio E made a proprietary specification; in other words, in all three versions of the NBS Specification Celotex FR5000 was specified as the product to be used.1500 However, that was subject to the qualification that the product could be substituted by a similar or equal alternative.1501 The contract preliminaries provided that if a contractor wished to suggest an alternative product it was required to provide reasons for that substitution to the client.1502 The NBS Specification was not unusually prescriptive and was no more detailed or prescriptive than specifications commonly written by Studio E.1503 56.44 Before specifying the product, neither Tomas Rek nor Bruce Sounes had investigated whether the use of Celotex FR5000 on a building above 18 metres in height complied with either the Building Regulations or the guidance contained in Approved Document B. Mr Sounes had not asked Max Fordham that question and he did not revisit it when overseeing the writing of the NBS Specification.1504 Similarly, Mr Sounes did not seek advice from Exova about the suitability of FR5000 for use in the refurbishment before the NBS Specification was prepared.1505 56.45 Bruce Sounes said that Studio E would not usually seek to satisfy itself that all materials and products complied with the regulatory requirements before submitting a full plans application to building control.1506 In his view it would be a waste of time to do so, because the contractor under a design and build contract might subsequently propose a change or building control might take a different view of their suitability.1507 He said it was not common practice to do a full assessment of the suitability of products at RIBA Stages D or E.1508 Mr Sounes did tell us, however, that before the submission of the full plans 1494 {SEA00000152}. 1495 {SEA00000153}. This was the version issued to tenderers. 1496 {SEA00000169}. 1497 Sounes {Day7/150:18-25}. 1498 Rek {SEA00014278/5} page 5; Rek {Day12/10:22}-{Day12/11:1}. Work had already begun on the NBS specification. Rek {Day12/12:7-13}. 1499 Rek {Day12/10:22}-{Day12/11:1}; {Day12/15:1-9}. 1500 See the “thermal insulation” section within section H92 at item 776. In the final version {SEA00000169/73}; Sounes {Day7/162:1-9}. 1501 {SEA00000169/64}. 1502 Clause 2.2.2 {RYD00094235/64}. 1503 Sounes {Day7/168:10-19}. 1504 Sounes {Day20/42:6-11}. 1505 Sounes {Day20/42:12}-{Day20/43:6}. Bruce Sounes said that he understood Adrian Jess and Tomas Rek to have had independent discussions with Exova, but he was not aware of their content. He said that he could not recall himself raising the use and suitability of FR5000 with CEP. Sounes {Day20/43:16-19}. 1506 Sounes {SEA00014273/121} page 121. 1507 Sounes {Day20/64:21-24}; {Day20/65:5-8}. 1508 Sounes {Day20/65:1-3}.

The Grenfell Tower Inquiry: Phase 2 Report 148 application to building control in August 2014, he had been reasonably confident that the materials specified in it complied with the Building Regulations and Approved Document B, because all the products had (as he believed) been used before in similar circumstances, either by Studio E itself or others.1509 However, the steps he had taken to investigate precisely what had been used and in what circumstances were negligible. 56.46 Following the submission of the full plans application to building control there was no subsequent occasion on which Studio E would check whether the materials complied with the Building Regulations. Mr Sounes said that, because this was a design and build project, once the contract had been awarded the architect was, as he put it, “sidelined” so that Studio E was not policing what other people were doing.1510 That, however, ignores the role played by Studio E after it had been engaged by Rydon. For the reasons we have explained below and in Chapter 63, it should have given further consideration to whether the insulation complied with the Building Regulations, but failed to do so. 56.47 At the time he prepared the NBS Specification, Tomas Rek did not know that the fire performance of each of the components of the cladding would need to be considered.1511 He had a general awareness of functional requirements B3 and B4, having come across them on a previous project1512 which had required one part of the facade to be Class 0.1513 In that context he had also had to consider diagram 40.1514 It was Mr Rek’s understanding that Class 0 was concerned with the external spread of flame and that if a material had that classification it would not encourage the spread of flame.1515 However, it became clear during his oral evidence that his knowledge of Approved Document B was very limited. He was not familiar with the various different routes to compliance described in paragraph 12.5 of Approved Document B,1516 or the definition of what would constitute a material of limited combustibility,1517 or the guidance in paragraph 12.7.1518 He could not recall having checked the requirements for external walls contained in Approved Document B when drawing up the specification.1519 Nor could he recall talking to anyone at Studio E about which route to compliance with the Building Regulations it had taken in respect of the refurbishment of the external wall.1520 56.48 The insulation to be used as part of the cladding was specified in clause H92/776 of the NBS Specification. Within section H92/776 of the RIBA software in use at the time for compiling an NBS Specification, the details were left blank for completion. Upon selecting clause H92/776, two tabs would appear: tab G, “Guidance” and tab H, “Manufacturers”. Under tab H there is a list of manufacturers available for selection derived from the NBS Plus database.1521 At the time of drawing up the specification for the thermal insulation in November 2013, four manufacturers appeared in tab H: Kingspan with its K15 Kooltherm product, Knauf, Rockwool and Siderise.1522 No Celotex product was listed under tab H. 1509 Sounes {Day20/67:5}-{Day20/68:11}. 1510 Sounes {Day20/71:3-14}. 1511 Rek {Day12/24:16-21}. 1512 Rek {Day12/16:7-23}. 1513 Rek {Day12/17:1-4}. 1514 Rek {Day12/25:24}-{Day12/26:11}. 1515 Rek {Day12/18:9-15}. 1516 Rek {Day12/20:15-20}. 1517 Rek {Day12/42:6-19}. 1518 Rek {Day12/26:20}-{Day12/27:21}. 1519 Rek {Day12/44:10-19}; Rek {Day12/45:16-20}. 1520 Rek {Day12/22:17-23}. Mr Rek did not himself give any consideration to that question. {Day12/22:25} – {Day12/23:2}. He did not know whether the proposed cladding system had been tested to BS 8414 and met the criteria in BR 135 criteria or if a fire engineer’s report had been obtained. {Day12/27:23}-{Day12/28:9}. 1521 {INQ00011333}. 1522 {INQ00011366}.

Part 6 | Chapter 56: The choice of insulation 149 Accordingly, in order to specify Celotex FR5000 it was necessary for the writer to enter the product manually. When Celotex FR5000 was manually entered under clause H92/776 a message appeared informing the compiler that that product had been authorised for an alternative clause, clause P10.1523 Clause P10 was the section covering insulation fitted between rafters.1524 It would therefore require a conscious decision to enter FR5000 under that section of the NBS Specification despite the warning. 56.49 Tomas Rek could not recall having seen that message but could recall having seen a similar notice when trying to alter clauses which were pre-filled.1525 He could not, however, recall being informed that the insulation that was being specified in clause H92/776 was identified by the software as suitable for a different application.1526 56.50 When a person drawing up the specification for clause H92/776 clicked on the drop- down box next to the entry for “Manufacturer”, the software would prompt him to select “mineral wool to BS EN 13162” as the only option and then provide a list of four manufacturers.1527 If the writer did not wish to select a mineral wool product, that entry would have to be manually overridden.1528 That is what happened here. Mineral wool was manually overridden and Celotex FR5000 was manually typed in at clause H92/776 of the NBS Specification. 56.51 Although he was responsible for drawing up most of the NBS Specification, Tomas Rek could not recall whether he himself had entered FR5000 or whether it had already been in the specification when he came to the project. He said that if he had entered that product he had derived that requirement from Studio E’s Stage D report and probably Max Fordham’s Stage C report.1529 Mr Rek thought he would have spoken to Bruce Sounes about the specification of products.1530 He said that he had assumed that the design of the cladding and the choice of materials had been considered by Studio E before he had started work on the project.1531 Mr Rek did not recall any discussion with Bruce Sounes about the reasons for choosing FR5000 for use in the cladding system,1532 nor could he recall considering whether FR5000 was combustible or non-combustible.1533 He did not consult any of the product information about FR50001534 and did not discuss its fire performance with anyone else at Studio E.1535 He did not seek any assistance or advice about whether he should override the software and manually enter FR5000. 56.52 Clauses H92/220 and H92/310 of the NBS Specification stipulated that the contractor was to comply with CWCT Standard for Systemised Building Envelopes, including Part 6, which related to fire performance.1536 It is not clear whether Mr Rek put that requirement into the NBS Specification, but he remembered having thought that it should be included.1537 1523 {INQ00011342}. 1524 {INQ00011341}. 1525 Rek {Day12/122:9-15}; {Day12/123:1-12}. 1526 Rek {Day12/123:17-21}. 1527 {INQ00011351}. 1528 Rek {Day12/127:3-8}. 1529 Rek {Day12/118:10}-{Day12/119:12}; {Day12/125:1-14}. 1530 Rek {Day12/130:20-25}. 1531 Rek {Day12/44:22}-{Day24/45:1}. 1532 Rek {Day12/135:17-20}. 1533 Rek {Day12/124:10-13}. 1534 Rek {Day12/131:14-25}. 1535 Rek {Day12/134:11-13}. 1536 {SEA00000169/68-69}. 1537 Rek {SEA00014278/33} page 33; Rek {Day12/34:18}-{Day12/35:2}.

The Grenfell Tower Inquiry: Phase 2 Report 150 Although he knew that CWCT had published guidance, he had not read it1538 and was not familiar with it.1539 Nor was he familiar with the guidance issued by the Building Control Alliance (BCA).1540 56.53 Tomas Rek would normally have expected tenderers to check that FR5000 complied with the CWCT performance requirements, but he did not do so himself.1541 He said that if the material specified did not comply with that standard there would be a conflict which would have to be resolved.1542 56.54 The NBS Specification was not sent to either Exova or Max Fordham for them to comment on the inclusion of FR5000 (or indeed at all). Bruce Sounes did not look to Exova to provide detailed checking of the specification because he did not consider that to be the focus of its work, which was to produce the fire safety strategy.1543 56.55 Following the inclusion of FR5000 in the NBS Specification, no further consideration was given to it during the procurement process or before the award of the contract to Rydon in March 2014. The “launch” of RS5000 and Harley’s initial discussions with Celotex: April to August 2014 56.56 Jonathan Roome was a manager at Celotex whose work mainly related to sales.1544 He joined Celotex in March 2014. On 28 April 2014, his colleague Jonathan Roper sent him information about the FR5000 range of products and the BS 8414 testing regime.1545 Mr Roome then familiarised himself with Approved Document B and knew that there were particular requirements relating to high-rise buildings.1546 He knew that if one wanted to follow the guidance in Approved Document B, a PIR product could be used in the external wall of a high-rise building only if it was of limited combustibility or formed part of a system that had undergone a BS 8414 test and met the criteria in BR 135.1547 He was also aware that FR5000 and other PIR products were neither materials of limited combustibility nor had been tested in a system that had undergone a BS 8414 test and met the criteria in BR 135. They could therefore not be used in the external walls of buildings above 18 metres in height consistently with the guidance contained in paragraphs 12.5-12.7 of Approved Document B.1548 He knew that there was a distinction between Class 0 materials and materials of limited combustibility1549 and was aware of the tests which a material needed to pass to obtain that classification.1550 56.57 In about April 2014 Mr Roome became aware that Celotex was seeking to develop an insulation product that could be marketed for use in buildings above 18 metres in height.1551 He understood that the new product (which was formally launched as RS5000 1538 Rek {Day12/19:14-18}. 1539 Rek {Day12/34:14-17}; {Day12/39:1-16}. 1540 Rek {Day12/19:20-23}. 1541 Rek {Day12/127:10}-{Day12/128:3}; {Day12/128:4-24}. 1542 Rek {Day12/129:2-3}. 1543 Sounes {Day20/51:2-10}. 1544 Roome {Day69/7:6-10}. 1545 {CEL00001200}; {CEL00001201}; {CEL00001203}. 1546 Roome {Day69/32:15-20}. 1547 Roome {Day69/39:16-22}. 1548 Roome {Day69/19:22-24}; {Day69/20:2-10}; {Day69/39:12-15}; {Day69/30:11-15}. 1549 Roome {Day69/36:10-15}. 1550 Roome {Day69/25:19-23}. 1551 Roome {Day69/43:16-25}.

Part 6 | Chapter 56: The choice of insulation 151 in August 2014) was an equivalent product to Kingspan’s K15, if not better.1552 As we have already explained, RS5000 was simply FR5000 re-marketed with the supposed benefit of having successfully met the BR 135 criteria in a particular wall construction, but that fact was not known to Mr Roome, who had been led to believe by his seniors in the marketing department that it was a brand new product. 56.58 On 10 June 2014 Mr Roome telephoned Ben Bailey of Harley to discuss another of Harley’s projects, Merit House.1553 Ben Bailey wanted to know if Celotex had an alternative to Kingspan K15 that might be used at Merit House. Mr Roome said that because Merit House was a building above 18 metres in height Celotex did not have a suitable product, but that he would contact Harley once Celotex’s 18 metre fire test was in hand. That was a reference to a BS 8414 test using RS5000 which had been carried out 2 May 2014, the results of which were awaited together with the BR 135 classification report. 56.59 By June 2014 Jonathan Roome was aware that Harley had been awarded two new overcladding projects in London1554 and between early June and the end of August 2014 Celotex saw Harley as a potential customer for RS5000.1555 56.60 As a result of his conversation with Mr Roome on 10 June 2014, Ben Bailey knew that Celotex did not then have any insulation products available that could be used on buildings above 18 metres in height.1556 When he began work on the Grenfell Tower project he read through those parts of the NBS Specification which he considered relevant to Harley’s work.1557 It did not occur to him, however, to question the specification of FR5000, despite knowing that Celotex did not have a suitable product.1558 56.61 Jonathan Roome met Ben Bailey on site at Merit House on 18 July 2014 when he was told that Grenfell Tower was one of Harley’s prospective projects.1559 Ben Bailey was under the impression by that time that Celotex was due to bring out an insulation product suitable for use above 18 metres1560 which would be a competitor to Kingspan’s K15.1561 Mr Roome promised to be in touch when the result of the test involving RS5000 was available. According to Ben Bailey, Jonathan Roome was very keen to stay in contact about the RS5000 product and to secure two overcladding projects, including the Grenfell Tower refurbishment.1562 56.62 RS5000 was launched at a meeting on 5 August 2014 attended by a number of Celotex’s employees, including Jonathan Roome.1563 It was made clear to him that the reason RS5000 had (supposedly) been created and brought to market was for use on buildings above 18 metres in height and the communications strategy was to emphasise that it could be used on buildings of that kind.1564 Mr Roome was provided with documents to pass on to potential customers,1565 including a product data sheet for RS5000, a document entitled 1552 Roome {Day69/163:14-22}. 1553 {CEL00009874}. 1554 Roome {Day69/160:14-21}. 1555 Roome {Day69/174:8-13}. 1556 And he knew that there were restrictions on insulation products being used on those buildings. Ben Bailey {Day39/55:15-25}; {Day39/56:1}. 1557 Ben Bailey {Day39/64:21-25}; {Day39/65:1-19}. 1558 Ben Bailey {Day39/66:16-21}; {Day39/68:13-25}; {Day39/69:3-7}. 1559 {CEL00009875}. 1560 Ben Bailey {Day39/61:4-20}. 1561 Ben Bailey {Day39/58:5-13}. 1562 {CEL00009875}; Ben Bailey {Day39/61:21-25}. 1563 Roome {CEL00010031/7} page 7, paragraph 29; {CEL00009709}; {CEL00008668}. 1564 Roome {Day69/48:19-24}; Roome {Day69/69:19-23}. 1565 Rome {CEL00010031/2} page 2.

The Grenfell Tower Inquiry: Phase 2 Report 152 Rainscreen Cladding Compliance Guide and a document entitled Rainscreen Cladding Specification Guide.1566 The purpose of the documents was to present RS5000 as a new product suitable for the insulation of buildings above 18 metres in height, which is what Mr Roome thought it was.1567 56.63 Having seen the documents, Mr Roome knew that RS5000 could not satisfy the requirements of paragraph 12.7 and table A7 of Approved Document B because it was not a material of limited combustibility.1568 The construction of the system that had been tested on 2 May 2014, apparently successfully, was discussed at the presentation on 5 August 2014, from which he understood that the classification of RS5000 under BR 135 applied only to the system as tested and not to its individual components.1569 He also knew that RS5000 could be used only in cladding systems that were identical to the system tested.1570 56.64 On 6 August 2014, Mr Roome sent Ben Sharman of Harley an email about RS5000 to which he attached a product comparison document, the rainscreen cladding compliance guide, the product datasheet and a rainscreen cladding datasheet.1571 In his covering email he said, “I have the pleasure of informing you as of yesterday we have now launched the first PIR Board To Successfully Meet The Performance Criteria in BR 135 For Insulated Rainscreen Cladding Systems, Therefore Acceptable For Use In Buildings Above 18m in Height”. 56.65 Jonathan Roome had taken that wording from a document prepared by Celotex’s marketing team. It did not include the qualification that RS5000 was suitable for use on high-rise buildings only as part of a cladding system that was identical to the system that had been tested1572 and therefore was, as he accepted, potentially misleading.1573 56.66 In his email of 6 August 2014 Mr Roome asked to visit Harley’s offices to present the new product.1574 Neither he nor any of Harley’s witnesses could recall the precise date or circumstances in which that had occurred, but various conversations took place between Mr Roome, Daniel Anketell-Jones, and Ben Bailey about RS5000.1575 56.67 Ben Bailey told us that Jonathan Roome regularly visited Harley’s offices and that he might have introduced RS5000 to a number of Harley’s employees at different times.1576 Mr Anketell-Jones, who was at that time the design manager at Harley, recalled a representative of Celotex visiting Harley’s offices on a number of occasions to discuss RS5000, and more generally that Jonathan Roome visited the office every couple of weeks and perhaps 30 times a year.1577 Jonathan Roome could not recall the number of visits to Harley’s offices, but would visit the offices to obtain information on Harley’s projects and 1566 {CEL00007961}; {CEL00000012/2}; {CEL00000013}; Roome {Day69/100:23-25}; {Day69/101:1-5}. 1567 Roome {CEL00010031/2} page 2, paragraph 6; {CEL00001237}. 1568 Roome {Day69/95:16-20}. 1569 Roome {Day69/52:1-9}. 1570 Roome {Day69/98:8-13}. 1571 {CEL00001237}; {CEL00001238}; {CEL00001239}; {CEL00001240}; {CEL00001241}. 1572 Roome {Day69/167:20}-{Day69/168:10}. 1573 Roome {Day69/168:7-10}. 1574 {CEL00001237}. 1575 Roome {Day69/190:15-25}; Ray Bailey {HAR00010184/29} page 29; Anketell-Jones {HAR00010149/6} page 6; Ben Bailey {Day39/63:14-17}; {Day39/64:4-7}; {Day39/75:15-25}; {Day39/76:1-11}. 1576 Ben Bailey {Day39/63:14-17}; {Day39/64:4-7}; {Day39/75:15-25}; {Day39/76:1-11}; {Day39/76:20-21}; {Day39/77:1-4}. 1577 Anketell-Jones {HAR00010149/6} page 6; Anketell-Jones {Day36/77:6-9}.

Part 6 | Chapter 56: The choice of insulation 153 organise his sales pipeline.1578 As at August 2014, Celotex was working on two projects for Harley (neither of them high-rise buildings) and Jonathan Roome hoped that Celotex could secure more work from Harley.1579 Harley’s understanding of the fire performance of Celotex RS5000 56.68 Ray Bailey said that because RS5000 was a new product, Harley had wanted to be sure that it was safe1580 and suitable for the Grenfell Tower project.1581 He said that Celotex had been keen to emphasise that it complied with BS 8414 and was suitable for buildings over 18 metres in height.1582 56.69 Daniel Anketell-Jones recalled that Jonathan Roome had made a sales pitch for RS5000, the essence of which had been that it was the first product suitable for use on buildings over 18 metres in height,1583 as claimed in Celotex’s communications strategy.1584 He also recalled seeing the marketing brochures provided to him by Mr Roome and recognised the pink branding on the documents.1585 He did not, however, read those brochures; he simply passed them on to others.1586 56.70 Ray Bailey said it had been Mr Anketell-Jones’ responsibility to examine the components of the cladding shown in the NBS Specification to check that they complied with the relevant statutory requirements1587 and thought that he had done so.1588 Mr Bailey himself just assumed that they were compliant and did not check for himself.1589 He was aware of the guidance in Approved Document B that the insulation should be of limited combustibility and thought that Celotex’s products were materials of limited combustibility because they were rated Class 0.1590 He thought that a Class 0 material was safe to use on any part of a building above 18 metres.1591 He was aware of the distinction between Class 0 and limited combustibility, and of the fact that additional tests were required to establish the latter,1592 but he appears to have regarded them largely as interchangeable concepts.1593 For example, he thought that Class 0 related to the outside of a product but that if it were described as Class 0 “throughout”, that meant the product as a whole was of limited combustibility.1594 He was wrong about that, as he accepted,1595 and was therefore wrong in thinking that Celotex products were materials of limited combustibility.1596 56.71 Mr Anketell-Jones had no recollection of the insulation products that were used on Grenfell Tower. He did not recall that the NBS Specification had required Celotex FR50001597 and said that he had become aware of the products used only from media reports 1578 Roome {Day69/174:15-23}. 1579 Roome {Day69/175:2-16}. 1580 Ray Bailey {Day33/68:23-25}. 1581 Ray Bailey {Day33/69:6-8}. 1582 Ray Bailey {Day32/16:21-24}. 1583 Anketell-Jones {HAR00010149/6} page 6; Anketell-Jones {Day36/79:2-13}; {Day36/88:6-9}. 1584 Roome {Day69/177:14-17}. 1585 Anketell-Jones {HAR00010149/6} page 6. 1586 Anketell-Jones {Day36/93:15-25}; {Day36/94:1-3}; {Day36/97:24-25}; {Day36/98:1-6}. 1587 Ray Bailey {Day32/51:4-13}. 1588 Ray Bailey {Day32/51:4-13}; {Day32/17:21}-{Day32/18:1}. 1589 Ray Bailey {HAR00010184/8} page 8, paragraph 31. 1590 Ray Bailey {Day33/22:12-15}. 1591 Ray Bailey {Day33/6:18-25}. 1592 Ray Bailey {Day33/9:2-9}. 1593 Ray Bailey {Day33/10:6-8}. 1594 Ray Bailey {Day33/12:12-15}; {Day33/13:3-10}; {Day33/14:7-12}; {Day33/15:8-11}; {Day33/11:7-9}. 1595 Ray Bailey {Day33/19:2}. 1596 Ray Bailey {Day33/21:3-7}; {Day33/23:2-24}. 1597 Anketell-Jones {Day36/70:21-24}.

The Grenfell Tower Inquiry: Phase 2 Report 154 following the fire.1598 He said that he had not known what “PIR” meant but considered it to be a better performing kind of insulation.1599 He thought that Class 0 meant that a material could not catch fire.1600 He did not investigate the materials provided in the NBS Specification to see whether they complied with the Building Regulations1601 because he did not regard that as part of his job. He said that it had been his practice to send technical information about materials to a project’s design team and building control for approval. He had not done so in the case of the Grenfell Tower project because he did not consider himself to be the main designer;1602 that role was being performed by Studio E and building control.1603 Mr Anketell-Jones was not aware that anyone at Harley had considered the suitability of FR5000 for the refurbishment.1604 56.72 Daniel Anketell-Jones was not aware that RS5000 had been tested as part of a particular cladding system or that the cladding system proposed for Grenfell Tower differed from that which had been tested.1605 He knew nothing about the BS 8414 test or BR 135 classification and did not form any view about whether testing under those regimes meant that RS5000 could be used on Grenfell Tower.1606 As a result of what he had been told by Jonathan Roome and what he had read on the front of the Celotex literature,1607 he thought that RS5000 could be used on any building above 18 metres in height, regardless of the other components of the external wall.1608 It is likely that Mr Roome pointed out the key aspects of Celotex’s marketing literature to Mr Anketell-Jones,1609 although he could not recall talking through the RS5000 specification or compliance guides with anyone at Harley or explaining the test regime.1610 Certainly no steps were taken by Mr Anketell- Jones to satisfy himself independently that RS5000 was suitable for use in buildings above 18 metres in height,1611 a claim which he took at face value.1612 He did not trouble to read the RS5000 sales literature and did not see the qualifications and warnings.1613 56.73 Ben Bailey also remembered the pink branded Celotex marketing literature, but was unsure whether he had read it,1614 although he did remember that the marketing literature had said that RS5000 was Class 0 throughout.1615 He said he had seen the product comparison sheet or the rainscreen cladding specification guide1616 and was unsure whether he had seen the rainscreen cladding compliance guide.1617 He said that he had not been aware that RS5000 would comply with Approved Document B in relation to buildings above 18 metres in height only if it was used as part of a cladding system that corresponded exactly with the one tested.1618 1598 Anketell-Jones {Day36/69:1-9}; {Day36/78:3-20}. 1599 Anketell-Jones {Day36/89:4-18}. 1600 Anketell-Jones {Day36/92:7-14}. 1601 Anketell-Jones {Day36/63:19-23}. 1602 Anketell-Jones {Day36/65:9-21}. 1603 Anketell-Jones {Day36/71:10-22}. 1604 Anketell-Jones {Day36/71:14-17}. 1605 Anketell-Jones {Day36/96:4-25}; {Day36/97:1}; {Day36/104:8-11}. 1606 Anketell-Jones {Day36/95:8-25}; {Day36/96:1-3}. 1607 Anketell-Jones {Day36/91:6-13}; {CEL00007961}. 1608 Anketell-Jones {Day36/90:10-13}. 1609 Anketell-Jones {Day36/93:15-25}; {Day36/94:1-3}; {Day36/97:24-25}; {Day36/98:1-6}. 1610 Roome {Day69/174:7-10}; {Day69/177:24-25}; {Day69/178:1-7}. 1611 Anketell-Jones {Day36/79:14-25}; {Day36/80:1-5}. 1612 Anketell-Jones {Day36/80:6-10}. 1613 Anketell-Jones {Day 36/98:20}-{Day36/99:12}. 1614 Ben Bailey {Day39/78:20-24}. 1615 Ben Bailey {Day39/79:2-5}. 1616 {CEL00000007}; {CEL00000013} which formed part of the package of documents sent by Jonathan Roome to Daniel Anketell-Jones on 27 August 2014 {CEL00011960}; Ben Bailey {Day39/82:10-17}; {Day39/82:1-24}. 1617 {CEL00000012}; Ben Bailey {Day39/81:18-25}; {Day39/83:6-14}. 1618 Ben Bailey {Day39/83:21-25}; {Day39/84:1}.

Part 6 | Chapter 56: The choice of insulation 155 56.74 Jonathan Roome did not discuss with anyone at Harley the differences between FR5000 and RS5000, despite the fact that FR5000 rather than RS5000 had been included in the NBS Specification which Mr Anketell-Jones had seen.1619 Similarly, Mr Roome did not point out to anyone at Harley that RS5000 could be used only on buildings over 18 metres in height if the cladding system corresponded exactly to the one that had been tested.1620 Neither Harley nor Celotex made a comparison between the cladding system tested and the cladding system proposed for Grenfell Tower.1621 56.75 Jonathan Roome accepted that the limited relevance of the BS 8414 test involving RS5000 was important and that it was important that Harley understood it. He accepted, however, that he had not specifically drawn Mr Anketell-Jones’s attention to it. His excuse was that Mr Anketell-Jones was a specialist and that he had thought he understood it from the information contained in the marketing literature Harley had been given.1622 Mr Roome did not insist on seeing the composition of the cladding system proposed for Grenfell Tower to enable him to advise Harley whether RS5000 was suitable,1623 nor did he point out to anyone at Harley that FR5000 might not be safe to use on buildings over 18 metres in height.1624 Harley did not ask Mr Roome for information about the BS 8414 test beyond that which was contained in the marketing literature and Mr Roome did not volunteer any.1625 Handover to Neil Crawford: August 2014 56.76 Neil Crawford began work on the Grenfell Tower project in about July 2014.1626 In about August 2014, Bruce Sounes had a handover meeting with him.1627 It is likely that Mr Sounes gave Mr Crawford a general description of the NBS Specification during the handover.1628 When Mr Crawford started work on the project, therefore, FR5000 was the insulation product included in the NBS Specification. Neil Crawford could not recall whether Mr Sounes had told him that FR5000 had been specified as the insulation to be used within the external facade, but it is likely that he had read Max Fordham’s Stage C report and had seen the reference to it there.1629 56.77 Mr Crawford accepted that it had been the architect’s duty to ensure that the insulation complied with the Building Regulations1630 and told us that based on his knowledge of Bruce Sounes’ work he would have expected Mr Sounes to have checked that FR5000 was suitable before completing the Employer’s Requirements.1631 Mr Crawford said that although he did not have any conversations with Mr Sounes about the suitability of FR5000 for use in the external wall, he had gained the impression that Mr Sounes was firm 1619 Roome {Day69/199:18-25}; {Day69/200:1-2}. 1620 Roome {Day69/178:19-25}; {Day69/200:3-12}; Anketell-Jones {Day 36/97:9-20}; {Day36/98:7-22}; {Day36/99:13-24}. Harley never asked Jonathan Roome to explain the precise differences between the system as tested and the proposed cladding system for Grenfell Tower. Roome {Day69/126:22-25}; {Day69/127:1-4}. Jonathan Roome did not qualify the suitability of RS5000 on buildings above 18 metres with any caveats. 1621 Roome {Day69/201:6-11}; Anketell-Jones {Day36/81:17-19}; {Day36/96:24}-{Day69/97:2}. 1622 Roome {Day69/179:4-20}; {Day69/200:13-16}; {Day69/201:3-5}; {Day69/200:13-20}; Anketell-Jones {Day36/79:4-8}. 1623 Roome {Day69/127:5-8}. 1624 Anketell-Jones {Day36/79:11-13}. 1625 Roome {Day69/192:7-18}. 1626 Crawford {Day9/116:19-21}. 1627 Crawford {Day9/49:23}-{Day9/50:3}. Neil Crawford was working on the project between July and August 2014, but his involvement had been minimal: Crawford {Day9/50:4-9}. 1628 Crawford {Day9/136:21}-{Day9/137:3}. 1629 Crawford {Day9/135:15}-{Day9/136:5}. Neil Crawford said that he would probably have read that Stage C report when he came on to the project. Crawford {Day9/136:9-14}. 1630 Crawford {Day10/124:11-20}. 1631 Crawford {Day9/140:7-11}.

The Grenfell Tower Inquiry: Phase 2 Report 156 in his view that it was suitable,1632 although he could not recall his saying it in terms.1633 Bruce Sounes, however, could not recall any conversation with Neil Crawford in which he had expressed any view about the suitability of FR5000.1634 In our view it is unlikely that by then Mr Sounes had any lingering doubts about using FR5000, and we therefore doubt that he had any reason to express a view of any kind about the suitability of FR5000 for use in the cladding system. 56.78 Neil Crawford had some recollection of having seen the product datasheet for FR5000 but could not recall when he first saw it.1635 At all events, he did not take any steps to check it when he learnt that FR5000 had been specified for use in the external wall.1636 The change from FR5000 to RS5000: August to September 2014 56.79 On 27 August 2014 Jonathan Roome sent an email to Daniel Anketell-Jones attaching further information about RS5000.1637 Mr Roome sent Mr Anketell-Jones a product comparison document, the product datasheet, the LABC Registered Details drawing and document list and certificate, a four-page version of the BRE Global Classification Report on a system which included 100mm RS5000 insulation board, the rainscreen cladding compliance guide, and the rainscreen cladding specification guide.1638 Mr Roome was not aware at that time that the full BRE report ran to 12 pages and neither he nor Mr Anketell‑Jones noticed that the four-page report was only a part of the document.1639 56.80 Mr Anketell-Jones said that at that time the only thing he knew about insulation was U-values,1640 but despite his lack of knowledge about the fire performance of different kinds of insulation and his assertion that he would normally send technical information to others for their consideration,1641 he did not send the package of documents he received from Mr Roome to anyone else within Harley or the wider design team because he did not regard himself as the designer.1642 56.81 Shortly after receiving the documents from Mr Roome, Mr Anketell-Jones carried out U-value calculations for FR5000 using a piece of software called “BuildDesk”.1643 On or around 28 August 2014 Mr Anketell-Jones and Mr Roome discussed those calculations. Mr Roome recorded their discussions in a note in which he recorded that Mr Anketell- Jones had said that the calculations had been performed using FR5000 but that he needed to use RS5000 at a thickness of 150mm.1644 That is the first reference we have seen to the use of RS5000 in place of FR5000 at Grenfell Tower. 56.82 Daniel Anketell-Jones was emphatic that he had not selected RS5000 for use at Grenfell Tower.1645 He explained that the NBS Specification as drawn up by Studio E was a prescriptive specification and the insulation product, RS5000, had been prescribed by 1632 Crawford {Day9/139:14-24}; {Day10/51:11-14}. 1633 Crawford {Day9/140:3-6}. 1634 Sounes {Day20/73:5-17}. 1635 {SEA00005841}; Crawford {Day9/142:1-12}. 1636 Crawford {Day9/142:14-19}. 1637 {CEL00011960}. 1638 {CEL00011960}; {CEL00000007}; {CEL00000411}; {CEL00011963}; {CEL00011415}; {CEL00011965}; {CEL00011966}; {CEL00000418}. 1639 Roome {Day69/209:10-19}; {Day69/213:2-9}; {Day69/213:10-12}. 1640 Anketell-Jones {Day36/87:1-15}. 1641 Anketell-Jones {Day36/93:15-25}; {Day36/94:1-3}; {Day36/97:24-25}; {Day36/98:1-6}. 1642 Anketell-Jones {Day36/88:13-19}. 1643 Anketell-Jones {Day36/106:5-23}. 1644 {CEL00001451}. 1645 Anketell-Jones {Day36/173:2-4}.

Part 6 | Chapter 56: The choice of insulation 157 Studio E.1646 However, that was plainly wrong. Studio E had specified FR5000, not RS5000, and Mr Anketell-Jones, like others at Harley, had no reason to think that they were the same product, especially in circumstances where Mr Roome himself thought that they were not. Mr Anketell-Jones thought, without any obvious foundation, that by pressing on with RS5000 Harley was simply adhering to Studio E’s specification. He believed that Studio E had already checked that RS5000 was suitable before it sent the NBS Specification to Harley1647 and assumed that it had been the subject of desktop studies.1648 We doubt that he did think that at the time, not least because if he had done so his mistake would have been obvious. The NBS Specification had been completed in January 2014, about eight months before the launch of RS5000. Studio E could not have checked the suitability of RS5000 before the NBS Specification had been finalised because the product did not then exist under that name. We reject Mr Anketell-Jones’ evidence about his reason for adopting RS5000 in place of FR5000, although we find it impossible to know what he actually thought at the time, if indeed he turned his mind to the point at all. 56.83 It is unlikely that Jonathan Roome expressly advised Harley that RS5000 was suitable for Grenfell Tower,1649 but he accepted that he knew Grenfell Tower was over 18 metres in height1650 and that he might well have told Mr Anketell-Jones that the product was suitable for use on such buildings because it was the only product available for that application.1651 56.84 Mr Anketell-Jones said that at some point he had been told that FR5000 could not be used but that RS5000 was equivalent,1652 but he could not recall when he was told that or by whom. He said that the only reason that RS5000 would have been put forward on any project was because it was appropriate for use above 18 metres and was one of the few insulation materials that were capable of achieving the high performance required.1653 In his mind, there was no difference between FR5000 and RS5000.1654 However, although he was quite right about that, he had no reason to think so. There had been no conversations between Harley and Celotex which could justify his coming to that view; indeed, quite the opposite. He thought that RS5000 was a new product,1655 not least because that was exactly what Jonathan Roome had told him. For his part, Mr Roome did not know otherwise, having been induced to think that RS5000 was indeed a new product by those at Celotex who briefed the marketing department. In circumstances where RS5000 was being marketed as a new product there is no credible basis on which Mr Anketell-Jones could have thought that it was the same as FR5000 and that there was therefore no need to investigate its fire performance. 56.85 Harley did not consider whether another insulation product, such as a mineral wool, might be more appropriate for use on the project. Mr Anketell-Jones explained that RS5000 had been specified by Studio E and that Harley was not considering any alternative products.1656 He was not aware whether the fact that RS5000 was rated Class 0 had affected the decision 1646 Anketell-Jones {Day36/116:13-17}; {Day36/141:13-16}; {Day36/149:18-19}; {Day36/173:2-4}. 1647 Anketell-Jones {Day36/102:2-12}; {Day36/93:5-13}; {Day36/141:22-25}; {Day36/142:1}. 1648 Anketell-Jones {Day36/102:13-19}. 1649 Roome {Day69/191:10-13}. 1650 Roome {Day69/191:5-9}. 1651 Roome {Day69/200:3-6}. 1652 Anketell-Jones {Day36/113:8-13}. 1653 Anketell-Jones {Day36/154:2-8}. 1654 Anketell-Jones {Day36/108:1-6}. 1655 Anketell-Jones {Day36/102:13-19}. 1656 Anketell-Jones {Day36/119:1-7}.

The Grenfell Tower Inquiry: Phase 2 Report 158 to use it,1657 but even so, a change from FR5000 to RS5000 ought to have led Harley to investigate why FR5000 had originally been specified, why RS5000 was being substituted and whether it was a suitable product for use on the tower. 56.86 Daniel Anketell-Jones did not ask Rydon or Studio E whether they were happy with the use of RS50001658 because he did not consider himself to be the design manager on the project.1659 He thought that was Ben Bailey’s or Kevin Lamb’s job as designer1660 and assumed as a result of having worked with him before that Mr Lamb knew that was his responsibility.1661 He said that he had expected Kevin Lamb to tell Studio E about the proposed use of RS5000 so that it could check its suitability and Rydon to have then checked with Building Control,1662 but he did not tell Mr Lamb that that was his responsibility.1663 For reasons explained below, we do not accept Mr Anketell-Jones’ explanation of his role at Harley; in particular, we do not accept that it was as limited as he suggested. 56.87 Daniel Anketell-Jones did not have any conversation with Kevin Lamb about the use of RS5000 and did not show him the Celotex documents. He could not explain how Mr Lamb could possibly have been aware of the change from FR5000 to RS5000 to enable him to check the position.1664 He did not know who at Harley was responsible for reading the Celotex specification guide for RS5000 and suggested that, if Mr Lamb had satisfied himself that RS5000 had been checked by Studio E and Building Control, he would not need to have read it.1665 56.88 Kevin Lamb was told on 12 August 2014 at his initial meeting with Ray Bailey and Daniel Anketell-Jones that the insulation to be used in the external wall was a rigid PIR- type material. He could not recall whether Celotex had been specifically mentioned but assumed that a product of that kind had been selected.1666 He did not recall seeing FR5000 in the NBS Specification.1667 There was no discussion between Kevin Lamb and either Mr Bailey or Mr Anketell-Jones about the specification of the insulation product; he was simply told which product had been selected.1668 56.89 Kevin Lamb had not previously used a product like Celotex in a rainscreen cladding system.1669 He did not see it as his responsibility to provide advice on compliance with the relevant regulatory requirements, although he said that he had had a brief look at literature relating to the use of Celotex on buildings over 18 metres in height and a brief look at the guidance published by the CWCT.1670 He knew that there was a difference between Class 0 and limited combustibility,1671 but he was not aware that limited combustibility was defined by reference to specific tests.1672 He did not consider the difference and 1657 Anketell-Jones {Day36/93:5-13}. 1658 Anketell-Jones {Day36/108:17-25}. 1659 Anketell-Jones {Day36/80:15-17}. 1660 Anketell-Jones {Day36/108:17-25}. 1661 Anketell-Jones {Day36/66:11-14}; {Day36/74:1-12}; {Day36/105:11-16}; {Day36/73:15-25}; {Day36/73:15-25}. 1662 Anketell-Jones {Day36/79:14-25}; {Day36/80:1-5}. 1663 Anketell-Jones {Day36/65:20-25}; {Day36/66:1-10}. 1664 Anketell-Jones {Day36/109:2-7}. 1665 Anketell-Jones {Day36/94:4-12}. 1666 Lamb {Day37/77:6-13}; {Day37/81:8-24}. 1667 Lamb {Day38/33:25}. 1668 Lamb {Day37/78:25}-{Day37/79:22}. 1669 Lamb {Day37/80:5-6}. 1670 Lamb {Day37/130:2-13}. 1671 Lamb {Day38/83:9-12}. 1672 Lamb {Day38/83:22-25}; {Day38/84:1-2}.

Part 6 | Chapter 56: The choice of insulation 159 assumed that if a material was rated Class 0 it was suitable for use.1673 He did not know that to comply with paragraph 12.7 of Approved Document B insulation materials used on buildings above 18 metres in height should be materials of limited combustibility.1674 He did not consider it part of his responsibility to review the insulation for compliance with the Building Regulations or Approved Document B.1675 He therefore read the Celotex Rainscreen Cladding Compliance Guide only to review the type of fixings it required within the cladding system.1676 56.90 Ben Bailey was not familiar with RS5000 but said he had thought that it had always been intended to use it on Grenfell Tower.1677 He thought (though why is not clear) that Studio E had chosen RS5000 for use on Grenfell Tower and possibly that “FR” had been a typographical error in the NBS Specification.1678 56.91 Ben Bailey told us that there he had had a conversation with Neil Crawford in which he had questioned the choice of FR5000 because he had been under the impression that RS5000 was to be used. He said that Neil Crawford had told him that RS5000 had been chosen, which he understood to mean that RS5000 should have been specified and that it was Studio E’s intention that RS5000 rather than FR5000 be specified.1679 Ben Bailey said that there had been no discussion between them about the suitability of either FR5000 or RS5000 for use in buildings above 18 metres in height.1680 He said that he had not told Mr Crawford that RS5000 was a new product nor had he asked him whether it complied with the Building Regulations. Neil Crawford merely confirmed, he said, that there was a typographical error in the NBS Specification; he therefore assumed that Studio E had checked the suitability of RS5000.1681 56.92 The difficulty with Ben Bailey’s evidence is, again, that the last version of the NBS Specification was dated 30 January 2014, some eight months before the launch of RS5000. Studio E therefore cannot have intended to specify RS5000. In response to that difficulty, Mr Bailey said that he had misremembered the conversation and changed his evidence to say that Neil Crawford had confirmed his expectation that RS5000 should be the chosen product.1682 Ben Bailey did not take any steps to amend the NBS Specification1683 and he did not ask whether anyone had checked that RS5000 was suitable. He assumed that Studio E had done that.1684 He did not consider whether a different kind of insulation might be more suitable for use on Grenfell Tower;1685 nor did he consider whether the use of a PIR product rather than a mineral wool product might affect fire safety.1686 1673 Lamb {Day38/83:16-17}. 1674 Lamb {Day37/150:2-4}. 1675 Lamb {Day37/160:15-18}; {Day37/165:13-18}; {Day37/170:4-8}. 1676 {CEL00002047}; Lamb {HAR00010419/14} page 14; Lamb {Day38/36:20-25}; {Day38/37:1-5}. 1677 Ben Bailey {Day39/71:13-15}; {Day39/70:19-23}; {Day39/69:6-7}. 1678 Ben Bailey {Day39/70:19-23}; {Day39/69:6-7}. 1679 Ben Bailey {Day39/67:6-25}; {Day39/68:1-11}; {Day39/71:3-4}. 1680 Ben Bailey {Day39/69:8-23}. 1681 Ben Bailey {Day39/73:6-21}. Albeit that Ben Bailey could not recall the exact words used by Neil Crawford. Ben Bailey {Day39/73:20-21}. 1682 Ben Bailey {Day39/74:4-13}. 1683 Ben Bailey {Day39/74:15-20}. 1684 Ben Bailey {Day39/72:6-17}; {Day39/72:10}-{Day39/73:2}. 1685 Ben Bailey {Day39/141:23-25}; {Day39/142:1}. 1686 Ben Bailey {Day39/143:2-5}.

The Grenfell Tower Inquiry: Phase 2 Report 160 56.93 If Ben Bailey did have a conversation with Neil Crawford of the kind he described, he did not tell anyone at Harley about it. Nor did he mention it in his witness statement. Neil Crawford did not mention any such conversation and there is no indication in the documents that Studio E expected RS5000 to be used. For those reasons we do not accept Ben Bailey’s evidence on that matter. 56.94 Ray Bailey thought that RS5000 was a new product and not a rebranded version of FR50001687 because that is what Celotex had told him. He told us that either Ben Bailey or Daniel Anketell-Jones had communicated the change to Studio E and that Neil Crawford had then accepted it.1688 He said it had been Harley that had pointed out that there was a difference between FR5000 and RS5000 and that RS5000 needed to be accepted to enable it to be used.1689 His evidence is at least consistent with the fact that Mr Roome thought that the RS5000 was a new product different from FR5000. 56.95 Ray Bailey was not aware of any discussions between Ben Bailey or Daniel Anketell-Jones and Studio E about the substitution of FR5000 with RS50001690 and he did not himself speak to Neil Crawford or anyone else at Studio E about the change.1691 None of the other Harley witnesses and none of the Studio E witnesses suggested that Neil Crawford, or anyone else at Studio E, had been informed of the change from FR5000 to RS5000 or that Studio E had accepted RS5000 for use on Grenfell Tower, as Mr Bailey maintained. We are therefore unable to accept Ray Bailey’s evidence on this question. We conclude that Studio E never investigated the suitability of RS5000 for use at Grenfell Tower and did not accept its use. 56.96 Looking at the evidence as a whole, we are satisfied that Jonathan Roome did tell Daniel Anketell-Jones that RS5000 was suitable for use in buildings above 18 metres in height. That was consistent with Celotex’s communications strategy and with the evidence given by both Mr Anketell-Jones and Mr Roome himself. We think it unlikely, however, that Mr Roome gave any assurance that RS5000 was suitable for use in the specific cladding system being proposed for Grenfell Tower. None of the witnesses could recall any conversation with Celotex about the proposed construction of the external wall and, at least in September 2014, Mr Roome had not seen any relevant drawings or specifications. He therefore had no basis for giving any specific assurance. Indeed, given the presence in the marketing literature of the warning that the BR 135 classification applied only to the system as tested, we think it unlikely that Mr Roome would have given an assurance of that kind in circumstances where there was a risk that someone in the design team might eventually read it and challenge him. 56.97 As it turned out, there was no discussion about that warning. No one at Harley read the marketing literature carefully or sent it to Studio E or Exova to comment on. Harley did not ask Celotex or Studio E whether a desktop study had been done to support the use of RS5000 and did not inquire whether any other members of the design team had asked for a desktop study or other assessment to support the proposed system.1692 Daniel Anketell- Jones simply accepted what Jonathan Roome had told him about the suitability of RS5000 for use on buildings above 18 metres in height and assumed that it complied with the relevant statutory requirements. On that basis he told Mr Roome that RS5000 was needed for use at Grenfell Tower.1693 1687 Ray Bailey {Day33/65:3-10}. 1688 Ray Bailey {Day33/75:2-7}. 1689 Ray Bailey {Day33/74:16-23}; Ray Bailey {HAR00010184/8} page 8, paragraph 31. 1690 Ray Bailey {Day33/75:8-17}. 1691 Ray Bailey {Day33/76:7-10}. 1692 Anketell-Jones {Day36/101:12-21}. 1693 {CEL00001451}.

Part 6 | Chapter 56: The choice of insulation 161 56.98 Although Jonathan Roome was canny enough to avoid giving any specific assurance to Harley that RS5000 was suitable for use on Grenfell Tower, we think he suspected that Harley had not understood the warning in Celotex’s marketing literature. He certainly never drew Harley’s attention to it, which was consistent with Celotex’s marketing strategy to downplay it and tuck it away in the small print.1694 56.99 There was a design team meeting on 2 September 2014 at which U-values were discussed with Rydon. The question arose whether they needed to be rechecked from an M&E and insulation point of view.1695 After a discussion everyone agreed to check their calculations. Neil Crawford did not know why Rydon had wanted to recheck the U-values; he understood that they had been derived from Max Fordham’s advice but did not recall in any detail how the target had been established.1696 Daniel Anketell-Jones and Kevin Lamb also attended that meeting and Mr Anketell-Jones checked the U-values by making another calculation using the “BuildDesk” software.1697 This time he used RS5000 in the calculation,1698 but that did not prompt him to consider its fire safety.1699 Harley’s Request for Information: September 2014 56.100 On 17 September 2014, Daniel Anketell-Jones sent a formal Request for Information to Rydon and Studio E about the extent to which horizontal fire breaks were required within the cladding.1700 In summary, Harley believed that horizontal firebreaks might be required at every floor level but not in the area between the windows, because there was no “chimney effect” at that location. Daniel Anketell-Jones accepted that he had drafted the request1701 but said that he had been asked by someone else to send it and had not fully understood the point. However, he could not remember who had asked him to send it1702 and said that he did not know what analysis had been done to support it.1703 We do not accept his evidence on this point. We think he drafted the request in his role as Harley’s design manager, part of which did involve considering the fire performance of the external walls which Harley was designing. 56.101 Neil Crawford sent the request to Terence Ashton of Exova and asked him to comment on Daniel Anketell-Jones’ “interpretation”.1704 Exova was then provided with some Harley drawings and Mr Ashton replied on 18 September 2014 saying that if the insulation in the cavities behind the rainscreen cladding were combustible it would be necessary to provide cavity barriers even if there was no continuous cavity from the top to the bottom of the building.1705 As we have explained in Chapter 54, that advice was incorrect in so far as it implied that combustible insulation could be used provided cavity barriers were installed. 1694 This is consistent with Mr Roome’s internal slides of 11 February 2015 {CEL00003544}. 1695 {SEA00011581/4}; {RYD00017128}. A post-meeting note states that the “Max Fordham tender U-value document was shared to team via email”. 1696 Crawford {Day10/66:9}-{Day10/67:4}. 1697 Anketell-Jones {Day36/118:11-19}. 1698 {CEL00000030}. 1699 Anketell-Jones {Day36/118:23-25}. 1700 {HAR00003638/4}; {EXO00001291}. 1701 Anketell-Jones {Day36/156:25}. 1702 Anketell-Jones {Day36/157:6-18}. 1703 Anketell-Jones {Day36/158:10-13}. 1704 {HAR00003638/4}. 1705 {HAR00003638/3}.

The Grenfell Tower Inquiry: Phase 2 Report 162 56.102 Neil Crawford sent that email on to Daniel Anketell-Jones the same day.1706 Mr Anketell- Jones said that he had read Mr Ashton’s response but formed no view about it.1707 He did not question why Mr Ashton appeared to be linking the combustibility of the insulation to the requirement for cavity barriers.1708 Mr Anketell-Jones replied to Mr Crawford and Rydon the same day saying that because the insulation was Class 0, he thought that a fire barrier (i.e. a cavity barrier) in those locations would not be necessary and asking for confirmation.1709 He attached the RS5000 product datasheet to his email.1710 That appears to have been the first time that Studio E had been informed of the change from FR5000 to RS5000.1711 56.103 Daniel Anketell-Jones told us that his message showed that he did not understand fire classifications or know where cavity barriers were required and that he believed that it was the responsibility of the consultants to tell Harley where they needed to be installed.1712 We do not accept that Mr Anketell-Jones was as naïve and ignorant as he pretended. In that email, he was giving his opinion of the fire classification of the insulation (Class 0) and whether that meant that fire barriers were necessary in certain locations. It reflects his view of what was meant by Class 0. He said he had not checked his opinion with any of his colleagues or against any published guidance1713 because he was concerned only with matters of structural engineering.1714 It is certainly true that he did not check his opinion with anyone else or against any available guidance, but we doubt whether he made any positive decision not to do so. 56.104 Daniel Anketell-Jones said that he had looked at the product datasheet, had seen that RS5000 was rated Class 0, and had passed that on to Studio E and Rydon.1715 Neil Crawford then asked Mr Ashton to provide his view on whether Class 0 insulation obviated the need for cavity barriers in certain locations.1716 In response Mr Ashton pointed out that a material which has a Class 0 rating is not necessarily non-combustible although the reverse is invariably true and that it was therefore necessary to prevent the spread of fire from one flat to the flat above. It was not clear from the information he had been given whether there was a continuous cavity from top to bottom in any part of the cladding, irrespective of the type of insulation.1717 56.105 Mr Anketell-Jones did not give any consideration to Mr Ashton’s advice that, in summary, a Class 0 insulation may not be sufficient for fire safety.1718 Even having read that advice, it did not occur to him to question whether RS5000 was suitable, as he continued to believe that RS5000 had already been approved by Studio E, building control, and the fire engineer.1719 56.106 We have already concluded that Daniel Anketell-Jones’ professed understanding was wrong and that RS5000 had not been checked for suitability by Studio E, nor had Studio E confirmed that RS5000 was suitable for use at Grenfell Tower. Mr Anketell-Jones’ belief that the fire engineer had already approved RS5000 makes little sense, given that Exova itself 1706 {HAR00003638/2}. 1707 Anketell-Jones {Day36/162:1-3}. 1708 Anketell-Jones {Day36/162:3-8}. 1709 {HAR00003638/1}. 1710 {HAR00012103}; {HAR00012104}. 1711 Anketell-Jones {Day36/163:24-25}; {Day36/164:1-2}. 1712 Anketell-Jones {Day36/164:25}; {Day36/165:1-4}. 1713 Anketell-Jones {Day36/167:2-7}. 1714 Anketell-Jones {Day36/167:7}. 1715 Anketell-Jones {Day36/166:18-24}. 1716 {HAR00003638/1}. 1717 {EXO00001430}. 1718 Anketell-Jones {Day36/170:13-22}. 1719 Anketell-Jones {Day36/171:1-5}; {Day36/171:11-12}.

Part 6 | Chapter 56: The choice of insulation 163 was inquiring about the type of insulation to be used in the external wall. It is clear that Exova did not know what insulation it was proposed to use and so could not have already approved it. Accordingly, we reject Mr Anketell-Jones’ evidence that he thought that RS5000 had already been approved by Exova. In fact, at no stage did he raise with anyone at Rydon, Studio E or Exova the combustibility of the insulation,1720 nor did he take any steps following the Request for Information to investigate whether RS5000 complied with the Building Regulations or the guidance in Approved Document B.1721 56.107 Although Neil Crawford was right to refer some of those questions to Exova, he regarded himself as little more than a post-box and failed to ask himself the question whether the switch to RS5000 was appropriate for Grenfell Tower. Once Studio E had been put on notice that an apparently new product was being proposed, it should have ensured that its fire performance was appropriate. Mr Crawford admitted that he had effectively taken it on trust from Harley that it was.1722 He also said that he had read the Celotex literature and was convinced that it was suitable for use,1723 but, if he did read it, he failed to notice that the product was not of limited combustibility1724 or that the system that Celotex had tested was not the same as the one intended for installation on the tower.1725 We accept Mr Hyett’s opinion that Studio E’s approach fell below the standards to be expected of a reasonably competent architect exercising reasonable skill and care.1726 Harley’s request for technical information in respect of RS5000: January 2015 56.108 On 16 January 2015, Daniel Anketell-Jones sent an email to Jonathan Roome seeking help with what he described as a “headache” and asking for the test results and certificates for RS5000.1727 Mr Anketell-Jones said that another client1728 wanted to know how RS5000 had been installed when it had been tested in accordance with BS 8414, how it had been fixed, what it had been covered with, and what cladding and supporting structure had been used. The client also wanted to see the certificates and results for the test to BS 476 Part 7. It did not occur to Daniel Anketell-Jones that no one at Harley had asked the same questions in relation to the Grenfell project. Mr Anketell-Jones also said that Harley had been hoping to use RS5000 on most of its other cladding projects and therefore wanted to have the information about testing to hand. 56.109 Mr Roome in turn sought the BS 476 test reports from a colleague at Celotex, Jamie Hayes, on 19 January 2015, saying that he could always discuss the BS 8414‑2 test report in person,1729 and offered to visit Mr Anketell-Jones at Harley’s office to do so. If that discussion had taken place, it would probably have revealed the very limited basis on which RS5000 could be used on buildings above 18 metres in height consistently with the Building Regulations and Approved Document B,1730 but that discussion did not take place. 1720 Anketell-Jones {Day36/171:13-16}. 1721 Anketell-Jones {Day36/171:5-12}. 1722 Crawford {Day10/48:5-9}. 1723 Crawford {Day10/53:5-7}. 1724 Crawford {Day10/50:20-24}. 1725 Crawford {Day10/63:2-8}. 1726 Hyett {Day65/16:23}-{Day65/19:20}. 1727 {CEL00000019/2}. 1728 Daniel Anketell-Jones did not recall the client, but thought it was likely to have been a main contractor or architect on a project unconnected to Grenfell Tower. Anketell-Jones {Day36/123:23-25}; {Day36/124:1-5}. He considered that it was likely to have been in connection with a job which required Harley to put forward an insulation that would meet certain U-value requirements, Anketell-Jones {Day36/124:18-22}. 1729 {CEL00000453}. 1730 Roome {Day70/67:2-9}; {Day70/62:8-22}. Jonathan Roome agreed with that proposition.

The Grenfell Tower Inquiry: Phase 2 Report 164 56.110 Mr Hayes told Mr Roome that he did not have access to those documents and had passed the request on to Paul Evans or Debbie Berger.1731 Whether he had or not, the BS 476 test reports were never provided to Mr Roome, who, of course, was unable to provide them to Daniel Anketell-Jones.1732 56.111 Mr Roome did not tell Mr Anketell-Jones that RS5000 could not be used on any of Harley’s projects unless the cladding system was, in each case, exactly the same as the one that had been tested.1733 Mr Roome accepted that Mr Anketell-Jones had either not read the warnings or had misunderstood them (or even intended to ignore them), but denied that he had realised that at the time.1734 56.112 Mr Anketell-Jones understood that RS5000 was not suitable for all rainscreen applications and that the suitability of the product had to be determined in relation to each building individually.1735 Despite his professed understanding, and despite the nature of the questions being asked by the client on the other project, however, he did not consider it important to check whether the proposed system was the same as the one that had been tested. He should have known by January 2015 that whether RS5000 was suitable for use in a particular application depended entirely on whether the proposed system corresponded precisely with the one tested, but he assumed, wrongly, that it depended on how the particular fire consultant or building control officer interpreted the information.1736 56.113 Daniel Anketell-Jones sent another email to Jonathan Roome on 20 January 2015 saying that he was hoping Celotex could provide the test information since otherwise they would have to change to Rockwool Duo Slab, which would satisfy “the specialists”.1737 Mr Roome responded on 21 January 2015, having discussed his response with his colleagues.1738 He attached the full (12-page) BRE Classification Report, the thermocouple data from the test (showing the maximum temperatures recorded during testing) and the RS5000 product information sheet.1739 Despite their obvious importance, Mr Roome and Mr Anketell-Jones did not discuss the documents.1740 56.114 The most natural reading of the emails sent by Mr Anketell-Jones on 16 and 20 January 2015 is that he knew that the construction of the external wall was critical when assessing the suitability of RS5000 for the purposes of fire safety. That has led us to doubt his attempts to play down the extent of his knowledge about fire performance testing and the importance of his role within Harley on the Grenfell project. We are satisfied that he understood more about the technical aspects of fire safety than he was prepared to admit and as design manager he should have been responsible within Harley, together with others, for checking the fire performance of the products used in the external wall. Indeed his emails suggest that he suspected that Celotex might not have the test evidence to support the claims being made for RS5000. It is a matter of serious concern, therefore, that he made no comparable efforts to check the suitability of RS5000 for use on the Grenfell Tower project, but merely assumed it without any investigation. He said 1731 {CEL00000453}. 1732 Roome {Day70/68:18-25}. 1733 Roome {Day70/70:20-25}. 1734 Roome {Day70/71:1-20}. 1735 Anketell-Jones {Day36/128:22-25}; {Day36/129:1-4}. Although he said he had not understood how the suitability of RS5000 was to be determined. 1736 Anketell-Jones {Day36/129:8-11}; {Day36/129:15-21}. 1737 {CEL00000019/1}. 1738 {CEL00000019}. 1739 {CEL00000020} (12pp report), {CEL00000021} (thermocouple graphs) and {CEL00000022} (product information sheet). 1740 Roome {Day70/76:9}.

Part 6 | Chapter 56: The choice of insulation 165 that he had not read the 12-page BRE report or the thermocouple data Mr Roome had sent to him on 21 January 2015 and had not sent it to Kevin Lamb, Studio E, or anyone else because he thought that had already been done1741 and that it was not Harley’s responsibility to do it.1742 56.115 Again we cannot accept his evidence on that point. These exchanges occurred almost a year after the final issue of the NBS Specification. If he believed that RS5000 was a new product, Mr Anketell-Jones cannot have thought that the technical information he had obtained from Celotex had been in Studio E’s possession when it specified the insulation material almost a year earlier. We consider that at that point, if not before, Mr Anketell‑Jones ought to have conducted his own research and, if necessary, asked Celotex, Studio E or Rydon whether RS5000 was suitable for use at Grenfell Tower. Celotex’s exploitation of Harley 56.116 On 11 February 2015 Jonathan Roome sent Debbie Berger and Paul Evans, a market analysis for RS5000, which split potential customers into three tiers.1743 Tier 1 comprised customers who were seen as being of no use to Celotex, because they used only non- combustible products or products of limited combustibility because they were not happy with current test data relating to combustible insulation products.1744 Tier 2 comprised customers who were willing to consider the use of combustible insulation. By contrast, Tier 3 comprised customers who always used combustible insulation because, in some cases, they were not aware of the 18-metre restriction. In our view the existence of that document shows that Celotex was aware of the differing technical sophistication of potential buyers and that it realised that the market for RS5000 was likely to be limited to those who lacked expertise or expert advice or who did not understand, or had not bothered to investigate, the fire performance of RS5000. That reflects a deeply cynical view that there were ignorant or reckless contractors in the market of whom advantage could be taken without any regard for the safety of occupants. Certainly there is no evidence that the safety of residents played any part in Celotex’s thinking on how to sell RS5000, at least when it came to Grenfell Tower. 56.117 Celotex regarded Harley as a Tier 3 customer and exploited its willingness to accept what it was told and its lack of interest in understanding when RS5000 could be used safely. It refrained from correcting Harley’s misunderstanding and encouraged it to pursue the purchase regardless of the product’s suitability for the project in hand. That was not the behaviour to be expected of an honest and plain-dealing manufacturer. 56.118 In our view Jonathan Roome suspected that Harley had not understood the contents of the Celotex marketing literature and in particular had failed to understand that RS5000 could not be used on a cladding project unless the proposed system as a whole was exactly the same as the one that Celotex had apparently tested in accordance with BS 8414. As noted above, Jonathan Roome accepted that Daniel Anketell-Jones had either not read the warnings to that effect or had misunderstood them or was proposing to ignore them. In our view he turned a blind eye to the failure of Daniel Anketell-Jones to ask the sort of questions in relation to Grenfell Tower that he had asked in relation to a different project in January 2015. Celotex recognised that Harley was ill-informed, or was acting recklessly, and exploited its lack of interest in the circumstances in which RS5000 could safely be used. 1741 Anketell-Jones {Day36/124:23-25}; {Day36/125:1-6}; {Day36/141:5-12}; {Day36/142:2-5}. 1742 Anketell-Jones {Day36/124:7-16}. 1743 {CEL00003543]; {CEL00003544}. 1744 {CEL00003544/3}.

The Grenfell Tower Inquiry: Phase 2 Report 166 Although it provided Harley with some technical information, it deliberately refrained from any attempt to ensure that Harley was fully informed about the suitability of RS5000, an approach that was entirely consistent with its marketing strategy. Finalising the specification of RS5000: February to April 2015 56.119 Ben Bailey took over as project manager at Harley in February 2015.1745 He assumed that RS5000 was suitable for use on Grenfell Tower because the U-value calculations made by Daniel Anketell-Jones all referred to RS5000 and because all the conversations he had had with Jonathan Roome related to RS5000.1746 He said that, although no one at Celotex had expressly confirmed or approved the use of RS5000 in combination with ACM panels, Mr Anketell-Jones had told him that a combination of RS5000 and ACM panels had been checked. He had understood that Mr Anketell-Jones had himself been told that it was suitable for use on the project.1747 However, by February 2015 no one working on the project had made any assessment of the suitability of RS5000, let alone in conjunction with ACM rainscreen panels, and if Mr Anketell-Jones had told Ben Bailey that RS5000 and ACM in combination had been checked, he had no basis for doing so. 56.120 On 11 February 2015, Jonathan Roome sent Ben Bailey an email asking for the final construction drawings.1748 He said that he had done so because if components of the external wall penetrated the insulation that could have an effect on the calculation of the U-value.1749 56.121 Ben Bailey responded the same day by providing a link to a folder of drawings.1750 He did not ask Mr Roome to review the drawings and advise whether the system was safe from a fire perspective.1751 Mr Roome did not examine all the drawings, but simply selected two which showed the insulation.1752 He did not note that the proposed cladding panels were not made of cementitious fibreboard, as used by Celotex in the BS 8414 tests on RS5000.1753 56.122 Jonathan Roome asked the Celotex technical team to make U-value calculations based on the drawings and sent the information back to Ben Bailey.1754 He did not turn his mind to the nature of the rainscreen to be used at Grenfell Tower or to whether the construction was compliant with Approved Document B.1755 He was only concerned to check the calculations made by Mr Anketell-Jones in September 2014 to support the target U-value.1756 He said that either 200mm of RS5000 or 160mm of RS5000 would be required to produce U-values of 0.15 W/m2K and 0.18 W/m2K respectively.1757 1745 {CEL00000024/2}; Ben Bailey {Day39/84:20-24}. 1746 Ben Bailey {Day39/70:1-18}. 1747 Ben Bailey {Day39/79:19-25}; {Day39/80:1-12}. 1748 {CEL00000024/2}. 1749 Roome {Day70/17:9-17}. 1750 {CEL00000024}. 1751 {CEL00000024}. 1752 Roome {Day70/21:11-21}; {Day70/22:7-22}; {CEL00000456}; {CEL00000457}. 1753 Roome {Day70/23:10-19}. 1754 {CEL00000029}; At that time, it appears that the specific width of RS5000 was still under consideration in order to achieve the target U-value {CEL00000025}. 1755 Roome {Day70/33:25}; {Day70/34:1-13}. 1756 Roome {Day70/34:4-6}. 1757 {CEL00000025}; {CEL00000027}; {CEL00000028}.

Part 6 | Chapter 56: The choice of insulation 167 56.123 Mr Bailey replied eight minutes later attaching the calculations Daniel Anketell-Jones had made on 3 September 2014 following the design team meeting the day before.1758 Mr Roome looked at them but did not appreciate that the proposed system contemplated the use of ACM rainscreen panels.1759 No one at Harley expressly told Mr Roome that the rainscreen was to be Reynobond ACM1760 and it did not occur to him that the construction of the external wall might be different from that tested in May 2014.1761 56.124 The system tested in 2014 had contained 100mm of RS5000 and had been classified on that basis. There was no BR 135 classification in respect of a system that included any thickness of RS5000 other than 100mm.1762 Mr Roome gave no consideration to the fact that Harley thought it was permissible to use 150mm of RS5000 as opposed to 100mm and did not turn his mind to the fact that the calculations based on 200mm or 160mm of RS5000 meant that the system proposed for Grenfell Tower would not be the same as that tested and would therefore not be covered by the BR 135 classification.1763 He said that at the time he had thought that the test related to the individual components of the system and that the classification was valid regardless of the quantity of material used.1764 If he thought that, he was wrong, but we do not think his evidence is reliable, not least because it is inconsistent with his earlier evidence and the very warnings in the Celotex literature that he well understood.1765 Did Celotex tell Harley that RS5000 was safe to use on Grenfell Tower? 56.125 In the course of his evidence Ray Bailey repeatedly asserted that Celotex had told Harley that RS5000 was safe to use on buildings over 18 metres in height. Initially he said that Daniel Anketell-Jones had identified the warning in the Celotex marketing literature and that Harley had taken advice from Celotex about the suitability of RS5000.1766 In the course of giving evidence he told us that Harley had sent details of the construction of the external wall to Celotex so that Celotex could confirm that the use of RS5000 was safe, although it did not expressly ask that question. He said he had thought that Celotex had in effect carried out a desktop study to compare the construction intended for use at Grenfell Tower with what had been tested.1767 He also insisted that Celotex had confirmed that it was safe to use it in that way.1768 56.126 We do not accept Ray Bailey’s evidence on that point. We doubt that he was deliberately seeking to mislead us; it is more likely that he had persuaded himself of the truth of a story he had told himself ever since the fire. We are satisfied, however, that Harley did not ask Celotex for a formal assessment of the kind he described and was not given one, let alone an unqualified assurance that RS5000 was suitable for use in the external wall construction proposed for Grenfell Tower, although it certainly allowed Harley to obtain that impression, and knew it. When pressed Mr Bailey himself accepted that he did not know whether Celotex had provided any such assessment.1769 He knew that the classification report 1758 {CEL00000030}. 1759 Roome {Day70/25:3-25}. 1760 Anketell-Jones {Day36/114:11-14}. 1761 Roome {Day70/17:18-25}. 1762 {CEL00007961/3}. 1763 Roome {Day70/31:1-5}. 1764 Roome {Day70/30:7-25}. 1765 He contradicted his own evidence. Roome {Day69/52:1-9}. 1766 Ray Bailey {HAR00010184/42} page 42, paragraph 170; Ray Bailey {Day33/82:7}-{Day33/83:3}. 1767 Ray Bailey {Day33/76:16-21}. 1768 Ray Bailey {Day33/91:1-2}. 1769 Ray Bailey {Day33/78:4-10}.

The Grenfell Tower Inquiry: Phase 2 Report 168 based on the BS 8414 test applied only to the system tested1770 and he knew that that system differed from the system proposed for Grenfell Tower.1771 It is hard to understand, therefore, on what basis he could possibly have thought that RS5000 was suitable for use in the external wall system at Grenfell Tower. For its own part, Harley cannot avoid responsibility for its own failures by blaming Celotex for not telling it what it should have known or discovered for itself. April 2015: further discussions 56.127 On 8 April 2015 Jonathan Roome sent BCA Technical Guidance Note 18, issue 0 to Daniel Anketell-Jones.1772 Mr Anketell-Jones said that he had not previously seen it and had not read through it.1773 The additional information should have led him to look again at the documentation sent to him by Celotex in August 2014, but he did not do so.1774 56.128 Jonathan Roome told us that he had thought at the time that Harley was adopting the desktop study route to compliance with the Building Regulations, as set out in Approved Document B.1775 However, he had not seen any desktop study relating to the proposed external wall of Grenfell Tower, or any reference to one.1776 In fact, none existed and Mr Roome had no grounds for thinking that that was Harley’s chosen approach. We do not accept that he formed any view at the time about how Harley intended to demonstrate compliance with the Building Regulations or that he cared. He suspected that Harley had either not read or not understood the warning in the Celotex marketing literature and pursued the sale regardless of the consequences. The first order of RS5000 for Grenfell Tower 56.129 SIG was one of a small number of major distributors of Celotex and other insulation products1777 and supplied RS5000 for use at Grenfell Tower. SIG invoiced Harley for its first order of RS5000 on 1 April 2015.1778 Grenfell Tower as a “case study” 56.130 On 8 April 2015, Jonathan Roome met Ben Bailey at Harley’s offices.1779 By then the first batch of RS5000 had been delivered to site but installation had not yet begun. Mr Roome proposed that Grenfell Tower could be used as a case study because it was one of the first major projects in which RS5000 was being used on a building above 18 metres in height.1780 Ben Bailey thought that any case study would focus on the U-value which could be achieved using RS5000.1781 Despite intending to publish a leaflet describing the product and its use on the tower, Mr Roome did not ask Mr Bailey what the rainscreen was to be.1782 Ben Bailey knew that RS5000 had not been widely used before, but he did not realise 1770 Ray Bailey {Day33/85:18-21}. 1771 Ray Bailey {Day33/86:1}-{Day33/87:6}. 1772 {CEL00003628}. 1773 Anketell-Jones {Day36/147:16-18}. 1774 Anketell-Jones {Day36/127:11-14}. 1775 Roome {Day70/80:21-24}. 1776 Roome {Day 70/81:2-14}. 1777 Roome {Day69/71:19-23}. 1778 {SIG00000022}. 1779 {CEL00000039}; {CEL00001443}. 1780 Harley agreed. {CEL00000039}; Roome {Day70/38:10-21}; {CEL00001443}; Roome {Day70/40:1-25}; {CEL00000558}; {CEL00000566}. Roome {Day70/41:19-23}, and the first project for Jonathan Roome. {Day70/43:4-7}. 1781 Ben Bailey {Day39/92:9-25}; {Day39/93:15-17}. 1782 Roome {Day70/41:1-10}.

Part 6 | Chapter 56: The choice of insulation 169 that Grenfell Tower was being treated by Celotex as a flagship project for the use of the product, although the very suggestion that it be treated as a case study might have alerted him to that fact.1783 56.131 Kingspan K15 insulation was used in substitution for RS5000 on Grenfell Tower from time to time when Harley encountered problems with the supply of RS5000. It was used in much smaller quantities than RS5000, but the amount was not insignificant. Photographs indicate that it was certainly used on the west side of the tower,1784 but the precise locations where it was used are not known and cannot be established given that much of the insulation was consumed in the fire. 56.132 K15 was not included in the NBS Specification and no substitution of materials described in the Employer’s Requirements or Contractor’s Proposals was permitted without the prior written consent of the TMO. It was Rydon’s responsibility to obtain that consent, but it failed to do so in relation to the substitution of K15 for RS5000. The decision to use K15: March – September 2015 56.133 Although Studio E was in possession of a product datasheet for K151785 and both Bruce Sounes and Neil Crawford were aware of the product, neither of them knew until after the fire that it had been used on Grenfell Tower.1786 They are not to blame for that, since they were never consulted about it, either by Harley or Rydon, and had no other means of knowing. 56.134 Harley was familiar with K15, having used it before on its Merit House1787 and Wayland House projects.1788 On 4 March 2015, Mark Stapley of Harley sent SIG an email requesting a quotation for K15 for comparison purposes with RS5000.1789 Ben Bailey could not remember having talked to Mr Stapley about it; nor could he remember why Mr Stapley wanted a price for an alternative product.1790 On 9 March 2015, he sent Mr Stapley an email to which he attached a leaflet relating to a different Kingspan insulation product.1791 One can see, therefore, that K15 and other products were being considered for use on the project as early as March 2015,1792 but no K15 was ordered at that time. 56.135 On 26 May 2015, Ms Walker of SIG sent an email to Ben Bailey explaining that a delivery of RS5000 that had been arranged for 3 June 2015 would be delayed until 10 June.1793 Mr Bailey replied, asking whether SIG held K15 in stock at the same thickness.1794 He told us that before receiving that email Ms Walker had told him that SIG had problems with obtaining products from Celotex and that in the course of their conversation Ms Walker had suggested K15 as an alternative,1795 as being equivalent to RS5000.1796 1783 Ben Bailey {Day 39/93:12}-{Day39/94:15}. 1784 {RYD00055130} showing west face where Kingspan logos can be seen on some insulation panels, and see Hughes {Day27/147:19}-{Day27/148:23}. 1785 {SEA00001009}; Sounes {Day12/188:2-7}. 1786 Crawford {Day10/139:21}-{Day10/140:10}. Sounes {Day12/189:3-11}. 1787 Ben Bailey {Day39/31:23}{Day39/32:3}; {Day39/142:11-14}. 1788 Ray Bailey {Day33/19:20}-{Day33/20:7}. 1789 {HAR00010030}. Quotation is at {HAR00009721}; {HAR00009722}; Ben Bailey {Day39/108:3-7}. 1790 Ben Bailey {Day39/104:10-18}. 1791 {HAR00009643} attaching {HAR00009644}, a brochure for Kingspan OPTIM-R which made clear, on page 7, that K15 was suitable for use in buildings over 18 metres. 1792 {HAR00009721}; Ben Bailey {Day39/108:3-7}. 1793 {SIG00000013/2}. 1794 {SIG00000013/2}. 1795 Ben Bailey {Day39/110:23}-{Day39/111:23}; {Day39/113:18-21}. 1796 Ben Bailey {Day39/109:11-20}.

The Grenfell Tower Inquiry: Phase 2 Report 170 56.136 We accept that Harley decided to substitute K15 for RS5000 because of difficulties obtaining RS5000 on time,1797 but we do not accept that Mr Bailey had a telephone conversation with SIG of the kind he described. Mr Bailey’s response to Ms Walker’s email of 26 May (“Are you joking?!”)1798 conveys an immediate reaction, not one that followed a telephone call during which he had already been told about the delay. Moreover, if Ms Walker had discussed with him the suitability of K15 as an alternative, it is likely that she would have referred to it in her next email. We think it much more likely that the use of K15 as an alternative to RS5000 was suggested by Ben Bailey in his reply to Ms Walker. We do not accept that she told him at any time that K15 was an equivalent product to RS5000. 56.137 Ray Bailey told us that K15 had been investigated and approved for use on high-rise buildings in in 2010 or 2011 by Graham Hackley, who was then Harley’s Technical & Estimating Manager1799 and that no further checks on its suitability had been made since it had received his approval.1800 However, Mr Bailey conceded that there was nothing in the documents to support the conclusion that Mr Hackley had undertaken any such investigation or provided any such approval.1801 In any event, Ray Bailey described K15 as a standard insulation product throughout the industry for tall buildings.1802 56.138 Ben Bailey was confident about using K15 because Harley had used it on other projects.1803 He shared his father’s understanding that K15 could be used on high-rise buildings1804 and in combination with any rainscreen.1805 He did not look at the LABC certificate1806 or the relevant BBA certificate;1807 indeed, Harley had on file only the 2008 version of the BBA certificate, which by June 2015 was more than five years old and had been superseded.1808 56.139 Ben Bailey’s evidence was that following receipt of Ms Walker’s email he had checked the U-values achievable by K15 and had looked at the 2008 BBA certificate or the product literature to check that it was rated Class 0, but no more than that. He said that he had made those enquiries in the office alongside Daniel Anketell-Jones and Mark Stapley.1809 56.140 Daniel Anketell-Jones told us that he had not been aware that K15 had been used on Grenfell Tower,1810 which, if true, casts some doubt on whether Ben Bailey really did make the enquiries to which he referred. The first purchase order for K15 appears to have been sent to SIG within an hour of Ms Walker’s initial email,1811 so any research or investigation conducted by Ben Bailey must necessarily have been very limited. He did not 1797 The evidence of all the relevant Harley witnesses was that the substitution was motivated by supply chain issues: Ray Bailey {HAR00010184/29} page 29, paragraph 114; Ben Bailey {HAR00010060/8} page 8, paragraph 26; Ben Bailey {Day39/113:4-6}; Lamb {Day38/38:8-25}. 1798 {SIG00000013/2}. 1799 Ray Bailey {Day32/16:6-16}; {Day32/17:10-23}; {Day32/18:3-5}; {Day33/19:6}-{Day33/20:9}. It was signed off as being “for use pretty much on all projects” {Day33/100:2-5}; {Day33/100:10-11}. 1800 Ray Bailey {Day33/30:2-3}; {Day33/99:6-10}. 1801 Ray Bailey {Day33/100:10-22}. 1802 Ray Bailey {Day33/98:21-25}. 1803 Ben Bailey {Day39/124:16-18}; {Day39/124:25}-{Day39/125:5}. 1804 Ben Bailey {Day39/56:4-7}. 1805 Ben Bailey {Day39/102:18-21}. 1806 {KIN00016733}. Ben Bailey {Day39/126:2-5}. He was not aware of the LABC as a body {Day39/126:11-13}. 1807 {KIN00000454}. The 2013 version. 1808 {BBA00000038}. Ben Bailey did not know that the BBA certificate was out of date, a second certificate having been issued in 2013 {BBA00000036}; Ben Bailey {Day39/119:5-19}. 1809 Ben Bailey {Day39/117:6-11}; Ben Bailey {Day39/117:22-25}; {Day39/118:1-16}; {Day39/119:1-4}. 1810 Anketell-Jones {Day37/1:23}-{Day37/2:2}. 1811 {SIG00000012}; {SIG00000013}; Ben Bailey {Day39/116:17-18}.

Part 6 | Chapter 56: The choice of insulation 171 consider whether the cladding system proposed for Grenfell Tower was the same as that which had included K15 and had apparently met the criteria in BR 135 following a test in accordance with BS 8414.1812 56.141 Ray Bailey accepted that Harley had not investigated whether there was any test evidence which showed that K15 was of limited combustibility1813 and agreed that Harley ought to have made further enquiries about the combustibility of K15 before using it on Grenfell Tower.1814 There was nothing in the 2008 BBA certificate1815 to confirm that K15 was a product of limited combustibility and nothing to indicate that it was appropriate for use in any configuration of cladding system. In short, the literature did not show that K15 was safe for use on Grenfell Tower. 56.142 Harley placed two orders for K15: 96 units with SIG on 26 May 20151816 and 49 units with CCF on 10 September 2015.1817 Hugh Bailey, a project manager at Harley, asked CCF for a further 60 units on 10 September 2015, but no purchase order or invoice was raised in respect of that quantity.1818 56.143 Ben Bailey did not consider finding an alternative supplier for RS5000 because he thought it would take too long to open a credit account with a new supplier.1819 He thought that the week-long delay to the supply of RS5000 was critical to the programme and Harley was under pressure from Rydon to keep up progress in accordance with the programme of works.1820 56.144 Ben Bailey said that in May 2015,1821 he had spoken to Simon Lawrence or Simon O’Connor about the substitution of K15 for RS5000. He said that they had discussed the U-values of both products and the fact that they were both rated Class 0.1822 Ben Bailey said that Mr Lawrence had understood the reason for the substitution and had agreed to it immediately.1823 There had been no mention of the need to obtain Rydon’s express consent.1824 56.145 The recollections of Mr Lawrence and Mr O’Connor differed substantially from that of Mr Bailey. They both said that they had been unaware of the use of K151825 and Mr Lawrence said that he had not been aware that Harley had ever sought permission for the use of K15.1826 Mr O’Connor also said that he had not been aware of any discussions about a substitution.1827 They accepted that Rydon had to obtain the TMO’s permission before substituting any product specified in the NBS Specification and that Harley was obliged to obtain the written approval of Rydon before any alternative insulation product could be used in the external wall envelope.1828 Simon Lawrence accepted that 1812 Ben Bailey {Day39/127:21-25}. 1813 Ray Bailey {Day33/102:17-25}. 1814 Ray Bailey {Day33/103:7-18}. 1815 {BBA00000038}. 1816 {SIG00000012}; {SIG00000013}. 1817 {CCF00000019}. 1818 {CCF00000015}. 1819 Ben Bailey {Day39/128:10-20}. 1820 Ben Bailey {Day39/130:12-13}; {Day39/131:13-17}. 1821 Ben Bailey {Day39/152:6-13}. 1822 Ben Bailey {Day39/129:15-21}. 1823 Ben Bailey {Day39/152:14-21}. 1824 Ben Bailey {Day39/129:22-25}. 1825 Lawrence {Day24/138:22-23}; {Day24/139:1-21}; {Day24/148:1-10}; {Day24/148:12-18}; {Day24/149:2-20}; {Day24/151:20-21}; O’Connor {Day26/98:8-11}. 1826 Lawrence {Day24/150:3-12}. 1827 O’Connor {Day26/110:10-13}; {Day26/111:10-14}. 1828 {INQ00011211/8} condition 2.4.1; Lawrence {Day24/147:2-5}.

The Grenfell Tower Inquiry: Phase 2 Report 172 obtaining consent from the TMO was his responsibility during his time on the project.1829 Mr Lawrence, Mr O’Connor and Mr Blake of Rydon said that the usual course would have been to confirm compliance with the architect before obtaining the written consent of the client to the substitution.1830 56.146 Ben Bailey said that Mr Lawrence had agreed to the substitution immediately, but that was not something he was entitled to do. He knew that the suitability of any substitute would need to be confirmed by Studio E before receiving the consent of the TMO. In those circumstances, we think it unlikely that Mr Lawrence would have agreed to the use of a new product without alerting Mr Bailey to the need to refer the proposal to Studio E for comment. If there had been such a conversation we are confident that it would have been recorded, or at any rate mentioned in some way, in one of the contemporaneous documents, but there is no such record and in those circumstances we are unable to accept Mr Bailey’s account. We are satisfied that Ben Bailey acted on his own initiative to substitute K15 for RS5000 in order to avoid a delay to the programme. Harley’s previous use of the product had led him to believe that K15 was suitable for use on high-rise buildings in conjunction with any rainscreen system. That assumption was, however, wrong. 56.147 It is not clear to us why a delay of a week was thought to make a sufficient difference to justify using a product that had not been specified and had not been considered by the design team as a substitute for one that had been prescribed in the NBS Specification and had been used extensively on the project. We think that Ben Bailey, who was a young and inexperienced site manager, succumbed to pressure, actual or perceived, from the main contractor to keep up with the construction programme. He thought that K15 was essentially the same as RS5000 and in his mind there was no reason to think that it was unsafe. The further use of K15: December 2015 56.148 In December 2015 or January 2016 David Hughes of Rydon discussed the use of a Kingspan insulation product with Ben Bailey who was again having difficulty obtaining RS5000.1831 Mr Bailey had sent him the K15 product datasheet and he read it to check that the U-value that could be achieved with K15 was similar to that which could be obtained using RS5000.1832 He had described it as a “like-for-like” swap.1833 Mr Hughes thought that Mr Bailey was asking his permission to use K15 in the future1834 and agreed that he could.1835 Shortly afterwards Mr Hughes told Stephen Blake and the clerk of works, Jon White, about the substitution.1836 56.149 K15 had first been ordered and supplied in May 2015, at least seven months before Mr Hughes’ conversation with Ben Bailey, and again in September 2015. Mr Hughes said he had no recollection of those orders and did not know that K15 had already been used on the tower.1837 It is therefore very difficult to understand why Mr Hughes should have been asking Mr Bailey about the suitability of K15 and, at least in his mind, giving Mr Bailey 1829 Lawrence {Day24/147:6-17}. 1830 Lawrence {Day24/156:11-14}; O’Connor {Day26/111:6-9}; Blake {Day29/116:11-18}; {Day29/116:19}-{Day29/117:11}. 1831 Hughes {RYD00094213/10} page 10, paragraph 55. 1832 Hughes {Day27/58:10-19}; {Day27/63:25}; {Day27/64:1-16}. 1833 Hughes {Day27/58:21-25}; Ben Bailey’s evidence was that it was “a common thought” within Harley that K15 and RS5000 were equivalent products: Ben Bailey {Day39/107:1-3}; {Day39/108:11-19}. 1834 Hughes {Day27/59:17-24}; {Day27/60:5-9}; {Day27/63:23-25}; {Day27/66:21-22}; {Day27/71:7-11}. 1835 Hughes {Day27/71:23}-{Day27/72:1}. 1836 Hughes {Day27/66:6-18}. 1837 Hughes {Day27/148:12-16}.

Part 6 | Chapter 56: The choice of insulation 173 permission to substitute K15 for RS5000 when K15 had been used on two occasions some months earlier.1838 For his part, Mr Bailey did not recall giving Mr Hughes the datasheet on K15, or indeed any discussion with Mr Hughes about it.1839 56.150 Having considered all the evidence, we have come to the conclusion that Rydon did not become aware of the use of K15 until December 2015 or January 2016, long after it had first been installed on parts of the facade. However, photographs from September and November 2015 clearly show Kingspan insulation on the building1840 and Rydon could have noticed that, if it had bothered to look. 56.151 Stephen Blake told us that he had become aware that a quantity of K15 was being used on the building towards the end of the project1841 and agreed that he had discussed the matter with David Hughes. He was not able to recall that conversation in any detail, however, or when it had occurred.1842 Mr Blake said that Mr Hughes had told him that the Kingspan and Celotex products were equivalent and that he had accepted that.1843 Mr Blake assumed that K15 was equivalent in every respect to RS5000 and did not take any steps to establish its suitability for use on the project.1844 In fact, he thought that Mr Hughes was describing the same material manufactured by different companies.1845 He acknowledged that he ought to have checked for himself whether the products were essentially the same.1846 56.152 None of the Rydon witnesses had ever seen the LABC or BBA certificates for K15 and they did not investigate the suitability of K15 for use on Grenfell Tower.1847 No one at Rydon consulted Studio E about the substitution; nor did Rydon take any advice from Exova or any other fire engineer to confirm that K15 was safe for the intended use. There was, therefore, a complete failure on Rydon’s part to investigate the suitability of K15 for its intended use. After it had become aware that K15 was being used, Rydon relied on Ben Bailey’s assurance that K15 was an equivalent product to RS5000, which everyone assumed was suitable.1848 56.153 Neither Mr Hughes nor Mr Blake consulted the TMO or informed building control that a substitution was going to be, or had in fact been, made.1849 Mr Hughes thought that K15 and RS5000 were very similar and that the substitution did not make any difference.1850 Building control was not provided with any document which showed that K15 was being used as insulation and no attempt was made to obtain the TMO’s consent to the substitution at that or any other stage. 1838 Ben Bailey’s explanation was that the discussion had been prompted by a change in site management. Ben Bailey {Day39/136:18}-{Day39/137:25}. 1839 Ben Bailey {Day39/136:1-11}. 1840 {RYD00051704}; {RYD00055130}. 1841 Blake {Day29/109:12-21}. 1842 Blake {Day29/14:14-25}; {Day29/111:1-11}; {Day29/112:8-13}. 1843 Blake {Day29/111:13}-{Day29/112:3}. 1844 Blake {day29/115:7-16}. 1845 Blake {Day29/113:3-4}. 1846 Blake {Day29/113:10-14}. 1847 {KIN00016733}; {KIN00000454}. Lawrence {Day24/155:4-8}; O’Connor {Day26/109:2-6}; Hughes {Day27/59:1-6}; Hughes {Day27/64:17-21}; Hughes {Day27/65:1-6}; Hughes {Day27/147:12-17}; Blake {Day29/114:17}-{Day29/115:16}. 1848 Blake {Day29/118:14-18}; {Day29/119:9-10}; {Day29/119:22-24}. 1849 Blake {Day29/117:13-17}; Hughes {Day27/67:5-8}; Hughes {Day27/67:17}-{Day27/68:8}. 1850 Hughes {Day27/68:1-8}; Hughes {Day27/70:4-5}.

174 The Grenfell Tower Inquiry: Phase 2 Report

175 Chapter 57 Cavity barriers Introduction 57.1 In this chapter we examine the use of cavity barriers on the Grenfell Tower refurbishment project, including the formulation of a cavity barrier strategy by Studio E and Harley and the installation of the cavity barriers themselves by Osborne Berry. We have concluded that none of the construction professionals gave adequate consideration to the use of cavity barriers at any stage of the design process. Moreover, it was also an aspect of the design that received scant attention from building control, either in the course of reviewing the drawings or during inspections on site. Although there were a number of detailed discussions between the design professionals about cavity barriers, none of them paid sufficient attention to the need for an overall strategy or gave sufficient consideration to the purpose of cavity barriers in preventing the spread of fire. As a result, cavity barriers were not installed in the correct positions and were entirely missing around the windows. In addition, many of the cavity barriers which were fitted were poorly installed. 57.2 Although the failure to ensure that cavity barriers were properly installed within the cladding probably had little effect on the ultimate development of the fire,1851 it demonstrates a worrying lack of attention to fire safety which we think it is important to record as part of our analysis of the events which led to the tragedy. Moreover, it is possible that the absence of cavity barriers around the windows played a part in enabling the fire to escape from Flat 16 and gain unrestricted access to the combustible insulation and ACM PE cassettes.1852 For those reasons we explain below how it came about that the cavity barriers at Grenfell Tower were so poorly designed and installed. 57.3 Two types of cavity barrier were used in the external wall at Grenfell Tower. The horizontal cavity barriers were “open state”, meaning that they were designed to be installed with a gap between the face of the barrier and the rainscreen to allow the passage of air and moisture. On the edge of the barrier facing the panels was an intumescent strip that expanded to close the gap when exposed to heat. The vertical cavity barriers were described as “full fill”, meaning that they consisted of a solid piece of material spanning the entire cavity, thus forming a permanent vertical barrier against the horizontal spread of fire. Consideration of Cavity Barriers at or before RIBA Stage D 57.4 Although Studio E began talking to building control at an early stage in the project, there was no discussion about the cladding or the requirement for the installation of cavity barriers within the facade.1853 There was no mention of cavity barriers or of the need to 1851 Grenfell Tower Inquiry Phase 1 Report, Chapter 23, paragraph 23.60. 1852 Grenfell Tower Inquiry Phase 1 Report, Chapter 22, paragraph 22.40. 1853 The first meeting with building control took place on 7 November 2012. Adrian Jess’ email notes of that meeting dated 7 November 2012 {SEA00006526}; Sounes {Day21/132:23}-{Day21/133:3}; there was a further meeting on 17 September 2013 but, again, there was no focus on cladding or cavity barriers: Sounes {Day21/135:1-25}; Sounes {SEA00014273/129} page 129.

The Grenfell Tower Inquiry: Phase 2 Report 176 maintain compartmentation in Studio E’s Stage D report1854 dated 20 August 2013,1855 nor was there any reference to the installation of cavity barriers in any version of Exova’s Outline Fire Safety Strategy, including Issue 3 dated 7 November 2013.1856 Tender documentation: August 2013 – January 2014 57.5 The first person at Studio E to give any serious consideration to the need for cavity barriers was Tomas Rek. He had been asked to develop the NBS Specification and tender drawings to send to potential contractors.1857 Part of that task involved revising the existing tender drawings to show the location of cavity barriers.1858 57.6 Although some preliminary design work on cavity barriers had been undertaken before September 2013, it was limited. Mr Rek could not recall the extent of the work that had already been done but said that the NBS Specification had not been completely blank when he started working on it.1859 Mr Sounes’ belief was that Studio E had done some work on cavity barriers between December 2012 and June 2013.1860 57.7 At the time of his work on the tender documents, Tomas Rek was aware of Diagram 33 in Approved Document B, which set out the requirements for cavity barriers in specified locations,1861 but could not remember whether he had reminded himself of it at the time.1862 Although Bruce Sounes, who was supervising him, was aware of the guidance in Approved Document B he did not review Diagram 33 at any stage.1863 57.8 The tender pack which Studio E prepared to send to potential contractors included several drawings depicting the “Employer’s Requirements”, which set out the basic principles of the design. Between 24 and 25 September 2013 Mr Rek revised one of the drawings1864 to show cavity barriers and their locations. The original version of the drawing (dated 24 September 20131865) contained a label which read, “Provision of cavity fire barrier TBC”. The version produced by Tomas Rek the following day, 25 September 2013,1866 contained some information about the location of cavity barriers. In particular: a. Hatching had been applied to the Proposed Plan and Proposed Section drawings showing where cavity barriers were to be placed. b. Cavity barriers were shown along the line of compartment floors, in particular, i. The sections entitled “Proposed Plan – Cill Level” and “Proposed Plan – Window Level” had annotations reading, “Cavity fire barrier in line with compartment wall structure. Leave no gap to cladding.” 1854 {SEA00008054}. 1855 Sounes {Day21/76:16-19}. 1856 See Chapter 54. 1857 Rek {Day12/11:17-20}. 1858 Rek {Day12/98:4-6}. 1859 Rek {Day12/12:7-17}. 1860 Sounes {Day21/77:5-21}. 1861 Rek {Day12/94:7-15}. 1862 Rek {Day12/95:6-7}. 1863 Sounes {Day21/70:22}-{Day21/71:3}; {Day21/71:16}-{Day21/72:3}. 1864 Studio E’s drawing entitled “Employer’s Requirements - Proposed Typical Bay Plans, Section & Elevation”; Rek {Day12/107:20}-{Day12/108:5} 1865 {SEA00002155} with Studio E reference 1279 (06) 110 Rev 00. 1866 {SEA00002163} with the same Studio E reference.

Part 6 | Chapter 57: Cavity barriers 177 ii. The section entitled “Proposed Section – Typical Bay” contained annotations reading, “Ensure horizontal and vertical cavity barriers meet tightly” and “Cavity fire barrier in line with compartment floor structure. Leave max 25mm gap to cladding for ventilation and drainage.” c. Cavity barriers were not shown around the windows. Mr Crawford accepted that Studio E’s cavity barrier strategy did not require the installation of cavity barriers around the windows.1867 57.9 Although the drawing contained some unlabelled hatching next to the window reveal, Mr Rek was not sure whether he had intended to specify a cavity barrier in that position; the hatching was not labelled as such (unlike other cavity barriers shown in the drawing) and he accepted that a subcontractor looking at the drawing would not have interpreted the hatching as a cavity barrier in the absence of some other indication that that was intended.1868 In our view, on a fair reading of the drawing it did not clearly indicate a cavity barrier in that position. 57.10 Neither Mr Sounes nor Mr Rek could remember what had been the source of the information about the location of cavity barriers that had been used to create those drawings.1869 Mr Rek was unable to recall any discussions when he revised the drawings1870 but said that it had been his practice to discuss drawings with Mr Sounes when he made any material changes.1871 Mr Sounes recalled Mr Rek’s having told him that he had consulted others who had specialist knowledge about such things, but he could not remember the names of any particular individuals or companies he had contacted.1872 There is no record of any such conversations and we think it unlikely that any took place.1873 57.11 The drawings that Tomas Rek revised were at 1:20 scale and he was not asked to produce more detailed drawings at a 1:5 scale. He accepted in his evidence that drawings on a 1:5 scale would have clearly shown where cavity barriers were to be located.1874 57.12 On 1 November 2013, Tomas Rek sent an email to Terence Ashton of Exova asking him to confirm that the rainscreen cavity barriers should have 60 minutes’ fire resistance to match that of the compartmentation.1875 He did not ask Mr Ashton where cavity barriers ought to be placed or send him any drawings showing where he proposed to place them. A few days later Mr Ashton replied, saying that cavity barriers needed to have only 30 minutes’ fire resistance.1876 Mr Rek did not recall having spoken to Mr Ashton about the positioning of cavity barriers1877 and although Mr Sounes thought that the guidance in Section 9 of Approved Document B was unclear, he did not seek advice or assistance from Exova.1878 57.13 At no point did Studio E produce detailed drawings of typical elevations or sections for use at tender stage showing precisely where cavity barriers were to be positioned.1879 1867 Crawford {Day10/192:1-5}. 1868 Rek {SEA00014278/30} page 30, paragraph 126; Rek {Day12/110:2-4}; {Day12/112:1}-{Day12/113:2}. 1869 Sounes {Day21/83:8}-{Day21/84:6}; Rek {Day12/100:14-23}. 1870 Rek {Day12/108:19-21}. 1871 Rek {Day12/108:7-10}. 1872 Sounes {Day 21/82:17}-{Day21/83:3}; {Day21/73:20}-{Day21/74:6}. 1873 Sounes {Day21/83:4-7}. 1874 Rek {Day12/115:7-15}. 1875 {EXO00000586/1}. 1876 {EXO00000586/1} dated 4 November 2013. 1877 Rek {Day12/105:3-7}. 1878 Sounes {Day21/81:2-20}. 1879 Sounes {Day21/84:20-24}.

The Grenfell Tower Inquiry: Phase 2 Report 178 57.14 The tender drawings were accompanied by the NBS Specification, which contained details of the types of cavity barriers to be installed in the horizontal and vertical positions.1880 Although there was an inconsistency in the specification, one part requiring 60 minutes’ integrity and insulation and another only 30 minutes’ integrity and insulation,1881 both exceeded the minimum requirement in Approved Document B of 30 minutes’ integrity and 15 minutes’ insulation.1882 Studio E drawing design after tender 57.15 Studio E did not revise its drawings in relation to cavity barriers after the invitation to tender had been issued on 29 November 20131883 and as a result Harley based its design for the facade on the tender drawings.1884 Studio E continued to be involved in the project until Harley began its detailed design work in late August 2014,1885 but there is no evidence that it carried out any further work on the cavity barrier strategy during that time. Harley’s initial design 57.16 Harley’s design work started in earnest after Kevin Lamb was appointed on 12 August 2014.1886 Mr Lamb said that he had based his work on the plans, sections and elevations produced by Studio E for the key aspects of the external facade.1887 He also made use of a set of preliminary drawings of a typical window detail prepared by Samuel Anketell-Jones and Ray Bailey before his involvement. They did not show any cavity barriers.1888 57.17 Kevin Lamb accepted that the requirements of the NBS Specification relating to cavity barriers took precedence over the tender drawings.1889 The NBS Specification required compliance with Approved Document B and the Standard for Systemised Building Envelopes published by the Centre for Window and Cladding Technology (CWCT).1890 Both documents clearly called for cavity barriers around windows.1891 57.18 On 22 August 2014, Kevin Lamb produced some preliminary drawings to establish the basic principles of the design which he sent to Simon Lawrence of Rydon and copied to Studio E and Daniel Anketell-Jones of Harley.1892 Those drawings did not indicate where cavity 1880 In section P10 “Sundry insulation/ proofing work” at Clause 435. All three versions of the NBS Specification (21 November 2013 {SEA00000152/263}, 29 November 2013 {RYD00001712/245} and 30 January 2014 {SEA00000169/246}) contained the same clause 435 in Section P10 in respect of ventilated cavity barriers. 1881 The products specified were “Lamatherm CW-RSH60” and “Lamatherm CW-RSV60” which could have been interpreted as a reference to 60 minutes’ integrity. However, the clause also stated: “Fire resistance rating: 30/30 to BS 476, Part 20:1987 and BS EN 1366-4:2006. See also the witness statement of Stephen Swales (Siderise) which sets out the coding conventions for Siderise cavity barriers at the time. Swales {SIL00000306/9-10} pages 9-10, paragraph 38. 1882 Table A1 of Approved Document B: {CLG00000224/125}. 1883 This was done by email to Studio E on 29 November 2013 {SEA00010081}. Five main contractors were invited to tender: Mullaley, Durkan, Keepmoat, Rydon, and Wates. 1884 Lamb {HAR00010419/5} page 5, paragraph 22. 1885 Lamb {HAR00010419/6} page 6, paragraphs 22-24. 1886 {HAR00010418}. 1887 Lamb {HAR00010419/5} page 5, paragraph 20. 1888 {HAR00010432}. 1889 Lamb {Day38/123:22}-{Day38/124:21}. 1890 Dated September 2008 {CWCT0000046}. 1891 Approved Document B at {CLG00000224/83} paragraph 9.3; {CLG00000224/96} paragraph 12.8; the CWCT Standard {CWCT0000046/14} section 6.4.4.2 under the heading “Cavities in rainscreen walls”. 1892 {HAR00010426}.

Part 6 | Chapter 57: Cavity barriers 179 barriers would be placed within the facade.1893 Neil Crawford commented on the drawings on 27 August 20141894 but did not draw attention to the absence of cavity barriers.1895 He could not recall having raised the absence of cavity barriers with Harley at that time.1896 57.19 Mr Crawford provided further comments on Harley’s drawings on 3 September 2014 following a design team meeting1897 but did not refer to the absence of cavity barriers.1898 On 12 September 2014, he confirmed that he had no further comments to make.1899 The Request for Information 57.20 On 17 September 2014, for reasons which remain unclear, Daniel Anketell-Jones sent a formal Request for Further Information to Rydon and Studio E, with a copy to Kevin Lamb, seeking instructions on the provision of horizontal cavity barriers within the area of the cladding.1900 He suggested that cavity barriers were required at every floor level on the vertical columns, but not in the area between the windows because there was no “chimney” effect there so the cladding would not exacerbate the spread of fire. 57.21 On 18 September 2014 Mr Crawford sent the request on to Mr Ashton at Exova asking for his comments.1901 In response, Mr Ashton asked for a set of drawings, which were provided to him by Mr Crawford, who told him that they represented an attempt to establish the basic approach.1902 They included a drawing produced by Harley, which did not show any cavity barriers,1903 and drawings produced by Studio E,1904 which showed cavity barriers around each flat but not around the window frames. 57.22 Mr Ashton’s response was that if the insulation in the cavities was combustible it would be necessary to provide cavity barriers in order to prevent fire from spreading from one flat to the flat above. That advice was wrong, however, because cavity barriers were required regardless of the nature of the insulation.1905 Mr Anketell-Jones did not ask Mr Ashton why cavity barriers were required only if the insulation was combustible1906 and Mr Ashton did not comment on the absence of cavity barriers from Harley’s or Studio E’s drawings. 57.23 Later that same day, Mr Crawford sent Mr Ashton’s response on to Mr Anketell-Jones with copies to Simon Lawrence, Simon O’Connor and Kevin Lamb.1907 In response, Mr Anketell- Jones asked Mr Ashton to confirm his own view that since the insulation was rated Class 0, a “fire barrier” was not required between the windows and attached the datasheet for 1893 {RYD00016100}. 1894 {HAR00010423/2}. 1895 Crawford {Day10/185:2-5}. 1896 Crawford {Day10/185:11-14}. 1897 {HAR00010413}. 1898 {HAR00010423/2}; {HAR00012086}. 1899 {HAR00010423/1}. 1900 Email dated 17 September 2014 {HAR00003638/4}; RFI attachment {EXO00001291}. 1901 {HAR00003638/4}. 1902 Email: {HAR00003638/3}; Studio E Drawings attached: {EXO00000710}; {EXO00000711}; {EXO00000712}; Harley Drawing attached: {EXO00000713}. 1903 {EXO00000713} Title: Typical Bay Levels 1 to 20 West Elevation Reference: C1059-200, drafted by Kevin Lamb and dated 20 August 2014; Crawford {Day10/82:13-20}. 1904 {EXO00000710}; {EXO00000711}; {EXO00000712}. 1905 Ashton {Day18/39:1-18}. 1906 Anketell-Jones {Day36/162:4-8}. 1907 {HAR00003638/2}.

The Grenfell Tower Inquiry: Phase 2 Report 180 Celotex RS5000.1908 Simon Lawrence did not pay much attention to the exchange because he expected Harley to carry out the design work and Studio E to check it before it was referred to building control1909 for approval.1910 57.24 Mr Ashton replied to Mr Anketell-Jones on 18 September 2014 without having looked at the datasheet.1911 He pointed out that a material that had a Class 0 rating was not necessarily non-combustible, although the reverse was invariably true. He said that it was not clear from the information he had been given whether there was a continuous cavity from top to bottom in any part of the cladding, thereby inviting him to provide further information.1912 Mr Anketell-Jones sent Mr Ashton’s email on to Mr Crawford the same day asking him for his view on Mr Ashton’s comments about combustibility and continuous cavity paths. 57.25 The matter was allowed to rest there, however. Mr Ashton did not chase Mr Anketell-Jones for further information1913 and Mr Anketell-Jones did not pursue the matter with either Mr Crawford or Mr Ashton.1914 Harley’s work on the design of the windows: September 2014–March 2015 57.26 On 22 September 2014 Kevin Lamb sent Simon Lawrence a set of drawings for final approval reflecting comments made by Studio E at their previous meeting.1915 None of them contained any details of cavity barriers.1916 Although both Bruce Sounes1917 and Neil Crawford1918 both commented on the design of the windows, neither of them referred to the absence of cavity barriers around the windows. Mr Lamb expected details of the cavity barriers to be provided at a later date,1919 so he could not have considered the drawings to be final. 57.27 Mr Lamb issued a revised set of drawings on 14 January 2015,1920 all of which were marked as “Approved for Construction” although they did not show any cavity barriers. No one in the design team at Harley noticed the omission, possibly because Harley did not have a fully effective procedure for reviewing the status or progress of the design at particular points in the life of the project or for reviewing the design as it developed. Mr Lamb was not directly supervised1921 and he confirmed that no one had checked the revised drawings before they had been issued.1922 1908 {HAR00012104}. 1909 Lawrence {Day24/124:4-13}. 1910 Lawrence {Day24/123:17-22}. 1911 Ashton {Day18/46:15-23}; {Day18/47:3-19}; {Day18/49:1-8}; {Day18/55:6-8}. 1912 {HAR00003638}. 1913 Ashton {Day18/59:5-22}. 1914 Anketell-Jones {Day36/167:22-24}. 1915 {SEA00011759}; Attached drawings at {RYD00018436}. 1916 {RYD00000431}. 1917 On 22 September 2014 {RYD00018537}. 1918 On 24 September 2014 {RYD00018687}. 1919 Lamb {Day38/89:4-7}. 1920 {RYD00027692}; Attached drawings at {RYD00027693}; {RYD00027694}; {RYD00027695}; {RYD00027696}; {RYD00027697}; {RYD00027698}; {RYD00027699}; {RYD00027700}; {RYD00027701}; {RYD00027702}; {RYD00027703}; {RYD00027704}. 1921 Anketell-Jones {Day36/176:4-23}. 1922 Lamb {Day38/90:6-12}.

Part 6 | Chapter 57: Cavity barriers 181 57.28 Despite the fact that the drawings were marked as having been approved for construction, on 16 January 2015 Mr Crawford responded with his comments.1923 They had been marked using Studio E’s stamp as being either “Status A: Conforms to Design Intent” or “Status B: Conforms to Design Intent subject to incorporation of comments. Revise and resubmit for Category A status.” No mention was made of cavity barriers.1924 Although Mr Lamb said that there had been discussions within the design team in relation to cavity barriers, he was certain that he had never discussed the detailed guidance in Approved Document B on where cavity barriers ought to be placed to comply with functional requirement B4.1925 The fire at Taplow House 57.29 On 16 January 2012 a fire occurred in a flat on floor 17 of Taplow House, part of the Chalcots Estate in Camden.1926 The facade had been installed by Rydon and Harley using mineral wool insulation (probably Rockwool) and riveted Reynobond PE 55 rainscreen panels.1927 Timothy Lovell of Harley inspected the building on 17 January 2012 and prepared an initial incident report, which was distributed to Ray Bailey and Daniel Anketell- Jones, amongst others.1928 In it he recorded that, despite the fire and the amount of flammable items in the flat, the fire breaks had still been intact and had prevented the fire spreading between flats.1929 Above that paragraph was a photograph showing a “fire break” at the head of the window, although Ray Bailey thought that it was in fact a firestop rather than a cavity barrier.1930 57.30 Mr Lovell made a further inspection on 18 January 2012 and set out his findings in a report dated 23 January 2012, copies of which were given to Stephen Blake at Rydon, Ray Bailey and Daniel Anketell-Jones, amongst others.1931 The report again drew attention to the containment of the fire by “fire breaks” located at the head and sill of each window.1932 Mr Anketell-Jones said that he had not been aware that “fire breaks” had played an important part in preventing the spread of fire and did not recall anyone at Harley discussing the importance of cavity barriers or firestopping around windows following that fire.1933 He confirmed that, when Harley came to design the facade of Grenfell Tower, the fire at Taplow House appears to have been forgotten.1934 Ray Bailey accepted that Harley’s failure to implement the lessons from Taplow House was an error.1935 57.31 Stephen Blake of Rydon agreed that the use of cavity barriers around the windows of Taplow House had been a critical factor in preventing the spread of fire.1936 He also agreed that he had first-hand knowledge of the importance of cavity barriers around windows,1937 but despite that, he did not think it necessary to check with Studio E or Harley that proper cavity barriers had been included in their designs.1938 1923 {SEA00012531}; Annotated drawings at {SEA00003040}. 1924 Lamb {Day38/92:5-7}; Crawford {Day10/196:13}-{Day10/197:2}; {Day10/197:15-22}. 1925 Lamb {Day38/92:16}-{Day38/93:9}. 1926 Ray Bailey {HAR00010184/4} page 4, paragraph 15. 1927 Ray Bailey {Day33/141:13-20}; {Day33/60:15-25}. 1928 {HAR00010169}. 1929 {HAR00010169/4}. 1930 Ray Bailey {Day33/143:20-25}. 1931 {CEP000003223}. 1932 {CEP000003223/2-3}. 1933 Anketell-Jones {Day35/149:1-8}. 1934 Anketell-Jones {Day35/149:14-19}. 1935 Ray Bailey {Day33/146:11-16}. 1936 Blake {Day29/126:25}-{Day29/127:8}. 1937 Blake {Day29/127:17-19}. 1938 Blake {Day29/130:3-10}.

The Grenfell Tower Inquiry: Phase 2 Report 182 57.32 The experience at Taplow House ought to have made clear to Harley (and to a lesser extent, Rydon) the importance of installing fire protection measures around the windows at Grenfell Tower. But Harley and Rydon did not bear those lessons in mind when considering the design in the areas surrounding the windows of Grenfell Tower. Ray Bailey accepted that it was a mistake not to have done so.1939 March 2015 emails 57.33 On 3 March 2015, Kevin Lamb sent a set of drawings to Rydon which had been revised to include cavity barriers.1940 He also sent copies to various persons in Harley. Mr Lamb said that he had included cavity barriers in the drawings because the cladding was going to be installed soon and so completing the design had become urgent.1941 Mr Lamb had looked at some industry guidance in relation to cavity barriers,1942 but only to find out what rating was required, rather than to where they should be placed.1943 57.34 Each of the drawings bore a revision date of 3 March 2015. Cavity barriers were marked as broken lines surrounding compartments and were labelled as “firebreaks”. Mr Lamb said that “firebreak” was a generic term and that at the time of his work on the Grenfell Tower refurbishment project he would probably not have used the term “cavity barrier”.1944 There were no cavity barriers shown immediately around the heads, sills or jambs of the windows.1945 Mr Lamb’s explanation for their absence was that Studio E’s drawings and Harley’s instructions were to show cavity barriers only around the compartment.1946 The positioning of horizontal cavity barriers above the windows and supposedly in line with compartment floors was different from that which had been shown at the tender stage by Studio E.1947 Studio E’s drawings showed a cavity barrier immediately at the head of the window, whereas Harley’s drawings showed it at some distance from the head of the window in the spandrel section.1948 That change was never expressly brought to Studio E’s attention, despite Mr Lamb’s acceptance that it was a development of the design made by Harley.1949 57.35 The detail of the window head1950 showed a horizontal cavity barrier at some remove from the window frame, marked with honeycomb hatching and labelled “Firebreak cut around cladding rails. All joints taped on top face.” When he gave evidence Mr Lamb suggested that the cavity barrier was positioned above the head of the window because the window hung down below the structure and the concrete did not provide a flat 1939 Ray Bailey {Day33/146:11-16}. 1940 Email {SEA00012850} sent to Simon Lawrence, copying Neil Crawford, Bruce Sounes, Daniel Anketell-Jones, Mark Stapley, Mr Robert Maxwell and Mr Ben Bailey. Drawings attached: Specification Notes C1059-100 Rev A {SEA00000256}; Drawing Register {SEA00012855}; Typical Bay Levels 1 to 20 South Elevation C1059-202 Rev C {SEA00012851}; Typical Bay Levels 1 to 20 West/East Elevation C1059-201 Rev D {SEA00003155}; Typical Bay Levels 1 to 20 East & West Elevation C1059-200 Rev I {SEA00003156}; Jamb Joint Upper Levels and Typical Joint Upper Levels C1059-305 Rev C {SEA00012856}; and, Window Head Upper Levels C1059-301 Rev E {SEA00012857}. 1941 Lamb {Day38/97:5-14}. 1942 Lamb {HAR00010419/13} page 13, paragraph 50 gives the following list of the guidance Mr Lamb recalls consulting: Approved Document B, the Centre for Window and Cladding Technology (“CWCT”) Standard for Systemised Building Envelopes Part 6 – Fire Performance, the CWCT Technical Note 73 and Siderise technical literature. 1943 Drawings 200 {SEA00003156}; 201 {SEA00003155}; 202 {SEA00012851}; 301 {SEA00012857}; 305 {SEA00012856} Lamb {HAR00010419/13} page 13, paragraph 50; Lamb {Day38/99:3-8}. 1944 Lamb {Day38/100:8-12}. 1945 Lamb {Day38/101:7-10}. 1946 Lamb {Day38/102:4-10}. 1947 The Employer’s Requirements - Proposed Typical Bay Plans, Section & Elevation drawing {SEA00002163}. 1948 Lamb {Day38/102:11-21}. 1949 Lamb {Day38/110:15-20}; {Day38/111:13-15}. 1950 Harley drawing 301 {RYD00000220}.

Part 6 | Chapter 57: Cavity barriers 183 surface.1951 However, he conceded that something would have to be added if the cavity barrier were positioned above the head of the window as he had suggested.1952 Mr Lamb never considered how the integrity of the horizontal cavity barrier would be maintained if it were cut to fit around the vertical cladding rail1953 and he gave no thought to whether the gaps created by the cladding rails should be filled to maintain the integrity of the cavity barriers.1954 57.36 On 3 March 2015, shortly after he had sent the drawings to the design team,1955 Kevin Lamb sent an email to Barnaby Carrick, the Technical Applications Engineer at Siderise seeking his advice on using the horizontal barriers in a cavity which was wider than the maximum dimension shown in Siderise’s literature.1956 Mr Carrick replied the same day,1957 confirming that the information that Mr Lamb had provided was consistent with Siderise’s recommendations and that the proposed cavity barrier fell within their standard test data.1958 He also confirmed that the fixing details shown in Harley’s drawings1959 were acceptable. Mr Lamb did not ask Siderise for any further advice on the cavity barrier strategy.1960 57.37 Neil Crawford responded to Kevin Lamb’s email on 6 March 2015.1961 He confirmed that he had sought advice from Exova, but that his own interpretation was that the fire rating of the cavity barriers would have to follow that of the adjacent walls. He attached the Fire Strategy drawing.1962 Bruce Sounes confirmed that he had not looked at the drawings that Mr Lamb or Mr Crawford had sent him as, by that stage, although he was still nominally leading the design team, Mr Crawford was “fronting it”.1963 When he commented on Harley’s revised drawings1964 Mr Crawford did not draw attention to the absence of cavity barriers around the windows as, according to him, the strategy had been simply to have cavity barriers at the junctions between compartments.1965 Similarly, Mr Crawford did not comment on Harley’s note that the cavity barrier was to be cut around the cladding rail because he regarded it as a specialist item and he expected Harley to know what it was doing.1966 57.38 On 11 March 2015 Kevin Lamb sought further advice from Siderise about the rating of the cavity barriers.1967 He did not ask where to place the barriers as, in his mind, it was clear where they were going to go and their positioning had been approved in discussions with Harley.1968 Christopher Mort (Technical Officer for Fire at Siderise) replied on 12 March 20151969 advising that to meet the guidance in Approved Document B the area between the compartment wall and outer cladding needed only to be a cavity barrier (not a firestop) with just 30 minutes’ integrity and 15 minutes’ insulation. He included in his 1951 Lamb {Day38/104:9-23}. 1952 Lamb {Day38/106:12-18}. 1953 Lamb {Day38/112:8-13}. 1954 Lamb {Day38/151:7-17}; {Day38/152:6-8}. 1955 Lamb’s email to the design team {SEA00012850} was timed at 12:58. His email to Carrick was at 13:06. 1956 {HAR00004013} the cavity was 316mm which was wider than the maximum cavity of 300mm shown by Siderise. 1957 {HAR00004013}. 1958 The void size was less than 325mm and a 25mm air gap was present. 1959 Drawing C1059-305 {HAR00009737}. 1960 Lamb {Day38/95:10-15}. 1961 {SEA00012906}. 1962 {SEA00003101}. 1963 Sounes {Day21/90:13-25}. 1964 {SEA00003160}. 1965 Crawford {Day11/2:20-25}; {Day11/3:1-5}. 1966 Crawford {Day11/6:1-9}. 1967 Email from Mr Lamb to Mr Carrick dated 11 March 2015 {HAR00003999}. 1968 Lamb {Day38/118:11-22}. 1969 {SIL00000038}.

The Grenfell Tower Inquiry: Phase 2 Report 184 message a copy of Diagram 33 of Approved Document B,1970 which showed cavity barriers around the windows and contained a label reading “Close around openings” with arrows pointing to the top and bottom of the window.1971 57.39 Mr Mort did not give Mr Lamb any advice about the risks associated with using cavity barriers in a rainscreen system.1972 Nor did he provide any information about the limitations of the testing that Siderise had carried out on its cavity barriers.1973 Despite having Diagram 33 expressly drawn to his attention and himself noticing that cavity barriers were marked around the windows, Kevin Lamb took no steps to revise the cavity barrier strategy for Grenfell Tower.1974 57.40 On 18 March 2015, Ben Bailey sent an email to Neil Crawford telling him that Siderise had given advice about the required rating of the cavity barriers that differed from that received from RBKC building control.1975 Shortly afterwards, Mr Crawford spoke to Mr Hoban, who, on 20 March 2015, sent him an email informing him that the fire rating for any new elements of structure (including the cavity barriers) should be 120 minutes’ insulation and integrity and drawing attention to Diagram 33.1976 Mr Hoban was unable to recall the content of his conversation with Mr Crawford.1977 57.41 On 25 March 2015, Mr Lamb sent revised versions of Harley’s drawings1978 to Simon Lawrence with copies to members of the design team.1979 The drawings contained revised details of the “firebreaks”, the ratings of which had all been increased to 120 minutes’ integrity and 60 minutes’ insulation. 57.42 Following a discussion they had had the day before, on 26 March 2015 Ben Bailey sent an email to Richard Kay, National Facades Manager at Siderise, asking him to identify the regulations which supported Siderise’s opinion that cavity barriers with 30 minutes’ integrity and 15 minutes’ insulation were all that was required.1980 He asked Mr Kay to do that because he was not familiar with them himself and was wholly dependent on Siderise for advice.1981 Mr Kay replied the following day, copying in Kevin Lamb and others at Harley.1982 He included in his email an extract from Approved Document B1983 which showed that 30 minutes’ fire integrity and 15 minutes’ insulation were recommended. Mr Bailey was unable to recall the conversation he had had with Mr Kay.1984 57.43 Ben Bailey forwarded that email to Simon Lawrence and Simon O’Connor on 26 March 2015 with the comment that there was quite a large difference in cost between the cavity barriers that Siderise had recommended (and the project specification required) and the 1970 {SIL00000038/7}. 1971 {BSD00001779}. 1972 Mort {Day103/16:19}-{Day103/17:10}. 1973 Mort {Day103/17:11-24}. 1974 Lamb {Day38/120:4-24}. 1975 {SEA00012953} The email was copied to Daniel Anketell-Jones, Mark Stapley, Robert Maxwell, John Hoban, and Kevin Lamb. 1976 {RBK00048734}. 1977 Hoban {Day46/112:10-14}. 1978 Harley drawings 100 {HAR00017787}, 301 {HAR00008901}, 304 {HAR00017785}, 305 {HAR00017784}, 325 {HAR00017783} and 326 {HAR00017782}. 1979 {HAR00017781}. Bruce Sounes, Neil Crawford, Daniel Anketell-Jones, Mark Stapley, Ben Bailey and Robert Maxwell were copied in. 1980 {HAR00004002/3}. 1981 Ben Bailey {Day40/61:21}-{Day40/62:3}. 1982 {HAR00004002/2}. 1983 Table A1 from Appendix A. 1984 Ben Bailey {Day40/61:1-5}.

Part 6 | Chapter 57: Cavity barriers 185 120 minute cavity barriers suggested by building control.1985 According to Neil Crawford, there was pressure from those on site not to specify cavity barriers with 120 minutes’ fire resistance due, at least in part, to the additional cost and delay that might be caused.1986 57.44 Subsequently Neil Crawford referred the question of the rating of the cavity barriers back to Mr Hoban.1987 On 27 March 2015, he sent the email from Siderise to Mr Hoban and asked him to review the position. However, Mr Hoban adhered to his original view and Mr Crawford reported that to the design team later that day.1988 57.45 On 27 March 2015 Ray Bailey sent an email to Simon Lawrence, Neil Crawford and Ben Bailey with copies to Simon O’Connor, Kevin Lamb and Daniel Anketell-Jones, explaining the difference between a firestop and a cavity barrier.1989 Ray Bailey did not comment on the absence of cavity barriers around the windows in the drawings produced by Harley. 57.46 Later the same day Ray Bailey sent the exchange to Daniel Anketell-Jones for his comments.1990 Mr Anketell-Jones replied: “Just that it’s ridiculous. There is no point in ‘fire stopping’, as we all know; the ACM will be gone rather quickly in a fire! The whole point is to stop ‘unseen’ fire spreading in the cavity and moving to other parts of the building.”1991 We have considered that exchange in Chapter 55 where we have set out our conclusions on the choice of ACM PE rainscreen panels for use on Grenfell Tower. Mr Anketell-Jones accepted that in his email he had been expressing an opinion about the risk of fire spreading within the cavity unseen and how that affected the cavity barrier strategy,1992 but that did not lead him to think about the importance of preventing fire from spreading from a compartment into the cavity in the first place.1993 57.47 On 30 March 2015 Neil Crawford sent another email to Mr Hoban, recommending that he speak to Ben Bailey,1994 but he did not check whether Mr Hoban had spoken to Mr Bailey or anyone else at Harley.1995 Neither Mr Hoban nor Mr Bailey was able to recall whether a conversation had taken place.1996 57.48 Shortly after,1997 on 30 March 2015, Mr Hoban replied to the project team and Mr Kay of Siderise setting out his view.1998 He referred to his email of 20 March 2015 and said that in his view Diagram 33 of Approved Document B required a firestop with 120 minutes’ resistance between compartment floors. 1985 {RYD00037117/2}. 1986 Crawford {Day11/45:1-10}. 1987 {HAR00003947/7}. 1988 {RYD00037117}. 1989 {RYD00037117}. 1990 {HAR00006585}. 1991 {HAR00006585}. 1992 Anketell-Jones {Day37/22:2-16}. 1993 Anketell-Jones {Day37/27:9-14}. 1994 {HAR00003947/7}. 1995 Crawford {Day11/52:3-7}. 1996 Hoban {Day46/119:10-17}; Ben Bailey {Day40/70:24}-{Day40/71:15}. 1997 Mr Crawford’s email suggesting Mr Ashton contact Mr Bailey was at 12:49. Mr Hoban’s response was at 14:22 on the same day. 1998 {EXO00000715/2}.

The Grenfell Tower Inquiry: Phase 2 Report 186 57.49 The repeated references to Diagram 33 throughout the email exchanges leaves little room for doubt that all the construction professionals involved either knew or ought to have known that a cavity barrier strategy in accordance with that diagram was required, but regrettably it appears to have been ignored. The “weak link” 57.50 On receipt of Mr Hoban’s email of 30 March 2015, Mr Kay asked Harley to send him drawings of the build-up of the cladding so that his technical officer could evaluate the position and provide a formal response.1999 In response Ben Bailey sent him two drawings2000 with copies to Mr Mort.2001 Mr Kay had also asked for a section drawing through the whole window to give to Mr Mort for comment,2002 but Ben Bailey was unable to provide that drawing. That struck Mr Mort as odd, because he would normally have expected to see a full section which clarified the window details.2003 57.51 Mr Mort replied the same day.2004 He said: “I have reviewed the drawings sent over and sketch a proposal to alleviate the issues raised by the BCO, also on the second page of the attachment I have highlighted the weak link so to speak in terms of fire and I think the [building control officer] would have also noticed this. The proposal requires the installation of RH25g 90/60 product in two layers one at the head of the window aligning with the compartment floor and the other at the top of the existing up stand, therefore two layers of 60 minutes protection that overall would provide if tested over 120 minutes protection, at the window locations…” 57.52 Mr Mort confirmed that he had prepared two sketches, one to show the proposed solution to increase the fire resistance of the cavity barriers to 120 minutes2005 and one to identify what he called a “weak link” for fire at the head of the window.2006 According to him, they were distinct sketches with distinct purposes.2007 The weak link that Mr Mort had identified was a gap at the head of the window, where there was nothing to stop a fire spreading from an internal compartment into the external cavity.2008 It was a clear error, to which Mr Mort felt he had to draw attention. It was his opinion that Harley or building control ought to have noticed it.2009 57.53 The first of Mr Mort’s sketches described his proposed means of producing cavity barriers with 120 minutes’ fire resistance.2010 It showed two pairs of cavity barriers, one pair above the window head and another pair at the sill, each made up of two individual barriers rated 90 minutes’ integrity and 60 minutes’ insulation to achieve a total of 180 minutes’ fire resistance and 120 minutes’ insulation.2011 Mr Mort said that it had not been clear 1999 {HAR00003947/4-5}. 2000 Drawing 300 showing a section of the windowsill and Drawing 301 showing a section of the window head {HAR00019402} and {HAR00019403}. 2001 {HAR00019401}. 2002 As shown on Mr Mort’s annotated drawing as “C-C”: {RYD00037413}. 2003 Mort {Day103/29:15}-{Day103/30:13}. 2004 {HAR00018971}. 2005 {HAR00003948}. 2006 {HAR00003948/2}. 2007 Mort {Day103/33:9-19}. 2008 Mort {SIL00000298/8} page 8, paragraph 31(c); Mort {Day103/34:25}-{Day103/35:10}. 2009 Mort {SIL00000298/8} page 8, paragraph 31(c); Mort {Day103/37:24}-{Day103/38:7}. 2010 {HAR00003948}. 2011 Mort {Day103/38:15-20}.

Part 6 | Chapter 57: Cavity barriers 187 from Harley’s drawings whether there were vertical cavity barriers at the window jambs. He accepted that the cavity barriers he had added at the sill of the window in his sketch were slightly below the sill itself, but said that the drawing was a schematic rather than a detailed design.2012 57.54 The second sketch which Mr Mort had prepared was based on a drawing produced by Harley, to which he had added a bubble containing the note “weak link for fire”.2013 The sketch showed the new window set back from the edge of the building, exposing a gap between the window brackets, as shown below.2014 Figure 57.1 – Harley drawing 301 57.55 Ben Bailey thought that the purpose of Mr Mort’s email and sketches was to provide a solution to the dispute about whether there should be cavity barriers or firestopping2015 and he noticed that Mr Mort had drawn cavity barriers at the head and sill of the window in the first sketch.2016 However, he did not communicate Mr Mort’s views, including about the weak link for fire, to anyone at Studio E, Rydon or building control, despite Mr Mort’s having said that he thought that the building control officer would have noticed the problem.2017 Nor did he ask Mr Mort to clarify exactly what he meant.2018 Ben Bailey’s explanation was that he had read the emails together and, as Mr Hoban had changed his position shortly afterwards, he did not feel the need to refer Mr Mort’s email to him.2019 2012 Mort {Day103/39:21}-{Day103/40:19}. 2013 Harley drawing 301 {HAR00003948/2}. 2014 Mort {Day103/36:11}-{Day103/37:3}. 2015 Ben Bailey {Day40/74:12-17}; {Day40/76:4-11}. 2016 Ben Bailey {Day40/80:17-24}. 2017 Ben Bailey {Day40/75:7-21}; {Day40/86:17-25}. 2018 Ben Bailey {Day40/76:20-25}; {Day40/85:17}-{Day40/86:2}; Crawford {Day11/6:11-15}. 2019 Ben Bailey {Day40/76:12-19}; {Day40/76:4-11}.

The Grenfell Tower Inquiry: Phase 2 Report 188 57.56 That explanation is far from satisfactory. It made no sense for Ben Bailey to disregard Mr Mort’s concerns about the design of the window head simply because the dispute over the rating of the cavity barriers had been resolved shortly afterwards. It was foolhardy to ignore the very clear warning about the design of the window, since it should have been plain to anyone reading Mr Mort’s email and reviewing his sketches that the two issues were distinct from one another.2020 57.57 Later the same day Ben Bailey forwarded the email from Mr Mort to others at Harley, including Ray Bailey and Kevin Lamb.2021 He expected them to read its contents and also the attachments.2022 Ray Bailey could not recall when he first saw Mr Mort’s email and accompanying sketches, but he confirmed that it was before the end of the project.2023 He did not bring Mr Mort’s concerns to the attention of Studio E or building control, nor did he ask Mr Mort to clarify the position.2024 His explanation was that the email needed to be read in the context of the debate about the requirement for firestopping or a cavity barrier,2025 but for the reasons set out above, we do not accept that explanation, even allowing for the fact that he may not have seen the email until 1 April 2015, or even later.2026 Whenever he read the email, Ray Bailey ought to have realised that the problem of the weak link was separate and distinct from the question about firestopping. Ray Bailey eventually accepted that the only sensible thing to have done was to raise Mr Mort’s concern with building control.2027 57.58 Mr Lamb denied having noticed Mr Mort’s warning about the weak link, despite admitting that he had scanned the email.2028 Mr Lamb did not discuss the drawing with anyone at Harley or anyone else connected with the project2029 and no changes were made to either of the drawings that Mr Mort had annotated.2030 Mr Mort’s email did not prompt Mr Lamb to consider whether the weak link could be rectified by some other change to the design.2031 57.59 Although Harley had been alerted in that way to the presence of a potential route for fire to spread at the head of the window, it did not take any steps to make good the defect, either by referring it to the design team for discussion, or by revising its design. The outcome: March–April 2015 57.60 On 31 March 2015, Mr Crawford replied to Mr Hoban’s email of 30 March 2015.2032 He noted that the subject of fire barriers was causing concern on site, not least due to the effect on programme and cost. He asked for Mr Hoban’s earliest response as the matter was beginning to hold up work. 2020 {HAR00018971} In particular, Mr Mort wrote in the introductory paragraph: “I have reviewed the drawings sent over and sketch a proposal to alleviate the issues raised by the BCO, also on the second page of the attachment I have highlighted the weak link so to speak in terms of fire.” 2021 {HAR00003947}. 2022 Ben Bailey {Day40/92:14-20}. 2023 Ray Bailey {Day33/158:5-15}. 2024 Ray Bailey {Day33/159:17-19}; {Day33/160:2-5}; {Day33/160:8-12}. 2025 Ray Bailey {Day33/159:20-23}. 2026 Ray Bailey {HAR00010184/17-18} pages 17-18, paragraph 69. 2027 Ray Bailey {Day33/160:13-25}. 2028 Lamb {Day38/138:8-20}; {Day38/141:24}-{Day38/142:4}. 2029 Lamb {Day38/142:21}-{Day38/143:2}; {Day38/144:3-5}. 2030 Lamb {Day38/144:6-14}. 2031 Lamb {Day38/146:2-15}. 2032 {SEA00000265}.

Part 6 | Chapter 57: Cavity barriers 189 57.61 Mr Crawford sent the correspondence to Mr Ashton and asked for his comment.2033 Mr Ashton responded by email later the same day.2034 He explained that, in his view, a cavity barrier was all that was required, since fire stopping would not stay in place in a fire which would cause the zinc cladding to fail. Mr Ashton was unaware of the type of cavity barrier that had been proposed for use at Grenfell Tower and did not think it necessary to clarify that with the design team at that stage.2035 Attached to Mr Crawford’s email was a drawing produced by Studio E showing a cavity barrier at the head of the window only.2036 However, Mr Ashton did not look at the drawing at the time and therefore did not know where cavity barriers were to be located.2037 57.62 On 1 April 2015 Mr Hoban replied to Mr Crawford saying that he had no objection to the proposal made by the design team, which provided for a cavity barrier with 30 minutes’ integrity and 15 minutes’ insulation.2038 57.63 Mr Crawford replied on the same day2039 and sent Mr Hoban two further drawings relating to the lower levels.2040 He also attached a drawing made by Harley.2041 Mr Hoban replied to that email, thanking Mr Crawford for the further drawings and confirming that he had no adverse comments.2042 Simon Lawrence sent that email onto Ben Bailey and Ray Bailey,2043 copying Neil Crawford and Simon O’Connor shortly afterwards and informing them that the building control officer now agreed that the fire protection in the cladding should be a cavity barrier rather a fire stop. Ray Bailey was aware that the drawings did not show cavity barriers around the windows but did not check with Rydon or Studio E whether building control had made any comments on that omission.2044 Mr Crawford did not expressly seek guidance from building control about the location of cavity barriers around the windows2045 and we have seen no evidence that he asked Mr Hoban to approve or comment on Harley’s cavity barrier strategy as a whole.2046 For his part, Mr Lawrence was unaware that there ought to have been cavity barriers around the windows.2047 57.64 When Mr Lawrence was asked what steps he had taken to ensure that cavity barriers were included as required in the external wall design, he said that he had used a lead designer and a specialist subcontractor and had consulted building control.2048 He accepted he had been largely a spectator in relation to the exchange of correspondence in March 2015 emails, as did the project manager, Mr O’Connor.2049 Mr Lawrence’s evidence, however, betrayed a failure to understand his responsibility for ensuring that the external wall of the building complied with the requirements of the Building Regulations. There were many occasions in the course of that correspondence when it was, or should have been, clear to 2033 {SEA00013044}. 2034 {EXO00000715}. 2035 Ashton {Day18/100:13-21}. 2036 Studio E drawing “Proposed Typical Bay Plans, Section & Elevation” {SEA00002499}. 2037 Ashton {Day18/123:7}-{Day18/124-10}. 2038 {HAR00013719/2}. 2039 {HAR00013719/2}. 2040 Detail Sections Sheet 2 Main Entrance 1279 (06) 121 Rev 00 {RYD00037743}; Detail Section Sheet 1 1279 (06) 120 Rev 00 {RYD00037744}. 2041 Harley Drawing C1059-325 Revision C which was a Walkway +1 Level Section {RYD00037745}. 2042 {HAR00013719}. 2043 {HAR00013719}. 2044 Ray Bailey {Day33/155:20}-{Day33/156:3}. 2045 Crawford {Day11/61:24}-{Day11/62:4}. 2046 Crawford {Day11/62:10-13}. 2047 Lawrence {Day25/13:18-22}. 2048 Lawrence {Day24/184:8-13}. 2049 Lawrence {Day25/8:1-4}; O’Connor {Day26/153:11-13}.

The Grenfell Tower Inquiry: Phase 2 Report 190 Mr Lawrence that Harley needed assistance2050 which it was not receiving from Studio E.2051 It was also clear that there was a significant degree of confusion over whether and to what extent cavity barriers were required2052 and that consideration should have been given to obtaining specialist advice. Mr Lawrence was not alive to any of these problems.2053 He should have been. Further advice from Siderise 57.65 Harley contacted Siderise on a number of other occasions during the life of the project seeking advice about cavity barriers.2054 Despite that, it did not occur to Ben Bailey to inform himself about the guidance which was available in Approved Document B.2055 The correspondence demonstrates a concerning lack of knowledge and expertise within Harley in relation to the use and siting of cavity barriers, which led to undue reliance on the advice of the manufacturer. Ben Bailey was unable to explain that lack of expertise and could not recall whether he had sought advice from Mr Anketell-Jones, Mr Lamb or Studio E.2056 It was reasonable to expect Harley, as a specialist cladding contractor, to possess a degree of technical knowledge about the function of cavity barriers in ensuring compliance with the Building Regulations, but the evidence shows that it did not. The piecemeal requests to Siderise demonstrate the pitfalls in failing to articulate a clear and detailed cavity barrier strategy at the design stage before construction work began. Installation of the cavity barriers 57.66 The installation of the external facade, including cavity barriers, was carried out by Osborne Berry Ltd as a subcontractor.2057 Mr Osborne had no formal training in the installation of rainscreen cladding facades.2058 The company had no experience of installing cavity barriers with intumescent strips and, as far as Mr Berry was aware, it had not previously installed cavity barriers manufactured by Siderise.2059 Harley did not maintain a permanent presence on site and there was no clerk of works in the traditional sense, so there were times when Osborne Berry and their workmen were unsupervised when installing the facade.2060 57.67 A subcontractor progress meeting was held on 28 April 2015. The minutes record that Ben Bailey was to issue elevation drawings to Daniel Osgood, a Rydon site manager, showing the position of the cavity barriers.2061 The minutes also recorded that windows and “firebreaks” were being fitted to the north, east and west elevations.2062 It therefore appears that the work of installing cavity barriers had begun before Harley had issued a full set of drawings. Mr Osgood said that he had assumed that Osborne Berry knew from experience where to place the cavity barriers.2063 2050 Email from Kevin Lamb to Simon Lawrence dated 3 March 2015 {HAR00017738}. 2051 Email from Neil Crawford to Kevin Lamb, copying Simon Lawrence and others dated 3 March 2015 {EXO00001461}. Mr Lawrence was surprised that Studio E required advice on a query of this nature, Lawrence {Day24/191:20-24}; but this did not trigger him to consider Studio E’s competence, {Day24/193:2-11}. 2052 Lawrence {Day24/193:2-11}. 2053 Lawrence {Day24/185:13-18}. 2054 Emails 6 May 2015 {HAR00004238}; 17 June 2015 {HAR00019012/2}. 2055 Ben Bailey {Day40/110:24}-{Day40/111:9}. 2056 Ben Bailey {Day40/113:3}-{Day40/114:3}. 2057 Ben Bailey {HAR00010060/3} page 3, paragraph 11. 2058 Osborne {Day43/72:9-12}. 2059 Berry {Day44/41:4-22}. 2060 Ben Bailey {Day40/120:17}-{Day40/121-3}. 2061 {HAR00000414}. 2062 {HAR00000414/3}. 2063 Osgood {Day30/146:25}-{Day30/147:4}.

Part 6 | Chapter 57: Cavity barriers 191 57.68 Ben Bailey did not recall having given Osborne Berry any guidance on how to install the cavity barriers.2064 Mr Osborne had never seen any such guidance, nor did he ask for any while he was on site.2065 He accepted that he should have checked that he understood how to install the product, which he had not fitted before, but apparently it did not occur to him at the time to do so.2066 Mr Berry had not seen any Siderise literature containing guidance on the installation of cavity barriers during the time he was working on the Grenfell Tower project, nor had he looked for guidance on Siderise’s website.2067 At the time that Osborne Berry was training their fitters, only horizontal cavity barriers were available on site.2068 57.69 Mr Osborne confirmed that the cavity barriers above the windows had been fitted above the level shown on Harley’s drawings2069 to prevent the fixing brackets penetrating the EPDM membrane.2070 He said that the change had been specifically agreed on site after Osborne Berry had produced a mock-up of a sample cladding arrangement.2071 He also said that it had been impossible to install the vertical cavity barriers under compression, as recommended in the Siderise product literature,2072 because the method of attaching the cassettes to the supporting rails allowed the cavity barrier to push the panel away from the building.2073 Mr Osborne did not raise the problem with anyone on site nor did he investigate a solution with Harley.2074 Osborne Berry instructed their fitters to trim the cavity barriers on site as the gap between the original concrete and the facade differed at different levels on the building.2075 57.70 Mr O’Connor did not attempt to check the positions of the horizontal cavity barriers against the drawings, because that was not his personal responsibility, and he therefore did not notice that they had not been positioned in accordance with the drawings.2076 However, he accepted that placing them incorrectly constituted defective workmanship, for which Rydon (amongst others) would be responsible.2077 He would have expected that kind of poor workmanship to be picked up under Rydon’s quality assurance and inspection regime and could not explain why that had not happened.2078 57.71 Ben Bailey was responsible for supervising Osborne Berry’s work on site on behalf of Harley2079 but he had not received any training that would enable him to ensure that the installation of the cavity barriers complied with the manufacturer’s advice, directions or guidance.2080 He thought it was likely that he had reviewed Siderise’s product literature 2064 Ben Bailey {Day40/134:4-18} such as the Siderise document “RH and RV cavity barriers for use in the external envelope or fabric of buildings” {HAR00008668}. 2065 Mr Osborne confirmed he had not seen either Siderise document shown to him {SIL00000230} or {SIL00000227}. Osborne {Day43/139:5-21}. 2066 Osborne {Day43/140:7-11}. 2067 Mr Berry was shown the guide at {SIL00000227} and confirmed that he did not read any guide like it while he worked on the project; Berry {Day44/45:12-14}; {Day44/49:18-22}. 2068 Berry {Day44/46:4-9}. 2069 Osborne {Day43/98:6-21}. 2070 Osborne {Day43/97:5-18}. 2071 Mr Osborne’s evidence was that this was agreed by either Daniel Anketell-Jones or Kevin Lamb at an early stage in the construction process, Osborne {Day43/97:25}-{Day43/98:5}; {Day43/98:22-24}. 2072 {SIL00000227/6}: “This cavity barrier is fitted vertically under compression, completely filling the void.” 2073 Osborne {Day43/142:13-21}. 2074 Osborne {Day43/142:23}-{Day43/143:7}. 2075 Berry {Day44/51:13-21}. 2076 O’Connor {Day26/166:25}-{Day26/167:6}. 2077 O’Connor {Day26/167:24}-{Day26/168:15}. 2078 O’Connor {Day26/172:18-25}. 2079 Ben Bailey {HAR00010060/3} page 3, paragraphs 11-13. 2080 Ben Bailey {Day40/138:15-19}.

The Grenfell Tower Inquiry: Phase 2 Report 192 and installation guidance,2081 but according to Mr Berry he gave Osborne Berry no specific guidance about how the cavity barriers were to be fitted.2082 Ben Bailey conducted visual inspections of the windows, insulation, cavity barriers and cladding rails before the cladding panels were installed on the north, east and west elevations, but not on the south elevation.2083 No formal record was kept of those inspections.2084 Ben Bailey’s inspections involved ensuring that the components had been installed in the same way as on the previous bays; he did not check the work against the drawings.2085 He did not notice any poor workmanship or flaws in the installation during any of his inspections.2086 57.72 After the fire the remaining cavity barriers were inspected and found to have various defects. In particular, a. The horizontal cavity barriers were found to have been installed with air gaps in excess of 25mm and in some places the material had been poorly cut and fitted to the surrounding structure with gaps between adjacent barriers at joints. b. Gaps had been left between the vertical cavity barriers and the cladding panels. c. Incorrect fixing brackets had been used. d. In some cases the fixing brackets had been spaced too widely. e. Some cavity barriers in the area of the columns were missing or had gaps. f. Horizontal cavity barriers had been used in the vertical position, with the intumescent edge installed directly against the concrete.2087 57.73 Ben Bailey said he had been very shocked when he was shown photographs of the cavity barriers taken after the fire. He said that he had not seen workmanship like that when he had been on site or when he had conducted his checks.2088 In his witness statement he sought to explain why he had not noticed the problems with the installation of the cavity barriers by saying that the insulation boards had obscured the junction between the concrete walls and the back of the cavity barriers, making it impossible to see any defects without dismantling and causing damage to the completed works.2089 However, that is in contrast with Mr Berry’s evidence that there had been plenty of opportunities to inspect the cavity barriers before the insulation was fitted.2090 Ben Bailey conceded that he ought to have been conducting inspections at each stage of the installation.2091 If he had done so, he would have inspected the work before the insulation obscured the rear of the cavity barriers and at a time when the problems would probably have come to light. As it was, Harley’s inspections of Osborne Berry’s work were insufficient to ensure that the defects we have described were identified. 2081 Ben Bailey {Day40/153:24}-{Day40/154:2}. 2082 Berry {Day44/55:12-16}. 2083 Ben Bailey {HAR00010060/4} page 4, paragraph13; Ben Bailey {Day40/148:13-19}; {Day40/149:17-20}. 2084 Ben Bailey {Day40/146:15-20}. 2085 Ben Bailey {Day40/150:4-17}. 2086 Ben Bailey {Day40/150:19-23}. 2087 Dr Lane, Phase 1 Report {BLAS0000008/40-48}; Swales {SIL00000306/25-26} pages 25-26, paragraphs 97-101. 2088 Ben Bailey {HAR00010060/10} page 10, paragraph 32. 2089 Ben Bailey {HAR00010060/10} page 10, paragraph 32. 2090 Berry {Day44/59:9-14}. 2091 Ben Bailey {Day40/164:1-9}.

Part 6 | Chapter 57: Cavity barriers 193 57.74 Mr Hoban of RBKC building control also visited the site and carried out inspections. He had not received any training on the installation of cavity barriers in cladding systems,2092 or indeed cladding systems more generally,2093 but a building control officer could be expected to be shown on site what to look for and to be aware of the need to check the manufacturer’s instructions about how the barriers should be installed.2094 Mr Hoban did not check whether cavity barriers had been installed around the windows because most of the windows had by that time been installed and therefore it was not possible to see where the cavity barriers should have been.2095 He did not ask to look behind the windows because he had seen cavity barriers being installed in other locations and so did not think it necessary to do so.2096 Mr Hoban accepted that he should have checked whether cavity barriers had been fitted around the windows but that he had failed to do so.2097 57.75 Mr Hoban’s evidence was that he would know through reading cavity barrier documentation how cavity barriers were to be installed.2098 However he also accepted that the lack of training meant he had been unable to detect whether the cavity barriers within the facade had been properly cut and installed or whether the right kinds of cavity barriers had been placed in the right positions.2099 He thought that the cavity barriers that he had been able to inspect when he went up the mast climbers were acceptable, and although he saw them being installed, the workmen were covering them up as they went along.2100 At no stage did he ask for a cassette to be removed so that he could check the installation of the cavity barriers.2101 Mr Hoban was unable to recall whether he had seen cavity barriers in place before they were covered by insulation.2102 He did not notice that the horizontal cavity barrier at the head of the window was being installed at a level higher than that shown on the drawings made by Studio E.2103 57.76 Mr Jonathan White of John Rowan Partners, which was engaged by the TMO to provide site supervision and inspection services, told us that it was not part of his job to check for compliance with the Building Regulations.2104 His role, as he saw it, was to find out whether building control had expressed any concerns about the work and report back to the TMO.2105 Mr White did not see design drawings of the windows2106 and did not notice during his inspections that there were no cavity barriers around the windows.2107 Although he inspected the cavity barriers and insulation, he was generally concerned only with whether the installation was consistent and the work neat and tidy.2108 He told us that he would have picked up any obviously poor workmanship, such as poorly fitted cavity barriers, but not defects such as horizontal barriers in a vertical orientation.2109 2092 Hoban {RBK00050416/11} page 11, paragraph 34g; Hoban {Day46/126:20}-{Day46/127:4}. 2093 Hoban {Day46/126:20}-{Day46/127:4}. 2094 Menzies {Day60/109:24}-{Day60/111:4}. 2095 Hoban {Day46/98:4-11}. 2096 Hoban {Day46/98:14}-{Day46/99:5}. 2097 Hoban {Day46/99:20-25}. 2098 Hoban {Day46/127:13}-{Day36/128:1}. 2099 Hoban {Day46/127:6-12}. 2100 Hoban {Day46/128:10-20}. 2101 Hoban {Day46/189:21}-{Day46/190:6}; {Day46/191:24}-{Day46/192:13}. 2102 Hoban {Day46/130:11-20}. 2103 Hoban {Day46/130:21-25}. 2104 White {Day42/112:11}-{Day42/113:4}. 2105 White {Day42/165:7-13}. 2106 White {Day42/158:2-12}. 2107 White {Day42/165:1-3}. 2108 White {Day42/171:4}-{Day42/172:9}. 2109 White {Day42/176:20}-{Day42/179:24}.

The Grenfell Tower Inquiry: Phase 2 Report 194 Siderise inspection at Wayland House 57.77 In December 2014, before Harley had begun installing the cladding at Grenfell Tower, Mr Kay of Siderise inspected the work on another of its projects, Wayland House in Brixton,2110 which involved a curtain wall refurbishment. Mr Kay inspected the firestopping following the installation of Siderise’s Lamatherm system. Following his inspection, on 19 December 2014 Mr Kay reported to Harley on the quality of the work. He found a. Installation of fire barriers in the incorrect orientation. b. Areas where the fire barriers had not been installed under sufficient compression, leaving gaps or loose material in the cavity. c. Gaps between the vertical fire barriers and the structure. Mr Kay considered it shocking to see so many defects in a cladding system2111 and asked Harley to arrange for him to visit the building again when remedial works had been carried out.2112 57.78 Mr Kay confirmed that a similar inspection service would have been provided to Harley in relation to the Grenfell Tower project,2113 but that no one from Harley had asked Siderise for it.2114 Ben Bailey was unaware of the email or Mr Kay’s findings when he began his work on the cavity barriers at Grenfell Tower.2115 Nor did he know whether anyone at Harley had communicated those findings to Osborne Berry so that lessons could be learned.2116 Harley failed to learn from the experience at Wayland House and did not make use of Mr Kay’s report to ensure that standards were improved at Grenfell Tower. Cavity barriers in the crown 57.79 Neither the second2117 nor the third2118 version of the NBS Specification contained any detailed information about the crown; each of them simply indicated that that part of the work was still to be completed.2119 Mr Sounes accepted that because the details of the crown had not yet been confirmed, little consideration had been given to where cavity barriers were to be placed within it.2120 During Mr Rek’s time working on the Grenfell Tower project (September to December 2013) no detailed design work had been carried out on the crown and questions relating to the design, material, finish and fixing were left until after the NBS Specification had been sent out to tenderers.2121 57.80 As part of the Employer’s Requirements prepared for the tender, Studio E prepared a drawing which showed a cross-section of different floors of the tower, including the top floor and roof (or “plant”) level.2122 The drawing bore a label “Design of the crown detail 2110 {SIL00000321}. 2111 Kay {Day103/97:17-25}. 2112 {SIL00000321/3}. 2113 Kay {Day103/106:20}-{Day103/107:23}. 2114 Kay {Day103/175:15-17}. 2115 Ben Bailey {Day40/157:23-25}. 2116 Ben Bailey {Day40/158:5-10}. 2117 Dated 29 November 2013 {SEA00000153}. 2118 Dated 30 January 2014 {SEA00000169}. 2119 At Clause 130 in Section H92 where it stated: “Major Nonstandard Components ‘Crown’: Manufacturer: TBC - Product Reference: TBC. Material: TBC. Finish: TBC…” {SEA00000153/66} and {SEA00000169/67}. 2120 Sounes {Day 21/92:16-22}. 2121 Rek {Day12/86:12-17}; {Day12/87:12-16}. 2122 Drawing entitled “Detail Section Sheet 1” {SEA00002551} dated 26 September 2013 with reference 1279 (06) 120 Rev 00.

Part 6 | Chapter 57: Cavity barriers 195 TBC by architect”. One cavity barrier was shown at the head of the window between the top floor and the roof level. There were, however, no other indications of where cavity barriers would be located within the crown. Mr Sounes accepted that little thought had gone into the matter at that stage.2123 Studio E never produced any elevation drawings showing how the horizontal cavity barriers at the top of the building would meet the vertical cavity barriers.2124 Mr Sounes confirmed that the risk that the crown might contribute to the spread of a fire in the external wall had not been considered because no one had been aware of the risks posed by ACM panels.2125 57.81 Mr Crawford was involved in the design of the crown after Studio E had been novated to Rydon.2126 He did not consider whether cavity barriers were required over and above those that would be fitted around compartments.2127 Since there were no compartments in the crown itself, it was his view that there was no requirement for cavity barriers.2128 57.82 On 29 May 2015 Mr Lamb sent Mr Crawford an email attaching drawings of the crown and asking for his approval.2129 On 12 June 2015, Mr Crawford replied attaching his comments on the design.2130 His annotated drawings2131 showed vertical cavity barriers which terminated at the base of the crown but no horizontal cavity barriers at the head of the columns.2132 Harley’s drawings2133 did not show a horizontal cavity barrier at the head of the columns or at the base of the crown, unlike the drawing produced by Studio E.2134 Mr Crawford agreed that that represented a worsening of the design2135 but he did not mention that when he commented on the drawings.2136 There was no discussion between Harley and Studio E about the provision of a cavity barrier at the head of the columns.2137 57.83 Mr Lamb intended to revisit the question of a cavity barrier in that location and left himself a note on the CAD2138 version of the drawing to remind him to do so.2139 However, the note appeared only on Mr Lamb’s CAD file; it did not appear on the printed versions of the drawing and therefore no one else saw it.2140 Mr Lamb said that there had been a discussion within Harley and that it had been felt that there was no need to include a cavity barrier at the head of the columns,2141 but he was unable to recall who in Harley had been involved in that discussion.2142 At any rate, the drawing was issued for the architect’s comments without a cavity barrier.2143 Mr Lamb explained that the drawing had then been overlooked and that it had never been re-issued as a drawing for construction.2144 However, that did not cause him any concern because Mr Crawford had not commented on the 2123 Sounes {Day21/92:19-22}. 2124 Sounes {Day21/93:8-16}. 2125 Sounes {Day21/101:5-20}. 2126 Crawford {Day11/63:1-3}. 2127 Crawford {Day11/63:7-12}. 2128 Crawford {Day11/63:22}-{Day11/64:8}. 2129 {SEA00013221}. 2130 {SEA00013221}. 2131 {SEA00003242}. 2132 Crawford {Day11/66:9-11}. 2133 For example C1058-216 {SEA00003242}. 2134 Entitled “Detail Section Sheet 1” {SEA00002551} dated 26 September 2013 with reference 1279 (06) 120 Rev 00. 2135 Crawford {Day11/69:20-25}. 2136 Crawford {Day11/70:3-9}. 2137 Crawford {Day11/71:24}-{Day11/72:4}. 2138 Computer Aided Design. 2139 {HAR00010427}; Lamb {Day38/166:17}-{Day38/167:2}. 2140 Lamb {HAR00010419/10} page 10, paragraph 36. 2141 Lamb {Day38/163:23}-{Day38/164:5}. 2142 Lamb {Day38/164:12-13}. 2143 Lamb {Day38/162:10-17}. 2144 Lamb {Day38/165:7-14}.

The Grenfell Tower Inquiry: Phase 2 Report 196 absence of a cavity barrier in that location. In his view, therefore, there was no need to revisit the point.2145 Despite Mr Lamb’s evidence we think it unlikely that he did discuss the matter with anyone else at Harley and that he simply overlooked it. 57.84 For his part, Daniel Anketell-Jones did not give any thought to whether steps needed to be taken to reduce the risk of fire spreading at the top of the building or around the crown.2146 and no discussions took place among the construction professionals about the risk of vertical or horizontal spread of fire at the level of the crown.2147 Work on the crown was left quite late because Harley was concentrating on the large area of cladding represented by the elevations of the building.2148 As a result, Mr Lamb based his design for the crown on very brief drawings from the architect and a design team meeting on site.2149 57.85 Mr Hoban’s understanding was that cavity barriers were not required at the junction between the cladding and the crown because the crown did not represent a concealed space.2150 Accordingly, despite the fact that he inspected the crown,2151 he did not remark on the absence of cavity barriers or any other fire mitigation measures in that location. 2145 Lamb {Day38/165:20-24}; see Mr Crawford’s annotations on the drawing at {RYD00043547/4}. 2146 Anketell-Jones {Day37/52:16-23}. 2147 Anketell-Jones {Day37/52:25}-{Day37/53:14}. 2148 Lamb {HAR00010419/9} page 9, paragraph 35. 2149 Lamb {Day38/162:1-2}. 2150 Hoban {Day46/102:10-19}. 2151 Hoban {Day46/138:1-3}.

197 Chapter 58 Window infill panels Introduction 58.1 The spaces between the vertical columns of Grenfell Tower were filled by window assemblies which were constructed as a single unit and contained both glazed sections (with opening parts) and solid sections acting as walls. The solid sections were known as window infill panels. 58.2 Two types of window infill panel were installed during the refurbishment of Grenfell Tower, a large panel with an insulating core, which was set between the glazed windows and a smaller panel, also with an insulating core, which housed the kitchen extractor fan.2152 They are shown in red and orange in the following figure taken from Dr Lane’s Phase 1 report. Figure 58.1 – Typical elevation for three-window configuration 58.3 After the fire it was found that both panels contained a core of Styrofoam, held between two sheets of aluminium.2153 Styrofoam is a form of extruded polystyrene (often referred to as “XPS”) and is combustible.2154 Although in his Phase 2 experimental work Professor Bisby found that those panels made the lowest contribution to the energy available in the external wall (only about 2–3% of the total energy available per floor),2155 he also found that they were relatively easy to ignite and, once ignited, had a comparatively high energy heat release rate per unit area.2156 He concluded that although they were not a primary cause of, or contributor to, the spread of fire across the external walls, they may have played an important part in the early development of the fire in and immediately outside Flat 16.2157 Accordingly, in this chapter we seek to explain how that combustible material came to be incorporated into the external wall of Grenfell Tower. 2152 Grenfell Tower Inquiry: Phase 1 Report, Chapter 6, 6.29 and 6.31. 2153 Grenfell Tower Inquiry: Phase 1 Report, Chapter 6, 6.29 and 6.31. 2154 Lane, Phase 1 Report {BLAS0000008/61-62} paragraphs 8.10.36, 8.10.4 and 8.10.42. 2155 Bisby, Phase 2 Experiments - Work Package 1 {LBYWP100000002/5} page 5, paragraph 32. 2156 Bisby, Phase 2 Experiments - Work Package 1 {LBYWP100000002/5-6} pages 5-6, paragraphs 33-34. 2157 Bisby, Phase 2 Experiments - Work Package 1 {LBYWP100000002/5-6} pages 5-6, paragraphs 39-40.

The Grenfell Tower Inquiry: Phase 2 Report 198 Specification at tender stage 58.4 In the NBS Specification, the final version of which was dated 30 January 2014, Studio E specified aluminium-faced window infill panels with insulating cores as part of the external wall. Although some thermal performance requirements were included, no particular material or product was prescribed at that stage.2158 It was therefore left to others to select suitable products which met the stipulated requirements.2159 Studio E did not prescribe any minimum fire performance standards for the panels. 58.5 Studio E’s tender drawings showed insulating panels between the areas of glazing, but they did not identify any particular product or type of insulation either.2160 Harley’s specification 58.6 When Kevin Lamb read the NBS Specification he thought that Studio E had simply overlooked the need to identify the insulating material to be used.2161 On 25 September 2014 he produced a drawing of the window arrangement which was revised on a number of occasions culminating in Revision D issued on 3 March 2015.2162 In his drawings the larger infill panels were designated “P1” and the smaller infill panels housing the kitchen extractor fans “P2”. Mr Lamb also produced specification notes dated 15 January 2015 which identified the products he proposed to use.2163 The P1 and P2 panels were both shown as comprising 2mm aluminium skins with a 24mm core of Kingspan TP10 rigid insulation. TP10 is a combustible insulation product manufactured by Kingspan.2164 58.7 When asked about his choice of insulating core material, Mr Lamb said that he had initially selected Kingspan TP10 for both panels because it was a standard product that he had used over many years and that he had put it into the specification as a starting point for discussions within Harley.2165 Based on a conversation he had had many years previously with a fabricator working for another client, he was confident that the result would be a “Class 0” panel.2166 However, he did not check the requirements of the Building Regulations or the guidance in Approved Document B before suggesting the use of TP10,2167 nor did he take any steps to investigate its fire performance, including its suitability for use on buildings over 18 metres in height. He did not discuss the matter with anyone else at Harley.2168 2158 {SEA00000169/145} clause 332. 2159 Crawford {Day9/112:14-22}; {Day9/147:5-8}; {Day9/154:17-18}. 2160 {SEA00002499}; Hyett, Module 1 Report {PHYR0000029/77} page 77, paragraph 4.3.90. 2161 Lamb {Day38/169:1-22}. 2162 {HAR00008886}. 25 September 2014 was revision A. “P1” appears in revision A. The final revision was D. dated 3 March 2015 in which both “P1” and “P2” appear. 2163 {HAR00003866}. 2164 Lane, Phase 1 Report {BLAS0000008/62} paragraph 8.10.39(b); BBA certificate {KIN00000276}. 2165 Lamb {Day38/173:9-10}; {Day38/173:12-18}; {Day38/178:25}-{Day38/179:2}. 2166 Lamb {Day38/179:5-9}. 2167 Lamb {Day38/174:2-5}; {Day38/175:13-17}. 2168 Lamb {Day38/178:20}-{Day38/179:18}.

Part 6 | Chapter 58: Window infill panels 199 58.8 The BBA certificate for Kingspan TP10 states that the product had in fact achieved a national Class 1 rating,2169 which is inferior to national Class 0.2170 However, Mr Lamb did not look at the certificate; instead, he went ahead on his understanding that when fabricated the panel would achieve a Class 0 rating because the outer surfaces would be aluminium.2171 58.9 Mr Lamb’s evidence suggests that he was not familiar with the guidance in Approved Document B that insulation products used in the external walls of buildings over 18 metres in height should be of limited combustibility. Although he was aware that there was a difference between limited combustibility and Class 0, he had never considered what the difference was and simply assumed that materials with a Class 0 classification were acceptable for use.2172 It did not occur to him that TP10 panels might contain combustible insulation and he therefore never considered whether combustible cores could be exposed in a fire.2173 That in turn demonstrated a lack of understanding on his part about how metal panels are liable to perform in a fire, a matter to which attention had been drawn in industry guidance long before 2015.2174 58.10 Mr Lamb’s specification notes relating to the P1 and P2 panels were subsequently changed. Someone added handwritten annotations in red to amend the specification of the P1 and P2 panels to show 25mm of Styrofoam held between two 1.5mm skins of aluminium.2175 That involved a reduction in the thickness of the aluminium skins and a corresponding increase in the thickness of the insulation, as well as a change of product. Mr Lamb said that the changes had been made by Mark Stapley, Operations Director at Harley.2176 We accept that evidence and think it likely that the changes were made by Mr Stapley after he had obtained the first quotation for the supply of panels. 58.11 Kevin Lamb produced a revised version of the specification notes,2177 which reflected the changes made by Mr Stapley, save that the insulation in the P2 panel was still shown as Kingspan TP10.2178 58.12 Kevin Lamb said that he had been told by Ben Bailey to obtain the infill panels from a company called Panel Systems Ltd, but that that company had been able to supply panels only with Styrofoam cores.2179 Ben Bailey, however, said that Mark Stapley had ordered the panels some time before he had become project manager.2180 We accept Ben Bailey’s evidence on this point. It is apparent from the documents that Mr Bailey did not take over as project manager until 3 March 2015. Mark Stapley made his first inquiry of Panel Systems for the manufacture and supply of the window infill panels in January 2169 {KIN00000276/6} section 7. 2170 See Chapter 5. National Class 1 means it has undergone testing in accordance with BS 476-7, not 476-6, which is also necessary for a national Class 0 classification. 2171 Lamb {Day38/181:18}-{Day38/182:14}. 2172 {CLG00000224/96} clause 12.7; Lamb {Day38/83:9-17}. 2173 Lamb {Day38/183:25}-{Day38/184:9}. 2174 See the 2nd Edition of BRE 135 dated 2003 {BRE00005554/17-18} and the CWCT Standard for Systematised Building Envelopes, 2008 {CWCT0000046/11} section 6.3. 2175 {HAR00003866}. 2176 Lamb {Day38/176:9-11}. 2177 {HAR00003869/1}. 2178 Now increased in thickness from 24mm to 25 mm. 2179 Lamb {HAR00010419/16} page 16, paragraph 63; Lamb {Day38/167:4} – {Day38/168:25}. 2180 Ben Bailey {Day39/158:2-12}; {Day39/159:19-24}.

The Grenfell Tower Inquiry: Phase 2 Report 200 2015,2181 and the first invoice for the supply of panels was dated 10 February 2015.2182 It seems clear, therefore, that the decision to obtain panels from Panel Systems Ltd was not made by Ben Bailey. 58.13 Mr Lamb’s evidence was also at odds with the evidence given by Christopher Ibbotson, the owner and managing director of Panel Systems, which we have no reason to doubt. According to him, in 2015 the company manufactured composite panels using a range of materials and various insulation products.2183 If asked to do so, it would give advice on the most suitable kind of panel to meet the customer’s needs. Any advice on fire performance of a product would be based on information obtained from the manufacturer.2184 It is worth noting that in September 2015 Ben Bailey asked Panel Systems for advice on the manufacture and supply of a panel for use in the mounting of an anti-arson letterbox at Grenfell Tower2185 and that two days later he was sent details of its Versafire Euroclass A1 rated non-combustible board.2186 58.14 If a customer did not specify a core material, Panel Systems offered Styrofoam as standard2187 because of its thermal efficiency.2188 In those circumstances it would not generally inform the customer of Styrofoam’s fire performance, nor would it tell the customer that it should check whether the use of that material in the particular circumstances they had in mind would comply with the Building Regulations.2189 Panel Systems marketed its insulating panels by reference to the fire rating of the core material, which was the primary factor in their performance. It therefore marketed panels with Styrofoam cores as European Class E.2190 58.15 In the light of Mr Ibbotson’s evidence, it is clear that panels with cores other than Styrofoam could have been obtained from Panel Systems and it follows that if Harley had wanted to do so it could probably have obtained panels with better fire performance which met the requirements for thermal efficiency. We are unable to say with confidence what led Mr Stapley to accept Styrofoam for the core, but the fact that it was a standard product combined with the reduction in the thickness of the aluminium skins leads us to think that considerations of cost may have played a part. At all events, there is no reason to think that anyone at Harley gave serious consideration to the fire performance of the panels. 58.16 On 19 January 2015 Mark Stapley asked Panel Systems to provide a price for the manufacture and supply of infill panels.2191 For that purpose he sent a schedule of Harley’s requirements2192 and requested prices for aluminium spandrel panels with an overall thickness of 28mm, without specifying the core material to be used.2193 Later that day Panel Systems gave Mr Stapley a quotation for 28mm thick Aluglaze panels with aluminium 2181 {PAN00000012}; {PAN00000007}. 2182 {MET00040281}; {MET00040279}. 2183 Ibbotson {Day104/6:24}-{Day104/7:3}; {Day104/8:12-13}; {Day104/8:16-25}. 2184 Ibbotson {Day104/14:7-21}; {Day104/16:6-19}. 2185 {HAR00020436}; Ben Bailey {Day39/176:2}. 2186 {HAR00002853}. 2187 {PAN00000017/2} page 2, paragraph 2.4. 2188 Ibbotson {Day104/20:15}–{Day104/21:2}. 2189 Ibbotson {Day104/21:4-23}. 2190 Ibbotson {Day104/24:21}–{Day104/25:25}. 2191 {PAN00000012}; Ibbotson {Day104/28:20-24}. 2192 {PAN00000006/2}; Stapley {HAR00020574/8} page 8, paragraph 28; {HAR00010003}. 2193 {PAN00000006/2}.

Part 6 | Chapter 58: Window infill panels 201 skins and 25mm Styrofoam cores.2194 On 20 January 2015, Mr Stapley sent a purchase order to Panel Systems for the supply of the panels set out in his original schedule.2195 There was no discussion about their fire performance. 58.17 Mark Stapley said that Panel Systems had specified the core material to be used in the P1 and P2 panels,2196 but we think that unlikely, save in the sense that its quotation was based on Styrofoam because that was the default product. Harley had not specified any minimum fire performance for the core and there had been no discussion about what fire performance was required. As an experienced member of Harley’s team Mr Stapley must have expected Panel Systems to quote for a basic product, unless asked to do otherwise. The responsibility for ensuring that the fire performance of the core was appropriate rested with Harley, not with Panel Systems. 58.18 Kevin Lamb accepted that he had never considered the fire performance of the window infill panels2197 or whether the use of Styrofoam in the external wall complied with the Building Regulations.2198 He was not aware that Styrofoam was not a product of limited combustibility, nor did he take any steps to assess whether the panel was suitable for use on high-rise buildings.2199 Mr Lamb assumed it was a product that Harley had used many times before.2200 58.19 When asked why his specification notes showed Kingspan TP10 for the P2 panel instead of Styrofoam, as had been indicated in Mr Stapley’s amendment, Kevin Lamb said that Panel Systems could not produce panels with inside and outside faces in different colours, as was required in the case of the P2 panels, so the specification had not been changed and the core remained Kingspan TP10. However, that does not strike us as very plausible. After the fire some surviving P2 panels were found to contain Styrofoam cores and there is no evidence that those or any other P2 panels had been obtained from a different supplier. We think Mr Lamb simply overlooked that part of the amendment and failed to make the required change. Studio E’s review of the specification 58.20 The revised version of Mr Lamb’s specification notes was sent to Studio E for review and on 26 January 2015 Mr Crawford stamped it “Conforms to design intent”, subject to the incorporation of certain comments, which did not include any comment on the window infill panels. Mr Crawford told us that he had not seen the handwritten annotations on the specification notes and that he did not think that he had been aware that Styrofoam had been substituted for Kingspan TP10 in the P1 panel.2201 He maintained that he had been commenting only on architectural intent and would not necessarily have been looking at the description of the materials in the specification.2202 Mr Crawford had no recollection 2194 {HAR00009866}; {HAR00009867}. 2195 Stapley {MET00040296/15} page 15. This was the same schedule as set by Mr Stapley on 19 January 2015 {PAN00000006/2}. 2196 Stapley {HAR00020574/10} page 10, paragraph 33. 2197 Lamb {Day38/171:15-17}; {Day38/192:16-20}. 2198 Lamb {Day38/187:1-9}. 2199 Lamb {Day38/188:4-9}. 2200 Lamb {Day38/193:1-5}. 2201 Crawford {Day11/110:4-24}. 2202 Crawford {Day11/111:22}–{Day11/112:5}; {Day11/115:5:13}.

The Grenfell Tower Inquiry: Phase 2 Report 202 of discussing the use of any particular insulation material for the infill panels with anyone at Studio E, Harley, or Rydon.2203 Mr Hyett was critical of Studio E for failing to identify the unsuitability of Styrofoam in the course of its design reviews.2204 58.21 On 15 July 2015, Kevin Lamb produced a further revision of the specification notes2205 but the specification for the P1 and P2 panels remained as it had been in the previous version. On 17 July 2015 Mr Crawford stamped it as conforming to design intent. Again, he could not recall having noticed the specification of Styrofoam and Kingspan TP10.2206 He thought that it was for Harley to check that the use of the material complied with statutory requirements and that it was not Studio E’s function to check Harley’s work.2207 Mr Crawford also said that he thought that the Styrofoam would be treated with fire retardant to limit its combustibility, but he could not recall taking any steps to find out whether that had been done.2208 58.22 We think it clear that Studio E had an obligation under its contract with Rydon to take reasonable steps to ensure that all designs, whether produced by itself or any sub-contractors, complied with the relevant statutory requirements, including the Building Regulations.2209 Mr Crawford’s understanding that it was not his role to check the materials specified by Harley to ensure that the external wall was compliant with the Building Regulations was therefore wrong. He ought to have applied his mind to the fire performance of the window infill panels, both as a matter of contractual obligation and in the exercise of reasonable skill and care,2210 but he failed to do so. Harley’s understanding of the products 58.23 Harley placed a number of orders for aluminium panels with a Styrofoam core between February and June 2015.2211 58.24 When Ben Bailey joined the project in March 2015 he was sent Harley’s drawings and specification notes2212 but could not remember whether he had reviewed them.2213 He was not aware that Styrofoam was extruded polystyrene and he did not know who had specified its use in the P1 infill panels.2214 He did not himself investigate whether it was appropriate to use panels with Styrofoam cores in the external wall.2215 58.25 Ben Bailey thought that the Kingspan TP10 product had been specified for the P2 panel by Kevin Lamb,2216 but it is not clear why, since he had not discussed the choice of material with Mr Lamb.2217 He did not look at the BBA certificate nor did he consider whether panels containing Kingspan TP10 would comply with the Building Regulations.2218 2203 Crawford {Day11/112:15-25}; {Day11/114:23}–{Day11/115:4}. 2204 Hyett, Module 1 Report (revised) {PHYR0000029/135} paragraphs 4.4.140 – 4.4.141. 2205 {RYD00046822/1}. 2206 Crawford {Day11/116:9-18}. 2207 Crawford {Day11/117:4}–{Day11/118:23}; {Day11/120:2-13}. 2208 Crawford {Day11/116:22}–{Day11/117:3}; {Day11/119:6-12}. 2209 {RYD00094228/9} paragraph 8. 2210 Hyett, Module 1 Report {PHYR0000029/135} paragraphs 4.4.140-4.4.141. 2211 Ibbotson {Day104/32:12-17}. 2212 {HAR00017738}; {HAR00003953}. 2213 {HAR00017762}; Ben Bailey {Day39/155:12-22}. 2214 Ben Bailey {Day39/156:14-23}. 2215 Ben Bailey {Day39/162:21-25}; {HAR00009696}; Ben Bailey {Day39/163:14}-{Day39/164:17}. 2216 Ben Bailey {Day39/164:24}-{Day39/165:1}. 2217 Ben Bailey {Day39/165:14}-{Day39/166:1}. 2218 Ben Bailey {Day39/172:9}-{Day39/173:11}; {Day39/175:6-7}.

Part 6 | Chapter 58: Window infill panels 203 58.26 Ben Bailey also thought that the window assemblies (which included both glazed sections and fixed insulating panels) did not fall within the guidance in Approved Document B on the construction of external walls. He therefore rejected the suggestion that Harley should have taken steps to satisfy itself that the insulation in the window infill panels was suitable for use on buildings of more than 18 metres in height. Other witnesses thought differently, however. Although we recognise that a distinction can be drawn between the concrete structure (including the columns), which plainly forms the external wall, and the window assemblies containing some glazed and some solid panels, which fill the gaps between the concrete, we think it clear that the purpose of the guidance in paragraph 12.7 of Approved Document B is to reduce the risk created by the use of combustible insulation in the walls of high-rise buildings. We therefore think it clear that the reference to “external wall construction” in paragraph 12.7 includes solid window infill panels and we do not think that a competent specialist facade contractor could reasonably have thought otherwise. 58.27 Simon O’Connor, Rydon’s project manager between May 2014 and August 2015,2219 received Harley’s drawings and specification notes on 6 March 20152220 but could not remember having looked at either the drawings2221 or the notes.2222 He had not come across Styrofoam, extruded polystyrene or Kingspan TP10 before.2223 58.28 As we noted in Chapter 62, John Hoban, the building control officer at RBKC responsible for the Grenfell Tower refurbishment, also received Harley’s specification notes on 6 March 2015.2224 He did not notice that Styrofoam and Kingspan TP10 were being proposed as the insulating material in the window infill panels2225 and did not look at the BBA certificates relating to either material; nor did he question the use of those materials.2226 He candidly accepted that he should have done so.2227 58.29 On 24 August 2015, for the first time Ben Bailey asked Panel Systems to give him a price for supplying aluminium-faced panels with a core of Kingspan TP10.2228 On 27 August 2015, Panel Systems provided Harley with a quotation as requested2229 but for panels with a PIR core, rather than Kingspan TP10. Michael Roache, a product manager at Panel Systems, said that he had advised Harley that Kingspan TP10 was not suitable for use as the core of a composite panel due to its manufacturing tolerance and uneven surface and that as a result a discussion had taken place (though between whom is uncertain) about an alternative PIR insulation.2230 Mr Ibbotson agreed that a TP10 core would not bond reliably to the aluminium skin. TP10 was therefore replaced with a generic PIR product.2231 Subsequently, Harley placed further orders with Panel Systems for panels with PIR cores.2232 2219 O’Connor {RYD00094221/7} page 7, paragraph 14; O’Connor {Day26/5:4-7}. 2220 {HAR00003951}. 2221 {HAR00003953}. 2222 {HAR00003955}; O’Connor {Day26/112:3}-{Day26/114:24}. 2223 O’Connor {Day26/115:17}-{Day26/116:16}. 2224 {HAR00003955}. 2225 Hoban {Day46/26:15}-{Day46/27:4}; {Day46/28:8-10}. He relied on Exova having looked at this specification. Hoban {Day46/27:16-21}. 2226 Hoban {Day46/28:18}-{Day46/29:14}. 2227 Hoban {Day46/29:15-17}. 2228 {HAR00020331}; {HAR00020332}. 2229 {HAR00018872}. 2230 Roach {PAN00000029/3} page 3, paragraph 14. Ben Bailey said that any such conversation was not with him. Ben Bailey {Day39/173:6}-{Day39/174:5}. 2231 Ibbotson {Day104/38:8-22}; {Day104/40:12-25}; {Day104/48:23}-{Day104/49:10}; Ibbotson {Day104/49:18-21}; {Day104/42:1-5}. 2232 {MET00040286}.

The Grenfell Tower Inquiry: Phase 2 Report 204 58.30 In total Panel Systems appear to have supplied a number of larger orders between January and June 2015 for panels with Styrofoam cores, and two smaller orders between August and October 2015 for composite panels with PIR cores. 58.31 Although Kevin Lamb had specified Kingspan TP10 insulation for the P2 panels2233 and although panels with PIR insulation had been ordered by Ben Bailey,2234 the Inquiry’s experts discovered after the fire that some of the P2 panels had Styrofoam rather than PIR cores.2235 Mr Ibbotson denied that Panel Systems had substituted Styrofoam for PIR2236 and Ben Bailey could not shed any light on how some of the P2 panels had come to be supplied with Styrofoam rather than PIR cores.2237 He said that most of the panels had been supplied directly to CEP for fabrication and insertion into the window frames, which might explain why the problem had not been picked up at the time.2238 However, he could not tell the products apart by their appearance.2239 Neither the Rydon witnesses, nor Mr Lamb could explain how Styrofoam came to be substituted for PIR.2240 However, neither material was suitable for use in the external wall of Grenfell Tower. Given the lack of interest shown by Harley, Rydon and Studio E in the fire performance of the insulating cores of the window infill panels, we think it unlikely that any of them would have objected to the use of Styrofoam in the P2 panels. 2233 {HAR00003869/1}. 2234 {HAR00000445/6}. 2235 Lane, Phase 1 Report {BLAS0000008/62} paragraph 8.10.41. 2236 Ibbotson {Day104/48:1-22}. 2237 Ben Bailey {Day39/167:12}-{Day39/168:21}. 2238 Ben Bailey {Day39/168:25}-{Day39/169:25}; Ben Bailey {Day39/171:12-21}. 2239 Ben Bailey {Day39/172:3-7}. 2240 Lamb {Day38/177:7-12}; O’Connor {Day26/117:9-13}; Hughes {Day27/76:16}-{Day27/77:6}; Martin {Day30/54:10}-{Day30/55:4}.

205 Chapter 59 Window reveals Introduction 59.1 The refurbishment of the windows at Grenfell Tower involved fitting new uPVC boards at the head of the window, the sill and the jambs (often referred to as the “window reveals”), in each case over a 25mm layer of insulation.2241 After the fire, the insulation that had been used was identified as either Celotex TB4000 or Kingspan Thermapitch TP10. 59.2 In his Phase 1 report the chairman concluded that the window reveals had provided a route for fire to spread from the interior of Flat 16 into the cladding. He found that the fire had probably entered the cladding as a result of hot smoke impinging on the uPVC window surrounds causing them to deform and fall away, together with the insulation which was attached to them. That created a gap which allowed the fire to gain access to the cavity behind the ACM panels and ignite combustible materials.2242 In Chapter 110 we have reconsidered that conclusion in light of the evidence provided by BRE reconstruction evidence but we consider that it remains sound. In this chapter we examine how those materials came to be present around the windows. The original specification 59.3 In the NBS Specification Studio E specified plywood window reveals2243 together with “compressible insulation in gaps”.2244 The compressible insulation was specified as mineral wool to BS EN 13162 manufactured by Rockwool.2245 (Mineral wool is inorganic and non-combustible.)2246 However, Studio E did not specify precisely which gaps were to be filled with mineral wool and the tender drawings did not do so either,2247 although they should have.2248 The substitution of uPVC for plywood 59.4 Although the NBS Specification provided for the window reveals to be constructed of plywood, Harley proposed the substitution of uPVC boards as part of Rydon’s value engineering exercise.2249 Neither Harley nor Rydon appears to have given any consideration to the relative fire performance of the two materials.2250 In general, plywood could be expected to provide a greater degree of fire resistance than uPVC, which softens and deforms at temperatures above 60°C.2251 2241 Phase 1 Report, Volume I, paragraph 6.28. 2242 Phase 1 Report, Volume IV, paragraph 22.38. 2243 National Building Specification (NBS) {SEA00000169/249} clause 240. It also stipulated that the fire-rating for the window reveals should be “fire-rating Class 1 or Class C-s3, d2”. 2244 National Building Specification (NBS) {SEA00000169/243} clause P10. 2245 National Building Specification (NBS) {SEA00000169/243} clause 191. 2246 Bisby, Phase 2 Experiments Work Package 2 {LBYWP200000001/36} paragraphs 239-240. 2247 {SEA00002499}. 2248 Crawford {Day9/149:15}–{Day9/150:11}; Hyett, Module 1 Report {PHYR0000029/80-82} paragraphs 4.3.94, 4.3.96 and 4.3.98. 2249 {RYD00003316}. 2250 Dixon {Day44/171:24}-{Day44/172:5}. 2251 Torero, Phase 1 Report {JTOS0000001/41} Figure 9; Dixon {Day 44/170:12-21}.

The Grenfell Tower Inquiry: Phase 2 Report 206 59.5 Simon Lawrence of Rydon originally expected Harley to undertake the package of works that included the replacement of the window reveals,2252 but that package was removed from the scope of Harley’s works when Rydon needed to find savings in its price for the work as a whole.2253 Accordingly, Harley’s detailed drawings of the window arrangements showed that the fitting of insulation around the windows would be undertaken by others.2254 59.6 On 16 January 2015, Neil Crawford reviewed Harley’s drawing dated 13 January 2015 showing the details of the window design,2255 which he accepted as conforming to design intent. He was not concerned that the drawing did not specifically indicate mineral wool around the windows because, as he told us, he knew that fitting the insulation was not part of Harley’s work.2256 However, he failed to take any steps to deal with the fact that there was no detailed drawing at all, whether by Harley or Studio E, which showed mineral wool around the windows in accordance with the specification. He had no explanation for that omission, which drew criticism from Mr Hyett. Mr Hyett’s opinion, with which we agree, was that, in accordance with its contractual obligations,2257 Studio E should have produced 1:5 drawings which showed in detail how the voids around the window linings would be packed with insulation and what materials were to be used.2258 59.7 On 12 March 2015, Jason North, Rydon’s site manager at the time, asked Neil Crawford where he could find details of the insulation behind the fixed panels at the side of the windows.2259 Mr North was referring to the gap between the larger window infill panel (panel P1) and the concrete spandrel of the original building.2260 Mr Crawford did not respond to that request, but he told us that he thought he had directed Mr North to Studio E’s 1:20 drawings.2261 However, those drawings did not show any details of the insulation around the windows and therefore it is unlikely that he did so.2262 59.8 The refurbishment of the window reveals was not part of Osborne Berry’s work,2263 which was limited to the removal of the original glazed windows to enable the new double-glazed window units to be installed.2264 59.9 By 23 February 2015 SD Carpentry Ltd had produced for the show flat (Flat 145) an example of the window reveals showing how they were intended to appear. Various companies, including a company called SD Plastering Ltd, looked at the finished example in order to decide whether to bid for the refurbishment of the window reveals.2265 (SD Plastering was a construction company predominantly engaged in dry-lining work and was unrelated to SD Carpentry.) 2252 Lawrence {Day25/39:22}-{Day25/40:8}; Berry {OSB00000091/10} page 10, paragraph 16 (b); Berry {Day44/14:15-18}. 2253 {RYD00086654/1}; Lawrence {Day25/39:22}-{Day25/40:8}; Berry {OSB00000091/10} paragraph 16 (b); Berry {Day44/14:15-18}. 2254 {SEA00003040/5}; {SEA00003040/7}. 2255 {SEA00003040/7}. 2256 Crawford {Day11/98:5}-{Day11/101:1}. 2257 Deed of appointment between Rydon and Studio E {RYD00094228/11} items 31(a)-(c). 2258 Hyett, Module 1 Report {PHYR0000029/82} paragraph 4.3.96. 2259 {SEA00012940}. 2260 Crawford {Day11/104:21}-{Day11/105:2}. 2261 Crawford {SEA00014275/41} page 41, paragraph 118. 2262 Hyett, Module 1 Report {PHYR0000029/82} paragraph 4.3.98. Bruce Sounes’ evidence was that the scale of those drawings did not permit references to the type of insulation to be used in these applications: Sounes {Day21/120:16-19}. 2263 Berry {OSB00000091/10} paragraph 16 (b); Berry {Day44/14:15}-{Day44/16:25}; Osborne {Day43/174:3-17}. 2264 Berry {Day44/15:22}-{Day44/16:7}; {Day44/18:17-21}. 2265 Dixon {Day44/102:25}-{Day44/103:4}; {RYD00032519}.

Part 6 | Chapter 59: Window reveals 207 59.10 SD Plastering had already been engaged to carry out remodelling work on the lower floors of Grenfell Tower when Rydon approached it to undertake the refurbishment of the window reveals.2266 (A director of the company, Mark Dixon, had previously been employed by Rydon.)2267 The first email correspondence in respect of the work occurred in February 2015;2268 a progress report by Rydon dated March 2015 referred to SD Plastering’s involvement.2269 59.11 Although it had not done work of that kind before,2270 SD Plastering ultimately undertook all the work to the window reveals, including the packing of gaps behind the uPVC boards with insulation,2271 apart from putting foam insulation into a small gap at the sides of the window jambs next to the columns.2272 We have not been able to determine which company or individual was responsible for that.2273 SD Plastering’s contract 59.12 Although SD Plastering had a formal contract with Rydon for the dry-lining work,2274 there was no formal contract between them for the work on the window reveals. On 17 February 2015, Adam Marriott of Rydon sent Mark Dixon in connection with the dry-lining work a copy of Rydon’s standard terms,2275 which required all workmanship to comply with manufacturers’ and suppliers’ instructions and recommendations and current British standards and codes of practice.2276 Mark Dixon understood that SD Plastering was required to comply with the same terms and conditions when carrying out the work on the window reveals.2277 Mr Dixon accepted that the work had to comply with any relevant standards and it follows that it had to comply with the Building Regulations in general and functional requirement B4(1) in particular. 59.13 Under the contract between Rydon and the TMO, it was Rydon’s responsibility to co-ordinate and complete the design of the window reveals, which included selecting the goods and materials to be used and setting the standards of workmanship.2278 Rydon was also responsible for co-ordinating and supervising the work of its subcontractors, including SD Plastering. Rydon’s responsibility extended to monitoring its work and providing it with the information necessary for it to do the work.2279 Rydon ought therefore to have provided SD Plastering with a copy of the relevant part of the NBS Specification identifying the materials to be used, and ought to have provided it with Harley’s drawings relating to the work, as accepted by Studio E. 2266 Dixon {Day44/99:19}-{Day44/100:14}; Dixon {SDP00000196/3} page 3, paragraph 13. On that basis we consider that Mark Dixon’s estimate that SD Plastering became involved in these works in April-May 2015 is incorrect. 2267 Dixon {Day44/95:3-23}. He knew Simon Lawrence, Simon O’Connor, Daniel Osgood and David Hughes, Dixon {Day44/97:21}-{Day44/98:24}. 2268 {RYD00032519}. 2269 {RYD00035207}. 2270 Dixon {Day44/119:3-10}; {Day44/152:6-10}. 2271 Dixon {Day44/157:6}-{Day44/164:22}. 2272 Dixon {Day44/172:7}-{Day44/173:8}. See this gap highlighted in red bubbles in Lane, Phase 1 Report {BLAS0000009/13} Figure 9.9 9.10. 2273 Osborne Berry said it did not carry out that work: Osborne {Day43/171:13-18}. 2274 {RYD00031801}; {RYD00031811}. 2275 {RYD00031806}. 2276 {RYD00031806/4} paragraph 2.18.1. 2277 Dixon {Day44/137:17}-{Day44/139:4}. 2278 {RYD00094235/63} clause 2.1.1; {RYD00094235/69} clauses 2.17.1-2.17.12. 2279 {TMO10041791/128} part 2A/44, section A32, paragraph 110.

The Grenfell Tower Inquiry: Phase 2 Report 208 59.14 Under its contract with Rydon Studio E was responsible for developing the design of the window reveals, advising on the appropriate method of construction, selecting materials and co-ordinating any design work undertaken by SD Plastering.2280 Design of the window reveals 59.15 In February 2015 a meeting took place between Rydon and SD Plastering in the show flat, during which Simon Lawrence told Mark Dixon that he was not happy with the window reveals because, among other things, the sill was prone to bowing.2281 It appears that Mr Dixon made some suggestions for improving the design and that Mr Lawrence asked for a quotation for the work.2282 In the event, Rydon instructed SD Plastering to produce an alternative design for the window reveals that was more aesthetically pleasing than the example, easy to install and which remedied the problem with bowing.2283 59.16 At some time between February and 6 May 2015 there was another meeting in the show flat to discuss the design of the window reveals. Mark Dixon attended, together with Simon O’Connor, Daniel Osgood and James Clifton of Rydon.2284 At that meeting Rydon and SD Plastering decided to use a rigid insulation board to fill the gaps behind the uPVC boards.2285 However Rydon did not tell SD Plastering what materials to use or provide it with any drawings of the window reveals.2286 In effect, Mr Dixon was simply asked to reproduce the effect of the work in the show flat but with a better finish.2287 59.17 SD Plastering initially tried to use plasterboard or ply packing pieces underneath the windowsill to bridge the gap and to prevent it from bowing but were unable to secure them in place. Mr Dixon said that Celotex rigid insulation board was chosen instead to achieve a better fit.2288 59.18 On 6 May 2015, Mark Dixon gave Rydon a quotation in which he described the work to be carried out.2289 After removing the existing timber structure2290 a plasterboard backing was to be applied, after which Celotex insulation would be fitted to the head, jambs and sill. Mr Dixon’s intention was to use either plasterboard or Celotex 25mm insulation board or a combination of the two to cover the gaps around the windows.2291 The Celotex board was expected to achieve the correct fit, act as a support to the uPVC and confer a thermal benefit.2292 He said the quotation had been drafted in such a way as to give SD Plastering flexibility about which materials to use.2293 In the event plasterboard was not used at all.2294 2280 {RYD00094228/9}; {RYD00094228/10}. 2281 {RYD00032519}; Dixon {Day44/106:3-8}; Dixon {SDP00000196/4} page 4, paragraph 17; Dixon {Day44/108:20}-{Day44/110:2}; {RYD00042486/2}; Lawrence {Day25/49:5-12}; {RYD00042487}. 2282 Simon Lawrence’s email of 23 February 2015 {RYD00032519}. 2283 Dixon {SDP00000196/4} page 4, paragraph 19; Lawrence {Day25/56:1-5}; Dixon {Day44/116:18}-{Day44/117:12}. 2284 Dixon {Day44/107:7-25}; Osgood {RYD00094212/2} page 2, paragraph 8. 2285 Lawrence {Day25/56:10}-{Day25/58:7}; {Day25/62:3-7}; Cole {SDP00000220/3} page 3, paragraph 14; Dixon {Day44/112:12-18}; {Day44/112:19}-{Day44/114:15}. 2286 Dixon {Day44/117:22}-{Day44/118:4}. 2287 Dixon {Day44/119:25}-{Day44/120:13}; {Day44/171:15-19}. 2288 Dixon {Day44/123:1-6}; {Day44/182:23}-{Day44/183:10}. 2289 {RYD00088957}. 2290 Dixon {Day44/125:10-21}. 2291 Dixon {Day44/128:6-12}. 2292 Dixon {Day44/127:14}-{Day44/128:4}. 2293 Dixon {Day44/126:15-20}. 2294 Dixon {Day44/125:3}-{Day44/127:7}; {Day44/185:1-6}; {Day44/196:16-20}.

Part 6 | Chapter 59: Window reveals 209 59.19 Neither Simon Lawrence nor Simon O’Connor read the quotation and neither could recall any discussions about it. Mr Lawrence knew that some sort of rigid insulation board was being used around the windows, but not necessarily that it would be made by Celotex.2295 59.20 SD Plastering was never shown the NBS Specification relating to the work on the window reveals, nor was it given any instructions about the materials to be used in the gaps around the windows.2296 It was not provided with any architectural drawings relating to the window reveals and did not discuss the design of the work or the products to be used with Studio E.2297 Neil Crawford was not told that PIR and phenolic insulation had been used to fill voids around the windows. He was not shown the work or asked to comment on it during his site visits.2298 There was no formal process within Rydon for approving the materials used around the windows.2299 59.21 Mark Dixon said that he would ordinarily have expected to receive more information from Rydon about the products to be used on work of that kind, but he does not appear to have asked for any.2300 SD Plastering did not itself produce any drawings relating to the work.2301 59.22 Neither Simon Lawrence nor Simon O’Connor examined the NBS Specification to see whether any insulation product had been specified for use in connection with the window reveals. Both accepted that they should have done so, although Mr Lawrence said that the Rydon site managers should also have paid closer attention to that.2302 If Rydon had looked at the NBS Specification it would have been obvious that the use of a rigid combustible insulation board was contrary to what had been specified.2303 Rigid combustible insulation boards were not a comparable substitute for compressible and non-combustible mineral wool.2304 Compliance of the design with the Building Regulations 59.23 Pursuant to functional Requirement B4(1) and if following the guidance in Approved Document B any insulation materials used in the external wall had to be of limited combustibility.2305 In addition, pursuant to functional requirement B3(4) the building had to be designed and constructed so that the unseen spread of fire and smoke within concealed spaces in its structure and fabric was inhibited. The need for compartmentation and the risk of fire spread around openings was highlighted in sections 8 and 9 of Approved Document B.2306 Rydon ought to have instructed SD Plastering that any insulation used around the windows was to be of limited combustibility or better and should have made sure that insulation of that kind was used. It did neither of those things, however. There was no discussion between Rydon and SD Plastering about how the choice of material to fill the gaps around the windows might affect fire safety generally.2307 Neither SD 2295 Lawrence {Day25/36:7}-{Day25/38:15}; O’Connor {Day26/212:17-22}. 2296 Dixon {Day44/167:20-21}. 2297 Dixon {Day44/133:14}-{Day44/134:9}. 2298 Crawford {Day11/106:10}-{Day11/107:7}. 2299 Lawrence {Day25/61:19-25}-{Day25/62:7}. 2300 Dixon {Day44/131:14-17}. 2301 Dixon {Day44/135:12-15}. 2302 Lawrence {Day25/45:1-22}; O’Connor {Day26/213:22}-{Day26/214:16}. 2303 Lawrence {Day25/47:12-22}. 2304 Lawrence {Day25/45:23}-{Day25/46:21}. 2305 Lane, Phase 1 Report {BLAS0000011/66-67} Table 11.10; see paragraph 12.7 of Approved Document B at {CLG00000224/96}. 2306 {CLG00000224/73} section 8; {CLG00000224/83} section 9, see in particular paragraph 9.3 which specifically warns about fire spread around openings. 2307 Dixon {Day44/114:16-23}.

The Grenfell Tower Inquiry: Phase 2 Report 210 Plastering nor Rydon gave any consideration to the fire performance of the materials used to fill the gaps around the windows2308 and it does not appear to have occurred to either of them that putting combustible insulation around the windows might affect fire safety.2309 59.24 Mr Lawrence accepted that Rydon had been responsible for ensuring that the products selected for the work complied with the Building Regulations and that it should have checked the choice of materials with Studio E.2310 However, neither he nor anyone else at Rydon gave any serious consideration to whether the construction of the window reveals was likely to result in a breach of the Building Regulations.2311 He admitted that he had not been aware that the Building Regulations might be relevant to the work on the window reveals;2312 he had thought that they were not part of the building envelope and were therefore unregulated.2313 Mark Dixon was also unaware that the Building Regulations might be relevant to the work.2314 He was not aware of the guidance in Approved Document B that insulation materials used in the external wall should be of limited combustibility.2315 The supply and fitting of the insulation 59.25 SD Plastering purchased Celotex TB4000 insulation boards from Travis Perkins Trading Co. Ltd. When it became difficult to obtain supplies of Celotex, it obtained Kingspan Thermapitch TP10 insulation boards from a company called CCF Ltd.2316 Mark Dixon told us that he had assumed that that was permissible because the boards were being used only to bridge the gap around the windows and provide support for the uPVC window reveals.2317 Mr Dixon could not recall any discussions with Rydon about whether Kingspan boards could be substituted for Celotex, but he thought that he had made Rydon aware of the substitution at some point,2318 and we think it likely that he did so. Supervision of the work 59.26 Daniel Osgood was a site manager for Rydon until July 2015 and was responsible for supervising SD Plastering’s work on the window reveals.2319 He did not discuss the need to maintain compartmentation or the risk of fire spread around the windows with anyone else in Rydon;2320 he just assumed that everything that was being used was “100% fireproof”.2321 He could not recall having reviewed the NBS Specification2322 and assumed that Rydon had sent it to SD Plastering.2323 He did not recall having noticed the use of Celotex insulation in SD Plastering’s quotation.2324 2308 Dixon {Day44/149:10-12}; {Day44/152:12-23}; {Day44/170:1-4}; {Day44/176:12-15}; O’Connor {Day26/207:17-22}; Osgood {Day30/181:25}–{Day30/182:12}; Cole {SDP00000220/4} page 4, paragraph 23; Dixon {Day44/152:1-5}. 2309 Dixon {Day44/118:25}-{Day44/119:2}; {Day44/131:19-25}; {Day44/149:13-16}. 2310 Lawrence {Day25/63:12-18}; {Day25/61:6-9}; {Day25/63:23-24}. 2311 Dixon {Day44/153:14-19}; O’Connor {Day26/207:23}-{Day26/208:2}; {Day26/209:12-18}. 2312 Lawrence {Day25/62:18-24}. 2313 Lawrence {Day25/60:11-21}; {Day25/62:25}-{Day25/63:9}. 2314 Dixon {Day44/142:23}-{Day44/143:3}; {Day44/144:24}-{Day44/145:24}. 2315 Dixon {Day44/145:25}-{Day44/146:3}. 2316 Dixon {Day44/147:25}-{Day44/148:12}; {Day44/141:17}-{Day44/142:14}. 2317 Dixon {SDP00000196/7} page 7, paragraph 32.2. 2318 Dixon {Day44/156:17-22}. 2319 Osgood {Day30/172:19-22}; {Day30/198:11-13}. 2320 Osgood {Day30/175:5-23}. 2321 Osgood {Day30/183:8}-{Day30/184:3}. 2322 Osgood {Day30/183:22}-{Day30/184:3}; {Day30/184:23}-{Day30/185:12}. 2323 Osgood {Day30/187:23}-{Day30/188:4}. 2324 Osgood {Day30/188:25}-{Day30/191:5}.

Part 6 | Chapter 59: Window reveals 211 59.27 Gary Martin took over from Daniel Osgood as Rydon’s site manager in July 2015 and became responsible for inspecting the work on the window reveals before the uPVC surrounds were fitted.2325 He said in his witness statement that SD Plastering had been fitting a fire resistant seal between the window unit and internal sill and that a “fire barrier” was fitted around the window void so there was no gap between the window unit and inner concrete sill.2326 However, that turned out to be merely an assumption on his part. When he was shown the photographs of the internal window reveals during his oral evidence it became clear that what he had assumed to be a fire-resistant seal or a fire barrier was in fact the aluminium foil on the insulation boards that he had seen during his site visits.2327 59.28 Mr Martin was not aware that combustible insulation had been used around the windows2328 and had not seen SD Plastering’s quotations, both of which referred to Celotex insulation being fitted in that location.2329 He knew that insulation was being used but did not notice any branding on it at the time.2330 He did not communicate any instructions to SD Plastering about the need to preserve compartmentation, the materials to be used, or fire safety generally.2331 As far as he understood it, SD Plastering was reproducing the example provided in the show flat.2332 59.29 Neither Rydon nor SD Plastering knew that Celotex TB4000 was a European Class F product or that Kingspan TP10 was European Class E and that their fire performance did not therefore correspond to the guidance in Approved Document B,2333 which called for products of limited combustibility (European Class A2).2334 59.30 Since it is likely that the failure of the window reveals played an important part in allowing the fire to escape into the cladding, we think we should summarise the factors that in our view contributed to their inadequate performance. First, Studio E should have produced detailed 1:5 scale drawings clearly identifying the insulation referred to in the NBS Specification and showing where it was to be placed. Next, Rydon should not have accepted Harley’s suggestion that uPVC boards, with poorer fire resistance, should be used for the window reveals in place of plywood just to cut cost, because there was a significant difference in fire performance. Next, Rydon should have sent the NBS Specification to SD Plastering or should at least have given it instructions about the fire performance of the materials to be used in the window reveals. It should not have allowed combustible Celotex or Kingspan insulation to be used instead of the mineral wool insulation specified by Studio E to be fitted around the windows. Finally, neither Rydon nor SD Plastering gave any consideration to the fire performance of the insulation or the construction of the window reveals as a whole, which was unsuitable for its purpose. 2325 Dixon {Day44/215:7-20}; Martin {Day30/43:4-18}; {Day30/44:23}-{Day30/47:5}; {Day30/48:15-19}; {Day30/34:21-23}. 2326 Martin {RYD00094216/1-2} pages 1-2, paragraph 6. 2327 Martin {Day30/26:6}-{Day30/29:19}; {Day30/33:8}-{Day30/34:20}. 2328 Martin {Day30/26:14}-{Day30/27:2}. 2329 Martin {Day30/37:8-18}. 2330 Martin {Day30/37:20}-{Day30/38:13}; {Day30/52:23}-{Day30/53:4}. 2331 Martin {Day30/38:22}-{Day30/39:14}. 2332 Martin {Day30/39:14-15}. 2333 Lawrence {Day25/62:9-14}; Dixon {Day44/153:20-22}; {Day44/154:25}-{Day44/155:5}; Osgood {Day30/188:12-21}. 2334 Lane, Supplemental Phase 1 Report {BLAS0000011/60} paragraph 11.15.18; Hyett, Module 1 Report {PHYR0000029/141} paragraph 4.4.149.

212 The Grenfell Tower Inquiry: Phase 2 Report

213 Chapter 60 The new smoke ventilation system 60.1 If a fire breaks out in a residential building, it is likely that some smoke will enter the corridors or lobbies, for example, through the door of the flat on fire when the occupants open it to escape. The purpose of a smoke ventilation system is to protect the escape route. In a high-rise building that may involve preventing smoke from entering the stairs and it may also involve at the same time removing it from the corridors and lobbies, which will thereby also obtain a measure of protection. 60.2 There are different ways of achieving that goal. Natural ventilation systems provide a means for hot smoke to escape through its own buoyancy, typically through a shaft that is open to the atmosphere at the top and can act as a chimney.2335 Mechanical ventilation systems use fans, ducts, vents, shafts and other features to draw smoke away from the stair and common corridors.2336 In some cases mechanical means are used for both the inflow and exhaust functions (sometimes called a “push-pull” system); in others they may be used for the exhaust function alone (sometimes called a “mechanical extraction, natural inlet” system).2337 60.3 The type of system originally installed in Grenfell Tower was a system based on natural ventilation, but with the addition of fans that firefighters could operate to assist the movement of air into and out of the building. If the fans were not operated, the system functioned as a natural inlet and outlet system.2338 The original system 60.4 The original natural smoke ventilation system installed at Grenfell Tower consisted of fresh air shafts and smoke extraction shafts serving the lift lobbies on each residential floor. Each lobby had a pair of fresh air inlets at low level on the south side connected to a pair of shafts drawing air from an inlet above the Walkway level, and a pair of exhaust vents at high level on the north side connected to a pair of shafts venting to an outlet on the roof. The pair of fresh air inlet shafts each had an opening area of 0.24m2, giving a total inlet area of 0.48m2. The pair of exhaust shafts were the same size, giving a total exhaust area of 0.48m2. Each vent had a set of motorised dampers that kept the vents closed. If smoke was detected, actuators opened the dampers on the relevant floor, while the dampers on the other floors remained closed. The mechanical ventilation “boost” function was operated by means of a switch on the ground floor. 2335 Lane, Phase 1 Report, Appendix J {BLAS0000031/12}. 2336 Lane, Phase 1 Report, Appendix J {BLAS0000031/12}. 2337 Lane, Phase 2 Module 3 Report {BLARP20000035/69} Sections 1-9 and 11. 2338 Lane, Phase 1 Report, Appendix J {BLAR00000025/14}.

The Grenfell Tower Inquiry: Phase 2 Report 214 60.5 The following diagram shows how the system was intended to work:2339 Figure 60.1 – Operation of the original smoke ventilation system on the fire floor 60.6 Accordingly, the system operated by ventilating the lobby area with the intention of protecting the escape route through the lobby. 60.7 The system did not follow the recommendations of British Standard Code of Practice CP3 1971 (the standard which appears to have been used when designing the building),2340 section 3.4.3.1(4) of which required that for buildings with a single stairway, cross ventilation in common access areas should be provided by an opening with a free area of at least 1.5m2.2341 The available aggregate free area of 0.48m2 at Grenfell Tower was significantly less than that. The decision to refurbish 60.8 As set out in Chapter 43 of this report, the original smoke ventilation system at the tower had fallen into disrepair and had failed to work in a previous fire in April 2010. In March 2014, following a visit to the tower, the LFB issued a deficiency notice to the TMO stating that about a quarter of the system’s dampers were not working2342 and by October 2014 the TMO was aware that the system was beyond repair.2343 2339 Lane, Phase 1 Report Appendix J {BLAS0000031/18} Figure J.5. 2340 Phase 1 Report Volume I paragraph 5.1. 2341 Lane, Phase 1 Report, Appendix J {BLAR00000025/6}. 2342 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. 2343 Email from Alex Bosman to Claire Williams, Janice Wray and Carl Stokes dated 9 October 2014 {CST00001244/1}.

Part 6 | Chapter 60: The new smoke ventilation system 215 60.9 During 2011, the TMO’s Assets and Regeneration Health and Safety Committee repeatedly discussed carrying out a feasibility study for the installation of a replacement smoke ventilation system.2344 At a meeting on 15 September 2011, the Asset Investment and Engineering Health and Safety Group decided that an invitation to tender for the work should be published immediately with a view to beginning work in December 2011.2345 60.10 In October 2011 AECOM, an engineering consultancy firm, prepared a draft tender for the refurbishment of the dampers and the conversion of the manually activated mechanical boost function to a system activated automatically by the presence of smoke.2346 The existing system did not comply with the statutory guidance current at the time of the refurbishment because of the size of the shafts but the AECOM proposal would have made the existing system more robust, thereby satisfying the requirement in regulation 4(3) of the Building Regulations 2010 not to make the building any more unsatisfactory in that respect than it had previously been.2347 60.11 At a design team meeting on 18 July 2012, the TMO instructed Max Fordham to expand the scope of the tower’s refurbishment to include improving the smoke ventilation system, as AECOM had recommended.2348 Even if the existing smoke ventilation system had been working at that time, it would have been necessary to extend it to the new lobbies that were being created on the lower floors.2349 Exova’s consideration of the smoke ventilation system 60.12 In the draft Existing Fire Safety Strategy for Grenfell Tower dated 16 August 2012 Exova summarised the position on smoke ventilation, noting that the existing shafts did not provide sufficient capacity to meet modern standards and recommending that they be ventilated by mechanical means.2350 The existing system was described as “significantly undersized”.2351 60.13 Exova also said that unless the fans of any new system were capable of producing flow rates equivalent to a compliant modern system, the improved system would not meet current standards.2352 It pointed out the particular importance of a smoke ventilation system in a building that had travel distances between flat entrance doors and the doors to the stairs of more than 7.5m. The maximum distance was said by Exova to be approximately 8.3m.2353 Exova said that provision of ventilation was critical to the tower’s “stay in place” evacuation principle and it therefore strongly recommended that the performance of both the existing and proposed smoke ventilation systems be assessed.2354 2344 Minutes of the Asset Investment and Engineering Health & Safety Group dated 3 February 2011 {TMO10000823}; Minutes of the Asset Investment and Engineering Health & Safety Group dated 31 March 2011 {TMO10000842}; Minutes of the Asset Investment and Engineering Health & Safety Group dated 26 May 2011 {TMO10000868}. 2345 Minutes of the Asset Investment and Engineering Health & Safety Group dated 15 September 2011 {TMO10000920/1}. 2346 AECOM tender report {SEA00000004}. 2347 McQuatt {MAX00017292/19} page 19, paragraph 82. 2348 Studio E Notes from Meeting 5 dated 18 July 2012 {MAX00000147}. 2349 McQuatt {MAX00017292/17-18} pages 17-18, paragraph 71. 2350 Existing Fire Safety Strategy for Grenfell Tower dated 16 August 2012 {EXO00001074/10-11} section 3.4. 2351 Existing Fire Safety Strategy for Grenfell Tower dated 16 August 2012 {EXO00001074/11} fourth paragraph. 2352 Existing Fire Safety Strategy for Grenfell Tower dated 16 August 2012 {EXO00001074/11} fourth paragraph. 2353 Existing Fire Safety Strategy for Grenfell Tower dated 16 August 2012 {EXO00001074/10} paragraph 3.3.6. 2354 Existing Fire Safety Strategy for Grenfell Tower dated 16 August 2012 {EXO00001074/11} fourth paragraph.

The Grenfell Tower Inquiry: Phase 2 Report 216 60.14 Minutes of a project meeting on 6 September 2012 record that Exova needed to understand the existing situation, including whether the LFB tested the smoke ventilation system twice a year and what lay behind the proposal to improve it. The minutes recorded that action would be taken by Exova.2355 60.15 On 10 September 2012 Cate Cooney of Exova sent an email to Terence Ashton stating that the existing smoke ventilation system was “questionable” and that adding additional residential floors to the building would make the existing condition worse. She noted that it was proposed to improve the smoke ventilation system but that it was not known what standard the new system would achieve.2356 60.16 In Issue 3 of the Outline Fire Safety Strategy dated 7 November 2013 reference to the smoke ventilation system was limited to noting that it would be overhauled as part of the refurbishment of the building and would be covered in a separate report by Max Fordham.2357 There was no further consideration of the system as part of the fire safety strategy. Max Fordham’s initial proposals 60.17 Max Fordham’s initial proposals for the refurbishment of the smoke ventilation system took a similar approach to AECOM’s and involved an improved version of the existing system.2358 In November 2012 Mr McQuatt sought advice on developing the design from Atrium Airconditioning Ltd,2359 which passed his enquiry to PSB, a specialist smoke ventilation company. 60.18 On 9 November 2012 PSB responded to Mr McQuatt saying that it did not see anything wrong with the proposed design.2360 Following the consultation with PSB the design intent for the improved system was revised to bring it as close to the current regulations as possible within the limitations imposed by the existing shafts.2361 In addition to providing a working smoke ventilation system, it was intended to use the system to provide ventilation to the lobbies to prevent overheating. RBKC Building Control 60.19 During 2013 there were continuing discussions between designers and other contractors engaged in the refurbishment of the tower about the modernisation of the smoke ventilation system. They included Max Fordham, Studio E, and Exova. Max Fordham’s proposals for the new system did not undergo any changes during that period, but it proved difficult to demonstrate to building control that the new system would be an improvement on the existing system or at least would not make it any worse.2362 The fact that the existing system was not in working order and the paucity of documentation surrounding its installation made it difficult for the designers to compare its performance with the expected performance of any proposed replacement. 2355 Studio E Notes from Meeting 8 dated 6 September 2012 {MAX00000311/2} section “Fire”. 2356 Email from Cate Cooney to Terry Ashton dated 10 September 2012 {EXO00000388}. 2357 Exova Grenfell Tower Outline Fire Safety Strategy Issue 3 dated 7 November 2013 {EXO00001107/7} section “Smoke Ventilation of Lobbies, Walkway +1 Level”. 2358 McQuatt {MAX00017292/20} page 20, paragraph 85. 2359 Email from Andrew McQuatt to Atrium Airconditioning dated 8 November 2012 {MAX00003356}. 2360 Email from Fergus MacGregor to Andrew McQuatt and others dated 9 November 2012 {PSB00000002/2}. 2361 Cross Smith {MAX00017304/10-11} pages 10-11, paragraph 28. 2362 Cross Smith {MAX00017304/13} page 13, paragraph 36.

Part 6 | Chapter 60: The new smoke ventilation system 217 60.20 On 25 October 2013, Max Fordham repeated its proposals for the new system, stating that, as it was not possible to adapt the existing system to meet current standards, its intention was to bring the existing system up to as high a standard as possible.2363 At that stage, therefore, the proposal was still to improve the existing system rather than replace it with an entirely new one. Max Fordham acknowledged that there were no directly applicable standards that could be used as a basis for the design of the improved system but considered that it was reasonable to aim at providing 15 air changes an hour.2364 That may have been based on conversations with Exova.2365 60.21 On 25 October 2013 Bruce Sounes of Studio E submitted Max Fordham’s proposals to RBKC building control, together with the draft Outline Fire Safety Strategy for the building prepared by Exova. In his covering email Mr Sounes said that the design team thought that agreement on the smoke ventilation system was the single biggest risk to the proposals, but that they did not think it was reasonable to leave the existing system in place.2366 60.22 On 11 November 2013 John Allen, the building control manager at RBKC, told Mr Sounes that the information submitted by Studio E was not adequate to enable an effective consultation to be held with the LFB.2367 However, he said that if it could be shown that the new system was no worse than the existing system, the design would be acceptable. He suggested that if there were no data available on the existing system, a way forward might be to measure the flow rates of the existing system and provide information about the capacity of the proposed new system. For the purpose of consulting the LFB Mr Allen suggested that information about the existing system be obtained, including the method of activation, the size of the shafts, and the powered extraction rate, that could be compared to similar information about the proposed improved system.2368 In the light of that response Mr Cross Smith decided to contact PSB to obtain further specialist advice on the design of the new system.2369 60.23 On 6 December 2013, in a memorandum to Mr Allen, Paul Hanson, then responsible for the Means of Escape Group within RBKC building control, provided further observations on the proposals.2370 He noted that it was not proposed to redesign the system to bring it up to modern standards, as that was likely to require larger shafts, but that building control had indicated that, provided the performance of the system was not made worse, the Building Regulations did not require it to be replaced. He suggested that a comparison of the flow rates of the system in its current and improved forms could provide a way forward. He did not think it was acceptable to base the design on a particular number of air changes an hour, as Max Fordham had proposed, as it did not correspond to any known guidance for lobby ventilation systems, being based on a generic value used for car parks.2371 60.24 In his memorandum Mr Hanson also said that, if the designers wished to design the system to achieve a particular performance, they would need to provide evidence to support the proposed rate of extraction, including performance modelling. He suggested that a reasonable approximation of ventilation rates could be obtained using computational fluid dynamics (CFD) or a simpler zone model.2372 2363 Cross Smith {MAX00017304/10-11} pages 10-11, paragraph 28. 2364 Max Fordham Grenfell Tower Smoke Control Proposals Rev A, dated 25 October 2013 {MAX00000867}. 2365 Cross Smith {Day157/174:16-20}. 2366 Email from Bruce Sounes to John Allen and Paul Hanson dated 25 October 2013 {SEA00000121}. 2367 Email from John Allen to Bruce Sounes dated 11 November 2013 {SEA00009805}. 2368 Email from John Allen to Bruce Sounes dated 11 November 2013 {SEA00009805}. 2369 Cross Smith {MAX00017304/14} page 14, paragraph 38. 2370 Memorandum from Paul Hanson to John Allen dated 6 December 2013 {RBK00003014}. 2371 Hanson {Day154/77:1-9}. 2372 Memorandum from Paul Hanson to John Allen dated 6 December 2013 {RBK00003014}.

The Grenfell Tower Inquiry: Phase 2 Report 218 The approach to PSB 60.25 At around the end of April 2014, Mr Cross Smith asked PSB to assist with satisfying building control’s request for a revised submission. That led to a proposal for the use of a pressure differential system as a possible alternative2373 which was described in a document written by Hugh Mahoney of PSB, entitled Smoke Ventilation Technical Proposal For Stair De‑pressurisation Systems at Grenfell Tower, Regeneration Project, dated 22 April 2014.2374 PSB also suggested a target extraction rate of 5.0m3/s for the system, which Mr Cross Smith incorporated into Max Fordham’s latest proposals in May 2014. Apparently, that was the rate PSB always used for those purposes.2375 60.26 In late April or early May 2014, PSB and Max Fordham discussed CFD modelling, but by then there was insufficient time to carry it out, so it was not pursued.2376 Simon Lay, one of the experts from whom we heard evidence, was of the opinion that, since the new system was being designed specifically for Grenfell Tower, Exova, Max Fordham and PSB ought to have ensured that a CFD analysis was carried out.2377 He considered that in failing to do so they had fallen below the standards reasonably to be expected of them.2378 Dr Lane also considered that Exova and Max Fordham should have made sure that a CFD analysis was carried out.2379 She said that she would have expected PSB to advise that that should be done or to do it themselves if they had the capability, and rejected the suggestion that shortage of time was a valid reason for not doing it.2380 60.27 It remains unclear to us why a CFD analysis of the proposed new system was not carried out once it had become apparent that it was not possible to obtain reliable information about the performance of the existing system. If such an analysis had been carried out, it would have ensured that the performance of the new system had been ascertained with reasonable confidence and suitably documented. We agree that it should have been considered further and that PSB should have suggested it to the design team. Pressure of time was not a reasonable justification for failing to carry out such an analysis. The existing system had not been in working order for a long time and a further delay of weeks or even months was not a sufficient reason not to analyse properly the performance of the proposed replacement. 60.28 On 24 November 2014 at a meeting between building control, Studio E, the TMO and Max Fordham to discuss the system, PSB and JS Wright (Rydon’s electrical and mechanical sub-contractor) put forward an alternative system, the outline of which was contained in a technical submission from PSB dated 12 November 2014 produced by Mr Mahoney.2381 2373 Cross Smith {MAX00017304/15-16} pages 15-16, paragraph 44. 2374 Smoke Ventilation Technical Proposal for Stair De-Pressurisation Systems at Grenfell Tower, Regeneration Project {PSB00001233}. 2375 Cross Smith {MAX00017304/16} page 16, paragraph 47. 2376 Mahoney {Day155/163:20}-{Day155/164:13}; {Day155/21:5-22}; {Day155/26:10-25}; {Day155/32:14-24}. 2377 Lay {Day286/169:15-23}. 2378 Lay {Day286/170:5-17}. 2379 Lane {Day287/136:14-17}. 2380 Lane {Day287/137:3}-{Day287/138:1}. 2381 Smoke Ventilation Technical Submission, Revision 0 dated 12 November 2014 {PSB00000207}.

Part 6 | Chapter 60: The new smoke ventilation system 219 60.29 Mr Mahoney understood that the essential purpose of the proposed work on the smoke control system was simply to make it better than the existing system.2382 In his view, provided it could be shown to deliver an extraction rate of 3m3/s, it would be acceptable to building control on the basis that that would be significantly better than the 1.2m3/s which was the estimated capacity of the existing system.2383 60.30 Mr Mahoney regarded the PSB design as an alternative approach. It did not follow any published guidance but would in his view be effective to protect the stairs and ventilate the lobby. He considered it impossible to install a system that complied in all respects with current standards.2384 The design of the new system 60.31 The design contained in PSB’s technical submission was subsequently developed, culminating in Revision 6 issued on 15 March 2016 which contained the design of the system that was ultimately installed at Grenfell Tower. All versions except the final one were produced by Mr Mahoney. 60.32 It is not necessary to describe every aspect of the system’s design because we are concerned only with those that could have played a part in the fire. In summary, the following are worth considering: a. The new system extracted air from the relevant lobby through all four vents and discharged it either at the top of the building through the north shafts or at the level of Floor 2 through the south shafts. Air entered the lobby around the door to the stairs in response to the change in pressure. Mr Mahoney saw the extraction of air from the lobby at the rate of 3m3/s as the system’s primary purpose,2385 thereby moving air from the stairwell into the lobby and protecting it from the ingress of smoke. In other words, the objective was to remove smoke from the lobby to prevent it entering the stairs.2386 b. According to PSB’s technical submission, the system was designed to provide an average air velocity of 2m/s across an open door between the lobby and the stairs. That velocity was derived from BS EN 12101:6, which contains standards for pressure differential systems, but the system was not intended to work as a pressure differential system and was not designed in full compliance with that standard.2387 c. The system was activated by smoke detectors in the lobbies. When smoke was detected on a particular floor, the dampers on that floor were designed to remain open and the dampers on all other floors to close, allowing the full capacity of the system to extract air from the lobby in which smoke had been detected.2388 d. A new pair of smoke extraction fans were installed at Level 2 and also an environmental extraction fan.2389 2382 Mahoney {Day155/25:1-7}. 2383 Mahoney {Day155/110:20}-{Day155/111:2}. 2384 Mahoney {Day155/86:5-12}. 2385 Mahoney {Day155/90:21-24}. 2386 Hanson {Day154/135:1-7}. 2387 Smoke Ventilation Technical Submission, Revision 6 dated 15 March 2016 {PSB00000214/3}. 2388 Smoke Ventilation Technical Submission, Revision 6 dated 15 March 2016 {PSB00000214/3}. 2389 Smoke Ventilation Technical Submission, Revision 6 dated 15 March 2016 {PSB00000214/4}.

The Grenfell Tower Inquiry: Phase 2 Report 220 e. Pressure sensors were also installed on every floor to control the speed of the extraction fans in order to ensure that the reduction in the air pressure in the lobbies did not prevent the door to the stairs from being opened. According to PSB’s technical submission, if the pressure differential fell below -25 pascals (“Pa”) (for example, if the door to the stairs were opened), the speed of the fans would increase until the differential of -25Pa had been restored.2390 f. New dampers were fitted to the openings in the south and north shafts on every floor. In addition, the new system included dampers within the ductwork on Level 2 to bypass the environmental ventilation ducts when the system was in smoke extraction mode. That reflected the dual purpose of the system: smoke control when smoke was detected and environmental ventilation when the building became too warm.2391 When the system was operating in environmental mode, the dampers would open on four floors at a time for 15 minutes in sequence to cool the building down to the activation temperature.2392 60.33 Below is an illustration of the way in which the new smoke ventilation system was intended to operate. The blue lines indicate fresh air from the roof vent at the top of the stairs entering the lobby through the door to the stairs; the red lines indicate the movement of smoke and hot gases out of the shafts on the north and south sides of the lobby.2393 Figure 60.2 - Design intent of the smoke extract system in Grenfell Tower for Level 2 to Level 23 2390 Smoke Ventilation Technical Submission, Revision 6 dated 15 March 2016 {PSB00000214/18}. 2391 Smoke Ventilation Technical Submission, Revision 6 dated 15 March 2016 {PSB00000214/4}. 2392 Lane, Phase 1 Report, Appendix J {BLAS0000031/87}. 2393 Lane, Phase 2 Module 3 Report, Sections 1-9 and 11 {BLARP20000035/260-261}.

Part 6 | Chapter 60: The new smoke ventilation system 221 60.34 Mr Mahoney said that the advantage of the design was that by using four shafts rather than two to extract smoke from the lobbies, the velocity required to achieve the required rate of extraction was reduced. In his opinion, seeking to achieve a higher flow rate using only two shafts for extraction and two for the entry of air was not viable, because the higher air speed required through each shaft would have disrupted the flow. It would also have risked creating velocity jets in the lobbies where air entered the vents, which might have caused smoke to enter the stairs.2394 Dampers 60.35 Dampers are mechanical devices used to prevent air or gases from passing through ducts or from the openings of ducts into the space beyond. Typically they take the form of louvred plates that overlap slightly to provide a solid barrier when in the closed position. In the open position they allow the passage of air and other gases. They are often opened or closed by an electric motor known as an actuator. Different kinds of dampers with different performance characteristics are available. It may therefore be helpful to begin this section by describing the ways in which dampers are classified and the purposes they are designed to serve. Fire dampers 60.36 Fire dampers sit within a duct or ventilation opening and are usually operated automatically. They are designed to prevent the passage of fire.2395 A damper is classed as a fire damper if it achieves an integrity classification of at least “E” as defined in BS EN13501- 3:2005 when tested in accordance with BS EN1366-2:1999. 60.37 The integrity classification “E” reflects the damper’s ability to prevent the transmission of fire as a result of the passage of significant quantities of flames or hot gases from the fire to the unexposed side, thereby causing ignition either of the surface not exposed to the fire or of any material adjacent to that surface.2396 Its purpose is to prevent the ignition of whatever is on the other side of the damper rather than to restrict the amount of smoke adversely affecting the adjoining space. A fire damper, therefore, is expected to close in the event of a fire and remain closed during it;2397 it is not intended to open and close repeatedly as part of a system’s normal operation. Fire and smoke dampers 60.38 Fire and smoke dampers are tested and classified by reference to their ability to limit the amount of smoke passing from one side to the other.2398 Such dampers must have been tested in accordance with BS EN 1366-2:1999 and meet both the integrity and smoke leakage criteria in EN 13501-3:2005. They are then classified “ES”. The function of a fire and smoke damper is also to close and remain closed during a fire,2399 but it must have a lower leakage rate than a fire damper. 2394 Mahoney {Day155/82:3-16}. 2395 Approved Document B {CLG00000224/144}. 2396 BS EN 13501-3 (Fire classification of construction products and building elements – Part 3) {BSI00000810/9} paragraph 5.1.2. 2397 Lane, Phase 2 Module 3 Report {BLARP20000035/86}. 2398 Approved Document B {CLG00000224/144}. 2399 Lane, Phase 2 Module 3 Report {BLARP20000035/88} Sections 1-9 and 11.

The Grenfell Tower Inquiry: Phase 2 Report 222 60.39 The ability of a damper to minimise the leakage of smoke was directly relevant to its suitability for use in the smoke ventilation system of the tower, because the vertical shafts used to extract smoke passed through the lobbies, which were part of the escape route for the occupants of the flats on those floors. A damper that prevented the passage of fire alone would not have been suitable. 60.40 The performance necessary to achieve the relevant classifications are set out as follows in EN 13501-3:2005:2400 a. For the classification “E” the leakage limit is 360 m³/h∙m²; b. For the classification “ES” the leakage limit is 200m³/h∙m² (corrected to 20°C). (The limit is the same at ambient temperature and during the fire test.) Smoke control dampers 60.41 Smoke control dampers are described in BS EN 1366-10:20112401 (“Fire resistance tests for service installations, Part 10 Smoke Control Dampers”) rather than in Approved Document B. A smoke control damper is a similar device that can be automatically or manually opened or closed in its operational position to control the flow of smoke and hot gases into, from or within a duct.2402 60.42 A smoke control damper is subject to the same performance requirements as a fire and smoke damper, but differs from the previous two types of damper in that it is capable of both opening and closing during a fire.2403 The design of the system 60.43 The shafts and ductwork for the smoke ventilation system were required to be in a protected area, as described in Approved Document B, in order to restrict the ability of fire and smoke to spread between compartments.2404 The effectiveness of the dampers in preventing excessive smoke leakage from the shafts into lobbies on floors other than the one affected by a fire was therefore an important feature of the system. Leakage through the dampers also adversely affects the ability of the fans to extract smoke and thus the performance of the system as a whole.2405 60.44 The design of the new smoke ventilation system envisaged that dampers might be changed from the closed to the open position during a fire, because the manual control function allowed firefighters to change the floor from which smoke was being extracted as required by the location of the fire. Accordingly, a damper that had previously shut on one floor might later be opened manually if the fire brigade required the system to extract smoke from another floor. 60.45 Only a smoke control damper is designed and tested to perform in that way. The key differences between the testing of smoke control dampers and the testing of the other two kinds of damper relate to:2406 2400 BS EN 13501-3 (Fire classification of construction products and building elements – Part 3) {BSI00000810/16}. 2401 BS EN 1366-10:2011 (Fire resistance tests for service installations – Part 10: Smoke control dampers) {BSI00001777/12} paragraph 3.27. 2402 Lane, Phase 2 Module 3 Report {BLARP20000035/90} Sections 1-9 and 11. 2403 BS EN 12101-8:2011 (Smoke and heat control systems – Part 8: Smoke control dampers) {BSI00000048/7}. 2404 Approved Document B {CLG00000224/73} paragraph 8.9. 2405 Lane, Phase 2 Module 7 Supplementary Report {BLARP20000043/16}. 2406 Lane, Phase 2 Module 3 Report {BLARP20000035/92-93} Sections 1-9 and 11.

Part 6 | Chapter 60: The new smoke ventilation system 223 a. the durability of operational reliability, which is tested by carrying out a minimum number of opening and closing cycles before fire testing – 10,200 for smoke control dampers but only 50 for fire dampers and fire and smoke dampers; and b. the ability to change from open to closed position and vice versa at elevated temperatures, which is not a requirement for fire dampers or fire and smoke dampers. 60.46 In this case durability of operational reliability was important because the dampers were part of a system that also provided environmental ventilation. They could therefore reasonably be expected to open and close many times each week. As a result of having been tested through over 10,000 cycles, smoke control dampers can be expected to be effective over a much longer operational lifetime. 60.47 The ability to move between an open and closed position at elevated temperatures was also of importance in this case because firefighters might need to control the system manually if the temperature on one floor rose considerably due to the fire. 60.48 Having regard to the properties of the three kinds of damper we have described, it is clear that only a smoke control damper could be expected to meet the requirements of the new system. The Gilberts Series 54 damper 60.49 The Gilberts Series 54 damper is shown in the open and closed positions in the following photographs taken after the fire.2407 2407 Lane, Phase 2 Module 3 Report {BLARP20000035/296}. 2408 Lane, Phase 2 Module 3 Report {BLARP20000035/297} Sections 1-9 and 11. Figure 60.3 – Examples of dampers in an open and closed position 60.50 It is opened and closed by an actuator (a small electric motor)2408 that moves the blades. When smoke is being drawn up the shaft the damper prevents it from entering the lobbies. It therefore plays a vital role in protecting the atmosphere in the lobbies not directly affected by the fire.

The Grenfell Tower Inquiry: Phase 2 Report 224 60.51 The damper was described in a brochure published by the manufacturer in October 20112409 as a “smoke evacuation damper”, a description not found in any published guidance. The brochure also stated that it had been fully tested to the requirements of EN1366 Part 2 for one hour.2410 However, BS EN 1366-2 contains the standard for testing fire dampers and fire and smoke dampers; it does not contain the standard for testing smoke control dampers.2411 Moreover, the damper had been tested from the closed, rather than the open, position, as the notes attached to the original quotation confirmed. The statement in the brochure was therefore inaccurate and misleading, because the test method to which it referred requires testing from the open position. There was no suggestion by Gilberts in the brochure or otherwise that the damper was a smoke control damper in the recognised sense. The choice of the Gilberts Series 54 damper 60.52 In January 2015 Hugh Mahoney asked Gilberts to quote for the supply of Series 54 dampers for use in a smoke ventilation system. At that stage he did not provide any information about the system in which they were to be used. 60.53 The quotation that Gilberts sent to Mr Mahoney on 22 January 2015 contained a note stating that the damper had undergone an EN 1366-2 test starting from the closed position which had lasted over 60 minutes for both fire integrity and smoke leakage (ES60) but that it had no formal certification.2412 (As we have said, the claim in respect of smoke leakage was wrong because the test had been started from the closed position.) The information that the test had been started from the closed position would have disclosed to a reasonably knowledgeable reader that the test had not been carried out entirely in accordance with the published standard, a conclusion reinforced by the reference to the absence of formal certification. 60.54 Another note recommended that the purchaser discuss the specific technical requirements of the damper with the relevant authority to ensure that it was acceptable but there is no evidence that any of the contractors involved in designing or installing the smoke control system discussed the matter with RBKC building control. 60.55 After receiving the original quotation from Gilberts, Mr Mahoney asked for further information about the Series 54 dampers, including test results, which were sent to him by email.2413 One of the documents attached to the email was a report dated 6 October 2011 of a fire resistance test on a Series 54 damper carried out by Exova on 23 August 2011 in accordance with BS EN 1366-2.2414 The report showed that the damper had been subjected to an integrity test with a threshold of 360m3/h∙m2 for over 60 minutes under a pressure of about 300 Pa.2415 The damper satisfied that test, with satisfactory performance for 74 minutes, but it failed to satisfy the requirement in relation to the leakage of smoke, for which the performance criterion was not to exceed 200m3/h∙m2 under a pressure of about 300 Pa. 2409 Gilberts, Series 54 Smoke Evacuation Damper brochure {PSB00000201}. 2410 Gilberts, Series 54 Smoke Evacuation Damper brochure {PSB00000201/2}. 2411 Lane, Phase 2 Module 3 Report {BLARP20000035/93} Sections 1-9 and 11. 2412 Quotation provided by Gilberts to PSB for Series 54 Dampers dated 22 January 2015 {GBL00000006/3}. 2413 Email from Mark Griffiths to Hugh Mahoney {GBL00000005/2}. 2414 Email from Mark Griffiths to Hugh Mahoney {GBL00000005/2-3}. 2415 Email from Mark Griffiths to Hugh Mahoney {GBL00000005/42}.

Part 6 | Chapter 60: The new smoke ventilation system 225 60.56 In the Conclusions section of the report the test result for smoke leakage was recorded as “0 minutes”, which represented an immediate failure to satisfy the performance requirement.2416 In the Test Procedure section,2417 Exova recorded that the specimen had been assessed on its ability to comply with the performance criteria for integrity, insulation and smoke leakage as required by BS EN 1366-2:1999 but that at Gilberts’ request the damper had been in the closed position at the commencement of the test and that the test had therefore not been conducted fully in accordance with the standard. As a result, it was not possible for the damper to obtain any kind of certification. 60.57 In spite of the incorrect and misleading statements about certification and testing in Gilberts’ 2011 brochure and its first quotation, any recipient of Exova’s report who carried out even a cursory review of those results would have understood that the Series 54 damper held no certification whatsoever and had failed the smoke leakage test immediately. The recipients of that report included Mr Mahoney and, in due course, RBKC building control. 60.58 Mr Mahoney appears to have thought that a certified smoke control damper of a size and configuration suitable for use in the walls at Grenfell Tower was not available.2418 He thought that the Gilbert’s dampers were the best that could be found to fit within the wall of the tower.2419 In any event, PSB chose to specify the use of the Gilberts Series 54 damper, despite the fact that it had not been classified in accordance with any of the standards mentioned earlier and had not been shown to meet the alternative specifications for dampers to be used in smoke control systems contained in the guides published by the Smoke Control Association. He could instead have specified performance criteria or a certification standard, such as ES60, against which a search of available products could have been made. Having carried out a limited internet archive search (including of the archived version of the LPCB2420 Redbook dated 23 August 2014) for dampers available on the market at the time, Dr Lane identified two smoke control dampers that might have been suitable for use in the system,2421 although she acknowledged that she did not have access to enough information to tell whether either of them could in fact have been used. 60.59 Mr Mahoney was aware when he designed the system that the shafts had to be protected2422 and he discussed with Mr Cross Smith the need to have fire-rated ductwork,2423 but he did not do enough to ensure that the dampers he selected to separate the protected shafts from the lobbies were fit for the purpose of protecting escape routes. Apart from anything else, in the absence of test data evidencing their durability there could be no confidence that the dampers would perform properly in a fire after many months of use in a combined environmental and smoke ventilation system. 2416 Email from Mark Griffiths to Hugh Mahoney {GBL00000005/43}. 2417 Email from Mark Griffiths to Hugh Mahoney {GBL00000005/8}. 2418 Mahoney {Day155/203:20}-{Day151/205:2}. 2419 Mahoney {Day155/213:20}-{Day155/214:1}. 2420 Loss Prevention Certification Board. 2421 Lane, Addenda and Errata Report {BLARP20000044/4-5}. 2422 Mahoney {Day155/198:14-23}. 2423 Mahoney {Day155/200:2-7}.

The Grenfell Tower Inquiry: Phase 2 Report 226 60.60 In due course, as a result of changes to the sizes of some of the dampers required, J S Wright asked Gilberts for another quotation.2424 Following the receipt of that quotation, J S Wright placed an order for the products which Gilberts supplied.2425 Gilberts did not provide advice on the suitability of the Series 54 dampers for the proposed system, about which it had little or no information.2426 60.61 Mr Hanson said that he had checked the specification of the Gilberts Series 54 damper2427 and had concluded on the basis of the product literature that it was regarded as being of an acceptable standard by the Smoke Control Association Guide 2012.2428 He said he could see from the drawings that the ducts were adequately fire-resistant.2429 He accepted that the dampers were of a lower standard than smoke control dampers but, in his opinion, they were still of an acceptable standard.2430 60.62 The Gilbert Series 54 damper had not been tested in a way that demonstrated it was capable of acting as anything more than a ventilator, which required the lowest standard of performance in the event of a fire.2431 It was far removed from a smoke control damper, which would have been the appropriate product to install in a complex and multi-functional system of the kind designed by PSB. Although it received a copy of the Exova report, PSB does not appear to have reviewed the specification of the dampers or to have discussed it with building control.2432 It should have done so, but we have seen nothing to suggest that the implications of Exova’s report were identified or acted upon. PSB should have realised that the Gilberts Series 54 damper was unsuitable for this application. 60.63 We do not know whether in 2015 fire and smoke dampers were available that would have been suitable for use in the system, but we are surprised that PSB does not appear to have tried to find appropriately certified dampers. At the very least, it should have told J S Wright about the limitations of the Series 54 damper so that the risks of using it could be properly assessed. 60.64 Mr Lay was of the opinion that, although the Series 54 dampers were not certified and did not meet the alternative Smoke Control Association recommendations, their performance characteristics could allow them to perform adequately as part of the system.2433 However, we do not agree. The Series 54 dampers did not meet the requirements for smoke leakage, which was important for protecting routes of escape, and had not been shown to meet the durability requirements. In the absence of reliable test results (i.e. results of tests conducted in accordance with recognised standards) from which to draw inferences, we cannot safely make any findings about how a component might have performed. The point of testing standards is to provide an assurance that a product meets the specified performance criteria and no such assurance was provided in relation to the Gilberts Series 54 dampers. 2424 Email from David Bradbury to Mark Griffiths {JSW00003607}. 2425 Jones {GBL00000010/3} page 3, paragraph 10. 2426 Jones {GBL00000010/3} page 3, paragraphs 11-17; {GBL00000010/4} page 4, paragraph 21. 2427 Hanson {Day154/204:5-8}. 2428 Hanson {Day154/208:12-15}. 2429 Hanson {Day154/210:1-2}. 2430 Hanson {Day154/214:10-15}. 2431 Lane, Phase 2 Module 7 Supplementary Report {BLARP20000043/264}. 2432 Lay, Smoke Control System Report {LAY00000001/201}. 2433 Lay, Smoke Control System Report {LAY00000001/203}.

Part 6 | Chapter 60: The new smoke ventilation system 227 Effect on the system’s performance 60.65 It is possible that the use of the Gilberts Series 54 dampers contributed to the breach of compartmentation by permitting more smoke to pass from the shafts into some of the lobbies than would have been the case if appropriately certified dampers had been used, but it is impossible now to tell whether that was in fact the case. However, circumstances surrounding the choice of dampers demonstrates insufficient concern for fire safety to which we think it important to draw attention as part of the events which led to the tragedy. Other shortcomings in the design process The lack of design records 60.66 A recurring theme of our investigation into the design of the smoke ventilation system was a failure to create a clear record of its objectives and how its performance characteristics related to the fire strategy for the building. The importance of creating such a record was made clear in the 2012 version of the Smoke Control Association’s guide, which strongly recommended that, except perhaps in the simplest cases, the objectives of the system, the circumstances to be calculated or modelled, the modelling criteria, the expected reporting and the criteria for success should all be agreed and recorded before the commencement of design.2434 60.67 The Smoke Control Association Guide 2012 advised that the records should include at least: i. A description of the residential area and the proposed ventilation system. ii. The design criteria and performance objectives. iii. The range of circumstance in which it was intended to operate. iv. Details of the techniques used and related information. v. The results of the analysis. vi. A statement whether the design criteria and objectives have been met.2435 60.68 That information was required in this case to enable the wider design team, and ultimately the TMO as the responsible person, to understand the design of the system and its limitations but not all of it had been recorded. 60.69 Information relating to the design of the system should also have been incorporated in the fire safety strategy but that was not done either. Instead, Issue 3 of the Draft Outline Fire Safety Strategy discussed the smoke control system in very general terms and left it to Max Fordham to take the matter forward. We consider that Exova and the TMO, as the client, should have ensured that the Outline Fire Safety Strategy specifically described the final design of the smoke control system and explained how it supported the fire safety strategy for the building. A fire safety strategy necessarily relies on certain assumptions, which should be made explicit.2436 That was particularly important in this case, since the new system did not correspond directly to any design described in the available guidance. 2434 Smoke Control Association Guide 2012 {LFB00059241/5} Introduction and fifth paragraph. 2435 Smoke Control Association Guide 2012 {LFB00059241/14-15} paragraph 5.4. 2436 Torero {Day289/7:5-25}.

The Grenfell Tower Inquiry: Phase 2 Report 228 Extended travel distances 60.70 We heard evidence about the distances between the entrance doors to flats and the door to the stairs. The guidance in Approved Document B is that the distance in an unventilated part of an escape route should not exceed 7.5 metres.2437 BS9991 contains similar guidance.2438 60.71 Measurements were made of the maximum distance between the front doors of the flats and the doors to the stairs on Floors 4 to 23. They ranged from 9.3 metres (BRE2439) to 10.3 metres (Dr Lane).2440 We do not consider the difference between 9.3 metres and 10.3 metres to be material. What is significant is that, even at 9.3 metres, the maximum distances exceeded that indicated by Approved Document B. 60.72 Mr Hanson accepted that if the travel distance exceeded 7.5 metres, the Smoke Control Association Guide indicated that the primary objective of the system should be the protection of both the lobby and the staircase.2441 His view, however, was that for an existing building it would be unreasonable to apply the standards applicable to a new building.2442 60.73 Mr Lay also thought that if the travel distances in a building were excessive, it would not be appropriate to concentrate solely on protecting the stairs and that protection would also need to be provided to the lobby.2443 He referred to the LGA Guide as indicating that extended travel distances of less than 10 metres in existing residential buildings would not be considered excessive and did not require mitigation. We consider, however, that some caution should be exercised in using the LGA Guide in this context, since it is intended to provide guidance on compliance with the Fire Safety Order and the Housing Act 2004, rather than the functional requirements of the Building Regulations and is directed at housing providers and enforcing authorities,2444 rather than designers of smoke control systems. Although that does not make it irrelevant, it is significant that the context is assessing existing fire safety arrangements, rather than controlled works under the Building Regulations. Furthermore, we note that Approved Document B stated at paragraph 0.21, that guidance documents intended specifically for assessing fire safety in existing buildings will often include provisions which are less onerous than those set out in Approved Document B and are therefore unlikely to be appropriate for use in relation to work controlled by the Building Regulations.2445 60.74 The LGA Guide itself states that the primary guidance is that maximum travel distances should not exceed 7.5 metres;2446 goes on to recognise that some existing blocks of flats do not comply with that guidance,2447 giving rise to a need to consider the overall risk.2448 The LGA Guide also refers to compensatory measures, such as automatic fire detection and automatic fire suppression systems, which were not present in Grenfell Tower. It suggests that the acceptance of standards that differ from current benchmarks should be subject 2437 Approved Document B {CLG00000224/28-30} Diagram 7, flats served by one common stair and Table 1. 2438 BS 9991:2011 (Fire safety in the design, management and use of residential buildings – Code of practice) {BSI00000621/36}. 2439 BRE Grenfell Tower Fire Investigation Report {MET00039807/24} paragraph 32. 2440 Lane, Phase 1 Report, Appendix J {BLAS0000037/25}. 2441 Hanson {Day154/167:16-22}. 2442 Hanson {Day154/169:5-9}. 2443 Lay {Day286/52:14}-{Day286/53:11}. 2444 LGA Guide on Fire Safety in Purpose Built Blocks of Flats {CST00014237/13-14} paragraph 4.1-4.2. 2445 Approved Document B {CLG00000224/13} section 0.21. 2446 LGA Guide on Fire Safety in Purpose Built Blocks of Flats {CST00014237/87} paragraph 58.24. 2447 LGA Guide on Fire Safety in Purpose Built Blocks of Flats {CST00014237/94} paragraph 62.1. 2448 LGA Guide on Fire Safety in Purpose Built Blocks of Flats {CST00014237/94} paragraph 62.2.

Part 6 | Chapter 60: The new smoke ventilation system 229 to careful scrutiny, which may require assessment by a suitable specialist,2449 in this case a fire engineer.2450 The LGA Guide goes on to say that in ventilated lobbies and corridors, increases from 7.5m up to 10m are likely to be acceptable in most situations with no additional measures.2451 However, we are not persuaded that any of the parties involved in the design of the new smoke ventilation system actually relied on the LGA Guide to support its design. It was not referred to in any of the design documents, the witness statements or the oral evidence of those who were involved at the time. Nonetheless, the travel distances at the tower exceeded 7.5 metres and some thought should therefore have been given to protecting the escape route within the lobbies. 60.75 Mr Hanson said that he had thought about extended travel distances at the time but had not written anything down, although he agreed that such information would have been helpful.2452 Mr Cross Smith said that he did not recall any discussion about travel distances.2453 Mr Whyte said that there might have been some discussion of travel distances, but he could not recall when and was not himself aware that the travel distances were more than the guidance in Approved Document B.2454 60.76 In the absence of any contemporaneous evidence we are not able to accept that there was any discussion with building control about the travel distances in the tower or the possible need for mitigation measures. We would have expected to have seen at least some record of such a discussion if it had occurred. Rather, the evidence suggests that the travel distances were overlooked or that it was assumed that they did not need to be considered because the increase in distance was only around 2 metres. That was not an acceptable approach. Proper consideration should have been given to whether the extended distance required mitigation. That is particularly so because the system was being changed and the focus of protection was being shifted from the lobby to the stairs. If that had been done, the design might have been considered acceptable despite the extended travel distance, taking in account the limited additional distance and the mitigation measures in place.2455 60.77 Considering the system as part of the wider fire safety strategy was not the responsibility of PSB but of those who were responsible for drafting that strategy, principally Exova.2456 When it was drafting the fire safety strategy Exova should have identified the extended travel distances in the lobbies and should have recorded its view of the need for mitigating measures to be provided. When the design of the system was changed, Exova should have been asked to consider the fire strategy again to ensure that it reflected developments in the design. Leakage 60.78 Little consideration appears to have been given to how the new smoke ventilation system would operate under different conditions of air leakage that were reasonably foreseeable. In order to assess the likely performance of the system there would need to be at least some consideration of the circumstances in which it was expected to function. Leakage paths were relevant, because the ability of the system to protect the stairs would be 2449 LGA Guide on Fire Safety in Purpose Built Blocks of Flats {CST00014237/94} paragraphs 62.3-62.4. 2450 Lay {Day286/63:9-25}. 2451 LGA Guide on Fire Safety in Purpose Built Blocks of Flats {CST00014237/95-96} paragraph 62.7. 2452 Hanson {Day154/154:8}-{Day154/156:5}. 2453 Cross Smith {Day157/138:12-21}. 2454 Whyte {Day158/52:12}-{Day158/53:9}. 2455 Menzies {Day169/32:22}-{Day169/33:10}. 2456 PSB Module 7 written closing submissions {PSB00001380/17} paragraph 82.

The Grenfell Tower Inquiry: Phase 2 Report 230 affected by the source of air entering the lobby. For example, the system could extract air from the lobby at a rate of 5.0m3/s but might not be able to maintain an air flow velocity of 2.0m/s across the door to the stairs if air was able to enter the lobby from other sources. 60.79 Dr Lane and Mr Lay both carried out calculations to demonstrate the effect of different combinations of door and window openings on the velocity of air through the door to the stairs. Although their analyses differed, each demonstrated that leakage paths were potentially significant. The calculations involved retrospective attempts to quantify the performance of the system; there was no evidence that those who designed it had carried out any similar analyses at the time. 60.80 Mr Mahoney said that the figure of 50% that he had used in his initial proposals to allow for unforeseen losses from all sources when calculating the appropriate rate of extraction was a notional number taken from the British Standard.2457 Mr Lay did not think that that was the right way to design a system of that kind, but acknowledged that it had become normal in the industry to make assumptions about such things.2458 He said that he would not have approved PSB’s specification without having calculations or a computer model indicating the leakage in the system.2459 60.81 Dr Lane’s view was that relying on experience to justify a suitable rate of extraction without explaining what assumptions about leakage had been made or without demonstrating how the rate had been calculated was not a reasonable professional approach. She said that it was not clear how Mr Mahoney had quantified the different elements that would cause resistance in the proposed system, such as leakage through the builders’ work shafts and blemishes in the ductwork. Dr Lane’s view was that it would be normal to identify them.2460 60.82 In its closing statement PSB accepted that those were matters which, with the benefit of hindsight, could, and should, have been spelled out in more detail in its technical submission.2461 However, although PSB obviously needed to rely on its previous experience when designing the system, there still needed to be some consideration of the building itself and the circumstances in which the system would be expected to operate. That required at least some consideration of the potential leakage from the building’s structure and routes of escape that would counteract the rate of extraction, rather than relying on a generic figure. The 5.0m3/s rate of extraction was a key part of the proposal and the primary basis on which the new system was said to be superior to the old one. We do not understand how that figure could reasonably be put forward as appropriate (if, for example, it failed to achieve an air flow of 2m/s across the door under certain conditions) without there being at least some consideration of how the particular nature of the building might affect leakage in a fire. The absence of any such analysis represents a defect in the design process. Air movement into the lobby 60.83 Dr Lane pointed out that if a door to one of the flats was left open the system might continue to operate at maximum capacity, even if the door to the stairs were closed, because the pressure difference between the lobby and the stairwell would have been lost, causing smoke to be drawn from the flat into the lobby.2462 She was of the view that if the 2457 Mahoney {Day155/98:13-15}. 2458 Lay {Day286/151:22}-{Day286/152:6}. 2459 Lay {Day286/152:7-14}. 2460 Lane {Day287/130:21}-{Day287/132:5}. 2461 PSB Module 7 written closing submissions {PSB00001380/22} paragraph 98. 2462 Lane {Day287/141:18}-{Day287/143:5}.

Part 6 | Chapter 60: The new smoke ventilation system 231 designer considered that that risk was mitigated by the presence of self-closing devices on the doors of the flats, that ought to have been made clear.2463 It would have ensured that their importance was understood by those responsible for the operation and maintenance of the building. 60.84 We do not think it is possible to know how the system would have responded if a flat door had been left open. Apart from anything else, the precise circumstances could have varied widely and could have included a tendency for the reduction in the air pressure in the lobby to draw the door closed. The possibility was not fanciful, however, and it was important for the designers of the system to identify the circumstances under which it would no longer be able to perform in accordance with its design. The design criteria should have been taken into account in the overall fire safety strategy for the building. Commissioning the system 60.85 Proper commissioning of a new smoke ventilation system is of critical importance in ensuring that it is capable in practice of performing the function required of it. It therefore needs to be carried out with great care and attention to detail. 60.86 Granville Partlow, PSB’s Group Service and Engineering Manager,2464 carried out the final commissioning of the new system between 26 and 28 April 2016.2465 He accepted that there had been errors in the commissioning method statement, which he attributed to his having adapted the document rather than preparing it from scratch.2466 He had not noticed the mistakes in the document, including in the description of the system, until he had read it again for the purposes of making a statement for the Inquiry. 60.87 Mr Partlow told us that during the commissioning process he had checked that all the fireman’s override switches were working, but certain matters escaped him.2467 PSB’s technical submission said the fireman’s override switches were in the stairs, when in fact they were in the lobbies, but Mr Partlow did not notice the discrepancy. It did not occur to him, therefore, that in the event of a fire they might be affected by rising temperatures in the lobbies, potentially leading to unintended activation.2468 60.88 There was also some confusion about measuring flow rates. Mr Partlow did not understand why building control was asking for readings of extraction flow rates in cubic metres per second, which suggests a failure of communication between building control and those designing the system.2469 PSB did not measure the flow in that way but Mr Partlow asked Mr Whyte to measure the area of one of the doors which he used together with the average velocity across the open door to calculate the flow in cubic metres per second.2470 60.89 When building control approved the proposed system on 24 June 2015 it gave no reasons for its decision but did say that it should conform to the Smoke Control Association Guide 2012.2471 That was repeated in a memorandum sent by Mr Hanson 2463 Lane, Module 7 Supplementary Report {BLARP20000043/94}. 2464 Partlow {PSB00001309/3} page 3, paragraph 11. 2465 Partlow {Day156/19:14-18}. 2466 Partlow {Day156/32:10-14}. 2467 Partlow {Day156/94:21-23}. 2468 Partlow {Day156/177:18-24}. 2469 Partlow {Day156/166:9-11}. 2470 Partlow {Day156/167:13-24}; Partlow {Day156/167:13-24}; Whyte {Day158/80:6-25}. 2471 Hanson {Day154/143:11-23}.

The Grenfell Tower Inquiry: Phase 2 Report 232 to Mr Hoban on 26 January 2016,2472 in which he said that by saying the system was acceptable he meant that it was compliant with functional requirements B1 and B5 of the Building Regulations.2473 60.90 The need for a cold smoke test of the system was also debated. Ms Menzies said that such a test should have been carried out as part of the commissioning process in order to demonstrate to building control that the system operated effectively. In her opinion that was an important part of the commissioning and acceptance process, since without one it would not be possible to know whether the system worked under different door-opening conditions. In her view, the failure to require a cold smoke test fell below the standard to be expected of a reasonable building control body. Mr Hanson did not think that carrying out a cold smoke test was an important part of commissioning any system protecting escape routes with extended travel distances, although he accepted it could be a useful guide.2474 Mr Lay did not expect cold smoke testing to be part of commissioning; he would expect to take flow measurements.2475 60.91 Mr Partlow said that a cold smoke test had not been considered in this case because the building was occupied and it would have been very frightening for residents to walk out of a flat and be confronted by a lobby full of smoke.2476 However, Ms Menzies, who has many years’ experience as a building control officer, said that she had never heard it suggested that a cold smoke test might be a problem in an occupied building.2477 60.92 We think that unless detailed flow measurements under different conditions of door opening had been made, a cold smoke test should have been performed as part of the commissioning process. The practical challenges identified by Mr Partlow were far from insurmountable. The inconvenience to residents and the additional cost was justified by the benefit of assessing the system’s operation in circumstances approaching those in which it would be expected to function and was to be preferred to measuring flow rates. 60.93 There were other respects in which the commissioning process had not captured all the information required to demonstrate that the system performed as intended.2478 They included a failure to record the performance of the fans, the commissioning of all dampers, door opening forces, or pressure measurements.2479 60.94 Mr Hanson accepted that there should have been a record of door opening forces, at least for a representative number of doors. He said that his ability to scrutinise the commissioning report was limited because the RBKC building control team no longer had an engineer. It therefore had to rely on the professionalism of the installer and designer of the system.2480 Ms Menzies did not think that was a reasonable approach for building control to take if it had not seen some evidence that the door opening forces had in fact been tested.2481 She also considered that building control could not have considered 2472 Hanson {Day154/144:8-16}. 2473 Hanson {Day154/145:5-9}. 2474 Hanson {Day154/151:22}-{Day154/152:6}. 2475 Lay {Day286/160:24}-{Day286/161:3}. 2476 Partlow {Day156/191:6-8}. 2477 Menzies {Day169/61:4-9}. 2478 Lane {Day287/213:7}-{Day287/214:1}. 2479 Lane, Phase 2 Module 3 Report {BLARP20000035/409} Sections 1-9 and 11. 2480 Hanson {Day154/201:19-24}. 2481 Menzies {Day169/48:14-21}.

Part 6 | Chapter 60: The new smoke ventilation system 233 whether the system ensured an adequate means of escape without some form of testing which demonstrated that a flow rate of 2m/s through the door to the stairs could be achieved in a variety of different conditions.2482 60.95 There was another reason why, in the opinion of Ms Menzies, building control should not have accepted the commissioning report. An additional vent had been added to the system at its suggestion after commissioning had been undertaken. In her view, the entire system needed to be commissioned after all the work on it had been completed.2483 60.96 Overall, we consider that the commissioning process was not sufficient for building control to be satisfied that the system would perform as intended. That was in part because it was not provided with a set of data that enabled it to be confident that the system operated correctly, but also because it did not require other forms of testing, such as a cold smoke test, to make up for that omission. More generally, the commissioning documents did not describe the performance expected of the system, details of the situations for which it was designed or how it related to the building’s fire safety strategy. Maintenance of the system 60.97 By the time of the refurbishment the original smoke ventilation system had fallen into disrepair, partly as a result of inadequate maintenance,2484 and the evidence suggests that maintenance remained inadequate after the system had been replaced. 60.98 The TMO had no formal procedures of its own for the maintenance of the smoke ventilation system, having entered into a contract with Allied Protection Ltd for the inspection and servicing of fire safety equipment, including the smoke ventilation system, which included the following: a. the annual servicing and testing of hardwired standalone and linked smoke detection equipment in communal areas in accordance with British Standards; and b. the six-monthly servicing of the smoke ventilation system in accordance with the manufacturer’s instructions, including checking interfaces with the fire alarm or control system panel and the checking and servicing of all damper activators and associated mechanisms.2485 60.99 Although Allied Protection was required to service the system at 6-monthly intervals in accordance with manufacturer’s instructions, the TMO did not provide those instructions until 14th June 2017.2486 60.100 Generally accepted standards for the maintenance of smoke control systems published by the British Standards Institution2487 included the need to test each zone of a smoke ventilation system separately, ensuring that any fans and powered exhaust ventilators operate correctly and that dampers close or, where relevant, open.2488 2482 Menzies {Day169/47:15}-{Day169/48:8}. 2483 Menzies {Day169/62:5}-{Day169/64:12}. 2484 See Chapter 43. 2485 Packer {LAK00000525/3} page 3, paragraph 7. 2486 Packer {LAK00000525/3} page 3, paragraph 8. 2487 BS EN 12101-6:2005, BS 5839-1:2013 (withdrawn 31.08.2017 and replaced by BS 5839-1:2017) and BS 9999:2008 (withdrawn 31.01.2017 and replaced by BS 9999:2017). 2488 Lane, Phase 2 Module 3 Report, Sections 1-9 and 11 {BLARP20000035/498-499}.

The Grenfell Tower Inquiry: Phase 2 Report 234 60.101 We were provided with copies of the inspection and servicing certificates produced by Allied Protection following maintenance visits to Grenfell Tower on 17 January 20172489 and 15 May 2017.2490 The visit on 17 January 2017 was carried out by Karl Russell. The certificate records that the smoke detectors were not tested, although the inspection should have included an operational test of the 26 smoke detectors between the ground floor and Floor 23. Moreover, there was no record in the call history of the auto-dialler that the smoke detectors had been activated, although they should have operated if the tests had been carried out properly.2491 The evidence suggests, therefore, that either the smoke detectors did not work or that an operational test of the system was not carried out on that occasion. The latter is the more likely explanation, because if the system had been tested and had failed to operate, that would have been recorded. 60.102 The inspection on 15 May 2017 was carried out by Barry McAuliffe. There were 20 logged activations of smoke detectors,2492 but there should have been 26 if all the smoke detectors had been tested properly. It was not possible to identify from the auto-dialler log which smoke detectors had been activated and which had not, but Mr McAuliffe said that he had not tested the ground floor lift lobby detectors because he had been called away to carry out an urgent repair.2493 60.103 Mr McAuliffe recorded his arrival time on 15 May 2017 as 12:15 and his departure time as 14.15, a period of two hours.2494 On each operational test of the system the maintenance engineer was required, as a minimum, to carry out the following steps to ensure that the system and all its components were operating correctly: a. Activate the system using a smoke detector. b. Inspect the position of the dampers in the lobbies on all floors. c. Inspect the position of the by-pass dampers at Level 2. d. Inspect the operation of the smoke extraction fans at roof level. e. Inspect the operation of the smoke extraction fans at Level 2. f. Inspect the control panel to check that it correctly indicated the system operation, floor activation and status of all dampers. g. Reset the control panel on the ground floor once all inspections of dampers and fans had been completed.2495 60.104 Mr McAuliffe described testing one floor at a time by setting off each smoke detector head using his own artificial smoke and checking that the smoke extraction system started. He then proceeded to the control panel in the ground floor lobby and reset the system. He said he had done that for each floor, using the emergency stairs for access.2496 2489 {LAK00000009}. 2490 {LAK00000011}. 2491 {THL00000019}. 2492 {THL00000019}. 2493 McAuliffe {LAK00000522/4} page 4, paragraph 26. 2494 {LAK00000011}. 2495 Lane, Phase 2 Module 3 Report {BLARP20000035/516} Sections 1-9 and 11. 2496 McAuliffe {LAK00000522/4} page 4, paragraph 25.

Part 6 | Chapter 60: The new smoke ventilation system 235 60.105 The period from the start to the end of the 20 activations on that day recorded in the auto- dialler log was about 1 hour 15 minutes.2497 That left Mr McAuliffe about 4 minutes a floor to carry out the required tests, which we do not think was long enough to carry out the tests he described.2498 60.106 When he was sent to inspect the system at Grenfell Tower Mr McAuliffe had had previous experience of only more basic smoke ventilation systems. He had not been provided with information about the system before his visit and called his manager to ask if he could decline the job. However, he was told to go ahead, despite making clear his lack of expertise.2499 60.107 Mr McAuliffe accepted that he had not opened the grilles on each floor to check that the dampers had activated properly during the tests2500 and if the grilles had not been opened, the dampers cannot have been inspected in sufficient detail to ensure that they sealed properly when closed.2501 It was not possible for all 91 dampers to be serviced and their operation checked during the relatively short visits made by Allied Protection, so the maintenance records did not provide any assurance that the system would operate correctly if a fire were to occur.2502 60.108 Overall, the maintenance documentation provided for the smoke ventilation system was poor and did not satisfy the guidance in BS 9999: 2008.2503 Neither the limited weekly test carried out by Mr Steadman (a TMO estate services assistant) or Allied Protection’s checks provided clear evidence of rigorous maintenance and inspection consistent with what was recommended by the guidance.2504 60.109 The smoke ventilation system was complex and contained many separate mechanical components. Dampers were subject to repeated wear through regular opening and closing while operating in environmental mode and therefore required regular inspection and maintenance. However, Allied Protection carried out inspection and maintenance visits without sight of the manufacturer’s instructions and sent an engineer to carry out the inspection on 15 May 2017 who lacked the skill to do the job properly. 60.110 There is little evidence that the fans on Level 2 had been properly inspected or maintained before the fire.2505 Mr McAuliffe said that he probably had inspected the operation of the smoke extraction fans at Level 2 but could not be certain.2506 We are doubtful that he had, however, given that he was not aware of all the testing requirements,2507 had little experience of complex systems of this type and had not been provided with a description of the system.2508 He did not test the by-pass damper at Level 2 and could not recall having tested the smoke extraction fans at roof level.2509 Moreover, it would not have been possible for him to check the operation of the fans at Level 2 given the length of his visit 2497 {THL00000019}. 2498 Lane, Phase 2 Module 3 Report {BLARP20000035/518} Sections 1-9 and 11. 2499 McAuliffe {LAK00000524/1-2} pages 1-2, paragraph 5. 2500 McAuliffe {LAK00000524/2} page 2, paragraph 9. 2501 Lay, Smoke Control System Report {LAY00000001/315}. 2502 Lane, Phase 2 Module 3 Report {BLARP20000035/523} Sections 1-9 and 11. 2503 The Code of practice for fire safety in the design, management and use of Buildings. 2504 Lay, Smoke Control System Report {LAY00000001/316-317}. 2505 Lane, Phase 2 Module 3 Report {BLARP20000035/516} Sections 1-9 and 11. 2506 McAuliffe {LAK00000524/6} page 6, paragraph 37. 2507 McAuliffe {LAK00000524/6} page 6, paragraph 35. 2508 McAuliffe {LAK00000524/1-2} pages 1-2, paragraph 5. 2509 McAuliffe {LAK00000524/6} page 6, paragraph 37.

The Grenfell Tower Inquiry: Phase 2 Report 236 and the extent of the other work he had to carry out.2510 There is little evidence, therefore, that the smoke extraction fan at Level 2 was inspected and maintained in a way that would give one confidence that it would operate effectively if there were a fire. Operation of the system on the night of the fire 60.111 The smoke ventilation system was designed to respond to a fire on one floor of the building only. It follows that the fire that occurred at Grenfell Tower on 14 June 2017 far exceeded anything that it was or could reasonably have been designed to deal with effectively. The system itself was complex and was significantly damaged by the fire. We have carefully considered the available evidence that might shed light on its performance on the night of the fire but given the nature and scale of the disaster that evidence, which is mainly derived from the condition of the dampers and fans after the fire, is inevitably of limited value. Unfortunately, it does not enable us to draw any reliable conclusions about how the system performed during the fire or how it would have performed under the circumstances for which it had been designed. Conclusions 60.112 The design of a new smoke ventilation system for Grenfell Tower provides a good illustration of the difficulties that can be faced by those seeking to refurbish an old building. Time and standards move on and it may be impossible because of the constraints imposed by the existing structure to provide systems that comply in all respects with current standards. In those circumstances the choice is between doing the best you can and doing nothing at all. 60.113 The Building Regulations do not require a building that undergoes a material alteration to comply with the current functional requirements on completion of the work, provided that it is no more unsatisfactory in relation to any particular requirement than it was before the work was carried out (the “no-worsening” principle). There may be good reasons for retaining that principle, but it may be due for reappraisal because one consequence is that many older buildings, including some that have been refurbished, do not meet current standards in relation to one or more of the functional requirements, including those relating to fire safety. The solution adopted by PSB in the present case was to use the existing structure in a different way that enabled it to double the volume of the shafts available for the extraction of smoke and to provide protection for the stairs that represented the main escape route as well as the means of access for the fire and rescue service. 60.114 The criticisms that were made of the design were directed in the main to PSB’s failure to record the basis for its design decisions and to ensure that certain processes and calculations, in particular a CFD analysis, were carried out, either by itself or others, that would have enabled a more rigorous assessment of the proposed system to be made. As a result, although it had good grounds for feeling confident that the new system would be considerably better than the original (and therefore satisfy the “no worsening” principle), it was difficult for PSB to provide evidence to that effect and difficult also for PSB to rebut the suggestion that it had not carried out the kind of rigorous analysis of the system that was to be expected. Its difficulty in demonstrating both to building control and to us 2510 Lane, Phase 2 Module 3 Report {BLARP20000035/497} Sections 1-9 and 11.

Part 6 | Chapter 60: The new smoke ventilation system 237 that the new system was better than the old one was made all the more difficult by the fact that the original system was inoperable and its performance therefore incapable of being measured. 60.115 The failure to record the basis for design decisions is not in itself a criticism of the system that was produced, but it may indicate a failure to take the process as seriously as required. However, designers need to bear in mind that there are others who need to understand the basis of their decisions, not least any fire engineer charged with producing a fire safety strategy for the building and the person responsible for the operation and maintenance of the building when in occupation. Proper recording of the calculations and assumptions that underpin the design of a complex system of that kind is therefore essential for the safety of the occupants in the longer term. Those are matters of which building control must be aware and in relation to which it must insist on being provided with cogent evidence. 60.116 The need to choose equipment and materials that have been properly tested and shown to conform to the appropriate requirements (such as the dampers for the system) should not be a contentious matter, but again it requires the careful attention of the system designer, the fire engineer and building control to ensure that appropriate decisions and choices have been made.

The Grenfell Tower Inquiry: Phase 2 Report 238

239 Chapter 61 The Health and Safety File 61.1 As we have explained in Chapter 48, the CDM Regulations applied to the Grenfell Tower refurbishment: the CDM Regulations 2007 applied up to 6 April 2015; after that date the CDM Regulations 2015 applied. Both sets of regulations require the production of a health and safety file once construction works have been completed. Under the 2007 Regulations the duty to produce a health and safety file lay on Artelia as CDM co-ordinator. Under the 2015 Regulations, the duty lay on the TMO as principal designer. 61.2 Regulation 20(2)(e) of the 2007 Regulations required the CDM co-ordinator (Artelia) to review and update any existing health and safety file for the tower or, if one did not exist, to prepare one. If the 2007 Regulations had remained in force, Artelia would have been required at the end of the construction phase to pass the health and safety file to the TMO.2511 61.3 The health and safety file is an important document. It contains detailed information about work carried out on a building (whether by way of a new construction or refurbishment), including fire safety information. As Dr Lane explained in her evidence, it enables anyone carrying out work on a building to know what construction work has previously been done and, of particular relevance in this case, where fire safety features are located.2512 She described it as part of the “golden thread” of information about the building, which, together with information produced pursuant to regulation 38 of the Building Regulations and the Fire Safety Order, is intended to be simple, easy to find and clear about what it contains. 61.4 There was no health and safety file for Grenfell Tower when the refurbishment began.2513 Work had been carried out on the tower over the years but, for reasons we do not need to consider, no health and safety file had been produced.2514 61.5 The Approved Code of Practice supporting the CDM Regulations 2007 advised that a CDM co-ordinator should make arrangements at the beginning of a project to collect and compile the information that is likely to be needed for the file and should have a discussion with the client about matters such as the format and type of information that should be obtained.2515 The Approved Code of Practice also advised that the client (in this case the TMO) should make sure that the CDM co-ordinator compiled the health and safety file.2516 Simon Cash, Artelia’s project director, said that the information needed for the health and safety file was not always available until the end of a project and that he would therefore not have expected Artelia to produce a health and safety file until the end of the refurbishment.2517 In his view that was normal practice, both on refurbishment projects and 2511 CDM Regulations 2007 {INQ00011315/11} Regulation 20(2)(f). 2512 Lane {Day62/175:18}-{Day62/176:11}. 2513 {RYD00092644/18} paragraph 3.14. 2514 Previous projects included improvements to the lifts and the replacement of fire doors. For more details see Lane, Health and Safety File Report {BLARP20000012}. 2515 Approved Code of Practice L144 {INQ00013936/22-23} paragraph 79; Lane, Health and Safety File Report {BLARP20000012/106}, paragraph 9.7.15. 2516 Approved Code of Practice L144 {INQ00013936/59} paragraph 261; Lane, Health and Safety File Report {BLARP20000012/106}, paragraph 9.7.17. 2517 Cash {Day49/80:22-24}; {Day49/81:7-13}.

The Grenfell Tower Inquiry: Phase 2 Report 240 new construction projects.2518 David Gibson, TMO’s Head of Capital Investment, said that he had never been provided with a health and safety file before the end of the work.2519 As a result, contrary to the guidance contained in the Approved Code of Practice, Artelia did not start gathering information for a health and safety file at the beginning of the refurbishment. It was not until February 2015 that it started work to prepare a file and sought information from contractors working on the refurbishment.2520 On 21 April 2015, Claire Williams, the TMO’s project manager, sent an email to Paul Burrows (who had taken over from Keith Bushell as CDM co-ordinator) asking him to check whether Artelia was up to date with compiling the health and safety file. Mr Burrows explained that Artelia had not received any information from contractors but that he did not think that was unusual and was expecting to receive information at the end of the project.2521 Change from CDM co-ordinator to principal designer 61.6 The CDM Regulations 2015 brought about some substantive changes to the legislative regime. They included the abolition of the position of CDM co-ordinator and the introduction of a new position of principal designer, one of whose duties is to prepare a health and safety file appropriate to the characteristics of the project during the pre‑construction phase, to keep it up to date and to pass it to the client at the end of the work.2522 Transitional provisions, which applied to the Grenfell Tower refurbishment, provided for the CDM co-ordinator to remain in position until a principal designer had been appointed or the project came to an end. They also imposed a duty on the client to appoint a principal designer by 6 October 2015.2523 If the client failed to do so, it automatically became the principal designer itself.2524 61.7 On 2 February 2015, Keith Bushell sent an email to Nick Valente2525 and Philip Booth2526 informing them that, in light of the forthcoming change to the CDM Regulations, the TMO would have to appoint a principal designer.2527 The email was internal to Artelia and we have not seen any evidence that at that time Artelia told the TMO that it would need to appoint a principal designer. 61.8 On 20 July 2015, Neil Reed of Artelia2528 sent an email to Claire Williams attaching a revised notice under the CDM regulations naming Artelia as the principal designer for the refurbishment.2529 Claire Williams questioned whether Artelia should be a “designer” and on 21 July 2015, Colin James2530 of Artelia responded, explaining that the new CDM Regulations 2015 required the TMO to appoint a principal designer by 6 October 2015.2531 2518 Cash {Day49/80:10-25}. 2519 Gibson {Day54/63:4-8}. 2520 {ART00003575}; {ART00006171}; {ART00009283}. 2521 {ART00006299/1}. 2522 CDM Regulations 2015 {INQ00011316/12} Regulation 12(5), (6) and (10). 2523 CDM Regulations 2015 {INQ00011316/41-42} Schedule 4, paragraph 4. 2524 CDM Regulations 2015 {INQ00011316/43} Schedule 4, paragraph 6(3). 2525 Nick Valente was an assistant employer’s agent employed by Artelia - Booth {ART00008527/3} page 3, paragraph 13. 2526 Philip Booth was brought into the project in April 2013 to assist his colleague at Artelia, Robert Powell, who was the employer’s agent. By July 2013 he was acting as employer’s agent – Booth {ART00008527/3} page 3, paragraph 12. 2527 {ART00009283}. 2528 Neil Reed was employed as an employer’s agent for Artelia from March 2015 – Reed {ART00006663/1} page 1, paragraph 2. 2529 This is known as the F10 Notice for CDM purposes. It is a formal notification sent to the Health and Safety Executive containing details of the project. It is required where a project is “notifiable”. Under the CDM 2007 Regulations a project was notifiable if it was likely to involve more than 30 days or 500 person days of construction work, CDM Regulations 2007 {INQ00011315} Regulation 2(3) and 21; Similar provisions apply under the CDM Regulations 2015 {INQ00011316/7} Regulation 6. 2530 Colin James was employed by Artelia as a CDM co-ordinator – James {MET00080879/4} page 4. 2531 {ART00009321/2-4}.

Part 6 | Chapter 61: The Health and Safety File 241 An internal email passing between employees of Artelia who were working on the refurbishment in July 2015 shows that they were aware that the TMO needed to be alerted to the change in the regulations.2532 Claire Williams said that she had been expecting Artelia to become principal designer but that it had told her in late September 2015 that it would not do so because its professional indemnity insurance did not cover it. It is clear, however, from an internal email sent at around that time that Artelia was not willing to take on that role in any event.2533 We note that following a progress meeting on 18 September 2015 Claire Williams was to appoint a principal designer from the TMO’s consultancy framework and it therefore seems that she was at least aware of the need to appoint a principal designer before the end of September 2015.2534 61.9 In September 2015 Claire Williams contacted external consultants and professionals working on the project, including Rydon, to see whether they would take on the position of principal designer, but they all declined to do so.2535 Ultimately, therefore, the TMO decided to take on the task itself on the basis of advice it had received, probably from Simon Cash of Artelia, that the design was “fundamentally complete”.2536 It took that decision on the basis that it would ask Rydon to complete the health and safety file.2537 For the purposes of the CDM Regulations 2015, however, it was the obligation of the TMO as principal designer to prepare the health and safety file.2538 61.10 Under the 2007 Regulations, CDM co-ordinators were under an obligation to prepare or revise the health and safety file2539 and pass it to the client at the end of the construction phase.2540 Although we were told that CDM co-ordinators did not typically construct a health and safety file until the end of a project,2541 the Approved Code of Practice said that it should be compiled as the project progressed,2542 allowing for material to be gathered while it was fresh. Judging by the limited and largely irrelevant documents that Artelia had gathered by October 2015, it is clear that no meaningful progress had been made since the efforts in February and March 2015.2543 Artelia did not make up for the lack of progress before October 2015, even though it must have been clear in the preceding months that the TMO and any principal designer it appointed would have been greatly assisted by the marshalling of appropriate documents. 2532 {ART00009321/8} see email sent by Paul Burrows to Colin James on 13 July 2015 and {ART00009321/1-2} email sent by Neil Reed to Colin James and Paul Burrows on 21 July 2015. 2533 Williams {TMO00853697/3} page 3, paragraphs 11-14; {ART00006344}; {ART00006195}. 2534 {ART00004725/7} item 7.3. 2535 Williams {TMO00853697/3} page 3, paragraph 15; {TMO00853697/4} page 4, paragraph 17; {ART00006174}; {ART00006195}; {ART00009336}; {ART00009342}. 2536 Williams {TMO00853697/5} page 5, paragraph 21; Cash {ART00009416/7} page 7, paragraph 25. 2537 {ART00009343}; {ART00005184/2-3} item 2.8; {ART00006735/2} item 2.8; Williams {TMO00853697/5} page5, paragraph 23. 2538 CDM Regulations 2015 {INQ00011316/12} Regulation 12(5), (6) and (10). 2539 CDM Regulations 2007 {INQ00011315/11} Regulation 20(2)(e). 2540 CDM Regulations 2007 {INQ00011315/11} Regulation 20(2)(f). 2541 Reed {Day50/183:17-23}; Cash {Day49/86:1-5}; Booth {Day50/101:5-14}; Artelia Modules 1 and 2 Closing Submissions for Phase 2 {ART00009458/32} paragraphs 103-106. 2542 {INQ00013936/58-59} paragraphs 258-59. 2543 {ART00004949} listing the only information collected, being a site inspection report {ART00004950}; CDM Reports {ART00004951}; {ART00004952}; CDM Risk Register {ART00004953}; F10 notifications {ART00004954}; {ART00004955}; Email from Rydon {ART00004957} attaching method statement and phasing plans; phase drawings {ART00004958}; {ART00004960}; {ART00004961}; {ART00004962}; Project specific method statement {ART00006176}; Rydon email {ART00004963} attaching site-wide risk assessment {ART00004964}; site layout plan {ART00004965}; emergency plan {ART00004966}; traffic management plan {ART00004967}; site rules; Rydon email {ART00005015} attaching construction phase health and safety plan {TMO00869734}; Email confirming construction phase plan is adequate {ART00004971}.

The Grenfell Tower Inquiry: Phase 2 Report 242 61.11 Claire Williams had been given short notice of the need to find a principal designer and the TMO was not given enough time to consider its options.2544 A number of emails sent at the time within Artelia show that some people, notably Mr Reed and Mr Cash, accepted that Artelia had not handled the transition to principal designer well.2545 However, the TMO was also to blame because it overestimated its own ability to review and scrutinise the health and safety file when it was produced (see further below). Neil Reed warned Claire Williams that if the TMO took on the role of principal designer, it would need someone to check the health and safety file and confirm that it was compliant. He offered to make someone available as a CDM adviser for that purpose2546 but the offer was refused. The health and safety file 61.12 Having been asked by the TMO to complete it, Rydon sub-contracted the preparation of the building manual for the refurbishment to a company called All Group Holdings Ltd.2547 In addition to its work on the building manual, All Group Holdings gathered information for inclusion in the health and safety file and produced a three-page document containing cross-references to parts of the building manual. All Group Holdings sent the document to Rydon, describing it as its proposals for the health and safety file.2548 The guidance describing the information that should be contained in a health and safety file has not materially changed since 1994.2549 The recommended contents include (among other things) (1) a brief description of the work carried out, (2) residual hazards and how they have been dealt with, (3) the nature, location and markings of significant services, including fire-fighting services and (4) information about, and as-built drawings of, the structure, its plant and equipment.2550 61.13 Claire Williams had received some training on the CDM Regulations and was familiar in general terms with what a health and safety file should contain.2551 She accepted that she would have needed help to assess the quality of the health and safety file provided by Rydon but she did not specifically ask Artelia for guidance.2552 She checked the health and safety file, but we got the impression that, although she identified some gaps and missing information, she did not make a serious effort to ensure that the defects were made good.2553 Dr Lane’s evidence 61.14 Dr Lane prepared a report on the health and safety file and gave evidence to the Inquiry during Module 1.2554 Her report contained a thorough analysis of the contents of the health and safety file presented to the TMO by Rydon and identified where information was missing, inaccurate or incomplete.2555 Her particular criticisms of the health and safety file, which we accept, were that it did not enable the persons responsible for any work on 2544 Williams {TMO00853697/4} page 4, paragraph 19. 2545 {ART00009356}. 2546 {ART00004824}; {ART00004865/4} item 4.2; {ART00009364}. 2547 Butler {MET00012822}. 2548 {RYD00080302}; {TMOM00001932}. 2549 Lane {Day62/178:18-23}; Lane, Phase 2, Health and Safety File Report {BLARP20000012/47-51} paragraphs 5.7.14 – 5.7.19 and Table 5.1; “Managing health and safety in construction, Construction (Design and Management) Regulations 2015, Guidance on Regulations” at Appendix 4 {HSE00000003/81-83}. 2550 Lane, Phase 2, Health and Safety File Report {BLARP20000012/48} paragraph 5.7.14-5.7.16. 2551 Williams {Day56/119:22}-{Day56/120:9}. 2552 Williams {Day56/120:11}-{Day56/122:25}. 2553 Williams {Day56/142:12}-{Day56/144:21}. 2554 Lane, Phase 2, Health and Safety File Report {BLARP20000012}; Lane {Day62/166:2}-{Day62/202:25}. 2555 Lane, Phase 2, Health and Safety File Report {BLARP20000012/144} paragraph 10.5.5.

Part 6 | Chapter 61: The Health and Safety File 243 Grenfell Tower to understand the condition of the building and the hazards and risks arising from the refurbishment.2556 Nobody sought to challenge Dr Lane’s evidence, which was to a large extent limited to the contents of the documents. 61.15 We are satisfied that the health and safety file did not contain the information referred to in the relevant guidance and was not presented in a form that made it readily usable. The TMO failed to ensure that the file was properly organised and contained accurate and up to date information about the refurbishment. Overall, it was incomplete, confusing and thoroughly unhelpful. 61.16 During her evidence Dr Lane was asked whether the health and safety file should have been available on the night of the fire to assist the fire brigade. Her view was that drawings containing basic information about the building should have been available rapidly.2557 She was unwilling to speculate about what might have happened if a complete health and safety file had been available on the night of the fire2558 and we express no view on the matter. 2556 Lane, Phase 2, Health and Safety File Report {BLARP20000012/145} paragraph 10.5.8; Lane {Day62/196:4}-{Day62/199:17}; {Day62/202:20-25}. 2557 Lane {Day62/206:25}-{Day62/208:11}. 2558 Lane {Day62/208:13-23}.

244 The Grenfell Tower Inquiry: Phase 2 Report

245 Chapter 62 Building Control 62.1 In Chapter 48 of this report we described the provisions of the Building Act 1984 and the Building Regulations 2010 which govern the process by which building work falling within their scope is checked by local authorities for compliance with the statutory requirements. In this chapter, we examine the role that RBKC building control played in the refurbishment of Grenfell Tower and the events leading up to the issue of a completion certificate in July 2016. 62.2 We have been greatly assisted in our investigations by Beryl Menzies, FCABE, PPBEng, CBuildE, CABE, MRICS, a consultant in fire safety and fire-related building services. Ms Menzies has over 40 years’ experience in building control, having worked in the Building Regulations Division of the Greater London Council between 1973 and 1985 and subsequently as a Chief Engineer at the London Borough of Tower Hamlets.2559 Her evidence was not challenged by any of the core participants and we were not asked to consider evidence from anyone else with similar professional experience. We have therefore relied on her expert opinion when reaching our conclusions. RBKC also made some admissions that the work of its employees fell below the standard that could reasonably be expected of competent building control officers.2560 62.3 RBKC was the building control body for the Grenfell Tower refurbishment. It was first approached by Studio E for initial advice in June 20122561 and was involved with the refurbishment until a completion certificate was issued in July 2016.2562 Within RBKC, two surveyors were largely responsible for the project, John Allen, the special projects manager, from 2012 to late 2013, and John Hoban, a senior surveyor, from late 2013 to July 2016.2563 Paul Hanson, a fire engineer in the department, also gave advice on matters concerning functional requirements B1 and B5 of the Building Regulations.2564 62.4 Until September 2013, the building control department had been managed by John Jackson.2565 As special projects manager John Allen had been responsible for the larger, more complicated buildings that RBKC had to deal with,2566 including the KALC project and the Grenfell Tower refurbishment,2567 (although it is not clear that the Grenfell Tower refurbishment would have been considered a special project but for its link to the KALC project.)2568 In September 2013 the department was restructured and John Allen became Building Control Manager.2569 During the restructuring, procedures for allocating work within the department changed. Thereafter work was allocated on a “patch” system, under which a surveyor was allocated to a particular area and was 2559 Menzies, Building Control {BMER0000004/3}. 2560 RBKC Module 1 Opening Submissions {RBK00055479/26-27} paragraphs 97-105; RBKC Module 1 and 2 Closing Submissions {RBK00064252/1} paragraph 4. 2561 {SEA00000023}. 2562 {RBK00018811}. 2563 Allen {RBK00033930/1-2} pages 1-2, paragraph 3, 5, 7 and 12; Hoban {RBK00033934/1} page 1, paragraph 4. 2564 Hanson {RBK00033894/23-25} pages 23-25, paragraphs 124-140. 2565 Allen {RBK00033930/1} page 1, paragraph 3. 2566 Allen {Day47/8:12-24}; Allen {RBK00033930/1} page 1, paragraphs 3-4. 2567 Allen {Day47/95:9-16}. 2568 Allen {Day47/95:17}-{Day47/96:3}. 2569 Stallwood {RBK00033910/2} paragraph 6.

The Grenfell Tower Inquiry: Phase 2 Report 246 expected to take whatever work came into the department from that area, regardless of its scale or complexity.2570 In December 2013, John Allen handed over day to day responsibility for KALC and the Grenfell refurbishment to John Hoban, although those projects were on another officer’s “patch” at that time.2571 Means of Escape group 62.5 In addition to its team of surveyors, RBKC had what was known as the “Means of Escape” group, which operated as an internal consultancy on matters relating to functional requirements B1 (means of warning and escape) and B5 (access and facilities for the fire service).2572 At the time of the refurbishment, the Means of Escape group consisted of just one person, Paul Hanson, a qualified fire engineer. Mr Hanson did not have the power to make decisions on full plans applications and did not conduct site inspections,2573 although in the case of Grenfell Tower he did attend some meetings on site. He also attended a demonstration of the smoke control system in 2016.2574 Although Mr Hoban formally had overall responsibility for building control matters, Mr Hanson effectively made decisions in relation to functional requirements B1 and B5 because Mr Hoban deferred to Mr Hanson on those matters. He also sought his advice on matters affecting functional requirements B2, B3 and B4 if he needed assistance.2575 The evidence suggests that the role of the Means of Escape group within the department was not well understood, particularly by other professionals working on the Grenfell refurbishment,2576 and Mr Hoban agreed that its relationship with the surveyors could have been clearer.2577 Ms Menzies thought that the department could have made better use of the Means of Escape group generally, in particular because Mr Hanson was a qualified fire engineer.2578 Records 62.6 At the time of the refurbishment, RBKC’s building control department kept records in a number of different ways: an electronic record-keeping system called “Acolaid”, hard-copy files, electronic diaries, a hard-copy office diary and individual surveyors’ notebooks.2579 The department adopted a “weeding” policy in relation to hard-copy files, with the result that not all the documents originally placed on the file were retained after a job had been closed.2580 RBKC was unable to find the hard-copy file for the Grenfell refurbishment or Mr Hoban’s personal notebooks covering the relevant period,2581 but because of the weeding policy it is not clear which documents would have been retained. Mr Hoban 2570 Anon {RBK00029897/3} page 3, paragraph 10; Allen {Day47/97:5-20}; Hoban {Day45/101:13-20}. 2571 {SEA00010232}; Hoban {Day45/100:20}-{Day45/101:6}; {Day45/100:17-24}. Mr Allen initially allocated the Grenfell project to Jose Anon, the deputy Building Control Manager, but Mr Anon did not feel he had the capacity to take on the additional work at the time. He also had friends who lived in the tower and felt a need to keep a professional distance. Anon {RBK00029897/8} page 8, paragraph 37-38; Allen {RBK00033930/2} page 2, paragraphs 7 and 10. 2572 Hanson {RBK00033894/5} page 5, paragraph 31. 2573 Hanson {RBK00033894/6} page 6, paragraph 38. 2574 {RBK00002965}; {RBK00010784}; {RBK00003856} (this document is misdated, and the meeting took place on 7 January 2016, see email attaching the minutes) {RBK00003855}. 2575 Hoban {RBK00033934/4} page 4, paragraph 36; Hoban {RBK00050416/3} page 3, paragraph 9(b); Hoban {Day45/121:25}-{Day45/124:15}; {RBK00048682}; {RBK00052478/7}. 2576 {RBK00048682/1}; Crawford {Day11/128:3}-{Day11/130:25}; Lawrence {Day25/173:20}-{Day25/174:18}. 2577 Hoban {Day45/124:16}-{Day45/125:12}. 2578 Menzies, Building Control {BMER0000004/52} paragraph 208. 2579 Hoban {Day45/85:5}-{Day45/86:13}. 2580 Stallwood {RBK00033910/8} page 8, paragraphs 37-38. 2581 Stallwood {RBK00033910/4-6} pages 4-6, paragraphs 17-24 and 27; Hoban {RBK00050416/10} page 10, paragraph 33(e).

Part 6 | Chapter 62: Building Control 247 thought that his plan check record sheet (an A4 sheet divided into topics such as “structure”, “fire”, “damp-proofing” and so on that he used when checking plans)2582 and his notes would probably have been weeded out.2583 62.7 Mr Hoban did not use a tracker to monitor the drawings that had been submitted in support of the Grenfell full plans application,2584 although the department did have a tracker which was available for surveyors to use, if a client requested it.2585 However, we have seen no indication that the use of a tracker in connection with the refurbishment was proposed by building control or that it was requested by Studio E or Rydon. 62.8 The absence of complete contemporaneous records means that in many instances we have had to rely on Mr Hoban’s personal recollection. That is unsatisfactory, not least because with the passage of time his memory had become understandably hazy and in places incomplete. Having said that, we are satisfied that we have been able to make reliable findings on the most important matters relating to building control’s work on the Grenfell refurbishment. While some points of detail were in dispute, the key points about what Mr Hoban and his colleagues knew about the refurbishment and how they went about their work were not contentious.2586 Initial approach 62.9 Mr Allen first became aware of the Grenfell refurbishment when his manager, Mr Jackson, asked him to contact Terence Ashton of Exova2587 but he could not remember when that was or exactly what they had discussed.2588 On 6 June 2012 Studio E approached building control seeking an indication of the fee likely to be charged for the project2589 and on 31 October 2012 Mr Ashton sent John Allen a copy of issue 1 of Exova’s Outline Fire Safety Strategy.2590 62.10 Mr Allen told us that he had not known that the refurbishment involved overcladding the building until around the time of the full plans application.2591 It is true that the Outline Fire Safety Strategy would not have alerted him to that fact, since cladding was not mentioned in it,2592 but in 2012 Studio E had given him an estimate of the costs involved which had included overcladding as a line item. When that was shown to him Mr Allen accepted that he probably had read it and that he had seen that the project involved overcladding.2593 62.11 On 7 November 2012 Studio E and Exova had a meeting with building control to discuss the fire safety strategy.2594 However, that meeting and subsequent communications between the design team and building control focused primarily on the lower four floors of the 2582 Hoban {Day45/80:13}-{Day45/81:8}. 2583 Hoban {RBK00050416/5} page 5, paragraph 18. 2584 Hoban {RBK00050416/6} page 6, paragraph 18(b)-(d). 2585 Allen {Day47/55:2}-{Day47/56:6}. 2586 RBKC Module 1 Opening Submissions {RBK00055479/26-27} paragraphs 97-105; RBKC Module 1 and 2 Closing Submissions {RBK00064252/1} paragraph 4. 2587 Allen {RBK00033930/2} page 2, paragraph 12. 2588 Allen {Day47/173:17}-{Day47/174:10}. 2589 {SEA00000023}; {SEA00004471}; Allen {Day47/202:4}-{Day47/203:1}. 2590 {EXO00001368}. 2591 Allen {Day47/176:16}. 2592 {EXO00000519/4}. 2593 {SEA00004471}; {ART00000053/4}; Allen {Day47/203:11}-{Day47/204:10}. 2594 The meeting was attended by John Allen and Dave Gammon from RBKC, Terry Ashton from Exova and Adrian Jess from Studio E {SEA00006526}.

The Grenfell Tower Inquiry: Phase 2 Report 248 tower and the smoke ventilation system.2595 The proposals for overcladding the tower were not discussed with building control either at that meeting or at any time before the full plans application was submitted in August 2014,2596 but by the time he took over responsibility for the project in late 2013, John Hoban had become aware that it involved overcladding, because he had seen it on the drawings.2597 He told us that he would have expected a contractor or architect to seek advice from building control on cladding proposals before it submitted a full plans application, but neither Rydon nor Studio E had done so in this case.2598 Having seen that the project included overcladding, we consider that Mr Hoban should at that stage have taken the initiative and asked for more information about the project as a whole.2599 62.12 On 25 October 2013, Studio E sent building control its proposed fire safety strategy for the tower, including Issue 2 of Exova’s Outline Fire Safety Strategy.2600 On 11 November 2013, John Allen told Bruce Sounes that he did not think that the information on the smoke control system that had so far been submitted was adequate to enable an effective consultation to be held with the fire authority on functional requirements B1 and B5 as required by the Fire Safety Order.2601 In January 2014, Studio E sent an email to building control asking them to consult the fire authority notwithstanding their concerns about the extent of the information available to them,2602 but they did not do so at that time.2603 There was no further contact between the design team and building control between January 2014 and July 2014.2604 The full plans application 62.13 On 4 August 2014 Studio E submitted a signed but undated full plans application to building control.2605 By that time some demolition and site clearance work had already begun2606 and Mr Hoban considered that the application had been made rather late in the day.2607 62.14 The drawings supporting the application were submitted nearly two months after the application itself2608 and were incomplete.2609 At the very least they ought to have shown that in principle the refurbishment was capable of complying with functional requirements B1 to B5 of the Building Regulations, but they did not. Indeed, on the basis of the information provided in relation to functional requirement B1 (means of escape) alone, the application ought to have been rejected.2610 Mr Hoban’s reason for not rejecting it was that he was trying to “work with” the applicant,2611 but that does not provide a good reason 2595 {EXO00001371}; {SEA00009805}; {SEA00000154}; {SEA00010232}; {SEA00010369}; {SEA00002629}; {SEA00002630}; {RBK00048649}; {RBK00003854}; {RBK00003810}. We deal with the smoke ventilation system, including the involvement of building control, in Chapter 60. 2596 Sounes {Day21/132:23}-{Day21/133:3}; {Day21/164:4-24}; Ashton {Day17/70:7-11}; Allen {Day47/175:4-11}. 2597 Hoban {Day45/138:2-11}. 2598 Hoban {Day45/154:13-21}. 2599 Menzies, Building Control {BMER0000004/9} paragraph 38; {BMER0000004/96} paragraph 303. 2600 {SEA00009805/2}. 2601 {SEA00009805/1}. 2602 {RBK00048649}. 2603 {RBK00003854}. 2604 {RBK00003810}; Hoban {Day45/142:23}-{Day45/143:2}. 2605 {RYD00014378} and {RYD00014379}. RBKC acknowledged receipt of the application on 5 August 2014{RBK00027424} and that is the date that the five-week statutory time limit for a decision started to run. Menzies, Building Control {BMER0000004/86} paragraph 274. 2606 {RYD00012259}. 2607 Hoban {Day45/154:22-24}. 2608 {RYD00018742}. 2609 Menzies {Day60/134:7}-{Day60/135:10}; Menzies, Building Control {BMER0000004/88}. 2610 Menzies, Building Control {BMER0000004/9} paragraph 37. 2611 Hoban {Day45/160:13}-{Day45/161:12}; Menzies {Day60/33:9-21}.

Part 6 | Chapter 62: Building Control 249 for failing to follow the statutory procedures. It does, however, reflect a fundamental misunderstanding among many of those who work in the construction industry, contractors, building control bodies and others, that the function of building control is to provide a service to applicants rather than to enforce the regulations robustly for the benefit of the community at large. In this case Mr Hoban accepted, in hindsight, that he ought to have rejected the full plans application for lacking the necessary supporting documentation.2612 62.15 As we have noted, a local authority is required to make a decision on a full plans application within five weeks of the deposit of the plans, although that can be extended by agreement to two months.2613 However, in this case building control did not make a decision within the prescribed time and there is no evidence that any extension of time was agreed with either Rydon or Studio E. Mr Allen said that the statutory time limits did not work in the context of design and build projects and that there was little point in rejecting an incomplete application because building work could still go on.2614 We found that part of his evidence rather disturbing, because it amounted to saying that in his eyes the legislation had to give way to commercial considerations and the practices of the construction industry. We do not think that is a proper approach to take to a statutory function and we are fortified in that conclusion by the evidence of Ms Menzies, who could see no reason why the statutory time limits could not be adhered to in the case of design and build projects.2615 62.16 There is a note on the Acolaid system dated 5 August 2014 headed “Meaningful response”, in which Mr Hoban recorded that he had asked for details of the works,2616 but he does not appear to have put his request in correspondence to Studio E or Rydon, either by email or letter. Mr Allen said that if a surveyor felt the need to go back to an applicant for further information, or if there was a problem with the application, such as a missing document or drawing, that should be recorded in writing, but in this case it was not.2617 Unfortunately, Mr Hoban’s response to the full plans application lacked rigour and fell short of the standard to be expected of a reasonably competent building control officer.2618 He accepted that if he had exercised reasonable care and skill he would have asked Studio E for the information that was needed,2619 but there is no record of his having done so, save for the “meaningful response” note, which does not record what further details he asked for.2620 62.17 We are not persuaded that Mr Hoban made a real effort to obtain the missing information from Studio E. He told us on more than one occasion that he had asked Rydon to provide him with information and that he had obtained some information for himself by looking at things on site,2621 but very little of that is documented in his notes and those requests, if they were made at all, were not followed up by letters or emails.2622 Mr Hoban ought to have asked for further information about the cladding at the full plans stage. His failure to do so represents a serious failing on the part of building control.2623 2612 Hoban {Day45/161:5-12}. 2613 Menzies, Building Control {BMER0000004/14} paragraph 62. 2614 Allen {Day47/168:1-22}. 2615 Menzies {Day60/33:4-7}; {Day60/34:2}-{Day60/35:2}. 2616 {RBK00044876/69}. 2617 Allen {Day47/48:7}-{Day47/49:25}. 2618 Menzies {Day60/126:9}-{Day60/127:15}; Menzies, Building Control {BMER0000004/9} paragraph 37; Menzies, Building Control {BMER0000004/98-99} paragraph 317. 2619 Hoban {Day45/96:10-22}. 2620 {RBK00044876/69}. 2621 Hoban {Day45/167:6-28}; {Day46/30:17}-{Day46/31:23}; {Day46/70:4-9}. 2622 Hoban {Day45/32:2-5}. 2623 Menzies, Building Control {BMER0000004/9} paragraph 39; Menzies, Building Control {BMER0000004/96} paragraph 303.

The Grenfell Tower Inquiry: Phase 2 Report 250 62.18 Mr Hoban made his first visit to the site on 29 August 2014.2624 He discussed the works with Simon O’Connor, Rydon’s Project Manager, but did not discuss the overcladding in any detail and was not told that there was an outstanding planning application to change the rainscreen from zinc to ACM.2625 Mr Crawford said that he had met Mr Hoban on site during the week of 25 August 2014 and had given him some drawings to take away,2626 but Mr Hoban did not recall any such meeting and said that he would not normally take drawings away from a site.2627 Mr O’Connor thought that Mr Crawford might have been at the initial meeting but did not remember Mr Hoban taking away any drawings.2628 The contemporaneous evidence does not refer to Mr Hoban meeting Mr Crawford on site at that time or to his taking drawings away.2629 On the basis of that evidence and the evidence of others, we think it likely that Mr Crawford’s recollection that Mr Hoban took drawings away with him is mistaken. 62.19 Studio E did not submit any drawings to building control until 24 September 2014 when Mr Crawford sent a zip file attached to an email.2630 The contents of the zip file did not reflect the drawings listed in the covering email2631 but Mr Hoban did not question that at the time.2632 Some of the drawings were older revisions or otherwise out of date; for example, they showed zinc rainscreen despite the fact that ACM had been in contemplation for many months and that the final colour and finish had been selected in July 2014, subject to planning approval.2633 The drawings did not show the type of cladding panel or insulation being proposed.2634 62.20 Mr Hoban was aware that insufficient information about the cladding had been provided and was waiting for more to be sent to him.2635 He could not recall whether he had directly asked anyone about the nature of the insulation,2636 although he said that he had asked for more details “on the job”.2637 He said that he had repeatedly asked for information and had discovered some for himself by talking with the contractor and seeing what was being done on site.2638 However, there is no record of his asking for more information, so if he did make any such request, he probably did so in the course of an informal conversation with someone from Rydon or Studio E on site. In any event, although no further details of the cladding were formally submitted, drawings sent to building control for other purposes in November 2014 and March 2015 showed ACM rainscreen panels on the facade.2639 Mr Hoban could not remember whether those drawings had alerted him to the change from zinc to ACM.2640 2624 {RBK00052478/8}; Hoban {Day45/142:4}. 2625 {SEA00000189}; Hoban {Day45/144:21}-{Day45/147:13}. 2626 Crawford {SEA00014275/65} page 65, paragraph 206; Crawford {Day11/137:12}-{Day11/139:1}. 2627 Hoban {Day45/145:14-16}; {Day45/148:1-21}; {Day45/153:10-24}. 2628 O’Connor {Day26/217:11-18}. 2629 {SEA00000189}. 2630 {RYD00018742}. 2631 Menzies, Building Control {BMER0000004/88} paragraph 277-281. 2632 Hoban {Day45/164:9}-{Day45/165:1}. 2633 {RYD00018750}. 2634 {RYD00018750}. 2635 Hoban {Day45/166:8-21}. 2636 Hoban {Day45/166:8-21}. 2637 Hoban {Day45/167:11-18}. 2638 Hoban {Day45/173:10-17}. 2639 {RYD00024038}; {SEA00000225}; {SEA00000252}; {HAR00003955}. 2640 Hoban {Day46/7:11-13}.

Part 6 | Chapter 62: Building Control 251 62.21 On 25 September 2014 RBKC planning officers approved the use of Reynobond smoke silver cassette-fixed ACM panels but Studio E did not inform building control of that at the time and, as we have noted, the drawings submitted to building control continued to refer to zinc panels.2641 62.22 On 29 September 2014 Studio E provided building control with a copy of Issue 3 of Exova’s Outline Fire Safety Strategy.2642 Mr Hoban could not remember whether he had read it at the time2643 and when it was shown to him in the course of his evidence he could not remember whether he had seen it before.2644 However, he had read Issue 2 when that had been sent to him and he was aware of what Exova had said in it about functional requirement B4.2645 Mr Hoban did not ask Exova (or anybody else for that matter) whether a further report had been or would be provided to complete the advice on functional requirement B4 and he conceded that he might not have gone back to the file and done everything necessary.2646 His failure to do so was another serious omission. 62.23 The same day, 29 September 2014, Mr Hoban also asked Mr Hanson for his comments.2647 It is not clear whether he gave Mr Hanson a copy of Issue 3 of the Outline Fire Safety Strategy, which he received shortly afterwards, although he thought he had probably given him a hard copy.2648 (Mr Hanson had already been given a copy of Issue 2 by Studio E in October 2013.2649) Mr Hanson responded to Mr Hoban on 10 November 2014 saying that building control was not in a position to approve the proposals due to a lack of information about the extraction rate of the smoke ventilation system.2650 Notwithstanding the absence of that information, on 11 November 2014, Mr Hoban submitted a formal request to the LFB for their comments on matters affecting functional requirements B1 and B5.2651 He did not ask for its comments on functional requirement B4. The LFB would not normally comment on requirement B4 unless it had been specifically asked to do so.2652 62.24 On 18 November 2014 Mr Hoban told Neil Crawford that a formal decision notice on the full plans application would be forwarded shortly.2653 At that point a response from the fire authority was still outstanding. Mr Hoban said that he had completed the standard form decision notice2654 with a schedule of conditions but no copy was available and there is no record of the conditions. Mr Hoban said that he had put it out for the business support group to process, but there is no evidence that a notice was actually sent out2655 and Mr Hoban did not check whether it had been.2656 62.25 There is no written record of the review of the full plans application that led Mr Hoban to issue the decision notice. He said that he had prepared a memorandum in relation to functional requirements B2, B3 and B42657 but no copy of any such document was made 2641 {IBI00001802}; Hoban {Day45/197:20}-{Day45/198:4}. 2642 {SEA00000215}. 2643 Hoban {Day45/167:19}-{Day45/168:12}. 2644 Hoban {Day45/168:20}-{Day45/168:6}. 2645 Hoban {Day45/169:2}-{Day45/170:25}. 2646 Hoban {Day45/169:2}-{Day45/170:25}. 2647 {RBK00048693}. 2648 Hoban {Day45/174:21}-{Day45/175:7}. 2649 {RBK00027290}. 2650 {RBK00033895/3}. 2651 {RBK00033896}. For further detail on the process for consulting the LFB, see Menzies, Building Control {BMER0000004/139-140} paragraphs 461-467. 2652 Menzies, Building Control {BMER0000004/139-140} paragraph 466; FSIGN 501 {LFB00054550/10-12}. 2653 {RBK00002974}. 2654 A blank copy of the standard form can be found at {RBK00052487}. 2655 Hoban {RBK00050416/4}, page 4 paragraphs 12-14. A copy of a blank pro forma can be seen at {RBK00052487}. 2656 Hoban {Day45/194:3-14}. 2657 Hoban {Day45/185:17}-{Day45/186:9}.

The Grenfell Tower Inquiry: Phase 2 Report 252 available to us. When asked how he had concluded that the proposals were likely to comply with the Building Regulations, Mr Hoban said that there would have been conditions2658 and when asked how he was able to issue a decision notice when Mr Hanson had said in his comments on functional requirement B1 that building control could not approve the proposals, he again said that it would be subject to conditions.2659 Mr Hoban apparently felt able to approve the full plans application, even though it did not contain any details of the proposed insulation or rainscreen panels, because he had included a condition that the facade as a whole should comply with section 12 of Approved Document B.2660 However, he did not have a specific recollection of the conditions he had attached to the decision notice and did not know whether he had recorded them elsewhere.2661 We have not seen any documents or correspondence referring to specific conditions of any kind. Mr Allen said that he would expect any conditions applied to a full plans approval to be recorded in writing and kept on the file.2662 In our view the failure to keep a formal record of a matter of that kind was a very serious omission. 62.26 On 12 December 2014, the LFB sent building control an email attaching a response to the consultation,2663 but neither building control nor the LFB has been able to find the response itself.2664 On 5 February 2016, following revisions to the smoke control proposals, building control consulted the LFB again2665 and on 4 March 2016 the LFB expressed itself satisfied with the proposals.2666 62.27 Mr Hoban approved the full plans application despite Mr Hanson’s advice that there was insufficient information in relation to functional requirement B1 to enable that to be done. He also consulted the fire authority without sufficient information2667 and did not wait for a response before making his decision.2668 In addition, he failed to carry out a methodical review of the documents submitted to him and failed to notice obvious errors and inconsistencies in the drawings. He either did not read version 3 of Exova’s Outline Fire Safety Strategy2669 or failed to appreciate that on its own terms it was incomplete in an important respect. The only evidence we have seen of a structured review of the full plans application is the memorandum prepared by Mr Hanson on Requirement B1.2670 We accept that Mr Hoban probably made some notes on the application, but, bearing in mind the evidence we heard about his working practices at the time, we think it unlikely that he made any detailed notes of his assessment of functional requirements B2, B3 or B4. RBKC’s own proforma for full plans applications, the P60 form, was basic and did not assist officers in carrying out a thorough review of a full plans application or recording their decisions.2671 We do not know what, if any, conditions Mr Hoban attached to his approval of the full plans, but if, as he suggested, they included a condition that the cladding comply with 2658 Hoban {Day45/187:3-8}. 2659 Hoban {Day45/187:19-25}. 2660 Hoban {Day45/188:2}-{Day45/190:25}. 2661 Hoban {Day45/192:13-20}; {Day45/193:8-20}. 2662 Allen {Day47/51:4}-{Day47/52:12}. 2663 {RBK00033896}. 2664 {LFB00000300}. 2665 {RBK00033897}. 2666 {LFB00000291}; {LFB00000292}; {SEA00014148}; {SEA00014149}. 2667 Menzies {Day60/191:4-10}. 2668 Mr Hoban informed Mr Crawford that a decision notice would be issued on 18 November 2014 {RBK00002974}, five days after he submitted the consultation request to the LFB {RBK00033896}. 2669 Hoban {Day45/167:19}-{Day45/168:12}. 2670 {RBK00033895/3}. 2671 Menzies, Building Control {BMER0000004/65}.

Part 6 | Chapter 62: Building Control 253 section 12 of Approved Document B, that would not have been sufficient to enable him to issue a completion certificate in due course. It ought to have required Studio E to provide sufficient evidence that functional requirements B2, B3 and B4 had been met.2672 62.28 Other formal aspects of the application were also handled poorly. RBKC failed to issue a formal decision notice, which it accepted was a failing on its part.2673 Mr Hoban accepted that he ought to have ensured that the decision notice he had prepared had been sent out, but he failed to do so.2674 All in all, RBKC’s approach to the full plans application shows a consistent lack of care and disregard for the procedural requirements of the Building Regulations. RBKC accepted that it bore some responsibility for the failure of the applicant to provide sufficient information in a structured and easily accessible format,2675 but its failings at full plans stage were far more extensive than that. Mr Hoban failed to ask for basic information about the cladding, did not carry out a proper review of the information he was provided with and gave a conditional approval in circumstances where he ought to have rejected the application altogether. Mr Hoban’s willingness to accommodate Studio E led him to disregard the primary function of building control, with the result that a critical opportunity to scrutinise the design of the cladding was missed. Building control’s knowledge of the construction of the external wall Rainscreen 62.29 There is no correspondence or documentation of any kind passing between building control and any of those engaged on the refurbishment which touches on the question whether the proposed composition of the external wall complied with the Building Regulations. Moreover, no comprehensive package of up-to-date drawings and information was ever provided to building control.2676 However, Mr Hoban knew that ACM was being used because the contractor had told him so at some stage and he had seen the materials once they had arrived on site.2677 He could not say with certainty that he had noticed that ACM had been indicated on the drawings sent to him in November 20142678 or March 2015,2679 but he thought that he had become aware that ACM panels were being used in around 2015 when he met Ben Bailey on site.2680 He was not surprised when he saw ACM being installed instead of zinc as, in his words, “things change”.2681 62.30 Mr Hoban said that after seeing ACM panels being installed on the building he had looked at the BBA certificate to see whether Reynobond ACM was Class 0,2682 although he said that he had probably looked only at the first page, from which he had understood that it was.2683 He had not mentioned that fact in any of his witness statements, however, and we think that if he had had a genuine recollection of checking the BBA certificate he would have said something about it. As a result we feel bound to treat his sudden recollection in the witness box as unreliable. 2672 Menzies {Day60/139:2}-{Day60/140:24}. 2673 RBKC Module 1 Opening Submissions {RBK00055479/27} paragraph 100. 2674 Hoban {Day45/194:10-13}. 2675 RBKC Module 1 Opening Submissions {RBK00055479/27} paragraph 99. 2676 Menzies {BMER0000004/96} paragraph 303; Hoban {Day45/173:4-9}. 2677 Hoban {Day45/167:2-5}. 2678 Hoban {Day46/3:18}-{Day46/4:10}. 2679 Hoban {Day46/7:6-13}. 2680 Hoban {Day45/197:2-15}; {Day45/200:24}-{Day45/201:24}. 2681 Hoban {Day45/201:10-16}. 2682 Hoban {Day45/205:1-7}. 2683 Hoban {Day46/18:12-25}; {Day46/23:14-17}; {Day46/23:11-17}.

The Grenfell Tower Inquiry: Phase 2 Report 254 62.31 Mr Hoban was not aware of the advice in Approved Document B that test evidence should be checked carefully2684 and at the time had not been aware of the way in which the polyethylene core of an ACM panel would react to fire.2685 He did not consider himself to be qualified to interpret test evidence and said that he would have needed the assistance of a fire engineer to do that.2686 Mr Allen did not consider that to be a specialist area, however, and considered that scrutinising manufacturers’ information was a core function of a building control officer. He did not train his officers in how to go about it because he expected them to be able to do it already.2687 Although Mr Anon, deputy Building Control Manager at RBKC, said that building control officers do not have the technical expertise to challenge a product’s certification,2688 Ms Menzies agreed with Mr Allen.2689 Given the nature of their role, we are satisfied that building control officers can be expected to examine certificates of that kind to ascertain whether materials are suitable for the use for which they are intended. 62.32 In view of its importance in enabling the fire to spread around the tower, it is worth noting that Mr Hoban paid little, if any, attention to the crown during his review of the drawings or his visits to the site. He was aware that it was composed of ACM panels2690 and ought to have asked for more information about it. He should have given some thought to the risk that it might provide a means whereby fire could spread from one part of the building to another, but he failed to do so.2691 Insulation 62.33 Mr Hoban’s evidence about his knowledge of the use of Celotex RS5000 in the external wall system and of its characteristics was not easy to follow. In his witness statements he did not specifically mention Celotex RS5000, although he did mention “Celotex insulation”.2692 He said that he had become aware that Celotex was to be used when he saw it on site, although he thought he might have been told about it before that.2693 He said in his statements that he had looked for information about the insulation on the Celotex website2694 and that what he had found there told him that it was fit for purpose.2695 When he was asked about that, however, he was unable to recall any details of his research. He could not recall which product he had looked at on the Celotex website2696 but he said he would have noted the particular brand of product in his notebook when he was on site.2697 He told us that he had also looked up Celotex RS5000 on the LABC website,2698 but he had not mentioned that in either of his witness statements. He could not say whether he had seen the LABC certificate, either on the Celotex website or that of 2684 ADB Appendix A, note 2 {CLG00000224/119}. “Any test evidence used to substantiate the fire resistance rating of a construction should be carefully checked to ensure that it demonstrates compliance that is adequate and applicable to the intended use. Small differences in detail (such as fixing method, joints, dimensions and the introduction of insulation materials etc.) may significantly affect the rating.” Hoban {Day46/25:14}-{Day46/26:1}. 2685 Hoban {Day46/21:1-14}. 2686 Hoban {Day46/77:9-22}. 2687 Allen {Day47/77:4-25}. 2688 Anon {RBK00029897/8} page 8, paragraph 36. 2689 Menzies {Day60/98:1}-{Day60/100:6}. 2690 Hoban {Day46/138:11-14}. 2691 Menzies Building Control {BMER0000004/123} paragraph 405; Menzies {Day60/165:18}-{Day60/168:11}. 2692 Hoban {RBK00050416/16} page 16, paragraph 43. 2693 Hoban {Day46/30:17-24}. 2694 Hoban {RBK00033934/8} page 8, paragraph 67; Hoban {RBK00050416/16} page 16, paragraph 43(a). 2695 Hoban {RBK00050416/17} paragraph 43(c). 2696 Hoban {Day46/32:18-23}. 2697 Hoban {Day46/33:2-10}. 2698 Hoban {Day45/39:14-15}.

Part 6 | Chapter 62: Building Control 255 LABC itself.2699 He could not identify the document or text he had seen online, although he said that it might have contained statements similar to those in the LABC registered details and drawing document list for RS5000.2700 That document said that Celotex RS5000 was suitable for use in rainscreen wall construction on buildings above 18 metres in height, had been successfully tested to BS 8414:2 2005, met the criteria set out in BR 135, and achieved a “Class 0” spread of flame rating.2701 Mr Hoban could not say whether he had had any discussions about the insulation with Rydon, Studio E or Harley before looking it up on line2702 and he could not remember whether he had asked any of them for evidence that the insulation was appropriate for use in the cladding system.2703 However, he said he had felt confident that they knew what they were doing.2704 62.34 Mr Hoban said that he had been aware at the time that in other contexts manufacturers and others would misuse common expressions such as “fire retardant”2705 and that he had been aware of the need to check that any test relied upon by a manufacturer to demonstrate a product’s suitability matched the intended use of the product.2706 He agreed that he had accepted at face value the statement that Celotex RS5000 had passed a BS 8414 test2707 and that he had not been entitled to assume that the design and construction team had checked the suitability of the cladding materials for themselves.2708 62.35 Mr Hoban’s evidence taken in the round has left us in some doubt about exactly what he did to identify the insulation or to satisfy himself that it complied with the Building Regulations. First, and most importantly, he failed to identify the fact that it was not of limited combustibility. It is not clear what information about Celotex he looked at online, but whatever it was, he did not examine it carefully. Instead, he simply accepted the assertion that RS5000 was suitable for use on tall buildings.2709 Critically, he failed to investigate whether the design of the cladding system proposed for Grenfell Tower was the same as that which had been tested in the BS 8414 test to which the product literature referred and did not ask Studio E to obtain test reports to justify its use. He accepted that that had been a serious failing on his part.2710 62.36 Mr Hoban did not become aware that Kingspan insulation was being used and no one from Rydon, Harley or Studio E told him that it had been substituted for Celotex RS5000 on occasions.2711 Mr Hoban said that if he had known that he would have looked at the BBA certificate relating to it.2712 Infill panels 62.37 Mr Hoban had not been aware that the P1 window infill panels contained Styrofoam2713 and did not know one way or another whether they complied with the guidance in paragraph 12.7 of Approved Document B, although he agreed that Styrofoam was not a 2699 Hoban {Day46/33:23}-{Day46/34:3}; {Day46/34:12-23}; {Day46/35:5-20}; {Day46/39:5-22}. 2700 {CEL00000009}; Hoban {Day46/35:6}-{Day46/36:20}. 2701 {CEL00000009}. 2702 Hoban {Day46/31:14-17}. 2703 Hoban {Day46/31:18-23}. 2704 Hoban {Day46/32:9-12}. 2705 Hoban {Day46/52:14}-{Day46/54:6}. 2706 Hoban {Day45/56:21}-{Day45/57:3}. 2707 Hoban {Day46/58:3-8}. 2708 Hoban {Day46/59:10-13}. 2709 Hoban {Day46/45:4-15}. 2710 Hoban {Day46/45:11-16}. 2711 Hoban {Day46/167:7-9}. 2712 Hoban {Day46/168:10-17}. 2713 Hoban {Day46/26:3-20}.

The Grenfell Tower Inquiry: Phase 2 Report 256 material of limited combustibility.2714 However, in March 2015 he had been provided with a copy of the Harley Specification which showed that the P1 panels contained Styrofoam.2715 When asked why he did not notice that at the time, he said that he thought that he had not read the document properly2716 and had relied on the fact that Exova had been working on the project.2717 He also had not checked whether the Kingspan TP10 insulation in the P2 window infill panels was of limited combustibility.2718 Mr Hoban accepted that he ought to have questioned the use of those materials.2719 During his site visits he ought also to have noticed that gaps around the windows were being packed with insulation and should have checked whether the material being used was of limited combustibility. Cavity barriers 62.38 The full plans application did not include a cavity barrier strategy and the drawings supplied with it did not show any cavity barriers.2720 Mr Hoban said that he would have expected them to be shown on the drawings and that he believed he had chased the contractor for information about them.2721 Studio E sent drawings showing cavity barriers to building control on 6 March 2015.2722 They showed cavity barriers in line with compartment walls and floors but not around the windows.2723 Mr Hoban said that he had understood that the framework supporting the window (which he had thought was steel) would act as a cavity barrier2724 but when he gave evidence he could not recall why he had thought that.2725 It is not clear to us how he could have come to such an understanding, as there is no indication in the drawings that the framework was steel2726 and Mr Lamb’s evidence was that the use of steel had not been part of the design.2727 We are sceptical of his explanation and think it likely that it was an afterthought on his part to explain his failure to notice the omission. At all events, Mr Hoban did not check the windows on site to see whether cavity barriers had been installed around them2728 because the work that he had seen had, in his view, been of an adequate standard. He accepted, however, that he should have done so.2729 Site visits 62.39 Mr Hoban told us that he had tried to visit the site once a month while the refurbishment was being carried out,2730 but he visited it much less often than that during the period when the cladding was being installed because the pressure of work had increased and he trusted the professionals working on the project.2731 He did not visit the site between 15 May 2015 and 17 August 2015.2732 In our view he should have visited more often during that period. The primary means of checking compliance with the Building Regulations is by 2714 Hoban {Day46/28:12-20}. 2715 {SEA00000252}; {HAR00003955}. 2716 Hoban {Day46/26:22-23}. 2717 Hoban {Day46/27:16-21}. 2718 Hoban {Day46/29:3-9}. 2719 Hoban {Day46/29:10-18}. 2720 Hoban {Day46/91:21-24} 2721 Hoban {Day46/92:2-12}. 2722 {RYD00034134}; drawings attached to the email included {RYD00034136}; {RYD00034135}; {RYD00034137}. 2723 {SEA00002499}. 2724 Hoban {Day 46/95:6-14}. 2725 Hoban {Day46/95:15}-{Day46/96:15}. 2726 Hoban {Day46/102:2-9}]. 2727 Lamb {Day38/146:2-15}. 2728 Hoban {Day46/98:4-22}. 2729 Hoban {Day46/99:9}-{Day46/100:8}. 2730 Hoban {RBK00050416/19} page 19, paragraph 48. 2731 Hoban {Day46/164:16}-{Day46/166:21}; Hoban {RBK00033934/9} page 9, paragraph 84. 2732 See site visit records {RBK00052478/4}.

Part 6 | Chapter 62: Building Control 257 visiting the site and looking at the work.2733 That calls for careful and detailed inspection. It is clear from Mr Hoban’s evidence that even when he did visit the site he did not check the installation of the cladding thoroughly and missed important defects, such as poorly installed cavity barriers.2734 Regulation 38 62.40 Regulation 38 of the Building Regulations requires the person carrying out the works to pass fire safety information to the Responsible Person for the purposes of the Fire Safety Order.2735 Under regulation 17 of the Building Regulations, if the Fire Safety Order applies to a building on completion of the work (as in the case of Grenfell Tower), the local authority has a duty to issue a completion certificate confirming that the requirements of regulation 38 have been satisfied if, after taking all reasonable steps to do so, it has been able to ascertain that that is the case. 62.41 The fourth edition of the Building Regulations Procedural Guidance, which was in force until March 2015, advised that a copy of the information provided under regulation 38 should be sent to the local authority.2736 The fifth edition, in force from March 2015 to July 2020, does not contain that guidance,2737 but both the fourth and fifth editions advise that local authorities should not issue completion certificates unless they have received written confirmation from the applicant that the information required by regulation 38 has been provided to the Responsible Person.2738 62.42 Mr Hoban was aware of the requirements of regulation 38 of the Building Regulations.2739 The practice at RBKC building control at the time of the Grenfell refurbishment was simply for officers informally to ask contractors whether they had provided the necessary information to building owners.2740 Mr Allen said that they did not take independent steps to satisfy themselves that that had been done2741 and that his personal practice was just to check with the client if someone happened to be on site towards the end of a project.2742 Not surprisingly, Mr Hoban adopted the same practice. He believed that he had asked David Hughes whether Rydon had sent the information to the TMO, but he did not record either the question or the answer in writing.2743 62.43 The practice adopted by RBKC did not in our view amount to taking all reasonable steps to ascertain whether regulation 38 had been satisfied and did not follow the procedural guidance in force at the time. It appears that a similar practice may have been followed by other local authority building control departments. If so, it suggests a widespread failure by building control bodies to comply with the regulations. Ms Menzies accepted in hindsight that the practice was not appropriate and we agree. It does not excuse the casual approach demonstrated by RBKC building control in this case. 2733 Menzies, Building Control {BMER0000004/61} paragraph 249. 2734 Hoban {Day46/127:6-12}; {Day46/130:21-25}. 2735 See Chapter 48. 2736 Lane, Phase 2, Fire Safety Information Report {BLARP20000021/88} paragraph 12.4.2. 2737 Lane, Phase 2, Fire Safety Information Report {BLARP20000021/92} paragraph 12.5.7. 2738 Lane, Phase 2, Fire Safety Information Report {BLARP20000021/89} paragraph 12.4.4; Lane, Phase 2, Fire Safety Information Report {BLARP20000021/128} paragraph 14.7.3. 2739 Hoban {Day46/197:18-23}. 2740 Hoban {Day46/199:23}-{Day46/200:16}; Allen {Day47/188:3}-{Day47/189:20}. 2741 Allen {Day47/189:11-16}. 2742 Allen {Day47/190:6-9}. 2743 Hoban {Day46/200:18-24} {Day46/201:23}.

The Grenfell Tower Inquiry: Phase 2 Report 258 Completion certificate 62.44 Mr Hoban caused a completion certificate for the Grenfell refurbishment to be issued in the name of Mr Allen on 7 July 2016.2744 He agreed that, given that the external wall did not comply with functional requirement B4 of the Building Regulations, he should not have done so.2745 We accept that when he caused the certificate to be issued Mr Hoban thought that the functional requirements of the Building Regulations had been satisfied,2746 but his failure to scrutinise the design and execution of the work with sufficient rigour meant that his confidence was entirely misplaced. In its statements to the Inquiry RBKC has rightly accepted that a completion certificate should not have been issued.2747 General observations 62.45 The two most serious errors made by Mr Hoban were, first, the failure to recognise that the presence of unmodified polyethylene cores rendered the ACM panels highly combustible, and second, the failure to recognise that the insulation, which was visible on the tower during his site visits,2748 was not of limited combustibility. For reasons we have explained elsewhere, neither of the insulation products should have been used in the overcladding of Grenfell Tower. In his statements Mr Hoban seems to suggest that the contractor might have used materials other than those that had been specified, but when he gave evidence he made it clear that he knew at the time that ACM was being used. 62.46 At the time of the refurbishment Mr Hoban was a senior building control surveyor and had worked at RBKC as a building control officer for over 25 years. However, part of the reason for those major errors was that he did not possess the knowledge and experience to be expected of a building control officer dealing with a project of that kind. In particular, there were some significant gaps in his understanding of the Building Regulations and important industry guidance so far as they concerned fire safety. He was an associate member of the Chartered Association of Building Engineers but understood that his grade of membership did not require him to engage in any regular professional training2749 and to a large extent it was left to him to decide what additional training he required. He attended conferences from time to time and read professional magazines,2750 but the only formal training he received was that which was provided by the department. 62.47 The building control department organised lunchtime seminars between four and six times a year2751 (although no lunchtime seminars were held in 2016).2752 They were generally delivered by the department’s managers and were directed to specific topics relating to building control, such as the publication of a new edition of an Approved Document.2753 Training was provided on the new Approved Document B following its publication in

1. On occasions, manufacturers or other industry professionals, such as architects or

2744 {RBK00018811}. 2745 Hoban {Day46/204:7-14}. 2746 Hoban {Day46/204:12-14}. 2747 RBKC Module 1 Opening Submissions {RBK00055479/27} paragraph 105. 2748 Hoban {Day46/167:21}-{Day46/168:17}. 2749 Hoban {Day45/13:23}-{Day45/14:7}. 2750 Hoban {Day45/14:3-24}, {Day45/23:16-23}. 2751 Allen {Day47/74:12-18}. 2752 {RBK00051200}. 2753 Hoban {Day45/17:18-21}; {Day45/20:2-25}.

Part 6 | Chapter 62: Building Control 259 surveyors, were invited to deliver lunchtime seminars,2754 but Mr Hoban had not attended any seminars dealing with the overcladding of high-rise residential buildings.2755 Nor was he given any specific training on any other industry guidance.2756 62.48 The Grenfell Tower refurbishment was Mr Hoban’s first residential high-rise overcladding project and, apart from the KALC project, for which he also assumed responsibility, his first design and build project. Surprisingly, Mr Allen was not aware of either fact,2757 although we think he should have been. 62.49 Mr Hoban had a very limited grasp of industry guidance on rainscreen cladding, such as BR 135, which he had not read,2758 and was not aware of BCA Technical Guidance Note 18.2759 He should have been. His understanding of the BS 8414 tests and how they could be used to demonstrate compliance with functional requirement B4 was limited.2760 None of the gaps in Mr Hoban’s knowledge appear to have come to the attention of his managers and Mr Hoban himself does not appear to have taken any steps to develop his knowledge in those areas as part of his work on the refurbishment. He was aware, however, that cladding could provide a means of fire spread and that there was a need to fit cavity barriers;2761 and he was aware that cladding fires had occurred, both in this country and abroad, having seen references to them in the media.2762 He was not aware of the warnings to be found in industry guidance that some materials used in facades could generate molten or flaming debris and thereby contribute to the spread of fire2763 and did not seem to have a firm grasp on whether materials such as PIR insulation were of limited combustibility. Again, he should have been aware of those matters. 62.50 Mr Hoban was aware that manufacturers tend to present fire test data in misleading ways, but he did not regard himself as competent to examine test data for himself. He thought that was the responsibility of a fire engineer. Mr Allen and Ms Menzies both took a different view. We agree with them that a building control officer should be capable of examining manufacturers’ information and test data critically and we do not understand why Mr Hoban thought otherwise. If he did not know how to read manufacturers’ information or how to evaluate test data, he ought to have asked someone within the department for assistance. 62.51 Mr Hoban’s opinion that the materials proposed for the refurbishment were suitable for their purpose appears to have been based at least in part on the fact that none of the other experienced professionals working on the project ever suggested that they might not comply with the Building Regulations.2764 He trusted Studio E and Exova because he had worked with them on the KALC project and was reassured by the fact that Mr Ashton was involved in the refurbishment.2765 In his written evidence Mr Hoban said that at an initial meeting on site in November 2014 he had been told by representatives of Max Fordham, Exova and Siderise2766 that the cladding would comply with the standards 2754 Hoban {Day45/30:1-10}. 2755 Hoban {Day45/27:13-15}. 2756 Hoban {Day45/21:4-17}. 2757 Hoban {Day45/183:20-24}; Allen {Day47/133:18}-{Day47/114:7}. 2758 Hoban {Day45/52:12}-{Day45/53:15}; {Day45/59:15-22}; Menzies, Building Control{BMER0000004/97} paragraph 310; Menzies {Day60/81:7}-{Day60/83:4}. 2759 Hoban {Day45/66:1-6}; {Day45/67:6-12}; Menzies {Day60/80:20}-{Day60/81:1}. 2760 Hoban {Day45/37:21}-{Day45/40:17}; {Day45/68:6-22}; Menzies {Day60/103:21-23; {Day60/104:5-23}. 2761 Hoban {Day45/54:21}-{Day45/59:5}; {Day45/61:15-16}. 2762 Hoban {Day45/91:9}-{Day45/96:15}. 2763 {BRE00005554/18}; Hoban {Day45/59:4-13}; {CEL00003364/11}; Hoban {Day45/60:4-16}; {Day45/64:7-23}. 2764 Hoban {RBK00050416/10} page 10, paragraph 34(a). 2765 Hoban {Day45/202:6}-{Day46/204:10}. 2766 Hoban {RBK00050416/17} page 17, paragraph 44.

The Grenfell Tower Inquiry: Phase 2 Report 260 set out in Approved Document B.2767 However, no one representing Siderise was present at that meeting, which the minutes suggest concerned the smoke control system,2768 and Mr Ashton categorically denied having said anything of the kind.2769 There is no record of any such assurance in Mr Hoban’s notes of the meeting and Mr Crawford could not recall a meeting where the compliance of the cladding system with Approved Document B had been discussed with him.2770 Mr Hoban was very confident in his recollection and it is possible that in the course of a casual conversation someone said that the cladding would comply with Approved Document B, but whatever was said, we do not accept that Mr Hoban was justified in relying on it to the extent of allowing important matters on a substantial project of this kind to go unchecked. 62.52 Mr Hoban also relied on statements made to him by others that the same cladding system had been used elsewhere on buildings over 18 metres in height. He told us that he had discussed the cladding system with a person whom he described as “Harley’s engineer” and had been told that it had been installed on many buildings of a similar height and construction throughout England and Wales.2771 Mr Hoban said that the person he had spoken to was probably Ben Bailey,2772 who had been introduced to him as an engineer by Simon O’Connor, Rydon’s project manager.2773 Mr Hoban did not accept that that had led him to be complacent about compliance, but he did accept that it gave him confidence that the system was not new and had been used elsewhere.2774 Ben Bailey could not recall having had any conversations with Mr Hoban about the cladding system2775 and doubted that he had told him that the cladding would comply with Approved Document B.2776 62.53 ACM rainscreen panels and PIR insulation had been used in the overcladding of other buildings over 18 metres in height and others involved in the project also felt reassured by that.2777 We think it quite likely that someone from Harley, possibly Ben Bailey, did tell Mr Hoban that similar materials had been used on other buildings and that that contributed to his understanding that they complied with the Building Regulations. We think he assumed that the other professionals involved in the project had satisfied themselves that the materials proposed for use in the cladding complied with Approved Document B and that he allowed himself to be lulled into a false sense of security. 62.54 Although Mr Hoban must bear primary responsibility for the failure of RBKC’s building control department to deal properly with the refurbishment project, his ability to carry out his task effectively was hampered by an excessive workload and poor management of the department as a whole. He told us that he had been very busy at the time of the refurbishment2778 and candidly accepted that that had affected his work. That had led him to give priority to other work, particularly in 2015 and 2016.2779 2767 Hoban {RBK00033934/8} page 8, paragraph 67; Hoban {RBK00050416/18} page 18, paragraph 44(c). 2768 {MAX00004666}; {RBK00052478/5}. 2769 Ashton {Day17/121:12}. 2770 Crawford {Day11/186:4-8}. 2771 Hoban {RBK00050416/11} page 11, paragraph 34(d); Hoban {RBK00033934/7} page 7, paragraph 66; Hoban {Day46/72:20-25}. 2772 Hoban {Day46/71:20-24}. 2773 Hoban {Day46/72:2-14}. 2774 Hoban {Day46/76:17-22}. 2775 Ben Bailey {Day40/23:20}-{Day40/24:9}. 2776 Ben Bailey {Day40/20:19-22}. 2777 Crawford {Day10/148:8-19}; Rek {Day12/73:19}-{Day12/75:9}; Osgood {Day30/118:16-20}; Harris {Day34/53:2-12}; Sakula {Day125/110:3}-{Day125/111:7}. 2778 Hoban {Day46/156:4}-{Day46/157:2}; {Day46/157:20}-{Day46/158:2}. 2779 Hoban {Day46/164:22}-{Day46/166:12}.

Part 6 | Chapter 62: Building Control 261 62.55 The restructuring of RBKC’s building control department in 2013 involved a substantial reduction in numbers.2780 Both Mr Hoban and Mr Hanson said that at times after the restructuring they had experienced heavy workloads.2781 John Allen said that with a small team there would be rare occasions on which a lot of work would come in at the same time and he would have to manage that and plug gaps,2782 but he did not accept that there had been a substantial increase in the amount of Mr Hoban’s work after the restructuring.2783 He also said that he had met his officers monthly to confirm that their workload was manageable and find out whether help was needed.2784 Mr Allen could recall occasions on which he had offered Mr Hoban help and had reallocated some work to other officers.2785 Mr Hoban said that he had asked for help in 2015 but his suggestions for lightening his load came at that time had come to nothing.2786 After he had left the witness box Mr Allen disclosed to the Inquiry his notes of his meetings with Mr Hoban. They show that Mr Allen had been aware that Mr Hoban had been struggling to carry out site visits between May 2014 and October 20152787 and that in December 2015 Mr Hoban’s records were not up to date.2788 62.56 There is some suggestion in the documents that in 2014 the building control department was overwhelmed with work.2789 Mr Hoban told Neil Crawford that he was working on hundreds of projects, although Mr Crawford thought at the time that he might have been exaggerating.2790 Mr Hoban told us, however, that at that time he had been coming in to work at weekends2791 and although Mr Allen did not think that the department as a whole was overstretched,2792 we think that Mr Hoban clearly was. At times during the period between 2014 and 2016 he was unable to manage his workload and the quality of his work suffered as a result. He did not feel able to ask for support from his manager and there was no one else to whom he could take his concerns.2793 As a result, he gave priority to other projects, particularly in April 2015 when an additional area or “patch” was allocated to him.2794 He said that, in hindsight, he wished that he had been given more time to deal with the Grenfell refurbishment.2795 Mr Hoban was also dealing with difficulties in his personal life during the summer of 2016, which he accepted may have meant that he did not do things as he should have done.2796 2780 Allen {Day47/99:14}-{Day47/100:4}; {Day47/101:17-22}; {Day47/102:19}-{Day47/103:6}, Hoban {Day45/107:1}-{Day45/109:16}. 2781 Hoban {Day45/110:7}-{Day45/113:12}. Mr Hoban’s appraisal for 2015-16 refers to Mr Hoban covering the work of other colleagues {RBK00048753/3} and {RBK00048753/7}. Mr Crawford gave evidence that Mr Hoban had told him that he was overseeing “hundreds of projects” but Mr Hoban did not recall saying that, although his recollection was that he had been overseeing between 120 and 130 projects. Crawford {Day11/131:18-25}; Hoban {Day45/111:14}-{Day45/112:2}. 2782 {Day47/46:20}-{Day47/47:3}. 2783 Allen {Day47/121:13}-{Day47/123:20}. 2784 Allen {RBK00033930/3} page 3, paragraph 16; Mr Hoban agreed that he would meet Mr Allen monthly but said that his workload had not been discussed. Hoban {Day45/115:3-16}. 2785 Allen {Day47/120:24}-{Day47/121:12}. 2786 Hoban {Day46/157:20}-{Day46/158:2}. 2787 {ALL00000003/3}-{ALL00000003/9}. 2788 {ALL00000003/9}. 2789 {RYD00004218}. 2790 Crawford {Day11/131:18-24}. 2791 Hoban {Day45/116:5-18}. 2792 Allen {Day47/105:8-10}. 2793 Hoban {Day46/158:22}; {Day46/159:12}-{Day46/160:3}; Allen {Day47/137:18}-{Day47/138:17}. 2794 Hoban {Day46/156:4}-{Day46.157:2}. 2795 Hoban {Day46/212:22}-{Day46/213:8}; {Day46/215:21}-{Day46/216:2}. 2796 Hoban {Day45/170:18}-{Day45/171:6}.

The Grenfell Tower Inquiry: Phase 2 Report 262 62.57 There was also a failure by RBKC’s building control department to ensure that officers within the department received the training they needed to do their work properly. A building control body should provide continuing professional development for its officers,2797 as is reflected in the Building Control Performance Standards.2798 As a member of the Royal Institute of Chartered Surveyors, Mr Allen was required to undertake regular training, and in the years 2013 to 2017 he had exceeded the minimum hours required of him. He took responsibility for providing technical training to his officers on matters to do with the Building Regulations,2799 but did not organise training on Approved Document B generally or on the fire safety risks posed by cladding systems on high-rise buildings. Similarly, there does not appear to have been any system for ensuring that officers had the knowledge and understanding to examine manufacturers’ information critically, nor were they told that it was important to read certificates, such as BBA certificates, critically and in their entirety. Mr Allen expected his officers to possess those skills already.2800 We do not think that building control officers would normally expect to receive formal training on examining product literature, but that they would normally acquire that skill through their work and from discussions with others.2801 62.58 On 31 December 2013, Paul Hanson sent Mr Allen a copy of a guide published by the British Standards Institution (BSI) entitled “Don’t be a flaming liability”.2802 The covering email drew attention to confusion within the construction industry about the meaning of Class 0 and the tendency of manufacturers to make misleading statements about the fire performance of their products. The guide itself drew attention to the fact that manufacturers often wrongly refer to Class 0 as meaning “fireproof”. Mr Allen was aware of confusion in the industry about the meaning of Class 0.2803 Mr Hoban could not recall whether he had been aware of it2804 but he had been aware of manufacturers’ propensity to use misleading terms more generally.2805 62.59 In October 2015, Jose Anon (John Allen’s deputy at the time) attended the London District Surveyors’ general meeting where those present discussed a building in Southwark over 18 metres in height on which PIR insulation had been installed. They were told that Kingspan had confirmed that its PIR insulation was combustible. The notes of the meeting also referred to the need for cladding to be of limited combustibility.2806 Mr Allen did not know whether Mr Anon had shared that information with the RBKC building control team2807 but in our view Mr Anon should have ensured that information of that kind was disseminated through the department. 62.60 Mr Allen told us that he had regular meetings with the officers and would assess their general competence2808 but we saw no concrete evidence to suggest that he actively checked the officers’ skills to ensure that they had a basic knowledge and understanding of the problems that could arise. The failure to monitor the knowledge and skills of individual officers and to ensure that they received the training needed for them to carry out their function effectively was in our view a serious weakness in the way RBKC’s building control 2797 Menzies {Day60/51:6-9}; {Day60/51:19}-{Day60/52:9}. 2798 Menzies, Building Control {BMER0000004/45} paragraph 178(a). 2799 Allen {Day47/72:19-35}. 2800 Allen {Day47/80:1-15}. 2801 Menzies {Day60/99:20-22}. 2802 {RBK00059350}; {RBK00059351}. 2803 Allen {Day47/151:18}-{Day47/153:1}. 2804 Hoban {Day46/47:20-24}. 2805 Hoban {Day46/51:18-25}, {Day46/52:14-25}, {Day46/53:23-24}. 2806 {RBK00001221/4}. 2807 Allen {Day47/85:12-16}. 2808 Allen {Day47/78:1-11}.

Part 6 | Chapter 62: Building Control 263 department was run. It was compounded by a failure to recognise that Mr Hoban was struggling to keep up with the work allocated to him and to take steps to ensure that he had the time and knowledge needed properly to oversee a project as substantial as the Grenfell refurbishment. The absence of a quality management system meant that the defects in Mr Hoban’s work were not identified. 62.61 Record-keeping within the department was poor. RBKC accepted that there was no formal procedure for tracking the progress of applications for building control approval and that that was a failure on its part. In addition, Mr Hoban’s own record-keeping was poor. He failed to make an electronic record of the conditions applied to the full plans approval and failed to record the full extent of his site visits on the Acolaid system. Someone ought to have noticed that at the time and taken steps to address it. Mr Allen was aware that Mr Hoban was behind in writing up site visit notes.2809 62.62 In addition to the electronic file the department maintained a paper file. Unfortunately, however, that file has been lost. That is itself a ground of criticism, but RBKC’s practice of weeding files before they were sent for storage means that even if the paper file had been available, the information it contained about Mr Hoban’s work on the refurbishment was likely to be limited. Weeding of files is to be discouraged because it carries a high risk that documents whose true significance is not appreciated at the time are likely to be lost. The department’s poor record-keeping practices have hampered our investigation. 62.63 We have no doubt that the shortcomings in the management of the department to which we have referred played a significant part in Mr Hoban’s failure to carry out his role properly. 62.64 In its opening and closing statements, RBKC candidly admitted that the work of its building control officers fell below the standard that could reasonably be expected of them, but in our view its admissions did not cover the full extent of its failures. Although we have found that other parties, in particular those responsible for the design of the cladding, bear considerable responsibility for the fact that following the refurbishment the external wall of Grenfell Tower did not comply with the Building Regulations and was dangerous, building control was the last line of defence and had a statutory obligation to check for compliance with the Building Regulations. It had a responsibility to protect the public and it wholly failed to perform that function. It therefore bears considerable responsibility for the dangerous condition of Grenfell Tower immediately on completion of the refurbishment. 2809 {ALL00000003/9}.

264 The Grenfell Tower Inquiry: Phase 2 Report

265 Chapter 63 The contribution of Studio E Introduction 63.1 Studio E was the architect for the Grenfell Tower refurbishment. It provided architectural services in respect of the project between approximately February 2012 and July

1. As architect, Studio E had primary responsibility for the design of the facade of

Grenfell Tower, among other aspects of the refurbishment. We have concluded that Studio E fell well below the standard to be expected of a reasonably competent architect in respect of that work. Its failures relating to the design of the external wall and the selection of materials to be used in its construction had catastrophic consequences. Studio E therefore bears a very significant degree of responsibility for the disaster. Paul Hyett’s evidence 63.2 Since we could foresee that questions of architectural practice might arise in the course of our investigations, we instructed Mr Paul Hyett to prepare a written report dealing with the various aspects of the refurbishment, including the professional standards to be expected of a reasonably competent architect, and the work of Studio E.2810 In its closing statement Studio E suggested that Mr Hyett did not have the experience or expertise needed to express an opinion on any aspect of overcladding a high-rise building, having had little or no personal experience of such work. It also suggested that, when expressing views about the use of the materials used in the cladding, he had ignored the fact that similar materials had been used on many buildings across the country on which reputable architects had presumably been employed. He had thus chosen not to consider evidence of what a responsible body of professional architects would have done at the time of the Grenfell Tower refurbishment. We were therefore asked to place little or no weight on his evidence.2811 63.3 It is not in dispute, however, that Mr Hyett has had a long and distinguished career as an architect, including over 40 years of post-qualification experience in England and internationally. Between 2004 and 2020 he was a principal at HKS Architects2812 before retiring in 2020 to run a consultancy advising on architectural services.2813 He is a member of the Royal Institute of British Architects (“RIBA”) and was its President from September 2000 to August 2002.2814 He also has a special interest in and experience of the education of architects. He was the RIBA Council member responsible for architectural education from 1998 to 2001, has acted as an external examiner at various universities, reported to the Burton Review of Architectural Education and later acted as deputy chair to the 2810 {PHYR0000032}; His main report was dated October 2019 and was revised in August 2020 {PHYR0000024}-{PHYR0000037}; He also produced a supplemental report in September 2020 which provided additional commentary on the opinions set out in his original report {PHYS0000001}-{PHYS0000005}. 2811 {SEA00014645/2} paragraph 1.5. 2812 Hyett, Module 1 Report (revised) {PHYR0000026/2} paragraph 1.1.5. 2813 Hyett {Day63/10:1-6}. 2814 Hyett, Module 1 Report (revised) {PHYR0000026/2} paragraph 1.1.2.

The Grenfell Tower Inquiry: Phase 2 Report 266 Stansfield Smith Review of Architectural Education. He is an honorary fellow of the American Institute of Architecture, the Royal Society of Architects in Wales and the Chartered Association of Building Engineers.2815 63.4 Mr Hyett candidly accepted that his personal experience of overcladding projects was limited.2816 However, the breadth and depth of his career made him well qualified to advise on how an architectural practice should approach a project that is outside the scope of its primary expertise. Much of his evidence was directed to identifying the steps that a competent practice should take and the questions it should ask itself in those circumstances and did not require direct experience of overcladding projects. We have no evidence of the circumstances in which similar materials may have been used on other buildings and in any event, we do not think that the use of what may have been inappropriate materials in other circumstances can assist us. In view of Mr Hyett’s professional experience we are satisfied that he was well qualified to give evidence about the standards that could reasonably be expected of a firm like Studio E when undertaking a new project such as the Grenfell Tower refurbishment. In general, we found his evidence to be thorough and careful, reflecting an awareness of what it was reasonable to expect from an architect in general practice. It is worth noting that Studio E did not ask us to hear evidence from someone whose opinions differed from his. Studio E’s experience and expertise 63.5 The refurbishment of Grenfell Tower was a new type of project for Studio E, which did not have any significant experience in refurbishing or overcladding high-rise residential buildings.2817 Andrzej Kuszell accepted that it is unlikely that the firm would have won the commission if it had been put out to tender because of its lack of relevant experience.2818 Having said that, we do not think that Studio E can be criticised for accepting the appointment, because architects can be expected to take on work outside their traditional areas of specialism from time to time.2819 However, even before it had agreed to undertake the project, it should have been readily apparent to Mr Kuszell that none of the existing partners or employees had the relevant knowledge, experience or skills that would be needed. Indeed, Bruce Sounes appears to have recognised that some steps were required to improve existing knowledge and skills because he told Mr Kuszell in February 2012 that Studio E was “a little green on process and technicality” and proposed “some rapid CDP” [sic].2820 However, he told us that his concerns related to the logistics of carrying out work in an occupied building rather than designing the external wall, which he considered to be straightforward.2821 In the end the “rapid CPD” consisted of nothing more than a discussion with Max Fordham and some research on the internet into overcladding high- rise residential buildings.2822 2815 Hyett, Module 1 Report (revised) {PHYR0000035} Appendix 4; For discussion of Mr Hyett’s previous experience on particular building projects, including high-rise overcladding projects, see Hyett {Day63/54:18}-{Day63/60:16}. 2816 Hyett {Day63/55:2-12}. 2817 Kuszell {Day6/20:7-19}; {Day6/11:19-22}; Sounes {Day6/173:14-16}; Sounes {SEA00014273/114} page 114, paragraph 271; Hyett, Module 1 Report (revised) {PHYR0000027/15} page 15, paragraph 2.5.5; {PHYR0000027/16} page 16, paragraph 2.5.12(a). 2818 Kuszell {Day6/70:10-16}. 2819 Hyett, Module 1 Report (revised) {PHYR0000027/17} paragraph 2.5.12(b); {PHYR0000027/18} paragraph 2.5.14. Hyett {Day63/80:5-18}; Hyett {Day63/82:7}-{Day63/83:17}. 2820 {SEA00003567}. 2821 Sounes {Day6/186:1-14}; {Day6/187:2-7}; {Day6/192:12-16}. 2822 Sounes {Day6/192: 3-16}; {Day6/192:18}-{Day6/193:14}.

Part 6 | Chapter 63: The contribution of Studio E 267 63.6 In our view it was necessary for Studio E to engage someone who could bring to the firm specific experience of overcladding a high-rise residential building2823 to ensure that it could provide the necessary services with appropriate skill and care.2824 However, Studio E did not do so and appears to have thought, both at the time and in hindsight, that that was unnecessary because it could acquire the necessary knowledge and skills as the project progressed.2825 As a result it failed to ensure that it was properly equipped to perform its obligations to the TMO. Studio E’s role and responsibilities 63.7 Studio E was appointed as lead consultant and lead designer. As lead consultant it was responsible for advising on the need for, and the scope of services to be provided by, consultants, specialists, sub-contractors and suppliers and for monitoring the work of other consultants. As lead designer it was responsible for co-ordinating the design of all constructional elements, including work by consultants, specialists and suppliers and for determining materials, elements and components.2826 However, Studio E appears to have laboured under a fundamental misunderstanding about the nature of its obligations. As a result, it treated sub-contractors and consultants as solely responsible for their work and assumed, without enquiry, that it met the required standards. Throughout its evidence and submissions to the Inquiry, Studio E’s witnesses sought to place responsibility on others, such as Max Fordham, Exova, Harley and building control for ensuring that work was of the required standard. In particular, Studio E maintained that it was for others to ensure that materials chosen for use in the construction of the cladding were suitable and would ensure compliance with the Building Regulations. That was clearly wrong. Although others involved in the refurbishment had incurred separate obligations of their own in relation to the quality of the work and materials used, Studio E had an overriding obligation, initially to the TMO and subsequently to Rydon, to ensure that the work was carried out properly and the choices of materials were suitable. The outline design 63.8 Bruce Sounes was given the responsibility of managing the project on behalf of Studio E. He said that he had been aware in a general way of the requirements of Part B of Schedule 1 to the Building Regulations and Approved Document B, but he did not take any steps to familiarise himself with it in any detail at the beginning of the project and did not take the trouble to understand its significance for the project he was taking on.2827 He occasionally referred to Approved Document B2828 but did not read the guidance relating to requirement B4 and did not appear to have any clear understanding of what it entailed.2829 2823 Hyett {Day63/86:2}-{Day63/87:23}; {Day64/3:20}-{Day64/4:3}; Hyett, Module 1 Report (revised) {PHYR0000027/17} paragraph 2.5.12(b) and {PHYR0000027/18} paragraph 2.5.14; Hyett {Day63/80:5-18}; {Day63/82:7}-{Day63/83:17}. 2824 Hyett, Module 1 Report (revised) {PHYR0000027/17} paragraph 2.5.12(b); {PHYR0000027/18} paragraph 2.5.14; Hyett {Day63/80:5-18}; {Day63/82:7}-{Day63/83:17}. 2825 Kuszell {SEA00014271/11} page 11, paragraph 41; Kuszell {Day6/77:1}-{Day6/78:14}, {Day6/79:12}-{Day6/80:24}; Sounes {Day6/199:11-17}. 2826 {SEA00009824/5}. 2827 Sounes {Day7/132:7-21}. 2828 Sounes {Day7/135:6-9}. 2829 Sounes {Day7/136:6-20}.

The Grenfell Tower Inquiry: Phase 2 Report 268 63.9 Although Mr Sounes agreed that it was Studio E’s responsibility to investigate any legislative requirements relating to the project at the earliest opportunity in the design process,2830 he did not do so or ensure that someone else did. That was a basic error and his consequent ignorance of paragraphs 12.5 to 12.9 of Approved Document B meant that he was unaware of the guidance it contained on the risks arising from the use of certain materials and the ways in which compliance with functional requirement B4(1) could be achieved. He therefore gave no thought to the manner in which compliance was to be ensured.2831 In its opening statement Studio E suggested that, taken as a whole, its design might have been capable of complying with the Building Regulations (presumably when the work had been completed) and that projects often proceed to advanced stages with designs in relation to which the method of achieving compliance with the Building Regulations has not yet been fully considered.2832 However, that is not consistent with Mr Sounes’ own evidence2833 or with the terms of the contract between Studio E and the TMO (and subsequently Rydon), under which Studio E had an obligation to seek to ensure that all designs complied with the relevant statutory requirements.2834 In our view, in failing to review Approved Document B and to consider carefully its significance for the project Mr Sounes fell seriously below the standard to be expected of a reasonably competent architect.2835 63.10 One consequence of the approach adopted by Mr Sounes was that he did not take active responsibility for the choice of the materials that were to form part of the external wall of the building. Instead of satisfying himself independently of their suitability, he assumed that, because others appeared to be satisfied that both the ACM panels and the Celotex insulation were acceptable for use in that context, there was nothing to worry about. He therefore failed to identify that both were composed of combustible materials and failed to recognise the dangers of using them in an external wall. As a consequence, the external wall did not comply with functional requirement B4(1).2836 Those were serious errors that had direct and catastrophic consequences. 63.11 Any reasonably competent architect should have known, or at any rate should have taken the trouble to discover, that paragraphs 12.5 and 12.7 of Approved Document B contained a warning against the use of combustible materials in external walls.2837 Indeed, Leadbitter warned Studio E against the use of combustible insulation behind the rainscreen in January 2013.2838 The Celotex FR5000 specified by Studio E was a polyisocyanurate material and as such was combustible. Any competent architect ought to have known that, or, if uncertain about its composition, should have discovered it. However, notwithstanding the clear terms of paragraph 12.7 of Approved Document B, Studio E specified Celotex FR5000 for use in the external wall without giving any consideration to whether the resulting structure would comply with functional requirement B4(1). That was a significant failure.2839 2830 Hyett {Day64/41:4-18}; {Day64/55:12-16}; Hyett, Module 1 Report (revised) {PHYR0000027/46} paragraph 2.9.2 and 2.9.4; {PHYR0000027/47-48} paragraphs 2.9.6 and 2.9.8; Hyett {Day64/41:19-24}; Sounes {Day7/85:1-8}; {Day7/88:1-18}; {Day7/127:8-22}; {Day7/128:18-23}; {Day7/130:14}-{Day7/131:9}; {Day7/184:15-19}; {Day7/134:25}-{Day7/135:5}. 2831 Hyett {Day64/43:6}-{Day64/44:14}; {Day64/58:5-9}. 2832 Studio E’s written opening statement {SEA00014642/20} paragraphs 9.10 and 9.11. 2833 See the references at footnote [2655] above. 2834 Schedule of services, clause 8. 2835 Hyett {Day64/63:23}-{Day64/64:2}. 2836 Phase 1 Report Volume IV paragraph 26.4. 2837 Hyett {Day64/65:14}-{Day64/66:23}. 2838 {MET00081282}. This email was only disclosed to the Inquiry by the MPS in May 2023. 2839 Hyett, Module 1 Report (revised) {PHYR0000029/49} paragraph 4.3.24; {PHYR0000029/93} paragraph 4.4.41.

Part 6 | Chapter 63: The contribution of Studio E 269 63.12 We have described in Chapter 56 how FR5000 came to be included in the NBS Specification and non-combustible insulation was ruled out. Mr Sounes accepted Max Fordham’s suggestion that they should aim for a U-value of 0.15 W/m2K, but neither he nor anyone else at Studio E gave any independent thought to whether an alternative solution was available or to whether the proposed U-value was acceptable if it could be achieved only by using combustible insulation. 63.13 As lead designer, Studio E was responsible for deciding what U-value could reasonably be achieved and how, and Mr Sounes was at fault in failing to recognise that. Max Fordham provided him with technical data relating to Celotex FR5000 by way of an example in order to assist his calculations; it was inappropriate for him to treat that as advice from Max Fordham to use FR5000. It was even more inappropriate to accept it uncritically without taking steps to understand the nature of the product and satisfying himself of its suitability. That was a serious error on the part of Mr Sounes. 63.14 Similarly, Mr Sounes did not take any steps to ensure that the rainscreen panels proposed for the cladding were consistent with the guidance in Approved Document B or were likely to meet the functional requirements of the Building Regulations. He appears to have been content to include ACM PE panels in the NBS specification (albeit as an alternative) for aesthetic reasons and because he knew they had been used on other projects,2840 rather than in reliance on any detailed information he had obtained about the nature of the product based on the manufacturer’s literature or the certificate of a recognised certifying body.2841 63.15 When he was first considering options for the cladding panels, Mr Sounes did not address his mind to fire performance.2842 He did not consider whether any of the panels he had in mind were consistent with the guidance in Approved Document B and although he did propose some panels that had a fire-resistant core2843 or were non-combustible,2844 that was coincidental and did not reflect a judgment based on information he had obtained about their reaction to fire.2845 Unfortunately, Mr Sounes was not aware that ACM panels could be produced with different cores.2846 63.16 The production of the NBS Specification, which identified the materials to be used in the facade, was left to junior assistants at Studio E, mainly Tomas Rek and before him Adrian Jess.2847 Bruce Sounes told us that only some of the initial draft of the specification had been discussed with him and that he had trusted them to complete it without reference to him,2848 but neither of them appears to have given any consideration to the suitability of the materials intended for use in the external wall. As the architect responsible for the project Mr Sounes should have supervised their work. In particular, he should have satisfied himself that they had properly investigated the suitability of any materials or products they had included in the specification or, if they had not, should have satisfied himself independently that they were suitable. In fact, no further consideration of the materials was undertaken after they had been included in the specification and his failure to do either of those things was a significant error.2849 2840 Sounes {Day7/170:2-5}; Sounes {SEA00014273/140} page 140, paragraph 343; Sounes {Day20/93:12}-{Day20/95:14}. 2841 Sounes {Day20/135:1-7}. 2842 Sounes {Day20/83:8-12}; Geof Blades did not recall the content of the conversation – see Blades {Day41/85:3-7}. 2843 {SEA00005320}; {SEA00005330}. This panel was not ultimately selected for inclusion in the NBS Specification. 2844 {SEA00014616/41} paragraph 1.2. 2845 Sounes {Day20/89:20-25}. 2846 Sounes {Day20/176:17-24}. 2847 Sounes {Day7/151:7}-{Day7/152: 3}. 2848 Sounes {Day7/152:4-8}. 2849 Hyett {Day64/69:6-18}; {Day64/72:21}-{Day64/73:15}; {Day64/76:14}-{Day64/77:5}; {Day64/123:23}-{Day64/124:25}.

The Grenfell Tower Inquiry: Phase 2 Report 270 63.17 Studio E produced three versions of the NBS Specification, one on 21 November 2013,2850 one on 29 November 20132851 and one on 30 January 2014.2852 Mr Sounes confirmed that no one at Studio E had satisfied themselves before they were drawn up that the materials referred to in any of those versions would ensure compliance with the Building Regulations.2853 That was a fundamental failing on the part of Studio E which had significant consequences. Mr Sounes sought to explain that omission by telling us that Studio E would not usually expect to verify compliance of all materials and products before submitting a full plans application to building control,2854 and that to do so would be wasted work if the contractor subsequently made a change.2855 He also suggested that building control might take a different view of the proposals and that it was not common practice to carry out a full assessment of compliance with the functional requirements of Part B of Schedule 1 at RIBA stages D or E.2856 63.18 Mr Sounes was wrong in his understanding. Under its contract with the TMO, it was Studio E’s responsibility to ensure that the materials included in the NBS Specification complied with the Building Regulations.2857 We accept Mr Hyett’s evidence that if an architect specifies a particular product to be used, he assumes responsibility for making sure that its use is compatible with the functional requirements in the Building Regulations.2858 Tomas Rek and Neil Crawford assumed that Mr Sounes had satisfied himself that the products and materials included in the specification were suitable, but neither of them took steps to verify that assumption or to satisfy themselves independently that they were. When he handed the project over to Mr Crawford, Bruce Sounes did not warn him that he had not carried out any investigation into the materials to be used in the cladding to satisfy himself that they were suitable.2859 In failing to satisfy itself that the materials specified would enable the refurbished building to comply with the Building Regulations, Studio E, and particular Mr Sounes, Mr Crawford and Mr Rek, fell seriously below the standard to be expected of persons in their positions. 63.19 Mr Sounes sought to justify the choice of materials by asserting that Studio E had asked for advice about them and that it was not for Studio E to satisfy itself that the products were suitable because it did not have the ability to do so.2860 We do not accept that. We saw no evidence that Mr Sounes had asked any specialist for advice or that he had received any advice that would satisfy a reasonably competent architect that the products specified in the proposed application were suitable for the purpose and would not result in the refurbished building contravening the Building Regulations. 63.20 Mr Sounes himself did not consider whether the proposed use of Celotex FR5000 above 18 metres met the guidance in Approved Document B or would result in the external wall’s complying with functional requirement B4(1). He did not ask Max Fordham that 2850 {SEA00000152}. 2851 {SEA00000153}. This version was issued to tenderers. 2852 {SEA00000169}. 2853 Sounes {Day7/170:2-5}; {Day20/173:12-24}; Rek {Day12/20:15-20}; {Day12/22:25}-{Day12/23:2}; {Day12/24:16-21}, {Day12/27:7-21}. 2854 Sounes {SEA00014273/121} page 121, paragraph 292. 2855 Sounes {Day20/64:21}-{Day20/65:7}. 2856 Sounes {Day20/65:1-3}. 2857 Appendix B: Schedule of Services {SEA00009824/7}: “co-ordinating design of all constructional elements, including work by consultants, specialists or suppliers” and “determining materials, elements and components, standards of workmanship, type of construction and performance in use”. 2858 Hyett {Day64/69:6-18}; {Day64/72:21}-{Day64/73:15}; {Day64/76:14}-{Day64/77:5}; {Day64/123:23}-{Day64/124:25}. 2859 Rek {Day12/44:22}-{Day12/45:1}; Crawford {Day9/139:14}-{Day9/140:13}; {Day9/146:4-6}. 2860 Sounes {Day7/170:21}-{Day7/171:4}.

Part 6 | Chapter 63: The contribution of Studio E 271 question2861 nor did he seek any advice from Exova about it.2862 Nor did anyone else at Studio E discuss the matter with Exova. Similarly, Mr Sounes did not investigate whether any of the various alternative rainscreen products proposed in the NBS Specification were suitable, including the ACM panels which were included as an alternative to zinc.2863 Although he said that he had carried out research and had consulted others, including Exova,2864 he was not able to point to any particular advice he had received,2865 and at no point did he ask Exova to comment on the suitability of any of the rainscreen products included in the NBS Specification. 63.21 Industry guidance was available at the time which contained warnings about the dangers associated with the use of certain kinds of rainscreen panels. In particular, the Standard for Systemised Building Envelopes, Part 6, published by the Centre for Window and Cladding Technology (CWCT), which was incorporated into the NBS Specification,2866 contained important information on the fire performance of materials to be used in the external envelope of a building and specific guidance on aluminium envelope systems to include composite components as well as insulation materials.2867 However, no one at Studio E was familiar with the CWCT standard or had even read it2868 and no one troubled to check it at the time. Similarly, it failed to consider the warnings about use of combustible materials in cladding systems contained in BR 135, even though the publication had been included in the structural engineer’s specification.2869 As a result, Studio E specified products that did not reflect any of that guidance. 63.22 The fact is that Mr Sounes simply assumed that all the cladding panels included in the NBS Specification were suitable for the refurbishment because they had been used on other projects.2870 In its opening statement Studio E sought to justify the use of ACM material and PIR insulation by reference to their frequency of use by others on previous projects,2871 but we do not accept that. Relying on what others have done in the past is not good enough when the practice in question affects people’s safety, is inconsistent with industry guidance and, most importantly, does not withstand rational scrutiny. 63.23 Mr Sounes was the lead designer responsible for the project at the time the NBS Specification was compiled. It was therefore his responsibility to ensure that the materials specified in it were consistent with the requirements of the Building Regulations. He failed to do so. He also failed to make it clear to the TMO, Rydon and Harley that Studio E had not taken steps to satisfy itself by reference to testing or other data that the materials included in the specification would result in an external wall that complied with the regulations. He was at fault in not doing so. 2861 Sounes {Day20/42:6-11}. 2862 Sounes {Day20/42:12}-{Day20/43:6}. 2863 Sounes {Day20/173:12-24}. 2864 Sounes {SEA00014273/140) page 140, paragraph 343.2. 2865 Sounes {Day8/57:2}-{Day8/58:6}. 2866 {SEA00000169/69} Clauses 310 and 342. 2867 {CWCT0000046}. 2868 Rek {Day12/19:14-18}; {Day12/34:14-17}; {Day12/39:1-16}; Crawford {Day9/146:15-17}; Sounes {Day7/164:14-18}. 2869 Crawford {Day10/69:8}-{Day10/70:5}; {CCL00001449/11} paragraph 7.1.13. 2870 Sounes {Day7/170:2-5}; Sounes {SEA00014273/140} page 140, paragraph 343; Sounes {Day20/93:12}-{Day20/95:14, {Day20/68:5-14}. 2871 Studio E’s Opening Submissions {SEA00014642/16-17} paragraph 8.16; {SEA00014262/24} paragraph 10.11; {SEA00014262/36} paragraph 15.17.

The Grenfell Tower Inquiry: Phase 2 Report 272 63.24 Studio E failed to devise a proper cavity barrier strategy for the overcladding system, which led to ever-increasing confusion as the project developed.2872 The cavity barrier strategy should have been established by the time the tender documents were published.2873 The strategy produced by Studio E was seriously deficient in failing to include a cavity barrier at the window sill.2874 In addition, the drawings did not place the cavity barrier above the window close enough to the head of the window,2875 there were no cavity barriers included in the bay elevations and none of the elevation drawings of the complete facade were marked to show the presence of cavity barriers.2876 No cavity barriers had been included at the junction of the cladding and the crown.2877 Those errors indicate that no one at Studio E had given any clear thought during the preparation of the tender documents to the strategy for dividing the cavities behind the rainscreen into fireproof compartments. 63.25 On the basis of Mr Hyett’s evidence we are satisfied that at tender stage Studio E should have produced drawings showing all vertical and horizontal cavity barriers for all bay and column conditions for all four facade elevations at 1:20 scale and at 1:5 scale for details around the windows where they abutted the columns.2878 We accept his criticism that Studio E should have identified the clash between the brackets and supporting angles and sought to resolve it.2879 63.26 We do not accept that the design of a cavity barrier strategy could be left entirely to Harley as the cladding sub-contractor. It was Studio E’s responsibility to explore and resolve the strategy at tender stage in order that the details subsequently produced by Harley were properly based.2880 Consultation with Exova 63.27 Although Exova became involved in the project at an early stage, Studio E’s interest in obtaining its advice was directed mainly to the work involved in creating new dwellings in the lowest floors of Grenfell Tower. In April 2012 Bruce Sounes sent Exova information about the refurbishment, including some architectural drawings, and later that month a representative of Exova attended a design team meeting at which the overcladding was discussed. However, Studio E did not consult Exova about that aspect of the project and did not keep it informed of progress generally.2881 Most importantly, Studio E failed to take a close interest in Exova’s work on the Outline Fire Safety Strategy, which, as we have noted elsewhere, remained materially incomplete in the absence of advice on the fire safety of the proposed overcladding and its effect on functional requirement B4. 2872 Hyett, Module 1 Report (revised) {PHYR0000029/66} paragraph 4.3.69 and {PHYR0000029/76} paragraphs 4.3.83 to 4.3.86. 2873 Hyett, Module 1 Report (revised) {PHYR0000029/64} paragraph 4.3.63 and {PHYR0000029/76} paragraph 4.3.86. 2874 Hyett, Module 1 Report (revised) {PHYR0000029/65} paragraph 4.3.68; {SEA00002499}; {PHYR0000029/76} paragraph 4.3.83. 2875 Hyett, Module 1 Report (revised) {PHYR0000028/62} paragraph 3.8.12.; Figure 3.30 and 3.29 produced by reference to {HAR00003958}. 2876 Hyett, Module 1 Report (revised) {PHYR0000029/66-67} paragraph 4.3.69; figure 4.50. 2877 Hyett, Module 1 Report (revised) {PHYR0000029/75} paragraph 4.3.81; {SEA00002551}. 2878 Hyett, Module 1 Report (revised) {PHYR0000029/68} paragraphs 4.3.71-4.3.72; {SEA00002499}; {SEA00010474}; {PHYR0000029/76} paragraph 4.3.85; {SEA00002551}. 2879 Hyett, Module 1 Report (revised) {PHYR0000029/69} paragraph 4.3.73; {PHYR0000029/71} paragraph 4.3.77-4.3.78; {PHYR0000029/76} paragraph 4.3.86. 2880 Hyett, Module 1 Report (revised) {PHYR0000028/63} paragraph 3.18.13; See also {SEA00009824/7} under the subheading “Designers, including Lead Designer”. Studio E had responsibility for: determining materials, elements and components, standards of workmanship, type of construction and performance in use for the design. 2881 See, for example, the failure to send the Stage D report. Hyett {Day64/205:5-12}.

Part 6 | Chapter 63: The contribution of Studio E 273 Studio E did not notice the absence from the strategy of any reference to the cladding.2882 More significantly, at no stage did Mr Sounes ask Exova to clarify its advice on functional requirement B4,2883 although he accepted that the implications of the overcladding for the spread of fire over the external walls of the building had never been discussed in writing by Exova or any other fire consultant.2884 He did not discuss it with Terrence Ashton because he did not regard it as a matter of concern.2885 Although Bruce Sounes originally expected Exova to complete its advice in a future version of the Outline Fire Safety Strategy,2886 he ought to have pressed for it to be completed when version 3 was issued just before the tender documents were published and it was clear that part of it remained outstanding.2887 However, he failed to do so. He thought it was the responsibility of the design and build contractor to ensure that the advice was completed,2888 but he failed to warn the TMO or Rydon that Exova’s work had not been finished. 63.28 Studio E was reassured generally by the fact that Exova had been instructed on the project, even though it did not provide Exova with the full range of information that would have enabled it to provide proper advice and did not question the limited advice that it did receive.2889 For example, Neil Crawford said that he had felt confident about the choice of insulation and the design of the cavity barriers because he had understood that Exova had a wealth of knowledge of similar projects.2890 However, he had no idea on what basis Exova might have concluded that the design of the external wall complied with the Building Regulations.2891 Design errors following the novation to Rydon 63.29 As had been envisaged at the outset,2892 Studio E’s services were eventually transferred to Rydon following its appointment as principal contractor for the refurbishment. Although proposals relating to a formal contract were exchanged in April 2014, it was not until nearly two years later that the relationship between them was eventually encapsulated in a deed dated 3 February 2016. No satisfactory explanation for the delay was put forward, although Neil Crawford said that it was not unusual for projects to run to the end with no formal contract in existence.2893 This seems to us to be another example of a cavalier attitude to formalities which appears to have been shared by many of those involved in the project and which is liable to lead to a failure to understand where responsibilities lie. 63.30 Under the deed Studio E warranted that it had exercised and would continue to exercise reasonable skill, care and diligence in the discharge of the services covered by the deed to the standard reasonably to be expected of a competent professional experienced in the provision of professional services for works similar in size, scope, complexity, quality and nature to the development.2894 The language thus made it clear that the undertaking covered all the work on the refurbishment that Studio E had done for Rydon in the past, as 2882 Sounes {Day8/65:5}-{Day8/66:5} (version 1 OFSS); {Day8/68:19}-{Day8/69:3} (version 2 OFSS); {Day12/149:13-24} (version 3 OFSS). 2883 Sounes {Day8/51:6-24}; {Day8/69:18-24}. 2884 Sounes {Day12/155:25}-{Day12/156:6}. 2885 Sounes {Day8/53:17-21}. 2886 Sounes {Day8/52:12-15}. 2887 Ashton {Day17/48:5-17}. 2888 Sounes {Day12/157:6}-{Day12/158:20}. 2889 Sounes {SEA00014273/140} page 140, paragraph 343.2. 2890 Crawford {Day9/177:6-11}. 2891 Crawford {Day9/177:3-5}. 2892 See Chapter 52. 2893 Crawford {Day9/68:18-19}. 2894 {RYD00094228/3} Clause 2.3.

The Grenfell Tower Inquiry: Phase 2 Report 274 well as any that it might do for it in the future.2895 Studio E also undertook to seek to ensure that all aspects of the architectural designs complied with the Employer’s Requirements,2896 and that all designs complied with the relevant statutory requirements.2897 It also agreed to co-ordinate any design work done by consultants, specialist contractors, subcontractors and suppliers2898 and to be responsible for co-ordinating the steps needed to obtain building control approval.2899 63.31 We think it clear that the deed imposed an obligation on Studio E to take reasonable steps to ensure that all designs, whether produced by itself or sub-contractors, complied with the relevant statutory requirements, including the Building Regulations 2010. That would include identifying any obvious instances of non-compliance with the Building Regulations and the associated statutory guidance, including Approved Document B, in any drawings which were provided to Studio E for review. However, Bruce Sounes did not think that Studio E had any obligation to check the work of Rydon’s subcontractors to ensure that it complied with the Building Regulations.2900 He thought that specialist sub-contractors were responsible for the design element of their work and were themselves responsible for ensuring that it complied with any statutory requirements. In his view, building control was primarily responsible for confirming compliance.2901 Neil Crawford’s understanding was fundamentally the same.2902 They appear to have had their own understanding of the obligations being assumed by Studio E, which did not bear much relationship to the language used in the document. Rainscreen panels 63.32 Bruce Sounes received a copy of the BBA certificate for the Reynobond ACM panels in April 20142903 but failed to read it in full carefully.2904 He thought that Rydon had taken over responsibility for the design and that it was not his function to assess the suitability of any material that might be used.2905 Mr Crawford, who came into the project in the summer of 2014, thought it unlikely that he had looked at the BBA certificate.2906 63.33 Although Mr Hyett did not think that the dangers posed by ACM PE panels were well known to architects generally at that time, he was nonetheless critical of Studio E’s failure to investigate their fire performance. In his report Mr Hyett said that he considered it reasonable for an architect reading just the first page of the BBA certificate relating to Reynobond to conclude that the product was rated Class 0 and so met the guidance given in paragraph 12.6 and diagram 40 of Approved Document B. He said that he did not consider that an architect could be criticised for taking the statement on the front of the certificate at face value and not going on to read section 6, which contained further 2895 And see also {RYD00094228/3} Clause 2.1 which provided that Studio E “has and will continue to perform for [Rydon] the Services in respect of the development”; Bruce Sounes understood the time that the obligation had retrospective effect: Sounes {Day7/102:15}-{Day7/103:5}. 2896 {RYD00094228/9} Item 4. Bruce Sounes confirmed that he understood at the time that that was Studio E’s obligation to Rydon: Sounes {Day7/105:6-25}; Neil Crawford said that in February 2016 he had not known that Studio E was under that obligation to Rydon: Crawford {Day9/53:4-10}; {Day9/60:15}-{Day9/61:3}. 2897 {RYD00094228/9}; Both Bruce Sounes and Neil Crawford understood that that ‘statutory requirements’ included the Building Regulations and the CDM Regulations: Sounes {Day7/107:8-16}; Crawford {Day9/62:8-13}. 2898 {RYD00094228/10} Item 13. 2899 {RYD00094228/9} Item 7. 2900 Sounes {Day7/112:15}-{Day7/113:8}. 2901 Sounes {Day7/124:4-11}. 2902 Crawford {Day9/62:20-24}; {Day9/70:25}-{Day9/71:5}; {Day9/63:7-12}; {Day9/71:20}-{Day9/72:5}. 2903 Sounes {SEA00014273/153} page 153, paragraph 377; {SEA00002686}. 2904 Sounes {Day21/12:5-7}; {Day21/13:1-3}. 2905 Sounes {Day21/16:22}-{Day21/18:12}. 2906 Crawford {Day10/149:22}-{Day10/150:13}.

Part 6 | Chapter 63: The contribution of Studio E 275 information about the product’s behaviour in relation to fire.2907 Mr Hyett noted, however, that the certificate related to only one colour sample and warned that other colours might not have met the same standard.2908 63.34 In the course of giving evidence, however, Mr Hyett changed his opinion. Having been asked to give further consideration to the contents and structure of the BBA certificate, he accepted that the first page was directing the reader to the various sections containing more detailed information on different characteristics. He agreed that it was directing the reader to section 6 for information about the product’s behaviour in relation to fire and that a reasonably competent architect would not read the statements on the first page in isolation from the rest of the document.2909 He thought that a reasonably competent architect would conclude from section 6.4 of the certificate that the panels used at Grenfell Tower were not covered by the certificate because they were not the same colour or finish as those described in the certificate.2910 In those circumstances he was of the view that the architect ought to have investigated the fire performance of the panels with the manufacturer.2911 He was also of the opinion that a reasonably competent architect ought to have understood from reading the BBA certificate that the product was available in a fire retardant version,2912 which should have prompted him to ask for advice about the difference between the two versions of the product and whether the use of the fire retardant version would be more appropriate.2913 63.35 We do not find Hr Hyett’s change of heart surprising, because a formal document such as a BBA certificate is designed to be read as a whole. There would be no point in including the information contained in the later sections if it were not of potential importance to the reader. We accept Mr Hyett’s opinion that once Studio E had become aware in or around March 2014 of the plan to substitute the Reynobond 55 PE for the zinc rainscreen panel originally specified,2914 it ought to have conducted an urgent investigation into its characteristics in order to satisfy itself that the external wall as a whole would comply with the requirements of the Building Regulations.2915 Studio E as lead designer was responsible for satisfying itself that the product was suitable for use and for obtaining advice from Exova if it was in any doubt.2916 We consider that in failing to do so Studio E fell seriously below the standard of a reasonably competent architect. Mr Sounes appears to have thought that, in relation to a project being carried out under a design and build contract, the architect, having become a consultant engaged by the contractor, had no responsibility for overseeing what others were doing.2917 That was wrong, however, because after its services had been transferred from the TMO to Rydon Studio E remained responsible for ensuring the suitability of the proposed cladding panels.2918 2907 Hyett, Module 1 Report (revised) {PHYR0000029/97} paragraph 4.4.55; {PHYR0000029/106} paragraph 4.4.88; {PHYR0000029/106} paragraph 4.4.90; Hyett {Day64/137:15}-{Day64/138:23}; {Day64/144:5-13}; {Day64/145:9-14}; {Day64/148:8-16}. 2908 Hyett, Module 1 Report (revised) {PHYR0000029/57} paragraph 4.3.35(a); {PHYR0000029/96} paragraph 4.4.51 and 4.4.54; {PHYR0000029/99} paragraph 4.4.59. 2909 Hyett {Day64/149:2}-{Day64/150:7}; {Day64/151:8-15}; {Day64/160:1-6}. 2910 Hyett {Day64/157:4-17}. 2911 Hyett {Day64/157:18}-{Day64/158:3}. 2912 Hyett {Day64/158:5}-{Day64/159:18}. 2913 Hyett {Day64/159:20}-{Day64/160:6}. 2914 Chapter 55. 2915 Hyett, Module 1 Report (revised) {PHYR0000029/94} paragraph 4.4.45. 2916 Hyett {Day64/128:25}-{Day64/130:5}; {Day64/130:15}-{Day64/131:9}. 2917 Sounes {Day20/71:3-14}. 2918 {RYD00094228/9} item 8 and {RYD00094228/10} item 13.

The Grenfell Tower Inquiry: Phase 2 Report 276 63.36 Mr Sounes and Mr Crawford should have read the BBA certificate in full carefully. It was a short document and plainly an important one. Even though by that time Studio E’s services had been transferred to Rydon, it remained under an obligation to exercise reasonable skill, care and diligence in the discharge of its services,2919 which included seeking to ensure that all designs complied with the relevant statutory requirements.2920 We were troubled by Mr Sounes’ practice of not reading the whole of the BBA certificate for any product he was planning to recommend for a project. His failure to do so fell very far below the standard of a reasonably competent architect. Checking Harley’s designs 63.37 Studio E told us that the cladding had been designed by Harley and that as specialist cladding sub-contractor it had assumed responsibility for all aspects of the design.2921 Bruce Sounes said that he did not expect Studio E to be required to check that Harley’s drawings were consistent with any legislative requirements,2922 since that was not a role it had agreed to undertake in relation to the project.2923 Neil Crawford’s understanding was the same.2924 They were both wrong about that, however, because they failed to pay attention to the obligations Studio E had assumed to the TMO and misunderstood the effect of the novation to Rydon. 63.38 Following the novation to Rydon, Studio E remained responsible for the design work it had already carried out for the TMO and became responsible for any further work it was required to carry out under the terms of its contract with Rydon.2925 Studio E’s design work before novation was not confined to matters of aesthetic intent or appearance and Harley clearly assumed that Studio E had satisfied itself that the tender drawings and specifications were consistent with the relevant statutory requirements and guidance. 63.39 It is clear that Studio E took an unduly narrow view of its responsibilities after the novation. Neil Crawford maintained throughout that Studio E was only responsible for checking Harley’s drawings and specifications for “architectural intent”, by which he meant conformity with the preliminary design only.2926 His understanding was inconsistent, however, with the terms of its contract with Rydon, which included seeking to ensure that all designs complied with the relevant statutory requirements.2927 Studio E’s role in relation to Harley’s work does not appear to have been the subject of any discussion with Rydon, which also appears to have assumed that Harley could be left to take responsibility for such matters. Neither Rydon nor Studio E appears to have understood properly the scope of their individual responsibilities. 63.40 Such a failure to understand the scope of its obligations might, perhaps, have been explicable if the terms on which Studio E had been engaged were unusual, but there is no reason to think that they were, since they were based on standard RIBA terms. Mr Hyett’s understanding was that when an architect stamps a sub-contractor’s drawing as complying with architectural intent it amounts to confirmation that the drawing demonstrates a proper understanding, interpretation and application of the architectural specification. 2919 {RYD00094228/3} clause 2.3. 2920 {RYD00094228/9} item 8 and {RYD00094228/10} item 13. 2921 Studio E’s written Opening Submissions {SEA00014642/3} paragraph 3.1.5(c). 2922 Sounes {Day7/131:21}-{Day7/132:5}. 2923 Sounes {Day7/113:9-17}; {Day7/122:5-18}; {Day7/123:2-8}; {Day7/125:9-11}. 2924 Crawford {Day9/62:20-24}; {Day9/70:25}-{Day9/71:1-5}; {Day9/63:7-12}; {Day9/71:20-25}; {Day9/72:1-5}. 2925 {RYD00094228/3} paragraphs 2.2 and 2.3. 2926 Studio E’s Opening Submissions {SEA00014642/31} paragraph 13.6; Crawford {SEA00014275/17-18} pages 17-18, paragraphs 41-42; Crawford {Day9/20:11-19}. 2927 {RYD00094228/9} items 4, 5 and 8.

Part 6 | Chapter 63: The contribution of Studio E 277 He considered that Studio E had an obligation to assess Harley’s designs for compliance with the employer’s requirements and the applicable statutory requirements.2928 In the light of his evidence we think that if Studio E’s work in relation to Harley’s designs was intended to be as narrow in scope as has been suggested, that would have been formally recorded in some way.2929 Insulation 63.41 As set out at Chapter 56, Harley substituted Celotex RS5000 for the Celotex FR5000 specified by Studio E in the NBS Specification without reference to Studio E, although a copy of the datasheet for RS5000 was sent to Neil Crawford on 18 September 2014 in connection with a question about cavity barriers and insulation.2930 63.42 Once Studio E had been made aware of the substitution, it had an obligation to satisfy itself that the use of RS5000 was consistent with the Building Regulations and approved guidance. (Since its use was not consistent with the approved guidance, Studio E should have drawn that to the attention of Rydon.)2931 That could have involved asking Exova to comment on the characteristics of RS50002932 or itself examining the suitability of RS5000 by a careful reading of the product literature.2933 We agree with Mr Hyett that Studio E would not have performed its obligations to Rydon merely by relying on Harley to check the characteristics of RS5000 when the substitution was made. In fact, Mr Crawford took it on trust that, if Harley thought RS5000 was suitable, he did not need to investigate further.2934 It was a serious omission on Mr Crawford’s part not to have made any independent assessment of RS5000 after he had been told that Harley intended to use it. 63.43 If Mr Crawford had looked into the characteristics of RS5000 he would have realised that the external wall system described in the Celotex Rainscreen Cladding Compliance Guide and the product datasheet for RS5000 was not the same as that which had been designed for Grenfell Tower.2935 He would, or certainly should, therefore have realised that RS5000 was not generally suitable for use on buildings over 18 metres in height and should not have been proposed for use in the refurbishment. The failure to investigate the characteristics of RS5000 was another serious failing on Mr Crawford’s part. 63.44 Mr Crawford also failed to notice that Harley’s specification did not identify the insulation to be used in the construction of the external wall.2936 Despite that omission, Mr Crawford stamped the specification as conforming to design intent when it did not.2937 Cavity barriers 63.45 Studio E’s failure to provide a comprehensive cavity barrier strategy at tender stage was carried through into Harley’s design. Most significantly, three of Harley’s typical bay drawings did not include cavity barriers around the window openings, contrary to the 2928 Hyett Supplemental Report {PHYS0000002/30} paragraph 2.3.21; Hyett {Day64/16:4}-{Day64/17:14}; Hyett, Module 1 report (revised) {PHYR0000029/141} paragraph 4.4.154; Hyett {Day64/19:13}-{Day64/20:13}; {Day64/26:11}-{Day64/28:9}; {Day64/29:2-10}; {Day64/25:2-9}; {Day64/27:18}-{Day64/28:2}. 2929 Hyett {Day64/24:9}-{Day64/26:8}; {RYD00094228/9} item 8. 2930 {HAR00012103}; {HAR00012104}. 2931 Hyett {Day64/183:23}-{Day64/184:3}; {Day64/204:13}-{Day64/205:4}; {Day65/17:12}-{Day65/19:20}. 2932 Hyett {Day64/204:25}-{Day64/205:4}. 2933 {RYD00094228/9}. 2934 Crawford {Day10/48:5-9}. 2935 Hyett {Day65/4:11-24}; {CEL00000416/3}; Hyett {Day65/6:3}-{Day65/7:1}; {Day65/7:3}-{Day65/9:14}; {Day65/14:9}-{Day65/15:18}; {Day65/19:9-23}; {Day65/22:1}-{Day65/24:19}. 2936 {HAR00003866}; {HAR00003869/1}; {HAR00017762}; {HAR00003955}; {RYD00046822/1}. 2937 {RYD00046822/1}; Hyett, Module 1 Report (revised) {PHYR0000029/89} paragraph 4.4.29.

The Grenfell Tower Inquiry: Phase 2 Report 278 guidance in Approved Document B. Studio E failed to notice that omission. Neil Crawford’s own view was that it was not possible to place cavity barriers around the windows2938 but Mr Hyett’s indicative scheme demonstrates that it was.2939 Studio E also failed to identify the fact that Harley had not provided for cavity barriers at the window head and sill level.2940 Ultimately, therefore, Studio E failed to recognise that the arrangement shown on Harley’s drawings would not inhibit the passage of fire around the windows in a way that complied with Approved Document B.2941 63.46 Harley’s construction drawings that were endorsed by Studio E were deeply flawed. Once fire was present within a cavity zone it could move freely up the sides of the windows and within the adjoining columns.2942 We agree with Mr Hyett that Studio E’s failure adequately to review Harley’s drawings flowed from a lack of technical knowledge and experience, exacerbated by the lack of a basic scheme design, which should have been completed at tender stage, against which Harley’s work could have been competently checked.2943 63.47 Studio E’s lack of technical knowledge and experience in respect of cavity barriers is evident from Neil Crawford’s approach to Harley’s request for information in September 2014.2944 Harley asked for confirmation from Rydon, through Studio E, on the placing of cavity barriers.2945 Mr Crawford sent the request on to Exova asking for advice. We agree with Mr Hyett that questions of that kind should have been resolved by Studio E much earlier, but at that point the parties were only starting to establish the basic approach.2946 It is clear from the email correspondence between Terence Ashton, Neil Crawford and Daniel Anketell-Jones that Mr Crawford abrogated responsibility for answering Harley’s questions about cavity barriers.2947 He simply passed information between Exova and Harley without becoming directly involved. For reasons we have already explained, it was quite wrong for Studio E to take the view that Harley alone was responsible for formulating the cavity barrier strategy. 63.48 Studio E also failed to notice that materials specified by Harley, including Styrofoam in the P1 window infill panel and Kingspan TP10 in the P2 panel, were not suitable for use in their intended applications.2948 Despite that, Mr Crawford accepted the specification without commenting on the choice of those materials.2949 We reject Mr Crawford’s assertion that it was not Studio E’s function to check that the designs complied with the statutory requirements.2950 Its contract with Rydon provided otherwise and we agree with Mr Hyett that Studio E should have noticed that unsuitable insulation products had been specified by Harley and should have challenged their use.2951 63.49 Harley’s construction drawings did not specify the materials to be used at the head, jamb and sill behind the window reveals. We agree with Mr Hyett that Studio E should have ensured that they did so, or should at least have referred to the NBS Specification to make 2938 Crawford {Day10/176:4}-{Day10/177:7}. 2939 Hyett, Module 1 Report (revised) {PHYR0000028/39} paragraph 3.7.20; {PHYR0000028/40-43} figures 3.16 – 3.19 and {PHYR0000028/58-59} paragraphs 3.8.8-3.8.11. 2940 Hyett, Module 1 Report (revised) {PHYR0000029/112} paragraph 4.4.102. 2941 Hyett, Module 1 Report (revised) {PHYR0000029/115} paragraph 4.4.105. 2942 Hyett, Module 1 Report (revised) {PHYR0000029/131} paragraph 4.4.134 2943 Hyett, Module 1 Report (revised) {PHYR0000029/142} paragraph 4.4.155. 2944 See Chapter 54 See also Hyett, Module 1 Report (revised) {PHYR0000029/119} from paragraph 4.4.109. 2945 {RYD00018043}. 2946 {EXO00000708}. 2947 {EXO00000714}. 2948 See Chapter 58. 2949 Crawford {Day11/116:9-18}. 2950 Crawford {Day11/117:4}-{Day11/118:23}; {Day11/120:2-13}. 2951 Hyett, Module 1 Report (revised) {PHYR0000029/135} paragraphs 4.4.140-4.4.141

Part 6 | Chapter 63: The contribution of Studio E 279 it plain to whoever undertook the refurbishment of the window reveals that mineral wool (Rockwool) had been specified by Studio E.2952 Studio E ought to have identified that omission on Harley’s part and sought to rectify it. Communication with building control 63.50 Studio E’s contract with Rydon included responsibility for co-ordinating Building Regulation approval.2953 However, its full plans submission to RBKC building control contained drawings that were out of date or inaccurate2954 and was insufficient to demonstrate compliance with the Building Regulations.2955 Further information was sent on a piecemeal basis. No complete package was ever sent to building control with clear information about the materials that were intended to make up the facade.2956 Studio E’s failure to provide comprehensive and accurate information to building control made it difficult for RBKC to discharge its own functions under the Building Regulations.2957 Quality control and training 63.51 Studio E’s internal review processes and quality assurance systems were weak and contributed to the failures in design that we have described above. Although Mr Sounes recognised at the outset of the project that it was necessary for the firm to educate itself in what was involved in overcladding a high-rise building, no obvious attempt was made to do so.2958 A reasonably competent architect undertaking a project of that kind for the first time would have researched it both from a technical and regulatory perspective.2959 That would have included identifying and familiarising itself with any relevant regulations and guidance, including guidance published by reputable industry bodies. As far as we can see, Studio E did none of that. 63.52 Studio E had processes in place under which design work was intended to be subject to peer review, including in relation to matters of regulatory compliance,2960 but the technical and design reviews it carried out on the Grenfell Tower project fell well short of what could reasonably be expected.2961 The technical review was carried out far too late2962 and no senior technically experienced member of staff not otherwise involved in the project had any involvement in checking the designs, in particular for compliance with the Building Regulations.2963 2952 {HAR00008469}; {HAR00008470}; {HAR00008880}; Hyett, Module 1 Report (revised) {PHYR0000029/139} paragraph 4.4.145; {PHYR0000029/141} paragraph 4.4.149. 2953 {RYD00094228/9}. 2954 See Chapter 62, see also Hyett, Module 1 Report (revised) {PHYR0000030/60-64} paragraphs 5.4.29-5.4.34. 2955 Menzies Module 1 Report {BMER0000004/9} paragraph 37. 2956 Menzies {Day60/137:9}-{Day60/138:10}. 2957 Hyett, Module 1 Report (revised) {PHYR0000030/64} paragraph 5.4.34. 2958 {SEA00003567}. 2959 Hyett, Module 1 Report (revised) {PHYR0000027/17} paragraph 2.5.14 and paragraph 2.5.12(b); Hyett {Day63/80:5‑18}; {Day63/82:7}-{Day63/84:10}. 2960 Kuszell {SEA00014271/7} page 7, paragraph 24.2; Kuszell {Day6/119:7-18}; Sounes {SEA00014273/62} page 62, paragraph 130. 2961 Hyett, Module 1 Report (revised) {PHYR0000031/33-38} paragraphs 6.7.10-6.7.15 and 6.8.6. 2962 Only one technical review was carried out by Studio E, on 28 October 2015. That was more than a year after it had submitted the full plans application to RBKC building control and when the external facade works were 60% complete – {RYD00014378}; {SEA00013508}; Hyett, Module 1 Report (revised) {PHYR0000031/33} paragraph 6.7.11. 2963 As Mr Kuszell said should have happened, usually at RIBA Stage E/F – see Kuszell {SEA00014271/7} page 17, paragraph 24.2 and Sounes {SEA00014273/62} page 62, paragraph 130.

The Grenfell Tower Inquiry: Phase 2 Report 280 “As-built” drawings 63.53 It was Studio E’s responsibility under its contract with Rydon to provide a set of “as-built” drawings at the end of the project.2964 Although Studio E did so, the “as-built” drawings did not accurately record the structure of the building. For example, they did not contain reference to the type of insulation used2965 and they inaccurately recorded that both zinc and ACM panels had been used in the cladding.2966 “As-built” drawings are part of the information that should be handed over to the building owner as part of the health and safety file2967 and are clearly an important record of the construction for future users of the building. 2964 {RYD00094228/10} item 19. 2965 {SEA00003436}. 2966 {SEA00003436}. 2967 See Chapter 61.

281 Introduction 64.1 Rydon failed in a number of important respects properly to perform its role as primary contractor for the Grenfell Tower refurbishment. It promised the TMO that when completed the refurbishment would comply with the Building Regulations, but it did not. When co-ordinating, supervising and monitoring the work it did not give sufficient importance to the safety of the building’s occupants and it displayed a casual attitude to fire safety throughout the project. As a result, Rydon bears considerable responsibility for the fire at Grenfell Tower. The nature of Rydon’s responsibilities on the project 64.2 Under its contract with the TMO Rydon was responsible for all aspects of the design and construction of the refurbishment2968 and was obliged to ensure, among other things, that when completed the building complied with the Building Regulations. That obligation existed whether the work was carried out by Rydon itself or by its sub-contractors, consultants or other specialists.2969 64.3 Although the contract contemplated that Rydon might delegate design work to specialists,2970 it remained responsible for the quality of the work carried out by those whom it engaged for that purpose. It also had an obligation to co-ordinate, integrate, supervise and monitor the work.2971 However, many people other than Rydon and the TMO were liable to be affected by work carried out by sub-contractors and consultants, not least those who would occupy the building when the refurbishment had been completed. It is of no comfort to them to be told that Rydon remains responsible to the TMO for poor design or faulty workmanship or worse, when they have to suffer the consequences. In our view, therefore, regardless of any legal obligations, Rydon should have ensured that those it appointed as sub-contractors and consultants were sufficiently qualified to undertake the work and provide the services required of them effectively. Accordingly, Rydon cannot avoid all blame simply by relying on the engagement of specialist sub-contractors and designers, such as Studio E, Harley and Exova.2972 Apart from anything else, Rydon itself had the important responsibility of overseeing their work and ensuring that it complied with the contract. 64.4 That was all the more so, given that Rydon was also the principal contractor under the CDM Regulations 2007 and 2015. Pursuant to the CDM Regulations 2007, its primary duty as principal contractor was properly to plan, manage and co-ordinate work during 2968 JCT Design and Build Contract 2011 {RYD00094235/69} clause 2.17.1.3. 2969 JCT Design and Build Contract 2011 {RYD00094235/69} clause 2.17.1.2. 2970 JCT Design and Build Contract 2011 {RYD00094235/69} clause 2.17.1.1. 2971 JCT Design and Build Contract 2011 {RYD00094235/69} clause 2.17.1.2; the Preliminaries, part 2A/44, s.A32 {TMO10041791/128} paragraph 110, which provided that Rydon was obliged to: “Accept responsibility for coordination, supervision and administration of the Works, including subcontracts”; the Preliminaries part 2A/57, s.A33 {TMO10041791/141} paragraph 630, which provided that Rydon had to establish and maintain quality control procedures, including in respect of the work of sub-contractors so that it complied with specified requirements. 2972 See, for example, Rydon’s Closing Submissions for Modules 1 & 2 at {RYD00094564/9} paragraphs 1.35-1.36. Chapter 64 The contribution of Rydon

The Grenfell Tower Inquiry: Phase 2 Report 282 the construction phase in order to ensure that health and safety risks were properly controlled.2973 That included ensuring that it was competent to deal with any health and safety problems that arose during the construction phase,2974 including risks from fire. It also included satisfying itself that the designers it engaged were competent and adequately resourced2975 and ensuring co-operation between contractors and designers and the co-ordination of their work.2976 In the event, Rydon failed to give fire safety the importance it deserved. Rydon’s expertise An inexperienced team 64.5 Rydon’s team working on the Grenfell Tower project were notably inexperienced. Simon Lawrence (contracts manager), Simon O’Connor (project manager) and Zak Maynard (commercial manager) were all acting in those capacities for the first time.2977 That was not necessarily inappropriate, but Rydon should have responded to their lack of experience by taking steps to ensure they received sufficient supervision, training and support from others with greater experience. In the event, it plainly failed to do so.2978 Although Stephen Blake said that Simon O’Connor’s promotion to project manager had been nominal, in the sense that his role on the project had been effectively that of a site manager, no attempt was made to explain that to him or to ensure that the position of site manager was filled by someone else with suitable experience.2979 64.6 Rydon’s failures in that respect contributed to a general lack of clarity about the responsibilities that its employees were expected to shoulder, a confusion that extended beyond Rydon. In many cases staff did not recognise the descriptions of themselves that Rydon had included in its tender documents. For example, Simon O’Connor was described as holding an HNC2980 in Building Studies and as being responsible for “co- ordinating design”, as “lead[ing] the on-site team in terms of design” and as “contribut[ing] technical expertise during value engineering”, but, when asked for his comments, he disagreed with each of those assertions. He did not have an HNC and had not been involved in any value engineering process on any project.2981 Stephen Blake accepted that the way in which Mr O’Connor’s qualifications and experience had been described was thoroughly misleading.2982 A lack of knowledge 64.7 Those whom Rydon employed on the project lacked even the most basic knowledge of the regulatory regime within which the refurbishment was being carried out, including the relevant statutory and industry guidance and descriptions of best practice. None of Rydon’s employees had any substantive knowledge of the Building Regulations or of the approved 2973 Regulation 22(1) of the CDM Regulations 2007 {INQ00011315/11}; Approved Code of Practice to the CDM Regulations 2007, L144 {INQ00013936/36} paragraph 146. 2974 Approved Code of Practice to the CDM Regulations 2007, L144 {INQ00013936/36} paragraph 150(b). 2975 Approved Code of Practice to the CDM Regulations 2007, L144 {INQ00013936/37} paragraph 150(h). 2976 Regulation 22(1)(i) of the CDM Regulations 2007 {INQ00011315/11}; Approved Code of Practice to the CDM Regulations 2007, L144 {INQ00013936/37} paragraph 151. 2977 Email from Stephen Blake on 9 May 2014 regarding changes of structure and promotions {RYD00004258}. 2978 O’Connor {Day26/179:15-23}; Blake {Day28/30:11}-{Day28/33:5}. 2979 Blake {Day28/31:12}-{Day28/33:5}. 2980 Higher National Certificate. 2981 O’Connor {Day26/19:2}-{Day26/22:16}. 2982 Blake {Day28/40:10-14}.

Part 6 | Chapter 64: The contribution of Rydon 283 documents that applied to the project.2983 Many of its witnesses did not even know that different kinds of rainscreen cladding panels were available, and those who did had no understanding of the ways in which the different materials reacted to fire.2984 64.8 Rydon had no, or no effective, system for ensuring that its employees received regular training during their employment. Simon Lawrence had never discussed training with his peers or supervisors and Stephen Blake conceded that he had not undertaken any continuing professional development in the period between leaving university in 1985 and the fire in 2017.2985 Rydon thus failed to take any steps to maintain or improve the competence of its employees or its awareness as a business of matters affecting fire safety. Reliance on third parties 64.9 The lack of knowledge and experience among Rydon’s own employees was such that it did not have a clear understanding of fire safety matters or any way of determining for itself whether the work of its sub-contractors satisfied basic fire safety standards, let alone the requirements of the Building Regulations. Importantly, it was in no position to know whether the right questions had been asked or to evaluate the information given to it. As far as fire safety was concerned, the evidence of Rydon’s witnesses showed that it was untroubled by either consideration and failed to consider even the simplest questions relating to the design of the facade from the point of view of fire safety. There was, for example, no discussion internally about the Building Regulations or Approved Document B, nor about which route to compliance was being followed for the cladding system, and it did nothing itself to find out whether the ACM panels proposed for use on the tower were suitable for that purpose.2986 64.10 Although Rydon was of course entitled to expect its sub-contractors to carry out their work competently and in accordance with their own contractual obligations, that did not relieve it of its responsibility to the TMO for the quality of their work, nor did it relieve it of its responsibility to co-ordinate and supervise their work. At the very least, Rydon should have been aware of all those aspects of the design that required the attention of appropriately qualified professionals so that it could satisfy itself that people with the necessary skill and training had applied their minds to them. That is what is involved in co-ordinating and supervising the design process. Rydon was not aware of any of the questions that needed to be considered as part of the design process and so failed to exercise the degree of supervision that we consider was required. 64.11 Rydon conceded that in substance it had provided the TMO with nothing more than a management service.2987 In reality, it had organised the work being carried out by a web of sub-contractors and consultants, acting as a channel of communication between the TMO and the various persons contributing to the project in their different capacities. However, it is clear that Rydon failed in number of important respects to perform even its management role properly. It was not appropriate or safe for a contractor undertaking a project on the scale of the Grenfell Tower refurbishment to conduct its business in that manner. 2983 Lawrence {Day22/71:1-4}; O’Connor {Day26/75:16-23}; Hughes {Day27/28:25}-{Day27/29:12}; Blake {Day28/63:11-13}; Martin {Day30/16:17}-{Day30/18:16}; Osgood {Day30/107:4-10}. 2984 Lawrence {Day24/21:13-23}; O’Connor {Day26/27:18-24}; Hughes {Day27/53:24} –{Day27/54:1}; Blake {Day28/48:20-24}; Osgood {Day30/141:5-7}; {Day30/184:1-3}; {Day30/185:17-24}; {Day30/188:9-11}; {Day30/115:13-15}; {Day30/141:5-7}; {Day30/110:1-6}. 2985 Lawrence {Day22/104:22-24}; Blake {Day28/41:10-15}. 2986 Blake {Day28/86:8-12}; Lawrence {Day23/179:2-7}. 2987 Blake {Day28/66:21}-{Day28/69:1}; Email from Simon Lawrence to David Brissenden on 22 April 2015 {RYD00039525/3}; Lawrence {Day22/108:10-19}.

The Grenfell Tower Inquiry: Phase 2 Report 284 Failure to investigate the competence of sub-contractors 64.12 Although Rydon relied entirely on its sub-contractors and consultants to perform its own contractual obligations to the TMO, it made no serious effort to find out whether the bodies it proposed to engage for that purpose were competent. 64.13 Studio E had been responsible for producing the outline design for the refurbishment and the NBS Specification. Although Rydon was required under its contract with the TMO to accept Studio E as lead designer and enter into a contract with it,2988 it did not attempt to assess the quality of the work that Studio E had already done.2989 Instead, it relied entirely on an assumption that Harley would take the initiative by raising any concerns it had about Studio E’s work. For its own part, Rydon never asked Harley to examine Studio E’s work on its behalf and never asked Harley directly whether it had evaluated the work Studio E had done.2990 64.14 Rydon did not become aware that Studio E had not previously undertaken a project of that kind and never had a clear understanding of, or even a desire to understand, the extent to which Studio E was conversant with the requirements of the Building Regulations or Approved Document B in so far as they applied to it.2991 If it had been aware of Studio E’s lack of experience in overcladding high-rise buildings, it is possible that Rydon would have taken more seriously the need to instruct a fire engineer to assess the safety of the external wall. 64.15 Similarly, Rydon made no specific assessment of Harley’s competence to undertake the refurbishment project, relying largely, if not solely, on the fact that it had previously employed Harley as a sub-contractor on other projects, including the Chalcots Estate and Ferrier Point projects.2992 The fire safety strategy 64.16 As principal contractor it was Rydon’s responsibility to ensure that sufficient expertise and resources were made available to the project and that the work carried out by external consultants, such as Exova, was satisfactory. In the event, Rydon’s approach to Exova, and to fire engineering generally, was alarmingly complacent. 64.17 Rydon appears to have had no interest in the use of a fire engineer on the Grenfell Tower project. It attended a contractor induction meeting on 1 April 2014, two weeks after it had been appointed as principal contractor, at which the involvement of Exova was discussed.2993 The minutes of that meeting record that Exova had completed the fire strategy at the tender stage and that the company’s services had not been transferred to Rydon but that Mr Lawrence would contact it with a view to instructing it for the future.2994 (The minutes, drafted by Artelia, were misleading because the fire strategy had not been completed at the tender stage and indeed never was completed.) Despite that commitment, however, he made no attempt to find out who was Exova’s client or what 2988 {RYD00003489/115} clause 7F. 2989 Rydon was fully responsible for the design of the works, including any design contained in the Employer’s Requirements, and for any discrepancy in or divergence between the Employer’s Requirements and/or the Contractor’s Proposals and/or any drawings, details, documents and other information submitted by him. It was also responsible for adopting and taking responsibility for any design work carried out by professional consultants at the request of the TMO {RYD00094235/69} clause 2.17.1.2; Lawrence {Day22/132:1}-{Day22/139:5}. 2990 Lawrence {Day22/133:11} – {Day22/135:5}. 2991 Lawrence {Day22/135:6}-{Day22/136:10}. 2992 Lawrence {Day23/48:17-25}. 2993 {ART00002255}. 2994 {ART00002255/4} item 5.3.

Part 6 | Chapter 64: The contribution of Rydon 285 were the terms on which it was acting.2995 He had no discussions with the TMO, Studio E or Artelia about the role that Exova might play in the future of the project.2996 He repeated his assurance that he would contact Exova at several subsequent site meetings, but failed to take any action in respect of it. 64.18 Mr Lawrence explained to Bruce Sounes in March or April 2014 that Rydon did not normally appoint fire engineering consultants on the assumption that the safety of the design had been established before it had been appointed and was not its responsibility.2997 In his view, it was the responsibility of building control to identify any defects in the design.2998 64.19 Simon Lawrence said that Rydon had considered asking Exova to advise on the alterations to the lower four floors of the tower between April and October 2014,2999 but there is no contemporaneous evidence that it considered using Exova or any other fire engineer for that purpose.3000 We do not think that Rydon gave any genuine consideration to seeking the advice of a fire engineer in respect of the lower four floors, or indeed at all. 64.20 In the event, Rydon took a positive decision not to appoint a fire engineer, probably because it did not think that it needed to do so in order to protect its own interests. The decision was taken without consulting the TMO, Studio E, Harley or any other party that might have had an interest in receiving fire safety advice.3001 Indeed, there is nothing in the contemporaneous evidence to indicate that Rydon told anyone that it had made a decision of that kind. Simon Lawrence professed not to know whether Rydon had told the TMO or Studio E that it was no longer considering the appointment of a fire engineer,3002 but the complete absence of any indication that it did so suggests strongly that it did not. Rydon should have appreciated that it was ill-equipped to make an informed judgement about the need for fire engineering advice and should therefore have consulted the TMO (its client) and Studio E (its principal designer) before making any decision. 64.21 To the extent that Rydon investigated the quality of Exova’s work at all, its actions were cursory and superficial. Rydon received Issue 3 of Exova’s Outline Fire Safety Strategy as part of the tender documents3003 and accepted that it contained the fire safety strategy underpinning the design work that had been carried out before its appointment.3004 Nonetheless, it did not ask Studio E whether Exova’s work had been sufficient for its purposes and did not attempt to familiarise itself with the terms on which Exova had been appointed.3005 It does not appear to have occurred to Rydon that the title of the Outline Fire Safety Strategy itself suggested that it might not be in final form.3006 Each of those was a serious failure on the part of Rydon. 64.22 Rydon’s evidence was that it believed that Issue 3 of Exova’s Outline Fire Safety Strategy was comprehensive and provided all the information needed to ensure that the design of the refurbishment was safe.3007 That was self-evidently not the case, however, given the 2995 Lawrence {Day23/51:9-15}; {Day23/53:11-21}. 2996 Lawrence {Day23/52:4-10}. 2997 See Chapter 54; Sounes {SEA00014273/152} page 152, paragraph 372. 2998 Sounes {SEA00014273/152} page 152, paragraph 372; Lawrence {Day23/65:17-24}; {Day23/74:8-12}. 2999 Lawrence {Day23/63:14-20}. 3000 See Chapter 54; Lawrence {Day23/79:13}-{Day23/80:7}. 3001 Lawrence {Day23/80:8-21}. 3002 Lawrence {Day23/80:22}-{Day23/81:17}. 3003 {TMO10007081/3} Item 115. 3004 Lawrence {Day23/85:4-6}; {Day23/88:4-9}. 3005 Lawrence {Day23/85:16-25}. 3006 Lawrence {Day23/89:2-7}. 3007 Lawrence {Day23/89:24}-{Day23/90-1-2}.

The Grenfell Tower Inquiry: Phase 2 Report 286 expressly provisional nature of the opinion provided in respect of functional requirement B4(1). Furthermore, Rydon did not ask what information Exova had used in compiling it, assuming instead that it had been prepared on the basis of all the information in the tender pack.3008 However, Simon Lawrence did not know whether Exova had seen the NBS Specification3009 and no one at Rydon appears to have noticed that Exova’s description of the project did not include overcladding or any reference to the system it was proposed to use.3010 Mr Lawrence assumed that Exova had been involved in the design of the refurbishment from the outset, but did not ask anyone whether that had actually been the case.3011 64.23 In fact, Issue 3 of the Outline Fire Safety Strategy contained no proper assessment of compliance with functional requirements B3 or B4 of the Building Regulations, and in the case of functional requirement B4 stated only that the provisional opinion that the proposed changes would have no adverse effect on the building in relation to external fire spread would be confirmed by an analysis in a future issue of the report.3012 Although Simon Lawrence had reviewed Issue 3 of the Outline Fire Safety Strategy in late 2013 or early 2014 and again in September 2014,3013 he failed to notice that no further issue of the report had been produced.3014 Rydon therefore took no steps to ensure that it was forthcoming.3015 64.24 Simon Lawrence appears to have understood that part of the report to mean that the cladding would have no adverse effect on the fire safety of the tower provided Rydon ensured that it complied with functional requirement B4.3016 However, if that had been its meaning, it would have rendered Exova’s analysis pointless. There could be no reasonable basis for any such understanding. 64.25 Rydon appears to have thought that any defects in the design or choice of materials would ultimately be identified by building control,3017 but that reflected a fundamental misunderstanding of the role of building control. 64.26 When giving evidence Simon Lawrence accepted that it was the responsibility of a design and build contractor to satisfy itself that the fire strategy for a given project was correct.3018 It seems clear to us, however, that Rydon simply did not trouble to understand what Issue 3 of the Outline Fire Safety Strategy did and did not cover and what reliance could reasonably be placed on it. Rydon understood that it was ultimately responsible for ensuring the fire safety of the refurbished building,3019 but it abdicated that responsibility by failing to take an interest in Exova’s work.3020 Rydon should have been aware that Exova had not provided 3008 Lawrence {Day23/90:13}-{Day23/91:1}. 3009 Lawrence {Day24/115:11-25}. 3010 Grenfell Tower Outline Fire Safety Strategy {CST00000085/4}; Lawrence {Day23/91:9}-{Day23/92:1}. 3011 Lawrence {Day23/92:18-24}. 3012 Grenfell Tower Outline Fire Safety Strategy {CST00000085/9} paragraph 3.14. 3013 Lawrence {Day23/84:20}-{Day23/85:2}; {Day23/94:14-16}. 3014 Lawrence {Day23/94:17}-{Day23/95:11}. 3015 Lawrence {Day23/95:12-19}. 3016 Lawrence {Day23/95:21-24}; {Day23/97:4-7}. 3017 Lawrence {Day23/94:17}-{Day23/97:21}. 3018 Lawrence {Day23/70:24}-{Day23/71:5}. 3019 Lawrence {Day23/83:17-25}. 3020 Lawrence {Day23/83:2-7}.

Part 6 | Chapter 64: The contribution of Rydon 287 a final opinion on compliance with functional requirement B43021 and should have ensured that it was provided. Simon Lawrence was content for Studio E to obtain free advice from Exova but clearly decided that Rydon would not be paying for it.3022 64.27 We have concluded that the exchanges of emails in September 2014 involving Exova3023 should have alerted Rydon to three important things. First, it should have been clear to Rydon that Exova was giving advice to the design team on the basis of incomplete information. Second, Rydon should have noticed that Harley and Studio E were unable to reach a settled view on the appropriate design strategy for cavity barriers in the facade of the tower and that they might therefore benefit from the assistance of an independent fire engineer. Third, if Rydon had been aware that in Issue 3 of its Outline Fire Safety Strategy Exova had provided only a provisional conclusion on compliance with functional requirement B4, it should have been alerted to the need to obtain a fully considered opinion to complete the work. None of those matters required Rydon to have its own specialist design or fire engineering expertise. On the contrary, they fall well within the capacity of a reasonably competent design and build contractor. 64.28 As we have already said, Rydon’s role was to take the lead in ensuring that important issues such as fire safety were properly considered. In our view, its approach to the involvement of Exova represents a serious failing. It is telling that Simon Lawrence conceded, in hindsight, that the advice of a fire engineer is essential on any construction project with any significant degree of complexity.3024 That Rydon did not realise that at the time indicates the extent of its general lack of concern for fire safety in relation to the project. Failure properly to evaluate and co-ordinate design work 64.29 Rydon’s internal system for evaluating and co-ordinating the design work was inadequate. One effective tool that it could and should have used to co-ordinate the design process effectively was a matrix of responsibilities identifying which of the many sub-contractors and consultants was responsible for particular aspects of the work. Such a matrix should ensure that everyone involved in a project knows where responsibility lies for each decision and is important for the effective management of any design and build contract.3025 In the absence of a matrix of responsibilities it was extremely difficult, if not impossible, for Rydon to ensure that its sub-contractors and consultants properly understood their separate responsibilities or that Rydon itself understood where responsibility for individual decisions lay. Its failure to establish a matrix of responsibilities resulted in a failure on the part of those responsible for the design of the cladding to recognise that they were responsible for various critical decisions affecting fire safety, including the compliance of the cladding with the Building Regulations. Failure properly to monitor sub-contractors 64.30 Rydon appears to have assumed that Studio E was co-ordinating the design work. As early as April 2014, it authorised Studio E and Harley to talk directly to each other about matters of design, provided that all correspondence was copied to itself.3026 For such an approach to be successful, however, Rydon had to take active steps to ensure that Harley and 3021 Hyett, ‘Failures of Statutory Compliance’ (Amended Report) {PHYR0000029/28} paragraph 4.2.22. 3022 Email from Simon Lawrence to Neil Crawford cc Simon O’Connor on 19 September 2014 at 14:25 {SEA00011754/1}; Lawrence {Day23/72:12-18}. 3023 {SEA00011754}. 3024 Lawrence {Day23/48:6-9}. 3025 Hyett, ‘Failures of Statutory Compliance’ (Amended Report) {PHYR0000029/87} paragraphs 4.4.17-4.4.18. 3026 {HAR00000927}; Lawrence {Day23/167:6}-{Day23/168:12}.

The Grenfell Tower Inquiry: Phase 2 Report 288 Studio E were working effectively together and that all relevant matters of design were being considered, but it failed to do so. On the contrary, it relied on Studio E and Harley to lead the design process, which it saw as a “free flow” of information between Studio E and Harley, in which it did not need to play an active role.3027 It intervened only if it saw that an element of the design was missing or if one of them complained about the other’s performance,3028 but it was ill-equipped to determine whether something was missing, given that it had no proper system for monitoring the design process and employed no one qualified to identify any defects. 64.31 Rydon also failed to make use of an electronic drawing control system, which meant that it was not able to co-ordinate the exchange of drawings between Harley and Studio E or indeed to understand which drawings had been issued and which were missing.3029 Rydon did not tell anyone at Studio E that it was expecting Studio E to co-ordinate the drawing exchange process on its behalf or that it had no proper drawing control system of its own.3030 Moreover, Rydon had no system in place for recording design changes throughout the project, save for a tracker that Simon Lawrence started himself to monitor changes that had programme and cost implications.3031 64.32 Design drawings produced by Harley were sent to Studio E for comment, but Studio E reviewed them only to ensure that they complied with architectural intent and contained no obvious errors. Rydon does not appear to have asked itself whether such a limited examination was sufficient to enable Studio E to discharge its contractual obligation to examine Harley’s drawings and report on them, or to discharge Rydon’s own obligation to the TMO to ensure that the design of the refurbishment complied with statutory requirements.3032 Indeed, Rydon never turned its mind to the question whether Studio E was actually considering statutory compliance when it reviewed design drawings.3033 By failing to ask those questions Rydon failed to ensure that the design of the cladding was safe, at least as far as fire was concerned. Undue reliance on previous projects 64.33 Insofar as Rydon turned its mind to the fire performance of the products used in the refurbishment at all, it assumed they were safe because it had used them on previous projects, particularly the Chalcots Estate and Ferrier Point projects, where it had worked with Harley to install ACM rainscreens.3034 64.34 However, Rydon failed to learn important lessons from the fire that took place at Taplow House on the Chalcots Estate on 16 January 2012. The fire gave it direct experience of the potential importance of fire barriers, particularly around windows, in preventing the spread of fire over the walls of high-rise residential buildings, but there is no evidence that it applied that knowledge to the Grenfell Tower refurbishment.3035 Rydon had no system for sharing that experience or the learning derived from it with its employees. Nor did it have any system for ensuring that such lessons were heeded in its future work.3036 3027 Lawrence {Day22/181:18-23}; Lawrence {Day23/25:17}-{Day23/28:14}. 3028 Lawrence {Day23/27:1-6}; O’Connor {Day26/37:16-24}. 3029 Lawrence {Day22/165:9}-{Day22/167:23}. 3030 Lawrence {Day22/168:1-9}. 3031 Lawrence {Day23/31:20}-{Day23/40:17}; {ART00003086}; {ART00008861}; {RYD00022907}. 3032 Lawrence {Day22/182:11}-{Day22/185:20}; Crawford {SEA00014275/78} page 78, paragraph 256; Crawford {Day9/85:11}-{Day9/92:12}. 3033 Lawrence {Day22/185:10-20}. 3034 Lawrence {Day22:178/11}-{Day22/179:8}. 3035 Blake {Day29/127:9-19}. 3036 Blake {Day29/124:3-9}.

Part 6 | Chapter 64: The contribution of Rydon 289 Inappropriate reliance on building control 64.35 Rydon attempted to mitigate its lack of expertise by excessive and inappropriate reliance on building control, epitomised by Simon Lawrence’s evidence that he saw building control as a “resource” on which he could rely because Rydon was paying a fee for it.3037 Rydon viewed building control as the body that would ensure that its sub-contractors were complying with their contractual obligations,3038 but in our view it is never appropriate for a principal contractor (or any other party) to rely on building control to ensure that its designs comply with the Building Regulations. 64.36 In this case, it was particularly inappropriate and unsafe for Rydon to rely on building control to the extent that it did because its haphazard communications with building control meant that it could never be confident that it had given building control the information it needed properly to evaluate the design. For example, Rydon approved the substitution of Celotex RS5000 by Kingspan K15 (a product with a different chemical composition) and took no steps to conduct any investigation of its own into the suitability of the product or to ensure that building control and the TMO had been alerted to the change.3039 Failure to respond to concerns about fire safety 64.37 Rydon failed on at least two occasions to provide proper responses to specific enquiries about fire safety, indicating a lack of interest in the subject. 64.38 On 12 November 2014 Claire Williams wrote to Simon Lawrence seeking clarification on the fire retardance of the new cladding and saying that she had just had a “Lacknall moment”.3040 There is no evidence that he or anyone else at Rydon responded in any way to the email. 64.39 On 10 April 2015, Ms Williams wrote to Simon O’Connor and asked him for the fire rating of the cladding and fixings and to confirm their acceptance by building control.3041 Although Ms Williams chased for a response, Rydon appears to have taken no action in response to her request. The window reveals 64.40 As set out in detail in Chapter 56, Rydon failed to ensure that the non-combustible insulation material which had been specified by Studio E in the NBS Specification was used around the windows and instead allowed the use of combustible Celotex and Kingspan insulation products. Rydon also changed the internal window surrounds from plywood to uPVC without seeking the approval of the TMO or considering the fire safety consequences of doing so. The consequences were very serious because the deformation of the uPVC window surrounds in the kitchen of Flat 16 is most likely to have been the means by which fire first entered the cladding on 14 June 2017. 3037 Lawrence {Day23/74:1-12}. 3038 Lawrence {Day22/68:7-15}; {Day23/2:21}-{Day23/3:12}; {Day24/192:12}-{Day24/199:10}; {Day25/12:18}-{Day25/14:1}; {Day25/18:14}-{Day25/24:9}; O’Connor {Day26/167:24}-{Day26/168:2}; Hughes {Day27/18:12}-{Day27/19:10}; Blake {Day29/70:22}-{Day29/74:1}; Sounes {SEA00014273/152} page 152, paragraph 372. 3039 Blake {Day29/117:13-17}. 3040 {RYD00023468}. 3041 {TMO00858290}.

The Grenfell Tower Inquiry: Phase 2 Report 290 Failures in site supervision 64.41 Rydon was responsible for inspecting the work done by Harley and other sub-contractors at Grenfell Tower,3042 but the inspections it carried out were inadequate because they failed to detect some serious defects in workmanship, particularly in relation to cavity barriers. In many cases the effectiveness of cavity barriers was reduced as a result of poor attachment to the concrete walls, fitting in the wrong orientation or installation in the wrong location.3043 Rydon accepted that the quality of workmanship in those cases was very poor, but could not explain how it had failed to detect it.3044 In substance, Rydon’s employees appeared to have regarded its quality control process as little more than a snagging inspection, but that fell far short of performing its obligation to ensure that the work had been properly carried out. 64.42 One important reason for Rydon’s failure to ensure that the work done at Grenfell Tower was of proper quality was that those appointed to manage and inspect it were ill-equipped to do so. Daniel Osgood was brought onto the project between 27 April 2015 and 24 July 2015 to oversee the installation of the cladding.3045 Although he had previously worked on similar projects as a fitter, he had never worked with ACM panels.3046 He had never received any training in how to inspect cladding installations or in the requirements of the Building Regulations and he did not know that there was statutory guidance on the construction of the external walls of buildings over 18 metres in height.3047 Mr Osgood assumed that all materials installed on the outside of buildings were entirely “fireproof”.3048 He did not know of the need for cavity barriers to be installed around windows and was not aware of the difference between Rockwool (a non-combustible mineral wool insulation product) and Celotex RS5000 (a combustible PIR insulation product).3049 64.43 David Hughes was appointed in October 2015 as lead site manager, which required him to take responsibility for the inspection of Harley’s work at a critical stage of the project.3050 He had not previously worked on a project that involved fitting cladding to a high-rise building.3051 He did not understand, even in broad terms, the functional requirements of the Building Regulations, was not aware that the external walls of buildings should adequately resist the spread of fire over the surface, was not aware that guidance had been published on the construction of the external walls of buildings over 18 metres in height, was not aware of the expression “limited combustibility” and was not aware that cavity barriers should be fitted around windows.3052 64.44 Rydon compounded the problem by failing to ensure that inspections were carried out in accordance with relevant guidance, such as the overcladding specification produced by Curtins Consulting and the manufacturers’ instructions for the installation of insulation and 3042 {TMO10041791/141} at A33/630. 3043 Lane, ‘Section 8 – The External Wall – Materials and Construction’ {BLAS0000008/40} figure 8.42; {BLAS0000008/41} figure 8.44; {BLAS0000008/44} figure 8.47; {BLAS0000008/46} figure 8.50; Hughes {Day27/115:5}-{Day27/116:11}. 3044 Osgood {Day30/154:17}-{Day30/158:11}; O’Connor {Day26/172:18-25}. 3045 Osgood {Day30/100:2}-{Day30/103:1}. 3046 Osgood {Day30/95:4}-{Day30/97:13}. 3047 Osgood {Day30/97:14}-{Day30/109:23}. 3048 Osgood {Day30/110:4-6.}; {Day30/115:13-15}; {Day30/118:19-20}. 3049 Osgood {Day30/141:5-7}; {Day30/184:1-3}; {Day30/185:17-24}; {Day30/188:9-11}; {Day30/115:13-15}; {Day30/110:1‑7}. 3050 Hughes {RYD00094213/5} page 5, paragraph 22. 3051 Hughes {Day27/6:7-9}. 3052 Hughes {Day27/28:25}-{Day27/34:20}.

Part 6 | Chapter 64: The contribution of Rydon 291 cavity barriers.3053 Rydon also exercised little, if any, meaningful control over the materials that were used on site by its sub-contractors, trusting them instead to use only those which were appropriate.3054 64.45 It is also clear that the quality of Rydon’s work and its approach to the project more generally was poor. From mid-2015, when the project was nearing completion, the TMO and Artelia repeatedly raised concerns with Rydon about the resources it had dedicated to the project and its apparent inability or unwillingness to resolve complaints about the quality of the work.3055 In June 2015, Simon Lawrence candidly reported to Stephen Blake that they had a poorly performing site, mainly the result of poor surveying and cheap, incompetent sub-contractors.3056 In May 2016 Neil Reed of Artelia reported to Simon Cash that he had never before worked with a contractor demonstrating such a level of nonchalance.3057 Both Simon Lawrence’s and Neil Reed’s statements reflect a contemporaneous perception, supported by other evidence before us, that the general quality of Rydon’s work fell significantly below that which could be expected of a reasonably competent design and build contractor. Regulation 38 and the health and safety file 64.46 Rydon sub-contracted the collation of information required for the purposes of complying with regulation 38 of the Building Regulations and the preparation of the health and safety file required by the CDM Regulations to All Group Holdings Ltd. However, nobody at Rydon checked the operation and maintenance manual or the health and safety file to ensure it was complete and accurate. Stephen Blake did not consider that to be Rydon’s responsibility.3058 Mr Hughes said that he had taken a quick look at a draft of the operation and maintenance manual3059 but had not received the final version.3060 Rydon ought to have checked All Group Holding’s work. It is doubtful whether the information provided to the TMO satisfied either regulation 38 or the requirements of the CDM Regulations. 64.47 Mr Hoban said that he had asked David Hughes whether Rydon had given the TMO the information required by regulation 38 and that Mr Hughes had told him that the necessary information was being sent to the TMO. We do not understand how Mr Hughes was able to give that assurance.3061 3053 {ART00000914}; Lawrence {Day22/58:22}-{Day22/60:19}; Hughes {Day27/21:1-22}. 3054 O’Connor {Day26/96:15-24}. 3055 {ART00006206}; {TMO00859230}; {ART00006681/3}; {ART00006657}; {ART00006641/1}. 3056 {RYD00044349}. 3057 {ART00006672}. 3058 Blake {Day29/170:16}-{Day29/171:9}. 3059 Hughes {Day27/205:1-2}. 3060 Hughes {Day27/205:3}. 3061 Hoban {Day46/200:18-24}; Hughes {Day27:202:25}-{Day27/203:8}.

292 The Grenfell Tower Inquiry: Phase 2 Report

293 Introduction 65.1 In July 2014 Rydon appointed Harley as a sub-contractor to carry out the design and construction of the overcladding of Grenfell Tower. On 25 July 20143062 Zak Maynard sent an undated letter of intent signed by Simon Lawrence3063 on behalf of Rydon as an attachment to an email to Mark Harris of Harley. The letter of intent stated that Rydon intended to appoint Harley as the envelope package sub-contractor. On 16 September 2014 Zak Maynard confirmed that the scope of the letter of intent had been increased to cover the full value of the work. Although the letter of intent contemplated that the parties would enter into a formal contract for the work, Rydon did not provide a document and Harley does not appear to have pressed for one. As a result, the parties did not execute a formal written agreement and their relationship was governed at all material times by the terms of the letter of intent.3064 65.2 The letter of intent provided that the contract between Harley and Rydon was subject to the terms of the DOM2 Articles of Agreement3065 and Subcontract Conditions.3066 It described the work to be carried out and the conditions under which the contract was to be performed by reference to nine Appendices.3067 Under the contract Harley was responsible for all aspects of the design of the facade. In particular, it bore responsibility for ensuring that the design of the facade complied with all statutory requirements, including the requirements of the Building Regulations. Moreover, all the provisions of the draft building contract between Rydon and the TMO were incorporated into the letter of intent, insofar as they were relevant to the sub-contract works.3068 They included an obligation to accept full responsibility for the design of the project and the selection of materials, including the work carried out by Studio E.3069 In those circumstances, Harley accepted responsibility to Rydon for the contents of the NBS Specification insofar as they related to the design of the facade.3070 65.3 In its closing statement Harley pointed out that it had no formal contract with Rydon, simply a letter of intent with a large number of appendices which incorporated the terms of Rydon’s contracts with the TMO, not all of which it had read in full.3071 That was put 3062 {RYD00013524}. 3063 Letter of Intent {HAR00000120}. 3064 Letter of Intent {HAR00000120}; Maynard {Day31/44:8-17}; {Day31/51:11-20}; {Day31/54:11}-{Day31/55:1}; Bailey {Day32/57:4-25}; Harris {Day34/14:7-11}; {Day34/16:2-7}. 3065 DOM2 2011 Sub-Contract Articles of Agreement {INQ00011295}. 3066 DOM 2011 2011 Sub-Contract Conditions {INQ00011211}. 3067 Appendix A: Scope of Works & Ascertainment of Lump Sum Price (Envelope Package) dated 25 July 2014 {HAR00000397}; Appendix B: Rydon Standard Terms and Conditions {HAR00000389}; Appendix C: The Rydon Way {HAR00000390}; Appendix D: Subcontractor Pre-Contract Interview dated 16 June 2014 {HAR00000391}; Appendix E: Traffic Management Plan {HAR00000392}; Appendix F: Schedule of Information {HAR00000396}; Appendix G: Site Protection Policy {HAR00000393}; Appendix H: Payment Schedule {HAR00000394}; Appendix P: Programme of Works {HAR00000395}. 3068 Letter of Intent {HAR00000120/2} clause 2(b). 3069 Letter of Intent {HAR00000120/2} clause 2(b); DOM2 Subcontract Conditions {INQ00011211/8} clause 2.5.1; The Design and Build Contract {RYD00094235/69} clause 2.17. 3070 Ray Bailey {Day32/85:12}-{Day32/87:10}. 3071 {HAR00020580/6}, paragraph 12. Chapter 65 The contribution of Harley

The Grenfell Tower Inquiry: Phase 2 Report 294 forward as an explanation of its failure to understand the full extent of its contractual obligations and as a reason for following common practices within the industry. However, it is clear that any organisation that enters into a contract of this kind, no matter how complex its terms, has a responsibility to understand the nature of the obligations it has undertaken. Simply failing to understand the contract and following industry practices will not do. Despite that, however, Harley was aware that it had a responsibility to check that the materials described in the NBS Specification were suitable and to ensure that on the completion of the work the external walls of the tower complied with the Building Regulations, including functional requirement B4(1). 65.4 It is clear that Rydon and Studio E both regarded Harley as an expert in the design and construction of ventilated rainscreen facades and expected it to bring to bear the skill and experience that could be expected of an expert sub-contractor of that kind. If it had stopped to think about it, Harley must have known that. With that in mind we obtained a report from Mr Jonathan Sakula MA, Ceng., FIStructE, FICE,3072 to help us understand what could be expected of a reasonably competent facade contractor in the period between January 2012 and June 2017. Mr Sakula also gave oral evidence.3073 65.5 In a closing statement Harley challenged Mr Sakula’s evidence on the grounds that he had limited experience of the use of ACM products on high-rise buildings and was himself a facade consultant rather than a cladding contractor, the suggestion being that he had little experience of the practical world in which companies such as Harley operate. We found that argument surprising, not only because it proceeds on the footing that Harley was not an expert in designing and installing building facades, but also because Harley accepted that it had undertaken significant responsibilities for ensuring the suitability of the materials that others had proposed using. We found Mr Sakula an impressive witness and we were not asked to hear evidence from anyone else who had experience of the cladding industry at the time in question. Although we have been mindful of the scope of his experience and of the various arguments put forward on Harley’s behalf, we have generally accepted his evidence as reliable. 65.6 In the light of the evidence as a whole, we consider that Harley’s work on the refurbishment was characterised by a failure to take its responsibilities seriously, ignorance, complacency and a failure properly to manage its staff. As the specialist contractor responsible for the external wall of the tower, the standard of Harley’s work fell well below that to be expected of a reasonably competent cladding contractor and it must therefore bear a significant degree of responsibility for the fire. Technical competence 65.7 We are satisfied that Harley failed to achieve the standard of a reasonably competent cladding contractor in several different aspects of its work. Many of those failures had the same root cause, namely, the inadequate technical expertise of its employees and representatives. 3072 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001}. 3073 Sakula {Day125}.

Part 6 | Chapter 65: The contribution of Harley 295 The Building Regulations and Approved Document B 65.8 At the time of the refurbishment Ray Bailey considered himself to be as well placed as anyone in the specialist cladding industry to advise on whether materials used in the construction of an external wall complied with the applicable regulations.3074 However, he conceded that he had not read through Approved Document B for some years and had then found it quite complicated.3075 He considered himself to have a working, but not a detailed, knowledge of it.3076 65.9 Although Daniel Anketell-Jones later completed an MSc in facade engineering, at the time of the refurbishment his knowledge of the Building Regulations did not extend beyond matters relating to structural stability and he was not very familiar at all with Approved Document B.3077 Ben Bailey said that he had seen parts of Approved Document B but had never received any training to help him understand the Building Regulations, Approved Document B or any of the associated guidance.3078 Both Mark Harris and Mike Albiston candidly admitted that they had not been competent to advise on any question of compliance with the Building Regulations or Approved Document B.3079 65.10 Before he became involved in the refurbishment, Kevin Lamb had never undertaken any formal training on the Building Regulations or the guidance in the approved documents.3080 He said that he had taken steps to refresh his memory of Approved Document B during the refurbishment3081 but did not think that it was his responsibility to look at it in any detail.3082 He did not give a second thought to which route to compliance was being adopted.3083 65.11 Accordingly, Harley’s own evidence was that none of those engaged on the refurbishment had any more than a passing familiarity with the relevant Building Regulations or approved documents. That, in our view, was unacceptable for an organisation which held itself out to be a specialist cladding contractor.3084 65.12 Harley held itself out as a specialist cladding contractor with sufficient technical expertise to undertake what was, on any view, a large and complicated project. Under its contract with Rydon it was responsible for the design of the cladding and for ensuring that it complied with the relevant statutory requirements.3085 At the very least, therefore, it should have been familiar with the regulations and with any statutory and industry guidance that was relevant to its work. It is difficult to understand how Harley could reasonably have believed it could discharge its obligations to Rydon without having that essential technical knowledge. 65.13 According to Jonathan Sakula, whose expert opinion on this point we accept, at that time a reasonably competent cladding contractor would have had a system in place for checking the suitability of any products proposed for use on a refurbishment project of that kind.3086 In order for such a system to function effectively it would have to be managed by someone 3074 Ray Bailey {Day32/8:2-9}. 3075 Ray Bailey {Day32/6:20-21}. 3076 Ray Bailey {Day32/6:21-22}. 3077 Anketell-Jones {Day35/119:3-15}; {Day35/122:22-23}. 3078 Ben Bailey {Day39/18:10-24}. 3079 Harris {HAR00010159/8} page 8, paragraph 34; Harris {Day34/7:12-24}; Albiston {Day35/35:18-25}. 3080 Lamb {Day37/70:18-22}. 3081 Lamb {Day37/130:2-5}. 3082 Lamb {Day37/131:3-5}. 3083 Lamb {Day37/142:1-14}. 3084 Sakula {Day125/27:16}-{Day125/30:12}; {Day125/34:1-7}. 3085 Undated Letter of Intent from Rydon Management Systems to Harley Curtain Wall Ltd {HAR00000120/1-2} Item 1. 3086 Sakula {Day125/26:23}-{Day125/27:2}; {Day 125/26:2-12}.

The Grenfell Tower Inquiry: Phase 2 Report 296 with sufficient technical knowledge.3087 However, Harley had no such system and does not appear to have employed anyone capable of managing one, despite its obligation to Rydon to ensure that suitable products and materials were used. 65.14 In our view Ben Bailey lacked the competence and experience to act as Harley’s project manager on a project of the size and complexity of the Grenfell Tower refurbishment. The project manager’s responsibilities included ensuring that work was done to a high standard;3088 and for that reason the project manager was the most senior person from Harley who regularly attended the site.3089 However, Ben Bailey was at the time a 25 year old graduate with a foundation degree in motor sport engineering, who had not previously held the position of project manager and had no obvious qualifications for the role. We consider that, for a project of this nature, Harley ought to have appointed as project manager someone who had the training and experience required to manage a large project of that kind. It failed to do so. Testing regime 65.15 It is clear from the evidence that none of those employed by Harley on the refurbishment had even a basic grasp of the fire testing regime that applied to the products used in the external wall of the tower. Ray Bailey thought that a Class 0 classification meant that a product was “difficult to ignite and if you take the source of flame away from it, it won’t continue to burn”.3090 He also thought, quite wrongly, that a Class 0 classification meant that a product was safe to use in any application on any building over 18 metres in height.3091 For the senior executive and owner of a specialist cladding sub-contractor, that was a striking misconception. 65.16 Daniel Anketell-Jones said that he had been unaware of the difference between “non- combustible”, “limited combustibility” and “Class 0”3092 and thought that “Class 0” meant that the material could not catch fire.3093 Such ignorance on the part of the one person whom Harley regarded as having technical expertise in matters of fire safety is remarkable. Mr Lamb claimed to have understood what Class 0 meant, but he said that he had had no need to understand the tests that underpinned that classification.3094 His assertion that all major elements of an external wall cladding system would have to be Class 0 betrayed a fundamental ignorance of the basic principles underlying the testing and classification regime set out in Approved Document B. If a designer seeks to follow the guidance provided by what has been called the “linear route” in relation to a building over 18 metres in height, paragraph 12.7 requires insulation products to be materials of limited combustibility. Mr Lamb did not understand that distinction. We consider that to be inexcusable in one who was employed to carry out design work.3095 65.17 Mr Anketell-Jones also claimed to be unaware of the BS 8414 test methods or the BR 135 criteria and said that he had never considered whether they were relevant to the question whether products were safe for use on high-rise buildings.3096 However, on 16 January 3087 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/25-26}; Sakula {Day125/140:25}-{Day125/141:9}. 3088 Ben Bailey {Day39/13:2-3}. 3089 Ben Bailey {Day39/13:4-10}. 3090 Ray Bailey {Day33/6:14-17}. 3091 Ray Bailey {Day33/6:18-25}. 3092 Anketell-Jones {Day35/180:23}-{Day35/181:5}. 3093 Anketell-Jones {Day36/92:7-14}. 3094 Lamb {Day37/144:1-5}. 3095 Lamb {Day37/149:22}-{Day37/150:4}. 3096 Anketell-Jones {Day36/95:8}-{Day36/96:3}.

Part 6 | Chapter 65: The contribution of Harley 297 2016, he sent an email to Jonathan Roome of Celotex asking for the test results and certificates for RS5000 for the purposes of advising a different client on a different project altogether. In that email he made detailed references to the fire testing regime and the limitations of the BS 8414 test.3097 We think, therefore, that he was seeking to play down his technical knowledge when giving evidence before us and that he knew more than he was prepared to admit. 65.18 Mr Sakula told us that at the time of the refurbishment it had been the practice of reasonably competent cladding contractors to obtain from one source or another information about technical developments and to make arrangements for disseminating that information within their organisations.3098 However, Harley had no such system in place and in that respect fell below the accepted standards prevailing at the time. 65.19 The general lack of understanding of these matters within Harley arose from its failure to take adequate steps to ensure that its employees were properly trained. Ray Bailey said that Harley’s previous Estimating and Technical manager, Graham Hackley, had attended a course run by the CWCT and that it had been his responsibility to ensure that knowledge gained in that way was shared with the rest of the team.3099 However, there is no evidence that Mr Hackley’s role involved training other employees of Harley and it was ultimately the responsibility of Ray Bailey, not Graham Hackley, to ensure that Harley was competent to perform the work it took on. In any event, whatever Mr Hackley may have learnt of any value, it seems that it was not shared. When Mr Hackley left Harley in late 2012 or early 20133100 his expertise, such as it was, does not appear to have been replaced. Daniel Anketell-Jones took over as technical manager but was scarcely qualified to do so given that it was not until 2014 that he began studying part time for an MSc in facade engineering (which he had still not completed when he left Harley in 2016).3101 Other standards and guidance 65.20 Harley’s knowledge of the industry standards and guidance that were relevant to its work was similarly weak. Ray Bailey said that he had read the CWCT Standard for Systemised Building Envelopes issued in 2008 in the past but conceded that he did not know it in detail.3102 He had not seen the CWCT’s Technical Guidance Note 73, published in March 2011, until after the fire.3103 Even at the time of their oral evidence to the Inquiry in September 2020, neither he nor Mr Anketell-Jones could recall ever having seen the Curtins specification.3104 That was a significant omission because the Curtins specification had been expressly incorporated into Harley’s contract and required the facade system to comply fully with the recommendations of the BRE document “Fire performance of External Insulation for Walls of Multi Storey Buildings”, 2nd ed. (2003) (BR 135). It also contained broader performance standards, such as a requirement that the system should not be a fire risk at any stage of installation, nor constitute a fire hazard after completion if for any reason the insulation were to become exposed.3105 Harley should have read in full and complied with the documents that were incorporated into its sub-contract.3106 3097 See Chapter 56 for further detail. 3098 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/29}. 3099 Ray Bailey {Day33/19:6-9}. 3100 Ray Bailey {Day32/9:8}. 3101 Anketell-Jones {HAR00010149/2} page 2, paragraphs 7-8. 3102 Ray Bailey {Day32/7:15-25}. 3103 Ray Bailey {Day33/2:1-13}. 3104 Ray Bailey {Day32/64:4-19}; Anketell-Jones {Day35/201:22}-{Day35/202:2}. 3105 {CCL00001449}. 3106 Sakula {Day125/151:12-17}.

The Grenfell Tower Inquiry: Phase 2 Report 298 65.21 Daniel Anketell-Jones said that he had not been aware that the facade had to meet the requirements of the CWCT Standard for Systemised Building Envelopes3107 or the Curtins specification,3108 that he had not been familiar with BR 135,3109 and that he had not been aware of any guidance published by the CWCT or the Building Control Alliance.3110 Indeed, he said that it was not until about the end of 2015 that he had begun to appreciate that those documents existed.3111 He said he had not been aware that there was any industry guidance that emphasised the importance of closing cavities around the windows of high- rise buildings,3112 and had not been aware that window openings required protection from the spread of fire at all.3113 If the gaps in his knowledge were as wide as he suggested, he should not have been working on the refurbishment in a design capacity. If they were not, his failure to take action was all the more serious. 65.22 Mr Anketell-Jones said many times during his evidence that his expertise was limited to structural matters,3114 but the contemporaneous evidence suggests that he knew rather more about the fire performance of some construction products than he was prepared to admit. For example: a. He was sent the abseil report on the fire at Taplow House, a Harley development on which ACM PE cladding had been used.3115 b. In response to a question from a client that he described as a “headache”, he made a detailed request to Celotex for certificates demonstrating that RS5000 insulation had passed certain fire performance tests.3116 c. He sent an email in which he expressed the view that ACM panels would disappear rather quickly in a fire.3117 d. He attended the Annual General Meeting of the CWCT on 7 October 20143118 at which Sarah Colwell of the BRE gave a detailed presentation on BS 8414 and BR 135,3119 as well as providing a list and images of previous national and international cladding fires.3120 65.23 In the light of those matters it is difficult to believe that Mr Anketell-Jones was as ignorant of matters relating to fire safety as he would have had us believe. Accordingly we can place little reliance on his protestations of ignorance or lack of expertise. We think that he knew more than he was prepared to admit about the combustibility of ACM PE and the technical requirements the cladding was required to meet. That is why he was regarded within Harley as the person who could give advice on fire safety matters. 65.24 Although Kevin Lamb was certain that he had reviewed the CWCT Standard for Systemised Building Envelopes during his work on the Grenfell Tower project, that had not gone beyond a brief look and he candidly admitted that he had not considered whether his 3107 Anketell-Jones {Day36/67:12-15}; {Day37/37:23-25}. 3108 Anketell-Jones {Day35/201:15-21}. 3109 Anketell-Jones {Day35/203:8-11}. 3110 Anketell-Jones {Day35/36:6-10}; {Day35/193:8-13}. 3111 Anketell-Jones {Day35/179:17-23}. 3112 Anketell-Jones {Day35/188:1-5}. 3113 Anketell-Jones {Day35/188:6-9}. 3114 For example, Anketell-Jones {Day36/10:7-13}; {Day36/72:8-12}. 3115 {HAR00010169/1}. 3116 Email from Daniel Anketell-Jones to Jonathan Roome on 16 January 2015 {CEL00000019/2}. 3117 {HAR00006585/1}. 3118 {CEL00001037}. 3119 {CEL00001038/4-7}. 3120 {CEL00001038/2-3}.

Part 6 | Chapter 65: The contribution of Harley 299 designs complied with it.3121 It was not until March 2015, when a conversation took place between Harley, Exova, Rydon and building control in respect of the fire performance of the cavity barriers,3122 that he had consulted any external guidance.3123 65.25 Since Mr Lamb was a sub-contractor, Harley ought to have referred him to relevant guidance documents or standards and ensured that he considered them.3124 It ought also to have had a system for checking that his work complied with the relevant statutory requirements and guidance documents.3125 Regrettably, however, it did not. Instead, neither Harley nor Kevin Lamb gave sufficient consideration to the documents which were key to their work, namely, BR 135, CWCT’s Standard for Systemised Building Envelopes, CWCT’s Technical Note 73 and BCA Technical Guidance Note 18 (Issue 0 and Issue 1).3126 A reasonably competent cladding contractor would have been aware of those documents and would have considered them, together with the functional requirements of the Building Regulations and Approved Document B.3127 International cladding fires 65.26 None of Harley’s staff involved in the refurbishment were aware of the many fires overseas involving ACM PE cladding, although they were well known within the cladding industry.3128 We are satisfied that a reasonably competent contractor in Harley’s position would have been aware of them and would have had them in mind when considering the suitability of ACM for Grenfell Tower. Conclusion 65.27 Harley’s striking lack of technical knowledge and its failure to implement any proper system to monitor and improve it fell far short of the standard of a reasonably competent cladding contractor. That fundamental failure was the cause of much of its inadequate work on the refurbishment. 65.28 It may be that, in the years when Harley was involved in the refurbishment, its understanding of the Building Regulations, Approved Document B, Class 0 and the concept of combustibility was similar to that of some other cladding contractors.3129 As the evidence of government officials, BRE and the certification bodies revealed, there was some confusion about those matters. Harley may well not have been alone in 2013 in thinking that all that was required in the case of a rainscreen panel was a Class 0 classification, but in our view a reasonably competent cladding contractor should have been aware of the guidance in paragraph 12.7 of Approved Document B and of the distinction between Class 0 and limited combustibility. In any event, the position became clearer in the summer of 2014 when the Building Control Alliance published its Technical Guidance Note 18 (issue 0) which stated in terms that all elements of the external wall had to be of limited combustibility. A reasonably competent cladding contractor would quickly have become 3121 Lamb {Day37/130:11-13}; {Day37/135:21}-{Day37/136:18}. 3122 See Chapter 57. 3123 Lamb {HAR00010419/13} page 13, paragraph 50; Lamb {Day37/162:5}. 3124 Sakula {Day125/72:8-21}. 3125 Sakula {Day125/72:22}-{Day125/73:1}. 3126 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/38-46}. 3127 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/38-44}; Sakula {Day125/85:11-21}. 3128 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/34} paragraph 8.1.1; {JOS00000001/36-37} paragraphs 9.2-9.5. 3129 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/54} paragraph 14.11; Sakula {Day125/48:6}-{Day125/49:21}.

The Grenfell Tower Inquiry: Phase 2 Report 300 aware of that guidance note and of the clarification it offered. It would also have been aware that Class 0 was not a measure of combustibility and therefore would not have thought that it equated to limited combustibility. The choice of ACM panels 65.29 Harley bears a significant degree of responsibility for the decision to use Reynobond ACM PE panels on the tower. Between late 2013 and September 2014, Studio E continued to seek assistance from Harley in relation to the products that would be included in the NBS Specification and, ultimately, in the TMO’s tender information for prospective contractors. During that process, Harley continued to promote the use of Reynobond ACM PE panels.3130 It had a strong preference for the use of ACM for the rainscreen because it was familiar with the product, having used it on many previous buildings, and could calculate its costs with confidence. It therefore encouraged the use of Reynobond PE 55 in its own interests,3131 among which were maintaining its commercial relationship with Deborah French (Arconic’s UK sales representative).3132 It is right to point out that Harley’s involvement at that stage was entirely voluntary in the hope of being appointed to the project by whoever was appointed by the TMO as main contractor. It was under no contractual obligation to give advice to Studio E or to investigate the suitability of ACM PE, but in encouraging its use as the rainscreen Harley had a responsibility to satisfy itself that it was suitable for that purpose. 65.30 Mark Harris accepted that he thought Studio E was relying on Harley, as the specialist cladding contractor, to propose materials that were suitable for use on the tower,3133 and although Ray Bailey did not think that Studio E was relying on Harley at all,3134 he agreed that Harley would not recommend a product that it did not believe complied with the Building Regulations.3135 However, the question whether ACM was suitable for use on the tower was never raised by Harley with Studio E (or indeed vice-versa). Both assumed that the product was safe because it had been used on many other buildings, but neither of them took any steps to investigate its fire performance. 65.31 That assumption was born of complacency and incompetence. The view of Mr Sakula, which we accept, was that no reasonably competent cladding contractor would have relied simply on the fact that ACM PE had been used on buildings for many years.3136 It is particularly surprising that Harley was able to make such an assumption, given the dramatic fires that in the previous two years had affected buildings overseas clad in ACM panels. They were well known in the cladding industry generally and, as a specialist cladding contractor, Harley ought to have been aware of them. A reasonably competent cladding contractor would have known about the combustibility of ACM PE and should therefore have known about the risks posed by the use of such material.3137 65.32 The NBS Specification was completed by Studio E on 30 January 2014. It included the use of Proteus HR zinc honeycomb rainscreen panels but required tendering contractors to provide alternative prices for other products, including Reynobond Duragloss 5000 ACM.3138 3130 {HAR00005509}; Harris {Day34/95:22}-{Day34/100:6}. 3131 Email from Mark Harris to Tomas Rek CC Ray Bailey, Mike Albiston, Bruce Sounes on 7 November 2013 {HAR00010172/3}. 3132 Harris {Day34/95:10}-{Day34/97:14}; {Day34/99:15}-{Day34/100:2} and {HAR00010172}. 3133 Harris {Day34/52:20}-{Day34/53:1}. 3134 Ray Bailey {Day32/145:3-11}. 3135 Ray Bailey {Day32/144:22}-{Day32/145:1}. 3136 Sakula {Day125/109:14}-{Day125/110:16}. 3137 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/59}. 3138 {SEA00000169/65}.

Part 6 | Chapter 65: The contribution of Harley 301 At no point did Studio E and Harley ever discuss whether the Reynobond product was suitable for use on Grenfell Tower;3139 they both appear simply to have assumed that ACM PE would perform well on any high-rise building. 65.33 Harley’s relationship with Arconic and its consequent ability to offer a significant reduction in the price of Reynobond panels was a factor which helped Rydon secure the contract, and in due course Harley was appointed by Rydon as cladding sub-contractor. 65.34 Once Rydon had secured the contract for the Grenfell Tower refurbishment in March 2014, there was no way back. Unless RBKC’s planning department objected on aesthetic grounds, it was inevitable that Reynobond PE 55 would be chosen for the rainscreen panels simply on the grounds of cost. Harley’s involvement thus made a significant contribution to the eventual use of ACM PE on Grenfell Tower. 65.35 The letter of intent and the DOM 2 sub-contract conditions, which in due course constituted the terms under which Harley carried out the work on the refurbishment, incorporated all the provisions of the contract between Rydon and the TMO relating to the installation of the cladding, including in relation to the choice of materials.3140 As a result, Harley had an obligation to ensure that the materials chosen for the work were suitable and it is therefore not surprising that Ray Bailey accepted that Harley had an independent obligation to examine the NBS Specification to ensure that the products to which it referred complied with relevant statutory requirements.3141 Harley failed to do so, however, because it assumed that if a material or product had been included in the specification, someone, principally Studio E, had ensured that it was suitable for its intended purpose. Kevin Lamb, who was responsible for producing most of the drawings required for the fabrication of the rainscreen, did not think that Harley was responsible for ensuring the suitability of the materials or products identified in the NBS Specification.3142 Ray Bailey said that he had assumed that Daniel Anketell-Jones had checked that they were suitable, but Daniel Anketell-Jones said that he had not turned his mind to the question.3143 65.36 That evidence is surprising because on 7 October 2014 Daniel Anketell-Jones attended the CWCT Annual General Meeting, together with Mark Stapley, at which a presentation was given which expressly referred to a number of cladding fires in high-rise buildings abroad and to the availability of fire-resistant cladding panels.3144 The next day Daniel Anketell- Jones’s brother, Samuel Anketell-Jones, who was also employed by Harley, asked Deborah French of Arconic for information about Reynobond ACM panels with fire- resistant cores.3145 Although we did not hear evidence on the question, his email strongly suggests that he had spoken to one or both of Daniel Anketell-Jones or Mark Stapley and that Harley knew more than it was willing to admit about the availability of panels with fire-resistant cores and about the dangers posed by panels with unmodified polyethylene cores.3146 65.37 The section of the NBS Specification that dealt with the design of the cladding was 11 pages long. We consider that Daniel Anketell-Jones, and indeed every other Harley employee involved in the refurbishment project, should have read and understood at least 3139 Harris {HAR00010159/6} page 6, paragraph 22; Harris {Day34/115:12-25}. 3140 Letter of Intent {HAR00000120} paragraph 2(b); DOM2 Subcontract Conditions {INQ00011211/8}) clause 2.5.1; Design and Build Contract {RYD00094235/69} clause 2.17. 3141 Ray Bailey {Day32/85:12-{Day32/87:10}. 3142 Lamb {Day37/110:4-7}. 3143 Ray Bailey {Day35/51:4-13}; Anketell-Jones {Day36/69:1-9}; {Day36/78:1-20}. 3144 {CEL00001038/3}. 3145 {MET00081175}. 3146 See Chapter 55.

The Grenfell Tower Inquiry: Phase 2 Report 302 those sections and should have kept them under consideration throughout the work. In our opinion, there is no reasonable excuse for a specialist contractor in Harley’s position not ensuring that they did so. 65.38 Unsurprisingly, perhaps, no check on the suitability of the ACM PE panels was subsequently carried out by anyone at Harley. ACM panels were included in the “Specification Notes” produced by Kevin Lamb in early 2015 describing the products that would be used in the construction of the external facade of the tower.3147 65.39 In the light of Mr Sakula’s evidence, we consider that the approach demonstrated by Harley generally fell below the generally applicable standards of the time. A reasonably competent cladding contractor would have carefully considered whether ACM PE cladding panels were suitable for use on a building such as Grenfell Tower and would have ensured that all other construction professionals involved in the project were aware of their combustibility.3148 Certifications and product literature 65.40 Mr Sakula thought that it was reasonable for a cladding contractor in Harley’s position to rely on certificates such as those issued by the British Board of Agrément (BBA) and Local Authority Building Control,3149 but he also said that he would have expected the contractor’s technical department to have looked at the details of the certificates more closely. In the light of his evidence we consider that a reasonably competent cladding contractor would have examined such certificates carefully and also the sales and technical literature produced by the manufacturer in order to understand the claims being made for the product and their relevance to the refurbishment. In that respect also, Harley failed to act appropriately. 65.41 On 23 April 2014 Deborah French of Arconic sent Harley a copy of the British Board of Agrément certificate for Reynobond PE 55 cladding panels.3150 Although Harley had an obligation under its contract with Rydon to consider documents of that kind in order to satisfy itself that the products being used on the tower were suitable, no one at Harley gave it more than the most cursory examination at any time.3151 65.42 Ray Bailey had read the British Board of Agrément certificate when it was first published in 2008 but did not look at it again after that or discuss it with anyone.3152 Daniel Anketell- Jones could not remember having seen the British Board of Agrément certificate during the Grenfell Tower project.3153 Kevin Lamb did not consider that it was part of his job to look at British Board of Agrément certificates relating to products that were included in his designs.3154 65.43 If Harley had examined the British Board of Agrément certificate carefully, it would have recognised that it included several important qualifications, among them that it applied only to panels with a grey/green Duragloss 5000 coating,3155 and that the fire performance of a wall incorporating the panel could not be ascertained from the certificate alone.3156 3147 {RYD00046822}; {HAR00010160/5}. 3148 Sakula {Day125/199:12}-{Day125/200:20}. 3149 Sakula {Day125/161:7}-{Day125/162:4}. 3150 {RYD00003932}. 3151 Ray Bailey {Day32/124:16-18}; {Day33/33:14}. 3152 Ray Bailey {Day33/35:15}-{Day33/36:20}. 3153 Anketell-Jones {Day37/6:16}-{Day37/7:22}. 3154 Lamb {Day38/24:15-18}. 3155 {BBA00000047/5} section 6.4. 3156 {BBA00000047/5} section 6.5.

Part 6 | Chapter 65: The contribution of Harley 303 In the light of Mr Sakula’s evidence, we are satisfied that a reasonably competent cladding contractor would have read the certificate in full, would have had the qualifications in mind,3157 would have alerted the design team to its limitations,3158 and would have asked the manufacturer for more information about the tests that had been carried out on the product before deciding whether it was suitable for use.3159 Insulation Celotex RS5000 65.44 From early June 2014, Harley was in close communication with Celotex in relation to the launch of Celotex RS5000 insulation3160 and representatives of Celotex, principally Jonathan Roome, subsequently made several visits to Harley’s offices to promote the new product.3161 65.45 The use of RS5000 in place of FR5000 resulted from those discussions. Since RS5000 was being promoted as a new product, Harley should have taken steps to satisfy itself that its use complied with the Building Regulations and any relevant statutory and industry guidance. However, it failed properly to do so. 65.46 Although Harley expected to be, and in due course was, appointed as a specialist cladding sub-contractor with responsibility for the design of the cladding, no one appears ever to have asked how functional requirement B4(1) was to be satisfied or which (if any) of the routes to compliance set out in Approved Document B it was proposed to follow. That was a serious failure, because unless it knew the answer to that question it could not tell whether RS5000 could properly be used. Indeed, Harley does not appear to have paid much attention to the fact that RS5000 was on the face of it a different product from that specified in the NBS Specification. The fact that RS5000 was in fact identical to FR5000 just means that in that respect Harley’s incompetence did not result in any harm. 65.47 As a result of the conversations between Jonathan Roome and Ben Bailey in June 2014, Harley was well aware that Celotex did not at that time offer a product that was suitable for use on buildings above 18 metres in height.3162 There was therefore no reasonable basis on which Daniel Anketell-Jones could have thought that the fire performance of RS5000 had been investigated by Studio E during the preparation of the NBS Specification or that it had been “checked through with desktop studies”,3163 not least since RS5000 was not in the NBS Specification. Indeed, it could not have been because it did not exist as a separate brand in November 2013. 65.48 Ben Bailey claimed that after he had become involved in the project in February 2015 he had read the parts of the NBS Specification that concerned Harley’s work.3164 They clearly prescribed the use of a different Celotex insulation product, FR5000. Nonetheless, he did not question the use of RS5000 even though he must have realised that it was not the 3157 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/49} paragraph 12.1. 3158 Sakula {Day125/166:7-17}. 3159 Sakula {Day125/163:17}-{Day125/164:18}. 3160 Task call record following call from Harley Facades regarding insulation {CEL00009874}. 3161 See Chapter 56. 3162 Ben Bailey {Day39/55:15-25}; {Day39/56:1}. 3163 Anketell-Jones {Day36/102:13-19}. 3164 Ben Bailey {Day39/64:21-25}; {Day39/65:1-19}.

The Grenfell Tower Inquiry: Phase 2 Report 304 product specified. Mr Anketell-Jones said that he was not aware that anyone at Harley had considered whether Celotex FR5000 was suitable;3165 indeed, he could not remember that it had been included in the specification at all.3166 65.49 Harley also failed properly to examine the sales and technical literature relating to the Celotex RS5000 insulation. On 27 August 2014, Jonathan Roome sent Daniel Anketell-Jones a pack of information about Celotex RS5000, which included a detailed specification and testing information.3167 Mr Anketell-Jones said that his usual practice had been to pass information of that kind to others so that the suitability of the materials in question could be checked, but in that particular case he had not sent it to anyone else, nor had he taken any other steps to check whether the fire performance of RS5000 made it suitable for use.3168 His explanation was that he would have done so if he had been the designer, but that he had not considered that to be part of his responsibility.3169 65.50 In fact, Mr Anketell-Jones did not know, or trouble himself to find out, whose job it was within Harley to check such matters and he appears not to have considered whether Kevin Lamb was likely to have read the information.3170 For his part, Ray Bailey did not read the literature himself; he simply assumed that Mr Anketell-Jones had read it.3171 Kevin Lamb said that he had read what he described as a “compliance guide” on RS5000 produced by Celotex but did not discuss its contents with anyone or look into the suitability of the product.3172 If Harley had properly considered Celotex’s product literature or got beyond the pink banner on the first page, it would have seen that the claim that RS5000 had been classed as suitable for use above 18 metres applied only if the product was incorporated into a cladding system identical to the one that had been tested.3173 65.51 Harley’s Specification Notes of 15 July 20153174 did not specify the type of insulation that was to be used. Further, although its drawings included references to insulation, they did not include a description of what product was to be used either. That deprived others who might review the drawings of the ability to identify the products and conduct their own checks. Kingspan K15 65.52 As we have said,3175 Kingspan K15 was used as a last-minute substitute for Celotex RS5000 when there was a delay in obtaining supplies of that product. It was used without any proper investigation being made into its suitability for that purpose or into whether its use would result in an external wall that complied with the Building Regulations or was consistent with statutory or industry guidance. Harley must bear primary responsibility for that failure, which was the result of a decision made without consulting Rydon or Studio E. 3165 Anketell-Jones {Day36/71:10-22}. 3166 Anketell-Jones {Day36/70:21}-{Day36/71:4}. 3167 {CEL00011960}; {CEL00011961}; {CEL00011962}; {CEL00011963}; {CEL00011964}; {CEL00011965}; {CEL00011966}; {CEL00011967}. 3168 Anketell-Jones {Day36/88:13-19}. 3169 Anketell-Jones {Day36/88:17-19}. 3170 Anketell-Jones {Day36/93:4-13}. 3171 Ray Bailey {Day33/78:4-20}. 3172 Lamb {Day38/37:24}-{Day38/38:4-7}. 3173 {CEL00000012/3}. 3174 {RYD00046822}. 3175 See Chapter 56.

Part 6 | Chapter 65: The contribution of Harley 305 65.53 Ben Bailey was aware that K15 had not been included in the NBS Specification, but the fact that Harley had installed it on other projects led him to assume that it was suitable for use on Grenfell Tower.3176 He said that he had asked around in the Harley office whether it could be substituted for RS5000, despite the fact that it was not referred to in the NBS Specification.3177 He referred to the version of the British Board of Agrément certificate relating to K15 dating from 2008, rather than the more recent version, because Harley happened to have had a copy on file at the time. He was not aware that a more recent certificate had been issued.3178 65.54 Ben Bailey did not examine the relevant LABC or British Board of Agrément certificates for the product (indeed, Harley possessed only a copy of the British Board of Agrément certificate issued in 2008, which was long out of date3179) and took no steps to find out whether Kingspan K15 was a material of limited combustibility.3180 Nonetheless, he proceeded to place orders for K15 in May and September 2015 and to install it on the tower without telling Rydon (or anyone else) that it was being used.3181 In both respects Harley failed to meet the standard of a reasonably competent cladding contractor. 65.55 It was not until December 2015 or January 2016, that Harley, facing another interruption to the supply of RS5000, sought permission from Rydon to substitute Kingspan K15 for Celotex RS5000.3182 Permission was readily granted, but without any thought having been given to the characteristics of the material.3183 Ben Bailey assured Rydon that the products were substantially the same, although he had no basis for doing so, both because he did not have the technical expertise to make that assessment and because he had taken no steps to check that it was correct.3184 Rydon failed to enquire into the suitability of the product or to inform the TMO or building control that it was being used.3185 65.56 Viewing the evidence in the round, it is clear to us that Harley failed adequately to examine the information it had been given about the products that it included in its designs. A reasonably competent cladding contractor would have taken steps to satisfy itself that any information it was given was relevant and reliable, but Harley failed to do so. In that respect it fell below the standard to be expected of a reasonably competent cladding contractor. Window infill panels 65.57 When he first prepared Harley’s Specification Notes in January 2015, Kevin Lamb proposed the use of Kingspan TP10 for the insulated panels within the window assemblies,3186 but he did not consult Approved Document B or any other guidance to help him understand the fire performance required of materials to be used for that purpose.3187 He had not seen any certificates relating to TP10 and failed to investigate its fire performance or 3176 Ben Bailey {Day39/31:23}-{Day39/32:3}; {Day39/142:11-14}. 3177 Ben Bailey {Day39/117:3-19}. 3178 Ben Bailey {Day39/118:20}-{Day39/119:7}. 3179 {BBA00000038}; Ben Bailey {Day39/119:5-19}. 3180 Ray Bailey {Day33/102:17-25}; Ben Bailey {Day39/127:21-25}. 3181 {SIG00000012}; {SIG00000013}. 3182 Hughes {RYD00094213/10} page 10, paragraph 55. 3183 Hughes {Day27/71:23}-{Day27/72:1}. 3184 Ben Bailey {Day39/107:1-3}; {Day39/108:11-19}. 3185 Blake {Day29/115:7}-{Day29/117:11}; Hughes {Day27/67:5}-{Day27/68:8}; {Day27/70:4-6}. 3186 {HAR00003866}. 3187 Lamb {Day38/174:2-5}.

The Grenfell Tower Inquiry: Phase 2 Report 306 otherwise to check that it was suitable for that purpose.3188 The specification for the panels was ultimately changed to Styrofoam, but, again, Harley did not take any steps to find out whether the material was suitable for the use to which it was to be put.3189 65.58 The guidance given in Approved Document B was that the insulation in the window infill panels should be of limited combustibility in order to comply with the requirements of the Building Regulations. We are satisfied that a reasonably competent cladding contractor would have carried out careful and thorough checks on products of that kind each time they used them.3190 We have concluded that Harley failed to act in accordance with the standards to be expected of a reasonably competent cladding contractor in selecting those products without properly investigating their suitability. Cavity barriers 65.59 Between August 2014 and May 2015, Harley produced fabrication drawings of the details around the windows of Grenfell Tower which contained a series of fundamental errors that were identified by Mr Hyett. The structures they described did not comply with the Building Regulations and did not reflect the guidance given in Approved Document B.3191 65.60 The initial design of the cavity barriers had been produced by Studio E and passed to Harley for development in August 2014.3192 Kevin Lamb first produced detailed drawings of the window arrangements on 22 August 2014,3193 but they did not show cavity barriers within the facade. As such, they did not reflect the guidance in Approved Document B and could not be expected to produce a building that complied with functional requirements B4(1) and B3(4) of the Building Regulations. Thereafter, further versions of Kevin Lamb’s designs were provided to Rydon and Studio E and were reviewed in design team meetings3194 but no one commented on the absence of cavity barriers.3195 65.61 Harley should have been aware of the need to install cavity barriers around windows because of its experience of the fire at Taplow House on the Chalcots Estate in January

1. That was one of its previous overcladding projects which had suffered a fire but at

which cavity barriers around the window had played a significant part in preventing the fire from spreading into the external wall. The significance of the cavity barriers had either not been properly appreciated or the lesson had been forgotten by the time Harley came to design the external wall of Grenfell Tower. 65.62 Nonetheless, the request for information which Daniel Anketell-Jones sent to Rydon and Studio E on 17 September 2014, in which he asked about the need for horizontal firebreaks within the cladding areas,3196 shows that Harley had given some thought to the need for cavity barriers and that it understood that cavity barriers were required within the facade at least to some extent. However, no one at Harley appears to have considered any of the available guidance before making that request.3197 3188 Lamb {Day38/179:10-18}. 3189 Lamb {Day38/187:1-9}. 3190 Sakula {Day125/111:18-24}. 3191 Hyett, Section 4 – Failures of Statutory Compliance {PHYR0000029/107-132} paragraphs 4.4.91-4.4.136. 3192 {HAR00010412/2}. 3193 {HAR00010426}. 3194 See Chapter 57. 3195 Crawford {Day10/185:2-5}; {Day10/185:11-14}; {HAR00010423/2}. 3196 {SEA00011703}. 3197 Anketell-Jones {Day36/158:10-13}, Lamb {Day38/74:5-11}.

Part 6 | Chapter 65: The contribution of Harley 307 65.63 Harley asked for advice from Studio E, Exova and building control on the level of fire resistance that was required for the horizontal cavity barriers within the facade.3198 On 18 September 2014, Daniel Anketell-Jones asserted in an email to Neil Crawford that cavity barriers were not required in certain locations since the insulation was Class 0,3199 but that was wrong. In his oral evidence, he accepted that in that email he had been expressing an opinion on what was required to comply with the guidance given in Approved Document B,3200 but he had not looked at it before doing so, nor had he sought any other advice to confirm that his view was correct.3201 65.64 Between September 2014 and March 2015, Harley (in particular, Kevin Lamb) continued to develop the design of the windows. Further versions of Harley’s drawings were circulated among the design team, none of which showed cavity barriers.3202 Ray Bailey was aware of the importance of effective cavity barriers around windows but did not draw attention to the absence of cavity barriers around the windows in Harley’s drawings. There appear to have been no discussions within Harley about what Approved Document B recommended in that respect.3203 65.65 It was not until 3 March 2015 that Kevin Lamb included cavity barriers in his designs for the first time.3204 His explanation for their inclusion at that stage was that completion of the designs had by then become urgent because construction had already begun and the cladding would soon be installed.3205 Even at that extremely late stage, however, Harley made no effort to satisfy itself that its designs complied with the guidance given in Approved Document B. In fact, as Mr Hyett explained, they did not. Among other things, there was still no provision for cavity barriers around the windows.3206 65.66 Harley and the design team more generally were evidently deeply unsure about what was required in the way of cavity barriers, because there followed further discussions between Studio E, Exova, building control and Siderise (the manufacturer) in an effort to ascertain whether Harley’s designs were acceptable.3207 The result of those conversations was yet further confusion and disagreement, largely because building control and Siderise differed in their view of what was required.3208 The issue was finally resolved to the satisfaction of building control in April 2015,3209 but Harley continued to seek advice from Siderise in May and June 2015.3210 65.67 This episode reflects very poorly on all those involved. As a result of the fire at Taplow House in 2012, at which cavity barriers had played an important part in restricting the spread of fire, Ray Bailey and Daniel Anketell-Jones should have been aware of their importance for fire safety, but the significance of that incident appears to have been forgotten.3211 3198 {HAR00003638/3-4}; see also Chapter 57. 3199 {HAR00012103}. 3200 Anketell-Jones {Day36/166:2-16}. 3201 Anketell-Jones {Day36/166:25}-{Day36/166:7}. 3202 {SEA00011759}, attaching {RYD00018436}; {RYD00018537}; {RYD00018687}; {SEA00012531} attaching {SEA00003040}. 3203 Lamb {Day38/92:16}-{Day38/93:9}. 3204 {SEA00012850}. 3205 Lamb {Day38/97:5-14}. 3206 Lamb {Day38/101:11-14}. 3207 {HAR00004013}; {EXO00001319}; {SEA00012906}; {SEA00000252}; {SEA00012927}; {HAR00003999}. 3208 See Chapter 57. 3209 See Chapter 57. 3210 {HAR00004238}; {HAR00019012/2}. 3211 Anketell-Jones {Day35/149:14-19}.

The Grenfell Tower Inquiry: Phase 2 Report 308 65.68 The evidence indicates that Harley was largely ignorant of the technical aspects of using cavity barriers and as a result was forced to rely too heavily on the advice of other members of the design team and the manufacturer. As the specialist cladding contractor, Harley could reasonably have been expected to possess a far greater degree of technical knowledge of the Building Regulations and Approved Document B in relation to the use and installation of cavity barriers than was the case. 65.69 It is particularly troubling that, although Kevin Lamb noticed that Studio E had failed to include cavity barriers around the windows3212 and told us that he had understood that Approved Document B required them in that location as an important means of ensuring the safety of residents,3213 he nonetheless failed to ask why they were missing or whether the designs complied with regulatory requirements. We do not accept his evidence that it was not his place to raise the matter.3214 He had no reason to think that others at Harley considered that cavity barriers were unnecessary or that anyone at Harley had consulted Studio E.3215 65.70 Harley ought to have played an active part in the design of the cavity barriers and should have ensured that a detailed cavity barrier strategy had been established before construction work began. Even by March 2015, however, some eight months after it had been appointed by Rydon,3216 Daniel Anketell-Jones remained unaware that Harley was working to the NBS Specification or what it contained.3217 The NBS Specification required Harley to design a system that contained fire stopping in accordance with the requirements of the Building Regulations, but Daniel Anketell-Jones did not ask himself what that meant because he failed to read it.3218 He repeatedly claimed that he did not have time to engage with the details of the NBS Specification, or design generally, because he was working on other projects.3219 65.71 Harley’s work on the architectural crown was carried out at a late stage.3220 Its designs for the crown omitted the cavity barrier at the top of the columns that had been included in the drawings produced by Studio E3221 and thus detracted from the original design.3222 Kevin Lamb said that he had intended to check whether the design required amendment to include a cavity barrier after it had been reviewed by the architect, but said that his question had ultimately been overlooked.3223 Overall it is clear that Harley failed to give any proper consideration to the fire performance of the crown. While the failure to include cavity barriers in the crown may not have contributed significantly to the spread of the fire,3224 it reflects Harley’s failure to give proper consideration to the fire safety of the facade. 3212 Lamb {Day38/54:5}-{Day38/56:24}. 3213 Lamb {Day38/58:5-18}. 3214 Lamb {Day38/56:23-24}. 3215 Lamb {Day38/57:25}-{Day38/58:3}. 3216 {HAR00005867}. 3217 Anketell-Jones {Day37/26:1-5}. 3218 Anketell-Jones {Day37/38:10-22}. 3219 Anketell-Jones {Day35/133:10-24}; {Day37/40:6-10}; Anketell-Jones {HAR00010149/3-4} pages 3-4, paragraph 14. 3220 Lamb {HAR00010419/9-10} pages 9-10, paragraph 35. 3221 {SEA00003242}; Crawford {Day11/66:9-11}; {SEA00002551}. 3222 Lamb {Day38/163:23}-{Day38/164:5}. 3223 Lamb {Day38/165:7-14}. 3224 Grenfell Tower Inquiry Phase 1 Report, Volume IV, {INQ00014817/59} paragraph 23.60.

Part 6 | Chapter 65: The contribution of Harley 309 The design process 65.72 Harley’s failure to produce designs for the refurbishment that complied with its contractual obligations reflected a failure properly to manage its own resources and a misunderstanding of its role in the refurbishment and the roles of other members of the design team. Supervision and management 65.73 As an organisation, Harley failed to ensure that the various people engaged on the project were aware of the scope of their individual responsibilities. Ray Bailey and Ben Bailey both thought that Daniel Anketell-Jones was responsible for ensuring that designs produced by Harley (including those produced by Kevin Lamb on its behalf) complied in all respects with regulatory requirements.3225 For his part, although he had been designated as design manager for the refurbishment, Mr Anketell-Jones said that he had not considered supervision of the design process to be part of his responsibility.3226 We find that difficult to understand and think his evidence is probably best explained by the fact that the amount of work he had on other projects made it difficult for him to look at the designers’ work.3227 65.74 As we have already said, we do not think that as a witness Mr Anketell-Jones was always candid or reliable. In particular, we do not accept that his role in the design process was as limited as he suggested. His evidence was inconsistent with communications between Harley and Rydon, which indicated that he would be reviewing drawings on Harley’s behalf.3228 We prefer the evidence of Ray Bailey and Ben Bailey that he was given responsibility for checking the design work carried out by Harley, including the work done by Kevin Lamb on its behalf. 65.75 Mr Anketell-Jones had not read the contract between Harley and Rydon and did not accept that it was important for him to understand the nature of Harley’s contractual responsibilities.3229 He thought that his responsibility as design manager was simply to ensure that the designers, in particular Kevin Lamb, were keeping up with the programme3230 and that the architect was responsible for approving the drawings Mr Lamb produced.3231 He was not aware, therefore, that Harley was contractually responsible for ensuring that the facade of the tower complied with the relevant statutory requirements3232 and did not apply his mind to the question whether the materials to be used would ensure that was the case.3233 If he did think at the time that the architect was responsible for checking the drawings produced by Mr Lamb (which we doubt), he was wrong and his responsibilities had not been properly explained to him. It was an important part of his role as design manager, and of Harley’s generally, to supervise the work of Kevin Lamb in order to ensure that the designs he produced would result in a building that complied with 3225 Ray Bailey {Day32/17:21}-{Day32/18:2}; Ben Bailey {Day39/19:13-21}. 3226 Anketell-Jones {Day35/133:10-14}. 3227 Anketell-Jones {Day35/133:17-19}. 3228 Email dated 24 April 2014 from Mark Harris, “Our Dan will be taking a look at these on Monday” {HAR00005711}; Email dated 31 July 2014 from Mark Harris, “Lead designer will be Dan Anketell-Jones.” {HAR00005916}. 3229 Anketell-Jones {Day35/195:3-15}. 3230 Anketell-Jones {Day36/19:16-18}. 3231 Anketell-Jones {Day35/195:3-15}. 3232 Anketell-Jones {Day35/195:16-21}. 3233 Anketell-Jones {Day35/183:13}-{Day35/184:5}.

The Grenfell Tower Inquiry: Phase 2 Report 310 the Building Regulations.3234 For his part, Kevin Lamb assumed that the suitability of the materials intended for use in the refurbishment had been considered and settled before he became involved on the project.3235 65.76 The development of the design of the windows of Grenfell Tower between September 2014 and March 2015 provides a telling example of Harley’s failure properly to supervise Mr Lamb’s work. During that period, Mr Lamb produced detailed drawings of the windows, none of which included cavity barriers in the required positions. The omission was not detected by Harley because it did not review the development of the design or examine with any care the drawings he produced.3236 65.77 In the light of Mr Sakula’s evidence, we are satisfied that a reasonably competent cladding contractor would have established a system for supervising its sub-contractors. Such a system should have ensured that the work they carried out complied with relevant statutory requirements, industry guidance and normally accepted standards of safety.3237 In our view there were fundamental deficiencies in Harley’s management which directly led to the creation of a design that did not comply with statutory guidance and could not be expected to result in a building that complied with the functional requirements of the Building Regulations. In that respect Harley fell short of the standard to be expected of a reasonably competent cladding contractor. Relationship with Studio E 65.78 Harley also failed properly to manage its relationship with the other key designer, Studio E. It was content to assume that Studio E had considered and checked all those aspects of the external wall construction that had a bearing on fire safety. That was not the case, however, and it was not appropriate or reasonable for Harley to make that assumption, particularly in the face of clear evidence that Studio E had not done so.3238 Harley should have taken steps to satisfy itself independently that the form of construction and the materials described in those drawings would result in a building that complied with the Building Regulations, but it failed to do so.3239 65.79 Daniel Anketell-Jones’ belief that Studio E was checking the drawings produced by Harley for compliance with the relevant requirements was founded on nothing more than an assumption; he did not speak to Studio E or take any other steps to confirm his understanding.3240 Ray Bailey said that if Harley was not entirely clear on a question of compliance, it would ask the architect and ultimately expect building control to decide whether the design complied with the regulations.3241 However, he assumed that the drawings were being checked by Studio E without ever taking steps to verify whether that was so.3242 There is very little evidence, however, that Harley ever sought to resolve doubts about compliance by referring a question to a third party. The reason may not be far to seek: it regarded everyone involved in any aspect of the design, other than itself, even including building control, as responsible for ensuring fire safety. Its approach to a matter of such importance was irresponsible, regardless of its contractual obligations. 3234 Anketell-Jones {HAR00010149/3-4} pages 3-4, paragraph 14. 3235 Lamb {Day38/21:2}-{Day38/22:12}. 3236 Anketell-Jones {Day36/176:4-23}; see also Chapter 57. 3237 Sakula {Day125/72:22}-{Day125/73:17}. 3238 For example, Harley knew that Studio E had not approved the use of Celotex RS5000, which did not appear in the NBS Specification – see Chapter 56. 3239 Ray Bailey {Day32/51:15}-{Day32/52:13}. 3240 Anketell-Jones {Day36/34:6-11}. 3241 Ray Bailey {Day32/53:7-12}. 3242 Ray Bailey {Day32/51:15}-{Day32/52:13}.

Part 6 | Chapter 65: The contribution of Harley 311 65.80 Studio E considered that its obligation to review drawings produced by Harley was limited to ensuring that they conformed to “architectural intent”, meaning that they were consistent with the appearance contemplated by the original design. We have already concluded that its understanding about that was wrong; it was not consistent with its contract with Rydon, nor did it reflect common practice among architects, as confirmed by Mr Hyett. However, as the specialist cladding sub-contractor, Harley should have taken steps to ensure that its own designs complied with any relevant legislation and guidance, regardless of Studio E’s approach to its work. Kevin Lamb 65.81 Kevin Lamb pointed out, correctly, that the decision to use ACM panels in place of the zinc originally specified by Studio E had been made before he had become involved in the work.3243 However, he took no steps to familiarise himself with the products that were the subject of his designs, particularly their fire performance. He understood that ACM panels comprised a core material between two thin sheets of aluminium but did not know what the core was made of and made no effort to find out.3244 65.82 Despite being responsible for creating Harley’s drawings, Kevin Lamb gave no thought to questions of compliance with the Building Regulations and was instead content to assume that such matters were being considered by someone else.3245 He said that it had never crossed his mind to consider whether there was a British Board of Agrément certificate for Reynobond PE 55 ACM,3246 let alone to look at it. Installation 65.83 Harley’s failure properly to supervise and manage its own staff extended to its management of Osborne Berry, which it had engaged to install the facade. Ben Bailey described his shock at seeing photographs of the cavity barriers taken after the fire and said that he had not seen workmanship like that on site.3247 He sought to explain his failure to notice the defects by suggesting that the insulation had covered the junction between the cavity barriers and the existing concrete walls, making it impossible to identify any defects without dismantling and damaging the finished works.3248 We do not accept that explanation, however, as there must have been many opportunities to inspect the cavity barriers before the insulation was fitted.3249 Ben Bailey accepted that he ought to have been carrying out inspections at each stage of the installation.3250 If he had done so, he would have inspected the work before the insulation obscured the back of the cavity barriers and it is likely that at least some of the problems would have come to light. We are satisfied that Harley failed to inspect the work of Osborne Berry with sufficient frequency or care to ensure that the defects noted above were identified. In our view the defects in the installation of the cavity barriers reflect a serious lack of competence on the part of Harley itself and Osborne Berry. 3243 Lamb {HAR00010419/5} page 5, paragraph 20. 3244 Lamb {Day38/19:2-14}. 3245 Lamb {Day38/19:15-19}; {Day38/37:14}-{Day38/38:7}; {Day38/40:7-10}. 3246 Lamb {Day38/23:17-20}. 3247 Ben Bailey {HAR00010060/10} page 10, paragraph 32. 3248 Ben Bailey {HAR00010060/10} page 10, paragraph 32. 3249 Berry {Day44/59:9-14}. 3250 Ben Bailey {Day40/164:1-9}.

The Grenfell Tower Inquiry: Phase 2 Report 312 Failure to concern itself with fire safety 65.84 Viewing the evidence as a whole, we are left with the clear impression that Harley did not concern itself sufficiently with fire safety at any stage during the refurbishment. Its attitude appears to have been that there was no need for it to do so, because others involved in the project, and ultimately building control, would ensure that the design was safe. Its approach is reflected in its response to the following situations. 65.85 The first arose from the formal request for information about the incorporation of cavity barriers or fire breaks in the external wall of the tower, in the course of which Mr Ashton referred to the possibility that the insulation might be combustible.3251 That should have prompted Harley to consider whether RS5000 was combustible and whether it could safely be used in that situation. It is particularly surprising that Mr Anketell-Jones did not think it necessary to make such enquiries, given that he understood it to be a different product from FR5000 that had been specified,3252 but he did not raise the question with any other member of the design team, nor did he take any other steps to find out whether the new product was acceptable to Rydon or Studio E.3253 He said that he had expected Kevin Lamb to tell Studio E that Harley intended to use Celotex RS5000 so that Studio E could consider its suitability,3254 but he had not discussed the use of Celotex RS5000 with Kevin Lamb and had not provided any of the relevant information to him.3255 65.86 The second arose out of a discussion in March 2015 about the fire resistance required of the cavity barriers to be installed in the external wall. In the course of that discussion Mr Anketell-Jones referred to the likelihood that ACM panels would disappear quickly in a fire. That did not, however, prompt him to look into the characteristics of ACM PE or to ask himself (or anyone else) whether it was suitable material for use on the tower. That is surprising because only a few months earlier, in October 2014, he had attended the Annual General Meeting of the CWCT at which a presentation had been given by Dr Colwell of BRE on the then recent spate of cladding fires in various countries.3256 Natural curiosity, if not professional competence, might have led Mr Anketell-Jones to enquire into the nature of Reynobond 55 PE to see whether it might give rise to a similar problem, but regrettably neither caused him to make or instigate the kind of enquiries that a reasonably competent cladding contractor would have made under those circumstances. 65.87 The third relates to a warning given by Mr Mort of Siderise Ltd, the company which made the cavity barriers, that the design of the window fixings contained what he described as a “weak link for fire.” Mr Mort identified the area of weakness on a copy of a drawing sent to him by Ben Bailey, but Ben Bailey failed to pass the comment to Studio E, Rydon or Exova and took no steps to ensure that it was removed. Mr Mort copied his email to Kevin Lamb and Ray Bailey, but neither of them took any action in response to it. Kevin Lamb said that he had not noticed the warning about a weak link at all, despite having read the email,3257 and did not raise the matter with any other member of the design team.3258 Ray Bailey could not explain why he had not pursued the matter with Mr Mort3259 but he ultimately accepted that the only sensible course of action had been to raise the matter 3251 See Chapter 54 and Chapter 57. 3252 Anketell-Jones {Day36/102:13-19}. 3253 Anketell-Jones {Day36/171:13-16}; {Day36/108:17-25}. 3254 Anketell-Jones {Day36/79:14}-{Day36/80:5}. 3255 Anketell-Jones {Day36/65:20}-{Day36/66:10}. 3256 {CEL00001038}. 3257 Lamb {Day38/138:8-20}; {Day38/141:24}-{Day38/142:4}. 3258 Lamb {Day38/142:21-24}; {Day38/144:3-5}. 3259 Ray Bailey {Day33/160:2-7}.

Part 6 | Chapter 65: The contribution of Harley 313 with building control to ensure that the design was safe.3260 The result of their inaction was that no attempt was made to address the weak link, which became part of the external wall of the tower. 3260 Ray Bailey {Day33/160:13-25}.

314 The Grenfell Tower Inquiry: Phase 2 Report

315 Chapter 66 The contribution of the Tenant Management Organisation 66.1 Responsibility for the dangerous condition of Grenfell Tower following the refurbishment project, including the presence of combustible materials in the walls and around windows, rests primarily on those who designed, constructed and approved the work and some of those who manufactured and sold the materials they used. However, the TMO itself must take a share of the blame for the disaster. In Chapters 51, 53, 54 we have made a number of criticisms of the TMO in its role as client and in Parts 4 and 5 we have described certain shortcomings in its management of the building. Overall, we have concluded that as the client for the refurbishment, the TMO failed to take sufficient care in its choice of architect and paid insufficient attention to fire safety matters, including the work of the fire engineer. The procurement of professional consultants 66.2 Neither Mark Anderson, the interim Director of Assets and Regeneration, who was primarily responsible for managing the project, nor anyone else within the TMO, gave proper attention to the choice of architect for the refurbishment project, being content to acquiesce in the desire of RBKC to engage the team that it had used on the KALC project in the hope of reducing both cost and delay.3261 Minimising cost and delay was a laudable aim, but not one that could justifiably be pursued at the risk of appointing a firm that lacked the necessary experience. 66.3 As a result of the TMO’s decision to appoint Studio E, there was no competitive process for the appointment of the architect and therefore no independent assessment of its experience in designing a project of the kind under consideration.3262 Instead, the TMO assumed that Studio E had the skills, knowledge, experience and resources to carry out a high-rise residential overcladding project, which was fundamentally different from designing a school or leisure centre. That assumption turned out to be incorrect and led to a series of decisions which had disastrous consequences. 66.4 As the client under the CDM Regulations 2007, the TMO had a duty to take reasonable steps to ensure that any designer, principal contractor or contractor it appointed was competent to take on the role in question3263 and had allocated sufficient time and resources to the project.3264 There is no evidence that the TMO was aware of that obligation. 66.5 The TMO ought to have taken steps to satisfy itself that Studio E had, or could obtain, the right skills and resources to carry out the work efficiently. If it had done so, it would have learnt that Studio E had no experience of overcladding a high-rise residential building and in those circumstances it might have looked elsewhere for an architect or insisted that Studio E hired someone with expertise in facade engineering.3265 3261 Chapter 52. 3262 Chapter 52. 3263 {INQ00011315/4} Regulation 4(1). 3264 Regulation 9 of the CDM Regulations 2007; Approved Code of Practice L144 {INQ00013936/15} paragraph 43 (a); {INQ00013936/16} paragraph 47. 3265 Hyett {Day63/86:2}-{Day63/87:23}; {Day64/3:20}-{Day64/4:3}.

The Grenfell Tower Inquiry: Phase 2 Report 316 66.6 The failure of the TMO to concern itself with Studio E’s previous experience is all the more remarkable in view of the fact that one of the residents of Grenfell Tower had raised that very question. At a meeting of the Lancaster West Estate Management Board on 15 May 2012, at which representatives of the TMO and Studio E were present, Edward Daffarn asked whether Studio E had experience of working on tower blocks and, if not, why it was proposed that it should be appointed as architect for the refurbishment.3266 Although he was told by Cllr Coleridge at some stage that Studio E had been chosen in the interests of financial and practical efficiency, it does not appear that Mr Daffarn ever received an answer to his question from the TMO.3267 It certainly never prompted the TMO to ask that question of itself or anyone else. Avoiding the procurement rules 66.7 We have described in Chapter 52 how in order to avoid holding a formal competitive procurement procedure for professional services the TMO insisted that the architect’s fees for work carried out before the appointment of a principal contractor be capped at £174,000.3268 Since that was insufficient to cover the amount of work required to produce the tender documents, it was necessary to resort to the device of deferring part of those fees until after the principal contractor had been appointed.3269 We need hardly say that it was quite improper for the TMO to resort to a scheme of that kind in order to evade the rules on procurement and, as Simon Cash implicitly accepted,3270 Artelia, as employer’s agent, ought to have made it clear to the TMO that it was in breach of procurement rules by capping the fees of its consultants. Instead, it appears that it simply acquiesced in the TMO’s plan. The unfortunate practical result was that the TMO deprived itself of the opportunity to select an architect from a wider range of applicants, some of whom might have had more relevant experience. Failure to notice that Exova’s work was incomplete 66.8 It does not seem that anyone at the TMO read any of the versions of Exova’s Outline Fire Safety Strategies, in detail or at all, even though they were produced for it as Exova’s client.3271 Both the draft Existing Fire Safety Strategy and the draft Outline Fire Safety Strategy should have been documents of particular interest to the TMO, both as a client which was managing works in a mixed-use occupied residential block and as the responsible person under the Fire Safety Order. The TMO should have taken care to make sure that the safety of the residents from fire had been comprehensively and finally addressed in detail. Instead, it assumed that others had considered the fire safety of the building and failed to appreciate its own responsibility for a matter of such importance. 66.9 David Gibson, Peter Maddison and Claire Williams should all have read Exova’s fire safety strategies carefully. In our view, the draft Outline Fire Safety Strategy was not difficult to understand and they should certainly have noticed that, in relation at least to the external wall, the advice it contained was provisional only. It appears, however, that none of them read it or, if they did, that they did not take proper note of its contents.3272 If they had paid attention to what it said, they would have realised that the strategy was incomplete in relation to functional requirement B4(1) and that it required further work. 3266 Treasury Report of 15 May 2012 at {TMO00848807/4}. 3267 Daffarn {Day118/20:17}-{Day118/22:1}. 3268 Chapter 52. 3269 Chapter 52. 3270 Cash {Day48/113:19}. 3271 Williams {Day55/69:14}-{Day55/70:19}. 3272 Gibson {Day53/142:23}-{Day53/143:22}; Maddison {Day59/122:11}-{Day59/128:20}.

Part 6 | Chapter 66: The contribution of the Tenant Management Organisation 317 66.10 There were at least two occasions during the life of the project when it was made clear to the TMO that Exova’s work was incomplete. Terry Ashton told Claire Williams on 4 November 2013 (three days before Issue 3 of the Outline Fire Safety Strategy was produced) that after invoicing everything as of that date, there would be a balance remaining from the initial quotation.3273 That should have alerted her to the fact that Exova had not by then done all that it had expected to do under its contract. By November 2013, many key design decisions had not been made, including the choice of rainscreen cladding. If anyone at the TMO had turned their minds at that stage to the point, they would have realised that the fire safety strategy had not been completed and that further work had to be done on it. Not to have done so was a serious failing on its part. Failure to challenge Rydon’s decision not to appoint a fire safety consultant 66.11 The TMO failed to ask why a fire engineer had not been engaged by Rydon after it had been appointed as principal contractor. The matter was raised at successive project meetings between June 2014 and October 2014 attended by the TMO and was mentioned in the minutes as requiring action by Rydon.3274 After October 2014 the matter ceased to be mentioned in the minutes, but the TMO appears to have taken no steps to find out whether a fire engineer had been appointed and if not, why. The TMO ought to have obtained a clear decision from Rydon and, if Rydon was unwilling to appoint a fire engineer, an explanation for it. Although Artelia, as employer’s agent, should have asked the same questions, the TMO as the employer had a responsibility of its own to monitor the work and ensure that it was being carried out effectively. In that case it failed to do so. 66.12 The TMO continued to retain the services of Exova, but in an unstructured way and on ill-defined terms. Members of the design team sought its advice from time to time, even though it was not a member of that team and had no insight into its thinking. The TMO paid for that advice as and when it was given but took no steps to clarify the terms of Exova’s engagement or to understand what services it wanted it to provide.3275 66.13 In these, as in other respects, the TMO relied too heavily on its professional advisers and failed to take responsibility for ensuring that the work was being carried out properly. Failure to resolve fire safety concerns 66.14 Having raised the fire performance of the cladding with Rydon in her email of 12 November 2014,3276 Claire Williams ought to have insisted on receiving a written response to her question. The matter was too important to be allowed to pass without comment. The fact that it had to be asked at all, in particular at what was a relatively late stage in the project (a year after the NBS Specification had been produced), is a matter of criticism in itself. The fact that an answer was not obtained is difficult to explain, even as an oversight. 3273 {TMO00855925}. 3274 Chapter 54. 3275 Chapter 54. 3276 Chapter 55.

The Grenfell Tower Inquiry: Phase 2 Report 318 Failure to involve residents 66.15 Since the refurbishment was being carried out while the building was occupied, it was particularly important for the TMO to engage with and consult the residents, both of the tower and of the surrounding area, in a meaningful and constructive way. Regrettably, however, it did not comply with the consultation and participation requirements in Schedule 3 of the Management Agreement.3277 No client review group3278 was established and no one from among the residents was nominated to join the project team or take part when consultants were appointed. 66.16 Similarly, as we have found in Chapter 53, any engagement the residents had with the procurement process was largely symbolic. Although consultation exercises and meetings with residents did take place,3279 they were given no formal role and had no voice during the refurbishment. In particular, they were given no opportunity to question or challenge key decisions, including decisions on the appointment of consultants and matters affecting fire safety. 3277 Volume 2, Chapter 2, Schedule 3 of the 2006 Modular Management Agreement {RBK00019006/163}. 3278 Paragraph 2.1 of Schedule 3 {RBK00019006/165}. 3279 See for example Sounes {Day 21/34:21}-{Day21/56:4}.

319 67.1 Having examined in the previous chapters the parts played by the main participants in the refurbishment, we are in a position to draw certain broader conclusions about the way in which they approached and carried out the project. It is appropriate to do so, because a number of common themes can be seen running through the story which, due to their nature, we think are likely to be repeated widely across the construction industry. By drawing attention to them now, we hope that we may encourage a change in the way that the various parties to large construction projects approach their work. Creating and understanding the contract 67.2 As the evidence progressed it became clear that many of those engaged on the project did not properly understand the nature and scope of the obligations they had undertaken, or, if they did, failed to pay much attention to them. The terms of Rydon’s contract with the TMO were lengthy and detailed, but in substance they imposed on it an obligation to carry out the whole of the design and construction work in accordance with all relevant statutory requirements. In particular, Rydon assumed responsibility to the TMO for all the design work that had previously been done by Studio E, including drawing up the NBS Specification and the Employer’s Requirements. 67.3 It is likely that some within Rydon were aware of the nature of the obligations it was taking on, but that does not appear to have been so in the case of those who were more directly involved in the construction work. Simon Lawrence, the contracts manager in charge of the Grenfell Tower project, appeared not to realise that Rydon was contractually responsible to the TMO for any mistakes made by Studio E in the pre-contract stage and by its various consultants and sub-contractors during the construction stage. However, at least Rydon had a formal contract to which it could resort to identify its obligations should the need arise. 67.4 Regrettably the same cannot be said of Harley, whose work as facade sub-contractor was carried out under a letter of intent that was clearly intended to be superseded by a formal contract but never was. The letter of intent expressly incorporated into the contract between Harley and Rydon the terms of Rydon’s contract with the TMO and contained a number of detailed appendices. Harley did not bother to read them, however, and in the absence of a formal contract did not concern itself with its legal obligations but set about its work following what it regarded as the standard practice in the industry. 67.5 Kevin Lamb was engaged to produce design drawings on behalf of Harley, but without any formal contract of any kind. 67.6 An even greater degree of informality affected the arrangements under which Osborne Berry was engaged to carry out the work of installing the cladding, comprising the insulation, the cavity barriers, the supporting rails and the rainscreen panels. The terms on which it was engaged were never reduced to writing; everything was done by word of mouth. It is not clear whether Mr Osborne or Mr Berry could have described in any detail the terms on which they were working. Chapter 67 Conclusions

The Grenfell Tower Inquiry: Phase 2 Report 320 67.7 A similar absence of formality characterised the engagement of some of the consultants. Although Studio E’s services were transferred from the TMO to Rydon in about April 2014, the deed containing the terms of that engagement was not executed until February 2016, when the work had been substantially completed. Exova, which had been instructed to produce fire safety strategies for the building, continued to be retained by the TMO after the appointment of Rydon, but neither the TMO nor Rydon nor Exova itself appear to have had a clear understanding of the terms on which it was acting or of its role or responsibilities, or to whom it owed them. 67.8 In our view, such a casual approach to contractual relations is a recipe for disaster if events take an unexpected turn. All those involved in whatever capacity in a complex project need to understand clearly what they have agreed to do and what they are responsible for. What appears to be a widespread culture of getting on with the job without waiting for terms to be formally agreed is unprofessional and likely to result in a failure by those carrying out the work on site to understand the scope of their responsibilities. It is an area in which the principal contractor has an important part to play, because it is at the level of sub-contracting and the engaging of consultants that the problem appears to be most acute. The principal contractor is the only person who can ensure that clear, documented contractual arrangements are in place before a sub-contractor or consultant begins work. Failure to identify responsibilities 67.9 The failure to put clear contract terms in place at the outset was likely to result in confusion if anything went wrong, but in this case it laid the ground for what turned out to be a more serious problem. As principal contractor, Rydon saw its role as little more than the conductor of a large and varied orchestra. It did not employ any of those whose knowledge and skills were required to design or carry out the refurbishment. They were engaged as sub-contractors and consultants as and when Rydon considered it necessary to obtain their services. Rydon saw its role as being to engage and manage a body of construction professionals, not to carry out any of the tasks itself. Insofar as it understood the broad scope of its obligations to the TMO, it considered them to have been satisfied by appointing others to perform them. 67.10 That had a number of unfortunate consequences. First, Rydon itself was ill-equipped to oversee the work of its sub-contractors and consultants, particularly those whose skills or expertise were of a more technical nature. Secondly, it was free to decide whether to obtain expert assistance and advice or do without it. Thus, in this case, Rydon originally agreed at the first project meeting in April 2014 that it would be desirable to instruct Exova to provide advice on fire safety, but eventually failed to make the appointment, probably because it thought it could manage without it, no doubt at a saving in cost. Thirdly, and in our view most importantly, there was a failure to establish clearly who was responsible for what, including who was responsible for ensuring that the designs were compliant with statutory requirements. That eventually resulted in the unedifying “merry-go-round of buck-passing” in which the construction professionals all pointed the finger at each other as being the person whose responsibility it was to make one or other of the critical decisions.

Part 6 | 67: Conclusions 321 67.11 Such is the complexity of modern construction that no principal contractor, particularly under a design and build contract, can be expected to retain in its own employment people with the full range of skills required for every project it takes on. Sub-contracting has been a feature of the construction industry for a very long time and will inevitably continue. Many sub-contractors are experts in their particular field and can afford to maintain skills and expertise in relation to a relatively narrow range of work of a kind that might be required by a principal contractor only occasionally. We do not criticise Rydon, therefore, for organising the work in a way that involved engaging sub-contractors to carry out individual elements, particularly of a specialist nature. However, if a contractor is to perform its obligations to the client in an effective and responsible way, it must ensure that within its organisation it has access to sufficient knowledge and expertise to be able to monitor the work of its sub-contractors and consultants effectively and to satisfy itself that their work complies with their obligations and with its own obligations to the client. In the present case, we do not think that Rydon did have that knowledge and expertise at its disposal. Instead, it relied blindly on its sub-contractors and consultants to exercise all relevant skill and care without being in a position to assess the quality of their work. 67.12 Although the model adopted by Rydon cannot in itself be criticised, it does make it essential that, as part of co-ordinating the work, the principal contractor establish clearly which person or organisation is to take responsibility for particular decisions. One of the striking features of the evidence was the number of times those involved in the refurbishment told us that a particular decision had been someone else’s responsibility. Rydon, as principal contractor, should have considered the various steps involved in designing and carrying out the work and identified which person, firm or company was responsible for the decisions relating to each of them. Since it undertook an obligation to the TMO for work done before it had been appointed, that should have included a retrospective examination of the preliminary design work, including the contents of the NBS Specification and the choice of materials included in it. It should also have identified clearly who was to take responsibility for the selection of materials chosen as a result of any value engineering exercise subsequently undertaken. In this case Rydon failed to do that and as a result all those involved, including Rydon itself, appears to have assumed that someone else was, or should be, taking responsibility for critical decisions, such as the choice of insulation, rainscreen panels and other materials. Competence 67.13 If the construction industry is to provide an effective service to society it is essential that those engaged in it at all levels and in whatever capacity be competent to carry out their functions and exercise all reasonable skill and care in doing so. Regrettably, the Grenfell Tower refurbishment was marked by a serious lack of competence on the part of many of those engaged on it and, in the case of some manufacturers of construction products, outright dishonesty. 67.14 It is not necessary to repeat here what we have said about the shortcomings of individual persons and bodies engaged in the refurbishment. It is clear from the findings we have made in the earlier chapters of this part of the report that in many respects those who were directly involved in the design and construction of the refurbishment failed in significant ways to meet the standards to be expected of competent professionals. That is particularly true of Studio E, Harley and Rydon. We were surprised at the limited knowledge of the Building Regulations, the statutory guidance and indeed industry guidance displayed by their employees, for whom a working knowledge of the regulatory regime should have been a fundamental requirement. We were also surprised by their

The Grenfell Tower Inquiry: Phase 2 Report 322 failure to inquire into the fire performance of the materials proposed for the external wall and their lack of concern about fire safety generally. None of them appears to have thought it possible that materials that had been used on previous occasions might not in fact be suitable in the context of the refurbishment and no one asked for advice or confirmation from a fire engineer. It is astonishing that none of those to whom Exova’s draft Outline Fire Safety Strategy was sent noticed that it was incomplete or thought it necessary to make sure that Exova had been given details of the build-up of the external wall. 67.15 The professionals’ lack of competence was also demonstrated by the way in which they communicated with each other in relation to the project. Although the TMO raised the fire safety performance of the cladding with Rydon on two occasions, it simply failed to respond and so a critical question at a key moment in the life of the project was left unanswered. The provision of information to building control was piecemeal and disorganised. Studio E on behalf of Rydon submitted old versions of drawings showing key features of the external wall that were never replaced with current versions. There was no attempt properly to document and record important design changes, not least the switch from zinc to ACM PE rainscreen panels, the introduction of Kingspan insulation when Celotex became unavailable and the use of uPVC window surrounds in place of plywood. At the end of the project the documentation provided was inaccurate, incomplete and disordered, not least the Health and Safety file required by the CDM Regulations. One result of that casual approach to record-keeping was that several of those involved in the project, including Exova and building control, were not told that ACM PE had been used for the rainscreen panels. 67.16 The way in which the Grenfell Tower refurbishment was handled raises serious questions for the whole of the construction industry. We were not asked to investigate the industry at large and we do not know whether the shortcomings we have identified are typical, although, judging by the evidence we heard, we think they are likely to have been widespread. It is not acceptable for large projects of this kind to be undertaken without proper contractual arrangements by parties who do not concern themselves with the regulatory regime and insist instead on carrying on in what they regard as the usual way. There is nothing wrong with a desire to “make it work”, provided that is not regarded as a sufficient reason for ignoring formalities and failing to keep safety high on the agenda. 67.17 Incompetence in the form of ignorance of the regulatory regime affecting construction has also infected both the approach of construction professionals to building control and, in some cases, the approach of building control itself. It became apparent that most, if not all, of those involved in the project regarded building control as, in effect, an additional consultant, whose function was to give advice on the design and choice of materials and act as a safeguard to ensure compliance with the Building Regulations. That contributed to a failure on the part of Rydon, Studio E and Harley to take proper responsibility for ensuring that the design of the external wall and the choice of materials it contained complied with the Building Regulations. That was bad enough, but it was compounded by the adoption of a similar attitude on the part of RBKC’s building control department, which saw its function as being to “work with” employers and contractors by enabling them to complete the work, rather than to act as the custodian and enforcer of the Building Regulations in the public interest.

Part 6 | 67: Conclusions 323 67.18 In our view there is a great deal to be done to raise the overall level of competence of those in the construction industry. They need to have a better knowledge and understanding of the regulatory regime and how it applies to the work they are carrying out. The disaster at Grenfell Tower has shown that it is not safe to assume without question that the way things have been done in the past is safe or satisfactory. A greater degree of scrutiny is called for, as is a better understanding of the function of building control. That needs to go hand in hand with a change in the way in which building control bodies understand their function, which is to police the regulatory regime. Their role is not to advise the applicant or building professionals how to comply with the regulatory regime and they should not be regarded by building professionals as a “safety net”. The role of the client 67.19 Even under a design and build contract the client has an important part to play because, among other things, it appoints the architect, who carries out the preliminary design work and in many cases continues to develop the design under a contract with the principal contractor. In most cases the choice of architect is likely to be dictated, at least in part, by experience of projects of a similar kind, unless the client is satisfied from enquiries that a particular firm has the capacity to undertake a project of the kind under consideration. 67.20 In the present case Studio E was chosen for reasons of a different kind and no steps were taken by the TMO to satisfy itself that the firm had the ability to tackle a project of a kind that it had not previously undertaken. That was a mistake, but not necessarily a serious one. In the event the real error lay in the failure of any of those at Studio E involved in the choice of materials for the external wall to pay proper attention to their reaction to fire. 67.21 The TMO consistently portrayed itself as an unsophisticated client, dependent on its professional consultants for advice. We accept that to a large degree it was, but there were some respects in which it failed to act as a prudent client. One conclusion that emerges clearly from the evidence is that the TMO was unduly concerned with reducing costs. From the outset the TMO was struggling to keep the project within budget. As the costs rose, it was dependent on the council for additional funds and from time to time they were made available, but still the TMO looked for reductions in the cost of the project rather than go back to the council for more money. The decision to appoint Studio E was driven in a large measure by a desire to keep the costs down, as evidenced by the device employed to avoid a proper procurement exercise, and costs played a part in the choice of Rydon as principal contractor, as evidenced by the “off-line” discussions that took place before it was awarded the contract. The decision to choose Reynobond PE was part of a “value engineering” exercise performed at the TMO’s insistence and designed to keep costs down, but responsibility for that disastrous decision cannot be laid at the door of the TMO. It is one that must be borne by those who could be expected to know, or at any rate discover, the nature of the product being recommended. 67.22 Cost is always an important factor in any construction project, of course, if only because clients want the maximum result for the minimum expense and contractors are usually working on narrow margins. Realism, however, is essential and a sound understanding of the nature of the exercise being undertaken. In this case, the cost of employing an independent professional project manager would have been money well spent. 67.23 Any substantial construction project needs to be managed by or on behalf of the client and unless the client has the necessary experience and skill to undertake that task, it will usually appoint a professionally qualified project manager. In the present case Artelia would have been willing to act as project manager, but the TMO persuaded itself that it could

The Grenfell Tower Inquiry: Phase 2 Report 324 perform that function itself. That was a mistake because it did not have the necessary skills or experience to undertake that task and to ensure that Rydon, and through it the other professionals involved in the refurbishment, carried out their work effectively. 67.24 What we have observed in the course of the evidence has led us to the conclusion that there is not only a need to improve the education and training of those involved in the construction industry but also a change in approach on the part of all concerned which prioritises safety over speed and cost and lays much greater emphasis on an understanding of the regulatory regime and its purpose.

ISBN 978-1-5286-5080-9 (Volume 4 of 7) 7 volumes not available separately

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Volume 5 Part 7 - Replacement of the gas riser Part 8 - The London Fire Brigade HC 19–V GRENFELL TOWER INQUIRY: PHASE 2 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 The Panel: Chairman: The Rt Hon Sir Martin Moore-Bick Ali Akbor OBE Thouria Istephan September 2024

Volume 5 Part 7 - Replacement of the gas riser Part 8 - The London Fire Brigade HC 19–V GRENFELL TOWER INQUIRY: PHASE 2 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 The Panel: Chairman: The Rt Hon Sir Martin Moore-Bick Ali Akbor OBE Thouria Istephan September 2024 Presented to Parliament pursuant to section 26 of the Inquiries Act 2005 Ordered by the House of Commons to be printed 4 September 2024

© Crown copyright 2024 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. This publication is available at www.gov.uk/official-documents. Any enquiries regarding this publication should be sent to us at contact@grenfelltowerinquiry.org.uk. ISBN 978-1-5286-5080-9 (Volume 5 of 7) 7 volumes not available separately E03165832 09/2024 Printed on paper containing 40% recycled fibre content minimum. Printed in the UK by HH Associates Ltd. on behalf of the Controller of His Majesty’s Stationery Office. This report contains content which some may find distressing.

5 Part 7 Replacement of the gas riser

6

7 Introduction 68.1 In his Phase 1 report the Chairman found that the supply of gas to the tower did not play a significant part in the outbreak or development of the fire on 14 June 2017 and that the employees of Cadent Gas Limited who attended to shut off the gas supply made appropriate decisions and executed their task admirably.1 In this phase of the Inquiry we have investigated the replacement of one of the gas risers between 2016 and 2017. The works had not been finished at the time the fire occurred and we therefore thought it appropriate to consider whether they might have contributed to the spread of smoke or fire within the tower. The supply of gas to the tower 68.2 On completion of the refurbishment work to the tower in 2016 gas was supplied to residents by two pipelines which entered the basement below ground level on the east side: a ten-inch steel pipe that fed the boilers supplying hot water to residents2 and a four‑inch steel pipe that supplied gas to the flats.3 68.3 The pipe providing gas to the flats entered the basement at a high level. Four pipes, known as “risers”, ran vertically up into the tower; two of them were then split into two, making six risers in total.4 These passed through the fabric of the building and directly into a cupboard in each flat. One of the risers supplied gas to all the “Flat 2s”. 68.4 The gas supply had been installed at the time the tower was built and by the time of the fire the pipework was almost 50 years old. It did not comply in a number of respects with current regulations. Supply to the tower following works commencing October 2016 68.5 On 1 October 2016, corrosion of the riser serving the “Flat 2s” made it necessary to cut off the supply of gas to all the “Flat 2s”. Cadent 68.6 Cadent Gas Limited (“Cadent”) is a gas transporter which owns and operates the pipes and apparatus that transport gas. Cadent does not own the gas itself but is paid by suppliers to deliver it through a network of pipes in a particular area. In the case of Grenfell Tower the area was that served by Cadent’s North London gas distribution network.5 Cadent was 1 Phase 1 Report Volume IV, paragraph 31.14. 2 Hancox, Gas Engineering Report {RHX00000012/15} paragraphs 30-31 and figure 6. 3 Hancox, Gas Engineering Report {RHX00000012/13-14} paragraph 29 and figure 4. 4 Hancox, Gas Engineering Report {RHX00000012/23} paragraph 44. 5 Mason {CAD00003005/2} page 2, paragraphs 7-8. Chapter 68 Replacement of the gas riser

The Grenfell Tower Inquiry: Phase 2 Report 8 responsible for the safety of the service pipework up to the point of the emergency control valve located at each customer meter; the installation pipework beyond the meter was the responsibility of RBKC as the owner of the building.6 68.7 The Health and Safety Executive monitors and oversees the health and safety of onshore gas distribution and supply7 and Ofgem determines the funding and ensures the competitiveness of gas pricing.8 Since the 1990s, in common with all gas transporters, Cadent is under certain statutory obligations, including obligations to: a. Connect and maintain a connection for customers within 23 metres of a main (measured horizontally),9 unless such a connection endangers the public;10 and b. Maintain service pipelines and apparatus, such as shut-off valves, in efficient working order and in good repair.11 Inspection on 30 September 2016 68.8 Part of Cadent’s strategy to maintain service pipework for buildings in multiple occupation was to conduct a rolling programme of surveys.12 On 30 September 2016 Cadent carried out a survey on Grenfell Tower13 and identified three significant problems: a. There was a gas leak between Flat 22 and the flat above, Flat 32, on floors 5 and 6 respectively;14 b. The pipeline isolation valves on the east side of the tower could not be found;15 and c. There was severe corrosion of some laterals.16 68.9 In response to the discovery of the leak Cadent immediately cut and capped the riser which supplied “Flat 2s”. That was completed in the early hours of 1 October 2016.17 68.10 Cadent used this and other information from the survey to calculate a building priority score18 which indicated how often a building should be surveyed. The score for Grenfell was such that Grenfell Tower was placed on the list for discussion at the regular Cadent hazard and operability meetings, known as “HAZOP” meetings. The inability to find the missing pipeline isolation valves and the severe corrosion was noted on a schedule presented at the HAZOP meetings of 5 December 2016 and 23 February 2017.19 6 Harrison {Day159/16:4-14}. 7 Harrison {Day159/17:4-8}; https://www.hse.gov.uk/regulating-major-hazards/energy-division.htm. 8 Harrison {Day159/18:7-16}. 9 Gas Act 1986 {INQ00014770/52-53} section 10; Mason {CAD00000004/2} page 2, paragraph 5. 10 Gas Act 1986 {INQ00014770/53} section 10(9)(b); Harrison {Day159/19:16}-{Day159/20:8}. 11 Pipelines Safety Regulations 1996 {INQ00014790/7} regulation 13; Pipelines Safety Regulations 1996 {INQ00014790/3} regulation 3(1)-(2). 12 Harrison {Day159/21:12-21}. 13 {CAD00000031}. 14 {CAD00000031} sheet 3: Riser Information, row 12, column AE; {CAD00000031} sheet 4: Lateral Information, row 9, column U; Hancox, Gas Engineering Report {RHX00000012/135} paragraph 310. 15 {CAD00000031} sheet 2: Supply Pipe Information, rows 11-12, column L; Hancox, Gas Engineering Report, {RHX00000012/68} paragraph 158. 16 {CAD00000031} sheet 4: Lateral Information, rows 7-12, column O; Hancox, Gas Engineering Report {RHX00000012/114-115} paragraph 248 and figures 65-66. 17 {CAD00000031} sheet 4: Lateral Information, row 9, column W; Hancox, Gas Engineering Report {RHX00000012/23- 24} paragraph 44 and figure 17. 18 Harrison {CAD00002985/8} page 8, paragraphs 30-32. 19 {CAD00002984}.

Part 7 | Chapter 68: Replacement of the gas riser 9 Lost pipeline isolation valves 68.11 Pipeline isolation valves, by which the supply of gas to a building can be shut off quickly, are the main emergency control mechanism for buildings in multiple occupation.20 They are mandatory on service pipelines to such buildings21 and are located outside the premises so that access to them can be obtained easily through valve chambers with marked covers visible at pavement level. For obvious safety reasons, as part of making appropriate arrangements for responding to incidents and emergencies, gas transporters have a duty to maintain access to pipeline isolation valves.22 Notwithstanding that, we were told that it was well known in the gas industry that pipeline isolation valves are often lost, for example, as a result of being covered over by landscaping or road works.23 The survey of Grenfell Tower carried out by Cadent in 2008 showed that “fire valves” (another term for pipeline isolation valves) had been installed on the pipes supplying gas to the tower.24 The fact that Cadent could not find them in 2016 was almost certainly attributable to the landscaping works completed as part of the refurbishment.25 68.12 Having discovered in October 2016 that the pipeline isolation valves could not be found, Cadent should have taken steps to reinstate them immediately but it appears that the appropriate team in Cadent was not notified about the need for that to be done. Mr Harrison, one of Cadent’s network directors, accepted that that had been a failure on its part which should not have occurred.26 68.13 The failure to reinstate the pipeline isolation valves did not affect the course of events surrounding the fire because burning debris falling on the east side of the tower would have prevented anyone from obtaining access to them.27 However, on another occasion access to them might be of critical importance and we therefore think that all gas transporters should have a legal duty to inspect these emergency valves at intervals to ensure that they are accessible and to reinstate them if they are not. Corrosion survey 68.14 Although steel pipes are very strong and have a long service life under normal conditions, they are susceptible to corrosion, particularly if exposed to damp. Because corrosion causes the steel to deteriorate and lose its integrity, keeping it within acceptable levels is an important part of maintaining the safety of pipelines. 68.15 Cadent commissioned a corrosion survey for Grenfell Tower on 5 December 2016.28 Mr Harrison explained that the survey was not completed because of problems over obtaining access to the tower. A Cadent engineer attended on two occasions but could not get into the relevant parts of the building.29 Although a decision was made 20 Harrison {Day159/40:11-16}. 21 {RHX00000005/64} paragraph 7.3.1; Pipelines Safety Regulations 1996 {INQ00014790/7} regulation 13. 22 Pipelines Safety Regulations 1996 {INQ00014790/7} regulation 12; see also the duty to maintain the pipeline (including all its related apparatus) in an efficient state, efficient working order and in good repair: Pipelines Safety Regulations 1996 {INQ00014790/7} regulation 13. 23 Hancox, Gas Engineering Report {RHX00000012/220} paragraph 470; Harrison {CAD00002985/22} page 22, paragraph 82; Harrison {Day159/108:18}-{Day159/109:1}. 24 {CAD00002989/5}. 25 Hancox {Day161/41:10-20}. 26 Harrison {Day159/127:19-20}. 27 Phase 1 Report Volume IV, paragraph 31.4. 28 {CAD00002984/1}. 29 Harrison {CAD00002985/10-11} pages 10-11, paragraphs 37-39.

The Grenfell Tower Inquiry: Phase 2 Report 10 in February 2017 to try again, the full corrosion survey had not been completed by the time of the fire, some eight months after the corrosion had been discovered.30 As Mr Harrison accepted, that was unacceptable.31 68.16 After the fire it was found that a riser in Flat 115 had ruptured. It is possible that that was a result of a failure to keep corrosion levels within acceptable limits and occurred during the fire or later as the building continued to deform from its effects,32 but we do not think it is necessary for us to reach a decision on that question and in any event do not have sufficient evidence to do so with any confidence. All we can say is that several factors may have contributed to the rupture of that particular pipe, one of which may have been corrosion that weakened it at one of its threaded joints.33 Inaccurate maps 68.17 By June 2017 Cadent’s map of the gas pipes running into the tower should have shown all three systems: the pipe supplying the boilers, the original pipe supplying gas to the flats and the new pipe supplying gas to the “Flat 2s”. However, the maps available to the Cadent engineers who attended the fire only showed the pipe supplying the boiler.34 Cadent should have known that its maps were inaccurate because those available when it carried out the survey in September 2016 also showed only the pipe supplying the boilers.35 68.18 Cadent maintained that its failure to correct the maps did not, in fact, have any material effect on the ability of its engineers to identify and isolate the gas supply pipes on the night of the fire, since they were able to obtain the correct information from other sources.36 That is true, but it was attributable more to luck than good organisation that the engineers concerned happened to know the true layout of the pipework and had accurate information readily available to them37 as well as the time and the means to provide it to those who needed it.38 68.19 It is important that all gas transporters have accurate maps of the pipelines serving buildings in multiple occupation.39 Although Cadent has a process for revising its maps, it was not implemented in good time in the case of Grenfell Tower.40 Accurate maps are essential in order that operatives can locate the pipeline isolation valves and may be of critical importance in emergencies. There appears to be no good reason why the map was not revised after the 2016 survey, or, failing that, after the installation and commissioning of the new pipe in early 2017. 30 Harrison {CAD00002985/11} page 11, paragraph 41; Harrison {Day159/137:22}-{Day159/138:7}. 31 Harrison {Day159/137:22}-{Day159/138:7}; {Day159/138:22}-{Day159/139:5}; {Day159/140:8-14}; {CAD00002987/14} paragraph 5.6.3; {CAD00003001/13-15} paragraphs 6 and 9. 32 Harrison {CAD00003043/13-14} pages 13-14, paragraph 43; Cadent Module 3 submissions {CAD00003047/23} paragraphs 64-65. 33 Hancox, Gas Engineering Report {RHX00000012/110-111} figures 60-61 and paragraph 242. 34 {CAD00002174}; {CAD00002241}. 35 {CAD00000031} Supporting Photos sheet: row 3, column B. 36 Cadent Module 3 submissions {CAD00003047/18-19} paragraphs 50-52; Harrison {MET00018804/8} page 8, paragraph 31. 37 Cadent employee Jason Allday and surveyor Simon Boygle. 38 {MET00018309/2-4}; Phase 1 Report Volume IV, paragraph 31.3. 39 Hancox {Day161/58:22}-{Day161/59:3}. 40 {CAD00002957}; Hancox, Gas Engineering Report {RHX00000012/74} paragraph 174 and figure 41; Harrison {Day159/145:5-14}.

Part 7 | Chapter 68: Replacement of the gas riser 11 Replacement gas supply: 2016-2017 68.20 UK designers of gas supply systems pay particular attention to the standards published by the Institution of Gas Engineers and Managers (IGEM) when planning and executing work of that kind.41 Although gas engineers should be aware of the Building Regulations,42 in 2016 there was a strong emphasis and reliance on IGEM publications and there existed within the gas industry a general understanding that if an engineer complied with that guidance, all relevant regulatory standards, including the Building Regulations, would be met.43 The IGEM publication applicable to the work to be carried out at Grenfell Tower in 2016 was IGEM/G/5, second edition.44 68.21 Having cut and capped the riser serving the “Flat 2s” on 1 October 2016, Cadent had to consider whether and, if so, how, to reinstate the supply of gas to them. 68.22 For that purpose it engaged tRIIO, a consortium formed by Morrison Utility Services Limited and Skanska Construction UK Limited, to design and install replacement gas pipes and connections.45 tRIIO entered into subcontracts with other organisations and individuals for some of the work.46 There was plainly some urgency and it is apparent that Cadent sought to reinstate customers’ gas supplies as quickly as possible.47 68.23 Two options were available to it: it could either find a way to install a new riser to reconnect the “Flat 2s”, or it could pay customers to replace their gas appliances with electric appliances. On 17 November 2016, Cadent rejected the latter option because only part of the building was affected.48 It therefore decided to restore the supply of gas, provided it could do so safely.49 The first design 68.24 IGEM/G/5 provides a hierarchy of options for siting gas pipes. It states that the best option is an external network of pipes so as to give them direct ventilation to natural air.50 In the case of Grenfell Tower however, the TMO and tRIIO agreed that installing pipes on the outside of the tower was not practicable because they would pierce the newly installed rainscreen cladding, would compromise the integrity of the facade and potentially invalidate any warranty for the cladding system.51 In our view, that was a reasonable position for the TMO to take. 68.25 tRIIO commissioned Simon Boygle, a surveyor trading under the name of London Ops Gas, to find an alternative route for a replacement riser. He and tRIIO considered several options, including running the new riser in the same place as the original riser, that is, vertically through the floors and ceilings of the flats and directly into the kitchens. That idea was quickly discounted as impracticable, however, because of the difficulties involved 41 Hancox {Day161/8:23}-{Day161/9:1}; Harrison {Day159/33:8-23}; Dolan {Day160/17:20}-{Day160/18:11}. 42 Dolan {Day160/17:2-18}. 43 Hancox {Day161/20:24}-{Day161/21:16}. 44 {RHX00000005}. 45 Dolan {MET00012711/2} page 2, paragraphs 7-10. 46 Dolan {MET00012711/4-7} pages 4-7, paragraphs 23-28. 47 Dolan {Day160/29:21}-{Day160/30:2}. 48 {CAD00000059}; Mason {CAD00003005/8} page 8, paragraph 23. 49 Gas Act 1986 {INQ00014770/53} section 10(9). 50 {RHX00000005/29-31} paragraph 4.2.1.4. 51 Dolan {MET00012711/8-9} pages 8-9, paragraph 34; Dolan {Day160/53:4-10}.

The Grenfell Tower Inquiry: Phase 2 Report 12 in obtaining access to the pipes embedded in the fabric of the building.52 They also considered running the new pipe through the existing utilities shaft,53 but that option was rejected, principally because the ventilation was considered to be inadequate.54 68.26 A key consideration was that any gas pipework must be adequately ventilated so that if a leak occurs it does not cause the atmosphere to become unsafe, with the consequent risk of an explosion. While external ventilation directly to fresh air is preferred,55 IGEM/G/5 allowed for any steel pipeline that had welded or screwed joints to be ventilated indirectly to outside air through an area that was “normally-occupied”, meaning occupied as an individual dwelling or a common corridor or lobby.56 However, IGEM/G/5 stated that mechanical ventilation should not be used to achieve the required ventilation level,57 which in the case of Grenfell Tower prevented siting gas pipes in the lobbies, since they relied on mechanical ventilation. IGEM/G/5 also required ventilation to be provided at the top and bottom of every fire compartment,58 consistently with the guidance in Approved Document B relating to ventilation in protected shafts.59 Approved Document B also provided further guidance on the ventilation of shafts, directing the reader to BS 8313:1997 on the size of ventilation openings.60 68.27 It is clear that there were two requirements that had to be taken into account: ventilation for gas safety and compartmentation for fire safety. Giving appropriate recognition to each of them is a challenge for anyone seeking to supply gas to any complex building in multiple occupation. 68.28 On 12 October 2016 Simon Boygle proposed that a new riser should be installed in the stairwell of Grenfell Tower.61 That was the only means by which to satisfy the twin requirements of ventilation and compartmentation.62 The new riser would travel from the basement, through the lower floors, through the stairs, and then by means of laterals restore the supply of gas to the “Flat 2s”. It was envisaged that at a later date the pipework would be extended to serve all the flats in the tower and the original pipework would be decommissioned. Firefighting stairs 68.29 What nobody involved in the project understood at the time was that although both IGEM/G/5 and Approved Document B allowed gas risers to be placed in protected stairs,63 if the stairs were also firefighting stairs, additional protections were required.64 Diagram 52 in Approved Document B advised that firefighting stairs should be constructed in accordance with BS 5588-5:2004,65 which in turn advised that such a shaft should contain only services associated with fire-fighting. In other words, the guidance in Approved Document B and the British Standard to which it referred was that gas supply equipment 52 Dolan {MET00012711/8} page 8, paragraph 31; Dolan {Day160/62:11-23}; Hancox {Day161/112:7}-{Day161/113:7}. 53 Dolan {MET00012711/9} page 9, paragraph 35; Mason {CAD00003005/11} page 11, paragraph 39; Dolan {Day160/64:20}-{Day160/65:12}. 54 Hancox {Day161/113:9-25}. 55 {RHX00000005/52} paragraph 6.4.3.1. 56 {RHX00000005/52} paragraph 6.4.3.5. 57 {RHX00000005/52} paragraph 6.4.3.2; {CAD00000054/2-3}; Dolan Day160/66:21}-{Day160/67:8}. 58 {RHX00000005/54-55} figures 18-19. 59 {CLG00000224/81} paragraph 8.41. 60 {CLG00000224/81} paragraph 8.41. 61 {CAD00000054}; updated on 1 November 2016 {CAD00000038}. 62 Dolan {Day160/55:24}-{Day160/56:14}. 63 {RHX00000005/52} paragraph 6.4.3.3; {CLG00000224/32} paragraph 2.42. 64 {CLG00000224/32} paragraph 2.35. 65 {CLG00000224/116} diagram 52.

Part 7 | Chapter 68: Replacement of the gas riser 13 should not pass through the same compartment as services associated with firefighting.66 Although it is arguable that appropriate standards of safety could have been achieved by separating the riser from the firefighting stairs with fire-resisting construction, as was explicitly permitted for gas pipework in protected stairs,67 the position is not clear in the guidance document or standards in relation specifically to firefighting stairs. We note that the first design did not have any boxing protecting the riser in the stairs. 68.30 That special consideration had to be given to firefighting stairs does not appear to have been widely understood in the gas industry before the Grenfell Tower fire68 and there is no evidence that any other professional expressly considered the point.69 Ventilation and compartmentation challenges 68.31 tRIIO’s first design did not provide much detail of how the ventilation of the pipework would be achieved.70 The riser was to be constructed of steel with welded joints, so indirect ventilation was available as a design choice pursuant to the guidance in IGEM/ G/5.71 On that basis the design included the following features: a. Ventilation for the basement was to be achieved by way of pre-existing ducts that vented to the outside air and were suitable for the gas installations that were already in the basement.72 b. Between the basement and level 2, the riser passed through the south-east utilities shaft and into a storeroom adjacent to the community meeting room. The utilities shaft, which rose more than one storey, had a louvered door at low level which would have provided some ventilation73 but there was no obvious ventilation at the top of the compartment.74 It was not clear what ventilation strategy applied to the storeroom.75 c. Through the stairs, the riser was ventilated across the whole shaft. d. At each floor, the lateral pipes passed through the compartment walls between the stairwell and the communal lobbies through oversized holes. On the lobby side, the lateral pipework was to be boxed in with fire-rated materials.76 The boxing in was necessary because the lobbies had mechanical ventilation, so the gas pipework could not ventilate directly into that space. The holes in the wall between the stairs and the lobby were left open so that any gas leaking from the pipework in the lobby would dissipate into the stairs, but the holes in the walls between the lobbies and the flats were to be fully fire‑stopped. e. At the top of the stairwell the riser vented directly to the air through the rooftop vents. 66 Fire Precautions in the design, construction and use of buildings – Part 5: Access and facilities for firefighting {BSI00000087/23} paragraph 7.1.4. While BS 5588-5 was superseded by BS9999:2008 (and ADB therefore referred to an out of date standard), identical provisions appeared in BS9999:2008 at paragraph 27.2.7.2, to the effect that only services associated with firefighting should pass through the firefighting shaft {BSI00000064/123}. 67 {CLG00000224/81} Note to paragraph 8.40. Neither BS 5580-5:2004 nor BS9999:2008 make any such provision. 68 Dolan {Day160/91:19}-{1Day160/92:14}; Hancox {Day161/117:7-18}. 69 {TMO10015305}; {TMO10016548}; {CST00001240}. 70 {TRI000000263}. 71 {RHX00000005/52} paragraph 6.4.3.5. 72 Dolan {Day160/101:6-10}; {Day160/104:4-9}. 73 Hancox, Gas Engineering Report {RHX00000012/30} figure 22; Thompson {TRI00002923/2} page 2, paragraph 8; Images of louvred doors {TRI00002921}; {TRI00002922}; Dolan {Day160/105:3-15}. 74 Hancox, Gas Engineering Second Supplementary Report {RHX00000027/21} paragraph 44. 75 Hancox, Gas Engineering Second Supplementary Report {RHX00000027/22} paragraph 50; Dolan {Day160/105:15- 23}; Hancox {Day161/135:5-18}. 76 {TRI000000392}.

The Grenfell Tower Inquiry: Phase 2 Report 14 68.32 No analysis was made of the ventilation available for each space through which the gas pipes were to pass.77 In our view, such a complicated design required detailed consideration of the ventilation arrangements in order to demonstrate that the pipework would be ventilated adequately and safely.78 tRIIO did not carry out a detailed analysis of that kind. 68.33 A detailed risk assessment should also have been carried out.79 According to IGEM/G/5, designers of gas pipework in buildings in multiple occupation should carry out a risk assessment to identify and mitigate hazards and maintain a written record of the results.80 In late 2016 tRIIO’s procedure was to record risks in its CDM Design Risk Register, which took the form of a spreadsheet that generated an initial risk score. If that score was 18 or more, tRIIO would carry out a fuller assessment by responding to a list of more probing questions.81 tRIIO completed the CDM Design Risk Register in relation to Grenfell Tower on 15 November 2016. It generated a score of 17.82 Although the designers could have manually over-ridden the process and carried out a fuller assessment of risk, they did not do so.83 68.34 We do not think that tRIIO’s risk assessment process was adequate for buildings in multiple occupation.84 We note that tRIIO’s own CDM Design Risk Register shows that any building of that kind would be “high risk” in and of itself85 and accordingly, the process should have required that it be the subject of a fuller assessment. That was particularly so in the case of an old building such as Grenfell Tower in circumstances where the proposed design was relatively complicated. tRIIO should therefore have overridden the scoring system and considered the risks posed by the installation in more detail. Mr Dolan, tRIIO’s director of operations, accepted that it had been at fault in failing to do so.86 68.35 Cadent’s contract with tRIIO did not require it to check design decisions and it did not expect to do so. However, once work began, Cadent was under a statutory duty to notify the Health and Safety Executive (HSE) using the form “F10”.87 tRIIO had produced an F10 covering all the work it intended to carry out during the period 2016-2017,88 but that did not constitute an adequate notification of the work at Grenfell Tower. Cadent should have produced an F10 to notify the HSE of that work.89 A generic F10 of the kind produced by tRIIO was inappropriate for a project affecting a large building in multiple occupation.90 68.36 Over the course of some months the original riser was replaced using a new pipe which entered the basement below ground level on the east side.91 From there it passed up through the lower floors and into the stairwell where it passed through holes cut in the floors of the landings.92 If the supply of gas was to be restored to a flat, a horizontal pipe, 77 Dolan {Day160/102:3}-{Day160/103:9}; {Day160/103:16-22}; {Day160/148:2-14}. 78 Hancox, Gas Engineering Report {RHX00000012/191} paragraph 385; Hancox, Gas Engineering Report {RHX00000012/195} paragraph 394; Hancox {Day161/139:15-17}. 79 Hancox {Day161/142:8-11}. 80 {RHX00000005/28} paragraph 4.2.1.1; {RHX00000005/94-102} Appendix 3. 81 {TRI000000369}. 82 {TRI000000369}. 83 Dolan {Day160/85:14-16}. 84 Hancox {Day161/150:10}-{Day161/151:9}; {Day161/172:3-16}. 85 {TRI000000369} at “MOBS” where a red “high-risk” categorisation is shown in the final column. 86 Dolan {Day160/89:11-23}. 87 The Construction (Design and Management) Regulations 2015 {INQ00011316/7} regulation 6; The Construction (Design and Management) Regulations 2015 {INQ00011316/29} regulation 6, schedule 1. 88 {TRI000001784}. 89 Lane, Phase 2 Report Version 2 {BLARP20000016/148-149} paragraphs 11.3.1-11.3.9. 90 Harrison {Day159/84:5-14}; Dolan {CAD00003044/13} page 13, paragraphs 51-52. 91 Hancox, Gas Engineering Report {RHX00000012/14} paragraph 29 (c) and figure 4. 92 Hancox, Gas Engineering Report {RHX00000012/31} figure 24.

Part 7 | Chapter 68: Replacement of the gas riser 15 or ‘lateral’ was led from the riser through the stairwell wall and into the lobby.93 The lateral then passed round the perimeter of the lobby just below the ceiling and a pipe from it entered the relevant flat through a hole in the wall between the flat and the lobby.94 The pipe was connected to a meter which had to be moved from its original position in the kitchen to the hallway near the front door.95 Further pipework was then installed between the meter and any kitchen appliances that burned gas. 68.37 After the gas pipework had been installed into the tower it was commissioned on 10 March 2017,96 even though the work in the lobbies of boxing it in had not been completed. At that stage the work did not comply with the guidance in IGEM/G/5 because a leak in the lobby would have been ventilated by mechanical ventilation, which was not permitted. It appears that tRIIO took a calculated risk and reconnected the supply of gas to customers before all the work had been completed. We understand the desire to reconnect occupants as quickly as possible, but the fact remains that tRIIO should not have introduced gas into a pipeline without all the ventilation requirements being in place.97 A change of design 68.38 On 21 March 2017, tRIIO’s design manager inspected the work and noted that flanged joints had been installed rather than welded joints.98 Flanged joints have a compression fitting which seals the connection between the two pipes with a gasket, as opposed to screwing or welding the pipes together.99 As a result, flanged joints are more prone to leaking and could not be used if the stairwell was to provide the necessary ventilation.100 The installation of the flanged joints compromised the ventilation strategy and the error was not noticed by tRIIO’s design team before gas was reintroduced into the pipeline.101 68.39 On 24 March 2017, in response to that discovery, tRIIO introduced a modification to the arrangement, under which the vertical riser (as well as the laterals) was to be fully boxed-in, both in the stairwell and also throughout the lower levels and the basement, using materials with a two-hour fire rating.102 Intumescent vents were to be installed in the boxing in the stairwell, which would close in the event of a fire but allow for some ventilation in normal circumstances.103 68.40 The description of the modified arrangement did not show how the boxing-in was to be achieved at the lower levels, i.e. through the utility duct and in the storeroom and basement. Nor did it show how the boxing-in would be connected to the vent in the roof.104 Moreover, the new design created other problems in relation to ventilation. It assumed that air would circulate within the boxing and across the pipework through the holes in the landings and the walls between the stairwell and the lobbies, but the holes through the landings had not been enlarged to allow for a flow of air within the new boxing.105 There was no evidence that calculations had been carried out to determine the size of 93 {CAD00001643}; {CAD00001640}. 94 {TRI000000263}; {TRI000001431}. 95 Hancox, Gas Engineering Report {RHX00000012/26} figure 18. 96 Dolan {Day160/125:7-9}. 97 Dolan {Day160/125:7}-{Day160/126:10}. 98 Dolan {MET00012711/11} page 11, paragraph 47. 99 Dolan {Day160/140:16}-{Day160/141:10}. 100 Dolan {Day160/139:23}-{Day160/140:10}. 101 Dolan {Day160/141:20}-{Day160/142:8}. 102 Dolan {Day160/144:13-25}; {Day160/145:15}-{Day160/146:3}; {TRI000001223}. 103 {TRI000001223}. 104 Dolan {Day160/157:16-23}; Hancox, Gas Engineering Report {RHX00000012/194} paragraph 391. 105 Hancox, Gas Engineering Report {RHX00000012/195-196} paragraphs 395-396; Hancox {Day161/158:3-16}.

The Grenfell Tower Inquiry: Phase 2 Report 16 the holes that would be required nor was it clear how an increase in the size of the holes and the boxing could be accommodated given the narrowness of the stairs.106 The use of intumescent vents was not consistent with the requirements of IGEM/G/5.107 68.41 In this case tRIIO manually over-rode its CDM Design Risk Register process and carried out a full design risk assessment that was recorded on a four-page spreadsheet identifying factors for consideration.108 Three of those factors related specifically to buildings in multiple occupation, namely, breach of compartmentation, failure due to thermal expansion of south-facing pipes, and ventilation.109 They were appropriate matters but they did not cover everything that a designer ought to consider, such as, for example, means of escape in fire, corrosion, inspection and maintenance, and valve access and security.110 68.42 In addition, the information tRIIO added to the Design Risk Register lacked sufficient detail. On the important question about fire compartmentation, the action recorded was simply to follow the Building Regulations and Fire Safety Order and seal the compartments accordingly. A gas engineer was to review the arrangements for ventilation, although they were not described in any detail in the design. Mr Dolan accepted that the assessment process fell below the standard required and that a more detailed consideration of matters affecting buildings in multiple occupation was needed.111 68.43 Although tRIIO adopted a more formal approach to the modified arrangement, there is no evidence that anyone calculated the amount of ventilation needed for the pipework.112 That was particularly important, given that the ventilation strategy had changed and that the degree of ventilation had been reduced by the boxing-in of the entire pipeline. Construction of the modified arrangement 68.44 Regrettably, tRIIO and its sub-contractors continued to make mistakes during the construction of the work. As Mr Dolan and tRIIO accepted,113 although the boxing-in of the pipework should have been carried out using two-hour fire-rated materials114 (and although the TMO was told that it would be),115 the sub-contractors, Express Building Contractors Ltd, in fact used materials that were rated as having a fire integrity of only 88 minutes.116 68.45 A further problem also arose from the need to move the gas meters from the kitchens closer to the front doors because tRIIO’s specifications required that there be no more than two metres of service pipework inside a residential property.117 As a result, a sub-contractor of K&S Pipe Contractors, Holland Gas Engineers Ltd, was obliged to place meters in or adjacent to the entrance hall, which was the only escape route.118 Meter points can present a particular fire risk because if there is a fire, gas can burn freely from open meter ends. IGEM/G/5 suggests relatively easy mitigations, including installing the meter inside a 106 Hancox {Day161/161:3-13}. 107 Hancox {Day161/154:15}-{Day161/155:4}. 108 {TRI000001218}. 109 {TRI000001218/4}. 110 Hancox, Gas Engineering Report {RHX00000012/156} paragraph 354; Dolan {Day160/171:1-15}; Hancox {Day161/173:3-9}. 111 Dolan {Day160/162:10-19}; {Day160/170:15-25}. 112 Dolan {Day160/186:9}-{Day160/187:9}; Hancox {Day161/156:14-25}. 113 Dolan {Day160/189:21-25}. 114 {TRI000001218}. 115 {TMO10016548}. 116 {TRI000001377}; Dolan {Day160/189:14-25}; Hancox, Gas Engineering Report {RHX00000012/196} paragraph 397. 117 Dolan {Day160/72:24}-{Day160/73:10}. 118 Hancox, Gas Engineering Report {RHX00000012/33} paragraph 61.

Part 7 | Chapter 68: Replacement of the gas riser 17 30-minute fire-rated cupboard with a self-closer or installing a thermal cut off device119 to stop the flow of gas either before or after the emergency control valve.120 However, neither of those steps were considered at Grenfell Tower.121 68.46 tRIIO maintained that the meters were often sited in an alcove or cupboard adjacent to the entrance hall and that the mitigation measures mentioned above were unnecessary.122 However, we have seen examples of meters being located behind curtains123 or behind doors that had rising hinges and were not self-closing124 and it is plain that in some cases the meter was sited close to the escape route from the flat. Although there is no evidence that any of the meters played a role on the night of the fire, we do not consider those arrangements to have been satisfactory. The night of the fire 68.47 There is no evidence that gas leaked from any part of the new installation during the fire on 14 June 2017.125 However, the works had not been completed by that time. The boxing-in in the stairs had almost been completed, with only the top floor and the connection to the roof vent outstanding, but the boxing-in of the laterals in the lobbies had not been completed, except on floor 5. Battens had been installed for the boxing-in in the lobbies on floors 4, 8, 9, 10 and 11 only. Mr Dolan estimated that the remaining work would have taken about five weeks.126 68.48 While the work was being carried out the oversized holes between the stairwell and the lobbies were not temporarily fire-stopped. It was possible, therefore, for smoke to move from one compartment space to another. Heavy smoke staining on the internal faces of the boxing in the stairs indicates that some smoke must have travelled from the lobbies into that boxing.127 There was also evidence of staining between adjacent floors which appears to indicate that smoke had travelled between floors through the boxing of the riser.128 It is possible, therefore, that during the fire smoke may have travelled from one lobby into the boxed-in riser and out into lobbies on other floors higher up the tower, thereby compromising the compartmentation between the lobbies. It is not possible, however, to know how much smoke may have travelled in that way or at what stage in the fire. We think it is likely to have been a much less significant route of smoke spread than open fire doors between the lobbies and the stairs. 68.49 In March 2017 Cadent expressed concern to tRIIO about the oversized holes between the lobby and the stairwell, which it thought might create an unsafe situation in the event of a fire.129 In those circumstances we think that tRIIO should have made sure that those holes were temporarily fire-stopped while the work remained incomplete,130 as 119 {RHX00000005/38} paragraph 5.2.3. 120 Hancox, Gas Engineering Report {RHX00000012/58-61} paragraph 133(f). 121 Hancox, Gas Engineering Report {RHX00000012/161} paragraph 364. 122 Dolan {Day160/190:18}-{Day160/191:1}. 123 {MET00016651}. 124 {MET00016558}; Hancox, Gas Engineering Report {RHX00000012/159} paragraph 362. 125 Hancox, Gas Engineering Report {RHX00000012/117} paragraph 252. 126 Dolan {TRI00001797/2-3} pages 2-3 paragraph 7; Mason {CAD00003005/11} page 11, paragraph 34. 127 {MET00016722}; {MET00016516}. 128 {MET00016516} showing smoke staining at the top of the boxed portion of gas riser on floor 17; {MET00016533} showing staining at the bottom of boxed portion of gas riser on floor 16; Hancox, Gas Engineering Report {RHX00000012/178-179}. 129 {TRI000000985/3}. 130 Hancox {Day161/166:8}-{Day161/170:6}.

The Grenfell Tower Inquiry: Phase 2 Report 18 Mr Dolan accepted.131 We are unable to tell whether the failure to do so had any adverse consequences on the night of the fire, but we think it important to record that the risks should have been identified and mitigated during the work. The involvement of building control 68.50 One question we thought it appropriate to consider is whether the work involved in the replacement of the gas riser required building control approval. In 2016, the gas industry did not routinely consult building control in relation to reinstatement work.132 In this instance, although Carl Stokes advised that the work was notifiable,133 tRIIO did not consult building control because it thought that the work did not require approval, despite the material changes to compartmentation that the riser design entailed.134 In March 2017 Janice Wray told John Allen, the head of RBKC’s building control department, that the new riser had been installed in the staircase and invited him to send a team to the site to look at the work.135 However, he told her that the riser works were regarded as a repair and were a matter for a fire risk assessment.136 tRIIO, for its part, appeared to believe that, if carried out in accordance with IGEM/G/5, the work would comply with the Building Regulations but that the TMO would make any necessary application for building control approval.137 68.51 Whether the work of replacing the gas riser required building control approval is a difficult question on which the evidence does not enable us to express a clear conclusion. However, we think that in cases where the structure of a building on which effective compartmentation depends is affected by the replacement of existing services, careful consideration should be given to the need to obtain building control approval as well as complying with any relevant industry guidance. 131 Dolan {Day160/175:15}-{Day160/176:20}. 132 Hancox, Gas Engineering Report {RHX00000012/187} paragraph 375. 133 Stokes {CST00003063/47} page 47, paragraph 138; {TRI000000405}. 134 Dolan {Day160/110:20}-{Day160/111:8}. 135 {TMO10016428/1}. 136 {TMO10016546}. 137 {TRI000000405}; Dolan {Day160/111:1-8}.

19 Part 8 The London Fire Brigade

20

21 69.1 In chapter 7 of his Phase 1 report the chairman described the statutory responsibilities, structure and organisation of the London Fire Brigade (LFB). In particular, he described in some detail the operation and management of the control room, the systems and procedures employed in it and the method of handling emergency calls. Later in the same chapter he described operations at the incident ground, with particular emphasis on the role and responsibility of the incident commander and support available from monitoring officers and command units. It is not necessary for us to repeat any of that in this report. 69.2 In that report the chairman expressed the view that there had been significant shortcomings in the way the LFB had responded to the fire at Grenfell Tower, both in the control room and on the incident ground, many of which were the result of a failure to provide its control room officers and firefighters at all levels with the skills, preparation and training needed to enable them to respond effectively to the situation they faced. He therefore considered it necessary in this second phase of the Inquiry to examine the organisation and training of the LFB in the years preceding the fire with a view to understanding how that situation had come about and how it might be avoided in the future. 69.3 We begin this Part of our report with a brief description of the way in which the management of the LFB is organised to enable the reader to understand the complicated structure that existed in the years immediately before the Grenfell Tower fire. That structure is of importance only because it sheds light on the way in which the organisation functioned during that period. We follow that with a description of the way in which training was organised and training packages obtained from the LFB’s provider, Babcock. It was essential to train officers at all levels in order to meet the challenges of incident command and to ensure that operations were conducted effectively. In view of the criticisms of the LFB made by the chairman in his Phase 1 report we considered it appropriate to pay particular attention to that aspect of the brigade’s management, particularly since it had been the subject of a specific recommendation by the coroner who conducted the inquests following the Lakanal House fire. 69.4 Although the fire at Lakanal House in 2009 emphasised the dangers posed by the use, especially in high-rise buildings, of certain kinds of materials and methods of construction, the sources of that knowledge had been available for some years. We therefore decided that we should investigate the extent to which the LFB had been aware of those dangers and, if so, how widely the information had been shared within the organisation. We have also considered other sources of information that were available to it in order to understand why the dangers of a loss of compartmentation and the rapid spread of fire were not understood or recognised by operational station crews. 69.5 One important aspect of preparation is gathering information about buildings that may present particular challenges. The LFB is unusual in having a large number of high-rise buildings in the area for which it is responsible, many of which pose particular challenges. We have therefore examined and report on the steps taken by the LFB to collect information about buildings, particularly those that may present particular challenges in the event of a fire. Chapter 69 Introduction to Part 8

The Grenfell Tower Inquiry: Phase 2 Report 22 69.6 The response of the control room to the huge volume of information it received as a result of the fire made it necessary for us to examine the quality of the training delivered to control room staff during the years leading up to it. That in turn required us to examine the way in which the control room had been managed and the importance attached to the delivery of regular training, particularly in handling calls from or about people trapped in high-rise buildings. In this Part, therefore, we set out our findings on those matters. 69.7 There are other aspects of the response to the fire that in our view called for examination. One significant obstacle encountered by the firefighters who entered the tower was the difficulty of maintaining effective radio communication. We have therefore considered the nature of the equipment then in use, the source of the difficulties in maintaining communication with the bridgehead and the steps that might be taken to overcome them in future. 69.8 Maintaining an adequate supply of water also presented difficulties. We have therefore examined the means by which water is made available for firefighting and the steps that were taken by the water undertaker, Thames Water, to improve the supply while the fire was being fought. We have also considered the equipment available to firefighters to deliver water at the fireground and the way in which it was used during the course of the fire.

23 Chapter 70 Organisation 70.1 This chapter provides a broad overview of the organisational structure of the LFB in the period leading up to June 2017. It is necessary to be aware of the key elements of that structure in order to understand which departments and individuals were responsible for different aspects of its functions before and at the time of the Grenfell Tower fire. 70.2 On 1 October 2007, Ron Dobson was appointed LFB Commissioner, a position which he held until his retirement on 31 December 2016.138 Following a period of handover from September to December 2016, Dany Cotton was appointed interim Commissioner on 1 January 2017 and subsequently appointed to the substantive rank on 14 June 2017.139 The permanent appointment on 14 June had been planned and was unrelated to the Grenfell Tower fire.140 70.3 The London Fire and Emergency Planning Authority (LFEPA) was abolished on 1 April 2018 and replaced by the London Fire Commissioner, who became the fire and rescue authority for Greater London. The London Fire Commissioner assumed responsibility for LFEPA’s statutory obligations under the Fire and Rescue Services Act 2004 outlined above.141 On 31 December 2019, Ms Cotton retired as Commissioner and was succeeded by Andrew Roe on 1 January 2020. 70.4 As an organisation the LFB was divided into three directorates, the heads of which reported directly to the Commissioner and were responsible for a number of different departments. The internal structure of the directorates was complex and subject to frequent changes, most notably in 2015 following a wide-ranging reorganisation of the LFB as a whole. In the following paragraphs we give a broad and simplified description of the LFB’s structure before and after 2015, focusing on the departments and functions which are most relevant to the Inquiry’s investigations. Before 2015 70.5 Before 2015, the LFB’s three directorates were the Deputy Commissioner’s directorate, the Directorate of Operational Resilience and Training (together sometimes known as the two operational directorates) and the Directorate of Financial and Contractual Services. The Deputy Commissioner’s directorate 70.6 Rita Dexter served as Deputy Commissioner between November 2009 and March 2015.142 In addition to deputising for the Commissioner, the Deputy Commissioner was responsible for the following departments within her directorate: Operational Prevention and 138 Dobson {LFB00032157/2} page 2, paragraph 5. 139 Dobson {LFB00032737/2-3} pages 2-3, paragraph 5. 140 Phase 1 hearing: {Day50/10:3-12}. 141 Section 1(2)(c) of the Fire and Rescue Services Act 2004, which came into force with effect from 1 April 2018 under The Policing and Crime Act 2017, section 9 and The Policing and Crime Act 2017 (Commencement No. 7) Regulations 2018, regulation 4 142 Dexter {LFB00032363/2} page 2, paragraph 4.

The Grenfell Tower Inquiry: Phase 2 Report 24 Response, Fire Safety Regulation, Strategy and Performance, Communications, and Legal and Democratic Services.143 The first three of those departments are relevant to the Inquiry’s work. The Operational Prevention and Response department 70.7 The Operational Prevention and Response department144 was responsible for the planning, direction and delivery of the LFB’s operational service, mobilising crews and community safety,145 including overall responsibility for the control room, fire stations and the collection, management and use of operational risk information.146 At all relevant times, the LFB’s 102 fire stations were grouped by the 33 London boroughs in which they were located,147 each headed by a Borough Commander. The boroughs were in turn grouped into four Areas (North East, North West, South East and South West) each headed by an Area Deputy Assistant Commissioner (DAC). Before 2012, many of the department’s responsibilities were split geographically between North London and South London, each headed by an Assistant Commissioner (AC). However, from June 2012 the role and responsibilities for the whole of London were brought together under a single Head of Operational Prevention and Response. The Fire Safety Regulation department 70.8 The Fire Safety Regulation department had two broad functions: Regulatory Fire Safety and Community Safety. The Regulatory Fire Safety arm of the department was headed by two DACs, who filled the roles of Head of Fire Safety Delivery and Head of Fire Engineering and Specialist Fire Safety.148 70.9 Fire Safety Delivery included the department’s fire safety teams, which had responsibility for managing the LFB’s audit and enforcement activities under the Regulatory Reform (Fire Safety) Order 2005 (the Fire Safety Order). As with the Operational Prevention and Response department, the Fire Safety Delivery arm of the department was split into the same four geographical London areas, each headed by an Area Fire Safety Manager, and further divided by boroughs.149 Fire Safety Delivery was responsible for the LFB’s programme of fire safety audits carried out by fire safety inspecting officers, who could be from either operational or non-operational backgrounds.150 Some fire safety inspecting officers received additional training to enable them to act as fire engineering liaison officers, who provided support to the more specialist fire engineering teams in relation to building control consultations.151 Fire Safety Delivery included the Fire Safety Enforcement team, headed by Andrew Jack, which was responsible for reviewing enforcement notices produced by inspecting officers, interpreting legislation and overseeing enforcement prosecutions.152 70.10 Some senior operational officers were also senior fire safety officers. Senior fire safety officers were typically station managers or group managers who were not part of the Fire Safety department but who would be mobilised to attend incidents requiring four or 143 Dexter {LFB00032363/2} page 2, paragraph 5. 144 Also later known as ‘Operations and Mobilising’. 145 Brown {LFB00032166/3} page 3, paragraph 7. 146 Brown {Day186/7:17}-{Day186/8:1}; Brown {Day186/5:2-21}. 147 Brown {LFB00032166/23} page 23, paragraph 74. 148 Daly {Day183/13:24}-{Day183/16:19}. 149 Jack {LFB00032244/3} page 3, paragraph 7. 150 Daly {LFB00032306/3} page 3, paragraph 9. 151 Daly {Day183/29:12-22}; Daly {Day183/39:4-21}. 152 Daly {Day183/18:1-20}.

Part 8 | Chapter 70: Organisation 25 more pumps to provide support to the incident commander.153 They undertook a relatively broad, short training course in the basic principles and practice of fire safety to enable them to fulfil that role.154 In practice, and as happened at Grenfell Tower,155 it was common for officers who were mobilised to incidents as senior fire safety officers to be assigned different roles by incident commanders.156 AC Daly, sometime Head of Fire Safety, said that, in his view, this practice of re-assigning senior fire safety officers to operational roles reflected a failure to give priority to fire safety expertise on the incident ground.157 70.11 The Fire Engineering and Specialist Fire Safety arm of the department included its more technical fire safety teams, such as the Fire Investigation and Fire Engineering teams. Fire Engineering, also known as the Fire Engineering Group, comprised a team of around 10 specialist fire engineers who held, or were studying for, degree-level qualifications in fire engineering.158 Led by two Senior Fire Engineers, the group’s main function was to consider complex references from building control bodies that were beyond the experience of inspecting officers.159 Most of the group’s work consisted of providing support to external bodies, though the group also contributed to the development of LFB policy as part of the standard process of internal consultation.160 Fire Engineers were not involved in the development of operational training unless they were specifically asked to contribute their expertise.161 70.12 The Fire Investigation team was made up of watch-based operational personnel whose function was to attend incidents to investigate the cause of the fire. The team used the information collected from such inspections to identify trends with a view to informing activities within the LFB and to advance the work carried out by the LFB with external bodies, including those in industry, to improve fire safety across the built environment.162 70.13 The other arm of the Fire Safety department, Community Safety, concentrated on actions designed to prevent fires (such as home safety visits), on people at particular risk and on community behaviour.163 The Strategy and Performance department 70.14 The Strategy and Performance department led the LFB’s work relating to the integrated risk management plan (the London Safety Plan), its internal risk management planning, and performance reviews.164 Despite its name, the department was not in fact central to the strategy or performance of the LFB’s core operational responsibilities. 153 Daly {MET00077774/16}. 154 Daly {Day183/51:8-21}. 155 Cohen-Hatton {Day185/59:18}-{Day185/61:14}. 156 Daly {MET00077774/16-17}; Daly {Day183/58:23-25}. 157 Daly {Day183/61:24}-{Day183/62:5}. 158 Daly {Day183/32:7-10}. 159 Daly {Day183/29:12-22}. 160 Daly {Day183/35:1-8}. 161 Daly {Day183/38:2-15}. 162 Daly {Day183/28:2-22}. 163 Daly {Day183/14:7-18}. 164 Dexter {Day178/30:1-24}.

The Grenfell Tower Inquiry: Phase 2 Report 26 The Directorate of Operational Resilience and Training 70.15 AC Gary Reason was appointed Director of Operational Resilience and Training in January 2012.165 On his retirement in January 2015, he was succeeded by AC James Dalgleish. 70.16 The Directorate of Operational Resilience and Training comprised the following departments: Operational Procedures, Operational Assurance, Operational Resilience, and Human Resources and Development. The Operational Procedures department 70.17 The Operational Procedures department was responsible for the creation and maintenance of the vast majority of the LFB’s operational policies,166 subject to certain exceptions, such as the Incident Command policy, for which Operational Assurance was responsible. The Operational Assurance department 70.18 The Operational Assurance department was primarily concerned with ensuring effective incident command, the safety of operations and the management of risks on the incident ground.167 Dany Cotton, who headed the department from its inception in 2012 before her term as Commissioner, said that it was designed to provide combined and streamlined leadership of two existing LFB functions, the Operational Review team’s quality assurance of incident ground operations, and the Health and Safety team’s learning from incidents to identify risks to LFB staff.168 The department was responsible for producing six-monthly reports which identified risks and trends from an analysis of a wide range of sources, including the LFB’s Incident Monitoring Process Database (IMPD), significant incidents, incident accident reports, fire investigation reports, training and sources from outside the LFB.169 The department was also responsible for overseeing the production of articles for Operational News, the LFB’s internal circular, by which it sought to draw the attention of staff to some of the risks it had identified and any lessons to be learnt.170 The functions of the Operational Assurance department were such that it was ultimately responsible for ensuring the operational effectiveness of the LFB and for ensuring that LFB staff were aware of, and adequately prepared to deal with, operational risks which might affect their safety. 70.19 Key teams within the Operational Assurance department included the Incident Management Policy Group (also known as the Incident Command Policy Group), which was responsible for collating the information from the sources mentioned above and producing the six-monthly reports for the Operational Directorates Co-ordination Board (the co-ordination board),171 and the Operations Review Team, which provided oversight of the LFB’s operational activities and routine training designed to maintain and develop operational skills.172 165 Reason {LFB00032747/2} page 2, paragraph 7. 166 Reason {Day180/93:3-7}; Cowup {LFB00032784/3} page 3, paragraph 10. 167 Cotton {Day208/10:8-11}. 168 Cotton {Day208/10:12}-{Day208/11:3}; Cotton {Day208/8:3-13}. 169 Cotton {Day208/30:16}-{Day208/32:1}; {Day208/33:24}-{Day208/34:4}; {LFB00067840} is an example of the reports produced by the department. 170 Cotton {Day208/12:21}-{Day208/13:10}. 171 Cotton {Day208/31:2-12}. 172 Cohen-Hatton {LFB00110660/2} page 2, paragraph 10.

Part 8 | Chapter 70: Organisation 27 The Operational Resilience department 70.20 The Operational Resilience department included contingency planning and a special operations group focused on policies, procedures and the provision of equipment related to terrorism. The Human Resources and Development department 70.21 The Human Resources and Development department, previously the Training department, was responsible for the management of the LFB’s contract with its external operational training provider, Babcock Training Limited (Babcock), as well as the LFB’s human resources function.173 The LFB’s operational training structure and the adequacy of particular aspects of the operational training that existed at the time of the Grenfell Tower fire, is covered in more detail below. The training of control room staff, which was not included in the Babcock contract, is covered separately in Chapter 78. The Directorate of Finance and Contractual Services 70.22 The Directorate of Finance and Contractual Services, led by Sue Budden, carried out the LFB’s non-operational functions, including Financial Services, Information and Computer Technology and Procurement. It is, on the whole, not relevant to the work of the Inquiry. The Third Officer 70.23 Before 2015, the title of Third Officer was held by a senior operational officer in addition to their day-to-day responsibilities. Its purpose was to ensure that there were three senior uniformed officers (the Commissioner, the Director of Operational Resilience and Training, and the Third Officer) able to provide operational cover for serious incidents. From 2010, the position of Third Officer was held by David Brown, who was then an Assistant Commissioner.174 The 2015 restructuring 70.24 In 2015, the LFB underwent an internal reorganisation and the rank of Deputy Commissioner was dropped. Commissioner Dobson said that the position was no longer required as the directors were able to deputise for him within their own areas of responsibility. In broad terms, the Deputy Commissioner’s directorate was reorganised into a new Directorate of Operations. The former Directorate of Operations, Resilience and Training was renamed the Directorate of Safety and Assurance, and the Directorate of Finance and Contractual Services continued as before. In addition to some internal restructuring within each directorate, some departments and functions were moved between directorates. 70.25 The separate role and title of Third Officer also ended, as there were now three senior uniformed officer positions: the Commissioner, the Director of Operations and the Director of Safety and Assurance. 173 Reason {Day180/93:8-15}. 174 Brown {Day186/10:7-21}.

The Grenfell Tower Inquiry: Phase 2 Report 28 Directorate of Operations 70.26 The newly created Directorate of Operations retained responsibility for many of the departments which had previously reported to the Deputy Commissioner. 70.27 The Fire Safety Regulation department, now simply called “Fire Safety”, continued to incorporate the LFB’s fire safety (including Fire Safety Enforcement and Fire Investigation), fire engineering and community safety functions. 70.28 The operational firefighting and control functions of the previous Operations, Prevention and Response department were divided between two new departments: Fire Stations and Central Operations and Control and Resource Management.175 70.29 AC Brown was appointed Director of Operations in April 2015. When he retired on 31 March 2017, he was succeeded by DAC Philip Thomas George (known as Tom George).176 Directorate of Safety and Assurance 70.30 The newly renamed Directorate of Safety and Assurance continued to include Operational Procedures (re-named Operational Policy), Operational Assurance, and Operational Resilience. The Human Resources and Development department was renamed Development and Training, with its human resources functions moved to the Legal and Democratic Services department within the Directorate of Finance and Contractual Services. Health and Safety and the Operational Review Team, previously sub-departments of Operational Assurance, now reported directly to the Director. 70.31 Following the restructuring, on 1 December 2015 AC James Dalgleish assumed the position of Director of Safety and Assurance on an interim basis before Dany Cotton’s appointment as Commissioner.177 Upon Ms Cotton’s appointment, AC Stephen Apter became Director of Safety and Assurance in December 2016. He was in post on 14 June 2017.178 Principal LFB boards and committees 70.32 This section describes the principal LFB boards and committees which existed before and after the 2015 restructuring. The Corporate Management Board 70.33 The Corporate Management Board was the LFB’s highest-level committee, with a membership comprising the Commissioner, the three directors and some heads of department, with other officers and advisers attending when required. The Corporate Management Board held regular meetings and provided a forum for the LFB’s most senior officers to discuss operational, managerial and strategic matters. It also reviewed key papers and reports before they were submitted to the LFEPA Strategy Committee for oversight.179 175 {LFB00000010}. 176 Brown {LFB00032166/4} page 4, paragraph 9; George {LFB00032823/2} page 2, paragraph 6. 177 Groves {Day177/11:4-13}. 178 Apter {LFB00067794/2} page 2, paragraph 4. 179 Dobson {Day210/59:20-25}; {Day210/63:4-25}.

Part 8 | Chapter 70: Organisation 29 The Commissioner’s Group 70.34 There was also a smaller, informal leadership group known as “the Commissioner’s Group”, consisting of the Commissioner, the three directors and, before the 2015 restructuring, the Third Officer. The Commissioner’s Group met about once a week for informal meetings, which were not minuted, to share information with the aim of improving communications between the Commissioner and the directors.180 Commissioner Dobson said that his day-to-day management and oversight of the directors was not exercised through the Commissioner’s Group, but by daily individual meetings and, more formally, at the Corporate Management Board.181 The Operational Directorates Co-ordination Board 70.35 The Operational Directorates Co-ordination Board (the co-ordination board) comprised the directors and most of the senior officers and heads of department in the LFB’s two operational directorates. It comprised the heads of Operational Prevention and Response, Fire Safety Regulation, Operational Procedures, Operational Resilience and Human Resources and Development (the training department). The control room was not represented. Until 2015 the co-ordination board was chaired by the Deputy Commissioner, Rita Dexter; following the restructuring in 2015 it was chaired by AC Brown in his capacity as Director of Operations. The Commissioner was not a member of the co-ordination board and did not attend its meetings.182 70.36 The primary function of the co-ordination board was to provide a forum in which the two operational directorates183 could discuss and co-ordinate their activities, identify risks to operational staff and identify and recommend training required in response to such risks.184 Trends and lessons identified by the Operational Assurance department were brought to the co-ordination board for discussion. The co-ordination board would then select the most significant operational topics for development into paper or computer-based training. 70.37 In late 2016, the name of the co-ordination board was changed to the Operational Professionalism Board185 but that had no effect on its working. 180 Dobson {Day210/62:1-10}; {Day210/64:25}-{Day210/65:6}. 181 Dobson {Day210/64:21}-{Day210/65:11}. 182 {LFB00040625/2}; Dexter {Day178/53:19}-{Day178/55:6}. 183 Operational Resilience and Training and the Deputy Commissioner’s directorate before the 2015 restructuring; Operations and Safety and Assurance following the restructuring. 184 Cotton {Day208/27:10-18}. 185 Brown {LFB00084020/19} page 19, paragraph 50; {LFB00040652/1} paragraph 2.

30 The Grenfell Tower Inquiry: Phase 2 Report

31 Chapter 71 Training 71.1 In the Phase 1 report, the chairman found various shortcomings in the LFB’s training, which were revealed in its response to the fire, both on the fire ground and in the control room.186 In this phase of the Inquiry, therefore, we have examined the way in which the LFB identified training needs (particularly those arising from incidents), its approach to the procurement and provision of training and its systems for monitoring the effectiveness of training. The dynamic and intelligent operational training process 71.2 The LFB had a complex system for identifying the need for training and delivering training to staff at various levels. A process known as the dynamic and intelligent operational training (DIOT) process was central to the operation of that system. Its purpose, as described in Policy No. 825 (PN825), was to monitor operational, health and safety and training performance, to identify trends and provide mechanisms to support the maintenance of competence on the part of operational staff.187 As Deputy Commissioner Dexter agreed, that somewhat complex description could fairly be summarised as learning from mistakes made in fighting fires and promoting good practice.188 Its principal purpose, and that of the co-ordination board more generally, was to identify risks to operational staff and to provide appropriate training.189 The process could also, in theory, result in the amendment of an existing policy or the introduction of a new policy, but PN825 described that outcome as rare.190 Ensuring that the objectives of the process were achieved was the main responsibility of the co-ordination board.191 71.3 Central to the process were the arrangements for monitoring incidents and the creation of the associated database described in PN825. The database was used to record comments on the performance of operational personnel or the brigade as a whole during incidents and training.192 Such comments, often referred to as “development points”,193 typically emerged from meetings held after operational incidents or training exercises specifically to consider the quality of the response and the performance of the incident commanders.194 PN825 made it clear that entries should be made on the database only in cases where the performance of an individual, team, piece of equipment or the organisation as a whole had fallen below the required standard or had exceeded expectations.195 186 Phase 1 Report Volume IV, pages 589-590, paragraphs 27.16-27.20. 187 {LFB00012695/2} page 2, paragraph 1.5. 188 Dexter {Day178/69:21}-{Day178/70:3}. 189 {LFB00055171/2} page 2, paragraphs 1.2 and 1.5; Dexter {Day178/75:17}-{Day178/76:3}. 190 {LFB00055171/8} page 8, paragraph 3.41. 191 Dexter {Day178/69:1-5}. 192 {LFB00055171/4} page 4, paragraphs 3.1-3.2. 193 Cohen-Hatton{LFB00110660/16} page 16, paragraph 58. 194 Dexter {Day178/78:5}-{Day178/79:12}. 195 {LFB00055171/4} page 4, paragraph 3.3.

The Grenfell Tower Inquiry: Phase 2 Report 32 71.4 Except in the case of monitoring officers, who were required to post comments on the database in certain cases, firefighters of all ranks could post comments if they wished to draw attention to something they considered to be of importance in relation to the operational response. (Comments made as a result of meetings to consider the performance of incident commanders were posted on the database in all cases.) 71.5 The Incident Management Policy group, which was part of the Operational Assurance directorate, was responsible for analysing the database and producing six-monthly reports to the co-ordination board identifying significant trends and matters that required attention.196 71.6 Although the system could be used by firefighters of all ranks, DC Dexter and Commissioner Cotton agreed that few firefighters made use of the opportunity to make comments.197 One biannual incident monitoring report in 2014 shows that entries were made in respect of only 4% of the 47,105 incidents recorded198 and it follows that 96% of incidents during that period generated no comments at all. The report indicated that those figures represented an increase on previous quarters, when the use of the system must have been even lower. 71.7 Commissioner Cotton and Dr Sabrina Cohen-Hatton, head of the Operational Review Team in June 2017, said that operational staff, especially incident commanders, saw development points as negative.199 Ms Cotton also said that both firefighters and officers found it difficult to accept criticism of their operational performance200 and Deputy Commissioner Dexter said that some staff had voiced fears that they might get into trouble if they admitted having done something wrong.201 71.8 Commissioner Cotton said that she saw no connection between the negative perception of development points and the less than enthusiastic use of the system.202 On the other hand, Deputy Commissioner Dexter told us that the negative perception of development points was the main reason given for not posting comments.203 That is the most plausible explanation we were given for the significant under-use of the system. The LFB did attempt to improve the use of the database by seeking to reassure staff that development points were not intended to be punitive and by informing officers of the importance of posting comments, but its efforts were unsuccessful.204 71.9 The low use made of the monitoring process and the very low proportion of incidents which gave rise to development points (even allowing for the fact that many of them were very minor) meant that the database was very narrow and could provide the co‑ordination board with only a limited picture of operational trends or training needs. The process concentrated too much on identifying long-term trends, with the result that a serious problem disclosed by a single significant incident could be missed.205 For example, the database entry for the Shepherd’s Court fire in 2016, a significant incident involving the 196 Dexter {Day178/105:25}-{Day178/106:3}. “IMPD report” refers to the six-monthly reports presented to the co- ordination board. “IMP report” refers to the individual reports produced following meetings to review operational responses and incident command. which provided material for the database. 197 Dexter {Day178/82:20-24}; Cotton {Day208/38:9-12}. 198 {LFB00067840/5-6}. 199 Cotton {Day208/40:12}-{Day208/41:16}; Cohen-Hatton {Day184/205:14-22}. 200 Cotton {Day208/40:21}-{Day208/41:6}. 201 Dexter {Day178/82:20}-{Day178/83:7}. 202 Cotton {Day208/41:17}-{Day208/43:23}. 203 Dexter {Day178/91:8-25}. 204 Dexter {Day178/83:8-25}; Cotton {Day208/44:2}-{Day208/45:10}. 205 Spooner {MET00078859/4} page 4, paragraph 4.

Part 8 | Chapter 71: Training 33 spread of fire across the combustible facade panels of a high-rise residential block and a partial evacuation, failed to identify the spread of fire across external walls or the use of combustible panels as matters to be considered.206 71.10 Deputy Commissioner Dexter accepted that the incident monitoring process fundamentally relied on the willingness of individual officers on the ground to provide information and that, in the context of a falling number of incidents, the amount of information available to it was steadily diminishing.207 Operational News 71.11 On receipt of a six-monthly database report, the co-ordination board considered whether any training was required in response to what it disclosed. Training was delivered primarily in the form of articles published in Operational News, the LFB’s internal information circular, some of which were accompanied by computer-based training packages. Indeed, Operational News and its associated training packages were the main focus of the co‑ordination board’s work.208 Commissioner Cotton estimated that only half to two thirds of the operational trends identified in the database reports were in fact chosen as subjects for articles in Operational News.209 71.12 The Incident Management Policy group was responsible for producing articles for publication in Operational News, although the articles themselves were drafted by experts from the relevant departments before being reviewed and approved by Operational Assurance.210 They typically took the form of a summary of an existing policy, drawing firefighters’ attention to its contents. Babcock produced reports every six months, in conjunction with the Human Resources and Development department, telling the co‑ordination board how the training it was providing had been, or was being, improved to support the topics covered in the previous edition of Operational News. In many of those reports Babcock simply stated that the topics in question were already adequately covered.211 Station-based training 71.13 Commissioner Cotton said that summarising an existing policy in Operational News did not amount to training but had been intended to raise awareness and provide personnel with links to the associated training delivered through fire stations.212 Initial training was provided to firefighters by Babcock, but the subsequent development and maintenance of operational skills was mainly carried out at station level in accordance with the Policy No. 427 (PN427) by means of computer-based training packages and lectures delivered by watch managers, attendance at which was recorded on crews’ training records.213 71.14 Watch managers were not provided with any centralised training materials for their lectures (apart from the policies themselves); instead, it was the responsibility of each watch manager to develop their own lectures and deliver them to crews.214 For at least five years preceding the Grenfell Tower fire watch managers were given no guidance on how 206 {LFB00120998}. 207 Dexter {Day178/165:6}-{Day178/166:6}. 208 Groves {Day177/29:3-4}; Dexter {Day178/72:10-15}. 209 Cotton {Day208/55:2-11}. 210 Dexter {Day178/111:9-16}; Cotton {Day208/61:17}-{Day208/62:9}. 211 {LFB00036796/4} for example, in relation to Fire Survival Guidance policy. 212 Cotton {Day208/72:3}-{Day208/73:2}. 213 {LFB00032798/2} page 2. 214 Cotton {Day208/73:21}-{Day208/75:7}.

The Grenfell Tower Inquiry: Phase 2 Report 34 to deliver training and there was no process to ensure that officers who provided training were competent to do so.215 Station-based training was monitored by Training Review Information Officers, who were responsible for ensuring that training was provided and that training records were complete and accurate.216 But we have seen no evidence that any assessment of the quality of station-based training was carried out by those officers or anyone else. 71.15 This station-based training was separate from the centralised training that was commissioned by the Human Resources and Development department (later known as the Training and Development department) and provided by Babcock. For ease of reference and consistency, we shall refer to the department simply as “the Training department”. The Training department made no contribution to the substance of station-based training and played no part in ensuring that adequate station-based training was provided.217 Nor did the Training department have any process by which to ensure that station-based training was consistent with the training provided by Babcock, which the LFB’s Head of Training, Peter Groves, accepted created an obvious risk of injury.218 Mr Groves said that responsibility for identifying and assessing any omissions from station-based training lay with the individual borough commanders to whom stations reported, but he accepted that, since 2012, borough commanders had not been trained in how to make such assessments.219 71.16 The Training department’s limited involvement in supporting, monitoring or assessing the quality of station-based training is surprising and difficult to justify. The importance of Operational News to the delivery of training meant that the LFB was heavily reliant on local crews, local station managers and particularly local watch managers for creating and providing the associated lectures. That clearly created a significant risk that the training that crews at different stations received differed in content and quality. Effectiveness of the system 71.17 Commissioner Cotton accepted that articles in Operational News could never provide more than a high-level, cursory exploration of an operational topic.220 She also agreed that the quality of station-based training depended entirely on the skills of individual watch managers.221 The co-ordination board’s principal method of evaluating the effectiveness of that training was to see whether a particular problem featured in later incident monitoring reports.222 Many of the reports considered by the co-ordination board indicated that it was difficult to teach some lessons, as evidenced by the fact that some problems kept recurring.223 Although the reports occasionally noted improvements resulting from certain steps that had been taken (presumably because the number of development points relating to that topic had reduced), there was no system by which the co-ordination board could assess the effectiveness of articles published in Operational News or station-based training.224 The co-ordination board’s approach, which lacked any active assessment of the effectiveness of its training interventions, was wholly inadequate. It was foreseeable 215 Cotton {Day208/77:25}-{Day208/79:5}; Groves {Day177/100:18-22}. 216 Groves {Day177/88:25}-{Day177/89:15}. 217 Groves {Day177/94:22}-{Day177/95:5}. 218 Groves {Day177/84:11}-{Day177/85:12}. 219 Groves {Day177/94:17}-{Day177/96:15}. 220 Cotton {Day208/80:25}-{Day208/81:3}. 221 Cotton {Day208/82:4-16}. 222 Dexter {Day178/149:25}-{Day178/151:15} 223 Dexter {Day178/157:6}-{Day178/158:19}. 224 Dexter {Day178/152:3-13}.

Part 8 | Chapter 71: Training 35 that it might fail to identify or resolve significant problems and in any event could identify problems only after they had occurred with sufficient frequency or severity to be noted in one or more incident monitoring reports. 71.18 At a meeting held on 14 October 2013, the co-ordination board decided to carry out a fundamental review of the system, because it realised that the same shortcomings were repeatedly occurring. The review was to examine whether the right tools were available to the brigade for monitoring the effectiveness of training and what systems were used by other organisations. It was envisaged that it might lead to a review of the way in which the LFB responded to incidents. Ms Cotton, then AC Operational Assurance, was asked to lead the review.225 In the event, however, it was not as fundamental or far-reaching as had originally been intended or as was required, and although it led to a number of recommendations, it did not result in any significant changes to the system for monitoring the effectiveness of training.226 No one was able to explain why the stated aim of the review had not been met or why the opportunity to reform the existing arrangements had not been seized.227 Centralised training courses 71.19 In April 2012, the LFB engaged Babcock to provide centralised training to operational firefighters but retained responsibility for training non-operational officers, including the control room and the Fire Safety department. Shortly after being appointed as training provider, Babcock agreed to undertake a review of all the LFB’s training courses within the first three years of the contract. The LFB’s course review board, chaired by Director Reason, was responsible for considering and approving Babcock’s proposals.228 71.20 Although Babcock was responsible for creating and providing operational training packages, the LFB alone determined learning objectives and in practice provided much, if not all, of the expertise necessary for the production of the content. At all times it retained ultimate responsibility for training its staff and no training package could be provided by Babcock unless it had been approved by the LFB.229 The systems and structures relating to the training provided by Babcock were entirely separate from those relating to station-based training. 71.21 Responsibility for managing the LFB’s relationship with Babcock lay with the Training department. The Training department had no role in identifying training needs, recommending new training or requesting changes to existing training. Those were the responsibility of other departments, known as “commissioning departments”. The Training department’s role was essentially administrative: it collated training needs and requirements received from other departments and organised the process by which they were ultimately translated into training by Babcock.230 225 {LFB00067818/2}. 226 {LFB00123806}. 227 {LFB00040719/2}; Cotton {Day208/88:10}-{Day208/90:9}. 228 Reason {Day180/100:12}-{Day180/103:22}. 229 Groves {Day177/12:14-20}; {Day177/52:6-11}. 230 Groves {Day177/14:7}-{Day177/15:3}.

The Grenfell Tower Inquiry: Phase 2 Report 36 71.22 The Training department had two teams. The Learning and Development Strategy team was responsible for managing the development of training packages and communicating with Babcock and the commissioning departments.231 The Training Assurance and Business Relationship team was responsible for ensuring that Babcock provided the training that had been agreed and that it met the LFB’s learning and training objectives.232 71.23 Training was commissioned in accordance with a process known as the “training commissioning and alterations process” (TCAP). When a training requirement had been identified, the commissioning department completed a form identifying in broad terms what was needed.233 Project managers in the Training and Professional Development team, in consultation with the commissioning department, then completed what was known as a “TCAP form” which built on the basic information provided in the training request by addressing practical aspects of both substance and implementation.234 When the team was satisfied that it was correct, the form was submitted to a group consisting of representatives of both Babcock and the LFB’s Training department to check that the training would not have a detrimental effect on operational services.235 Babcock could suggest additions or changes to training but did so only once in the period before the Grenfell Tower fire.236 71.24 The next stage of the process was the development of the substantive training. Babcock proposed and designed the content of the training package to meet the identified learning objectives, subject to the approval of the commissioning department.237 Although it managed the commissioning process, the Training department did not play a part in designing the training itself.238 Babcock usually produced three options for providing the training for consideration by the LFB, which then made a choice.239 71.25 When the training materials had been assembled, a pilot training course was developed (except for some computer-based training), which was attended by experts and representatives of the commissioning department to ensure that it met the LFB’s needs.240 If the pilot course was considered satisfactory, it was necessary to obtain the commissioning department’s approval, confirmation from Babcock that the design was complete and approval from the Head of Fire Stations and the Training department for the provision of the training to operational staff.241 At that point the training could be rolled out. Some training packages were either delayed or not released at all following the completion of a TCAP form. 71.26 A consistent theme of the evidence was that Babcock lacked the expertise required to develop appropriate training. As a result, the LFB frequently had to provide experts from within its own ranks to assist it, which was a significant drain on resources.242 The problem was most acute at the start of the contract in 2012, particularly in relation to incident command training. It was therefore forced to rely on LFB officers to provide the necessary expertise, with the result that it was not always possible to implement much-needed 231 Groves {Day177/8:16}-{Day177/9:7}. 232 Groves {Day177/8:3-13}. 233 Groves {Day177/20:12}-{Day177/21:4}. 234 Groves {Day177/21:8-19}. 235 Groves {Day177/22:20}-{Day177/23:22}. 236 Groves {Day177/35:8-23}; Groves {MET00071103/11}. 237 Groves {LFB00102138/29} page 29, paragraph 49. 238 Groves {Day177/45:3-14}. 239 Groves {LFB00102138/22} page 22, paragraph 32. 240 Groves {LFB00102138/23} page 23, paragraph 33; Groves {Day177/65:25}-{Day177/66:11}. 241 Groves {Day177/65:12-24}; {Day177/67:18-25}. 242 Graham Ellis {LFB00118230/15} page 15, paragraph 69; Reason {Day181/30:16-23}.

Part 8 | Chapter 71: Training 37 changes to incident command training with sufficient urgency.243 Babcock’s reliance on the LFB for expertise also delayed other areas of training, including training on the use of breathing apparatus and real fire training.244 71.27 Although Mr Groves considered that it was Babcock’s responsibility to secure the expertise it needed, he rightly accepted that, whatever its contractual arrangements with Babcock, the LFB ultimately remained responsible for ensuring that firefighters were adequately trained.245 71.28 A report by Ribband Starr Ltd, commissioned by the LFB after the Grenfell Tower fire, found that many within the LFB regarded the commissioning process as cumbersome and capable of causing significant delay in the design and delivery of new courses.246 All the LFB witnesses who gave evidence about training were of that view.247 We agree with their assessment. 71.29 We were told that all training courses referred to in the annual statement of training requirements produced by the Training department were audited separately at least once a year by the LFB and Babcock and that the results were discussed at monthly meetings between Babcock and the Training department to decide whether any change to a particular training course was needed.248 The Inquiry has not seen any evidence of audits or discussion of their findings. In particular, there is no evidence that audits resulted in the creation or amendment of any training packages. If audits were carried out, they appear to have had no effect on the content of training. 71.30 PN825 refers to four levels of evaluation used by the LFB to assess the effectiveness of training. Level 1 involves the use of questionnaires seeking the opinions of those who have attended courses,249 Level 2 gauges what trainees have learnt, Level 3 assesses whether trainees have been able to apply their new skills and knowledge to the workplace, and Level 4 considers the effect of the training on the organisation as a whole.250 We were told that training courses, apart from computer-based training, had been subject to Level 1 evaluation but that no formal Level 3 or Level 4 evaluations had been carried out.251 71.31 There was no system in place for evaluating the performance of staff who had attended training courses by reference to previously agreed criteria. Once a training package had been developed by Babcock and approved by the commissioning department it was assumed to be suitable.252 That might have been a reasonable approach if the LFB had implemented adequate arrangements to review the effectiveness of training courses, but it is plain that it had made no such arrangements. The approach was particularly unsound in circumstances where there was no process at all by which the Training department was able to review the overall effectiveness of a training programme.253 243 Groves {Day177/47:16}-{Day177/48:9}; {Day177/48:20-25}. 244 Groves {Day177/55:2-19}. 245 Groves {Day177/52:6-11}. 246 {LFB00067786/33}. 247 Groves {Day177/56:17}-{Day177/57:5}; Reason {Day180/106:10-22}; Cotton {Day208/65:7-8} and Dexter {Day178/125:6-8}. 248 {LFB00055127/23} page 23, paragraph 7.1; Groves {Day177/68:15}-{Day177/69:23}. 249 Groves {Day177/70:2}-{Day177/71:8}. 250 {LFB00055171/13} page 13, paragraph 6.10. 251 Groves {Day177/71:21}-{Day177/73:7}. 252 Groves {Day177/74:16-25}. 253 Groves {Day 177/82:8-12}.

38 The Grenfell Tower Inquiry: Phase 2 Report 71.32 We have been left with the clear impression that, instead of adopting a system which measured the effectiveness of training by reference to previously agreed criteria, the LFB simply waited to see what, if any, problems subsequently arose at incidents. Such an approach might or might not reveal any deficiencies in training, but if it did, it was by then likely to be too late. The obvious weaknesses of that approach were aggravated by the fact that, as the number of incidents declined, progressively less confidence could be placed in a system that relied on problems being identified at incidents.254 Conclusions 71.33 The procedure adopted by the LFB for commissioning training in the years leading up to the Grenfell Tower fire placed much emphasis on ensuring that the right courses were produced and that training did not interfere with operational requirements. Both were laudable aims. However, the process was very cumbersome and inevitably led to excessive delay in providing new courses. There was also a disturbing absence of any system for evaluating the effectiveness of courses once they had been introduced. At a local level too much responsibility was placed on watch managers to devise and deliver training, with insufficient support and oversight. Since the quality of training at that level depended to a considerable extent on the skills of individual watch managers, the quality was bound to be variable. 71.34 In the Phase 1 report the chairman found that the incident commanders who were present during the early stages of the fire had not received sufficient training to enable them to understand the nature of the fire that confronted them and how it was likely to develop. We do not think that the deficiencies in the system for commissioning training or the arrangements for delivering training at station level that we have identified were responsible for that shortcoming, although we cannot be confident that, if there had been sufficient understanding of the need for training in the risks of cladding fires in high-rise buildings, it would have been delivered promptly and effectively. In the next chapter we examine why the LFB failed to ensure that those who acted as incident commanders were properly trained for the task. 254 McGuirk, Firefighting Expert Report {SMC00000046/47-50} pages 47-50, paragraphs 123-126.

39 Chapter 72 Incident command training 72.1 It became apparent during the course of the Grenfell Tower fire that few, if any, of those who were called upon to act as incident commanders in the early stages of the fire had received training in how to recognise a fire in the external wall of a high-rise residential building or to understand its likely consequences. Nor had they received any training in the principles of evacuation from high-rise residential buildings when a “stay put” strategy was no longer tenable, in how to decide whether evacuation was necessary or in how to carry it out safely and efficiently.255 It was therefore necessary for us to examine the way in which the LFB trained those who might be expected to assume the responsibility of incident commander and in doing so we must assess its response to the recommendations on incident command made by the coroner in March 2013, following the Lakanal House inquests. The coroner’s recommendations 72.2 There appears to be little doubt that before the Lakanal House fire in July 2009 only a small number of officers in the LFB were aware of the dangers posed by combustible materials when used in external walls of buildings or could recognise and understand the significance of a fire of the kind that broke out in Grenfell Tower in June 2017. Those who could and did were almost entirely confined to the Fire Safety department and did not include any of those who could be expected to act as incident commanders. 72.3 The Lakanal House fire should have changed that for ever, because operational firefighters at many levels witnessed at first hand the effects of fire spreading across an external wall as a result of the presence of combustible panels. They also witnessed the extensive loss of compartmentation caused in part by the spread of fire both externally and internally, the latter as a result of the use of unsuitable materials in the refurbishment of the interior, in particular some of the corridors. That should have been enough to prompt the LFB to take urgent steps to ensure that in future incident commanders were able to recognise a rapid loss of compartmentation and the spread of fire on the exterior of a building, if it occurred, and knew how to respond, almost certainly by evacuating the whole or part of the building. However, the need for such training should have been put beyond doubt by the coroner’s rule 43 letter, written over three years after the fire. 72.4 In her rule 43 letter to the LFB the coroner recommended that consideration be given to the training of incident commanders to enhance their performance in a number of respects, including their ability to understand and react quickly to changing circumstances and to anticipate that a fire might behave in a manner inconsistent with the compartmentation principle.256 255 Phase 1 Report Volume IV paragraph 27.16. 256 {LFB00032158/2-3}.

The Grenfell Tower Inquiry: Phase 2 Report 40 The LFB’s response 72.5 AC Cotton, who was head of the department responsible for incident command policy and training at the time, was asked to respond to the coroner’s recommendations.257 Her suggested response, which was ultimately adopted by the Commissioner’s Group, was that the LFB should work with Babcock to ensure that all the points raised by the coroner were covered in its current review of incident command training in the period up to 2015 and to create a case study training package which would teach the lessons to be learnt from the Lakanal House fire and other high-rise fires, such as the one at Shirley Towers. The suggestion ultimately resulted in the Lakanal House case study, to which we will refer later. However, as noted there, the case study did not provide adequate training for incident commanders facing a widespread failure of compartmentation of the kind experienced at Lakanal House, nor did it specifically address the coroner’s incident command recommendations.258 72.6 The LFB accordingly instructed Babcock to incorporate the coroner’s recommendations into its review of incident command training, which by then was already in progress. In addition, the LFB instructed Babcock to conduct a separate review to confirm that all the coroner’s recommendations relating to incident command were fully covered by existing training courses.259 That review was carried out in mid-September 2013 and the results were provided to the Operational Assurance department.260 The results of Babcock’s review were not considered by Director Reason.261 72.7 Babcock concluded that the existing training explicitly or implicitly covered all the areas identified by the coroner. Some were the subject of both theoretical and practical training; in other cases the extent to which the areas identified by the coroner were covered and the performance of trainees assessed depended on the exercises they undertook. Babcock recommended that the LFB revise its existing exercises in order to implement the coroner’s recommendations and identified 16 exercises which could provide starting points for new exercises which would fully implement those recommendations.262 72.8 In Chapter 74 we describe how in June 2013 LFEPA had set up a working group to monitor the LFB’s response to the Lakanal House fire. The LFB’s report to the working group on 30 September 2013 gave a different impression from that indicated by Babcock in its review. It said that Babcock had confirmed that all the coroner’s recommendations were covered by the existing training on incident command, although there might be opportunities for emphasising the experience obtained from the Lakanal House fire in some cases.263 That was inaccurate. Babcock had concluded that further work was required on the existing exercises and had identified the fact that some candidates for incident command might not have taken part in any of the relevant exercises.264 In such cases they would not have received any training on matters covered by the coroner’s recommendations. However, the fact that some incident commanders would not receive training on matters falling within the coroner’s recommendations was an important fact that was omitted from the LFB’s report. 257 Reason {Day180/169:1}-{Day180/170:8}; Cotton {Day208/157:10}-{Day208/159:10}; {Day208/160:5}-{Day208/162:7}. 258 {LFB00034062/22}. 259 {LFB00067820/13-14}, action 3; {LFB00003716/5}; {LFB00038170}; Reason {Day181/28:7}-{Day181/55:13}. 260 {LFB00038170}. 261 Reason {Day181/49:2}-{Day181/50:21}; {Day181/54:14-23}. 262 {LFB00038170}; {LFB00115289}. 263 {LFB00067820/13-14}. 264 {LFB00038170}; {LFB00115289}.

Part 8 | Chapter 72: Incident command training 41 72.9 In the LFB’s report to the working group in November 2013 that task was marked as having been completed. For reasons explained below, that too was inaccurate, since the work was by then far from complete.265 Director Reason accepted that the reports did not disclose that Babcock had found that some individuals were not receiving training in the areas identified by the coroner, that incident command training therefore required enhancement, and that the work to develop training exercises was continuing.266 He said that he had relied on the information he had received from the co-ordination board’s monitoring of the response to the recommendations and that it had been the responsibility of AC Cotton and her commissioning department to ensure the accuracy of the information.267 He told us that he had provided the working group with the information that AC Cotton’s department had collated for the co-ordination board.268 72.10 AC Cotton considered that the reports were misleading but said that she was puzzled why the tasks had been marked as completed, because at that stage they were very far from completing the enhancement to the training programme that Babcock was going to undertake.269 She said that she could not recall ever having seen a report to the co‑ordination board indicating that the task had been completed; if she had, she would have challenged it.270 72.11 AC Cotton disputed Director Reason’s evidence that he had depended on reports emanating from the co-ordination board. In her view, he had a far better understanding of the position than his evidence suggested. She thought he had been fully aware that a number of tasks were outstanding because he was a member of the co-ordination board and had seen the progress reports. She said that the reports on incident command training had been discussed at length in directorate management board meetings and in her meetings with him. She added that Director Reason was not the sort of person who would accept what was given to him at face value. He would explore the detail. 72.12 In January 2014 Director Reason asked Adrian Bevan, a health and safety manager in the LFB,271 to provide him with a document to support the paragraph in the report to the working group which stated that all seven recommendations were adequately covered by the existing training exercises. Having made some enquiries, Mr Bevan reported that the position was not as clear as had been thought because there had been some confusion between current training exercises and the new exercises that Babcock were developing. At that point, if not before, therefore, Director Reason must have been aware that the position was not as had been reported to the working group. However he did not attempt to correct the reports.272 Director Reason should have ensured that his reports to the Lakanal House Working Group accurately reflected the delay to the new incident command training programme. 265 {LFB00067832/24-25}. 266 Reason {Day181/84:3-18}. 267 Reason {LFB00067846/13-14} pages 13-14, paragraph 17; Reason {Day181/48:12}-{Day181/50:21}; {Day181/82:11}- {Day181/84:18}. 268 Reason {Day180/150:11}-{Day180/151:8}; {Day180/157:1-7}. 269 Cotton {Day208/224:21}-{Day208/226:12}; {Day208/235:7-25}. 270 Cotton {Day209/17:17}-{Day209/21:21}. 271 Hayward {Day201/30:1-10}. 272 {LFB00094806/2}; {LFB00118750}; Reason {Day181/101:11}-{Day181/109:18}; {Day181/141:14}-{Day181/148:5}.

The Grenfell Tower Inquiry: Phase 2 Report 42 Additional training 72.13 Babcock’s initial proposal to revise and refine 16 command training exercises was not carried out. First the number was reduced to six and in the end only one, the Holcroft House exercise, was developed. The reasons for that are not entirely clear.273 72.14 The Holcroft House exercise became available in 2016. It centred on a fire at a high-rise residential block in Battersea which was undergoing decorative and remedial building works. The overview of the exercise described it as increasing in complexity to involve persons reported as trapped and needing rescue, fire survival guidance calls, significant fire growth and the need for mass evacuation, compounded by the hazards and risks associated with the remedial building works. It was intended to create significant challenges for crew managers and watch managers. A detailed description of the exercise and its potential variations disclosed that it involved only two fire survival guidance calls (at the Lakanal House fire there had been five) and the spread of fire from the original compartment only to the communal corridor, rather than to other floors. The training guide stated that trainees were expected to consider partial or full evacuation of the block, but there was nothing in the course materials designed to help them understand why they might need to consider an evacuation or how they might organise one.274 For all those reasons, as Director Reason accepted, that particular training package was not an adequate response to the coroner’s recommendations.275 Director Reason was not involved in the development of that package but did have ultimate responsibility for changes to the LFB’s incident command training in response to the coroner’s recommendations until his retirement on 2 January 2015. 72.15 There was conflicting evidence about whether it was intended to make the Holcroft House exercise available to all potential incident commanders,276 but in the event, it was restricted, for reasons which are not clear, to Level 1 incident commanders (crew managers and watch managers), rather than being provided to all four levels of incident commander as had been envisaged by Babcock’s initial proposal.277 As a result, a significant number of incident commanders did not receive the training which had been designed to implement the coroner’s recommendations. 72.16 Director Reason told us that the LFB was likely to have partially implemented the coroner’s recommendations before August 2016 through Babcock’s making simple adjustments to existing courses and by changing the procedures for assessing suitability for senior officer positions.278 However, apart from a report which stated that assessments of suitability for incident command covered the challenges of managing incidents affecting high-rise buildings,279 there was no contemporaneous evidence that changes to training courses or to the assessment procedures had been made to reflect the coroner’s recommendations. If changes of that kind had been made, we think they would almost certainly have been recorded, if only informally. We are therefore unable to accept what Director Reason said on that matter. 273 {LFB00003716}; Reason {Day181/62:16}-{Day181/75:20}; Cotton {Day209/2:10}-{Day209/3:10}; {Day209/13:11-18}. 274 {BAB00000011}; Reason {Day181/110:10}-{Day181/129:21}. 275 Reason {Day181/128:18}-{Day181/129:21}. 276 {LFB00004801/29}, action 3b; Groves {Day177/123:12}-{Day177/127:13}. 277 {LFB00003716}; {LFB00115289}; Reason {Day181/73:4-22}. 278 Reason {Day181/76:2}-{Day181/77:12}. 279 {LFB00067812/5}.

Part 8 | Chapter 72: Incident command training 43 72.17 We have no doubt that the LFB intended to incorporate the coroner’s seven incident command recommendations into Babcock’s review of incident command courses,280 which should have ensured that from 2015 the recommendations were reflected in new incident command courses. However, the evidence clearly shows that they were not considered in any detail by either Babcock281 or by the LFB during its review of the courses.282 That was a significant failing by the LFB, which should have ensured that the lessons to be learnt from the Lakanal House fire were at the heart of the review that it had instructed Babcock to undertake. 72.18 Director Reason told us that the LFB’s Course Review Board and Babcock’s review of the training courses were separate from the recommendations of the Lakanal House Board and those made by the coroner.283 Although they may have had separate origins, however, it was clear that the LFB intended to incorporate the coroner’s recommendations into Babcock’s review of training, as indeed had been conveyed to the coroner.284 That was also confirmed by AC Cotton, who was involved in the review of training courses relating to incident command that was overseen by the Incident Command Project Board.285 Both AC Cotton and Director Reason could and should have ensured that the incident command recommendations were taken into account in that course review. 72.19 Even if the new incident command courses adequately reflected the lessons to be learnt from the Lakanal House fire, most of them had not been made available to operational personnel by the time of the Grenfell Tower fire. Courses for Level 1 incident commanders were made available between 2016 and 2017, but courses for Level 2 (station managers and group managers), Level 3 (Deputy Assistant Commissioners) and Level 4 (Assistant Commissioners and above) were either yet to be made available or were still being worked on at the time of the Grenfell Tower fire.286 That was almost three years after the LFB had received Babcock’s report on its review of training courses and over two years after the revisions should have been completed.287 AC Cotton described that rate of progress as “worse than slow”. She said that she had regularly reported her frustrations and serious concern about the lack of progress that was being made.288 72.20 We heard forthright evidence from a number of witnesses about the difficulties that Babcock had experienced in providing incident command training, which they attributed to its lack of expertise (which required a greater contribution from the LFB than had been expected), delay in creating training packages and difficulty translating proposals for training into courses.289 AC Cotton described Babcock’s inability to develop incident command training as one of her greatest frustrations. She said that the LFB could not take back control of training because it had lost the teams that it had previously relied on for developing courses.290 280 {LFB00042089}; {LFB00067832/25}; {LFB00003716/8}. 281 {LFB00042089}; {LFB00073973}. 282 {LFB00043552}; Reason {Day181/130:1}-{Day181/138:10}; Cotton {Day209/40:6}-{Day209/47:23}. 283 Reason {Day180/100:12}-{Day180/103:22}. 284 {LFB00042089}. 285 Cotton {Day208/208:3}-{Day208/210:17}; Cohen-Hatton {Day185/69:9-14}. 286 Groves {Day177/140:16}-{Day177/141:18}; Cotton {Day209/73:21}-{Day209/76:23}. 287 Groves {Day177/142:11}-{Day177/143:7}; Cotton {Day209/75:22}-{Day209/76:4}. 288 Cotton {Day209/76:5}-{Day209/77:15}. 289 Ellis {LFB00118230/15} page 15, paragraphs 69-71; Groves {Day177/46:3}-{Day177/55:19}; {Day177/116:7}- {Day177/120:24}; Reason {Day181/30:16-23}; {Day181/70:5}-{Day181/73:3}; Cotton {Day208/205:21}- {Day208/206:3}; {Day208/206:19}-{Day208/207:3}; {Day209/15:23}-{Day209/17:7}; {Day209/26:4-13}; {Day209/76:5}- {Day209/78:11}; {LFB00118213/11}; Dobson {Day211/186:24}-{Day211/188:21}; {Day211/190:6}-{Day211/192:9}. 290 Cotton {Day209/76:5}-{Day209/79:12}.

The Grenfell Tower Inquiry: Phase 2 Report 44 72.21 Babcock’s lack of expertise clearly contributed to the significant delay in the development and release of the revised incident command training. Peter Groves told us that it should normally take no more than a year to produce a new course but that the complexity of training for incident command and Babcock’s lack of expertise had delayed the process. He agreed, however, that a lapse of three years between the receipt of the coroner’s recommendations and the release of the Holcroft House exercise was unduly long. He attributed the delay to Babcock’s lack of expertise,291 but the LFB was ultimately responsible for the protection of life and property and of its own staff and had a duty to ensure that adequate training was provided to its crews for that purpose. Although we heard evidence that Commissioner Dobson had raised the delay with the chief executive of Babcock, they appear to have concluded that neither Babcock nor the LFB was at fault and to have confined themselves to repeating the importance of complying with the coroner’s recommendations.292 The discussions had little or no effect on the delay. We do not think that the steps taken by the LFB to remedy the problems with Babcock were sufficiently robust. 72.22 Some senior LFB officers thought that the coroner’s recommendations did not require any substantive revisions to the LFB’s existing incident command training. For example, Commissioner Dobson told us that the LFB had not needed to revise its incident command training; all that was needed, he thought, was for the seven recommendations to be enhanced and properly embedded.293 Similarly, AC Cotton said that the recommendations were not inconsistent with existing policy and procedures294 and Director Reason did not think that the recommendations reflected the existence of a systemic problem.295 We think that views of that kind held by senior officers are likely to have undermined the importance attached to the training packages and to have added to the delay. Incident command revalidation 72.23 Another aspect of incident command training that was under development at the time of the Grenfell Tower fire was a programme of continuing assessment of competence to undertake incident command, known as incident command revalidation. The purpose of the programme was to ensure that operational officers of crew manager rank and above maintained the required level of competence as incident commanders throughout their operational careers. That contrasted with the position under the LFB’s incident command training arrangements existing at the time of the Grenfell Tower fire, under which competence to undertake incident command was assessed by way of an exercise undertaken only when an officer was being considered for promotion. Under those arrangements no further assessment took place unless and until that officer was being considered for further promotion. None of the continuing incident command training that existed immediately before the Grenfell Tower fire contained any form of assessment, and officers who undertook that training continued in their existing rank regardless of their performance during training. 291 Dobson {Day211/127:19}-{Day211/128:14}. 292 Dobson {Day211/185:23}-{Day211/192:9}. 293 Dobson {Day211/178:12-23}. 294 Reason {Day181/36:5-17}. 295 Reason {Day181/137:1-13}.

Part 8 | Chapter 72: Incident command training 45 72.24 Proposals for an incident command revalidation programme had first been put forward to the Commissioners’ Group by Dr Sabrina Cohen-Hatton, then a DAC and the LFB’s Head of Development, in a report dated 17 November 2015.296 She referred to the declining number of incidents in the years preceding the report, which had resulted in a reduction in operational experience across the board and, in particular, a reduction in the number of opportunities for officers to undertake command roles. Her department had consulted five other fire and rescue services, all of which were operating a revalidation system of some kind involving a formal assessment of competence to undertake incident command roughly every 18 to 24 months.297 72.25 The report to the Commissioners’ Group also referred to the remarkably low pass rates for the LFB’s existing incident command promotional exercises, in which just 25% of station managers and group managers and 36% of Deputy Assistant Commissioners were successful. Dr Cohen-Hatton said that the low pass rates were likely to be explained by the fact that candidates received no training in how to command an incident of the scale and complexity that they were required to tackle as part of the promotional exercise, meaning that the first time that many of them had encountered such an environment was at the assessment itself.298 72.26 The report recommended a revalidation programme consisting of three elements: a test to assess levels of technical and procedural knowledge, another test to assess command skills by means of an incident command exercise, and the demonstration by means of a continuing professional development (CPD) log that incident command skills had been consistently and effectively applied on the incident ground. Dr Cohen-Hatton proposed that the three elements should be assessed every two years, with provision for additional training to be undertaken by those who scored below a minimum threshold, or, in the most serious cases, removal from operational duties. 72.27 The proposed revalidation programme was developed separately from the work being carried out on the coroner’s recommendations, but its implementation depended on the delivery of the new incident command training exercise being developed as part of Babcock’s wider review. Since the LFB lacked the necessary resources to provide and assess a separate exercise just for the revalidation programme, the incident command exercise to be used for the revalidation process had to form part of the new incident command refresher training.299 The delay in the development of the new course therefore delayed the progress of the incident command revalidation programme. 72.28 The original timetable for the revalidation programme had been set out in a report to the Corporate Management Board dated 16 December 2015, which recorded that the knowledge tests and the incident command exercise were to be launched in April 2016 and the use of CPD logs in April 2017.300 However, by the time that Dr Cohen-Hatton reported to the Corporate Management Board on 8 June 2016 those dates had been pushed back to some indeterminate time in 2016 or 2017, in the case of the knowledge tests and incident command exercise, and 2017 or 2018 in the case of the CPD logs.301 At a meeting of the Incident Command Project Board on 23 February 2017, Dr Cohen-Hatton expressed her concern that the implementation of a revalidation programme was being pushed back as 296 {LFB00118186}. 297 The FRSs consulted were Tyne and Wear, Greater Manchester, Hampshire, Derbyshire and Hertfordshire. 298 Cohen-Hatton {Day185/125:4-15}. 299 Cohen-Hatton {Day185/145:11-16}; {Day185/147:1-15}. 300 {LFB00118193}. 301 {LFB00118189}.

46 The Grenfell Tower Inquiry: Phase 2 Report a result of the delay in the broader review of incident command training.302 A briefing note prepared for the Corporate Management Board in March 2017 stated that pilots of some of the knowledge tests would be carried out in May 2017 and indicated that a draft policy was in the final stages of development.303 By that stage Dr Cohen-Hatton’s team had done most of what they could do pending the delivery of the incident command training being developed in response to the broader review.304 72.29 The revalidation programme had still not been implemented at the time of the Grenfell Tower fire, nor by the time of the inspection of the LFB by Her Majesty’s Inspectorate of Constabulary and Fire and Rescue Service (HMICFRS) in May and June 2019, which identified the lack of any revalidation system as a cause for concern requiring immediate action by the LFB.305 302 Cohen-Hatton {LFB00110660/24} page 24, paragraph 87; {LFB00118192/2}. 303 {LFB00118187}; Cohen-Hatton {Day185/163:1-17}. 304 Cohen-Hatton {Day185/164:4-8}. 305 {INQ00014796/39}.

47 Chapter 73 Modern materials and methods of construction 73.1 In the Phase 1 report, the chairman found that the absence of any training for incident commanders in how to recognise the need for evacuation reflected a failure to recognise the risk of fire taking hold on the outside of modern buildings.306 He expressed the view that it was a surprising failure, given the long history of fires involving cladding on high-rise buildings both in this country and abroad, a history of which some people within the LFB had been aware for some time.307 Knowsley Heights and Garnock Court 73.2 Before the Lakanal House fire in July 2009, there had already been two significant fires in the UK which had involved the extensive spread of fire through combustible external panels. On 5 April 1991, a fire was started deliberately in a rubbish compound outside Knowsley Heights, an 11-storey residential building in Liverpool. The fire spread rapidly through a 90mm gap between the building’s concrete outer wall covered with rubberised paint and rain screen panels which had recently been installed. The fire spread to the highest floor and seriously damaged the outer walls and windows of all the upper floors.308 73.3 On 11 June 1999, a fire started on the fifth floor of Garnock Court, a 14-storey residential building in Irvine, Scotland. The fire spread rapidly to the higher floors through a vertical strip of external cladding, resulting in one fatality.309 73.4 The fire at Garnock Court was the subject of a report by the Environment, Transport and Regional Affairs Committee entitled Potential Risk of Fire Spread in Buildings via External Cladding Systems.310 The report, published in December 1999, drew attention to the risk of the unexpectedly rapid spread of fire through cladding systems, which could lead to disproportionate difficulties in firefighting and a shorter period available for escape from the building, potentially endangering life.311 The committee concluded that the evidence before it did not suggest that the majority of external cladding systems in the UK posed a serious threat to life or property in the event of fire, but went on to say that, notwithstanding that conclusion, it did not believe that it should take a serious fire in which many people were killed before all reasonable steps were taken towards minimising the risks. It recommended that all external cladding systems be required to be either entirely non-combustible or proved through full-scale testing not to pose an unacceptable level of risk from the spread of fire.312 306 Phase 1 Report Volume IV paragraph 27.9. 307 Phase 1 Report Volume IV paragraph 27.10. 308 {LFB00031816/5-6}. 309 {LFB00031816/6}. 310 {CLG00019478}. 311 {CLG00019478/8} paragraph 10. 312 {CLG00019478/9-10} paragraphs 18-20.

The Grenfell Tower Inquiry: Phase 2 Report 48 73.5 Apart from a passing reference to the Garnock Court fire in a presentation on the spread of fire across the facades of tall buildings created in 2016, the LFB failed to create any training materials which communicated to operational staff the key lessons to be learnt from those two fires. Deputy Commissioner Dexter said that she had been aware of the Knowsley Heights and Garnock Court fires during her time at the LFB position;313 Commissioner Dobson said that he had been aware of the Knowsley Heights fire but not the Garnock Court fire.314 Both agreed that those fires contained lessons for the LFB.315 Commissioner Dobson’s recollection was that the fires had been considered by the Operations and Fire Safety departments, which had concluded that the lessons from those incidents had already been learnt by the LFB or were not relevant to it.316 The letter to London Boroughs and social housing landlords 73.6 Also on 23 March 2009, AC Stephen Turek, then in charge of Fire Safety Regulation, wrote to London Boroughs and social housing landlords about fire safety in social housing.317 In his letter he said that it had been written in the light of a number of recent fires in social housing blocks,318 and drew attention to several aspects of construction that could present dangers. They included the following: a. Replacement windows, particularly uPVC window units, installed in a way that created gaps that had been covered with non-fire-resisting materials which, in the event of a fire, distorted and allowed fire to enter the wall cavity; b. Panels on the exterior walls of flats replaced with non-fire-resisting uPVC panels as part of replacement window units, which might have contributed to the total failure of windows during a fire, allowing the fire to pass upwards across the exterior wall and enter the windows of flats above; c. A lack of fire-stopping in wall cavities, allowing the unrestricted rapid spread of fire through the building; d. A lack of fire-stopping in service riser ducts allowing fire to spread rapidly through blocks of flats, trapping some residents due to smoke-logging and high temperatures in the escape routes; e. A lack of fire-stopping between routes of escape and individual flats, which led to residents becoming trapped in smoke-filled flats and requiring rescue. 73.7 The letter had apparently been based on fire investigation reports relating to premises where such defects had been noticed following inspections by fire safety regulation officers.319 313 Dexter {Day179/94:9-18}. 314 Dobson {Day210/102:19}-{Day210/103:12}. 315 Dexter {Day179/94:19-23}; Dobson {Day210/103:9-20}. 316 Dobson {Day210/103:21}-{Day210/104:16}. 317 {LFB00001805}. 318 {LFB00001805/1}. 319 Dobson {Day210/117:9-16}.

Part 8 | Chapter 73: Modern materials and methods of construction 49 Conclusions 73.8 The evidence as a whole, but particularly the letter of 23 March 2009, shows that by that date some senior officers within the LFB had become aware: a. that non-fire-resisting panels which could contribute to the spread of fire had been used on the external walls of some blocks of flats; b. that a failure of compartmentation caused by a lack of fire-stopping could lead to an unrestricted, rapid spread of fire through a building; c. that such defects created a risk of residents’ becoming trapped in areas of the building in which they should have been safe; d. that those hazards had already been encountered at some incidents; and e. that the Building Regulations could not be relied upon to prevent buildings being exposed to risks of that kind.

50 The Grenfell Tower Inquiry: Phase 2 Report

51 Chapter 74 The response to the Lakanal House fire 74.1 As the chairman explained in Chapter 8 of the Phase 1 report, Lakanal House was a high‑rise residential tower block in Camberwell, South London. On 3 July 2009, a fire broke out in a flat on the ninth floor of the building. Within 30 minutes it had spread down to the fifth floor and up to the twelfth floor as well as to communal areas, including corridors and the building’s single staircase. Six people lost their lives and 15 people were taken to hospital suffering from smoke inhalation. The incident involved a widespread failure of compartmentation and extensive spread of fire and smoke.320 The fire was able to spread across the external wall (both upwards and downwards) as a result of the presence of combustible window panels that did not comply with the Building Regulations.321 The incident was also characterised by an unusually high number of fire survival guidance calls (five in total),322 poor communication between the control room and the incident ground, difficulties with radio communications generally and confusion among firefighters about the layout of the building and the locations of flats.323 74.2 The Lakanal House fire in July 2009 was a watershed moment for the LFB and was undoubtedly the most significant residential fire in which it had been involved in the years immediately preceding the Grenfell Tower fire. It is of particular importance because it marked a milestone in the history of the LFB’s response to fires in high-rise residential buildings and the handling of emergency calls. It prefigured in many respects the Grenfell Tower fire some eight years later and it is therefore appropriate to consider how the LFB responded to the experience and the extent to which it learned from it. The Lakanal House Board 74.3 In October 2009, Commissioner Dobson set up the Lakanal House Board to oversee the LFB’s internal investigation into the fire and its response to it. It was chaired by the Commissioner and attended by a wide range of senior officers. The board was responsible for identifying the lessons to be drawn from the incident and for making any recommendations for organisational change that were thought necessary.324 It met monthly and provided a forum for senior officers to discuss matters arising from the LFB’s investigation into the fire, to agree a response and to allocate responsibility for action to relevant departments and officers.325 74.4 The Lakanal House Board identified 34 steps that could be taken to improve the LFB’s operational response. They were set out in an action plan agreed at a meeting of the Board on 15 September 2010. Each step was assigned to an officer who was responsible for its implementation.326 At subsequent meetings those officers provided regular reports on 320 Dobson {Day210/73:6-10}. 321 Dobson {Day210/75:8-20}. 322 The LFB’s Lakanal Control Report, produced for the purpose of the Lakanal inquests, identified five calls to the control room during which fire survival guidance advice was given {HOM00001124/35-37}. Two of those calls were from the same flat and three of the calls were in progress at the same time. 323 Dobson {Day210/75:21}-{Day210/76:13}. 324 {LFB00039696} Lakanal House Board Terms of Reference; Dobson {Day210/79:3}-{Day210/80:15}. 325 Dobson {Day210/86:21}-{Day210/87:3}. 326 {LFB00084031/7-10}.

The Grenfell Tower Inquiry: Phase 2 Report 52 progress which were reflected in a rolling plan of action.327 The 34 steps became known internally as the “pre-inquest actions”, or simply “pre-actions”. They covered a wide range of subjects, from the development of a policy relating to the risk of falling cables to writing to the government to obtain clarity on aspects of national guidance. They included a review of the LFB’s existing policies on firefighting in high-rise buildings and the management of emergency calls. Although some are of no relevance to our investigations, others are of central importance, such as the review of the LFB’s policy on firefighting in high-rise buildings and the provision of training to control room officers in handling fire survival guidance calls. However, the pre-inquest actions failed to include any response to what should have been the principal concerns arising from the Lakanal House fire, namely, the widespread failure of compartmentation and the spread of fire across external walls due to the use of combustible construction materials. The Lindridge Review 74.5 In September 2012, more than three years after the fire and in preparation for the Lakanal House inquests, Commissioner Dobson asked the Operational Assurance department, then headed by AC Cotton, to review the pre-actions to identify those which had been completed and those which had not.328 Director Reason (to whom AC Cotton reported) delegated the task of carrying out the review to GM David Lindridge,329 subject to the oversight of AC Cotton.330 74.6 GM Lindridge understood that his review was to involve no more than identifying which pre-actions had been carried out and which had not. He did not express a view on whether the actions taken were sufficient to meet the expectations of the board; he simply described the steps that had been taken so that others could make that assessment for themselves.331 74.7 In January 2013, GM Lindridge produced a report of his findings entitled Review of the Lakanal Action Plan (the Lindridge Review).332 He found that 16 of the 34 tasks were still being worked on in one way or another and was unable to confirm that another 13 had achieved their expected outcomes.333 GM Lindridge attached to his report a list of the pre‑actions together with his findings on each of them. He also set out a list of his key findings in relation to ten of the pre-actions for the attention of the Commissioner’s Group. Most of them related to the control room. 74.8 GM Lindridge produced a revised version of his report in November 2013, in which he found that 8 actions had still not been completed (although in all but one of those cases the LFB was awaiting action by another organisation).334 They included actions concerning the training of control room supervisors, pre-planning and correspondence with the government relating to aspects of fire safety.335 327 {LFB00084032/5-8}. 328 Dobson {LFB00032157/10} page 10, paragraph 38; Reason {LFB00032747/18} page 18, paragraph 53; Dobson {Day211/153:12-24}. 329 Lindridge {LFB00083925/4} page 4, paragraph 17. 330 Cotton {LFB00032737/6} page 6, paragraph 21. 331 Lindridge {LFB00083925/3} page 3, paragraph 12. 332 {LFB00033943}. 333 {LFB00033943/4-5} pages 4-5, paragraphs 5.2 and 5.3. 334 {LFB00083988}. 335 {LFB00083988/6-23}.

Part 8 | Chapter 74: The response to the Lakanal House fire 53 74.9 After receiving the Lindridge Review, neither AC Cotton nor anyone else appears to have considered whether the implementation of the Lakanal pre-inquest actions had been effective. Commissioner Cotton said that she had not been sufficiently qualified in a number of the areas being audited to express an opinion. In her view, it was the function of the Lakanal House Board to satisfy itself that the work had been done. She did not see it as part of her role as Head of Operational Assurance to be concerned with the detail of the actions referred to in the Lindridge Review.336 74.10 In the event, the Lindridge Review was never presented to the Lakanal House Board, which held its last meeting in September 2013 (though it was never formally disbanded). Commissioner Dobson said that his intention had been to have a final meeting formally to review and accept the revised Lindridge Review, but that it had been overlooked.337 Nor was the Lindridge Review ever presented to the Lakanal House Working Group, referred to below, because the working group was directing its attention to the steps required in response to the findings made by the coroner.338 74.11 Although Commissioner Dobson said that responsibility for overseeing the progress of outstanding pre-inquest actions had been taken over by the co-ordination board,339 we have seen no evidence of any such oversight in the minutes of its meetings. The Lindridge Review was, however, circulated to the Commissioner’s Group and discussed at a meeting in November 2013.340 Director Reason’s recollection was that he and Deputy Commissioner Dexter had each accepted responsibility for the outstanding actions that fell within their respective directorates.341 74.12 After the Lakanal House Board effectively ceased to exist in September 2013, the LFB was left with no means of ascertaining whether the outstanding pre-inquest actions had been completed. Nor did it carry out any systematic inquiry to find out whether the work that had been done had been successful in making good the deficiencies the fire had uncovered. As a result, by 14 June 2017 significant steps that were relevant to dealing with the hazards that were later to confront the LFB at Grenfell Tower had not been taken. The LFB’s failure effectively to oversee the progress and completion of the changes in training and procedure it had identified as necessary in the light of the Lakanal House fire was a significant failing which prevented it from responding more effectively to the fire at Grenfell Tower. 74.13 Commissioner Cotton told us that monitoring the work on the Lakanal pre-inquest actions had not been the responsibility of the Operational Assurance department.342 Although that may be true, it is unfortunate that the department responsible for ensuring the operational effectiveness of the LFB (and with learning from significant incidents) did not have, and did not seek, that responsibility, especially as no other department of the LFB did. Operational Assurance was the department to which the Commissioner had assigned responsibility for the review of the 34 pre-inquest actions in the first place and Commissioner Dobson should have ensured that there was no doubt about where responsibility for overseeing the implementation of the Lakanal pre-inquest actions lay. Ms Cotton had also been a member of the Lakanal House Board and she continued to sit on the co-ordination board, two key boards attended by the heads of service responsible for implementing the various changes. 336 Cotton {Day208/110:10}-{Day208/111:6}. 337 Dobson {Day211/171:3}-{Day211/172:7}. 338 Reason {Day180/130:19-25}; Dobson {Day211/172:8-25}. 339 Dobson {Day210/88:15}-{Day210/89:5}; {Day211/171:24}-{Day211/172:4}. 340 Reason {Day180/130:15-18}. 341 Reason {LFB00032747/19} page 19, paragraph 58; Reason {Day180/132:4}-{Day180/133:6}. 342 Cotton {Day208/114:5-19}.

The Grenfell Tower Inquiry: Phase 2 Report 54 The Operational Assurance department was best placed to oversee the necessary changes, with the assistance of relevant experts where required, and to monitor the progress of any that remained outstanding. The Commissioner’s failure to assign responsibility clearly to the Operational Assurance department was a significant error. 74.14 There is no evidence that the LFB subsequently reviewed the 34 pre-inquest actions in the light of the Lakanal House coroner’s recommendations to see whether further changes might be required.343 The Lakanal House inquests and the coroner’s rule 43 letter 74.15 The Lakanal House inquests were conducted by Her Honour Frances Kirkham CBE between January and March 2013. The coroner heard evidence from a number of LFB witnesses, including Commissioner Dobson. 74.16 Rule 43 of the Coroners Rules then in force allowed the coroner to make such recommendations as she considered necessary, based on the evidence heard during the inquest, to eliminate or reduce the risk of further deaths. On 28 March 2013, she sent Commissioner Dobson a letter pursuant to that rule (a rule 43 letter).344 She also wrote to the Department for Communities and Local Government, the London Borough of Southwark and the Fire Sector Federation. 74.17 In her letter to the Commissioner the coroner acknowledged the work that the LFB had already carried out and recommended further action in five areas: public awareness of fire safety, visits made pursuant to section 7(2)(d) of the Fire and Rescue Services Act 2004, incident command, the control room, and communications. The substance of those recommendations will be considered in later chapters. 74.18 Following receipt of that letter, Commissioner Dobson instructed Director Reason to put together an action plan in response to the coroner’s recommendations.345 In April 2013, Director Reason held a meeting with the heads of service responsible for the activities in question and asked each of them to produce a draft plan of action on the recommendations affecting their areas of responsibility.346 Draft plans, referred to internally as “pro formas”, were produced by four heads of service, AC David Brown (Head of Operations, Procedures and Response), AC Stephen Turek (Head of Fire Safety Regulation), AC Dany Cotton (Head of Operational Assurance), and AC James Knighton (Head of Operational Procedures). They contained an analysis of the recommendations and proposed responses.347 The pro formas were submitted to the Commissioner’s Group, which used them to draft the LFB’s response to the coroner’s letter.348 That response was discussed and approved at a meeting of the Commissioner’s Group and the heads of service on 14 May 2013. The meeting was not minuted, but Director Reason’s recollection was that it had been concerned principally with the Commissioner’s review of the proposals and the time required to implement them.349 343 Cotton {Day208/139:1-22}. 344 {LFB00032158}. 345 Reason {LFB00032747/5} page 5, paragraph 19. 346 Reason {Day180/139:2}-{Day180/140:21}. 347 {LFB00073406}; {LFB00034062}. 348 Reason {Day180/141:5}-{Day180/142:16}. 349 Reason {Day180/142:9}-{Day180/143:7}.

Part 8 | Chapter 74: The response to the Lakanal House fire 55 74.19 On 23 May 2013, Commissioner Dobson sent the LFB’s response to the coroner.350 The letter set out the action which the LFB proposed to take in response to each recommendation and the time within which it would be completed. The Commissioner estimated that all the proposed actions would be completed by the end of 2013. 74.20 Responsibility for overseeing the progress of the steps that the LFB proposed to take was allocated to the co-ordination board and the Lakanal House Working Group.351 (One of the co-ordination board’s existing functions was to monitor the progress of proposals for responding to rule 43 recommendations.)352 At a meeting of the board on 3 June 2013 it was agreed that AC Cotton would develop a plan to monitor the progress of the response to the coroner’s recommendations.353 A consolidated plan combining the response to the coroner with the LFB’s reaction to some rule 43 recommendations made by the Hampshire coroner following a fire at Shirley Towers in Southampton in which two firefighters had died was therefore produced for a meeting of the co-ordination board on 4 July 2013.354 74.21 Commissioner Dobson told us that he took personal responsibility for overseeing the response to the coroner’s letter, which, in addition to his role on the working group, he exercised in the course of meetings with individual directors and through the Commissioner’s Group.355 74.22 Overall, the response of the LFB to the Lakanal House fire was slow and ineffective. Although it soon established a process for identifying the lessons to be learnt and the steps needed to implement them, it took the best part of a year for it to identify those steps, several of which had not been implemented by the time that the first Lindridge Review was delivered two years later. Some had still not been implemented by the time that GM Lindridge produced his revised review in November 2013. The Lakanal House Board appears to have been allowed to lapse without any proper consideration of the extent to which the recommendations had been implemented, much less whether they had been successful. In our view, senior officers failed to provide the energetic and effective response that was required to an incident of such significance, for which Commissioner Dobson must bear primary responsibility. The Lakanal House Working Group 74.23 The Lakanal House Working Group was established by LFEPA in June 2013 to review and oversee the LFB’s actions following the fire at Lakanal House and to provide regular information and any additional recommendations to LFEPA’s Strategy Committee.356 It consisted of three elected members of the authority, Valerie Shawcross, Maurice Heaster and Peter Truesdale.357 The working group was intended to provide political oversight, scrutiny and accountability for the LFB’s response to the coroner’s recommendations.358 Although membership of the working group was formally limited to the three elected members, its meetings were also attended by Commissioner Dobson, Deputy Commissioner Dexter, Director Reason and other senior LFB officers as required in order to provide information on progress and answer members’ questions. 350 {LFB00042089}. 351 Reason {LFB00032747/6} page 6, paragraph 22. 352 Reason{Day180/145:6}-{Day180/146:8}. 353 Cotton {LFB00032737/7} page 7, paragraph 25. 354 {LFB00089127}. 355 Dobson {LFB00032157/7} page 7; Dobson {Day210/100:14}-{Day210/101:3}. 356 {LFB00032156/3}. 357 Dobson {LFB00032157/7} page 7, paragraph 23; {LFB00032156/3}. 358 Reason {Day180/148:18-23}; Dobson {Day210/96:7-18}.

The Grenfell Tower Inquiry: Phase 2 Report 56 74.24 The outstanding pre-inquest actions were never brought to the attention of the working group, nor did it receive a copy of the Lindridge Review. When Director Reason was asked whether the working group might have benefited from seeing the review or from being told about the items that remained outstanding, he said that the elected members would probably not have wanted that level of information.359 74.25 Director Reason was responsible for presenting a report on the progress of the response to the coroner’s rule 43 letter at each meeting of the working group and reporting the current position in each case.360 He said that his reports had been based on those that had been provided to the co-ordination board, presented in a slightly different way.361 In reality, the difference was more than slight. The reports submitted to the working group did not provide its members with an accurate summary of the LFB’s incomplete progress in responding to the rule 43 letter. Most notably, as we have set out in detail in Chapter 72, some reports provided to the working group were misleading because they indicated that important changes to incident command training had been completed, when that was far from the case. 74.26 The Lakanal House Working Group met six times between July 2013 and March 2014. LFEPA’s Strategy Committee was told about the LFB’s actions on only two occasions, once in November 2013,362 when work was still continuing, and once in July 2014.363 That was clearly at odds with the working group’s objective of providing information to the Strategy Committee regularly.364 74.27 At its meeting in July 2014, the Strategy Committee received a report from Deputy Commissioner Dexter and Director Reason. The report summarised the LFB’s work in response to the coroner’s recommendations, recorded that the members of the working group were satisfied that they had fulfilled its original purpose and recommended that it be wound up.365 That recommendation was accepted and the working group was formally closed. However, the report failed to disclose that a number of important items remained outstanding and the closure of the working group gave the misleading impression that all the proposed changes had been made. 74.28 Director Reason said that he had not intended to mislead the Strategy Committee and that it had not been the purpose of the report to rehearse all the information that had been put before the working group, merely to give a flavour of the subjects that had been covered.366 He also told us that the members of the working group had been less interested in the details of operational procedures, policy and training than in wanting to understand broadly what the LFB had been doing.367 We found his explanation unconvincing. The report presented to the Strategy Committee was not merely short on detail; it was, for the reasons summarised above and set out in greater detail in Chapter 72, misleading. With the closure of the working group, the report also ended active scrutiny by LFEPA of the outstanding responses to the rule 43 letter.368 Director Reason said that it had not been the LFB but the members of the working group who had decided that it should be closed down, because, based on the information they had been given, they were satisfied 359 Reason {Day180/131:6}-{Day180/132:3}; {Day180/133:7-22}. 360 Reason {LFB00032747/7-8} pages 7-8, paragraphs 27 and 30. 361 Reason {Day180/151:4-8}. 362 {LFB00089117}. 363 {LFB00029746}. 364 {LFB00032156/3}. 365 {LFB00067819/1}, {LFB00067819/5}. 366 Reason {Day181/143:6}-{Day181/144:11}. 367 Reason {Day181/144:12-18}. 368 Reason {Day181/147:15-25}.

Part 8 | Chapter 74: The response to the Lakanal House fire 57 that they had completed what they had set out to achieve.369 However, for the reasons we have given, that information was incomplete and therefore misleading. Although we accept that was not Director Reason’s intention, it was the practical effect of providing incomplete reports. 74.29 In fact, certain steps identified by the LFB as necessary in response to the coroner’s rule 43 letter remained outstanding at the time of the Grenfell Tower fire. In July 2014, the Lakanal House Working Group could and should have been given an accurate summary of the extent to which the LFB had implemented the various changes required in response to the Lakanal House fire. If it had been given that information, it would have been obvious to the working group that the LFB had not responded fully to the coroner’s recommendations. By failing to provide it the LFB denied members of the working group the opportunity to challenge the Commissioner about the LFB’s dilatory and incomplete progress and, more broadly, prevented them exercising their public duty of holding the LFB to account. We are satisfied that the closure of the working group and the consequent lack of active scrutiny by LFEPA contributed to the LFB’s failure to implement the coroner’s recommendations fully. That lack of scrutiny was compounded by the LFB’s failure to complete its own pre-inquest actions. Not only did the LFB fail to learn from the Lakanal House fire, the premature end of the Lakanal House Working Group ensured that its failure properly to oversee the progress and completion of the steps that it had itself identified as necessary went unremedied. The lessons – Spread of fire over external walls 74.30 The Lakanal House fire demonstrated, if not for the first time then beyond any lingering doubt, that combustible facade panels could enable fire to spread through the external wall of a high-rise building and that a failure of effective compartmentation, whether resulting from combustible facade panels or otherwise, could lead to the rapid total failure of a building. Understanding those risks, which were later to be exemplified in the Grenfell Tower fire, was essential, given the increasing prevalence of modern materials and methods of construction. We have therefore considered it appropriate to examine the extent to which the LFB understood the significance of the Lakanal House fire and how it affected its understanding of the hazards posed by combustible facade panels. 74.31 By December 2009, the LFB was aware that other buildings in London might be constructed of materials that would allow fire to spread rapidly across the external walls and result in a consequent widespread failure of compartmentation. Indeed, the exchange between Commissioner Dobson and Sir Ken Knight during December 2009 was prompted by the LFB’s belief that the regulatory regime was inadequate or was being widely ignored.370 74.32 When Commissioner Dobson was asked why the LFB had not taken steps at the time to advise its operational crews how to respond to the spread of fire across the external wall of a building, he said that he did not think that the way in which the fire had spread at Lakanal House had been unusual and that firefighters would not have been surprised to see the fire spread in the way it did, although they might have been surprised by the speed at which it had happened. He did not think there had been anything particularly unusual about the Lakanal House fire that crews needed to be notified of.371 369 Reason {Day181/144:3}-{Day181/146:13}. 370 {LFB00123737/11} page 11, paragraph 26. 371 Dobson {Day210/131:18}-{Day210/132:9}; {Day210/132:16}-{Day210/133:5}.

The Grenfell Tower Inquiry: Phase 2 Report 58 74.33 We do not agree with the Commissioner’s assessment. Other witnesses told us that the spread of fire downwards at Lakanal House had been unusual. For example, Dr David Crowder described it as very unusual and not something that had been encountered commonly, if at all, previously.372 Sir Ken Knight said that it had been almost unique.373 Furthermore, it is clear that the crews at Lakanal House were surprised by both the speed and the direction in which the fire had spread.374 Given that the LFB knew about the use of combustible panels in external walls and the risks associated with them, crews should have been expressly warned about the danger of fire spreading across them and the consequent risk of compartmentation failure. The lessons - Failure of compartmentation 74.34 National operational guidance on firefighting in high-rise buildings is to be found in Generic Risk Assessment (GRA) 3.2 issued by the DCLG. The version of GRA 3.2 in force at the time of the Lakanal House fire, published in September 2008, had identified the failure of compartmentation and the potential need for multiple rescues as an event for which contingency plans ought to be developed.375 At the Lakanal House inquests, however, Commissioner Dobson told the coroner that under normal circumstances operational firefighters would expect a fire in a high-rise residential building to remain within the compartment of origin and not to enter communal areas before crews could reach the compartment and attack the fire.376 He said that crews would have been aware that the fire might spread to flats immediately above the fire flat, but would not expect it to spread to flats that were adjacent to the flat of origin.377 Peter Holland, who was the Chief Fire and Rescue Adviser at the time of the Lakanal House inquests, told the coroner that, although the compartmentation of a building was sometimes not as good as it was designed to be, a failure of compartmentation was an infrequent rather than a regular occurrence.378 74.35 On 9 July 2009, six days after the Lakanal House fire, Commissioner Dobson sent a letter to the housing departments of all London boroughs, housing associations and other social housing providers referring them to AC Turek’s letter of 23 March 2009.379 In his letter he reminded recipients about certain fire safety matters, including the need for a suitable and sufficient risk assessment, which the letter said should include consideration of compartmentation, particularly where it protected escape routes. He also reminded them that a risk assessment should be reviewed if any material change was made to the premises, including any changes to the compartmentation arrangements or refurbishment. 74.36 In that letter the Commissioner drew attention to the need to have an evacuation strategy appropriate to the circumstances of the individual premises, but he emphasised that it should be safe for residents to remain in their flats if a fire occurred elsewhere in the building, providing that the premises complied with both the Building Regulations and the Fire Safety Order and suitable management and maintenance procedures were in place. 372 Crowder {Day230/4:15-21}. 373 Sir Ken Knight {Day245/187:11-13}. 374 This was clear from firefighters’ evidence at the inquests following the Lakanal House fire: https://www.lambeth. gov.uk/about-council/transparency-open-data/lakanal-house-coroner-inquest. 375 {HOM00002128/12}. 376 Johnson, Expert Communications Report {CWJ00000010/83} page 83. 377 Johnson, Expert Communications Report {CWJ00000010/35} page 35. 378 {HOM00045826/34-35} page 34-35. 379 {LFB00001232}.

Part 8 | Chapter 74: The response to the Lakanal House fire 59 74.37 Commissioner Dobson agreed that when that letter had been written the early indication from the LFB’s own investigations had been that a failure of compartmentation had been one of the primary reasons for the spread of fire at Lakanal House and that he had been concerned that other buildings in London might suffer from the same defect.380 However, he said that the reference to strategies for evacuating buildings had not been intended to suggest that a “stay put” strategy might not be appropriate for such buildings; rather, it had been prompted by the LFB’s understanding that the escape balconies at Lakanal House had not been used by residents because they had not been aware of their purpose.381 74.38 The widespread failure of compartmentation at Lakanal House was also identified in the action plan drawn up by the Lakanal House Board. Item 20 required the LFB’s Fire Safety department to carry out a review of high-rise fires involving the spread of fire beyond the compartment of origin to identify those incidents which could have provided opportunities for learning before 3 July 2009.382 DC Dexter said that that had been a response to both the spread of fire that had occurred at Lakanal House and to emerging findings reported by the Fire Safety team.383 Given the contents of AC Turek’s letter, it is surprising that a search of the LFB’s incident management system had not revealed any record of a high‑rise incident at which fire had spread by mechanisms similar to those identified at Lakanal House.384 DC Dexter later questioned that finding with the LFB’s Information Management department, which was responsible for collating and managing data of that nature.385 In response, Clive Eustice, a member of the department, expressed doubt about the absence of any such records, which he thought reflected a very lazy response. Mr Eustice said that on being given the relevant criteria the department could provide a report setting out the relevant incidents, but no such report was made available to us. 74.39 When she was asked why she had raised the matter with the Information Management department, DC Dexter said that, having read a number of fire investigation reports, she could see that there had been breaches of compartmentation or the spread of fire beyond the compartment of origin and thought it unlikely that no incidents of that kind could be identified.386 There is evidence that she did in fact obtain some data as a result of her inquiries and that she questioned whether Item 20 had been clearly defined.387 Ultimately, however, the LFB concluded that there was no record of a high-rise incident at which fire had spread in ways similar to those at Lakanal House. 74.40 The conclusion that there had been no similar incidents before the Lakanal House fire was inconsistent with AC Turek’s letter of 23 March 2009. It was also inconsistent with concerns that were being discussed both within the LFB itself and by the LFB with outside bodies soon after the Lakanal House fire. On or around 21 April 2010, there was a meeting at the LFB’s headquarters between Commissioner Dobson and representatives of the construction industry, local authority building control, and representatives of the DCLG, including Brian Martin. AC Turek wrote a briefing note for the Commissioner in advance of the meeting which said that its purpose was to discuss the LFB’s concerns about the quality of construction and checking of newly built and newly refurbished residential properties.388 Those concerns resulted from a significant number of fires during the previous two 380 Dobson {Day210/119:17}-{Day210/120:1}. 381 Dobson {Day210/120:11-21}. 382 {LFB00004801/16} page 16, action 20; {LFB00033943/15} page 15, action 20. 383 Dexter {Day179/82:21-25}. 384 {LFB00004801/16} page 16, action 20, {LFB00051803/135}; see also {LFB00033943/15} page 15, action 20. 385 {LFB00096647}. 386 Dexter {Day179/86:12-23}. 387 {LFB00083970}. 388 {LFB00025654/13-14}.

The Grenfell Tower Inquiry: Phase 2 Report 60 years which had exhibited an unusual spread of smoke or fire. The note stated that the causes had often been identified as breaches of the Building Regulations, either during construction or refurbishment, and that the fires had led to people becoming trapped and requiring rescue, the collapse or other unnecessary damage to buildings and to firefighters’ being placed at unnecessary risk. There had been about 50 significant cases in the London area, most of which were said to have involved major construction companies. The note referred to the concern felt within the LFB about whether the regulations covering the construction and approval of building work were being enforced with sufficient vigour to ensure that new residential buildings in London were fit for their purpose, as well as to concern about how many such buildings there might be in the city. 74.41 The briefing note did not provide details of any of those significant cases in London, but other evidence suggests that the fire at Bush House on 2 February 2007 had prompted the meeting. Bush House was a six-storey, newly constructed residential block. A fire had started in the basement parking area and entered a service shaft, through which it spread vertically to all floors of the building, including the building’s only escape route, resulting in residents having to be rescued by the fire brigade from the balconies of their flats.389 As a result of the concerns raised by that and other similar incidents, those present at the meeting agreed that the National House Building Council (NHBC), in conjunction with the Chief Fire Officers Association, would provide training to raise awareness of the need for effective fire stopping. That training was provided in 2011.390 74.42 Commissioner Dobson was unable to recall any details of the meeting, but he agreed that by April 2010 the LFB had identified the risk across the built environment of failure to comply with the Building Regulations and was aware that it had resulted in a significant number of fires in London.391 He told us that the way in which the fire had spread at those incidents had been predictable, given the defects in the buildings,392 and he agreed with DC Dexter that the failure of compartmentation was common, although for a wide range of reasons.393 Nonetheless, the LFB did not seek to communicate the existence of those defects or their concerns about defective buildings to operational crews. Commissioner Dobson said that he had had concerns about the proliferation of guidance and information given to operational crews, because complaints had been made in the past that guidance notes often duplicated or conflicted with one another.394 Mr Dobson also told us that in any event, the spread of fire as a result of inadequate compartmentation would generally not be a surprise to operational firefighters.395 74.43 Although the Commissioner’s concern not to over burden operational crews with excessive guidance was understandable, we think it would have been possible to communicate to crews in a simple way that the LFB was coming across a significant number of buildings that did not comply with the Building Regulations and that crews therefore needed to be ready for smoke and fire to spread in unusual ways as a result of a failure of compartmentation. That would have sent a clear message that was consistent with national guidance and, more importantly, would have reflected the dangers that the LFB was encountering 389 {LFB00025654/3} page 3. 390 {LFB00025654/3} page 3, paragraph 18. 391 Dobson {Day210/135:13-24}. 392 Dobson {Day210/135:24}-{Day210/136:2}. 393 Dobson {Day210/136:4-9}. 394 Mr Dobson was referring to observations made by Mr Justice MacDuff, the judge who presided over the trial of the incident commanders at the Atherstone-on-Stour fire in November 2007 and was critical of the large volume of operational guidance notes and other materials considered during the trial, Dobson {Day210/140:4-25}; see also {LFB00046278/21}. 395 Dobson {Day210/141:1-22}.

Part 8 | Chapter 74: The response to the Lakanal House fire 61 on the ground. If there was an unhelpfully large amount of operational guidance in circulation, the LFB should have taken steps to reduce it, but that was not a good enough reason not to draw the attention of operational personnel to concerns about inadequate compartmentation that were very much in the minds of those at senior management level. 74.44 Inadequate compartmentation in residential high-rise buildings continued to be a concern to the LFB throughout its investigations into the Lakanal House fire. On 11 December 2012, Commissioner Dobson wrote to Brandon Lewis MP, then Parliamentary Under-Secretary of State with responsibility for fire and resilience,396 setting out seven recommendations that the LFB thought should be considered by the government. The first was that the government should provide further guidance on which parts and areas of buildings containing multiple domestic premises could be described as ‘parts used in common’ for the purposes of the Fire Safety Order and how that order was intended to operate in relation to premises where the responsible person did not necessarily have control over features affecting the common parts or common fire precautions. Commissioner Dobson said that the recommendation had been identified by the LFB following the failure of compartmentation that had occurred at Lakanal House and, in particular, the fact that the fire had spread from the flat of origin into the adjacent corridor much faster than it would have expected.397 We consider the other recommendations in the letter elsewhere.398 74.45 In her rule 43 recommendations the coroner at the Lakanal House inquests also identified a failure of compartmentation as a matter that required greater consideration by both the LFB and DCLG. In her letter to the LFB, she recommended that consideration be given to the training of incident commanders and potential incident commanders to enhance their performance in seven specific respects, including the ability to recognise that a fire might behave in a manner inconsistent with the principle of compartmentation.399 The LFB’s response to that recommendation is considered below. In her letter to DCLG, the coroner recommended that consideration be given to reviewing GRA 3.2 to provide consolidated national guidance on four particular matters, including awareness that insecure compartmentation can permit the transfer of smoke and fire between a flat or maisonette and common parts of high-rise residential buildings, which has the potential to put the lives of residents and others at risk.400 In the event, the LFB effectively took charge of the review of GRA 3.2 following the Lakanal House fire. 74.46 It is clear from her rule 43 letter that the coroner considered that operational crews, and incident commanders in particular, needed to be prepared for the risk that compartmentation within a high-rise residential building might fail, even though Commissioner Dobson had told her that in his view it remained appropriate to base plans for firefighting and rescue operations on the assumption that compartmentation would be effective. The coroner did not find that the LFB should have reversed the “stay put” advice to residents or that it should have evacuated the building, but in the DCLG’s response to the rule 43 letter sent to the coroner on 20 May 2013 by the Rt. Hon. Eric Pickles MP, Secretary of State for Communities and Local Government, there was explicit recognition of the possibility that “stay put” might no longer be a tenable strategy if there were a failure of compartmentation. Referring to the pending review of GRA 3.2, the letter confirmed that 396 {LFB00032154}, Brandon Lewis {Day257/3:4-7}. 397 Dobson {Day210/152:23}-{Day210/153:5}. 398 See Part 2, Chapter 9. 399 {LFB00032158}. 400 {CLG00000401/2}.

The Grenfell Tower Inquiry: Phase 2 Report 62 the revised guidance would include advice to incident commanders to inform decisions on evacuation, should it become clear during an incident that the “stay put” principle was no longer tenable.401 74.47 In contrast, it appears that no-one within the LFB gave any serious thought to the potential limitations of the “stay put” strategy either before or after the Lakanal House fire, notwithstanding the concerns expressed within the organisation about inadequate compartmentation and the rapid spread of smoke and fire that had occurred at Lakanal House. AC Daly, the head of the Fire Safety department at the time of the Grenfell Tower fire, rightly acknowledged that the “stay put” strategy is absolutely dependent on effective compartmentation.402 The LFB’s own documents, even those which pre-dated the Lakanal House fire, such as AC Turek’s letter of 23 March 2009, referred to breaches of compartmentation that were significant and posed a real threat to residents’ safety. Those concerns should have prompted an analysis by the LFB of the circumstances in which a “stay put” strategy would need to be kept under review, and potentially abandoned, during the course of an incident. 74.48 It is not clear why the LFB failed to undertake such an analysis following the Lakanal House fire. On the one hand, there was sufficient concern within the organisation about inadequate compartmentation for it to call a meeting with government and industry in April 2010; on the other, senior officers appear to have assumed that operational personnel were accustomed to dealing with failures of compartmentation when they occurred. Consequently, no serious thought was given to sharing with station-based crews the concern of senior officers about the prevalence of inadequate compartmentation in London or the potentially very serious consequences that could follow if compartmentation were to fail. The response – The Lakanal House Case Study 74.49 In the light of the Lakanal House inquests it became clear to the LFB that there was a need to provide additional training to firefighters and more senior officers in responding to events of the kind that had occurred at that fire. A training package was therefore produced known as the Lakanal House Case Study.403 It was commissioned in June 2013, but staff did not start to receive training until July or August 2014, over a year later and five years after the fire.404 The case study consisted of a computer-based training package for station-based staff and a half-day presentation for those of station manager rank and above.405 74.50 In 2018 the LFB produced a report for the Inquiry containing a review of the action it had taken in response to the Lakanal House fire.406 Both that report and several LFB witnesses407 suggested that a wide range of measures that had been taken in response to the fire had been covered in the case study, but that was not correct, because it dealt with only a relatively narrow range of operational topics, in particular: 401 {HOM00047743}. 402 Daly {Day183/157:3-4}. 403 {LFB00004801/29} page 39, action 3c. 404 Reason {Day181/14:18-19}. 405 {BAB00000073}; {LFB00030044}. 406 {LFB00004801}. 407 {LFB00004801/13} page 13, action 6; {LFB00004801/15} page 15, action 14; {LFB00004801/17-18} pages 17- 18, actions 21-23; Reason {Day180/177:9}-{Day180/178:6}, {Day180/208:10}-{Day180/209:8}, {Day181/37:16}- {Day181/38:17}, {Day181/88:18}-{Day181/89:13}; Daly {Day184/11:11-17}, {Day184/126:5-19}; David Brown {Day187/73:23}-{Day187/75:16}; Cowup {Day195/116:11-20}; Cotton {Day208/194:13-17}; Dobson {Day211/6:6-11}, {Day211/11:24}-{Day211/12:4}.

Part 8 | Chapter 74: The response to the Lakanal House fire 63 a. the confusion caused by the unusual layout of the flats at Lakanal House and the need for effective pre-planning; b. the unusual downward spread of fire caused by falling burning debris and the resulting need to move the bridgehead to a lower floor; c. the difficulties arising from the large amount of information that had been received from residents, as well as information relating to fire survival guidance calls, and the need for clear two-way communication between the control room and the incident ground; and d. the consequent difficulties in carrying out search and rescue operations. 74.51 The case study did not provide any or adequate training in the following important operational matters in respect of which the Lakanal House fire had exposed weaknesses: a. recognising when a fire might behave in a manner inconsistent with the principle of compartmentation; b. understanding the dangers arising from a widespread loss of compartmentation or the spread of fire across an external wall (apart from drawing attention to the possible need to move the bridgehead due to downward fire spread, as had occurred at Lakanal House); c. understanding the dangers arising from the use of combustible panels in external walls, whether cladding panels or, as was the case at Lakanal House, window infill panels; and d. the correct handling of fire survival guidance calls by control room staff. 74.52 Director Reason said that the risk of a failure of compartmentation had been implicit in the training,408 that the whole package had been concerned with recognising when compartmentation had failed,409 and that the graphics and all the material used in the package had been self-evident410 or otherwise should have been obvious to firefighters.411 However, the contents of the package do not, in our view, bear that out. They did not make it clear that compartmentation could not always be relied on and did not provide guidance on how to identify or deal with a failure of compartmentation. Those omissions, together with the emphasis on the Lakanal House fire being highly unusual, tended to perpetuate the assumption that compartmentation in high-rise buildings could be relied on. 74.53 The omission of any reference in the package to the dangers arising from the use of combustible panels in external walls is particularly surprising in view of the fact that Commissioner Dobson had written to the government in December 2009 expressing the LFB’s concern about compliance with the Building Regulations in general and the particular risks posed by certain kinds of external cladding. By that time the LFB had discovered that other buildings in London might be constructed from materials that could result in the rapid or unusual spread of fire across or through external walls. 74.54 The present Commissioner, Andrew Roe, suggested that the case study was more sophisticated than might appear from the slides that had been put to certain LFB witnesses. He pointed out that the computer-based package had been accompanied by a training guide and that use had been made of the radio messages sent during the incident 408 Reason {Day180/208:17}-{Day180/209:8}. 409 Reason {Day180/209:3-4}. 410 Reason {Day180/210:11-16}. 411 Reason {Day180/196:4}-{Day180/197:8}; {Day180/205:16)-{Day180/206:24}; {Day180/208:10)-{Day180/211:10}; {Day181/3:5}-{Day181/8:16}; Cotton {Day208/192:3}-{Day208/193:8}; {Day208/194:13}-{Day208/195:23}.

The Grenfell Tower Inquiry: Phase 2 Report 64 as well as interviews with principal officers who had attended the fire.412 Although they may have made the training more engaging and provided an insight into the attending officers’ experience, they did not make up for the omissions identified above. 74.55 Commissioner Roe rightly accepted that the case study should have dealt with the failure of compartmentation on a widespread scale and the danger of external fire spread, both of which had played a critical part in the Lakanal House fire. He accepted that knowledge held by one part of the organisation should have been shared widely and included as part of the package.413 74.56 Director Reason said that the training package had been seen by the Commissioner, Deputy Commissioner and the Directors and that, to his recollection, no concerns had been raised about its general content or whether it covered the coroner’s recommendations effectively.414 The training package was not subsequently reviewed to ensure that it dealt with them adequately,415 other than by identifying any deficiencies in operational responses identified through routine IMP database reports submitted to the co-ordination board.416 74.57 Although a number of senior LFB witnesses regarded the case study as a key element of its response to the Lakanal House fire,417 it fell far short of what was required. The delay of five years between the fire and the release of the training package emphasises the LFB’s failure to identify quickly the important lessons to be learnt from the incident and provide the necessary training as quickly as possible. That failure was compounded by the fact that the training package failed to address the most important aspects of the Lakanal House fire. It was primarily a narrative account of the incident, which limited its value as training for crews. Director Reason said that the package had not been intended for use in isolation, but together with other training packages, although he accepted that it was necessary for officers themselves to find the relevant packages or policies to study.418 Given the nature and potential scale of the dangers revealed by the Lakanal House fire, it was not appropriate to rely on individual officers to take the initiative to that extent. The situation was further worsened by the failure of other LFB training programmes to cover all the coroner’s recommendations. 74.58 The LFB’s knowledge about the risks posed by combustible panels should have been communicated to operational crews through appropriate additions to the training programme in late 2013 after it had become clear from correspondence with DCLG about the meaning of functional requirement B4(1) that the government would not take any steps (at least in the short term) to address the problem. Regrettably, however, that did not happen. There were no relevant changes in training and the information was not adequately communicated to operational crews. When asked about the failure to inform crews about these risks, Commissioner Dobson said they were matters that concerned the Fire Safety and Enforcement arms of the LFB, rather than the operational crews.419 That view was both wrong and short-sighted. Although compliance with the Building Regulations was no doubt a primary concern of the Fire Safety and Enforcement departments, the consequences of an extensive failure of compartmentation resulting from 412 {LFB00123737/47} page 47, paragraph 131. 413 Roe {Day212/155:2-12}. 414 Reason {Day181/9:3-22}. 415 Reason {Day181/11:3-9}. 416 Reason {LFB00067846/28} page 28, paragraph 61; Reason {Day181/20:2}-{Day181/22:1}. 417 Reason {Day181/88:18}-{Day181/89:13}, {Day180/177:9}-{Day180/178:6}, {Day181/37:16}-{Day181/38:17}; David Brown {Day187/73:23}-{Day187/75:16}; Cowup {Day195/116:11-20}; Dobson {Day211/6:6-11}, {Day211/11:24}- {Day211/12:4}. 418 Reason {Day181/3:23}-{Day181/5 -18}. 419 Dobson {Day211/4:16}-{Day211/6:19}; {Day211/26:19}-{Day211/27:14}.

Part 8 | Chapter 74: The response to the Lakanal House fire 65 the use of combustible materials which allowed fire to spread rapidly across the external wall of a building would directly affect operational crews. They had particular implications for incident commanders implementing a “stay put” strategy that was still regarded within the LFB as underpinning the approach to fighting fires in high-rise buildings at the time of the Grenfell Tower fire. Conclusions 74.59 The Lakanal House fire should have alerted the LFB to the possibility that ineffective compartmentation throughout a high-rise residential block might result in a rapid total failure of the building. LFB witnesses maintained in their evidence to us that the risk of a failure of compartmentation was an important lesson taken from the Lakanal House fire and referred to training initiatives subsequently introduced, including the case study, as having enhanced operational crews’ understanding of that risk and how to respond to it.420 However, that was far from the case. In fact, the important subject of how to identify and respond to a failure of compartmentation remained strikingly absent from LFB training and policy following the Lakanal House fire. It was not mentioned in the revised edition of GRA 3.2 published in 2014, which the LFB was largely responsible for drafting, or in the incident command training that the LFB introduced in response to the coroner’s recommendation. 74.60 The LFB’s response to the Lakanal House fire placed undue reliance on process. Plans were made, boards were established and reviews were commissioned, but the process failed to ensure that the organisation fully understood and acted on the different aspects of its experience at the Lakanal House fire, in particular the danger of relying on compartmentation, the risk of fire spreading across external walls and the importance of being able to handle many fire survival guidance calls simultaneously. The LFB’s failure to understand the importance of those matters is illustrated by their omission from the training package. The truth is that the LFB failed to consider in a systematic and rigorous way whether the outcome of the process provided an effective response to the questions raised by the fire. 420 Cowup {Day195/49:1-8}, {Day195/163:5-7}, Dobson {Day211/11:16}-{Day211/12:8}, {Day211/44:15-23}, {Day211/6:6- 11}, Cotton {Day208/178:5-19}.

66 The Grenfell Tower Inquiry: Phase 2 Report

67 Chapter 75 Existing sources of information 75.1 By the summer of 2016, the Lakanal House fire was not the only source of information available to the LFB about the risk of rapid external fire spread and the consequent loss of compartmentation associated with the use of modern building materials and the problems to which that can give rise. In this chapter, we consider other sources of information about the dangers posed by the use of combustible materials in external walls and the experience of the LFB at other fires in high-rise buildings in London. 75.2 First, we consider a fire that occurred in a building called Madingley in Kingston-on‑Thames in July 2010 and certain correspondence between the LFB and DCLG about the effect of functional requirement B4 that took place between February 2011 and October

1. We then consider in this context fires in high-rise buildings abroad, to which we

referred in Chapter 11. Finally, we consider two fires that broke out in high-rise residential buildings in London, Adair Tower in October 2015 and Shepherd’s Court in August 2016. Both incidents illustrated the LFB’s practical approach, following the Lakanal House fire, to the risks posed by combustible cladding (in particular, the prospect of a complete failure of compartmentation), the need to evacuate parts of a high-rise building and how best to carry out an evacuation. The Madingley fire 75.3 Not long after Commissioner Dobson’s exchange of correspondence with DCLG at the end of 2009, another incident occurred in London involving the spread of fire through combustible materials in a building’s façade. The fire at Madingley, a 17-storey residential building in Kingston-upon-Thames, occurred on 12 July 2010. It started in a flat on floor 12, spread rapidly through a plastic rainwater pipe system to flats on floors 13, 14 and 15 and thence to the roof of the building. Smoke entered the building’s escape stairs on floor

1. Twenty fire appliances attended the incident. About 80 people evacuated the building;

no‑one was injured.421 75.4 Tests carried out by both Bureau Veritas and the LFB established that the rainwater pipe system was the principal means by which the fire had spread, but other materials forming part of the balconies and the edge of the roof were also examined. It was found that glass‑reinforced plastic fascia panels and polystyrene insulation on the balconies were easily ignited and, once ignited, continued to burn and spread flames rapidly, producing large amounts of black smoke. A castellated roof fascia panel was found to behave in the same way. Bureau Veritas concluded that those elements could contribute significantly to the overall intensity of a fire and its combustion products.422 75.5 Messages passing between some of those in the LFB who were investigating the Madingley fire show that they considered the possibility that the other three blocks on the estate could contain similar materials and discussed whether it would be appropriate 421 {LFB00028515}. 422 Bureau Veritas report {LFB00028515/91-94}; LFB report {LFB00028515/95-102}.

The Grenfell Tower Inquiry: Phase 2 Report 68 to implement an “early evacuation” strategy rather than “defend in place” if there were another fire.423 The evidence we have seen, however, suggests that the change was not made and that crews were not given any warning about those risks.424 Correspondence about the meaning of functional requirement B4(1) 75.6 Between February 2011 and October 2013, the LFB entered into correspondence with DCLG in an attempt to obtain clarification of the effect of functional requirement B4(1) (the requirement that the external walls of a building shall adequately resist the spread of fire over the walls and from one building to another, having regard to the height, use and position of the building). Following the receipt of advice from a retired building surveyor, the Commissioner had become concerned that the language used did not make it clear that the ability adequately to resist the spread of fire over external walls was a requirement in its own right. Indeed, the person from whom the Commissioner had taken advice thought it was not. As the LFB recognised at the time, that was an incorrect interpretation, but it suggested that there might be widespread misunderstanding about the effect of functional requirement B4(1) that was shared even by some building control officers. That was potentially a matter of national importance. 75.7 The attempt to obtain a definitive interpretation of the regulations failed because DCLG was unwilling to provide formal clarification of the effect of functional requirement B4(1), but the correspondence clearly shows that senior officers in the LFB were aware that there was considerable uncertainty in the construction industry about its meaning and that there was a potentially widespread failure to comply with the requirements of the Building Regulations in relation to the external walls of high-rise buildings. They expected the problems to increase in the absence of effective regulatory intervention.425 The LFB did all it reasonably could to persuade the government that action was required, but its concerns were not properly addressed. Nonetheless, the episode had served to draw the attention of the LFB to the uncertainty in the construction industry surrounding the meaning of functional requirement B4(1), and provided it with an opportunity to consider what, if any, changes were required to existing training, operational policies and procedures. 75.8 The LFB’s knowledge of the risks posed by combustible panels should have been communicated to operational crews through appropriate additions to the training programme in late 2013 after it had become clear that the government would not take any steps (at least in the short term) to address the problems identified in the correspondence. Regrettably, however, that did not happen. There were no relevant changes in training and the information was not adequately communicated to operational crews. When asked about the failure to inform crews about those risks, Commissioner Dobson said that they were matters that concerned the Fire Safety and Enforcement arms of the LFB, rather than the operational crews.426 That view was both wrong and short-sighted. Although compliance with the Building Regulations was no doubt a primary concern of the Fire Safety and Enforcement departments, the consequences of an extensive failure of compartmentation resulting from the use of combustible materials which allowed fire to spread rapidly across the external wall of a building would directly affect operational crews. They had particular implications for incident commanders following a “stay put” strategy, which was still regarded within the LFB as underpinning the approach to fighting fires in high-rise residential buildings. 423 {LFB00028515/64}. 424 {LFB00028515/117-122}. 425 Dobson {Day211/26:11-18}. 426 Dobson {Day211/26:19}-{Day211/27:14}.

Part 8 | Chapter 75: Existing sources of information 69 International fires 75.9 In Chapter 11 we have referred to the information available about fires in high‑rise buildings in other countries, all of which involved to a greater or lesser degree the spread of fire across external walls. Before the Grenfell Tower fire occurred, the LFB had no system for recording fires of that kind, for investigating why or how they had occurred, or for considering whether they contained any lessons for fire prevention or high-rise firefighting in London. The main reason for that omission appears to have been a widely‑held assumption that fires of that kind could not occur in this country because the Building Regulations did not allow buildings to be constructed in a way that would allow the spread of fire over the external walls. There was also a prevalent view that the UK’s regulatory regime was superior to, and more robust than, those in other countries.427 Two examples demonstrate the shortcomings of this approach to the gathering and analysis of information from fires outside this country. The Lacrosse fire, Melbourne, Australia (November 2014) 75.10 The Lacrosse fire caused the authorities to carry out an audit of Melbourne’s high-rise buildings. In March 2016, the LFB was provided with the results of that audit, which revealed that 51% of the buildings surveyed did not comply with the regulations. AC Daly was asked whether that ought to have alerted the LFB to the possibility that the position in London might be similar. It was a relevant question, because, as we have pointed out, the LFB’s reliance on the existence of a robust regulatory system in the UK necessarily depended on compliance with it. His response was that it was likely that the question had been raised within the LFB at the time, but that there was no evidence that there were buildings in London that used external wall cladding that did not comply with the Building Regulations.428 The explanation was unsatisfactory, first, because there is no evidence that the question had actually been considered in that way, and secondly, because the purpose of any investigation would have been to discover whether there had been a widespread failure to comply with the regulatory requirements. In our view, the unexpectedly high rate of non-compliance found in Melbourne was a compelling reason for the LFB to consider whether the same problem existed in London. The Address fire, Dubai, UAE (December 2015) 75.11 Information about the fire at the Address building in Dubai reached senior officers of the LFB through DAC Graham Ellis who sent an email to two of his LFB colleagues containing a link to an article about flammable polyurethane and aluminium cladding involved in a fire in Dubai.429 He copied his message to AC Cotton in her capacity as Head of Operational Assurance. The article said that the fire had resurrected fears about the widespread use of highly combustible materials on skyscrapers across the UAE. It also said that a fire safety expert had estimated that up to 70% of Dubai’s high-rise buildings could be clad in polyurethane and aluminium composite cladding, notwithstanding the requirement in the UAE that buildings over 30 metres in height be constructed from non-combustible materials. Towards the end of the article the author referred to the regulatory position in Britain, which he said did not permit any surface spread of flame.430 427 Dexter {Day179/95:21}-{Day179/97:19}; Reason {Day182/101:2}-{Day182/102:25}; Daly {Day183/117:22}- {Day183/136:9}; {Day183/163:8}-{Day183/164:8}; Cotton {Day209/231:10}-{Day209/232:11}; Cotton {Day209/233:11- 21}; Dobson {Day211/33:4}-{Day211/36:1}. 428 Daly {Day183/170:12}-{Day183/178:17}. 429 {LFB00024217}. 430 {INQ00014890}.

The Grenfell Tower Inquiry: Phase 2 Report 70 75.12 Responding to the email from DAC Ellis, GM Biles made a flippant comment about paragraph 12.7 of Approved Document B, which provided by way of guidance that insulation products and filler materials should be of limited combustibility. AC Cotton replied to his comment, also in flippant terms. Neither paragraph 12.7 nor the broader requirements of Approved Document B had been mentioned in the body of the article, but they had been mentioned in a comment made by an online user who drew attention to the distinction between a Class 0 surface and a combustible core and asserted that there were large schemes still being constructed in the UK for which similar panels were being incorrectly specified due to a fundamental misunderstanding of the regulations. 75.13 AC Cotton said that she had not read the comments below the main body of the article,431 but the reference to clause 12.7 in his comment shows that, at the very least, GM Biles had. We think it surprising that none of those who received the email thought it necessary to draw the attention of the Fire Safety department to the article or the online comment, given that the comment suggested that there was a fundamental misunderstanding within the construction industry about the requirements of the Building Regulations relating to materials used in external walls. The exchange also revealed a failure by senior officers adequately to probe and question information they did not fully understand. Most importantly, the LFB should have been alert to the risk that there might be many buildings in London with dangerous cladding, but it was too complacent to discover the existence and extent of any problem in London before it was too late. NHBC seminar – ‘Facades to Tall Buildings’ 75.14 On 7 July 2016 members of the LFB’s Fire Safety department attended a seminar organised by the NHBC entitled “Facades to Tall Buildings”. One presentation contained images of fires in high-rise buildings both in the UK and abroad, including the Address Tower fire in 2015 and the Tamweel Tower fire in 2012, both in Dubai, and the Garnock Court fire in Glasgow in 1999.432 It also contained diagrams depicting different mechanisms of external flame spread taken from BR135 Fire performance of external thermal insulation for walls of multi-storey buildings (3rd ed., 2013) and relevant extracts from Approved Document B and Building Control Alliance Technical Guidance Note 18.433 The content of the seminar was subsequently used to create the LFB’s own presentation entitled “Tall Buildings Facades”. 75.15 AC Daly said that the conference had been seen as providing reassurance about conditions and regulations in this country.434 However, we draw exactly the opposite conclusion. First, in the course of the seminar the NHBC warned about the dangers of highly combustible polythene-cored ACM products, the omission of cavity barriers around openings, unrealistic assumptions about the fire resistance of glazing and confusion between the fire resistance of a wall assembly and fire spread across or within it.435 Secondly, the Building Control Alliance, in a presentation on demonstrating compliance with the Building Regulations, had separately sounded a warning about a number of matters, including the absence of any tests using lightweight metal claddings, desktop assessments by fire engineers being based on opinion rather than fact, and the substitution of materials.436 Thirdly, Brian Martin’s presentation on regulatory requirements contained a diagram taken from BR135 which showed how combustible cladding systems could contribute to the spread of flame and 431 Cotton {Day210/9:12-13}. 432 {LFB00032916/2-4}. 433 {LFB00032916/5-9}. 434 Daly {Day183/135:12}-{Day183/136:9}; {Day183/145:16}-{Day183/146:13}. 435 {LFB00032892/10-11}. 436 {LFB00032891/14}.

Part 8 | Chapter 75: Existing sources of information 71 the risk of secondary fires.437 Fourthly, the BRE explained the mechanisms of external fire spread involving combustible materials and stated that the BS 8414 test method was being used in the same or a substantially similar way in the UAE, Australia and China.438 75.16 The LFB was well aware of those warnings. It should, therefore, have been aware of the importance of understanding the risk of rapid external fire spread in buildings in London. The LFB’s own “Tall Buildings Facades” presentation439 carried a number of relevant warnings. First, it warned that although it was a general principle that the external envelope of a building should not contribute to the spread of fire, new construction materials and methods of construction were being used in facades with a limited understanding of their behaviour when exposed to fire. The same slide warned that such materials could affect the way that fires develop and spread in a building. Secondly, it warned of the importance of the facade’s not contributing significantly to the spread of fire. Thirdly, it identified combustible materials in the facade as likely to lead to the spread of fire. Fourthly, it reproduced the diagrams in BR135 depicting the mechanisms of external fire spread. Finally, it concluded that the construction of the facade of Shepherd’s Court might have contributed to the fire spread. There was, therefore, nothing in the various presentations to justify an unqualified assumption that the risk of rapid external fire spread was, in some way, restricted to methods of construction used abroad. 75.17 The evidence from fires abroad and the warnings and concerns expressed about building methods used in this country partly reflected, but certainly confirmed, the LFB’s knowledge of, and longstanding anxiety about, a widespread failure to comply with the Building Regulations in London and, in particular, about modern construction materials which caused or permitted the unusual spread of smoke and fire. That knowledge and those worries pre-dated the Lakanal House fire in July 2009 and were reinforced by the Shepherd’s Court fire in August 2016, discussed below. 75.18 Commissioner Cotton said she was unaware that anyone in the LFB had ever brought the risk of failure to comply with the Building Regulations to the attention of senior officers.440 She told us that neither she nor the Operational Assurance department had been made aware that the LFB knew about problems caused by poor compartmentation (and the implications for a “stay put” strategy) until April 2017, when a letter raising the question had been drafted by the LFB’s Fire Safety department and sent in her name (as Commissioner) to Gavin Barwell MP and Brandon Lewis MP (Minister for Housing and Minister for Policing and the Fire Service respectively).441 She said that the Operational Assurance department had never been asked to consider the risks resulting from failure to comply with the Building Regulations or the spread of fire resulting from an inappropriate choice of materials, which had never been brought to its attention.442 75.19 It is clear to us that communications between the different departments of the LFB were very limited and that as a result there was a significant failure to ensure that important information, in this case information about threats to the built environment, was shared with departments which really needed to receive it. The Fire Safety department should have worked much more closely with the Operational Assurance department to investigate significant fires in other countries and to understand whether there was anything important to be learnt from them. Instead, there is no evidence that either of those 437 {LFB00032895/6}. 438 {LFB00032922/21-22}. 439 {LFB00032916}. It was produced in draft in July 2016 and finalised in October 2016 after the fire at Shepherd Court. 440 Cotton {Day209/233:22}-{Day209/234:5}. 441 Cotton {Day210/3:18}-{Day210/4:17}; {Day210/19:4}-{Day210/28:17}. 442 Cotton {Day210/5:3}-{Day210/6:13}.

The Grenfell Tower Inquiry: Phase 2 Report 72 departments, or indeed any other department, used them as a means of improving their understanding of the risks associated with modern and refurbished buildings and their ability to fight fires in high-rise buildings. That reflected both a failure of organisation and management and a failure on the part of individual officers to display the breadth of vision to be expected of them. The Adair Tower and Shepherd’s Court fires 75.20 Two other fires in high-rise residential buildings occurred in London following the Lakanal House fire, both of which gave rise to challenges similar to those that had been encountered at that fire and were to be encountered again at the Grenfell Tower fire. The first was the fire at Adair Tower; the second was the fire at Shepherd’s Court. The Adair Tower fire 75.21 Adair Tower is a 14-floor residential building. On 31 October 2015, a fire was started by a lighted firework being put through the letterbox of a flat on the third floor. When the first crews arrived, they reported a fully developed fire that had spread into the adjoining lobby. Neighbouring flats were affected by smoke and heat, as were the main stairwell and communal lobbies on higher floors. There were no self-closing devices on the doors of the flats, which made it easier for smoke to spread. 19 pump appliances attended the fire.443 75.22 A considerable number of calls were made by residents of Adair Tower to the control room during the course of the incident, including calls during which fire survival guidance was given. The LFB’s records were not consistent in recording the number of fire survival guidance calls.444 Up to six fire survival guidance calls (depending on how they were characterised) were received between 08.54 and 09.08, together with 15 other calls.445 In any event, the total number of fire survival guidance calls made during the Adair Tower fire exceeded the five received during the Lakanal House fire.446 The incident commander, GM Anthony Biles, who had 34 years of operational experience, said that it was the highest number of fire survival guidance calls that he had dealt with in his career.447 Fifty residents were helped to escape the building, either by firefighters or by control room officers (CROs) who provided advice and guidance.448 75.23 When GM Biles arrived at the incident ground, he realised that many people were trapped and needed to be rescued, or believed that they did, so he obtained additional crews with extended duration breathing apparatus (EDBA) to conduct search and rescue operations on higher floors and hand over residents they had rescued to firefighters wearing standard breathing apparatus on the lower floors. GM Biles did not formally revoke the “stay put” strategy, but he briefed crews to clear the building.449 75.24 The incident monitoring process report recorded that there had been good handling of a large volume of fire survival guidance information with finite resources. There was no reference to the evacuation of residents or the “stay put” strategy.450 443 {LFB00001708}. 444 Contemporaneous documents referred variously to 9 and 24 fire survival guidance calls: {LFB00001711}; {LFB00031757}. 445 {LFB00035092/5}; FSG database {LFB00031757}; Smith {Day202/201:1-20}. 446 {HOM00001124}. 447 {MET00080605/13}. 448 {LFB00001708/2}; {LFB00035109}. 449 Biles {MET00080605/7-8} pages 7-8. 450 {MET00080621}.

Part 8 | Chapter 75: Existing sources of information 73 The Shepherd’s Court fire 75.25 Shepherd’s Court is a 20-floor residential building in Shepherd’s Bush. On 19 August 2016, a fire started in a faulty appliance in a flat on floor 7. It spread to floors 8, 9, 10 and 11 through external facade panels and entered some of the flats on those floors through open windows. The block’s single stairwell had a good level of compartmentation and individual flats had good fire doors with self-closing devices. Twenty appliances attended the fire, which was ultimately extinguished.451 75.26 SM Charles Hanks was the second incident commander, having assumed command about 34 minutes after the first crews had arrived.452 He remained in command for about ten minutes until GM Richard Ogden arrived.453 During that ten-minute period he saw that the fire had spread to the floor above the flat of origin, which he recognised indicated a possible failure of compartmentation. Soon after, SM Hanks was told that a third floor had become involved in the fire. He became concerned that there was a risk that the fire might spread further externally and also a risk that it might spread in the interior of the building.454 He described the spread of fire as “exceptional”, although there had been very little spread of smoke and flame in the interior and the stairwell had not been affected.455 75.27 Once SM Hanks had become aware that three floors had become involved in the fire, he decided that he needed to ensure that the flats immediately above the fire were empty and that any occupants were moved to safety when possible. (He said that, if necessary, he would have carried out a controlled evacuation of the occupants from the flats on the 9 floors immediately above because the fire was spreading vertically but not sideways.) At the same time, he directed crews to begin a systematic search from the top of the building, moving downwards to obtain information about the conditions within the building rather than to carry out search and rescue operations or to evacuate flats on those higher floors. His strategy was not intended to undermine the “stay put” policy, which in his view was maintained throughout, but was in his view a sensible precaution for one or two flats when conditions allowed, given that fires can occasionally jump a compartment boundary.456 The LFB’s Fire Investigation report records that approximately 50 people had been evacuated from the building.457 75.28 The LFB has rightly accepted that, before the Grenfell Tower fire, it had failed to train its incident commanders to understand when and how to carry out an evacuation of a high‑rise residential building with a “stay put” strategy in the absence of an existing plan.458 It was a failing which had the most serious consequences for the residents of Grenfell Tower on the night of 14 June 2017.459 75.29 It must also be acknowledged, however, that the LFB was not alone in this failing. At the time of the Grenfell Tower fire there was no national operational guidance on how to evacuate a residential high-rise building460 and it does not appear that any other fire and rescue service in the United Kingdom had included in their operational policies or training 451 {LFB00118245}; {LFB00000084}. 452 {LFB00060951/8}. 453 Hanks {LFB00032724/2} page 2, paragraph 5. 454 Hanks {LFB00032724/2-3} pages 2-3, paragraph 6. 455 Hanks {LFB00032724/3} page 3, paragraph 7. 456 Hanks {LFB00032724/4-5} pages 4-5, paragraph 8. 457 {LFB00000084/8} paragraph 4.26. 458 Roe {LFB00060655/9} page 9, paragraph 21; Roe {LFB00083834/7-8} pages 7-8, paragraph 28; Closing statement for Modules 5 and 6 {LFB00123737/14} paragraph 35; {LFB00123737/35} paragraph 93. 459 Phase 1 Report Volume IV {INQ00014817/87} paragraph 27.3. 460 McGuirk Report {SMC00000046/35} paragraph 83.

The Grenfell Tower Inquiry: Phase 2 Report 74 any guidance on the practical aspects of carrying out an evacuation, beyond saying that it should be considered, as in PN63. On that basis, we agree with DAC Cowup’s description of evacuation as a blind spot for the LFB. There is also some evidence to suggest that it may be a blind spot for other fire and rescue services, although we have not heard evidence about current firefighting practice outside London and Kent.461 75.30 Nonetheless, the operational responses to the Adair Tower and Shepherd’s Court fires demonstrate that, although the LFB was not training its commanders on the evacuation of high-rise residential buildings, nor providing for it in its policies, it contained officers who were capable of carrying out some form of successful evacuations in high-rise residential buildings and, when circumstances required, did so. Commissioner Roe referred to incidents within his own knowledge where there had been a partial failure of compartmentation and where the incident commander had made a decision to evacuate the floors above and below the fire, while the rest of the residents remained in their flats. Commissioner Dobson also agreed that evacuation was not an unusual occurrence and that firefighters were well acquainted with evacuating all sorts of buildings, including high-rise buildings.462 DAC Cowup similarly told us that evacuation was a fairly routine and intuitive process, though he accepted that before the Grenfell Tower fire the LFB had not understood the need to provide firefighters with specific guidance on it.463 75.31 It is important to note that evacuation is not necessarily inconsistent with a “stay put” strategy. If residents are being adversely affected by heat, fire or smoke, their evacuation is entirely consistent with such a strategy. However, the evacuation of flats which are not adversely affected by heat, fire or smoke does involve a revocation, at least in part, of a “stay put” strategy. There was no reference to the “stay put” strategy or to the partial evacuation of residents in the IMP reports on either the Adair Tower or the Shepherd’s Court fires,464 but we are satisfied that in practice some incident commanders have carried out emergency evacuations, including the evacuation of flats not adversely affected by smoke or fire, of some kinds of residential high-rise buildings with “stay put” strategies without recording the fact. It is not possible to say with confidence how frequently they have done so, but Adair Tower and Shepherd’s Court do not appear to have been isolated incidents. The incident commanders at both fires appear to have acted intuitively, without notifying the control room, and no one appears to have regarded their actions as particularly significant. That suggests that the approach taken at both those incidents was not out of the ordinary. Indeed, Commissioner Roe referred to incidents within his own knowledge where there had been a partial failure of compartmentation and where the incident commander had made a decision to evacuate the floors above and below the fire, while the rest of the residents remained in their flats.465 75.32 The evidence suggests that before the Grenfell Tower fire evacuations of high-rise residential buildings had been partial rather than total.466 (At any rate, we have not been provided with any evidence of a total evacuation of a residential high-rise building in London or elsewhere in the United Kingdom.) As was the case at Adair Tower and Shepherd’s Court, such evacuations were probably carried out without discussion with the control room and perhaps without the commander necessarily considering whether the “stay put” strategy had been revoked. In such instances, it was the individual commander 461 Cowup {Day195/63:20}-{Day195/67:21}. 462 Dobson {Day211/127:10-12}. 463 Cowup {Day195/66:1-22}. 464 {MET00080621}; {LFB00120998}. 465 Roe {Day213/147:15-23}. 466 Roe {Day213/147:5-23}.

Part 8 | Chapter 75: Existing sources of information 75 who made the decision based on his or her own judgement, deploying such practical strategies for the implementation of the evacuation as he or she saw fit. Before the Grenfell Tower fire, it was, ultimately, a matter of chance whether the officer acting as incident commander at any given time had sufficient experience and confidence to evacuate a high‑rise residential building, despite the absence of any training on when and how to do so. 75.33 None of this undermines the conclusion in the Phase 1 report that “stay put” had become an article of faith for the LFB.467 Institutionally, it was indeed so and the response at Grenfell Tower reflected that fact. However, the evidence heard in Phase 2 identified an inconsistency of approach and whether the incident commander considered evacuation owed nothing to established policy. 75.34 Another aspect of the Shepherd’s Court fire that prefigured the hazards encountered at Grenfell Tower was the use of combustible facade panels, in that case containing polystyrene insulation. On his arrival at the incident AC Daly, who was the most senior incident commander to attend the fire, saw fire spreading over the walls, which he thought was unusual because he would not have expected exterior panels to support combustion.468 He thought it was the same phenomenon as had been observed at the Lakanal House fire.469 AC Daly consulted SM James Flin, who was in attendance as a fire safety officer and was also a fire engineer, and the two of them agreed that it was necessary to find out why the spandrel panels appeared to have spread the fire.470 75.35 On 29 August 2016, sample panels were duly sent to Bureau Veritas for testing which was witnessed by personnel from the Fire Engineering team in the LFB’s Fire Safety department.471 The panels contained a blue polystyrene foam insulation mounted on a plywood board. One of the samples had a steel facing sheet; the steel sheet of the other had become detached during the fire, exposing the foam beneath. The sample panels were exposed to three flame tests. In the case of the panel without a steel facing sheet, the blue foam was rapidly destroyed, creating flaming droplets and sustaining burning even after the removal of the flame source. One of the tests had to be stopped due to concerns about the height of the flames. In its report of 30 November 2016 Bureau Veritas confirmed that the panels were likely to have assisted the fire in spreading up the outside of Shepherd’s Court.472 75.36 On receipt of those findings, Charles Elie-Romeyer, a fire engineer in the LFB’s Fire Safety department who had witnessed the tests, revised the “Tall Buildings Facades” presentation to reflect the Shepherd’s Court incident so that it could be used at a training day for senior fire safety officers.473 In the section on the Shepherd’s Court fire added by Mr Elie-Romeyer, the results of the Bureau Veritas tests were set out, including photographs of the burning sample panels together with the observation that the facade might have contributed to the spread of fire.474 75.37 AC Daly confirmed that the presentation had not been shared with anyone outside the Fire Safety Department, and, in particular, that it had not been shared with operational crews because of what he described as the very technical nature of the information relating 467 Phase 1 Report Volume IV {INQ00014817/108} paragraphs 28.53 and 28.54. 468 Daly {MET00077774/4}; Daly {Day183/206:11-18}. 469 Daly {Day183/205:17}-{Day183/206:13}. 470 Daly {Day183/210:24}-{Day183/211:20}. 471 {LFB00052135/6}. 472 {LFB00000091/2-4} paragraphs 3.5 and 3.6. 473 Green {LFB00032917/1-2} pages 1-2, paragraphs 3-5; Green {LFB00032917/5} page 5, paragraphs 23-26. 474 {LFB00032916/15-20}.

The Grenfell Tower Inquiry: Phase 2 Report 76 to quite a complex area which operational personnel could not be expected to grasp or understand.475 The Commissioner accepted that the presentation reflected the Fire Safety department’s knowledge of the potential for modern construction materials to promote the rapid spread of fire, and that there had been a failure to ensure that that information was communicated to the rest of the LFB, including operational staff.476 The Parkin-Coates report: November 2015 75.38 The Fire Safety Department’s continuing concern about compartmentation had previously been reflected in a report by Ms Adreena Parkin-Coates entitled Compartmentation Issues within the Built Environment published on 26 November 2015. Ms Parkin-Coates was a qualified fire engineer and a business support manager in the Fire Safety Department.477 Like the later Jack report of August 2016, the Parkin-Coates report referred to the importance of adequate compartmentation in defining a building’s evacuation strategy. It also asserted that instances of inadequate compartmentation were widespread. In her summary of the report Ms Parkin-Coates noted that the success of many evacuation strategies, particularly “stay put” strategies, depended on adequate compartmentation, but that fire safety officers were becoming increasingly aware of defects in fire-stopping in new and refurbished buildings. She concluded that defects in compartmentation were widespread due to poor workmanship or a lack of oversight by building control bodies and contractors and that an overall strategy to address them was needed.478 75.39 In her report Ms Parkin-Coates accepted a view expressed by others that there was an endemic problem of sub-standard fire-stopping.479 AC Daly thought that the use of the word “endemic” was likely to reflect the frequency with which defects in compartmentation had been identified in the pool of buildings that had been found not to comply with the Building Regulations during fire safety audits conducted by the LFB. (He said that about 70% of premises were found to be broadly compliant.) He accepted, however, that within that smaller pool of buildings, defects in compartmentation were identified reasonably regularly. He did not agree that sub-standard compartmentation was endemic across the built environment as a whole.480 75.40 Ms Parkin-Coates also referred to the Bush House fire in 2007, which had prompted a meeting with the government and other interested parties in 2010, and to the NHBC training initiatives that had been implemented in association with the Chief Fire Officers Association in 2011.481 She also referred to and annexed a separate report entitled Structural Fire Safety Failures – Quarterly/Annual Reporting dated March 2015, which was provided to the Performance Management Board with her report because it was said to identify a number of other fires at which structural defects had been found.482 The quarterly report for the period April to December 2014 recorded that 25 fires had occurred, three of which had exhibited possible defects in structural fire safety features that might have contributed to the development of the fire. All three of those fires, which included the fire at Holcroft House, had occurred in residential blocks of flats.483 As noted 475 Daly {Day183/138:24}-{Day183/139:11}; {Day183/142:9}-{Day183/143:16}. 476 Closing statement in Modules 5 and 6 {LFB00123737/19} paragraphs 44 and 45. 477 {LFB00025654}; Daly {Day184/85:3-5}. 478 {LFB00025654/1}. 479 {LFB00025654/2} paragraph 1. 480 Daly {Day184/88:2-14}. 481 {LFB00025654/3-4}. 482 {LFB00025654/10}. 483 {LFB00025654/11-12}.

Part 8 | Chapter 75: Existing sources of information 77 earlier, the report recorded that some of the structural defects affecting fire safety identified at those incidents ought to have been recorded on the relevant building’s ORD entry, but had not been.484 75.41 AC Daly told us that the Parkin-Coates report, with all its appended reports, had been waiting for his attention when he took over as Head of Fire Safety in March 2016.485 He told us that the material had given him cause for concern and that it had indicated that there were systemic issues that needed to be addressed.486 He accepted that his concerns suggested that there were things that operational firefighters as well as the Fire Safety department needed to learn and accepted that the LFB had not always gained as much from the work of the Fire Safety department as it could have, in particular by involving operational crews in its thinking.487 It is notable that, in the revised version of the Parkin‑Coates report prepared in December 2016 for presentation to the Corporate Management Board, the range of suggestions for action related to the Fire Safety department and Fire Safety personnel alone. There was no suggestion that operational personnel should be involved in any way in the measures proposed for remedying inadequate compartmentation.488 We accept that it was not a deliberate omission,489 but it is significant for what it tells us about the nature and extent of the collaboration between the fire safety and operational sides of the LFB. The Jack report: August 2016 75.42 In late 2016, at the time that the Fire Safety department was discussing its concerns about the misinterpretation of functional requirement B4, it was also doing work on compartmentation in residential blocks of flats.490 As it had in relation to the exterior walls of such properties, the department continued to question whether its enforcement powers under the Fire Safety Order extended to the fire-resisting walls between individual flats. That was not a new issue. It had featured in discussions between the LFB and DCLG in 2012, which had culminated in Louise Upton’s advice of 6 February 2013 that the Fire Safety Order did not extend to the external walls of a building.491 In August 2016, Andrew Jack produced a report entitled Fire Resisting Compartmentation – Flats (the Jack report) that was presented to the Principal Management Board, a departmental management board chaired by AC Daly and attended by the heads of the different teams in Fire Safety.492 The Jack report described the benefits of taking enforcement action, where necessary, in respect of inadequate compartmentation, even though its power in law to do so was considered to be unclear. It noted that compartmentation between flats was of vital importance to prevent the spread of fire through a building containing multiple dwellings and was essential if an evacuation strategy based on “defend in place” was to be employed.493 (“Defend in place” is essentially the same as a “stay put” strategy.) 484 {LFB00025654/12} paragraphs 11 and 13. 485 Daly {Day184/92:12-13}. 486 Daly {Day184/94:9-13}. 487 Daly {Day184/94:22}-{Day184/95:20}. 488 {LFB00000155/6} paragraph 37. 489 Daly {Day184/112:13-24}. 490 Jack {LFB00120308/18} page 18, paragraph 61; {LFB00120296}. 491 {LFB00032153}. 492 {LFB00120301}; Daly {Day184/65:14-22}. The report refers to the “Performance Management Board”, which Dan Daly clarified in his evidence was likely to be a typographical error: {Day184/67:2-15}. 493 {LFB00120301/2}.

The Grenfell Tower Inquiry: Phase 2 Report 78 75.43 Mr Jack observed that fire risk assessments rarely consider compartmentation in areas of the building away from the means of escape and that there was therefore scant factual basis to justify the use of a “stay put” emergency plan.494 That reflected the fact that a “stay put” strategy for any building is fundamentally dependent on compartmentation being effective and that, in order to rely on “stay put” as a strategy, the building’s compartmentation must be sound. It also follows that, from an operational perspective, it cannot be assumed that compartmentation will in fact be effective. 75.44 The Jack report contained examples of buildings whose compartmentation had been found to be inadequate, including Lakanal House, and noted that more examples were likely to be discovered as a result of fire risk assessments.495 AC Daly said that a great deal of the LFB’s enforcement work concerned breaches of compartmentation and that his own operational experience had been that it was often possible to find products of combustion where you would not expect them.496 However, he did not accept that the LFB had reason to think that inadequate compartmentation was a widespread problem.497 It is also clear that no thought was given by the LFB at that stage to the potential combination of inadequate compartmentation and combustible facade systems, even though the report was being written while Bureau Veritas was carrying out tests on the panels taken from Shepherd’s Court.498 The Fire Safety department did not take the opportunity to raise its concerns about inadequate compartmentation in the letter it sent to chief executives on 6 April

1. This might have been due to the fact that compartmentation had been effective at

Shepherd’s Court, thereby keeping the single staircase clear of smoke and fire and enabling the partial evacuation of residents. 75.45 On 3 April 2017, Commissioner Cotton wrote to the then Gavin Barwell MP, Minister of State for Housing and Planning and Minister for London, requesting a meeting to discuss the LFB’s concern about inadequate compartmentation in residential blocks of flats.499 In her letter she pointed out that effective compartmentation is essential to the operation of the “stay put” policy that applies to most residential buildings. She expressed concern that since the beginning of 2017 the LFB had identified, on average, at least one residential property (or development) a month in London that had significant defects in compartmentation and that there were many other cases that had not come to the LFB’s attention. 75.46 Commissioner Cotton told us that the letter had been drafted by AC Daly and that she had not been aware of the problems to which it referred before he had spoken to her about the draft.500 She did not take any steps to check what training was being provided to operational personnel about the risks posed by failures of compartmentation or their effect on a building’s “stay put” strategy.501 494 {LFB00120301/3}. 495 {LFB00120301/3}; {LFB00120301/8}. 496 Daly {Day184/74:1}-{Day184/75:1}. 497 Daly {Day184/78:19-24}. 498 Daly {Day184/76:10}-{Day184/77:4}. 499 {CLG10009016}. 500 Cotton {Day210/28:5-17}. 501 Cotton {Day210/26:21}-{Day210/27:15}.

Part 8 | Chapter 75: Existing sources of information 79 Conclusions 75.47 By the end of 2016, the LFB as an organisation was well aware of the dangers posed by some kinds of modern construction materials and techniques and of the particular dangers presented by various kinds of combustible materials, mainly those used for their insulating properties. That included sandwich panels, insulation boards made of organic materials and, most importantly for present purposes, external panels containing organic materials intended to provide rigidity as well as insulation, all of which had the propensity to lead to a loss of compartmentation in a major fire. Regrettably, however, that knowledge was almost entirely confined to the Fire Safety department and was not shared with those who were responsible for operations. As a result, those who were deployed to fight fires were not trained to deal with situations which could become catastrophic both for them and, in the case of residential buildings, their occupants. In particular, incident commanders were not sufficiently aware that a “stay put” strategy may not be reliable in all circumstances and that evacuation may be necessary.

80 The Grenfell Tower Inquiry: Phase 2 Report

81 Chapter 76 Operational planning Introduction 76.1 In his Phase 1 report the chairman found that the information available to the first crews mobilised to attend the Grenfell Tower fire was incomplete and in some respects inaccurate.502 He also found that the LFB had failed properly to train its crews in how to obtain information when visiting premises for that purpose and had a narrow understanding of its obligations under section 7(2)(d) of the Fire and Rescue Services Act 2004 (the 2004 Act).503 He said that the reason for those failures would be investigated in the next phase of the Inquiry. We have therefore examined the LFB’s approach to operational planning, with particular reference to fighting fires in high-rise residential buildings. 76.2 Section 7(2)(d) of the 2004 Act requires fire and rescue authorities to make arrangements for obtaining information needed for the purpose of extinguishing fires and for protecting life and property in the event of fires in their areas. Traditionally, visits by station-based staff to premises in their areas have been regarded as the primary means of discharging that duty and was the method adopted by the LFB.504 76.3 Information gathered from visits to premises and other sources was entered on the Operational Risk Database (ORD) which was intended to act as the main source of information for incident commanders and other officers responding to an incident. In his Phase 1 report the chairman considered the entries on the ORD for Grenfell Tower, which indicated that the LFB had failed to obtain relevant information from the manager of the building, the TMO, including information relating to the building’s cladding system.505 Contrary to the plain meaning of the words of Appendix 1 of PN633, it was not the practice for operational personnel responsible for conducting visits to high-rise premises to consider the full list of items set out there. 76.4 In Phase 2 of the Inquiry we have considered what information section 7(2)(d) requires fire and rescue services to gather and how the LFB sought to discharge its duty, including the type of information it thought it needed to obtain, particularly about high-rise residential buildings. We have also considered whether the LFB’s policies and practices that were designed to discharge the duty under section 7(2)(d) were appropriate. Duty to obtain information 76.5 The duty to obtain information for the purpose of fighting fires was originally contained in section 1(1)(d) of the Fire Services Act 1947, which was to all intents and purposes the same as section 7(2)(d) of the 2004 Act. Steve McGuirk, the former Chief Executive and County Fire Officer of Greater Manchester Fire and Rescue Service, who was called to give expert evidence on fire-fighting, explained that the duty had originally been interpreted 502 Phase 1 Report Volume IV, paragraph 27.30 503 Phase 1 Report Volume IV, paragraphs 27.36. 504 Phase 1 Report Volume IV, paragraphs 27.22, 27.24 and 27.37. 505 Phase 1 Report Volume IV, paragraphs 27.35 and 27.37.

The Grenfell Tower Inquiry: Phase 2 Report 82 by fire and rescue authorities as requiring the collection of simple information that would be readily and quickly accessible to the first crews attending an incident,506 and that had remained their approach to discharging the duty under section 7(2)(d) of the 2004 Act.507 76.6 In April 2012, the government issued guidance to fire and rescue services on the collection and management of operational risk information, that is, the information they are required to collect under section 7(2)(d).508 It contained a model approach entitled Provision of Operational Risk Information System, or PORIS for short. It was the first substantive national guidance on the management of operational risk information since the 2004 Act had come into force.509 Mr McGuirk said that PORIS had marked a change in what was expected of fire and rescue authorities because it required a much more sophisticated system for managing information about risks, but he doubted whether it had brought about a widespread change in the way that most fire and rescue authorities went about gathering information. That may have been because the guidance was released with little publicity, but in any event, there has been no monitoring of whether any, and if so, how many, authorities have adopted the model.510 76.7 The PORIS model involved five steps: (1) review existing information; (2) where necessary, collect additional information by way of a site visit; (3) use that information to assess the risk presented by the particular building or site; (4) determine the appropriate risk management process; (5) provide the relevant information for use by incident commanders in a timely manner. The guidance provided a template “data capture” form, to be used for the collection of information, including information collected during visits to premises.511 It is notable that the form included a section entitled “cladding and roof” and invited the user to select from a number of different alternatives, including “sandwich panel”, “metal sheet” and “uPVC”.512 76.8 It is immediately apparent when looking at the data capture form (which is almost 20 pages long, extremely broad in scope and in parts very technical) that the guidance issued in 2012 envisaged a process for the collection and management of operational risk information very different from the simple and practical approach that had previously been adopted by fire and rescue authorities. Mr McGuirk described the guidance as prescribing a much more expansive approach which required a significant amount of additional training.513 Following the introduction of PORIS, as Mr McGuirk put it, operational firefighters were intended to become “more rounded risk assessors, capable of assembling and evaluating a much greater range of information.”514 Collection and management of operational risk information by the LFB 76.9 The LFB policies for the management of operational risk information were PN800, which applied to all properties, and PN633, which related specifically to high-rise buildings. Appendix 1 of PN633 contained a list of 22 items to be considered by crews during section 7(2)(d) visits.515 In addition, PN784 governed the sharing of information relevant to operational planning between the LFB’s Fire Safety department and fire stations. 506 McGuirk {Day190/11:18-23}; {Day190/12:2-11}; {Day190/13:12-23}; {Day190/15:7-24}. 507 McGuirk {Day190/14:9}-{Day190/15:2}. 508 {HOM00045364}. 509 McGuirk {Day190/16:7-16}. 510 McGuirk {Day190/18:5}-{Day190/19:14}; {Day190/37:7-25}. 511 McGuirk {Day190/20:1-8}. 512 {HOM00045364/85}. 513 McGuirk {Day190/25:25}-{Day190/26:23}. 514 McGuirk, Firefighting Report {SMC00000046/15} paragraph 21. 515 {LFB00083849}; {LFB00001256}.

Part 8 | Chapter 76: Operational planning 83 76.10 In broad terms, the version of PN800 in force in June 2017 mirrored the five stages of the PORIS model. In particular, it required crews to carry out a premises risk assessment based on the risks identified during section 7(2)(d) visits using the form in Appendix 1 of the policy. That resulted in the premises achieving a certain risk score, which determined the frequency of further visits, the need for exercises on the premises and whether a tactical plan was required. Grenfell Tower had been placed in the medium- to low-risk category by the risk assessment carried out at the last visit before 14 June 2017. As a result, it qualified for at least one visit by a local crew every three years and a tactical plan. An exercise on the premises was not required unless the local station manager thought it necessary.516 No tactical plan was ever put in place for Grenfell Tower.517 76.11 PN800 recognised the role of the LFB’s Fire Safety department in the collection, management and analysis of operational risk information. In particular, the policy noted that one of the ways in which premises giving rise to certain hazards or risks were identified was by notification from the Fire Safety department. PN800 also directed crews to consider whether the risk assessment process required specialist knowledge, including knowledge available from the Fire Safety Regulation department.518 76.12 PN784 governed the way in which information was to be shared between the Fire Safety team and operational crews.519 In short, PN784 set out a procedure under which officers in the Fire Safety department were to communicate to station-based personnel information likely to be relevant when planning for operational incidents, and vice versa. Such information was to be communicated in a prescribed form and, on receipt, the station manager or Fire Safety team leader was to decide what action was appropriate, which might include a joint visit. 76.13 In practice, the procedure for sharing information between the Fire Safety department and fire stations was not consistently followed. Reports were compiled by the Director of Operations on a quarterly basis showing the number of “risk notifications” made by the Fire Safety department to stations during that period and the action taken by the relevant stations in response. We have been provided with a copy of one of those reports, dated 12 May 2015.520 It records that in Kensington and Chelsea, where Grenfell Tower was situated and which contained three fire stations,521 the Fire Safety department had made a total of six notifications to fire stations in the previous year and just two notifications had been made by fire stations to the Fire Safety department. More generally, the proportion of notifications in respect of which follow-up action was recorded varied from station to station, with some recording 100% and others as low as 40%. The report noted that the Fire Safety department sent more notifications to the stations than the stations sent to the department, which could have been the result of the stations not being fully aware of the administrative recording process, alternative channels of communication for recent team management changes or differences of opinion about the level of information that should be referred. The Fire Safety department made similar observations.522 76.14 The picture recorded in the report of 12 May 2015 was consistent with the evidence of AC Daly. He said that on the whole, the flow of information between the Fire Safety department and the fire stations did not work well and was patchy, in the sense that it 516 {LFB00003596}. 517 Phase 1 Report Volume IV, paragraph 27.30. 518 {LFB00083849/4}; {LFB00083849/7} paragraph 7.20. 519 {LFB00012734}. 520 {LFB00122962}. 521 North Kensington, Kensington and Chelsea fire stations. 522 {LFB00025654}.

The Grenfell Tower Inquiry: Phase 2 Report 84 worked better in some areas than others.523 Both Commissioner Dobson and Commissioner Roe agreed with that assessment.524 The LFB’s Director of Operations, Dave Brown, said that the LFB had put measures in place to address the shortcomings in the system which had led to improvements.525 Whatever measures had been implemented, they were ineffective, because the sharing of information between the Fire Safety department and fire stations remained unsatisfactory at the time of the Grenfell Tower fire. AC Daly was a frank and reliable witness, who had much closer contact with the day-to-day management of the Fire Safety department than Director Brown. On this point, we prefer AC Daly’s evidence. Indeed, Grenfell Tower was a tragic illustration of the failings in the LFB’s arrangements for sharing information. The North Kensington crews who carried out section 7(2)(d) visits to the tower did not obtain from the TMO information relating to the building’s cladding system or even basic floor plans showing the layout and numbers of individual flats. Under the LFB’s own policies and procedures that information should have been obtained by the local crews. Application to high-rise buildings 76.15 Neither PN800 nor PN784 provided any direction or guidance on the management of operational risk information relating specifically to high-rise buildings, which at the time of the Grenfell Tower fire was contained in PN633, the LFB’s policy on firefighting in high‑rise buildings. PN633 was considered in some detail in Phase 1 of the Inquiry. Appendix 1 of PN633 transposed national guidance on firefighting in high-rise buildings, contained in GRA 3.2, into the LFB’s local policy, insofar as the collection of operational risk information was concerned. Specifically, the LFB’s list of items to be considered during visits to high-rise buildings broadly corresponded to that prescribed by GRA 3.2, apart from the omission from Appendix 1 of any reference to cladding.526 76.16 Mr McGuirk thought that it would take an operational crew at least two hours properly to consider all 22 items listed in Appendix 1 of PN633.527 He disagreed with Commissioner Cotton’s characterisation of the list as being, in parts at least, unrealistic or incorrect. In his view, it was necessary and appropriate for crews in London to be directed to consider all 22 items as well as the information required by the PORIS model. He did not think it was beyond the capacity of station-based operational crews to undertake risk assessments of that scope and level of detail, provided they were given appropriate training. In his opinion, the practical simplicity of the former approach to management of operational risk information can still be maintained, thereby preserving the need for essential information to be readily available to the first responding crews, if measures are taken to filter the information properly as it is provided to those on the incident ground.528 76.17 The LFB’s policy documents did not make it clear whether all high-rise buildings should be the subject of section 7(2)(d) visits and have an entry on the operational risk database or only some. AC Brown said that ideally every high-rise building in London would be visited and subject to a risk assessment, a view with which Commissioner Dobson agreed.529 However, that might or might not have led to their being recorded on the ORD, since 523 Daly {Day183/46:10}-{Day183/47:11}; {Day184/107:17}-{Day184/108:7}. 524 Dobson {Day211/210:14-19}; Roe {Day213/122:10-19}. 525 Brown {Day187/38:8-14}; {Day187/40:8-14}. 526 {LFB00001255/18}. 527 The full list is set out in the Phase 1 Report Volume IV, paragraph 27.23. 528 McGuirk, Firefighting Report {SMC00000046/33-34} paragraphs 79 and 80. 529 Brown {Day211/197:22}-{Day211/198:8}.

Part 8 | Chapter 76: Operational planning 85 PN800 prescribed a minimum threshold risk score for that purpose.530 AC Brown accepted that he had faced considerable difficulties in achieving that ideal during his time in the brigade, not least because the LFB did not know, and had no obvious means of finding out, how many high-rise buildings there were in London and where they were situated.531 76.18 The figures that have been provided to us indicate that the LFB was a long way from achieving AC Brown’s ideal. The Lakanal Assurance Report, a review carried out by the LFB in August 2018 of the action taken in response to the Lakanal House fire, recorded that in October 2017 approximately 1,700 high-rise buildings had been subject to a risk assessment out of a total of about 6,900 such buildings in London.532 The LFB has since confirmed that the total number is in fact about 8,500.533 76.19 The reason why such a low number of high-rise buildings appeared on the ORD might have been the apparent confusion within the LFB over whether crews were expected to visit all high-rise buildings on their ground and, if not, which ones they were expected to visit. AC Brown sent an email to station managers in April 2009 directing them to ensure that crews visited all the high-rise buildings on their ground every year.534 His recollection was that, at that time, he had felt that that was not an unreasonable expectation, because he had not been quite sure how many there were. At a later stage, however, when the magnitude of the task became more apparent, a more risk-based approach was adopted.535 76.20 It appears that AC Brown’s instructions still stood in 2010, when PN633 underwent one of the several reviews that were carried out following the Lakanal House fire. Peter Cowup, who was then a DAC in the LFB’s Operational Policy department and was leading the review of PN633, sent an email on 1 August 2010 to various senior officers within the LFB noting that the feasibility of crews visiting all high-rise buildings on their station’s ground required further consideration, because of the size of the task, especially for stations in central London.536 76.21 In November 2011, the LFB published Operational News 20, which contained an article on high-rise firefighting. In that article personnel were told that any high-rise buildings which posed a particular risk should be the subject of section 7(2)(d) visits.537 AC Brown denied that the article reflected a departure from his earlier direction that all high-rise buildings should be visited. He said that the article had been intended to refer to the fact that high-rise buildings would be subject to regular section 7(2)(d) visits in future only if they were considered to pose a particular risk after they had been subject to an initial risk assessment.538 We do not accept that. The text of the article in Operational News is clear and is not qualified in the way he suggested. The article is a straightforward guide for station-based crews on the LFB’s statutory obligations in relation to high-rise buildings. We think that it illustrates the lack of a consistent approach to whether section 7(2)(d) of the 2004 Act required the LFB to visit all high-rise buildings or only those deemed on some undefined basis to present a high risk. 530 Brown {Day186/54:15-20}. PN800 required all premises that scored 150 or above on the risk assessment to be recorded on the ORD {LFB00083849}. 531 Brown {Day186/55:4-22}; {Day186/101:5-15}. 532 {LFB00004801/28}. 533 Roe {Day213/125:8-20}. 534 {LFB00032161}. 535 Brown {Day186/59:16-25}. 536 {LFB00082695}. 537 {LFB00047224}. 538 Brown {Day186/69:19}-{Day186/70:1}.

The Grenfell Tower Inquiry: Phase 2 Report 86 76.22 As has been noted, Appendix 1 of PN633 listed 22 items which crews were required to consider during section 7(2)(d) visits to high-rise buildings. Mr McGuirk and Commissioner Cotton expressed different views about the practicability of complying with Appendix 1 to the letter. From around 2012 until his retirement in March 2017, Director Brown had ultimate oversight of the LFB’s fire stations and responsibility for discharging its obligations under section 7(2)(d).539 His evidence was therefore of particular help in understanding the nature of the information the LFB expected its operational crews to gather. 76.23 AC Brown expected crews to use the list in Appendix 1 to PN633 as an aide memoire and to consider the items where practicable. He accepted that that was not reflected in its language, which required crews to ensure that they were familiar with the various items contained in the list.540 However, he did not think that station-based crews had the technical knowledge to look in depth at factors that might give rise to breaches of compartmentation, despite that being one of the items mentioned in the list. He said that, leaving aside obvious problems, such as an open vent in a communal stairwell, it was beyond the skill and knowledge of operational crews to identify defects likely to have that effect.541 Similarly, when asked whether he would expect crews to identify features of a building that might promote the rapid or abnormal spread of fire (another item in the list) AC Brown said that that was at the extreme of the knowledge to be expected of a firefighter and that the LFB would rely on a member of the Fire Safety department to identify features of that kind.542 Commissioner Dobson was similarly sceptical. He said that some of the items in the list would have required very specialist training to enable crews to carry them out properly. He doubted the likely benefit of such training in any event.543 76.24 AC Brown did not expect crews to look at a building’s cladding system during a section 7(2)(d) visit or to decide whether it should be taken into account in the risk assessment.544 Again, he thought that was beyond the ability and training of operational personnel.545 There was no discussion internally following the Lakanal House fire about whether to direct crews to consider cladding systems,546 despite the fact that Commissioner Dobson had been sufficiently concerned about unsuitable panels to write to Sir Ken Knight on the subject in December 2009.547 AC Brown told us that other steps had been taken to deal with that, which did not involve operational firefighters in that level of detail.548 Nor was any consideration given to requiring crews to collect information about cladding systems of high-rise buildings following the fire at Shepherd’s Court in August 2016.549 76.25 The lack of any advice or direction to crews about how to carry out visits to high-rise premises for the purposes of section 7(2)(d) is clear from the operational risk information training materials that were provided to the Inquiry, which were limited to a single, interactive computer-based training programme produced by Babcock in around May 2013.550 AC Brown confirmed that that was the first time crews had received formal 539 Brown {Day186/7:17}-{Day186/18:1}. 540 Brown {Day186/29:17}-{Day186/32:4}. 541 Brown {Day186/32:15}-{Day186/33:7}. 542 Brown {Day186/37:13}-{Day186/38:3}. 543 Dobson {Day211/208:15-24}. 544 Brown {Day186/40:11-21}. 545 Brown {Day186/43:13-19}. 546 Brown {Day186/46:25}-{Day186/47:4}. 547 {LFB00104291}. 548 Brown {Day186/45:6-22}. 549 Brown {Day186/47:6-10}. 550 Stills from the programme are at {LFB00123288}; the accompanying trainer guide dated May 2013, is at {BAB00000058}.

Part 8 | Chapter 76: Operational planning 87 training on how to conduct such visits,551 and we are satisfied that it was the only time. The package was not directed specifically to high-rise buildings and did not contain any reference to PN633. Although it did provide some commentary on what to look for on such a visit, that commentary did not address the risk of fire spreading beyond the compartment of origin or the existence of features of construction that might promote the rapid or abnormal spread of fire, both of which are included in the list contained in Appendix 1. Perhaps unsurprisingly, the training did not ensure that crews understood the purpose of their visits, nor what information they were expected to obtain and record. That is apparent from the deficiencies in the ORD entry for Grenfell Tower, considered in detail in the Phase 1 report.552 Although AC Brown and DAC George sought to suggest otherwise,553 Commissioner Roe confirmed that such deficiencies were not confined to Grenfell Tower, as might be expected.554 He told us that a review of the entries on the ORD carried out after the Grenfell Tower fire had revealed a range of inconsistencies, poor information and a misunderstanding of risk.555 76.26 The LFB’s failure, following the Lakanal House fire, to instruct operational crews visiting premises pursuant to section 7(2)(d) to consider the potential for widespread compartmentation failure and the rapid or abnormal spread of fire was significant. It is not sufficient for it to point to measures that might have been taken by the Fire Safety department if the concerns of senior officers had been brought to its attention. Operational crews were not provided with the direction or training to enable them to identify the matters that should have been reported and largely disregarded the system for sharing such information. The LFB’s response to PORIS 76.27 The publication of PORIS in April 2012 provided another opportunity for the LFB to review and consider the effectiveness of its processes for the management of operational risk information. On 27 February 2013, a report by Susan Ellison-Bunce, Head of Strategy and Performance, was submitted to the Corporate Management Board, which considered the new guidance and the extent to which the LFB complied with it.556 She concluded that the existing processes were robust and largely complied with national guidance and that it was not necessary or practicable to make significant adjustments to the current arrangements.557 76.28 Ms Ellison-Bunce also noted that the national guidance referred to the importance of periodic audits as a means of monitoring whether operational risk management systems had been properly implemented and maintained and were effective in meeting their objectives. She found that there were inconsistencies in the approaches taken by stations to what was included on the ORD and that the quality of the work done in obtaining and using information varied. Ms Ellison-Bunce therefore recommended that the Head of Operational Assurance (then AC Cotton) review how stations identified sites and buildings that might present a risk and whether they adopted an approach consistent with PN800.558 AC Brown told us that that review had not been carried out.559 551 Brown {Day186/146:17-24}. 552 Phase 1 Report Volume IV, paragraph 27.30. 553 Brown {Day186/202:22-25}; George {Day205/186:2-9}. 554 Roe {Day213/108:6-22}. 555 Smith {Day203/108:11-22}. 556 {LFB00091785}. 557 {LFB00091785/20}. 558 {LFB00091785/15}. 559 Brown {Day186/150:5}-{Day186/153:10}.

The Grenfell Tower Inquiry: Phase 2 Report 88 The rule 43 recommendations on section 7(2)(d) visits 76.29 In her Rule 43 letter to the LFB the coroner recommended that it review its procedures for sharing information obtained pursuant to section 7(2)(d) with crews both within the station in question and at other local stations.560 In response the LFB created a regime for inspecting what Commissioner Dobson had referred to in his letter to the coroner of 23 May 2013 as “high priority” buildings, with a view to increasing the number of premises in respect of which information was available on the ORD.561 The term “high priority” did not appear in either PN800 or PN633. AC Brown told us that he did not know where it had come from and thought it had caused some unnecessary confusion.562 The purpose of the new regime was to identify buildings that had not been the subject of a risk assessment but should have been.563 It was not specifically aimed at high-rise buildings, but they were regarded as a priority.564 AC Brown wanted to create an inspection regime that resulted in more entries on the ORD and was concentrated on those that presented higher risks.565 76.30 In November 2013 AC Brown asked DAC Tom George to set up the new regime, but he immediately delegated the task to GM John Elwell.566 DAC George provided GM Elwell with little guidance on what was required, apart from telling him that he needed to strengthen the inspection programme and increase the number of entries on the ORD.567 76.31 On 11 December 2013, GM Elwell produced a careful and considered report for DAC George and AC Brown,568 in which he identified the following questions that he thought were raised by the concern that there were too few entries on the ORD: “a) Is the existing guidance (PN800) fit for purpose to achieve the desired outcomes? b) What other Brigade data could be deployed to identify relevant premises for inclusion on the ORD. c) Are the 7000 we have all relevant and in compliance with the guidance in PN800? d) Which premises are ‘missing’ from the ORD given the guidance in PN800? e) What is the capacity of a station/watch in terms of the number of ORD entries that can be effectively entered and revisited with the existing guidance. A pertinent point, given the disparity of the numbers, risk and types of premises on different stations ground. f) Is the quality of existing ORD entries providing data to underpin safe systems of work? g) Are our staff competent to carry out the 72d visits and enter meaningful data and professional tactical plans? h) What are the existing Performance Evaluation Tools to monitor performance? i) What Service Standard is in place to Quality Assure the relevant extant policies?” 76.32 The questions identified by GM Elwell demonstrated a perceptive understanding of the difficulties that beset the LFB’s systems for the collection and management of operational risk information. Indeed, they foreshadowed many of the concerns that have been raised 560 {LFB00032158/2}. 561 {LFB00042089/4}. 562 Brown {Day186/175:16}-{Day186/176:3}. 563 Brown {Day186/176:13-22}. 564 Brown {Day186/179:5-9}. 565 Brown {Day186/176:13}-{Day186/177:2}; {Day186/182:6-23}. 566 George {LFB00032823/17}, page 17, paragraph 69. 567 {LFB00042252/2}. 568 {LFB00032825}.

Part 8 | Chapter 76: Operational planning 89 during this Inquiry, in particular, about the capacity of individual stations to manage the number of premises on their grounds effectively, the quality of the existing entries on the ORD and the competence of operational staff to carry out visits and record relevant information. 76.33 When he came to deliver his report569 and recommendations GM Elwell concentrated on the following: a. The importance of the direct involvement of operational crews and their managers in meetings and workshops to reinforce the provisions of PN800 and make clear what it expected of them. In particular, he warned that the then current practice of announcing new policies by email would not be adequate to explain effectively the requirements of PN800, a revised edition of which was due to be published soon after the report. b. The need for a feasibility study to be carried out in relation to the use of existing data held by the LFB for the purpose of risk assessments, including the information recorded on the “Farynor” database, which held information collected on fire safety inspections. (The Farynor database had preceded and was separate from the ORD, but crews had access to it).570 c. The need to review the disparity in the number and nature of the risks across different station grounds and the development of a means of determining the optimal number of ORD entries for stations with a large number of high risk properties. d. The need for further training to be provided to all personnel with a role in the process of creating the ORD to ensure that they had the necessary skills. e. The need to be able to measure the number and quality of the entries on the ORD to determine whether they complied with the requirements of PN800. 76.34 AC Brown’s response to the report was that, although it was interesting and helpful, it did not amount to the creation of a high priority inspection regime.571 He accepted that the report had raised some significant broader concerns about the adequacy of the LFB’s existing arrangements, but he told us that some of the recommendations had either been implemented already, were in the course of being implemented, or were within GM Elwell’s power to implement. He thought that one or two were very aspirational and, although desirable in principle, would not work in practice.572 76.35 AC Brown thought that discussions between managers about section 7(2)(d) visits were an established part of normal business and that nothing further needed to be done in that respect.573 He said that work had already been done by the LFB’s Information Management department to link information obtained from previous section 7(2)(d) visits with data available from other internal sources, including the Fire Safety department. He did not think that there could be a review of the varying levels of risk across different stations because the LFB did not have the necessary information. It could therefore not determine an optimal number of entries on the ORD for any individual station; all it could do was to direct crews that in due course all premises should be inspected to determine their suitability for inclusion on the database. He was satisfied that training on section 7(2) (d) visits had recently been given to crews (meaning, the training package distributed in 569 {LFB00032825}. 570 Brown {Day187/35:11}-{Day187/36:5}. 571 Brown {Day186/190:21}-{Day186/191:7}. 572 Brown {Day186/191:8-18}; {Day187/4:6-11}. 573 Brown {Day186/192:9-15}; Brown {LFB00123276/7} pages 6-7, paragraph 19.

The Grenfell Tower Inquiry: Phase 2 Report 90 May 2013)574 and considered that the LFB needed first to assess the results of that training in order to determine whether more was required. When asked about the need to monitor the quality as well as the quantity of the entries on the ORD, he said that it was incredibly difficult to measure quality in any meaningful way.575 76.36 We are unable to accept that AC Brown carefully considered each of GM Elwell’s recommendations when the report was presented to him in late 2013. The weight of the evidence shows that he was concentrating on the introduction of an inspection regime aimed at “high priority” buildings, however defined. We think that he rejected the recommendations because they were not directly related to the creation of such a regime. In so doing, he did not properly reflect on the very real concerns that had been raised by GM Elwell. 76.37 We gained the strong impression that AC Brown did not wish to become involved in considering the complexities of an inspection regime, a problem which deserved more careful consideration than he was willing or able to give it. If the letter and spirit of the coroner’s recommendation were to be satisfied and more effective inspection arrangements introduced, the matters raised by GM Elwell required proper consideration. AC Brown failed to give them that consideration and, as far as we can see, there was no good reason for that. If GM Elwell’s recommendations had been implemented, they could have gone some way towards remedying the deficiencies in the LFB’s arrangements for gathering and managing operational risk information. 76.38 On 22 January 2014, following AC Brown’s effective rejection of GM Elwell’s report, DAC George compiled a list of different types of property for inspection in order of priority that he proposed should be given to station managers and borough commanders.576 High‑rise residential buildings of six floors and above appeared on the list second only to sites such as industrial plants of a kind which present major accident hazards. A list of that kind was exactly what AC Brown wanted.577 DAC George said, however, that in his view and that of his colleagues, a satisfactory banding system was not entirely achievable and that he had reservations about such a simplistic approach.578 In particular, he was concerned that the system was more concerned with numbers than quality and that it would be virtually impossible for crews to carry out meaningful inspections of such a large number of premises.579 AC Brown did not agree with DAC George’s reservations580 and on 24 May 2014 he sent an email to all operational crews directing them to have regard to the priority banding system when conducting section 7(2)(d) visits.581 76.39 The priority banding system was never formally incorporated into any policy,582 but DAC George told us that he had monitored its implementation by watch managers through regular meetings with the borough commanders beneath him in the LFB’s organisational structure. AC Brown had no further involvement in the inspection regime and did not ask to be provided with any further information about its success in increasing the number of entries on the ORD or its progress generally.583 574 {LFB00123288}; {BAB00000058}. 575 Brown {LFB00123276/8} page 8, paragraph 24. 576 {LFB00083388}. 577 Brown {Day187/9:19}-{Day187/10:3}. 578 George {LFB00032823/20} page 20, paragraphs 75-76; George {Day206/17:1-14}. 579 George {LFB00083884/19} page 19-20, paragraph 74. 580 Brown {Day187/12:13-16}; {Day187/13:7-13}. 581 {LFB00032160}; Brown {Day187/15:2-6}; {Day187/15:18-25}. 582 Brown {Day187/18:21-24}. 583 George {Day206/29:15}-{Day206/30:20}; {Day206/32:1-13}.

Part 8 | Chapter 76: Operational planning 91 Communications 76.40 The references in PN800 to factors liable to affect communications were confined to circumstances likely to be encountered underground or in other places which may have alternative communications infrastructure, including fixed radio repeaters. However, the list of matters in Appendix 1 to PN633 on high-rise firefighting that were to be considered on visits to high-rise buildings did include potential problems with communications.584 76.41 The evidence given in Phase 2 about the practical application of those policies was inconsistent and uncertain. In particular, senior officers did not clearly understand whether there was a need to test the performance of radios when visiting a high-rise building.585 PN633 contained no guidance for crews on how to identify potential difficulties with communications or how to test radio reception reliably.586 Although WM Ricketts from North Kensington fire station tested the transmission of radio signals between the basement and the ground floor using his handheld UHF radio during a visit to Grenfell Tower immediately before the fire, that could have given only a limited indication of the performance of radios in the tower under operational conditions.587 Professor Johnson suggested that a more detailed test, using validated procedures, may be needed in structures known to pose a particular risk of deteriorating communications.588 584 {LFB00001256/19}. 585 Documents created during and immediately after the Lakanal House inquests give conflicting views on whether radio testing formed a standard part of every s.7(2)(d) visit: {LFB00036836} and {LFB00098636/2}. 586 Brown {Day187/26:4}-{Day187/32:4}. 587 Johnson, Communications Report {CWJ00000119/110} paragraphs 5.4.4-5.4.5; Johnson {Day189/153:15}- {Day189/154:24}. 588 Johnson {Day189/155:2}-{Day189/156:1}; {Day189/156:13}-{Day189/157:16}.

92 The Grenfell Tower Inquiry: Phase 2 Report

93 Chapter 77 High-rise firefighting: policy and guidance Introduction 77.1 The Generic Risk Assessments were published by the Chief Fire and Rescue Adviser in conjunction with DCLG to provide operational guidance to fire and rescue authorities. In his Phase 1 report the chairman described the purpose of Generic Risk Assessment (GRA) 3.2, which contained the national guidance on firefighting in high-rise buildings, as being to assist fire and rescue services in drawing up their own assessments of risk to meet their statutory obligations under the relevant Health and Safety at Work legislation.589 The provisions of GRA 3.2 that are most relevant to the hazards encountered at Grenfell Tower were identified in the Phase 1 report.590 In summary, they relate to planning, training and competence, and the provision of fire survival guidance. 77.2 Individual fire and rescue services are obliged to have regard to national guidance when carrying out the risk assessments which underpin their operational policies.591 The LFB’s policy on high-rise firefighting was PN633; the version published in June 2015 was in force at the time of the Grenfell Tower fire.592 The review of Generic Risk Assessment 3.2 77.3 The second version of GRA 3.2 had been published in 2008, and in 2010 a review of the full GRA series was commissioned by DCLG and the Chief Fire and Rescue Adviser.593 Although DCLG in conjunction with the Chief Fire and Rescue Adviser had final editorial control of the series as a whole, DCLG retained particular responsibility for the contents of GRA 3.2.594 The review process began in 2010 and culminated in a revised version published in 2014.595 DCLG delegated the management of the review to Surrey Fire and Rescue Service under the terms of a memorandum of understanding,596 but oversaw the process through a strategic management board established for the purpose. 77.4 The review of GRA 3.2 was given priority over the work on other Generic Risk Assessments because it was thought that important insights had been gained into fighting fires in high- rise buildings as a result of the experience at Lakanal House.597 In March 2011 the LFB was appointed to lead the work on GRA 3.2; no other fire and rescue service was involved in the drafting.598 The LFB was seen as the appropriate organisation to take on that role because much of the learning that needed to be incorporated into the guidance had been derived from the Lakanal House fire.599 The close involvement of the LFB in the revision of GRA 3.2 gave it a unique opportunity to gain a deep understanding of the risks to which firefighters 589 Phase 1 Report Volume IV paragraph 27.1. 590 Phase 1 Report Volume IV paragraph 27.3. 591 {LFB00001255/7}. 592 {LFB00001256}. 593 {LFB00032783/6} paragraph 2.2.1. 594 Cowup {Day195/24:4-8}; Knight {Day245/146:10}-{Day245/148:11}. 595 {HOM00002128}. 596 {HOM00050078}. 597 Cowup {Day195/22:23}-{Day195/23:6}; {Day195/39:20}-{Day195/40:25}. 598 Cowup {Day195/20:9-19}. 599 Cowup {Day195/41:16-24}.

The Grenfell Tower Inquiry: Phase 2 Report 94 and members of the public may be exposed in such situations, particularly in buildings that have been constructed using novel products and modern materials and methods of construction. It is therefore worth considering in a little detail the way in which the revision of GRA 3.2 proceeded and the extent to which the guidance it contained was reflected in the revision of the LFB’s own policy on fighting fires in high-rise buildings. 77.5 Within the LFB, DAC Cowup was given primary responsibility for producing the revised version of GRA 3.2 with support from members of the Operational Policy department.600 In December 2011, he and his team produced a draft revised version of GRA 3.2,601 which was then the subject of a regional and national consultation until September 2012.602 The draft was revised during the course of that process to reflect some of the responses that had already been received. At that stage, DAC Cowup was confident that it fully reflected the lessons to be learnt from the Lakanal House fire, subject to the findings of the inquests which were due to start in January 2013.603 77.6 The draft produced during the consultation period contained new sections on evacuation and handling fire survival guidance calls. It contained the same direction to the incident commander to follow any evacuation plan devised as part of the occupier’s fire risk assessment,604 but there was no express reference to the potential need to carry out an evacuation of a residential building with a “stay put” strategy. In particular, the oblique reference to the “stay put” principle did not accurately reflect the national guidance that residents are usually safest remaining in their property unless affected by fire, heat or smoke (whatever the source).605 There was also no reference to the need to re-evaluate the advice being given to callers during the course of an incident or to the possibility that “stay put” advice might have to be reversed. 77.7 DAC Cowup did not accept that he and his team had failed to consider the potential need to revoke “stay put” advice during the course of an incident at a residential high-rise building. On the contrary, he said that they had recognised that it was one of the lessons of the Lakanal House fire. Although he accepted that the draft was not as explicit as it might have been, he thought that people would have understood that to be necessary, having seen the reference to the need to change the evacuation strategy if and when the situation made it appropriate.606 77.8 Following the Lakanal House inquests, DAC Cowup was provided with copies of the coroner’s rule 43 letters to the LFB and DCLG, which contained recommendations relating to section 7(2)(d) visits and incident command training. He examined them to ensure that all the points raised in the letters had been covered in the draft revision of GRA 3.2.607 That exercise resulted in further changes to the text, but he did not think that any substantial amendments were required.608 77.9 The section relating to handling fire survival guidance calls was changed, however, by the addition of a direction to re-evaluate the caller’s situation from time to time to ensure that the balance of risk between leaving the building and remaining in place was reconsidered 600 Cowup {Day195/91:4-16}. 601 Cowup {LFB00119849/37} page 37, paragraph 82. 602 Cowup {LFB00119849/51} page 51, paragraph 115. 603 Cowup {Day195/133:20}-{Day195/134:3}. 604 {LFB00033886/25}. 605 {LFB00033886/25}; {HOM00001124/4}; {LFB00001257/2} paragraph 2.2. 606 Cowup {Day195/113:4-18}. 607 Cowup {Day195/182:20-25}. 608 Cowup {Day195/187:7-19}; {LFB00102462}.

Part 8 | Chapter 77: High-rise firefighting: policy and guidance 95 as circumstances changed.609 An amendment to that effect was ultimately included in the published version of GRA 3.2 and was also incorporated into the edition of PN633 published in 2015.610 The oblique reference to the “stay put” principle was also changed so that it was consistent with the advice contained in national guidance and PN790,611 but no reference was made to the potential need to carry out an evacuation of a high-rise residential building with a “stay put” strategy. 77.10 In his response to the coroner’s rule 43 letter to his department, the Secretary of State for Communities and Local Government had given a clear undertaking that the revised version of GRA 3.2 would include advice to incident commanders to help them make decisions on evacuation if it became clear during an incident that a “stay put” strategy was no longer tenable.612 DAC Cowup could not recall having seen the Secretary of State’s letter.613 None of the witnesses who gave evidence to the Inquiry, including those who had worked for DCLG at the time, was able to explain why that was so, despite the letter’s obvious relevance to the work on GRA 3.2. 77.11 After the Lakanal House inquests ended in March 2013, DCLG officials became involved in the review of GRA 3.2 at what was intended to be the final stage of the preparation of the revised version for publication. Their involvement led to the incorporation of much of the significant new content, including provisions on the need for an evacuation plan and for incident commanders to be able to evacuate buildings with “stay put” strategies. 77.12 On 19 June 2013, representatives of the LFB and DCLG met to put the finishing touches to the draft. No one raised any concerns about the text.614 Following that meeting, however, the draft was reviewed by other officials within DCLG and significant comments were made by Louise Upton, the Head of Fire Safety Policy. In her evidence, Ms Upton said that she had previously known nothing about the review of GRA 3.2, apart from the commitment made in the Secretary of State’s letter and having occasionally received various versions of the draft.615 Possibly as a result of her distance from the subject matter, Ms Upton drew attention to significant defects in the treatment of the “stay put” principle and other important aspects of firefighting in high-rise buildings. In an internal email sent to a number of her colleagues on 1 July 2013 she concentrated on the extent to which the document satisfied the Secretary of State’s undertaking that the revised version of GRA 3.2 would include advice to incident commanders to help them make decisions about evacuation.616 In a later internal email sent on 29 July 2013 she expressed the view that a more fundamental review of the document was required. She referred to the work done by the LFB since the Lakanal House fire to revise its own operational guidance and considered it odd that the revised draft GRA 3.2 did not appear to reflect the lessons learnt by the LFB as a result of that fire.617 In saying that, she clearly thought that the LFB had given consideration to the potential need to evacuate a high-rise residential building.618 609 {LFB00102462/2}. Those amendments had in fact been suggested by GM Michael Curran, in an email sent to DAC Cowup on 18 March 2013 {LFB00090754}. 610 {LFB00001255/20}; {LFB00001256/14}. 611 {LFB00102462/3}. 612 {HOM00047743/2}. 613 Cowup {Day195/191:3}-{Day195/192:22}. 614 Cowup {Day195/195:18-23}. The draft GRA 3.2 was sent by Les Britzman, who was part of the Chief Fire and Rescue Adviser’s team, to Louise Upton, Peter Holland, Brian Martin, Dawn Eastmead, and others within DCLG, on 9 May 2013 {CLG00001921/2}. 615 Upton {Day248/61:22-24}; {Day248/100:4-7}. 616 {CLG00000624}. 617 {CLG10005807}. 618 Upton {Day248/85:3-19}.

The Grenfell Tower Inquiry: Phase 2 Report 96 77.13 Another meeting took place on 30 July 2013 to discuss Louise Upton’s concerns. It was attended by DAC Cowup and Philip Morton from the LFB, Les Britzman (a member of the Chief Fire and Rescue Adviser’s team) and Anthony Maude of DCLG and Leigh Brinton, an employee of Surrey Fire and Rescue Service, who was also involved in the review of GRA 3.2.619 Louise Upton did not attend the meeting because she did not consider that she could contribute on matters relating to operational firefighting. She believed that her concerns would be voiced by Les Britzman.620 77.14 At the meeting Mr Britzman led the discussion, which concentrated on the treatment of the “stay put” principle.621 According to DAC Cowup, that was the first time that questions of that kind had been raised by DCLG and he had been deeply frustrated by the fact that substantive changes were being proposed at such a late stage.622 Nonetheless, his understanding was that the changes were minor rather than fundamental; DCLG did not tell him that he needed to start again.623 He said that he had not become aware of DCLG’s concern that the draft did not meet the Secretary of State’s commitment to the coroner until he was preparing to give evidence.624 Although the point may not have been made to DAC Cowup with the same clarity as it had been made in Ms Upton’s emails, the correspondence following the meeting on 30 July 2013 made clear the department’s desire for greater clarity about, and greater emphasis on, the advice to incident commanders about evacuation in order to fulfil the commitment given by the Secretary of State to the coroner.625 77.15 Following the meeting on 30 July 2013, DAC Cowup and his team made further changes to the draft626 by adding passages on the need to re-evaluate “stay put” advice during the course of an incident and to change it if circumstances made that necessary (both points that had been identified by DAC Cowup in his response to the coroner’s rule 43 letters).627 However, the draft still did not mention the need for incident commanders to understand when to carry out an evacuation of a building with a “stay put” strategy or to the need for there to be an evacuation plan if a “stay put” strategy became untenable. 77.16 Notwithstanding those revisions, DCLG continued to have misgivings about the draft. On 15 October 2013, Louise Upton said in an email to Les Britzman and others at DCLG that her earlier concerns appeared not to have been particularly well addressed in the revised version.628 She sent a large number of comments on the draft document to Mr Britzman, including a reference to the need for contingency plans to provide for evacuation,629 but they were not sent on to DAC Cowup.630 The substance of Ms Upton’s comment on the need for an evacuation strategy was ultimately retained in the published version of GRA 3.2. 619 Cowup {Day196/10:11-16}; {Day195/151:19}-{Day195/152:6}. 620 Upton {Day248/86:3-15}. 621 Cowup {Day196/12:1-11}. 622 Cowup {Day196/12:15-25}; {Day196/13:11-20}. 623 Cowup {Day196/14:2-19}. 624 Cowup {Day196/86:22}-{Day196/87:3}. 625 {LFB00102486/2}. 626 {LFB00052471}. 627 {LFB00034198/29}; {LFB00057988}. 628 {CLG00002780}. 629 {CLG00002781/16}. 630 Cowup {Day196/60:6-9}.

Part 8 | Chapter 77: High-rise firefighting: policy and guidance 97 77.17 Ms Upton’s comments also included a reference to the need for training to give incident commanders an understanding of when a full or partial evacuation of a residential building subject to a “stay put” strategy might be necessary.631 Again, her comment ultimately appeared in the published version of GRA 3.2 in substantially the same terms. 77.18 Following various discussions, and notwithstanding DCLG’s reservations, the decision was taken to publish the revised GRA 3.2 without any further substantive amendments. The decision followed a conversation between Commissioner Dobson and Peter Holland,632 Chief Fire and Rescue Adviser, who, DAC Cowup recalled, had also been of the view that they should move towards publication.633 Within DCLG, however, the document was described by some as a wasted opportunity and “not fit for purpose”.634 77.19 Be that as it may, GRA 3.2 in its final form clearly contemplated that the total evacuation of a high-rise building should be an important part of any fire and rescue service’s contingency plan for a building and that incident commanders should not assume that compartmentation would invariably be maintained.635 Review and amendment of PN633 77.20 In November 2011, the LFB published a revised version of PN633 which reflected changes to the policy considered necessary in the light of the Lakanal House and the Shirley Towers fires.636 DAC Cowup described it as a comprehensive revision.637 However, the revised policy contained no reference to the need to make contingency plans for evacuating the whole building, although crews visiting buildings pursuant to section 7(2)(d) of the 2004 Act were directed to have regard to the risk of fire spreading beyond the compartment of origin and the possible need for multiple rescues.638 There were references to evacuation throughout the policy, including a direction that the incident commander should follow the evacuation plan devised as part of the occupier’s fire risk assessment unless the situation dictated otherwise,639 but there was no reference to the possibility that a building with a “stay put” strategy might need to be evacuated or indeed any explicit reference to the “stay put” principle at all. 77.21 The LFB’s review of PN633 to bring it in line with the revised GRA 3.2 began in early 2013. DAC Cowup asked GM James A’Court, then part of the Operational Policy department, to co-ordinate it.640 GM A’Court asked SM Patrick Utting, then part of the Incident Management team, to take the lead on drafting the revised policy.641 DAC Cowup expected GM A’Court and SM Utting to keep him informed about any revisions to the draft GRA 3.2 as work went on and take them into account. He also expected them to have regard to any lessons arising out of the Lakanal House inquests, which had recently begun.642 631 {CLG00002781/19-20}. 632 Cowup {Day196/106:2-10};{Day196/108:21}-{Day196/109:2}; {HOM00043991/3}. 633 Cowup {Day196/107:15-19}. 634 {HOM00043991/2}. 635 Phase 1 Report Volume IV paragraphs 27.2 and 27.3. 636 {LFB00102306}. 637 Cowup {LFB00119849/84} page 84, paragraph 187. 638 {LFB00102306/15}. 639 {LFB00102306/12}. 640 {LFB00085313}. 641 {LFB00086677}. 642 {LFB00085313}; Cowup {Day196/143:8}-{Day196/141:15}.

The Grenfell Tower Inquiry: Phase 2 Report 98 77.22 DAC Cowup told SM Utting that transposing the relevant elements of GRA 3.2 into LFB policy was likely to be a relatively straightforward task.643 He did not recall specifically asking SM Utting to consider the coroner’s rule 43 letters and SM Utting confirmed that he had not been asked to consider them as part of his work.644 SM Utting was similarly unaware of the contents of the Secretary of State’s response to the coroner or of his commitment to including in the revised GRA 3.2 advice to incident commanders to inform decisions on evacuation.645 77.23 The version of PN633 produced in 2015 was neither as clear nor as comprehensive as GRA 3.2. In particular, both the risk assessment and the gap analysis that SM Utting had produced for the purpose of his review of PN633 were based on an earlier draft of GRA 3.2 that pre-dated Ms Upton’s comments in relation to “stay put” and evacuation.646 Further, neither of them contained any reference to cladding as a feature that crews should consider when gathering information, despite its being referred to in both the 2008 and the 2014 editions of GRA 3.2. There was no satisfactory explanation why the revised PN633 did not fully or accurately reflect the 2014 edition of GRA 3.2 on these important points. 77.24 In the section dealing with competence and training GRA 3.2 advised that incident commanders should understand when an evacuation strategy might become necessary in a residential building where a “stay put” strategy is normally in place. That was transposed into paragraph 7.46 of PN633 and to that extent, therefore, the policy did reflect a recognition that compartmentation may fail and that the incident commander may need to carry out a partial or total evacuation of a building subject to a “stay put” strategy.647 However, no guidance was provided about when or how a decision of that kind should be made. SM Utting doubted whether it was feasible to include in a policy advice that would apply in all situations.648 That may be so, but it does not explain why no attempt was made to identify factors that might indicate to an incident commander that “stay put” advice should be withdrawn and an evacuation of some nature carried out. In those circumstances, it is not surprising that PN633 did not refer to the need to train incident commanders to recognise the need to withdraw “stay put” advice and carry out an evacuation.649 but no request for training was initiated in conjunction with the revision of PN633.650 As Commissioner Roe accepted, at the time of the Grenfell Tower fire the LFB did not provide any guidance or direction in either its training or its policies about when and how a “stay put” strategy should be reversed.651 77.25 The guidance in GRA 3.2, to the effect that contingency plans for individual premises should cover the spread of fire beyond the compartment of origin and the possible need for multiple rescues, found its way into paragraph 4.8 of PN633, but without any specific reference to the need for a contingency plan. There was no reference to the need for an operational evacuation plan that could be implemented if a “stay put” policy became untenable.652 SM Utting was unable to explain why that particular aspect of GRA 3.2 had 643 Cowup {Day196/146:18}-{Day196/147:9}; Utting {Day198/12:23}-{Day198/13:4}. 644 Cowup {Day196/147:15-20}; Utting {Day198/16:9-18}. 645 Utting {Day198/55:17}-{Day198/57:6}. 646 Utting {LFB00121173/2} page 2, paragraph 5; {LFB00121174}; {LFB00030368}; Utting {Day198/94:21}- {Day198/95:19}. 647 Phase 1 Report Volume IV paragraph 27.6. 648 Utting {Day198/47:21}-{Day198/48:16}. 649 Utting {Day198/66:3-12}. 650 The Inquiry received no evidence to indicate that any training had been developed for the 2015 edition of PN633, and neither DAC Cowup nor SM Utting were able to confirm otherwise: Cowup {Day197/29:18-23}; Utting {Day198/91:2-18}. 651 Roe {LFB00083834/7-8} pages 7-8, paragraphs 28 and 29. 652 {LFB00001255/19}.

Part 8 | Chapter 77: High-rise firefighting: policy and guidance 99 not been incorporated into PN633.653 DAC Cowup told us that he had understood the phrase “contingency plans” in GRA 3.2 to relate only to high-risk premises, such as national heritage sites or landmark high-rise buildings, and that it would not be practicable to have individual contingency plans for every high-rise building in London.654 SM Utting expressed a similar view.655 However, that is not the natural meaning of the expression as it appears in GRA 3.2, where it appears to refer to all high-rise buildings. Although it might not have been practicable to require crews to draw up individual contingency plans for all high-rise buildings, GRA 3.2 required fire and rescue services to consider generally whether and how contingency plans could assist crews and incident commanders. The stark conclusion is that PN633 did not properly reflect the requirements of GRA 3.2 in that respect. Conclusions 77.26 The history of the revision of GRA 3.2 and the review of PN633 is of interest primarily for the light it sheds on the attitude of the LFB to the need to prepare for the evacuation of high-rise residential buildings subject to a “stay put” policy. The need to prepare contingency plans for an evacuation was included in GRA 3.2 as a result of the insistence of officials at DCLG rather than at the instigation of the LFB. The review of PN633 failed fully to reflect the current version of GRA 3.2, possibly because those at the LFB responsible for it did not think that the LFB needed such detailed advice and guidance or possibly because they did not attach sufficient importance to it. Whatever the reason, the close involvement of the LFB in the revision of GRA 3.2, coupled with the critical intervention of officials at DCLG, should have made it clear that producing contingency plans for a full evacuation was an essential part of fighting fires in high-rise buildings. Regrettably, however, that message was not properly absorbed by senior managers, and as a result operational firefighters were not properly prepared to deal with another major failure of compartmentation when it eventually occurred at Grenfell Tower. 653 Utting {Day198/60:13-25}-{Day198/61:2}. 654 Cowup {Day195/55:9-25}; {Day195/56:16-25}. 655 Utting {Day198/58:3-15}.

100 The Grenfell Tower Inquiry: Phase 2 Report

101 Chapter 78 The control room 78.1 The Grenfell Tower fire presented the control room and all those who worked there with a challenge of unprecedented proportions. All those present on that night did what they could to deal with the huge volume of emergency calls and to pass vital information to the incident ground. However, mistakes were made, as described in the Phase 1 report, mainly as a result of inadequate training. It was therefore important for us to examine the way in which the control room had been run and its staff trained in the years immediately preceding the fire, to ensure, as far as possible, that a similar situation does not arise in the future. Structure and management 78.2 The control room lies at the heart of the LFB’s response to fires and other unexpected events as a result of which people’s lives are at risk. It takes emergency calls from the public, despatches fire appliances to incidents and maintains communications with the incident ground. A description of its organisation and method of operation at the time of the Grenfell Tower fire is contained in chapter 7 of the Phase 1 report. 78.3 It is important to note at the outset that control room officers (CROs) are not merely call- handlers. As part of responding to emergency calls, they provide fire survival guidance when circumstances require. When providing fire survival guidance, a CRO becomes a first responder, giving critical advice to someone facing a life-threatening situation. Their role is, therefore, complex and proper performance of their functions is critical to the effective operation of the LFB. It depends on effective management of the organisation and the maintenance of critical skills through regular training. 78.4 Before 2015, responsibility for the operation of the control room lay with the Operational Prevention and Response department, itself part of the Deputy Commissioner’s directorate.656 When in 2015 the Deputy Commissioner’s directorate was abolished, that responsibility was transferred to the newly formed Directorate of Operations.657 From 2015 until 2017, the Director of Operations was AC Brown. From March 2017, AC George took over as Director of Operations. 78.5 Until 2011, CROs were divided into four watches covering two shifts within a 24-hour period.658 Each watch comprised 16 CROs and seven senior control officers under the command of a control commander.659 Two senior operations managers (SOMs) managed two watches each and held certain other responsibilities which are discussed below. From 2010, the two SOMs were SOM Joanne Smith and SOM Lindsay Turner.660 They were supported by assistant operations managers (AOMs). In overall command of the control room was the principal operations manager (POM), Scott Hayward. 656 Dexter {LFB00032363/2} page 2, paragraphs 4 and 5. 657 Brown {LFB00032166/3-4} pages 3-4, paragraphs 5 and 9; George {LFB00032823/2} page 2, paragraph 6. 658 Lakanal Control Report {HOM00001124/7} paragraph 21. 659 Lakanal Control Report {HOM00001124/8} page 8, Chart 1. 660 Smith {LFB00121219/2-3} pages 2-3, paragraph 7. Following the fire, Joanne Smith was promoted to the rank of Deputy Assistant Commissioner and gave her evidence while holding that rank. At all material times she was a Senior Operations Manager and so, for clarity and consistency with the contemporaneous documentation, she will be referred to in that rank in this report.

The Grenfell Tower Inquiry: Phase 2 Report 102 78.6 In addition to the watches staffing the control room, there were two support teams, each led by one of the SOMs. SOM Smith led the Technical Support Group, made up of one OM and two AOMs. SOM Turner led the Training team, made up of one OM and three AOMs. The Technical Support Group was responsible for ensuring that the systems used by the control room, including the mobilising system, were suitable for their purpose and capable of carrying out the functions required to enable CROs to do their work.661 The Training team was responsible for developing core training and delivering it to CROs.662 Its members were full-time trainers, although they were not trained as such. All of them were experienced CROs.663 78.7 In April 2011, the shift pattern was changed. Instead of operating two shifts over 24 hours, CROs worked one of four shifts: a 12-hour day or night shift, or one of two overlapping ‘short’ shifts of eight hours.664 78.8 At about the time that the shift pattern was changed, the Technical Support Group and the Training team were merged to form a single team known as the Operational Support Team.665 Although the rest of the control room operated a shift system, the Operational Support Team, as a support body, operated only during the day shift.666 The Operational Support Team trained CROs while the latter were ‘on watch’, i.e. when their watch was on duty, but during periods when they were not required to undertake control room duties.667 Training was occasionally provided to CROs outside normal working hours. 78.9 The newly formed Operational Support Team contained five AOMs, later reduced to four.668 Within the Operational Support Team, the members of the former Technical Support Group retained their previous responsibilities and continued to report to SOM Smith.669 Those officers responsible for training reported to SOM Turner.670 SOM Smith said that following the merger no one person had been formally placed in charge of the Operational Support Team and that she and Lindsay Turner had shared that responsibility.671 78.10 In September 2012, SOM Smith was seconded to the Chief Fire Officers Association.672 At around the same time, SOM Turner left the control room for medical reasons.673 As a result, Victor Bagnelle and Keith Diamond were temporarily promoted to SOMs, replacing SOM Smith and SOM Turner respectively.674 78.11 In 2015, the LFB changed its mobilising system from one known as ‘ProCAD’ to a system known as ‘Vision 4DS’. The introduction of a new mobilising system meant that between 2013 and 2015 the Operational Support Team had to design, prepare and deliver intensive training to enable the CROs to use it.675 661 Smith {LFB00121219/2-3} pages 2-3, paragraph 7, Smith {Day202/9:2-16}; Hayward statement {LFB00055191/17} page 17, paragraph 49. 662 Hayward {LFB00055191/17} page 17, paragraph 49; Lakanal Control Report {HOM00001124/8} paragraph 22. 663 SM Kelly’s training audit report {LFB00055220/4} paragraph 9. 664 The operation of the shifts and the impact of the shift system on the time available for training is covered in more detail below. The shift times and watch numbers, together with the minimum staffing numbers, are set out in tabular form in POM Hayward’s first witness statement: {LFB00055191/5} page 5, paragraphs 15-17 665 Hayward {LFB00055191/17-18} pages 17-18, paragraph 49. Smith {LFB00121219/3} page 3, paragraph 7. 666 Smith {Day202/13:22-24}. 667 Hayward {LFB00055191/18} page 18, paragraph 52. 668 Hayward {LFB00055191/17-18} pages 17-18, paragraph 49. 669 Smith {LFB00121219/3} page 2-3, paragraph 7. 670 Smith {LFB00121219/3} page 2-3, paragraph 7. 671 Smith {Day202/15:15-18}. 672 Smith {LFB00121219/3} page 3, paragraph 8. 673 Hayward {Day200/189:11-21}. 674 Bagnelle {LFB00122821/2} page 2, paragraph 6; Smith {LFB00121219/3} page 3, paragraph 8. 675 Hayward {LFB00055191/19-20} pages 19-20, paragraph 56-60.

Part 8 | Chapter 78: The control room 103 78.12 In January 2015, SOM Smith returned from her secondment and assumed overall responsibility for the Operational Support Team.676 She continued to hold that responsibility until January 2020.677 Senior officers and lines of responsibility 78.13 POM Hayward was in day-to-day command of the control room and reported directly to an Assistant Commissioner. Inevitably, the position held by that Assistant Commissioner within the LFB structure varied over time.678 For present purposes, it is sufficient to say that between 2009 and 2016 (apart from the period between May 2012 and October 2013 when the control room was commanded by its own Assistant Commissioner, AC Richard Chandler) POM Hayward usually reported to AC Brown, who had a broad range of other responsibilities. It was not until the appointment of AC George as Head of Operational Response in March 2016 that the control room once again had the benefit of its own Assistant Commissioner. 78.14 In December 2015, a few months before his appointment as Assistant Commissioner and Head of Operational Response, AC George was asked by AC Brown to lead what he described as a “cultural review” of the control room and its position within the organisation.679 In his role as Head of Operational Response, AC George was also responsible for the operation of the control room and mobilising, the operation of the Resource Management and Logistics Centre and the UK Fire and Rescue Services’ National Co-ordination Centre.680 He was also POM Hayward’s line manager. AC George agreed that during that period POM Hayward had run the control room on a day-to-day basis, although he knew that AC George wanted to be kept informed about the type of decisions he was making.681 AC George was also ultimately responsible for the delivery of training to CROs.682 AC George knew that POM Hayward had delegated responsibility for training to SOM Smith and was content with that.683 He explained that he had satisfied himself that it was an appropriate and effective step and had considered SOM Smith a very professional and experienced officer.684 As Head of Operational Response, AC George reported directly to AC Brown.685 78.15 In April 2017, AC George succeeded AC Brown as Director of Operations.686 He was not replaced as Head of Operational Response, a position that ceased to exist.687 Although AC George retained responsibility for managing POM Hayward, he delegated all matters relating to the management of the control room to him.688 78.16 Following the Grenfell Tower fire, the management structure of the control room changed. In late 2018 or early 2019, AC George decided that a more senior officer needed to take over the day-to-day management of the control room.689 POM Hayward was made redundant and Commissioner Cotton appointed AC Jonathan Smith as a new 676 Smith {LFB00121219/4} page 4, paragraph 9. 677 Smith {LFB00121219/4} page 4, paragraph 9. 678 Lakanal Control Report {HOM00001124/7} page 7, paragraph 19. 679 George {Day205/10:1-2}; George {LFB00032823/4} page 4, paragraphs 13 and 15. 680 George {Day205/11:3-16}. 681 George {LFB00032823/4} page 4, paragraph 16; George {Day205/15:6-11}. 682 George {Day205/22:1-5}. 683 George {Day205/21:2-10}. 684 George {Day205/21:11-23}. 685 George {Day205/4:20-22}. 686 George {LFB00032823/10} page 10, paragraph 39. 687 George {LFB00032823/10} page 10, paragraph 39. 688 George {LFB00032823/10} page 10, paragraphs 39 and 42. 689 George {Day205/108:19-23}.

The Grenfell Tower Inquiry: Phase 2 Report 104 AC Operational Resilience and Control.690 On 1 January 2021, SOM Joanne Smith was promoted to the newly created position of DAC for Control and Mobilising, reporting to AC Jonathan Smith.691 Management meetings 78.17 Control room staff held regular meetings, usually monthly, which were attended by all staff other than the CROs.692 Although AC Chandler regularly attended those meetings, AC Brown and AC George did not.693 AC Brown considered that, as they were meetings of middle managers, it was for the POM and SOMs to manage them.694 78.18 POM Hayward regarded the meetings as an opportunity to discuss matters generally and inform the watch managers about any changes in the work.695 He also said that he would use them as a barometer to gauge whether there were any negative comments about training.696 78.19 For a long time, POM Hayward reported to AC Brown as his line manager. AC Brown said that he used a variety of methods to monitor the performance of the control room and the way in which it was being managed. As Director of Operations he chaired a monthly Principal Management Board meeting of the area DACs, which he encouraged POM Hayward to attend,697 but it appears that matters relating to the control room arose only occasionally and even then represented a relatively small part of what was discussed.698 He also met Scott Hayward once between each of those meetings, so that they met about every two weeks.699 They also saw each other at meetings relating to one of the other areas for which AC Brown had strategic responsibility, if the subject matter affected the control room.700 78.20 AC Brown did not exercise any particular oversight over the training of CROs701 because he considered that they were highly managed, in the sense that the control room contained approximately the same number of staff as a large fire station but a much higher proportion of managers.702 The identification of remedial measures 78.21 The Lakanal House fire was a particularly significant event for the control room. The Lakanal House Board identified 13 pre-inquest actions relating to the control room, the most important of which for present purposes were those concerning a review of 690 George {Day205/108:21}-{Day205/109:4}. Hayward said that he left Brigade Control in July 2019: Hayward {Day199/5:1-3} and Hayward {LFB00086213/2} page 2, paragraph 7. Jonathan Smith {LFB00121171/4} page 4, paragraph 7. 691 Smith {LFB00121219/2} page 2, paragraph 6; Smith {Day202/6:8-15}. 692 Hayward {Day199/27:20-23}. 693 AC Chandler is recorded as attending or sending apologies to at least 6 meetings between 8 July 2012 and 9 November 2013. AC George is recorded as attending only part of the meeting on 8 March 2016 {LFB00123152/1} by way of an introduction to the staff. 694 George {Day205/13:2-5}. 695 Hayward {Day199/27:16-19}. 696 Hayward {Day199/32:19} – {Day199/33:1} and Hayward {Day199/50:20} – {Day199/51:13}. 697 Brown {Day206/42:19-25}. 698 See for example Principal Management Board Meeting draft minutes, 18 December 2013 {LFB00032168/5} where there the only involvement of Brigade Control is in relation to item 3.7 concerning the Lakanal Rule 43 Letter and item 4.3 regarding a report on a Radio MDT trial. 699 Brown {Day206/42:25}-{Day206/43:4}. 700 Brown {Day206/43:4-10}. As an example, AC Brown referred to meetings concerning the Vision mobilising system. 701 Hayward {Day199/37:16-18}; Brown {Day207/22:11-12}. 702 Brown {Day207/22:13-21}; Brown {Day207/11:4-20}.

Part 8 | Chapter 78: The control room 105 national guidance and LFB policy on providing fire survival guidance,703 the training of CROs and their supervisors,704 amendments to LFB Policy No. 539 (PN539) on emergency call-handling,705 the creation of a policy (Policy No. 790 (PN790)) on handling fire survival guidance calls,706 and amendments to the Reference Information Files (RIFs).707 78.22 AC Brown was given responsibility for carrying out the pre-inquest actions,708 a task which he delegated to POM Hayward, although he provided him with support and met him from time to time to monitor progress.709 POM Hayward did not ask AC Brown for additional resources to carry out the work.710 Policy and guidance – the gap analysis 78.23 Action 5 of the pre-inquest actions was the production of a gap analysis to identify any differences between national guidance on handling fire survival guidance calls and PN539.711 The analysis was fundamental to shaping the control room’s response to the Lakanal House fire. 78.24 The gap analysis had been completed by April 2010. It was produced by POM Hayward in conjunction with SOM Smith, DAC Cutbill, who was leading the investigation into the Lakanal House fire, and Thomas Davies, a member of the LFB’s legal department.712 SOM Turner, SM Hams and GM Zymanczyk also contributed to the first draft.713 The analysis involved a comparison between two national guidance documents on the training of control room staff and the LFB’s policy on emergency call management and its training materials on fire survival guidance.714 The report made recommendations designed to address deficiencies identified in both national guidance and LFB policy and training.715 78.25 Although it is not clear whether the recommendations in the gap analysis were formally approved by the Lakanal House Board, some of the gaps that had been identified and some of the resulting recommendations gave rise to further pre-inquest actions intended to address them.716 That was certainly the case for the following recommendations: 703 The actions are set out in detail in the Lakanal Assurance Report {LFB00004801/12-15} Pre-Inquest actions 5 and 13. 704 Lakanal Assurance Report {LFB00004801/13-16} Pre-Inquest actions 8, 11, 12, 16 and 17. 705 Lakanal Assurance Report {LFB00004801/14} Pre-Inquest action 10. 706 Lakanal Assurance Report {LFB00004801/15} Pre-Inquest action 14. 707 Lakanal Assurance Report {LFB00004801/13} Pre-Inquest action 9. 708 Hayward {Day199/146:2-7}; Minutes of Lakanal House Board on 15 September 2010 {LFB00055192/7-8} Appendix 1; Brown {LFB00032166/5-6} pages 5-6, paragraph 14. 709 Brown {Day206/72:23-25}; Brown {LFB00084020/6} page 6, paragraph 10; Brown {Day206/73:6-16}. He was also received reports from DAC Cutbill who was a part of the Lakanal House action team: Brown {Day206/73:6-16}. 710 Brown {Day206/73:17-24}. 711 Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/12}; Annex B to Lakanal Control Report entitled ‘Comparison between national guidance and LFB policy and training’ {HOM00001125/7-24}. 712 Hayward {LFB00055191/6} page 6, paragraph 20, first bullet point; Hayward {LFB00086213/2-3} pages 2-3, paragraphs 10-12; Smith {LFB00121219/9} page 9, paragraph 20; Email from SOM Smith to DAC Cutbill, POM Hayward, Thomas Davies and GM Zymanczyk on 2 February 2010 {LFB00118272}. 713 Email from SOM Turner to DAC Cutbill and SM Hams copying in POM Hayward on 17 November 2009 {LFB00082629}; Email from SOM Turner to SM Hams on 19 November 2009 {LFB00075090}; Email from SOM Smith to DAC Cutbill, POM Hayward, Thomas Davies and GM Zymanczyk on 2 February 2010 {LFB00118272}. 714 Annex B to Lakanal Control Report entitled ‘Comparison between national guidance and LFB policy and training’ {HOM00001125/7-24}; Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/12}. 715 Annex B to Lakanal Control Report entitled ‘Comparison between national guidance and LFB policy and training’ {HOM00001125/7-24}. 716 Brown {Day206/79:5-9}; POM Hayward recalled that the gap analysis recommendations were accepted by the Lakanal House Board: {Day199/170:19-24}. However, the minutes of the meetings on 7 April, 5 May 2010 and 22 June 2010 do not make that clear: {LFB00060782/2}; {LFB00084028/3}; {LFB00055208/2-3}.

The Grenfell Tower Inquiry: Phase 2 Report 106 a. To include contributions from fire safety officers in training on handling fire survival guidance calls to make it consistent with national guidance.717 b. To amend PN539 to ensure that it reflected or complied with national guidance.718 c. To carry out refresher training on handling fire survival guidance calls.719 d. To improve certain points in national guidance on training on handling fire survival guidance calls.720 e. To establish a procedure for continuous communication between the control room and firefighters.721 f. To audit training arrangements for the control room.722 g. To review LFB policy to ensure that it recognised the need to train supervising officers to provide support for CROs handling fire survival guidance calls.723 78.26 Although the RIFs used by CROs when handling fire survival guidance calls were not specifically addressed in the gap analysis, SOM Smith said that they had used the findings of the gap analysis to revise the RIFs after the Lakanal House fire.724 78.27 On 8 December 2004, the government issued Fire and Rescue Service Circular 54-04 on ‘Emergency Call Management’ (FSC 54-04).725 It provided advice and a description of good practice developed jointly by the Chief Fire Officers Association and HM Fire Service Inspectorate to assist effective emergency call‑handling by fire and rescue services.726 It was produced following a review of emergency call‑handling which they had commissioned jointly in 2001.727 One of the review’s objectives was to review existing guidance on handling emergency calls (including fire survival guidance calls).728 78.28 The document summarised, in the form of national guidance, a three-stage approach to handling emergency calls with the objective of improving the way in which they were managed.729 Annex A set out a generic three-stage approach to call‑handling called the “Emergency Call Management Protocol”.730 In summary, stage 1 involved obtaining 717 Annex B to Lakanal Control Report entitled ‘Comparison between national guidance and LFB policy and training’ {HOM00001125/12} see ’Recommendations’. 718 Annex B to Lakanal Control Report entitled ‘Comparison between national guidance and LFB policy and training’ {HOM00001125/8}; {HOM00001125/16} see ’Recommendations’. 719 Annex B to Lakanal Control Report entitled ‘Comparison between national guidance and LFB policy and training’ {HOM00001125/23} see ’Recommendations’. 720 Annex B to Lakanal Control Report entitled ‘Comparison between national guidance and LFB policy and training’ {HOM00001125/8}; {HOM00001125/11-20}; {HOM00001125/24}. 721 Annex B to Lakanal Control Report entitled ‘Comparison between national guidance and LFB policy and training’ {HOM00001125/21}. 722 Annex B to Lakanal Control Report entitled ‘Comparison between national guidance and LFB policy and training’ {HOM00001125/24}. 723 Annex B to Lakanal Control Report entitled ‘Comparison between national guidance and LFB policy and training’ {HOM00001125/23}. 724 Smith {Day202/105:22-25}; Action Plan appended to the minutes of the meeting of the Lakanal House Board on 15 September 2010 {LFB00084031/8}; Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/13-14}. 725 FSC 54/04{LFB00055201/1}. 726 FSC 54/04{LFB00055201/1}. 727 FSC 54/04{LFB00055201/2-3}. 728 FSC 54/04{LFB00055201/2-3}. 729 Annex A of FSC 54/04 entitled ‘Emergency Call Management Protocol’ {LFB00055201/10}. 730 Annex A of FSC 54/04 entitled ‘Emergency Call Management Protocol’ {LFB00055201/7-12}.

Part 8 | Chapter 78: The control room 107 information to assist the mobilising decision,731 stage 2 involved obtaining information to support continuous assessment and ensure the safety of everyone involved,732 and stage 3 was directed to ensuring the safety of the caller and members of the public.733 78.29 Annex D contained “Fire call prompts”, which included various ‘prompts’ in relation to fire survival guidance calls to be used at stage 3 of the call-handling approach, as well as a warning that stages 1 and 2 might need to be revisited during stage 3.734 78.30 FSC 54-04 did not supersede FSC 10-93, so the available national guidance was to be found in a combination of the two documents.735 Despite that, the LFB excluded FSC 54-04 from the scope of its gap analysis.736 POM Hayward told us that FSC 54-04 had been discussed with DAC Cutbill and Thomas Davies at the time and that they had all considered that it did not need to be included737 because it was concerned with the use of scripts, which the control room did not use at that time.738 He also said that he did not think that FSC 54-04 added anything to the training described in FSC 10-93.739 SOM Smith said the same.740 AC Brown did not believe that the decision had been discussed with him and he did not recall approving it.741 78.31 Notwithstanding the view of PO Hayward that FSC 54-04 added nothing of substance to FSC 10-93, it is hard to reconcile the decision to exclude FSC 54-04 either with the purpose of the gap analysis or with the contents of FSC 54-04 itself. One of the stated aims of the emergency call‑handling review had been to review FSC 10-93 and the training package ‘Keeping People Safe’ which the Home Office had issued to complement it. (‘Keeping People Safe’ described the training requirements for CROs and set out a recommended programme of training).742 The express purpose of issuing FSC 54-04 had been to improve the handling of emergency calls.743 Moreover, it was expressly intended to provide national guidance.744 It is surprising, therefore, that it was excluded from an analysis which was specifically aimed at comparing LFB policy and training with existing national guidance. Nor was it simply about using scripts or prompts, as suggested by POM Hayward. It provided general guidance on managing emergency calls, including fire survival guidance calls.745 Finally, and most significantly, FSC 54-04 went beyond the guidance in FSC 10-93 and ‘Keeping People Safe’ in a number of important respects. For example, it advised CROs that when taking fire survival guidance calls they should positively assess the age, gender, ethnicity and any mental and physical disability of the caller.746 Although ‘Keeping People Safe’ referred to the possibility that a caller might be incapacitated, or 731 Annex A of FSC 54/04 entitled ‘Emergency Call Management Protocol’ {LFB00055201/7-8}. 732 Annex A of FSC 54/04 entitled ‘Emergency Call Management Protocol’ {LFB00055201/8-9}. 733 Annex A of FSC 54/04 entitled ‘Emergency Call Management Protocol’ {LFB00055201/9-10}. 734 Annex D of FSC 54/04 entitled ‘Emergency Call Management Protocol’ {LFB00055201/16-17}. 735 Emails between Michele McHugh (LFB) and Howard Jones (CLG) on 17 February 2010 {LFB00056548}. The minutes of the meeting of the Lakanal House Board on 5 May 2010 record that “It has been confirmed with CLG it is not intended that 54/04 supersede 10/93. However, it was noted that 10/93 was not on the CLG’s website, although it has now been confirmed as an extant document.” {LFB00084028/3}. 736 Hayward {Day199/158:25} – {Day199/159:1-2}; Smith {Day202/102:14-23}; Smith {LFB00121219/9} page 9, paragraph 21; Brown {Day206/82:14-18}. 737 Hayward {Day199/158:25}-{Day199/159:1-2}. 738 Hayward {Day199/158:9-18}. 739 Hayward {Day199/158:9-18}. 740 Smith {Day202/102:14-23}. 741 Brown {Day206/82:19-24}; Brown {Day206/88:18-21}; Dobson {Day211/140:12-20}. 742 Lakanal Control Report {HOM00001124/14} paragraph 61. 743 FSC 54/04{LFB00055201/2-3}; Annex A of FSC 54/04 entitled ‘Emergency Call Management Protocol’{LFB00055201/10}. 744 Annex A of FSC 54/04 entitled ‘Emergency Call Management Protocol’ {LFB00055201/10}. 745 Hayward {Day199/158:9-18}. 746 Annex D of FSC 54/04 entitled ‘Emergency Call Management Protocol’ {LFB00055201/17}.

The Grenfell Tower Inquiry: Phase 2 Report 108 unable to communicate effectively because of language difficulties or confusion, it did not encourage CROs to explore those matters as part of their assessment.747 Further, FSC 54-04 encouraged CROs continually to assess the caller’s situation and review their initial assessment in the light of changing circumstances.748 Neither FSC 10-93 nor ‘Keeping People Safe’ provided or reflected that guidance.749 78.32 FSC 54-04 should therefore have been included in the gap analysis. The fact that it had not been included was noticed in November 2012, when those drafting the Lakanal Control Report realised that the guidance in FSC 54-04 on handling fire survival guidance calls had been omitted from training materials. It was noticed again in January 2013 when GM Lindridge drew attention to it in his review of the pre-inquest actions. Yet, for no obvious reason, no action was taken to ensure that all relevant national guidance had been incorporated into LFB policy and training. 78.33 The Lakanal Control Report (dated November 2012) noted that, although some CROs handling fire survival guidance calls had tried to find out what was happening at different stages of the call, the importance of continual re-assessment had not been included in LFB training materials. Despite that finding, the Lakanal Control Report did not recommend that FSC 54-04 should be specifically referred to in the gap analysis or that a reference to the need continually to reassess the caller’s situation should be incorporated into LFB training and policy. 78.34 On 14 January 2013, DC Dexter forwarded a copy of GM Lindridge’s review to AC Brown, to which she had added her comments, and invited his response.750 She asked why the gap analysis did not include any reference to FSC 54-04.751 On 16 January 2013, AC Brown provided her with his response, which he said he had discussed with GM Lindridge.752 He said that, as FSC 54-04 only partially addressed fire survival guidance calls, and then only in relation to age, gender and disability, the analysis had concentrated on the requirements of FSC 10-93. However, he said that AC Chandler had been instructed to remedy the omission in November 2013.753 78.35 In evidence AC Brown accepted that, because age, gender and disability were factors that might affect a caller’s ability to escape from a fire, FSC 54-04 should have formed part of the original gap analysis.754 However, it was also important that the guidance it provided in relation to those factors be included in LFB policy and training. In those respects, AC Brown’s reply to DC Dexter understated the relevance and importance of FSC 54-04. His reply also failed to draw her attention to the guidance in FSC 54-04 that a CRO should continually reassess the caller’s situation, guidance that had been identified in the Lakanal Control Report as missing from LFB training.755 AC Brown said he believed that he had brought it to DC Dexter’s attention during one of their regular meetings,756 but in common with many similar assertions, we have seen no independent evidence that he did so. 747 ‘Keeping People Safe’ training {LFB00118948/5}. 748 Two of the stated objectives of stage two of the emergency call‑handling protocol were to “review assessment in light of further information” and to “continue to assess the call” {LFB00055201/8}. Annex D warned CROs that they might need to revisit stage one and two of the emergency call-handling protocol {LFB00055201/17}. 749 FSC 10/93{LFB00084051}; ‘Keeping People Safe’ training {LFB00118948/5}. 750 Email from DC Dexter to AC Brown on 14 January 2013 {LFB00085853/1}. 751 GM Lindridge’s review dated 4 January 2013 with DC Dexter and AC Brown’s comments {LFB00085854/5}. 752 Email from AC Brown to DC Dexter on 16 January 2013 {LFB00085853/1}. 753 GM Lindridge’s review dated 4 January 2013 with DC Dexter and AC Brown’s comments {LFB00085854/5}. 754 Brown {Day206/83:17-23}. 755 Lakanal Control Report dated November 2012 {HOM00001124/50} paragraph 295. 756 Brown {Day206/85:4-10}.

Part 8 | Chapter 78: The control room 109 78.36 AC Brown said that the purpose of his reply to DC Dexter was just to confirm that he had asked AC Chandler to consider FSC 54-04 when GM Lindridge’s review was revised.757 AC Chandler was absent from work from late 2012 until April 2013. AC Brown said he could not remember whether AC Chandler had told him that POM Hayward would carry out the task in his absence or whether he had himself asked POM Hayward to do so,758 but either way POM Hayward could not recall having received any such request.759 78.37 When he revisited his review in November 2013 and May 2014, GM Lindridge again noted that FSC 54-04 had not been included in the gap analysis. He sought to justify its omission primarily on the basis that it did not seek to provide a full account of how fire survival guidance calls should be handled.760 78.38 Although the exclusion of FSC 54-04 was apparently reconsidered, the gap analysis was not revised to include a comparison between LFB policy and training and FSC 54-04, despite AC Brown’s assurance to DC Dexter that the omission would be remedied. The reasons given for not doing so are clearly unsound, because the purpose of the gap analysis was to compare LFB policy and training with national guidance and the guidance in FSC 54-04 on handling fire survival guidance calls clearly went beyond that contained in FSC 10-93 and ‘Keeping People Safe’. 78.39 The failure to consider FSC 54-04 created a real risk that the guidance it contained, especially on assessing any impairments which might affect a caller’s ability to leave and on continually reassessing the caller’s situation, was not effectively reflected in LFB policy and training. As was found in the Phase 1 report, that risk materialised when PN539 was produced.761 78.40 The gap analysis was defective in two other significant respects: first, it failed to identify the fact that PN539 did not include the warning contained in FSC 10-93 about the dangers of offering false reassurance to a caller; secondly, despite having noted that FSC 10-93 and the LFB’s training material did not emphasise the need for continual reassessment of the caller’s situation, it failed to identify the fact that that guidance had also been omitted from PN539. We explore those defects and the likely consequences of them in relation to the revision of PN539 below. 78.41 FSC 10-93762 and ‘Keeping People Safe’763 both contained warnings that providing calming reassurance to callers trapped in buildings or otherwise exposed to danger could itself be dangerous. The gap analysis noted that FSC 10-93 acknowledged the possibility that an emotional bond might be formed between CROs and callers as calls progressed and emphasised that the relationship might be unhelpful because it might lead to callers’ giving answers that they think CROs want to hear. CROs were therefore advised to exercise caution when offering reassurance to avoid giving callers a false sense of security. The gap analysis also noted that the LFB’s training programme tended to encourage a strong attachment between callers and CROs by encouraging the use of reassuring phrases, 757 Brown {Day206/85:9-15}. 758 Brown {Day206/86:9-20}. 759 Hayward {Day199/164:5}-{Day199/165:1}. 760 GM Lindridge’s review dated November 2013, as amended in May 2014 {LFB00083988/8}. 761 Phase 1 Report Volume IV, paragraphs 29.45.e and 29.45.h. 762 FSC 10/93 {LFB00003617/1}. 763 ‘Keeping People Safe’ training {LFB00118948/6}.

The Grenfell Tower Inquiry: Phase 2 Report 110 which might have that effect.764 It therefore recommended that LFB training reflect more closely the guidance in FSC 10-93 to prevent an emotional link being formed and false reassurance being given.765 78.42 The gap analysis did not state whether PN539 dealt with the need for caution when offering reassurance to callers and therefore did not identify a gap or make any recommendation to amend PN539 in that respect. As it was, the version of PN539 dated 14 November 2007, which was current at the time, did not include a warning similar to that found in FSC 10-93 or ‘Keeping People Safe’.766 SOM Smith thought that that was because that guidance was to be delivered by the LFB through training rather than by policy,767 but if that was the LFB’s position, it was unreasonable. First, it does not explain why consideration of that aspect of PN539 was entirely omitted from the gap analysis. Secondly, it does not explain why the version of PN539 dated 14 November 2007 actively encouraged CROs to provide reassurance, including by the use of phrases such as “the firefighters will be with you very soon” and “I’m going to talk to you until the firefighters arrive”, both of which might well promote a false sense of security.768 Thirdly, it ignored, or at least underestimated, the importance of PN539’s stating clearly and fully the objectives and principles of, as well as the correct approach to, handling fire survival guidance calls. The clear and full expression of those principles would ensure that they would not be lost on anyone reading the policy (such as a CRO) and would provide a clear and comprehensive framework for training. 78.43 The failure to amend PN539 in those two respects was significant. As the chairman found in the Phase 1 report, PN539 had not been amended by the time of the Grenfell Tower fire and CROs invariably told callers that firefighters were on their way without having a sound basis for doing so.769 As a result, some callers were lulled into a false sense of security, remained in their flats and did not attempt to leave with sufficient vigour, or at all, despite the fact that escape was possible.770 78.44 The gap analysis also recommended that any revision of national guidance should contain advice to CROs to reassess the situation continually in order to be aware of changing conditions in the building and the caller’s state of mind.771 The basis for that recommendation is not entirely clear. The analysis failed to identify the fact that the current version of PN539 did not contain guidance that a CRO should continually reassess the caller’s situation,772 so it did not include an analysis of that aspect of the policy. POM Hayward said that it had been intended to amend PN539 in that way, but he could not explain why, if that had been the case, the gap analysis had not said so.773 That may explain why PN539 advised CROs to reassess the caller’s situation, but did not emphasise the need for continual reassessment.774 We discuss below the reasons for the deficiencies in the version of PN539 that was current at the time of the Grenfell Tower fire. 764 Annex B to Lakanal Control Report entitled ‘Comparison between national guidance and LFB policy and training’ {HOM00001125/11}. 765 Annex B to Lakanal Control Report entitled ‘Comparison between national guidance and LFB policy and training’ {HOM00001125/11}. 766 PN539 dated 14 November 2007 {LFB00028382/20-21}. 767 Smith {Day202/119:13-20}. 768 PN539 dated November 2007 {LFB00028382/21}. 769 Phase 1 Report Volume IV, paragraph 29.45.f; Phase 1 Report Volume IV, paragraph 29.54.c. 770 Phase 1 Report Volume IV, paragraph 29.54.c. 771 Annex B to Lakanal Control Report entitled ‘Comparison between national guidance and LFB policy and training’ {HOM00001125/14}. 772 PN539 dated 14 November 2007 {LFB00028382/20-21}. 773 Hayward {Day199/182:2-11}. SOM Smith could also not explain why: Smith {Day202/135:16-22}. 774 PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737}; Phase 1 Report Volume IV, paragraph 29.45.e.

Part 8 | Chapter 78: The control room 111 The Lakanal Control Report 78.45 The LFB also undertook a detailed internal review of the part that the control room had played in the LFB’s response to the fire at Lakanal House.775 The outcome was contained in a report entitled Fire at Lakanal, Havil Street, SE5 on 3 July 2009 – Role and Actions of the LFB Control published in November 2012 (the Lakanal Control Report).776 It was informed by the gap analysis, completed in April 2010, which had identified differences between national guidance and LFB policy and training on handling fire survival guidance calls.777 It set out the policy framework relating to the control room, the arrangements for training of CROs, and the working practices of the control room.778 It examined the Lakanal House fire from the perspective of the control room and identified numerous lessons.779 The report included nine recommendations and points for further action.780 78.46 Of particular interest to us is the fact that the report suggested improvements to national and LFB policy on the training of CROs in handling fire survival guidance calls and managing the performance of control room staff.781 The report identified some recommendations that had already been completed, with some subject to a continuing process of review and implementation.782 The Lakanal Control Report was submitted to the coroner and on the basis of its contents she decided not to make any recommendations about handling fire survival guidance calls or training for CROs.783 In her rule 43 letter she noted that the LFB had already undertaken extensive work to learn from its experience at Lakanal House.784 The striking similarities between the failings of the control room in handling fire survival guidance calls during the Lakanal House fire and those which were later seen in its response to the Grenfell Tower fire led us to examine whether the assurances given to the coroner about policy and training relating to handling fire survival guidance calls had been properly implemented and met their objective.785 The short answer is that they had not and did not. We shall need to return to the Lakanal Control Report more than once in this chapter. Review of PN539 78.47 The LFB’s policy on emergency call management is contained in Policy No. 539. Pre-inquest action 10 was to review PN539 to ensure that it complied with national guidance.786 That was a response to the identification in the gap analysis that PN539 did not reflect current guidance, particularly the appendix on fire survival guidance calls.787 775 Lakanal Control Report {HOM00001124/4} paragraph 1. 776 Lakanal Control Report {HOM00001124/4}. 777 Lakanal Control Report {HOM00001124/4} paragraph 3. 778 Lakanal Control Report {HOM00001124/4} paragraph 1. 779 Phase 1 Report Volume I, paragraphs 8.5-8.8. 780 Lakanal Control Report {HOM00001124/51-55} Chapter G. 781 Lakanal Control Report {HOM00001124/51-53}, paragraphs 303 to 309, Recommendations 1, 2, 3, 4, 5. 782 Lakanal Control Report {HOM00001124/51-53}, paragraphs 303 to 309, Recommendations 1, 2, 3, 4, 5. 783 Hayward {Day199/147:13} – {Day199/148:4}; Rule 43 Letter to Mr Ron Dobson, London Fire Commissioner dated 28 March 2013 {LFB00032158}. 784 Rule 43 Letter to Ron Dobson, London Fire Commissioner dated 28 March 2013 {LFB00032158/1}. 785 Phase 1 Report Volume IV, paragraph 29.5. 786 Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/14}. 787 Annex B to Lakanal Control Report entitled ‘Comparison between national guidance and LFB policy and training’ {HOM00001125/8}; {HOM00001125/11-12}; {HOM00001125/16}; {HOM00001125/20}.

The Grenfell Tower Inquiry: Phase 2 Report 112 78.48 Responsibility for carrying out the action was assigned to AC Brown,788 who had overall responsibility for PN539 as Head of Service Delivery & Mobilising.789 However, he was not involved in reviewing and revising PN539, which he had delegated to POM Hayward.790 POM Hayward, in turn, said that SOM Lindsay Turner and the Operational Support Team had carried out the task,791 although in fact both he and SOM Smith were involved in and oversaw the work.792 78.49 The initial review and revision of PN539 was completed by 3 September 2010,793 as POM Hayward and SOM Smith reported to the Lakanal House Board on 15 September 2010.794 However, they did not present the revised version of PN539 to the board,795 which never formally approved it.796 Nor did AC Brown,797 who told us that it was not normal practice for managers in his position to read through a policy and approve the changes.798 As a result, the revisions made to PN539 after the Lakanal House fire were not subjected to any form of approval process and were not examined by the senior manager responsible for them.799 78.50 PN539 was amended nine more times before the Grenfell Tower fire, most significantly Appendix 3, which covered fire survival guidance calls. It was amended on 3 February 2011 and 28 March 2014.800 The version of PN539 that was in force at the time of the fire had last been amended on 6 April 2017.801 The Phase 1 report found that the policy was significantly defective in many respects. In particular, it failed to state clearly that the four principles of “escape, assess, protect and rescue” required continual reassessment of the caller’s situation,802 it did not contain a warning that it is not always safe to assume that the fire and rescue service is on its way to rescue the caller,803 it did not make it clear that, if a fire survival guidance call required a CRO to remain on the line, the number of simultaneous fire survival guidance calls could never exceed the number of CROs available,804 it contained no advice or guidance to assist CROs and senior managers when 788 Action Plan appended to the minutes of the meeting of the Lakanal House Board on 15 September 2010 {LFB00084031/8}. The action was assigned to ‘AC/SD’, which meant “AC Service Delivery”, who was AC Brown at the time. 789 In both the version of PN539 dated 14 November 2007 that was current at the time of the Lakanal House fire {LFB00028382/1} and the version reviewed as current on 3 September 2010 {LFB00004735}, the ‘owner’ was designated as ‘Head of Service Delivery & Mobilising’. 790 Brown {Day206/91:2-6}. Hayward {Day199/193:10-13}; Brown {LFB00084020/6} page 6, paragraph 10; Brown {LFB00084020/11} page 11, paragraph 23. 791 Hayward {LFB00055191/7} page 7, paragraph 20. 792 Smith {LFB00121219/14} page 14, paragraph 34; Hayward {LFB00086213/5} page 5, paragraph 24; Emails between and Amelia Reynolds, Brigade Control Training Team Leader, POM Hayward, SOM Turner copying in SOM Smith between 13-21 July 2010 {LFB00057934}; Emails between SOM Smith and Amelia Reynolds between 2-3 September 2010 {LFB00109145}; Hayward {Day199/189:5}-{Day199/190:5}. 793 PN539 reviewed as current on 3 September 2010 {LFB00004735}. 794 Minutes of the Lakanal House Board meeting on 15 September 2010 {LFB00055192/2} item 5.15(1). 795 Smith did not recall the reviewed version of PN539 being presented to the Lakanal House Board: Smith {Day202/113:22}-{Day202/114:17}. There is no record of the updated policy being presented for approval at the meetings of the Lakanal House Board on 15 September 2010 {LFB00055192/2-3}, 8 November 2010 {LFB00084032/1} or 22 December 2010 {LFB00084033/2}, when the action was marked as completed. It ceased to be an agenda item thereafter. 796 SOM Smith did not think anyone had approved it: Smith {Day202/112:21-23}. 797 Brown {Day206/91:5-6}. 798 Brown {Day206/91:15-24}. SOM Smith said that the owner of the policy had ultimate responsibility for approving it, but in practice she did not think that had happened: Smith {Day202/111:22}-{Day202/112:1}. 799 SOM Smith did not think that anyone had approved it: Smith {Day202/112:21-23}. She said that she was not aware of anyone whose authority was required to make changes to PN539: Smith {Day202/110:23}-{Day202/111:6}. 800 As shown by the audit trail to PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737/22}. 801 PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737}. 802 Phase 1 Report Volume IV, paragraph 29.45.e. 803 Phase 1 Report Volume IV, paragraph 29.45.f.8. 804 Phase 1 Report Volume IV, paragraph 29.45.b.7.

Part 8 | Chapter 78: The control room 113 handling a large number of fire survival guidance calls concurrently805 and it did not require CROs to find out whether the caller was, or had with them, a person who, for whatever reason, would require help to evacuate.806 We explore the reasons for those defects below. 78.51 The exclusion of FSC 54-04 from the gap analysis created a risk that the guidance it contained on the need continually to reassess the caller’s situation would not be reflected in PN539. Curiously, however, the version of PN539 dated 3 September 2010, which was the result of the first revision following the Lakanal House fire, did add advice to CROs to reassess continually the caller’s situation,807 but it was replaced in the version dated 3 February 2011 with advice to reassess the caller’s situation, providing some example questions.808 The clear and unambiguous emphasis on continual reassessment had thus been removed and the policy remained in that form until the Grenfell Tower fire.809 78.52 It is evident from the version of PN539 that SOM Smith sent to POM Hayward on 3 February 2011 with tracked changes that she was the person who removed the requirement for continual reassessment.810 When asked, she could not account for that,811 but she suggested that the amendments amounted to the same thing and that the training made that clear.812 She told us that the need for continual reassessment, although not stated explicitly, was implied in the revised version813 and that training emphasised the need for continual reassessment.814 AC Brown said essentially the same.815 However, those explanations ignored, or at least underestimated, the vital importance of ensuring that PN539 stated clearly and comprehensively the objectives, principles and approach for handling fire survival guidance calls. 78.53 As set out above, the Lakanal Control Report, dated November 2012, which post-dated the removal by SOM Smith of the passage emphasising the need for continual re-assessment, found that the guidance in FSC 54-04 was not included in LFB training and that there might be a tendency among CROs to limit reassessment due to a desire to keep the caller safe.816 It recommended that PN539 should be revised to ensure compliance with national guidance and to reflect the lessons identified in the report.817 However, it also recorded that PN539 had already been revised in February 2011,818 implying that no further action was required. There is nothing to suggest that the recommendation prompted any further consideration of PN539 to ensure that it reflected in full the experience of the Lakanal House fire. AC Brown confirmed that he had not asked for any further work to be done on it.819 805 Phase 1 Report Volume IV, paragraph 29.45.g. 806 Phase 1 Report Volume IV, paragraph 29.45.h. 807 PN539 dated 3 September 2010 {LFB00004735/16}; PN539 dated November 2007 {LFB00028382/20}. 808 PN539 dated 3 February 2011 {LFB00028601/16-17}. 809 PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737/16-17}. 810 Email from SOM Smith to POM Hayward on 3 February 2011 {LFB00109464}; Version of PN539 with tracked changes made by SOM Smith attached to her email to POM Hayward on 3 February 2011 {LFB00109465/17}. 811 Smith {Day202/137:5-8}. 812 Smith {Day202/137:8-12}. 813 Smith {Day202/137:12-15}. 814 Smith {Day202/137:8-17}. 815 Brown {Day206/99:3-22}. 816 Lakanal Control Report dated November 2012 {HOM00001124/50} paragraph 295. 817 Lakanal Control Report dated November 2012 {HOM00001124/52} paragraph 304. 818 Lakanal Control Report dated November 2012 {HOM00001124/52} paragraph 304. 819 Brown {Day206/102:4}-{Day206/103-4}.

The Grenfell Tower Inquiry: Phase 2 Report 114 78.54 In his review dated 4 January 2013, GM Lindridge found that PN539 did not incorporate the guidance in FSC 54-04,820 a conclusion which he said had been reported to AC Brown as AC Operations, Prevention and Response. GM Lindridge understood that his observations would be considered in a forthcoming review of policy on handling fire survival guidance calls,821 but no such review was undertaken, as AC Brown confirmed.822 AC Brown said that he had asked AC Chandler and then POM Hayward, in AC Chandler’s absence, to review the gap analysis in relation to FSC 54-04 and to apply any resulting recommendations,823 but that was not done and no good explanation was given for the omission. 78.55 Those were yet more missed opportunities to ensure that PN539 contained the important requirement for continual reassessment. 78.56 The version of PN539 dated 3 September 2010, which was the result of the initial revision following the Lakanal House fire, actively encouraged CROs to offer callers reassurance,824 suggesting the use of phrases such as “the firefighters will be with you very soon” and “the firefighters know where you are”.825 It also referred the CROs to the RIFs to assist them in providing reassurance to the caller that help was on its way.826 However, the version dated 3 February 2011 largely removed that guidance, apart from the reference to the RIFs.827 It simply included advice to reassure the caller.828 It would seem that those carrying out the review of PN539 in 2011 had in mind, to an extent, the guidance in FSC 10-93 and ‘Keeping People Safe’. SOM Smith confirmed as much when she said that the emphasis on reassurance had been removed because of the warning in FSC 10-93 and the investigation into the Lakanal House fire.829 78.57 In those circumstances, it is hard to understand why those who updated PN539 in February 2011, a group which included SOM Smith and POM Hayward, did not include an explicit warning to CROs, as set out in the national guidance, against providing reassurance to callers which might promote a false sense of security.830 78.58 SOM Smith said that training had included clearer instructions on the warning and there might also have been advice in the RIFs.831 That was certainly not so in the case of the RIFs, as the chairman found in the Phase 1 report. In any event, it ignored or, at least, underestimated the important role of the policy and placed too much reliance on training.832 78.59 The Lakanal Control Report dated November 2012 noted that CROs handling fire survival guidance calls during the Lakanal House fire expected fire crews to arrive quickly (as they usually did) and advised callers to remain in their flats and wait to be rescued rather than helping them to assess whether escape was possible.833 The implication was that an assumption that firefighters would rescue a caller promptly, or at all, was not always 820 GM Lindridge’s review dated 4 January 2013 {LFB00085854/6}. 821 GM Lindridge’s review dated 4 January 2013 {LFB00085854/6}. 822 Brown {Day206/95:6-18}. 823 Brown {Day206/94:22}-{Day206/95:5}. 824 PN539 dated 3 September 2010 {LFB00004735/16}. 825 PN539 dated 3 September 2010 {LFB00004735/16}. 826 PN539 dated 3 September 2010 {LFB00004735/16}. 827 PN539 dated 3 February 2011 {LFB00028601/16}. 828 PN539 dated 3 February 2011 {LFB00028601/16}. 829 Smith {Day202/124:12-22}. 830 Email from SOM Smith to POM Hayward on 3 February 2011 {LFB00109464}; Version of PN539 with tracked changes made by SOM Smith attached to her email to POM Hayward on 3 February 2011 {LFB00109465}; Emails between SOM Smith and POM Hayward on 3 February 2011 {LFB00058030}. 831 Smith {Day202/125:13}-{Day202/126:3}. 832 Phase 1 Report Volume IV, paragraph 29.49.c. 833 Lakanal Control Report dated November 2012 {HOM00001124/50} paragraph 293.

Part 8 | Chapter 78: The control room 115 well founded. That echoed the warning in FSC 10-93 and ‘Keeping People Safe’ against providing reassurance to a caller which might produce a false sense of security.834 However, despite the recommendation in the Lakanal Control Report, that aspect of PN539 was not reconsidered and the policy was not amended to include an appropriate warning. 78.60 Further, in his review dated 4 January 2013, GM Lindridge found that PN539 had been reviewed and did not contradict FSC 10-93, but that it might be said not to contain all the information in the national guidance.835 In a comment on the draft DC Dexter asked whether PN539 complied with national guidance, to which AC Brown replied that it did and that the action had been completed, both in word and spirit,836 but that was wrong because PN539 did not include a warning against providing false reassurance.837 It appears that, as a result, no action was taken to investigate and deal with this particular aspect of GM Lindridge’s review. 78.61 The failure to include FSC 54-04 in the gap analysis created a real risk that the guidance it contained about assessing any impairments which might impede a caller’s ability to escape would not be reflected in LFB policy and training. In fact, the version of PN539 dated 14 November 2007 did include a requirement for CROs to assess whether callers had any relevant disabilities,838 but for no obvious reason that requirement was removed from later versions and was not reinstated before the Grenfell Tower fire.839 SOM Smith could not explain why.840 She told us that she had not been involved in the revision of PN539 in 2010,841 but email exchanges at the time reveal that she, together with POM Hayward, SOM Turner and Amelia Reynolds, had all contributed to it.842 SOM Smith said that she was not aware of any positive decision to omit the advice on assessing disability843 and could not say whether it had been omitted accidentally.844 She said that she had made sure that the questions on disability were included in the training and the RIFs,845 but that was not the case as far as the RIFs were concerned. 78.62 The RIF for Operators dated 12 March 2007 had contained a prompt to ask whether a caller had a disability and whether their mobility was impaired, but that prompt was removed from the revised version approved by SOM Smith on 23 February 2011.846 However, unlike PN539, a later version of the RIF for Operators approved by SOM Bagnelle on 3 April 2014 reinstated a prompt that did effectively address the requirement to assess disability, albeit with rather less emphasis than previously.847 834 FSC 10/93 {LFB00003617/1} paragraph 2; ‘Keeping People Safe’ training {LFB00118948/6}. 835 GM Lindridge’s review dated 4 January 2013 {LFB00085854/13}. 836 GM Lindridge’s review dated 4 January 2013 {LFB00085854/13}. 837 PN539 dated 3 February 2011 {LFB00028601/16}; FSC 10/93 {LFB00003617/1} paragraph 2; ‘Keeping People Safe’ training {LFB00118948/6}. 838 PN539 dated 14 November 2007 {LFB00118944/20}. 839 PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737/16-17}. 840 Smith {Day203/13:24}-{Day202/14:4}. 841 Smith {Day203/14:3-5}. 842 Emails between and Amelia Reynolds, Brigade Control Training Team Leader, POM Hayward, SOM Turner copying in SOM Smith between 13-21 July 2010 {LFB00057934}; Emails between SOM Smith and Amelia Reynolds on 2-3 September 2010 {LFB00109145}; Hayward {Day199/189:5}-{Day199/190:5}. 843 Smith {Day203/14:13-16}. 844 Smith {Day203/15:3-7}. 845 Smith {Day203/14:5-9}; Smith {Day203/14:20-22}. 846 RIF for Operators approved on 12 March 2007 {LFB00121224/2}; RIF for Operators approved on 23 February 2011 {LFB00121240}. 847 RIF for Operators approved on 3 April 2014 {LFB00122837/2} paragraph 1.5. That was included following a report from a command unit training workshop with the control room: Bagnelle {LFB00122821/5} page 5, paragraph 15 and report {LFB00122833/2}.

The Grenfell Tower Inquiry: Phase 2 Report 116 78.63 SOM Smith’s evidence was that she had thought that the reason why the requirement to assess disability had not been reinstated in PN539 in February 2011 and thereafter was because it had been covered by training and in the RIFs and it was felt that that was sufficient.848 However, the RIFs were not amended until April 2014 and we do not consider that training could adequately compensate for its omission from the policy, since that leaves too much to the discretion of the individual trainer. SOM Smith told us that it was not unusual for a CRO to assess the caller’s age and ability to leave the building,849 She effectively accepted that much depended on what information the caller provided.850 If so, that was not consistent with national guidance, because FSC 54-04 clearly required CROs to carry out a positive assessment of a caller’s age, gender, ethnicity and mental or physical disability.851 SOM Smith accepted that the LFB was not following the guidance in FSC 54-04;852 she also accepted that, if it were left to the caller to volunteer information, there was a risk that it might not be given, which is exactly what happened in some cases during the Grenfell Tower fire.853 78.64 In his review dated 4 January 2013 GM Lindridge found that PN539 did not include the guidance called for by FSC 54-04.854 That omission might, therefore, have been made good if some action had been taken in response to his finding. However, it was not. 78.65 A further opportunity to remedy the omission came in the form of GRA 3.2, published in February 2014,855 which introduced new requirements for handling fire survival guidance calls.856 AC Brown was involved in the consultation process which preceded the document.857 However, it is reasonably clear that he did not discuss it with anyone else responsible for the operation of the control room. 78.66 GRA 3.2 introduced a requirement for fire and rescue authorities to have effective arrangements in place for handling fire survival guidance calls from those who believe they are unable to leave a building due to disability, poor mobility, illness or the effects of fire. However, AC Brown admitted that he had taken no specific steps following the publication of GRA 3.2 to ensure that the LFB had such arrangements in place because he was satisfied that CROs would obtain that information and that adequate arrangements were therefore already in place.858 He had not considered asking anyone responsible for the control room to review PN539 to ensure that it was consistent with GRA 3.2.859 Unsurprisingly, in the light of their ignorance of GRA 3.2, POM Hayward and SOM Smith did not carry out any such review themselves, nor did POM Hayward ask anyone else to do so.860 78.67 The direct result of this cluster of failings was that the LFB did not introduce, or reintroduce, into PN539 a provision for CROs to enquire positively whether callers had disabilities or other impairments of a kind that might affect their ability to leave the building. 848 Smith {Day203/16:14-22}. 849 Smith {Day203/16:22-25}. 850 Smith {Day203/17:1-13}. 851 FSC 54/04 {LFB00055201/17}. 852 Smith {Day203/17:14}-{Day203/18:3}. 853 Smith {Day203/17:14}-{Day203/18:3}; Phase 1 Report Volume IV, paragraph 29.76. 854 GM Lindridge’s review dated 4 January 2013 {LFB00085854/6}. 855 GRA 3.2 ‘Fighting fires – In high rise buildings’ dated February 2014 {LFB00001255}. 856 GRA 3.2 {LFB00001255/20}; GRA 3.2 {LFB00001255/29-31}; Cowup {Day195/64:4-8}; Cowup {Day195/99:1-5} 857 Email from Michele Kunneke to AC Brown and others on 10 May 2012 {LFB00093616}. 858 Brown {Day206/153:22}-{Day206/154:4}. 859 Brown {Day206/154:24}-{Day206/155:10}. 860 Smith {Day203/20:9-16}; Hayward {Day200/54:2-17}.

Part 8 | Chapter 78: The control room 117 78.68 A further, and perhaps final, opportunity to remedy that particular deficiency was by way of an equality impact assessment, which ought to have been undertaken in order to consider the likely effect of the policy on different groups of people. However, it is evident from the audit trail in the version of PN539 which was current at the time of the Grenfell Tower fire that no one carried out such an assessment after 17 September 2008.861 78.69 AC Brown accepted that it had been his responsibility to ensure that an equality impact assessment was carried out,862 but he said that such an assessment was carried out only when changes were made that required one.863 He did not think that they had decided it was necessary to carry out an equality impact assessment when PN539 had subsequently been reviewed after 2008.864 However, he acknowledged that in hindsight one should probably have been carried out at some point.865 78.70 In our view, the warning signs were there at the time for all to see. AC Brown simply did not heed them. It is surprising that he took no steps to alert the LFB’s senior management to the existence, let alone the contents, of GRA 3.2 or to recognise the need for an equality impact assessment. We regard those as serious failings on his part. The Reference Information Files 78.71 Pre-inquest action 9 was to revise the Reference Information Files (RIFs) used by CROs when giving fire survival guidance in order to ensure that they complied with national guidance.866 There were two RIFs: a RIF for Operators, which was a prompt sheet or script to assist with handling fire survival guidance calls, and a RIF for Supervisors, which described their role in supporting CROs during fire survival guidance calls and passing information to the incident ground.867 78.72 SOM Turner, SOM Smith and the Operational Support Team carried out the revisions to the RIFs in discussion with POM Hayward.868 SOM Turner undertook the initial review;869 SOM Smith then proposed further revisions.870 They were completed by January 2011 and circulated to control room staff on 23 February 2011.871 78.73 SOM Smith said that the primary reason for revising the RIFs following the Lakanal House fire was to prepare for the next large-scale incident.872 Senior management wanted to ensure that the RIFs contained clear advice in relation to fires in high-rise residential buildings.873 The RIF for Operators was, therefore, amended so that there 861 PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737/22}. 862 Brown {Day206/109:20}-{Day206/110:2}. 863 Brown {Day206/110:13-16}. 864 Brown {Day206/110:3-25}. 865 Brown {Day206/110:19-21}. 866 Lakanal Assurance Review dated August 2018 {LFB00004801/13}. 867 Lakanal Assurance Review dated August 2018 {LFB00004801/14}. 868 Hayward {LFB00055191/7} page 7, paragraph 20; Smith {LFB00121219/11} page 11, paragraph 26; Smith {Day203/26:11}-{Day203/28:7}. 869 Smith {Day203/26:11-24}. 870 Smith {LFB00121219/11} page 11, paragraph 26; Smith {Day203/26:11-24}. 871 Smith {LFB00121219/12} page 12, paragraph 27; Email from SOM Smith to all Brigade Control Staff on 23 February 2011 {LFB00121237}; RIF for Operators approved on 23 February 2011 {LFB00121240}; RIF for Supervisors approved on 23 February 2011 {LFB00111192}. 872 Smith {LFB00121219/12} page 12, paragraph 28. 873 Smith {LFB00121219/12} page 12, paragraph 28.

The Grenfell Tower Inquiry: Phase 2 Report 118 were sections on different types of buildings, with a separate section on purpose-built blocks of flats.874 SOM Smith said that she had also used the findings of the gap analysis to amend the RIFs.875 78.74 SOM Smith approved the revisions to the RIFs.876 Although she discussed some of them with POM Hayward, it is reasonably clear that he did not review or approve the revisions, even though responsibility for final approval lay with him.877 Further, although POM Hayward and SOM Smith informed the Lakanal House Board on 15 September 2010 and 4 February 2011 of the fact that the RIFs had been revised, they did not describe the substance of the revisions.878 As a result, the Lakanal House Board did not formally review and approve the changes. 78.75 On 27 June 2011, AOM Bonnett sent an email to SOM Smith, SOM Turner, AOM Sharp and AOM O’Shea in which he criticised the training relating to fire survival guidance as being inconsistent with the revised RIF for Operators.879 He concluded that, because the RIF had been specifically designed to assist CROs during fire survival guidance calls, it should be central to, and consistent with, training.880 He also suggested that training exercises should be carried out to test the suitability of both the RIF for Operators and the RIF for Supervisors.881 78.76 SOM Smith forwarded the email to POM Hayward, expressing her agreement with AOM Bonnett’s findings.882 Despite her agreement, however, no training was provided on the RIFs, nor were they subject to a test exercise.883 Control room staff were simply notified that the RIFs had been revised and told to familiarise themselves with their contents.884 SOM Smith said that was because staff could look at the RIFs at any time they wished and because, contrary to AOM Bonnett’s opinion, they were consistent with the fire survival guidance training.885 78.77 We do not understand how senior management could have satisfied themselves that CROs and supervisors understood the nature and extent of the changes to the RIFs that had been brought about as a consequence of the Lakanal House fire without providing them with any formal training. As it was, the training records we have seen show that no staff reviewed the RIFs in 2011 and that only two did so in 2012.886 874 Smith {LFB00121219/12} page 12, paragraph 28; RIF for Operators approved on 23 February 2011 {LFB00121240/10-19}. 875 Smith {Day202/105:22-25}. 876 RIF for Operators approved on 23 February 2011 {LFB00121240/24}; RIF for Supervisors approved on 23 February 2011 {LFB00111192/5}; Smith {Day203/26:25}-{Day203/27:4}. 877 Smith {Day203/27:5}-{Day203/28:17}. 878 Minutes of Lakanal House Board meeting on 15 September 2010 {LFB00055192/2} item 5.6; Minutes of Lakanal House Board meeting on 4 February 2011 {LFB00055215/2} item 5.5; Smith {Day202/28:14-20}. 879 Email from AOM Bonnett to SOM Smith, SOM Turner, AOM Sharp and AOM O’Shea on 27 June 2011{LFB00028381/1-2}. 880 Email from AOM Bonnett to SOM Smith, SOM Turner, AOM Sharp and AOM O’Shea on 27 June 2011{LFB00028381/3}. 881 Email from AOM Bonnett to SOM Smith, SOM Turner, AOM Sharp and AOM O’Shea on 27 June 2011{LFB00028381/3-4}. 882 Email from SOM Smith to POM Hayward on 27 June 2011{LFB00028381/1}. 883 Smith {Day203/29:16}-{Day203/30:24}; Smith {Day203/34:3}-{Day203/35:8}; Smith {LFB00121219/13} page 13, paragraphs 30-31; Smith {MET00080606/20}. 884 Email from SOM Smith to all Brigade Control Staff on 23 February 2011 {LFB00121237/1}. 885 Smith {Day203/30:25}-{Day203/32:5}. 886 Brigade Control training records 2011-2018 {LFB00041763} columns Y, Z and AA.

Part 8 | Chapter 78: The control room 119 78.78 The RIFs were revised again in early 2013 following discussions with GM Lindridge.887 SOM Vic Bagnelle instructed AOM Bonnett and AOM Pope of the Operational Support Team to carry out the revisions, which he then reviewed and approved on 18 February 2013.888 The primary aim of those revisions was to reduce the length of the RIFs to make them more manageable.889 As a result, the separate sections on different building types, including purpose-built blocks of flats, were removed.890 78.79 Although SOM Bagnelle reported to POM Hayward and AC Brown on the progress of their work, we have not seen any evidence that POM Hayward or the Lakanal House Board reviewed or approved the revised versions.891 78.80 AOM Bonnett circulated the revised RIFs to control room staff on 18 February 2013.892 As before, they were simply instructed to familiarise themselves with the contents.893 The training records indicate, however, that most staff did not review the RIFs in 2013 and there are no records of any staff having done so thereafter.894 78.81 SOM Sharp made further amendments to the RIFs in 2014, which were approved by SOM Victor Bagnelle on 3 April 2014.895 That then remained the version of the RIF for Operators in force at the time of the Grenfell Tower fire.896 The RIF for Supervisors, however, was revised once more before the Grenfell Tower fire in April 2016, although the revisions do not appear to have been formally approved.897 The version in force at the time of the Grenfell Tower fire had, therefore, been approved on 3 April 2014 and subsequently amended on 2 April 2016.898 78.82 In his Phase 1 report the chairman found that the RIF for Operators was unsatisfactory in a number of respects.899 It contained no clear guidance on what was meant by “affected” by heat, smoke or fire or how it was to be assessed, it contained no clear guidance on how to assess the safety of escape routes if the caller was, or claimed to be, affected by heat, smoke or fire, or simply felt unsafe, it did not tell CROs that assurances that firefighters would rescue callers should be based on information from the incident ground rather than expectations or assumptions, it contained no guidance on what information CROs should gather in order to assist the control room supervisor or incident commander to decide whether a partial or total evacuation of the building should be carried out and it contained no guidance on what advice CROs should give to a caller once a decision had been made to carry out a full or partial evacuation of the building. He also found that the 887 Bagnelle {LFB00122821/5} page 5, paragraphs 14-15; Email from AOM Bonnett to SOM Bagnelle on 10 January 2013 {LFB00122822/2-3}. 888 Bagnelle {LFB00122821/5} page 5, paragraph 15; RIF for Operators approved on 18 February 2013 {LFB00122835}; RIF for Supervisors approved on 18 February 2013 {LFB00122836}. 889 GM Lindridge’s Review dated 4 January 2013 {LFB00085854/5}; Email from GM Lindridge to SOM Bagnelle, POM Hayward, AC Brown and others on 9 January 2013 {LFB00118958/1}; Email from SOM Bagnelle to OST on 11 January 2013 {LFB00122822/2}; Email from AOM Bonnett to all Brigade Control staff on 18 February 2013 {LFB00055234/1}; Bagnelle {LFB00122821/6} page 6, paragraph 17. 890 Smith {LFB00121219/12} page 12, paragraph 28; RIF for Operators approved on 18 February 2013 {LFB00122835}; RIF for Supervisors approved on 18 February 2013 {LFB00122836}. 891 Bagnelle {LFB00122821/5} page 5, paragraph 15. 892 Email from AOM Bonnett to all Brigade Control staff on 18 February 2013 {LFB00055234/1}; RIF for Operators approved on 18 February 2013 {LFB00122835}; RIF for Supervisors approved on 18 February 2013 {LFB00122836}. 893 Email from AOM Bonnett to all Brigade Control staff on 18 February 2013 {LFB00055234/1}. 894 Brigade Control training records 2011-2018 {LFB00041763}; Hayward {LFB00055191/27} paragraph 77. 895 Bagnelle {LFB00122821/5-6} pages 5-6, paragraph 14-16; RIF for Operators approved on 3 April 2014 {LFB00003542}. 896 RIF for Operators approved on 3 April 2014 {LFB00003542}. 897 Bagnelle {LFB00122821/5} page 5, paragraph 14; RIF for Supervisors approved on 3 April 2014 and updated on 2 April 2016 {LFB00003541}. 898 RIF for Supervisors approved on 3 April 2014 and updated on 2 April 2016 {LFB00003541}. 899 Phase 1 Report Volume IV, paragraph 29.49.

The Grenfell Tower Inquiry: Phase 2 Report 120 RIF for Supervisors contained similar defects. In particular, it contained no guidance on how supervisors should gather information from CROs to enable them to form an overall assessment of the situation in order to assist incident commanders to decide whether to revoke “stay put” advice.900 We consider the reasons for those defects below. 78.83 The section of the RIF for Operators dated 23 February 2011 that dealt with giving fire survival guidance to a person trapped in a purpose-built flat, advised the CRO to ask the caller whether the flat was being “affected” by heat or smoke. If the caller said it was not, the advice was to say that it would usually be safer to stay in the flat, but that if the situation changed, or the caller felt unsafe, the better course was to get out and stay out.901 78.84 SOM Smith had been responsible for drafting that advice.902 She said that she had taken the word “affected” from FSC 10-93, although that word is not used in the circular.903 She understood it to mean that heat or smoke was entering the flat and directly affecting the caller in some way, such as interfering with their breathing;904 in effect, that compartmentation had been breached.905 When preparing the RIFs, SOM Smith had asked John Bradbury, DAC Fire Safety Regulation Delivery, and AC James Knighton, AC Operational Policy, what information it would be helpful to obtain from a caller to enable a CRO to determine whether the person was affected by fire, heat or smoke,906 but they had not given her any help.907 However, despite her own understanding and her difficulty in obtaining assistance, she did not consider including in the RIF an explanation of what “affected” meant or further prompts to guide a CRO when giving advice.908 78.85 The RIF for Operators also suggested that, if a caller was, or felt themselves to be, “affected” by fire, heat or smoke, CROs should ask about possible escape routes.909 It then set out questions aimed at finding out whether an alternative escape route was available.910 However, the RIF did not suggest how to assess the safety of any potential escape route. SOM Smith said that when she drafted the RIF she must, at some point, have considered whether such guidance was needed, given the questions on exploring alternative escape routes that she had included.911 If so, it must follow that she decided not to include such guidance. 78.86 The revised versions of the RIFs for Operators dated 18 February 2013 and 3 April 2014 contained the same defects.912 The revision in 2013 concentrated principally on reducing its length and making it easier to use rather than on making substantive changes.913 It is not surprising, therefore, that SOM Bagnelle and SOM Sharp do not appear to have considered providing guidance on the meaning of being “affected” by fire, heat or smoke or on assessing the safety of an escape route. However, SOM Bagnelle said that the amendments 900 Phase 1 Report Volume IV, paragraph 29.50. 901 RIF for Operators approved on 23 February 2011 {LFB00121240/14}. 902 Smith {Day203/70:17-20}. 903 Smith {Day203/70:21}-{Day203/71:1}. 904 Smith {Day203/71:2-14}. 905 Smith {Day203/71:2-14}. 906 Smith {LFB00121219/15} page 15, paragraph 36. 907 Smith {Day203/69:24}-{Day203/70:6}. 908 Smith {Day203/70:3-10}; Smith {Day203/71:15}-{Day203/72:8}. 909 RIF for Operators approved on 23 February 2011 {LFB00121240/14-15}. 910 RIF for Operators approved on 23 February 2011 {LFB00121240/15}. 911 Smith {Day203/73:1-3}. 912 RIF for Operators approved on 18 February 2013 {LFB00122835}; RIF for Operators approved on 3 April 2014 {LFB00003542}. 913 GM Lindridge’s Review dated 4 January 2013 {LFB00085854/5}; Email from GM Lindridge to SOM Bagnelle, POM Hayward, AC Brown and others on 9 January 2013 {LFB00118958/1}; Email from SOM Bagnelle to OST on 11 January 2013 {LFB00122822/2}; Email from AOM Bonnett to all Brigade Control staff on 18 February 2013 {LFB00055234/1}; Bagnelle {LFB00122821/6} page 6, paragraph 17.

Part 8 | Chapter 78: The control room 121 made in April 2014 had included additional questions for CROs to use following comments made by command unit staff during training workshops914 to the effect that finding out how far the caller’s flat was from the nearest stairwell would help a CRO decide whether the caller could reach it.915 It was suggested that a conversation of that kind might cause the caller to consider the layout of the property and realise that escape was possible916 and that a prompt might be included in the RIF to that effect.917 78.87 Despite that, when they revised the RIF for Operators in April 2014 neither SOM Sharp nor SOM Bagnelle included a prompt of that kind.918 Moreover, it is reasonably clear that the comments from the workshops did not cause either of them to consider whether guidance on assessing the safety of escape routes, beyond the distance to the stairwell, should be included. 78.88 The failure to include such guidance was significant because, as the chairman found in the Phase 1 report, CROs failed properly to assess escape routes on the night of the Grenfell Tower fire and advised callers to stay put, even though they may not in fact have been trapped, with the result that some callers may have stayed in their flats when they could have escaped to safety.919 78.89 The gap analysis drew attention to the warnings in both FSC 10-93 and ‘Keeping People Safe’ about forming an emotional bond with a caller and providing false reassurance.920 It identified that the training of CROs encouraged the creation of a strong attachment between the caller and the CRO and that it recommended using reassuring phrases that might promote a false sense of security.921 Accordingly, the gap analysis recommended that training be changed in those respects.922 78.90 SOM Smith used the findings of the gap analysis to revise the RIFs,923 but despite that, the revised RIF for Operators she approved on 23 February 2011, like PN539, actively encouraged CROs to reassure the caller.924 It suggested the use of phrases such as “the firefighters are on the way” and “the firefighters know where you are”.925 However, the RIF included no warning to the CROs against providing false reassurance nor did it make it clear that such statements must be made only if based on information received from the incident ground.926 914 Bagnelle {LFB00122821/5} page 5, paragraph 15. 915 Reports from command unit training workshops {LFB00122833/1}. 916 Report from command unit training workshops {LFB00122833/1}. 917 Report from command unit training workshops {LFB00122833/2}. 918 RIF for Operators approved on 3 April 2014 {LFB00003542}. 919 Phase 1 Report Volume IV, paragraph 29.54.c and paragraph 29.60. 920 Gap Analysis {LFB00004750/10-11}. 921 Gap Analysis {LFB00004750/11}. 922 Gap Analysis {LFB00004750/11}. 923 Smith {Day202/105:22-25}. 924 RIF for Operators approved on 23 February 2011 {LFB00121240/17}. 925 RIF for Operators approved on 23 February 2011 {LFB00121240/17}. 926 RIF for Operators approved on 23 February 2011 {LFB00121240/17}.

The Grenfell Tower Inquiry: Phase 2 Report 122 78.91 On 3 January 2011, SOM Smith had emailed AOM Bonnett and AOM Suarez with a draft of the revised RIF for Operators.927 Anticipating the concerns of the Lakanal House Board that it did not appear in national guidance, she had removed the word “bonding”.928 It is evident, therefore, that SOM Smith had the gap analysis and national guidance in mind when she was revising the RIF.929 In those circumstances, it is hard to understand why she did not include the explicit warning against providing a false sense of security or why she felt it was sufficient to remove only the word “bonding” from the RIF and not the associated statements which had been designed to reassure and create a bond with the caller.930 78.92 SOM Smith said she had not included a warning against providing false reassurance because it was guidance on what should be done rather than what should not be done, so it had not occurred to her or the Operational Support Team to include it.931 Even if that were right, however, it presented no bar to including positive guidance in the RIF that a CRO should provide reassurance to callers only if it were based on information received from the incident ground. The suggestion by SOM Smith that it was a matter covered in training932 placed too much reliance on training and ignored, or at least underestimated, the importance of ensuring that the RIFs stated accurately and comprehensively the correct approach to handling fire survival guidance calls in accordance with national guidance. 78.93 The work on revising the RIFs should have included a comparison with the guidance contained in FSC 10-93 and ‘Keeping People Safe’ in order to ensure that they were compatible and that nothing had been omitted. However, that was not done and all the later versions of the RIFs suffered from the same defect.933 Again, that was significant because CROs invariably told callers on the night of the Grenfell Tower fire that firefighters were on their way without having a sound basis for doing so. The tragic result was that some callers remained in their flats despite the fact that escape may have remained possible.934 78.94 SOM Smith and SM Utting were together responsible for drafting PN155 (which later became PN790), the policy on fire survival guidance calls.935 The draft version of PN155 dated 10 February 2011 included a warning that in exceptional circumstances the incident commander might tell the control room to advise callers seeking fire survival guidance to do their best to leave their properties.936 SOM Smith said that she had recommended the inclusion of that paragraph, although she had not been responsible for drafting it.937 The wording suggests that the incident commander was responsible for any decision to revoke “stay put” advice. SOM Smith, however, said that she had it in mind that the 927 Email from SOM Smith to AOM Bennett and AOM Suarez copying in POM Hayward on 3 January 2011 {LFB00033220}. 928 Email from SOM Smith to AOM Bennett and AOM Suarez copying in POM Hayward on 3 January 2011 {LFB00033220/1}. 929 See also Smith {LFB00121219/16} page 16, paragraph 39. 930 Draft RIF for Operators dated 16 November 2010 as edited by SOM Smith {LFB00083530/15}. 931 Smith {Day203/78:10-24}. 932 Smith {Day203/78:22}-{Day203/79:2}. 933 RIF for Operators approved on 18 February 2013 {LFB00122835}; RIF for Supervisors approved on 18 February 2013 {LFB00122836}; RIF for Operators approved on 3 April 2014 {LFB00003542}; RIF for Supervisors approved on 3 April 2014 and updated on 2 April 2016 {LFB00003541}. 934 Phase 1 Report Volume IV, paragraph 29.54.c. 935 See, for example, email from SOM Smith to SM Utting on 23 January 2011 {LFB00028301}; Email from SOM Smith to POM Hayward on 24 January 2011 {LFB00058020}; Utting {LFB00118918/3} page 3, paragraph 8; Smith {Day203/128:20}-{Day203/129:7}. 936 Draft version of PN155 dated 10 February 2011 {LFB00083447/4} paragraph 6.6. 937 Smith {LFB00121219/26} page 26, paragraph 69; Smith {Day203/91:4}-{Day203/92:12}.

Part 8 | Chapter 78: The control room 123 decision would be made jointly by the control room and the incident commander.938 Indeed, in its final form PN790 stated that the decision would be made by agreement between the incident commander and the officer in charge of the control room.939 78.95 SOM Smith does not appear to have given any thought to what might constitute “exceptional circumstances” sufficient to justify the revocation of “stay put” advice.940 Nor did she consider providing guidance, whether to the CROs handling fire survival guidance calls or those supervising them, on what information to look out for or gather in order to help decide whether exceptional circumstances requiring an evacuation existed.941 Nor, it appears, did POM Hayward,942 with the result that no such guidance was included in the RIFs. 78.96 Perhaps more importantly, SOM Smith did not consider including in the RIFs guidance about what a CRO should tell a caller if the decision had been made to revoke the “stay put” advice.943 SOM Smith said that had been because the advice would differ depending on the particular circumstances, so that, in effect, it could not be the subject of generic guidance.944 However, she also said that they did not think that such extreme circumstances were likely to occur.945 POM Hayward said much the same,946 but their position makes little sense, given that the policy specifically envisaged that the “stay put” advice might need to be revoked. It is also regrettable, given what was said about it in GRA 3.2,947 which AC Brown unfortunately failed to pass on to POM Hayward or SOM Smith. 78.97 On 13 April 2011, a draft of PN155 was sent to all Assistant Commissioners, including AC Brown, with a request that they assess its effect on their respective departments.948 AC Brown thought that CROs would need guidance on the implementation of the provision relating to the revocation of “stay put” advice,949 in the form of policy, RIFs and training, but he did not consider what form that guidance should take.950 He assumed that those working on the policy and the RIFs would do that, but it is clear, not least from the absence of any guidance, that he did not take steps to ensure that it was done.951 78.98 The failure to include guidance of that kind in the RIFs was significant because, as the chairman found in the Phase 1 report, on the night of the Grenfell Tower fire SOM Smith and DAC Fenton had to make the difficult decision to revoke the “stay put” advice without the benefit of any established guidance. Moreover, many CROs struggled to deliver clear advice to callers that they must leave the building.952 938 Smith {Day203/92:22}-{Day203/93:12}. 939 PN790 issued on 23 February 2012 and reviewed as current on 17 April 2014 {LFB00001257/5} paragraph 8.7. 940 Smith {Day203/94:19}-{Day203/95:7}. 941 Smith {Day203/94:19}-{Day203/95:7}. 942 Hayward {Day199/220:8-21}. 943 Smith {Day203/96:9-16}. 944 Smith {Day203/96:17}-{Day203/97:6}. 945 Smith {Day203/97:20-25}; Smith {MET00080606/13}. 946 Hayward {Day199/221:10-23}. 947 GRA 3.2 {LFB00001255/19}. 948 Email from Michele Kunneke to all ACs on 13 April 2011 {LFB00033332/1}. 949 Brown {Day206/120:9-22}. 950 Brown {Day206/120:9}-{Day206/121:4} 951 Brown {Day206/121:2-4} 952 Phase 1 Report Volume IV, paragraph 29.99

The Grenfell Tower Inquiry: Phase 2 Report 124 Letter to DCLG about handling fire survival guidance calls 78.99 Pre-inquest action 13 was to draft a letter to DCLG seeking clarification of the national guidance on handling fire survival guidance calls in order to ensure a consistent approach among fire and rescue services.953 The letter was also intended to recommend a review of national guidance on the subject.954 78.100 By April 2010 POM Hayward and SOM Smith had produced a draft letter to DCLG.955 However, on 20 April 2011 the Lakanal House Board decided not to pursue the matter until the Lakanal Control Report had been completed.956 Notwithstanding that decision, on 20 November 2011, after the letter had been reviewed by the LFB legal team, POM Hayward asked for it to be sent to DCLG.957 On 12 December 2011, Commissioner Dobson confirmed that it should be sent and asked for a copy to sign.958 78.101 On 3 February 2012, a draft of the letter dated 23 December 2011 was sent by Linda Armstrong, Deputy Head of Legal Service, by email to Sue Marshall, Commissioner Dobson’s secretary, for final approval and signature by the Commissioner with a request that it be addressed to Sir Ken Knight, then Chief Fire and Rescue Adviser.959 There is another version of the letter dated 3 February 2012 addressed to Sir Ken Knight.960 78.102 The letter suggested that the relationship between FSC 10-93 and FSC 54-04 should be reviewed and that in any review of the provision of fire survival guidance there were seven areas to which particular consideration should be given. They included better guidance on engaging with callers when assessing their situation and exploring possible means of protection and escape, continual reassessment of changing conditions and the caller’s physical and mental condition, guidance on effective communications between the control room and the incident ground and training on the role of supervisors in the control room.961 78.103 SOM Smith said that she had felt that national guidance needed to be revised in that way because of the LFB’s experience at the Lakanal House fire and because a lot had changed since FSC 10-93 had been published.962 She had felt that it was necessary that someone with that degree of experience should investigate whether there were new practices that could help control room staff.963 She had assumed that other fire and rescue services might make the same mistakes as the LFB had made at the Lakanal House fire and would benefit from what the LFB had learnt.964 953 Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/15}. 954 Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/15}. 955 Hayward {Day199/194:8-11}; Smith {LFB00121219/10} page 10, paragraph 24. 956 Minutes of Lakanal House Board meeting on 20 April 2011 {LFB00084035/1} item 4.4. 957 Minutes of Lakanal House Board meeting on 30 November 2011 {LFB00084038/2} item 8.1. 958 Minutes of the Lakanal House Board meeting on 12 December 2011 {LFB00084039/2} item 8.1; Dobson {Day211/143:19}-{Day211/144:1}. 959 Email from Linda Armstrong to Sue Marshall copying Commissioner Dobson and DAC Cutbill dated 3 February 2012 {LFB00100551}. Draft Letter to DCLG dated 23 December 2011 {LFB00004744}. 960 Letter from Ron Dobson to Sir Ken Knight dated 3 February 2012 {LFB00004728}. 961 Letter from Ron Dobson to Sir Ken Knight dated 3 February 2012 {LFB00004728}. 962 Smith {Day202/143:17-24}. 963 Smith {Day 202/144:1-11}. 964 Smith {Day202/144:22}-{Day202/144:3}.

Part 8 | Chapter 78: The control room 125 78.104 Despite SOM Smith’s view and the decision in December 2011 to send the letter to DCLG, it was not in fact sent. A later decision was made in July 2012, apparently by DC Dexter, to defer once again sending the letter until work on the Lakanal Control Report had been completed.965 78.105 The version of the Lakanal Control Report dated November 2012 was unequivocal in recommending that Commissioner Dobson should write to DCLG to prompt a review of national guidance on handling fire survival guidance calls.966 However, despite that recommendation, Commissioner Dobson decided on 19 November 2012 not to send the letter.967 His decision was reconsidered at the meeting of the board on 14 December 2012, however, when he decided that it would be reviewed after the conclusion of the Lakanal House inquests.968 Commissioner Dobson thought that decision had been discussed at the Lakanal House Board.969 He said that he had been persuaded that it was better to wait for the coroner’s conclusions.970 However, in September 2013, he decided that the letter was no longer required and had been dealt with by the outcomes of the inquest.971 He said that he had taken that decision on the advice of the Lakanal House Board.972 78.106 However, the coroner’s rule 43 letters did not deal with the matters raised in the draft letter to the DCLG,973 so it is not clear why Commissioner Dobson thought that the matters it raised had been dealt with by the outcome of the inquests. The consequence of the decision not to send the letter in September 2013 was that, almost three and half years after the pre-inquest action had been raised and the letter to DCLG had been drafted, it had still not been sent. As a result, the respects in which national guidance on the handling of fire survival guidance calls needed to be improved were not considered by DCLG. It also meant that the recommendation in the Lakanal Control Report was not carried out. The coroner was not informed of that, an omission which Commissioner Dobson described as an oversight.974 78.107 In his review dated 4 January 2013 GM Lindridge found that the gap analysis had identified areas in which national guidance could be improved which had not been incorporated into LFB policy.975 DC Dexter asked why that had not been done. AC Brown said that all the suggestions had been adopted where relevant.976 However, AC Brown’s confidence was misplaced because not all GM Lindridge’s recommendations for improvement in national guidance had been considered and adopted. In particular, the gap analysis had recommended that national guidance be improved to emphasise the need for continual reassessment of the caller’s circumstances,977 but PN539 did not emphasise that, although AC Brown thought it was implicit.978 965 Minutes of the Lakanal House Board meeting on 2 July 2012 {LFB00084043/1} item 5.1; Minutes of Lakanal House Board meeting on 7 September 2012 {LFB00084044/1} item 4.1; Minutes of Lakanal House Board meeting dated 17 October 2012 {LFB00084045/2} item 6.1; Hayward {Day199/194:17-25}. 966 Lakanal Control Report dated November 2012 {HOM00001124/51} paragraph 303. 967 Minutes of the Lakanal House Board meeting on 19 November 2012 {LFB00084046/1} item 6.1. 968 Minutes of the Lakanal House Board meeting on 14 December 2012 {LFB00040033/1}; Dobson {Day211/144:23}- {Day211/145:1}. 969 Dobson {Day211/145:2-6}. 970 Dobson {Day211/145:7-15}. 971 Minutes of Lakanal House Board meeting on 30 September 2013 {LFB00050644/1} item 5.1. 972 Dobson {Day211/148:15-19}. 973 There is nothing dealing with those issues in the coroner’s rule 43 letter to DCLG dated 28 March 2013 {CLG00000401} nor in her rule 43 letter to the LFB dated 28 March 2013 {LFB00032158}. 974 Dobson {Day211/148:3}-{Day211/149:5}. 975 GM Lindridge’s review dated 4 January 2013 {LFB00085854/5}. 976 GM Lindridge’s review dated 4 January 2013 with DC Dexter and AC Brown’s comments {LFB00085854/5}. 977 Annex B to Lakanal Control Report entitled ‘Comparison between national guidance and LFB policy and training’ {HOM00001125/14}; {HOM00001125/17}. 978 Brown {Day206/99:6-13}.

The Grenfell Tower Inquiry: Phase 2 Report 126 78.108 AC Brown said that when AC Chandler had returned to work he had asked him to review the audit and satisfy himself that everything had been done.979 It is clear, however, from the terms of AC Brown’s instructions that he did not ask AC Chandler to check whether all the recommendations to improve national guidance had been covered by LFB policy.980 It is equally clear that AC Chandler did not deal with it in his response.981 POM Hayward could not recall whether any other action had been taken in response to the recommendation.982 78.109 We have come to the conclusion that no action was taken in response to that particular recommendation and that as a result, an opportunity was missed to correct some of the defects in PN539, including the absence of the important emphasis on the need for continual reassessment of the caller’s situation. Handling multiple fire survival guidance calls 78.110 In the Phase 1 report the chairman identified the need to examine whether, when, and to what extent the LFB was aware of the deficiencies that existed in its policy and training for fires that gave rise to a large number of concurrent fire survival guidance calls.983 He found that PN539 was defective, in part because it did not recognise the important fact that, because a fire survival guidance call (as defined) requires the continued presence of a CRO on the line, the number of calls that could be handled concurrently could not exceed the number of CROs available.984 78.111 The definition of a fire survival guidance call in PN539 was introduced after the Lakanal House fire because the LFB had wanted something more robust than had previously existed.985 It was formulated by those working in the control room, together with DACs Tim Cutbill and Tom Davies, and was agreed by the Lakanal House Board.986 It did not come from national guidance.987 SOM Smith said that people had realised at the time that the number of simultaneous fire survival guidance calls could not exceed the number of CROs and supervisors available, but that in the past the control room had never received more fire survival guidance calls than it could handle.988 78.112 In PN539 a fire survival guidance call is defined as “a call to Brigade Control where the caller believes that they are unable to leave their premises due to the effects of fire, and where the Control Room Officer remains on the line providing appropriate advice until either the caller is able to leave by their own means, is rescued by the Fire brigade or the line is cleared”. 78.113 It became apparent during the evidence, particularly that of SOM Smith, that the definition is open to different interpretations,989 since it depends on an exercise of judgement by the relevant CRO about the content of the call.990 As a result, the precise number of fire survival guidance calls reported at any one incident could itself be a matter of debate.991 For example, evidence about the Marriott Hotel fire on 11 November 2010, a ten-pump 979 Brown {Day206/100:4-12}. 980 Email from AC Brown to AC Chandler on 4 April 2013 {LFB00028942/1}. 981 Email from AC Chandler to AC Brown on 28 June 2013 {LFB00060701}. 982 Hayward {Day199/200:2-5}. 983 Phase 1 Report Volume IV, paragraph 29.42. 984 Phase 1 Report Volume IV, paragraph 29.45(b). 985 Smith {Day202/153:4} – {Day202/154:25}. 986 Smith {Day202/154:7-13}. 987 Smith {Day202/154:14-15}. 988 Smith {Day202/156:18} – {Day202/157:12}. 989 Smith {Day202/183:18} – {Day202/185:22}. 990 Smith {Day202/183:18} – {Day202/185:22}. 991 For example, see Smith {Day202/183:18} – {Day202/185:22}.

Part 8 | Chapter 78: The control room 127 fire in a hotel and private residential block of 32 floors in Poplar, East London,992 variously suggested that the control room had received between four and seventeen fire survival guidance calls.993 The LFB’s contemporaneous documentary evidence from the Adair Tower fire on 31 October 2015, an eight-pump fire in a high-rise residential block of flats located in the Royal Borough of Kensington and Chelsea, suggested that nine fire survival guidance calls had been received,994 but SOM Smith told us that when she had listened to the calls before giving evidence, she had reached the conclusion that only six could properly be described as fire survival guidance calls.995 78.114 It is difficult to understand how the identification of a fire survival guidance call could have remained a source of debate within the LFB after the Lakanal House fire, particularly when handling three fire survival guidance calls concurrently was a complex and intense experience. If the LFB could not consistently and accurately identify a fire survival guidance call, it could not tell how many had been generated by any particular incident, making it impossible to draw reliable conclusions or plan for future incidents. We have therefore sought to examine what lessons for handling fire survival guidance calls the LFB learned from the Lakanal House fire, which gave rise to five fire survival guidance calls, three of which were being dealt with at the same time.996 78.115 Before the Grenfell Tower fire, there had been a consensus among senior managers that the Lakanal House fire had been an exceptional event and that under normal circumstances the control room was unlikely to receive more than two or three fire survival guidance calls from any incident.997 Although SOM Smith initially said that the expression “multiple fire survival guidance calls” was not used within the LFB or nationally,998 it is clear that the LFB had made preparations for the receipt of two simultaneous calls, which could be viewed as “multiple” fire survival guidance calls.999 78.116 One striking aspect of the senior managers’ evidence was their common belief that the control room’s experience with the Lakanal House fire would not be repeated and that it was highly unlikely that more than three fire survival guidance calls would ever be received during one incident.1000 That belief should have been questioned following a number of major fires attended by the LFB which involved a significant number of fire survival guidance calls, and certainly more than two or three. 78.117 The first such incident was the fire at the Marriott Hotel in Poplar, London, on 11 November 2010.1001 SOM Smith was in attendance that night as control duty manager.1002 On that occasion the control room received between four and seventeen fire survival guidance calls (depending on how one defines them) during the course of 992 Daily Bulletin {LFB00109347/3}. 993 SOM Smith reported that four fire survival guidance calls had been received {Day202/185:14-22}; the ‘End of Incident Report’ suggested that approximately eight fire survival guidance calls had been received because of the number of fire survival guidance messages transferred from the control room to the incident ground {LFB00123671/3-8}. The figure of 17 fire survival guidance calls was contained in a comment to a draft of PN155 at paragraph 6.2 {LFB00109485/3}. 994 Debrief proforma for Adair Tower {LFB00035092/3}; FSG Database {LFB00031757} rows 20 to 28. 995 Smith {Day202/201:1-20}. 996 Lakanal Control Report {HOM00001124/35-37}, Table 4, rows 4, 28, 31, 38 & 43. 997 Hayward {LFB00121176/16} page 16, paragraph 66; Bagnelle {LFB00122821/2} page 2, paragraph 6 and {LFB00122821/6} page 6, paragraph 19. 998 Smith {LFB00121219/12-13} pages 12-13, paragraph 29. 999 Smith {Day202/162:5} – {Day202/163:12}. 1000 Hayward {LFB00121176/16} page 16, paragraph 66; Bagnelle {LFB00122821/2} page 2, paragraph 6 and {LFB00122821/6} page 6, paragraph 19; Smith {LFB00121219/17} page 17, paragraph 43. 1001 Smith {Day202/183:18-24}. 1002 Smith {Day202/183:18-24}.

The Grenfell Tower Inquiry: Phase 2 Report 128 the incident, which led to seven or eight messages being passed to the incident ground about persons trapped in their flats.1003 SOM Smith thought that there had been two concurrent fire survival guidance calls which had lasted for 45 minutes and one hour respectively.1004 After the incident, AC Hickmott sent an email to Commissioner Dobson, Deputy Commissioner Dexter, AC Cowup, AC Brown and POM Hayward, in which he described the particularly challenging nature of many of the fire survival guidance calls, some of which had lasted for more than an hour.1005 By contrast, AC Brown saw the incident as little more than a normal, if busy, day,1006 a remark which we consider revealed a degree of insouciance about the magnitude of the problem. 78.118 Although the incident generated more fire survival guidance calls than the Lakanal House fire, their number did not prompt any discussion about the control room’s capacity to handle multiple fire survival guidance calls.1007 According to AC Brown, that was because the control room had handled them very well.1008 Be that as it may, it did not prompt any consideration of the need to plan or train for an incident which generated eight simultaneous fire survival guidance calls.1009 According to AC Brown that was because the LFB was already taking the steps identified in the Lakanal Control report by developing PN790 and had started giving training on handling fire survival guidance calls.1010 78.119 On 16 June 2011, the LFB carried out an eight-pump exercise called the Heygate Challenge.1011 It was developed to test the proposed amendments to the high-rise firefighting policy and the new draft policy on fire survival guidance calls.1012 POM Hayward and SOM Smith representing the control room were involved as observers and facilitators.1013 As part of the exercise the control room simulated a live incident, allocating specific pumps and passing information from mock fire survival guidance calls to the incident ground.1014 The exercise included four fire survival guidance calls, although it is unclear whether they were concurrent.1015 It is unclear why only four fire survival guidance calls were chosen, given that five calls had been received at the Lakanal House fire.1016 78.120 After the exercise, a debriefing meeting was held.1017 SOM Smith could not recall attending it or being involved in any discussion or meeting after the exercise.1018 Although POM Hayward thought that he had attended the meeting, the minutes do not record any contribution from the control room.1019 Later reports from the command units recorded 1003 SOM Smith reported that four fire survival guidance calls had been received {Day202/185:14-22}; the end of incident report suggested that between seven and eight fire survival guidance calls had been received {LFB00123671}; the figure of 17 fire survival guidance calls was recounted in a comment to a draft of PN155 at paragraph 6.2 {LFB00109485/3}. 1004 {Day202/185:14-22}. 1005 Email from Andy Hickmott to Scott Hayward, Dave Brown, Peter Cowup, Rita Dexter and Ron Dobson titled “FW: Daily Bulletin.12-11-10.doc” dated 12 November 2010 {LFB00110785/2}. 1006 Brown {Day206/126:9-16}. 1007 Brown {Day206/126:1-7}. 1008 Brown {Day206/126:8-9}. 1009 Brown {Day206/126:17} – {Day206/127:11}. 1010 Brown {Day206/126:17} – {Day206/127:11}. 1011 Email from Andy Roe to numerous LFB participants {LFB00033345/1-4}. 1012 Email from Andy Roe to numerous LFB participants {LFB00033345/1-4}. 1013 Email from Andy Roe to numerous LFB participants {LFB00033345/1-4}. 1014 Smith {Day202/171:3-10}; Hayward {Day199/210:11-20}. 1015 ‘Feedback: High Rise and FSG Policies Test Exercise 16 June 2011 Southwark’ {LFB00033384/11}; Smith {Day202/172:1-18}. 1016 Smith {Day202/176:23} – {Day202/177:10}; Hayward {Day199/212:21} – {Day199/214:7}. 1017 Minutes of debrief meeting {LFB00056628}. 1018 Smith {Day202/173:20} – {Day202/173:24}; Feedback: High Rise and FSG Policies Test Exercise 16 June 2011 Southwark’ {LFB00033384/11}. 1019 Hayward {Day199/212:7-12}; Feedback: High Rise and FSG Policies Test Exercise 16 June 2011 Southwark {LFB00033384/10}; Minutes of debrief meeting {LFB00056628}.

Part 8 | Chapter 78: The control room 129 a consensus that the form used by staff in the command units had worked adequately for four flats as simulated in the exercise, but that the process would have been unmanageable for 20 or more calls, as one command unit had experienced at a previous incident.1020 Further analysis noted that recording fire survival guidance calls was hard enough with four flats involved, but would be almost impossible if 60 flats were involved.1021 78.121 Although the Heygate Challenge involved only four fire survival guidance calls, the reports on that exercise show that the LFB was aware that multiple fire survival calls could arise from a single incident and that in those circumstances an efficient flow of information to the command units could not be maintained. Despite that, no attempt was made to plan for an incident that could generate as many as 60 fire survival guidance calls,1022 probably because the LFB had never experienced an incident involving 60 flats.1023 At all events, it seems clear that there was no discussion among those responsible for the operation of the control room about how it would handle more than four concurrent fire survival guidance calls. It is also clear that by mid-2011 a picture was developing that showed that incidents could give rise to more (and conceivably many more) than two or three calls of that kind. 78.122 As we noted earlier, during 2011, PN155 was being drafted predominantly by SM Utting and SOM Joanne Smith.1024 Paragraph 7.10 of one draft specifically contemplated that the control room might receive multiple fire survival guidance calls, because it suggested that the incident commander should consider calling for an additional command unit to help managing a large number of such calls .1025 However, there was no consensus between SM Utting and SOM Smith, or indeed between other senior managers of the LFB, on what a large number of fire survival guidance calls might mean or about how many fire survival guidance calls might be generated by any one incident.1026 It is unclear why no consensus had been reached on that, given that the policy was specifically directed to handling multiple fire survival guidance calls, or why officers had up to five calls in mind when it had already become apparent from the Marriott hotel fire and the Heygate Challenge that it was possible for a single incident to generate many more calls. 78.123 In February 2014, GRA 3.2 was published.1027 It included a section entitled “Fire Survival Guidance” which emphasised that numerous fire survival guidance calls could be received during a single high-rise incident.1028 The guidance was relevant to the control room’s ability to handle numerous fire survival guidance calls, but none of those responsible for its operation appears to have been asked to review GRA 3.2 or even to have been consulted about its contents. Although it contained advice on handling fire survival guidance calls, neither POM Hayward nor SOM Smith had been aware of it before the Inquiry brought it to their attention because of its focus on operational matters.1029 The result was that there was no discussion about how the control room would handle multiple fire survival guidance calls as GRA 3.2 contemplated.1030 1020 Feedback: High Rise and FSG Policies Test Exercise 16 June 2011 Southwark {LFB00033384/10-11}. No witness was able to identify that incident. 1021 Minutes of debrief meeting {LFB00056628/4}. 1022 Hayward {Day199/215:12-21}. 1023 Hayward {Day199/215:12-21}. 1024 Utting {Day198/103:10-25}; Smith {LFB00121219/26} page 26, paragraph 69. 1025 Draft PN155 issue date 10 February 2011 {LFB00111471/5} 1026 Brown {Day206/122:23} – {Day206/123:11}; Smith {Day202/198:3} – {Day202/199:7}; Patrick Utting could not recall having discussed or even having considered the possibility of more than 5 fire survival guidance calls being generated by a single incident or how the control room would manage such an occurrence: Utting {Day198/118:17} – {Day198/119:18}. 1027 GRA 3.2 {LFB00001255/3}. 1028 GRA 3.2 {LFB00001255/30}. 1029 Smith {Day202/199:8-19} and {Day203/20:3-8}; Hayward {Day200/53:13} – {Day200/54:22}. 1030 Smith {Day202/199:20} – {Day202/200:3}; Hayward {Day200/53:13} – {Day200/54:22}.

The Grenfell Tower Inquiry: Phase 2 Report 130 78.124 During Phase 1 the chairman heard evidence about a tactical decision exercise training programme involving seven fire survival guidance calls that SM Peter Johnson had devised in 2014. Its purpose was to ascertain the maximum number of fire survival guidance calls that the control room and incident ground could handle satisfactorily at any one time. He also expected it to demonstrate that the procedures for handling fire survival guidance calls were inadequate.1031 In Phase 2, we have investigated why the LFB did not proceed with SM Johnson’s programme. His exercise was sent to borough commander Terence Harrington on 27 February 2014 and presented to the fire survival guidance policy group on 12 March 2014.1032 At that time, GM Harrington was trying to develop a practical exercise involving the structured delivery of training to impart knowledge, clarify roles and responsibilities and better understand the complexities of handling fire survival guidance calls arising from a small-scale incident that escalates to something larger.1033 He decided that SM Johnson’s training programme did not meet that aim and it was therefore not implemented.1034 However, even though SM Johnson’s proposal was not taken any further, it demonstrates that there was some recognition in 2014 that more than four or five concurrent fire survival guidance calls might arise from a single incident, that the systems might not be capable of managing them and that preparations should be made to deal with them. Unfortunately, that view was neither shared nor discussed more widely within the LFB.1035 78.125 The last significant incident before the Grenfell Tower fire which gave rise to fire survival guidance calls was an eight-pump fire at Adair Tower on 31 October 2015.1036 Between six and nine fire survival guidance calls were received between 08.54 and 09.08, together with 15 other calls.1037 The incident made it clear that the control room could receive more than two or three fire survival guidance calls during a single high-rise fire. Although SOM Smith described the incident as manageable,1038 she was able to shed little light on why senior officers continued to believe that a single incident would be unlikely to give rise to more than two or three fire survival guidance calls and that more than five such calls was unthinkable. 78.126 Even though the control room had received an exceptional number of fire survival guidance calls during the Adair Tower fire, the incident did not prompt any consideration of how so many calls should be managed.1039 It was not just the number of calls that should have prompted a review. A novel practice of recording information relating to calls on a whiteboard, which was not provided for in policy, was adopted at that incident.1040 More importantly, most of the calls were taken by CROs who had less than two years’ 1031 Phase 1 Report Volume IV, paragraph 29.40. 1032 Harrington {LFB00102245/8} page 8, paragraph 18; Withers {LFB00084123/5} page 5, paragraph 16; Minutes of Fire Survival Guidance Meeting on 12 March 2014 {LFB00084124}. 1033 Harrington {LFB00102245/12} page 12, paragraph 31. 1034 Harrington {LFB00102245/12} page 12, paragraph 31. 1035 Withers {LFB00084123/5} page 5, paragraph 16. 1036 FSG Database {LFB00031757}. 1037 Debrief proforma for Adair Tower {LFB00035092/5}; FSG Database {LFB00031757}; Smith {Day202/201:1-20}. 1038 Smith {Day202/205:6-18}. 1039 Smith {Day202/206:18} – {Day202/207:14}. The FSG Database did not record any lessons to be learnt or systems to be reviewed {LFB00031757}. The Incident Debrief form did not record any learning about fire survival guidance management {LFB00035092}. The IMP report for the incident did not record any learning about fire survival guidance management {MET00080621}. 1040 {LFB00035092/5}. It should be noted that on 20 December 2016, following a command unit training exercise, Liz Hymns expressed concern that a whiteboard had not been set up for managing multiple fire survival guidance calls to enable the control room to manage the information, even though she considered that to be standard practice: {LFB00052219/1}.

Part 8 | Chapter 78: The control room 131 experience and for some it was their first fire survival guidance call. The incident should, therefore, have prompted careful consideration about how best to manage multiple fire survival guidance calls. 78.127 Regrettably, we have come to the conclusion that despite all the indications that a large number of calls seeking fire survival guidance could be generated by a single incident, particularly one involving a large or high-rise residential building, the LFB failed to recognise that possibility and therefore failed to take any steps to prepare for it by training its staff or putting in place systems and procedures to respond to such an eventuality. The result was that when faced with an unprecedented number of callers from Grenfell Tower seeking fire survival guidance, the control room and those at the fireground were unable to rely on tried and tested systems and were forced to resort to various improvised methods of varying reliability to handle the large amount of information generated. That represents a major failing on the part of the LFB.

132 The Grenfell Tower Inquiry: Phase 2 Report

133 Chapter 79 Fire survival guidance: training and management Background 79.1 Taking emergency calls from the public, particularly those who are directly affected by a fire or other life-threatening event, and passing essential information quickly and accurately to those who need to receive it requires reserves of character and effective training. Control room staff receive training when they are recruited, but they also need regular training to ensure that their skills are kept up to date and that they benefit from any advances in learning. In the Phase 1 report the chairman was critical of some of the ways in which CROs handled emergency calls. He also identified various deficiencies in the Reference Information Files (RIFs) provided for the assistance of control room staff.1041 We have therefore examined the way in which the LFB managed the training of control room staff in the years preceding the Grenfell Tower fire. 79.2 Ultimate responsibility for control room training lay with the senior officers, primarily AC George and AC Brown,1042 but none of them exercised very much oversight of it.1043 AC Brown delegated to POM Hayward responsibility for monitoring control room training and ensuring that the training needs of control room staff had been properly identified and effectively met.1044 POM Hayward in turn delegated that responsibility to the SOM in charge of the Operational Support Team,1045 who was responsible for identifying the training required, deciding its content and ensuring that it was delivered effectively.1046 The SOM took full responsibility for training and did not need to obtain the approval of POM Hayward for training packages that were developed.1047 The Operational Support Team was responsible for creating, organising and delivering all training documents and training packages for new entrants to the control room and existing staff.1048 In the period between 2009 and 2019 the SOMs responsible for training were Lindsay Turner (2009–2012), Victor Bagnelle (2012–2015) and Joanne Smith (2015–2019).1049 79.3 POM Hayward generally adopted a laissez-faire style of management under which he did not expect to receive reports on matters relating to training unless there was a problem.1050 He therefore did not actively monitor training; he expected the SOM to tell him if there was a problem of some kind.1051 Otherwise, he assumed that the Operational Support Team was carrying out its job properly.1052 In practice, POM Hayward’s monitoring of training was confined to discussions with the SOM about problems as they arose and the observation of 1041 Phase 1 Report Volume IV paragraphs 29.49-29.50. 1042 Hayward {Day199/36:21}-{Day199/37:15}; George {Day205/12:3-6}; Brown {Day206/156:13-17}. 1043 Hayward {Day199/37:16}-{Day199/38:3}; George {Day205/152:5}-{Day205/153:24}. 1044 Brown {Day206/156:10-17}. 1045 Hayward {LFB00086213/7} page 7, paragraph 38; Hayward {Day199/38:4-8}. 1046 Hayward {Day199/33:21}-{Day199/34:1}; Hayward {LFB00055191/17} page 17, paragraph 48; Smith {LFB00121219/6} page 6, paragraph 15. 1047 Hayward {Day199/34:2-7}. 1048 Hayward {LFB00055191/7} page 7, paragraph 20; {LFB00055191/17} page 17, paragraph 47; Hayward {Day199/38:9- 13}. 1049 Hayward {LFB00086213/8} page 8, paragraph 39. 1050 Hayward {Day199/32:6-14}; {Day199/51:6-24}. 1051 Hayward {Day199/51:6-24}. 1052 Hayward {Day199/32:15-21}; {Day199/51:6-24}.

The Grenfell Tower Inquiry: Phase 2 Report 134 some training.1053 He did not regularly inspect the training records, despite the provisions of PN164, which contemplated that he would do so.1054 He made none of the decisions about the content of control room training, nor did he consult AC Brown, AC Chandler or AC George about it.1055 He expected any problem with training to be raised at Brigade Control Management meetings or in his meetings with the SOMs,1056 but apparently none ever had been.1057 In the absence of any problems he felt confident that the SOMs were managing training properly.1058 For their part, neither AC Brown nor AC Chandler nor (to a lesser extent) AC George, exercised any active supervision of his oversight of training or monitored what he was doing to keep abreast of it. 79.4 In our view, such a detached approach to training should never have been allowed. Although POM Hayward was entitled to delegate the delivery of training to senior managers whom he knew and trusted, he had a personal responsibility to satisfy himself that the training programmes were suitable and were being delivered appropriately. He also had a personal responsibility to satisfy himself that the training was effective. As far as we can see, he did none of those things. 79.5 Most of the training was delivered to staff on watch. Accordingly, if during training there was a significant incident or a significant increase in the number of calls, staff could be recalled to their positions in the control room.1059 Generally, training took place in a side room of the premises at Merton where the control room was located.1060 When training had been completed, it should have been recorded manually by the Operational Support Team in a spreadsheet. From April 2019 it was recorded electronically in a system called System Training Evaluation and Performance (STEP).1061 Fire survival guidance training after the Lakanal House fire 79.6 The Lakanal House Board was responsible for the introduction of a programme of fire survival guidance training introduced in response to the Lakanal House fire.1062 The relevant pre-inquest actions were action 8 (involvement of fire safety officers in training), action 11 (ensure that initial training on handling fire survival guidance calls complied with national guidance) and action 12 (provide refresher training on handling fire survival guidance calls).1063 79.7 National guidance on fire survival guidance training for CROs was published by the Home Office in 1993 and 1994 respectively in the form of FSC 10-93 and ‘Keeping People Safe’,1064 to which we have referred. FSC 10-93 provided that recruits with between 8 and 12 weeks of service should be given fire survival guidance training to enable them, when dealing with callers trapped in domestic accommodation, to make a proper assessment of the situation, give appropriate advice where necessary and otherwise assist in minimising the danger to 1053 Hayward {Day199/32:15-21}; {Day199/34:5-14}. 1054 Hayward {Day199/118:17-19}; PN164 amended on 28 January 2009 {LFB00084054/3} paragraph 2.5; PN164 reviewed as current on 6 May 2015 {LFB00084054/8} paragraphs 2.5-6. 1055 Hayward {Day199/34:19}-{Day199/35:3}. 1056 Hayward {Day199/32:19}-{Day199/33:17}; {Day199/50:20-24}. 1057 Hayward {Day199/32:19}-{Day199/33:1}; {Day199/51:6-13}. 1058 Hayward {Day199/32:19}-{Day199/33:1}. 1059 Hayward {LFB00055191/18} page 18, paragraph 52. 1060 Hayward {LFB00055191/17} page 17, paragraph 49. 1061 Hayward {LFB00055191/17} page 17, paragraph 48; Hayward {LFB00055191/25} page 25, paragraph 72; Training Spreadsheet {LFB00055223}. 1062 Hayward {LFB00055191/24} page 24, paragraph 68. 1063 Lakanal Assurance Report {LFB00004801/13-14}. 1064 Lakanal Control Report {HOM00001124/13-16} paragraphs 49-74.

Part 8 | Chapter 79: Fire survival guidance: training and management 135 the caller.1065 FSC 10-93 also recommended that continuation training be provided to CROs, which should include the fire survival guidance training set out in Appendix B.1066 Appendix B recommended that fire survival guidance training should be presented by a fire safety officer and a fire control officer jointly and should comprise a lecture lasting one to one- and-a-half hours followed by a practical role-play session.1067 79.8 One of the key recommendations of ‘Keeping People Safe’ was that fire survival guidance refresher training should be undertaken at intervals of no more than 12 months.1068 The training emphasised the need for an assessed role-play session in which CROs should actively participate.1069 Its purpose was to test the ability of CROs to establish whether a caller can leave the building, recognise unusual responses, determine the caller’s location and provide appropriate guidance by following a sequence of prompts.1070 79.9 After the Lakanal House fire, the LFB created an initial fire survival guidance training package in 2010 for all control room staff which consisted of three training presentations1071 entitled Building Types and Concepts,1072 Fire Survival Guidance1073 and Fire Survival Training: Introduction to Fire and Human Behaviour.1074 SOM Lindsay Turner was responsible for drafting the new training package, although the senior management team as a whole was involved in decisions about it.1075 79.10 In 2010, fire survival guidance training was delivered to all control room staff, except those on long-term absence.1076 A full day was allocated for it, off the watch. It was delivered by one of the trainers and included opportunities to ask questions.1077 Half of the training was delivered by the Fire Safety team, in accordance with national guidance.1078 At a meeting on 15 September 2010, the Lakanal House Board was informed that all control room staff had received refresher fire survival guidance training which had been fully in accordance with FSC 10-93.1079 79.11 In February 2010, before the fire survival guidance training package had been provided to staff, POM Hayward asked for role-play to be introduced as part of an assessment at the end of the week to consolidate the training and to give CROs an opportunity to practise giving fire survival guidance in a controlled environment.1080 As a result, the fire survival guidance training in 2010 included active role-play, in which the trainer would act as the caller and a CRO would take the call.1081 The trainer would improvise a situation based on 1065 Fire Service Circular {LFB00003617/1} paragraph 6. 1066 Fire Service Circular {LFB00003617/2} paragraph 7. 1067 Fire Service Circular {LFB00003617/6}. 1068 Lakanal Control Annexures {LFB00004750/37}. 1069 Lakanal Control Annexures {LFB00004750/28}; Hayward {Day200/120:14}-{Day200/121:25}. 1070 Lakanal Control Annexures {LFB00004750/28}. 1071 Hayward {LFB00121176/3-4} pages 3-4, paragraphs 13 and 14; Lakanal House Assurance Review {LFB00004801/14}. Further training was developed for new entrants {LFB00107484}. 1072 Refresher training presentation on building types and concepts (2011) {LFB00086228}. 1073 Fire Survival Guidance presentation {LFB00028265}. 1074 Fire Survival Training: Introduction to Fire and Human Behaviour presentation, dated March 2010 {LFB00119961}. 1075 Smith {LFB00121219/18} page 18, paragraph 47; Smith {Day203/191:10-16}. 1076 Hayward {LFB00055191/25} page 25, paragraph 74; Minutes of Lakanal House Board Meeting of 15 September 2010 {LFB00055192/1}. 1077 Hayward {Day200/79:9}-{Day200/80:16}; {Day200/80:19-23}; Hayward {LFB00055191/24} page 24, paragraph 69. 1078 Minutes of Lakanal House Board Meeting of 15 September 2010 {LFB00055192/2} item 5.6; Hayward {LFB00055191/6-7} pages 6-7, paragraph 20. 1079 Minutes of Lakanal House Board Meeting of 15 September 2010 {LFB00055192/1} item 5.4. 1080 Email from Scott Hayward to Chris Sharp, Lindsay Turner, Joanne Stibbards and Robin Hannan dated 23 February 2010 regarding Fire Survival Planning Meeting 22nd February 2010 {LFB00028258/1}. 1081 Hayward {LFB00121176/6} page 6, paragraph 20.

The Grenfell Tower Inquiry: Phase 2 Report 136 their own experience and act out a fire survival guidance call to which the CRO would be expected to respond.1082 No specific responses were required but the trainer was expected to ensure that the trainee followed the structure set out in the fire survival guidance RIF.1083 79.12 The initial fire survival guidance training package was outdated, being based on a fatal fire in the West Midlands in 1990 which had prompted the dissemination of FSC 10-93 and the ‘Keeping People Safe’ training. It was flawed in a number of respects. First, none of the initial training presentations referred to the Lakanal House fire or to the rapid spread of fire that had occurred on that occasion and the dangers involved.1084 SOM Smith could not explain why that was the case1085 and the 2011 training did not remedy the omission.1086 79.13 Secondly, none of the training presentations enabled CROs to understand significant features of modern buildings, such as cladding systems, and how they could contribute to a rapid and unusual spread of fire.1087 It was a serious oversight not to have referred to the Lakanal House fire and modern methods of construction to ensure that control staff understood the relevance and importance of the training. 79.14 Thirdly, neither the 2010 nor the 2011 presentations complied fully with national guidance. FSC 10-93 warned that, in situations where the caller was prevented from escaping, CROs needed to be aware that reassuring the caller might not be appropriate and in some circumstances might even be dangerous.1088 Yet the 2010 training presentation told CROs to reassure the caller, to remain positive in order to create a bond and to provide reassurance by saying that the firefighters were on their way and would be there very soon.1089 SOM Smith was “extremely surprised” that the fire survival guidance training provided to CROs in 2010 included that advice and accepted that it reinforced bad practice.1090 The advice to create a bond with the caller was removed from the 2011 training package, but that version still encouraged CROs to reassure the caller by telling them that the firefighters were at the scene.1091 POM Hayward accepted that that was contrary to national guidance but could not explain why it had been included.1092 79.15 Fourthly, neither the 2010 nor the 2011 training presentations addressed some of the problems that CROs had encountered in connection with the Lakanal House fire, such as difficulty in identifying a safe room or problems in understanding the layout of the flat caused by the caller’s moving between rooms or even between flats.1093 79.16 Fifthly, neither the 2010 nor the 2011 presentations referred to FSC 54-04 or the need to ask specifically about the caller’s age, gender, ethnicity or mental or physical ability.1094 1082 Hayward {LFB00121176/6} page 6, paragraph 20; Hayward {Day200/127:22}-{Day200/128:19}. 1083 Hayward {LFB00121176/6} page 6, paragraph 20. 1084 2010 FSG Training {LFB00028265}; 2011 FSG Training {LFB00086214}; Hayward {Day200/96:12} – {Day200/97:11}; Building Types and Concepts presentation {LFB00086228}; Hayward {Day 200/107:3-20}; Fire and Human Behaviour Training presentation, dated March 2010 {LFB00119961}; Hayward {Day200/111:2}-{Day200/112:7}. 1085 Smith {Day203/202:7-11}. 1086 2011 FSG Training {LFB00086214/1}. 1087 Hayward {Day200/112:9-14}. 1088 Fire Service Circular {LFB00003617/1} paragraph 2. 1089 2010 FSG Training {LFB00028265/19-28}. 1090 Smith {Day203/200:5}-{Day203/201:25}. 1091 2010 FSG Training {LFB00028265}; 2011 FSG Training {LFB00086214/21}. 1092 Hayward {Day200/102:2-24}; {Day200/108:13}-{Day200/110:1}. 1093 Hayward {Day200/104:2-16}; FSG Refresher Presentation {LFB00086214/15-16}; 2010 FSG Training {LFB00028265}. 1094 2010 FSG Training {LFB00028265}; 2011 FSG Training presentation {LFB00086214/21}.

Part 8 | Chapter 79: Fire survival guidance: training and management 137 79.17 In August 2011, POM Hayward asked SOM Smith to review the fire survival guidance training packages to ensure that they were consistent with FSC 10-93.1095 SOM Smith did not review the role-play exercise,1096 but she did review the 2011 version of the fire survival guidance training presentation and concluded that it was materially incomplete, in particular, because it used neither the definition of a fire survival guidance call found in PN539 nor that found in current national guidance.1097 However, her criticisms, which were bluntly expressed, were not acted on. SOM Smith could not explain why, in August 2011, more than two years after the Lakanal House fire, fire survival guidance training for CROs still contained the errors she had identified.1098 79.18 A new fire survival guidance training presentation was created in 2012, but most of SOM Smith’s comments were not acted on and the contents of the presentation were substantially similar to those of the 2011 version.1099 SOM Smith could not explain why that was the case.1100 She thought she had discussed her criticisms with POM Hayward but there is no record of any such discussions having taken place.1101 79.19 The history of this matter only reinforces our view that POM Hayward failed to exercise proper control over the development and delivery of training. The fault does not lie solely with him, however, since more senior officers should have been taking responsibility for ensuring that a matter of such importance was being properly managed. SM Kelly’s audit of control room training 79.20 On 3 August 2010, SM Stephen ‘Ned’ Kelly completed an audit of the Training team’s systems for managing the quality of training courses and assessing the performance of trainees, using the fire survival guidance refresher training course as an example.1102 Having witnessed some practical role-play exercises, he noted that each candidate was exposed to a single fairly simple fire survival guidance call lasting between 90 seconds and two minutes, during which their performance was monitored.1103 He made a number of criticisms, noting in particular that each trainee took part in only one fairly straightforward exercise and that the assessment of their individual performances was very informal, there being no documented note of what was expected of them or any record kept of their performance. He therefore recommended that the role-play element of the training be reviewed and that a robust assessment process be implemented.1104 79.21 POM Hayward told us that the control room had implemented some, though not all, of SM Kelly’s suggestions to improve the assessment of trainees’ performance.1105 Four fire survival guidance role-play exercises were produced in 2011, for which a document 1095 Hayward {Day200/116:24}-{Day200/118:1}. 1096 Smith {Day204/49:20}-{Day204/50:2}. 1097 Comments on FSG {LFB00083547/1}. 1098 Smith {Day204/65:11-15}. 1099 FSG Brigade Control Training presentation (2012) {LFB00086226}; Smith {Day204/42:4}-{Day204/48:12}. 1100 Smith {Day204/42:4-19}. 1101 Smith {Day204/42:4-19}. 1102 Audit of Quality Management Systems Fire Survival Training Course dated 3 August 2010 {LFB00109082}. 1103 Audit of Quality Management Systems Fire Survival Training Course dated 3 August 2010 {LFB00109082/6} paragraph 40. 1104 Audit of Quality Management Systems Fire Survival Training Course dated 3 August 2010 {LFB00109082/11}. 1105 Hayward {Day200/131:22}-{Day200/132:22}.

The Grenfell Tower Inquiry: Phase 2 Report 138 was provided to enable CROs’ performance to be recorded and assessed.1106 However, the control room did not implement any of his other recommendations because they considered that the course was already long enough.1107 Fire survival guidance refresher training 79.22 The Lakanal Control report noted that at the time of the Lakanal House fire there had been a lack of structured, regular fire survival guidance training.1108 The Lakanal House Board decided, therefore, by way of pre-inquest action 12, that a recurring programme of fire survival guidance refresher training should be established for all control personnel in accordance with national guidance.1109 At a meeting of the Board on 15 September 2010, Commissioner Dobson noted that one of the areas that needed to be considered was to ensure that refresher training for the control room on handling fire survival guidance calls was maintained and recorded on STEP.1110 Despite his comment, however, nothing appears to have been done, either to maintain refresher training or to record it on STEP. 79.23 National guidance required that refresher training on fire survival guidance calls should take place at least every 12 months and should include the training described in Appendix B of FSC 10-93. It recommended that training be delivered jointly with a fire safety officer and include active practical role-play.1111 FSC 10-93 also recommended that refresher training be given systematically on the watch to all CROs, and should be scheduled and monitored.1112 It emphasised that such training should cover little-used procedures and areas of weakness.1113 AC Brown and SOM Smith accepted that fire survival guidance was a little-used procedure and SOM Smith accepted that the LFB’s response to the Lakanal House fire had demonstrated that it was an area of weakness.1114 For those reasons AC Brown accepted that the need for fire survival guidance refresher training should have been made clear to CROs.1115 79.24 The programme of fire survival guidance refresher training was approved at the Lakanal House Board. In the second half of 2010, it was decided that there should be a two-year refresher training programme, under which a full day of classroom training would be delivered in the first year and a computer-based training package in the second.1116 It was always intended that the full day of refresher training would include active role-play and would be delivered jointly with the fire safety team.1117 The plan was that in alternate years CROs would complete the computer-based training package on their own,1118 the intention being for them to be allocated time to complete it while on the watch.1119 There was no plan to provide role-play exercises in the years when the computer-based training package 1106 Hayward {LFB00055191/26} page 26, paragraph 75; 2011 FSG Role Play scenario 1 {LFB00055226} 2011 FSG Role Play scenario 2 {LFB00055227}; 2011 FSG Role Play scenario 3 {LFB00003788}; 2011 FSG Role Play scenario 4 {LFB00003682}. 1107 Hayward {Day200/131:22}-{Day200/132:22}. 1108 Lakanal Control Report {HOM00001124/52} paragraph 308. 1109 Minutes of Lakanal House Board Meeting 15 September 2010 {LFB00055192/2}; Minutes of Lakanal House Board Meeting 15 November 2010 {LFB00055213/1}. 1110 Minutes of Lakanal House Board Meeting 15 September 2010 {LFB00055192/2}. 1111 Fire Service Circular {LFB00003617/6}; Lakanal Control Annexures {LFB00004750/37}. 1112 Fire Service Circular {LFB00003617/3} paragraph 11. 1113 Fire Service Circular {LFB00003617/3} paragraph 11. 1114 Smith {Day204/13:23}-{Day204/14:6}. 1115 Brown {Day207/59:8-11}. 1116 Hayward {LFB00055191/24} page 24, paragraph 68. Minutes of Lakanal House Board Meeting of 22 June 2010 {LFB00055208}; Minutes of Lakanal House Board Meeting of 15 September 2010 {LFB00055192}; Minutes of Lakanal House Board Meeting of 8 November 2010 {LFB00055213}. 1117 Hayward {Day200/143:8-19}; Smith {Day204/19:6-12}. 1118 Hayward {Day200/147:16}-{Day200/148:3}. 1119 Hayward {Day200/157:3-6}.

Part 8 | Chapter 79: Fire survival guidance: training and management 139 was delivered; instead, CROs would be asked to complete a questionnaire designed to test their understanding of the principles involved.1120 The intention was to deliver the first computer-based training package in 2011.1121 79.25 The two-year programme did not comply with national guidance because it did not provide for annual fire survival guidance training delivered jointly by a fire control officer and a fire safety officer and did not include an annual role-play exercise. Although the Lakanal House Board formally approved it,1122 there was no discussion at its meetings about whether the programme complied with national guidance.1123 At the meeting of the Lakanal House Board on 8 November 2010 action 12 was marked as “complete” because a system for delivering training had been established.1124 The Board did not continue to exercise oversight of the action despite the continuing nature of refresher training. 79.26 AC Brown thought that the biennial programme was a reasonable and efficient approach to training.1125 He regarded delivering a full day of classroom training every year as a significant workload for a team that was already delivering other training.1126 SOM Smith, on the other hand, did not think that a two-year training programme was appropriate and expressed her concerns to Scott Hayward and Lindsay Turner.1127 POM Hayward said that a two-year programme had been adopted to allow other training to take place.1128 SOM Smith also pointed to the need for CROs to continue working while training was being provided.1129 79.27 Although we understand the difficulty of making CROs available for training, we do not think that it was sufficient to justify a two-year programme, given the weaknesses in providing fire survival guidance exposed by the Lakanal House fire and the fact that SM Kelly’s audit had revealed the need to strengthen the role-play element of training. The training required would take one day and SOM Smith accepted that it was possible to arrange shift patterns in a way that would allow training when staff were off duty, as had been done with training for the Vision system.1130 In the circumstances, we do not think that POM Hayward was right to conclude that a one-day training course each year would exclude other important training. 79.28 Finally, in the Lakanal Control report the LFB told the coroner that a two-year refresher training plan, which had an active role-play element to it, had been put in place.1131 However, by the time of the inquests in January 2013, it is clear that training of the kind that had been described was not in fact being provided. The LFB failed to notify the coroner that, in this respect at least, its intentions had not been realised, and no satisfactory explanation was given for that failure. 1120 Hayward {Day200/147:16}-{Day200/148:3}. 1121 Hayward {Day200/154:24}-{Day200/155:2}. 1122 Brown {Day207/64:7-17}. 1123 Minutes of Lakanal House Board Meeting of 22 June 2010 {LFB00055208}; Minutes of Lakanal House Board meeting of 15 September 2010 {LFB00055192}; Minutes of Lakanal House Board Meeting of 8 November 2010 {LFB00055213}; Hayward {Day200/148:19-23}. 1124 Minutes of Lakanal House Board Meeting of 8 November 2010 {LFB00055213/6}; Brown {Day207/64:1}- {Day207/65:8}. 1125 Brown {Day207/61:16}-{Day207/63:4}. 1126 Brown {Day207/62:8-21}. 1127 Smith {Day204/21:8-25}. 1128 Hayward {Day200/149:3-11}. 1129 Smith {Day204/23:20-24}. 1130 Smith {Day204/25:4-12}. 1131 Lakanal Control Report {HOM00001124/53}.

The Grenfell Tower Inquiry: Phase 2 Report 140 79.29 In the event, refresher training on fire survival guidance was not delivered as intended. In 2011 the computer-based training package that it had been intended to deliver to CROs that year was still under development and was therefore unavailable.1132 As a result, POM Hayward approved the use by staff of the materials they had used in their initial fire survival guidance training.1133, 1134 The course was not led by trainers but was designed for CROs to study alone for about an hour to an hour and a half.1135 It is likely that staff undertook the training on the watch during the four-hour rest period that became available after the shift patterns had changed.1136 The training plan for 2011 did not include active role-play, but CROs used call scripts and the RIF1137 to confirm their understanding of procedures.1138 However, the exercise did not involve active role-play and the performances of the CROs were not assessed.1139 79.30 POM Hayward provided us with information about the number of CROs who had undergone fire survival guidance training between 2011 and 2017.1140 He accepted that the figures might not be entirely accurate and AC George and AC Brown both cast doubt on their reliability. However, we think they provide a helpful indication of the numbers who had received fire survival guidance training during that time. The evidence indicates that 94% of the available control room staff received training in 2011,1141 but when compared to later years the figure looks very high. POM Hayward could not explain it and we have some doubt about its accuracy.1142 79.31 In 2012 CROs should have received a full day of fire survival guidance refresher training, including active role-play.1143 However, in that year the provision of training was much reduced. The role-play element of the fire survival guidance refresher training was changed to a passive exercise in which staff were required to listen to pre-recorded simulated fire survival guidance calls and discuss their positive and negative aspects.1144 Either SOM Turner or SOM Bagnelle (it is not clear which) approved the change,1145 which was made in response to indications from staff that they felt very uncomfortable taking part in that element of the training.1146 POM Hayward told us that he had not been consulted about the change and had not been aware that it had happened. He did not think that embarrassment was a sufficient reason for abandoning role-play, which he thought was an effective way of confirming CROs’ understanding of the training.1147 This episode only goes to reinforce our criticisms of POM Hayward’s management of the control room. 1132 Hayward {Day200/154:24}-{Day200/155:5}. 1133 Email from Scott Hayward to Lindsay Turner and Joanne Stibbards dated 31 May 2011 regarding Fire Survival Refresher Package {LFB00058087/1}; Hayward {Day200/180:15-25}. 1134 Hayward {Day200/154:24}-{Day200/155:25}; Hayward {LFB00055191/10} page 10, paragraph 21.8. 1135 Hayward {Day200/155:6}-{Day200/157:15. 1136 Hayward {Day200/167:6-16}; FSG Training Record {LFB00041763}. 1137 Hayward {Day200/162:17}-{Day200/163:3}; Hayward {LFB00055191/26} page 26, paragraph 75; Hayward {Day200/184:14-17}. 1138 Hayward {Day200/162:10-16}. 1139 Hayward {Day200/162:17}-{Day200/163:3}; Hayward {LFB00055191/26} page 26, paragraph 75. 1140 Hayward {LFB00055191/26} page 26, paragraph 74. 1141 Hayward {LFB00055191/26} page 26, paragraph 75. 1142 Hayward {Day200/168:16-22}. 1143 Hayward {Day200/171:15-17}. 1144 Hayward {LFB00086213/14} page 14, paragraph 73; Email from Chris Sharp to Natalie Bagnelle, Vic Bagnelle, Sam Coaker, Scott Hayward, David Hughes, Steve Perry, Joanne Stibbards and Lindsay Turner dated 27 September 2012 {LFB00060696}. 1145 Hayward {LFB00086213/14} page 14, paragraph 73; Hayward {LFB00055191/24} page 24, paragraph 69; Hayward {Day200/190:6-11}. 1146 Hayward {LFB00086213/14} page 14, paragraph 74; Email from Victor Bagnelle to Scott Hayward regarding Control Report {LFB00122840/1}. 1147 Hayward {Day200/192:8-15}.

Part 8 | Chapter 79: Fire survival guidance: training and management 141 79.32 At about the same time, the length of fire survival guidance refresher training was reduced.1148 Instead of a whole day off the watch, the training took place during a four- hour short shift.1149 The decision to reduce the length of the training was made by SOM Bagnelle without reference to POM Hayward.1150 POM Hayward said that the same training had been delivered but that by reducing the number of breaks and the number of staff involved, it could be condensed into a four-hour period.1151 However, that ignores the fact that the content was much reduced because there was only a brief discussion about difficult calls, as opposed to the one and half hour discussion originally included, and the element of active role-play was removed.1152 Passive role-play reduced the time it took to complete that part of the training because a group discussion was substituted for individual participation.1153 79.33 In addition, fire safety officers were withdrawn from delivering the training. From 2012 onwards, fire survival guidance training for control room staff was intermittent and did not comply with national guidance. As a result, the refresher training that had been approved by the Lakanal House Board was not implemented. 79.34 POM Hayward said that he had become aware of the change to the training only during the Lakanal House inquests,1154 but the evidence suggests that AOM Sharp had told the control room senior management team, including POM Hayward, about the change to the fire survival guidance role-play in September 2012.1155 POM Hayward did not recall either having received her message or having discussed the proposal with AOM Sharp.1156 79.35 When on 5 February 2013 POM Hayward discovered that the duration and content of the fire survival guidance training had been changed, he asked SOM Bagnelle, who was by then the SOM in charge of training, how it had come about.1157 AOM Sharp and SOM Bagnelle told him that the reason for the change was to prevent staff from being taken off duty1158 and because there were not enough staff on duty between 08.00 and 14.00 to allow training to take place before the afternoon.1159 POM Hayward said that nobody had told him that staffing difficulties prevented training taking place for a whole day.1160 He had been aware generally that there were staff shortages and had understood that there were often no staff available to carry out training,1161 but said he had never thought that training might need to be cut back as a result. 1148 Hayward {LFB00055191/24} page 24, paragraph 70. 1149 Hayward {LFB00055191/24} page 24, paragraph 70. 1150 Hayward {Day200/195:24}-{Day200/196:6}. 1151 Hayward {Day200/196:10-24}. 1152 Hayward {LFB00055191/24-25} pages 24-25, paragraph 71. 1153 Hayward {Day200/197:4-10}. 1154 Hayward {Day200/195:24}-{Day200/196:6}; Hayward {LFB00055191/24} page 24, paragraphs 69-71. 1155 Email from Chris Sharp to Natalie Bagnelle, Vic Bagnelle, Sam Coaker, Scott Hayward, David Hughes, Steve Perry, Joanne Stibbards and Lindsay Turner dated 27 September 2012 {LFB00060696}. 1156 Hayward {Day200/218:1}-{Day200/219:5}. 1157 Hayward {LFB00055191/24} page 24, paragraph 69; Email from Thomas Davies to Scott Hayward dated 5 February 2013 {LFB00060872/4}; Email from Scott Hayward to Vic Bagnelle dated 7 February 2013 {LFB00039935/1-2}; Bagnelle {LFB00122821/12} page 12, paragraphs 41-43. 1158 Hayward {LFB00055191/24-25} pages 24-25, paragraph 71. 1159 Email chain with Scott Hayward, Chris Sharp, Nicola O’Shea and Vic Bagnelle dated 6 February 2013 {LFB00122840/3-4}. 1160 Hayward {Day200/205:19}-{Day200/206:14}. 1161 Hayward {Day200/205:19}-{Day200/206:14}.

The Grenfell Tower Inquiry: Phase 2 Report 142 79.36 On or about 7 February 2013, during the course of the Lakanal House inquests, POM Hayward spoke to AC Brown about the changes to fire survival guidance training.1162 AC Brown told him that he was very unhappy about the changes, particularly as the Lakanal Control report had said that the LFB was carrying out a full day’s training with active role- play.1163 Although AC Brown intended to provide the coroner with information about the changes to fire survival guidance training,1164 it is unclear what, if anything, was done. 79.37 AC Brown expected the biennial plan for fire survival guidance training to be reinstated with a full day of training every other year and a half day of computer-based training in alternate years.1165 On the instructions of AC Brown, POM Hayward directed SOM Bagnelle to ensure that the active role-play was reinstated in accordance with SM Kelly’s recommendation in August 2010.1166 However, POM Hayward did not instruct SOM Bagnelle to change the duration of training from four hours to a full day as AC Brown had expected.1167 79.38 Despite AC Brown’s instruction, active role-play was not reinstated.1168 The episode illustrates our broader concerns about the LFB’s management systems at the time. POM Hayward should have been made aware of the change to the role-play exercise.1169 Equally, once he had become aware of that change, it should have caused him to question the effectiveness of his supervision and monitoring of training.1170 Had he done so, the failure to reinstate an element of active role-play in fire survival guidance training might have been identified and cured in time to make a significant difference to the performance of the control room in response to the Grenfell Tower fire. 79.39 In early 2012, AC Brown and AC Turek decided that fire safety officers did not need to deliver fire survival guidance refresher training.1171 The decision was inconsistent with both national guidance (FSC 10-93) and pre-inquest action 8.1172 AC Brown explained that the decision coincided with a restructuring of the brigade (including the Fire Safety department)1173 and reflected the view that using fire safety officers to provide training on fire survival guidance was an unnecessary use of resources. There was a dedicated control room training team to provide that training and fire safety officers could be better employed inspecting premises.1174 79.40 AC Brown and AC Turek were satisfied that the fire safety officers had had sufficient involvement in the design and content of the new fire survival guidance training and they continued to be involved in the training of new control room staff.1175 AC Brown also 1162 Email from Scott Hayward to Vic Bagnelle dated 7 February 2013 {LFB00039935/1}; Hayward {Day200/208:9}- {Day200/209:19}. 1163 Email from Scott Hayward to Vic Bagnelle dated 7 February 2013 {LFB00039935/1}. 1164 Brown {Day207/82:4}-{Day207/83:3}. 1165 Email from Dave Brown to Scott Hayward dated 9 February 2013 {LFB00060872}; Brown {Day207/78:7-14}. 1166 Hayward {LFB00055191/24} page 24, paragraph 69; Bagnelle {LFB00122821/12} page 12, paragraphs 41-43; Email from Scott Hayward to Vic Bagnelle dated 7 February 2013 {LFB00122840/2}; Hayward {Day200/209:16-25}; Brown {Day207/78:7-14}. 1167 Hayward {LFB00055191/24} page 24, paragraph 69; Bagnelle {LFB00122821/12} page 12, paragraphs 41-43; Email from Scott Hayward to Vic Bagnelle dated 7 February 2013 {LFB00122840/2}; Hayward {Day200/209:16-25}; Brown {Day207/78:7-14}. 1168 Hayward {LFB00055191/26-29} pages 26-29, paragraphs 67.5 and 69; Hayward {Day201/15:20}-{Day202/16:8}. 1169 Hayward {Day200/188:7-25}. 1170 Hayward {Day200/190:22}-{Day200/191:10}. 1171 Brown {LFB00032166/21} page 21, paragraph 65; Brown {LFB00084020/10} page 10, paragraph 20; Brown {Day207/43:21-24}. Email chain between Scott Hayward, Lindsay Turner and Joanne Stibbards dated 22 February 2012 {LFB00058256/1-2}. 1172 This was accepted by AC Brown. Brown {LFB00084020/10} page 10, paragraph 20. 1173 Brown {Day207/43:21-24}; Brown {Day207/48:25} – {Day207/49:8}; Brown {LFB00032166/21} page 21, paragraph 65. 1174 Brown {LFB00032166/21} page 21, paragraph 65. 1175 Brown {LFB00032166/21} page 21, paragraph 65; Brown {LFB00084020/10} page 10, paragraph 20.

Part 8 | Chapter 79: Fire survival guidance: training and management 143 appears to have thought that as fire safety officers had been involved in a full day of fire survival guidance training in 2010, that was sufficient.1176 However, national guidance required the contribution of a fire safety officer to each refresher training session and the longer CROs remained in their roles, the greater the importance of refresher training. At all events, the training team subsequently provided training without any contribution from a fire safety officer.1177 AC Brown may have had confidence in the competence of the trainers, as he said he did, but we find it difficult to identify any steps that he had taken to satisfy himself of their ability to teach matters relating to fire safety.1178 Although AC Brown said that he had relied on his personal knowledge of the members of the team and information obtained from senior managers, POM Hayward did not remember ever having discussed the withdrawal of fire safety officers with him.1179 79.41 Between 2013 and the Grenfell Tower fire, existing control room staff did not receive the full day of fire survival guidance refresher training that had been planned and approved by the Lakanal House Board and promised to the coroner.1180 Some of the CROs were given training relevant to fire survival guidance, such as reviewing the RIF for Operators. They were also given some informal training and were involved in command unit training exercises, but none of that reflected the training that national guidance recommended.1181 79.42 The command unit training exercises involved units attending the control room at Merton and carrying out exercises to test activities such as two-way communication between the control room and the incident ground.1182 The exercises had an element of role-play because CROs were required to take calls on the mobilising system and ensure that the information was passed to the command unit.1183 However, the training was not designed for control room staff and those who took part did little more than help train the crews of the command units.1184 79.43 Some computer-based training was available, but not all CROs were able to take advantage of it due to technical problems that had not been resolved by the time of the Grenfell Tower fire.1185 Moreover, the content of the fire survival guidance presentations used in the computer-based training was out of date, not having changed between 2013 and 2017.1186 As POM Hayward accepted, the system for delivering them deteriorated as the presentations improved.1187 The Operational Support Team did not create an alternative training opportunity for CROs who could not obtain access to computer-based training.1188 SOM Smith’s preference was to introduce a computer-based training package because of the shortage of staff, particularly due to the introduction of Vision,1189 but that made little sense in the face of the long-standing technical problems. Sessions led by trainers 1176 Brown {Day207/46:13-21}. 1177 Brown {LFB00032166/21} page 21, paragraph 65. 1178 Brown {LFB00084020/10} page 10, paragraph 20. 1179 Brown {Day207/47:25}-{Day207/48:18}; Hayward {Day201/8:15}-{Day201/9:7}. 1180 Hayward {LFB00055191/26-29} pages 26-29, paragraphs 77 to 78.4; Hayward {Day201/16:6-8}; Smith {Day204/87:19}-{Day204/88:4}. 1181 Hayward {LFB00055191/26-29} pages 26-29, paragraphs 77 to 78.4; Hayward {Day201/16:6-8}; Joanne Smith {LFB00121219/23} page 23, paragraph 60; Smith {Day204/110:23}-{Day204/111:16}. 1182 Hayward {LFB00055191/28} page 28, paragraph 78.2.2. 1183 Smith {Day204/123:7-20}; Brown {Day207/109:10-24}. 1184 Hayward {LFB00055191/28} page 28, paragraph 78.2.2; Smith {Day204/123:7-25}; {Day204/132:1-9}; Minutes of Operational Review Team Meeting on 11 January 2017 {LFB00040541/2}; Brown {Day207/109:10-24}. 1185 Smith {LFB00121219/24} page 24, paragraph 62; Smith {Day204/113:23}-{Day204/116:12}. 1186 Hayward {LFB00055191/29} page 29, paragraph 78.3; Hayward {LFB00086213/7} page 7, paragraph 35; Hayward {Day201/80:13}-{Day201/84:8}. 1187 Hayward {Day200/110:24-25}. 1188 Smith {Day204/116:17-23}. 1189 Smith {Day204/117:11-22}.

The Grenfell Tower Inquiry: Phase 2 Report 144 without the need for computer resources had been tried previously with only partial success. AC Brown said he had been taken by surprise to discover in 2016 that computer- based training had still not been implemented, but he refused to accept that the failure to implement the recommendation made in 2010 to introduce computer-based training for all control room staff on fire survival guidance reflected a chronic failure of management.1190 79.44 Assuming that the statistics produced by POM Hayward are broadly correct, the number of control room staff involved in fire survival guidance training, such as it was, between 2013 and 2017 was strikingly low. In 2013 and 2014, only 28% and 29% respectively of control room staff received any form of training.1191 In 2015, no fire survival guidance training was carried out at all because of the introduction of Vision.1192 In 2016, only 46% of control room staff received fire survival guidance training, and by the time of the Grenfell Tower fire in 2017, no fire survival guidance training at all had been delivered to any existing control room staff member that year.1193 79.45 POM Hayward explained that in 2013 the LFB’s priority had been to ensure that its new mobilising system, Vision, was working, as they had initially been given less than 14 months to deliver it.1194 We shall return to Vision, but it is sufficient for present purposes to note that its introduction was a significant undertaking, which diverted attention from chronic problems affecting the management of fire survival guidance calls and related training. The control room also suffered from significant staffing problems and underwent restructuring between 2009 and 2017.1195 During that period, none of the senior control room managers sought to take stock of training needs or take steps to ensure that all necessary training was given.1196 79.46 In January 2015, when SOM Smith returned from her secondment to the Chief Fire Officers Association, she assumed responsibility for the Operational Support Team and control room training.1197 She asked for a list of CROs who had fire survival guidance training outstanding. She thought she must have received one, but had no specific recollection of it.1198 We were not shown any such list. 79.47 On returning to her position in the control room SOM Smith had a handover discussion with SOM Bagnelle, but it did not touch on the numbers of control room staff who had received fire survival guidance training during her time on secondment (i.e., from September 2012 to January 2015).1199 She was not told that the number of staff receiving fire survival guidance training had collapsed in 2013 and 2014,1200 nor was she told about the changes that had been made to the training or that active role-play had been changed to passive role-play in 2012.1201 She was unaware that in 2013 and 2014 fire survival guidance training had been limited to CROs reviewing presentations and being involved in command unit training sessions.1202 She was told that fire survival guidance training had 1190 Brown {Day207/105:15}-{Day207/106:25}. 1191 Hayward {LFB00055191/26} page 26, paragraph 74. 1192 Hayward {LFB00055191/26} page 26, paragraph 74. 1193 Hayward {LFB00055191/26-29} pages 26-29, paragraph 74 and paragraph 78.4; Smith {Day204/91:13-21}. 1194 Hayward {Day201/16:9-22}. 1195 Hayward {LFB00055191/30} page 30, paragraph 79; Hayward {Day201/17:12-18}. 1196 Hayward {LFB00055191/30} page 30, paragraph 79; Hayward {Day201/17:12-18}. 1197 Smith {LFB00121219/6} page 6, paragraph 15. 1198 Smith {LFB00121219/22} page 22, paragraph 56; Smith {Day204/79:22}–{Day204/80:15}. 1199 Smith {Day204/79:9-20}. 1200 Smith {Day204/78:3-18}. 1201 Smith {Day204/81:13}-{Day204/82:10}. 1202 Smith {Day204/83:1-6}.

Part 8 | Chapter 79: Fire survival guidance: training and management 145 been reduced from a full day to four hours,1203 but she did not ask why training had not been delivered as originally planned. She assumed that appropriate training had been provided while she had been away.1204 79.48 In 2015, SOM Smith discovered that there were not enough trainers to provide fire survival guidance training in the way that had been intended in 2011.1205 Although she asked POM Hayward to make additional resources available to the Operational Support Team and two or three members of staff were seconded from the watch, they were required for training on Vision and were not available for fire survival guidance training.1206 79.49 From the latter part of 2016, SOM Smith monitored fire survival guidance training because she was trying to revise the computer-based training packages and resolve the problems with access.1207 It is not clear why she had not been doing that from the time she returned in January 2015. During 2017, she worked with the training team to create a new fire survival guidance refresher training package which was due to be delivered in September 2017,1208 but it did not lead to an increase in the number of CROs being trained in fire survival guidance or to any improvement in the content of the training. 79.50 Although the LFB could not reasonably have foreseen the considerable difficulties that were encountered in implementing Vision, that does not excuse the failure of the senior officers responsible for the operation of the control room, namely, SOM Smith, POM Hayward and AC Brown, to keep fire survival guidance training under close review and, in particular, to decide how to deliver such training once it became clear that the problems flowing from the introduction of Vision were dominating the control room’s attention, time and resources. 79.51 Despite the failure to deliver fire survival guidance refresher training, neither POM Hayward nor AC Brown informed the Lakanal House Board, the Lakanal House Working Group or the co-ordination board that training had fallen far short of that which had been approved and promised to the coroner.1209 It seems that no one in senior management was aware of the true scale of the failure to provide fire survival guidance training between 2012 and 2017. For example, in January 2013, AC Brown told AC Dexter that 94 out of 104 staff had been given fire survival guidance refresher training.1210 That figure, which amounted to 90.4% of staff, was far in excess of the figure of 61% provided by POM Hayward in his witness statement,1211 but although the basis of his figure of 90.4% could not be identified, AC Brown remained confident that training had been taking place. He thought that any apparent shortfall in numbers was attributable to poor record-keeping.1212 1203 Smith {Day204/81:17-20}. 1204 Smith {Day204/84:1-15}. 1205 Smith {LFB00121219/25} page 25, paragraph 68; Smith {Day204/96:7-21}. 1206 Smith {Day204/96:22}-{Day204/98:9}. 1207 Smith {Day204/91:22}-{Day204/92:7}. 1208 Smith {Day204/92:4-7}. 1209 Brown {Day201/21:22}-{Day201/22:4}; Hayward {Day201/73:12-25}. 1210 Draft LFB Report ‘Review of the Lakanal Action Plan’ {LFB00085854/14} and {LFB00085854/26}. See comment “d10”. 1211 Draft LFB Report ‘Review of the Lakanal Action Plan’ {LFB00085854/14} and {LFB00085854/26}. See comment “d10”; Hayward {LFB00055191/25} page 25, paragraph 74. 1212 Brown {Day207/72:14-22}; Brown {LFB00032166/21} page 21, paragraph 66.

The Grenfell Tower Inquiry: Phase 2 Report 146 79.52 In his review of the Lakanal pre-inquest actions in June 2013, AC Chandler said that the refresher training programme had been put in place and that no further action was required.1213 The Chandler review was sent to AC Brown and POM Hayward for information,1214 but POM Hayward did not correct him and provide the true picture.1215 79.53 In 2014, Adrian Bevan, an LFB health and safety manager,1216 asked for information from AC Brown about control room training to enable him to answer a request from the Health and Safety Executive for information on control room practices, procedures and training following the Lakanal House inquests.1217 On 3 July 2014, AC Brown told Mr Bevan that between February 2011 and June 2014 277 individual fire survival guidance training sessions had been delivered by senior control room officers in addition to the regular watch training sessions.1218 However, although the source of that particular statistic is not clear,1219 it is plain that POM Hayward did not tell AC Brown that by July 2014 fire survival guidance refresher training was being given to less than a quarter of control room staff.1220 It is also notable that the Health and Safety Executive was not told that since 2012 fire survival guidance training had not met national guidance in some material respects.1221 79.54 AC Brown accepted that he did not know how many CROs were actually being trained in fire survival guidance at the time, but he said that after his discussions with POM Hayward and the CROs he had been left with the impression that fire survival guidance refresher training was being delivered where practically possible.1222 However, at no stage did POM Hayward ever provide AC Brown with a reliable record of fire survival guidance training, which would have enabled it to be effectively monitored, and AC Brown never asked for one.1223 Nevertheless, AC Brown was aware of periods during which fire survival guidance refresher training was not being provided as had been agreed – for example, between 2015 and 2017, when the training of control room staff concentrated on the Vision mobilising system.1224 Although he accepted in the light of the Lakanal House fire and the findings of the Mayor’s Office for Policing and Crime1225 (to which we refer later) that fire survival guidance training was of critical importance, AC Brown sought to justify its absence on the grounds that all available resources had been taken up by the need to train staff on Vision. He maintained that the quality of the control room’s response to fire survival guidance calls had been kept under continuous review.1226 1213 Email from Chandler to Brown dated 28 June 2013 regarding Lakanal Audit {LFB00060701/1}. 1214 Email from Chandler to Brown dated 28 June 2013 regarding Lakanal Audit {LFB00060701/1}. 1215 Email from Chandler to Brown dated 28 June 2013 regarding Lakanal Audit {LFB00060701/1}; Hayward {Day201/29:8-19}. 1216 Hayward {Day201/30:1-10}. 1217 Email from Brown to Bevan copied to Scott Hayward, Philip Evans and Danielle Cotton dated 3 July 2014 regarding HSE info – control training {LFB00037428/1-2}. 1218 Email from Brown to Bevan copied to Scott Hayward, Philip Evans and Danielle Cotton dated 3 July 2014 regarding HSE info – control training {LFB00037428/2}. 1219 Hayward {Day201/31:8}-{Day201/32:16}. 1220 Hayward {Day201/35:11-22}. 1221 Email from Brown to Bevan copied to Scott Hayward, Philip Evans and Danielle Cotton dated 3 July 2014 regarding HSE info – control training {LFB00037428/1-2}. 1222 Brown {Day207/92:1-14}; Brown {LFB00084020/13} page 13, paragraph 29. 1223 Hayward {Day201/55:6-24}. 1224 Brown {LFB00084020/13} page 13, paragraph 30; Hayward {Day201/55:22}-{Day201/57:14}; Brown {Day207/94:15- 20}. 1225 Email chain between Scott Hayward and Karen Mason dated 17-18 November 2014 regarding Brigade Control Audit {LFB00030108}; Hayward {Day201/42:1-4}; Internal Audit – Progress Report Quarter 3 2014/2015 dated 9 March 2015 {LFB00044640/1}. 1226 Brown {Day207/94:10}-{Day207/95:16}.

Part 8 | Chapter 79: Fire survival guidance: training and management 147 79.55 The introduction of Vision clearly made great demands on the resources available for training, but the fact remains that there was a chronic, systemic failure to ensure that effective fire survival guidance refresher training was consistently provided to all control room staff. Such quality assurance as existed had signally failed to identify the fact that, from 2012 onwards, the number of CROs receiving such training was low. There was a consistent failure to comply with national guidance or with the assurances given to the coroner. 79.56 In July 2016, at the instigation of AC Brown, AC George carried out a review of the control room, but did not identify fire survival guidance training as an area of concern.1227 It had not been included in his terms of reference,1228 which had been informed by discussions with staff between September and November 2015.1229 In these discussions, CROs had not expressed concern about the lack of fire survival guidance training1230 or about their readiness to handle fire survival guidance calls.1231 AC George himself was not concerned about fire survival guidance training because when he started his review AOM Sharp had given him a schedule of planned training.1232 He was not aware of the changes that had been made to the fire survival guidance refresher training by the Lakanal House Board;1233 nor was he aware that in 2015 and 2016 training on Vision had, to say the least, placed severe restrictions on it.1234 79.57 AC George was confident that fire survival guidance training was taking place because he witnessed it in 2016 and early 20171235 and he was assured by AOM Sharp, POM Hayward and SOM Smith that it was being delivered.1236 However, the training he witnessed was command unit training, which was not aimed at CROs, and he did not attend the training sessions himself, having simply seen from his office window a number of people and command units gathered outside.1237 AC George did not examine the content of the fire survival guidance training packages and he had no direct knowledge of the extent to which they had been delivered in 2016 and 2017.1238 79.58 In the report of his review that he presented to the Corporate Management Board in February 2017 AC George said that additional familiarisation training on fire survival guidance had been given to all staff.1239 Insofar as that gave the impression that additional fire survival guidance training had been provided to all CROs since his first report in July 2016,1240 it was misleading. AC George accepted that, as head of the Operational Response department and, from March 2017, Director of Operations, he should have been aware of the consistent failure to provide fire survival guidance training to CROs in 2016 and 20171241 and that that failure was both chronic and systemic.1242 He said that POM 1227 Review of Brigade Control Report dated July 2016 {LFB00032826}; George {LFB00083884/11} page 11, paragraph 34; George {Day205/55:6}-{Day205/57:6}. 1228 Review of Brigade Control Terms of Reference {LFB00032827/1}. 1229 Review of Brigade Control – the issues raised by staff prior to the review commencing {LFB00032831/3}; George {Day205/36:13-20}; George {LFB00032823/4} page 4, paragraphs 12 and 13. 1230 George {Day205/55:6-14}. 1231 George {Day205/57:3-6}. 1232 George {Day205/65:4-8}. 1233 George {Day205/65:9}-{Day205/67:3}. 1234 George {Day205/80:8-19}. 1235 George {Day205/151:6-25}. 1236 George {Day205/151:6-25}; George {Day205/153:16-24}. 1237 George {Day205/151:20}-{Day205/153:5}. 1238 George {LFB00032823/8} page 8, paragraph 31; George {LFB00083884/14} page 14, paragraph 49. 1239 CMB report on Review of Brigade of Control for CMB, dated 15 February 2017 {LFB00032824/6}. 1240 Hayward {Day201/75:2}-{Day201/76:3}. 1241 George {Day205/165:9-22}. 1242 George {Day205/165:9-22}.

The Grenfell Tower Inquiry: Phase 2 Report 148 Hayward and SOM Smith had regularly told him about the problems being encountered with Vision, which had crowded out other training,1243 but there is no evidence that he made any effective effort to ensure that regular and structured fire survival guidance training was provided. 79.59 The importance of fire survival guidance refresher training cannot be over-stated. The senior officers responsible for the control room plainly understood the need to give priority to such training, particularly because of the weaknesses in handling emergency calls exposed by the Lakanal House fire in 2009. At that time no structured or regular fire survival guidance refresher training was being conducted by the LFB and at the time of the Grenfell Tower fire in June 2017 that remained the case. The failure to provide CROs with regular fire survival guidance refresher training is undoubtedly a serious indictment of the LFB. Even allowing for the difficulties resulting from the introduction of Vision, there is no justification for such a longstanding failure to address a vital element of the control room’s work that was well known to senior management. 79.60 Even though the Lakanal House fire demonstrated the real danger to life posed by the failure to provide effective fire survival guidance training, the fact is that none of senior officers responsible for the operation of the control room ever tackled the challenge of providing the necessary training with the seriousness or dedication it deserved. Monitoring the quality of responses to fire survival guidance calls 79.61 The need to monitor and manage the performance of CROs, particularly in relation to handling fire survival guidance calls, was identified in the Lakanal Control Report, which recommended the introduction of a policy identifying the standards that staff were expected to reach and how performance would be assessed and monitored, particularly in relation to calls where fire survival guidance was given.1244 That recommendation was said to have been implemented by senior managers’ undertaking a review of all high-rise or fire survival guidance calls and amending the RIFs and training packages to ensure that they reflected FSC10-93 and ‘Keeping People Safe’.1245 Although it did not give the impression that a new policy of the kind envisaged by the recommendation had been introduced, the statement was misleading insofar as it gave the impression that the omissions and flaws that we identified earlier had been put right.1246 AC Brown explained the failure to introduce a policy of the kind contemplated by the recommendation by the fact that those with responsibility for the control room had revised the existing materials in a way that met the substance of the recommendation.1247 79.62 In late 2009, after the Lakanal House fire, a quality assurance system known as ‘Call Coach’ was introduced. At the suggestion of SOM Smith it was supplemented by a review of fire survival guidance calls to check whether the training introduced after the Lakanal House fire had been effective.1248 79.63 Call Coach was a structured system of reviewing and learning from the way in which CROs handled calls coming into the control room. In summary, a supervisor would choose at random from a short list of three calls at least one call a month for each call-handler and 1243 George {Day205/165:23}-{Day205/166:10}; {Day205/169:23}-{Day205/170:2}. 1244 Lakanal Control Report {HOM00001124/53}; Lakanal Control Report {HOM00001124/31} paragraphs 161-163. 1245 Lakanal Control Report {HOM00001124/53}; Lakanal Control Report {HOM00001124/31} paragraphs 161-163. 1246 Brown {Day207/28:5-20}. 1247 Brown {Day207/28:21}-{Day207/29:5}. 1248 Smith {Day202/49:11-15}.

Part 8 | Chapter 79: Fire survival guidance: training and management 149 one call every three months for each team leader.1249 The supervisor would listen to the call and assess the call‑handler using a prescribed standard which included a scoring system.1250 After the assessment, a meeting would be held between the call-handler (or team leader) and the supervisor to discuss and review the assessment.1251 The supervisor assessing the call was then responsible for coaching the call-handler or team leader and monitoring the results obtained from successive assessments.1252 SOM Smith was responsible for introducing the system,1253 which had been operated monthly between 2010 and November 2015.1254 79.64 However, fire survival guidance calls were not included in the Call Coach assessments.1255 The decision to exclude them appears to have flowed from an agreement between DAC Payton, then Deputy Assistant Commissioner for Control and Mobilising, and the trade unions.1256 The reason for any such agreement is unclear, but it meant that supervisors did not have an opportunity to assess the quality of the response to fire survival guidance calls except when they supported a CRO handling such a call or during the fire survival guidance review process described below.1257 Since assessment was not the purpose of the supervisor’s involvement, supporting a CRO during a fire survival guidance call did not amount to an effective form of monitoring and managing performance. 79.65 Call Coach provided supervisors with a degree of reassurance about CROs’ ability to handle calls, but POM Hayward did not think it was a particularly good system.1258 However, partly because of the money that had been spent acquiring it and partly because of the time spent bringing it into operation, POM Hayward was not inclined to look into other ways of assessing those skills.1259 SOM Smith was not aware of Operational Support Team’s analysis of the CROs’ performance and AC Brown did not ask her to consider the outcome of reviews.1260 79.66 In November 2015, when Vision was introduced, Call Coach became obsolete and was replaced by a new system called Neptune Intelligence Computer Engineering (Neptune).1261 However, Neptune was not used to review call-handling by CROs and no formal arrangements were made to make up for the loss of Call Coach.1262 No quality assurance review process was therefore in place to monitor CROs’ call-handling in the years leading up to the Grenfell Tower fire.1263 1249 Call Coach Management Note {LFB00121231/6}; Smith {Day202/31:10}-{Day202/32:23}. 1250 Call Coach Management Note {LFB00121231/2-3}; Smith {Day202/34:1-23}. 1251 Call Coach Management Note {LFB00121231/2-3}. 1252 Call Coach Management Note {LFB00121231/4}. 1253 Smith {LFB00121219/7} page 7, paragraph 17. 1254 Smith {Day202/35:10-14}; {Day202/45:10}-{Day202/47:11}. 1255 Smith {Day202/38:1-18}; The detail required to assess a fire survival guidance call was not included in the call‑handling excellence standard, Call Coach Management Note {LFB00121231} Appendix B; Smith {Day202/38:11- 18}. 1256 Smith {Day202/39:4-13}; {Day202/59:15-21}. 1257 Smith {Day202/38:19-22}. 1258 Hayward {Day199/56:22}-{Day199/57:17}; see SOM Smith’s comments on the draft training audit report prepared by SM Kelly {LFB00109082/9}; Smith {Day202/41:25}-{Day202/43:13}. 1259 Hayward {Day199/58:1-10}. 1260 Smith {Day202/37:3-16}; Brown {Day207/27:9-17}. 1261 Hayward {LFB00055191/39} page 39, paragraph 96. 1262 Hayward {LFB00055191/39} page 39, paragraph 97; Hayward {Day199/59:15-19}. 1263 Smith {Day202/47:10-12}.

The Grenfell Tower Inquiry: Phase 2 Report 150 79.67 Following an incident, however, it was standard practice for senior managers on duty to review fire survival guidance calls.1264 There was no policy or guidance document available to direct their reviews so they relied on their own experience and training.1265 A description of the circumstances in which each call had been made and a summary of its contents were recorded in an electronic database, but the database did not include any comments critical of the call-handler.1266 Although SOM Smith said that the database was of some value, for example, in identifying causes of concern or examples of good practice, the process did not amount to a systematic appraisal of the performance of CROs.1267 There was no evidence of how the review was used or how it contributed to their training or development.1268 79.68 In addition to the review carried out by senior managers, SOM Smith reviewed every fire survival guidance call and every call from a high-rise building on the system1269 to check that the correct advice had been given in accordance with FSC 10-93, and later, PN539.1270 If deficiencies were found, the CRO’s line manager would take the necessary action.1271 POM Hayward said that he and SOM Adam Crinion had also listened to the calls.1272 However, the findings of SOM Smith’s review were not recorded anywhere and we have seen only a few of the reports that were provided to OMs and CROs about the handling of fire survival guidance calls.1273 Those that we have seen are all positive and do not identify any mistakes in the way that calls were handled.1274 79.69 Although SOM Smith told us that the obligation to review fire survival guidance calls fell to the person on duty at the time a call was received,1275 SOM Keith Diamond and SOM Bagnelle assumed that task after she had been seconded to the Chief Fire Officers Association in September 2012.1276 79.70 When SOM Smith returned to the LFB in January 2015, she did not ask SOM Diamond or SOM Bagnelle for a report on the fire survival guidance reviews they had undertaken in her absence,1277 but she did resume her review of all fire survival guidance calls, relying on her expertise rather than PN539.1278 By that time she found it had become impossible to review all the calls from high-rise buildings because the number of calls typically received by the LFB during high-rise incidents had become too great and her workload had increased with the introduction of Vision.1279 She did not delegate the task to anyone else and was confident that the Operational Support Team had not had the capacity to take it on because its workload had also increased as a result of the introduction of Vision.1280 Given that Call Coach had become obsolete at the same time, there was no review of CROs’ call‑handling after 2015, apart from the limited and uncritical review described above. 1264 Smith {Day202/50:15-25}. 1265 Smith {Day203/9:2-21}. 1266 Smith {Day203/10:13-19}; FSG Database {LFB00031757}. 1267 Smith {Day203/11:6-14}. 1268 The FSG Database did not record any lessons to be learnt or systems to be reviewed {LFB00031757}. 1269 Smith {LFB00121219/8} page 8, paragraph 18; Smith {Day202/50:13}-{Day202/51:12} and {Day202/52:20-23}. 1270 Smith {LFB00121219/8} page 8, paragraph 18; Smith {Day202/54:4}-{Day202/55:6}; {Day202/54:7}-{Day202/57:6}. 1271 Smith {LFB00121219/8} page 8, paragraph 18; Hayward {Day199/64:16}-{Day199/65:5}; Smith {Day202/49:16-20}. 1272 Hayward {Day199/62:21-25}; SOM Smith also thought that Peter Suarez, Control Commander in the Technical Support Group, also listened to the call {Day202/52:15-19}. 1273 Hayward {Day199/63:22-24} and {Day199/65:10-12}. The only email about feedback after a fire survival guidance call review provided to the Inquiry was: Email from Joanne Stibbards to Keith Diamond dated 22 October 2011 {LFB00121235}. 1274 Email from Joanne Stibbards to Keith Diamond dated 22 October 2011 {LFB00121235}. 1275 Smith {Day202/62:21-24}. 1276 Hayward {Day199/64:3-7}. 1277 Smith {Day202/64:10-24}. 1278 Smith {LFB00121219/8} page 8, paragraph 19; Smith {Day202/66:7-17}. 1279 Smith {LFB00121219/8} page 8, paragraph 19; Smith {Day202/69:3-14}. 1280 Smith {Day202/69:15-18}.

Part 8 | Chapter 79: Fire survival guidance: training and management 151 SOM Smith told us that a structured debriefing process had been in place since 2011 to enable CROs, supervisors and OMs to share and discuss their experiences following an incident.1281 On any view, however, that was not the kind of independent review of call- handling that she had previously undertaken. 79.71 The absence of any effective arrangements for undertaking a critical review of the quality of responses to fire survival guidance calls compounded the pre-existing problem surrounding the correct description of a fire survival guidance call that the LFB had failed to resolve effectively. After Call Coach became obsolete in 2015, the LFB failed to introduce an alternative system for critically reviewing fire survival guidance calls to make sure that CROs were meeting the standard required by PN539. No good explanation was provided for that failure, which provides another example of the LFB’s continuing inability to recognise the importance of fire survival guidance calls in ensuring the safety of people affected by fire and smoke. Policy No. 790 79.72 On 23 February 2012, the LFB issued a new policy, Policy No. 790 (PN790) ‘Fire survival guidance calls’ to replace PN155.1282 It was an operational policy designed for use by firefighters and covered the exchange of fire survival guidance information between the control room and the incident ground.1283 It was not designed for use by the control room itself, even though it had a significant bearing on the handling of fire survival guidance calls.1284 It was developed primarily by SM Patrick Utting, working closely with SOM Smith throughout the drafting, consultation and approvals process.1285 79.73 Although PN790 recognised that a large number of fire survival guidance calls could be received during a single incident,1286 it offered no guidance to control room staff on how best to respond to such a situation.1287 Neither AC Brown nor any other senior officer asked POM Hayward to assess the effect of the new policy on the control room or to determine what training might be required as a result. AC Brown sought to justify that omission on the basis that the control room was used to handling many different incidents at the same time and that although fire survival guidance calls were different and not received very often, CROs used the same knowledge, skills and experience as they used on a daily basis when handling them.1288 We cannot accept that. The seriousness of fire survival guidance calls and the fact that incidents giving rise to multiple fire survival guidance calls occurred relatively infrequently make it difficult to see how he could reasonably have considered them to be a part of normal business. The various failures in handling fire survival guidance calls identified by the LFB itself following the Lakanal House fire required a more considered approach to making sure that CROs were given as much help as possible in responding to the challenges presented by the need to handle several fire survival guidance calls at the same time. We do not understand why that never occurred to AC Brown or any other senior officer responsible for the control room. 1281 Smith {Day202/69:19}-{Day202/70:9}. 1282 Fire Survival Guidance Calls (PN790) {LFB00001257}; It was designed to complete Pre-Inquest action 14, Lakanal Assurance Report {LFB00004801/15}; For the Phase 1 findings in respect of PN790, Phase 1 Report Volume IV paragraphs 29.18 – 29.23, 29.47 and 29.48. 1283 Utting {LFB00118918/3} page 3, paragraph 8; Smith {Day203/129:12-14}; {Day203/155:16-23}; Smith {MET00080606/13}. 1284 Smith {MET00080606/13}. 1285 Utting {LFB00118918/3} page 3, paragraph 8; Smith {Day203/128:20}-{Day203/129:7}. 1286 Fire Survival Guidance Calls (PN790) {LFB00001257} paragraphs 4.1, 5.13, 6.2, 7.6 and 9.4, and Appendix 3. 1287 Brown {Day206/124:3-19}. 1288 Hayward {Day206/124:3-19}.

The Grenfell Tower Inquiry: Phase 2 Report 152 79.74 Following its introduction, supervisors discussed PN790 with CROs to ensure that they were generally familiar with its contents, but no formal or structured training was provided.1289 The training records indicate that only some of the control room supervisors themselves received any training on it.1290 Although that may reflect poor record-keeping, that fact alone meant that the LFB had no accurate note of who had received training on the new policy and who had not.1291 79.75 Paragraph 8.7 of PN790 recognised that in exceptional circumstances an incident commander might consider informing control that the “stay put” advice to callers should be changed and that they should try to leave their property. At the same time, it warned the incident commander that such advice might be contrary to national policy for control staff engaged on fire survival guidance calls and that it would be necessary to communicate with the officer in charge at the control room to get agreement for such a change.1292 79.76 In the context of the Grenfell Tower fire that was an important provision. SOM Smith was the principal author of paragraph 8.7, so after the Lakanal House fire she was aware that “stay put” advice might have to be changed.1293 However, even though she and POM Hayward were aware of that paragraph, they gave no consideration to training CROs on how to explain to a caller that the advice previously given had been changed.1294 SOM Smith’s explanation for that failure was that the LFB did not think that in practice it would be necessary to do that.1295 POM Hayward’s evidence echoed that of SOM Smith. He said that the LFB had not expected “stay put” advice ever to be withdrawn, so no training had been given on how best to respond to that situation.1296 79.77 It is impossible to reconcile the attitude displayed by POM Hayward and SOM Smith with the clear terms of paragraph 8.7. In effect, they simply ignored it and by doing so deprived those who worked in the control room, and thereby the LFB as a whole, of the training designed to prepare them for the challenges they would face if “stay put” advice had to be revoked. That was a very serious failure for which no plausible excuse has been offered. Moreover, the procedures that the control room would rely on if multiple fire survival guidance calls were received were never properly tested in a training exercise. After the Lakanal House fire a few training exercises were held to test the handling of fire survival guidance calls, and in particular, the arrangements for passing information to the incident ground, but none of them tested the effectiveness of the control room’s own procedures. 79.78 The first of those tests was the Heygate Challenge, held on 16 June 2011, which was designed to test the proposed amendments to the high-rise firefighting policy (PN633) and the new fire survival guidance policy (then PN155).1297 Four fire survival guidance calls were used in the exercise.1298 POM Hayward explained that the exercise had been designed to test communications rather than to assess the capacity of the control room to 1289 Hayward {LFB00121176/6} page 6, paragraph 21: Hayward {Day199/223:3}-{Day199/224:10}. 1290 Training Spreadsheet {LFB00055223}; AOM Christine Sharp and AOM Gary Court were provided with training “Fire Survival Guidance calls – 790” but there is no other training recorded about PN790 in respect of any other control staff member. There was no training for PN790 recorded on the Control FSG Training Record {LFB00041763}. 1291 Training Spreadsheet {LFB00055223}; AOM Christine Sharp and AOM Gary Court were provided with training “Fire Survival Guidance calls – 790” but there is no other training recorded in respect of PN790. There was no training for PN790 recorded on the Control FSG Training Record {LFB00041763}; Hayward {Day199/224:25}-{Day199/225:7}. 1292 Fire Survival Guidance Calls (PN790) {LFB00001257/5} paragraph 8.7. 1293 Smith {MET00080606/13}. 1294 Hayward {Day199/221:10-14}; Smith {MET00080606/13}. 1295 Smith {MET00080606/13}; Smith {Day203/97:7-25}. 1296 Hayward {Day199/221:15-23}. 1297 Email from Andy Roe to numerous LFB participants {LFB00033345/1-4}. 1298 Minutes of the Heygate Estate high-rise exercise de-brief meeting {LFB00056628/4}; Feedback: High Rise and FSG Policies Test Exercise 16th June 2011 Southwark {LFB00033384/11}.

Part 8 | Chapter 79: Fire survival guidance: training and management 153 deal with a significant number of fire survival guidance calls.1299 In other words, the focus was not on the training of CROs. No-one representing the control room appears to have had any influence on the number of fire survival guidance calls used. As we have noted in chapter 78, neither POM Hayward nor SOM Smith could explain why the exercise had assumed the existence of only four fire survival guidance calls, given that five had been received at the Lakanal House fire.1300 79.79 Although the magnitude of the challenge presented by multiple fire survival guidance calls was identified in the exercise, the LFB never organised an exercise specifically to test the number of calls that the control room could effectively handle.1301 In view of the difficulties experienced by CROs in handling the five calls generated by the Lakanal House fire, no good reason was given for that failure. 79.80 The second exercise, held on 20 December 2012, was Exercise Florian, which simulated a fire on the seventh floor of a 15-floor purpose-built block of maisonettes, generating three fire survival guidance calls involving four persons, three of whom were rescued and one of whom escaped without assistance.1302 The aim of the exercise was to find out how well PN790 worked in practice and whether it contained any defects.1303 79.81 However, the exercise did not focus on all aspects of PN790. For example, it did not practise the revocation of “stay put” advice or consider the consequences that might flow from that.1304 Nor did it use the same number of fire survival guidance calls as had been received during the Lakanal House fire, although AC Brown thought that the three calls that formed the basis of Exercise Florian had reflected the three calls received simultaneously at the Lakanal House fire.1305 He said that no consideration had been given to including more than five fire survival guidance calls in order to test the arrangements in PN790 because there was an unspecified exercise going on in the background in the control room, which simulated other incidents. AC Brown believed that together they would have put the control room under the same pressures.1306 Even if that were so, however, the exercise did not address the important function of rigorously testing the arrangements for handling multiple fire survival guidance calls. 79.82 Unfortunately, Exercise Florian did not test the control room’s ability to handle a growing number of fire survival guidance calls.1307 As with the Heygate Challenge, its focus was on the response of operational crews rather than the control room’s ability to handle multiple fire survival guidance calls. The CROs’ function appears to have been to assist in the exercise and act as observers rather than undergo training.1308 Given the failings in handling fire survival guidance calls later identified in the Lakanal Control Report, appropriate training for the CROs should have been included in the exercise. One of the suggestions made following that exercise was that someone should turn the documents created for the exercise into a regular training programme.1309 POM Hayward said that regular training 1299 Hayward {Day199/213:24}-{Day199/214:7}. 1300 Hayward {Day199/213: 24}-{Day199/214:7}; Smith {Day202/172:1-16}. 1301 Feedback: High Rise and FSG Policies Test Exercise 16th June 2011 Southwark {LFB00033384/11}; Minutes of the Heygate Estate high-rise exercise de-brief meeting {LFB00056628/4}; Hayward {Day199/214:15-23}. 1302 Exercise Florian Facilitator Briefing {LFB00122827/5}; Bagnelle {LFB00122821/15} page 15, paragraph 55. 1303 Hayward {Day200/4:16}-{Day200/5:2}; Fire Survival Guidance Calls (PN790) {LFB00001257/1}. 1304 Brown {Day206/134:9-18}. 1305 Brown {Day206/135:8-15}. 1306 Brown {Day206/135:16}-{Day206/136:9}. 1307 Brown {Day206/134:9-18}; Exercise Florian Facilitator Briefing {LFB00122827/5}. 1308 This is also recognised by Vic Bagnelle in an email dated 5 November 2013 regarding Exercise Penfold {LFB00050721/1}. 1309 Email from David Lindridge to Dave Brown, Patrick Utting, Martin Corbett, Scott Hayward and Victor Bagnelle dated 9 January 2013 {LFB00118958/1}.

The Grenfell Tower Inquiry: Phase 2 Report 154 took the form of training with the command units, which ran from mid-2013 until 2015 and again from mid-2016,1310 but again, that training was not designed for the benefit of CROs.1311 It appears, therefore, that no training was introduced for CROs following Exercise Florian. 79.83 The third exercise was Exercise Penfold, which was held on 14 November 2013.1312 It simulated a ten-pump high-rise fire with several seats of fire and persons trapped on various floors.1313 The exercise involved four fire survival guidance calls, to which the CROs were expected to respond using the RIF for guidance.1314 An AOM was available to assist the CROs.1315 Again, it is unclear why the decision was taken to limit the exercise to four fire survival guidance calls, given that five had been received at Lakanal House, or why the LFB did not seek to test the limits of PN790 by using more than five calls.1316 After the exercise, it was suggested that AOMs and the OM be more directly involved in an exercise of that kind in order to practise their roles within fire survival guidance procedures, such as communicating directly with the fire survival guidance command unit.1317 POM Hayward could not say whether that suggestion had been pursued.1318 Following Exercise Penfold, no further exercise or training on PN790 was organised for CROs. At most, they were asked to assist at and observe command unit training exercises which practised communicating fire survival guidance information from the control room to the incident ground. Such exercises were not designed to benefit them. Fire survival guidance training for supervisors 79.84 Pre-inquest action 17 in the Lakanal Control report recommended that an enhanced fire survival guidance training package be developed for control room supervisors to enable them to provide support to CROs handling fire survival guidance calls to ensure a standard commensurate with national guidance.1319 In June 2011, the Operational Support Team produced a training package for supervisors in response to that recommendation, supported by a slide presentation.1320 The presentation stated that the supervisors’ main function was to support CROs taking fire survival guidance calls and to make sure that the information they gathered was passed to the incident commander or the command unit.1321 It suggested ways in which a supervisor could support a CRO taking a fire survival guidance call, including ways of gathering relevant information from the caller.1322 It also suggested ways in which a supervisor could assist in passing information to the incident ground, for example, by appointing a supervisor to act as the sole contact between the control room and the incident ground.1323 The presentation contemplated that multiple fire survival guidance calls might be received but did not include any advice about how a supervisor should collate the relevant information and transmit it to the incident 1310 Hayward {Day200/14:11}-{Day200/15:24}. 1311 Hayward {LFB00055191/28} page 28, paragraph 78.2.2. 1312 Brief for Exercise Penfold {LFB00122841}; Bagnelle {LFB00122821/14} paragraphs 51-53. 1313 Email chain between Paul Trew and Scott Hayward and Vic Bagnelle dated 27 June 2013 {LFB00050487/2}. 1314 Bagnelle {LFB00122821/14} page 14, paragraph 52. 1315 Bagnelle {LFB00122821/14} page 14, paragraph 52. 1316 Scott Hayward could not assist, Hayward {Day200/42:9-24}. 1317 Feedback from N O’Shea following Exercise Penfold {LFB00122826/2}. 1318 Hayward {Day200/48:1-4}. 1319 Lakanal Assurance Report {LFB00004801/16}. 1320 Hayward {LFB00055191/8} page 8, paragraph 20; Hayward {Day201/94:18-23}; Supervisor FSG Training Presentation {LFB00086222}. 1321 Supervisor FSG Training Presentation {LFB00086222/7}. 1322 Supervisor FSG Training Presentation {LFB00086222}. 1323 Supervisor FSG Training Presentation {LFB00086222/7-10}.

Part 8 | Chapter 79: Fire survival guidance: training and management 155 ground.1324 The presentation included a list of prompts for information that should be collected and passed immediately to the incident ground, but did not refer to the need to remind the CRO to obtain information about any vulnerabilities the caller or others with them might have.1325 POM Hayward said that CROs normally asked for information of that kind but that in any event they expected callers to volunteer it without needing to be asked.1326 The training did not include any reference to the Lakanal House fire, nor did it identify any lessons to be learnt from it.1327 Notwithstanding SOM Smith’s evidence to the contrary, the training does not appear to have been revised after November 2012 to reflect the reasoning and conclusions of the Lakanal Control report, despite its relevance to any supervisor who might need to manage the control room during an incident of that kind.1328 79.85 In 2014, the Operational Support Team developed another short training exercise for control room supervisors lasting between 30 and 60 minutes.1329 It partly remedied one of the defects in the previous training by reminding supervisors that CROs should ask whether the caller was disabled, used a wheelchair or whether they were ill and used oxygen,1330 but it did not tell supervisors to remind CROs that such information should be passed to the incident ground.1331 79.86 It is not clear whether the training we have described was provided to all supervisors.1332 It seems clear, however, that they were not trained how to manage the control room during a large incident that gave rise to multiple concurrent fire survival guidance calls.1333 Nor were they trained in how to deal with a major incident.1334 That was another serious failure for which no satisfactory explanation was given. Isolation of the control room 79.87 There were a number of other causes, mainly of an organisational nature, that contributed to the failure of the LFB to provide the training and guidance needed by control room staff. One clear and consistent theme that emerged from the evidence was the existence of a perception within the control room and the wider LFB that the control room was a separate entity distinct and different from the rest of the brigade.1335 That was reflected in the opinion of AC Jonathan Smith when he was instructed by the then Commissioner in July 2019 to undertake a root and branch review of the brigade’s control function.1336 He concluded that the control room needed to be more closely integrated into the brigade, rather than exist as a separate and distinct part of the organisation, as it had become over time. In his view there needed to be a fundamental reappraisal of the position of the control room to ensure that it was given an importance equal to that enjoyed by other sections of the brigade.1337 1324 Hayward {Day201/99:16-22}; Supervisor FSG Training Presentation {LFB00086222/13}. 1325 Supervisor FSG Training Presentation {LFB00086222/9}. 1326 Hayward {Day201/98:8-16}. 1327 Supervisor FSG Training Presentation {LFB00086222/9}; Hayward {Day201/99:23}-{Day201/102:25}. 1328 Smith {Day204/150:18}-{Day204/153:1}. 1329 Bagnelle {LFB00122821/17} page 17, paragraph 62; Supervisor FSG Training Powerpoint {LFB00122832}. 1330 Supervisor FSG Training Powerpoint {LFB00122832/5}. 1331 Supervisor FSG Training Powerpoint {LFB00122832/13}. 1332 There is no reference to it in Scott Hayward’s witness statements or in the Control FSG Training Record {LFB00041763}; Training Spreadsheet {LFB00055223} does record that a number of supervisors received various forms of fire survival guidance training between 2014 and 2017. 1333 Hayward {Day201/103:21}-{Day201/104:6}; Real {MET00080520/6-9}; May {MET00080506/16-17}. 1334 Hayward {Day201/118:21}-{Day201/119:9}. 1335 Smith {Day202/174:24-25}. 1336 Jonathan Smith {LFB00121171/9} page 9, paragraph 24. 1337 Jonathan Smith {LFB00121171/10} page 10, paragraph 30; AC Smith’s ‘Control: Overview and Control Improvement Plan’ {LFB00084097/11}.

The Grenfell Tower Inquiry: Phase 2 Report 156 79.88 The reasons for the isolation of the control room are complex, but were essentially historical, geographical and technological. 79.89 Originally, there had been a number of area control rooms across London, each located within an operational fire station. At some point they were consolidated and became based centrally at LFB headquarters in Lambeth.1338 Throughout both those periods, therefore, control room staff were able to meet their operational colleagues on a daily basis.1339 79.90 In April 2004, the control room moved from Lambeth to Greenwich View Place on the Isle of Dogs and in January 2012 it moved again to a purpose-built London Operations Centre in Merton, which is its current location.1340 When the control room moved to Greenwich View Place, CROs became physically separated from other staff within the organisation.1341 79.91 Technology also played a part in the separation. Over the course of time systems were introduced in other parts of the organisation which could not be used by the control room or were not properly adapted to its needs. The most significant examples are the Staff Attendance Recording System (StARS) and the STEP system.1342 STEP, which was linked to StARS, was designed to enable a senior officer to review the training undertaken by junior officers and plan for future training needs.1343 Although the rest of the LFB used STEP to record training, the control room was unable to do so because StARS could not accommodate its shift patterns. It was therefore obliged to use a spreadsheet to record information about training which was then added to STEP manually.1344 In contrast to the live tracking available to operational staff on STEP, the information on the control room’s spreadsheet was added at monthly or quarterly intervals.1345 It is not clear to us why the adjustment to StARS required to accommodate the control room’s shift patterns was not made before it was introduced. 79.92 AC George said that when he had started working with the control room in 2016 it was like going back in time ten years. The systems were out of date.1346 He concluded that the control room had not kept pace with the rest of the organisation because managers had not ensured that the LFB’s systems operated as effectively for it as they did for fire stations.1347 POM Hayward said that changes to the programming of STEP and StARS had been needed to accommodate the control room’s shift patterns, but that things had moved slowly.1348 He said that he had asked for changes to be made, but had been told that other requirements took priority.1349 79.93 There was also a marked difference between the control room and the operational departments in the way that training was organised and procured. As set out above, in April 2012, the LFB entered into a contract with Babcock for most of its training requirements,1350 but that contract did not extend to the training of control room staff. Their training was 1338 George {Day205/17:16-19}; AC George recalled the control centres being located at Wembley, Croydon and Lewisham. 1339 George {Day205/17:19-24}. 1340 LFB Lakanal Control Report {HOM00001124/26} paragraph 132. George ‘Review of Brigade Control’ July 2016 {LFB00032826/4} paragraph 13. 1341 George {Day205/18:7-9}. 1342 George {Day205/75:6-8}; LFEPA Self-assessment 2015 – LGA Peer Challenge {LFB00047742/56}. 1343 George {Day205/82:11-18}. 1344 Training Audit Recommendations 15 January 2013 {LFB00106102/2}. 1345 Smith {Day202/93:5-8}. 1346 George {Day205/82:21-23}. 1347 George {Day205/85:7-9}. 1348 Hayward {Day199/125:5-18}. 1349 Hayward {Day199/127:22}-{Day199/128:1}. 1350 LFB Report ‘How Training Works’ {LFB00055127/5} paragraph 2.7.

Part 8 | Chapter 79: Fire survival guidance: training and management 157 provided by the Operational Support Team1351 and, as POM Hayward confirmed, there were no arrangements for assessing the quality of the training it provided.1352 When SM Kelly reviewed the Training team’s quality assurance systems in 2010 he found that there was no general plan for ensuring that training was of the appropriate quality, but he identified various systems which enabled the team to assess the quality of the training it had provided. Among them was Call Coach, described above, which he considered to be a very effective tool.1353 However, although his audit was based on fire survival guidance training, SM Kelly was apparently not aware that fire survival guidance calls were not monitored using Call Coach or any other system.1354 As a result, he appears not to have appreciated that fire survival guidance calls were not subject to any quality review or assurance process. 79.94 In June 2013, AC Chandler reviewed the progress made by the control room in carrying out the Lakanal pre-inquest actions. He concluded that the training syllabus needed to be entirely refreshed and recommended that a fundamental review of training should be undertaken in 2015 or 2016.1355 However, no such review was undertaken1356 because of the overriding focus on implementing Vision.1357 Although AC George covered aspects of training in his review of the control room, it did not amount to the fundamental reappraisal which AC Chandler had called for.1358 79.95 In the report into his review of the control room AC George had recommended that responsibility for control room training should be transferred to Babcock.1359 Although that was considered, AC George and Angela Hale, the LFB’s Training Commissioning manager,1360 subsequently agreed that the nature of the training required by control staff was so specific that there was limited value in employing Babcock and that it should be retained by the LFB.1361 It was also decided that the Operational Support Team should continue to deliver that training, apart from certain computer-based training packages.1362 As a result, control room training was not subject to any regular audit by either the LFB’s training department or any other organisation. 79.96 The Operational Support Team was in practice the only body within the LFB responsible for the development and delivery of control room training and for ensuring that it was of an appropriate standard. However, its members were not recruited as specialist trainers; they were all staff who had previous experience as CROs.1363 Until 2016 or 2017, when they received a “train the trainers” course from Babcock, its members did not receive any formal training on how to create and deliver training packages.1364 1351 LFB Report ‘How Training Works’ {LFB00055127/5} paragraph 2.7. 1352 Hayward {Day201/123:10-12}. 1353 SM Kelly report {LFB00055220/9} paragraphs 63-64 and 66-68. 1354 Smith {Day202/38:1-7}. 1355 Email from AC Chandler to AC Brown, 28 June 2013 {LFB00060701/2} item 16. 1356 Brown {Day207/121:2-3}. 1357 Hayward {Day201/129:16-22}. 1358 Review of Brigade Control July 2016 {LFB00032826/11-13} paragraph 49; Brown {Day207/120:25}-{Day207/121:12}. 1359 Review of Brigade Control July 2016 {LFB00032826/11} paragraph 49(b). 1360 George {LFB00083884/7} page 7, paragraph 29(b). 1361 George {LFB00083884/12} page 12, paragraph 40 and George {LFB00083884/6} page 6, paragraph 29(b). 1362 George {LFB00083884/13} page 13, paragraphs 41-42. 1363 SM Kelly’s Report of Training Audit {LFB00055220/4} paragraph 9. 1364 Hayward {Day199/28:25}–{Day199/29:9}.

The Grenfell Tower Inquiry: Phase 2 Report 158 79.97 SOM Smith had not received any training or preparation before assuming responsibility for the training function of the Operational Support Team and had not asked for any.1365 In particular, she received no training in quality assurance,1366 which is a cause for concern, given the absence of any regular or formal process for assessing the quality of training.1367 79.98 The control room’s isolation was increased by the marginalisation of its senior managers in brigade meetings. POM Hayward attended monthly Departmental Management Board meetings, at which AC David Brown met the DACs to discuss current matters affecting the brigade.1368 POM Hayward said that the meetings had been mainly concerned with operational matters, to the point at which he did not always understand the subject-matter and did not contribute greatly to discussions.1369 That was unfortunate for a number of reasons: first, because POM Hayward clearly felt isolated and ill-equipped to participate, and secondly, because they were one of the points of contact with POM Hayward on which AC Brown relied to be informed about the running of the control room.1370 If POM Hayward did not participate effectively in the meetings, there was a risk that AC Brown would not have sufficient information to enable him to exercise effective management oversight of the control room. The introduction of Vision 79.99 The mobilising system enables CROs to carry out their core role of despatching crews to fight fires. As mentioned earlier, in 2015, the LFB changed the mobilising system used by the control room from ProCAD to Vision,1371 a system which had been developed and delivered by a commercial company, Capita. Since the effective despatch of crews is the primary function of the control room, at least in the initial stages of the response, it was vital that staff received adequate training on the new system before it entered service.1372 79.100 Vision had been due to enter service in 2014, but the complexity of the LFB’s requirements meant that Capita was unable to deliver the system on time.1373 From early 2013 the Operational Support Team started to prepare for its introduction.1374 Initial training on Vision for existing control room staff took place between 24 June 2013 and 14 January 2014 and following further delays, tailored training for CROs continued to be delivered until the system eventually entered service on 17 November 2015.1375 79.101 The introduction of Vision resulted in a reduction in response times, with the result that appliances reached their destinations about 10 seconds earlier than had been the case when the control room had been using ProCAD.1376 That was no doubt an improvement in performance, but, as AC George told us, the introduction of Vision had been extremely difficult for the control room.1377 1365 Smith {Day202/73:2-18}. 1366 Smith {Day202/98:17-18} 1367 LFB Report ‘How Training Works’ {LFB00055127/23} paragraphs 7.1; Groves {LFB00102138/44} page 44, paragraph 81. 1368 Hayward {Day199/20:7-12}. 1369 Hayward {Day199/20:10-17}. 1370 Brown {LFB00032166/5} page 5, paragraph 13. 1371 Hayward {LFB00055191/11} page 11, paragraph 26. 1372 Hayward {LFB00055191/12} page 12, paragraph 29. 1373 Hayward {LFB00055191/111-12} pages 111-112, paragraph 27. 1374 Hayward {LFB00055191/19} page 19, paragraph 56. 1375 Hayward {LFB00055191/20} page 20, paragraphs 59-60; George {Day205/7:4-5}. 1376 George {Day205/19:16-19}. 1377 George {Day205/19:19-22}.

Part 8 | Chapter 79: Fire survival guidance: training and management 159 79.102 For a number of years after its introduction, Vision continued to be plagued by significant system failures. More than 500 faults were reported to Capita in the first six months.1378 There were also six occasions during the first year when the system failed altogether for periods of between 40 minutes and three hours, requiring the use of contingency measures.1379 AC George described instances when the mobilising system slowed to the point of stopping completely, causing the CROs to resort to a secondary mobilising system that he described as “basically pen and paper”.1380 That was extremely stressful for staff, who had occasionally left the control room in tears.1381 The scale of the difficulties was such that in the period from 2016 to 2017 the Operational Support Team spent about 60% of its time reporting problems with Vision, revising training packages to reflect changes to the system and training staff on ways to circumvent problems. During the first two years in which Vision was in use, ways were devised to circumvent about 100 problems.1382 Put briefly, between 2013 and 2017, the introduction of Vision generated a very substantial amount of additional work for the control room and the Operational Support Team in particular. 79.103 It was accepted by LFB officers that the task of implementing Vision had been all- consuming and had completely swamped the control room.1383 One of the most significant consequences was its effect on training, which manifested itself in a number of ways. 79.104 One immediate consequence of the introduction of Vision was that all the control room’s training capacity was directed towards training staff on the new system. When SOM Smith returned from the Chief Fire Officers Association she was asked to create a plan to train all 100 staff in the control room on Vision,1384 which was regarded as a priority. That meant arranging 2,000 hours of training on Vision before it went into service.1385 Inevitably, resources were directed to ensuring that the system was effective as soon as possible.1386 Between 2015 and 2017, most, and sometimes all, of the Operational Support Team’s resources were devoted to that task, because it was essential that the brigade had an effective mobilising system.1387 POM Hayward said that the control room had been unable to plan any training until Vision was fully operational and officers could see how it performed.1388 That applied even to areas where annual training was expected, such as fire survival guidance refresher training.1389 79.105 In order to cope with the pressure of work expected to result from the introduction of Vision, from 2014 and throughout its implementation the number of AOMs in the Operational Support Team was increased from four to six.1390 The increase was originally expected to be temporary, but throughout 2016 the amount of work produced made any reduction impossible and the increase was made permanent by AC George in 2016.1391 1378 Hayward {LFB00055191/13} page 13, paragraph 35. 1379 Hayward {LFB00055191/13} page 13, paragraph 33. 1380 George {Day205/20:4-12}. 1381 George {Day205/20:12}; {Day205/20:2-4}. 1382 Hayward {LFB00055191/21} page 21, paragraph 63. 1383 Brown {Day207/89:8}; Hayward {Day201/56:12-25}. 1384 Smith {Day202/74:12-15}. 1385 Smith {Day 202/74:22-25}. 1386 Smith {Day204/93:19-24}. 1387 Smith {LFB00121219/23} page 23, paragraph 61. 1388 Hayward {Day201/63:21-24}. 1389 Hayward {Day201/63:25}-{Day201/64:2}. 1390 Hayward {LFB00055191/18} page 18, paragraph 49. 1391 Hayward {LFB00055191/18} page 18, paragraph 51.

The Grenfell Tower Inquiry: Phase 2 Report 160 79.106 The training requirements imposed by Vision did not cease when the system entered service. Minutes of a Brigade Control Management meeting on 8 December 2015 (about three weeks later) refer to a list of problems that Capita had already been asked to resolve and referred to staff having to work around problems with the paging system.1392 From that point on, the minutes of Brigade Control Management meetings and the Joint Committee for Control Staff record concerns about the performance and stability of Vision.1393 79.107 The problem was not simply one of confidence in the system, because faults needed to be corrected as they were identified. Accordingly, it was necessary to make changes to the system, which in turn made it necessary to train CROs urgently on the revised version. Frequent amendments were very disruptive. On many occasions staff returned from their rest days to find that a change had been made to the system that required them to undergo immediate further training.1394 The burden of training was both substantial and, until at least 2017, constant.1395 The inevitable consequence was that other areas of training, including training on fire survival guidance, were delayed or deferred indefinitely. POM Hayward said that no fire survival guidance training at all had been given in 2015 because of the introduction of Vision.1396 In 2015, the control room had been concentrating entirely on implementing Vision and therefore no other training had been given.1397 79.108 POM Hayward told AC Brown that there were occasions when fire survival guidance refresher training had not been delivered in accordance with the agreed programme, for example, between 2015 and 2017 while the CROs were being trained on Vision.1398 The explanation AC Brown gave us for allowing that situation to continue was that Vision was a critical project and that it had been essential to deliver it on time.1399 He did not agree, however, that all other training had ceased as a result.1400 AC George had also been aware of the general adverse effect that Vision was having on control room training, although he too said that he had not been specifically informed of its effect on fire survival guidance training.1401 79.109 Training on Vision also put a temporary halt to the command unit training on fire survival guidance in which the control room had been involved. POM Hayward said that that training, which had run since mid-2013, had been stopped in 2015 because of the demands of Vision, although it had been resumed to a limited extent in mid-2016.1402 Staff training and development as a whole was adversely affected.1403 79.110 It is not clear what, if anything, was done to mitigate the effect on other areas of training of introducing Vision. AC George said that the sheer volume of work needed to implement Vision made it extremely difficult to devote resources to other training.1404 It does not appear that consideration was given to evaluating the competing priorities of training on Vision and other forms of training, including training on fire survival guidance, until after 1392 Brigade Control Management Meeting Minutes 8 December 2015 {LFB00123099/2}. 1393 JCC Meeting Minutes {LFB00123113/7}. 1394 George {Day205/95:12-21}. 1395 George {Day205/20:19-23}. 1396 Hayward {LFB00055191/26} page 26, paragraph 74 (table). 1397 Hayward {Day201/52:2-5}. 1398 Brown {LFB00084020/13} page 13, paragraph 30. 1399 Brown {LFB00084020/13} page 13, paragraph 30. 1400 Brown {Day207/93:7-17}. 1401 George {Day205/80:8-14}. 1402 Hayward {Day200/15:7-15}. 1403 George {LFB00032823/11} page 11, paragraph 46; George {LFB00083884/14-15} pages 14-15, paragraph 50. 1404 George {Day 205/173:16-20}.

Part 8 | Chapter 79: Fire survival guidance: training and management 161 Vision had become operational in 2015.1405 POM Hayward said that at that point the control room had taken stock of the training needs of staff and had examined how they could run more general training as well as the continuing training on Vision.1406 79.111 The fundamental review of training proposed by AC Chandler in June 2013 did not take place because of the overriding concentration on getting Vision into service.1407 Although AC George covered aspects of training in his review of the control room, it did not amount to the fundamental reappraisal for which AC Chandler had called.1408 79.112 It is clear that the introduction of Vision was a significant challenge for the LFB, particularly for the control room, and required a substantial amount of work to stabilise the system. Its success in reducing the average time taken for an appliance to arrive at an incident together with other operational benefits came at the cost of a reduction in the ability of the control room to provide broader training to CROs, including fire survival guidance refresher training. Given the endless cycle of faults, revisions and need for further training created by Vision, it is unsurprising that the Operational Support Team struggled to deliver fire survival guidance training. 79.113 Although it was obviously of the first importance that CROs should be able to mobilise appliances quickly, the LFB should not have allowed training on Vision to squeeze out other forms of training so completely during the four years between 2013 and 2017. For a number of years, but particularly in 2015 and 2016, the introduction of Vision was treated as a reason for ignoring or deferring essential training and even the reappraisal of training proposed by AC Chandler, despite the fact that the “Vision Training Plan” contemplated that training on handling fire survival guidance calls would take precedence and might cause delay to training on Vision.1409 The failure of senior managers to ensure that training on fundamental skills required by CROs was maintained during that period reflects a failure to establish proper priorities and a weakness of organisation. When AC Brown was told that essential training was not taking place or had been severely curtailed, he should have required POM Hayward to ensure that the Operational Support Team provided essential training to the control room. 79.114 His failure to do so was particularly acute in the case of fire survival guidance training. Following the fire at Lakanal House and the LFB’s subsequent investigations, the importance of fire survival guidance training ought to have been clear to those responsible for the operation of the control room, including the Operational Support Team. It was a significant failure on the part of the LFB that fire survival guidance training was allowed to lapse during the introduction of Vision. Training “on the watch” 79.115 One longstanding problem affecting the control room was the perception that it was too difficult to arrange for CROs to undertake training while maintaining operational capability in the control room. A number of witnesses said that training on the watch was regularly interrupted by the need to recall staff to the control room to respond to incoming calls.1410 1405 Hayward {Day201/16:23}–{Day201/17:2}. 1406 Hayward {Day201/17:12-18}. 1407 Hayward {Day201/129:16-22}. 1408 Review of Brigade Control, July 2016 {LFB00032826/11-13} paragraph 49; Brown {Day207/120:25}-{Day207/121:12}. 1409 {LFB00058876/2}. 1410 Real {MET00080520/14} page 14, paragraph 4; Hayward {LFB00055191/18} page 18, paragraph 52; Hayward {Day199/50:2-6}; Smith {Day202/95:9-13}; George {Day205/111:10-12}; Brown {Day206/160:3-7}.

The Grenfell Tower Inquiry: Phase 2 Report 162 79.116 That was not a problem peculiar to the LFB or one which arose shortly before the fire at Grenfell Tower. The Fire Service Manual Volume 1: Fire Service Technology, Equipment and Media Communications and Mobilising, published in 1998, noted that training for control personnel had always been hindered by the small numbers of staff available and the need to maintain cover in the control room. Training was usually organised by watches and delivered at the place of work, thereby ensuring that the maximum number of personnel were available. Brigades were therefore advised to consider appointing a Training Officer and organising training days away from the control room.1411 That document, published nearly 20 years before the Grenfell Tower fire, makes it clear that the difficulties posed by training at work were, or should have been, well known to fire and rescue authorities throughout the country. It is equally clear that it also proposed a solution to the problem. 79.117 In the Phase 1 report the chairman described the shift pattern operated by the control room, which was staffed by six watches. From the introduction of the new shift system in 2011 there had been a four-hour overlap between the early and late short shifts, which provided sufficient cover to enable training to take place during that period,1412 but in 2014 the shift pattern had been altered, with the result that the short shifts overlapped by only two hours. It had been intended that staff on duty during one of the short shifts would undertake training during the hours with overlapping cover,1413 but in his review AC George expressed the view that the shift pattern did not allow enough time for supervisors to provide regular effective training to their watches outside the control room.1414 AC Brown had been heavily involved in consideration of the shift change in 2011 and had asked AC George to see how it could better accommodate training.1415 In the report into his review AC George recommended that the control room should revert to the original shift pattern to allow four hours overlap between the short shifts that could be used for training. 79.118 Although the problem had been identified by AC George in 2016, the LFB had not tackled the reduction in the overlap between the two short shifts by the time of the Grenfell Tower fire. Indeed, it remained a contentious subject when AC Jonathan Smith produced his own review of the control room in 2019.1416 He found even then that the use of the short shift was not providing the structured training that was required.1417 79.119 The importance of an adequate overlap between the two short shifts lay in the level of cover available for responding to the demands of the control room. In essence, the more staff present in the building, the lower the likelihood of the training watch needing to be called to control room duty.1418 If there were a short increase in the number of calls to the control room, CROs could resume training, but if a significant incident occurred, a new date for their training had to be arranged by the Operational Support Team.1419 The concern about the interruption of training is understandable, but to an extent misplaced. The evidence does not suggest that there was a frequent need to redeploy staff from training to the control room. On the contrary, POM Hayward said that it happened only 1411 Fire Service Manual Volume 1: Fire Service Technology, Equipment and Media Communications and Mobilising {INQ00014945/129}. 1412 Review of Brigade Control, July 2016 {LFB00032826/9} paragraph 39; Hayward {LFB00055191/18} page 18, paragraph 52. 1413 Review of Brigade Control, July 2016 {LFB00032826/11} paragraph 49. 1414 Review of Brigade Control, July 2016 {LFB00032826/9} paragraph 39. 1415 Brown {Day206/66:18-24}; {Day206/157:19-20}. 1416 Control - Overview and Control Improvement Plan, dated 22 July 2019 {LFB00084097/4}. 1417 Control - Overview and Control Improvement Plan, dated 22 July 2019 {LFB00084097/4}. 1418 Tables setting out the minimum numbers of staff required from 2011, Hayward {LFB00055191/5} page 5, paragraphs 15-17. 1419 Smith {Day202/95:9-13}.

Part 8 | Chapter 79: Fire survival guidance: training and management 163 infrequently1420 and he was unable to recall being aware of any problems arising from the fact that staff were unable to complete their training because they had been recalled to the control room.1421 There were other problems, however. For example, a shortage of staff in the control room meant that staff from the short shift were often needed to fill gaps in the duty watch.1422 That inevitably reduced their availability for training. 79.120 As mentioned above, the Fire Service Manual recommended that brigades should consider appointing a Training Officer and arranging training days away from the control room.1423 As a general rule, however, the LFB did not organise training “off-watch” or away from the control room. 79.121 It is clear from the evidence of control room staff that there was a commonly held belief that it was simply not possible to organise training “off-watch”. SOM Smith considered that the difficulty of making control room staff available for training at work was common to all fire and rescue services because it was not possible for them to go “off the run,”1424 i.e. to be unavailable for duty. POM Hayward said that he had been unable to use overtime to provide training because he could not require staff to work overtime for that purpose and because he had already been making excessive use of overtime to maintain the necessary number of CROs on duty.1425 However, in our view senior managers did not give sufficient consideration to delivering fire survival guidance training off-watch, given that in some other cases training was indeed delivered off-watch. For example, POM Hayward recalled that in August 2006, shortly after he had joined the LFB, staff had been trained on the ProCAD mobilising system off watch following a major revision.1426 He thought that had been the only time staff had received training “off-watch”,1427 but in 2010 the initial one- day fire survival guidance training had also been delivered “off‑watch”.1428 POM Hayward said that although at that time it had been possible to deliver training in that way, the introduction of the new shift patterns in 2011 and staff losses in 2012 had made training “off-watch” “problematic.”1429 Despite that, SOM Smith told us that training “off-watch” had been provided in 2015 for the introduction of the new Vision mobilising system.1430 CROs needed to receive a number of hours of training on Vision, which had been delivered to most of them “off-watch”.1431 It is also the fact that in 2016 and 2017 some CROs worked overtime to support the command unit training exercises.1432 79.122 Those examples suggest that the belief that training could not be delivered “off-watch” was unjustified and unreasonable. They also suggest that fire survival guidance training was not considered by the LFB to be necessary to enable CROs to perform their role effectively. It is telling that although the introduction of Vision was considered to be of sufficient importance to justify “off-watch” training, the delivery of refresher fire survival guidance training was not. In view of the number of fire survival guidance calls the LFB had received during the Lakanal House fire and the lessons that it had itself identified, as well as the 1420 Hayward {Day199/43:19-21}. 1421 Hayward {Day199/49:9}-{Day199/50:1}. 1422 George {Day205/111:23-25}. 1423 Fire Service Manual Volume 1: Fire Service Technology, Equipment and Media Communications and Mobilising {INQ00014945/129}. 1424 Smith {Day204/23:12-24}; Real {MET00080520/14} page 14, paragraph 4. 1425 Hayward {Day199/47:1-8}. 1426 Hayward {Day199/43:2-5}. 1427 Hayward {Day199/43:6-7}. 1428 Hayward {Day200/80:19}-{Day200/81:1}. 1429 Hayward {Day200/81:2-10}. 1430 Smith {Day202/97:23}-{Day202/98:5}. 1431 Smith {Day204/24:4}-{Day204/25:3}. 1432 Smith {Day204/127:20}-{Day204/128:16}; Hayward {LFB00055191/28} page 28, paragraph 78.2.

The Grenfell Tower Inquiry: Phase 2 Report 164 critical nature of the advice provided by CROs taking fire survival guidance calls, the failure to make any obvious effort to provide refresher fire survival guidance training “off-watch” was a serious error of judgment. 79.123 The shortage of staff to which POM Hayward referred had an obvious effect: in order to maintain the minimum number of staff in the control room, training would sometimes have to be cancelled.1433 A shortage of staff, together with sickness and a need for breaks, was one reason why it had not been possible to train watches away from the control room during the short shift.1434 However, the shortage of staff, its causes and consequences were well known. Between 2011 and 2012 the LFB was considering a proposal to enter into a contract with a third party for the provision of control room services, which resulted in a temporary halt to recruitment.1435 That remained the position until 2016, when AC George asked for recruitment to resume after he had assumed responsibility for the control room.1436 During his time as a director, AC George also increased the number of CROs and supervisors on each watch.1437 Planning and recording control room training 79.124 Following the Lakanal House fire, the Lakanal Control report identified serious deficiencies in the provision and recording of fire survival guidance training over the long period between 1981 and 2009.1438 In his report following the audit of the training arrangements SM Kelly observed that, if fire survival guidance and other control room training were to be provided effectively, systems had to be established for planning training and recording its delivery.1439 Yet, it is clear that, in the years following the Lakanal House fire, senior managers failed to establish such systems, so that the problems persisted up to, and indeed well beyond, 14 June 2017.1440 79.125 The need for fire survival guidance training to be structured and planned had been identified in FSC 10-931441 and in the Fire Service Manual published in 1998.1442 Although national guidance was silent on keeping adequate records of training, the LFB’s own policy, PN164, issued on 29 September 1994 and amended on 28 January 2009, included detailed requirements on training records. In particular, paragraph 2.5 required a clear record to be kept of the contents of the training, together with details of dates, the trainers and any relevant notes,1443 but it was not complied with. Moreover, PN164 did not require training plans to be produced for individual officers or watches or for the control room more generally.1444 Those requirements ought to have been added to PN164 after the Lakanal House fire. 1433 Review of Brigade Control - the issues raised by staff prior to the review commencing {LFB00032831/2} paragraph 3a; George {Day205/52:7}-{Day205/53:6}. 1434 Review of Brigade Control {LFB00032826/11} paragraph 49. 1435 Hayward {Day199/47:4-6}; Hayward {Day199/87:11-13}; Brown {Day206/40:25}-{Day206/41:1}; George {Day205/53:25}-{Day205/54:3}. 1436 George {Day205/114:5-7}. 1437 George {Day205/114:22-25}. 1438 Lakanal Control Report dated November 2012 {HOM00001124/26} paragraphs 130 and 134 and {HOM00001124/31} paragraph 167. 1439 Gap Analysis dated 7 April 2010 {HOM00001125/23}; SM Kelly’s draft audit of Brigade Control training dated August 2010 {LFB00055203/7} paragraphs 46-49. 1440 AC Jonathan Smith’s briefing note titled ‘Control – Overview and Control Improvement Plan’ dated 22 July 2019 {LFB00084097/3}. 1441 Fire Service Circular {LFB00003617/3} paragraph 11. 1442 Appendix 1 of the Fire Service Manual 1: Fire Service Technology, Equipment and Media, Communications and Mobilising (Published 1998) entitled ‘Control Staff – Training, Competence and Promotion’ {INQ00014945/129}. 1443 PN164 as issued on 29 September 1994 and amended on 28 January 2009 {LFB00084054/3}. 1444 That was the case for all of its subsequent revisions. PN164 reviewed as current on 6 May 2015, which was the version in force on 14 June 2017 {LFB00084054/11}.

Part 8 | Chapter 79: Fire survival guidance: training and management 165 79.126 The LFB had originally intended that records of control room training should be brought into the StARS and STEP systems used by the rest of the brigade.1445 In that way they would be automatically entered on STEP without the need for manual intervention1446 and control room managers would easily be able to check what training each CRO had received and plan future training.1447 The training records, as they existed at the time, were entered on STEP by 8 November 2010.1448 79.127 AC Brown accepted that, although he considered the biennial plan for fire survival guidance training to be robust, it did not amount to an all-encompassing training plan which met SM Kelly’s recommendation that an adequate system be introduced for planning training.1449 However, neither he nor POM Hayward took any steps at the time to put such a plan in place. 79.128 At a Brigade Control Management meeting on 18 July 2012, AC Chandler discovered that there was no single document, such as a training matrix, which recorded what training had been delivered to control room staff and what was needed in the future. He therefore asked the OMs to collate that information for their own watches and present it in the form of spreadsheets. He also asked the Operational Support Team to produce a training matrix.1450 It is clear, therefore, that SM Kelly’s recommendation to introduce an adequate system for planning training had still not been carried out almost two years after he had reported and that training records were still not being entered automatically on the StARS and STEP systems. It is also clear that after he became Head of Mobilising and Control in May 2012, AC Chandler recognised the importance of an effective system of planning training and took some steps to improve the position.1451 POM Hayward could not explain why a training plan had not been established before July 2012.1452 79.129 At the meeting on 18 July 2012 OM Victor Bagnelle referred to the system of record- keeping introduced by the Operational Support Team as a temporary solution while adjustments were being made to the StARS and STEP systems to enable them to accept information relating to the control room.1453 It involved recording information on a spreadsheet which was sent to the information management team once a month to be manually entered on STEP.1454 The system was cumbersome and subject to human error, because different staff recorded training in different ways.1455 Moreover, information about watch-based training was not always sent to the Operational Support Team for inclusion in the spreadsheet.1456 1445 Hayward {Day199/77:16}-{Day199/79:11}; Hayward {Day199/121:22-25}; Brown {Day207/4:15-25}; Minutes of the Lakanal House Board Meeting on 22 June 2010 {LFB00055208/3} item 8.8; Minutes of the Lakanal House Board Meeting on 21 July 2010 {LFB00055210/3} item 7.5; Minutes of the Lakanal House Board meeting on 15 September 2010 {LFB00084031/2} item 5.10. 1446 Hayward {Day199/77:16}-{Day199/79:11}. 1447 George {Day205/82:7-20}. 1448 Minutes of the Lakanal House Board Meeting on 8 November 2010 {LFB00055213/1}; Hayward {Day199/123:8-23}. 1449 Brown {Day206/163:2-17}. 1450 Minutes of the Brigade Control Management Meeting held on 18 July 2012 {LFB00113237/7-8} item 5. 1451 Brown {LFB00032166/3-4} pages 3-4, paragraph 7. 1452 Hayward {Day199/85:23}-{Day199/86:2}. 1453 Hayward {Day199/78:13}-{Day199/79:2}; Hayward {Day199/123:1-3}. 1454 Hayward {Day199/126:6-9}; {Day199/78:23}-{Day199/79:2}; George {Day205/86:22}-{Day205/87:5}. 1455 Hayward {Day199/126:12-22}. 1456 Hayward {Day199/126:12-22}.

The Grenfell Tower Inquiry: Phase 2 Report 166 79.130 Training was discussed at the following Brigade Control Management meeting held on 12 September 2012, but no conclusion was reached.1457 Obviously, therefore, no agreement had been reached on a training plan at that stage.1458 AC Chandler recognised that the LFB would not have a robust defence if anything went wrong in the control room, but although another meeting was due to be held in October 2012 to discuss training,1459 no training plan was in fact put in place. 79.131 In January 2013, GM Lindridge found that the control room was still recording all training on a spreadsheet to be entered on STEP manually.1460 He also found that the technology made it impossible for control room managers to create a training plan on STEP and therefore recommended that a two-year rolling plan should be set out on a spreadsheet by January 2013.1461 It is clear, therefore, that almost two and half years after SM Kelly’s report and six months after AC Chandler’s request for a training matrix, no training plan had been put in place and that StARS and STEP could still not be used to create training records for the control room. 79.132 POM Hayward could not explain why no training plan had been introduced by that point.1462 Nor could he recall whether a training matrix had ever been produced.1463 Apparently one reason why training records still had to be entered manually on StARS was because the programme still did not recognise the control room’s short shift patterns.1464 He said that there had been competing priorities for attention, in the form of an amendment to StARS to accommodate a change in operational shifts and the introduction of Vision.1465 He said that, because there had already existed a method of recording control room training, the necessary amendment had been moved down the list of priorities.1466 79.133 AC Brown agreed that there had been competing priorities, but he did not accept that operational demands routinely trumped the demands of the control room.1467 He accepted that, although he had tried to push matters along, greater pressure could have been exerted to ensure that the control room’s training needs were given priority.1468 He also suggested that the fact that the control room was based in Merton and was not a presence within the LFB’s headquarters probably made it difficult for its managers to make their case to senior officers.1469 79.134 On 4 April 2013, when AC Chandler returned from leave, AC Brown asked him to satisfy himself that the pre-inquest actions had been completed. He also asked AC Chandler to talk him through the training plan for the control room.1470 AC Brown said that he had asked for that to be done because he remained dissatisfied with progress towards a training 1457 Minutes of the Brigade Control Management Meeting on 12 September 2012 {LFB00113402/6} item 5. 1458 Hayward {Day199/96:17-21}. 1459 Minutes of the Brigade Control Management Meeting on 12 September 2012 {LFB00113402/6} item 5. 1460 GM Lindridge’s Review dated 4 January 2013 {LFB00033943/14}. 1461 GM Lindridge’s Review dated 4 January 2013 {LFB00033943/14}. 1462 Hayward {Day199/104:15-17}. 1463 Hayward {Day199/104:18-23}. 1464 Hayward {Day199/125:3-18}; {Day199/126:24}-{Day199/127:15}; {Day199/131:9-18}; Hayward {LFB00055191/23} page 23, paragraph 67; Brown {Day207/6:23}-{Day207/7:14}. 1465 Hayward {Day199/127:16-24}; {Day199/131:5-8}; Hayward {LFB00055191/23} page 23, paragraph 67. 1466 Hayward {Day199/127:16}-{Day199/128:3}. 1467 Brown {Day207/8:6-14}. 1468 Brown {Day207/7:18-23}; {Day207/8:15-25}. 1469 Brown {Day207/8:15-25}. 1470 Email from AC Brown to AC Chandler on 4 April 2013 {LFB00028942/2}.

Part 8 | Chapter 79: Fire survival guidance: training and management 167 plan, which by then was overdue.1471 He said that AC Chandler had told him that it was in hand.1472 He also said that he had asked AC Chandler for the training matrix, but had not received it.1473 79.135 On 9 May 2013, POM Hayward sent an email to OM Victor Bagnelle expressing concern that the training database did not provide an accurate picture of the current state of training or the programme for future training.1474 It is evident, therefore, that the planning of training was still not fully under control at that time. However, on 28 June 2013, AC Chandler reported to AC Brown on progress in completing the pre-inquest actions.1475 In relation to action 16 he reported that the planning and recording of general control room training had improved.1476 In light of the continuing problems with planning and recording training, the basis for that statement is unclear. 79.136 Very little happened until a year later, when on 22 July 2014, POM Hayward sent an email to SOM Bagnelle, SOM Diamond and SM Ajimal expressing concern at the absence of a robust system of recording control room training.1477 His concerns were well-founded, and it is disquieting that in July 2014, although work had started, still no robust records existed and the objective of a training programme that was considered, planned and delivered to a measured outcome had not been met. 79.137 When SOM Smith took charge of the Operational Support Team and control room training in January 2015, she did not ask whether a training plan had been developed.1478 She told us that POM Hayward had asked her to deliver a training plan for Vision.1479 Although they had discussed delivering other training after Vision had been implemented, at that time attention was clearly concentrated on Vision.1480 Accordingly, there had been a training plan for Vision but not for other training, such as training on handling fire survival guidance calls.1481 SOM Smith told us that at that time the training plan had taken the form of large calendars displayed on a wall of the Operational Support Team’s office on which entries were made following discussions by email within the team.1482 As she accepted, that did not constitute a detailed formally documented training plan. 79.138 In November 2014, the Directorate of Audit, Risk and Assurance in the Mayor’s Office for Policing and Crime audited the LFB’s arrangements for the management of the control room.1483 It was the first time such an audit had been carried out.1484 One of the matters that interested the auditor was how the training team ensured that all staff received fire survival guidance training annually.1485 1471 Brown {Day206/170:15-24}. 1472 Brown {Day206/170:25}-{Day206/171:2}. 1473 Brown {Day206/171:3-9}. 1474 Email from POM Hayward to OM Vic Bagnelle on 9 May 2013 {LFB00042081/1}. 1475 Email from AC Chandler to AC Brown on 28 June 2013 {LFB00060701/1}. 1476 Email from AC Chandler to AC Brown on 28 June 2013 {LFB00060701/2}. 1477 Email from POM Hayward to SOM Bagnelle, SOM Diamond and Tejinder Ajimal on 22 July 2014 {LFB00051294}. 1478 Smith {Day204/160:2-5}. 1479 Smith {Day204/160:2-10}; {Day204/161:1-4}. 1480 Smith {Day204/160:2-10}; {Day204/161:1-4}; {Day204/166:1-6}. 1481 Smith {Day204/165:13-19}. 1482 Smith {Day204/162:23}-{Day204/163:4}; {Day204/166:25}-{Day204/167:3}. 1483 Email chain between Scott Hayward and Karen Mason dated 17-18 November 2014 regarding Brigade Control Audit {LFB00030108}; Hayward {Day201/42:1-4}; Internal Audit – Progress Report Quarter 3 2014/2015 dated 9 March 2015 {LFB00044640/1}. 1484 Hayward {Day201/42:1-4}. 1485 Email from Karen Mason to SOM Bagnelle on 14 November 2014 {LFB00030108/3}.

The Grenfell Tower Inquiry: Phase 2 Report 168 79.139 The audit identified a number of risks, including: a. intentional or unintentional alteration of the training spreadsheet, affecting the monitoring of training and reporting to senior management; b. inconsistent and inaccurate completion of the spreadsheet, leading to inappropriate decisions; c. ineffective monitoring of fire survival guidance training, leading to reputational damage if serious incidents were dealt with by inadequately trained staff; and d. inadequate training, resulting in inappropriate responses to incidents.1486 79.140 It recommended that an independent record of fire survival guidance training be maintained and monitored for all control staff to ensure that all staff were in receipt of training at least annually and that a monthly report be produced by the Operational Support Team setting out the position in relation to training for the current year.1487 79.141 Both POM Hayward and AC Brown acknowledged that the risks identified in the audit had existed and that a failure to ensure that staff received adequate fire survival guidance training could result in serious injury or death,1488 and we have no reason to think that they were not aware of those matters at the time. Yet, neither of them took effective steps to ensure that the auditor’s recommendations were implemented. AC Brown probably used the report as the basis for a discussion with POM Hayward to satisfy himself that everything was working correctly, but did not go further than that.1489 It is unlikely that POM Hayward did anything beyond asking SOM Smith to check that the Operational Support Team was maintaining training records, because at that time they were concentrating entirely on training for the introduction of Vision.1490 We do not consider that the drain on personnel resources caused by problems with Vision excuses the failure by senior management to give the auditor’s findings and recommendations the importance they deserved. That was a significant failure. 79.142 When he conducted his review of the control room in 2016 AC George found that training to maintain skills was irregular, not robustly planned and often not recorded on an individual’s training record. Staff often failed to record training and were seldom instructed to do so.1491 He recommended that each OM ensure that an appropriate, robust, annual training plan was put in place for their own watch, agreed by their SOM and made available to all watch members and managers, and that training be recorded on an individual’s training record. He also recommended that senior managers should work with the LFB’s information management team to produce a solution similar to the training diaries used by station staff and make effective use of the brigade’s systems, including StARS.1492 79.143 SOM Smith was given the task of implementing AC George’s recommendations,1493 although he accepted that he had been ultimately responsible for ensuring that that was done.1494 He said that he had monitored progress through POM Hayward,1495 but despite 1486 Summary of MOPAC Audit of Brigade Control dated February 2015 {LFB00044640/25-26}. 1487 Summary of MOPAC Audit of Brigade Control dated February 2015 {LFB00044640/25-26}. 1488 Hayward {Day201/45:19}-{Day201/47:2}; Brown {Day207/87:6-18}. 1489 Brown {Day207/88:18-25}. 1490 Hayward {Day201/51:17}-{Day201/52:18}. 1491 AC George Review of Brigade Control dated July 2016 {LFB00032826/11} paragraph 47. 1492 AC George Review of Brigade Control dated July 2016 {LFB00032826/12} paragraphs 49 c-f. 1493 Appendix 2 to AC George’s Review of Brigade Control dated July 2016 {LFB00032826/31}; George {Day205/105:15- 25}. 1494 George {Day205/100:23}-{Day205/101:1}. 1495 George {Day205/101:2-19}.

Part 8 | Chapter 79: Fire survival guidance: training and management 169 the force of his findings, StARS and STEP were not fully adapted to accommodate the control room until December 2018, nearly 18 months after the Grenfell Tower fire.1496 It is also reasonably clear that although some work had been done, robust training plans for individual watches had not been put in place by the time of the fire.1497 79.144 The failure to adapt StARS and STEP to accommodate the control room was the root cause of the difficulties encountered with planning and recording training.1498 AC George expressed surprise that previous managers had not made sure that the systems had been adapted to include the control room.1499 Commissioner Dobson attributed the failure to a decision not to contract out the training of control room staff in 2012. He thought that, if that had been done, as it had for operational firefighters, the problems with training generally, and record-keeping in particular, would have been identified earlier. Regardless of the merits of Mr Dobson’s view, however, it is not a good excuse for the failure to plan, record and provide training after 2012. 79.145 When he carried out his review of the control room in July 2019, AC Jonathan Smith found that the current provision of training, assurance and professional development required a complete and systematic overhaul. Training was irregular and lacking in structure, there was no system of quality assurance and the recording of training was inconsistent. Those criticisms were linked to wider concerns relating to culture, accountability and leadership.1500 The management of fire survival guidance training 79.146 The failure to deliver regular fire survival guidance training after the Lakanal House fire represents a significant omission on the part of those responsible for the management of the control room. When senior officers were warned in the years after the Lakanal House fire that fire survival guidance training was not taking place, they should have taken effective action to make sure that it was provided. The management of fire survival guidance training was lacking in two other important respects: first, no objective criteria had been established by which to evaluate and monitor training or the quality of emergency call-handling; secondly, fire survival guidance training was not subject to consistent reporting or monitoring. 79.147 The LFB monitored only three aspects of the control room’s performance,1501 all of which reflected performance indicators relating to the control room in the London Safety Plan.1502 They were: a. the average time taken to answer an emergency call; b. the percentage of emergency calls answered within 7 seconds; and c. the average time taken to deal with an emergency call.1503 1496 George {LFB00083884/6} page 6, paragraph 29(b); George {Day205/104:12}-{Day205/105:7}; Hayward {Day199/133:16-18}; Hayward {Day199/143:23-25}. 1497 Email from POM Hayward to AC George on 7 November 2016 {LFB00083865/9}; George {LFB00083884/6} page 6, paragraph 29(b); Smith {Day204/182:12}-{Day204/184:17}; Hayward {Day199/113:13}-{Day199/114:1}; George {Day205/106:7-14}. 1498 Brown {Day206/173:6-17}; George {Day205/82:7}-{Day205/84:14}; {Day205/86:6-15}; Hayward {Day199/110:2-24}. 1499 George {Day205/83:3-4}. 1500 AC Smith’s briefing note entitled ‘Control – Overview and Control Improvement Plan’ dated 22 July 2019 {LFB00084097/3-4}. 1501 Review of Brigade Control, July 2016 {LFB00032826/5} paragraph 22. 1502 George {Day205/69:14-17}; London Safety Plan 2014 {LFB00032107/70}. 1503 Review of Brigade Control, July 2016 {LFB00032826/5} paragraph 22.

The Grenfell Tower Inquiry: Phase 2 Report 170 79.148 As far as the control room itself was concerned, it was for the AC and the POM to decide which aspects of performance should be monitored, but no discussion appears to have taken place between them about whether any other aspects of performance should be considered.1504 That may have been because AC Brown thought that performance indicators were relevant only to things that can easily be measured.1505 He thought that it was difficult to monitor quality because that required the evaluation of a process.1506 There was no key performance indicator relating to training, although he took the view that, if the three indicators mentioned above were moving in the wrong direction, that would be a clear sign that training was not effective. For that reason, he thought that the three existing indicators provided some assurance that training was taking place.1507 That was not the case, of course, because they related only to response times and did not reflect the content or quality of responses to calls, particularly fire survival guidance calls. It is, therefore, unreal to suggest that the key performance indicators could be treated as indicating the overall quality of training. It was a significant failure on the part of senior management not to recognise that there were no effective means of assessing the quality of responses to fire survival guidance calls. 79.149 AC George said that the three aspects of the control room’s performance to which we have referred reflected the information that LFEPA, as the LFB’s supervising authority, required.1508 He thought that LFEPA was interested only in numbers and quantities, which effectively dictated their scope.1509 Although he had reservations about that approach, there is no evidence that he or any other senior officer ever suggested that some other objective standard might be adopted by which to assess the quality of the control room’s responses to emergency calls generally or the quality of its responses to fire survival guidance calls in particular.1510 Arrangements for reporting and monitoring control room training 79.150 We referred earlier to POM Hayward’s laissez-faire style of management. He treated the absence of any reports of difficulties as an indication that the SOMs were managing training effectively, but the fact that fire survival guidance refresher training was not being consistently or effectively provided from 2012 onwards without his apparent knowledge demonstrates the weakness in his approach. There should have been a mechanism by which the SOMs or the Operational Support Team reported to him regularly about training generally and fire survival guidance training in particular. Together with a proper training plan and reliable training records that would have enabled him to monitor the provision of training against established criteria and satisfy himself and more senior managers that the LFB’s duty to train control room staff was being properly discharged.1511 79.151 It is significant that when AC Chandler was Head of Control and Mobilising, he recognised the need for improved arrangements for planning and recording control room training and was taking action to put them in place so that they could be easily audited.1512 1504 Hayward {Day199/15:22}-{Day199/16:7}; Brown {Day206/47:2-13}. 1505 Brown {Day206/46:24-25}. 1506 Brown {Day206/46:21-24}. 1507 Brown {Day206/45:23}-{Day206/46:15}. 1508 George {Day205/71:9-21}. 1509 George {Day205/71:11-21}. 1510 George {Day205/71:23}-{Day206/72:3}. 1511 Summary of MOPAC Audit of Brigade Control dated February 2015 {LFB00044640/25}. 1512 Minutes of Brigade Control Management Meeting on 18 July 2012 {LFB00113237/7-8} item 5; Minutes of Brigade Control Management Meeting on 12 September 2012 {LFB00113402/6} item 5; Email from POM Hayward to OM Vic Bagnelle dated 9 May 2013 {LFB00042081/1}.

Part 8 | Chapter 79: Fire survival guidance: training and management 171 Some improvements had been made by June 2013,1513 but it is clear that progress came to a halt when he left the LFB in October 2013,1514 because, when AC George carried out his review in July 2016, he discovered that planning and recording training was still a problem.1515 It is also clear that he did not address the problem effectively before he became Director of Operations in April 2017.1516 79.152 On any view, as AC Brown rightly accepted, the involvement of the assistant commissioner was important in the management of the control room.1517 The consequences of leaving POM Hayward without effective supervision between October 2013 and March 2016 are clear from our description of how matters developed during that period.1518 79.153 AC Brown requested the appointment of an assistant commissioner to join the management of the control room as Head of Control and Mobilising in May 2012 precisely because he needed someone senior to manage it more closely than he could himself.1519 He said that his position, which at that time was AC Operations, Prevention and Response and Third Officer, effectively combined two important functions, each previously performed by an assistant commissioner, with a significant increase in his responsibilities.1520 POM Hayward said that as a result, his scheduled meetings with AC Brown would sometimes be cancelled or curtailed and he found it difficult to contact him.1521 AC Brown accepted that, but said that meetings would be rearranged and that even if POM Hayward had not been able to get hold of him when he wanted to, there had been ample opportunity to discuss matters.1522 He did accept, however, that when he had become Director of Operations in April 2015 the extent of his responsibilities had adversely affected his capacity to manage the control room generally and POM Hayward in particular.1523 In an echo of AC George’s observation, AC Brown thought that the geographical separation of the control room had also contributed to difficulties in managing it, because when the control room had been moved to Merton, it had become both more difficult and more time-consuming to visit it.1524 The net effect, according to POM Hayward, was that AC Brown did not actively supervise the management of control room training.1525 POM Hayward made similar comments about AC Chandler and AC George, although it is evident that AC Chandler did exercise a greater degree of oversight.1526 79.154 AC Brown did not think it was his responsibility to examine the control room training records personally to ensure that fire survival guidance refresher training was being delivered properly. He relied on POM Hayward to schedule and monitor it and checked on the position at monthly management meetings. He could not remember having received 1513 Email from AC Chandler to AC Brown dated 28 June 2013 {LFB00060701/2}. 1514 Email from POM Hayward to SOM Bagnelle, OM Diamond and SM Ajimal on 22 July 2014 {LFB00051294}. 1515 AC George’s Review of Brigade Control dated July 2016 {LFB00032826/11-12} paragraphs 47-49.c. 1516 AC Jonathan Swift’s conclusions in respect of the planning and recording of Brigade Control training in July 2019 {LFB00084097/3}. 1517 Brown {Day206/56:19-21}; {Day206/58:2-7}. 1518 George {LFB00032823/2}; Performance Information Folder: Operations, Prevention and Response for Performance CMB dated 12 February 2014 {LFB00042326/73}. 1519 Brown {Day206/53:5-17}. 1520 Brown {Day206/43:25}-{Day206/44:10}; {Day206/53:8-17}; Brown {LFB00032166/3} page 3, paragraph 5. 1521 Hayward {Day199/14:3-9}; {Day199/19:2-5}. 1522 Brown {Day206/44:4-10}; {Day206/52:12-17}. 1523 Brown {Day206/60:12-20}. 1524 Brown {Day206/49:21-25}. 1525 Hayward {Day199/37:16}-{Day199/38:8}. 1526 Hayward {Day199/37:19}-{Day199/38:8}; {Day199/95:17-20}; {Day199/100:21-25}; Brown {Day206/56:8-15}.

172 The Grenfell Tower Inquiry: Phase 2 Report any complaints about the response of CROs to fire survival guidance calls after the introduction of the regular training that followed the Lakanal House fire and therefore had not had any reason to question whether refresher training was taking place.1527 79.155 We accept that an officer of AC Brown’s seniority could not be expected to review details of training records personally, but the failures affecting the provision of training (and fire survival guidance training in particular) were longstanding and were well known to him and other senior officers responsible for the control room. As the various audits carried out between 2010 and 2016 consistently made clear, nothing effective had been done to remedy them. The responsibility for that failure must ultimately lie with AC Brown. 79.156 The criticisms of the way in which fire survival guidance calls were handled during the Lakanal House fire provided a powerful reason for senior management to satisfy themselves that fire survival guidance refresher training was taking place.1528 Moreover, the discovery in February 2013 that the Operational Support Team had both reduced the time allocated for fire survival guidance training and removed the active role-play element1529 should have sounded a clear warning that fire survival guidance training was not being provided as agreed in the wake of the Lakanal House fire. It should also have alerted him to the fact that positive action and close and regular scrutiny was required. In fact, although both POM Hayward and AC Brown demanded that fire survival guidance training be delivered as promised, neither of them did anything effective to ensure that it was. 79.157 The failure to provide the fire survival guidance training agreed by the Lakanal House Board should have prompted AC Brown to question the effectiveness of POM Hayward’s oversight of training, particularly given his more general concern about his day-to-day management of the control room.1530 Although AC Brown said that he had raised his concerns with POM Hayward directly and had taken action to address them, POM Hayward said that the only concern that AC Brown had ever raised with him was that he did not communicate with him enough.1531 Whatever the truth of the matter, the practical result was that AC Brown did not act on his concerns about POM Hayward’s management of fire survival guidance training. His failure to do so was serious, given the obvious risks to public safety. Conclusion 79.158 The history of fire survival guidance training is long and complex, but the evidence gives rise to clear and consistent themes that reflect and confirm the broader failings of the LFB identified in this report. The control room was inadequately managed by POM Hayward who, in turn, was ineffectually led by senior managers, most notably AC Brown. The latter, in particular, was ultimately responsible for ensuring that CROs received the fire survival guidance training that they needed and also for ensuring that it reflected national guidance and the LFB’s experience at the Lakanal House fire. As is plain from what we have said above, AC Brown failed to do that, leaving CROs ill-prepared to meet the admittedly exceptional challenges of the Grenfell Tower fire. 1527 Brown {LFB00032166/21} page 21, paragraph 66. 1528 Lakanal Control Report dated November 2012 {HOM00001124/49-50}. 1529 Brown {Day207/78:2-6}; {Day207/80:2-14}; Hayward {Day200/188:7-23}; {Day200/193:4}-{Day200/194:2}; {Day200/196:4-6}; {Day200/208:2-7}; {Day200/209:10-15}; Hayward {LFB00055191/24-25} pages 24-25, paragraphs 69-70; Emails between POM Hayward and SOM Bagnelle on 7-8 February 2013 {LFB00055221/1-3}. 1530 Brown {LFB00084020/12-13} pages 12-13, paragraph 28; Brown {Day206/50:19}-{Day206/52:5}. 1531 Brown {Day206/50:19}-{Day206/52:5}; Hayward {Day199/18:20}-{Day199/19:17}.

173 Chapter 80 Communications 80.1 In his Phase 1 report, the chairman found that from the earliest stages of the incident the deployment of firefighters inside the tower was hampered by generally ineffective communications, that communication difficulties significantly limited the efficiency of search and rescue operations1532 and that it was well known within the LFB that BARIE sets performed badly in concrete high-rise buildings. He concluded that greater efforts should therefore have been made to establish and maintain effective communications inside the tower on the night.1533 In this phase of the Inquiry we have examined the communication equipment used by the LFB in order to identify the source of the problems and have considered whether sufficient steps were taken to solve them. 80.2 A general description of the communication equipment used by the LFB on 14 June 2017 can be found in paragraphs 7.66–7.69 of the Phase 1 report, but for the purposes of this chapter it is necessary to describe it in a little more detail. Overview 80.3 At the time of the Grenfell Tower fire the LFB relied on radio for communication between the control room and the fireground and between firefighters, both at the fireground and more widely. It used two kinds of radio equipment:1534 ultra-high frequency (UHF) analogue radios and Airwave digital radios. (“Airwave” is the name of the network and of the network services provider.) In broad terms, UHF radios were used for localised, personal, operational use, principally on the fireground; Airwave radios were used for tactical functions, including communication with the control room and other emergency services. 80.4 The primary method of using UHF radio was by operation of a handset which acted as both transmitter and receiver. In addition, however, breathing apparatus radio interface equipment (BARIE) was used with the helmets and masks of many breathing apparatus sets. 80.5 UHF radio communications can be enhanced by radio repeaters, which receive and re‑broadcast a radio signal, and by “leaky feeders”, which are cables that connect radio repeaters to form a series while simultaneously ‘leaking’ the radio signal to improve its reception between repeaters.1535 Repeaters can be portable or fixed in buildings, tunnels and similar environments, or on LFB appliances. 80.6 Airwave digital radio, sometimes referred to within the LFB as the “main scheme radio”, was also mainly operated using handsets. In addition, however, all LFB appliances contained a fixed digital radio in the vehicle’s cab, which allowed crews to use the Airwave system to communicate with the control room and senior officers. 1532 Phase 1 Report Volume IV {INQ00014817/133} paragraph 28.130. 1533 Phase 1 Report Volume IV {INQ00014817/133} paragraph 28.131. 1534 Christopher Johnson {Day189/8:14}. 1535 Christopher Johnson {Day189/45:1-11}; {Day189/45:12-25}; Policy 700 {LFB00001762}.

The Grenfell Tower Inquiry: Phase 2 Report 174 80.7 The central LFB policy on communications was Policy No 488 on Incident Communications.1536 It set out the intended uses of each UHF channel as well as the responsibilities of a communications operator and command unit staff. A number of other policies that we do not need to mention here governed the deployment and use of specific items of communication equipment. Analogue (UHF) radio equipment 80.8 The LFB’s UHF radios had 10 channels, which were used for the following purposes:1537 a. Channel 1: the primary incident command and control channel. b. Channel 2: a back-up incident command and control channel, which could be used only with a radio repeater.1538 c. Channel 3: a channel used by specific teams for particular activities, for example, organising the supply of water or dealing with fire survival guidance calls. d. Channel 4: a back-up channel, which offered additional capacity, but was not routinely used. e. Channel 5: a back-up channel for communicating with BA wearers, which could be used only with a radio repeater. f. Channel 6: the primary channel for communicating with BA wearers. g. Channel 7: a channel which had previously been used by the police, but had been assigned to the LFB. It provided additional capacity, but was not routinely used. h. Channel 8: another channel made available by the police which provided additional capacity but was not routinely used. It required a radio repeater. i. Channel 10: a channel used by command unit crews for communications relating specifically to their work. j. Channel 11: for communications between the LFB and the Airport Fire Service at Heathrow Airport. This channel was loaded only on to radios at the Heathrow fire station. 80.9 UHF radios are intended for use locally, usually within the area of a particular incident. The signals travel a finite distance which, without interruption or interference, is determined primarily by the power of the transmitting handset.1539 Professor Chris Johnson, a communications expert retained by the Inquiry, pointed out that the limited and localised range of UHF signals could be used to an organisation’s advantage by restricting the number of people who can receive a transmission to a localised team.1540 However, that was not a relevant consideration in this case because of the almost complete loss of communications in the tower on the night of the fire. 1536 {LFB00000736}: this policy was extant at the time of the Grenfell Tower fire. The Inquiry does not have a copy of the policy in place at the time of the Lakanal House fire. 1537 As summarised in Ellis {LFB00089131/7-9} pages 7-9, paragraph 26. 1538 Radio repeaters are explained further below but, in summary, they are items of equipment intended to extend the range of a radio signal. 1539 Christopher Johnson {Day189/9:22}-{Day189/10:1-3}. 1540 Johnson, Communications Expert Report {CWJ00000119/142} paragraph 6.6.5; Christopher Johnson {Day189/16:1}- {Day189/17:12}.

Part 8 | Chapter 80: Communications 175 80.10 The LFB’s handheld radios operated at a maximum power of 4 watts, but when transmitting on many channels were limited for historical reasons to 2.3 watts. BARIE sets, on the other hand, operated at only 1 watt. As a result, when crews were operating in the confines of a building, voice communications using BARIE sets might not reach their intended recipients without distortion or interference, or at all.1541 80.11 The LFB deliberately restricted the power of its BARIE sets to make them what is known as “intrinsically safe”, that is, of sufficiently low power to minimise the risk of creating a source of ignition when operating in a dangerous environment. Generally speaking, an increase in the power of a radio increases the risk of creating a source of ignition.1542 For that reason, the LFB was reluctant to allow the use of more powerful radios in BARIE sets, particularly in environments that posed a risk of explosion, such as compartments or tunnels where gas might collect, and certain kinds of industrial premises. However, the need for intrinsic safety is less pressing in some circumstances, for example, when a fire has already started in a residential building. Although even in those circumstances there remains a risk that a radio might cause a gas explosion,1543 the justification for not using intrinsically safe devices is that the risk is lower than in other environments in which flammable gas is likely to be encountered. 80.12 For similar reasons, the use of handheld radios by those wearing breathing apparatus was generally prohibited,1544 but there were also practical reasons for not using them, principally the difficulty of operating them when wearing personal protective equipment. Nonetheless, the use of handheld radios was one way of trying to achieve better communications.1545 It had therefore become common practice for firefighters wearing breathing apparatus to use their handheld radios without the incident commander’s approval and some certainly did so on 14 June 2017.1546 As each team wearing breathing apparatus had only one BARIE set between them, one member of the team would be obliged to use a handheld radio if they became separated.1547 There was also evidence that the earpieces in BARIE sets frequently became loose or dislodged, thereby preventing effective communication.1548 In the event, therefore, BARIE sets were not a reliable means of communication in the difficult circumstances confronting firefighters in the tower. 80.13 As had become clear to the LFB during its investigations into the Lakanal House fire, the distance over which UHF signals travel is affected by surrounding objects and the built environment. It is common for nearby objects or materials to block, distort or reflect signals, thereby interfering with transmissions. That, in turn, can distort the message received by the recipient or block the signal entirely.1549 As a result of the complex interactions between radio signals and objects in the built environment, Professor Johnson was unable to give a reliable estimate of the distance over which either the handheld radios or the BARIE sets would operate effectively in practice.1550 However, he considered that the LFB’s estimated range of 500 metres or more using a 4 watt transmitter (assuming 1541 Christopher Johnson {Day189/25:14}-{Day189/26:16}. 1542 Johnson, Communications Expert Report {CWJ00000119/42} paragraph 3.2.5 - 3.2.13; Christopher Johnson {Day189/26:17}-{Day189/29:4}. 1543 Reason {Day182/39:18}-{Day182/40:13}; {Day181/204:12}-{Day181/205:9}. 1544 Policy No. 458 {LFB00013039/2} fourth bullet point. The general prohibition may be lifted where BARIE radios are unavailable and, following a risk assessment, the incident commander consents to the use of UHF radios. 1545 Christopher Johnson {Day189/44:4-20}; Ellis {LFB00089131/7} page 7, paragraph 21. 1546 Johnson, Communications Expert Report {CWJ00000119/55} paragraph 4.2.7. 1547 Christopher Johnson {Day189/38:5}-{Day189/39:9}. 1548 Johnson, Communications Expert Report {CWJ00000119/151} paragraph 6.9.4. 1549 Johnson, Communications Expert Report {CWJ00000119/43} paragraphs 3.2.15 - 3.2.16; Christopher Johnson {Day189/14:1}-{Day189/15:10}. 1550 Christopher Johnson {Day189/21:5}-{Day189/22:2}.

The Grenfell Tower Inquiry: Phase 2 Report 176 that the signals were unobstructed) was plausible.1551 He was unable to estimate the range of signals transmitted at 1 watt (e.g., from a BARIE set), but was of the view that it would be significantly lower.1552 80.14 In fact, by 2017 it had been well known for some time that some kinds of construction materials (including metals, thick concrete, insulation, foil-backed materials and energy efficient windows) can interfere significantly with UHF radio signals, particularly if there is an accumulation of obstructions.1553 As a result, UHF signals cannot travel to their full potential range between the floors of a high-rise building,1554 given the distances involved, the materials used in their construction and other forms of obstruction. Those limitations are particularly important when considered against the backdrop of the limited transmission power of BARIE sets and the congestion in radio traffic caused by many users.1555 80.15 Congestion, which arises when more people attempt to use the system than it can handle at any one time, can affect both analogue and digital systems. In the case of an analogue system, only one person can transmit at a time,1556 which means that firefighters need to wait for others to complete their transmissions before they can send their own messages. At a large incident there may be a lot of people waiting to send a message, which in turn can delay urgent or critical messages, as happened on 14 June 2017. If one person attempts to interrupt a message in the course of transmission that is likely to interfere with both signals.1557 Those effects are likely to have been one cause of the communication difficulties experienced in and around the tower on 14 June 2017. 80.16 A rudimentary solution to the problem of congestion is to reduce the number of people using any given channel. That reduces the time a user has to wait for an opportunity to transmit, as well as the chances of users interrupting one another and causing signal interference. Using a larger number of channels for different groups of firefighters, or for specific activities,1558 can go some way towards achieving that aim. 80.17 Radio signals can be enhanced by the use of portable radio repeaters and leaky feedercables but both pieces of equipment have a limited power to propagate signals and leaky feeders are typically effective only within sight of the cable,1559 which significantly limits the value of deploying them in the stairwell of a high-rise building. Professor Johnson told us that he had seen no evidence to suggest that portable radio repeaters in combination with leaky feeders would restore communications in the majority of high-rise buildings in London.1560 It should be noted that the Inquiry is not concerned with and has not considered the advantages of leaky feeders that are embedded within a building. 1551 Christopher Johnson {Day189/97:1}-{Day189/98:7}; {Day189/100:2-21}. 1552 Christopher Johnson {Day189/100:2-21}. 1553 Christopher Johnson {Day189/103:4}-{Day189/104:5}; {Day189/107:10-14}. 1554 Christopher Johnson {Day189/97:1}-{Day189/98:7}. 1555 Christopher Johnson {Day189/99:6-20}. 1556 Johnson, Communications Expert Report {CWJ00000119/181} paragraph 7.4.2. 1557 Christopher Johnson {Day189/11:3-20}. 1558 In the way that channel 3 was used to relay fire survival guidance information on the night of the fire: Johnson, Communications Expert Report {CWJ00000119/149} paragraph 6.8.9. 1559 Johnson, Communications Expert Report {CWJ00000119/176} paragraph 7.2.4; Christopher Johnson {Day189/51:12}-{Day189/52:19}; Dobson {Day212/45:23}-{Day212/46:4}. 1560 Christopher Johnson {Day189/136:1-12}.

Part 8 | Chapter 80: Communications 177 80.18 Commissioner Dobson and AC Reason said that the LFB resorted primarily to radio repeaters and leaky feeders as the fallback mechanism to combat difficulties with communications because they were understood to be effective and were the best solution available at the time of the Grenfell Tower fire.1561 However, that approach failed to take account of the following points: a. First, the equipment is not intrinsically safe,1562 so its use was inconsistent with the use of intrinsically safe radios in the BARIE sets. There is no evidence that firefighters were warned about that. b. Secondly, the equipment is time-consuming to install and is therefore likely to be deployed only after communications have deteriorated significantly. Furthermore, the cables can pose a trip hazard to firefighters and residents.1563 Commissioner Dobson accepted that neither radio repeaters nor leaky feeders would be an incident commander’s first choice. c. Thirdly, radio repeaters and leaky feeders can only be as effective as their deployment. The LFB provided training on the use of this equipment to Extended Duration Breathing Apparatus (EDBA) wearers only,1564 leaving the majority of firefighters with insufficient training on how to use it.1565 That failure was exemplified by the inability of crews at the Grenfell Tower fire to identify the correct equipment. As a result of their lack of training, crews mistook portable telemetry repeaters for radio repeaters.1566 d. Finally, as stated earlier in this chapter, radio repeaters and leaky feeders operated on dedicated channels. Deploying radio repeaters and leaky feeders therefore required a change of channel. At the time of the Grenfell Tower fire, the LFB had no policy, training or strategy in place for co-ordinating a change of that kind. 80.19 Although it was reasonable for the LFB to use radio repeaters and leaky feeders to alleviate difficulties with communications, given the limitations outlined above, it was not reasonable for it to rely on such equipment as its primary fallback mechanism for solving the problem of poor communications when operating in a high-rise residential building. Digital radio equipment 80.20 In Phase 1, there was evidence to suggest that at the Grenfell Tower fire digital radios had performed to a higher standard or provided better coverage than UHF radios. Digital devices essentially encode soundwaves into digital values and, in doing so, enable the signal to be encrypted.1567 Digital radios can operate in two modes: direct mode (which is much like UHF radio in that the user communicates directly with another handset) and trunk mode, in which the radio transmission is sent via a base station, similar to a mobile telephone signal. When communicating in trunk mode, users join Airwave talk groups (equivalent to channels). The national Airwave network hosts a large number of talk groups; a document produced by the LFB in 2015 indicates that at that time it had access to about 70 talk groups but used only a handful at any given time.1568 Because of 1561 Dobson {Day212/45:1}-{Day212/46:11}; Reason {Day182/24:16-22}; {Day182/50:3-14}. 1562 Christopher Johnson {Day189/54:14-25}. 1563 Lakanal House Inquest – Day 42 Transcript {CWJ00000010/73-74}. 1564 Johnson, Communications Expert Report {CWJ00000119/193}. 1565 Training packages on communications were developed following the Lakanal House fire as part of TCAP 0039, but were not released before the Grenfell Tower fire. In any event, those packages gave only a description of the operation and set up of repeaters and leaky feeders and did not distinguish between the two {LFB00122846}; {LFB00122844}. 1566 Ashman {LFB00102269/3} page 3, paragraphs 11-12. 1567 Christopher Johnson {Day189/8:9-23}. 1568 {LFB00084685/25} paragraph 85; Reason {Day182/87:7-15}.

The Grenfell Tower Inquiry: Phase 2 Report 178 their national coverage, talk groups can be assigned to a specific incident, location or activity, which provides an incident ground with more flexibility than the UHF system of separate channels.1569 80.21 Professor Johnson attributed the superior coverage of Airwave radios to their national, trunk mode operation,1570 but it is important to note that, as in the case of analogue radio, digital radio signals are susceptible to blocking, degradation and interference.1571 Although it is possible to enhance digital signals with repeaters,1572 we have not seen any evidence that the LFB used, or contemplated using, such equipment in conjunction with digital radios. 80.22 Digital radios offer additional benefits, including the ability to compress data, enabling it to be transmitted using less bandwidth and thus reducing the chances of the network reaching the limit of its capacity.1573 However, congestion can affect digital radios, although in a different way. Large numbers of people communicating over a talk group can result in Airwave reaching the limit of its capacity, which, in turn, prevents a signal from being transmitted.1574 It follows that it is important to observe radio discipline, whichever technology is being used. 80.23 Most firefighters who attended the Grenfell Tower fire had only analogue radios (whether handheld or as part of a BARIE set). The LFB’s handheld digital radios were reserved for officers of the rank of station manager and above.1575 80.24 The use of handheld Airwave radios was subject to stringent security requirements due to their ability to gain access to encrypted radio channels used by the police and ambulance services and for reasons of cost.1576 However, it is not clear that the security concerns surrounding the use of Airwave radios were insurmountable. The police and ambulance service use Airwave radios at all levels of seniority.1577 Awareness of the limitations of radio equipment 80.25 Even at the time of the Lakanal House fire in July 2009, the limitations of radio equipment of the kind used by the LFB were by no means unknown, having been demonstrated at several previous large-scale incidents.1578 The following provide particularly clear examples. a. The King’s Cross Fire, 1987. At the King’s Cross fire radio communications were hindered by underground tunnels because the thick concrete walls obstructed signals. Officers could not communicate by radio unless they could see each other. Following the fire, fixed repeaters were installed in a number of underground stations and it was recommended that the LFB deploy radio repeaters and leaky feeders. However, that had not been done by the time of the London bombings on 7 July 2005.1579 1569 Christopher Johnson {Day189/177:18-23}; {LFB00033375/2}. 1570 Christopher Johnson {Day189/57:11-23}; Christopher Johnson {Day189/58:9-12}. 1571 Christopher Johnson {Day189/58:14}-{Day189/59:4}. 1572 Christopher Johnson {Day189/59:5-10}. 1573 Christopher Johnson {Day189/59:11}-{Day189/60:9}. 1574 Christopher Johnson {Day189/93:20}-{Day189/94:12}. 1575 {LFB00089144/2} paragraph 3.1. 1576 Christopher Johnson {Day189/159:11-20}; {LFB00012913/10} section 13. 1577 Christopher Johnson {Day189/181:5-24}. 1578 Dobson {Day212/8:24}-{Day212/9:4}. 1579 Johnson, Communications Expert Report {CWJ00000119/59-60}; Johnson, Communications Expert Report {CWJ00000119/183}.

Part 8 | Chapter 80: Communications 179 b. The World Trade Center incidents, 1993 and 2001. The attacks on the World Trade Center in New York are significant because they provided early warning signs that low- powered UHF radios used by emergency responders might have difficulty penetrating high-rise buildings constructed of large amounts of concrete and steel or other metal.1580 The attacks also demonstrated that repeaters (whether fixed or portable) did not always provide an answer to that problem, particularly if they became damaged or unavailable during an incident.1581 The 2001 World Trade Center attacks prompted DCLG to undertake research into the problems with communications that emerged during those incidents because of their importance to fire and rescue services in the United Kingdom.1582 Consideration was given to requiring developers or owners of large buildings to restrict the use of materials which limit the efficiency of radio equipment or to provide fixed radio infrastructure to assist fire and rescue services. Consideration was also given to reassigning UHF channels to minimise technical limitations and interference and to replacing analogue systems with digital systems. As far as we are aware, however, no action was taken in response to that exercise. c. The Bethnal Green Road Fire, 2004. A failure of radio communications was identified as part of the circumstances which resulted in the deaths of two firefighters. At the subsequent inquests into those deaths, the coroner expressed surprise that it had been standard practice in the LFB for a team of two firefighters wearing breathing apparatus to be committed with only one BARIE set between them and recommended that the LFB revise its allocation of BARIE equipment. However, at the time of the Grenfell Tower fire it was still the LFB’s practice to provide one BARIE set for each team of two wearing breathing apparatus, although Commissioner Dobson told us that every firefighter was issued with a fireground (UHF) radio and that an instruction has been given that all teams committed to an incident should have a BARIE set.1583 d. The London Bombings, July 2005. This incident again revealed difficulties with UHF communications underground, particularly as fixed radio repeaters had been damaged during the attacks. As a result, the Review Committee appointed by the Greater London Assembly to identify lessons to be learnt from the incident recommended that the LFB, the Metropolitan Police Service and the London Ambulance Service give it information about the provision of digital radio systems. In the meantime, it recommended an emergency underground communications system which could be put in place more quickly than a leaky feeder cable. The committee noted that no serious consideration had been given to using alternative technologies pending the provision of CONNECT (a radio communications project developed under the aegis of London Underground) and Airwave or as a backup measure in the longer term.1584 The force of those observations was demonstrated at the Grenfell Tower fire, at which most LFB crews did not have access to an Airwave radio.1585 1580 Johnson, Communications Expert Report {CWJ00000119/60-61}. 1581 Johnson, Communications Expert Report {CWJ00000119/183-185}. 1582 Incident Communications Final Report {CWJ00000092}. 1583 Johnson, Communications Expert Report {CWJ00000119/64-66}; Dobson {Day212/9:21}-{Day212/11:24}. 1584 London Assembly’s Report of the 7th July Review Committee {CWJ00000007/22} paragraph 2.30; cited in Johnson, Communications Expert Report {CWJ00000119/70-71} paragraph 4.9.12. 1585 Johnson, Communications Expert Report {CWJ00000119/68-71}; Johnson, Communications Expert Report {CWJ00000119/185-187}.

The Grenfell Tower Inquiry: Phase 2 Report 180 80.26 The evidence showed that various people within the LFB held a substantial amount of technical knowledge about how construction materials of different kinds could attenuate or block radio signals,1586 but that those who held that knowledge did not share it widely, with the result that the organisation as a whole did not make appropriate use of it. Although national guidance could have provided a clearer explanation of why high-rise buildings cause interference with radio signals, it did draw attention to the problem and recommend that fire and rescue services have contingency plans in place to ensure the safety of firefighters. For example, GRA 3.2, issued in February 2014, pointed out that high-rise buildings may cause difficulties with radio reception, including the creation of “blind spots”.1587 The National Operational Guidance on Breathing Apparatus gave the same message when it warned that crews wearing breathing apparatus should be aware of the potential for limited penetration of radio signals through buildings and structures below ground and either make other arrangements or put contingency plans in place.1588 The Lakanal House fire 80.27 At the Lakanal House fire in July 2009, problems with the UHF radio signal made it difficult for the breathing apparatus entry control officer1589 to communicate with crews relying on BARIE sets. Communications were also adversely affected by the volume of radio traffic at the incident.1590 80.28 Despite not being a new problem,1591 the difficulties were serious enough to prompt the LFB to investigate their cause. The LFB’s Lakanal House Investigation Team, led by DAC Cutbill, was charged with that investigation. In April 2010, a radio expert, Roger Tuckley, produced a report for the LFB on the effect that steel-framed buildings can have on radio signals. It is unclear why the LFB focused attention on steel-framed buildings, since the purpose of the report was to provide answers to questions that might arise during the Lakanal House inquest.1592 80.29 Mr Tuckley’s report, a one-page note entitled “In Building Radio User Difficulties”,1593 described a number of inherent restrictions affecting the use of UHF radio in the built environment, including the attenuating effect that buildings and objects within them can have on signal propagation. He also described the particular effects of certain construction materials, notably concrete, metal, solid foam insulation and insulation with foil backing. UHF radios operate best in situations where there is nothing between the transmitter and the receiver, which is typically not the case when they are used by BA crews. In view of its importance for understanding the performance of BARIE sets, the report was essential reading for the senior managers of the LFB’s operational departments. Despite that, it was not brought to the attention of AC Reason when he became Director of Operations, Resilience and Training in January 2012 or when he joined the Lakanal House Board in February 2012.1594 1586 {LFB00001843/61} paragraph 9.3.11; Dobson {LFB00110652/3} page 3, paragraph 11; {LFB00041759}; {LFB00110654}; {LFB00001256/3} paragraph 2.9. 1587 {LFB00001255/9}. 1588 {LFB00029438/55} paragraph 6B3.24. 1589 An entry control officer manages the deployment of firefighters wearing breathing apparatus. For more information, see the Phase 1 Report Volume I, paragraphs 7.70 - 7.71. 1590 Dobson {Day212/12:24}-{Day212/13:10}. 1591 Reason {Day182/6:21-25}. 1592 {LFB00110657}. 1593 {LFB00110659}. 1594 Reason {Day182/3:15-23}; {Day182/4:18}-{Day182/5-22}.

Part 8 | Chapter 80: Communications 181 80.30 Despite the fact that Mr Tuckley had exposed significant limitations on the LFB’s UHF radios and had provided an explanation for the poor radio communications at the Lakanal House fire, the evidence suggests that little was done in response to his report beyond including it as an appendix to the LFB’s Lakanal House Operational Response Report.1595 That report recorded only that most of the radios deployed at the Lakanal House fire had not been defective and that an unidentified report (which can only have been Mr Tuckley’s report) had advised that the height and construction of the building may have contributed to some of the comments made by crews. Mr Tuckley’s report did not prompt the LFB to consider how it might improve the resilience of its UHF radios or otherwise make up for their inherent limitations. 80.31 After the Lakanal House fire, the LFB’s Incident Communications department suggested that the power of handheld radios be reviewed and that the need for intrinsically safe radios in some circumstances be re-examined, but those suggestions were not passed to AC Reason1596 and neither he nor Commissioner Dobson could recall having given them any detailed consideration when preparing the LFB’s response to the coroner’s rule 43 recommendations. They both said that the limited power of the BARIE radios reflected national guidance, from which the LFB was unlikely to depart.1597 However, national guidance on breathing apparatus published by DCLG in January 20141598 had recommended that the level of intrinsic safety should be appropriate to the hazards likely to be encountered and should take account of other equipment being deployed by those wearing breathing apparatus. It also stated that electrical equipment other than that which was intrinsically safe might be considered appropriate for all normal operational requirements where it would confer a significant benefit to the safety and effectiveness of teams wearing breathing apparatus.1599 We are not persuaded by Commissioner Dobson’s evidence that no steps were taken to implement that guidance because of disruption caused by industrial action. It was clear from his evidence that he was not familiar with it and there was no evidence within the LFB’s documents that it had been considered at all, let alone of any decision to delay its implementation between January 2014 and June 2017.1600 In our view it is better understood as another example of the LFB’s reluctance to depart from established practices. 80.32 Improving radio communications was not one of the LFB’s pre-inquest action points (see Chapter 74). Commissioner Dobson could not account for that omission, but thought that it might have been because the problems with communications encountered at Lakanal House were not unusual and because advice had been received from technical experts that it was not possible to overcome some of them, given the circumstances in which radios were used.1601 However, we have seen no evidence that the LFB’s senior officers were told that the problems were insurmountable, or that any consideration was given to whether they could be overcome or at least mitigated. Indeed, Commissioner Dobson’s evidence was that there was no review, let alone a root and branch review, of the existing technology following the Lakanal House fire.1602 1595 {LFB00034805/59}. 1596 {LFB00098635}; {LFB00098636}; Reason {Day181/208:8-11}. 1597 Reason {Day181/207:20}-{Day181/208:20}; {Day182/41:7-10}. 1598 {LFB00031268}. 1599 {LFB00031268/83-84}. 1600 Dobson {Day212/40:2}-{Day212/41:14}. 1601 Dobson {Day212/13:17}-{Day212/15:7}. 1602 Dobson {Day212/47:16-21}.

The Grenfell Tower Inquiry: Phase 2 Report 182 80.33 We find that surprising. Given the importance of the observations made by Mr Tuckley, the LFB should have taken steps to investigate the practicability of mitigating or eliminating the problems he had identified. We have been left with the strong impression that the LFB viewed the kinds of communications difficulties experienced at the Lakanal House fire as an unavoidable incident of firefighting, particularly in modern high-rise buildings. A consequence of that attitude was that nothing was done between the Lakanal House fire in July 2009 and the Grenfell Tower fire in June 2017 properly to investigate the nature, extent and causes of those well-known difficulties to see whether it might be possible to mitigate or eliminate them. No satisfactory explanation has been offered for the LFB’s failure to pursue an enquiry into a matter of such importance to effective firefighting and the protection of crews. Another review of the problem: 2013 80.34 In February 2013, during the course of the Lakanal House inquests, the LFB looked again at why its incident ground radios had not been wholly effective. DAC Cutbill asked GM A’Court (who was a member of the Incident Communications team) to consider the matter, but it is unclear why he did so, since, as DAC Cutbill knew, the LFB had already received detailed advice from Roger Tuckley which it had not taken seriously into account. 80.35 In his response dated 28 February 2013 GM A’Court explained once again that UHF radios work best in the absence of obstructions which reduce the propagation of signals and the distance over which they are effective.1603 He explained that steel-framed buildings are more difficult for radio signals to penetrate than simple brick or timber-framed buildings and that the transmission strength of a signal has a bearing on its propagation. He described the signal strengths of the different channels used at incident grounds and noted that the transmission strength of BARIE radios was limited to 1 watt for safety reasons. Again, however, there was no evidence that anyone made use of that valuable description of the current equipment and the factors affecting its performance to consider the possibility of making changes to the LFB’s communications policies, equipment or practices. It is surprising, to say the least, that GM A’Court’s email was not brought to the attention of AC Reason, who by then was Director of Operational Resilience and Training.1604 80.36 At the conclusion of the Lakanal House inquests, the coroner recommended that the LFB consider whether it would be beneficial to use additional breathing apparatus radio communication channels and personal radio channels at major incidents to reduce the amount of traffic on each channel.1605 In his response to the coroner of 23 May 2013 Commissioner Dobson explained that the LFB had considered doing so but had decided that using separate channels might make it difficult for crews to maintain an overview of an incident and might adversely affect operations, for example, by delaying the exchange of critical information and adversely affecting co-ordination between teams.1606 The LFB concluded that the need to pass information across several channels might negate any apparent benefit because of the need to transmit the same information across all channels in use, thus reducing radio capacity and creating a risk of duplication and confusion.1607 The Commissioner also said that the LFB had introduced breathing apparatus telemetry (a system which enables the entry control officer to monitor the air consumption of those 1603 {LFB00106755}. 1604 Reason {Day182/15:3-14}. 1605 {LFB00032158/3}. 1606 {LFB00042089}. 1607 {LFB00042089/8}.

Part 8 | Chapter 80: Communications 183 wearing breathing apparatus),1608 which reduced the amount of radio communication at incidents. He said that the LFB would ensure that the constraints on communication were covered in operational training, but he did not refer to the use of additional personal radio channels. 80.37 Responsibility for drafting the LFB’s response to the coroner’s recommendations on communications rested with the Incident Communications team, which was part of the Operational Policy department.1609 The draft identified some potential improvements to communications which went beyond the coroner’s recommendation relating to the use of additional radio channels.1610 The improvements suggested were sound and, if adopted, would have forestalled some of the concerns that have arisen during this Inquiry. They included: a. Raising crews’ awareness of problems with communications at incidents and explaining how to identify and overcome them; b. Using a dedicated UHF channel for passing fire survival guidance information; c. Using additional UHF channels which had been vacated by the police; and d. Using Airwave radios to provide additional incident command channels if communication difficulties occurred at larger incidents. 80.38 For the sake of completeness, we note that an earlier draft of the document,1611 which GM A’Court sent only to AC Knighton (then the Head of Operational Procedures)1612 also suggested the following: a. Carrying out a detailed risk assessment of the need to use intrinsically safe radios and equipment; b. Including the effectiveness of UHF radios in the information to be gathered during section 7(2)(d) visits; and c. Training command unit staff to provide communications advice to incident commanders. 80.39 The Commissioner’s Group rejected the suggestions. Neither Commissioner Dobson nor AC Reason could remember why they had done so, beyond referring to a general (but not obviously well-founded) belief that the LFB’s systems were adequate. 80.40 Following the Grenfell Tower fire, the Operational Policy and Assurance department reviewed the specifications for fireground and breathing apparatus radios in advance of procuring new equipment. The review recommended that a single specification providing a transmitting power of 4 watts should be adopted for all UHF radios, but that a stock of radios with a higher intrinsic safety rating should be retained for specialist operational use.1613 That approach could have been taken earlier in response to the national operational guidance on breathing apparatus issued by the DCLG in January 2014. 1608 For a more detailed explanation of this process and the equipment involved, see the Phase 1 Report Volume I, paragraphs 7.70 - 7.71. 1609 Reason {Day181/166:7}-{Day181/167:9}. 1610 {LFB00034062/9}. 1611 {LFB00098636}. 1612 {LFB00098635}; Reason {Day181/208:8-11}. 1613 {LFB00105466/1}.

The Grenfell Tower Inquiry: Phase 2 Report 184 Communications training: the failure to implement TCAP 0039 80.41 The LFB’s response to the coroner’s rule 43 letter was that it would ensure that the constraints on communications at incidents were covered in current operational training. In May 2013, however, the LFB provided very little training on the use of radio equipment beyond the initial training given to recruits as part of their firefighter development programme.1614 The estimated completion date for the enhanced incident communications training was December 2013. 80.42 AC Reason said that he had understood that the new training would cover subjects such as using the correct equipment, using the correct channel, the availability of alternative channels, highlighting potential interference with the propagation of radio signals, the effect that certain kinds of buildings can have on the propagation of signals, options for circumventing problems and the equipment available for that purpose.1615 The view within the LFB was that its communications procedures had broken down at Lakanal House because of the immense pressure under which firefighters were operating and that training might help to ensure that the procedures required to communicate more effectively were fixed in the minds of firefighters.1616 80.43 The process for commissioning that training was initiated by TCAP No. 0039,1617 which was first issued on 27 July 2012, a date which indicates that the need for such training had been identified even before the Lakanal House inquests had begun. The training requirement was described in the form as being to ensure that all operational personnel had the knowledge and understanding required to use radio communication equipment in accordance with LFB policy to ensure effective communication at incidents.1618 The final version, dated 10 March 2015, did not refer to the problems with communications experienced at Lakanal House or to the coroner’s recommendation. AC Reason said that he would have expected it to have done so, but plainly it did not.1619 The absence of any reference to the LFB’s experience at the Lakanal House fire or to the coroner’s recommendation meant that the substance of the training programme was not informed by the matters it was intended to address. Once more, no senior LFB officer was able to explain that omission and there is no contemporaneous, or indeed any, document that explains it. 80.44 The resulting training packages were examined in detail during the oral evidence. Although the training package for station-based staff (that is, firefighters up to and including the rank of watch manager) described LFB radio equipment and radio enhancing equipment, it failed to explain how to use it or how to overcome communication failures. It did not explain the effect that the built environment can have on the propagation of radio signals, although that had emerged clearly from the Lakanal House fire and the LFB’s own investigations.1620 Although the package for senior officers (station managers and above) provided more detailed information about the LFB’s radio equipment, it too failed to provide advice on how to overcome communications difficulties or information about the effect of the built environment on radio signals.1621 Neither training package suggested 1614 Groves {Day177/191:22}-{Day177/198:1}. 1615 Reason {Day182/43:1-15}; {Day182/44:3-9}. 1616 Dobson {Day212/20:19}-{Day212/21:8}. 1617 {LFB00004729}. 1618 {LFB00004729/7}. 1619 Reason {Day182/58:8-15}. 1620 Reason {Day182/60:9}-{Day182/63:17}; Groves {Day178/3:2-13}; {Day178/4:13-17}. 1621 Reason {Day182/63:18}-{Day182/67:13}.

Part 8 | Chapter 80: Communications 185 the use of Airwave radios as a way of overcoming communication difficulties,1622 nor did either of them distinguish between radio repeaters and telemetry repeaters, which became a source of confusion on the night of the Grenfell Tower fire.1623 In short, the substance of the training packages did not adequately address the problems that had been clearly identified by both the LFB itself and the Lakanal House coroner. We have seen no evidence to suggest that anyone reviewed the content of the packages to see whether they covered those matters adequately. 80.45 However, the shortcomings of both training packages are completely overshadowed by the LFB’s failure to deliver them. Although they were approved, after some delay, in May 2015, they were not delivered to staff. The LFB attributed that failure to problems with its computer training system, which at many stations could not support training packages containing videos.1624 However, only the package designed for senior officers contained video; the package designed for station-based crews was not affected by the limitations of the system. Peter Groves, the former Head of Development and Training, explained that a number of attempts had been made to solve the problem, none of which had been successful, and accepted that the videos could easily have been provided to stations by other means, such as CDs. That solution was apparently not considered, although it had been adopted for other training packages.1625 Management failures 80.46 The story of communications is one of a succession of senior management failures to take active steps to improve what was known to be an unsatisfactory position. The rejection of GM A’Court’s proposals and the absence of any record of the reasons for rejecting them illustrate the LFB’s defeatist attitude towards the difficult task of providing effective communications. Our overriding impression is that the LFB’s senior officers saw the difficulties with communications as an intractable problem not amenable to any solution and for that reason nothing was ever done about them. However, given the obvious importance to firefighting operations of effective communications, such an attitude also suggests an unjustified complacency about the LFB’s ability to fulfil its role effectively without reliable communications. 80.47 The decision of the Commissioner’s Group not to adopt GM A’Court’s proposals is even more striking in the light of the publicity then being given to the problems with communications that had been encountered by the Hampshire Fire and Rescue Service during the Shirley Towers fire and were being investigated by the Hampshire coroner. The Hampshire Fire and Rescue Service’s report into that fire had been published on 8 April 2013, a few weeks before the Commissioner’s Group met in May 2013. It recorded that the handheld radios used by Hampshire Fire and Rescue Service did not always operate effectively in high-rise buildings and that the problem of poor radio communications in high-rise buildings was well known.1626 80.48 The report of the investigation into the Shirley Towers fire was released a week after the coroner at the Lakanal House inquests had made her rule 43 recommendations. AC Reason said that he had read the report when it was released and that it had been the subject of a report to the co-ordination board.1627 In his evidence he agreed with the report’s conclusion 1622 Reason {Day182/83:5-21}; {Day182/88:9-11}; {Day182/92:15}-{Day182/93:7}. 1623 Reason {Day182/67:14}-{Day182/68:3}. 1624 Groves {Day177/174:15}-{Day177/176:7}. 1625 Groves {Day177/179:2}-{Day177/181:3}; {Day177/197:7}-{Day177/198:1}. 1626 {LFB00107130/53}. 1627 Reason {Day182/16:24}-{Day182/17:8}; {Day182/18:10}-{Day182/19:8}.

The Grenfell Tower Inquiry: Phase 2 Report 186 that it had been well known that radio communications within high-rise structures could present problems, a matter of which the LFB had already been aware,1628 but he had no clear recollection of the extent to which, if at all, the report had affected the LFB’s response to the coroner’s rule 43 recommendations.1629 The LFB did produce a draft plan, dated 8 October 2012, for responding to various aspects of the operations at Shirley Towers, which included reviewing the meaning of a prolonged breakdown in radio communications referred to in materials such as procedures and training materials. The task was given to Operational Procedures,1630 but we saw no evidence that any review had been carried out. AC Reason did not know whether any action had been taken in response.1631 80.49 The problems identified by the investigation into the Shirley Towers fire echoed problems which were well known to the LFB and the reaction of its senior officers reflected their defeatist response to the problems experienced during the Lakanal House fire. Although the causes of those problems had been identified by some within the organisation, the LFB failed to consider how best to address them. In essence, the Shirley Towers report did not prompt the LFB to reconsider its communications practices or policies, or, importantly, its response to the Lakanal House coroner’s recommendations on radio communications. As the Shirley Towers fire was yet another high-rise incident at which difficulties had been encountered using UHF radios, it should have elicited a more energetic response. Senior officers were unable to provide a satisfactory explanation for why nothing had been done. 80.50 In 2014, the LFB’s Operations, Resilience and Training Directorate had intended to replace the existing BARIE sets with more modern equipment, but the purchase of the new equipment was deferred because the current equipment was still available and was thought to operate effectively.1632 That decision was unfortunate, given the wealth of evidence that many firefighters regarded the existing BARIE sets as unsatisfactory due to their limited range and the difficulties encountered in using them. 80.51 Apart from the BARIE sets, whose transmission power was limited to 1 watt, handheld radios could transmit at up to 4 watts. However, although channel 1 (the default incident command channel) operated at the full 4 watts, for historical reasons related to the previous generation of equipment, radios were set to transmit on other channels at 2.3 watts.1633 Although that must have been known to some people in the LFB, by June 2017 no steps had been taken to increase the transmission power of handheld radios to 4 watts on all channels following the introduction of the current equipment in about 2007.1634 80.52 The story of TCAP No. 0039 is one of incompetence and inefficiency. The aim of the training packages was to address the kind of problems with communications that had been experienced at the Lakanal House fire, but their contents owed little to the LFB’s consideration of those problems or to the coroner’s recommendation and did not deal with them adequately. The LFB had access to three ‘spare’ UHF channels (channels 4, 7 and 8), but in June 2017 it was not its policy or practice to use them.1635 The Incident 1628 Reason {Day182/19:10-18}. 1629 Reason {Day182/19:19}-{Day182/22:2}. 1630 {LFB00100307} item 23. 1631 Reason {Day182/100:9-25}. 1632 {LFB00088188} first row. 1633 {LFB00106755}. 1634 In his statement to the MPS, Dominic Ellis explained that the LFB’s working assumption was that the wattage of the other channels was based on previous radios held by the LFB, known as the Maxon radio. Director Reason’s evidence was that the Maxon radios were replaced by the HX series in 2007/2008, following the Bethnal Green fire in 2004: Reason {Day182/57:1-6}. There is no evidence, whether in this statement or elsewhere, that the issue of restricted wattage had been rectified by 14 June 2017: Ellis {MET00077839/9} page 9. 1635 Johnson, Communications Expert Report {CWJ00000119/48} paragraphs 3.5.8 and 3.5.9.

Part 8 | Chapter 80: Communications 187 Communications department drew attention to the possibility of using those additional channels,1636 but senior officers decided against doing so, on the grounds that the benefits were likely to be outweighed by a lack of oversight of communications, a lack of co- ordination, and the possibility of delay in sending critical information.1637 However, that reasoning is not consistent with the policy that firefighters wearing breathing apparatus should transfer from channel 6 to channel 5 if radio repeaters or leaky feeders have been deployed.1638 80.53 AC Reason told us that interference between channels had been a factor in the decision not to bring one of the available spare channels (channel 4) into regular use.1639 Although that may be the case, we agree with Professor Johnson’s view that it might have been possible to persuade the government to reallocate the channels to maximise the use of the available frequencies.1640 The fact that the LFB has brought some of those channels into regular use following the Grenfell Tower fire suggests that the problems of interference were not insurmountable. 80.54 An increased number of radio channels adds complexity to an incident and requires a robust system to ensure that the incident commander is made aware of all important communications. However, that should not represent an unduly onerous burden for a fire and rescue service responding to a large incident. A system of that kind is required at any incident where more than one radio channel is used, because an incident commander cannot be aware of all the communications generated, as LFB policy recognises.1641 That complexity, and the potential need for a communications officer to oversee communications at larger incidents, will often be justified by the resilience that additional radio channels bring to fireground communications. 80.55 The LFB knew that the transmitting power of a radio and the surroundings in which it is being used both have a direct effect on the range of the signal. It should, therefore, have increased the transmitting power of handheld UHF radios and considered providing more powerful BARIE sets for use at residential fires, particularly those in high-rise buildings. A good start would have been to make a detailed assessment of the level of risk that wearers of breathing apparatus are exposed to using equipment with different levels of power, how frequently such risks arise, the effect of using more or less powerful radios and how the quality of communications could be improved in situations in which it was considered necessary for BARIE sets to remain intrinsically safe. AC Reason said that no such assessment had been carried out during his time.1642 80.56 The abundance of concrete, steel and more modern construction materials in Grenfell Tower is likely to have contributed to the significant deterioration of radio communications experienced by firefighters and officers in and around the tower on 14 June 2017. After the fire, the LFB tested radios at Grenfell Tower and found that they performed better than on the night of the fire. As a result, it attributed the problems it had experienced to congestion.1643 We agree with Professor Johnson that that is an oversimplification.1644 Although congestion is likely to have played a part in the failure of effective 1636 {LFB00034062/10}. 1637 {LFB00042089/8}. 1638 Christopher Johnson {Day189/88:20}-{Day189/89:22}. 1639 Reason {Day181/179:18}-{Day181/180:7}. 1640 Christopher Johnson {Day189/80:13}-{Day189/81:4}. 1641 Johnson, Communications Expert Report {CWJ00000119/50} paragraphs 3.5.10 - 3.5.15. 1642 Reason {Day182/40:22-25}-{Day182/41:1-10}; Christopher Johnson {Day189/32:12}-{Day189/33:21}. 1643 Johnson, Communications Expert Report {CWJ00000119/159} paragraph 6.14.1. 1644 Christopher Johnson {Day189/108:5-9}; {Day189/115:1}-{Day189/122:3}.

The Grenfell Tower Inquiry: Phase 2 Report 188 communications, we think it likely that the significant changes to the structure of the building brought about by the fire itself (including the destruction of most of the facade) explain most of the difference between the test results and the conditions experienced by firefighters on 14 June 2017.1645 We also accept Professor Johnson’s opinion that signal propagation can be influenced by factors such as the weather and the presence of fire itself,1646 and that those factors must also be borne in mind when considering the results of the LFB’s tests. Conclusions 80.57 Notwithstanding its experience at the Lakanal House fire, the LFB did not teach firefighters or officers that the structure of a building and the materials from which it is made can interfere with radio signals, beyond giving them a broad indication that there can be blind spots within high-rise (or indeed other) buildings.1647 More significantly, the LFB did not provide sufficient guidance to firefighters and incident commanders on how best to overcome difficulties with communications encountered in high-rise buildings. Such training may also have helped crews identify the risk of poor radio communications during section 7(2)(d) visits. 80.58 The LFB’s communications at the Grenfell Tower fire were generally ineffective.1648 That was the result of many different failings and shortcomings, but in summary, the equipment deployed by the LFB on 14 June 2017 was inadequate, firefighters were not trained to identify and mitigate well-known and frequently encountered problems and LFB policies did not contemplate a widespread loss of communications or provide guidance on how they could be effectively restored.1649 80.59 Occasional failures of equipment are only to be expected and major incidents will always suffer from obstacles to consistently effective communications. However, that makes it all the more important to have contingency arrangements in place that can function cohesively to ensure the effective transmission of information. The LFB’s communication system on the night of the Grenfell Tower fire fell well short of achieving that objective.1650 80.60 In our view, the LFB’s approach to communications was to do the best it could with what it had available. As a result, it failed to make sufficient efforts to modernise its equipment and eliminate well-recognised defects in its systems.1651 The LFB’s senior management concentrated almost exclusively on congestion as the primary cause of problems at large incidents, but for reasons given earlier, although a contributory factor, that was not the real difficulty. Senior managers appear to have accepted that communication problems were only to be expected and since little was done to challenge that conclusion and the suggestions made by the incident communications team were not implemented, no improvements were made. As a result, the LFB’s operational efficiency was significantly impaired. 1645 This was acknowledged by the LFB in its testing methodology {LFB00084087/3}. 1646 Johnson, Communications Expert Report {CWJ00000119/43} paragraphs 3.2.15 – 3.2.18; Christopher Johnson {Day189/15:11-18}. 1647 Groves {Day177/192:6}-{Day177/194:4}; Reason {Day182/60:9}-{Day182/63:17}; {Day182/63:18}-{Day182/67:14}. 1648 Phase 1 Report Volume IV {INQ00014817/133} paragraph 28.130. 1649 Although Commissioner Dobson thought that wholesale loss of communications was covered in training Dobson {Day212/49:18}-{Day212/50:6}, it was clear from Mr Groves’ evidence that that was not the case: Groves {Day177/192:6}-{Day177/194:4}. 1650 Christopher Johnson {Day189/198:3}-{Day189/199:6}. 1651 Christopher Johnson {Day189/202:2}-{Day189/208:1}.

Part 8 | Chapter 80: Communications 189 80.61 The history of this matter neatly encapsulates the chronic defects in the LFB’s approach to well-known problems with incident ground communications. It consistently failed to accord to radio communications the significance and attention that they deserved, to address the problems that had been clearly identified and to train its personnel on how to deal with them when they arose. None of the senior officers who gave evidence was able to explain satisfactorily why the LFB had persistently failed to make a serious effort to solve problems which, although undoubtedly complex, were critically important for effective firefighting operations. For example, it is possible to set up a number of temporary Airwave talk groups for specific incidents or aspects of incidents, which is how the police and ambulance service use the system.1652 There was no evidence to suggest that the LFB had considered using talk groups in that way, other than for training exercises, which may be a reflection of the limited number of officers who had personal Airwave radios. The broader adoption of digital radios (whether Airwave or otherwise), combined with the effective use of talk groups or channels, should have received more active consideration by the LFB before the Grenfell Tower fire. That might have improved the poor quality of communications inside the tower on 14 June 2017. 1652 Christopher Johnson {Day189/95:2}-{Day189/96:2}.

190 The Grenfell Tower Inquiry: Phase 2 Report

191 Chapter 81 The supply of water 81.1 There were understandable concerns that there might have been a failure on the part of the utility company to make as much water available as possible on 14 June 2017 for firefighting purposes or a failure by the LFB to make the most effective use of the water that was available. We therefore considered it appropriate to investigate the supply and use of water in order to find out whether there had been any shortcomings and, if so, how they might be avoided in the future. Regulatory requirements 81.2 Fire and rescue authorities have a statutory duty to take all reasonable measures for securing that an adequate supply of water will be available for the authority’s use in the event of fire.1653 If a fire and rescue authority asks for a greater supply and pressure of water than a water company would otherwise provide, the water company must take all necessary steps to comply and may shut off the water in any area to do so.1654 81.3 Due to the vast volume of water available in the Barrow Hill and Willesden reservoirs and accessible through the Thames Water Ring Main, there was more than enough water available to meet the demand for firefighting at Grenfell Tower.1655 81.4 The minimum water pressure in the network at the location of the hydrants used by the LFB was about 25 metres (2.5 bar),1656 which exceeded both the minimum regulatory pressure of 7 metres (0.7 bar)1657 and the 15 metres (1.5 bar) recommended by Ofwat.1658 There is no minimum pressure requirement applicable to the provision of water for firefighting. Water companies and the water distribution system 81.5 The water used for firefighting at Grenfell Tower was drawn from the general water distribution system, a complex network of pipes and valves used to transport water from storage (such as reservoirs and water towers) to customers and hydrants. The function of the water distribution network is to deliver an appropriate quantity and quality of water at a suitable pressure with minimal leakage, which it achieves using the force of gravity and the use of pumps.1659 81.6 Thames Water Utilities Limited (Thames Water) is the company which supplies water to London, including the Barrow Hill Zone in which Grenfell Tower is located. The Barrow Hill Zone is supplied by water from the Barrow Hill and Willesden reservoirs and has access to additional capacity provided by the Thames Water Ring Main.1660 1653 Section 38 of the Fire and Rescue Services Act 2004. 1654 Section 40 of the Fire and Rescue Services Act 2004. 1655 Stoianov, Water Expert Report {ISTRP00000008/229} paragraphs 3-5. 1656 Stoianov, Water Expert Report {ISTRP00000008/237}. 1657 Regulation 17G(1) of the Water Supply and Sewerage Services (Customer Service Standards) Regulations 2008. 1658 Stoianov, Water Expert Report {ISTRP00000005/48} paragraph 2; Stoianov, Water Expert Report {ISTRP00000008/234-5} paragraph 29. 1659 Stoianov, Water Expert Report {ISTRP00000003/5}. 1660 Stoianov, Water Expert Report {ISTRP00000008/229}.

The Grenfell Tower Inquiry: Phase 2 Report 192 81.7 When fire and rescue authorities require water for firefighting, they connect fire hoses to hydrants to deliver water to pump appliances, which in turn pump it through hoses to firefighting equipment.1661 81.8 The three most important factors affecting the supply of water from a distribution network to firefighting equipment are:1662 a. The quantity of water available, that is, the volume of water in the distribution network that can be made available through hydrants, which determines the time for which water can be provided to appliances. b. The rate at which water can be extracted from fire hydrants for delivery to pump appliances. The flow rate describes the volume of water passing through a pipe or hose in a given time.1663 The flow rate provided by any particular hydrant is dependent on many factors, including the water pressure in the pipe supplying it, the hydrant’s flow coefficient (a measure of the flow rate the hydrant can provide given the pressure of water it receives),1664 and the energy losses between the hydrant and the pump appliance (such as those caused by gravity or by kinks in the hose). c. The flow rate and water pressure at the discharge point of the firefighting equipment itself. There is a maximum flow rate and pressure at which any piece of equipment can safely be operated that are determined by the manufacturer.1665 Supplying water to equipment at less than its maximum rated flow rate or pressure reduces the size of the water jet produced. The flow rate and pressure of water at the firefighting equipment depends on the flow rate and pressure of water pumped out of the pump appliance and on the extent of energy losses between the appliance and the firefighting equipment. The use of water at Grenfell Tower 81.9 At the Grenfell Tower fire the LFB used fire hoses to draw water from the four hydrants shown in Figure 81.1 below: H1, a fire hydrant located to the south-east of the tower under Grenfell Walk,1666 H3, a fire hydrant located at the intersection of Grenfell Road and Bomore Road,1667 H8, a fire hydrant located on Bramley Road1668 and H5, a wash-out hydrant located next to the Kensington Leisure Centre, which was wrongly labelled as a fire hydrant. (Wash-out hydrants are used by water companies for operational and maintenance purposes to flush out sediment and stagnant water, generally at significantly lower flow rates than fire hydrants. They are not designed to supply water for firefighting.)1669 1661 Stoianov {Day288/12:4-12}; Stoianov, Water Expert Report {ISTRP00000003/8-9}. 1662 Stoianov, Water Expert Report {ISTRP00000003/17-18}. 1663 Stoianov, Water Expert Report {ISTRP00000003/20}. 1664 Stoianov {Day288/19:3-9}. 1665 Stoianov, Water Expert Report {ISTRP00000006/3}; Stoianov {Day288/23:17}-{Day288/24:18}. 1666 Stoianov, Water Expert Report {ISTRP00000008/76}. 1667 Stoianov, Water Expert Report {ISTRP00000008/78}. 1668 Stoianov, Water Expert Report {ISTRP00000008/86}. 1669 Stoianov, Water Expert Report {ISTRP00000008/79}.

Part 8 | Chapter 81: The supply of water 193 Figure 81.1: The four hydrants, highlighted in yellow, used to supply water at Grenfell Tower on 14 June 2017. 81.10 On 14 June 2017, between the first deployment of water at 01.15 and about 13.00,1670 the LFB projected water on to the external face of the tower using aerial appliances, ground monitors and handheld branches. 81.11 Aerial appliances are fire engines with extendable ladders or cages from which water can be directed onto buildings.1671 Three aerial appliances were deployed at Grenfell Tower: turntable ladder A213 TL (from 01.47 to 02.05),1672 aerial ladder platform A245 (for less than a minute at 02.13, from 03.28 to 06.47 and from 07.14 to 09.45)1673 and Surrey Fire and Rescue Service’s aerial ladder platform S13A1 (from 10.47 onwards).1674 81.12 Ground monitors are water nozzles which sit in a frame, enabling them to be placed on the ground and aimed in a particular direction without needing to be held by firefighters.1675 Two ground monitors were used, albeit intermittently, at Grenfell Tower. One was sited on Grenfell Walk to the south-east of the tower (from 02.41 to 11.30)1676 and another on the terrace of the Kensington Aldridge Academy to the north-west of the tower (from 02.43 to 10.52).1677 81.13 Branches are nozzles attached to fire hoses held by firefighters.1678 Many handheld branches, including the first jet projected towards the window of Flat 16 from 01.15, were used at different times to project water onto the tower.1679 Many were also used to extinguish burning debris on the ground surrounding the building.1680 1670 Stoianov, Water Expert Report {ISTRP00000006/8}. 1671 Stoianov {Day288/30:16-19}. 1672 Stoianov, Water Expert Report {ISTRP00000006/7} ‘Jet B’. 1673 Stoianov, Water Expert Report {ISTRP00000006/7} ‘Jet D’. 1674 Stoianov, Water Expert Report {ISTRP00000006/7} ‘Jet E’. 1675 Stoianov {Day288/31:3-10}. 1676 Stoianov, Water Expert Report {ISTRP00000006/7} ‘Jet C’. 1677 Stoianov, Water Expert Report {ISTRP00000006/8}; {ISTRP00000006/26} ‘Jet H’. 1678 Stoianov {Day288/28:14-16}. 1679 Stoianov, Water Expert Report {ISTRP00000006/7-8} ‘Jet A’, ‘Jet H’, ‘Jet I’, ‘Jet J’. 1680 Stoianov, Water Expert Report {ISTRP00000006/7-8}; {ISTRP00000006/25-26} Jet F’, ‘Jet G’, ‘Jet I’, ‘Jet J’.

The Grenfell Tower Inquiry: Phase 2 Report 194 81.14 Water for firefighting inside the tower was supplied through the building’s dry rising main from 01.06,1681 and through an additional improvised fire hose into the south-west corner of the building from about 03.30.1682 81.15 None of the aerial appliances or ground monitors deployed at the incident was supplied at its maximum capacity due to restricted flow rates at the hydrants.1683 That had three consequences. a. First, it limited the vertical reach of the water jets directed onto the exterior of the building.1684 Appliance A213 produced a jet with a maximum vertical reach of 50–52 metres (floors 18–19).1685 Appliance A245 reached a maximum height of approximately 35 metres (floor 13).1686 Appliance S13A1 reached a maximum height of approximately 47 metres (floor 17).1687 If supplied at their maximum rated flow and pressure, each of them was capable of projecting a water jet reaching the full height of the tower (approximately 65 metres).1688 b. Secondly, the rate at which water was supplied to the pump appliances did not always match that at which it was being pumped out to firefighting equipment, which in turn resulted in periodic interruptions in the use of some equipment.1689 c. Thirdly, some firefighting equipment could not be used as intended. 81.16 In the light of the report produced for the Inquiry by Dr Stoianov, the LFB carried out a series of tests to determine the maximum height of the jet that could be practically achieved by aerial appliances and ground monitors of the kind used at Grenfell Tower.1690 The maximum heights achieved during the tests were (with one exception) higher than those achieved on 14 June 2017, but not high enough to reach the top of the tower.1691 In his supplementary report1692 and oral evidence to the Inquiry,1693 Dr Stoianov made strong, and in our view, persuasive, criticisms of the testing method used by the LFB, most significantly, that it had failed to supply the appliances with water at their maximum rated flow rates or pressures. For that reason, he did not accept its conclusion that the aerial appliances were unable to project a water jet to a height of 65 metres. 81.17 Although Dr Stoianov’s calculations provide some helpful indication of the maximum height that aerial appliances could reach in optimal conditions, he rightly accepted that there were matters beyond his knowledge and expertise that could limit the height to which a water jet could be projected in practice. They included weather conditions,1694 the performance of pump appliances1695 and, most significantly, operational factors affecting 1681 Stoianov, Water Expert Report {ISTRP00000006/18}. 1682 Stoianov, Water Expert Report {ISTRP00000006/8} ‘Supply K’. 1683 Stoianov, Water Expert Report {ISTRP00000006/236} paragraph 2. 1684 Stoianov, Water Expert Report {ISTRP00000006/236} paragraph 2. 1685 Stoianov, Water Expert Report {ISTRP00000006/20} lines 31-32. 1686 Stoianov, Water Expert Report {ISTRP00000006/24} lines 8-9. 1687 Stoianov, Water Expert Report {ISTRP00000006/174} lines 26-28. 1688 Stoianov, Water Expert Report {ISTRP00000006/238} paragraph 3; Stoianov {Day288/42:12}-{Day288/43:23}. 1689 Stoianov {Day288/62:1}-{Day288/63:3}. 1690 {LFB00123672}, ‘Flow tests conducted on aerial appliance types used at Grenfell Tower fire’. 1691 {LFB00123672/16}, ‘Conclusions’’ {ISTRP00000006/236-238}. 1692 Stoianov, Water Expert Supplemental Report {ISTRPS00000001/21-28}. 1693 Stoianov {Day288/53:4}-{Day288/56:20}. 1694 Stoianov {Day288/57:7-19}. 1695 Stoianov {Day288/58:8}-{Day288/59:4}.

Part 8 | Chapter 81: The supply of water 195 the use, siting or angle of the jet.1696 Examples include obstructions impeding the siting of appliances, including burning debris falling from a building,1697 and a possible reduction in the firefighting effectiveness of a jet when operated at the limit of its vertical reach.1698 81.18 For these reasons, we cannot safely make any finding about the height to which aerial appliances might have been able to project water on 14 June 2017 if they had been supplied at their maximum rated flow and pressure. However, we have no hesitation in accepting Dr Stoianov’s opinion that the height of the jets produced by the aerial appliances at Grenfell Tower was limited by the low flow rates at which water was supplied to the pump appliances. 81.19 An example of periodic interruptions in the use of equipment caused by low flow rates can be seen in the operation of appliance A213 from 01.47 to 02.05. The tank of the pump appliance supplying it repeatedly became empty after less than a minute, requiring A213’s water jet to be interrupted for about 20 seconds to allow the tank to refill before it could be started again. Firefighter Raymond Keane improvised a partial solution by turning down the settings of the pump supplying A213, resulting in a continuous, but less powerful, jet.1699 Similarly, the initial operation of appliance A245 at 02.13 lasted for only 47 seconds until the tank of the pump supplying it became empty.1700 The same problem affected the ground monitor on Grenfell Walk and aerial ladder platform S13A1, resulting in repeated stoppages throughout their operation.1701 81.20 Aerial ladder platform A245 was one piece of equipment that could not be deployed as originally intended. Following its redeployment at 03.28, the flow rate delivered to A245 was too low to enable its monitor to be used effectively. Firefighters therefore improvised by strapping a smaller 22 mm high-pressure hose to the cage of A245 to produce a jet which could reach the tower,1702 the equivalent of pinching the opening of a garden hose to produce a longer but narrower stream of water.1703 Similarly, the flow rate delivered to S13A1 was insufficient to make use of its built-in monitor without interruption and firefighters tried using a smaller diameter hose to produce a jet that could reach the tower. However, that was unsuccessful and they reverted to using the monitor of S13A1 for 20 seconds and then waiting about a minute for the tank of the pump supplying it to refill.1704 81.21 One significant factor contributing to the low flow rates delivered at the outlets was a loss of pressure in the hoses between the hydrants and the pump appliances.1705 Some pressure loss is unavoidable, but on the night of the fire this was exacerbated by the long distance from the hydrants to the tower (about 95 metres and 125 metres for hydrants H3 and H8 respectively). Those losses were partially redressed by using pumps in relays (i.e. two pump appliances deployed in series) for hydrant H8 and, from about 06.00 onwards, for hydrant H3.1706 The main cause of the problem, however, was the low flow rates delivered by the hydrants themselves,1707 which were caused principally by the following three factors:1708 1696 Stoianov {Day288/59:6-14}. 1697 Stoianov {Day288/59:6-14}. 1698 Stoianov {Day288/59:15-25}. 1699 Stoianov, Water Expert Report {ISTRP00000006/20} lines 20-28. 1700 Stoianov, Water Expert Report {ISTRP00000006/23} lines 17-24. 1701 Stoianov, Water Expert Report {ISTRP00000006/22} lines 24-29; {ISTRP00000006/24} line 30 -{ISTRP00000006/25} line 2. 1702 Stoianov, Water Expert Report {ISTRP00000006/23} lines 25-30. 1703 Stoianov {Day288/64:22}-{Day288/65:7}. 1704 Stoianov, Water Expert Report {ISTRP00000006/24-25}. 1705 Stoianov, Water Expert Report {ISTRP00000006/238} paragraph 6; Stoianov {Day288/91:14-19}. 1706 Stoianov, Water Expert Report {ISTRP00000006/11}lines 32-37; {ISTRP00000006/239} paragraph d. 1707 Stoianov {Day288/91:14-19}. 1708 Stoianov, Water Expert Report {ISTRP00000006/238} paragraph 6; Stoianov {Day288/91:7-11}.

The Grenfell Tower Inquiry: Phase 2 Report 196 a. the low flow coefficients of the fire hydrants; b. the use in one case of a wash-out hydrant instead of a fire hydrant; and c. the continued use of pressure reduction mechanisms in the water distribution network and a lack of efficient co-ordination between the LFB and Thames Water. 81.22 Water companies have a statutory duty to keep all fire hydrants attached to their pipes in good working order and to replace any hydrant when necessary.1709 British Standard 750:20121710 (BS 750) states that fire hydrants should have a flow coefficient of not less than 92.1711 BS 750 does not state whether that relates to a simple hydrant tested under factory conditions or to a hydrant installed in the pipework necessary to connect it to the water network. The distinction is relevant because the flow coefficient of a hydrant installed in a pipework system will necessarily be lower than (or, at best, equal to) that of a simple hydrant due to pressure losses introduced by the connecting pipework.1712 81.23 Paragraph 10.2 of BS 750 requires the flow coefficient of a fire hydrant to be specified in the manufacturer’s literature. If the flow coefficient of a hydrant installed in a pipework system may be affected by pressure losses introduced by the particular characteristics of the connecting pipework, as Dr Stoianov told us was the case, its performance in service will, or may, depend to some extent on the system into which it has been incorporated, which is inherently variable and not something of which the manufacturer could be aware. We therefore think that the requirement in BS 750 must be understood as relating to the hydrant tested under factory conditions. However, it would avoid confusion if the British Standards Institution were to make the position clear. 81.24 Testing carried out by Dr Stoianov showed that the flow coefficients of the fire hydrants used at Grenfell Tower ranged between 31 and 74.1713 As the hydrants were installed in the network, he was unable to test their factory standard flow coefficients. We have not had access to the manufacturers’ literature relating to those hydrants and do not know whether their flow coefficients under factory conditions were 92, as required to conform to BS 750. However, Dr Stoianov told us that he would expect the installation of hydrants to be carried out in such a way as to maximise their flow coefficients and that he would have expected the flow coefficients of the hydrants used at the Grenfell Tower fire to be higher.1714 If that had been the case, they would have provided greater flow rates to firefighting appliances and equipment. 81.25 Hydrant H5, which was used to supply aerial appliances A245 and S13A1, is not a fire hydrant but a wash-out hydrant, which is not designed to supply water for firefighting. It had a flow coefficient of 31, lower than the flow coefficients of the other three hydrants used at the Grenfell Tower fire, which ranged between 50 and 74.1715 Hydrant H5 had been wrongly labelled as a fire hydrant. The labelling of the hydrant was the responsibility of Thames Water.1716 1709 Section 57 of the Water Industry Act 1991. 1710 “Specification for underground fire hydrants and surface box frames and covers”. 1711 {BSI00001767/13} paragraph 10.2. 1712 Stoianov {Day288/69:20-24}. 1713 Stoianov, Water Expert Report {ISTRP00000008/100}; Dr Stoianov also tested three other hydrants in the vicinity of Grenfell Tower. All three had similar flow coefficients of between 32 and 58. 1714 Stoianov {Day288/77:9}-{Day288/78:5}. 1715 Stoianov, Water Expert Report {ISTRP00000008/100}. 1716 Section 42 of the Fire and Rescue Services Act 2004.

Part 8 | Chapter 81: The supply of water 197 81.26 On 14 June 2017, neither the LFB nor Thames Water realised that H5 was a wash-out hydrant, although its status was indicated on Thames Water’s Geographical Information System,1717 to which its technicians and the staff of its Network Management Centre referred during the incident.1718 Having been mislabelled as a fire hydrant, there was no practical way for firefighters to tell that H5 was in fact a wash-out hydrant.1719 81.27 In his evidence to the Inquiry, Dr Stoianov said that he had notified Thames Water of the mislabelling of H5 while undertaking hydraulic testing in 2018.1720 At some point between September 2018 and July 2019, Thames Water then replaced the metal frame of the wash‑out chamber and the metal lid of H5 with a correctly labelled “W” plate.1721 Thames Water’s interventions in the network 81.28 The LFB contacted Thames Water’s Network Management Centre by telephone at 01.28 on 14 June 2022 to ask for the attendance of a water technician and an increase in the water pressure.1722 Two water technicians attended the incident at 02.15 and two more at 04.15, followed by two more at approximately 07.30. After the initial call and subsequent confirmation from Thames Water that technicians were on their way, there was no further direct contact between the LFB’s control room and Thames Water. Communications between the LFB and Thames Water took place between firefighters and water technicians at the incident ground. They included two requests from the LFB to increase the supply of water, one from WM Beale at about 02.30 and one from SM Payton at about 10.05.1723 81.29 Thames Water made two changes to the water distribution network in an attempt to increase the amount of water available for firefighting. Technicians opened two boundary valves, at 03.091724 and 11.051725 respectively, with the aim of increasing the water pressure in the area around Grenfell Tower by connecting it to different parts of the water network and so spreading any pressure losses across a larger area.1726 However, that did not significantly increase the pressure at the hydrants being used by the LFB. It therefore had no significant effect on the flow rate at those hydrants1727 and caused no material improvement in the supply of water to the firefighting equipment.1728 81.30 Technicians from Thames Water also provided assistance at the incident ground. Between 06.00 and 06.30 they helped to clear blocked drains that were causing flooding around the tower and hindering firefighters’ access to the building. At approximately 06.30, a technician opened fully the valve on a hydrant which had previously been only partially opened, resulting in an increased flow.1729 1717 Stoianov, Water Expert Report {ISTRP00000009/21} paragraph 2. 1718 See {THA00000036}. 1719 Stoianov {Day288/85:8}-{Day288/86:13}. 1720 Stoianov {Day288/87:16-21}. 1721 Stoianov, Water Expert Report {ISTRP00000008/79} lines 24-26; {ISTRP00000008/81} figure 6-37. 1722 {THA00000012/2}. 1723 Stoianov, Water Expert Report {ISTRP00000009/91-92}. 1724 Stoianov, Water Expert Report {ISTRP00000009/85} paragraph 1(a). 1725 Stoianov, Water Expert Report {ISTRP00000009/85} paragraph 1(b). 1726 Stoianov, Water Expert Report {ISTRP00000009/26} lines 12-17; Stoianov {Day288/94:16}-{Day 288/95:1}. 1727 Stoianov, Water Expert Report {ISTRP00000009/85} paragraph 2; Stoianov, Water Expert Report {ISTRP00000008/213-214}. 1728 Stoianov {Day288/95:24}-{Day288/96:8}. 1729 Stoianov, Water Expert Report {ISTRP00000009/86} paragraph 4.

The Grenfell Tower Inquiry: Phase 2 Report 198 81.31 Water companies commonly use pressure reduction valves at certain points in the network to minimise water leaks and burst pipes, which are more likely to occur at higher pressures.1730 During normal operations in June 2017, Thames Water operated a pressure reduction scheme in the Grenfell Tower area, which was implemented by the use of pressure reduction valves which it could operate remotely.1731 On 14 June 2017, the pressure reduction valves remained open throughout the incident, which Dr Stoianov estimated resulted in a reduction in water pressure of between 0.7 and 1.3 bar.1732 At 03.55, the Thames Water’s Network Management Centre told the technicians at the incident how to switch off the pressure reduction valves, but the technicians decided against doing so because they were concerned that if the pressure became too high it might burst the pipes, a decision with which the Network Management Centre appears to have agreed.1733 If a pipe had broken, it could have led to the loss of a substantial amount of water and a widespread loss of pressure, putting the entire water supply to Grenfell Tower at risk.1734 81.32 We think it likely in the light of Dr Stoianov’s evidence that the pressure reduction system could have been switched off to produce an increase in water pressure of 0.7 to 1.3 bar, with only a minimal risk of a broken pipe,1735 although that would have provided only a modest increase in the flow rate from the hydrants of between about 180 and 420 l/ min.1736 A single handheld firefighting branch requires a flow rate of 400 l/min. 81.33 Another feature of the day-to-day operation of the water distribution system at Grenfell Tower was the automatic cycle of the Hammersmith pumping station. The Hammersmith pumps operated to increase water pressure in the area during the day, when demand from customers was higher, and were automatically switched off between 00.30 and 05.30, when demand was lower. On 14 June 2017, the pumps operated as normal.1737 At 02.59, Thames Water appears to have decided against switching on the pumping station, again due to the risk of bursting a pipe.1738 In the light of Dr Stoianov’s evidence we think that the Hammersmith pumps could have been switched on before 05.30 to increase the pressure available in the network with a minimal risk of breaking a pipe,1739 but again, that would have provided an increase in the flow rate at the hydrants of only about two to three litres per minute.1740 Given the scale and intensity of the fire, it is difficult to see that that would have made any significant difference to the LFB’s firefighting efforts. 81.34 We should note that Dr Stoianov was critical of the level of technical and engineering support provided by the Thames Water’s Network Management Centre during the incident. In particular, he thought that better use of available data, modelling and information about the network might have allowed it to recommend more efficient arrangements for the supply of water.1741 However, it seems unlikely that they would have secured a significantly greater supply. 1730 Stoianov, Water Expert Report {ISTRP00000005/8} section 4.1.2.1. 1731 Stoianov, Water Expert Report {ISTRP00000008/47-48}; {ISTRP00000008/224} lines 9-13. 1732 Stoianov, Water Expert Report {ISTRP00000008/231} paragraph 13. 1733 Stoianov, Water Expert Report {ISTRP00000009/103-104} paragraph 52. 1734 Stoianov {Day288/111:12-20}. 1735 Stoianov, Water Expert Report {ISTRP00000009/106} section 7.8.7. 1736 Stoianov, Water Expert Report {ISTRP00000008/236} paragraph (iii); Stoianov {Day288/107:6-21}. 1737 Stoianov, Water Expert Report {ISTRP00000008/11} paragraph 1. 1738 Stoianov, Water Expert Report {ISTRP00000009/30}. 1739 Stoianov, Water Expert Report {ISTRP00000009/102-103}; {ISTRP00000009/106} paragraph 59. 1740 Stoianov {Day288/104:12}-{Day288/105:14}. 1741 Stoianov, Water Expert Report {ISTRP00000009/99-102}.

Part 8 | Chapter 81: The supply of water 199 Misunderstandings about the water network 81.35 Dr Stoianov drew our attention to several misunderstandings and incorrect assumptions made by firefighters and Thames Water personnel on 14 June 2017 about the water network. Most notably, they included: a. confusing flow rate, pressure and volume;1742 b. an incorrect assumption that the water supply from a hydrant was reduced because water was being drawn from other hydrants, or as a result of “overuse”;1743 and c. a misunderstanding by technicians that it was possible by opening the boundary valve to give firefighters more flow to work with without increasing the water pressure, whereas increasing the pressure in the network was the only way to increase the flow rate from the hydrants.1744 1742 Stoianov, Water Expert Report {ISTRP00000009/97} paragraph b; Stoianov, {ISTRP00000009/91} paragraph 19(a). 1743 Stoianov, Water Expert Report {ISTRP00000006/239-240} paragraph 8(a); Stoianov, Water Expert Report {ISTRP00000009/89} paragraph (b). 1744 Stoianov, Water Expert Report {ISTRP00000009/98} paragraph (e); see also {ISTRP00000009/101} paragraph (c).

200 The Grenfell Tower Inquiry: Phase 2 Report

201 Chapter 82 Aspects of firefighting at Grenfell Tower 82.1 The operational firefighting response to the Grenfell Tower fire was investigated in Phase 1. In this chapter we address two particular topics relating to operational firefighting which the chairman considered called for further consideration in Phase 2: a. the effectiveness of the equipment used by the LFB on the night of 14 June 2017, including aerial ladder platforms, ground monitors, positive pressure ventilation systems and lightweight portable pumps; and b. the benefits offered by items of equipment that were not used at the Grenfell Tower fire, but which were available to fire and rescue services at the time, including smoke hoods and smoke curtains. Aerial appliances, ground monitors and handheld branches 82.2 In the Phase 1 report the chairman made findings about the deployment of the principal items of equipment used by the LFB as part of its operational response to the fire. They included findings, to the extent that the evidence allowed, about the times and locations at which equipment was used during the course of the incident. In Phase 2, we have considered the effectiveness of that equipment and its deployment on the night of the fire, as contemplated in the Phase 1 report.1745 82.3 The aerial ladder platform brought to the incident by Surrey Fire and Rescue Service (S13A1) could deploy water from a height of 42 metres, in contrast to similar vehicles operated by the LFB, which could project water from a maximum height of 32 metres.1746 Given that S13A1 was not used until after the last casualty had been rescued, the effectiveness of that aerial appliance has not been considered as part of our investigations. 82.4 In Mr McGuirk’s opinion the LFB was successful in applying water to all four sides of the building, based on his own appraisal of the contemporaneous evidence and Dr Barbara Lane’s analysis of the extent to which fire spread over the external walls on each side of the tower.1747 The available images show a clear inverse correlation between the deployment of external firefighting equipment and the downward spread of fire, which was more limited on the south and east faces of the tower (down to floors 10 and 18 respectively) than it was on the north and west faces (down to floors 9 and 7 respectively). The images also show that a higher reach was achieved by the equipment deployed against the south and east faces of the tower, namely the ground monitor on the south side walkway and aerial ladder A245 on the east side. A213 contributed to the external firefighting on the east side, but to a much more limited degree, given the relatively early stage at which it needed to be moved away from the tower. 1745 Phase 1 Report Volume IV paragraph 28.132. 1746 Phase 1 Report Volume IV paragraph 28.133. 1747 McGuirk, Firefighting Expert Report {SMC00000046/68-69} paragraph 183.

The Grenfell Tower Inquiry: Phase 2 Report 202 82.5 It is clear that water was applied to the external faces of the north and west sides of the tower, albeit to a lower height, either by ground monitors or handheld jets or, more likely, a combination of the two, and appears to have been effective in limiting the downward spread of fire. That is consistent with Dr Stoianov’s assessment of the application of water to the tower over the course of the incident.1748 82.6 It is indisputable that the operators of the two aerial appliances on the east side of the tower, CM Daniel Harriman and FF Christopher Reynolds (who were in charge of A213) and CM Christopher Frost and FF Jason King (who were in charge of A245, overseen by WM Stuart Beale), demonstrated considerable courage and ingenuity on the night of 14 June

1. CM Harriman and FF Reynolds operated their appliance for as long as practicable

in very difficult circumstances, putting their own safety at risk from the burning debris that began falling from the tower soon after the appliance had been set up. CM Frost and FF King were successful in setting up A245 on the grass by the tower, although that was not in accordance with established procedure.1749 As Mr McGuirk said, that was a calculated risk and an appropriate exercise of initiative.1750 CM Frost and FF King, overseen by WM Beale, also successfully devised a system that enabled their aerial to apply water up to floor 13 of the tower by strapping a high-pressure hose on to the cage of the platform.1751 That measure ensured an effective supply of water at the top of the appliance, despite the problems that the crew had initially experienced when trying to operate the monitor built into the cage of A245.1752 That was pure improvisation on the crew’s part and, again, it was an appropriate and considered use of initiative, which assisted in the external firefighting efforts on the east side of the tower. 82.7 Taking all that into account, the LFB personnel who were responsible for external firefighting acted diligently and professionally in extremely difficult circumstances, including the fact that the ability of each of the aerial appliances to project water was limited primarily by the low water flow provided by the hydrants. That was particularly so in relation to A245, the water for which was supplied by the incorrectly labelled wash-out hydrant.1753 To a great extent, those factors were outside the control of the LFB personnel managing the appliances. It was not the LFB’s responsibility to ensure that hydrants were correctly labelled1754 and we therefore make no criticism of the firefighters who used that hydrant. 82.8 There are, however, two points that should be made. First, it is unfortunate that the information on the Mobile Data Terminal about the location and operational status of hydrants in the vicinity of Grenfell Tower was inaccurate. Hydrant H1, which was used to supply appliance G272, was not identified at all and Hydrant H4 was incorrectly labelled as defective,1755 but it is unlikely that those inaccuracies made any material difference to the effectiveness of the operational response. However, it is yet further evidence of more general problems with the LFB’s systems for the collection and management of operational risk information. 1748 Stoianov, Water Expert Report {ISTRP00000006/7-8}. 1749 Policy 822: Operational use of aerial appliances {LFB00000189}. 1750 McGuirk, Firefighting Expert Report {SMC00000046/64} paragraph 170. 1751 Stoianov, Water Expert Report {ISTRP00000006/24} lines 8-9. 1752 McGuirk, Firefighting Expert Report {SMC00000046/64} paragraph 170. 1753 Stoianov, Water Expert Report {ISTRP00000006/238} lines 20-22. 1754 Stoianov, Water Expert Report {ISTRP00000006/67} lines 14-16; {ISTRP00000006/69}. 1755 Stoianov, Water Expert Report {ISTRP00000006/65}; {ISTRP00000008/73} lines 18-24; {LFB00024354}.

Part 8 | Chapter 82: Aspects of firefighting at Grenfell Tower 203 82.9 Secondly, we agree with Dr Stoianov’s view that the communications between firefighters on the incident ground and Thames Water’s technicians, who relayed information to the Network Management Centre,1756 were essentially casual in nature causing relevant information to be lost or not communicated at all. We recognise that the firefighters who spoke to Thames Water either in person or by telephone were operating under enormous pressure and were doing their best to improve the effectiveness of the equipment being used. Nonetheless, there is no record of any clear and explicit request having been received by the Network Management Centre to make water available in accordance with the requirements of the main appliances in use at the incident.1757 WM Beale said that he had asked one of the technicians on the incident ground for more water, but in the absence of any formal or consistent system for passing requests to Thames Water, it is not surprising that the request was not received or formally noted at the Network Management Centre.1758 In any event, it was not the responsibility of operational personnel, who were trying to carry out or oversee firefighting operations, to ensure that the specific requirements of those appliances were communicated to the Network Management Centre. In the first instance, that should have been the responsibility of a bulk media adviser. 82.10 Subject to those qualifications, the firefighters involved in the firefighting operations outside the tower did all that they reasonably could to extinguish the fire and to protect the lives of those inside the building. Other equipment 82.11 Positive Pressure Ventilation fans (PPVs) provide forced ventilation which can be used to clear smoke-filled environments or to prevent smoke from entering a clear space. The fan increases the pressure of the air in the area in which it is placed, thereby causing air to flow into the adjacent space. The technique is commonly used in multi-storey buildings.1759 82.12 At the Grenfell Tower fire a PPV fan was requested at 02.57 and again at 03.07. Two PPV fans arrived at the incident ground at about 04.00 and were used for a very short time in the lobby of the tower, before being stopped because they were increasing, rather than reducing, the amount of smoke in the lobby.1760 82.13 Mr McGuirk explained that, when fighting a fire in a high-rise residential building, a PPV fan needs to be sited in the first instance at the entrance to the stairwell where it can direct fresh air into the stairwell to clear it of smoke.1761 There may be an opening at the top of the stairwell through which air and smoke can escape, but fans can still be deployed effectively even if there is no opening.1762 82.14 It is clear that PPV fans could not have been used effectively at the Grenfell Tower fire, primarily because of the layout of the ground and mezzanine floors. For example, positioning them in the lobby area on the ground floor, as was done, would only have pressurised that area because of the door that led to the stairwell on the mezzanine on floor 2. They could have been moved into the stairwell, but would then have been able to draw air only from within and not from outside the building. The effect would have been to 1756 Stoianov, Water Expert Report {ISTRP00000009/4}; {ISTRP00000009/7}. 1757 Stoianov, Water Expert Report {ISTRP00000009/93}. 1758 Phase 1 hearings: {Day34/84:9-19}; Stoianov, Water Expert Report {ISTRP00000009/93}. 1759 McGuirk, Firefighting Expert Report {SMC00000046/73} paragraphs 199-201. 1760 Phase 1 Report Volume III paragraph 16.87; Wilson {MET00019953/3-4}, pages 3-4. 1761 McGuirk, Firefighting Expert Report {SMC00000046/73} paragraphs 199-201; McGuirk {Day190/140:3-5}. 1762 McGuirk, Firefighting Expert Report {SMC00000046/73} paragraph 201.

The Grenfell Tower Inquiry: Phase 2 Report 204 recirculate the smoke that was already in the stairwell,1763 which was precisely the problem encountered by the firefighters who tried to use them. It is highly unlikely, therefore, that the fans that were brought to the tower could ever have reduced the spread of smoke within the stairwell or anywhere else in the building outside the lobby area. 82.15 A light portable pump is a small, purpose-built, petrol-powered pump capable of providing a water supply from sources that are not accessible to standard pump appliances (for example, a lake). Pumps of that kind are normally used in rural locations and are designed to deliver small quantities of water. They have a limited pumping capacity of no more than 1,000 litres per minute and can produce relatively limited pressure. They require regular refuelling and, because they emit exhaust fumes, are suitable for use in the open air rather than inside buildings.1764 82.16 There is some evidence that a light portable pump was brought to Grenfell Tower in the later stages of the incident, but it is unclear whether it was used.1765 It is unlikely, however, to have made any material difference to the supply of water or indeed the operations that the LFB was able to carry out inside or outside the tower. In particular, the limited pumping capacity and pressure achievable by a pump of that kind meant that it was not capable of providing any significant increase in the supply of water for firefighting. It would also have been unsuitable for use inside a residential high-rise block due to the emission of exhaust fumes. Equipment not used on 14 June 2017 82.17 The Inquiry heard evidence in Phase 1 about two other pieces of equipment that were potentially available, but which were not used at Grenfell Tower: smoke hoods and smoke curtains. 82.18 Smoke hoods are used to protect members of the public from smoke and noxious fumes for a limited period while they are being helped by firefighters to leave the building.1766 Smoke hoods were not commonly used before the Grenfell Tower fire, but they have since been adopted by a number of fire and rescue services, including the LFB and Kent Fire and Rescue Service.1767 82.19 We think that smoke hoods could certainly have helped in the rescue of some residents of the tower, as is illustrated by the rescue by CM Tillotson’s crew of two residents from floor 9 of the tower with the aid of two additional breathing apparatus sets that they had collected from the bridgehead to be worn by the residents as they were helped out of the building.1768 82.20 Smoke curtains are sheets of fire-resistant material attached to a frame that is designed to be inserted into an existing door frame. A small opening in the base of the curtain allows firefighters to pass in and out through the door, while preventing or minimising the passage of smoke.1769 The function of the curtain is to protect the integrity of the smoke-free area on the other side (typically the stairwell) while allowing firefighters to enter the smoke- filled area to carry out firefighting or search and rescue operations. 1763 McGuirk {Day190/140:11}-{Day190/141:10}. 1764 McGuirk, Firefighting Expert Report {SMC00000046/76} paragraph 207; ORR v0.7 {LFB00032988/501}. 1765 McGuirk, Firefighting Expert Report {SMC00000046/76} paragraph 207. 1766 McGuirk {Day190/157:144}-{Day190/158:11}. 1767 McGuirk {Day190/158:13}-{Day190/159:7}. 1768 Phase 1 Report Volume II paragraphs 12.3-12.5, 13.18-13.19, 13.69-13.70 and 14.112-14.114. 1769 Grimwood {Day188/54:12}-{Day188/55:16}.

Part 8 | Chapter 82: Aspects of firefighting at Grenfell Tower 205 82.21 Like smoke hoods, smoke curtains were not commonly used before the Grenfell Tower fire but have since been introduced by a number of fire and rescue services,1770 including the LFB. 82.22 Smoke curtains may be a useful way of preventing or minimising the spread of smoke within a building where there has not been widespread compartmentation failure. We think they could have been used in the first hour or so of the incident to reduce the amount of smoke entering the stairwell and thereby help residents escape. However, we do not think they would have been likely to help much after that time because of the extent to which the smoke had spread and the number of compartmentation failures. 1770 McGuirk, Firefighting Expert Report {SMC00000046/85} paragraph 235; McGuirk {Day190/163:9-16}.

206 The Grenfell Tower Inquiry: Phase 2 Report

207 Chapter 83 Conclusions 83.1 In the Phase 1 report the chairman recognised that the firefighters who attended the Grenfell Tower fire displayed enormous courage and selfless devotion to duty.1771 We echo that finding, but their bravery and commitment to duty is only a part (albeit a significant part) of the picture. Another part is the inescapable fact that the systemic failings of the LFB on the night of the Grenfell Tower fire relating to training, incident command, communications and the operation of the control room had all been foreshadowed by previous fires, most particularly, the Lakanal House fire on 3 July 2009. 83.2 The LFB did not fail to identify or understand the lessons to be learnt from the Lakanal House fire and other major fires involving high-rise buildings constructed using modern materials and methods of construction. On the contrary, its response to the Lakanal House fire in particular showed that it understood its significance immediately. The LFB quickly analysed the incident and identified the appropriate lessons including the broader implications of the increasing use of modern materials and their role in promoting external fire spread. In that regard, Commissioner Dobson’s correspondence with DCLG in December 2012 showed commendable foresight in anticipating many of the questions that have been investigated in Phase 2. 83.3 The LFB’s failure lay in its inability to implement any effective response. That failure had many causes, but it is possible to identify in the evidence summarised in previous chapters a number of distinct but closely related aspects of the way in which the LFB was managed which, in our view, account for it. The evidence clearly shows that the LFB’s failure was attributable to a chronic lack of effective leadership, combined with an undue emphasis on process and a culture of complacency. Senior officers appear to have thought that establishing bodies to review and report would inevitably lead to action without the need for effective monitoring of progress and further action being taken as necessary to ensure completion. Complacency led to a failure to ensure that knowledge of the dangers presented by the increasing use of combustible materials were reflected in operational policies and procedures. 83.4 Ron Dobson and Dany Cotton, as former Commissioners, bear ultimate responsibility for the LFB’s inability to take effective action after the Lakanal House fire. It is to their credit that neither of them shirked nor sought to qualify that responsibility. However, their acknowledgment should not obscure the failures of other senior officers who were directly responsible for the efficiency and effectiveness of their departments. In the decade before the Grenfell Tower fire, Dave Brown, as Third Officer and Director of Operations, oversaw a broad range of the LFB’s activities which have featured heavily in Phase 2. 1771 Phase 1 Report Volume IV paragraph 28.1.

The Grenfell Tower Inquiry: Phase 2 Report 208 83.5 Two failings, in particular, illustrate AC Brown’s approach to command and management and explain in part why recommendations were not carried out effectively. The first concerns the inspection of high-risk high-rise residential buildings. That function was (and remains) a necessary and important means of making sure that the LFB discharges its duties under the 2004 Act and the Health and Safety at Work Act 1974. AC Brown did not wish to become involved in considering the complexities of an inspection regime, a problem which deserved more careful consideration than he was willing or able to give it. If the letter and spirit of the Lakanal House coroner’s recommendation were to be met and more effective inspection arrangements introduced, GM Elwell’s recommendations required proper consideration. AC Brown failed to give them that consideration and, as far as we can see, there was no good reason for that. If those proposals had been implemented, they could have gone some way towards remedying the deficiencies in the LFB’s arrangements for gathering and managing operational risk information. 83.6 The second example relates to the control room. The importance of fire survival guidance refresher training for CROs is obvious. The senior officers responsible for the control room (including AC Brown and POM Hayward) plainly understood that importance, particularly because of the weaknesses in handling calls exposed by the Lakanal House fire. In 2009, no structured or regular fire survival guidance refresher training was provided by the LFB and this was still the case at the time of the Grenfell Tower fire in 2017. The failure to give CROs regular fire survival guidance refresher training is a serious shortcoming, particularly by those officers who were responsible for making sure that effective training was provided. Even allowing for the difficulties flowing from the introduction of Vision, there is no justification for such a longstanding failure to address a vital element of the control room’s work and one which touched directly upon public safety. 83.7 An aggravating feature is that even though the Lakanal House fire demonstrated the real danger to life posed by the failure to provide effective fire survival guidance training, none of senior officers responsible for the operation of the control room ever tackled the challenge of providing the necessary training with the dedication it deserved. 83.8 Although individuals undoubtedly had a role in the failings which have been examined here, it is important to stress that they were committed in the context of broader structural and cultural problems. It is clear that the LFB’s response to the Lakanal House fire placed undue reliance on process. Boards were established, plans were made and reviews were commissioned, but no effective steps were taken to ensure that recommendations had been effectively implemented, particularly in relation to the danger of relying uncritically on compartmentation, the risk of fire spreading across external walls and the ability to handle many fire survival guidance calls simultaneously. Because those matters were not addressed in the resulting training packages, the recommendations were not fully implemented and so the defects that had been identified were not remedied. 83.9 The root cause of the problem was that the LFB’s senior officers lacked the necessary degree of managerial competence to recognise and correct problems. One stark illustration of that shortcoming is the failure to translate its longstanding knowledge of the dangers posed by modern materials and methods of construction into operational policies that recognised and reflected those dangers. Another is the failure to ensure effective management of the control room, particularly in relation to training. Commissioner Dobson was alert to the danger posed by the use of combustible materials and in December 2012 recommended certain measures to DCLG that might have alleviated it. However, in the eight years between the Lakanal House fire and the Grenfell Tower fire neither he nor his successor took any steps to review and revise the LFB’s operational policies, procedures

Part 8 | Chapter 83: Conclusions 209 and training to make sure that firefighters (and incident commanders in particular) understood how best to respond to a fire that had taken hold in the external wall of a high-rise building. Nor did they take any effective steps to ensure that control room staff received essential training. 83.10 The managerial weaknesses we have identified resulted in part from the historic separation between the departments responsible for operational matters and those responsible for support functions and a lack of effective communication between them. Historically, the Fire Safety department, like the control room, had become isolated from the operational departments, leading to a failure to communicate information about the dangers of combustible materials and a corresponding failure to ensure that they were taken into account in the policies and training. For a long time that failure was compounded by an entrenched but unfounded assumption that the regulatory regime in the Building Regulations was sufficient to prevent such dangers from arising in this country. After the Lakanal House fire senior officers recognised that compliance with the regulations could not be guaranteed, but no one appears to have thought that firefighters needed to be trained to recognise and deal with the consequences. That was partly because senior officers were confident that existing training and operational practices were comprehensive and that the additional measures identified following the Lakanal House fire had been implemented. The Grenfell Tower fire showed, however, the extent to which that confidence was misplaced. 83.11 Confidence in existing practices and procedures manifested itself in other ways. When a problem arose which called for careful and detailed consideration, on too many occasions the LFB’s response was that change was unnecessary or too difficult, even in matters which touched upon operational or public safety. The problems with radio communications in high-rise concrete buildings provide one example. Although they were well known and regularly encountered, no effective steps were taken to investigate them to identify reliable and effective solutions. The problems were simply considered too intractable. That attitude to perennial communications difficulties was unsustainable, primarily because they were a recurring feature of inquests into the deaths of both firefighters (as at the Shirley Towers fire) and members of the public (pre-eminently, at the Lakanal House fire). Given the evident danger to the life and safety of its personnel and the public, there were compelling reasons for the LFB to invest considerable effort in seeking to resolve the problems that had afflicted radio communications for so long, but regrettably nothing effective was done. 83.12 There is one further point that we need to address in this context. Although we acknowledge the strength of opinion held by some that the approach to funding public services adopted by the government between 2010 and 2015 and by the Mayor of London between 2012 and 2016 constrained the LFB’s operational effectiveness, none of the witnesses from whom we heard told us that insufficient financial or other resources had caused or contributed to the failings that occurred on the night of the Grenfell Tower fire. In that respect, it is telling that the LFB did not suggest that budgetary constraints had been responsible for any of its shortcomings and it is worth noting that the report of Her Majesty’s Inspectorate of Constabulary and Fire and Rescue Services on the LFB, published after the Phase 1 report on 17 December 2019, stated that, although the brigade was inefficient in its spending, it was not under-funded.1772 1772 “Effectiveness, efficiency and people 2018/19 – London Fire Brigade” pages 30-33.

The Grenfell Tower Inquiry: Phase 2 Report 210 83.13 The tragic conclusion is that the Lakanal House fire in July 2009 forewarned the LFB about the existence of the shortcomings which revealed themselves once more on the night of 14 June 2017. Those shortcomings could have been avoided if the LFB had been more effectively led in a number of respects, particularly in its response to the Lakanal House fire, and if use had been made of its knowledge of the dangers flowing from modern materials and methods of construction. On any view, that is a serious indictment of an organisation whose principal purpose is to protect the public and of the quality of its leadership.

ISBN 978-1-5286-5080-9 (Volume 5 of 7) 7 volumes not available separately

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Volume 6 Part 9 - The deceased HC 19–VI GRENFELL TOWER INQUIRY: PHASE 2 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 The Panel: Chairman: The Rt Hon Sir Martin Moore-Bick Ali Akbor OBE Thouria Istephan September 2024

Volume 6 Part 9 - The deceased HC 19–VI GRENFELL TOWER INQUIRY: PHASE 2 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 The Panel: Chairman: The Rt Hon Sir Martin Moore-Bick Ali Akbor OBE Thouria Istephan September 2024 Presented to Parliament pursuant to section 26 of the Inquiries Act 2005 Ordered by the House of Commons to be printed 4 September 2024

© Crown copyright 2024 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. This publication is available at www.gov.uk/official-documents. Any enquiries regarding this publication should be sent to us at contact@grenfelltowerinquiry.org.uk. ISBN 978-1-5286-5080-9 (Volume 6 of 7) 7 volumes not available separately E03165832 09/2024 Printed on paper containing 40% recycled fibre content minimum. Printed in the UK by HH Associates Ltd. on behalf of the Controller of His Majesty’s Stationery Office. This report contains content which some may find distressing.

5 Part 9 The deceased

6

7 84.1 In the preceding chapters we have examined the circumstances in which the fire at Grenfell Tower came about. Most of the facts we have found and the conclusions we have drawn are relevant to all the deaths that occurred that night. The only exceptions are our findings about the treatment of those who for one reason or another were vulnerable and in respect of whom we have identified particular shortcomings. In this Part of the report, we set out our findings about the circumstances in which each person who died came to lose his or her life, a matter which it is the coroner’s duty to investigate. We begin by explaining our purpose in doing so. 84.2 Grenfell Tower is in an area of London which falls within the jurisdiction of Professor Fiona Wilcox, His Majesty’s Senior Coroner for London (Inner West). Between 20 June and 22 November 2017, Professor Wilcox opened 70 separate inquests into the deaths of those who died in the fire. She subsequently suspended those investigations pending the conclusion of this Inquiry and, if necessary, the police investigation. An inquest was not opened for Logan Gomes, the son of Marcio Gomes and Andreia Perestrelo, who was delivered stillborn following his mother’s escape from the tower. Professor Wilcox concluded that Logan did not have a life independent of his mother and so was outside her jurisdiction. We have, however, included in this Part of our report findings relevant to Logan. Maria del Pilar (Pily) Burton survived the fire but died in January 2018. The cause of her death was not found to be related to the fire. Pily Burton died within the jurisdiction of a different coroner and no inquest has been opened into her death. Nonetheless, in recognition of the regard in which she was held by the community at Grenfell Tower, we have included in this Part of our report the facts concerning her experience on 14 June 2017. 84.3 An inquest, whether conducted by a coroner alone or with a jury, is required to answer the four questions set out in section 5 of the Coroners and Justice Act 2009: who the deceased was and how, when and where the deceased came by his or her death. When the inquest is one in which article 2 of the European Convention on Human Rights (the Convention) is engaged, the question “how” is to be interpreted as including the circumstances in which the deceased came by his or her death. 84.4 At an early stage of the Inquiry, the chairman decided that, in discharging its Terms of Reference and insofar as it was properly permissible to do, the Inquiry would investigate the deaths caused by the fire to the same extent as would be required of the coroner. The chairman’s hope was to minimise the need for Professor Wilcox to conduct further detailed investigations, so sparing the relatives of those who died the stress of prolonged proceedings.1 84.5 Subsequently, the chairman issued a direction in which he said that, on the material then available, he saw no significant difficulty in making findings sufficient to meet the requirements of article 2 of the Convention. He proposed that while the Phase 1 report was being written the Inquiry would hold an oral hearing in which those representing the bereaved families could present the evidence relating to those who had died in order to 1 Phase 1 Report Volume I paragraph 1.9; Fegan-Earl {Day298/4:9-17}. Chapter 84 Introduction to Part 9

The Grenfell Tower Inquiry: Phase 2 Report 8 enable him to make the appropriate findings in that report. In the end, however, it did not prove necessary to hold such a hearing. As is evident from the Phase 1 report, the Inquiry obtained a considerable amount of material, in particular the written and oral evidence of the firefighters, the bereaved and those who had survived the fire, that was analysed and presented in that report. Further, there were some aspects of the circumstances in which people had died, principally the physiological causes of death, that called for more detailed examination than was possible at that stage. Accordingly, further consideration of the circumstances of the deaths was deferred to Phase 2. The chairman made it clear that it remained his intention in Phase 2 to make the findings necessary to assist the coroner.2 84.6 Following further submissions and correspondence in 2019 and 2020, we concluded that the facts that we should investigate and record in relation to each deceased were:

Their name, gender and age.

The number of the flat in which they lived and the floor number.

The background and composition of their household.

What messages, if any, passed between them and the emergency services or between them and others and what information about them was held by the emergency services.

Whether the firefighters tried to rescue them.

Where they died.

The time of death, as far as it could be ascertained.

Their movements between the outbreak of the fire and their death.

The medical cause of death.

1. Whether they had any vulnerabilities and if so, whether they were known to

the TMO or RBKC. 84.7 We began hearing evidence about those matters on 4 July 2022. The hearings took a slightly different form in that, although Counsel to the Inquiry retained responsibility for adducing evidence, the greater part of them were taken up by a series of presentations of the essential circumstances surrounding the individual deaths by those representing the bereaved. 84.8 Those presentations were very helpful, not only in assisting us to identify the essential facts to be found in each case but also in reminding all those present and those watching the proceedings remotely of the personalities of the deceased and the lives they had led until the night of the fire. Our findings are based in part on evidence that had not been considered in any detail at the time the presentations were delivered, as well as on findings made in the Phase 1 report, none of which were disputed. 84.9 We have borne in mind throughout that we are not conducting an inquest; that remains the responsibility of the coroner. For that reason we have refrained from expressing any view about the conclusions a coroner might record. However, we continue to hope that our findings about the circumstances in which each of the deceased died will assist her in fulfilling her statutory obligations. It will be for her to decide what to make of our findings. 2 Fegan-Earl {Day298/4:18-24}; Phase 1 Report Volume IV paragraph 34.2.

Part 9 | Chapter 84 : Introduction to Part 9 9 84.10 The Inquiry opened in May 2018 with a public commemoration of the deceased through the voices of their relatives and friends. Those reflections and memories are recorded in Chapter 32 of the Phase 1 report. As the Inquiry began, so it ended, by remembering those who lost their lives that night. It is of the utmost importance that our description of the circumstances in which people died are placed in the larger context of their lives and the pictures of them painted at the memorial hearings. Only in that way can they be remembered as the people they really were. 84.11 Many of those who died on 14 June 2017 were found in their own homes; others had sought shelter elsewhere in the tower or were overcome while trying to leave the building and were found in the lobbies or on the stairs. Three fell from the tower. Our findings are set out floor by floor and deal in turn with each of those who died on, or fell from, the particular floor. For those who died on the stairs we have described the circumstances relating to the floor on which their flat was located. None of the occupants of floors 12 or 13 died in the fire. 84.12 In making our findings we have relied on the following: a. the evidence of survivors; b. transcripts of emergency calls; c. the way in which fire and smoke spread around and through the building; d. the accounts of those who spoke to the deceased in the period before their deaths; e. the record of communications between the LFB control room and the fire ground and within the fire ground, including the building; f. the evidence of individual firefighters; g. telemetry data recording the deployment of firefighters within the tower; h. the evidence of the expert witnesses. 84.13 Almost all of that evidence was heard in Phase 1 and was the subject of findings made in chapters 9 to 20 of the Phase 1 report. 84.14 In some cases the deceased could be identified only by scientific means but in each case the coroner was satisfied that identification had been correctly established and was therefore able to issue an interim certificate of the fact of death. In those cases we have not thought it necessary to describe in detail the way in which the identity of the deceased was established.

10 The Grenfell Tower Inquiry: Phase 2 Report

11 85.1 In making our findings on the circumstances surrounding the deaths of those who lost their lives in the Grenfell Tower fire we have drawn heavily on the evidence of a number of eminent experts in a variety of fields. Their evidence may be conveniently described under the following headings: a. The recovery and identification of the remains of the deceased. b. The determination of the medical cause of death. c. The effects of the smoke and gases produced by the fire. The recovery and identification of the remains 85.2 In respect of each deceased person the coroner, Professor Wilcox, issued an interim certificate of the fact of death pursuant to regulation 9 of the Coroners (Investigations) Regulations 2013. She was able to do so because she was satisfied in each case that the remains in question were those of the particular deceased. That resolves conclusively the doubts that at one time were aired about how many people died in the fire and who they were. However, we think it appropriate to describe in general terms the careful and painstaking process by which the remains of those who died were recovered and their identities confirmed. The procedure adopted followed the guidance contained in the Disaster Victim Identification (DVI) Guide published by Interpol in 2014, which set the standards for the identification of victims of disasters and was used in conjunction with protocols developed by the archaeologists and anthropologists working with police officers trained in identifying victims of disasters.3 The recovery of human remains 85.3 The task of recovering the human remains was led by Dr Karl Harrison MSc PhD DSc, the lead forensic archaeologist. Dr Harrison had 20 years’ experience as an expert forensic archaeologist, including working on police investigations.4 Together with Dr Deborah Ryder PhD, he co-ordinated a team of 36 forensic archaeologists with expertise in the identification of human remains.5 Archaeologists were attached to teams instructed to search individual flats, each of which was treated as a closed fire scene to prevent the mixing of debris and to maximise the opportunity to identify any human remains.6 Those search teams included DVI officers and licensed search officers (LSOs). It was the responsibility of the DVI officers to maintain the continuity of the evidential chain in order to minimise the possibility of a fragment of human remains being missed or wrongly attributed. The LSOs had a more general search function.7 3 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/13}; Harrison {Day302/18:5}-{Day302/19:3}; {KHA00000001/3} page 3, paragraphs 9-12; Harrison {Day302/12:18}; {Day302/19:4}; {Day302/19:21} -{Day302/20:7}. 4 Harrison {KHA00000001/1} page 1, paragraphs 1 - 4. 5 Harrison {KHA00000001/2} page 2, paragraphs 5, 6 and 8. 6 Harrison {Day302/11:4}. 7 Harrison {Day302/15:8} -{Day302/17:1}. Chapter 85 The expert evidence

The Grenfell Tower Inquiry: Phase 2 Report 12 85.4 Forensic archaeologists arrived at the tower on Friday 16 June 2017 and carried out their work over the next five months.8 They worked in different places at different times in response to the requirements of the police.9 Dr Harrison divided the work of his team between June and December 2017 into three phases,10 the first two of which concentrated on those flats which were thought likely to contain human remains.11 85.5 The first phase, which began on 16 June 2017 at a time when the team of archaeologists was smaller and the number of deceased was still unknown, had four elements. The first involved a visual assessment of the flats that were suspected to contain human remains. The search teams noted the significant volume of debris in those flats and assessed the challenges to the recovery and recording of human remains. The fragility of the remains that were visible led to a decision to search the debris in each flat in situ rather than remove it to another site. That avoided the risk of damaging the remains or mixing them up in circumstances where more than one person had died in a relatively small space.12 85.6 The second element was the early development of search strategies. Given the extensive fire damage to the flats, with internal walls almost entirely destroyed, each flat to be searched was divided into sectors. It was decided at the outset that all spaces within the tower that had been destroyed by fire would be searched to the same extent.13 85.7 The third element took place on 15 and 16 June 2017 and before archaeologists had become involved in searching the tower’s interior. Archaeologists assisted officers using victim recovery dogs to search the base of the tower and the area around it for human remains, since it was known at that stage that at least one person had fallen from the building.14 At that time the area remained under the control of the LFB and debris was still falling. 85.8 The fourth and final element of the initial phase also began on 16 June 2017. That was the recovery of visible remains from flats and bodies from the communal areas and the stairwell. That operation was undertaken at a time when the authorities were still responding to an emergency and the debris in the flats remained hot enough to present a risk of re-ignition. The structural integrity of the tower was also being assessed at that time, which required additional safety measures, including a limit on the number of people entering a flat at any one time. In the circumstances, emphasis was placed on the speed of recovery.15 85.9 The initial phase allowed areas of particular interest to be identified. They included flats where fragments of human remains might be found because people had been reported as missing or witnesses believed they had seen people at the windows, even if there was no obvious sign of remains.16 Acrow props were installed in flats to maintain structural stability. 8 Harrison {KHA00000001/1} page 1, paragraph 5. 9 Harrison {Day302/9:23}. 10 Harrison {KHA00000001/3} page 3, paragraph 7 and Table 1; Harrison {Day302/21:3}. 11 Harrison {Day302/22:2} {Day302/23:10}. 12 Harrison {KHA00000001/4} page 4, paragraph 15; {KHA00000001/5} page 5, paragraph 17; Harrison {Day302/23:13}-{Day302/27:24}. 13 Harrison {KHA00000001/5} page 5, paragraph 18; {KHA00000001/6} page 6, paragraph 20; Harrison {Day302/21:1}-{Day302/34:23}. 14 Harrison {KHA00000001/6} page 6, paragraph 21; Harrison {Day302/34:25}-{Day302/37:9}. 15 Harrison {KHA00000001/8} page 8, paragraph 23; {KHA00000001/9} page 9, paragraph 25; Harrison {Day302/37:10}-{Day302/41:3}. 16 Harrison {KHA00000001/9} page 9, paragraph 27.

Part 9 | Chapter 85: The expert evidence 13 That made it necessary to move debris, which, wherever possible, was retained in the sector in which it had been found. If it was necessary to move debris out of a sector, it was not moved beyond the flat or lobby in which it had originated.17 85.10 The second phase involved the careful excavation of debris to preserve any remains, which could then be lifted out. The debris was then left in situ. A record was made of the location of remains as well as of the position of any fixtures and fittings. Personal effects such as jewellery were recovered.18 85.11 The third phase began in August and continued until November 2017. It involved the comprehensive searching and sieving of the debris in all areas which had been subjected to burning to recover any other human remains, to identify and retain any material that might assist in understanding the spread of the fire and fire protection within flats and in identifying individuals, and to locate valuable or sentimental items, which could then be returned to the family.19 85.12 The stairwell, part of the flats from floor 4 to floor 9 and all flats and lobbies from floor 10 to floor 23 were searched sector by sector. All debris in those areas of the tower was searched by hand by teams of DVI officers and LSOs led by a team leader and under the supervision of an archaeologist. Sieved material was bagged. The DVI officers and LSOs were given training in advance in recognising burnt bone, but the supervising archaeologist made a second check of any material that might be fragments of bone or tissue. In that way, any human remains as well as other items of potential significance, such as personal effects, medical implants or identification documents, were located and retained.20 85.13 A quality assurance process was adopted through the introduction in search areas of a foreign control object. There were no occasions on which a DVI or LSO team failed to find that object.21 A system was put in place to ensure that all the debris had been searched and sieved and then retained in labelled bags. Each searched area went through two inspection stages. The second stage required an inspection panel comprising Dr Harrison or Dr Ryder as the lead archaeologist, the DVI co-ordinator, and the Scene Evidence and Recovery Manager to certify that all required steps had been taken.22 85.14 Once a certificate had been issued, the bagged debris was removed from the tower so that no extraneous material was left in the flat.23 85.15 In accordance with DVI protocols, when human remains were located, they were given a Unique Reference Number (URN) and placed in a sealed bag before being taken under secure conditions from the site of recovery to a holding area and then to the Westminster mortuary. The steps involved in this process were documented. A parallel system was followed in relation to items recovered from the building, such as identification documents and valuables, all of which were handed over to an exhibits officer.24 17 Harrison {KHA00000001/9} page 9, paragraph 28; Harrison {Day302/43:6} -{Day302/48:13}. 18 Harrison {KHA00000001/9} page 10, paragraph 29; {KHA00000001/12} page 12, paragraph 36; {Day302/50:21}-{Day302/53:25}. 19 Harrison {KHA00000001/12} page 12, paragraph 37; Harrison {Day302/62:3}. 20 Harrison {KHA00000001/12} page 12, paragraph 37; {KHA00000001/17} page 17, paragraph 45; Harrison {Day302/55:2}-{Day302/57:24}; {Day302/59:5}; {Day302/62:13}-{Day302/57:24}; {Day302/64:17}. 21 Harrison {KHA00000001/19} page 19, paragraphs 47-48; Harrison {Day302/72:1}-{Day302/73:23}. 22 Harrison {KHA00000001/19} page 19, paragraph 49; {KHA00000001/20} page 20, paragraph 51; Harrison {Day302/68:21}-{Day302/71:15}; {Day302/78:1}-{Day302/80:25}. 23 Harrison {KHA00000001/20} page 20, paragraph 52. 24 Harrison {KHA00000001/39} page 39, paragraphs 87-91.

The Grenfell Tower Inquiry: Phase 2 Report 14 85.16 Following arrival at the mortuary, each bag was scanned and a preliminary assessment of the remains carried out.25 Forensic pathologists conducted an initial post mortem examination, which was attended by forensic anthropologists when necessary.26 85.17 Dr Gaille MacKinnon, BA MSc MCIfA FRAI (ChFA) was a director of Alecto Forensic Services Ltd with over 24 years’ experience, including working on major terrorist incidents.27 She led the team of forensic anthropologists instructed to identify the human remains recovered from the tower.28 85.18 Working with DVI-trained police officers, forensic pathologists and experts in DNA analysis, forensic odontology (a branch of forensic science that assists with identification of remains through the examination of dental records and dental remains) and fingerprints,29 the role of Dr MacKinnon’s team was to construct a biological profile for each victim.30 Following the initial post mortem examinations, they conducted a detailed anthropological examination of each of the 17 separate locations in the tower from which remains had been recovered, working on each flat or communal space separately.31 85.19 The remains were carefully documented, mapped and reconstructed, if possible.32 An individual biological profile was constructed according to internationally recognised standards accepted in the wider scientific community.33 It included looking at age at death, sex, ancestry and any features or variations that differ from one person to another.34 85.20 The purpose of the anthropological examinations was to ensure that all human remains were attributed to the individual deceased to whom they belonged.35 A particular challenge was the commingling of remains where a number of victims had died in the same location. That challenge was met by using standard operating procedures and by undertaking examinations of each flat or communal space individually.36 Dr MacKinnon’s team worked alongside experts in DNA analysis (which could be used to confirm identification)37 and odontology.38 85.21 On completion of the forensic anthropology and odontology examinations for each deceased recovered from a particular flat or communal space, the human remains and documentation were reviewed in a procedure called “Anthropology Grand Rounds” involving Professor Wilcox, Detective Chief Inspector Andrew Chalmers (Deputy Senior 25 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/68}; {GMK00000001/15-16}. 26 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/16}. 27 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/85-87}. 28 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/20}. 29 MacKinnon {Day298/65:22}‑{Day298/66:22-1}; {Day298/71:10-23}; MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/15}. 30 MacKinnon {Day298/63:9-14}. 31 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/16}. 32 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/28}. 33 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/34}. 34 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {Day298/63:9-14}; MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/35}; {GMK00000001/37}. 35 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/38}; {GMK00000001/41}. 36 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/21} 37 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {Day298/82:22-25}; MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/23-24}. 38 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/21-22}.

Part 9 | Chapter 85: The expert evidence 15 Investigating Officer and Scene Senior Identification Manager), the Post Mortem Coordinator, Andrew Langley (Operational Forensic Manager (OFM), Metropolitan Police Service), and the lead anthropologists and odontologists.39 85.22 Dr MacKinnon confirmed that, based on her examination and having regard to the rigour with which the recoveries and clearance of the flats had been undertaken, she was very confident that the remains of all the victims had been recovered and correctly identified.40 85.23 The information reviewed during the Anthropology Grand Rounds procedure informed the deliberations of the Identification Commission, conducted under the direction of Professor Wilcox.41 The identification of an individual deceased also drew upon other sources including comparative DNA and odontology.42 At the Identification Commission, Professor Wilcox reached a final decision on the identity of the deceased whose remains had been recovered from the tower. The medical cause of death 85.24 We have already referred to the involvement of forensic pathologists. Dr Ashley Fegan‑Earl BSc (Hons) MB BS DMJ(Path) FRCPath FFFLM RCPathME led a team of 12 Home Office registered forensic pathologists who conducted post mortems on those who died in the fire and provided an opinion on the medical cause of death.43 85.25 Dr Fegan-Earl explained that although the work of experts in other disciplines could assist in determining the cause of death, it was for the pathologist, as the registered medical practitioner, to certify the medical cause of death.44 The certification system uses a form which has two parts. The first gives the primary cause of death, which can be subdivided into two, Ia and Ib. For example, a doctor might record cardio-respiratory arrest as cause Ia and carbon monoxide poisoning as cause Ib, thereby indicating that cardio-respiratory arrest was due to carbon monoxide poisoning. Part II is used to record conditions that may have contributed to death, for example, heart disease.45 85.26 The destructive nature of the fire meant that a full post mortem was not possible in every case. Where a full post mortem could be conducted, a toxicology examination to ascertain whether there was carbon monoxide in the blood and an histology examination to ascertain whether there was soot in the airways was also undertaken, where possible. However, if a deceased’s body had been subject to extensive heat damage, a full post mortem was not possible.46 85.27 The results of the post mortems were reviewed by other members of the team.47 The medical cause of death for many of those who died as a result of the fire was recorded as “Inhalation of fire fumes”, “Inhalation of the products of combustion” or “Consistent with the effects of fire”. Dr Fegan-Earl explained that the first two were essentially the same 39 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/42}. 40 MacKinnon {Day298/90:5-14}; {Day298/77:7-6}; {Day298/78:5-6}; {Day298/124:16-25}; {Day 298/125:4-10}. 41 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/18}. 42 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/22}. 43 Fegan-Earl {AWF00000001/2} page 2; Fegan-Earl {Day298/19:17-21}-{Day298/27:16}. 44 Fegan-Earl {Day298/42:14}-{Day298/43:2}. 45 Fegan-Earl {Day298/43:3-23}. 46 Fegan-Earl {AWF00000001/2} page 2; {AWF00000001/3} page 3; Fegan-Earl {Day298/25:11}-{Day298/40:25}. 47 Fegan-Earl {Day298/28:8}.

The Grenfell Tower Inquiry: Phase 2 Report 16 and had been used where there was pathological evidence to show that the deceased had inhaled fire fumes.48 The third formulation had been adopted where it had not been possible to conduct a full post mortem.49 85.28 Dr Fegan-Earl agreed with Professor Purser’s opinion that those who died in the tower had very probably been rendered unconscious by inhalation of poisonous gases, including carbon monoxide and hydrogen cyanide. One possible description of the cause of death, therefore, was inhalation of asphyxiant gases. In his opinion it was overwhelmingly likely that the deaths were the result of the inhalation of fire fumes rather than burning.50 Nonetheless, while not disputing Professor Purser’s opinion, Dr Fegan-Earl maintained that it was appropriate to use the expression “Consistent with the effects of fire” as the medical cause of death if it was not possible to confirm with certainty that the death was caused by inhalation of asphyxiant gases, although that conclusion might be strongly supported by scientific evidence and pathological experience.51 85.29 We have given careful consideration to the evidence of Dr Fegan-Earl and understand why he and his colleagues felt the need to show caution when ascertaining the medical cause of death. We keep in mind that it will be for the coroner to decide what to find as the cause of death in each case. However, as Dr Fegan-Earl acknowledged, we have the benefit of the evidence of a range of witnesses, including the expert evidence of Professor Purser. It is because of that additional evidence, and in particular the work done by Professor Purser, that we have reached the conclusion that, save for those who fell from the tower, we can safely find that death was due in each case to the inhalation of asphyxiant gases. The analysis and conclusions of Professor Purser 85.30 Professor David Purser CBE BSc PhD DipRCPath was instructed to give expert evidence on toxicology. In broad terms, he considered the causes of the incapacitation and death of those who died in the tower,52 building on the preliminary conclusions he had reached in the report he provided for Phase 1.53 85.31 We found Professor Purser’s evidence helpful and it has informed our findings about the individual deceased in the following chapters. Having considered his evidence, we regard him as a reliable expert on whose evidence we can rely in drawing conclusions about the circumstances of the individual deaths. 85.32 Professor Purser’s expertise includes the physiological effects on the human body of the inhalation of toxic smoke and gases.54 At the time he gave evidence, he was a visiting professor in the Centre for Fire and Hazards Science at the University of Central Lancashire.55 His extensive experience is described in his report. He has wide practical experience of investigating the effects of major fires in this country and abroad, including taking part in an investigation by the French authorities into a fire inside the Mont Blanc tunnel.56 48 Fegan-Earl {Day298/46:142}-{Day298/47:8}. 49 Fegan-Earl {AWF00000001/4-5} pages 4-5; Fegan-Earl {Day298/44:15}-{Day298/46:5}. 50 Fegan-Earl {AWF00000001/4} page 4; Fegan-Earl {Day 280/49:2}-{day298/51:3}. 51 Fegan-Earl {Day298/51:5}-{Day298/52:11}. 52 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005}; Purser, Phase 2 Report, Section 5 {DAPR0000011}; Purser, Phase 2 Report, Section 6 {DAPR0000006}; Purser, Phase 2 Report, Appendix A {DAPR0000007}; Purser, Phase 2 Report, Appendix B {DAPR0000008}; Purser, Phase 2 Report, Appendix C {DAPR0000009}; Purser, Phase 2 Report, Appendix D {DAPR0000010}. 53 Purser {Day296/4:13-17}; {Day296/5:12-15}. 54 Purser {Day296/11:25}-{Day296/12:4}. 55 Purser {Day296/12:11-15}. 56 Purser, Phase 2 Report, Appendix D {DAPR0000010/5]; Purser {Day296/15:2-13}.

Part 9 | Chapter 85: The expert evidence 17 85.33 In order to reach a conclusion on the cause of the incapacitation and death of each deceased,57 Professor Purser examined the changing conditions in the flats, lobbies and stairs throughout the night of the fire, relying on medical records of survivors, transcripts of emergency calls, photographs of the exterior of the tower, the evidence of other experts and the chairman’s findings in the Phase 1 report.58 85.34 To estimate the exposure of an individual to irritant smoke and its effect Professor Purser estimated the fuel load and range of materials involved in the fire to calculate the average composition of the asphyxiant gases entering the tower. For that purpose he relied upon a study published by BRE in March 2003 entitled The potential for including fire chemistry and toxicity in fire safety engineering59 which contained the results of two experiments measuring yield and concentrations of various gases produced when certain products were burned.60 He also relied on tests carried out by Professor Anna Stec61 to determine the composition of smoke particulates and the yield of toxic gases obtained from burning samples taken from Grenfell Tower itself.62 Professor Purser used descriptions given by witnesses of conditions in the tower and medical records of survivors to estimate the extent of smoke obscuration and irritancy.63 85.35 The mechanism of death from exposure to asphyxiant gases is twofold: first, the carbon monoxide bonds with haemoglobin to form carboxyhaemoglobin.64 That prevents the haemoglobin from carrying oxygen65 which deprives the brain and heart of oxygen.66 Second, the carboxyhaemoglobin impairs the ability of the rest of the haemoglobin to deliver oxygen to tissues.67 Ultimately that causes a lack of oxygen to the heart and brain.68 Cyanide also prevents the tissues from metabolising.69 Both can cause hypoxia.70 He agreed that in describing the cause of death, the effect of carbon monoxide in combination with hydrogen cyanide would appropriately be termed, “asphyxia from asphyxiant gases”.71 85.36 Professor Purser’s study of conditions in the tower and information obtained from survivors added to the conclusions he drew from the toxicology and pathology reports on the deceased. The forensic data derived from those reports that record the concentration of carboxyhaemoglobin in the blood are important for measuring the toxicological effects of asphyxiant gases.72 85.37 Professor Purser’s study enabled him to reach with some confidence a conclusion on the production of toxic gases in the tower, how those who died were overcome and the causes of their deaths. In most cases he was also able to provide an opinion about the 57 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/64-103}; Purser, Phase 2 Report, Appendix A {DAPR0000007}. 58 Purser {Day296/40:18}-{Day296/41:5}. 59 {DAP00000002}. 60 Purser {Day296/47:3}-{Day296/49:7}. 61 Stec, Assessment of the toxicity and extent of penetration of smoke from combustible products on the Grenfell Tower Report {AASR0000010}. 62 Purser {Day296/49:15}-{Day296/50:8}. 63 Purser {Day296/50:11-16}. 64 Purser {Day296/168:22}-{Day296/169:5}. 65 Purser {Day296/167:15-21}. 66 Purser {Day296/168:5-21}. 67 Purser {Day296/169:6-14}. 68 Purser {Day296/168:22}-{Day296:169:5}. 69 Purser {Day296/169:10-15}. 70 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/107}. 71 Purser {Day296/171:15-18}. 72 Purser {Day296/164:17-20}.

The Grenfell Tower Inquiry: Phase 2 Report 18 time when death occurred.73 His conclusions were necessarily approximate due to the number of factors involved,74 but we think that in each case they offer the most reliable estimate available. 85.38 Professor Purser reached a number of conclusions that are applicable to all the deceased and have informed the findings made in the following chapters. However, he accepted that they were subject to a number of qualifications. First, it was not possible to measure exact concentrations of smoke and toxic gases during the fire, so his conclusions were estimates based on the available evidence.75 Second, the concentration of carboxyhaemoglobin sufficient to cause incapacitation and ultimately death depends on the particular characteristics of the individual concerned.76 Third, if the amount of carboxyhaemoglobin in the blood of the deceased could not be measured, an estimate had to be made and it was not always possible to be confident about the level persisting at the time of death.77 Fourth, Professor Purser drew information from a wide range of sources, as mentioned above. Fifth, in some cases there was very sparse information available about the person in question, which limited the confidence that could be placed in his conclusion.78 85.39 Moreover, the rate at which asphyxiant gases are absorbed depends on an individual’s personal characteristics.79 Infants and children absorb gases at about twice the rate of adults, which hastens the time to collapse and death.80 If infants and young children were sheltering with their parents, it is likely that they lost consciousness and died before their parents.81 Respiratory conditions, such as asthma, also affect any response because they make people more susceptible to irritant particles in smoke82 and those with the condition are generally more sensitive to their effect.83 If people were unable to leave their flats or descend the stairs, their prospects of escape were reduced.84 85.40 Professor Purser identified three groups of material that contributed to the smoke within the tower: the external cladding and insulation and the window infill panels, the window surrounds and the contents of the flats.85 During the early stages of the fire it is likely that the cladding, the window infill panels and the window surrounds were the main contributors to the smoke.86 The smoke from the fire on the outside of the building entered the tower87 and the contents of the flats became involved in the fire at different times as it progressed.88 The contribution made by the different materials to the smoke varied.89 We are satisfied that the cladding, insulation, window surrounds and window infill panels made a significant contribution90 but we are unable to say how much of a contribution each of them made at different times and in different places. 73 For Professor Purser’s range of time in each individual case, see Purser, Phase 2 Report, Section 6 {DAPR0000006}. 74 Purser {Day296/33:6}-{Day296/39:5}. 75 Purser {Day296/32:16-20}. 76 Purser {Day296/34:19}-{Day296/35:18}; {Day296/164:10-20} and {Day296/39:13}-{Day296/40:9}. 77 Purser {Day296/39:8-12}. 78 Purser {Day296/41:10-15}. 79 Purser {Day296/107:3-10}. 80 Purser {Day296/107:11-15}. 81 Purser {Day296/109:2-9}. 82 Purser {Day296/112:5-11}. 83 Purser {Day296/113:10-14}. 84 Purser {Day296/120:19}-{Day296/122:23}. 85 Purser, Phase 2 Report, Section 5 {DAPR0000011/4}. 86 Purser {Day297/166:5}-{Day297/167:6}. 87 {DAPR0000015/2}; Phase 1 Report Volume IV paragraph 24.8. 88 Purser {Day297/168:24}-{Day297/170:17}. 89 {DAPR0000015/2}. 90 Purser, Phase 2 Report, Section 5 {DAPR0000011/5}; Purser {Day297/186:18-21}.

Part 9 | Chapter 85: The expert evidence 19 85.41 From the descriptions of dense, irritant smoke in the lobbies, the very limited visibility described by the witnesses and the general fire conditions, Professor Purser estimated that the concentration of carbon monoxide and hydrogen cyanide was likely to have been high and in the lobbies sufficient to cause a person to collapse within about three-to-five minutes of exposure.91 85.42 He estimated that moderate concentrations persisted in the stairs,92 which would have led to collapse (assuming no prior exposure) in approximately 15 to 30 minutes, if one were walking, or between 30 minutes and one hour, if static.93 85.43 Having studied data collected from 21 survivors, Professor Purser concluded that their exposure to asphyxiant gases had occurred mainly during their descent of the stairs, rather than while they were sheltering in their flats.94 When considering the density of smoke in the stairs, and therefore the risk of inhaling a large enough dose to cause collapse while on the way down, Professor Purser drew a distinction between conditions up to about 01.49 and those thereafter.95 He considered that until about 01.49 it was still possible to descend the stairs without danger of collapse.96 After that it was still possible to escape by the stairs, but was more hazardous due to the dense smoke and absence of visibility in both the lobbies and the stairs.97 85.44 Most of those who left the tower after 01.49 used cloths or towels to avoid inhaling smoke. The greatest danger was of collapse due to the inhalation of asphyxiant gases, which causes breathlessness, dizziness, light-headedness and weakness, followed by collapse and loss of consciousness.98 Continued inhalation of those gases causes death from asphyxia.99 85.45 Based on Professor Purser’s evidence we find that:100 a. Anyone whose blood contained between 20% and 40% carboxyhaemoglobin had almost certainly inhaled enough smoke and carbon monoxide to be unconscious at the point of death, even if their remains showed signs of severe burns.101 b. Anyone whose blood contained more than 40% carboxyhaemoglobin died from smoke inhalation and if serious burns were present, they were most likely to have occurred after death.102 c. A person whose blood contained less than 40% carboxyhaemoglobin but whose body showed no signs of burns probably died as a result of inhaling carbon monoxide and other toxic gases, such as hydrogen cyanide.103 85.46 In the light of Professor Purser’s evidence we think it likely that those who died in the tower after having left their flats inhaled most of the carbon monoxide that killed them while they were descending the stairs. The time it took them to do that was therefore a 91 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/49}. 92 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/50}. 93 Purser {Day296/67:17}-{Day296/68:16}. 94 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/153}; Purser {Day296/214:17}-{Day296/215:4}. 95 Purser, Phase 2 Report {DAPR0000005/95} Sections 1-4; Purser {Day296/159:11-20}. Professor Purser relied on the accounts of Petra Doulova, floor 20, who exited the tower at 01:41:26 and Branislav Lukic, floor 11, who exited the tower at 01:49:09. Phase 1 Report Volume III Annex A. 96 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/96}. 97 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/96}. 98 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/97}. 99 Purser, Phase 2 Report, Sections 1-4 {DPAR0000005/97}. 100 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/109}. 101 Purser {Day296/165:22}-{Day296/166:3}. 102 Purser {Day296/166:4-9}. 103 Purser {Day296/166:10-15}.

The Grenfell Tower Inquiry: Phase 2 Report 20 significant factor.104 If people left their flats before they were overcome, they had a good chance of being able to escape from the tower successfully.105 Those who did not survive the journey down the stairs had inhaled a significant amount of asphyxiant gases while in their flats and before entering the stairs.106 Those who remained in their flats until the fire arrived but were then able to escape successfully had probably not been exposed to a large amount of asphyxiant gases.107 85.47 People were inhaling an increasing quantity of asphyxiant gases while they remained in their flats108 and the longer they did so, the greater the danger of their accumulating enough to cause collapse and death.109 However, in most cases they had inhaled a dose of asphyxiant gases sufficient to impede escape by the time the fire on the outside of the building reached the flats in which they were sheltering.110 The key distinction between those who survived and those who died is that those who survived left before the fire spread to the outside of their flats or the rooms in which they were sheltering.111 In some individual cases, personal characteristics affected both their ability to escape and their vulnerability to asphyxiant gases.112 85.48 When the fire reached the outside of the rooms in which people were sheltering, conditions deteriorated very rapidly and they were exposed to a large amount of asphyxiant gases.113 When they then tried to evacuate, they had already accumulated a significant dose and collapsed quickly when exposed to further gases in the lobby or stairs.114 Those who remained in their flats and did not leave were rapidly overcome.115 85.49 Almost all those who died in the tower had concentrations of carboxyhaemoglobin in their blood consistent with death from asphyxia rather than from heat or burns.116 The two bodies with concentrations of less than 50% carboxyhaemoglobin that were recovered from the flats had heart disease which explained the lower result.117 For eight of those who died in the lobbies or stairs, all except one had very high carboxyhaemoglobin concentrations and did not have significant burns.118 85.50 From those findings we conclude that all the deceased were comatose, and in most cases dead, before they were exposed to significant heat.119 The severe burning of bodies was likely to have occurred in all cases sometime after death when the fire entered the flats and consumed all the combustible contents.120 85.51 Professor Purser was unable to say whether any of those who died had inhaled enough hydrogen cyanide to make a significant contribution to incapacitation and death.121 He was of the opinion, which we accept, that it had made some contribution but that the dominant toxic gas causing incapacitation and death had been carbon monoxide.122 104 Purser {Day296/214:17}-{Day296/215:4}. 105 Purser {Day296/27:4-9}. 106 Purser {Day296/217:23}-{Day296/218:1}. 107 Purser {Day296/25:19}-{Day296/26:2}. 108 Purser {Day296/218:2-5}. 109 Purser {Day297/7:18}-{Day296/8:2}. 110 Purser {Day296/218:6-10}. 111 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/153}. 112 Purser {Day296/218:19-23}. 113 Purser {Day296/28:4-12}. 114 Purser {Day296/28:15-22}. 115 Purser {Day296/28:23-25}. 116 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/124} figure 18. 117 Purser {Day296/182:15-18}. 118 Purser {Day296/182:20}-{Day296/183:2}. 119 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/138}; Purser {Day296/183:18}-{Day296/184:16}. 120 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/139}; Purser {Day296/229:1-8}. 121 Purser {Day296/197:22}-{Day296/198:17}. 122 Purser {Day297/51:14-17}; {Day297/52:4-17}.

21 86.1 By 01.21 on 14 June 2017, the fire had spread up the east face of Grenfell Tower to reach the outside of Flat 76 on floor 10.123 All the flats on floor 10 were still occupied at that time, but none of the occupants had contact with those who died on that floor. 86.2 Hoang Khanh Quang, who lived in Flat 76, and her former husband, Van Quang Ho, who was there that night, were the first to leave floor 10. Having been woken by a smoke alarm, Hoang Khanh Quang saw flames at the kitchen window. Both she and Van Quang Ho then became aware of black smoke filling the hallway. Leaving at speed and in obviously difficult circumstances, neither of them closed the front door of the flat, which did not have an effective self-closing device. They left the tower together at 01.26.124 86.3 Flat 76 rapidly filled with smoke, which then entered the floor 10 lobby. Within five minutes the lobby became so full of smoke that when the north lift unexpectedly stopped at that floor it was already dark and full of smoke. Some of the smoke penetrated the closed lift doors. More came in when the doors opened. The volume and density of the smoke that entered the lift made Nadia Jafari, who was in the lift, think that the lights had gone out. In the ensuing panic, three of the five people in the lift, Ali Yawar Jafari, Mohamednur Tuccu and Khadija Khalloufi, stumbled out and became trapped in the lobby of floor 10.125 86.4 The lift then continued its descent, reaching the ground floor at 01.26. Only Nadia Jafari and Rhea Rojo emerged. The extent of the smoke billowing from the lift as they left it, seen on CCTV, gives an indication of the amount of smoke on floor 10.126 Nadia Jafari said that the smoke had been much thicker when the lift was at floor 10. At 01.28, in a call to the emergency services, the occupants of Flat 73, located in the south-west corner of the tower, reported smoke coming through their front door.127 86.5 Nagawa (Prossy) Nalukwago, who was staying in Flat 71, next to Flat 76, left the tower at 01.35. On leaving Flat 71, she had been confronted by thick black smoke which felt hot. Despite the conditions, she was able to make her way to the stairwell. While doing so, she stumbled over what she thought were three bodies.128 They were the bodies of Ali Yawar Jafari, Mohamednur Tuccu and Khadija Khalloufi, all of whom had by then been overcome by the conditions in the lobby. That none of them had been able to reach the stairs shows how disorientating conditions on floor 10 were. 86.6 Clarita Ghavimi was woken at around 01.30 by a smoke alarm. She saw flames from her bedroom window. When she opened her front door, she found the lobby dark and smoky. She made her way to the stairwell door by touch because the lobby was too thick with smoke for her to see her way.129 She was then rescued by another resident, Branislav Lukic, and carried down. They left the tower at 01.49.130 123 Phase 1 Report Volume II paragraphs 10.115-10.116; Phase 1 Report Volume IV paragraph 24.18. 124 Phase 1 Report Volume II paragraphs 10.197-10.202; Phase 1 Report Volume IV paragraph 24.31. 125 Phase 1 Report Volume II paragraphs 10.215 and 10.221-10.225. 126 Phase 1 Report Volume II paragraphs 10.94 and 10.215-10.219; Phase 1 Report Volume IV paragraph 25.6. 127 Phase 1 Report Volume II paragraph 10.203. 128 Phase 1 Report Volume II paragraph 11.114. 129 Phase 1 Report Volume II paragraphs 11.115 and 12.40-12.43. 130 Phase 1 Report Volume II paragraphs 12.41-12.43. Chapter 86 Floor 10

The Grenfell Tower Inquiry: Phase 2 Report 22 86.7 Between 01.40 and 01.42 a group of five firefighters led by CM Guy Tillotson began searching the tower to rescue anyone they could find. They went to floor 10 but found it so full of thick, black smoke that CM Tillotson decided that the firefighters could not enter the lobby without water.131 Ali Yawar Jafari Date of birth: 1 January 1936 (81 years). Place of birth: Kandahar, Afghanistan. Gender:

Male. Occupation: Retired jeweller. Usual address: Flat 86, floor 11, Grenfell Tower, London. Place of death: Lobby of floor 10, Grenfell Tower, London. Time of death: By about 01.37 on 14 June 2017. Cause of death: la. Inhalation of asphyxiant gases. II. Coronary and hypertensive heart disease. Background and composition of household 86.8 Born on 1 January 1936 in Kandahar, Afghanistan, Ali Yawar Jafari was an 81-year-old retired jewellery maker. He lived in Flat 86 on floor 11 of Grenfell Tower with his wife, Fatima Jafari, and their two adult daughters, Maria and Nadia Jafari. The family had lived there since 2003.132 Vulnerability 86.9 Ali Yawar Jafari suffered from diabetes and heart disease.133 Rydon’s survey of residents, prepared in November 2014 and provided to the TMO, recorded that he suffered from diabetes.134 On the night of the fire, David Noble, a policy and diversity advisor with the TMO,135 produced a spreadsheet listing the residents of the tower which was designed to record any known vulnerability or disability.136 That spreadsheet was compiled from information held on the TMO’s Capita Insight system.137 It did not identify Ali Yawar Jafari as a vulnerable resident. Events of 14 June 2017 86.10 Ali Yawar Jafari was last seen entering the tower at 19.40 on 13 June 2017.138 He remained in his home preparing to break the Ramadan fast with his family.139 131 Phase 1 Report Volume II paragraphs 12.3-12.5 and 12.29. 132 Phase 1 Report Volume II paragraph 10.204; Phase 1 Report Volume IV paragraph 32.293. 133 Phase 1 Report Volume II paragraph 10.204. 134 Rydon Residents Survey {RYD00024466/33}. 135 Noble {TMO00000884/1} page 1, paragraph 3. 136 Noble {Day119/75:19-22}. 137 Noble {Day119/77:17}-{Day119/82:5}. 138 O’Riordan {MET00013136/3} page 3. 139 Nadia Jafari {IWS00000683/3} page 3, paragraph 10.

Part 9 | Chapter 86: Floor 10 23 86.11 By 01.22 the fire had reached the top of floor 11 outside the kitchen of Flat 86.140 By then the Jafari family were already aware of it and Fatima and Maria Jafari had started to make their way out of the building. Before doing so, Fatima asked Nadia to wake her father and help him outside. Nadia and her father were still in the flat when she saw flames push through the extractor fan of the kitchen window, the glass in that window shatter and the frame fall out. She shut the kitchen door and together with her father left the flat.141 86.12 In the lobby, Nadia Jafari and her father knocked on the doors of neighbours. She spoke to Natasha Elcock in Flat 82 and even tried to go back into Flat 86. She was not able to lock the door of the flat, which was left partly open. The smoke emerging from Flat 86 did not immediately fill the lobby of floor 11 and the lights were still visible. Nadia suggested to her father that they use the lift to leave the tower.142 By that time, Ali Yawar Jafari had been exposed to only a limited amount of smoke. 86.13 Mohamednur Tuccu and Rhea Rojo were already in the north lift when it stopped at floor 11. Khadija Khalloufi, who had made her way down from her own flat on floor 17, entered the lobby of floor 11 and got into the lift at the same time as the Jafaris.143 There appears to have been no smoke in the lift when it reached floor 11. 86.14 The lift started to descend but suddenly stopped at floor 10. Smoke began to seep in through the closed doors. When they opened, the inward rush of smoke filled the lift obscuring the lights. The occupants were left coughing and shouting. In the panic Ali Yawar Jafari, Mohamednur Tuccu and Khadija Khalloufi went into the lobby, which by then was filled with dense black smoke.144 Unable to find a way out, Ali Yawar Jafari became trapped in the lobby on floor 10. 86.15 The lift probably stopped on floor 10 shortly before 01.26 (the time when Nadia Jafari and Rhea Rojo are seen leaving the lift on the ground floor).145 Initially, Nadia Jafari thought her father had left the lift on the ground floor ahead of her.146 86.16 When they had left the tower and realised that their father had not escaped the building, Nadia and Maria Jafari tried to re-enter it but were stopped by a police officer, possibly PC Kiran Sangha, who recalled being told by a family he had prevented from entering the tower that their grandfather was stuck in the lift. The officer told a fireman outside the tower that there were people stuck in a lift but was told that the fire brigade had control of the lifts in the tower.147 There is no evidence of what, if any, further steps were taken in response to what the officer had said. Recovery and identification 86.17 CM Martin Hoare and FF Matthew Tanner tallied out at 02.55.148 Having originally been sent to search Flat 74 on floor 10, they were reassigned with other firefighters to search for a missing firefighter on floor 12. Once that emergency had been resolved, they returned to their original task. When they reached floor 10 and opened the door to the lobby, they were confronted by intense heat with smoke extending down to a foot above the floor. 140 Phase 1 Report Volume II paragraph 10.116; Phase 1 Report Volume IV paragraph 25.6. 141 Phase 1 Report Volume II paragraphs 10.204-10.206. 142 Phase 1 Report Volume II paragraphs 10.206-10.209. 143 Phase 1 Report Volume II paragraphs 10.208 and 10.221-225. 144 Phase 1 Report Volume II paragraph 10.225. 145 Phase 1 Report Volume II paragraph 10.216. 146 Phase 1 Report Volume II paragraph 10.217. 147 Sangha {MET00007837/3} page 3. 148 Phase 1 Report Volume II paragraph 10.225.

The Grenfell Tower Inquiry: Phase 2 Report 24 Crawling into the lobby, they found Ali Yawar Jafari’s body near the lift and brought him out into the stairwell. CM Hoare accepted that he had originally wrongly identified the casualty as Mohamednur Tuccu.149 86.18 As he and FF Tanner were carrying Ali Yawar Jafari down the stairs, CM Hoare realised that he was running out of air.150 Concluding that Ali Yawar Jafari had already died, the firefighters laid his body on the stairs.151 Returning to the bridgehead, they reported where they had left him. FFs Charlie Rawlings, Andrew Brooks and James Morcos were sent to recover his body.152 It was carried out of the tower at 03.34.153 At 03.35, paramedic Mark Hodson confirmed that he was dead.154 86.19 The coroner, Professor Wilcox, was satisfied that the casualty recovered by CM Hoare and FF Tanner was Ali Yawar Jafari and therefore issued an interim certificate of the fact of death.155 Cause and time of death 86.20 The post-mortem on Ali Yawar Jafari found that his body was intact. There were soot deposits around his nose and mouth and some superficial burns and heat damage to the skin. The post-mortem also confirmed that he had suffered from severe heart disease which affected the blood supply to his heart and made him more vulnerable to the conditions produced during a fire, so contributing to his death.156 86.21 The level of carboxyhaemoglobin in a blood sample taken from Ali Yawar Jafari was found to be 47%.157 That is within the toxic range for someone whose pre-existing heart disease made him more vulnerable to conditions in the lobby.158 No cyanide was detected in the sample when it was later tested. As cyanide was found in samples taken from Mohamednur Tuccu and Khadija Khalloufi, its absence in the case of Ali Yawar Jafari was probably due to degradation of the sample over time.159 It is likely therefore that Ali Yawar Jafari inhaled hydrogen cyanide, although we cannot say how much. 86.22 The medical cause of death was recorded as: Ia. Inhalation of fire fumes. II. Coronary and hypertensive heart disease. 86.23 In the light of Professor Purser’s evidence we find that a more accurate description of the primary cause of death is “inhalation of asphyxiant gases”. 86.24 Given his poor health, the manner in which he came to leave the lift on floor 10, the conditions in the lobby on that floor and the fact that his body was recovered near the lift, we find that Ali Yawar Jafari probably collapsed due to the inhalation of asphyxiant gases 149 Hoare {MET00008027/15-25} pages 15-16 and 25; Phase 1 Report Volume II paragraphs 10.224-10.225; Phase 1 Report Volume III paragraphs 17.13 (e) and 20 (c). 150 Standard duration breathing apparatus provides a working time of about 30 minutes depending on a range of factors, including workload and environmental conditions: Phase 1 Report Volume I paragraph 7.63. 151 Phase 1 Report Volume III paragraph 17.20 (c). 152 Rawlings {MET00005588/2} page 2; Brooks {MET00005262}; Morcos {MET00005585/1} page 1. 153 Phase 1 Report Volume II paragraph 10.225. 154 Hodson {MET00017061/5} page 5. 155 Interim certificate of the fact of death for Ali Yawar Jafari {MET00065589}. 156 Jafari post-mortem report {COR00000088/11}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/122} Table 17. 157 Jafari toxicology report {COR00000092/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/124} paragraph 493. 158 Jafari post-mortem report {COR00000088/11}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/125} paragraph 493. 159 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447.

Part 9 | Chapter 86: Floor 10 25 within a minute or so of stepping out of the lift. While unconscious, he continued to inhale those gases until his respiration and circulation ceased some minutes later and he died at about 01.37,160 mainly from the effects of carbon monoxide poisoning.161 He would have had to be rescued before about 01.35 to have had a reasonable prospect of survival.162 Mohamednur Tuccu Date of birth: 24 May 1973 (44 years). Place of birth: Eritrea. Gender:

Male. Occupation: Security Officer. Usual address: Arne House, Tyers Street, London Place of death: Lobby of floor 10, Grenfell Tower, London Time of death: By 01.46 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 86.25 Born in Eritrea, Mohamednur Tuccu had lived in the United Kingdom since 1991. Aged 44 years (born 24 May 1973), he was working as a security guard at the time of the fire. Mohamednur Tuccu is not listed as a resident in the spreadsheet163 produced on the night of the fire by David Noble.164 His wife, Amal Ahmedin, and daughter, Amaya Tuccu- Ahmedin, lived in Flat 166 on floor 19. On the evening of 13 June 2017, Amna Idris, Amal Ahmedin’s cousin, was visiting the family.165 Events of 14 June 2017 86.26 Mohamednur Tuccu was seen on CCTV entering Grenfell Tower at 00.36.166 His movements thereafter are unknown, but it is very likely that he visited his family. By 01.25, the fire had reached the top of floor 19 and was outside Flat 166.167 Shortly after 01.25, Meron Mekonnen, who lived in Flat 163, left her home having been alerted to the fire. She saw Amal Ahmedin and Amna Idris in the lobby of floor 19. They told each other that there was a fire in the building.168 Meron Mekonnen left the tower at 01.32. Amal Ahmedin, with her daughter, and Amna Idris subsequently made their way up to shelter in Flat 201 on floor 23. It is likely that they reached it by about 01.30.169 They died on floor 23 and we deal with the circumstances of their deaths in Chapter 97. 160 Purser, Phase 2 Report, Section 6 {DAPR0000006/167-170} paragraphs 925-935; Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 943 and Figure 46. 161 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/136} paragraph 568; Purser, Phase 2 Report, Section 6 {DAPR0000006/171-172} paragraphs 942 and 946. 162 Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 945. 163 Noble {Day119/75:19-22}. 164 Noble {TMO00000884/1} page 1, paragraph 3. 165 Phase 1 Report Volume IV paragraphs 32.154-32.163. 166 O’Riordan {MET00013136/4} page 4. 167 Phase 1 Report Volume II paragraph 10.118. 168 Phase 1 Report Volume II paragraphs 10.255-10.257. 169 Phase 1 Report Volume II paragraphs 10.260 and 10.287-10.289.

The Grenfell Tower Inquiry: Phase 2 Report 26 86.27 There is no evidence that Mohamednur Tuccu was in Flat 166 when Meron Mekonnen saw Amal Ahmedin or that he was among those who made their way up the tower. He was, however, in the north lift when Rhea Rojo entered it on floor 12.170 It is not known where Mohamednur Tuccu entered the lift, but it would have been somewhere above floor 12. Since the lift stopped at floors 11 and 10 and reached the ground floor at 01.26,171 it is reasonable to conclude that he left Flat 166 before the fire had reached floor 19. 86.28 When the lift stopped at floor 11, Khadija Khalloufi, who had made her way down the stairs from her home on floor 17 and had entered the lobby on floor 11, got into the lift together with Nadia Jafari and her father, Ali Yawar Jafari.172 86.29 The lift probably stopped on floor 10 shortly before 01.26, when Nadia Jafari and Rhea Rojo can be seen leaving the lift on the ground floor.173 86.30 It is unlikely that Mohamednur Tuccu had been exposed to any smoke before the lift reached floor 10. When the doors opened, the inward rush of smoke filled the lift obscuring the lights. Those in the lift were left coughing and shouting. In the panic Mohamednur Tuccu, together with Ali Yawar Jafari and Khadija Khalloufi, entered the lobby on floor 10, by then filled with dense black smoke.174 Unable to find a way out, he was trapped there. Recovery and identification 86.31 At 02.04,175 FFs Oliver Desforges and Robert Mitchell were deployed with other firefighters to rescue Mariko Toyoshima-Lewis and her family from Flat 9 on floor 3. They were then deployed to floor 24. Climbing the stairs, the two firefighters realised that they did not have enough air to get there. They decided to search a floor they could reach,176 which turned out to be floor 10. 86.32 FF Desforges said that the heat they encountered on opening the door from the stairwell into the lobby was the most intense he had ever experienced. The lobby was filled with hot black smoke and it was impossible to see anything. Keeping low to the ground, the two firefighters found and were able to recover two casualties, Mohamednur Tuccu and Khadija Khalloufi.177 86.33 With the assistance of other firefighters, Mohamednur Tuccu was carried down the stairs and out of the tower at 02:28.178 At 02.37, paramedic Stuart Matthews formally confirmed that he was dead.179 86.34 The coroner, Professor Wilcox, was satisfied that the casualty recovered by FFs Desforges and Mitchell was Mohamednur Tuccu and therefore issued an interim certificate of the fact of death.180 170 Phase 1 Report Volume II paragraphs 10.219 and 10.224-10.225. 171 Phase 1 Report Volume II paragraphs 10.216-10.217. 172 Phase 1 Report Volume II paragraphs 10.208 and 10.221-10.224. 173 Phase 1 Report Volume II paragraph 10.216. 174 Phase 1 Report Volume II paragraph 10.225. 175 BA Telemetry Data {LFB00023326/1} page 1. 176 Phase 1 Report Volume II paragraphs 14.225-14.227; Mitchell {MET000086063/4-5} pages 4-5; Desforges {MET00008013/4-5} pages 4-5. 177 Mitchell {MET000086063/5} page 5; Desforges {MET00008013/5-6} pages 5-6. 178 Phase 1 Report Volume II paragraph 10.224. 179 Matthews {MET00013948/4} page 4. 180 Interim certificate of the fact of death for Mohamednur Tuccu {MET00065634}.

Part 9 | Chapter 86: Floor 10 27 Cause and time of death 86.35 The post-mortem on Mohamednur Tuccu recorded that his body was intact without any burns and that there were significant soot deposits on his face, in his nostrils and in his respiratory system.181 There was bruising on the back of the head consistent with minor blows sustained during an attempt to escape.182 86.36 The level of carboxyhaemoglobin in a blood sample taken from him was found to be 73%,183 which indicates that he had inhaled a considerable amount of carbon monoxide before he died. Later analysis of the blood sample measured a cyanide concentration of 0.18 milligrams/litre.184 That is not in the toxic range but is elevated by comparison with the level naturally occurring in the blood.185 It is likely that it was affected by degradation of the sample and did not reflect the level of cyanide in the blood at the time of death.186 Its presence shows that Mohamednur Tuccu had inhaled some hydrogen cyanide at the time of his death but it is not possible to say how much. 86.37 The post-mortem recorded the medical cause of death as “inhalation of fire fumes” but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”. 86.38 Given the circumstances in which Mohamednur Tuccu left the lift on floor 10, the conditions in the lobby on that floor and the level of carboxyhaemoglobin subsequently found in his blood, we are satisfied that he probably collapsed due to the inhalation of asphyxiant gases within a few minutes of stepping out of the lift. While unconscious, he continued to inhale those gases until his respiration and circulation ceased some minutes later and he died. The level of carboxyhaemoglobin in his blood indicates that the exposure to carbon monoxide alone would have been fatal, although he also inhaled some hydrogen cyanide.187 He would have had to be rescued before about 01.35 at the latest to have had a reasonable prospect of survival.188 86.39 Having considered the evidence, we find that Mohamednur Tuccu had died by 01.46 before being exposed to the direct effect of the flames. Khadija Khalloufi Date of birth: 6 September 1964 (52 years). Place of birth: Mohammedia, Morocco. Gender:

Female. Occupation: Homemaker. Usual address: Flat 143, floor 17, Grenfell Tower, London. 181 Tuccu post-mortem report {COR00001106/10}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/136} paragraph 570. 182 Tuccu post-mortem report {COR00001106/10}. 183 Tuccu first toxicology report {COR00001119/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/137} paragraph 571. 184 Tuccu second toxicology report {INQ00011095/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/141} paragraph 604. 185 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. 186 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. 187 Purser, Phase 2 Report, Section 6 {DAPR0000006/173-174} paragraphs 948-949. 188 Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 945.

The Grenfell Tower Inquiry: Phase 2 Report 28 Place of death: Lobby of floor 10, Grenfell Tower, London. Time of death: By 01.44 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 86.40 Born in Mohammedia, Morocco on 6 September 1964 as the eldest of seven siblings, Khadija Khalloufi was 52 years old at the time of her death. A graduate, she had managed a pharmacy in Morocco before moving to Holland to live and work and ultimately settling in London. At the time of the fire, Khadija Khalloufi lived in Flat 143 on floor 17 with her husband Sabah Abdullah. They had married in 1990.189 Events of 14 June 2017 86.41 Khadija Khalloufi returned to Grenfell Tower on 13 June 2017 at 16.02190 and remained in her home. Mesrob Kassemdjian, who lived in Flat 146 with his aunt, Rita Tankarian, alerted Khadija Khalloufi to the fire before leaving floor 17. She then turned back into her flat to speak to her husband, Sabah Abdullah. Mesrob Kassemdjian left the tower at 01.25 just ahead of Rita Tankarian. She recalled Sabah Abdullah telling her outside the tower that he had lost his wife on the stairs at some point between floors 14 and 17.191 86.42 Khadija Khalloufi was next seen by Nadia Jafari. She entered the lobby of floor 11, called the lift and waited for it with Nadia Jafari and her father, Ali Yawar Jafari.192 We do not know why Khadija Khalloufi chose to enter floor 11. It is unlikely that at that stage she had been exposed to any smoke. 86.43 Mohamednur Tuccu and Rhea Rojo were already in the lift when it reached floor 11 and Khadija Khalloufi, Nadia Jafari and her father all entered it. When the lift suddenly stopped at floor 10, smoke began to seep in through the closed doors. When they opened, the inward rush of smoke filled the lift obscuring the lights. Those in the lift were left coughing and shouting. In the panic Khadija Khalloufi, together with Ali Yawar Jafari and Mohamednur Tuccu, came out into the lobby of floor 10, by then filled with thick black smoke.193 Unable to find her way out, Khadija Khalloufi became trapped. Recovery and identification 86.44 At 02.04,194 FFs Oliver Desforges and Robert Mitchell were deployed with other firefighters to rescue Mariko Toyoshima-Lewis and her family from Flat 9 on floor 3. They were then deployed to floor 23. Climbing the stairs, the two firefighters realised that they did not have enough air to reach that floor. They decided to search a floor that they could reach.195 That turned out to be floor 10. 189 Phase 1 Report Volume IV paragraphs 32.234-32.239; Presentation relating to Khadija Khalloufi {Day306/24:22}-{Day306/26:19}. 190 O’Riordan {MET00013136/3} page 3. 191 Phase 1 Report Volume II paragraph 10.222. 192 Phase 1 Report Volume II paragraph 10.208. 193 Phase 1 Report Volume II paragraph 10.215. 194 BA Telemetry Data {LFB00023326/1} page 1. 195 Phase 1 Report Volume II paragraphs 14.222-14.227; Mitchell {MET000086063/4-5} pages 4-5; Desforges {MET00008013/4-5} pages 4-5.

Part 9 | Chapter 86: Floor 10 29 86.45 FF Desforges described the heat they encountered on opening the door from the stairwell into the lobby was the most intense he had ever experienced. The lobby was filled with hot black smoke and it was impossible to see anything. Keeping low to the ground, he and FF Mitchell found and were able to recover two casualties, Mohamednur Tuccu and Khadija Khalloufi.196 86.46 Khadija Khalloufi was carried out of the tower at 02.28.197 At 02.41, paramedic Stuart Matthews formally confirmed that she was dead.198 86.47 The coroner, Professor Wilcox, was satisfied that the casualty recovered by FFs Desforges and Mitchell was Khadija Khalloufi and therefore issued an interim certificate of the fact of death.199 Cause and time of death 86.48 The post-mortem on Khadija Khalloufi recorded that her body was intact without any burns and that there was dense soot staining around the nostrils and ears and extensive soot contamination in the respiratory system. There were some minor abrasions and bruising which she probably sustained during attempts to find her way out of the lobby on floor 10.200 86.49 The carboxyhaemoglobin level in a sample of blood taken from Khadija Khalloufi was 66%,201 which indicated the inhalation of a significant amount of carbon monoxide. Later analysis of the sample showed a cyanide concentration of 0.59 milligrams/litre.202 That is significantly higher than the background level of cyanide found naturally in the blood.203 That it was detected shows that Khadija Khalloufi had inhaled hydrogen cyanide, but since the sample is likely to have degraded over time,204 we do not know how much cyanide was in her blood at the time of her death. 86.50 The post-mortem recorded the medical cause of death as “inhalation of fire fumes” but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”. 86.51 Given the circumstances in which Khadija Khalloufi left the lift when it reached floor 10, the conditions in the lobby and the level of carboxyhaemoglobin in her blood, we find that she probably collapsed due to the inhalation of asphyxiant gases within a few minutes of exiting the lift. While unconscious, she continued to inhale those gases until her respiration and circulation ceased some minutes later and she died. The level of carboxyhaemoglobin subsequently found in her blood indicates that the degree of exposure to carbon monoxide alone would have been fatal, but she must have also inhaled some hydrogen cyanide.205 196 Mitchell {MET000086063/5} page 5; Desforges {MET00008013/5-6} pages 5-6. 197 Phase 1 Report Volume II paragraph 10.224. 198 Matthews {MET00013948/4} page 4. 199 Interim certificate of the fact of death for Khadija Khalloufi {MET00065597}. 200 Khalloufi post-mortem report {COR00000840/14}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/122} Table 17. 201 Khalloufi first toxicology report {COR00000842/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/136} paragraph 569. 202 Khalloufi second toxicology report {INQ00011089/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/141} paragraph 604. 203 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. 204 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. 205 Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 947.

The Grenfell Tower Inquiry: Phase 2 Report 30 86.52 Having considered the evidence, we are satisfied that Khadija Khalloufi had died by 01.44. She would have had to be rescued no later than 01.35 to have had a reasonable prospect of survival. We are satisfied that she died before being exposed to the direct effect of the flames.

31 87.1 By 01.22 on 14 June 2017 the fire on the outside of the building had reached the top of floor 11 outside Flat 86.206 All six flats on floor 11 were still occupied. Except for Ali Yawar Jafari, whose body was recovered from the lobby of floor 10, and Abdeslam Sebbar, who remained in Flat 81, all the occupants of floor 11 survived the fire. 87.2 The Jafari family, in Flat 86, were the first to leave. Of that family, Nadia Jafari and her father, Ali Yawar Jafari, left last. By that time, flames and smoke had begun to penetrate Flat 86.207 87.3 The front door of Flat 86 did not have an effective self-closing device and when she left Nadia Jafari left the door partly open.208 She did not see or smell smoke while she was in the lobby. She and her father then entered the lift when it stopped on that floor.209 Since Nadia Jafari left the lift at 01.26 when it reached the ground floor,210 it is likely that they entered the lift shortly before that time. As we have explained, Ali Yawar Jafari died after leaving the lift on floor 10.211 87.4 The occupants of Flat 85 (Youssef Khalloud, Mouna El-Ogbani and their three children) were the next to leave floor 11, followed by the occupants of Flat 84 (Miran Lovsin and Branislav Lukic). They all left the building between 01.27 and 01.49.212 That left Abdeslam Sebbar in Flat 81, Natasha Elcock and her family in Flat 82 and Elpidio Bonifacio in Flat 83. 87.5 Between 01.28 and 04.41, those on floor 11 or their relatives outside the tower made 22 calls to the emergency services. Abdeslam Sebbar and his grandson made four calls between them.213 Elpidio Bonifacio’s daughter-in-law made four calls about him between 02.58 and 05.31.214 Natasha Elcock made 14 calls between 01.28 and 04.33.215 The first two calls from Natasha Elcock showed how quickly conditions worsened in the lobby of floor 11. She described a rapid change in the density of the smoke between her first call at 01.28 (when there was only a small amount of smoke) and her second call at 01.33 (at which time she described the lobby as pitch black).216 When at some time before 01.40, Miran Lovsin and Branislav Lukic made an unsuccessful attempt to leave Flat 84, they found the lobby full of thick black smoke.217 206 Phase 1 Report Volume II paragraph 10.116. 207 Phase 1 Report Volume II paragraphs 10.204-10.206. 208 Phase 1 Report Volume II paragraph 10.207. 209 Phase 1 Report Volume II paragraph 10.208. 210 Phase 1 Report Volume II paragraph 10.216. 211 See Chapter 86. 212 Phase 1 Report Volume III Annex A. 213 Phase 1 Report Volume II paragraphs 10.91 and 11.106; Phase 1 Report Volume III paragraphs 15.119 and 19.72. 214 Phase 1 Report Volume III paragraphs 16.73, 16.90, 18.73, 19.74 and 20.49. 215 Phase 1 Report Volume II paragraphs 10.209-10.210, 10.316, 11.103, 11.105, 11.146, 12.54-12.55, 14.207-14.209, 14.237, 14.257; Phase 1 Report Volume III paragraphs 15.113-15.116, 15.154, 15.182, 17.105-17.108, 17.123, 18.48- 18.50, 18.68, 19.42-19.44 and 19.71. 216 Phase 1 Report Volume II paragraphs 10.209-10.210 and 11.103-105. 217 Phase 1 Report Volume II paragraphs 11.108-11.112. Chapter 87 Floor 11

The Grenfell Tower Inquiry: Phase 2 Report 32 87.6 No firefighters were deployed to floor 11 before 04.00. Between then and 04.50, firefighters were sent to search Flats 81 to 84. They had difficulty searching floor 11 because of the intense heat in the lobby.218 Another team that had been sent to floor 9 miscalculated and arrived on floor 11, where they helped Natasha Elcock, her partner and child, to leave.219 The family left the tower at 04.47.220 87.7 Elpidio Bonifacio was the last surviving resident of the tower to be rescued, reaching the base of the tower at 08.07.221 87.8 No resident of floor 11 had contact with Abdeslam Sebbar on the night of the fire and there is no evidence to suggest that he ventured from Flat 81. Abdeslam Sebbar Date of birth: 11 September 1939 (77 years old). Place of birth: Larache, Morocco. Gender:

Male. Occupation: Retired. Usual address: Flat 81, floor 11, Grenfell Tower, London. Place of death: Flat 81, floor 11, Grenfell Tower, London. Time of death: Between 3.50 and 04.05 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 87.9 Born on 11 September 1939 in Larache, Morocco, Abdeslam Sebbar was a 77-year-old retired coffee shop owner and chef. He lived alone in Flat 81, a one-bedroom flat on the east side of floor 11 of Grenfell Tower.222 He had been the tenant of Flat 81 since 1978 and very involved in his local community.223 Vulnerability 87.10 In a letter to RBKC dated 9 November 2016 the TMO stated that Abdeslam Sebbar was diabetic and frail, had difficulty using stairs and needed accommodation at ground level or with a lift.224 He appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system,225 but it contained no information about his physical limitations.226 218 Phase 1 Report Volume III paragraphs 19.18(b), 19.19(c), 19.19(d), 19.19(f), 19.22(b) and 19.29(b). 219 Phase 1 Report Volume III paragraphs 19.19(g) and 19.44; Barritt {MET000083284/5-6} pages 5-6. 220 Phase 1 Report Volume III paragraphs 19.42–19.44. 221 Phase 1 Report Volume III paragraph 20.37. 222 Phase 1 Report Volume IV paragraph 32.301; Presentation relating to Abdeslam Sebbar {Day301/1:23}-{Day301/2:6}. 223 Sebbar {IWS00002375/1} page 1, paragraph 3; Presentation relating to Abdeslam Sebbar {Day301/2:3-18}. 224 Letter from TMO to RBKC dated 9 November 2016 {BSR00000108}. 225 Noble {Day119/77:17}-{Day119/82:5}. 226 Noble spreadsheet {TMO00862588}.

Part 9 | Chapter 87: Floor 11 33 Events of 14 June 2017 87.11 Abdeslam Sebbar returned home at approximately 00.23 on 14 June 2017 and did not leave again.227 He called the emergency services at 01.25, shortly after the fire reached the top of floor 11 at about 01.22.228 In that call, he reported a fire but did not say where he was.229 87.12 Abdeslam Sebbar also called his son, Mohamed Sebbar, who, having learned of the fire, was driving to the tower with his own son, Youness Sebbar.230 Mohamed Sebbar tried to reassure his father and told him to leave, although he believed his father would need help to do so. They were still speaking to each other when Mohamed Sebbar reached the tower at around 01.30.231 87.13 At 01.33, Abdeslam Sebbar made a second call to the emergency services which was the last direct contact he had with them. Before disconnecting the call, he reported that he was on floor 11 and that the fire was in his flat. He did not give the number of his flat.232 By that time the fire had not penetrated Flat 81, but was established in the adjacent flat, Flat 86. As Natasha Elcock reported in the emergency call she made at the same time, smoke had by then reached the lobby of floor 11.233 87.14 Having reached the tower, Mohamed Sebbar spoke to his father twice more, the first time between 01.45 and 02.30.234 At 02.46, Youness Sebbar made a call to the emergency services which was connected to Merseyside Fire and Rescue Service. He said that his grandfather was stuck in Flat 81 and had stopped talking and that help was needed urgently. That information was passed on to the LFB in a call timed at 02.47.235 The Phase 1 report concluded that Abdeslam Sebbar stopped responding to his family shortly before 02.46.236 However, in a statement dated 20 May 2022, Mohammed Sebbar recalled that his last call with his father had taken place after Youness Sebbar had made an emergency call at about 02.46. In that last call, Abdeslam Sebbar was sheltering in the lavatory of Flat 81 and was struggling to breathe. The call continued until approximately 03.30 when Abdeslam Sebbar stopped responding.237 87.15 Youness Sebbar made a second emergency call at 04.39 that was taken by CRO Pamela Jones, in which he asked if there was any information about his grandfather. Youness Sebbar gave the number of his grandfather’s flat and asked if it could be checked. He also asked where casualties were being taken. CRO Jones was not able to provide any information.238 227 O’Riordan {MET00013136/4} page 4. 228 Phase 1 Report Volume II paragraph 10.116. 229 Phase 1 Report Volume II paragraph 10.91; Phase 1 Report Volume III paragraph 15.117. 230 Phase 1 Report Volume II paragraph 11.107. 231 Phase 1 Report Volume II paragraph 11.107. 232 Phase 1 Report Volume III paragraph 15.117; 999 call transcript {LFB00000312}. 233 Phase 1 Report Volume II paragraphs 10.116, 10.204-10.206 and 11.102-11.105. 234 Sebbar {IWS00002375/2} page 2, paragraph 7. 235 Phase 1 Report Volume III paragraph 15.119; 999 call transcript {INQ00000532}. 236 Phase 1 Report Volume III paragraph 15.119. 237 Sebbar {IWS00002375/2} page 2, paragraph 8. 238 Phase 1 Report Volume III paragraph 19.72.

The Grenfell Tower Inquiry: Phase 2 Report 34 Information to the incident ground 87.16 Two of the emergency calls made by or about Abdeslam Sebbar (his own call at 01.33 and that of his grandson at 02.46) included information about his location and the fact that he was still in his flat. However, information about Abdeslam Sebbar did not reach the incident ground until 03.00: a. Although Natasha Elcock’s first two emergency calls at 01.28 and 01.33 prompted service requests relating to Flat 82,239 none was generated in response to the calls relating to Abdeslam Sebbar. b. Flat 81 was not listed on the whiteboards which SM Jason Oliff was using between about 02.33 and 06.41 to collate information to pass from the LFB control room to the command units, although information relating to Flats 82 and 83 was recorded.240 c. No information about Flat 81 appears on the white laminated sheet used in Command Unit 7 (CU7) to collate information about those needing to be rescued.241 d. WM Glynn Williams began recording information about people needing to be rescued on a wall of the ground floor lobby from 02.15. Nothing was recorded in relation to Flat 81.242 e. After the bridgehead had been moved from floor 3 to the ground floor at about 03.10,243 SM Gareth Cook photographed the wall on floor 3 where information about those needing to be rescued had been recorded. Although “11” had been written on the wall (denoting floor 11), nothing else had been recorded.244 87.17 From about 03.00, CU7 moved to recording information on a whiteboard using a grid system.245 Photographs of that whiteboard,246 taken much later, show that the following had been entered on the grid: “81 1 1 P” with the first “1” in green indicating an adult, the second “1” in black indicating a child, and the “P” in red and circled, indicating a priority.247 A red tick was used on the grid to indicate that a crew had been deployed. No red tick appeared in the entry. The mention of a child is an error but, in any event, we do not know when the entry was made or how the information reached CU7. It was probably sent after Youness Sebbar made his call at 02.46. 87.18 Once the bridgehead had been moved to the ground floor, information was recorded on a green wall at the bottom of the stairs.248 The inscription “BABY 81 82 83 84 – 11” appears in photographs of that wall taken by SM (now GM) Michael Mulholland at about 04.45.249 It is not clear when that information was put there. It may have been after 04.05 as one of the manuscripts notes delivered to WM Brien O’Keeffe by runners refers to “81 11” together with what appears to be a time stamp of “04.05”.250 239 LFB Short Incident Log Report {MET00013830/18}. 240 Phase 1 Report Volume III paragraphs 15.139-15.141 and 20.54 and Figures 15.8 and 15.9. 241 Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3. 242 Phase 1 Report, Volume II paragraphs 14.103-14.105 and Figure 14.5; Photographs of ground floor wall {MET00005774} and {MET00005776}. 243 Phase 1 Report Volume III paragraph 17.11; Phase 1 Report Volume IV paragraph 28.86. 244 Cook Exhibit GAC/2 - Grenfell Tower statement notes {MET00015779/16} page 16; Phase 1 Report Volume II Figure 15.7. 245 Phase 1 Report Volume III paragraphs 15.13 and 16.12. 246 Phase 1 Report Volume III Figure 16.5; Photograph of whiteboard {MET00015924}. 247 Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. 248 Phase 1 Report Volume IV paragraph 28.87. 249 Mulholland Exhibit MBM/02 - Photograph of green wall {MET00018721}; Mulholland Exhibit MBM/02 -Photograph of green wall {MET00018731}. 250 O’Keeffe {MET00013967/15} page 15; O’Keeffe notes {LFB00001929/1} page 1.

Part 9 | Chapter 87: Floor 11 35 Recovery and identification 87.19 The remains of Abdeslam Sebbar were recovered from the bathroom of Flat 81.251 The coroner, Professor Wilcox, was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.252 Cause and time of death 87.20 The post-mortem on Abdeslam Sebbar found soot in his airways and no clear evidence of burns or trauma before death.253 The level of carboxyhaemoglobin in his blood was 90%,254 indicating that he must have inhaled a considerable amount of carbon monoxide before he died. Later analysis of the same blood sample detected cyanide at a level of 0.17 milligrams/litre.255 That is only slightly elevated compared to naturally occurring levels, probably as a consequence of degradation of the sample over time.256 While the level of cyanide in his blood at the time of death is therefore unknown, its presence shows that he had been exposed to hydrogen cyanide before he died. 87.21 The post-mortem recorded the medical cause of death as “inhalation of fire fumes” but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”. 87.22 By 02.46, Abdeslam Sebbar had been sheltering in the bathroom for some time. Its location meant that it was one of the last parts of the flat to be affected by internal fires. While that afforded Abdeslam Sebbar some protection, he was still exposed to asphyxiant gases entering the flat from the lobby and the outside. By 02.53 the fire had reached the outside of Flat 81.257 Flames could be seen inside the windows of Flat 81 from about 03.45.258 87.23 Mohamed Sebbar’s evidence about the last time he spoke to his father was not available when Professor Purser was preparing his report. However, the evidence did not affect his conclusion that Abdeslam Sebbar died from the inhalation of asphyxiant gases. Professor Purser estimated that Abdeslam Sebbar died within 20 to 30 minutes of losing consciousness.259 87.24 In the light of Mohamed Sebbar’s evidence, Professor Purser’s evidence of the effect of asphyxiant gases and the post-mortem evidence, we find that Abdeslam Sebbar lost consciousness at about 03.30 due to the inhalation of asphyxiant gases. He continued to inhale those gases until his respiration and circulation ceased some minutes later and he died before any flames reached his body. Although he must have inhaled hydrogen cyanide, the level of carboxyhaemoglobin in his blood was such that his exposure to carbon monoxide alone would have been fatal. Abdeslam Sebbar died between 03.50 and 04.05. 251 Purser, Phase 2 Report, Section 6 {DAPR0000006/159} paragraph 877. 252 Interim certificate of the fact of death for Abdeslam Sebbar {MET00065630}. 253 Sebbar post-mortem report {COR00000009/10} page 10; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/119} Table 17. 254 Sebbar first toxicology report {COR00000020/1} page 1; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/116} Table 16. 255 Sebbar second toxicology report {INQ00011094/1} page 1; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/116} Table 16. 256 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. 257 Phase 1 Report Volume III paragraph 16.3. 258 External Spread of Fire Report {MET00012593/78-79} Images 45-56 (applying a +58 minute correction to timestamps). 259 Purser {Day297/145:10}-{Day297/148:6}.

The Grenfell Tower Inquiry: Phase 2 Report 36

37 88.1 When the fire began, all the flats on floor 14 were occupied apart from Flat 114. Nina Mangoba and her family in Flat 116 were the first residents to leave. As the fire progressed the remaining residents were gathered in Flat 113, the home of Oluwaseun Talabi and Rosemary Oyewole. They were Denis Murphy from Flat 111, brothers Omar Alhaj Ali and Mohammad Alhajali from Flat 112 and Zainab Deen and her son, Jeremiah Deen, from Flat 115. Firefighters subsequently rescued Oluwaseun Talabi, Rosemary Oyewole and their daughter as well as Omar Alhaj Ali. Following that rescue, Mohammad Alhajali, Denis Murphy, Zainab and Jeremiah Deen remained in Flat 113. They died during the fire. 88.2 In Phase 1, the chairman made findings about the events on floor 14 and in Flat 113 in particular.260 He said that the circumstances under which four people, one a child, had been left behind in Flat 113 required a more detailed examination than could conveniently be carried out in the context of the narrative description of the events of 14 June 2017 and proposed to undertake that examination at a later date after further submissions and possibly additional evidence had been received.261 88.3 In the end it was not necessary to hear any further evidence. We have, however, been assisted by representations made on behalf of the family of Mohammad Alhajali, the family of Denis Murphy and the LFB, as well as by a further statement from FF Peter Herrera, one of the firefighters involved in the partial evacuation of Flat 113.262 88.4 Since they are of particular importance to understanding the circumstances of the individual deaths on floor 14, we set out first not only our general findings about the events that took place on that floor but also our findings on how four people came to be left behind in Flat 113. The arrival of the fire 88.5 By 01.23, the fire had spread up the eastern face of the tower and had reached the top of floor 15.263 Flat 116 was the first flat on floor 14 to be affected by the fire. When Nida Mangoba and her family left it, there was thick black smoke in the hallway but only light smoke in the lobby.264 In Phase 1, the chairman was unable to decide whether Nida Mangoba’s recollection that she had left the front door open was faulty or whether the door had closed sometime after she left; FFs Desmond Murphy and Charles Cornelius later found the front door closed.265 In any event, the front door did not impede the rapid ingress of smoke into the lobby. 260 Phase 1 Report Volume II paragraphs 14.109-14.111; Phase 1 Report Volume II paragraphs 14.195-14.206; Phase 1 Report Volume III paragraphs 15.91-15.95. 261 Phase 1 Report Volume III paragraph 15.96. 262 Herrera {LFB00032237}. 263 Phase 1 Report Volume II paragraph 10.118. 264 Phase 1 Report Volume II paragraphs 10.233-10.235. 265 Phase 1 Report Volume II paragraph 14.206. Chapter 88 Floor 14

The Grenfell Tower Inquiry: Phase 2 Report 38 88.6 According to Denis Murphy, who made an emergency call at 01.25 to report a fire in the tower, by then there was already significant smoke in the lobby.266 Oluwaseun Talabi and Rosemary Oyewole found the lobby filled with smoke when they tried to leave shortly before their first call to the emergency services at 01.37.267 The conditions in the lobby were such that those who remained on floor 14 after 01.30 felt unable to cross the lobby and reach the stairs.268 The first deployments to floor 14 88.7 By 01.45, Denis Murphy,269 Zainab Deen,270 and Rosemary Oyewole,271 had made six emergency calls of which four were to the LFB control room.272 At that stage Omar Alhaj Ali and Mohammad Alhajali in Flat 112 had not made any calls to the emergency services but had communicated to firefighters on the ground by shouting from the windows.273 88.8 As a result of emergency calls being made from floor 14, the incident ground was informed that there were occupants trapped on that floor, which probably prompted the following actions: a. At 01.35, having answered the call from Denis Murphy, OM Alexandra Norman in the LFB control room asked WM Daniel Meyrick in CU8 to arrange for crews to check on people trapped on different floors, including a person trapped in Flat 111 on floor 14.274 At 01.43, CRO Sharon Darby informed CU8 that smoke was coming into flats on floor 14, although she did not mention any particular flat.275 b. WM Meyrick passed the information he received to WM Mark Kentfield who was near the tower. WM Kentfield wrote it down on pieces of paper which he passed to SM Brett Loft. That included an A4 sheet of paper, which came to be known as the “Sadler envelope” and on which was written, “111, 115 14th FLOOR”. SM Loft passed the information he received to the bridgehead on floor 2, probably by radio.276 c. At the bridgehead information was recorded on a wall and, from some time after 01.50, on a forward information board.277 Although no written record was made of Flats 111 or 115, it is likely that a message about Flat 111 was received from SM Loft, since two teams of firefighters were deployed to that flat, although none were sent to Flat 115. 88.9 FFs Desmond Murphy and Charles Cornelius were sent to Flat 111 on floor 14 to rescue a man. They tallied out at 01.51.278 At about the same time, FFs Harvey Sanders and Nicke Merrion were also sent to floor 14. FF Sanders recalled that they had been sent 266 Phase 1 Report Volume II paragraph 10.236. 267 Phase 1 Report Volume II paragraphs 11.91-11.92. 268 Phase 1 Report Volume II paragraphs 11.90-11.96 and 14.195; Phase 1 Report Volume IV paragraphs 25.10 (b) and 25.11 (b). 269 Phase 1 Report Volume II paragraphs 10.236 and 11.89. 270 Phase 1 Report Volume II paragraphs 10.237, 11.93, 12.58 and 12.96. 271 Phase 1 Report Volume II paragraphs 11.90-11.92. 272 Phase 1 Report Volume II paragraph 14.195. 273 Alhaj Ali {IWS00000781/6} page 6, paragraph 17. 274 Phase 1 Report Volume II paragraph 11.149. 275 Phase 1 Report Volume II paragraph 12.73 (d). 276 Phase 1 Report Volume II paragraphs 11.5-11.6, 12.18-12.19 and Figure 12.4. 277 Phase 1 Report Volume IV paragraph 28.84 (b); Phase 1 Report Volume II paragraphs 13.52-13.53 and Figures 14.4 and 13.2. 278 Phase 1 Report Volume II paragraph 13.7.

Part 9 | Chapter 88: Floor 14 39 specifically to Flat 111, but FF Merrion could not recall whether they had been sent to Flat 111 or Flat 112. FF Merrion recalled that he had been instructed to tell the occupants to remain in their flat.279 88.10 FFs Murphy and Cornelius arrived on floor 14 first. They found Denis Murphy in Flat 111 which was quite heavily smoke-logged.280 FFs Sanders and Merrion arrived on floor 14 soon afterwards. FF Merrion went to Flat 112, where he spoke to Omar Alhaj Ali and his brother, while FF Sanders went to Flat 113, where he met Rosemary Oyewole and Oluwaseun Talabi with their daughter. Those two flats were relatively clear of smoke.281 88.11 Denis Murphy was moved initially to Flat 112.282 The four firefighters met in the lobby and agreed to move all the occupants remaining on floor 14 to Flat 113, which was furthest from the fire.283 Rosemary Oyewole and Oluwaseun Talabi agreed to their request to bring their neighbours into their flat.284 88.12 Flat 113 was a two-bedroom flat in the southwest corner of the tower.285 FF Murphy was one of the firefighters who went into the flat. Before leaving it, he counted six adults and two children. He told them that the crew were low on air and were going to change their cylinders. Although the residents wanted to leave, FF Murphy told them to stay in the flat with the door shut and that another crew would come up to them.286 88.13 The firefighters’ decision to move all the occupants into one flat arose from their belief that conditions in the stairwell made it impossible for eight people to leave safely,287 their view that Flat 113 was the safest place for them to be288 and their concerns about how much air was left to them.289 Although it was in the stairs that people escaping from floor 14 were most exposed to asphyxiant gases, those who had absorbed only a minimal amount of carbon monoxide in their flats and the lobbies before entering them could at all times survive the descent.290 Since people were inhaling an increasing amount of asphyxiant gases while in their flats, the longer they remained in them, the greater the danger of their accumulating an amount sufficient to cause collapse and death.291 We note that some of the occupants of Flat 113 were later able safely to evacuate floor 14 without the assistance of any specialist equipment at a time when conditions were described by Rosemary Oyewole as significantly worse.292 Although we accept that it might have been possible for the occupants of floor 14 to have escaped safely at that time, we do not consider that the decision made by FFs Merrion, Sanders, Murphy and Cornelius can be criticised, given the circumstances confronting them. 88.14 Some time after the firefighters left floor 14, another crew of firefighters visited Flat 113 by chance. They were FFs Luke Cook and Brian Flanagan, who went to Flat 113 between 02.03 and 02.37, probably at around 02.20. They noted that the flat contained eight 279 Phase 1 Report Volume II paragraphs 13.11-13.12. 280 Phase 1 Report Volume II paragraph 13.8. 281 Phase 1 Report Volume II paragraphs 14.197 and 14.200. 282 Phase 1 Report Volume II paragraphs 13.9 and 14.198. 283 Phase 1 Report Volume II paragraphs 14.88-14.89 and 14.201-14.203. 284 Phase 1 Report Volume II paragraph 14.202. 285 External Spread of Fire Report {MET00012593/12}. 286 Phase 1 Report Volume II paragraphs 14.90 and 14.203. 287 Phase 1 Report Volume II paragraphs 13.9, 13.13, 13.64 and 14.90. 288 Merrion {MET000086060/8} page 8; Merrion {Day38/16:4-15}. 289 Desmond Murphy {Day38/46:2-7}. 290 Purser {Day296/217:19-22}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/7} paragraph 26. 291 Purser {Day297/7:18}-{Day296/8:2}. 292 Oyewole {Day58/75:5-13}.

The Grenfell Tower Inquiry: Phase 2 Report 40 people, including two children. They left the residents in the flat and returned to the bridgehead. There is no evidence that they reported the location those still on floor 14 to the bridgehead.293 The second deployments to floor 14 88.15 On returning from floor 14, FFs Merrion, Sanders, Murphy and Cornelius told the bridgehead that residents remained on that floor. a. FFs Merrion and Sanders probably reached the bridgehead first at around 02.15. Information appearing on both the forward information board and on a wall on floor 2294 supports the conclusion that they reported that eight people were in Flat 113 on floor 14. b. FFs Murphy and Cornelius’ end of wear times were 02.19 and 02.18 respectively. They told WM Brien O’Keeffe, who was commanding the bridgehead on floor 3 after 02.17, that there were six adults and two children in Flat 113 in safe air, but that crews needed to go back up with second BA sets as the air was not safe for those residents to be brought down. A photograph of a wall on floor 3 shows that the words “113 8 PEOPLE” were written to the left of a sketch plan drawn on the wall.295 88.16 The LFB control room continued to pass information about floor 14 to the incident ground even after the first deployment of firefighters: a. At 01.48, it received a call from Surrey Police passing on information that Denis Murphy was trapped in Flat 111 on floor 14 and struggling to breathe. The information had come from Denis Murphy’s brother. CRO Christine Howson created a service request and CRO Darby passed the information to the incident ground at 01.53.296 b. At the same time, Zainab Deen, still in Flat 115, spoke to CRO Howson in the LFB control room. CRO Howson created a service request at 01.54 which led, a minute later, to CRO Darby passing on a message to CU8 about a woman with a baby in Flat 115, which was heavily smoke-logged.297 c. A note on a control information form identified both Flats 111 and 115 as priorities.298 It is difficult to track this through to the bridgehead but it may explain the deployment of FFs McAlonen and Juggins, at 02.31, to which we refer below. d. At 02.09, CRO Angie Gotts took a call from the police reporting that a woman was trapped with her son in Flat 115. That call was the outcome of contact between the police and Zainab Deen which had begun with her first call to the emergency services at 01.29. That call had been put through to the police but had ended abruptly. The police called her back at 02.01.299 It is difficult to track that information through to the bridgehead. 293 Phase 1 Report Volume II paragraph 14.111. 294 Phase 1 Report Volume II paragraphs 13.53, 14.73, and 14.110, Figures 13.2 and 14.4. 295 Phase 1 Report Volume II paragraph 14.110; Photograph of wall on floor 3 {MET00016948}. 296 Phase 1 Report Volume II paragraph 12.95. 297 Phase 1 Report Volume II paragraphs 12.58 and 12.96-12.97. 298 Control Information Form {LFB00001968/40}. 299 Phase 1 Report Volume II paragraphs 10.237 and 14.249; 999 call transcripts {LFB00000341}; {INQ00000270}.

Part 9 | Chapter 88: Floor 14 41 88.17 WM Glynn Williams began recording information on a ground floor wall of the tower at 02.15. He explained that he had written “FSG @2.15” on the wall and had then begun listing information immediately below that heading. (A second list was subsequently created on the wall to the left of the first.) The order in which he listed information initially matched that on the Sadler envelope and included Flats 111 and 115.300 That WM Williams was also receiving fresh information, however, is suggested by his having written “1xA 1xK” (for 1 adult and 1 kid) next to Flat 115.301 88.18 In any event, the information that had been received from returning fire fighters and from the control room prompted the deployment of two more crews to floor 14 within minutes of FFs Murphy and Cornelius reaching the bridgehead. 88.19 FFs Herrera and Teresa Orchard tallied out at 02.26 and 02.27 respectively with instructions from WM Louisa de Silvo to go to Flat 113. A sketch of what looks like a football in which is written “113, FL 14th” and “Lambeth PL” (for pump ladder) was made on the wall on floor 3. Although WM De Silvo said that it was not in her handwriting, it may have related to the deployment of FFs Herrera and Orchard, given that the former was based at Lambeth Fire Station.302 88.20 FF Herrera recalled having been told that a man, woman and child needed to be rescued. On the other hand, FF Orchard recalled that they had been instructed to rescue six people in Flat 113. Although in the Phase 1 report the chairman noted that it was unlikely that WM De Silvo had given two members of the same crew inconsistent instructions relating to the same flat, he was not able to find which account was correct.303 88.21 FF Herrera’s recollection of the briefing reflects the emergency call made by Rosemary Oyewole at 01.37. However, although she mentioned that she had a baby, she did not confirm how many people were in the flat.304 No other emergency calls were made from Flat 113 until after FFs Herrera and Orchard had set off. Although FF Orchard did not refer to six people in her contemporaneous note, we think that her recollection was more reliable on this point. It is closer in time to the earlier, but still recent, reports to the bridgehead provided by FF Merrion, Sanders, Murphy and Cornelius, even though the information about two children was lost. We find that it was those reports, and in particular the explicit reference of FFs Murphy and Cornelius to the need for crews to return to floor 14, that prompted the deployment of FFs Herrera and Orchard. It is possible, however, that some reference was made during the briefing to a family of three which, amid all the noise and activity at the bridgehead, FF Herrera mistook as his instructions. 88.22 CM Benjamin McAlonen and FF Elliot Juggins tallied out at 02.31 shortly after FFs Herrera and Orchard. They had been instructed by WM Paul Watson to find a woman and child in Flat 111 on floor 14.305 That is, we think, confirmed by the inscription on the wall of floor 3 which referred to Flat 111 and floor 14, together with the word “Lambeth”. Since both CM McAlonen and FF Juggins were based at Lambeth Fire Station, the note probably refers to their deployment.306 In our view, this briefing resulted from the information received 300 Phase 1 Report Volume II paragraphs 14.100-14.103 and Figure 14.5; Williams {Day31/100:8}-{Day31/101:10}. 301 Williams {Day31/113:3-5}; Phase 1 Report Volume II Figure 14.5. 302 Phase 1 Report Volume III paragraph 15.91; Photograph of wall on floor 3{MET00015819}; De Silvo {Day30/45:15-25}; Herrera {Day38/97:20-22}. 303 Phase 1 Report Volume III paragraph 15.91. 304 Phase 1 Report Volume II paragraph 11.92; 999 call transcript {LFB00000678}. 305 Phase 1 Report Volume III paragraph 15.92. 306 Photograph of wall on floor 3{MET00015819}; McAlonen {Day38/160:8-10}; Juggins {Day40/62:16-18}.

The Grenfell Tower Inquiry: Phase 2 Report 42 from the calls to the emergency services made at 01.48. It was wrong in that Zainab and Jeremiah Deen had been in Flat 115 and, more importantly, were by then in Flat 113 together with others. 88.23 The two crews were not aware that they were both being deployed to floor 14.307 The effect of the separate briefings was that only one crew (FFs Herrera and Orchard) was deployed to Flat 113 and without the spare BA sets that FF Cornelius had said were necessary. Neither member of that crew was aware that their task was to rescue eight people from Flat 113.308 The partial evacuation of Flat 113 88.24 CM McAlonen and FF Juggins reached floor 14 first. They searched Flat 111 before then searching Flat 112.309 CM McAlonen tried to make radio contact with the bridgehead to gain more information but could not get through. FF Orchard and FF Herrera had reached floor 14 by then and went to Flat 113.310 The two crews described the stairwell as being full of black smoke from the bridgehead up to floor 14 and the lobby on that floor to be smoke‑logged.311 Rosemary Oyewole and Oluwaseun Talabi said that when they left Flat 113, the lobby was full of acrid black smoke which made it difficult to breathe. The stairs were full of the same smoke but felt much hotter than the lobby. They ran down the stairwell and did not see any light until about floor 3.312 Omar Alhaj Ali recalled the lobby and stairwell being filled with hot smoke and without any visibility. He did not see any light in the stairwell until he reached floor 2 or 3.313 88.25 There was a conflict of evidence relating to much of what happened when the firefighters reached Flat 113, but the following is not disputed. First, the evidence from both firefighters and occupants shows that Rosemary Oyewole and Oluwaseun Talabi (with their daughter tied to his back) left Flat 113 first, followed by Omar Alhaj Ali.314 Second, FF Herrera was the only firefighter to enter Flat 113.315 Third, as the chairman found in the Phase 1 report, FF Herrera did not conduct a search or secondary sweep of Flat 113.316 Fourth, as we have already observed, four people did not leave Flat 113. 88.26 That four people were left behind is, on the face of it, an extraordinary state of affairs and makes it necessary to consider how it could have come about. We answer that question by reference to the evidence given by the firefighters and those who were present in Flat 113 at the time and survived the ordeal. In doing so we have considered the representations that we have already mentioned. 88.27 Unfortunately, the evidence bearing on the question is rather confusing. Rosemary Oyewole, Oluwaseun Talabi and Omar Alhaj Ali all gave evidence, as did FF Herrera and Orchard, but their accounts were difficult to reconcile with each other and in some cases were internally inconsistent. 307 Herrera {Day38/105:22-23}; Orchard {Day39/50:18-20}; McAlonen {Day38/167:11-14}; Juggins {Day40/65:18-21} 308 Phase 1 Report Volume III paragraph 15.91. 309 Phase 1 Report Volume III paragraph 15.93. 310 Phase 1 Report Volume III paragraph 15.94. 311 Herrera {Day38/106:13-19}; McAlonen {Day38/168:1-8}; Orchard {Day39/51:13-19}; {Day39/52:6-22}; Juggins {Day40/68:20}-{Day40/69:23}. 312 Oyewole {Day58/76:3}-{Day58/79:13}; Talabi {IWS00000851/14-15} pages 14-15, paragraphs 57-62. 313 Alhaj Ali {Day59/83:18}-{Day59/85:12}. 314 McAlonen {Day38/171:10}-{Day38/173:25}; Juggins {Day40/78:7}-{Day40/81:11}; Orchard {Day39/58:1-16}; Oyewole {Day58/73:24}-{Day58/74:11}; Talabi {Day59/148:6-18}; Alhaj Ali {Day 59/71:9-19}. 315 Orchard {Day39/57:9-11}; Herrera {Day38/110:9-12}; McAlonen {Day38/170:20-22}; Juggins {Day40/81:18-23}. 316 Phase 1 Report Volume III paragraph 15.96.

Part 9 | Chapter 88: Floor 14 43 88.28 Rosemary Oyewole said that when her neighbours from Flats 111, 112 and 115 had been brought into her flat they had dispersed around the various rooms, as might be expected. However, after having been advised by one of the firefighters who had returned to Flat 113 that they should all go into her bedroom (the larger bedroom opposite the front door) they had congregated in that room. The two children had been sitting on the bed, Denis Murphy on the side of the bed nearer the door and Zainab Deen on the floor near the door into the hall.317 88.29 Rosemary Oyewole said that at the time there had been some smoke in the flat, but not enough to reduce visibility to a significant extent.318 She said that after they had all gone into the bedroom she had kept the door closed in order to prevent smoke from coming into the room from the hall. Earlier, Oluwaseun Talabi had threatened to leave the flat by the bedroom window using an improvised rope made of bedsheets but had been dissuaded from doing so. As they waited to be rescued, however, they had become more desperate and, with the assistance of Omar Alhaj Ali and Mohammad Alhajali, Oluwaseun Talabi had begun to make a serious attempt to escape from the window with his daughter tied tightly to his back.319 At that stage, according to Rosemary Oyewole, the bedroom door flew open and she saw a firefighter (who must have been FF Herrera) standing by the front door.320 She rushed out of the room into the hall and out into the lobby, closely followed by Oluwaseun Talabi, who was still carrying their daughter on his back. She did not appear to have a clear recollection of having passed Denis Murphy or Zainab Deen, although she said that she must have done so; nor did she remember having said anything to the others in the room at that time.321 88.30 Oluwaseun Talabi recalled that when their neighbours had been brought into Flat 113 they had moved around quite a lot but had eventually all congregated in the larger bedroom.322 He said he remembered Mohammad Alhajali sitting on the side of the bed further from the door reading his Qur’an.323 As he was preparing to make a second attempt to leave from the window he had heard a knock at the front door. As he remembered it, the bedroom door had been open and he could see through to the front door. There was smoke in the flat, but visibility was reasonable.324 He was asked by counsel to confirm that everyone had been in the bedroom at that point. He was clear that Zainab and Jeremiah Deen had been there and also Denis Murphy, as well as himself and Rosemary Oyewole, but he was unsure whether Omar Alhaj Ali and Mohammad Alhajali had also been there or whether they had been elsewhere in the flat. He thought that if the bedroom door had been open it would have been possible to see Denis Murphy and Jeremiah Deen from the hallway.325 88.31 Oluwaseun Talabi thought that the firefighter who had come to the door had not come far into the flat; indeed, he thought that he had scarcely crossed the threshold. Everything happened very quickly. He and Rosemary Oyewole had left the flat hand in hand with their daughter still tied to his back. He did not remember whether any of his neighbours had been ahead of him, or indeed what they had done. Again, he was not sure whether Omar Alhaj Ali and Mohammad Alhajali had been in the bedroom at that critical point.326 317 Oyewole {IWS00000852/9-11} pages 9-11, paragraphs 31-43; Oyewole {Day58/45:12}-{Day58/52:7}; {Day58/69:23}-{Day58/70:20}. 318 Oyewole {Day58/48:4-8}; {Day58/59:4-22}. 319 Oyewole {Day58/55:15}-{Day58/56:11}; {Day58/57:13}-{Day58/58:23}; {Day58/60:9}-{Day58/65:1}. 320 Oyewole {Day58/67:3}-{Day58/69:22}; {Day58/85:23}-{Day58/86:20}. 321 Oyewole {Day58/72:7-21}; {Day58/73:22}-{Day58/75:23}; {Day58/88:3}-{Day58/89:9}. 322 Talabi {Day59/127:9}-{Day59/128:19}. 323 Talabi {Day59/132:8-11}. 324 Talabi {Day59/137:6}-{Day59/138:21}. 325 Talabi {Day59/139:2}-{Day59/140:23}. 326 Talabi {Day59/141:2}- {Day59/143:25}.

The Grenfell Tower Inquiry: Phase 2 Report 44 88.32 Omar Alhaj Ali recalled that when they had been moved into Flat 113, they had all initially gathered in the lounge.327 He remembered Oluwaseun Talabi’s first attempt to leave by way of the window, but was not sure whether that had been the window in the bedroom or the window in the lounge.328 He remembered that they had all gathered in the bedroom, but that it had seemed quite small and that he and his brother had walked around at times.329 He described smoke coming under the front door and getting thicker in the hallway. Visibility, as he recalled, had reduced significantly.330 He was not sure whether he had been in the bedroom when the firefighters came to rescue them, because people had been moving around in the flat. He said that when the firefighter opened the front door he had seen Oluwaseun Talabi run towards it, so he had followed him. He initially said that he thought Mohammed might have been in the lounge at that time, but later said that he thought he had been with everyone else in the bedroom. When the door was opened, thick black smoke had come into the flat making it difficult to see. He was not very sure whether he himself had been in the bedroom or the living room when the firefighter had opened the door, but he had followed Oluwaseun Talabi; everyone else, including Mohammed, had been behind him. Just before that he had been talking to Mohammed, who had been standing close to him. He did not remember any firefighter going into the bedroom or the lounge and was adamant that he had not had any conversation with FF Herrera. He just remembered being bundled out of the flat and across the lobby. 331 88.33 When he had left the building, Omar Alhaj Ali looked for his brother and, realising that he might still be inside the tower, telephoned him. He told firefighters that Mohammed was still in Flat 113 with two other adults and a child332 but denied, as FF Herrera recalled, ever having used words to the effect that he had been mistaken.333 88.34 FF Herrera said that, when he had been briefed by WM De Silvo, he had not been told to search the flat; simply that there were three people there waiting to be rescued, so he had expected them to be ready to leave as soon as he arrived.334 As explained above, we consider it more likely that WM De Silvo’s briefing had reflected the information most recently received at the bridgehead. 88.35 FF Herrera said that he had banged on the door of Flat 113 and had shouted to those inside that they were the fire brigade and had come to take them down. He recalled that the occupants had at first appeared reluctant to open the door, perhaps because inside they were in clean, safe air, but that once they had opened the door a little he had been able to push his way in.335 Although he said that at first he had gone only into the hall, he said that he had then gone as far as the living room. That might suggest that he had gone into the main reception room (at no point did he suggest that he had gone into a bedroom), but when asked whether he had formed an impression of the number of people there he said that there had been four, two men, one woman and a child.336 327 Alhaj Ali {Day59/42:8-14}. 328 Alhaj Ali {Day59/47:6}-{Day59/49:6}. 329 Alhaj Ali {Day59/60:18}-{Day59/62:19}. 330 Alhaj Ali {Day59/58:17}-{Day59/59:17}; {Day59/67:15}-{Day59/68:22}. 331 Alhaj Ali {Day59/69:18}-{Day59/80:17}; {Day59/81:2}-{Day59/83:10}. 332 Alhaj Ali {Day59/85:18}-{Day59/93:5}. 333 Alhaj Ali {Day59/93:21}-{Day59/95:17}. 334 Herrera {Day38/102:22}-{Day38/103:11}; {Day38/120:16-20}; {Day38/128:21}-{Day38/129:7}. 335 Herrera {Day38/108:25}-{Day38/110:12}. 336 Herrera {Day38/109:7}-{Day38/112:6}.

Part 9 | Chapter 88: Floor 14 45 88.36 In his first statement FF Herrera had said that he had seen the silhouette of a man standing in the living room. He said that he had asked him whether there was anyone else in the flat, to which the reply had been “No, I am the last one”. FF Herrera said he had then taken him out into the lobby and towards the stairs. He said that he had not thought it necessary to search the flat because the man had been clear that there was no one else left in it. 337 88.37 FF Herrera recalled that having told WM De Silvo and WM Williams that Flat 113 was empty, he and the other firefighters left the tower and were approached by Omar Alhaj Ali who told him that his brother was still inside the building. As FF Herrera recalled it, Omar Alhaj Ali had said words to the effect that he had been mistaken, possibly implying that he had been wrong to say that there was no one else in the flat. As a result of that conversation FF Herrera returned to the ground floor lobby and told WM Williams that there was another person in Flat 113. He then went to the bridgehead where he also told WM De Silvo, but he did not know what she had done with the information.338 Another witness, Ammar Alkabib, who described himself as a friend of Omar Alhaj Ali and Mohammad Alhajali, provided a statement to the police, in which he said that he had been at the tower when Omar was brought out. He described Omar as asking in desperation where Mohammad was and saying, “It’s my mistake, it’s my mistake.”339 Omar Alhaj Ali denied, however, having said anything of the kind.340 88.38 It is difficult to know what to make of this rather confused body of evidence. We are entirely confident that the man with whom FF Herrera said that he had had a brief conversation inside Flat 113 must have been Omar Alhaj Ali, since he was the only person taken out in addition to Oluwaseun Talabi, Rosemary Oyewole and their daughter, but Omar Alhaj Ali firmly denied that words of any kind had passed between himself and FF Herrera. Although the witnesses gave different descriptions of the amount of smoke in the flat, we think that by the time FFs Herrera and Orchard arrived it had probably become dense enough to restrict visibility to a significant extent. The fact that FF Herrera said that he had seen the silhouette of a man, tends to suggest that that was the case. 88.39 Despite the clear evidence of Rosemary Oyewole that everyone in the flat was together in her bedroom when the firefighters arrived, we think that is unlikely to have been the case. The evidence of Rosemary Oyewole and Oluwaseun Talabi suggests that as soon as the front door had been opened and the bedroom door was at least ajar, they rushed out of the room to be met by FF Herrera. In doing so they may have inadvertently obstructed his view into the room. At that point FF Herrera, who had walked further into the flat than Oluwaseun Talabi remembered and had reached the hall, saw the silhouette of a man in the lounge which caught his attention. That is not something about which he could reasonably have been mistaken and we do not think he was making it up. The man he saw was Omar Alhaj Ali, who had moved out of the bedroom into the lounge. FF Herrera said that he had reached the point at which he could see into the lounge and Omar Alhaj Ali accepted that he and his brother had moved around the flat from time to time, although the evidence suggests that the others had not done so once they had been advised to stay in the bedroom. We think it likely that, after FF Herrera had entered the flat (allowing a cloud of dense smoke to enter the hallway), the door to Rosemary Oyewole’s bedroom remained partly closed, thereby obstructing his view of Denis Murphy and Jeremiah Deen, both of whom were sitting on the bed. It is difficult to know why he did not see Zainab Deen or Mohammad Alhajali; it may have been because she was sitting on the 337 Herrera {MET00010876/5} page 5; Herrera {Day38/112:7}-{Day38/114:22}. 338 Herrera {Day38/116:6-20}; {Day38/118:4}-{Day38/120:25}; {Day38/122:23}-{Day38/124:9}. 339 Alkabib {MET00021446/2} page 2. 340 Alhaj Ali {Day59/94:14-24}.

The Grenfell Tower Inquiry: Phase 2 Report 46 floor and he was sitting on the far side of the bed, or perhaps because of a combination of poor visibility and the speed at which events unfolded at that point. We say that because, if the door had been wide open and the room substantially free of smoke, it is difficult to see how FF Herrera could have failed to see them. 88.40 We do not think FF Herrera’s evidence that he had formed the impression that there were four people in the “sitting room” is reliable. His reference to two men, one woman and a child can in the circumstances only have been to Omar Alhaj Ali, Oluwaseun Talabi, Rosemary Oyewole and their daughter. He was plainly unaware, for whatever reason, of the presence of Mohammad Alhajali, Denis Murphy, Zainab Deen and Jeremiah Deen, but we think it is reasonably clear that they were all in the bedroom when he arrived. No one suggested that FF Herrera had gone into that room at any stage and, for the reasons we have given, we think it quite likely that his view of it was obstructed. 88.41 The sharpest conflict of evidence relates to the conversation which FF Herrera said he had had in Flat 113 with Omar Alhaj Ali. We think it very unlikely that Omar Alhaj Ali actually said that he was the last person in the flat, since, knowing that there were others, including his brother, in the bedroom, he had no reason at that stage to think that he was. On the other hand, we do not think that FF Herrera invented the conversation. One has to remember that things were happening very quickly in only moderate visibility and that FF Herrera had been expecting to find only three people. On finding a fourth, it would be natural to ask whether there was anyone else, but the question, spoken through the mask of a BA set, might have been misinterpreted as referring only to the lounge, in which there was indeed no one else. 88.42 Although the weight of the evidence suggests that when he had left the tower and realised that his brother had not escaped with him, Omar Alhaj Ali did say that it was his mistake, we do not think that much significance can be attached to that. When describing his escape from Flat 113 Omar Alhaj Ali said he had thought that his brother was behind him, but he did not remember what he had been doing. When saying that he had been mistaken, he may well have been referring to his assumption that Mohammed was following him out of the building and we think it likely that, having himself escaped, he felt responsible for the fact that Mohammad had not. We accept that FF Herrera was anxious to leave the flat as quickly as possible but, having discovered that it contained at least one more person than he had been led to expect, he should not have relied on what he understood to be an assurance that there was no one else there and should have looked in the other rooms. 88.43 We have reached these conclusions with varying degrees of confidence, but given the uncertainties inherent in the evidence, we think they provide the most likely explanation of what occurred. The third deployment to floor 14 88.44 Omar Alhaj Ali left the tower at 02.45 followed a minute later by Rosemary Oyewole, Oluwaseun Talabi and their daughter.341 CM McAlonen and FF Juggins followed them down.342 At the bridgehead on floor 3 CM McAlonen told WM De Silvo which flats he and FF Juggins had visited and reported that three people had been brought down but that they could not confirm that Flat 113 was clear. By then the following had been written on the wall on floor 3: “14, 111, 115, 112, 113”. WM Silvo put a tick through Flats 111, 112 341 Phase 1 Report Volume III Annex A. 342 McAlonen {Day38/171:10}-{Day38/172:23}; Juggins {Day40/78:7}-{Day40/79:11}.

Part 9 | Chapter 88: Floor 14 47 (which CM McAlonen and FF Juggins had visited) and 113, against which she wrote “3 rescues”.343 CM McAlonen only mentioned “3 rescues” because, as he explained, he had not seen Rosemary Oyewole and Oluwaseun Talabi’s daughter.344 88.45 FF Herrera told WM De Silvo that Flat 113 had been searched and was empty. He said the same to WM Williams who put a tick next to the flat number on the ground floor wall, indicating that it had been cleared.345 That may explain why “113/14” (with 113 circled and ticked) appears next to “3 rescues” on the wall.346 As recorded in the Phase 1 report, a circle indicated that further information had been received and a cross through the number of the flat indicated that it had been searched and a rescue carried out.347 It may also explain why a tick and “BA” (to show a crew had been deployed to and reached a flat) appears next to “113 14th” towards the bottom of the first list that WM Williams had made.348 88.46 We have mentioned that, on reaching the ground floor of the tower, Omar Alhaj Ali spoke to firefighters. The first of those conversations occurred even before FF Herrera spoke to WM Williams. Omar Alhaj Ali explained, by reference to a set of CCTV stills timed at 02.44, that he had been telling firefighters that other people remained in Flat 113, including his brother.349 One of those firefighters was WM Williams.350 That occupants still remained in Flat 113 was reinforced by FF Herrera’s return at 02.57351 following his conversation with Omar Alhaj Ali outside the tower. 88.47 The information now available at the bridgehead probably prompted the deployment of FFs Jon Wharnsby and Terence Lowe, a crew based at Shoreditch, who tallied out at 03.04 to go to Flat 113 on floor 14.352 The word “Shoreditch” appears just above “14 113” on the wall on floor 3, where the bridgehead was located up to about 03.10, which supports the conclusion that the entry relates to the deployment of that crew. However, the two firefighters did not reach floor 14. They encountered people in the stairwell whom they assisted down. FF Wharnsby recalled that by the time he and his colleague returned to the bridgehead it had moved to the ground floor. He said that he had made sure that others were aware that they had not completed their original task.353 Information to the incident ground after 03.00 88.48 Zainab Deen made two further emergency calls at 03.06 and 03.17, both of which were answered in the LFB control room.354 In the first, CRO Sarah Russell took care to confirm her location, which she gave as Flat 113 on floor 14. The call ended abruptly.355 In the first 343 McAlonen {Day38/166:8-11}; {Day38/174:2-12}; De Silvo Exhibit LDS/3 - Photograph of wall on floor 3 {MET00015819}. 344 McAlonen {Day38/173:9}. 345 Herrera {Day38/116:6-9}. 346 De Silvo Exhibit LDS/3 - Photograph of wall on floor 3 {MET00015819}. 347 Phase 1 Report Volume IV paragraph 28.86. 348 Williams {Day31/106:17}-{Day31/107:21}; Phase 1 Report Volume II Figure 14.5. 349 Alhaj Ali {Day59/85:24}-{Day59/90:17}. 350 CCTV Stills {INQ00000449}, {INQ00000450}, {INQ00000253}, Williams {Day31/140:18}. In each still, WM Williams is the firefighter without a helmet. 351 LFB Operational Response Report {LFB00119333/248}. 352 BA Telemetry data {LFB00023326}; Wharnsby {Day38/186:16}-{Day38/187:13}. 353 Wharnsby {Day38/188:19}-{Day38/189:3}; {Day38/191:18}-{Day38/197:4}. 354 Phase 1 Report Volume III paragraphs 17.93 and 17.94. 355 999 call transcript {LFB00000405}.

The Grenfell Tower Inquiry: Phase 2 Report 48 call Zainab Deen did not say how many people were in Flat 113, but in the second she said that she was there with her baby. She did not mention anyone else.356 That this information reached the incident ground is apparent from the following: a. A reference to Flat 113 appears on the second of two whiteboards used by SM Jason Oliff to collate information to pass from the control room to the command units. The entry includes the following: “Inside can’t leave phone went dead.”.357 b. A control information form on which is written “Flat 113, line gone dead” and “call from CU”. The form is marked priority and timed at 3.21.358 c. The first entry in the second list created by WM Williams on the ground floor wall concerns Flat 113 and has “line dead” written next to it.359 88.49 From about that time, friends of Zainab Deen and Mohammed Alhajali, who were in contact with them by telephone, approached police officers and firefighters with information as follows: a. Mahmoud Al-Karad, a friend of Omar Alhaj Ali and his brother who also lived in Flat 112, spoke to Mohammad Alhajali by telephone several times during the fire. Their last call was at 03.19 during which Mohammad Alhajali said that there had been eight people in Flat 113 and now there were only four. Mahmoud Al-Karad passed that information on to the police at the scene and was told that the control room would be informed.360 Whether it was passed on is uncertain but we observe that among the material found in CU7 was a note from the police recording that four people were in Flat 112 and four in Flat 113.361 That was wrong in part, because there were never four people trapped in Flat 112, but it is possible that the information provided by Mahmoud Al-Karad became confused at some point in transmission. It may also explain a note on the ground floor wall used by WM Williams to record information later in the night that eight people were trapped in Flat 112.362 b. Francis Dean, a friend of Zainab Deen, began his last call with her at 03.34.363 During that call, Francis Dean passed the telephone to CM Christopher Batcheldor, who then continued to speak to Zainab Deen for over an hour. He gave her location to WM Thomas Furnell who was organising FSG information. WM Furnell confirmed that he was already aware of Zainab Deen.364 CM Batcheldor subsequently took a note on which Francis Dean had written his name and telephone number and the names and ages of Zainab and Jeremiah Deen to CU7.365 88.50 In the Phase 1 report the chairman found that CM Mayne and FF Lundquist, a crew wearing extended duration breathing apparatus, were deployed as a result of FF Herrera’s report to the bridgehead that he had apparently not rescued all the occupants of Flat 113.366 356 999 call transcript {LFB00000418}. 357 Phase 1 Report Volume III paragraphs 15.139-15.141 and Figures 15.8 and 15.9. 358 Control Information Form {LFB00001968/44}. 359 Phase 1 Report Volume II Figure 14.5; Williams {Day31/137:13}-{Day31/139:21}. WM Williams said that the note “BA” which appears next to”113” was not intended to be linked by an arrow to that flat but to Flat 123 which appears immediately next in the list. 360 Al-Karad {IWS00000821/8-9} pages 8-9, paragraph 35; Al-Karad Exhibit MAK2 – telephone log {IWS00000791}. 361 Metropolitan Police Memo {LFB00001968/26}. 362 Phase 1 Report Volume II Figure 14.5. 363 Zainab Deen call records. These records were not available to the Inquiry at the time of publication of the Phase 1 Report. 364 Phase 1 Report Volume III paragraphs 17.95-17.97; Furnell {Day40/5:8-14}; {Day40/6:7-20}; {Day40/8:20}. 365 Batcheldor {Day34/172:5}-{Day34/173:10}; Notebook entry {LFB00001968/17}. 366 Phase 1 Report Volume IV paragraph 28.114.

Part 9 | Chapter 88: Floor 14 49 However, having reviewed the evidence further, we now think it more likely that they were in fact deployed in response to the two emergency calls made by Zainab Deen after 03.00. They were instructed to go to Flat 113 on floor 14 and tallied out at 03.29.367 FF Lundquist recalled that the briefing was to rescue a mother and baby or small child. That must have been Zainab Deen and Jeremiah. When the crew reached the front of the queue of BA wearers at the bridgehead, however, their instructions were changed and they were redeployed to floors 3 and 4.368 As we have explained above, it is likely that the information FF Herrera gave to the bridgehead prompted the earlier deployment of FFs Wharnsby and Lowe at 03.04. The time of the deployment and the nature of the briefing approximate more closely to the contents of Zainab Deen’s calls than the information FF Herrera had given to the bridgehead. 88.51 Even without the additional information, the bridgehead was aware shortly after the partial evacuation of Flat 113 that people were still trapped there. The fire did not reach the exterior of the bedroom, where the occupants had sheltered, before 03.35.369 Even though conditions in the flat began to deteriorate rapidly thereafter,370 Zainab Deen and Mohammad Alhajali were still in contact with friends outside the tower. However, no more firefighter crews were able to reach Flat 113. Denis Murphy Date of birth: 10 October 1960 (56 years). Place of birth: Hammersmith, London. Gender:

Male. Occupation: Painter and Decorator. Usual address: Flat 111, floor 14, Grenfell Tower, London, W11. Place of death: Flat 113, floor 14, Grenfell Tower, London, W11. Time of death: Between 04.05 and 04.35 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 88.52 Born on 10 October 1960, Denis Murphy was 56 years old in June 2017. He was the eldest of four children in a close-knit family and had two brothers and a sister. Denis Murphy had first moved into Grenfell Tower in 1984 with his wife and was still living there when his son was born in 1989. He returned to the tower in 1997 after he and his wife separated amicably. Denis Murphy continued to live at Grenfell Tower for the next 20 years and lived alone in Flat 111. A painter and decorator by trade, he was not working at the time of the fire. His passion for sport was something he maintained throughout his life.371 367 Phase 1 Report Volume III paragraph 17.20 (d). 368 Phase 1 Report Volume III paragraph 17.20 (d). 369 Purser, Phase 2 Report, Section 6 {DAPR0000006/143} paragraph 769; External Fire Spread Report {MET00012593/78} image 42 (applying a +58 minute correction to timestamp). 370 Purser, Phase 2 Report, Section 6 {DAPR0000006/146-147} paragraph 793. 371 Phase 1 Report Volume IV paragraphs 32.285-32.291.

The Grenfell Tower Inquiry: Phase 2 Report 50 Vulnerability 88.53 Denis Murphy had emphysema.372 The spreadsheet produced on the night of the fire by David Noble based on information held on the TMO’s Capita Insight system373 identified Denis Murphy as a resident but not as having any particular vulnerability. Events of 14 June 2017 88.54 We have set out our general findings about the events on floor 14 above. We focus here on factual matters of specific relevance to the death of Denis Murphy. 88.55 Denis Murphy returned to Grenfell Tower during the afternoon of 13 June 2017.374 He did not leave after that. 88.56 As we have already observed, Flat 116 was the first flat on floor 14 to be affected by the spread of the fire up the tower. Flat 111 was on the east side of Grenfell Tower located between Flats 116 and 112375 and was close to the exterior fire once it reached Flat 116. When he made his first 999 call from floor 14 at 01.25, Denis Murphy told OM Norman that the fire was outside his window. There was no smoke in the flat although he could smell it. Later in the call Denis Murphy reported that smoke was entering the flat from the lobby. The amount of smoke in the lobby was sufficient to deter him from leaving.376 88.57 Denis Murphy then called his brother Timothy Murphy and left a message. Timothy returned the call at about 01.36. During the call he could hear a smoke alarm in the background. Denis Murphy was coughing and sounded distressed and in a state of panic. He opened the front door when his brother told him to leave but then told Timothy Murphy that it was pitch black in the lobby and that smoke was coming into the flat. Timothy told Denis that he would call the emergency services and to shelter in the bathroom.377 88.58 The conditions in Flat 111 deteriorated rapidly. When at 01.40, Denis Murphy spoke to CRO Howson in his second 999 call, he told her that his flat was full of smoke coming in from the windows and front door and that he was sheltering in the bathroom. CRO Howson advised him to block the bathroom door with towels and reassured him that firefighters were on their way.378 88.59 Having spoken to Surrey Police, Timothy Murphy rang Denis Murphy again and reassured him that help was on its way.379 Surrey Police spoke to the LFB control room at 01.48. They gave Denis Murphy’s name and location and said that he was trapped in the bathroom and struggling to breathe.380 88.60 As we have explained earlier in this part of the report, these calls to the emergency services (together with calls from other occupants trapped on floor 14) led to the deployment of firefighter crews to that floor. 372 Murphy {IWS00001049/2} page 2, paragraph 4. 373 Noble {Day119/77:17}-{Day119/82:5}. 374 O’Riordan {MET00013136/2} page 2. 375 External Fire Spread Report {MET00012593/7}. 376 Phase 1 Report Volume II paragraphs 10.236 and 10.312. 377 Murphy {IWS00001049/2} page 2, paragraph 4. 378 Phase 1 Report Volume II paragraphs 11.89 and 12.70. 379 Murphy {IWS00001049/2} page 2, paragraph 6. 380 Phase 1 Report Volume II paragraph 12.95.

Part 9 | Chapter 88: Floor 14 51 88.61 FFs Murphy and Cornelius were the first crew to arrive on floor 14. They found Flat 111 to be heavily smoke logged. Denis Murphy was conscious but bent over and coughing with soot on his face. The firefighters immediately brought him into the lobby where the air was clearer. They decided not to escort him down the stairs, given the smoke conditions that they had encountered in the stairwell.381 Following the arrival of FFs Sanders and Merrion on floor 14, Denis Murphy was moved to Flat 112 where the air was clear. Omar Alhaj Ali recalled that he had been coughing and having difficulty breathing when he came into Flat 112.382 Subsequently, Denis Murphy was moved into Flat 113.383 88.62 Rosemary Oyewole did not recognise Denis Murphy when he first came into Flat 113; his face was covered in thick, black soot.384 While he was able to move without help, Denis Murphy was quiet and appeared to be in shock.385 Rosemary Oyewole helped him to wash his face and removed some of the soot from his eyes.386 She left him in the living room, but when another set of firefighters (FFs Cook and Flanagan) visited the flat and told them to stay in the bedroom, she and Oluwasean Talabi encouraged Denis Murphy to move there. When he did do so, Denis Murphy sat on the edge of the bed.387 88.63 Denis Murphy remained in contact with his family. Timothy Murphy and his partner, Angela, spoke to him several times during the fire, but he could not remember the precise times of those calls or what they had said. The last contact Denis Murphy had with his family was at about 02.30 when he spoke to his sister Anne Murphy and his son Peter Murphy. He told them that he was in a neighbour’s flat and that he was struggling with his breathing.388 Anne Murphy continued to call Denis Murphy’s telephone until 06.00 but received no answer.389 88.64 Although all those in Flat 113 were initially sheltering in different parts of it, most of them began to congregate in the bedroom facing the front door.390 We have set out above our analysis of their movements and how Denis Murphy came to be left behind during the partial evacuation which followed the deployment of CM McAlonen and FFs Juggins, Herrera and Orchard to floor 14. We conclude that the bridgehead was aware shortly after that partial evacuation that people remained trapped on floor 14. No other firefighters were able to reach that floor. 88.65 There was no direct contact with Denis Murphy after the partial evacuation. There is nothing in the 999 calls made by Zainab Deen at 03.06 and 03.17391 or from the longer call that she had with CM Batcheldor392 which offers any information about Denis Murphy. That call ended at 04.48.393 381 Phase 1 Report Volume II paragraphs 13.8-13.9. 382 Phase 1 Report Volume II paragraphs 14.198-14.199. 383 Phase 1 Report Volume II paragraphs 14.90 and 14.202. 384 Oyewole {IWS00000852/9} page 9, paragraph 34. 385 Oyewole {Day58/47:8-13}. 386 Oyewole {IWS00000852/10} page 10, paragraph 37; Talabi {Day59/127:17}–{Day59/128:8}. 387 Oyewole {IWS00000852/11} page 11, paragraph 42; Alhaj Ali {Day59/62:2-5}. 388 Phase 1 Report Volume III paragraph 19.40. 389 Phase 1 Report Volume III paragraph 19.40. 390 Phase 1 Report Volume II paragraph 14.206. 391 999 call transcript {LFB00000405}; 999 call transcript {LFB00000418}; Phase 1 Report Volume III paragraphs 17.93-17.94. 392 Phase 1 Report Volume III paragraphs 17.95-17.97. 393 Zainab Deen call records. These records were not available to the Inquiry at the time of completion of the Phase 1 Report.

The Grenfell Tower Inquiry: Phase 2 Report 52 88.66 Mohammad Alhajali’s friends and family gathered outside the tower and were able to reach him by telephone. His last conversation was with his brothers Omar and Hashem, during which Mohammad said that others in the flat were no longer responding to him. The precise time at which the call ended is uncertain. Hashem Alhajali thought that it had ended between 04.00 and 05.00, but Omar Alhaj Ali was taken to hospital at 04.26.394 A friend and flatmate, Mahmoud Al-Karad, was with Omar when he was speaking to Mohammad. Mahmoud Al-Karad was unable to reach Mohammad Alhajali after 04.26.395 A cousin, Aesem Alhajali, said that there came a time between 04.00 and 05.00 when no one was able to reach Mohammad Alhajali. It was as if his phone had been switched off. 396 In a 999 call at 05.05, Ammar Al Kabir, a cousin, said that he had last spoken to Mohammad Alhajali an hour earlier (evidence which we think is more reliable than his later recollection that the call had taken place at 04.30). In the circumstances, we conclude that the last contact with Mohammad Alhajali probably occurred at about 04.05. Following that contact, Mohammad Alhajali fell to his death from the tower. 88.67 The fire first reached the outside of the bedroom where those in Flat 113 had sheltered at about 03.33.397 If they had not already done so, it would have caused them to move into the living room, which, being the most south-westerly part of the flat, would have been furthest away from the approaching fire. The fire reached the south side of the living room at about 03.52 but the west side of the flat remained unaffected.398 The fire did not begin to affect the west side of the flat until sometime between 04.23 and 04.28.399 In calls with friends and family outside the tower, Mohammed Alhajali asked that firefighters continue directing water at the part of the tower where Flat 113 was located.400 From 03.28 a ground monitor was used to apply a jet of water to the south side of the tower although its reach varied.401 Recovery and identification 88.68 Denis Murphy’s remains were recovered from the kitchen area of Flat 113.402 The coroner was satisfied about the identification of those remains and so issued an interim certificate of the fact of death. Cause and time of death 88.69 The post-mortem report on Denis Murphy recorded the medical cause of death as “consistent with the effects of fire”, but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”. Toxicological testing was not possible. 88.70 We accept Professor Purser’s conclusion that Denis Murphy had suffered significant exposure to smoke by the time he was moved to Flat 113.403 In the time that he sheltered in Flat 113 he continued to be exposed to asphyxiant gases in the smoke coming into the 394 Hashem Alhajali {MET00007745/4} page 4; Phase 1 Report Volume III paragraphs 19.32-19.33 395 Phase 1 Report Volume III paragraph 19.34. 396 Aesem Alhajali {MET00039851/6} page 6. 397 Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} Images 41-42 (applying a +58 minute correction to timestamps). 398 Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} page 78, Image 47 (applying a +58 minute correction to timestamps). 399 External Spread of Fire Report {MET00012593/85} Images 44-47 (applying a +58 minute correction to timestamps). 400 Phase 1 Report Volume III paragraphs 17.88 and 19.35. 401 Stoianov, Chapter 5 {ISTRP00000006/141}, {ISTRP00000006/142}; {ISTRP00000006/148-153}. 402 Purser, Phase 2 Report, Section 6 {DAPR0000006/151} paragraph 826. 403 Purser, Phase 2 Report, Section 6 {DAPR0000006/139} paragraph 748.

Part 9 | Chapter 88: Floor 14 53 flat, particularly from the lobby. That exposure increased significantly with the arrival of the fire outside the bedroom where he was sheltering. Conditions in Flat 113 continued to worsen as the fire spread to the south side of the living room. 88.71 The location of Denis Murphy’s remains is consistent with his having moved from the bedroom once the fire had reached that point. Although we do not have a record of the level of carboxyhaemoglobin in his blood, we note that in a sample taken from Mohammad Alhajali it had reached the threshold lethal level of 50%.404 That supports our conclusion that the level of asphyxiant gases in Flat 113 after 03.33 was sufficient to cause Denis Murphy to lose consciousness. He continued to inhale those gases until his respiration and circulation ceased and he died at some time between 04.05 and 04.35. We are satisfied that Denis Murphy died before suffering any direct effects of fire. Zainab Deen Date of birth: 25 May 1985 (32 years). Place of birth: Freetown, Sierra Leone. Gender:

Female. Occupation: Unemployed. Usual address: Flat 115, floor 14, Grenfell Tower, London, W11. Place of death: Flat 113, floor 14, Grenfell Tower, London, W11. Time of death: 04.35 to 04.50 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Jeremiah Deen Date of birth: 4 December 2014 (2 years). Place of birth: London, UK. Gender:

Male. Occupation: N/A. Usual address: Flat 115, floor 14, Grenfell Tower, London, W11. Place of death: Flat 113, floor 14, Grenfell Tower, London, W11. Time of death: Between 03.30 and 04.00 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 88.72 Zainab Deen lived in Flat 115 with her son Jeremiah Deen. She was born on 25 May 1985 in Freetown, Sierra Leone and was 32 years old. She had moved to the UK at the age of 16. Jeremiah was born on 4 December 2014 in London. He was two and a half years old at the time of the fire and attending a local nursery.405 404 Purser, Phase 2 Report, Section 6 {DAPR0000006/154} paragraph 845. 405 Phase 1 Report Volume IV paragraphs 32.266-32.273.

The Grenfell Tower Inquiry: Phase 2 Report 54 Vulnerability 88.73 Zainab and Jeremiah Deen moved into Flat 115 in February 2015. When signing her tenancy agreement with RBKC Zainab Deen confirmed that she did not have a disability.406 The spreadsheet produced on the night of the fire by David Noble based on information held on the TMO’s Capita Insight system407 identified Zainab and Jeremiah Deen as residents. Jeremiah was identified as being under 18. Events of 14 June 2017 88.74 We have set out our general findings about the events on floor 14 above. We focus here on factual matters of specific relevance to the deaths of Zainab and Jeremiah Deen. 88.75 On 13 June 2017, Zainab Deen had had a successful job interview.408 She returned to the tower with Jeremiah and her friend, Francis Dean, between 21.30 and 22.00.409 Zainab and Jeremiah Deen were seen on CCTV in the lift lobby at 23.20 having come down with Francis Dean when he left the tower.410 88.76 Zainab Deen made her first call to the emergency services a few minutes after the fire had reached floor 14.411 Having been connected to the police control centre at 01.29, she reported that she was on floor 14 and had a baby with her. The call then disconnected.412 88.77 At 01.38, Zainab Deen spoke to CRO Yvonne Adams in the LFB control room. She sounded distressed. She was able to tell CRO Adams that smoke was coming into her flat through the door and windows. CRO Adams advised Zainab Deen to block up the doors and shut the windows, which she did. She was not able to confirm Zainab Deen’s location before the call ended abruptly.413 88.78 At 01.48, Zainab Deen spoke to CRO Christine Howson in the LFB control room and was able to say that she was in Flat 115 on floor 14 with her baby. There was now smoke throughout the flat. CRO Howson advised her that the flat was “the safest place” and to keep trying to stop smoke coming in. She told Zainab Deen that the fire was not on floor 14 and said that she would alert the firefighters who would come to her.414 88.79 As we have explained earlier in this part of the report, Zainab Deen’s calls to the emergency services (together with those from others trapped on floor 14) led to the deployment of firefighter crews to that floor, albeit none were sent specifically to Flat 115. 88.80 At 02.01 and before any firefighters had visited Flat 115 the police operator who had spoken to Zainab Deen at 01.29 called her back. Zainab Deen was very distressed. The operator advised her that the fire brigade was trying to evacuate everyone and asked whether she could go downstairs.415 At 02.12 the operator told the LFB control room that Zainab Deen and her son were trapped in Flat 115.416 406 Tenancy Agreement for Zainab Deen {TMOH00013271}. 407 Noble {Day119/77:17}-{Day119/82:5}. 408 Dean {IWS00001048/2} page 2, paragraph 10. 409 Dean {IWS00001048/3} page 3, paragraph 11. 410 O’Riordan {MET00013136/4} page 4; Dean {IWS00001048/3} page 3, paragraph 14. 411 Phase 1 Report Volume II paragraph 10.118. 412 Phase 1 Report Volume II paragraph 10.237; 999 call transcript {INQ00000270/3-4}. 413 999 call transcript {LFB00000321/7}. 414 Phase 1 Report Volume II paragraphs 12.58 and 12.96. 415 999 call transcript {INQ00000270/3-4}. 416 999 call transcript {LFB00000341}.

Part 9 | Chapter 88: Floor 14 55 88.81 FF Murphy recalled that, when they found Zainab Deen in Flat 115, she was very frightened and asked the firefighters not to leave her and her son alone.417 Others sheltering in Flat 113 describe her as panicking for much of the time she was there.418 Rosemary Oyewole carried Jeremiah Deen to the bedroom opposite the front door and put him on the bed with her own daughter.419 Once in Flat 113, Zainab Deen spent much of her time on the telephone.420 After she had moved to the bedroom opposite the front door she got up three or four times to open the door believing she could hear that help had arrived. Zainab Deen was very frightened and so Rosemary Oyewole had to be forceful when shouting at her to close the door. At that time, there was already smoke in the hallway of Flat 113.421 After that Zainab Deen remained sitting on the floor by the door to the bedroom.422 88.82 At 02.12, Zainab Deen made another 999 call. It could not be put through to the LFB control room and the operator was in the course of transferring it to North West Fire Control when it was abandoned.423 When that fire service called Zainab Deen back at 02.21, she gave her address as Flat 115 on floor 14, although she had by now been moved to Flat 113.424 Francis Dean also spoke to North West Fire Control at 02.17 and told them that a woman and her son (he described them as his sister and her son) were trapped in Flat 115 on floor 14.425 It does not appear that North West Fire Control passed the information from those calls to the LFB, but by then Zainab and Jeremiah Deen had already been moved to Flat 113. 88.83 Francis Dean had returned to the tower when Zainab Deen called him at 01.38 to tell him of the fire. They remained in contact, speaking again at 02.00 and 02.03, when she said she was now in Flat 113.426 As well as making calls to the emergency services, Francis Dean spoke to firefighters and police officers telling them that Zainab Deen and her son were still in the tower.427 88.84 While initially all those now sheltering in Flat 113 were in different parts of the flat, they began to congregate in the bedroom facing the front door.428 We have set out above our analysis of their various movements and how Zainab and Jeremiah Deen came to be left behind during the partial evacuation of Flat 113 which followed the deployment of CM McAlonen and FFs Juggins, Herrera and Orchard to floor 14. 88.85 Following that partial evacuation, Zainab Deen made two further 999 calls, both of which reached the LFB control room. At 03.06, Zainab Deen spoke to CRO Sarah Russell who was able to confirm that she was in Flat 113 on floor 14. It appears that Zainab Deen was still in the bedroom (she is heard to tell someone not to open the door). She also said that they were covered with smoke and that her baby was unconscious. When CRO Russell asked if they could leave, Zainab Deen replied: “No, we can’t leave. Nobody is coming for us.”429 At 03.17, Zainab Deen made her last 999 call. She told CRO Howson that she was in 417 Phase 1 Report Volume II paragraph 14.203. 418 Oyewole {Day58/46:16}; Omar Alhaj Ali {Day59/46:17-18}. 419 Oyewole {Day58/46:19-23}. 420 Oyewole {Day58/46:24}-{Day56/Day47:4}. 421 Oyewole {Day58/59:4-15}. 422 Oyewole {Day58/61:19-20}; {Day58/69:23}-{Day58/70:20}; {Day58/87:15}. 423 Phase 1 Report Volume II paragraph 14.255. 424 999 call transcript {MET00017520}. 425 999 call transcript {LFB00000694}. 426 Phase 1 Report Volume III paragraph 17.91. 427 Phase 1 Report Volume III paragraph 17.92. 428 Phase 1 Report Volume II paragraph 14.206. 429 Phase 1 Report Volume III paragraph 17.93.

The Grenfell Tower Inquiry: Phase 2 Report 56 Flat 113. CRO Howson advised her to cover herself with a towel and make her way down the stairwell. She told Zainab Deen to expect smoke in the stairwell. Zainab Deen appeared to agree to leave with Jeremiah.430 88.86 Those 999 calls led to the deployment of CM Mayne and FF Lundquist. However, no firefighter was able to reach floor 14 after the partial evacuation of Flat 113. 88.87 Zainab Deen’s final call to Francis Dean was the last contact with her. The call began at 03.34 and ended at 04.48.431 She told Francis Dean that Jeremiah had collapsed. Francis Dean tried to tell Zainab Deen to cover herself and her son in wet blankets and leave but she refused to do so because of the smoke.432 88.88 As the call continued, Francis Dean encountered CM Batcheldor and passed his telephone to him. CM Batcheldor remained on the call with Zainab Deen for what he estimated to be over an hour. Shortly after beginning to speak to her, CM Batcheldor gave her location to WM Furnell who confirmed he was already aware of a call from her. He did not know that firefighters had already been sent to Flat 113 but had then had their instructions changed before they set out.433 88.89 Zainab Deen told CM Batcheldor that she could not get out and that she had been told to stay in the flat, which he took to mean that the stay put policy was still in place. His view was that Zainab Deen was trapped in the flat. CM Batcheldor sought to reassure her and concentrated on keeping her safe by advising her to move to the least smoky room, to lie down on the floor and to cover Jeremiah’s face with a cloth. When their conversation began, Zainab Deen said there was smoke in the flat but made no mention of fire.434 88.90 When he first began speaking to Zainab Deen, CM Batcheldor was able to hear Jeremiah Deen in the background. About 35 minutes into the call, she told him that her son had died. At this point CM Batcheldor passed the phone to Francis Dean for a few seconds, asking him to encourage Zainab Deen not to give up.435 He returned to WM Furnell to ask what the position was and was told that firefighters could not get past floor 12.436 88.91 CM Batcheldor remained on the line speaking to Zainab Deen for about another 35 minutes. She was coughing and spluttering but became increasingly quiet. He could not hear anyone else in the background. There was silence for about five or 10 minutes before CM Batcheldor then heard her screaming before becoming silent again. After about another 10 minutes he believed Zainab Deen had died. He waited a few more minutes before disconnecting the call.437 88.92 CM Batcheldor did not tell Francis Dean that the line had gone silent, just that the battery had died. Francis Dean tried to call Zainab Deen again, but she did not answer.438 430 Phase 1 Report Volume III paragraph 17.94. 431 Zainab Deen call records. These records were not available to the Inquiry at the time of completion of the Phase 1 Report. 432 Phase 1 Report Volume III paragraphs 17.94-17.95. 433 Phase 1 Report Volume III paragraphs 17.96-17.97. 434 Batcheldor {Day34/162:3}-{Day34/164:20}. 435 Batcheldor {Day34/164:23}-{Day34/168:24}. 436 Batcheldor {Day34/168:24}-{Day34/169:22}. 437 Batcheldor {Day34/170:3}-{Day34/171:9}; Batcheldor {MET00007511/7} page 7. 438 Phase 1 Report Volume III paragraph 17.99.

Part 9 | Chapter 88: Floor 14 57 88.93 The fire first reached the outside of the bedroom where those in Flat 113 had sheltered at about 03.33.439 If they had not already done so, that would have caused them to move into the living room, which, being the most south-westerly part of Flat 113, was farthest from the approaching flames. The fire reached the south side of the living room at about 03.52 but the west side of the flat was not affected.440 It did not begin to affect the west side of the flat until sometime between 04.23 and 04.28.441 In calls with friends and family outside the tower, Mohammed Alhajali asked that firefighters continue to direct water at the part of the tower where Flat 113 was situated.442 From 03.28 a ground monitor was used to apply a jet of water to the south side of the tower although its reach varied.443 Recovery and identification 88.94 The remains of Zainab and Jeremiah Deen were recovered from the living room of Flat 113.444 The coroner was satisfied about the identification of those remains and so issued interim certificates of the fact of death for both Zainab Deen and her son.445 Cause and time of death 88.95 The post-mortem for Zainab Deen found evidence of soot inhalation. Analysis of a blood sample detected carboxyhaemoglobin but it was not possible to measure its concentration.446 The post-mortem for Jeremiah Deen found soot stained mucus in the respiratory system. Carboxyhaemoglobin was detected in a blood sample at a high concentration albeit the level could not be measured.447 88.96 In both cases, the examining pathologist was able to give the medical cause of death as “inhalation of fire fumes”. In light of more recent evidence, we find that a more precise description is “inhalation of asphyxiant gases”. 88.97 The exposure of Zainab and Jeremiah Deen to asphyxiant gases increased once the fire reached the west side of Flat 113 with the consequent deterioration of conditions inside. They and the other occupants were able, at least initially, to move to those parts of the flat which the fire had yet to reach. However, conditions worsened once the fire reached the south side of the flat. 88.98 During the call with CM Batcheldor, Zainab Deen was increasingly affected by the significant levels of toxic smoke permeating Flat 113 and as a result she struggled to respond to him. At a relatively late stage of the call Zainab Deen screamed out. We think that is more likely to have been because she realised that the fire was very close (and may even have begun to penetrate the flat) rather than because she was being directly affected by the fire itself. A significant period of time then elapsed (we think it could have been as much as 10 to 439 Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} page 78, Images 41-42 (applying a +58 minute correction to timestamps). 440 Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} Image 47 (applying a +58 minute correction to timestamps). 441 External Spread of Fire Report {MET00012593/85} Images 44-47 (applying a +58 minute correction to timestamps). 442 Phase 1 Report Volume III paragraphs 17.88 and 19.35. 443 Stoianov, Chapter 5 {ISTRP00000006/141}, {ISTRP00000006/142}; {ISTRP00000006/148-153}. 444 Purser, Phase 2 Report, Section 6 {DAPR0000006/152} paragraph 827. 445 Interim certificate of the fact of death for Zainab Deen {MET00065637}; Interim certificate of the fact of death for Jeremiah Deen {MET00065619}; 446 Zainab Deen post-mortem report {COR00001553}; Zainab Deen toxicology report {MET00039590}; Purser Phase 2 Report, Section 6 {DAPR0000006/152} paragraph 827. 447 Jeremiah Deen post-mortem report {COR00000735}; Jeremiah Deen toxicology report {MET00039530}; Purser Phase 2 Report, Section 6 {DAPR0000006/152} paragraph 828.

58 The Grenfell Tower Inquiry: Phase 2 Report 15 minutes) before CM Batcheldor disconnected the call, during which Zainab Deen made no response at all. We think that she died during that period, probably between 04.35 and 04.50. We are satisfied that Zainab Deen died before suffering the direct effects of fire. 88.99 The rate at which a child absorbs asphyxiant gases is roughly twice that of an adult,448 which supports our conclusion that Jeremiah died before his mother. He was already beginning to be unresponsive by 03.06 when she spoke to CRO Russell. In the light of CM Batcheldor’s evidence we conclude that Jeremiah Deen died at some time between 03.35 and 04.10. Like his mother he would have lost consciousness but continued to inhale asphyxiant gases until his respiration and circulation ceased and he died. Jeremiah Deen died before suffering the direct effects of fire. Mohammad Alhajali Date of birth: 27 November 1993 (23 years). Place of birth: Damascus, Syria. Gender:

Male. Occupation: Student. Usual address: Flat 112, floor 14, Grenfell Tower, London, W11. Place of death: Grenfell Tower, Grenfell Road, London, W11. Time of death: Between 04.30 and 04.56 on 14 June 2017. Cause of death: Multiple injuries consistent with a fall from height. Background and composition of household 88.100 Mohammad Alhajali was born on 27 November 1993 in Damascus, Syria. He grew up in Darra, a small city in the south of Syria, with his parents and four siblings. In 2014, he left Syria with his brother Omar and came to the United Kingdom. He remained in close contact with his family in Syria, speaking to them every day.449 88.101 In June 2017, Mohammad Alhajali was 23 years old. He was studying engineering at university and working part-time. He was engaged to be married and was looking forward to building a life for his family in the United Kingdom.450 88.102 Mohammad Alhajali lived in Flat 112 with his brother, Omar Alhaj Ali, and their childhood friend, Mahmoud Al-Karad.451 Vulnerability 88.103 Mohammad Alhajali did not have any known vulnerabilities. He was not recorded in the spreadsheet produced on the night of the fire by David Noble based on information held on the TMO’s Capita Insight system452 because he was a tenant of a private landlord. 448 Purser, Phase 2 Report, Section 6 {DAPR0000006/153} paragraph 834. 449 Phase 1 Report Volume IV paragraph 32.279. 450 Phase 1 Report Volume IV paragraph 32.281. 451 Phase 1 Report Volume IV paragraph 32.274. 452 Noble {Day119/77:17}-{Day119/82:5}.

Part 9 | Chapter 88: Floor 14 59 Events of 14 June 2017 88.104 We have set out our general findings about the events on floor 14 above. We concentrate here on factual matters of specific relevance to the death of Mohammad Alhajali. 88.105 On the evening of 13 June 2017, Omar Alhaj Ali and Mohammad Alhajali went to their cousins’ house to break the Ramadan fast together.453 They returned to the tower at around midnight.454 Mohammad Al-Karad was still at work.455 He returned after the fire had started. 88.106 The two brothers were alerted to the fire when they heard shouting outside and smelt smoke. The sight of flames at the level of floors 4 and 5 prompted them to leave. When they approached the front door of Flat 112, they saw smoke coming into the flat under the door. Finding the lobby dark and full of smoke, they decided not to leave. That was at about 01.30. The brothers then began to call for help from a window until a firefighter shouted back telling them to stay where they were.456 They continued calling for help and firefighters next to the main entrance told them to stop shouting and that they were coming up to help them.457 Given the absence at that time of information indicating that the occupants of Flat 112 needed to be rescued, it appears that the brothers’ calls for help did not result in a message being sent to the bridgehead. 88.107 The brothers opened their front door again at around 02.00 to see if it was now easier to leave. There was still smoke in the lobby with limited visibility. Flat 112 was still clear of smoke and they remained in the flat.458 88.108 We have described how calls to the emergency services made by those trapped on floor 14 led to the deployment of FFs Merrion and Sanders and FFs Cornelius and Murphy to that floor. When FF Merrion entered Flat 112, the brothers pleaded with him to take them out but he told them to remain in the flat.459 Subsequently, they agreed to a request from FF Murphy to be allowed to move Denis Murphy into Flat 112, which had clean air.460 At that time the visibility in the lobby had improved to the point at which Omar Alhaj Ali was able to make out firefighters there.461 The firefighters then returned and moved Omar Alhaj Ali, Mohammad Alhajali and Denis Murphy from Flat 112 and Zainab Deen and Jeremiah Deen from Flat 115 to Flat 113.462 Omar Alhaj Ali recalled that at that time the smoke in the lobby was not as thick as before.463 For the reasons we have already given we conclude that no criticism can be made of the decision not to evacuate those on floor 14 at that time. 88.109 Although all those sheltering in Flat 113 were initially in different parts of the flat, most of them eventually congregated in the bedroom facing the front door.464 We have set out above our analysis of their various movements and how Mohammed Alhajali came to be left behind during the partial evacuation of Flat 113, following the deployment of 453 Alhaj Ali {IWS00000781/4} page 4, paragraph 12. 454 Mohammad Alhajali appears on CCTV returning to the tower at 00.07. O’Riordan {MET00013136/4}. 455 Phase 1 Report Volume II paragraph 11.94. 456 Phase 1 Report Volume II paragraphs 11.94 - 11.96. 457 Alhaj Ali {IWS00000781/7} page 7, paragraph 20. 458 Phase 1 Report Volume II paragraphs 14.196 - 14.197. 459 Phase 1 Report Volume II paragraphs 13.12 and 14.197. 460 Phase 1 Report Volume II paragraphs 13.9-13.10 and 14.198. 461 Phase 1 Report Volume II paragraph 14.199. 462 Phase 1 Report Volume II paragraph 14.88. 463 Phase 1 Report Volume II paragraph 14.202. 464 Phase 1 Report Volume II paragraph 14.206.

The Grenfell Tower Inquiry: Phase 2 Report 60 CM McAlonen and FFs Juggins, Herrera and Orchard to floor 14. We have also concluded that the bridgehead was aware shortly after the partial evacuation that people remained trapped on floor 14. However, no other firefighters were able to reach that floor. 88.110 Gathered outside the tower, Mohammad Alhajali’s friends and relations were in contact with him by telephone. Mahmoud Al Karad’s last conversation with Mohammad Alhajali was at 03.19. He told Mahmoud Al-Karad that he could not leave because he was with a mother and child. (He did not mention Denis Murphy.)465 His last conversation was with his brothers Omar and Hashem. In that call Mohammad said that the others in the flat were no longer responding to him. The evidence of the precise time at which the call ended is uncertain. Hashem Alhajali estimated that it ended between 04.00 and 05.00, but Omar Alhaj Ali was taken to hospital at 04.26.466 Mahmoud Al-Karad was with Omar when he was speaking to Mohammad. He was unable to reach Mohammad Alhajali after 04.26.467 A cousin, Aesem Alhajali, said that no one was able to reach Mohammad Alhajali after some time between 04.00 and 05.00.468 In a call to the emergency services at 05.05, Ammar Al Kabir, a cousin, said that he had last spoken to Mohammad Alhajali an hour earlier (evidence which we think is more reliable than his later recollection that the call had taken place at 04.30). In the circumstances, we conclude that the last contact with Mohammad Alhajali probably occurred at about 04.05. 88.111 Following that contact, Mohammad Alhajali fell to his death from the tower. His body was found by WM Steven Collins469 by the gate on the elevated walkway leading to Grenfell Tower from Grenfell Walk and at the base of a 13.5 metre ladder. The ladder was not in use at the time but was leaning against the south face of the tower. The body of Mohammad Alhajali was covered in debris suggesting that he had fallen some time before his body was found. Together with CM Jamal Stern and FF William Murphy, WM Collins moved the body to a protected area inside the lobby of one of the walkways. No sign of life was found, and WM Collins then assigned another firefighter to locate a paramedic.470 That paramedic pronounced life extinct at 04.56.471 88.112 The coroner, Professor Wilcox, subsequently issued an interim certificate of the fact of death for Mohammad Alhajali.472 Cause and time of death 88.113 The post-mortem for Mohammad Alhajali recorded injuries consistent with a fall from a height. The injuries were such that there would have been a near-instantaneous collapse and loss of consciousness with no protracted suffering. There were no signs of burns to the skin or airways were recorded. Soot deposits were found in the respiratory system, consistent with the inhalation of fire fumes. The level of carboxyhaemoglobin in a blood sample was found to be 50%, which confirms that Mohammad Alhajali had 465 Phase 1 Report Volume III paragraph 17.88. 466 Hashem Alhajali {MET00007745/4} page 4; Phase 1 Report Volume III paragraphs 19.32-19.33. 467 Phase 1 Report Volume III paragraph 19.34. 468 Aesem Alhajali {MET00039851/6} page 6. 469 Collins {MET00010086/5} page 5. 470 Collins {MET00010086/10-13} pages 10-13; Collins Exhibit SMC/5 - Photographs of Grenfell Tower {MET00015914/24}. 471 Sibthorpe {MET00015658/5} page 5. 472 Interim certificate of the fact of death for Mohammad Alhajali {MET00065645}.

Part 9 | Chapter 88: Floor 14 61 inhaled sufficient carbon monoxide to bring him within the fatal range.473 Later analysis in April 2019 did not detect the presence of cyanide but that may simply have been due to the degradation of the sample over time.474 88.114 The reporting pathologist concluded that the inhalation of a potentially lethal dose of carbon monoxide was not inconsistent with an attempt by a fit young man to jump from the building.475 The medical cause of death was recorded as “Multiple injuries consistent with fall from height”. We accept that conclusion. 88.115 The absence of any burns to Mohammad Alhajali’s skin suggests that he jumped before the exterior fire had enveloped the south side of Flat 113 and before a fire had developed in the interior of the flat. The time it took for WM Collins and his colleagues to move the body of Mohammad Alhajali, check for signs of life and then find a paramedic means that some minutes elapsed between finding the body and pronouncing life extinct. Taking these factors into consideration, we are satisfied that Mohammad Alhajali fell from the tower at some time between 04.05 and 04.30. 473 Alhajali post-mortem report {COR00001135}; Purser, Phase 2 Report, Section 6 {DAPR0000006/152} paragraphs 829-831. 474 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. 475 Alhajali post-mortem report {COR00001135}; Purser, Phase 2 Report, Section 6 {DAPR0000006/152} paragraphs 830.

The Grenfell Tower Inquiry: Phase 2 Report 62

63 89.1 All six flats on floor 15 were occupied at 00.54 when the fire started.476 Between 01.21 and 01.36, the occupants of Flats 121, 123, 125 and 126 left the tower. Only Steve Power, his daughter Rebecca Ross (both in Flat 122) and Christos Fairbairn (in Flat 124) then remained. Steve Power did not survive the fire. 89.2 Aziza El-Ouahabi Raihani from Flat 126 had left the tower477 by the time the fire reached the outside of her flat at 01.23.478 A few minutes earlier, Rashida Ali, who lived in Flat 125, had ventured into the lobby on floor 15 to find that it was still clear of smoke.479 She left the tower at 01.23.480 89.3 Conditions quickly changed as the fire on the outside of the building entered Flat 126. At 01.27, FF David Badillo entered the tower on his way to floor 20 in search of Jessica Urbano Ramirez.481 When the lift stopped at floor 15 and the doors opened it filled with black smoke. Struggling to breathe and see, FF Badillo left the lift, found his way to the stairwell door and went down the stairs.482 He had no contact with any of the residents on floor 15.483 By 01.31, FF Badillo had left the tower.484 Reem Dedrich (Flat 123) and Sid Ali Atmani (Flat 125) left the tower at 01.33 and 01.36 respectively. The lobby on floor 15 was full of thick dark smoke when each of them escaped.485 89.4 FF Steven Mills and Geoffrey Campbell tallied out at 01.51 to go to Flat 175 on floor 20. When they reached floor 15, they realised that they could not reach floor 20 without extended duration breathing apparatus.486 FF Mills recalled that before descending the stairs he and FF Campbell had banged on the doors of all the flats on floors 15 and 14.487 FF Campbell was less certain whether they had stopped on floor 14 or floor 15 before descending and thought that they may have searched floor 9.488 Christos Fairbairn heard banging on his front door,489 but he did not become aware of the fire until much later, probably not before 02.20.490 Since the firefighters had logged off the system by 02.11,491 it is unlikely that what Christos Fairbairn heard had anything to do with them. 89.5 Neither Rebecca Ross, her father nor any relatives or friends made an emergency call reporting that persons were in Flat 122, although the LFB received that information by other means. Christos Fairbairn made six emergency calls, the first at 03.00 and the last 476 Phase 1 Report Volume II paragraph 10.15. 477 Phase 1 Report Volume III Annex A. 478 Bisby, Supplemental Phase 1 Expert Report {LBYS0000001/159}. 479 Ali {Day67/47:8-17}. 480 Phase 1 Report Volume III Annex A. 481 Phase 1 Report Volume II paragraph 10.79 (b). 482 Phase 1 Report Volume II paragraph 10.101 (a). 483 Badillo {Day13/119:6}-{Day13/123:7}. 484 Phase 1 Report Volume II paragraph 11.10. 485 Phase 1 Report Volume II paragraphs 11.86 and 11.87. 486 Phase 1 Report Volume II paragraph 13.14. 487 Mills {MET000080584/6} page 6. 488 Campbell {MET00010788/8-10} pages 8-10. 489 Phase 1 Report Volume II paragraph 14.194. 490 Phase 1 Report Volume II paragraph 14.194. 491 BA Telemetry Data {LFB00023326/1} page 1. Chapter 89 Floor 15

The Grenfell Tower Inquiry: Phase 2 Report 64 at 03.31, four of which were to the fire and rescue service.492 He was advised to leave the building and when he did do so he encountered firefighters who helped him out. Christos Fairbairn left the tower at 03.54.493 His calls did not result in the deployment of any firefighters to floor 15. Steven Power Date of birth: 18 August 1953 (63 years). Place of birth: London, UK. Gender:

Male. Occupation: Retired. Usual address: Flat 122, floor 15, Grenfell Tower, London. Place of death: Flat 122, floor 15, Grenfell Tower, London. Time of death: Between 03.15 and 04.00 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Coronary artery atheroma. Background and composition of household 89.6 Steven (Steve) Power lived in Flat 122 with his daughter Rebecca Ross, his son Bobby Ross and his three dogs Stevie, Diva and Jess. A retired driver, he was a keen fisherman and disc jockey who had lived in the tower since 1985.494 Vulnerability 89.7 Steve Power suffered from emphysema, which made walking difficult.495 He had also been diagnosed with bowel cancer.496 Rydon’s resident survey of November 2014 notes that they had yet to speak to him.497 He did not appear in the spreadsheet listing vulnerable residents produced on the night of the fire by David Noble of the TMO based on information from the TMO’s Capita Insight system.498 Events of 14 June 2017 89.8 Both Steve Power and Rebecca Ross were home in Flat 122 on the evening of the fire. Steve Power woke his daughter at about 01.30 to tell her that there was a fire in the building. She wanted to leave, but he thought they should remain in the flat.499 492 Phase 1 Report Volume III paragraphs 17.85, 17.138, 18.43 and 18.44. 493 Phase 1 Report Volume III paragraphs 18.46 and 18.47. 494 Phase 1 Report Volume IV paragraphs 32.259-32.263. 495 Ross {IWS00001036/6} page 6, paragraph 15. 496 Bobby Ross Exhibit BR/4 – Letters from North Kensington Law Centre to KCTMO {IWS00002360}. 497 Rydon Residents Survey {RYD00024466/24}. 498 Noble {TMO00000884}. 499 Phase 1 Report Volume II paragraph 14.191.

Part 9 | Chapter 89: Floor 15 65 89.9 Rebecca Ross was able to see something of the fire from the flat, but it was only on seeing an image on Twitter that she realised its extent. By that time friends and family members were calling and urging Steve and Rebecca to leave and she tried to persuade her father to do so. At about 02.00, she opened the front door to see a cloud of thick grey smoke in the lobby although the lighting was still visible.500 89.10 At about 02.22, while Rebecca Ross was on the telephone to her brother Wayne Power‑Davis, black smoke began to fill the flat. She and her father agreed to leave. While he put on his shoes, she soaked towels for them both. As she was moving to the front door, Rebecca Ross noticed that flames appeared to be about to come through the kitchen window. She found the lobby so full of black smoke that it was impossible to see. Her father was still in the flat when she left. Leaving the front door open, she managed to find her way to the stairwell and began to make her way down the stairs.501 89.11 At 02.47, FF Robert Dwyer and Christopher Perez encountered Rebecca Ross on the stairs between floors 10 and 11. She was struggling to breathe, so they decided to carry her down the stairs.502 Rebecca Ross was able to tell them that her father was trapped in Flat 122 on floor 15. As well as sending that information to the bridgehead, the firefighters briefed the bridgehead directly when they reached it.503 89.12 Rebecca Ross left the tower at 02.54.504 She subsequently learned that a friend of her father had spoken to him on the telephone after she had left Flat 122.505 There is no further evidence of when the call was made or what was said, but it appears to have been the last contact with Steve Power. Information to the incident ground 89.13 Between 02.10 and 02.22 CU7 was given the task of managing information about people who needed to be rescued from the tower.506 The crew used a laminated sheet to record information obtained from pieces of paper created in CU8.507 It included the following information: “122 15 2 Persons”.508 The same information appears on the whiteboard used by CU7 after 03.00 to record information.509 There the number “2” was written in green indicating two adults.510 89.14 FF Mandeep Singh acted as a runner taking messages from the command units to the bridgehead and to WM Glynn Williams in the ground floor lobby of the tower.511 From 02.15 WM Williams began using the wall of the lobby to record information that was then 500 Phase 1 Report Volume II paragraphs 14.192-14.193. 501 Phase 1 Report Volume III paragraphs 16.64-16.66; Ross {IWS00001036/15} page 15, paragraph 35. 502 Dwyer {MET00012781/5-6} pages 5-6; Perez {MET00017426/6} page 6; LFB Operational Response Report dated July 2020 {LFB00119333/231}. 503 Perez {MET00017426/6} page 6. 504 Phase 1 Report Volume III Annex A. 505 Ross {IWS00001036/21} page 21, paragraph 55. 506 Phase 1 Report Volume IV paragraph 28.84 (d). 507 Phase 1 Report Volume II paragraphs 12.8-12.9. 508 Phase 1 Report Volume II Figure 12.3. 509 Phase 1 Report Volume III paragraph 15.13; Phase 1 Report Volume III paragraph 16.12 and Figure 16.5; Photograph of whiteboard {MET00015924}. 510 Goodall {MET000083296/11} page 11. 511 Singh {MET000083327/12} page 12.

The Grenfell Tower Inquiry: Phase 2 Report 66 passed to the bridgehead.512 One note in FF Singh’s handwriting read: “Glen Williams” at the top and then “15th Floor 122 x 2 people x 2 dogs.”513 WM Williams did not see FF Singh’s note and the information was not added to the wall.514 89.15 The information in FF Singh’s note must be linked to his recollection of having been approached by a man to say that his father was on floor 15 in Flat 122. The man had told him that there were two people and two dogs in the flat and that his father was refusing to leave. FF Singh said he had recorded the information in a note and had taken it to the bridgehead.515 89.16 In any event, at some point, information about Flat 122 was recorded on the lobby wall. Photographs of that wall show the following had been written on it: a. “BA 122 15th” and “Smoke log” on the right-hand side. WM Williams said that the entry was in his handwriting and that the information had come from the command unit. The notation of “BA” was to show that a crew had been deployed to that flat.516 b. “122 15?” on the left-hand side. WM Williams said that that entry was also in his handwriting but he could not remember what the question mark meant.517 c. “122 15 1P” also on the left-hand side. WM Williams said that that entry was not in his handwriting.518 89.17 At the time that FF Dwyer relayed the information from Rebecca Ross, the bridgehead was still on floor 3. WM Louisa De Silvo recorded information about people needing to be rescued on a wall on that floor. It included: “122 FIRE IN THE KITCHEN 122”. The first “122” was circled and marked with two ticks and the second underlined and circled.519 A tick against a particular flat indicated that a crew had been deployed there and a circle indicated that WM de Silvo had received further information, either by runner or radio or from a returning crew. A cross through the flat indicated that it had been searched. She thought that “122” had probably been written and circled again, and underlined, for emphasis because she had received further information about it or because firefighters had been unable to reach it.520 It is likely that some of the information came from FFs Dwyer and Perez, since it appears on a control information form together with the time 2.47.521 89.18 Although WM De Silvo could not recall having deployed a crew to Flat 122,522 FF Leon Whitley and Ricky Nuttall tallied out at 02.44 and 02.45 respectively with instructions to go to Flat 122. They took a hose with them. On reaching floor 15, they charged the hose and located Flat 122 but then realised they were low on air. Being concerned that they would not be able to carry out an effective rescue, they decided to return to the bridgehead. FF Nuttall described the visibility on floor 15 as zero with thick black smoke. By the time they reached the bridgehead, it had been moved to the ground 512 Phase 1 Report Volume II paragraphs 14.103-14.105 and Figure 14.5; Photographs of ground floor wall {MET00005774} and {MET00005776}. 513 Singh Exhibit MSI/1 – pages from notebook {MET00013089/1}. 514 Phase 1 Report Volume IV paragraph 28.85 (a). 515 Singh {MET000083327/16} page 16. 516 Williams {Day31/113:23}-{Day31/114:1}; {Day31/162:9-22}. 517 Williams {Day31/164:18-21}. 518 Williams {Day31/164:9-17}. 519 Phase 1 Report Volume II Figure 15.7; The photograph was taken at 03.08 when the bridgehead was about to be relocated to the ground floor: Cook Exhibit GAC/2 - Grenfell Tower statement notes {MET00015779/16} page 16. 520 De Silvo {Day30/24:16}-{Day30/25:6}; {Day30/31:6}-{Day30/32:17}. 521 Control information form {LFB00001955/1}. The forms were used at the incident ground to record information about people needing to be rescued. 522 De Silvo {Day30/32:8-17}.

Part 9 | Chapter 89: Floor 15 67 floor. FF Nuttall tried to tell WM Williams about Flat 122, but he was too busy to take the information in. Outside the tower, FF Nuttall gave the information to a watch manager who said he would deal with it.523 89.19 The reference to two adults makes it likely that the information recorded in CU7 and by FF Singh was received before Rebecca Ross had left Flat 122. One source was probably a friend of Rebecca Ross outside the tower.524 The proximity in timing between FFs Dwyer and Perez finding Rebecca Ross and FFs Nuttall and Whitley being deployed suggests that it was the information from FFs Dwyer and Perez that prompted their deployment. WM De Silvo may have added the detail about a fire in the kitchen of Flat 122 after that deployment. Of the notes made on the ground floor lobby, the reference to “BA” and “smoke log” are likely to refer to that deployment. 89.20 The information received from FFs Dwyer, Perez, Nuttall and Whitley did not prompt a further deployment to Flat 122. Recovery and identification 89.21 The remains of Steve Power were recovered from the bedroom of Flat 122.525 The coroner, Professor Wilcox, was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.526 Steve Power was found with his dogs, Stevie, Diva and Jess.527 Cause and time of death 89.22 The post-mortem and toxicological investigations on Steve Power found soot in, and mild heat damage to, the respiratory system. Carboxyhaemoglobin was present in the blood but it was not possible to quantify the concentration. There was significant evidence of coronary artery atheroma, which, although not a direct cause of death, rendered Steve Power more vulnerable to the effects of carbon monoxide. A lower concentration would therefore have resulted in drowsiness, unconsciousness, and death.528 89.23 In the post-mortem report on Steve Power the medical cause of death was recorded as: Ia. Inhalation of products of combustion II. Coronary artery atheroma. 89.24 In the light of Professor Purser’s evidence, we find that a more accurate description of the primary cause of death is “inhalation of asphyxiant gases”. 89.25 The fire on the outside of the building reached Flat 122 between 02.23 to 02.29. By 02.49, it had spread from the east face of the living room to the south face. Between about 03.02 and 03.12 it spread to and across the external walls of the bedrooms.529 523 Phase 1 Report Volume III paragraphs 15.59-15.60; Nuttall {MET00012561/11-14} pages 11 and 13-14. 524 Ross {IWS00001036/11} page 11, paragraph 29. 525 Purser, Phase 2 Report, Section 6 {DAPR0000006/134} paragraph 723. 526 Interim certificate of the fact of death for Steven Power {MET00065616}. 527 Presentation relating to Steven Power {Day307/92:10-15}. 528 Power post-mortem report {COR00001432}; Power toxicology report {COR00001444}; Purser, Phase 2 Report, Section 6 {DAPR0000006/134} paragraph 723. 529 Purser, Phase 2 Report, Section 6 {DAPR0000006/133} paragraph 715.

The Grenfell Tower Inquiry: Phase 2 Report 68 89.26 Steve Power’s pre-existing health conditions made it difficult for him to leave the tower with his daughter. Having regard to the extent to which Rebecca Ross was exposed to asphyxiant gases, the time at which the fire spread to his flat and his underlying health condition, we are satisfied that Steve Power lost consciousness soon after his daughter left Flat 122. The mild heat damage to his respiratory system probably occurred after he had lost consciousness. Steve Power died between 03.15 and 04.00.530 530 Purser {Day297/114:14-25}.

69 90.1 All the flats on floor 16 were occupied on 14 June 2017. Two residents of this floor, Sheila in Flat 132 and Joseph Daniels in Flat 135, died in the fire. 90.2 The fire reached floor 16 outside Flat 136 by 01.24.531 Thereafter, conditions on that floor deteriorated rapidly. 90.3 Hamid Wahbi, the sole occupant of Flat 136 on the night of the fire, left his home on seeing smoke and flames enter through the kitchen window. The smoke had already reached the living room and hallway by the time he left. When he did so, Hamid Wahbi found the lobby on floor 16 clear of smoke.532 He left his front door open533 and, since it did not have an effective self-closing device, smoke entered the lobby.534 90.4 In Flat 135, Samuel Daniels, who lived there with his father Joseph Daniels, became aware of a burning smell. That was before Hamid Wahbi had left his flat. Samuel Daniels went into the lobby on three occasions to investigate. Initially, it was clear of smoke. When he next entered the lobby, he saw smoke from the ceiling down to waist level. On the third occasion there was still smoke in the lobby, but it remained possible to breathe. On all three occasions, he found the stairwell clear of smoke.535 90.5 When, having failed to persuade his father to leave, Samuel Daniels finally left Flat 135, thick black smoke came into the flat when he opened the front door. The lobby was filled with smoke and visibility was limited. The stairs at that time remained free from smoke.536 90.6 The occupants of Flat 131, Richard Fletcher, his wife, Hime Gashaw and their daughter left their flat at about the same time. There was thick black smoke in the lobby when they opened their front door. The family crossed the lobby and left the tower at 01.31.537 90.7 Samuel Daniels met FF Justin O’Beirne on the stairs and told him about his father.538 FF O’Beirne called for assistance for a bedbound man on floor 16.539 CM Jamal Stern and FF Richard Hippel responded to that call and went to floor 16.540 CM Stern found the lobby of floor 16 to be smoke-logged when he first opened the stairwell door.541 FF Hippel recalled black smoke coming out from the open stairwell door.542 On floor 16 they found a man by the lobby door (Hamid Wahbi) and another man in the lobby (Edward Daffarn).543 531 Bisby, Supplemental Phase 1 Expert Report {LBYR00000001/149} Figure 96. 532 Phase 1 Report Volume II paragraph 10.238. 533 Phase 1 Report Volume II paragraph 10.238. 534 Wahbi {IWS00001157/6-10} pages 6 and 10, paragraphs 26 and 55; Wahbi {Day62/36:18}-{Day62/37:1}. 535 Phase 1 Report Volume II paragraphs 11.68 and 11.70. 536 Phase 1 Report Volume II paragraphs 11.77 and 11.78. 537 Phase 1 Report Volume II paragraphs 1171-11.73. 538 Phase 1 Report Volume II paragraph 11.79. 539 Phase 1 Report Volume II paragraphs 11.79, 10.101 (b) and 10.101 (c). 540 Phase 1 Report Volume II paragraphs 10.101 (b) and (c). 541 Stern {MET00012483/10} page 10. 542 Hippel {Day26/63:7}-{Day26/68:21}. 543 Phase 1 Report Volume II paragraphs 10.101 (c), 11.81 and 11.82. Chapter 90 Floor 16

The Grenfell Tower Inquiry: Phase 2 Report 70 90.8 When Edward Daffarn left Flat 134, the smoke in the lobby was so thick it was difficult for him to see. He struggled to find his way out until he was found by CM Stern and FF Hippel. Edward Daffarn left the tower at 01.34.544 90.9 Having assisted Edward Daffarn, CM Stern and FF Hippel then entered the first flat they found on floor 16, which is likely to have been Flat 136. They found it empty, extremely hot and heavily smoke-logged.545 As they were low on air, they left before searching any other flats.546 CM Stern said that they had knocked on the doors of two other flats, which he thought had been Flats 134 and 135.547 FF Hippel said that when searching floor 16, he and CM Stern had kicked the front door of each flat and shouted out.548 He could not explain why the occupants of Flat 133 had not heard them but suggested that they might have been asleep.549 Sener Macit, in Flat 133, said that he had not heard any knocking on his door or any noises coming from the lobby.550 90.10 CM Stern and FF Hippel returned to the bridgehead on floor 2 at about 01.38. CM Stern told WM O’Keeffe that they had rescued one person (Edward Daffarn) but had been unsuccessful in rescuing another (Joseph Daniels). CM Stern was not sure if he had mentioned that the person they had been unable to rescue had been bedbound.551 FF O’Beirne said that when he had left the tower, he told SM Brett Loft that there was a bedbound man on floor 16 whom crews had not been able to reach. SM Loft did not recall that exchange.552 90.11 After leaving the tower, Hamid Wahbi spoke to two firefighters, SM Loft and WM Watson.553 He told them that there was a man and a woman on floor 16. Although he did not give a flat number, he was referring to Joseph Daniels in Flat 135 and Sheila in Flat 132.554 SM Loft did not recall that conversation.555 90.12 By 01.45, only Sheila in Flat 132, Joseph Daniels in Flat 135 and Sener and Hanife Macit in Flat 133 remained on floor 16. Sener Macit was the only one to call the emergency services. His first call was at 01.37 and was put through to the police. He told them that he was on floor 16 but was not asked for, and did not give, the number of his flat.556 The police passed the information that people were trapped on floor 16 to the LFB in a call taken by CRO Heidi Fox at 01.43.557 The information was passed to CU8 at 01.46.558 544 Phase 1 Report Volume II paragraphs 10.101 (c) and 11.81. 545 Phase 1 Report Volume II paragraph 10.101 (c); Hippel {Day26/93:7}-{Day26/94:14}. 546 Phase 1 Report Volume II paragraph 10.101 (c). 547 Stern {MET00012483/12-13} pages 12-13; Stern Exhibit JAS/3 – Floorplan of Floor 16 {MET00016893}. 548 Hippel {Day26/93:7}-{Day26/96:13}. 549 Hippel {Day26/95:19-25}. 550 Macit {Day65/130:14-19}. 551 Phase 1 Report Volume II paragraph 11.15; Stern {Day26/190:3}-{Day26/193:20}. 552 Phase 1 Report Volume II paragraph 11.15. 553 CCTV Stills {INQ00000478}; {INQ00000477}; {INQ00000479}. 554 Wahbi {Day62/62:12}-{Day62/64:20}. 555 Loft {Day29/37:17}-{Day28/39:9}. 556 999 call transcript {INQ00000280}. 557 Phase 1 Report Volume II paragraph 12.79; 999 call transcript {LFB00000497}. 558 Phase 1 Report Volume II paragraph 12.88; Short Incident Log Report {MET00013830/19-20}; LFB Radio Messages {LFB00002952}.

Part 9 | Chapter 90: Floor 16 71 90.13 Sener Macit’s first emergency call led to a conference call at 01.46 between the police operator, Sener Macit and CRO Adams in the LFB control room. Sener Macit told CRO Adams that he was in Flat 133 and that smoke was coming under his front door. He could not escape as it was pitch black.559 CRO Adams passed on the details of that call to the incident ground at 01.50.560 90.14 Between 02.10 and 03.33, Sener Macit made a further six emergency calls. At 02.10, he was connected to North West Fire Control to whom he spoke for almost half an hour. At a late stage in that call, he was told that firefighters were on their way to floor 16 but was advised to leave his flat.561 Following a failed attempt to leave, Sener Macit spoke to the LFB again at 02.41,562 02.49,563 03.02,564 and 03.12.565 His daughter also called the LFB at 03.01566 and 03.45.567 Sener and Hanife Macit eventually managed to escape without assistance, leaving the tower at 03.47.568 90.15 After CM Stern and FF Hippel had left floor 16, there were two further deployments, both after 03.00. CM Aldo Diana and FF Dean Nelson tallied out at 03:24.569 They were sent to Flat 133 but failed to reach floor 16 as they stopped to help other residents escape.570 The last crew deployed to floor 16 were SM Gareth Cook and CM Ben Gallagher who tallied out at 04.04.571 They were sent to investigate reports of ten people trapped in a flat on floor 16 and 11 people trapped on floor 18. However, SM Cook’s alarm sounded between floors 6 and 12 and CM Gallagher’s air was low, so they returned to the bridgehead without reaching floor 16.572 It is unclear what prompted that deployment, given the absence of information to support the suggestion that so many people were trapped on floor 16. Joseph Daniels Date of birth: 10 February 1948 (69 years). Place of birth: Lucknow, India. Gender:

Male. Occupation: Retired. Usual address: Flat 135, floor 16, Grenfell Tower, London. Place of death: Flat 135, floor 16, Grenfell Tower, London. Time of death: Between 02.55 and 03.15 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. 559 Phase 1 Report Volume II paragraph 12.89. 560 Phase 1 Report Volume II paragraph 12.90. 561 Phase 1 Report Volume II paragraph 14.188; Phase 1 Report Volume III paragraphs 15.86-15.87. 562 Phase 1 Report Volume III paragraph 15.89. 563 Phase 1 Report Volume III paragraph 15.89. 564 Phase 1 Report Volume III paragraph 17.80. 565 Phase 1 Report Volume III paragraphs 17.80-17.82. 566 999 call transcript {LFB00000560}. 567 999 call transcript {LFB00000529}. 568 Phase 1 Report Volume III paragraphs 18.39-18.42. 569 BA Telemetry Data {LFB00023326/2} page 2. 570 Diana {MET00018800/8-12} pages 8-12; Nelson {MET00010926/4-9} pages 4-9; Phase 1 Report Volume III paragraph 18.20 (b). 571 BA Telemetry Data {LFB00023326/3} page 3. 572 Phase 1 Report Volume III paragraph 19.9; Cook {MET00007882/14-15} pages 14-15.

The Grenfell Tower Inquiry: Phase 2 Report 72 Background and composition of household 90.16 Joseph Daniels was born on 10 February 1948 in Lucknow, India. He was 69 years old at the time of the fire.573 He came to the United Kingdom from India in 1982 after marrying Lucy Smyth. They moved into Flat 135 in 1983 and had one son, Samuel Daniels. The couple subsequently divorced and Joseph Daniels continued to live in Flat 135. He also had a daughter, Stephanie Hillier, from another relationship.574 90.17 By June 2017, Joseph Daniels was retired and in poor health. He shared Flat 135 with his son, Samuel Daniels, who was registered as his father’s full-time carer.575 Vulnerability 90.18 By June 2017, Joseph Daniels was suffering from dementia and diabetes and had limited mobility.576 He was not, however, bedbound. He needed the lift to leave the tower.577 Samuel Daniels said his father had not been able to walk up and down the stairs for about a year and a half before the fire and had not left the flat at all for the last two months of his life.578 90.19 Rydon’s resident survey of November 2014 did not identify Joseph Daniels as having any known physical or mental health vulnerabilities, although it was noted that he had some vulnerabilities associated with his self-care.579 90.20 The TMO was aware of Joseph Daniels’ vulnerability. In 2015, it had referred him to an occupational therapist as he was having difficulty getting in and out of the bath. The referral recorded that he had mobility problems but did not want to use a walking stick or glasses for his poor vision.580 An assessment in May 2015 carried out by RBKC’s social services department noted that he suffered from dementia, brain damage, type 2 diabetes, breathlessness and tremors.581 90.21 The spreadsheet produced on the night of the fire by David Noble582 based on information held on the TMO’s Capita Insight system583 did not identify Joseph Daniels as having any vulnerability. Events of 14 June 2017 90.22 Joseph Daniels was at home with his son, Samuel Daniels, on the evening of 13 June 2017.584 90.23 Samuel Daniels first became aware of the fire when he noticed a faint burning smell. He checked the flat, lobby and stairs but could not find its source. Nonetheless, he was sufficiently concerned to decide that he and his father should leave. Between efforts to persuade his father to leave, Samuel Daniels went into the lobby twice more, noticing 573 Phase 1 Report Volume IV paragraph 32.255. 574 Presentation relating to Joseph Daniels {Day307/46:19}-{Day307/47:22}; Tenancy Agreement {TMOH00024682}. 575 Presentation relating to Joseph Daniels {Day307/47:24}-{Day307/48:3}. 576 Phase 1 Report Volume II paragraph 11.67. 577 Daniels {IWS00000608/2} page 2, paragraph 8. 578 Daniels {Day56/5:8-22}; Phase 1 Report Volume II paragraph 11.67. 579 Rydon Residents Survey {RYD00024466/20}. 580 TMO Referral Form {TMOH00024715}; Daniels {IWS00002065/9} page 9, paragraph 55. 581 Daniels {IWS00002065/8} page 8, paragraph 52; Email from RBKC regarding adult social care {RBK00038674}; Care and Support Plan Review of Samuel Daniels {RBK00059536/4}. 582 Noble {TMO00000884/1} page 1, paragraph 3. 583 Noble {Day119/77:17}-{Day119/82:5}. 584 Daniels {IWS00000608/8} page 8, paragraph 47.

Part 9 | Chapter 90: Floor 16 73 an increasing amount of smoke there on each occasion.585 The smoke entering the lobby at that stage was coming from Flat 136, the door to which had not closed after Hamid Wahbi left.586 90.24 Samuel Daniels could not persuade his father to leave. He left on his own, leaving the door open for his father to follow. Samuel Daniels had told the TMO on 4 April 2017 that the front door of Flat 135 did not close itself. A recommendation for a complete overhaul was made on the following day but the job was later recorded as “fully abandoned”.587 However, it is likely that Joseph Daniels shut the door after his son had left because CM Stern and FF Hippel found it closed when they searched floor 16. 90.25 Samuel Daniels met FF O’Beirne in the stairwell at around floor 11 at some time between 01.28 and 01.38.588 He told FF O’Beirne that his father was trapped in his flat on floor 16. FF O’Beirne told the bridgehead by radio that a man was bedbound on floor 16 and asked for assistance.589 CM Stern and FF Hippel responded to that request. 90.26 On arriving at floor 16, CM Stern and FF Hippel found the lobby full of thick smoke and visibility very limited.590 Having first helped Edward Daffarn, they searched the first flat they came to, probably Flat 136.591 They could not search other flats, because they were running low on air,592 but they did knock on other doors. There was a difference in recollection between them about how many doors they knocked on, but there is no evidence that Joseph Daniels was aware of the presence of the firefighters on floor 16.593 90.27 Samuel Daniels was waiting on the stairs when he saw the firefighters return from floor 16. He tried to ask them about his father but was told to leave the tower. He did so at 01.38.594 Information to the incident ground 90.28 CM Stern and FF Hippel returned to the bridgehead on floor 2 at around 01.38. CM Stern told WM O’Keeffe that he and FF Hippel had rescued one person (Edward Daffarn) but had not been able to rescue another (Joseph Daniels). He was not sure if he had said that that person was bedbound.595 FF O’Beirne said that he told SM Brett Loft that there was a bedbound man on floor 16 who the crews had been unable to reach. SM Loft did not recall this exchange with FF O’Beirne.596 585 Phase 1 Report Volume II paragraphs 11.68 and 11.70. 586 Phase 1 Report Volume IV paragraph 24.31; Wahbi {IWS00001157/10-11} pages 10-11, paragraph 55. 587 Daniels {IWS00000608/6} page 6, paragraph 40; Daniels {Day56/18:18}-{Day56/20:4}; Daniels Exhibit SD/02 -TMO repairs log for Flat 135 regarding front door not closing {IWS00002067}; Daniels Exhibit SD/03 - TMO dashboard snapshot of front door repair at Flat 135 {IWS00002068}; Daniels Exhibit SD/04 - TMO dashboard snapshot of the repairs log for Fat 135 {IWS00002069}. 588 Phase 1 Report Volume II paragraph 11.79. 589 Phase 1 Report Volume II paragraph 10.101 (b). 590 Stern {MET00012483/10} page 10; Hippel {Day26/63:7}-{Day26/68:21}. 591 Phase 1 Report Volume II paragraphs 11.81 and 10.101 (c). 592 Phase 1 Report Volume II paragraph 10.101 (c). 593 Stern {MET00012483/12-13} pages 12-13; Stern Exhibit JAS/3 - Floorplan of Floor 16 {MET00016893}; Hippel {Day26/69:19}-{Day26/73:7}. 594 Phase 1 Report Volume II paragraph 11.82. 595 Phase 1 Report Volume II paragraph 11.15; Stern {Day26/190:3}-{Day26/193:20}. 596 Phase 1 Report Volume II paragraph 11.15.

The Grenfell Tower Inquiry: Phase 2 Report 74 90.29 Shortly after 02.17, CM Charles Batterbee made a note of the information on a forward information board that had been used while the bridgehead was located on floor 2.597 His note did not include any reference to floor 16, which may explain why the information provided by the firefighters on their return from floor 16 did not lead to a further deployment before the bridgehead moved from floor 2 at about 02.17.598 90.30 The bridgehead was located on floor 3 between 02.17 and 03.10.599 During that time information about people needing to be rescued was recorded on a wall in the lobby of floor 3. The only information about floor 16 on the wall was a note relating to Flat 133.600 90.31 The bridgehead was moved to the ground floor lobby at about 03.10. Once it was there, a green wall by the stairs was used to record information about those needing to be rescued.601 A photograph of that wall taken at about 04.45 shows the numbers “134” and “135” on the wall.602 We do not know who put that information on the wall but its limited detail reflects that recorded on a control information form provided to the Inquiry. The forms were used at the incident ground to record messages about people needing to be rescued. The relevant form recorded just the following, “133+134+135 16”.603 On the form, “133” is scrubbed out and marked “left”, indicating that those in Flat 133 had got out but that Flats 134 and 135 remained occupied. It is not possible to say with any confidence who wrote on the form. (WM Sadler used a pad of such forms604 but they were also used, for example, by those in CU7.)605 90.32 We cannot say when the information was put on the green wall (save that it must have been after 03.10) or indeed when the control information form was completed. If the information on the wall is associated with the control information form, it may have been recorded after Sener and Hanife Macit left the tower at 03.47. The information recorded in the control information form and the green wall may have come from more than one source. It is unlikely that Hamid Wahbi was the source of the information relating to Flat 135, as he did not provide the firefighters he spoke to outside the tower with the numbers of any flats.606 It is more likely that the source, at least in relation to Flat 135, was Samuel Daniels. Once outside the tower, and having found his mother, he told someone, who may have been either a firefighter or a police officer, that his father was still in Flat 135. That was at about 02.00.607 His mother gave the officer the number of the floor and the flat.608 90.33 The information that someone might still be in Flat 135 did not prompt any further deployments. The two deployments which took place after 03.24 were not sent to Flat 135 and neither of them reached floor 16. CM Diana and FF Nelson tallied out at 03.24609 to go to Flat 133 but stopped to help other occupants escape. They reported that to the 597 Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c). 598 Phase 1 Report Volume IV paragraph 28.84 (b). 599 Phase 1 Report Volume IV paragraphs 28.86 and 28.87. 600 Phase 1 Report Volume II Figure 15.7; The photograph was taken at 03.08 when the bridgehead was about to be relocated to the ground floor: Cook Exhibit GAC/2 - Grenfell Tower statement notes {MET00015779/16} page 16. 601 Phase 1 Report Volume IV paragraph 28.87. 602 Mulholland Exhibit MBM/02 - Photograph of green wall {MET00018739}. 603 LFB Control Information Forms {LFB00001955/10} page 10. 604 Phase 1 Report Volume IV paragraph 28.84 (e). 605 Phase 1 Report Volume IV paragraph 28.84 (g). 606 Wahbi {Day62/63:5}-{Day62/65:18}; CCTV Stills {INQ00000476}; {INQ00000477}; {INQ00000478}; Loft {Day28/37:17}-{Day28/39:9}. 607 Daniels {IWS00000608/14} page 14, paragraph 85; Daniels {Day56/71:13-23}. 608 Daniels {Day56/71:20}-{Day56/72:3}. 609 BA Telemetry Data {LFB00023326/2} page 2.

Part 9 | Chapter 90: Floor 16 75 bridgehead.610 SM Gareth Cook and CM Ben Gallagher set off at 04.04 to investigate reports of 10 people trapped in a flat on floor 16, but a shortage of air prevented them from reaching that floor.611 90.34 There was no further contact from Joseph Daniels after his son left Flat 135. Recovery and identification 90.35 The remains of Joseph Daniels were recovered from the living room of Flat 135.612 The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.613 Cause and time of death 90.36 The post-mortem on Joseph Daniels found soot deposits in his respiratory system. Analysis of a sample of his blood confirmed the presence of carbon monoxide, but the condition of the sample meant that its concentration could not be measured.614 The medical cause of death was recorded as “consistent with the effects of fire”, but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”. 90.37 If, as we think likely, the front door of Flat 135 was closed after Samuel Daniels left, it would have slowed the passage of smoke from the lobby into the flat. Exposure to asphyxiant gases was limited until the fire reached the outside walls of the bedrooms at between 02.32 and 02.34. Conditions in the living room deteriorated rapidly when the fire on the outside of the building reached the north side of the living room between 02.49 and 02.55.615 90.38 It is likely that Joseph Daniels lost consciousness and died from the inhalation of asphyxiant gases at some time between 02.55 and 03.15.616 Accordingly, the last chance to rescue him was some time before 03.00. That was well before the deployments of CM Diana and FF Nelson at 03.24 and of SM Cook and CM Gallagher at 04.04. Sheila Date of birth: 17 September 1932 (84 years). Place of birth: Market Harborough, Leicestershire. Gender:

Female. Occupation: Retired. Usual address: Flat 132, floor 16, Grenfell Tower, London. Place of death: Flat 132, floor 16, Grenfell Tower, London. 610 Diana {MET00018800/8-12} pages 8-12; Nelson {MET00010926/4-9} pages 4-9; Phase 1 Report Volume III paragraph 18.20 (b). 611 Phase 1 Report Volume III paragraph 19.9; Cook {MET00007882/14-15} pages 14-15. 612 Purser, Phase 2 Report, Section 6 {DAPR0000006/126} paragraph 678; Presentation relating to Joseph Daniels {Day307/71:3-6}. 613 Interim certificate of the fact of death for Joseph Daniels {MET00065647}. 614 Daniels post-mortem report {COR00000793/10}; Daniels supplementary post-mortem report {COR00000791/2}; Daniels toxicology report {MET00039529}; Purser, Phase 2 Report, Section 6 {DAPR0000006/127} paragraph 688. 615 Purser, Phase 2 Report, Section 6 {DAPR0000006/127} paragraph 686. 616 Purser, Phase 2 Report, Section 6 {DAPR0000006/127} paragraph 686; Purser {Day297/111:4-5}.

The Grenfell Tower Inquiry: Phase 2 Report 76 Time of death: Between 03.09 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 90.39 Sheila was born on 17 September 1932 and was 84 years old.617 In life, she made the decision to use only her first name, a decision that we have respected during the Inquiry. Retired, Sheila was a mother and grandmother, living alone in Flat 132. She had lived there since 23 April 1984.618 Sheila led an independent life with a longstanding interest in meditation, yoga and alternative therapies.619 Vulnerability 90.40 Sheila was physically fairly mobile but her health had deteriorated before the fire.620 Like some other residents, she struggled when the lifts in the tower were not working,621 but she did not appear in the TMO’s records as being vulnerable. Rydon’s resident survey of November 2014 recorded that she was over 80, had slight deafness and a poor memory.622 90.41 The spreadsheet produced on the night of the fire by David Noble623 based on information held on the TMO’s Capita Insight system624 did not identify Sheila as having any vulnerability. Events of 14 June 2017 90.42 Sheila returned to the tower at 14.22 on 13 June 2017. She does not appear to have left her flat again.625 She usually went to bed between 20.00 and 21.00 and wore an eye mask and ear plugs.626 90.43 It is possible that Sheila never became aware of the fire. CM Stern and FF Hippel reached floor 16 sometime before 01.38,627 but there is no evidence that she was aware of their presence. Sheila is not known to have made any telephone calls to friends or family. Nor did she make any calls to the emergency services. 90.44 Despite the repeated emergency calls made by Sener Macit in Flat 133 and the information reaching the incident ground about a man (Joseph Daniels) and a woman (Sheila) still on floor 16, only two crews were deployed there after CM Stern and FF Hippel. CM Diana and FF Nelson tallied out at 03.24628 but stopped before reaching floor 16 to assist other occupants to escape. They reported back to the bridgehead.629 SM Gareth Cook and CM Ben Gallagher tallied out at 04.04. They were sent to investigate reports of 10 people trapped in a flat on floor 16, but a shortage of air prevented them from reaching it.630 617 Phase 1 Report Volume IV paragraph 32.257. 618 Tenancy Agreement {TMOH00018942}. 619 Presentation relating to Sheila {Day304/58:24}-{Day304/59:18}. 620 Smith {COR00001396/4} page 4. 621 Video footage of the meeting with residents on 17 July 2015 {MET00078076}. 622 Rydon Residents Survey {RYD00024466/21}. 623 Noble {TMO00000884/1} page 1, paragraph 3. 624 Noble {Day119/77:17}-{Day119/82:5}. 625 O’Riordan {MET00013136/2} page 2. 626 Smith {COR00001396/4} page 4. 627 Phase 1 Report Volume II paragraph 10.101 (c). 628 BA Telemetry Data {LFB00023326/2} page 2. 629 Diana {MET00018800/8-12} pages 8-12; Nelson {MET00010926/4-9} pages 4-9; Phase 1 Report Volume III paragraph 18.20 (b). 630 Phase 1 Report Volume III paragraph 19.9; Cook {MET00007882/14-15} pages 14-15.

Part 9 | Chapter 90: Floor 16 77 90.45 Neither crew was briefed to find Sheila and neither crew reached floor 16. Even if they had done so and had been able to search it, it is likely that Sheila would already have been dead. Recovery and identification 90.46 Sheila’s remains were recovered from the bedroom of Flat 132. She was lying on her back with her head towards the window and near the remains of the mattress, indicating that she had probably been in bed when she died.631 The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.632 Cause and time of death 90.47 The post-mortem examination on Sheila found that it was not possible to obtain samples suitable for toxicology analysis.633 Although the examination concluded that it was not possible to give a definite cause of death, the medical cause of death was recorded as “consistent with the effects of fire”, but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”. 90.48 Sheila was in her bedroom throughout the fire. By 02.22, the fire was outside the living room and by 02.29 it had spread across the outside wall of that room. Between 03.09 and 03.17 it had begun to spread across the outside of the bedroom.634 From the time the fire reached floor 16, Sheila was exposed to an increasing level of asphyxiant gases infiltrating her home, initially from the lobby. That exposure and the rate of absorption of asphyxiant gases increased rapidly once the fire reached the outside of her bedroom.635 Given her prolonged exposure to asphyxiant gases, Sheila may have been unconscious before the fire reached her bedroom. If not, she became unconscious shortly after. She then continued to inhale asphyxiant gases until she died sometime between 03.09 and 03.30.636 90.49 We are satisfied that Sheila died through the inhalation of asphyxiant gases before suffering any direct effects of flames entering her bedroom. 631 Purser, Phase 2 Report, Section 6 {DAPR0000006/130} paragraph 702; Presentation relating to Sheila {Day304/68:14-19}. 632 Interim certificate of the fact of death for Shiela {MET00065609}. 633 Sheila post-mortem report {COR00001397}. 634 Purser, Phase 2 Report, Section 6 {DAPR0000006/129} paragraphs 696-698. 635 Purser, Phase 2 Report, Section 6 {DAPR0000006/129} paragraphs 699-701. 636 Purser, Phase 2 Report, Section 6 {DAPR0000006/130} paragraphs 704-705.

The Grenfell Tower Inquiry: Phase 2 Report 78

79 91.1 All six flats on floor 17 were occupied at the time of Behailu Kebede’s telephone call to the emergency services.637 By 01.30, the occupants of Flats 141, 143, 145 and 146 had left the building safely,638 apart from Khadija Khalloufi, who died on floor 10.639 Those residents who remained on floor 17, Kamru Miah, his wife, Rabeya Begum, and their adult children Mohammed Hamid, Mohammed Hanif and Husna Begum, all of whom lived in Flat 142, and Vincent Chiejina, who lived in Flat 144, all died in the fire. 91.2 Rita Tankarian, her nephew, Mesrob Kassemdijan, and his girlfriend, Fung Hee-Cheung, were in Flat 141 and were the first to leave floor 17. Although Rita Tankarian and Mesrob Kassemdijan could smell smoke in the lobby on floor 17, none was visible.640 They left the tower between 01.25 and 01.26.641 91.3 The fire reached the outside of Flat 146 at about 01.24.642 Virgilio (Larry) Castro lived there with his friend, Genaro Batoan. His girlfriend was also staying that night. Shortly before he and his girlfriend followed Genaro Batoan out of the flat, Larry Castro saw flames coming through the extractor fan in the kitchen window. The door to Flat 146 needed to be pulled shut as the self-closing device did not work effectively. Larry Castro thought that he had not pulled it shut. The black smoke that then came into the lobby made him cough.643 91.4 On leaving Flat 145, Corinne Jones saw Larry Castro outside his front door. Thick black smoke was coming from the top of the door and moving along the ceiling. She briefly went back into her flat and on returning to the lobby found that the amount of smoke had increased significantly.644 She and Larry Castro both left the tower at 01.30.645 91.5 At 01.29, Husna Begum made an emergency call which was connected to the police. She reported that there was smoke coming into the flat, that flames could be seen outside, and that the fire was “in the house right next to us”.646 Like Flat 146, Flat 142 was on the east side of the tower. 91.6 It is likely that the lobby of floor 17 rapidly filled with smoke within a few minutes after the fire reached the outside of Flat 146 and then entered it. The contents of Flat 146 were alight between 02.19 and 02.25.647 91.7 The kitchen window of Flat 142 faced east; its living room windows faced south and east. The bedroom windows faced south.648 By about 02.23, the fire was outside the kitchen of Flat 142. By about 02.31, having spread south, it covered the entire east side of the flat. 637 Phase 1 Report Volume II paragraph 10.15. 638 Phase 1 Report Volume III Annex A. 639 See Chapter 86. 640 Phase 1 Report Volume II paragraphs 10.239-10.240. 641 Phase 1 Report Volume III Annex A. 642 Phase 1 Report Volume II paragraph 10.118. 643 Phase 1 Report Volume II paragraphs 10.242-10.243; Phase 1 Report Volume VI paragraph 24.31 (e). 644 Phase 1 Report Volume II paragraphs 10.244-10.245. 645 Phase 1 Report Volume II paragraphs 10.239-10.240. 646 Phase 1 Report Volume II paragraph 10.247. 647 Lane, Supplemental Phase 1 Report, Section 12 {BLAS0000012/19} paragraph 12.3.17. 648 External Spread of Fire Report {MET00012593/12} page 12. Chapter 91 Floor 17

The Grenfell Tower Inquiry: Phase 2 Report 80 By 02.48, the fire had reached the south-facing windows of the living room. By 03.20 the fire was well established on the south face of Flat 142, affecting both the living room and bedroom windows. By 03.33, it had almost ceased outside the east and south faces of the flat and had spread west to Flat 143.649 The evidence does not suggest that the contents of Flat 142 were alight at 03.33.650 91.8 Flat 144 was a one-bedroomed flat situated on the west side of the tower.651 By 03.39 the fire was approaching the bedroom of Flat 144 and by 03.44 it was established outside it. By 03.58, the fire was outside the kitchen and was beginning to affect the living room. Flames continued to burn outside the living room but by about 04.30 they had ceased.652 91.9 Following Husna Begum’s emergency call at 01.29, the occupants of Flat 142 made three more emergency calls in the period up to 03.18. Those were the only emergency calls made from floor 17. None resulted in the deployment of firefighters. The Miah / Begum family Kamru Miah Date of birth: 12 August 1937 (79 years of age). Place of birth: Sylhet, Bangladesh. Gender:

Male. Occupation: Retired. Usual address: Flat 142, floor 17, Grenfell Tower, London. Place of death: Flat 142, floor 17, Grenfell Tower, London. Time of death: Between 03.20 and 03.33 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Ischaemic heart disease. Rabeya Begum Date of birth: 15 November 1952 (64 years of age). Place of birth: Bangladesh. Gender:

Female. Occupation: Homemaker. Usual address: Flat 142, floor 17, Grenfell Tower, London Place of death: Flat 142, floor 17, Grenfell Tower, London. Time of death: Between 03.20 and 03.33 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. 649 Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 640. 650 Purser, Phase 2 Report, Section 6 {DAPR0000006/118-119} paragraphs 640 and 648. 651 External Spread of Fire Report {MET00012593/12} page 12. 652 Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraph 667.

Part 9 | Chapter 91: Floor 17 81 Mohammed Hamid Date of birth: 19 January 1989 (28 years of age). Place of birth: London. Gender:

Male. Occupation: Sales Assistant. Usual address: Flat 142, floor 17, Grenfell Tower, London. Place of death: Flat 142, floor 17, Grenfell Tower, London. Time of death: Between 03.20 and 03.33 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Mohammed Hanif Date of birth: 20 February 1991 (26 years of age). Place of birth: London. Gender:

Male. Occupation: Sales Assistant. Usual address: Flat 142, floor 17, Grenfell Tower, London Place of death: Flat 142, floor 17, Grenfell Tower, London. Time of death: Between 03.20 and 03.33 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Husna Begum Date of birth: 4 February 1995 (22 years of age). Place of birth: London. Gender:

Female. Occupation: Sales Assistant. Usual address: Flat 142, floor 17, Grenfell Tower, London. Place of death: Floor 17, Grenfell Tower, London. Time of death: Between 03.20 and 03.33 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

The Grenfell Tower Inquiry: Phase 2 Report 82 Background and composition of household 91.10 Kamru Miah, his wife Rabeya Begum and three of their adult children, Mohammed Hamid, Mohammed Hanif and Husna Begum lived in Flat 142. The family had moved to Grenfell Tower in August 2016.653 Their eldest son, Mohammed Hakim, lived nearby but his wife, Farhana, was staying with his family in Flat 142. She was not there on the night of the fire.654 91.11 Kamru Miah was born on 12 August 1937 and was 79 years old. Respected within his community, he had moved to the United Kingdom in 1963 and was a retired baker and tandoori chef.655 Rabeya Begum was born on 15 November 1952 and was 64 years old. She came to London after marrying Kamru Miah. Committed to her family, she had devoted herself to raising the couple’s four children. 91.12 Mohammed Hamid was born on 19 January 1989 and was 28 years old. He spent much time caring for his father, who had suffered two strokes.656 Mohammed Hanif was born on 20 February 1991 and was 26 years of age. He was particularly creative with a talent for drawing and animation.657 Husna Begum was born on 4 February 1995 and was 22 years old. Like her mother she was an excellent cook and enjoyed creative writing.658 She was the youngest member of the family and the only daughter and was due to marry on 29 July 2017.659 All three siblings worked full-time in the retail sector.660 Vulnerability 91.13 Kamru Miah had previously suffered a heart attack and two strokes. He used a walking stick and easily got out of breath when walking.661 Before the family moved to Grenfell Tower, Rohema Khanom, the niece of Rabeya Begum, had helped her complete an assessment form on which they had recorded that Kamru Miah had suffered a heart attack and a stroke and could not manage stairs. Rohema Khanom had also attended a meeting in August 2016 with RBKC to interpret for her aunt and uncle. She recalled that her uncle’s health had been discussed at that meeting.662 91.14 The spreadsheet produced on the night of the fire by David Noble663 based on information held on the TMO’s Capita Insight system664 did not identify Kamru Miah as a vulnerable person. Events of 14 June 2017 91.15 The family were all at home on the night of the fire. Mohammed Hakim had visited them so they could break the Ramadan fast together. He left at about 22.00. On arriving at his home, he telephoned his mother at about 23.00.665 653 Hakim {IWS00000019/2} page 2, paragraph 4. 654 Phase 1 Report Volume IV paragraph 32.240. 655 Phase 1 Report Volume IV paragraph 32.241. 656 Phase 1 Report Volume IV paragraphs 32.242 and 32.248-32.249. 657 Phase 1 Report Volume IV paragraphs 32.242 and 32.251. 658 Phase 1 Report Volume IV paragraphs 32.242 and 32.252-32.253. 659 Hakim {IWS00000019/7} page 7, paragraph 21. 660 Hakim {IWS00000019/1} page 1, paragraph 3. 661 Khanom {COR00001147/7-8} pages 7-8; Hakim {IWS00000019/2} page 2, paragraph 6. 662 Khanom {COR00001147/2} page 2. 663 Noble {TMO00000884/1} page 1, paragraph 3. 664 Noble {Day119/77:17}-{Day119/82:5}. 665 Hakim {IWS00000019/3} page 3, paragraphs 9-10.

Part 9 | Chapter 91: Floor 17 83 91.16 At 01.29, Husna Begum made an emergency call that was connected to the police. She reported that smoke was entering the flat, that the family could see flames from a window and that the fire was in a nearby flat. She asked for help. The police operator told her that the LFB had been informed and that someone would be coming to help them. The sound of a smoke alarm could be heard in the background.666 The mention of the fire being in a nearby flat must be a reference to Flat 146 and it is clear that smoke had started to infiltrate Flat 142 from the lobby by the time of the call. 91.17 At 01.38, the police notified the LFB that a family of five were in Flat 142 on floor 17 and that smoke was coming into the flat. OM Alexandra Norman passed the information to CU8 at 01.43.667 91.18 How it then reached the bridgehead, then on floor 2, is unclear, but a note recording “17th Fl, 142 FSC” was written on a wall, probably on the second-floor mezzanine.668 While the bridgehead was on floor 2 WM Louisa De Silvo used a forward information board to record information about those awaiting rescue.669 Shortly before the bridgehead moved to floor 3 (at around 02.17), CM Charles Batterbee went to the bridgehead and copied the information on a forward information board into his own notebook.670 There was no reference to floor 17 and no deployment was made to that floor before the bridgehead moved to floor 3. Following that move, no information relating to Flat 142 was recorded on the wall on floor 3 used to record information about people needing to be rescued.671 91.19 At 02.27, Husna Begum made a second emergency call, speaking to CRO Heidi Fox in the LFB control room. She told CRO Fox that the family had been waiting for help for an hour and included two elderly adults. Husna Begum told her that the fire was right next to their window and that they were afraid they were going to die. CRO Fox told her that they were not going to die and that she would pass the information to the command unit.672 By that time the fire was outside the kitchen window of Flat 142.673 91.20 At 02.29, CRO Fox created a service request in relation to Flat 142 and CRO Sharon Darby then sent a radio message at 02.30 which referred to five adults, including two elderly persons, being trapped inside Flat 142.674 Although Husna Begum’s call at 02.27 probably explains the reference to Flat 142 which appears on the white laminated sheet used in CU7,675 there is no evidence about what happened to that information once it had been received by CU7,676 apart from the fact that it was recorded on a control information form.677 91.21 Having spoken to Husna Begum, who told her that there was a fire in the tower, Rohema Khanom made her way there. On the way she telephoned Husna Begum between 02.20 and 02.50 and then spoke to Rabeya Begum, who told her that the fire was now in 666 999 call transcript {INQ00000264}; Phase 1 Report Volume II paragraph 10.247; Phase 1 Report Volume IV paragraph 28.102 (a). 667 Phase 1 Report Volume IV paragraphs 28.102 (b) and 28.102 (c). 668 Photograph of notes made by LFB on walls inside Grenfell Tower {MET00005789}. 669 Phase 1 Report Volume II paragraphs 13.52-13.53. 670 Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c). 671 Phase 1 Report Volume IV paragraph 28.102 (c); Phase 1 Report Volume II Figure 15.7. 672 999 call transcript {LFB00000354}; Phase 1 Report Volume III paragraph 15.85; Phase 1 Report Volume IV paragraph 28.102 (d). 673 Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 640. 674 Phase 1 Report Volume III paragraph 15.149; LFB radio message {LFB00002784}. 675 Phase 1 Report Volume II paragraphs 12.8-12.9; Phase 1 Report Volume IV paragraphs 28.86 and 28.102 (f). 676 Phase 1 Report Volume IV paragraph 28.102 (e). 677 LFB Control Information Forms {LFB00001955/12} page 12. The forms were used at the incident ground to record messages about people needing to be rescued.

The Grenfell Tower Inquiry: Phase 2 Report 84 the flat. Her aunt said that the family were all in the bedroom used by Mohammed Hanif and Mohammed Hamid. She then returned the phone to Husna Begum, who said it was pitch black in the flat, before ending the call.678 By that time the fire covered the entire east side of Flat 142.679 91.22 At about 03.00, Rohema Khanom spoke to Mohammed Hanif, who told her that the family were all together.680 91.23 Husna Begum called her brother Mohammed Hakim at 03.08. She told him about the fire and said that the family were trapped in the flat. She said she did not think she would survive. She then ended the call.681 Mohammed Hakim then tried to call all five members of his family, but the calls all went to voicemail.682 91.24 At 03.09, CRO Adams answered an emergency call from Husna Begum and one of her brothers. That was the third such call from Flat 142. Husna Begum told CRO Adams that there were five people in the flat and that there was fire in the kitchen and the hallway. There is no record of the call being passed to CU7. CRO Adams advised them to leave but was told that it was not possible to do so as the smoke in the stairs was too thick.683 That suggests that the family must have tried at some point to leave Flat 142. 91.25 Husna Begum also spoke to Rohema Khanom again, but we do not know when. She told Rohema Khanom that it was smoky and dark and that she could not see anything. She was having difficulty breathing and was coughing continuously.684 91.26 The fourth and last emergency call from Flat 142 was made at 03.18. Husna Begum spoke again to CRO Fox, who advised the family to leave. Husna Begum said that they were unable to do so because it was too hot outside the door, probably meaning in the lobby. She said that there were five adults in the flat, including two elderly people, and that they were near the front door. Husna Begum asked for someone to come to the flat. CRO Fox said that she would pass the information on by radio. However, there is no entry on the LFB Short Incident Log of any service request to that effect and no other record of any radio call.685 After that, no one in Flat 142 contacted the emergency services or anybody else outside the tower.686 91.27 The second of the two whiteboards used by SM Jason Oliff to collate information in the LFB control room to pass to the command units contained a reference to Flat 142.687 It is likely, in view of its low position on the second whiteboard, that that reflected one of the later calls made by Husna Begum at 03.09 and 03.18. Flat 142 also appeared on the whiteboard grid on CU7, showing five persons and a “P” for priority, which might have indicated the presence of elderly persons. The photograph of the whiteboard grid was taken between about 03.15 and 04.00. It is therefore at least possible that it recorded the information given in Husna Begum’s call at 03.18.688 678 Phase 1 Report Volume III paragraph 15.84. 679 External Spread of Fire Report {MET00012593/77} Image 25 (applying a +58 minutes time correction); Lane, Supplemental Phase 1 Report, Section 12 {BLAS0000012/10} Figure 12.3; Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 640. 680 Phase 1 Report Volume III paragraph 17.76. 681 Phase 1 Report Volume III paragraph 17.76. 682 Hakim {IWS00000019/1} page 5, paragraph 15. 683 Phase 1 Report Volume III paragraph 17.77; Phase 1 Report Volume IV paragraph 28.102 (h). 684 Phase 1 Report Volume III paragraph 17.76. 685 999 call transcript {LFB00000419}; Phase 1 Report Volume IV paragraph 28.102 (i). 686 Phase 1 Report Volume III paragraph 17.79. 687 Phase 1 Report Volume III paragraphs 15.139-15.141 and Figures 15.8 and 15.9. 688 Phase 1 Report Volume IV paragraph 28.102 (j).

Part 9 | Chapter 91: Floor 17 85 91.28 By the time Husna Begum made her last call at 03.18 the bridgehead had been moved to the ground floor (at around 03.10). After that, a green wall by the stairs was used to record information about those needing to be rescued.689 A photograph of that wall taken at about 04.45 shows the number “142”.690 It is not clear when it was put there. 91.29 The last crew that would have been able to reach floor 17 or above consisted of FFs Michael Pole, Niki Mitchell and Chris Cheesman, who were deployed to floor 23 between 02.51 and 02.53. However, having stopped at floor 18 to help evacuate the occupants of Flat 153, they realised that they did not have enough air to reach floor 23.691 The last opportunity of rescue for the family in Flat 142 lay in the timely communication to the bridgehead of the information provided in Husna Begum’s second call at 02.27 and its being acted upon swiftly. The information did eventually arrive, but there is no evidence that it was acted on.692 Recovery and identification 91.30 The body of Husna Begum was recovered from the lobby of floor 17. Those of the other members of the family were recovered from the bedroom nearest the front door of Flat 142, which was the last area to be affected by the westward spread of the fire.693 The coroner, Professor Wilcox, was satisfied about the identification of the remains recovered, and therefore issued interim certificates of the fact of death for all five members of the family.694 91.31 Husna Begum probably tried to leave after making her call to the emergency services at 03.18. We do not know whether other members of the family also tried to leave at the same time but were forced to return to Flat 142 by the conditions they encountered. Cause and time of death 91.32 It is possible that until the time of the last emergency call, the family in Flat 142 were able to reduce their exposure to asphyxiant gases by keeping a bedroom window open.695 However, once the fire had reached the window of the bedroom where they were sheltering, conditions in the room deteriorated rapidly within a few minutes.696 The fire had reached the bedrooms of Flat 142 by 03.20 and had passed them by 03.33.697 In the circumstances, we are satisfied that Kamru Miah, Rabeya Begum, Mohammed Hamid and Mohammed Hanif all died at some time between 03.20 and 03.33. 91.33 Husna Begum’s last emergency call to CRO Fox lasted one minute and 20 seconds.698 By then the fire was affecting both the living room and bedroom windows on the south side of Flat 142.699 It is likely that from about 01.29 to 03.20, Husna Begum (and indeed the other members of her family) was increasingly exposed to asphyxiant gases. Husna Begum 689 Phase 1 Report Volume IV paragraph 28.87. 690 Mulholland Exhibit MBM/02 - Photograph of green wall {MET00018739}; Phase 1 Report Volume IV paragraph 28.102.(l). 691 See Chapter 92. 692 Phase 1 Report Volume IV paragraph 28.103. 693 Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 638. 694 Interim certificates of the fact of death for Kamru Miah, Rabeya Begum, Mohammed Hamid, Mohammed Hanif and Husna Begum {MET0006560}; {MET00065588}; {MET00065642}; {MET00065628}, {MET00065594}. 695 Purser, Phase 2 Report, Section 6 {DAPR0000006/118-119} paragraphs 645 and 646. 696 Purser, Phase 2 Report, Section 6 {DAPR0000006/119} paragraph 646. 697 Bisby, Phase 1 Expert Report {LBYR00000001/175} Figure 116; Lane, Supplemental Phase 1 Report, Section 12 {BLAS0000012/11} Figure 12.4; Purser, Phase 2 Report, Section 6 {DAPR0000006/118} paragraph 640. 698 LFB Operational Response Report dated July 2020 {LFB00119333/289} page 289. 699 Purser, Phase 2 Report, Section 6 {DAPR0000006/118} paragraph 640.

The Grenfell Tower Inquiry: Phase 2 Report 86 had therefore already been exposed to a significant level of asphyxiant gases while she remained in Flat 142. On leaving the bedroom where she had been sheltering with her family, she encountered a high concentration of smoke and gases in the hallway of Flat 142 and then in the lobby.700 91.34 We find that Husna Begum sought to leave Flat 142 shortly after she had made her last emergency call and while the fire was still outside the bedroom where the family was sheltering. We are satisfied that she also died between 03.20 and 03.33. 91.35 The remains of the members of the family found in Flat 142 were extensively charred.701 Heavy soot deposits were found in Kamru Miah’s airways. There was evidence of mild heat-related damage to the lining of the trachea which would have occurred while he was alive.702 Soot deposits were also found in the airways of Rabeya Begum703 and Mohammed Hamid.704 91.36 The level of carboxyhaemoglobin in a blood sample taken from Kamru Miah was 47%;705 that in a sample taken from Mohammed Hanif was 69%.706 Both are within the range associated with death from carbon monoxide poisoning. Toxicological analysis confirmed that Mohammed Hamid’s blood contained carboxyhaemoglobin but the concentration could not be measured.707 It was not possible to conduct a toxicological examination of Rabeya Begum.708 91.37 Given the high levels of carboxyhaemoglobin in Kamru Miah and Mohammed Hanif’s blood and the fact that the four members of the family were together in the bedroom, we find that they were all exposed to a level of asphyxiant gases which was so high that it caused loss of consciousness and death before their bodies suffered any serious effects of direct heat or fire.709 In Kamru Miah’s case, significant heart disease made him more vulnerable to collapse and death from the effects of asphyxiant gases.710 91.38 The body of Husna Begum was recovered intact. There was no obvious soot staining to her airways. Carboxyhaemoglobin appeared to be present in the blood, but it was not possible to measure the concentration due to the condition of the sample. There was significant heat damage to the body that is unlikely to have occurred while Husna Begum was still in Flat 142.711 700 Purser, Phase 2 Report, Section 6 {DAPR0000006/119-122} paragraphs 647 and 662-663. 701 Miah post-mortem report {COR00000814/4}; Rabeya Begum post-mortem report {COR00001322/5-6}; Hamid post- mortem report {COR00001153/4}; Hanif post-mortem report {COR00000812/4}; Purser, Phase 2 Report, Section 6 {DAPR0000006/119-121} paragraphs 649-652 and 657. 702 Miah post-mortem report {COR00000814/6-8}; Purser, Phase 2 Report, Section 6 {DAPR0000006/119} paragraph 650. 703 Rabeya Begum post-mortem report {COR000001322/8-9}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 652. 704 Hamid post-mortem report {COR00001153/4-5}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 653. 705 Miah toxicology report {COR00000822/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 651. 706 Hanif toxicology report {MET00039589/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 651. 707 Hamid post-mortem report {COR00001153/8}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 653. 708 Rabeya Begum post-mortem report {COR00001322/9}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 652. 709 Phase 2 Report, Section 6 {DAPR0000006/119-121} paragraphs 650-653 and 658. 710 Miah post-mortem report {COR00000814/8}; Purser, Phase 2 Report, Section 6 {DAPR0000006/119} paragraph 650. 711 Husna Begum post-mortem report {COR00000636/4}; Husna Begum toxicology report {COR00000642}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120-122} paragraphs 654, 659 and 664.

Part 9 | Chapter 91: Floor 17 87 91.39 Although the examining pathologist could not completely exclude the possibility that some heat damage had occurred before death, we think it more likely that it occurred after Husna Begum had died. We think that the extent of her exposure to asphyxiant gases (carbon monoxide with some hydrogen cyanide) and the physical exertion involved in leaving Flat 142 caused her to collapse and lose consciousness soon after entering the lobby. She continued inhaling those gases while unconscious and died shortly after.712 91.40 The medical cause of death in the case of Kamru Miah was recorded as: Ia. Inhalation of products of combustion. II. Ischaemic heart disease. In the light of Professor Purser’s evidence, we find that a more accurate description of the primary cause of death is “inhalation of asphyxiant gases”. 91.41 The post-mortems on Rabeya Begum, Mohammed Hamid, Mohammed Hanif and Husna Begum recorded the medical cause of death in each case as “consistent with effects of fire”. A more accurate description would be “inhalation of asphyxiant gases”. Vincent Chiejina Date of birth: 1 June 1957 (60 years old). Place of birth: Nigeria. Gender:

Male. Occupation: Retired. Usual address: Flat 144, floor 17, Grenfell Tower, London Place of death: Flat 144, floor 17, Grenfell Tower, London Time of death: Between 04.00 and 04.15 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 91.42 Vincent Chiejina was born on 1 June 1957 and was 60 years old at the time of the fire. He spent his early years in Nigeria before travelling to the United Kingdom with his mother, Magdalene, and his sister, Jindu Maria. The eldest of four siblings, Vincent Chiejina and his family had lived on the Lancaster West estate between 1974 and 1981. He studied Electrical and Electronic Engineering at Sheffield University.713 Vincent Chiejina had lived alone in Flat 144 on floor 17 of Grenfell Tower since February 2001.714 He was an active member of the Roman Catholic Church715 and a men’s group.716 712 Purser, Phase 2 Report, Section 6 {DAPR0000006/119-122} paragraphs 647 and 662-663. 713 Phase 1 Report Volume IV paragraphs 32.228-32.230; Chiejina {IWS00002348/2} page 2, paragraphs 6 and 10. 714 Tenancy Agreement for Vincent Chiejina {TMOH00025056}. 715 Presentation relating to Vincent Chiejina {Day307/27:17-18}. 716 Phase 1 Report Volume IV paragraph 32.232.

The Grenfell Tower Inquiry: Phase 2 Report 88 Vulnerability 91.43 Vincent Chiejina had a history of mental health difficulties. He had been diagnosed with schizophrenia, for which he received medication.717 Rydon’s survey of Grenfell Tower residents carried in November 2014 and provided to the TMO recorded that he suffered from learning disabilities and schizophrenia.718 91.44 The spreadsheet produced on the night of the fire by David Noble719 based on information held on the TMO’s Capita Insight system identified Vincent Chiejina as a vulnerable person but contained no information about his mental health or learning difficulty.720 Events of 14 June 2017 91.45 Vincent Chiejina remained in his home throughout the course of the fire. He did not contact the emergency services and there is no evidence of his having contact with anyone else, either inside or outside the tower.721 91.46 There is no direct evidence of what Vincent Chiejina did during the course of the fire but it is possible that he may have been awake for part of the time, since his remains were recovered from the living room rather than the bedroom. The living room was affected by the fire later than the bedroom and kitchen.722 Recovery and identification 91.47 The remains of Vincent Chiejina were recovered from the living room of Flat 144 close to the window.723 The coroner, Professor Wilcox, was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.724 Cause and time of death 91.48 The post-mortem on Vincent Chiejina recorded that he had mild coronary heart atheroma (heart disease). His remains were extensively charred. Soot was found in his respiratory system, including the lungs. There was evidence of damage to the lungs which could have been caused by the inhalation of hot smoke.725 Toxicological analysis of a sample of his blood showed a carboxyhaemoglobin level of about 39%, but that must be regarded as little more than an estimate because of the condition of the sample.726 91.49 Over the course of the fire, the quantity of smoke in Flat 144 increased, with smoke initially penetrating the flat from the lobby from about 01.30. The rate at which smoke entered the flat increased from about 03.44, when the fire became established outside the bedroom before spreading to the outside of the kitchen.727 717 Chiejina {IWS00002348/2} page 2, paragraphs 11-13. 718 Rydon Residents Survey {RYD00024466/18}. 719 Noble {TMO00000884/1} page 1, paragraph 3. 720 Noble spreadsheet {TMO00862588}. 721 Phase 1 Report Volume II paragraph 11.64. 722 Purser, Phase 2 Report, Section 6 {DAPR0000006/122} paragraph 666. 723 Purser, Phase 2 Report, Section 6 {DAPR0000006/122} paragraph 665. 724 Interim certificate of the fact of death for Vincent Chiejina {MET00065620}. 725 Chiejina post-mortem report {COR00001473/10}; Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraphs 669-670. 726 Chiejina toxicology report {COR00001483/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraphs 669-670. 727 Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraph 672.

Part 9 | Chapter 91: Floor 17 89 91.50 Vincent Chiejina was therefore exposed to a rising level of asphyxiant gases that increased even more when the fire reached the outside of his living room at about 03.58, resulting in a rapid deterioration of conditions in that room. The level of carboxyhaemoglobin in his blood indicates that he inhaled a considerable amount of asphyxiant gases before his death, probably sufficient to cause a loss of consciousness within minutes. The exposure to asphyxiant gases could of itself have been sufficient to cause death. The inhalation of hot gases before death may have contributed by causing breathing difficulties, again leading to rapid collapse followed shortly thereafter by death due to asphyxia.728 It is possible that Vincent Chiejina’s mild heart disease increased his susceptibility to carbon monoxide.729 91.51 The post-mortem report recorded the medical cause of death as “inhalation of products of combustion” but in the light of more recent evidence we consider that a more accurate description is “inhalation of asphyxiant gases”. 91.52 We are satisfied that Vincent Chiejina died between 04.00 and 04.15 before suffering the direct effects of heat or fire.730 728 Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraphs 670 and 673-674; Purser {Day297/102:13} -{Day297/103:18}. 729 Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraph 670; Purser {Day297/103:19}-{Day297/104:11}. 730 Purser {Day297/99:3}-{Day297/103:18}.

The Grenfell Tower Inquiry: Phase 2 Report 90

91 92.1 All six flats on floor 18 were occupied when Behailu Kebede made an emergency call to report a fire in his flat.731 By 01.26, the fire had reached the outside of Flat 156 on floor 18,732 the home of Shah Ahmed and his wife, Sayeda Ahmed. Woken by smoke alarms, Shah Ahmed saw fire outside his kitchen window, which then appeared to explode inward. He called the emergency services at 01.27 and was connected to the police. He was not able to speak to the operator before leaving with his wife. Together they knocked on their neighbours’ doors. Shah Ahmed left the door of his home shut. He and his wife then left floor 18, leaving the tower by 01.31.733 92.2 Rabia Yahya, who was in Flat 152 with her children, heard a knocking at her door. When she opened it she saw Shah and Sayeda Ahmed by the door to the stairwell. Sayeda Ahmed warned her of the fire and told her to leave.734 Shortly after Shah and Sayeda Ahmed had raised the alarm, Hamid Kani, who lived alone in Flat 154, Sakina Afrasehabi and her sister, Fatemeh Afrasiabi, who was staying with her in Flat 151, left their homes. Berkti and Biruk Haftom, who lived in Flat 155, may have decided to leave even before the Ahmeds alerted their neighbours.735 They all died, having sought refuge on floor 23. We return to the circumstances of their deaths in Chapter 97. 92.3 At 01.33, Rabia Yahya made a call to the emergency services which was put through to the LFB. She told CRO Angela Gotts that she was pregnant and trapped on floor 18 with her three children. Rabia Yahya was not asked for the number of her flat. She reported that she had been unable to leave because of thick black smoke which, she later recalled, had been in the stairwell. Rabia Yahya was advised to stay in her flat.736 At 01.36, CRO Gotts created a service request in response to that call, recording that the caller was on floor 18.737 OM Alexandra Norman and CRO Sharon Darby then told WM Daniel Meyrick in CU8 and the crew in appliance G261 that there was a person trapped on floor 18.738 At 01.43, during the course of a radio exchange with CU8, CRO Darby again passed on information about a caller on floor 18 with thick smoke outside her flat.739 At 01.45, CRO Darby recorded the service request as complete.740 92.4 WM Mark Kentfield recorded the information reaching CU8 on pieces of paper, which were then passed to SM Brett Loft positioned outside the tower.741 They included the A4 sheet of paper that later became known as the “Sadler envelope”. The last entry in that document reads “152 – 18th pregnant”.742 How the information passed from SM Loft to 731 Phase 1 Report Volume II paragraph 10.15. 732 Phase 1 Report Volume II paragraph 10.118. 733 Phase 1 Report Volume II paragraphs 10.249-10.250; Phase 1 Report Volume III Annex A. 734 Phase 1 Report Volume II paragraph 10.251. 735 Phase 1 Report Volume II paragraphs 10.254, 10.289 and 14.125. 736 Phase 1 Report Volume II paragraph 11.59; 999 call transcript {LFB00000662/1-2} pages 1-2. 737 Short Incident Log Report {MET00013830/19} page 19. 738 Phase 1 Report Volume II paragraphs 11.148-11.154. 739 Phase 1 Report Volume II paragraphs 12.72-12.73. 740 Short Incident Log Report {MET00013830/19} page 19. 741 Phase 1 Report Volume II paragraph 11.6; Phase 1 Report Volume IV paragraph 28.84 (a). 742 Phase 1 Report Volume II paragraphs 12.18-12.19 and 14.71 and Figure 12.4. Chapter 92 Floor 18

The Grenfell Tower Inquiry: Phase 2 Report 92 the bridgehead is unclear.743 A photograph taken by FF Justin O’Beirne shows that after the bridgehead had moved to floor 3 there was written on the wall “18 MOTHER +CHLD NO FLAT NUMBER” followed by the number 152 circled. The number 18 was ticked.744 92.5 In any event, as a result FFs Katie Foster and Gregory Lawson were deployed at 01.53 to floor 18 in general rather than to a specific flat or to find a pregnant resident.745 The crew probably reached floor 18 at or shortly after 02.00. By then, just two flats, adjacent to each other on the south side of floor 18, remained occupied. Rabia Yahya and her children were still in Flat 152. Yehualashet Enyew, Berkti Haftom’s lodger, had moved from Flat 155 to Flat 153 to join Paulos Tekle, Genet Shawo and their two sons.746 92.6 When they arrived at floor 18, FFs Foster and Lawson found the visibility in the lobby to be restricted by thick black smoke. They conducted a sweep of the floor. The door of the first flat they reached (Flat 151) was locked. When they reached Flat 152, they spoke to Rabia Yahya inside her home, which was still clear of smoke. They told her that they would check on neighbouring flats and get everyone out together. She was advised to put damp blankets against her front door.747 FFs Foster and Lawson then moved to Flat 153. When Yehualashet Enyew opened the front door, Paulos Tekle was sitting on the ledge of a sitting room window. He moved back into the flat to speak to the firefighters. Their advice was again to block up the front door. Those in Flat 153 then covered the letterbox and front door and sat down to wait.748 92.7 FFs Foster and Lawson then searched Flat 154 followed by Flat 155. They found the doors to both flats open and their interiors to be pitch black and full of smoke. The door of Flat 156 was closed and they decided not to force an entry, given the indication that there was now fire inside.749 The crew concluded that conditions were too difficult to enable them to rescue the nine remaining occupants on floor 18 at that time. They both tried to contact the bridgehead by radio but without success. As they were running low on air, they made their way down the stairs without returning to Flat 152 or 153.750 92.8 The fire reached Flat 152 by about 02.22.751 Rabia Yahya thought that the fire had broken into her kitchen at about 02.30. She immediately left with her children and went to Flat 153. She found conditions in the lobby worse than when she had answered the door to FFs Foster and Lawson. The lobby felt hot and visibility was so poor that she had to use the wall as a guide. There was no smoke in Flat 153 when she arrived there.752 92.9 By about 02.30, all those remaining on floor 18 were sheltering in Flat 153. The fire brigade was aware that there were people there, both from information provided by FF Lawson when he returned to the bridgehead and from calls to, and between, the emergency services. However, no more firefighters were sent to floor 18 until shortly after 03.00 and those then deployed had to abandon their task. At about the same time, those in Flat 153 left the building. During the descent from floor 18, Isaac Paulos became separated from the group and died shortly afterwards. 743 Phase 1 Report Volume IV paragraph 28.84 (b). 744 O’Bierne {MET000083321/19} page 19; Phase 1 Report Volume III Figure 16.6. 745 Phase 1 Report Volume II paragraph 13.47. 746 Phase 1 Report Volume II paragraphs 11.60-11.62 and 14.180-14.181. 747 Phase 1 Report Volume II paragraphs 13.51, 13.67, 14.181 and 14.182. 748 Phase 1 Report Volume II paragraphs 13.49 and 14.184-14.186. 749 Phase 1 Report Volume II paragraph 13.50. 750 Phase 1 Report Volume II paragraphs 13.51 and 14.182. 751 Phase 1 Report Volume III paragraph 15.3. 752 Phase 1 Report Volume III paragraphs 15.79-15.81.

Part 9 | Chapter 92: Floor 18 93 Isaac Paulos Date of birth: 22 September 2011 (5 years old). Place of birth: London. Gender:

Male. Occupation: N/A. Usual address: Flat 153, floor 18, Grenfell Tower, London. Place of death: Lobby of floor 13, Grenfell Tower, London Time of death: Between 03.09 and 03.15 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 92.10 Isaac Paulos lived in Flat 153 with his mother, Genet Shawo, and his younger brother. His father, Paulos Tekle, did not live in Grenfell Tower but visited almost every day.753 Isaac loved Taekwondo, swimming, and football. His teachers described him as especially gifted at maths and reading.754 Vulnerability 92.11 Apart from his age, Isaac Paulos was not known to have any vulnerabilities. He was recorded as a child in the spreadsheet produced on the night of the fire by David Noble.755 Events of 14 June 2017 92.12 Isaac Paulos returned home from a Taekwondo session at about 18.30 on 13 June 2017.756 The family spent the evening together.757 At some time after the fire had started, his parents were woken by sounds from the lobby. Opening the front door, they saw Rabia Yahya, who told them about the fire.758 That conversation must have occurred just after Rabia Yahya had spoken to Sayeda Ahmed and before 01.32 when Paulos Tekle telephoned his friend Abraham Abebe who lived in Flat 44.759 At 01.43, Genet Shawo spoke to Hashim Kedir, who lived in Flat 192. He told her that he had been advised by the emergency services to remain in his flat. He advised her to do the same.760 Information to the incident ground after 02.30 92.13 After leaving floor 18, FFs Foster and Lawson returned to the bridgehead, which by that time was on floor 3.761 Their end of wear time was 02.27.762 FF Lawson gave a debrief, drawing a plan on a wall to indicate which flats on floor 18 the crew had visited and which they had found empty. He also explained why they had not brought anyone down and 753 Tekle {IWS00001051/1-2} pages 1-2, paragraph 5. 754 Phase 1 Report Volume IV paragraphs 32.214-32.217. 755 Noble {TMO00000884/1} page 1, paragraph 3; Noble {Day119/75:19-21}; Noble spreadsheet {TMO00862588}. 756 O’Riordan {MET00013136/3} page 3. 757 Tekle {IWS00001051/3-4} pages 3-4, paragraphs 11-14. 758 Phase 1 Report Volume II paragraph 10.252. 759 Phase 1 Report Volume II paragraph 10.252. The call was not answered. 760 Phase 1 Report Volume II paragraph 11.61. 761 Phase 1 Report Volume III paragraph 17.11; Phase 1 Report Volume IV paragraph 28.86. 762 Phase 1 Report Volume III paragraph 15.31.

The Grenfell Tower Inquiry: Phase 2 Report 94 that it was necessary to send more crews to floor 18 immediately.763 A photograph taken by SM Gareth Cook at 03.08764 shows that the information recorded on a wall of floor 3 while the bridgehead was located there included the following: “18 MOTHER + CHILD, NO FLAT NO 152” with a tick next to the number 18 and with “152” circled.765 A tick against a particular flat indicated that a crew had been sent there and a circle indicated that the bridgehead had received further information by runner or radio or from a returning crew.766 That information related to the deployment of FFs Foster and Lawson. 92.14 Leaving the bridgehead, FF Lawson went out through the ground floor lobby. There he spoke to CM Charles Batterbee, drawing another plan of floor 18 and repeating the information that he had given at the bridgehead. He did not see what CM Batterbee did with the information.767 CM Batterbee recalled that FF Lawson had given him the numbers of two flats. CM Batterbee’s recollection was that those flats were on floor 18. He wrote the information on a piece of paper and WM Glynn Williams then wrote it on the wall of the ground floor lobby. The information was then passed to WM Paul Watson who took it to the bridgehead.768 92.15 Three control information forms contain information that relates to floor 18. The first refers to about four people being in Flat 153. The second, timed at 03.01, refers to Flat 153 but also records “People in Flat C+B waiting by window. CAME FROM BA CREW.” (The form then names FF Lawson as the source of information. A note in a different hand referring to four adults and 5 children appears on the blue copy of the form). The third (a yellow copy) is timed at 03.02 and refers (wrongly) to a family waiting in Flat 154. Again, FF Lawson is given as the source of the information.769 The references to Flats 153 and 154 may explain why those flats were recorded by CM Batterbee.770 92.16 WM Williams had begun putting information on the ground floor wall at about 02.15.771 Photographs of that wall772 taken at a later stage show that it included references to Flats 154, 153 and 152. The letters “BA” appear against each flat number with ticks next to 153 and 152. All three flats are linked by a bracket to Floor 18 (written as “18th”). A reference to four people is written by Flat 152 (i.e. Rabia Yahya and her three children). These details reflect information provided by FF Lawson. 92.17 FF Lawson’s debrief did not prompt any further deployment to floor 18. 92.18 Rabia Yayha and her children had reached Flat 153 by 02.32, when Paulos Tekle made an emergency call reporting that there were four adults and five children in his flat. He told CRO Yvonne Adams that the fire was coming nearer and that they could not leave. CRO Adams told him that everyone should move to the room with the least smoke, that the fire service would get to them as soon as possible and that he should ring back if 763 Phase 1 Report Volume III paragraph 15.31. 764 Cook Exhibit GAC/2 - Grenfell Tower statement notes {MET00015779/16} page 16. 765 Phase 1 Report Volume III Figure 15.7. 766 De Silvo {Day30/31:13}-{Day30/32:17}. 767 Phase 1 Report Volume III paragraph 15.32. 768 Batterbee {Day12/156:4}-{Day 12/158:25}. 769 Control Information Forms {LFB00001955/21-26} pages 21-22 and 26. The forms were used at the incident ground to record messages about people needing rescue. 770 Phase 1 Report Volume II paragraph 14.73. 771 Phase 1 Report Volume II paragraph 14.103. 772 Wolfenden Exhibit PFW/2 - Photograph of ground floor wall {MET00017597}; De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}.

Part 9 | Chapter 92: Floor 18 95 conditions got worse. Paulos Tekle later recalled that there had been no smoke or fire in Flat 153 at the time but that he had been able to see flames outside coming from the direction of Flat 152.773 92.19 Paulos Tekle’s call to the emergency services overlapped with a similar call made by Rabia Yahya at 02.34. She told CRO Heidi Fox that she was in Flat 153 and that the fire had reached Flat 152. CRO Fox told her that they should all try to leave. Rabia Yahya said they could not do so because of the thick black smoke and added that the firefighters had said they would return but had not done so. When asked who was there, Rabia Yahya told CRO Fox that there were four adults and five children sheltering in Flat 153 and that she was pregnant. CRO Fox said that she would alert the command unit to go to them.774 92.20 Although no service request was created following Paulos Tekle’s call at 02.32,775 CRO Fox did create one at 02.40 following the call from Rabia Yahya and repeated it a minute later. However, neither call led to a radio message being sent to the incident ground.776 References to both calls appear on the whiteboards used from about 02.33 by SM Jason Oliff to collate information coming into the LFB control room. It is likely therefore that he passed information about Flat 153 to the incident ground by mobile telephone.777 92.21 Paulos Tekle made another call to the emergency services at 02.35 which was taken by CRO Peter Duddy. He did not respond to CRO Duddy’s requests for information and the line then dropped out.778 Shortly after, at 02.42, a further call from someone in Flat 153 was connected to the control room. The caller was probably Yehualashet Enyew. He told CRO Gotts that there were about nine people in the flat, that smoke was coming in and that the fire had reached Flat 152. Her advice was to block out the smoke if they could not leave and that the fire service would be informed to come and find them.779 The call did not result in a service request. 92.22 At 02.45, CRO Christine Howson took a call from the police passing on information that three children and a pregnant woman were still in Flat 152 on floor 18.780 That information, which plainly referred to Rabia Yahya and her children, had come from calls to the police made from outside the tower.781 Shortly afterwards, at 02.47, CRO Gotts took a call from a relative of Rabia Yahya who was concerned that her sister-in-law was trapped on floor 18. The caller did not give the number of the flat. CRO Gotts replied that the control room had just received a message about floor 18 and told the caller that, if she spoke to Rabia Yahya, she should tell her to leave.782 92.23 That information from these calls reached the incident ground is apparent from the white laminated sheet used in CU7 to collate information.783 It contained the following notations: “152 18 3 kids, 1 PREGNANT adult”. There is a red asterisk next to the entry. And a little lower: “151 18 3 kids, 1 adult” 773 Phase 1 Report Volume III paragraph 15.82; 999 call transcript {LFB00000361/5-6} pages 5-6. 774 Phase 1 Report Volume III paragraph 15.81; 999 call transcript {LFB00000365}. 775 Phase 1 Report Volume III paragraph 15.152. 776 Phase 1 Report Volume III paragraphs 15.152 and 15.173; Short Incident Log Report {MET00013830/23} page 23. 777 Phase 1 Report Volume III paragraphs 15.139-15.141, 15.152 and 15.173 and Figure 15.8. 778 999 call transcript {LFB00000362}. 779 999 call transcript {LFB00000371}. 780 999 call transcript {LFB00000541}. 781 999 call transcripts {INQ00000265}; {INQ00000266}. 782 999 call transcript {LFB00000542}. 783 Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3.

The Grenfell Tower Inquiry: Phase 2 Report 96 And as the last entry: “153 18 4 adults 5 children can’t escape”.784 92.24 At 02.48, CRO Howson answered a call in which Rabia Yahya said that they were trapped in Flat 153 on floor 18. When told that the fire had reached Flat 152, CRO Howson told her that the fire service would not be able to reach the flat and that its occupants should leave.785 They spoke over each other at the relevant point in the call, so Rabia Yahya can only be heard saying that there were four people in Flat 153.786 92.25 At about that time, radio messages were being exchanged between CRO Sharon Darby and CU7, during which she said that about four people were trapped in Flat 153.787 The calls from Yehualashet Enyew at 02.42 and Rabia Yahya at 02.48 were probably the source of the information. 92.26 At 02.51, Essex Fire and Rescue Service received a call from Paulos Tekle, who reported that smoke was entering Flat 153. CRO Russ White told him to block out the smoke, to try to get some fresh air, or to leave if it was safe to do so.788 Having been advised by the LFB control room that callers from the tower should be told to leave, CRO White telephoned Paulos Tekle at 02.54 and left a message telling him that he and his family should cover themselves with wet towels and try to leave. He repeated that advice when he spoke to Paulos Tekle at 02.56.789 Those in Flat 153 began to collect wet towels. 92.27 At 03.02, as the occupants of Flat 153 were preparing to leave, CRO Duddy telephoned Paulos Tekle to tell him that everyone in the flat had to leave.790 At the same time, FF Joe Worley set out791 together with three other firefighters to rescue a family of four from Flat 153 on floor 18.792 However, the crew had to be stood down shortly after as they did not have extended duration breathing apparatus.793 That deployment was probably prompted by the radio message sent by CRO Darby at 02.48. 92.28 From about 03.00, the crew of CU7 began recording information on a whiteboard using a grid system.794 At some point they became aware that there were nine people in Flat 153, which was marked as a priority.795 The evacuation of Flat 153 92.29 Yehualashet Enyew was the first to leave Flat 153 holding Isaac Paulos by the hand. Rabia Yahya and her children followed. Paulos Tekle, carrying his youngest son, and Genet Shawo were at the rear of the group as they all left.796 92.30 Coincidentally, a group of firefighters arrived on floor 18 at that time. FFs Michael Pole, Niki Mitchell and Chris Cheesman had tallied out at 02.53, to go to floor 23. As they went up the stairs, the crew realised that they would not have enough air to get to floor 23 784 It is not clear what that was intended to indicate, but it may have been priority. 785 Phase 1 Report Volume III paragraphs 15.83 and 15.192. 786 999 call transcript {LFB00000384/3} page 3. 787 LFB Radio messages {LFB00002340}; {LFB00002128}; {LFB00002031}; LFB Operational Response Report dated July 2020 {LFB00119333/234-235} pages 234-235. 788 999 call transcript {LFB00000691}; Phase 1 Report Volume III paragraph 16.79. 789 Phase 1 Report Volume III paragraphs 17.57-17.58; White {MET00012847/5} page 5. 790 Phase 1 Report Volume III paragraphs 17.58 and 17.122; LFB callback transcript {INQ00000193}. CRO Duddy’s call was prompted by a conversation with Essex FRS {LFB00000557}. 791 BA Telemetry data {LFB00023326/2} page 2. 792 Worley {MET00007891/5} page 5; LFB Operational Response Report dated July 2020 {LFB00119333/286} page 286. 793 Grant {MET00007883/4-5} pages 4-5. 794 Phase 1 Report Volume III paragraphs 15.13 and 16.12. 795 Phase 1 Report Volume III Figure 16.5; Photographs of whiteboard {MET00008663}; {MET00015924}. 796 Phase 1 Report Volume III paragraph 17.58.

Part 9 | Chapter 92: Floor 18 97 and back. They therefore decided to rescue anyone they could from the floor they had reached (floor 18) rather than continue going up. When they entered the lobby of floor 18, the crew came across the people leaving Flat 153. The group then formed a chain descending the stairs.797 92.31 By that time conditions were hazardous and disorientating. The lobby of floor 18 was dark and full of smoke. Dense smoke in the stairwell made it hot and difficult to breathe. Both Paulos Tekle and Yehualashet Enyew felt themselves beginning to lose consciousness. Rabia Yahya’s asthmatic son collapsed on the stairs and was carried down by firefighters.798 92.32 At some point during the descent from Flat 153, Isaac Paulos became separated from Yehualashet Enyew.799 In the Phase 1 report the chairman found that the body of Isaac Paulos had been recovered from floor 13.800 Further evidence suggests that he collapsed and died in the stairwell at the level of floor 13 and that his body was later moved into the lobby on that floor.801 92.33 In the Phase 1 report the chairman found that it was not possible on the evidence to reach a clear conclusion about how and when Yehualashet Enyew lost his grip on Isaac Paulos’ hand.802 We have not received any further evidence that allows us to reach a more positive conclusion. 92.34 Paulos Tekle, Genet Shawo and their youngest son, Rabia Yahya and her three children and Yehualashet Enyew all left the tower between 03.13 and 03.18.803 Recovery and identification 92.35 Isaac Paulos probably collapsed on the stairs. His body was recovered from the lobby of floor 13.804 The coroner, Professor Wilcox, was satisfied about the identification of his remains and therefore issued an interim certificate of the fact of death for Isaac Paulos.805 Cause and time of death 92.36 The post-mortem report on Isaac Paulos noted soot deposits over much of his body. Soot was also present in his airways and lungs. The signs of heat damage to his body were consistent with its having occurred after death. There was no sign that he had sustained any recent injuries before he died.806 92.37 The level of carboxyhaemoglobin in a blood sample taken from Isaac Paulos was found to be 67%, which is within the toxic range. Cyanide was detected at a level of 0.060 milligrams/litre.807 That is below what is normally considered to be a toxic level but, 797 Phase 1 Report Volume III paragraphs 16.15-16.20 and 17.66-17.69. 798 Phase 1 Report Volume III paragraphs 16.19 and 17.58-17.71. 799 Phase 1 Report Volume III paragraph 17.61. 800 Phase 1 Report Volume III paragraph 17.72. 801 Tyldesley {MET000083333/7} page 7; Stevenson {MET00012860/2} page 2; Gray {MET00010806/14} page 14; Hiscock {MET00010877/4} page 4; Simpson {MET00008040/10} page 10; Purser, Phase 2 Report, Section 6 {DAPR0000006/112} paragraph 616. 802 Phase 1 Report Volume III paragraphs 17.56-17.74. 803 Phase 1 Report Volume III paragraph 17.72. 804 Phase 1 Report Volume III paragraph 17.72. 805 Interim certificate of the fact of death for Isaac Paulos {MET00065641}. 806 Paulos post-mortem report {COR00000675/9} page 9; Purser, Phase 2 Report, section 6 {DAPR0000006/111} paragraphs 607 and 609. 807 Paulos toxicology report {MET00053154}; Purser, Phase 2 Report, Section 1-4 {DAPR0000005/121} Table 17.

The Grenfell Tower Inquiry: Phase 2 Report 98 since the sample is likely to have degraded over time,808 it is not a reliable indication of the level of cyanide in the blood at the time of death. However, the presence of cyanide shows that Isaac Paulos was exposed to hydrogen cyanide before he died. 92.38 The post-mortem recorded the medical cause of death as “inhalation of fire fumes” but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”. 92.39 Professor Purser observed that, if those in Flat 153 had left by about 01.40, the concentration of asphyxiant gases in the stairwell would have been considerably lower. However, if they had waited until FFs Foster and Lawson reached floor 18, conditions in the stairwell might have been similar to those they encountered when leaving about an hour later.809 The occupants had had minimal exposure to asphyxiant gases before they left the flat.810 92.40 If the occupants of Flat 153 began to leave at about 03.04, as Professor Purser estimated,811 it must have taken them at most 15 minutes to leave the tower. He thought that the group had been exposed to a significant dose of asphyxiant gases as they crossed the lobby on floor 18 and descended the stairs, but not enough to incapacitate them.812 92.41 However, the rate of uptake of toxic gases is more rapid in children than in adults.813 Taking into account his size and the physical activity involved in descending the stairs, we are satisfied that Isaac Paulos is likely to have absorbed asphyxiant gases at almost twice the rate of an adult,814 leading to rapid incapacitation and collapse.815 We are therefore satisfied that he collapsed and lost consciousness within a few minutes of entering the stairs. Having lost consciousness, he continued to inhale asphyxiant gases until his respiration and circulation ceased shortly afterwards and he died.816 Death was rapid and occurred between 03.09 and 03.15. 808 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112-113} paragraph 447. 809 Purser, Phase 2 Report, Section 6 {DAPR0000006/108} paragraphs 601–602. 810 Purser, Phase 2 Report, Section 6 {DAPR0000006/108-109} paragraphs 588 and 593. 811 Purser, Phase 2 Report, Section 6 {DAPR0000006/109} paragraph 593. 812 Purser, Phase 2 Report, Section 6 {DAPR0000006/111-112} paragraphs 609 and 614-615. 813 Purser, Phase 2 Report, Section 6 {DAPR0000006/112} paragraph 611. 814 Purser, Phase 2 Report, Section 6 {DAPR0000006/112-113} paragraph 618-623. 815 Purser, Phase 2 Report, Section 6 {DAPR0000006/112} paragraph 611. 816 Purser, Phase 2 Report, Section 6 {DAPR0000006/111-112} paragraphs 607 and 617; Purser, Phase 2 Report, Section 6 {DAPR0000006/114} paragraphs 627-628.

99 93.1 All the flats on floor 19 were occupied on the night of the fire. By 01.25, the fire had reached the top of floor 19 and was outside Flat 166.817 Within a short time, nearly everyone had left their flats. By 01.30, only Flat 165, the home of Nicholas and Pily Burton, was still occupied. 93.2 Meron Mekonnen in Flat 163 had been alerted to the fire at 01.25 and told to leave. Although there was light smoke in the lobby when she left with her children, it did not affect her visibility or have any physical effect on her or her children. Meron Mekonnen and her children left the tower at 01.32.818 93.3 Amal Ahmedin and her daughter Amaya Tuccu Ahmedin lived in Flat 166. On 14 June 2017, her cousin, Amna Idris, was visiting them. All three took shelter on floor 23, where they died. Marjorie and Ernie Vital from Flat 162 were also among those who moved to floor 23. By 01.34, they were already in Flat 202, where they also eventually died. We return to the circumstances of the deaths of these individuals in Chapter 97. 93.4 Fadumo Ahmed lived alone in Flat 164. At around 01.20, she received a call alerting her to the fire. When she left her flat, she found the lobby full of dark grey smoke;819 it is likely that it had come from Flat 166. 93.5 Fadumo Ahmed saw her neighbour Deborah (Debbie) Lamprell, who lived in Flat 161, near the lifts. They both took shelter in Flat 201 on floor 23. Amal Ahmedin, her daughter and Amna Idris were already in Flat 201 when Fadumo Ahmed reached it.820 Later, Fadumo Ahmed left Flat 201. She was rescued by firefighters and carried out of the tower at 02.25.821 Debbie Lamprell died in the fire, as did a friend, Gary Maunders, who had been visiting her that night and who took shelter in Flat 203. We return to the circumstances of their deaths in Chapter 97. 93.6 Shortly after 01.30, Nicholas Burton was woken by the sound of banging on his front door. We do not know who banged on the door; it is possible that he was woken by the sounds of neighbours leaving. In any event, when he opened the front door, there was so much black smoke outside that he could see little.822 93.7 At 01.41, a BT operator informed North West Fire Control that a caller from the tower had hung up. CRO Aisha Jabin called the number back and spoke to Debbie Lamprell. She said that she was one of a group of 10 people sheltering in a flat on floor 23; she later gave her flat number as 161.823 Flat 161 was Debbie Lamprell’s home on floor 19. The information that there were people trapped in Flat 161 on floor 23 was passed to the LFB’s control 817 Phase 1 Report Volume II paragraphs 10.118 and 10.122. 818 Phase 1 Report Volume III Annex A. 819 Phase 1 Report Volume II paragraph 10.259. 820 Phase 1 Report Volume II paragraphs 10.259-10.260. 821 Phase 1 Report Volume II paragraphs 14.128–14.131. 822 Phase 1 Report Volume II paragraphs 11.56-11.57. 823 Phase 1 Report Volume II paragraphs 12.64-12.67 and 12.86; 999 call transcripts {MET00014977}; {LFB00055500}. Chapter 93 Floor 19

The Grenfell Tower Inquiry: Phase 2 Report 100 room at 01.46 and to the incident ground at 01.47.824 As a result, FFs Adam Johnson and Terence Roots were sent to Flat 161. They found it empty but found Nicholas and Pily Burton still in Flat 165 and helped them leave the tower. 825 Maria del Pilar (“Pily”) Burton Date of birth: 10 August 1946 (70 years of age). Place of birth: Ferrol, Galicia, Spain. Gender:

Female. Occupation: Retired. Usual Address: Flat 165, floor 19, Grenfell Tower, London. Date of death: 29 January 2018. Background and composition of household 93.8 Maria del Pilar (Pily) Burton lived with her husband Nicholas Burton and their beagle, Lewis Hamilton II, in Flat 165 on floor 19.826 Pily had moved to Grenfell Tower in the 1970s. She worked for the National Health Service as a contract manager until she had to leave work in 2015 due to ill-health.827 Vulnerability 93.9 The spreadsheet produced on the night of the fire by David Noble828 based on information held on the TMO’s Capita Insight system829 identified Pily Burton as a vulnerable person but contained no information about her condition.830 Events of 14 June 2017 93.10 Having opened the front door of Flat 165 to find black smoke in the lobby, Nicholas Burton decided that he and Pily should remained where they were. He was aware of the stay put advice displayed in the tower. He placed wet towels across the bottom of the front door, woke Pily and helped her dress. They waited in their living room. A friend called him urging him to leave, but he felt it was too dangerous to do so as Pily was so frail.831 93.11 At 01.56, Nicholas Burton made a call to the emergency services which was answered by CRO Christine Howson. He told her that he was in Flat 165 on floor 19 with his wife and dog and that there was a lot of smoke in the lobby, some of which had come into the hallway of his flat when he opened the front door. CRO Howson told him that firefighters would visit them and advised him to remain in his flat.832 824 Phase 1 Report Volume II paragraph 12.86. 825 Phase 1 Report Volume II paragraphs 12.86 and 14.116. 826 Burton {IWS00000064/2} page 2, paragraph 9. 827 Phase 1 Report Volume IV paragraph 32.174. 828 Noble {TMO00000884/1} page 1, paragraph 3. 829 Noble {Day119/75:19-21}. 830 Noble spreadsheet {TMO00862588}. 831 Phase 1 Report Volume II paragraph 11.57. 832 Phase 1 Report Volume II paragraphs 13.75-13.77; 999 call transcript {LFB00000334}.

Part 9 | Chapter 93: Floor 19 101 93.12 Prompted by another call from his friend, Nicholas Burton decided that the bathroom would be the safest place in which to wait. He moved Pily there and closed all the internal doors. Seeing the glow of the fire, he made his second and final emergency call at 02.13. He told CRO Yvonne Adams that he was trapped on floor 19, that no one had come, and that the flames were getting very close to their windows. CRO Adams told him that firefighters were trying to get to people and said that he should call back if conditions in the flat deteriorated. At the time of the call, the only smoke in the flat was that which had entered from the lobby when he had opened the front door just after 01.30.833 93.13 The bathroom was near the front door. Waiting there, Nicholas Burton heard a noise at the front door. FFs Johnson and Roots who were outside the door told him to get wet towels and to be ready to come out.834 Having confirmed the number of people present and that the flat was not on fire, FF Johnson told the occupants to cover their heads with wet towels. He and FF Roots then searched Flat 161 before returning to Flat 165 to rescue Nicholas and Pily Burton.835 93.14 By that time, the lobby of floor 19 was full of thick black smoke and visibility was limited. The firefighters helped the couple across the lobby, into the stairwell and down the stairs. The stairwell was also full of thick black smoke and felt very hot. Both firefighters were concerned that they were low on air and tried to descend as quickly as they could. Pily Burton fell more than once and FF Johnson had to carry her down. 93.15 At some point the two firefighters became separated. FF Roots and Nicholas Burton reached the ground floor first, but Nicholas Burton refused to leave the building until he knew where his wife was. At about floor 10, two other firefighters appeared and helped FF Johnson to carry Pily Burton. They reached the ground floor a few minutes after Nicholas Burton. He followed as Pily Burton was carried out of the tower.836 The couple left the tower at 02.32.837 93.16 FFs Johnson and Roots returned to the bridgehead and told WM O’Keeffe that they had brought two casualties down from Flat 165. They gave the same information to a firefighter who was recording information about people needing to be rescued and saw him write something on a wall. 838 Information to the incident ground 93.17 No service requests were generated in response to either of Nicholas Burton’s 999 calls839 and no firefighters were deployed to Flat 165. The circumstances of Pily Burton’s death 93.18 Pily Burton’s condition deteriorated in the months that followed her escape from Grenfell Tower. She suffered a severe stroke in early January 2018 and died in hospital on 29 January 2018 with Nicholas Burton by her side.840 833 Phase 1 Report Volume II paragraphs 14.173-14.175; 999 call transcript {LFB00000344}. 834 Phase 1 Report Volume II paragraph 14.176. 835 Johnson {MET00010082/7} page 7; Johnson {Day45/14:1}-{Day45/15:20}. 836 Johnson {MET00010082/9-10} pages 9-10; Roots {MET00012876/6-7} pages 6-7; Burton {IWS00000064/12-13} pages 12-13, paragraphs 54-56. 837 Phase 1 Report Volume II paragraph 14.179. 838 Johnson {MET00010082/10} page 10. 839 Short Incident Log Report {MET00013830/21-22}. 840 Phase 1 Report Volume IV paragraph 32.174.

The Grenfell Tower Inquiry: Phase 2 Report 102

103 94.1 On 14 June 2017, all the flats on floor 20 were occupied. Victoria (Vicky) King and her daughter Alexandra Atala, who lived in Flat 172, Mary Mendy and her daughter Khadija Saye, who lived in Flat 173, and four of the five members of the Belkadi family, who lived in Flat 175, died in the fire. Jessica Urbano Ramirez, whose family home was Flat 176, was among those who died in Flat 201 on floor 23. We describe the circumstances of Jessica Urbano Ramirez’s death in Chapter 97. 94.2 Emma O’Connor and Luke Towner from Flat 171 were the first of those who lived on floor 20 to leave the tower, doing so shortly before 01.20. When they left, smoke was coming through the vents on floor 20, but the lobby was otherwise clear.841 94.3 By 01.26, the fire had reached the outside of Flat 176.842 At that time, the only person there was Jessica Urbano Ramirez. She must have left by or before 01.26, since she spoke to CRO Sarah Russell from Flat 201 at 01.29. 94.4 The lobby on floor 20 became full of smoke within minutes after the fire reached the outside of Flat 176.843 Farah Hamdan spoke to CRO Alexandra Norman at 01.30 and reported that there was smoke coming into the flat from the lobby.844 Petra Doulova and her husband, who lived in Flat 174, left the tower at 01.41. She described the lobby on floor 20 as being pitch black and full of smoke, making it difficult to breathe. The couple had to feel their way across the lobby to the stairwell door.845 94.5 FF David Badillo was one of the first firefighters to arrive at the tower.846 He met Melanie Urbano Ramirez, Jessica Urbano Ramirez’s sister, outside the tower and agreed to go to Flat 176 to find her.847 After a failed attempt to reach floor 20 alone, FF Badillo returned with CM Christopher Secrett and FF Christopher Dorgu. They tallied out at 01.33848 and were the first firefighters to reach that floor. 94.6 The lobby on floor 20 was so full of smoke that CM Secrett could not see equipment he had put on the floor.849 The firefighters moved around the lobby using touch and torches.850 When they found Flat 176, FF Badillo found the front door slightly ajar. The flat was full of smoke but the contents were not alight, although fire could be seen outside a window which was about to fail. CM Secrett’s warning whistle on his breathing apparatus began to sound shortly after they returned to the lobby having searched the flat and found it empty. The crew decided to make their way back to the stairwell and down. They did not knock on the doors of any other flats.851 841 Phase 1 Report Volume II paragraph 10.261. 842 Phase 1 Report Volume II paragraph 10.118. 843 Phase 1 Report Volume IV paragraph 25.10 (b). 844 Phase 1 Report Volume II paragraph 11.47. 845 Phase 1 Report Volume II paragraphs 11.48-11.51. 846 Phase 1 Report Volume II paragraph 10.19. 847 Phase 1 Report Volume II paragraph 10.79. 848 Phase 1 Report Volume II paragraphs 11.10-11.11 and 12.6. 849 Phase 1 Report Volume II paragraph 12.30. 850 Badillo {Day13/154:15}. 851 Phase 1 Report Volume II paragraphs 12.6, 12.31 and 13.6. Chapter 94 Floor 20

The Grenfell Tower Inquiry: Phase 2 Report 104 Firefighter deployments to floor 20 94.7 Between 01.30 and 03.33 several emergency calls were made to the control room from inside and outside the tower reporting that Flats 173 and 175 were still occupied.852 94.8 Three crews were deployed to floor 20 between 01.50 and 02.00. 94.9 FFs Geoffrey Campbell and Steven Mills tallied out at 01.51 to go to Flat 175, the home of the Belkadi family, but were unable to reach floor 20.853 On their descent they met a Paddington crew led by CM Philip Wigley that had been sent to the roof of the tower.854 FFs Campbell and Mills told them that they had been unable to rescue a woman on floor

1. Having continued upward but realising that they would not be able to reach the roof,

the Paddington crew made their way to floor 20 intending to rescue the woman they had been told about. FF Duane Harris opened the door to the lobby which was full of smoke. Members of the crew shouted but did not go into the lobby to knock on the doors to the flats. At about that time FF Roberts found Fadumo Ahmed on the stairs between floors 20 and 21. The crew assisted her down the stairs and out of the tower.855 94.10 CM Craig Eden and FF Tom Welch were instructed by WM O’Keeffe to go to floor 20 to assess the situation and report to the bridgehead. CM Eden said they had been told that there were persons trapped on floor 20. FF Welch said that they had not been told that there were people who needed rescuing and that he had assumed that the building had been evacuated.856 The crew tallied out at 01.59. A minute later, FFs Vincent Williams and Agnel Fernandes tallied out with instructions to go to Flat 175 on floor 20.857 94.11 CM Eden and FF Welch reached floor 20. By that time, they were running low on air, so they decided to connect a fire hose to the dry riser.858 Both firefighters described the lobby as so full of hot smoke that they could not see anything. CM Eden banged loudly on three doors but received no response. FF Welch said that, as they followed a wall left past two flat doors to find the dry riser, CM Eden had banged on those doors and announced that they were firefighters. Given the location of the dry riser, they are likely to have been the doors of Flats 172 and 173.859 94.12 FFs Williams and Fernandes reached floor 20 shortly after CM Eden and FF Welch and met them there. They too recalled thick smoke and no visibility. They tried to find their way to Flat 175, kicking and banging on doors and shouting through letterboxes as they went.860 94.13 There were no further deployments to floor 20 after 02.00. FFs Luke Cook and Brian Flanagan were sent to floor 20 at some time after about 02.03 but we think it likely that they went to a different floor.861 852 Phase 1 Report Volume II paragraphs 11.47, 12.60, 14.167, 16.59 and 16.60. 853 Phase 1 Report Volume II paragraphs 13.14-13.15 and 14.85. 854 Phase 1 Report Volume II paragraphs 11.12-11.13. 855 Phase 1 Report Volume II paragraphs 13.14-13.15, 14.85-14.87 and 14.131-132; Gillam {Day27/71:20}-{Day27/73:16}. 856 Eden {MET00008019/5} page 5; Welch {MET000080606/7} page 7. 857 Phase 1 Report Volume II paragraph 14.80. 858 Phase 1 Report Volume II paragraph 14.81. 859 Eden {MET00008019/10} page 10; Welch {MET000080606/7} page 7. 860 Williams {MET00010829/6-7} pages 6-7; Fernandes {Day39/176:19}-{Day39/177:4}. 861 Cook {MMET00012855/3} page 3; Flanagan {MET00012855/7} page 7.

Part 9 | Chapter 94: Floor 20 105 Victoria (Vicky) King Date of birth: 12 June 1946 (71 years old). Place of birth: Highgate, London, England. Gender:

Female. Occupation: Retired. Usual address: Flat 172, floor 20, Grenfell Tower, London. Place of death: Flat 172, floor 20, Grenfell Tower, London. Time of death: By 3.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Alexandra Catherine Atala Date of birth: 24 April 1977 (40 years old). Place of birth: Reading, England. Gender:

Female. Occupation: NA. Usual address: Flat 172, floor 20, Grenfell Tower, London. Place of death: Flat 172, floor 20, Grenfell Tower, London. Time of death: By 3.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 94.14 Born on 12 June 1946, Victoria (Vicky) King was 71 years old in 2017. She had been the registered tenant of Flat 172 since 26 January 1998862 and lived there with her daughter, Alexandra Atala. Born on 4 April 1977, Alexandra Atala was 40 years old.863 Vicky King and Alexandra Atala had a very close relationship and lived together throughout their lives.864 Vulnerabilities 94.15 Both Vicky King and Alexandra Atala had mental health difficulties.865 Alexandra Atala suffered from panic disorder associated with agoraphobia.866 RBKC and the TMO were aware of their vulnerabilities. 862 Lancaster West EMB New Letting form {IWS00001930/2}. 863 Phase 1 Report Volume IV paragraph 32.150. 864 Phase 1 Report Volume IV paragraph 32.153. 865 Bennett {IWS00001882/2} page 2, paragraphs 7-8. 866 Letter from Dr Meena Nathan to Stella Fitzgerald dated 12 December 2017 {BSR00000141}.

The Grenfell Tower Inquiry: Phase 2 Report 106 94.16 On 9 July 2006, Janice Jones recorded that both Vicky King and Alexandra Atala had mental health difficulties.867 In a survey of tower residents carried out by Rydon in 2014 during the refurbishment both women were recorded as having problems with their mental health.868 94.17 In the spreadsheet produced on the night of the fire by David Noble869 based on information held on the TMO’s Capita Insight system870 Vicky King was listed as a resident but there was no reference to any vulnerability. Alexandra Atala was recorded as being vulnerable on the grounds of mental health. Events of 14 June 2017 94.18 Both Vicky King and Alexandra Atala were in Flat 172 when the fire started. Vicky King had returned to the tower in the afternoon of 13 June 2017.871 Alexandra Atala had not left her home for some time. Neither mother or daughter had any contact, whether by telephone or otherwise, with anyone either in or outside the tower during the fire. 94.19 Although firefighters did manage to reach floor 20, none were sent specifically to Flat 172. There is no evidence that Vicky King or Alexandra Atala ever became aware of the fire or that they heard other residents leaving floor 20 or firefighters arriving on that floor. 94.20 The fire reached the east side of the kitchen and living room of Flat 172 between about 02.02 and 02.08.872 At some time after 02.55 it had spread to the south face of the living room and the two bedrooms of Flat 172.873 Recovery and identification 94.21 The remains of Vicky King and Alexandra Atala were recovered from the second bedroom in Flat 172 (the most southerly room in the flat and so farthest away from the fire).874 The coroner, Professor Wilcox, was satisfied about the identification of the remains recovered and therefore issued interim certificates of the fact of death for Vicky King and Alexandra Atala.875 Cause and time of death 94.22 The post mortem examination on Vicky King noted that there was soot in the oesophagus. The carboxyhaemoglobin content of a blood sample taken from her was 58%, which is within the fatal range and indicated that she had inhaled carbon monoxide before her death. It was not possible to test the remains of Alexandra Atala.876 94.23 Drawing on the evidence of other occupants of floor 20, the evidence of the occupants of flats in a similar location on other floors and the evidence of Professor Purser, we are satisfied that from about 01.30 smoke probably began to enter Flat 172 from the lobby. When the fire reached the east side of Flat 172 shortly after 02.00, smoke began 867 Floating Support Service Referral Form {IWS00001908}. 868 Rydon Residents Survey {RYD00024466}. 869 Noble {TMO00000884/1} page 1, paragraph 3. 870 Noble {Day119/77:17}-{Day119/82:5}. 871 O’Riordan {MET00013136/2} page 2. 872 Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 478. 873 Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 478. 874 Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 482; Presentations relating to Victoria King and Alexandra Atala {Day305/15:10}. 875 Interim certificates of the fact of death for Victoria King and Alexandra Atala {MET00065648}; {MET00065622}. 876 King post-mortem report {COR00001454/5} page 5; Atala post-mortem report {COR00000066/6} page 6; Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 481.

Part 9 | Chapter 94: Floor 20 107 to enter the flat from outside. Until about 02.45 Vicky King and Alexandra Atala could probably have escaped from the building if they had been able to cross the lobby and descend the stairs.877 94.24 Conditions in the second bedroom began to deteriorate once the fire started to spread across the southern face of Flat 172.878 Since their remains were found in a bedroom, it is possible that Vicky King and Alexandra Atala were asleep by the time the fire started and slept through it.879 94.25 Taking into account the presence of soot in Vicky King’s respiratory system, the level of carboxyhaemoglobin in her blood and that her remains and those of Alexandra Atala were recovered from a bedroom, we are satisfied that inhalation of asphyxiant gases caused both of them to lose consciousness and die before the contents of Flat 172 caught fire. 94.26 The post mortem reports on Vicky King and Alexandra Atala recorded the medical cause of death in each case as “consistent with the effects of fire”,880 but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”. 94.27 There is not enough evidence to allow us to determine the time of death with any precision but we think that Vicky King and Alexandra Atala had probably both died by about 03.30. Mary Mendy Date of birth: 11 June 1963 (54 years). Place of birth: Banjul, The Gambia. Gender:

Female. Occupation: Carer. Usual address: Flat 173, floor 20, Grenfell Tower, London. Place of death: Stairwell, Grenfell Tower, London. Time of death: Between 03.50 and 04.10 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Khadija Saye Date of birth: 30 July 1992 (24 years). Place of birth: Hammersmith, London. Gender:

Female. Occupation: Artist. Usual address: Flat 173, floor 20, Grenfell Tower, London. Place of death: Stairwell, Grenfell Tower, London. 877 Purser, Phase 2 Report, Section 6 {DAPR0000006/87-88} paragraphs 482 and 484. 878 Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 482. 879 Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 480. 880 Atala post-mortem report {COR00000066}; King post-mortem report {COR00001454}.

The Grenfell Tower Inquiry: Phase 2 Report 108 Time of death: Between 03.50 and 04.10 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 94.28 Mary Mendy had been the sole tenant of Flat 173 since 17 January 1994.881 She lived there with her daughter, Khadija Saye. 94.29 Mary Mendy was born on 11 June 1963 in The Gambia and was 54 years old.882 She had moved to the United Kingdom in the 1980s.883 Khadija Saye was born on 30 July 1992 in London.884 She was 24 years old. At the time of the fire Mary Mendy was working as a care assistant. Khadija Saye had attended Rugby School on a scholarship and studied photography at the University of the Creative Arts in London. In May 2017, her work was exhibited at the Venice Biennale.885 Vulnerabilities 94.30 There is no evidence that Mary Mendy or her daughter suffered from any vulnerability that would have impeded their escape. Events of 14 June 2017 94.31 Khadija Saye and Mary Mendy returned home during the evening of 13 June 2017. Khadija was seen on CCTV entering the lift lobby on the ground floor of the tower at 21.08. Her mother was seen on CCTV in the lift lobby at 23.06.886 They remained in Flat 173 thereafter. 94.32 We do not know when they first became aware of the fire but at 01.49 Khadija Saye posted a message on Facebook saying that there was a fire in the tower and that she and her mother could not leave their flat.887 The contents of that post suggest that neither Khadija Saye nor her mother had become aware of the presence on floor 20 of FFs Badillo, Dorgu and CM Secrett, who searched Flat 176 for Jessica Urbano Ramirez at some time between 01.33 and 01.57.888 That may be because Flat 176 was in the northeast corner of the tower and Flat 173 in its southwest corner. It appears that Khadija Saye became aware of the presence of one or both of the other crews which later reached floor 20, since she told a friend in a telephone call at 02.50 that she had heard firemen “arguing” outside her door and then nothing else.889 As Khadija Saye was able to say that those outside were firefighters, she must have heard them announce themselves as such. However, there is no evidence that Khadija Saye or her mother tried to call out to them. Information to the incident ground 94.33 At 02.26, Khadija Saye made an emergency call, in the course of which she told CRO Sarah Russell that a lot of smoke was coming into the flat. She and her mother were in the living room and had shut all but one of the windows. CRO Russell said that they could 881 Tenancy Agreement {TMOH00011129}. 882 Phase 1 Report Volume IV paragraph 32.142. 883 Phase 1 Report Volume IV paragraph 32.144. 884 Phase 1 Report Volume IV paragraph 32.142. 885 Phase 1 Report Volume IV paragraphs 32.147-32.148. 886 O’Riordan {MET00013136/3} page 3. 887 Phase 1 Report Volume II paragraph 12.61. 888 Phase 1 Report Volume II paragraph 11.10 and 13.16. 889 Email from Adele Evelyn to Marion Tefler dated 19 June 2017 {BSR00000102}.

Part 9 | Chapter 94: Floor 20 109 stay or to try to leave but Khadija Saye told her that they were too high up to leave and that there was too much smoke outside the front door. CRO Russell then advised her to try to prevent the smoke coming in by blocking doors and shutting windows. CRO Russell said she would notify the firefighter crews and explained that they were trying to make their way up but that it would take them some time.890 94.34 That was the only emergency call Khadija Saye made. She communicated with friends on Facebook who then made emergency calls to the LFB on her behalf reporting that she and her mother were trapped in Flat 173 on floor 20. There were five such calls between 02.50 and 03.33. On each occasion, the caller was advised to tell Khadija Saye to leave her flat.891 No service requests appear to have been generated in response to any of those calls or to Khadija Saye’s earlier call. However, an entry reading “173 20th – 2 adults” appears on the second of the two whiteboards which SM Jason Oliff was using in the LFB control room from 02.33 to collate information to pass to the command units.892 The position of that entry suggests that it had been prompted by one of the later calls about Flat 173. 94.35 Information about Flat 173 did reach the incident ground. Although no mention of Flat 173 appears on the white laminated sheet used in CU7 to collate information,893 a reference to it was made on a whiteboard used in CU7 from about 03.00.894 That whiteboard used a grid system. The figure “2” appears against Flat 173 indicating two adults. Next to it is a “P” in red, circled, indicating a priority.895 A red tick was used on the grid to indicate that a crew had been deployed. No red tick appears on the grid. 94.36 The bridgehead was located on floor 3 between 02.17 and 03.10.896 No note about Flat 173 appears on the wall of floor 3 where WM Louisa De Silvo recorded information while the bridgehead was located there. That may be because information about Flat 173 did not reach CU7 before 03.00. 94.37 WM Glynn Williams began recording information on the wall of the ground floor lobby at about 02.15. Someone had written “173 20 2P”.897 The note was probably made by SM Peter Wolfenden, who entered the ground floor after the bridgehead had been moved there and started recording information on the wall from about 03.21.898 He said that a tick had been used to indicate that a crew had been sent to a particular flat.899 No tick appears next to the entry for Flat 173. 94.38 We are satisfied, therefore, that no crews were deployed specifically to Flat 173 in response to the calls made from or about it. 890 Phase 1 Report Volume IV paragraph 16.59; 999 call transcript {LFB00000355/2}. 891 Phase 1 Report Volume III paragraph 16.60. 892 Phase 1 Report Volume III paragraphs 15.139-15.140 and Figure 15.9. 893 Phase 1 Report Volume II paragraphs 12.8-12.9; Phase 1 Report Volume IV paragraph 28.86. 894 Phase 1 Report Volume III paragraphs 15.13 and 16.12; Phase 1 Report Volume III Figure 16.5; Photograph of whiteboard {MET00015924}. 895 Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. 896 Phase 1 Report Volume IV paragraphs 28.86 and 28.87. 897 Phase 1 Report Volume II paragraphs 14.103-14.105 and Figure 14.5. 898 Wolfenden {Day40/168:3}-{Day40/172:16}; {Day40/182:14}-{Day40/186:9}. 899 Wolfenden {Day40/188:5}-{Day40/190:4}.

The Grenfell Tower Inquiry: Phase 2 Report 110 The last movements of Khadija Saye and Mary Mendy 94.39 The advice for people to remain in their flats was changed at 02.35900 after Khadija Saye’s call to the LFB. After her first post on Facebook, Khadija Saye next posted at 02.41.901 At 02.55 she learned that the LFB’s advice was now to leave the building when a friend, who had called the control room, sent her a message. The same friend, having spoken to the control room again, repeated the advice to leave at 02.57.902 94.40 Khadija Saye replied that she was afraid to leave. At 03.05, as the exchange continued, she said that there was a lot of smoke in the flat. Having been reassured that there was only smoke in the stairwell, Khadija Saye sent another message at 03.14 saying that she had tried to leave but that the smoke had been too strong. Asked if she had found the way to the stairs, Khadija Saye replied that it was too dark and that she had begun to choke after a few steps. At 03.27, she described another attempt to leave, adding that it was impossible and that she had felt as though she was going to faint. At 03.30, in what was her last message, she said “It’s in my rooms”. We do not know if that was a reference to the fire or smoke. Her friend continued to send her messages, but we do not know if Khadija Saye saw them.903 94.41 Between 03.20 and 03.29, the fire reached the outside of the two bedrooms of Flat 173 on the south side of the tower. Between 03.37 and 03.53, it had reached the south side of the living room and moved round to the west side of the living room and to the kitchen of the flat.904 94.42 The arrival of the fire outside Flat 173 did not immediately cause Mary Mendy and Khadija Saye to try for a third time to leave their home, but they did so shortly after 03.30. This time they were able to cross the lobby and enter the stairwell. Recovery and identification 94.43 FFs Methusael Sonson and James Cuthbert tallied out at 03.46 with instructions to search floor 5. Their end of wear time was 04.12. After they had been deployed, they were instructed to go to Flat 84 on floor 11. Making their way up the stairs, they found the body of Khadija Saye in the stairwell near floor 10. FF Sonson confirmed that she had no pulse.905 Given where these firefighters found Khadija Saye, that must have been shortly before 04.12. 94.44 Khadija Saye’s body was subsequently moved to the lobby on floor 9 from which it was later carried out of the tower.906 The coroner, Professor Wilcox, was satisfied about the identification of the casualty found by FFs Sonson and Cuthbert and therefore issued an interim certificate of death for Khadija Saye.907 94.45 CM Timothy Cutbill and FF Steven Bolton tallied out at 05.28 as part of a crew of four sent to floor 11 to search for casualties and, if possible, to go further up the tower. Their end of wear time was 05.59. As they ascended the stairs, they came across the body of 900 Phase 1 Report Volume II paragraph 15.161. 901 Telfer Exhibit MT/1 – Facebook timeline {IWS00001188/18}. 902 Phase 1 Report Volume III paragraph 17.51; Telfer Exhibit MT/1 – Facebook timeline {IWS00001188/18}. 903 Phase 1 Report Volume III paragraphs 17.51-17.55; Telfer Exhibit MT/1 – Facebook timeline {IWS00001188/18-20}. 904 Purser, Phase 2 Report, Section 6 {DAPR0000006/102} paragraph 557. 905 Sonson {MET00010824/8} page 8; Cuthbert {MET00012878/11-12} pages 11-12; BA Telemetry Data {LFB00023326/3}. 906 Phase 1 Report Volume III paragraph 17.55. 907 Interim certificate of the fact of death for Khadija Saye {MET00065605}.

Part 9 | Chapter 94: Floor 20 111 Mary Mendy between floors 12 and 13.908 Her body was later moved into the lobby on floor 13 and then taken out of the tower. 909 The coroner, Professor Wilcox was satisfied about the identity of the casualty found by FFs Cutbill and Bolton and issued an interim certificate of the fact of death for Mary Mendy.910 Cause and time of death 94.46 The post-mortems on Mary Mendy and Khadija Saye noted that, although it was not possible to obtain a blood sample from either of them, the presence of soot in their upper airways together with the discolouration of soft tissues showed that they had both inhaled carbon monoxide and hydrogen cyanide.911 94.47 Professor Purser calculated that, if Mary Mendy and Khadija Saye had entered the stairs at 03.36, the latest time at which they could have safely left the building without collapsing was about 03.16.912 We accept his conclusion that, taking account of the conditions on floor 20 and in Flat 173 and the experience of survivors from flats in similar locations, Mary Mendy and Khadija Saye died from the inhalation of asphyxiant gases, mainly carbon monoxide but some hydrogen cyanide. They were exposed to a substantial amount of such gases while still in Flat 173, though not enough to incapacitate them. Conditions in the flat deteriorated by 03.30, when the fire had reached the bedrooms on the south side of the flat. Once they had left their home, their exposure to asphyxiant gases increased as they ventured into the smoke-filled lobby and then, albeit to a lesser degree, the stairwell. That exposure, coupled with the physical exertion required to descend from floor 20, caused them to collapse in the stairwell.913 94.48 Mary Mendy probably collapsed and lost consciousness between floors 12 and 13. Khadija Saye was able to continue for a short distance before she lost consciousness near floor 10. Thereafter, they both continued inhaling asphyxiant gases for a short time until their respiration and circulation ceased some minutes later and they died. 94.49 The post-mortem report on Khadija Saye recorded the medical cause of death as “inhalation of fire fumes and burns”. 94.50 The post-mortem report on Mary Mendy recorded the medical cause of death as “consistent with the inhalation of fire fumes”. 94.51 In the light of Professor Purser’s evidence we find that in each case a more accurate description is “inhalation of asphyxiant gases”. 94.52 Although Professor Purser estimated that Mary Mendy and Khadija Saye died between 04.00 and 04.20,914 having regard to the evidence as a whole, including the time at which Khadija Saye made her last post on Facebook, we find that Mary Mendy had collapsed before FFs Sonson and Cuthbert found Khadija Saye. We therefore conclude that Mary Mendy and Khadija Saye both died between 03.50 and 04.10. 908 Cutbill {MET00010872/5} page 5; Boulton {MET000080564/8} page 8. 909 Phase 1 Report Volume III paragraph 17.55. 910 Interim certificate of the fact of death for Mary Mendy {MET00065585}. 911 Mendy post-mortem report {COR00001031}; Saye post-mortem report {COR00000855}; Purser, Phase 2 Report, Section 6 {DAPR0000006/103} paragraphs 565 and 567. 912 Purser {Day297/91:22}–{Day297/94:1}. 913 Purser, Phase 2 Report, Section 6 {DAPR0000006/104} paragraphs 568-574. 914 Purser {Day297/91:22}–{Day297/94:1}.

The Grenfell Tower Inquiry: Phase 2 Report 112 The Belkadi Family Farah Hamdan Date of birth: 23 February 1986 (31 years). Place of birth: London, UK. Gender:

Female. Occupation: Nursery Assistant. Usual address: Flat 175, floor 20, Grenfell Tower, London. Place of death: Stairwell between floors 19 and 20, Grenfell Tower, London. Time of death: Between 02.45 and 03.10 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Omar Belkadi Date of birth: 1 August 1984 (32 years). Place of birth: Morocco. Gender:

Male. Occupation: Courier. Usual address: Flat 175, floor 20, Grenfell Tower, London. Place of death: Stairwell between floors 19 and 20, Grenfell Tower, London. Time of death: Between 02.45 and 03.10 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Malak Belkadi Date of birth: 26 September 2008 (8 years). Place of birth: London. Gender:

Female. Occupation: Student. Usual address: Flat 175, floor 20, Grenfell Tower, London. Place of death: St Mary’s Hospital, Paddington, London. Time of death: 15:01 on 15 June 2017. Cause of death: Inhalation of asphyxiant gases.

Part 9 | Chapter 94: Floor 20 113 Leena Belkadi Date of birth: 12 December 2016 (6 months). Place of birth: London. Gender:

Female. Occupation: N/A Usual address: Flat 175, floor 20, Grenfell Tower, London. Place of death: Stairwell between floors 19 and 20, Grenfell Tower, London. Time of death: Between 02.45 and 03.10 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 94.53 Farah Hamdan and Omar Belkadi had lived in Flat 175 on floor 20 since 18 November 2013.915 They lived there with their three daughters, Malak Belkadi, Leena Belkadi and their middle daughter who survived the fire. 94.54 Farah Hamdan was born on 23 February 1986 in London.916 She was 31 years old and a teacher. Omar Belkadi was born on 1 August 1984 in Morocco. He was 32 years old and was working for a restaurant in June 2017 while training to be a taxi driver.917 Malak, their eldest daughter, was born on 25 September 2008 at St Mary’s Hospital, London. She was eight years old when she died. Leena was born on 14 December 2016 at St Mary’s Hospital, London. She was six months old when she died.918 Vulnerability 94.55 Farah Hamdan and Omar Belkadi did not have any known impairments. Their three children were under 18 years of age. The two elder daughters were recorded as living in the tower in the spreadsheet produced on the night of the fire by David Noble919 and were known to be under 18. Leena was not listed. Events of 14 June 2017 94.56 The family were at home on the night of the fire. Farah Hamdan was seen on CCTV entering the lift lobby of the tower at 18.31 with her daughters.920 Omar Belkadi returned home later and was seen on CCTV in the lift lobby at 00.12.921 They became aware of the fire at an early stage, since Farah Hamdan called her sister, Samira Hamdan, at about 01.00 to tell her of a fire at the tower.922 94.57 At 01.30, OM Alexandra Norman answered an emergency call from Farah Hamdan, who told her that the family were in the living room, that smoke was coming into the flat and that the fire was in a neighbour’s flat. That must have been a reference to Flat 176; the 915 Tenancy Agreement {TMOH00011495}. 916 Phase 1 Report Volume IV paragraph 32.134. 917 Phase 1 Report Volume IV paragraph 32.139; Presentation relating to the Belkadi family {Day305/44:12-13}. 918 Phase 1 Report Volume IV paragraph 32.134. 919 Noble {TMO00000884/1} page 1, paragraph 3. 920 O’Riordan {MET00013136/3} page 3. 921 O’Riordan {MET00013136/4} page 4. 922 Phase 1 Report Volume II paragraph 14.168.

114 The Grenfell Tower Inquiry: Phase 2 Report smoke was probably coming from the lobby. OM Norman’s advice was to stay in the flat unless it was safe to leave. She added that she did not know what conditions were like in the stairs.923 94.58 At 01.31, CRO Peter Duddy created a service request telling the incident ground that there was a fire on floor 20 and that people were trapped there.924 A little later, following a call from Natasha Elcock at 01.33, he created another service request containing the same information and including a reference to Flat 82.925 94.59 At 01.35, OM Norman spoke to WM Daniel Meyrick in CU8, which had just arrived at the incident ground. She told him that five people were in Flat 175 on floor 20 with a lot of smoke entering the premises.926 WM Meyrick was passing the information he received to WM Mark Kentfield at the incident ground by radio. He was also recording the information on a piece of paper.927 It is likely that WM Meyrick recorded the information he received from OM Norman on such a piece of paper, which was subsequently used to populate a white laminated sheet in CU7. That sheet included the following notation: “175 20 5 PERSON”.928 94.60 While OM Norman was speaking to WM Meyrick, CRO Sharon Darby contacted appliance G261 with the information that there were persons on floor 20 reporting that smoke was coming into their flat. CRO Darby was not able to give the numbers of the flats affected.929 At 01.35, she noted that the service requests relating to floor 20 were being acted upon and at 01.41 she marked them as completed.930 94.61 The calls made by OM Norman and CRO Darby were the first messages to reach the incident ground. At around 01.40, SM Brett Loft, who was positioned at the front of the tower to handle incoming information, received a piece of A4 paper from WM Kentfield containing a list of flats from which people needed to be rescued. It included a reference to Flat 175 on floor 20. SM Loft passed the information he received to the bridgehead.931 94.62 At that time the bridgehead was on floor 2, where it remained until 02.17. While it was there, WM Louisa De Silvo recorded information on a forward information board.932 At about 02.13, CM Charles Batterbee went to the bridgehead and copied the information on a forward information board into his own notebook. It included Flat 175 on floor 20, against which a tick appeared. CM Batterbee explained that this indicated a flat to which crews had been deployed, as reported by WM De Silvo.933 We find that the tick related to the deployment of FFs Mills and Campbell who had been sent to Flat 175 but did not reach floor 20.934 94.63 At 01.43, Farah Hamdan’s second emergency call was connected to North West Fire Control. She gave the number of her flat and the floor and reported that the fire had reached the floor below. She said that the family had tried to leave but that black smoke in 923 Phase 1 Report Volume II paragraph 11.47. 924 Phase 1 Report Volume II paragraph 11.144. 925 Phase 1 Report Volume II paragraphs 11.145 and 11.146. 926 Phase 1 Report Volume II paragraph 11.149. 927 Phase 1 Report Volume II paragraph 11.5. 928 Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3. 929 Phase 1 Report Volume II paragraphs 11.147-148 and 11.152. 930 Short Incident Log Report {MET00013830/19}. 931 Phase 1 Report Volume II paragraphs 11.6 and 12.8-12.9 and Figure 12.4. 932 Phase 1 Report Volume II paragraphs 13.52-13.53. 933 Phase 1 Report Volume II paragraphs 14.73-74 and Figure 14.4. 934 See Chapter 89.

Part 9 | Chapter 94: Floor 20 115 the lobby had prevented them from doing so. Farah Hamdan also said that there was now smoke inside her own flat. She was advised to block the smoke from coming in and was told that her location had been passed to the crews.935 94.64 At about the same time, OM Norman in the LFB control room took a call from Team Leader Paula Craig at North West Fire Control, who told her that five people were in Flat 175 on floor 20.936 It is unclear how that information was passed to the incident ground. No service request was created and when CRO Yvonne Adams called CU8 by telephone at 01.50 and 02.00 she did not refer to Flat 175.937 However, an entry at 02.01.43 in the LFB’s short incident log notes that CU8 was told at about 01.50 that five people were trapped in Flat 175 on floor 20.938 It may be that SM Jason Oliff, who was in contact with CU8 throughout on his personal mobile, passed the information on.939 94.65 At around 02.00 CM Eden and FF Welch left the bridgehead to investigate the situation on floor 20 while FFs Williams and Fernandes were sent to Flat 175 on floor 20.940 That may have been the result of the emergency call made by Farah Hamdan at 01.43 or of information received from FFs Campbell and Mills on their return to the bridgehead.941 94.66 At 02.11, CRO Heidi Fox answered a third emergency call from Farah Hamdan. She told CRO Fox that, despite having put sheets under the front door, there was now a lot of smoke in the flat. Farah Hamdan gave her the number of the flat and the floor on which it was situated and said that the five people sheltering there included three children. CRO Fox confirmed that she was passing the information on. She advised Farah Hamdan to keep trying to stop smoke coming in with damp towels and sheets and to call back if the situation worsened.942 94.67 The notation “175 20th Flr – 2 adults 2 children” appears on a whiteboard in the LFB control room used by SM Oliff to record information about people needing to be rescued. Despite the error about the number of children, that note was probably made in response to Farah Hamdan’s call at 02.11, since that was the last call in which she provided her location.943 94.68 The final emergency call from Flat 175 at 02.17 was incomplete. The BT operator heard the caller say, “No Malak, it’s not safe” and then ask for the fire brigade. The call was then put through to the LFB but there was no further response from the caller.944 It was at about that time that CM Eden and Welch and, shortly after them, FFs Williams and Fernandes reached floor 20.945 Although the visibility there was extremely limited the two crews were aware of each other.946 935 Phase 1 Report Volume II paragraph 12.60. 936 Phase 1 Report Volume II paragraphs 12.75-12.76. 937 Phase 1 Report Volume II paragraphs 13.86 and 14.230. 938 Short Incident Log Report {MET00013830/21} page 21. 939 Phase 1 Report Volume II paragraph 14.243. 940 Phase 1 Report Volume II paragraphs 14.80-14.81. 941 Campbell {MET00010788/12} page 12; Mills {MET000080584/7} page 7. 942 Phase 1 Report Volume II paragraph 14.167; 999 call transcript {LFB00000342}. 943 Phase 1 Report Volume III paragraphs 15.138-15.140. 944 Phase 1 Report Volume II paragraph 14.169. 945 Phase 1 Report Volume II paragraph 14.170. 946 Williams {MET00010829/3-8} pages 3 and 8; Fernandes (Day39/171:14-22}; Eden {MET00008019/11} page 11.

The Grenfell Tower Inquiry: Phase 2 Report 116 94.69 When FF Williams and Fernandes reached Flat 175, FF Williams went in and spoke to Omar Belkadi and Farah Hamdan. He told them they needed to leave but they made no move to do so. FF Williams called the bridgehead to ask for assistance but could not hear the response. He then took the couple’s second daughter by the hand to encourage the rest of the family to follow him.947 94.70 FF Fernandes had also tried to use his radio to report that they had located a casualty but discovered that it was not working. CM Eden and FF Welch were still on floor 20. Both FF Williams and Fernandes shouted out to them for assistance. CM Eden positioned himself at the stairwell door while FF Welch moved closer towards Flat 175. In conditions of near zero visibility, FF Fernandes made his way to the stairwell door to hold it open. There was a similar lack of visibility in the stairwell.948 94.71 CM Eden’s recollection was that, while on floor 20, he had become aware that there were five people needing to be rescued from Flat 175.949 He heard a man (Omar Belkadi) shouting for help and a woman (Farah Hamdan) calling out for her baby. FF Fernandes heard something similar. He first saw the family when they arrived at the stairwell door but was not aware how many of them there were. When FF Williams reached the stairwell, they began their descent. FF Fernandes went down first backwards, so that he could guide FF Williams, who was carrying the Belkadis’ second daughter.950 He could not recall any conversation with CM Eden and FF Welch about evacuating the family.951 94.72 CM Eden and FF Welch tried to help Omar Belkadi. In response to CM Eden, Omar Belkadi said that apart from himself, the group was made up of his wife, two children and a baby. Omar Belkadi was, understandably, panicking and finding it difficult to breathe. CM Eden and FF Welch helped him down the stairs. CM Eden described the stairwell as full of smoke and hot. FF Welch thought that without breathing apparatus one would struggle to breath there.952 94.73 Although we are satisfied that FF Fernandes and Williams, carrying the Belkadi’s second daughter, entered the stairwell first, the evidence does not enable us to make a finding about the order in which the Belkadi family, supported by the firefighters, left floor 20. They did so in conditions that were particularly difficult and the firefighters were conscious that they were low on air.953 FF Welch recalled that Omar Belkadi had collapsed as soon as they began descending. On CM Eden’s account they had got no further than the half landing between floors 20 and 19. At about that time, the low-pressure warning on the firefighters’ breathing apparatus began to sound.954 94.74 CM Eden and FF Welch decided that CM Eden would return to the bridgehead to seek help while FF Welch stayed with Omar Belkadi. In the event, FF Welch was able to leave Omar Belkadi with another crew as he had to return to the bridgehead because his air was running low.955 947 Phase 1 Report Volume II paragraph 14.82; Williams {MET00010829/7-9} pages 7-9. 948 Fernandes {MET000083292/4-5} pages 4-5; Williams {MET00010829/10} page 10; Eden {MET00008019/11} page 11. 949 Eden {MET00008019/11} page 11; Welch {MET000080606/9} page 9. 950 Phase 1 Report Volume II paragraph 14.83; Fernandes {Day39/181:5-20}. 951 Fernandes {Day39/183:2-14}. 952 Eden {MET00008019/11} page 11; Welch {MET000080606/9} page 9. 953 Eden {MET00008019/11} page 11; Williams {MET00010829/7} page 7. 954 Phase 1 Report Volume II paragraph 14.83; Eden {MET00008019/11} page 11; Welch {MET000080606/9} page 9. 955 Phase 1 Report Volume II paragraph 14.83.

Part 9 | Chapter 94: Floor 20 117 94.75 FF Williams carried the second daughter of Farah Hamdan and Omar Belkadi out of the tower at 02.26.956 FF Fernandes provided a debrief on reaching the bridgehead but could not remember what he had said.957 The end of wear time for CM Eden and FF Welch was between 02.27 and 02.29.958 Neither of them said that he had provided any kind of debrief to the bridgehead on his return.959 94.76 When the bridgehead moved to floor 3 after 02.17, WM De Silvo started recording information about people needing to be rescued on a wall. There was a list of floors from 3 to 23 against which the numbers of specific flats were written as information came in. WM De Silvo put a tick against a flat number to show that a BA crew had visited it, a circle to indicate when further information was received and a cross to show that it had been searched and a rescue carried out. There was a tick to show that that Flat 175 had been visited. Given that there were no deployments to that flat after 02.00, it is likely that the information recorded on floor 3 was brought across from floor 2.960 94.77 No firefighters were deployed to look for Omar Belkadi, Farah Hamdan or their two children after CM Eden and FF Welch returned. At 02.44, FFs Tom Reddington and Nikki Upton tallied out to go to floor 21. They had reached what they believed was floor 18, when they came upon Farah Hamdan. She was unresponsive and the firefighters were unable to move her body as her leg was trapped in the banister railings. FF Upton found Malak Belkadi near her mother. They were able to move her and made the difficult decision to take her down since they could not free her mother.961 94.78 It is likely that FFs Upton and Reddington found Farah Hamdan and her daughter on the stairs higher than floor 18. As they were descending with Malak Belkadi, they encountered a four-person crew who were ascending to go to floor 23. They told them that they had left a female casualty who needed assistance. One of that crew, FF Jessamine Bate, then assisted FFs Upton and Reddington to carry Malak Belkadi down the stairs. The remaining three firefighters, FFs Michael Pole, Niki Mitchell and Chris Cheesman, continued upwards. When they realised that they had insufficient air to reach floor 23, they stopped at floor 18 and helped evacuate occupants in Flat 153. None of these firefighters describe seeing a female casualty on the stairs.962 94.79 Malak Belkadi was carried out of the tower at 03.07.963 Recovery and identification 94.80 After the fire the bodies of Farah Hamdan, Omar Belkadi and their daughter, Leena, were found on the stairs between floors 20 and 19.964 The coroner was satisfied about their identification and therefore issued an interim certificate of the fact of death for each of them.965 956 Phase 1 Report Volume III Annex A. 957 Fernandes {Day39/184:22-24}. 958 BA Telemetry Data {LFB00023326/1} page 1. 959 Phase 1 Report Volume II paragraph 14.83. 960 Phase 1 Report Volume IV paragraph 28.86; Phase 1 Report Volume II paragraphs 15.23 and 15.25, Figure 15.7. 961 Phase 1 Report Volume III paragraph 15.57. 962 Phase 1 Report Volume III paragraph 15.58; LFB Operational Response Report dated July 2020 {LFB00119333/263} page 263. 963 Phase 1 Report Volume II paragraph 14.172. 964 Phase 1 Report Volume II paragraph 14.172. 965 Interim certificates of the fact of death for Omar Belkadi, Farah Hamdan and Leena Belkadi {MET00065583}; {MET00065592}; {MET00065638}.

The Grenfell Tower Inquiry: Phase 2 Report 118 Cause and time of death 94.81 The post-mortem on Omar Belkadi noted significant soot staining of the body and minor heat damage, both of which had occurred after death. Similarly, there was heavy soot staining and minor heat damage to Farah Hamdan’s body. Leena Belkadi had soot staining to her face and again some minor heat damage. In all three cases, there was soot staining of the respiratory airways, indicating inhalation of smoke-filled air. Toxicological analysis of blood samples taken from Farah Hamdan, Omar Belkadi and Leena Belkadi found the levels of carboxyhaemoglobin in their blood to be 85%, 87%, and 84% respectively,966 in each case significantly higher than the lethal threshold. 94.82 Malak Belkadi was unconscious and in cardiac arrest when carried from the tower. Resuscitation efforts began at the scene and continued at St Mary’s Hospital where, at 03.41, a return of circulation was recorded. With treatment, the concentration of carboxyhaemoglobin in her blood dropped from 45% on arrival at hospital to 26%. Toxicological analysis of a sample taken five hours after the start of the fire recorded the level of carboxyhaemoglobin in her blood to be approximately 10%. As the post-mortem report for Malak Belkadi observes, that followed treatment in an oxygen-enriched environment. The level of cyanide in her blood, when first measured some hours after she had been brought out of the tower, was 0.19 milligrams/litre. That reflected the elimination half-life of cyanide being one to two hours. A CT scan showed general cerebral oedema with possible superimposed hypoxic ischaemic brain injury. No brain activity could be found. At 15.01 on 15 June 2017, Malak Belkadi was declared dead.967 The coroner, Professor Wilcox, also issued an interim certificate of the fact of death for Malak Belkadi.968 94.83 The reports of the post-mortems carried out on Omar Belkadi, Farah Hamdan, Malak Belkadi and Leena Belkadi gave the medical cause of death as “inhalation of fire fumes” but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”. 94.84 In the light of the evidence as a whole, including that given by Professor Purser, we are satisfied that the family entered the stairwell at about 02.19. They all collapsed soon after doing so because they had already had a significant exposure to asphyxiant gases entering from the lobby rather than from the outside. Their departure from Flat 175 was made in difficult circumstances into a lobby which was heavily smoke logged. As the family crossed the lobby, they inhaled hot smoke and asphyxiant gases and continued to do so on entering the stairwell. The result was that they quickly accumulated an incapacitating dose of asphyxiant gases. The inhalation of hot gases contributed by causing breathing difficulties. The family continued to inhale asphyxiant gases (mainly carbon dioxide but also hydrogen cyanide) until their breathing ceased and they died. In the case of Malak Belkadi, she continued to breathe until she suffered cardiac arrest and fatal brain damage. 966 Omar Belkadi post-mortem report {COR00001303/11}; Hamdan post-mortem report {COR00000397/9}; Leena Belkadi post-mortem report {COR00000876/9}; Leena Belkadi toxicology report {COR00000885}; Purser, Phase 2 Report, Section 6 {DAPR0000006/94} paragraph 522-524. 967 Report of paediatric intensive care consultant concerning Malak Belkadi {COR00001720/3-9} pages 3-9; Malak Belkadi toxicology report {COR00000966/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/95} paragraphs 525-527. 968 Interim certificate of the fact of death for Malak Belkadi {COR00001713}.

Part 9 | Chapter 94: Floor 20 119 94.85 A blood carboxyhaemoglobin level of 30–40% is enough to cause a person to lose consciousness.969 The lethal threshold is around 50%.970 In children, because of their smaller body size, the rate of absorption of asphyxiant gases is more rapid than in adults.971 It is likely that the blood carboxyhaemoglobin level of the Belkadi family reached the lethal threshold by about 02.49; it is unlikely that anyone would have survived if rescued after that time.972 94.86 All the times mentioned above are to some degree conjectural. All we can say with any confidence is that Omar Belkadi, Farah Hamdan and Leena Belkadi died between 02.45 and 03.10, probably closer to 02.45, and that both Farah Hamdan and Leena Belkadi were already dead by the time FFs Upton and Reddington found them. By that time Malak Belkadi was close to the point of death. Having been carried from the tower and despite the treatment provided at hospital, she died at 15.01 on 15 June 2017. 969 Purser, Phase 2 Report, Section 6 {DAPR0000006/97} paragraph 535. 970 Purser, Phase 2 Report, Section 6 {DAPR0000006/99} paragraph 543. 971 Purser, Phase 2 Report, Section 6 {DAPR0000006/99} paragraph 543. 972 Purser, Phase 2 Report, Section 6 {DAPR0000006/98} paragraphs 541-543.

The Grenfell Tower Inquiry: Phase 2 Report 120

121 95.1 Except for Flat 185, all remaining five flats on floor 21 were occupied when the fire started. Ligaya Moore, who lived in Flat 181, and all five members of the El Wahabi family who lived in Flat 182, died in the fire. 95.2 By 01.26 on 14 June 2017 the fire on the outside of the building had already spread to floor 21.973 Mustapha Abdu in Flat 184 was the first occupant of the floor to leave. He left the tower at 01.28 and had no contact with anyone else on floor 21.974 95.3 Helen Gebremeskel lived in Flat 186 with her daughter. Woken by her kitchen smoke alarm, she went into her kitchen to see black smoke and flames coming through the window. She and her daughter quickly left the flat closing the front door behind them975 because it did not have an effective self-closing device.976 95.4 At 01.26, when she was in the lobby, Helen Gebremeskel called the emergency services to report a fire in her flat. She and her daughter tried to leave together with the El Wahabi family, but they abandoned the attempt and by 01.30 had taken shelter in Flat 183, the home of Marcio Gomes and Andreia Perestrelo.977 By that time there was a layer of black smoke close to the ceiling of the lobby.978 The El Wahabi family returned to Flat 182. 95.5 From about 01.25 the lobby of floor 21 rapidly filled with smoke to an extent that it deterred those who remained on that floor from trying to leave. a. At about 01.30 Abdulaziz El Wahabi told his sister Hanan Wahabi, who had already escaped, that the amount of smoke in the lobby had prevented him and his family from leaving.979 At about 01.41 in the course of an emergency call to the LFB control room he told CRO Pam Jones that it was very smoky in the lobby.980 b. At 02.32, Marcio Gomes used his mobile phone to make a video recording of black smoke coming through the sides of his closed front door. When he opened the door, the lobby was pitch black with no indication that the lighting was working.981 95.6 Further emergency calls alerted the control room to the fact that occupants were trapped on floor 21. Those still on floor 21 spoke to the control room on no fewer than 11 occasions. In Flat 182, the El Wahabi family were in contact with the control room in a call which lasted from 01.38 to 02.37.982 They spoke to the control room again at 02.43, 02.46, 973 Phase 1 Report Volume II paragraph 10.118. 974 Phase 1 Report Volume II paragraph 10.271. 975 Phase 1 Report Volume II paragraph 10.265. 976 Gebremeskel {Day68/133:1-2}; {Day68/143:15}. 977 Phase 1 Report Volume II paragraphs 10.269. 978 Phase 1 Report Volume II paragraph 10.270. 979 Phase 1 Report Volume III paragraph 11.42. 980 999 call transcript {LFB00055498/6}. 981 Phase 1 Report Volume II paragraphs 15.74-15.76. 982 Phase 1 Report Volume II paragraph 13.103. Chapter 95 Floor 21

The Grenfell Tower Inquiry: Phase 2 Report 122 02.51, 02.53 and 02.57.983 A call made at 02.39 was connected to the London Ambulance Service.984 Marcio Gomes in Flat 183 spoke to the LFB control room at 02.21, 02.46, 02.55, 03.09 and 03.25.985 95.7 Only one firefighter crew, FFs Nikki Upton and Tom Reddington, was sent to floor 21. They set out at 02.44 but failed to reach floor 21 because they stopped to assist casualties they found on the stairs.986 95.8 However, one firefighter did reach floor 21. FF Dean Roberts was part of a five-member crew sent to the roof of the tower987 that set out between 01.56 and 01.57.988 Somewhere between floors 20 and 21, they found Fadumo Ahmed collapsed in the stairwell. While his colleagues helped her, FF Roberts continued up to floor 21 and opened the door to the lobby. He found it to be pitch black with smoke from floor to ceiling. He shouted and kicked the stairwell door but he did not see or hear any reaction before he left that floor.989 There is no evidence that the occupants on floor 21 heard FF Roberts shout into the lobby. Ligaya Moore Date of birth: 28 October 1938 (78 years). Place of birth: San Luis, Philippines. Gender:

Female. Occupation: Retired. Usual address: Flat 181, floor 21, Grenfell Tower, London. Place of death: Flat 181, floor 21, Grenfell Tower, London. Time of death: Between 01.40 and 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 95.9 Ligaya Moore was retired and was 78 years old in June 2017. Born in the Philippines, she had moved to London in 1972 and worked as a nanny. She met her husband, James Moore, in London and they moved into Grenfell Tower in 1981. Ligaya Moore continued to live in Flat 181 after the death of her husband.990 Vulnerability 95.10 In 2013 the TMO became aware that Ligaya Moore was prone to hoarding and advised her that it could affect her tenancy.991 The situation did not improve. In October 2014, following their survey of residents, Rydon informed the TMO that the accumulation 983 Phase 1 Report Volume III paragraphs 15.180 and 15.186-15.187. 984 Phase 1 Report Volume III paragraph 16.53. 985 Phase 1 Report Volume III paragraphs 15.130, 16.56, 16.84, 17.48, 17.50, 17.132, 17.139 and 18.29. 986 Phase 1 Report Volume III paragraph 15.57. 987 Phase 1 Report Volume II paragraphs 11.12-11.13. 988 BA Telemetry Data {LFB00023326}. 989 Phase 1 Report Volume II paragraphs 14.85-14.87; Roberts {Day27/125:5}-{Day27/127:17}. 990 Phase 1 Report Volume IV paragraphs 32.119 -32.124. 991 RBKC Core Assessment for Ligaya Moore {RBK00059526/2}.

Part 9 | Chapter 95: Floor 21 123 of items in Flat 181 made it impossible for it to carry out works.992 Janice Jones, TMO neighbourhood officer, referred Ligaya Moore to RBKC’s social services department for assistance. They tried to carry out an assessment in May 2015, but she was not willing to co-operate. Hoarding was noted to be a possible fire safety risk, the consequences of which would be catastrophic. Ligaya Moore was recorded as being independently mobile and able to call out if in danger. She did agree to a referral to a de-cluttering service but would not consent to social services contacting her doctor or to being contacted by the LFB for a fire safety check.993 95.11 A care and support plan completed in September 2015 noted that Ligaya Moore had had three sessions with the de-cluttering service and had agreed to be referred to Age UK’s de-cluttering service but had refused further involvement with social services. The housing department were to continue to monitor the situation.994 Nerita Bunggay, a friend of Ligaya Moore who saw her every day, described her as so embarrassed by the state of her home that she did not want others to see it. Hoarding was still a problem for her in June 2017.995 95.12 Ligaya Moore appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system.996 It recorded that she was over 65 years of age but did not mention any other vulnerability. Events of 14 June 2017 95.13 Ligaya Moore returned to Grenfell Tower shortly after 22.20 on 13 June 2017.997 She did not leave her home after that. 95.14 It is likely that she never became aware of the fire. No other occupant of floor 21 had any communication with her during its course and there is no evidence to suggest that she became aware of the movements of the other occupants trapped on that floor or that she had contact with the emergency services, family or friends by telephone or otherwise. Recovery and identification 95.15 All the combustible contents of Flat 181 were destroyed in the fire.998 Ligaya Moore’s remains were recovered from the bedroom area. They were associated with the remains of a bed which suggests that she was in bed at the time of the fire. The coroner was satisfied about the identification of the remains recovered and therefore issued an interim certificate of the fact of death.999 Cause and time of death 95.16 The post-mortem report for Ligaya Moore recorded the medical cause of death as “consistent with the effects of fire”, but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”. 992 Report dated 31 October 2014 from Rydon RLO {RYD00022561}. 993 RBKC Core Assessment for Ligaya Moore {RBK00059526/9-13}. 994 RBKC Care and Support Plan Review for Ligaya Moore {RBK00059524/3}. 995 Bunggay {IWS00002374/2} page 2, paragraphs 7-13. 996 Phase 1 Report Volume III paragraphs 20.65-20.66; Noble Spreadsheet {TMO00862588}. 997 O’Riordan {MET00013136/4} page 4. 998 Purser, Phase 2 Report, Section 6 {DAPR0000006/65} paragraph 315. 999 Interim certificate of the fact of death for Ligaya Moore {MET00065603}; Purser, Phase 2 Report, Section 6 {DAPR0000006/65} paragraph 319.

The Grenfell Tower Inquiry: Phase 2 Report 124 95.17 Flat 181 was a one-bedroom flat situated on the east side of the tower between Flats 186 and 182.1000 The fire had reached floor 21 before 01.30.1001 It was outside the living room of Flat 181 by about 01.32 and from then on smoke began to leak into Flat 181 both from the outside and the lobby. By about 01.52 the fire was outside the bedroom window.1002 95.18 It is very difficult to make a finding with any confidence about the time at which Ligaya Moore died. However, in the light of all the evidence including that of Professor Purser1003, we think it likely that she became incapacitated as a result of inhaling asphyxiant gases, including carbon monoxide and hydrogen cyanide, by about 01.40 and that she had died in her sleep by about 02.00, well before fire took hold in her bedroom. The El Wahabi family Abdulaziz El Wahabi Date of birth: 01 December 1964 (52 years old). Place of birth: Larache, Morocco. Gender:

Male. Occupation: Hospital Porter. Usual address: Flat 182, floor 21, Grenfell Tower, London. Place of death: Flat 182, floor 21, Grenfell Tower, London. Time of death: Between 03.00 and 03.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Faouzia El Wahabi Date of birth: 01 June 1975 (42 years old). Place of birth: Larache, Morocco. Gender:

Female. Occupation: Homemaker. Usual address: Flat 182, floor 21, Grenfell Tower, London. Place of death: Flat 182, floor 21, Grenfell Tower, London. Time of death: Between 03.00 and 03.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. 1000 External Spread of Fire at Grenfell Tower {MET00012593/7}. 1001 Phase 1 Report Vol II paragraph 10.118. 1002 Purser, Phase 2 Report, Section 6 {DAPR0000006/64} paragraph 314. 1003 Purser, Phase 2 Report, Section 6 {DAPR0000006/65} paragraph 319 and {DAPR0000006/66} paragraphs 320-321.

Part 9 | Chapter 95: Floor 21 125 Yasin El Wahabi Date of birth: 09 August 1996 (20 years old). Place of birth: Paddington, London. Gender:

Male. Occupation: Student. Usual address: Flat 182, floor 21, Grenfell Tower, London. Place of death: Flat 182, floor 21, Grenfell Tower, London. Time of death: Between 03.00 and 03.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Nur Huda El Wahabi Date of birth: 27 June 2001 (15 years old). Place of birth: Paddington, London. Gender:

Female. Occupation: Student. Usual address: Flat 182, floor 21, Grenfell Tower, London. Place of death: Flat 182, floor 21, Grenfell Tower, London. Time of death: Between 03.00 and 03.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Mehdi El Wahabi Date of birth: 22 February 2009 (8 years). Place of Birth: Chelsea, London. Gender:

Male. Occupation: Student. Usual address: Flat 182, floor 21, Grenfell Tower, London Place of death: Flat 182, floor 21, Grenfell Tower, London. Time of death: Between 03.00 and 03.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

The Grenfell Tower Inquiry: Phase 2 Report 126 Background and composition of household 95.19 Abdulaziz El Wahabi and Faouzia El Wahabi lived in Flat 182 on floor 21 of Grenfell Tower with their three children, Yasin, Nur Huda and Mehdi. Abdulaziz El Wahabi was born on 1 December 1964 in Larache, in northern Morocco. He was 52 years old and had worked as a hospital porter at University College Hospital for 22 years.1004 His wife Faouzia was born on 1 June 1975, also in Larache. She was 42 years old and was a homemaker.1005 95.20 The couple’s three children were all born in London. Yasin was 20 years old, having been born on 9 August 1996. A trained football referee, he was studying accountancy at Greenwich University. 1006 Nur Huda was 15 years old, having been born on 27 June

1. She was studying for her GCSEs at Holland Park Secondary School.1007 Mehdi was

eight years old, having been born on 22 February 2009. He was a pupil at Oxford Gardens Primary School.1008 Vulnerability 95.21 None of the family had a disability that affected their ability to respond to an emergency. Nur Huda and Mehdi El Wahabi were both under 18 years of age at the time of the fire. In the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system Nur Huda was recorded as being under 18 but Mehdi did not appear.1009 Events of 14 June 2017 95.22 Nur Huda El Wahabi was the first member of the family to return home on the evening of 13 June 2017, coming into the tower at 18.16. Abdulaziz, Faouzia and Mehdi El Wahabi returned at 21.17. Yasin El Wahabi was the last of the family to return to the tower, at 00.47 on 14 June 2017.1010 The first evacuation attempt 95.23 Hanan Cherbika, a friend of the El Wahabi family, called Nur Huda El Wahabi soon after 01.10. She told her that there was a fire in the tower and that the family needed to leave. Nur Huda El Wahabi reassured her that the fire was downstairs. Hanan Cherbika encouraged her to wake her mother and to let her decide what to do.1011 Yousra Cherbika, Hanan Cherbika’s daughter, also spoke to Nur Huda El Wahabi, who told her that she was going to come down.1012 95.24 Hanan Wahabi, Abdulaziz El Wahabi’s sister, who lived in Flat 66 on floor 9, left the tower at 01.21. She called her brother just after 01.25 to warn him of the fire. She advised the family to leave the tower.1013 Shortly afterwards, Helen Gebremeskel saw the El Wahabi family in the lobby on floor 21 and warned them there was a fire in her flat, Flat 186. They told her the whole building was affected. Together with Helen Gebremeskel and her daughter, the 1004 Phase 1 Report Volume IV paragraphs 32.106 and 32.109. 1005 Phase 1 Report Volume IV paragraphs 32.106 and 32.110. 1006 Phase 1 Report Volume IV paragraphs 32.106 and 32.113. 1007 Phase 1 Report Volume IV paragraphs 32.106 and 32.115. 1008 Phase 1 Report Volume IV paragraphs 32.106 and 32.118. 1009 Noble Spreadsheet {TMO00862588}. 1010 O’Riordan {MET00013136/3} page 3. 1011 Hanan Cherbika {IWS00000016/5} page 5, paragraph 18. 1012 Yousra Cherbika {IWS00001032/6} page 6, paragraph 21. 1013 Phase 1 Report Volume II paragraph 10.266.

Part 9 | Chapter 95: Floor 21 127 El Wahabi family then tried to leave the tower. They reached the stairs but could not go down as a group of people were coming up. Those coming up told them that they should all go back to their flats.1014 The El Wahabi family returned to Flat 182. Helen Gebremeskel and her daughter went to Flat 183, the home of Marcio Gomes, Andreia Perestrelo and their two daughters.1015 95.25 Hanan Wahabi spoke to her brother again at about 01.30. He said the family had tried to leave but there had been too much smoke and they had been unable to see or breathe.1016 The first emergency call from Flat 182 95.26 Flat 182 was in the south-east corner of the tower. The windows of the living room faced east and south.1017 The El Wahabi family had converted it into a three-bedroom flat, with the bedroom of Abdulaziz and Faouzia El Wahabi being opposite the front door with a window facing south.1018 95.27 The first emergency call from Flat 182 was made at 01.38 and lasted for just over 59 minutes. It was answered by CRO Pam Jones in the LFB control room. While various members of the family spoke to CRO Jones at different times, Abdulaziz El Wahabi spoke to her for most of the call.1019 He told CRO Jones that he was with his wife and three children in Flat 182.1020 95.28 During the call, the family told CRO Jones that they had tried to go down the stairs but had been forced to return as it was too smoky.1021 CRO Jones advised them to stay in the flat if it was too smoky to leave, to block up any places where smoke was coming in and to get fresh air from a window.1022 She said that she would let the firefighters know which flat the family were in and that they would try to reach them as soon as possible.1023 At 01.47, the family reported that, despite the use of blankets, smoke was still coming into the flat through the front door. At this time they were sheltering in the living room.1024 95.29 At about 01.55, Abdulaziz El Wahabi told CRO Jones that someone outside had told the family that the fire had reached the flat next door (i.e. Flat 181).1025 Over the next few minutes the family were able to see the fire next door and smoke began to come into the living room. CRO Jones advised them to move to another room and they then moved to the bedroom of Abdulaziz and Faouzia. By then the fire had reached the kitchen of Flat 182.1026 95.30 Hanan Wahabi called her brother for the last time at 02.15. Faouzia El Wahabi answered the telephone and Hanan Wahabi urged her to leave. Faouzia said they were trying to do so. She said that the fire was in the kitchen of Flat 182 and that the family had been told to 1014 Phase 1 Report Volume II paragraphs 10.267 and 10.268. 1015 Phase 1 Report Volume II paragraph 10.270. 1016 Phase 1 Report Volume II paragraph 11.42. 1017 External Spread of Fire at Grenfell Tower {MET00012593/7}. 1018 Wahabi {IWS00000074/3} page 3, paragraph 9 and {IWS00000074/22} page 22, Appendix I. 1019 Phase 1 Report Volume II paragraphs 13.103 and 14.157; 999 call transcript {LFB00055498/7}; {LFB00055498/16}; Wahabi {IWS00001146/9} page 9, paragraph 29. 1020 999 call transcript {LFB00055498/8}. 1021 999 call transcript {LFB00055498/3}; {LFB00055498/9-10}. 1022 999 call transcript {LFB00055498/4-6}; {LFB00055498/10}. 1023 999 call transcript {LFB00055498/11-12}; {LFB00055498/14-15}. 1024 999 call transcript {LFB00055498/16-17}; {LFB00055498/20}. 1025 999 call transcript {LFB00055498/31-32}. 1026 999 call transcript {LFB00055498/35-50}; Phase 1 Report Volume II paragraphs 14.159-14.160.

The Grenfell Tower Inquiry: Phase 2 Report 128 go to the bedroom.1027 Meanwhile, the call with CRO Jones was continuing. She ascertained that the bedroom was smoke-free and advised the family to remain there with the door shut and a window open for air. She assured them that firefighters would come to them.1028 95.31 Throughout the call with CRO Jones, members of the El Wahabi family were in contact with friends and family outside the tower who were telling them to leave. The family responded that they had been advised to remain in their flat.1029 However, at about 02.24 smoke began to enter the bedroom through the open window and CRO Jones advised them to close the window.1030 At about 02.34, having been told by OM Alexandra Norman that those in the tower should now be advised to leave, CRO Jones told the El Wahabi family to cover themselves with wet clothes and towels and to leave the flat.1031 She continued to encourage the family to leave until the call was disconnected at 02.37.1032 Information to the incident ground 95.32 The LFB control room passed messages about Flat 182 to the incident ground while CRO Jones was speaking to the El Wahabi family. 95.33 At about 01.47, CRO Jones told them that a message had been passed to firefighters about Flat 182 but she did not create a service request.1033 At about 01.50, CRO Jones told them that the control room was calling the firefighters again.1034 At that time, CRO Yvonne Adams, who was sitting next to CRO Jones, spoke to command unit CU8 and passed on information about two flats, one of which was Flat 182. CRO Adams told CU8 that those in Flat 182 had not been able to stop smoke coming under the front door, were in the living room and sounded “panicked”.1035 95.34 WM Mark Kentfield recorded the information reaching CU8 on pieces of paper which were then passed to SM Brett Loft who at that time was positioned outside the tower. He had taken charge of managing information about people needing to be rescued and was passing it to the bridgehead, probably by radio.1036 The information provided to SM Loft included an A4 sheet of paper at the top of which was written “BRETT LOFT IC”. The seventh entry down on that document read: “182 – 21st FLOOR”.1037 Given that SM Loft recalled receiving information on paper from WM Kentfield at around 01.40,1038 it is likely that the mention of Flat 182 was the result of CRO Adams’s call to CU8. 95.35 At 02.00, CRO Adams made a second call to CU8, during which she passed on information about several flats, including Flat 182. She reported that there were two adults and three children trapped in the flat, that the fire was next door to them and that smoke was pouring in. An officer in CU8 replied that they had the impression that floors 21 to 23 were the most severely affected.1039 1027 Wahabi {IWS00000074/16} page 16, paragraph 55. 1028 999 call transcript {LFB00055498/57-67}; {LFB00055498/73-76}. 1029 Phase 1 Report Volume II paragraph 14.162. 1030 999 call transcript {LFB00055498/80}. 1031 Phase 1 Report Volume III paragraph 15.156; Jones {LFB00032090/6} page 6, paragraph 30. 1032 999 call transcript {LFB00055498/95-101}. 1033 999 call transcript {LFB00055498/15}; LFB Short Incident Log {MET00013830}. 1034 999 call transcript {LFB00055498/23}. 1035 Phase 1 Report Volume II paragraphs 13.85-13.86; Transcript of call between LFB control room and CU8 {INQ00000203}. 1036 Phase 1 Report Volume II paragraph 11.6 and Phase 1 Report Volume IV paragraphs 28.84 (a) and 28.84(b). 1037 Phase 1 Report Volume II paragraphs 12.18-12.19 and figure 12.4. 1038 Phase 1 Report Volume II paragraphs 11.7 and 12.19. 1039 Phase 1 Report Volume II paragraphs 14.230 and 14.231; Transcript of call between LFB control room and CU8 {INQ00000195}.

Part 9 | Chapter 95: Floor 21 129 95.36 Between 02.10 and 02.22 CU7 was designated as the command unit responsible for handling information about people needing to be rescued.1040 Initially the crew used a laminated white sheet to record information previously recorded in CU8 on pieces of paper.1041 The entries on that sheet included a reference to Flat 182 where two adults and three children were trapped (although the flat was incorrectly recorded as being on floor 18). The reference to the composition of the family makes it likely that the call made by CRO Adams to CU8 at 02.00 was the source of that information. Indeed, the information on the laminated sheet appeared on a control information form on which was also written “From CU list”.1042 95.37 Shortly after 02.17, CM Charles Batterbee made a note of the contents of a forward information board used while the bridgehead had been located on floor 2 of the tower to record information about people needing to be rescued. There was no reference to Flat 182 but there was a reference to Flat 204 on floor 21.1043 That suggests either that the message about Flat 182 that had been passed to CU8 at 01.50 and then again at 02.00 did not reach the bridgehead on floor 2, or that the information was passed on incorrectly. In any event, there was no deployment of firefighters to floor 21 while the bridgehead was located on floor 2. 95.38 At about 02.33, SM Jason Oliff began recording information about people needing to be rescued on two whiteboards in the LFB control room. The first entry, and the first information he passed to the command unit, was recorded as “182 21st Flr – 3 children 2 adults. Leave.”1044 That follows the change of advice communicated to the El Wahabi family by CRO Jones. 95.39 That information did reach the bridgehead on floor 3, as is confirmed by a reference to Flat 182 on the wall used by WM Louisa De Silvo at the bridgehead to record information about those needing to be rescued.1045 Flat 182 was circled and ticked to indicate that a crew had been deployed. (A circle indicated that she had received further information, including information from a returning crew.)1046 In this case, the tick referred to the deployment at 02.44 of FFs Nikki Upton and Tom Reddington wearing EDBA to floor 21.1047 FF Upton recalled that she and her colleague had been briefed by WM de Silvo and WM O’Keeffe but she could not remember whether they were to go to Flats 182 and 183 or to Flats 183 and 184.1048 We think it was probably the former, because her contemporaneous note1049 records that the crew were deployed to Flats 182 and 183. Moreover, no call for help had been received from Flat 184, whose occupant, Mustapha Abdu, had already escaped. 95.40 The two firefighters did not reach floor 21 because as they were going up the stairs they found Farah Hamdan and Malak Belkadi and brought Malak Belkadi down. On returning to the bridgehead, FF Upton told a crew manager that she and her colleague had not been able to reach floor 21. She could not recall to whom she had spoken.1050 1040 Phase 1 Report Volume IV paragraph 28.84d. 1041 Phase 1 Report Volume II paragraphs 12.8-12.9. 1042 Control Information Form {LFB00001922/6}. 1043 Phase 1 Report Volume II paragraph 14.73 and Figure 14.4; Phase 1 Report Volume IV paragraphs 28.84(b) and 28.84(c). 1044 Phase 1 Report Volume III paragraphs 15.139-15.141 and Figure 15.8. 1045 O’Beirne {MET000083321/19} page 19; Phase 1 Report Volume III Figure 16.6. 1046 Phase 1 Report Volume IV paragraph 15.25. 1047 Phase 1 Report Volume III paragraph 15.57. 1048 Upton {MET00007524/5} page 5; Upton {Day38/144:22}-{Day38/147:21}. 1049 Upton {MET00005625/1} page 1. 1050 Upton {Day38/150:24}- {Day38/151:11}.

The Grenfell Tower Inquiry: Phase 2 Report 130 Further emergency calls from Flat 182 95.41 After the call with CRO Jones had been disconnected at 02.37, the El Wahabi family made a series of short emergency calls. At 02.39, they were put through to the control room of the London Ambulance Service,1051 which at that time was not aware that the LFB had revoked the stay put advice.1052 The caller said that five people were trapped in Flat 182 and was told that help was on the way. The call handler then put the call on hold to ask a manager what instructions to give the caller, but at that point the connection was lost. The call handler did not call back as the protocols of the London Ambulance Service required.1053 95.42 At 02.43, Nur Huda El Wahabi spoke to CRO Heidi Fox in the LFB control room. She reported that there were two adults and three children in Flat 182 and, when asked, said that they could not leave. CRO Fox was in the course of advising her to cover herself in wet blankets when the call was disconnected.1054 95.43 Nur Huda El Wahabi made another emergency call that was answered by CRO Adams at 02.46. She confirmed that there were five people in Flat 182 and said there was too much smoke for them to get out. CRO Adams said they should try to cover themselves in wet towels and leave, as the fire brigade could not reach them. Nur Huda replied: “… too much smoke, I can’t breathe.”1055 95.44 When the call was disconnected, the line remained open to the BT operator who reconnected the call to the LFB on three further occasions at 02.51, 02.53 and 02.57.1056 The transcripts of those calls,1057 including the family’s exchanges with the BT operator,1058 show that they were coughing, having difficulty breathing and saying that they were feeling faint. We conclude from that that by that time there was a significant amount of smoke in the bedroom. 95.45 The first two calls were answered by CRO Adams and CRO Christine Howson respectively. Both advised the El Wahabi family that they had to leave. During the calls the CROs were told that the family could not breathe and that they had tried to leave but had been unable to see because of the smoke. In the second of those calls, the family said that they were again trying to leave.1059 95.46 At 02.57, the El Wahabi family was connected to the LFB control room for the third and last time. The call ended at 02.58, the line going silent before CRO Howson could speak to any member of the family.1060 That was the last contact anyone had with the El Wahabi family. 95.47 The whiteboard used in CU7 from about 03.00 to record information about people needing to be rescued shows that those later emergency calls may have resulted in information reaching that command centre.1061 Photographs taken later show that Flat 182 appeared on 1051 Phase 1 Report Volume III paragraph 16.53. 1052 Phase 1 Report Volume III paragraph 15.172. 1053 999 call transcript {INQ00000383}; Woodrow {LAS00000009/12} page 12; Woodrow {Day72/129:10}-{Day72/131:22}. 1054 Phase 1 Report Volume III paragraph 16.53; 999 call transcript {LFB00000374}. 1055 Phase 1 Report Volume III paragraphs 15.186 and 16.54; 999 call transcript {COR00000376/6}. 1056 Phase 1 Report Volume III paragraph 16.54. 1057 999 call transcript {COR00000376/8} and {COR00000376/10}. 1058 999 call transcript {COR00000376/1-5}. 1059 999 call transcript {COR00000376/8} and {COR00000376/10}. 1060 Phase 1 Report Volume III paragraph 16.54 (c). 1061 Phase 1 Report Volume III paragraphs 15.13 and 16.12.

Part 9 | Chapter 95: Floor 21 131 the grid with “5” in green and “2” in black next to it.1062 There was no red tick, which would have indicated a deployment.1063 We conclude that those later emergency calls did not prompt a deployment to Flat 182. Recovery and identification 95.48 The remains of the five members of the El Wahabi family were recovered from the bedroom of Abdulaziz and Faouzia El Wahabi.1064 The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for all members of the family.1065 Cause and time of death 95.49 The post-mortem reports for all five members of the El Wahabi family recorded the medical cause of death as “consistent with the effects of fire”, but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”. 95.50 Toxicological analysis was not possible. 95.51 We are satisfied that the members of the El Wahabi family probably lost consciousness shortly after the last emergency call from Flat 182 ended at 02.58 and perhaps rather earlier in the case of the younger members of the family. Death due to inhalation of asphyxiant gases, particularly carbon monoxide and hydrogen cyanide, occurred a few minutes later and before any internal fires had become established in the bedroom. Death probably occurred within 20 minutes of loss of consciousness, that is, by 03.20, and before suffering the direct effects of fire.1066 Logan Gomes Date of birth: 14 June 2017. Place of birth: London, UK. Gender:

Male. Background and composition of household 95.52 Andreia Perestrelo and Marcio Gomes lived in Flat 183 on floor 21 with their two daughters. At the time of the fire, Andreia Perestrelo was pregnant with the couple’s son Logan whose birth was expected on 21 August 2017.1067 It had been a healthy pregnancy and Andreia was intending to begin her maternity leave on 14 August 2017.1068 The whole family was eagerly awaiting the new arrival.1069 95.53 Logan Gomes was delivered stillborn on 14 June 2017 following his mother’s evacuation from the tower. 1062 Phase 1 Report, Volume III Figure 16.5; Photograph of whiteboard {MET00015924}. 1063 Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. 1064 Purser, Phase 2 Report, Section 6 {DAPR0000006/68} paragraph 369. 1065 Interim certificate of the fact of death for Abdulaziz El Wahabi, Faouzia El Wahabi, Yasin El Wahabi, Nur Huda El Wahabi and Mehdi El Wahabi {MET00065595}; {MET00065626}; {MET00065631}; {MET00065627}; {MET00065652}. 1066 Purser, Phase 2 Report, Section 6 {DAPR0000006/69} paragraphs 371 and 373 and {DAPR0000006/70} paragraph 378; Purser {Day297/69:11}-{Day297/72:6}. 1067 Phase 1 report Volume IV paragraphs 32.101-32.102. 1068 Perestrelo {IWS00000349/1} page 1, paragraph 5. 1069 Phase 1 report Volume IV paragraphs 32.102-32.103.

The Grenfell Tower Inquiry: Phase 2 Report 132 Events of 14 June 2017 95.54 The family returned home on the evening of 13 June 2017 after dinner with friends.1070 They became aware of the fire shortly before 01.30, when Helen Gebremeskel knocked on their door following her attempt to leave floor 21 with the El Wahabi family. Helen Gebremeskel and her daughter were invited to shelter in Flat 183.1071 95.55 Some 20 minutes later, Marcio Gomes began to use wet towels to block out smoke which was by then seeping around the sides of the front door to Flat 183.1072 He was in contact with Miguel Alves, another resident of the tower, who had already left. Miguel Alves passed on the advice of a policeman that Marcio Gomes should stay in the flat.1073 95.56 The two families then in Flat 183 decided to try to leave but were deterred by the amount of smoke in the lobby.1074 Marcio Gomes then made his first emergency call at 02.21 and spoke to CRO Heidi Fox in the LFB control room. She explained that firefighters were going to the flats and that she would tell them about Flat 183. At 02.24, CRO Fox created a service request recording that three adults, including one pregnant lady and three children, were trapped. CRO Sharon Darby passed the message by radio to CU7 at 02.24.1075 95.57 Between 02.10 and 02.22 CU7 began handling information relating to people needing to be rescued.1076 Initially, a white laminated sheet was used to record information. The entries on that sheet included “183 21 6 adults, 1 pregnant” (the number 6 was written in red pen and appeared to replace an erased 3).1077 At about the same time, WM Paul Sadler was instructed to collate information about people needing to be rescued for onward transmission to the bridgehead which, from 02.17, was located on the third floor of the tower. He communicated with the bridgehead either by radio or through paper control information forms.1078 95.58 No note relating to Flat 183 appears on the wall on floor 3 used to record information about people needed to be rescued during the period when the bridgehead was located on that floor.1079 However the existence of a control information form which contains information consistent with the service request created by CRO Fox (in particular the reference to a “pregnant lady”) suggests that the message did reach the bridgehead.1080 The consequence was the deployment at 02.44 of FFs Nikki Upton and Tom Reddington to Flats 182 and 183 on floor 21, which was prompted not only by information about those needing to be rescued from Flat 182, but also, we find, by similar information relating to Flat 183. 1070 Perestrelo {IWS00000349/8} page 8, paragraph 46. 1071 Phase 1 Report Volume II paragraphs 10.267-10.269. 1072 Phase 1 Report Volume II paragraph 14.163. 1073 Phase 1 Report Volume II paragraph 14.164. 1074 Phase 1 Report Volume II paragraph 14.165. 1075 Phase 1 Report Volume II paragraph 14.165; Phase 1 Report Volume II paragraph 15.130; LFB Short Incident Log {MET00013830/22}. 1076 Phase 1 Report Volume IV paragraph 28.84d. 1077 Phase 1 Report Volume II Figure 12.3 and paragraphs 12.8-12.9; Phase 1 Report Volume III Figure 15.6 and paragraphs 15.11-15.13. 1078 Phase 1 Report Volume I1 paragraph 14.65-14.72; Phase 1 Report Volume IV paragraph 28.84e. 1079 Phase 1 Report Volume II Figure 15.7. 1080 Control Information Form {LFB00001922/10}.

Part 9 | Chapter 95: Floor 21 133 95.59 However, FFs Upton and Reddington did not reach floor 21. They found Farah Hamdan and Malak Belkadi in the stairwell and brought Malak Belkadi down. On returning to the bridgehead, FF Upton told a crew manager that she and her colleague had not been able to reach floor 21. She could not recall to whom she had spoken.1081 95.60 Marcio Gomes made a second emergency call from Flat 183 at 02.46. He reported that the fire had reached the flat next door and was coming through the windows. CRO Christine Howson advised him to leave if he no longer considered it safe to remain. When he replied that there was too much smoke to leave, she advised him to use wet clothes as protection against the smoke and to get to the stairwell. It was not clear whether CRO Howson had been told of the change in the “stay put” advice at that time, as she gave the impression during the call that firefighters were still on their way up the building.1082 95.61 The two families made a further attempt to leave Flat 183 but could not cross the lobby. Marcio Gomes then made a third emergency call at 02.55 and spoke to CRO Angela Gotts. He told her that they were unable to leave and that smoke was coming into the flat despite towels being used to block it out. During that call, Marcio Gomes said that there were “...three kids and three adults and one heavily pregnant wife” in the flat. CRO Gotts said she would let the firemen know to come up to them. She did not create a service request but passed a message to CRO Sharon Darby, who then sent it by radio to CU7 at 02.58. The message stated that there were six persons in the flat, one of whom was pregnant. The information was also entered on a whiteboard in the LFB control room by SM Jason Oliff.1083 95.62 At 03.09, Marcio Gomes made a fourth emergency call and spoke to CRO Howson again. He was advised to leave but said it was not possible to do so. He said that there were six people in the flat, including someone who was pregnant. CRO Howson said she would inform the crews and make reaching him a priority. She asked him again to try to leave.1084 By that time conditions in Flat 183 had deteriorated, with more smoke entering the flat.1085 95.63 Although we cannot trace the passage of the information given in the three emergency calls made by Marcio Gomes between 02.46 and 03.09 individually to the bridgehead, the fact that information about Flat 183 was reaching it is indicated by the following: a. Entries for Flat 183 appeared on the whiteboard used in CU7 after 03.00 to record information about people needing to be rescued. The number of entries for Flat 183 suggests that more than one message was received and that the information on the whiteboard was revised accordingly.1086 b. The completion of control information forms that refer to six people, one pregnant, in Flat 183.1087 One of the forms contains a reference to floor 23 and a list of other flats in the tower identified as priorities.1088 WM Sadler may have amended the form to include floor 23 following the receipt of fresh information. The list of priorities was added after the form left him,1089 but we cannot say with any confidence when that was done or whether Flat 183 was one of the flats designated as a priority. 1081 Upton {Day38/150:24}-{Day38/151:11}. 1082 Phase 1 Report Volume III paragraphs 15.78, 15.189 and 15.191. 1083 Phase 1 Report Volume III paragraphs 15.139-15.141, 16.56 -16.57, 16.84, Figures 15.8 and 15.9; 999 call transcript {LFB00000392}; Radio transcript {LFB00002017}. 1084 Phase 1 Report Volume III paragraph 17.48; 999 call transcript {LFB00000412}. 1085 Phase 1 Report Volume III paragraphs 17.50 and 17.132. 1086 Phase 1 Report Volume III paragraphs 15.13 and 16.12 and Figure 16.5; Photograph of whiteboard {MET00015924}. 1087 Control Information Forms {LFB00001922/12-15}. 1088 Control information form {LFB00001922/14}. 1089 Sadler {Day29/95:5}-{Day29/100:20}.

The Grenfell Tower Inquiry: Phase 2 Report 134 c. A reference to Flat 183 on the wall on the ground floor where, from 02.15, WM Glynn Williams had started recording information about people needing to be rescued.1090 The notation “183 21” appeared in a list created on the left hand side of the wall. It is likely that that list was begun after the bridgehead had been moved down to the ground floor and that the first entry on it was made some time after 03.21.1091 95.64 In any event, there was no further deployment of firefighters to Flat 183 or even to floor 21. 95.65 At 03.25, Marcio Gomes spoke to CRO Fox in what was his fifth emergency call. It lasted for 33 minutes and 53 seconds.1092 By the time the call began conditions in Flat 183 had worsened, with smoke continuing to come through the front door. Initially, Marcio Gomes told CRO Fox that it was not possible to leave and that they had tried three times to do so. CRO Fox told him that she would try to make them a priority. After the call had continued for about a minute and a half, Marcio Gomes told CRO Fox that the fire had entered the flat. The two families then covered themselves with wet towels and made their way to the stairwell.1093 95.66 They found the lobby and the stairwell to be hot and full of smoke; there was no visibility or breathable air. CRO Fox continued talking to Marcio Gomes and encouraged him to continue through the lobby and down the stairs. While doing so she spoke to a colleague in the control room, passing on information and telling her that he was struggling to breathe. CRO Fox told him that firefighters were aware of their location and making their way up to them.1094 Although CRO Fox said that a message was being sent to the incident ground by radio, we have not been able to confirm that that was done or whether any information reached the incident ground either by radio or telephone. 95.67 As he went down the stairs Marcio Gomes lost contact with his wife and daughters. He tried to make his way back up but encountered firefighters who said they would find them. He also spoke to a firefighter who asked which flat and which floor his family had started from.1095 That contact may explain how WM Louisa De Silvo came to write “183 – Daughter” (underlined), with “21 or 22” written underneath on the green wall used on the ground floor to record information about people needing to be rescued after the bridgehead had moved there.1096 CM Aldo Diana and FF Dean Nelson were the firefighters who told Marcio Gomes that they would find his family. Originally sent to Flat 133 on floor 16, they found Andrea Perestrelo, her younger daughter and Helen Gebremeskel, who were all close to collapse. The two firefighters then went up again to find Helen Gebremeskel’s daughter and Andrea Perestrelo’s elder daughter, both of whom had collapsed on the stairs. They carried them down.1097 1090 Phase 1 Report Volume II paragraphs 14.103-14.105 and Figure 14.5; Photographs of ground floor wall {MET00005774} and {MET00005776}. 1091 Williams {Day31/137:13}-{Day31/139:21}. 1092 Phase 1 Report Volume III paragraph 17.50; 999 call transcript {LFB00055501}. 1093 Phase 1 Report Volume III paragraphs 18.29-18.31. 1094 Phase 1 Report Volume III paragraphs 18.30-18.34; 999 call transcript {LFB00055501/17}; {LFB00055501/6-21}. 1095 Phase 1 Report Volume III paragraph 18.35; 999 call transcript {LFB00055501/30}. 1096 De Silvo {Day30/63:1}; De Silvo Exhibit LDS/7 - photo of green wall {MET00015820}. 1097 Phase 1 Report Volume III paragraph 18.20; Nelson {MET00010926/6} page 6; Diana {MET00018800/10} page 10.

Part 9 | Chapter 95: Floor 21 135 95.68 The group left the tower between 03.37 and 03.55.1098 Andreia Perestrelo, her daughters and Marcio Gomes were taken by ambulance to King’s College Hospital.1099 Andreia Perestrelo and her daughters were put into induced comas. An emergency caesarean section was performed on Andreia Perestrelo at 23.03 on 14 June 2017. Sadly, Logan Gomes was stillborn.1100 Cause of death 95.69 The post-mortem on Logan Gomes found features of terminal pathophysiological stress and nothing to suggest developmental abnormality, malformation or any other underlying pathology. There was less than 5% carboxyhaemoglobin in his blood.1101 95.70 When admitted to hospital, Andreia Perestrelo had significant carbon monoxide poisoning and possible hydrogen cyanide poisoning. The resulting severe acidosis is likely to have been the cause of Logan’s death at some time during the day on 14 June 2017.1102 95.71 It is likely that those who were sheltering in Flat 183 absorbed a relatively small amount of asphyxiant gases before they left the flat.1103 However, their exposure to the conditions in the lobby and the stairs, coupled with the physical effort involved in making their way down, resulted in their accumulating a quantity of asphyxiant gases by the time they reached the ground floor that was nearly sufficient to incapacitate them.1104 1098 Phase 1 Report Volume III paragraph 18.37. 1099 Perestrelo {IWS00000349/14} page 14, paragraph 83. 1100 Perestrelo {IWS00000349/14} page 14, paragraphs 84-87. 1101 Purser, Phase 2 Report, Section 6 {DAPR0000006/80} paragraph 433. 1102 Letter from Dr Leonie Penna to Andreia Perestrelo dated 28 July 2017 {BSR00000140}; Purser, Phase 2 Report, Section 6 {DAPR0000006/84} paragraph 462. An extract from Dr Penna’s letter was read out during the presentation concerning Logan Gomes {Day306/19:8}. 1103 Purser, Phase 2 Report, Section 6 {DAPR0000006/77-84} paragraph 416 and 460. 1104 Purser, Phase 2 Report, Section 6 {DAPR0000006/76-79} paragraphs 426-431.

The Grenfell Tower Inquiry: Phase 2 Report 136

137 Chapter 96 Floor 22 96.1 On the night of 14 June 2017 all six flats on floor 22 were occupied. Only Chia-Yuan (Naomi) Li and her cousin, Chin-Hsuan (Lydia) Liao from Flat 195 survived. Those who died were Nura Jemal, her husband, Hashim Kedir, and their three children who lived in Flat 192, Nadia Choucair, her husband, Bassem Choukair, and their three children, who lived in Flat 193, Sirria Choucair, the mother of Nadia Choucair, who lived in Flat 191, and Anthony (Tony) Disson, who lived in Flat 194. Mariem and Eslah Elgwahry, who lived in Flat 196, died in Flat 205 where they had taken shelter. We deal with the circumstances of their deaths in Chapter 97. 96.2 Naomi Li was alerted to the fire at about 01.15 when she became aware of a smell like burning plastic. Having spoken to Lydia Liao, she checked the lobby. Although she could smell smoke, she saw very little sign of it in the lobby. Returning to her flat, she telephoned her husband, Lee Chapman, who was abroad. At 01.21 she made an emergency call and spoke to CRO Yvonne Adams in the LFB control room, who told her that the fire brigade was attending a fire on the fourth floor of the tower and that she should stay in her flat. During that call Naomi Li gave CRO Adams the number of her flat.1105 96.3 Naomi Li decided to tell her neighbours. In the lobby she met and spoke to Nura Jemal, who then returned to Flat 192. She then saw Mariem and Eslah Elgwahry leaving Flat 196. When she told them that there was a fire on floor 4, Mariem Elgwahry replied that the fire was in their kitchen. At that time the door to Flat 196 was closed and Naomi Li could not see any smoke coming from it.1106 She saw Mariem and Eslah Elgwahry enter the stairwell. Naomi Li next spoke to Tony Disson, who then returned to his own flat.1107 96.4 Naomi Li and Lydia Liao tried to leave but could not go down the stairs because a group of people were coming up. Returning to the lobby, they met Nadia Choucair, who invited them into Flat 193.1108 Sirria Choucair was probably already there. 96.5 By 01.26, the fire on the outside of the building had reached floor 23. It is likely that from that time Flat 196, like other ‘Flat 6s’ in the tower, rapidly filled with smoke. The front door of Flat 196, although closed, failed to prevent smoke coming from the flat into the lobby of floor 22. In separate calls made at 01.30, both Naomi Li and Tony Disson reported that there was a lot of smoke on floor 22.1109 96.6 In subsequent calls to the emergency services, those trapped on floor 22 referred to the presence of a significant amount of smoke in the lobby.1110 That was a significant factor in preventing them from leaving the building, despite their efforts to do so. Nura Jemal, 1105 Phase 1 Report Volume II paragraphs 10.272, 10.276 and 10.308. 1106 Phase 1 Report Volume II paragraph 10.277. 1107 Phase 1 Report Volume II paragraph 10.277. 1108 Phase 1 Report Volume II paragraph 10.279. 1109 Phase 1 Report Volume II paragraphs 11.37-11.40. 1110 Phase 1 Report Volume II paragraph 12.62; Phase 1 Report Volume III paragraphs 16.33-16.39.

The Grenfell Tower Inquiry: Phase 2 Report 138 Hashim Kedir and their children were able to move from Flat 192 to Flat 193, arriving there shortly before 03.00.1111 Tony Disson was able to reach the stairwell but collapsed and died on the stairs.1112 Only Naomi Li and Lydia Liao managed to escape from the building.1113 Deployments to floor 22 96.7 There were numerous emergency calls to the LFB, to North West Fire Control and to Kent, Essex and Surrey Fire and Rescue Services by and about those trapped on floor 22 during the fire. a. Having made her first call from Flat 195 at 01.21, Naomi Li spoke to the LFB on three more occasions from Flat 193 at 01.30, 02.51 and at 03.07.1114 b. Nadia Choucair and Bassem Choukair made six calls from Flat 193 at 01.48, 02.37, 02.43, 02.55, 03.02 and 03.05.1115 At 03.15, Nadia Choucair spoke to a BT operator, but the line cleared before she could be put through to a fire and rescue service.1116 At 03.21, the Metropolitan Police called Nadia Choucair in response to her earlier call to the emergency services, when the line had been disconnected before contact had been established.1117 c. At 01.34,1118 while they were in Flat 192, Hashim Kedir and Nura Jemal spoke to the emergency services and called them again a further seven times at 02.03,1119 02.10, 02.18, 02.31, 02.34, 02.45 and 02.53.1120 Shortly after they and their children had moved to Flat 193 a call from Hashim Kedir was put through to Kent Fire and Rescue Service but he did not respond to the call handler.1121 Hashim Kedir and Nura Jemal made another call at 03.08 when they spoke to CRO Gotts in the LFB control room.1122 The final contact with those in Flat 193 occurred at 03.24 when Hashim Kedir spoke to CRO Peter Duddy.1123 d. Tony Disson in Flat 194 spoke to the emergency services six times between 01.30 and 03.01.1124 In five calls made between 02.28 and 03.22, family members and a friend reported that Tony Disson was trapped in the tower.1125 A CRO in the LFB control room and one from Surrey Fire and Rescue Service called him back at 02.51 and 03.27 respectively.1126 The latter call was the last contact the emergency services had with Tony Disson. 96.8 Despite the information provided in those calls, the only deployment of firefighters to floor 22 was made in response to the call made by Naomi Li at 01.21. 1111 Phase 1 Report Volume III paragraph 16.42. 1112 Phase 1 Report Volume III paragraphs 18.27-18.28. 1113 Phase 1 Report Volume III paragraphs 17.35-17.36 and 17.104. 1114 Phase 1 Report Volume II paragraph 10.280; Phase 1 Report Volume III paragraphs 16.39 and 17.32-17.37. 1115 Phase 1 Report Volume II paragraphs 12.62, 14.155 and 14.269; Phase 1 Report Volume III paragraphs 16.34-16.35, 16.41, 17.38-39 and 17.126; 999 call transcript {LFB00000396}. 1116 Phase 1 Report Volume III paragraph 17.38. 1117 Phase 1 Report Volume III paragraph 17.39. 1118 Phase 1 Report Volume II paragraph 11.41. 1119 Phase 1 Report Volume II paragraph 14.153. 1120 Phase 1 Report Volume II paragraphs 14.153-14.154; Phase 1 Report Volume III paragraphs 16.47-16.50. 1121 999 call transcript {LFB00000658}. 1122 Phase 1 Report Volume III paragraphs 16.51 and 17.130. 1123 Phase 1 Report Volume III paragraph 18.23. 1124 Phase 1 Report Volume II paragraphs 11.37, 12.63 and 14.152; Phase 1 Report Volume III paragraphs 16.43-16.46, 16.45-16.46 and 17.41. 1125 Phase 1 Report Volume III paragraphs 15.148, 15.183, 15.195, 17.44-17.46, 17.127 and 17.131; 999 call transcript {LFB00000549}. 1126 999 call transcript {LFB00000469}; Phase 1 Report Volume III paragraph 18.27.

Part 9 | Chapter 96: Floor 22 139 a. At 01.32, a service request was created referring to persons on floor 22 who reported smoke coming into Flat 195. At 01.35, CRO Sharon Darby passed a message to the incident ground that there were persons trapped on floor 22 with “smoke coming into their flat”.1127 That message reflected the information provided by Naomi Li and Tony Disson in their calls at 01.21 and 01.30. b. WM Mark Kentfield recorded the information reaching command unit CU8 about people needing to be rescued on pieces of paper, which were then passed to SM Brett Loft who was positioned outside the tower.1128 SM Loft passed the information he received to the bridgehead, probably by radio.1129 He was receiving information of that kind from about 01.40. Some was written on the A4 sheet of paper that later became known as the “Sadler envelope”, at the top of which was written “BRETT LOFT IC”. The third entry on that document reads “Flat 195 22nd FLOOR”.1130 c. The bridgehead was located on floor 2 until 02.17.1131 Shortly after that time, CM Charles Batterbee made a note of the contents of a forward information board used at the bridgehead to record information while it was located on floor 2. It contained no reference to floor 22.1132 d. At 02.17 the bridgehead was moved to floor 3, where it remained until 3.10, when it was moved down to the ground floor.1133 While the bridgehead was located on floor 3, a wall was used to record information about people needing to be rescued. The second entry at the top of this wall read “22 195”, next to which was written “CODD + JOSEPH”.1134 e. CM Raoul Codd and FF John Joseph were sent to floor 22 by WM Louisa De Silvo but not to a specific flat. They set out between 03.03 and 03.05. CM Codd and FF Joseph did not reach floor 22 because when they came across casualties in the stairs they decided instead to help them escape.1135 96.9 Although information about those in Flats 192, 193 and 194 did reach the incident ground, none of it reached the bridgehead, with the result that there were no deployments to those flats. We do not know why information about Flat 195 given in a call made at 01.21 reached the bridgehead only after it had been moved to floor 3 (i.e. after 02.17), but we are satisfied that when it was received it prompted the deployment of CM Codd and FF Joseph. 96.10 One firefighter did reach floor 22. FF Dean Roberts was one of the five-member Paddington crew from appliance A216, which included CM Philip Wigley and FFs Martin Gillam, Russell Gonzalez and Andrew Harris. The crew was sent to the roof of the tower to carry out firefighting operations.1136 They tallied out between 01.56 and 01.57. The crew did not reach the roof because they found Fadumo Ahmed on the stairs between 1127 Phase 1 Report Volume II paragraphs 11.152-11.153. 1128 Phase 1 Report Volume II paragraph 11.6; Phase 1 Report Volume IV paragraph 28.84 (a). 1129 Phase 1 Report Volume II paragraph 12.18. 1130 Phase 1 Report Volume II paragraphs 12.18-12.19, 14.71 and Figure 12.4. 1131 Phase 1 Report Volume IV paragraph 28.84 (b). 1132 Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c). 1133 Phase 1 Report Volume IV paragraphs 28.86-28.87. 1134 O’Beirne {MET000083321/19} page 19; Phase 1 Report Volume III Figure 16.6. 1135 Phase 1 Report Volume III paragraph 17.13 (g); LFB Telemetry data {LFB00023326}; Codd {MET00012539}. 1136 Phase 1 Report Volume II paragraphs 11.13 and 13.5.

The Grenfell Tower Inquiry: Phase 2 Report 140 floors 20 and 21 and helped her down. FF Roberts appears to have been able to make his way up to floor 22. He opened the stairwell door and shouted but received no response and re‑joined his crew.1137 The Kedir and Jemal family Hashim Kedir Date of birth: 7 March 1973 (44 years). Place of birth: Addis Ababa, Ethiopia. Gender:

Male. Occupation: Black Cab Driver. Usual address: Flat 192, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Nura Jemal Date of birth: 1 August 1981 (35 years). Place of birth: Silte, Ethiopia. Gender:

Female. Occupation: Homemaker. Usual address: Flat 192, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Yahya Hashim Date of birth: 5 August 2003 (13 years). Place of birth: London, UK. Gender:

Male. Occupation: Student. Usual address: Flat 192, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. 1137 Phase 1 Report Volume II paragraphs 14.85-14.87; Roberts {MET00007890/6} page 6.

Part 9 | Chapter 96: Floor 22 141 Firdaws Hashim Date of birth: 13 January 2005 (12 years). Place of birth: London, UK. Gender:

Female. Occupation: Student. Usual address: Flat 192, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Yaqub Hashim Date of birth: 18 May 2011 (6 years). Place of birth: London, UK. Gender:

Male. Occupation: Student. Usual address: Flat 192, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 96.11 Hashim Kedir, Nura Jemal and their three children lived in Flat 192 on floor 22 of the tower.1138 96.12 Nura Jemal was born on 1 August 1981 in Silte, Ethiopia. She was 35 years old. Her husband, Hashim Kedir, was born on 7 March 1973 in Addis Ababa, Ethiopia. He was 44 years old. Their three children were all born in London. The eldest, Yahya Hashim was born on 5 August 2003 and was 13 years old. Firdaws Hashim was born on 13 January 2005 and was 12. Their youngest child, Yaqub Hashim, was born on 18 May 2011 and was 6 years old.1139 96.13 Hashim Kedir had moved to the UK in 2000. He took various jobs before successfully passing the test to become a black cab driver. He and Nura Jemal met in the UK where they married. Their children were thriving at local schools.1140 Vulnerability 96.14 No member of Nura Jemal and Hashim Kedir’s family had a known vulnerability. 1138 Phase 1 Report Volume IV paragraph 32.89. 1139 Phase 1 Report Volume IV paragraph 32.90. 1140 Phase 1 Report Volume IV paragraphs 32.93-32.98.

The Grenfell Tower Inquiry: Phase 2 Report 142 Events of 14 June 2017 96.15 The family came home at various times on 13 June 2017, Hashim Kedir being the last to return at 23.21.1141 They became aware of the fire at an early stage. Naomi Li spoke to Nura Jemal in the lobby of floor 22 between her two emergency calls at 01.21 and 01.30.1142 At 01.34, Hashim Kedir made his first call to the emergency services. During it he told CRO Duddy that smoke on the stairs had prevented the family from leaving and was now coming into their flat from the lobby. CRO Duddy’s advice was to close all doors and windows and to block any smoke coming through the door. He concluded by explaining that firefighters were on their way.1143 When he gave that reassurance, CRO Duddy did not have confirmation that firefighters would attend but assumed that they would do so if they were told that a flat needed to be checked.1144 96.16 CRO Duddy did not create a service request in response to that call but one had already been created following calls from other occupants of floor 22. It recorded “PERSONS ON THE 22ND FLOOR SMOKE COMING INTO FLAT.”1145 CRO Darby passed the information to appliance G261 at 01.35, stating that she could not provide flat numbers.1146 The service request was marked as completed at 01.41.1147 96.17 No information relating to floor 22, including that passed on by CRO Darby, reached the bridgehead while it was located on floor 2.1148 96.18 At 01.43, Hashim Kedir spoke to Genet Shawo, who lived in Flat 153 on floor 18. He told her that the emergency services had told him to remain in his flat and he advised her to do the same.1149 96.19 Hashim Kedir and Nura Jemal continued to make calls to the emergency services. a. At 02.03, Hashim Kedir told CRO Angie Gotts that there was smoke in the corridor (probably meaning the lobby) and that the fire could be seen approaching the flat. He gave the number of his flat and floor. CRO Gotts did not confirm the number of people in the flat.1150 b. By 02.10 the fire on the outside of the building had begun to affect Flat 192.1151 During a call which began at 02.10, Hashim Kedir told CRO Christine Howson that the fire had reached the kitchen of Flat 192 and that the smoke was making everyone in the flat cough. CRO Howson initially said that firefighters were dealing with a fire on the fourth floor but then said that, although the advice was for people to stay in their flats, the family would have to decide whether they should leave because there was a fire in the flat. Hashim Kedir told CRO Howson that the family was trapped. The line was disconnected before he could clarify what CRO Howson thought she had heard, namely that there were two adults and five children in the flat.1152 1141 O’Riordan {MET00013136/3-4} pages 3-4. 1142 Phase 1 Report Volume II paragraph 10.277. 1143 Phase 1 Report Volume II paragraph 11.41; 999 call transcript {LFB00000315/3}. 1144 Duddy {Day42/215:7}-{Day42/216:5}; Phase 1 Report Volume II paragraph 11.157. 1145 LFB Short Incident Log {MET00013830}. 1146 Phase 1 Report Volume II paragraph 11.152. 1147 LFB Short Incident Log {MET00013830}. 1148 Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraphs 28.84b and 28.84c 1149 Phase 1 Report Volume II paragraph 11.61. 1150 Phase 1 Report Volume II paragraph 14.153; 999 call transcript {LFB00000339}. 1151 Phase 1 Report Volume II paragraph 14.3. 1152 Phase 1 Report Volume II paragraphs 14.153 and 14.251; 999 call transcript {LFB00000345}.

Part 9 | Chapter 96: Floor 22 143 c. At 02.18, CRO Howson spoke to Hashim Kedir again. He told her that the kitchen was on fire and that a considerable amount of smoke was entering the living room. Having been told that there were two adults and three children in the flat, CRO Howson told him that the family could either make their way to the stairwell or move to somewhere in the flat with less smoke. Asked when the firefighters were coming, CRO Howson told him that they were on their way but making slow progress. She appeared to mistake Hashim Kedir for a woman, and asked if the caller’s husband was present.1153 d. At 02.30, the Metropolitan Police contacted the LFB control room to pass on the information that a woman, her husband and their three children were trapped in Flat 192.1154 That information had come from a friend of Nura Jemal who had called on her behalf from outside the tower.1155 e. At 02.34, CRO Howson answered another call from Flat 192. She was told that there were two adults and three children in the flat. The fire had reached the living room and the family were being affected by the conditions. CRO Howson advised them to leave. She said she would alert the firefighters, who would try to meet them.1156 f. At 02.35, a police operator spoke to Nura Jemal who confirmed her location. She said that there were two adults and three children in the flat and that the fire had reached a bedroom.1157 There is no record of the police passing on that further message to the LFB. g. At 02.45, Hashim Kedir spoke to CRO Heidi Fox. He told her again that the lobby was full of smoke. The family had tried unsuccessfully to leave and were now trapped in a bedroom. Hashim Kedir asked why a helicopter could not be sent to rescue them. CRO Fox again encouraged him to leave, saying that the firefighters were on different floors.1158 h. At 02.53, Hashim Kedir spoke to CRO Pam Jones and reported that the family were still in Flat 192. CRO Jones advised them to leave.1159 Information to the incident ground 96.20 Although the calls set out above cannot be traced individually to the incident ground, in light of the following facts we have concluded that information about Flat 192 did get through. a. Although the first three calls did not generate a service request, in a radio message timed at 02.09, CRO Sharon Darby told CU8 that there was a caller in Flat 192 on floor 22 who was unable to leave.1160 That information must have come from the call made by Hashim Kedir at 02.03. b. Between 02.10 and 02.22 CU7 was the command unit designated to receive information about people needing to be rescued.1161 Initially a laminated white sheet 1153 Phase 1 Report Volume II paragraphs 14.154 and 14.266; 999 call transcript {LFB00000351}. 1154 999 call transcript {LFB00000671}. 1155 999 call transcript {INQ00000289}. 1156 Phase 1 Report Volume III paragraph 16.48. 1157 999 call transcript {INQ00000276/3} page 3. 1158 Phase 1 Report Volume III paragraph 16.49; 999 call transcript {INQ00000378}. 1159 Phase 1 Report Volume II paragraph 16.50. 1160 Phase 1 Report Volume II paragraphs 14.247-14.248. 1161 Phase 1 Report Volume IV paragraph 28.84 (d).

The Grenfell Tower Inquiry: Phase 2 Report 144 was used to record information that had previously been recorded on pieces of paper in CU8.1162 The following was noted on that sheet: “192 22 1 woman 3 children unable to leave”. That reflects in part the entry on a control information form that records “192 22 1 woman 3 kids”.1163 It cannot, however, be linked to any of the three calls made by Hashim Kedir between 02.03 and 02.18, although it is possible that SM Jason Oliff, in the LFB control room, may have passed on information about Flat 192 when he called WM Daniel Meyrick in CU8 on his mobile phone.1164 c. The information recorded on the whiteboards used by SM Oliff from about 02.33 to collate information coming into the control room included the following: “192 22nd flr – fire entering flat* (left flat) Bedroom Living room 2 women 3 children.”1165 It is likely that the calls made by Hashim Kedir at 02.10 and 02.18 were the source of that information. d. From about 03.00, CU7 changed to recording information on a whiteboard using a grid system.1166 In relation to Flat 192, there was recorded the number “2” in green, the number “5” in black and the letter P in red and circled.1167 That indicated that two adults and five children were in the flat and that it was a priority rescue.1168 The source of that information must have been the call made by Hashim Kedir at 02.10, given the reference to five children. 96.21 Information relating to floor 22 did not reach the bridgehead while it was on floor 2. Between 02.17 and 03.10 it was located on floor 3.1169 No note relating to Flat 192 appears on the wall used by WM De Silvo to record FSG information while the bridgehead was located on floor 3.1170 The family’s move to Flat 193 96.22 Having been unsuccessful in their efforts to leave their home, Hashim Kedir, Nura Jemal and their children were able to make their way to Flat 193, reaching it shortly before 03.00. Naomi Li recalled Nura Jemal and her daughter coming into Flat 193 shortly after the Choucair family had tried unsuccessfully to leave. At that time the amount of smoke in Flat 193 made it difficult to see anyone.1171 At 03.02 a BT operator put an emergency call from Hashim Kedir through to Kent Fire and Rescue Service explaining that they could not get the caller’s attention but could hear coughing and commotion in the background. The call‑handler at the Kent Fire and Rescue Service was also unable to obtain a response.1172 96.23 Naomi Li made an emergency call at 03.07 during which she told CRO Howson that there were 12 people in Flat 193. She said that the smoke was very bad and that they could not leave. CRO Howson’s advice was to make their way to the stairwell.1173 At that time everyone was in the living room of Flat 193. Naomi Li told them they had to leave. She was unable to see any reaction because of the amount of smoke in the flat. She and Lydia Liao 1162 Phase 1 Report Volume II paragraphs 12.8-12.9. 1163 LFB Control Information Forms {LFB00001955/10} page 10. 1164 Phase 1 Report Volume II paragraphs 14.243 and 14.261. 1165 Phase 1 Report Volume III paragraph 15.140 and Figure 15.8. 1166 Phase 1 Report Volume III paragraphs 15.13 and 16.12. 1167 Phase 1 Report Volume III Figure 16.5; Photograph of whiteboard {MET00015924}. 1168 Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. 1169 Phase 1 Report Volume IV paragraphs 28.86 and 28.87. 1170 Phase 1 Report Volume III Figure 15.7. 1171 Phase 1 Report Volume III paragraphs 16.41-42 and 16.50-51. 1172 999 call transcript {LFB00000658}. 1173 Phase 1 Report Volume III paragraphs 16.51 and 17.33; 999 call transcript {LFB00000404}.

Part 9 | Chapter 96: Floor 22 145 were able to reach the stairwell.1174 Making their way down the stairs, they were found by WM Peter Clarke, WM Alexander Cardy and FF Enrico Beltrami who helped them and Karen Aboud and her two children from Flat 92 to leave the tower.1175 96.24 Naomi Li said that she had told the firefighters that there were more than ten people still in Flat 193 on floor 22, but that she did not know what the firefighters had done with that information.1176 WM Cardy said that he had made a report to WM De Silvo at the bridgehead but it is not clear whether he gave her any information about Flat 193.1177 By that time the bridgehead had been moved to the ground floor where information was being recorded on a green painted wall at the rear of the lobby.1178 There was no reference to Flat 193 on that wall. 96.25 That the information may have been passed on is suggested by an entry on the ground floor wall where, from 02.15, WM Glynn Williams had begun recording information about people needing to be rescued. SM Peter Wolfenden started recording information on the same wall from about 03.21.1179 He said that a tick had been used to indicate that a crew had been sent to a particular flat.1180 SM Wolfenden may well have been responsible for an entry on that wall which recorded “192 22 10 3K”,1181 meaning ten people, including 3 children. No tick appears next to the entry. Although it is possible that that information may have been the result of emergency calls from those in Flat 193, and although the flat number is wrong, the reference to ten people reflects Naomi Li’s explanation. In any event, however that information came to reach the ground floor, it did not lead to the deployment of a crew to floor 22. The final calls from Flat 193 96.26 At 03.08, CRO Angie Gotts answered a call during which she spoke to both Hashim Kedir and Nura Jemal. They said they were in Flat 193 on floor 22 and that they could see a helicopter; they asked if it could help them to escape. CRO Gotts advised them to try and get out using wet towels to cover their heads.1182 96.27 At 03.14 Nadia Choucair told a BT operator that her baby was unconscious. The BT operator said the advice was to get out of the tower. As the call was being put through to the LFB, Nadia Choucair could be heard telling everyone that they needed to get to the stairs. The call ended before a call-handler could speak to her.1183 At 03.21, a police operator telephoned Nadia Choucair and told her that she needed to leave. She said that there was too much smoke, but as the call ended she could be heard telling those in Flat 193 that they needed to leave.1184 96.28 The last contact with those still in Flat 193 was a call made by Hashim Kedir at 03.24 that was answered by CRO Duddy. He told CRO Duddy that there were 12 adults and seven children in the flat (in fact there were five adults and six children) and that they were trapped. As the call continued, CRO Duddy repeatedly told him that the only chance of 1174 Phase 1 Report Volume III paragraphs 17.34-36. 1175 Phase 1 Report Volume III paragraph 17.20 (a). 1176 Phase 1 Report Volume III paragraph 17.104. 1177 Cardy {MET00010085/10} page 10. 1178 Phase 1 Report Volume IV paragraph 28.87. 1179 Wolfenden {Day40/168:3}-{Day40/172:16}; {Day40/182:14}-{Day40/186:9}. 1180 Wolfenden {Day40/188:5}-{Day40/190:4}. 1181 De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}. 1182 Phase 1 Report Volume III paragraph 17.130; 999 call transcript {LFB00000406}. 1183 Phase 1 Report Volume III paragraphs 17.37-17.38; 999 call transcript {COR00001081}; 999 call transcript {LFB00000414}. 1184 999 call transcript {LFB00000337} page 3.

The Grenfell Tower Inquiry: Phase 2 Report 146 survival was to leave by the stairs; a rescue by helicopter was not possible. Hashim Kedir said that it was not possible to leave; they had tried but had been unable to do so because of the smoke. Towards the end of the call, he could be heard calling out “I love you”. He was speaking to his children.1185 Recovery and identification 96.29 The remains of the five members of the Kedir and Jemal family were recovered from the living room of Flat 193.1186 The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for Hashim Kedir, Nura Jemal and their children, Yahya, Firdaws and Yaqub.1187 Cause and time of death 96.30 The medical causes of death in the cases of Hashim Kedir, Nura Jemal, Yahya Hashim and Yaqub Hashim were recorded as “consistent with the effects of fire”. The medical cause of death in the case of Firdaws Hashim was recorded as “inhalation of products of combustion”. In light of Professor Purser’s evidence, we find that a more accurate description of the cause of death in the case of all five members of the family is “inhalation of asphyxiant gases”. 96.31 It was possible to detect carboxyhaemoglobin in tissue recovered from Yahya Hashim and Firdaws Hashim, although the concentration could not be measured.1188 The fact that two of those sheltering in Flat 193 inhaled smoke containing carbon monoxide indicates that it is likely that all those in the flat also did so.1189 They would all have been exposed to asphyxiant gases entering Flat 193, particularly from the lobby. 96.32 Given that Naomi Li and Lydia Liao were able to escape, it is likely that until about 03.11, despite increasing amounts of smoke, those in Flat 193 had accumulated a relatively limited dose of asphyxiant gases.1190 From about 03.11, however, they accumulated increasing amounts of asphyxiant gases as the fire on the outside of the building reached Flat 193, in particular, when it reached the living room at about 03.37.1191 From that time, conditions deteriorated rapidly, causing the occupants to lose consciousness by about 04.13 and within a few more minutes they had inhaled a lethal dose of asphyxiant gases. Since children take up asphyxiant gases at twice the rate of adults, they are likely to have lost consciousness soon after 03.50.1192 96.33 We are satisfied that Hashim Kedir, Nura Jemal and their children Yahya, Firdaws and Yaqub all lost consciousness and died from the inhalation of asphyxiant gases between 03.37 and 04.20, before the fire reached their bodies. It is likely that the three children died before their parents. 1185 Phase 1 Report Volume III paragraphs 18.24-18.26. 1186 Purser, Phase 2 Report, Section 6 {DAPR0000006/46} paragraph 219. 1187 Interim certificates of the fact of death for Hashim Kedir, Nura Jemal, Yahya Hashim, Firdaws Hashim and Yaqub Hashim {MET00065640}; {MET00065629}; {MET00065633}; {MET00065587}; {MET00065644}. 1188 Purser, Phase 2 Report, Section 6 {DAPR0000006/47} paragraph 220. 1189 Purser, Phase 2 Report, Section 6 {DAPR0000006/55} paragraph 263. 1190 Purser, Phase 2 Report, Section 6 {DAPR0000006/47-51} paragraphs 224 and 240. 1191 Purser, Phase 2 Report, Section 6 {DAPR0000006/51-54} paragraphs 238 and 251. 1192 Purser, Phase 2 Report, Section 6 {DAPR0000006/54} paragraph 253.

Part 9 | Chapter 96: Floor 22 147 The Choucair / Choukair family Sirria Choucair Date of birth: 25 October 1956 (60 years). Place of birth: Nahle Village, Lebanon. Gender:

Female. Occupation: Retired. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Bassem Choukair Date of birth: 1 December 1976 (40 years). Place of birth: Nahle Village, Lebanon. Gender:

Male. Occupation: Supermarket Section Co-Ordinator. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Nadia Choucair Date of birth: 14 January 1984 (33 years). Place of birth: London, UK. Gender:

Female. Occupation: Nursery School Teacher Assistant. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

The Grenfell Tower Inquiry: Phase 2 Report 148 Mierna Choucair Date of birth: 22 November 2003 (13 years). Place of birth: London, UK. Gender:

Female. Occupation: Student. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Fatima Choucair Date of birth: 1 March 2006 (11 years). Place of birth: London, UK. Gender:

Female. Occupation: Student. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Zainab Choucair Date of birth: 17 May 2014 (3 years). Place of birth: London, UK. Gender:

Female. Occupation: N/A. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 96.34 Sirria Choucair was born on 25 October 1956 in Lebanon. She was 60 years old. Her daughter, Nadia, was born on 14 January 1984 in London. She was 33 years old. Bassem Choukair, Nadia’s husband, was born on 1 December 1976 in Lebanon and

Part 9 | Chapter 96: Floor 22 149 was 40 years old. Their three daughters were born in London. Mierna Choucair, born on 22 November 2003, was 13 years old, Fatima Choucair, born on 1 March 2006, was 11 years old and Zainab Choucair, born on 17 May 2014, was three years old. 96.35 At the age of 17 Sirria Choucair moved to the UK, where she married and brought up her family. She worked at the Royal Marsden Hospital until her retirement.1193 Bassem Choukair and Nadia Choucair met when Nadia was visiting members of her family in Lebanon. He moved to the UK following their marriage and was Section Co-ordinator in a supermarket. Nadia Choucair worked at Avondale Park Primary School as a nursery officer. Mierna and Fatima were at school; the couple’s youngest daughter, Zainab, attended nursery.1194 96.36 Nadia Choucair, Bassem Choukair and their three children lived in Flat 193. Sirria Choucair lived in Flat 191 on the same floor. Vulnerability 96.37 Sirria Choucair had severe arthritis and back pain that affected her mobility.1195 The survey of residents prepared by Rydon in November 2014 recorded that she had high blood pressure, back pain and difficulty in walking.1196 She was recorded as a resident of Flat 191 in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system,1197 but not as having any vulnerabilities. Nadia Choucair, Bassem Choukair and their eldest daughter, Mierna, were recorded as residents of Flat 193. Their younger daughters did not appear in the spreadsheet. Events of 14 June 2017 96.38 On the evening of 13 June 2017, the Choucair family were at home. CCTV shows Bassem Choukair returning to the tower at 15.02, shortly before his three children came back with Sirria Choucair at about 15.38. Nadia Choucair returned to the tower at 16.13.1198 96.39 It is unclear when the family became aware of the fire. Shortly before 01.30 Nadia Choucair opened her front door and saw Naomi Li from Flat 195 in the lobby. Naomi Li told her that the fire brigade had said that there was a fire on floor 4 but their neighbour said it was in her kitchen. (Naomi Li was referring to Mariem Elgwahry from Flat 196.)1199 Nadia Choucair invited Naomi Li and her cousin, Lydia Liao, into her home, which was still free of smoke.1200 96.40 Naomi Li made her second emergency call from Flat 193 at 01.30. She told CRO Gotts in the LFB control room that she was in a neighbour’s flat on floor 22.1201 96.41 Between 02.17 and 03.00, the LFB control room received further emergency calls relating to eight people trapped in Flat 193. 1193 Phase 1 Report Volume IV paragraphs 32.76–32.81. 1194 Phase 1 Report Volume IV paragraphs 32.82-32.84. 1195 Sawson Choucair {IWS00001799/9} page 9, paragraph 9; Hisam Choucair {IWS00001851/2} page 2, paragraph 8; Nabil Choucair {IWS00002365/2} page 2, paragraph 8. 1196 Rydon Residents Survey {RYD00024466/17}. 1197 Phase 1 Report Volume III paragraphs 20.65-20.66; Noble Spreadsheet {TMO00862588}. 1198 O’Riordan {MET00013136/2-3} pages 2-3. 1199 Phase 1 Report Volume II paragraphs 10.279-10.281. 1200 Phase 1 Report Volume II paragraph 10.279. 1201 Phase 1 Report Volume II paragraph 10.281.

The Grenfell Tower Inquiry: Phase 2 Report 150 96.42 Nadia Choucair made her first emergency call at 01.40. After seven minutes trying to connect her to the LFB, the BT operator redirected the call to Essex Fire and Rescue Service at 01.48.1202 Nadia Choucair spoke to CRO Sharon Lancaster and gave her address as Flat 193 Grenfell Tower. She said that she was on floor 22 and that it was smoky in the flat.1203 CRO Lancaster told her that the fire service was at the scene and that she would report to London for her.1204 96.43 CRO Lancaster and her colleague CRO Katrina Marshall tried to contact the LFB to pass on the information from Nadia Choucair but were unable to get through until 02.18.1205 CRO Marshall spoke to CRO Adams in the LFB control room and told her that they had received a call from a person on floor 22 who said that it was starting to get smoky. Although she said that they had not obtained a flat number from the caller, that was incorrect as Nadia Choucair had told CRO Lancaster that she was in Flat 193. It appears that the information had not been entered on the incident log.1206 CRO Adams told CRO Marshall that they had given the correct advice when telling Nadia Choucair to stay put.1207 96.44 Nadia Choucair and Bassem Choukair made two separate emergency calls at 02.37 and 02.43. On each occasion they were connected to the LFB control room and each spoke to CRO Adams. In both calls, CRO Adams was told that there were eight people in the flat (i.e. the six members of the Choucair family and Naomi Li and Lydia Liao).1208 96.45 When she called at 02.37, Nadia Choucair was advised to block any smoke coming in to the flat and to close the windows.1209 CRO Adams reassured her that the firefighters were on their way and would get to her.1210 When Bassem Choukair called at 02.43, CRO Adams encouraged him to try to find the stairs and get out.1211 He said that it was not possible to leave because of the smoke. CRO Adams said that he should make the decision whether to leave or not.1212 96.46 At about 02.35, DAC Adrian Fenton in the LFB control room decided to revoke the stay put advice and tell people to try to leave the building. He was aware that at the time crews could not get above floor 15.1213 It took some time for the change in advice to be disseminated to, and implemented by, the CROs.1214 That might explain why at 02.37 CRO Adams advised Nadia Choucair to stay put, but at 02.43 she told Bassem Choukair to try to leave. 96.47 The information from the calls was passed to the incident ground. a. From 02.33 SM Jason Oliff began recording information about those in the tower needing rescue on two whiteboards in the LFB control room.1215 The following was recorded on one of the boards: “193 22 fl – 8 adults 3 children get out advice.” The number of people recorded as being in Flat 193 was incorrect, since until 03.00 1202 999 call transcript {MET00015407}. 1203 999 call transcript {LFB00000325}. 1204 Phase 1 Report Volume II paragraph 12.62. 1205 Phase 1 Report Volume II paragraph 12.94. 1206 Phase 1 Report Volume II paragraph 14.269. 1207 Phase 1 Report Volume II paragraph 12.94; 999 call transcript {LFB00000347}. 1208 Phase 1 Report Volume III paragraph 16.36. 1209 Phase 1 Report Volume III paragraph 16.34. 1210 Phase 1 Report Volume III paragraph 16.34. 1211 Phase 1 Report Volume III paragraph 16.35. 1212 Phase 1 Report Volume III paragraph 16.35. 1213 Phase 1 Report Volume III paragraphs 15.161–15.163. 1214 Phase 1 Report Volume III paragraph 15.168. 1215 Phase 1 Report Volume II paragraphs 15.140-15.141 and Figure 15.8.

Part 9 | Chapter 96: Floor 22 151 there were only eight people in the flat, including three children. That may have led to command unit CU7 being told that more people were present in Flat 193. b. Until about 03.00 officers in CU7 were using a white laminated sheet to record information about people needing to be rescued. On it was the notation “193 22 10 people.”1216 The number of persons recorded must have been a mistake, as only eight people were in Flat 193 before 03.00. 96.48 In any event, that information did not reach the bridgehead, which from 02.17 was on floor 3. Attempts at evacuation 96.49 After Bassem Choukair had spoken to CRO Adams at 02.43 the family tried to leave the flat covering their heads with wet towels.1217 They reached Flat 194 and spoke to Tony Disson but then returned to Flat 193.1218 96.50 Soon after they had returned, Hashim Kedir, Nura Jemal and their children came into Flat 193.1219 There were now 13 people in the flat. Those sheltering there spoke to the LFB control room on a number of occasions. They were encouraged to try to get out. a. At 02.55, Nadia Choucair and Lydia Liao spoke to CRO Duddy who told them to leave and get to the stairwell. Lydia Liao told us that by then the smoke in the flat had become so dense that they could not see each other. She was now aware of the fire approaching Flat 193.1220 b. At 03.02, Bassem Choukair spoke to CRO Howson, telling her that there were 20 people in Flat 193 on floor 22. He asked for a helicopter. CRO Howson told him they should leave the building.1221 c. At 03.05, Bassem Choukair told CRO Duddy that they had been unable to reach the stairwell as there was too much smoke and they could not see. CRO Duddy told him to cover himself in wet towels and feel his way along the wall. He was told that their only chance of survival was to get to the stairwell.1222 d. At 03.06, CRO Darby sent a radio message to CU7 passing on information from the NPAS helicopter, which had identified the presence of people on floors 17, 21 and 22.1223 e. At 03.07, Naomi Li spoke to CRO Howson who told her to leave.1224 f. At 03.08, CRO Gotts answered another call from Flat 193, which overlapped with Naomi Li’s call to CRO Howson.1225 The callers asked for a helicopter to rescue them. They said the fire had reached the flat. CRO Gotts told them to use wet towels and leave. She said she would pass the information on to the firefighters. 1216 Phase 1 Report Volume II Figure 12.3. 1217 Phase 1 Report Volume III paragraphs 16.36-16.37. 1218 Phase 1 Report Volume III paragraph 16.45. 1219 Phase 1 Report Volume III paragraph 16.42. 1220 Phase 1 Report Volume III paragraph 16.41; Liao second witness statement {IWS00001191/2} page 2, paragraphs 7, 8 and 9. 1221 999 call transcript {LFB00000396}. 1222 Phase 1 Report Volume III paragraph 17.126. 1223 Phase 1 Report Volume III paragraph 17.128. 1224 Phase 1 Report Volume III paragraph 17.33. 1225 Phase 1 Report Volume III paragraph 17.37.

The Grenfell Tower Inquiry: Phase 2 Report 152 96.51 Following her call at 03.07, Naomi Li told everyone in the flat that they had to leave. She was not able to see their reactions because there was too much smoke in the room. Naomi Li and Lydia Liao did then leave. On the stairs they encountered WM Peter Clarke, WM Alexander Cardy and FF Enrico Beltrami, who helped them, and also Karen Aboud and her two children from Flat 92 to leave the building.1226 96.52 Naomi Li said that she told the firefighters that there were more than ten people in Flat 193 on floor 22. She did not know what the firefighters did with that information.1227 WM Cardy said that he had reported to WM De Silvo at the bridgehead but it is not clear if he passed on any information about Flat 193.1228 From 03.10, the bridgehead was on the ground floor and a green painted wall at the rear of the lobby was being used to record information about those still trapped in flats.1229 No reference to Flat 193 appeared on that wall. 96.53 Separately, from 02.15, WM Glynn Williams had begun recording information about those needing rescue on a different wall on the ground floor. SM Peter Wolfenden began recording information on the same wall from about 03.21.1230 He may well have been responsible for an entry on that wall that recorded “192 22 10 3K”,1231 meaning ten people including three children. SM Wolfenden explained that a tick had been used to show that a crew had been sent to a flat1232 but no tick appears next to that entry. Although the entry refers to Flat 192, the reference to ten people indicates that the source may have been Naomi Li, but it is also possible that the information came from calls made by others on floor 22. In any event, however the information recorded on the wall came to reach the ground floor, it did not lead to a deployment to floor 22. The final calls from Flat 193 96.54 At 03.08, CRO Gotts answered a call during which she spoke to both Hashim Kedir and Nura Jemal. They said they were in Flat 193 on floor 22. They said they could see a helicopter and asked for it to help them escape. CRO Gotts told them to try to get out using wet towels to cover their heads.1233 96.55 At 03.14 Nadia Choucair told a BT operator that her baby was unconscious. She was speaking of her youngest daughter, Zainab. The operator said the advice was to get out of the tower. As the call was being put through to the LFB, Nadia Choucair could be heard telling everyone in the room that they needed to get to the stairs. The call ended before someone in the control room could speak to her.1234 At 03.21, a police operator telephoned Nadia Choucair and told her that she needed to leave. She said that there was too much smoke, but as the call ended she could be heard telling those in Flat 193 that they needed to leave.1235 96.56 Hashim Kedir’s call at 03.24 was the last contact with those still in Flat 193. He told CRO Duddy that there were 12 adults and seven children trapped in Flat 193 (in fact there were five adults and six children). As the call continued, CRO Duddy repeatedly told him that 1226 Phase 1 Report Volume III paragraph 17.20 (a). 1227 Phase 1 Report Volume III paragraph 17.104. 1228 Cardy {MET00010085/10} page 10. 1229 Phase 1 Report Volume IV paragraph 28.87. 1230 Wolfenden {Day40/168:3}-{Day40/172:16}; {Day40/182:14}-{Day40/186:9}. 1231 De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}. 1232 Wolfenden {Day40/188:5}-{Day40/190:4}. 1233 Phase 1 Report Volume III paragraph 17.130; 999 call transcript {LFB00000406}. 1234 Phase 1 Report Volume III paragraphs 17.37-17.38; 999 call transcript {COR00001081}; 999 call transcript {LFB00000414}. 1235 999 call transcript {LFB00000337/3} page 3.

Part 9 | Chapter 96: Floor 22 153 the only chance of survival was to leave by the stairs and that it was not possible to rescue them by helicopter. Hashim Kedir told CRO Duddy that it was not possible for them to leave; they had tried but had been unable to do so because of the smoke.1236 96.57 Information received by the LFB control room after 03.00 was passed on to the incident ground but did not result in any deployments. It was recorded in the following places: a. SM Oliff in the control room recorded on the second whiteboard in green “193 22th 10 people” followed by “Told to leave flat” in black ink. The floor number had been rubbed out making it possible that it had been written as 23. A note in grey ink had been added just above “10 people” stating “12 adults 3 children”. That additional information may have come from a further call.1237 b. After 03.00, a whiteboard with a grid system was used in CU7 to record information about people needing to be rescued. Next to Flat 193 there was a notation reading “12 3 P”, indicating that 12 people and 3 children were trapped in Flat 193. The letter ‘P’ written in red and circled indicated that it was a priority destination.1238 c. WM Williams wrote “193 22 10P” at the bottom of the central column of notes he made on the wall of the ground floor lobby. He accepted that that information may have come from a control information form that records that ten people were in Flat 193 on floor 22 and gives the source as “unknown via CU”.1239 Later entries were made to the left of that central column,1240 including one which read “Flat 222” on floor 22.1241 (This note seems to have been made before that relating to Flat 192). d. At some time before 03.47 WM Tom Furnell had made a note in his notebook that there were 11 people in Flat 193 on floor 22.1242 He was not sure how he had obtained that information but suspected that it had come from CU7.1243 He said he had sent the information to the bridgehead but did not know who would then have been responsible for sending a crew to Flat 193.1244 Recovery and identification 96.58 The remains of the six members of the Choucair / Choukair family were recovered from the living room of Flat 193.1245 The coroner was satisfied about the identification of the remains and issued interim certificates of the fact of death for Sirria Choucair, Bassem Choukair, Nadia Choucair and their three daughters, Fatima, Mierna and Zainab.1246 1236 Phase 1 Report Volume III paragraphs 18.24-18.26. 1237 Phase 1 Report Volume III Figure 15.9. 1238 Phase 1 Report Volume III Figure 16.5. 1239 De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}; Williams {Day31/155:18}-{Day31/157:8}; Control information form {LFB00001922/20}. 1240 Williams {Day31/99:13-16}; Wolfenden {Day40/183:24}-{Day40/184:25}. 1241 Phase 1 Report Volume II Figure 14.5. 1242 Furnell Exhibit TGF/2 - original notes {MET00017035}; Furnell {Day40/37:2-25}. 1243 Furnell {Day40/24:15-24}. 1244 Furnell {Day40/38:9-19}. 1245 Purser, Phase 2 Report, Section 6 {DAPR0000006/46} paragraph 219. 1246 Interim certificates of the fact of death for Sirria Choucair, Bassem Choukair, Nadia Choucair, Mierna Choucair, Fatima Choucair and Zainab Choucair {MET00065600}; {MET00065610}; {MET00065613}; {MET00065651}; {MET00065599}; {MET00065618}.

The Grenfell Tower Inquiry: Phase 2 Report 154 Cause and time of death 96.59 The medical cause of death in the case of the members of the Choucair / Choukair family was recorded as consistent with the effects of fire. In light of Professor Purser’s evidence we find that a more accurate description of the cause of the deaths of all six members of the family is “inhalation of asphyxiant gases”. 96.60 Although there is no toxicological analysis available for any member of the family, the fact that carboxyhaemoglobin was found in tissue recovered from the remains of Yahya Hashim and Firdaws Hashim (who also died in Flat 193) makes it likely that all those in Flat 193 had inhaled carbon monoxide,1247 particularly as a result of gases entering the flat from the lobby of floor 22. 96.61 The fact that Naomi Li and Lydia Liao were able to escape from the tower makes it likely that until about 03.11 those in Flat 193 had accumulated a relatively low dose of asphyxiant gases, despite the increasing amounts of smoke in the flat.1248 Their accumulation of such gases increased as the fire on the outside of the building reached Flat 193 and particularly when it reached the living room at about 03.37.1249 From that time onwards conditions deteriorated rapidly, with the result that the inhalation of asphyxiant gases caused them to become unconscious by about 04.13. Within a few more minutes they had acquired a lethal dose. Since children absorb asphyxiant gases at twice the rate of adults, they are likely to have lost consciousness sooner, at about 03.50 or shortly after.1250 96.62 We find that Sirria Choucair, Bassem Choukair and Nadia Choucair and their three children, Mierna, Fatima and Zainab had all lost consciousness and died from the inhalation of asphyxiant gases between 03.37 and 04.20 before the fire reached their bodies. It is likely that the three children died before their parents. Anthony (Tony) Disson Date of birth: 27 November 1951 (65 years). Place of birth: Hammersmith, London, UK. Gender:

Male. Occupation: Retired. Usual address: Flat 194, floor 22, Grenfell Tower, London. Place of death: Stairwell, Grenfell Tower, London. Time of death: By 04.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. 1247 Purser, Phase 2 Report, Section 6 {DAPR0000006/55} paragraph 263. 1248 Purser, Phase 2 Report, Section 6 {DAPR0000006/47-50} paragraphs 224 and 235. 1249 Purser, Phase 2 Report, Section 6 {DAPR0000006/51-54} paragraphs 238 and 251. 1250 Purser, Phase 2 Report, Section 6 {DAPR0000006/54} paragraph 253.

Part 9 | Chapter 96: Floor 22 155 Background and composition of household 96.63 Anthony (Tony) Disson was born on 27 November 1951. In June 2017 he was 65 years old and had retired. He and his wife, Cordelia, had three sons, Harriboy, Alfie and Charlie.1251 Tony Disson had lived in Flat 194 since June 2010.1252 His son, Charlie, lived with him but was not at home on the night of the fire.1253 Vulnerability 96.64 A priority needs assessment for RBKC completed in June 2009 in support of Tony Disson’s application for emergency housing recorded that he had problems with his legs, which were getting worse, and that he needed access to a lift or a ground floor flat.1254 Tony Disson’s tenancy agreement for Flat 194 recorded that he did not suffer from any disability.1255 96.65 In April 2016, a doctor at his local surgery wrote to the TMO in support of Tony Disson’s request for repairs to be carried out in his flat. The letter indicated that the current condition of the flat was having a detrimental effect on his health and well-being but did not refer to his having any difficulties with mobility.1256 96.66 Tony Disson was not identified as having any vulnerabilities in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system.1257 Events of 14 June 2017 96.67 Tony Disson returned to the tower shortly before the fire began on 14 June 2017,1258 having spent the day with his son, Alfie, and his wife, Cordelia.1259 He became aware of the fire at an early stage, having spoken briefly to Naomi Li in the lobby on floor 22 at about 01.25.1260 Conditions on floor 22 had deteriorated by 01.30 when he made his first call to the emergency services. He described conditions in the lobby as terrible and told CRO Heidi Fox in the LFB control room that he could not see anything. Although he said that he was on floor 22, he did not give her the number of his flat. She told him to use towels to block any smoke coming into his flat and said that firefighters were on their way.1261 96.68 At 01.32 a service request was created which recorded “PERSONS ON THE 22ND FLOOR SMOKE COMING INTO FLAT.”1262 That was probably the result not only of Tony Disson’s first call but also of a call at 01.30 from Naomi Li, in which she reported that she was trapped on floor 22.1263 CRO Darby passed that information to appliance G261 at 01.35, confirming that she could not provide the number of the affected flats.1264 The service request was marked as completed at 01.41.1265 The information was not passed to the bridgehead, which at 1251 Phase 1 Report Volume IV paragraphs 32.68- 32.69. 1252 Tenancy Agreement {TMOH00000779}. 1253 Charles Disson {IWS00000239/1} page 1, paragraph 2. 1254 Priority Needs Assessment {TMOH00000849}. 1255 Tenancy Agreement {TMOH00000779}. 1256 GP Liaison letter to KCTMO dated 26 April 2016 {TMOH00000861}. 1257 Noble Spreadsheet {TMO00862588}. 1258 O’ Riordan {MET00013136/4} page 4. 1259 Alfie Disson {IWS00000241/4} page 4, paragraph 60; Cordelia Disson {IWS00000242/9} page 9, paragraphs 113-114. 1260 Phase 1 Report Volume II paragraph 10.277. 1261 Phase 1 Report Volume II paragraphs 11.37-11.39; 999 call transcript {LFB00000459}. 1262 LFB Short Incident Log {MET00013830}. 1263 999 call transcript {INQ00000472}. 1264 Phase 1 Report Volume IV paragraph 28.84 (b). 1265 LFB Short Incident Log {MET00013830}.

The Grenfell Tower Inquiry: Phase 2 Report 156 that time was on floor 2, where it remained until 02.17.1266 The forward information board used on floor 2 to record information about people needing to be rescued contained no reference to floor 22.1267 96.69 Tony Disson next spoke to the LFB control room at 01.50. He told CRO Peter Duddy that smoke was coming into his flat. CRO Duddy told him to close all the windows and said that firefighters were making their way to floor 22.1268 That call did not prompt a message to the incident ground. 96.70 At 02.00, Tony Disson made his third emergency call. He told CRO Howson that conditions were deteriorating in his flat. He gave the numbers of his floor and his flat and was reassured that firefighters were coming to him.1269 CRO Adams, who was speaking to command unit CU8 at the time, passed on the information that a pensioner was trapped in Flat 194 on floor 22.1270 However, that information did not reach the bridgehead. 96.71 Tony Disson made further calls to the emergency services. a. In a call at 02.24 he told CRO Adams that he was frightened and that he had been waiting for 45 minutes; he threatened to jump out of the window. The line was disconnected before he could be given any advice.1271 b. A call made at 02.40 cleared before the operator could put it through to North West Fire Control. Nonetheless, the operator was able to pass on the message that the caller was in Flat 194 and had said that he could not breathe.1272 It appears that that information was not passed to the LFB control room. c. At 02.49, Tony Disson spoke again to CRO Adams. He asked for someone to come and get him. For the first time he was told to leave the tower.1273 96.72 It was probably after the last of those calls that Bassem Choukair knocked on Tony Disson’s door, having left Flat 193 with his family. At the time Tony Disson was on the telephone to his wife, Cordelia. She heard Bassem Choukair ask him for help and Tony Disson reply that he could not help himself. She described Tony Disson as becoming more desperate from that point.1274 The Choucair / Choukair family were back in Flat 193 by 02.55 when Nadia Choucair made another emergency call.1275 96.73 Tony Disson was also in contact with his son, Alfie, and his partner, Chanade Prentice. She made two emergency calls at 02.28 and 02.45 which were connected to Surrey Fire and Rescue Service.1276 Surrey in turn contacted the LFB control room saying that a man was trapped in Flat 194 on floor 22.1277 At 02.54, Sharon Haley, a friend and resident of the tower who had already left the building, also spoke to the LFB control room and gave it the same information.1278 1266 Phase 1 Report Volume IV paragraph 28.84 (b). 1267 Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c). 1268 Phase 1 Report Volume II paragraph 12.63. 1269 Phase 1 Report Volume II paragraph 14.152; 999 call transcript {LFB00000337/3}. 1270 Phase 1 Report Volume II paragraphs 14.230-14.231; 999 call transcript {INQ00000195/5}. 1271 999 call transcript {LFB00000352}. 1272 999 call transcript {LFB00000695}. 1273 Phase 1 Report Volume III paragraphs 16.43 and 17.41. 1274 Phase 1 Report Volume III paragraphs 16.44-16.45. 1275 Phase 1 Report Volume III paragraph 16.41. 1276 Phase 1 Report Volume II paragraph 17.44. 1277 999 call transcript {LFB00000357}; 999 call transcript {LFB00000544}. 1278 999 call transcript {LFB00000549}; Haley {IWS00001219/11} page 11, paragraph 123.

Part 9 | Chapter 96: Floor 22 157 96.74 Surrey gave the LFB control room Tony Disson’s mobile number. CRO Gotts called him at 02.51 and told him to leave.1279 When Tony Disson called the LFB control room again at 03.01, CRO Fox gave him the same advice. He told CRO Fox that it was too dark and hot for him to leave.1280 In calls to his family, Tony Disson described the conditions in his flat as worsening and said that it was filling with smoke.1281 Information to the bridgehead 96.75 The bridgehead was located on floor 3 between 02.17 and 03.10, when it was moved to the ground floor.1282 Notwithstanding the significant number of calls to the emergency services from and about Tony Disson, information about him did not reach the bridgehead while it was on floor 3. a. From about 02.33, SM Jason Oliff began using two whiteboards to collate information received by the LFB control room about people needing to be rescued to enable him to pass it to the incident ground. One of the earliest entries read “194 22 flr – Heavy smoke 1 adult.”1283 However, we do not know whether that information reached the incident ground before 03.00. b. The white laminated sheet initially used in CU7 to record information about people needing to be rescued contained a reference to Flat 193 but no reference to Flat 194.1284 c. From 03.00, CU7 began to record information on a whiteboard using a grid system.1285 Against Flat 194, the number “1” had been written on the grid in green (indicating an adult) with next to it the letter “P” in red and circled,1286 indicating a priority.1287 A red tick was used in CU7 to indicate that a crew had been despatched. No red tick appears against Flat 194. It is possible that information about a person trapped in Flat 194 had been passed to CU7 by SM Oliff. d. WM Glynn Williams began recording information about people needing to be rescued on a wall of the ground floor lobby from 02.15. Nothing was recorded in relation to Flat 194.1288 e. During the period that the bridgehead was located on floor 3, similar information was recorded on a wall there. Flat 194 is not listed on that wall.1289 96.76 It follows that the emergency calls concerning Flat 194 did not prompt the decision to send CM Raoul Codd and FF John Joseph to floor 22 shortly after 03.00.1290 1279 999 call transcript {LFB00000469}. 1280 999 call transcript {LFB00000395}; Phase 1 Report Volume II paragraph 17.41. 1281 Phase 1 Report Volume II paragraph 17.43 1282 Phase 1 Report Volume IV paragraphs 28.86-28.87. 1283 Phase 1 Report Volume III paragraphs 15.139-15.141 and Figures 15.8 and 15.9. 1284 Phase 1 Report Volume II paragraphs 12.8-12.11 and Figure 12.3. 1285 Phase 1 Report Volume III paragraphs 15.13 and 16.12. 1286 Phase 1 Report, Volume III Figure 16.5; Photograph of whiteboard {MET00015924}. 1287 Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. 1288 Phase 1 Report, Volume II paragraphs 14.103-14.105 and Figure 14.5; Photographs of ground floor wall {MET00005774} and {MET00005776}. 1289 Phase 1 Report Volume III paragraphs 15.23-15.24; Phase 1 Report Volume II Figure 15.7. 1290 Phase 1 Report Volume III paragraph 17.13 (g).

The Grenfell Tower Inquiry: Phase 2 Report 158 Final contact with Tony Disson 96.77 At about 03.00, Tony Disson told his son Alfie that the firefighters were not coming for him and that he was going to try to leave.1291 Chanade Prentice spoke to Surrey Fire and Rescue Service again at 03.05 telling CRO Caili Beckham that the fire had now reached Tony Disson’s flat and that he was struggling to breathe.1292 96.78 When Surrey Fire and Rescue Service passed the information on to the LFB control room, they were told that the occupants of the tower were now being advised to leave. At 03.09, CRO Beckham called Alfie Disson to tell him of the change of advice. He said that his father would not leave because he could not see well enough to reach the stairs. CRO Beckham said that she would let the LFB know, as Tony Disson should be treated as a priority. She spoke to CRO Jones in the LFB control room at 03.10. CRO Jones could not offer any more advice but did call Tony Disson at 03.15. The call was not answered.1293 96.79 By about 03.20, Flat 194 was being affected by the fire on the outside of the building.1294 Cordelia Disson spoke to Kent Fire and Rescue Service at 03.22. She said that she had just spoken to Tony Disson, that the fire had reached his front door and that he was having difficulty breathing. CRO Zoe Martin said that she would call him.1295 96.80 CRO Martin’s call to Tony Disson was the last contact anyone had with him. By that time, he had left his flat and had reached the stairs. The call ended abruptly.1296 In the Phase 1 report the call is said to have been made at 03.31 but evidence received since shows that it was in fact made at 03.27. Recovery and identification 96.81 Tony Disson’s body was found in the stairwell at the level of floor 18.1297 The coroner was satisfied about his identity and issued an interim certificate of the fact of death.1298 Cause and time of death 96.82 The medical cause of death was recorded as “inhalation of fire fumes” but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”. 96.83 The post-mortem on Tony Disson noted that there were heavy soot deposits on his head, face and arms. Soot was also found in the airways consistent with the inhalation of smoke‑filled air. There was some heat damage to the skin. Toxicological analysis found the level of carboxyhaemoglobin in Tony Disson’s blood to be 71%. The post-mortem noted that such a level would be associated with death in any individual, even without the pre‑existing widespread coronary artery disease from which he suffered.1299 1291 Phase 1 Report Volume III paragraph 17.43. 1292 Phase 1 Report Volume III paragraph 17.44. 1293 Phase 1 Report Volume III paragraphs 17.45 and 17.131. 1294 Phase 1 Report Volume III paragraph 17.7. 1295 Phase 1 Report Volume III paragraph 17.46. 1296 Phase 1 Report Volume III paragraph 18.27; 999 call transcript {LFB00000660}. 1297 Phase 1 Report Volume III paragraph 18.28. 1298 Interim certificate of the fact of death for Anthony Disson {MET00065649}. 1299 Disson post-mortem report {COR00000181/12}; Purser, Phase 2 Report, Section 6 {DAPR0000006/57} paragraphs 278-279.

Part 9 | Chapter 96: Floor 22 159 96.84 The carboxyhaemoglobin level in his blood shows that Tony Disson had inhaled a significant quantity of carbon monoxide before he died. Later analysis in April 2019 of the blood sample did not detect any cyanide.1300 However, it is likely that the sample had degraded over time, so the finding does not necessarily reflect the level of cyanide in his blood at the time of death.1301 96.85 Tony Disson was still in Flat 194 when he spoke to Cordelia Disson shortly before 03.22 and had not got very far down the stairs when CRO Martin spoke to him at 03.27. That suggests that he did not spend long in the lobby after leaving his flat. We conclude that by the time he left his flat Tony Disson had inhaled close to an incapacitating dose of asphyxiant gases.1302 He lost consciousness and collapsed shortly after the call with CRO Martin. Tony Disson had probably suffered a lethal exposure to asphyxiant gases by about 03.56 and died before 04.30.1303 In our view, the heat damage to the skin noted at the time of the post-mortem very probably occurred after death. 1300 Disson toxicology report {INQ00011096/1} page 1; Purser, Phase 2 Report, Section 6 {DAPR0000006/61} paragraph 296. 1301 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. 1302 Purser, Phase 2 Report, Section 6 {DAPR0000006/61} paragraphs 296-304. 1303 Purser, Phase 2 Report, Section 6 {DAPR0000006/60} paragraph 295; Purser {Day297/43:3-7}.

The Grenfell Tower Inquiry: Phase 2 Report 160

161 Chapter 97 Floor 23 97.1 On the night of the fire the six flats on floor 23 were occupied as follows: Flat 201 by Raymond (Moses) Bernard. Flat 202 by Gloria Trevisan and her partner, Marco Gottardi. Flat 203 by Rania Ibrahim and her two daughters, Fethia Hassan and Hania Hassan. Flat 204 by Hesham Rahman. Flat 205 by Mohammed (Saber) Neda, his wife, Flora (Shakila) Neda, and their son, Shekeb (Farhad) Neda. Flat 206 by Fathia Ahmed Elsanousi and her daughter, Isra Ibrahim. Fathia Ahmed Elsanousi’s son, Abufras Mohamed Ibrahim, was visiting. Conditions and the upward migration from lower floors 97.2 The fire reached floor 23 by 01.26. The exterior of Flat 206, in the north-east corner of the tower, was enveloped by flames by 01.30.1304 97.3 Farhad Neda in Flat 205, which had two bedrooms in the north-west corner of the tower, saw smoke entering the lobby from the smoke extraction vents at some time before 01.30. The smoke gradually filled the lobby. The Neda family tried to walk down the stairs but were unable to do so due to a group of people coming up from lower floors who told them that there was a fire. Altogether, 16 people moved up from lower floors to floor 23, only one of whom survived the fire. In the Phase 1 report the chairman set out the possible reasons why that upward movement occurred.1305 It has not proved possible for us to reach any more confident conclusion. 97.4 There is evidence that by 01.39 the lobby on floor 23 was dark, probably due to smoke.1306 97.5 Between 01.50 and 02.20, Fadumo Ahmed ran to the stairwell from Flat 201. At that time the lobby was full of black smoke with no visibility. There was dark smoke in the stairwell which made her cough and feel dizzy. She had difficulty breathing. 97.6 Farhad Neda and Shakila Neda encountered similarly difficult conditions when leaving Flat 205 at some time after 02.15. The temperature in the lobby was higher than in the flat and the smoke caused a burning sensation that made Shakila Neda vomit and choke. The stairs were thick with black smoke and the handrail was not visible. Farhad Neda and Shakila Neda were rescued by firefighters and left the tower by 02.43.1307 They were the last occupants of floor 23 to escape the tower. 1304 Phase 1 Report Volume II paragraphs 10.118 and 10.122; External Fire Spread Report {MET00012593/14}. 1305 Phase 1 Report Volume II paragraphs 10.284-10.286 and 10.290-10.292. 1306 Phase 1 Report Volume II paragraphs 11.29-11.34; External Fire Spread Report {MET00012593/14}. 1307 Phase 1 Report Volume III paragraphs 15.64-15.67 and Annex A.

The Grenfell Tower Inquiry: Phase 2 Report 162 Deployments to Floor 23 97.7 There were numerous emergency calls reporting people trapped on floor 23. Some identified specific occupants and flats; others were made by members of the public who could see people signalling and waving from the top floor of the building.1308 The information received at the incident ground resulted in deployments of firefighters to floor 23 but no firefighters succeeded in reaching it. 97.8 One crew was briefed to go to the roof.1309 Three other crews were sent to floor 23.1310 A fourth deployment to floor 23 was changed to a search and rescue operation just before the firefighters set off.1311 The deployment of FFs Terence Roots and Adam Johnson to Flat 161 on floor 19 at about 02.05 had been to rescue Debbie Lamprell, but by then she had already moved to floor 23.1312 97.9 Having arrived at the incident ground at about 01.35, the Paddington crew (CM Philip Wigley, FFs Martin Gillam, Russell Gonzalez, Andrew Harris and Dean Roberts) equipped with extended duration breathing apparatus were sent by WM Michael Dowden to the roof of the tower to run a jet of water down from the top of the building.1313 They tallied out between 01.56 and 01.57. They met FFs Steven Mills and Geoffrey Campbell coming down, who told them that they had been sent to rescue a woman in Flat 175 or a woman on floor 20. At about floor 15 or 16, the Paddington crew realised that they could not reach the roof. They went to floor 20 instead to try to rescue the woman FFs Mills and Campbell had told them about. They found Fadumo Ahmed between floors 20 and 21 and helped her. Fadumo Ahmed had come from Flat 201, where others were also sheltering. FF Gillam told us that she had told him that there was no one left on her floor but that none of the crew had asked her from which floor she had come. The crew’s end of wear times were between 02.21 and 02.23.1314 97.10 FFs John Wright, Zade Alassad and Scott Bell were sent to two flats on floor 23, which are likely to have been Flats 201 and 205. It is not clear exactly which emergency call or calls had prompted their deployment, but the call by Jessica Urbano Ramirez from Flat 201 at 01.29 may have prompted it, as messages were passed to the incident ground relating to it. The crew tallied out between 02.08 and 02.10. They stopped at floor 10 and helped other firefighters to carry the bodies of Mohamednur Tuccu and Khadija Khalloufi out of the tower. FF Bell recalled telling someone they had not reached floor 23, but he could not remember to whom he had spoken or what that person had done with the information. Their end of wear times were between 02.28 and 02.29.1315 97.11 CM Richard Evans and FF Gemma Bloxham were sent to Flat 205 on floor 23. They tallied out at 02.24. Between floor 18 and floor 20, they came across two occupants, probably Farhad Neda and Shakila Neda, and helped them to escape. Shakila Neda had been on the telephone to members of her family on floor 23. On overhearing the conversation, 1308 Phase 1 Report Volume II paragraph 14.235. 1309 Phase 1 Report Volume II paragraphs 11.12-11.13, 13.5, 13.15 and 14.85-14.87; Phase 1 Report Volume III paragraph 15.30. 1310 Phase 1 Report Volume II paragraph 14.117; BA Telemetry Schedule {LFB00023326}; Phase 1 Report Volume III paragraphs 15.54-15.56 and 15.66; Phase 1 Report Volume III paragraphs 16.15-16.20 and Figure 16.6. 1311 Phase 1 Report Volume III paragraph 18.15 (b). 1312 Phase 1 Report Volume II paragraph 12.86. 1313 Phase 1 Report Volume II paragraphs 11.12-11.13, 13.5, 13.15 and 14.85-14.87; Phase 1 Report Volume III paragraph 15.30. 1314 Phase 1 Report Volume II paragraphs 11.12-11.13, 13.5, 13.15 and 14.85-14.87; Phase 1 Report Volume III paragraph 15.30. 1315 Phase 1 Report Volume II paragraph 14.117; BA Telemetry Data {LFB00023326}.

Part 9 | Chapter 97: Floor 23 163 CM Evans tried to make radio contact with the bridgehead but did not obtain a response. Farhad Neda told the firefighters that his father and four other people were trapped in Flat 205. One of the firefighters wrote that in his notebook. Once CM Evans had got back down, he told the officer in charge at the bridgehead that he and FF Bloxham had not reached Flat 205. The crew’s end of wear time was 02.42.1316 97.12 FFs Michael Pole, Niki Mitchell, Chris Cheesman and Jessamine Bate from Euston Fire Station were deployed to floor 23, probably to Flats 204 (a west-facing flat) and 205. The crew had tallied out by 02.53. On the stairs, they met FFs Upton and Reddington carrying Malak Belkadi. FF Bates helped them to carry her. FFs Mitchell, Pole and Cheesman continued upwards and reached floor 18. There they realised that they did not have enough air to reach floor 23 and get back down again. Instead they helped to rescue those who had sheltered in Flat 153. FF Mitchell recalled telling WM Louisa De Silvo that they had not reached floor 23. The crew’s end of wear times were 03.15 to 03.17.1317 97.13 FFs Matthew Harold, David Friend and Richard Peacock tallied out between 03.31 and 03.32. They had originally been sent to Flat 203 on floor 23 in the south-west corner of the tower but their instructions were changed just before they set off. Instead, they were told to carry out search and rescue operations from the ground floor upwards. They searched floors 4 and 5 and found no casualties.1318 Events surrounding Flat 201 97.14 Flat 201, the home of Raymond (Moses) Bernard, was a one-bedroom flat facing east.1319 Those who took refuge there included Fadumo Ahmed (Flat 164, floor 19), Debbie Lamprell and Gary Maunders (Flat 161, floor 19), Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris (Flat 166, floor 19), Berkti Haftom and Biruk Haftom (Flat 155, floor 18), Hamid Kani (Flat 154, floor 18) and Jessica Urbano Ramirez (Flat 176, floor 20). Most of those who moved up to floor 23 probably reached it by around 01.30.1320 97.15 Amna Idris and Gary Maunders did not live in Grenfell Tower. Amna Idris was visiting her cousin, Amal Ahmedin, and her family. Gary Maunders was visiting Debbie Lamprell.1321 He moved from Flat 201 to Flat 203 at around 01.39.1322 97.16 There were three children in the group sheltering in Flat 201: Jessica Urbano Ramirez (12 years old), Biruk Haftom (12 years old) and Amaya Tuccu Ahmedin (3 years old).1323 97.17 Of the 11 people who were in Flat 201 at some point, only Fadumo Ahmed survived. She left the tower at 02.25 with the assistance of firefighters.1324 97.18 The remains of Moses Bernard, Debbie Lamprell, Amna Idris, Berkti Haftom, Biruk Haftom, Hamid Kani and Jessica Urbano Ramirez were all recovered from Flat 201. 1316 Phase 1 Report Volume III paragraphs 15.54-15.56 and 15.66. 1317 External Fire Spread Report {MET00012593/14}; Phase 1 Report Volume III paragraphs 16.15-16.20 and Figure 16.6. 1318 Phase 1 Report Volume III paragraph 18.15(b); External Fire Spread Report {MET00012593/14}. 1319 Phase 1 Report Volume IV paragraph 32.55; External Fire Spread Report {MET00012593/14}. 1320 Phase 1 Report Volume II paragraphs 10.257, 10.258, 10.260, 10.289 and 14.125. 1321 Phase 1 Report Volume II paragraphs 10.223 and 14.136. 1322 Phase 1 Report Volume II paragraphs 11.30-11.31. 1323 Phase 1 Report Volume IV paragraphs 32.126, 32.154 and 32.198. 1324 Phase 1 Report Volume II paragraph 14.131; Phase 1 Report Volume III Annex A.

The Grenfell Tower Inquiry: Phase 2 Report 164 97.19 The remains of Gary Maunders were recovered from Flat 203. Those of Amal Ahmedin and her daughter, Amaya Tuccu Ahmedin, were recovered from the lobby of floor 23. We do not know when or under what circumstances Amal Ahmedin and Amaya Tuccu Ahmedin left Flat 201.1325 Conditions in Flat 201 97.20 By 01.29 the fire had spread to the eastern and northern sides of floor 23, affecting first Flat 206 in the north-east corner.1326 The fire moved across Flat 206 in a southerly direction along the east face and towards Flat 201, which was next door.1327 97.21 Smoke had been entering the lobby on floor 23 since before 01.30.1328 From about 01.30, Flat 201 filled with smoke from the lobby and from the fire outside the living room windows.1329 97.22 By 01.34, the occupants of Flat 201 were struggling to breathe. There were about ten people sheltering in the hallway of the flat. Fadumo Ahmed and Amal Ahmedin tried unsuccessfully to put out a fire which was burning at the top of the living room window.1330 97.23 The fire entered the living room and set things alight. The conditions in the flat prompted the group to move from the hallway to the bedroom.1331 While in the bedroom, both Debbie Lamprell and Jessica Urbano Ramirez had long telephone calls with the emergency services. 97.24 By the time Fadumo Ahmed decided to leave thick smoke was coming into the flat from the lobby. At some time between 01.50 and 02.20 she left the flat and ran straight to the stairwell. Both the lobby and the stairs were filled with thick, dark smoke. Due to the smoke, there was no visibility in the lobby and the stairs could not be seen.1332 97.25 By about 01.56, the fire on the outside of the building had spread across the exterior of the living room and kitchen. It then spread outside the bedroom window where the occupants were sheltering.1333 97.26 By 02.01 the windows of the bedroom of Flat 201 were cracking. By 02.06, flames were entering the bedroom window and the interior of the flat was on fire.1334 97.27 By 02.20, towards the end of their respective emergency calls, Jessica Urbano Ramirez and Debbie Lamprell had stopped responding; they both probably lost consciousness at about that time.1335 97.28 It is likely that all those in Flat 201 lost consciousness from about 02.15 and had been exposed to a lethal dose of asphyxiant gases by about 02.23.1336 1325 Phase 1 Report Volume II paragraph 14.132. 1326 Phase 1 Report Volume II paragraph 10.107. 1327 Lane, Phase 1 Supplemental Report, Section 12 {BLAS0000012/8-9}; External Fire Spread Report {MET00012593/18-19}. 1328 Phase 1 Report Volume II paragraphs 10.285-10.286. 1329 Purser, Phase 2 Report, Section 6 {DAPR0000006/9} paragraph 18. 1330 Phase 1 Report Volume II paragraphs 11.25-11.26; 999 call transcript {LFB00055504/5-10}. 1331 Phase 1 Report Volume II paragraph 11.25. 1332 Phase 1 Report Volume II paragraphs 14.128-14.130. 1333 Purser, Phase 2 Report, Section 6 {DAPR0000006/9} paragraph 19. 1334 Phase 1 Report Volume II paragraphs 14.134 and 14.138. 1335 Phase 1 Report Volume II paragraphs 14.135 and 14.140; 999 call transcript {LFB00055500/42-43}; 999 call transcript {LFB00055504/78-82}; Purser, Phase 2 Report, Section 6 {DAPR0000006/12} paragraph 36. 1336 Purser, Phase 2 Note on Toxicity Endpoints {DAPR0000013}.

Part 9 | Chapter 97: Floor 23 165 97.29 The firefighting crews deployed to floor 23 all tallied out after 02.08. Conditions in the stairwell between 02.00 and 02.20 had deteriorated to the point at which they posed a risk to anyone who attempted to escape.1337 It is therefore doubtful that firefighters would have been able to rescue the occupants of Flat 201, even if they had succeeded in reaching floor 23. Emergency services calls, information at the incident ground and deployment to Flat 201 97.30 Jessica Urbano Ramirez and Debbie Lamprell each made a long emergency call while they were in Flat 201. Although the calls overlapped in time, there does not appear to have been any direct communication between the two callers. Biruk Haftom also made an emergency call from Flat 201.1338 97.31 Although messages from Flat 201 were passed to the incident ground and recorded in various places, there was only one deployment of firefighters specifically to Flat 201.1339 Jessica Urbano Ramirez’s long emergency call 97.32 Jessica Urbano Ramirez used Berkti Haftom’s telephone to make an emergency call at 01.27, but it was disconnected before the BT operator could transfer it to the LFB control room.1340 The BT operator contacted the LFB control room at 01.29 and spoke to CRO Sarah Russell, telling her that the caller was a child who had asked for the fire brigade. CRO Russell called back using Berkti Haftom’s number and was connected to Jessica Urbano Ramirez at 01.29. The call lasted until 02.24. Jessica stopped responding towards the end of the call. Early in the conversation she reported her location as floor 23 and said that there were about ten other people in the flat.1341 She said that smoke was coming from the floor and that people were having difficulty breathing. She later said that fire had entered the living room and that the group had moved from the hallway to the bedroom. She said she was in Flat 201. She also described the group as containing about 11 people, including a two-year-old child, who must have been Amaya Tuccu Ahmedin.1342 97.33 At 01.45, CRO Russell created a service request which sought assistance for 11 people trapped in the bedroom of a flat on floor 23.1343 That was the first service request created as a result of information received from Jessica Urbano Ramirez.1344 CRO Sharon Darby contacted CU8 at 01.46 and passed on a message about 11 people in a bedroom of a flat on floor 23.1345 The service request was then marked as completed at 01.47.1346 97.34 The call continued. A further service request referring to 11 persons and a baby in Flat 201 was created at 01.58 (once CRO Russell had become aware of the flat number and the presence of a baby) and messages were passed to CU8 about Flat 201.1347 The service request relating to 11 persons and a baby in Flat 201 was marked as completed 1337 Phase 1 Report Volume IV paragraph 25.28. 1338 Phase 1 Report Volume II paragraphs 10.289 (d) and 14.127. 1339 Phase 1 Report Volume II paragraph 14.117. 1340 999 call transcript {MET00015554}. 1341 Phase 1 Report Volume II paragraph 10.317. 1342 Phase 1 Report Volume II paragraphs 11.25, 12.66 (b) and 12.67. 1343 Phase 1 Report Volume II paragraph 12.84. 1344 Phase 1 Report Volume II paragraph 12.84. 1345 Phase 1 Report Volume II paragraph 12.88. 1346 LFB Short Incident Log {MET00013830/20}. 1347 Phase 1 Report Volume II paragraph 13.104.

The Grenfell Tower Inquiry: Phase 2 Report 166 at 02.00.1348 Also at 02.00, CRO Adams rang CU8 to pass on a number of messages to WM Meyrick. One of those messages related to Flat 201 on floor 23 containing 11 adults and one child.1349 97.35 While Jessica Urbano Ramirez’s call to CRO Russell was going on, there was an unrelated attempt to rescue her. Her sister, Melanie, thought that Jessica was still in Flat 176. At 01.26 she told FF David Badillo that her sister was in Flat 176 on floor 20 and gave him the keys. FF Badillo first tried to reach the flat alone, then recruited CM Christopher Secrett and FF Christopher Dorgu to go with him. They set out by 01.35. Having reached Flat 176 and found it empty, they returned to the ground floor. Their end of wear time was 01.57. No information about the emergency call from Jessica Urbano Ramirez reached the crew during their deployment.1350 97.36 The messages about Flat 201 sent by the control room to the incident ground at 01.46 and 02.00 were passed on to the bridgehead, which was located on floor 2 until 02.17.1351 Shortly after 02.17, CM Charles Batterbee recorded in his notebook the information written on a forward information board that had been used while the bridgehead was located on floor 2.1352 Flat 205 appears in that entry, but not Flat 201. A circled note written on the wall on floor 2 refers to Flats 201 and 205 and the names Alassad, Bell and Wright.1353 That is likely to have related to the unsuccessful deployment of firefighters John Wright, Zade Alassad and Scott Bell to floor 23 before 02.10. There were no further deployments to Flat 201 after that. 97.37 From about 02.33 SM Jason Oliff recorded information coming into the LFB control room on two whiteboards. In a photograph taken at the end of the incident the first whiteboard can be seen to include the notation “Flat 201 23rd flr – 2 yr old 11 people – now unconscious”.1354 That probably reflected the call from Jessica Urbano Ramirez. 97.38 Between about 02.00 and 03.00, a white laminate sheet was being used by firefighters in command unit CU7 at the incident ground to record information about people needing to be rescued. The laminate sheet recorded “Flat 201 Floor 23 1 person lost call”.1355 That message must have related to Jessica Urbano Ramirez’s call, during which she had stopped responding towards the end. Firefighters at the incident ground were therefore informed that contact with her had been lost.1356 Debbie Lamprell’s long emergency call 97.39 At 01.41, a BT operator connected to North West Fire Control said that a caller for the LFB had hung up after waiting for about five minutes.1357 That caller was Debbie Lamprell. At 01.41 CRO Aisha Jabin’s call back to Debbie Lamprell was connected. The call lasted for over 40 minutes, until 02.21. The group in Flat 201 had by then moved from the hallway to the bedroom. During the call, Debbie Lamprell confirmed her location as Flat 161 on floor 23.1358 Flat 161 was her home address and was not on floor 23. 1348 LFB Short Incident Log {MET00013830/21}. 1349 Phase 1 Report Volume II paragraphs 14.230-14.232; LFB Short Incident Log {MET00013830/19-21}. 1350 Phase 1 Report Volume II paragraphs 10.79 (b), 10.101 (a), 11.10 and 13.17. 1351 Phase 1 Report Volume IV paragraphs 28.11, 28.84 (b) and 28.86. 1352 Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c). 1353 Phase 1 Report Volume II Figure 13.2 and paragraph 13.53. 1354 Phase 1 Report Volume III paragraphs 15.139-15.140 and Figure 15.8. 1355 Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3; Phase 1 Report Volume IV paragraph 28.85 (d). 1356 As there had been no further update passed on from NWFC to the LFB control room in relation to Debbie Lamprell’s call (see below), this must have related to Jessica Urbano Ramirez’s call. 1357 999 call transcript {MET00014977}. 1358 Phase 1 Report Volume II paragraph 12.86.

Part 9 | Chapter 97: Floor 23 167 97.40 At 01.46, Team Leader Paula Craig at North West Fire Control contacted the LFB control room and spoke to AOM Debbie Real. Based on inaccurate information from Debbie Lamprell’s continuing emergency call she reported a call from “Flat 161 on Floor 23” with ten people trapped in the bedroom. AOM Real did not record the information contemporaneously in the incident log, but she appears to have passed it on to OM Alexandra Norman. OM Norman passed the information to the incident ground at 01.47 and at 02.01 recorded having done so in the incident log.1359 97.41 However, at around 01.52 Debbie Lamprell explained to CRO Jabin that she was in fact in Flat 201 on floor 23. As a result, CRO Jabin made further entries in the incident log, first to record that she was unsure of the flat number and then at 01.53 to record “10 PEOPLE IN FLAT 201 23rd FLOOR”.1360 97.42 The correct location of Flat 201 was not communicated to the LFB control room, nor was it recorded in the incident log or in radio messages, even after CRO Jabin had become quite sure that it was on floor 23. The forward information board at the bridgehead included an entry for Flat 161 on floor 19, which probably reflected the message passed by North West Fire Control to the LFB following Debbie Lamprell’s call.1361 97.43 As a result of that message, at about 02.05 FFs Terence Roots and Adam Johnson were deployed to Flat 161 on floor 19, which was empty. Having swept Flat 161, FFs Roots and Johnson helped Nicholas and Pily Burton from Flat 165 to leave the building.1362 Other emergency calls and information recorded at the incident ground 97.44 At 01.32 CRO Christine Howson answered an emergency call from Biruk Haftom, who was in Flat 201 at the time. He said, “My actual door number is 155 but I’m at someone else’s house”. Biruk Haftom reported that eight children and a lot of adults were in a flat on the top floor and that the window was already “burning up”. He said they could not get out. He also reported a lot of smoke in the flat and in the building. CRO Howson told him and an adult who also spoke to her to try to stop smoke coming into the flat.1363 97.45 No service request appears to have been created in response to Biruk Haftom’s call, but OM Norman rang CU8 at 01.35 and reported that there were eight children and a number of adults on the top floor and that smoke was entering their flat.1364 At 01.36, CRO Darby contacted appliance G261 and passed on that information.1365 97.46 FF Mandeep Singh arrived at the tower at 01.35 and was instructed to pass information about people needing to be rescued from the command unit to the bridgehead. He recalled having been handed telephones and speaking to residents inside the tower. During one such call, FF Singh spoke to a woman who gave her location as “the 23rd floor, doors 205 and 201”. She said that she had brought all the occupants of floor 23 into her flat. FF Singh advised her to stay put.1366 A page from his notebook contains the following entry “23rd FLOOR ALL OCCUPANTS 205/201 [illegible] WM BRIAN O’KEITH 1359 Phase 1 Report Volume II paragraph 12.85. 1360 Phase 1 Report Volume II paragraph 12.86. 1361 Phase 1 Report Volume II paragraphs 12.86 and 14.73. 1362 Phase 1 Report Volume II paragraphs 12.85-12.86 and 14.116. 1363 Phase 1 Report Volume II paragraphs 10.289 (d) and 11.28. 1364 LFB Short Incident Log {MET00013830}; Phase 1 Report Volume II paragraphs 11.148-11.149. 1365 Phase 1 Report Volume II paragraph 11.155. 1366 Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17;

The Grenfell Tower Inquiry: Phase 2 Report 168 WM (Illegible)”.1367 In his witness statement FF Singh said that he thought the woman he had spoken to was the person who can be heard in a video recording saying that she will let people in. That was probably Rania Ibrahim, who was in fact in Flat 203, not Flat 201 or Flat 205.1368 97.47 WM Glynn Williams started to record information on the wall of the lobby on the ground floor at 02.15. He said the information had come from CU7. A photograph of the wall taken much later on in the incident includes the notation “201 23 11”.1369 97.48 The bridgehead was moved from floor 2 to floor 3 at about 02.17, where it remained until 03.10.1370 Messages were recorded on the wall of that floor. There is no reference to Flat 201 on the wall during that time.1371 Accordingly, it is likely that no further messages about Flat 201 were passed from CU7 to the bridgehead after 02.17. 97.49 After 03.00, the laminated sheet in CU7 was replaced by a whiteboard with a grid. A photograph of the whiteboard taken much later in the morning shows Flat 201 annotated with “11 1” and a red mark, which is difficult to read. The “11” is in green indicating 11 people and the “1” is in black indicating a child.1372 The red mark may signify a “P” for priority. People who died in or near Flat 201 Raymond (Moses) Bernard Date of birth: 22 May 1954 (63 years old). Place of birth: Penal, Republic of Trinidad and Tobago. Gender:

Male. Occupation: Retired electrical engineer. Usual address: Flat 201, floor 23, Grenfell Tower, London. Place of death: Flat 201, floor 23, Grenfell Tower, London. Time of death: About 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 97.50 Born in Trinidad on 22 May 1954, Raymond (Moses) Bernard was 63 years old at the time of the fire. He came to the UK in 1969 to join his parents and completed his schooling here. At the age of 16, he began an electrical engineering apprenticeship working, once qualified, at the House of Lords and Buckingham Palace. A father of four, Moses Bernard had lived in Flat 201 for over 30 years. He lived there with his dog, Marley.1373 1367 Singh Exhibit MS/1 - pages from notebook {MET00013089/2}. 1368 Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17. 1369 Phase 1 Report Volume II paragraphs 14.103-14.104 and Figure 14.5. 1370 Phase 1 Report Volume IV paragraphs 28.86-28.87. 1371 Phase 1 Report Volume III Figure 15.7. 1372 Phase 1 Report Volume III Figure 16.5; Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. 1373 Tenancy Agreement {TMOH00001235}; Phase 1 Report Volume IV paragraphs 32.55 -32.58.

Part 9 | Chapter 97: Floor 23 169 Vulnerability 97.51 Moses Bernard had been diagnosed with arthritis ten years before his death in the fire. As a result, his mobility had deteriorated and he walked with the assistance of a cane. He had difficulty climbing stairs.1374 97.52 Moses Bernard’s sister, Sheramin Bernard, wrote to RBKC several years before the fire informing them of her brother’s medical and mobility problems in an attempt to have him re-housed on medical grounds. Sheramin Bernard received no reply. No assessment or review was carried out in light of the information provided.1375 97.53 Rydon carried out surveys of residents during the refurbishment and compiled a list of their vulnerabilities in November 2014. They carried out a survey on Moses Bernard’s home on 14 October 2014 and recorded that he had no problems with his health and no pets.1376 97.54 Moses Bernard was not identified as a vulnerable resident in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system.1377 Events of 14 June 2017 97.55 Moses Bernard returned to Grenfell Tower in the early evening of 13 June 2017.1378 It is uncertain when he first became aware of the fire but by about 01.30 he had offered refuge in his home to ten people.1379 97.56 Moses Bernard did not make any calls to the emergency services himself, but during the course of Biruk Haftom’s call to the LFB control room at 01.32 he took over and spoke briefly to CRO Howson, when towards the end of the call she asked to speak to an adult. Moses Bernard told her that the fire was approaching and that smoke was coming through the window.1380 97.57 Jessica Urbano Ramirez was sheltering in the bedroom of Flat 201 during her extended call with CRO Russell. About 17 minutes into the call she referred to a man who may have been Moses Bernard. She said he could not talk to CRO Russell because he was struggling to breathe.1381 Recovery and identification 97.58 The remains of Moses Bernard were recovered from the bedroom of Flat 2011382. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.1383 1374 Bernard {IWS00002337/3} page 3, paragraphs 21-23. 1375 Bernard {IWS00002337/3-4} pages 3-4, paragraphs 21-24. 1376 Rydon Residents Survey {RYD00024466/5}. 1377 Phase 1 Report Volume III paragraphs 20.65-20.66; David Noble Spreadsheet {TMO00862588}. 1378 O’Riordan {MET00013136/3} page 3. 1379 Phase 1 Report Volume II paragraphs 10.257, 10.258, 10.260, 10.289 and 14.125. 1380 Phase 1 Report Volume II paragraph 11.28; Presentation relating to Raymond (Moses) Bernard {Day300/77:17}-{Day300/78:14}. 1381 999 call transcript {LFB00055504/32-33}. 1382 Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14. 1383 Interim certificate of the fact of death for Raymond Bernard {MET00065646}.

The Grenfell Tower Inquiry: Phase 2 Report 170 Cause and time of death 97.59 The post-mortem report on Moses Bernard recorded a cause of death as “consistent with the effects of fire.”1384 In the light of Professor Purser’s evidence, we find that a more accurate description is inhalation of asphyxiant gases. 97.60 We are satisfied that Moses Bernard died at about 02.45 before suffering the direct effects of fire.1385 Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris Amal Ahmedin Date of birth: 1 January 1982 (35 years old). Place of birth: Sudan. Gender:

Female. Occupation: Retail assistant. Usual address: Flat 166, floor 18, Grenfell Tower, London. Place of death: Floor 23 lobby, Grenfell Tower, London. Time of death: Between about 02.20 and 02.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Amaya Tuccu Ahmedin Date of birth: 25 February 2014 (3 years old). Place of birth: London, UK. Gender:

Female. Occupation: N/A. Usual address: Flat 166, floor 18, Grenfell Tower, London. Place of death: Floor 23 lobby, Grenfell Tower, London. Time of death: Between about 02.20 and 02.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Amna Mahmud Idris Date of birth: 1 January 1990 (27 years old). Place of birth: Eritrea Gender:

Female. Occupation: Student. 1384 Bernard post-mortem report {COR00000150/5}. 1385 Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20.

Part 9 | Chapter 97: Floor 23 171 Usual address: Grafton Road, London W3. Place of death: Flat 201, floor 23 Grenfell Tower, London. Time of death: About 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 97.61 Amal Ahmedin was born in Sudan on 1 January 1982 and was 35 years old in 2017. She lived in Flat 166 on floor 19 of Grenfell Tower with her daughter, Amaya Tuccu Ahmedin, who had been born in London on 25 February 2014 and was 3 years old when she died.1386 Mohamednur Tuccu, the husband of Amal Ahmedin and the father of Amaya Tuccu Ahmedin, was also in Grenfell Tower on the night of the fire, probably visiting his family. We have dealt with the circumstances of his death in Chapter 86. 97.62 On the evening of 13 June 2017, Amna Idris, Amal Ahmedin’s cousin, was also visiting the family. Amna Idris had been born in Eritrea on 1 January 1990 and was 27 years old. She had joined her husband Ibrahim in London in March 2016.1387 Vulnerability 97.63 Amal Ahmedin had no known vulnerabilities. She and Amaya Tuccu Ahmedin both appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system.1388 Amaya Tuccu Ahmedin’s age (3 years) was recorded in the spreadsheet.1389 Events of 14 June 2017 97.64 Amal Ahmedin, Amna Idris and Amaya Tuccu Ahmedin all entered the tower on 13 June

1. Mohamednur Tuccu entered the tower at 00.36 on 14 June 2017.1390
2. 65

Meron Mekonnen was a neighbour of Amal Ahmedin and Amaya Tuccu Ahmedin. She lived at Flat 163 on floor 19 and was alerted to the fire at 01.25 by telephone. When she left her flat, she saw Amal Ahmedin and Amna Idris in the lobby of floor 19. She did not see Mohamednur Tuccu. The door to Flat 166 (the home of Amal Ahmedin and Amaya Tuccu Ahmedin) was wide open. It had a door closer but it was not working. Amal Ahmedin and Meron Mekonnen told each other about the fire before Amal Ahmedin ran back into Flat 166. 97.66 That was the last time Meron Mekonnen saw Amal Ahmedin. Amna Idris followed Meron Mekonnen and her daughters into the stairwell, probably before 01.30. It is likely that Flat 166 was affected by the fire at an early stage and that Amal Ahmedin and Amaya Tuccu Ahmedin left soon after.1391 1386 Phase 1 Report Volume IV paragraph 32.154. 1387 Phase 1 Report Volume IV paragraphs 32.163-32.165. 1388 Noble {TMO00000884/1} page 1, paragraph 3. 1389 David Noble’s list {TMO00862588}. 1390 O’Riordan {MET00013136/2-4} pages 2-4. 1391 Phase 1 Report Volume II paragraphs 10.223, 10.255-10.257 and 10.289(e); Mekonnen {Day55/23:25}-{Day55/24:6}; BRE Investigation Report {MET00039807/77}.

The Grenfell Tower Inquiry: Phase 2 Report 172 97.67 There is no evidence that Mohamednur Tuccu was in Flat 166 when Meron Mekonnen saw Amal Ahmedin or that he was among those who made their way up the tower. He was, however, in the north lift when Rhea Rojo entered it on floor 12.1392 97.68 Amna Idris initially went down the stairs with a group of people including Meron Mekonnen and her children. At around floor 15 or floor 16, she heard a man shouting at them to go back and the group (including Amna Idris) began to run back upstairs. When she reached floor 19, Meron Mekonnen stopped and decided to go back downstairs again. She could not recall what Amna Idris had done at that time, but she must have gone upstairs to floor 23, as she was later seen in Flat 201 by Fadumo Ahmed.1393 97.69 Fadumo Ahmed, who lived in Flat 164 on floor 19, was made aware of the fire at around 01.20. When she left her flat, the lobby was full of thick, dark grey, steamy smoke which was hard to see through. She went up to floor 23 where she found that the smoke in the lobby was worse than it had been on floor 19. She recalled that Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris had been part of the group sheltering in Flat 201 by 01.30.1394 97.70 In her call to CRO Russell that had started at 01.29, Jessica Urbano Ramirez said that the group in the bedroom of Flat 201 included a two-year-old child, whom she also referred to as a baby. Debbie Lamprell also referred to a baby in her call to CRO Jabin that had started at 01.41. It is likely that they were both referring to Amaya Tuccu Ahmedin.1395 97.71 Between 01.50 and 02.20, Fadumo Ahmed left Flat 201. The remains of Amal Ahmedin and Amaya Tuccu Ahmedin were later found in the lobby of floor 23. It is not possible to determine at exactly what time Fadumo Ahmed left Flat 201 or whether Amal Ahmedin and Amaya Tuccu Ahmedin followed her out at the same time or left Flat 201 later.1396 97.72 At around 02.00, Jessica Urbano Ramirez was still talking to CRO Russell, and was heard to ask someone in the room not to leave. CRO Russell asked if someone was leaving, and Jessica Urbano Ramirez replied to say she had been mistaken. It is possible though, that she had been referring to Amal Ahmedin and Amaya Tuccu Ahmedin. At about 02.06, Jessica Urbano Ramirez said that the fire was in the flat and later confirmed that flames were coming through the bedroom window. CRO Russell tried to persuade her to move to another room. She told CRO Russell that people had tried to leave but had been unable to do so because of the smoke.1397 97.73 Meanwhile, Debbie Lamprell had told CRO Jabin at 02.01 that the windows were cracking and at 02.06 that the flat was on fire. CRO Jabin spoke to her team leader and told Debbie Lamprell to leave. Debbie Lamprell said she was unable to leave because people on the other side of the room were trying to get out. She confirmed that she was still in the bedroom.1398 We do not know whether Debbie Lamprell was referring to Amal Ahmedin. 97.74 At some point Amal Ahmedin left Flat 201 with Amaya Tuccu Ahmedin. She was unable to cross the lobby on floor 23 and collapsed there. Amna Idris remained in Flat 201. 1392 Phase 1 Report Volume II paragraphs 10.219 and 10.224-10.225. 1393 Phase 1 Report Volume II paragraph 10.258; Mekonnen {IWS00000912/3-4} pages 3-4, paragraphs 17-20; Phase 1 Report Volume III Annex A. 1394 Phase 1 Report Volume II paragraphs 10.259-10.260 and 10.289; Phase 1 Report Volume III Annex A; External Fire Spread Report {MET00012593/12}. 1395 Phase 1 Report Volume II paragraphs 12.66-12.67, 12.86, 14.127 and 14.132; 999 call transcript {LFB00055504/36-37}. 1396 Phase 1 Report Volume II paragraphs 14.128 and 14.132. 1397 Phase 1 Report Volume II paragraphs 14.132-14.134. 1398 Phase 1 Report Volume II paragraphs 12.86, 14.127 and 14.138-14.140.

Part 9 | Chapter 97: Floor 23 173 Recovery and identification 97.75 The remains of Amal Ahmedin and Amaya Tuccu Ahmedin were recovered from the communal lobby on floor 23.1399 The remains of Amna Idris were recovered from the bedroom of Flat 201.1400 The coroner was satisfied about the identification of the remains recovered and therefore issued interim certificates of the fact of death in respect of Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris.1401 Cause and time of death 97.76 Conditions in Flat 201 were deteriorating quite seriously at and after the time that Fadumo Ahmed left. If Amal Ahmedin and Amaya Tuccu Ahmedin left Flat 201 at any time after about 02.00, they would already have accumulated a significant proportion of the amount of asphyxiating gases needed to incapacitate them. We think it likely that they left Flat 201 between about 02.00 and 02.10, when the fire reached the bedroom window and conditions further deteriorated. By that time even the effort involved in getting up and walking from the flat into the lobby could have been sufficient to result in immediate collapse. Their remains were recovered from the lobby just outside Flat 201.1402 97.77 The post-mortems on Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris recorded the cause of death in each case as “consistent with the effects of fire” but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”. Toxicological testing was only possible for Amna Idris. That showed a level of blood carboxyhaemoglobin in her blood of 68%.1403 97.78 We are satisfied that Amal Ahmedin and Amaya Tuccu Ahmedin died between about 02.20 and 02.30 and that Amna Idris died at about 02.45.1404 Berkti Haftom and Biruk Haftom Berkti Haftom Date of birth: 2 November 1987 (29 years old). Place of birth: Asmara, Eritrea. Gender:

Female. Occupation: Cleaner / Catering. Usual address: Flat 155, floor 18, Grenfell Tower, London. Place of death: Flat 201, floor 23, Grenfell Tower, London. Time of death: About 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. 1399 Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 16. 1400 Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14. 1401 Interim certificates of the fact of death for Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris {MET00065590}; {MET00065639} and {MET00065591}. 1402 Purser, Phase 2 Report, Section 6 {DAPR0000006/10} paragraphs 21 and 24; {DAPR0000006/11} paragraphs 26-28. 1403 Amal Ahmedin post-mortem report {COR00000111/5-7}; Amal Ahmedin post-mortem report {COR00000111/5-7}; Amna Idris post-mortem report {COR00000155/3-8}. 1404 Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser {Day296/28:15}-{Day296/29:8}.

The Grenfell Tower Inquiry: Phase 2 Report 174 Biruk Haftom Date of birth: 27 April 2005 (12 years old). Place of birth: London, UK. Gender:

Male. Occupation: Student. Usual address: Flat 155, floor 18, Grenfell Tower, London. Place of death: Flat 201, floor 23 Grenfell Tower, London. Time of death: About 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 97.79 Berkti Haftom was born on 2 November 1987 in Eritrea and was 29 years old. Her son Biruk was born on 27 April in London and was 12 years old. They had lived in Flat 155 on floor 18 of Grenfell Tower since 2007. At the time of the fire, they were living in Flat 155 with Berkti’s partner Michele Chiapetto and a lodger, Yehualashet Enyew. Berkti Haftom was pregnant at the time of the fire.1405 Vulnerability Both Berkti and her son appear on the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system.1406 Biruk Haftom’s age (12 years) was recorded.1407 Neither had any known vulnerabilities. Events of 14 June 2017 97.80 Berkti Haftom and Biruk Haftom both returned to Grenfell Tower during the evening of 13 June 2017.1408 97.81 Yehualashet Enyew was awoken at about 01.15 on 14 June 2017 by the smell of smoke. He alerted Berkti Haftom to the fire at about 01.20. As he prepared to leave, he heard Berkti Haftom calling him from the hallway and then heard the door slam. When he left Flat 155, probably at about 01.30 or soon after, Berkti and Biruk Haftom were not in the lobby. At that point he found the stairwell filled with thick, choking smoke.1409 97.82 At some point before 01.27, Berkti and Biruk Haftom met Jessica Urbano Ramirez. She used Berkti Haftom’s phone to make an emergency call at 01.27,1410 but the call was disconnected before the operator could put it through to the LFB.1411 When Jessica called her mother, Adriana Ramirez, shortly afterwards, she said that she was on floor 18. Adriana Ramirez could hear voices in the background, which were probably those of Berkti and Biruk Haftom.1412 1405 Phase 1 Report Volume IV paragraphs 32.197-32.198 and 32.203; Tenancy Agreement {TMOH00026234}. 1406 Noble {Day119/77:17}-{Day119/82:5}. 1407 Noble spreadsheet {TMO00866002}. 1408 O’Riordan {MET00013136/3} page 3. 1409 Phase 1 Report Volume II paragraphs 10.253 and 11.58-11.60. 1410 999 call transcript {MET00015554}. 1411 999 call transcript {LFB00000481}. 1412 Phase 1 Report Volume II paragraph 10.289 (f); Ramirez {IWS00001116/4-5} pages 4-5, paragraphs 21 and 22.

Part 9 | Chapter 97: Floor 23 175 97.83 Shah and Sayeda Ahmed, who lived in Flat 156 on floor 18, were woken by the smoke alarms in their flat. They left their flat at about 01.27 and knocked on their neighbours’ doors. There was no answer from Flat 155, so Berkti and Biruk Haftom had probably already left Flat 155 to go upstairs.1413 97.84 Berkti Haftom, Biruk Haftom and Jessica Urbano Ramirez probably all reached floor 23 before 01.30.1414 CRO Russell’s call to Jessica Urbano Ramirez at 01.29 was made on Berkti Haftom’s telephone.1415 By that time, Jessica Urbano Ramirez was in Flat 201. When Fadumo Ahmed reached Flat 201 she joined a group in the hallway that included Berkti and Biruk Haftom.1416 97.85 Biruk Haftom spoke to CRO Howson at 01.32 from Flat 201. He told her that he lived in Flat 155 but was calling from someone else’s flat. He told her that there were eight children and a lot of adults in a flat on the top floor and that the window was already burning up. He said that there was a lot of smoke in the flat and in the building and that they could not get out. CRO Howson told him and the adult to whom she also spoke briefly to try to stop smoke coming into the flat.1417 There is no evidence that Berkti Haftom contacted the emergency services. 97.86 Michele Chiapetto (Berkti Haftom’s partner) and the family of Berkti and Biruk Haftom made several unsuccessful attempts to contact them by phone during the night. Berkti Haftom’s phone stopped ringing at about 07.00.1418 Recovery and identification 97.87 The remains of Berkti and Biruk Haftom were recovered from the bedroom of Flat 201.1419 97.88 The coroner was satisfied about their identification and therefore issued interim certificates of the fact of death for Berkti and Biruk Haftom.1420 Cause and time of death 97.89 We are satisfied that the occupants of Flat 201, including Berkti and Biruk Haftom, had died by about 02.45 as the result of the inhalation of asphyxiant gases before they suffered from the direct effect of the flames.1421 97.90 The post-mortem recorded causes of death for both Berkti and Biruk Haftom as “consistent with the effects of a fire”,1422 but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”. 1413 Phase 1 Report Volume II paragraphs 10.249-10.250, 10.254 and 10.289 (b). 1414 Phase 1 Report Volume II paragraph 10.289. 1415 Phase 1 Report Volume II paragraph 10.289 (f). 1416 Phase 1 Report Volume II paragraphs 10.259-10.260. 1417 Phase 1 Report Volume II paragraphs 10.289 (d) and 11.28. 1418 Chiapetto {IWS00000679/2-4} pages 2-4, paragraphs 10-17; Semre {IWS00000954/4} page 4, paragraphs 24-25. 1419 Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14. 1420 Interim certificates of the fact of death for Berkti and Biruk Haftom {MET00065608}; {MET00065623}. 1421 Purser, Phase 2 Report, Section 6 {DAPR0000006/13} paragraph 38; Purser {Day296/28:15}-{Day296/29:8}. 1422 Berkti Haftom post-mortem report {COR00000216/5}; Biruk Haftom post-mortem report {COR00000240/3}.

The Grenfell Tower Inquiry: Phase 2 Report 176 Hamid Kani Date of birth: 24 January 1956 (61 years). Place of birth: Shahr-e-Ray, Iran. Gender:

Male. Occupation: Retired. Usual address: Flat 154, floor 18, Grenfell Tower, London. Place of death: Flat 201, floor 23, Grenfell Tower, London. Time of death: About 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of the household 97.91 Hamid Kani had been the sole tenant of Flat 154 on floor 18 since 10 September 1990.1423 He lived alone. Having been born in Iran on 24 January 1956, he had come to London in the 1970s to study. In the 1980s he had been an actor and comedian but later changed careers, working in restaurants as a chef.1424 Vulnerability 97.92 Hamid Kani suffered from backache and hip pain, making it difficult for him to climb stairs.1425 He included a reference to his disability in the tenancy information form he completed on 23 April 2015.1426 He was not identified as vulnerable in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system.1427 Events of 14 June 2017 97.93 Hamid Kani returned to Grenfell Tower for the last time in the early evening of 13 June 2017.1428 97.94 When Shah and Sayeda Ahmed left their flat and knocked on their neighbours’ doors at about 01.27, Hamid Kani opened his door in response. He had therefore been alerted to the fire by 01.27.1429 97.95 Hamid Kani went up to floor 23 to take shelter and was able to enter Flat 201. He probably got there by about 01.30 and did not leave.1430 97.96 There is no evidence that he spoke to the emergency services or to relatives or friends during the fire. 1423 Tenancy agreement {TMOH00026143}. 1424 Phase 1 Report Volume IV paragraphs 32.204-23.209. 1425 GP Letter dated 23 July 1990 {TMOH00026128}. 1426 KCTMO Tenancy Information form {TMOH00026145/10}. 1427 Phase 1 Report Volume III paragraphs 20.65–20.66; David Noble Spreadsheet {TMO00866002}. 1428 O’Riordan {MET00013136/3} page 3. 1429 This timing is derived from the fact that at 01.27 the MPS operator asked the BT operator for a playback of Shah Ahmed’s 999 call, in which Shah Ahmed had not spoken to the BT operator. Phase 1 Report Volume II paragraphs 10.249-10.250 and 10.289 (b). 1430 Phase 1 Report Volume II paragraphs 14.125 and 10.287-10.289.

Part 9 | Chapter 97: Floor 23 177 Recovery and identification 97.97 The remains of Hamid Kani were recovered from between the bedroom area and the entrance to the bathroom from the hall of Flat 201.1431 The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.1432 Cause and time of death 97.98 Hamid Kani was in a protected location in the hallway and bathroom area of the flat and was therefore more shielded from exposure to the heat. We are satisfied that he died at about 02.45, before suffering the direct effects of fire.1433 97.99 The post-mortem report on Hamid Kani recorded the cause of death as “consistent with the effects of fire”1434 but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”. Debbie Lamprell Date of birth: 3 August 1971 (45 years). Place of birth: Walthamstow, London. Gender:

Female. Occupation: Personal Assistant / Safety Officer. Usual address: Flat 161, floor 19 Grenfell Tower, London. Place of death: Flat 201, floor 23 Grenfell Tower, London. Time of death: Between 02.20 and 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 97.100 Debbie Lamprell grew up as an only child in Highams Park. She worked as a safety officer at the Holland Park Opera. She had lived in Flat 161 on floor 19 of Grenfell Tower since 2005.1435 Vulnerability 97.101 Debbie Lamprell had no known vulnerabilities. 1431 Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14. 1432 Interim certificate of the fact of death for Hamid Kani {MET00065623}. 1433 Purser, Phase 2 Report, Section 6 {DAPR0000006/13} paragraph 38; Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20. 1434 Kani post-mortem report {COR00000566/7}. 1435 External Fire Spread Report {MET00012593/12}; Phase 1 Report Volume IV paragraphs 32.186-32.189; Presentation relating to Debbie Lamprell {Day300/1:21}-{Day300/2:20}.

The Grenfell Tower Inquiry: Phase 2 Report 178 Events of 14 June 2017 97.102 Debbie Lamprell returned from work at 22.57 on 13 June 2017. Her friend Gary Maunders was visiting her that night. He also died in the fire.1436 97.103 Fadumo Ahmed was Debbie Lamprell’s neighbour and lived in Flat 164 on floor 19. She first became aware of the fire at around 01.20. When she left her flat, the lobby was full of thick, dark grey, steamy smoke that was hard to see through. Fadumo Ahmed saw Debbie Lamprell, who said people were going upstairs. Fadumo Ahmed said that Debbie Lamprell was not panicking, but behaved as if she had received instructions to go upstairs. Fadumo Ahmed and Debbie Lamprell went upstairs together. There was only a little bit of smoke in the stairwell between floors 19 and 23. Fadumo Ahmed said that she saw nobody other than Debbie Lamprell on the stairs.1437 However, Debbie Lamprell later told CRO Jabin that she and her friend had gone up together, which suggests that Gary Maunders may have also climbed the stairs with Fadumo Ahmed and Debbie Lamprell.1438 97.104 Fadumo Ahmed and Debbie Lamprell joined a group of people sheltering in the hallway of Flat 201 on floor 23. Debbie Lamprell probably reached Flat 201 at about 01.30 or soon after.1439 97.105 Gary Maunders moved to Flat 203 at around 01.39.1440 At about that time, Debbie Lamprell made an emergency call which lasted for under a minute. She was heard to shout for Gary, which indicates that she had lost contact with Gary Maunders by that time.1441 97.106 At 01.41 a BT operator spoke to North West Fire Control and said that a caller asking to speak to the LFB had hung up after waiting for around five minutes.1442 The number belonged to Debbie Lamprell. When CRO Aisha Jabin called the number back, Debbie Lamprell answered and they spoke for over 40 minutes. During that call there was a misunderstanding about Debbie Lamprell’s location. She first gave her location as Flat 161 on floor 23, but later corrected that to Flat 201 on floor 23. Unfortunately, the correct location was not passed from North West Fire Control to the LFB control room. As a result, just before 02.10 FFs Roots and Johnson were sent to Flat 161 on floor 19 but there was no one there.1443 97.107 At about 01.55, Debbie Lamprell told CRO Jabin that the smoke was making it difficult for everyone to breathe and that the fire was “burning through the windows”.1444 97.108 At 02.01 Debbie Lamprell told CRO Jabin that the windows were cracking and at about 02.05 she said that she had lost her friend; he had disappeared and she did not know where he was. They had come up together, but he had gone.1445 She must have been referring to Gary Maunders, who by then had already moved to Flat 203. 1436 O’Riordan {MET00013136/4} page 4; Presentation relating to Debbie Lamprell {Day300/2:21-25}; Phase 1 Report Volume II paragraph 14.136; Phase 1 Report Volume III Annex A. 1437 Phase 1 Report Volume II paragraphs 10.259-10.260. 1438 999 call transcript {LFB00055500/29}. 1439 Phase 1 Report Volume II paragraphs 10.259-10.260 and 10.289. 1440 Phase 1 Report Volume II paragraphs 11.30-11.31. 1441 999 call transcript {COR00000269}. 1442 Phase 1 Report Volume II paragraphs 12.66-12.67; 999 call transcript {MET00014977}. 1443 Phase 1 Report Volume II paragraphs 12.85-12.86 and 14.116. 1444 Phase 1 Report Volume II paragraph 12.64. 1445 Phase 1 Report Volume II paragraphs 14.127 and 14.138; 999 call transcript {LFB00055500/26-29}.

Part 9 | Chapter 97: Floor 23 179 97.109 At 02.06 Debbie Lamprell told CRO Jabin that she could feel the heat and that the flat was on fire. CRO Jabin spoke to her team leader and then advised Debbie Lamprell to leave. She tried to leave the bedroom and could be heard telling someone to move out of the way of the door. Debbie Lamprell said that people on the other side of the room were trying to get out and that was why she could not get out. She confirmed that she was still on the floor in the bedroom. She stopped responding at about 02.20, just before the end of the call. That was the last known contact anybody had with Debbie Lamprell.1446 Recovery and identification 97.110 The remains of Debbie Lamprell were recovered from the bedroom of Flat 201.1447 The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death for Debbie Lamprell.1448 Cause and time of death 97.111 Toxicology analysis was not possible.1449 The post-mortem on Debbie Lamprell recorded the medical cause of death as “consistent with the effects of fire,”1450 but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”. 97.112 We find that Debbie Lamprell probably lost consciousness due to the effects of asphyxiant gases at about 02.20 when she stopped responding to CRO Jabin. We are satisfied that she died between 02.20 and 02.451451 before suffering the direct effects of fire.1452 Jessica Urbano Ramirez Date of birth: 4 July 2004 (12 years old). Place of birth: London, UK. Gender:

Female. Occupation: Student. Usual address: Flat 176, floor 20, Grenfell Tower, London. Place of death: Flat 201, floor 23, Grenfell Tower, London. Time of death: Between 02.17 and 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. 1446 Phase 1 Report Volume II paragraphs 14.138-14.140; 999 call transcript {LFB00055500/42-43}. 1447 Archaeology Report Volume 2 {COR00001585/190}. 1448 Interim certificate of the fact of death for Debbie Lamprell {MET00065596}. 1449 Coroner’s report for Lamprell {COR00000254/7}. 1450 Lamprell post-mortem report {COR00000263/6-7}. 1451 Purser {Day297/12:14-25}. 1452 Purser, Phase 2 Report, Section 6 {DAPR0000006/13} paragraph 38; Purser {Day296/28:15}-{Day296/29:8}.

The Grenfell Tower Inquiry: Phase 2 Report 180 Background and composition of household 97.113 Jessica Urbano Ramirez lived in Flat 176 on floor 20 with her family. She moved into Grenfell Tower in September 2013 with her mother, Adriana Ramirez, her father Ramiro Urbano and her sister Melanie.1453 At the time of the fire, she was looking forward to celebrating her 13th birthday with her friends.1454 Vulnerability 97.114 Jessica Urbano Ramirez appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system as a child and was known to be under 18. She had no other known vulnerabilities. Events of 14 June 2017 97.115 On 13 June 2017, Jessica Urbano Ramirez returned to Grenfell Tower at 18.20.1455 Adriana Ramirez and Melanie Urbano Ramirez were at home at the time. Adriana Ramirez left at around 18.30 to go to work.1456 Melanie Urbano Ramirez stayed at the flat until about 22.00 when she also went out.1457 Adriana Ramirez returned home at about midnight and checked on Jessica, who was asleep. She left the flat again at about 00.40 to take some medicine to the home of a friend who lived nearby.1458 Jessica remained alone in the flat. 97.116 At some time before 01.27, Jessica Urbano Ramirez met Berkti and Biruk Haftom. At 01.27 she used Berkti Haftom’s phone to make an emergency call1459 before calling her mother.1460 The call was disconnected before the BT operator could connect it to the LFB. The BT operator contacted the LFB control room at 01.29 and spoke to CRO Russell telling her that the caller was a child and had asked for the fire brigade. CRO Russell agreed to call the number back.1461 97.117 Jessica Urbano Ramirez then called her mother and told her that she was on the “landing” on floor 18.1462 They agreed that she should come down the stairs.1463 However, instead of continuing down to the ground floor, Jessica went up to floor 23 with Berkti and Biruk Haftom and a group of other residents. She probably reached floor 23 by 01.30.1464 97.118 At 01.29, CRO Russell called Berkti Haftom; the call was answered by Jessica Urbano Ramirez.1465 The call probably interrupted Jessica’s call with her mother as she answered the call saying ‘Mum’ three times and CRO Russell’s call overlapped in time with Jessica’s call to Adriana Ramirez. 97.119 The call between CRO Russell and Jessica Urbano Ramirez lasted 55 minutes. During the first 10 minutes of the call (between 01.30 and 01.40), Jessica told CRO Russell that she was in the hallway of a flat on floor 23 with about 10 other people. She later identified it as 1453 Tenancy Agreement {IWS00002062/7}. 1454 Phase 1 Report Volume IV paragraph 32.132. 1455 O’Riordan {MET00013136/3} page 3. 1456 Ramirez {IWS00001116/4} page 4, paragraph 18; Ramirez {MET00007773/3} page 3. 1457 Ramirez {IWS00001116/4} page 4, paragraph 20; {MET00007773/3} page 3. 1458 Ramirez {IWS00001116/4} page 4, paragraph 19; {MET00007773/4} page 4. 1459 999 call transcript {MET00015554}. 1460 999 call transcript {COR00000774}. 1461 999 call transcript {LFB00000481}. 1462 Ramirez {IWS00001116/4-5} page 4-5, paragraph 21. 1463 Ramirez {IWS00001116/4-5} page 4-5, paragraph 21; Phase 1 Report Volume II paragraph 10.289(f). 1464 Phase 1 Report Volume II paragraph 10.289. 1465 Phase 1 Report Volume II paragraph 10.289(f).

Part 9 | Chapter 97: Floor 23 181 Flat 201.1466 She said that smoke was coming “from the floor” and that people were having difficulty breathing. Jessica and the group of people in Flat 201 moved from the hallway to the bedroom. 97.120 Adriana Ramirez said that she spoke to Jessica a second time about 10 minutes later.1467 The call records for Berkti Haftom’s phone show that she called Jessica back and it is likely that they spoke while the call with CRO Russell was on hold for a short period of time.1468 97.121 While the call was in progress, FF David Badillo from North Kensington made an attempt to rescue Jessica, who was still believed to be in Flat 176. At 01.26, he met Melanie Urbano Ramirez, Jessica’s sister, outside the tower. She gave him the keys to Flat 176 on floor 20 and told him that her sister was still there. At 01.27 FF Badillo went into the tower to rescue Jessica Urbano Ramirez.1469 He was not able to make it to floor 20 immediately. He tried to take the lift to floor 20 but it stopped on floor 15 and the lift filled with black smoke. He found his way to the lobby doors and went down the stairs and out of the tower to get BA equipment.1470 He returned to the tower with BA equipment and recruited CM Christopher Secrett and FF Christopher Dorgu to go to Flat 176 with him.1471 They tallied out between 01.33 to 01.35. 97.122 When the crew reached floor 20 they found that the communal lobby and Flat 176 were smoke logged. They searched Flat 176 after finding the front door slightly ajar.1472 They did not find anyone in Flat 176 and returned to the ground floor. Their end of wear time was 01.57.1473 No information about the emergency call from Jessica Urbano Ramirez reached the crew during their deployment.1474 97.123 At 02.01, Jessica Urbano Ramirez was still talking to CRO Russell.1475 She repeatedly said that she was having difficulty breathing.1476 97.124 At 02.06, Jessica Urbano Ramirez and Debbie Lamprell each reported separately that the flat was on fire.1477 Jessica said that people had tried to leave but could not do so because of the smoke.1478 She stopped responding to CRO Russell at around 02.17 but could be heard breathing until 02.24.1479 Recovery and identification 97.125 The remains of Jessica Urbano Ramirez and others were recovered from the bedroom of Flat 201.1480 The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.1481 1466 Phase 1 Report Volume II paragraphs 10.317 and 11.25. 1467 Ramirez {IWS00001116/5} page 5, paragraph 22. 1468 999 call transcript {LFB00055504/19}. 1469 Phase 1 Report Volume II paragraph 10.79 (b). 1470 Phase 1 Report Volume II paragraph 10.101 (a). 1471 Phase 1 Report Volume II paragraph 11.10. 1472 Phase 1 Report Volume II paragraphs 12.6, 12.30 and 13.16. 1473 Phase 1 Report Volume II paragraph 13.16. 1474 Phase 1 Report Volume II paragraph 13.17. 1475 Phase 1 Report Volume II paragraph 14.133. 1476 Phase 1 Report Volume II paragraph 14.133. 1477 Phase 1 Report Volume II paragraphs 14.134 and 14.138. 1478 Phase 1 Report Volume II paragraph 14.134. 1479 999 call transcript {LFB00055504/76-82}. 1480 Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14. 1481 Interim certificate of the fact of death for Jessica Urbano Ramirez {MET00065625}.

The Grenfell Tower Inquiry: Phase 2 Report 182 Cause and time of death 97.126 The post-mortem on Jessica Urbano Ramirez noted that it was not possible to be definite on the cause of death due to the condition of the remains, but that their appearance was consistent with the effects of fire.1482 It was not possible to carry out toxicological analysis or DNA testing. 97.127 The post-mortem report recorded the medical cause of death as being consistent with the effects of a fire. However, in the light of Professor Purser’s evidence we find that the cause of death is more accurately expressed as inhalation of asphyxiant gases. 97.128 Jessica probably lost consciousness due to the inhalation of asphyxiant gases at around 02.17 when she stopped responding to CRO Russell. She would have continued to inhale those gases while unconscious until she died.1483 97.129 Professor Purser estimated that the level of carboxyhaemoglobin in Jessica Urbano Ramirez’s blood had exceeded the lethal threshold of 50% by about 02.23 and that she had died by 02.45.1484 While the time of death might be different for children, he observed that she had lost consciousness at about the same time as Debbie Lamprell and there may not have been much difference in the time of death.1485 97.130 In the light of Professor Purser’s evidence we are satisfied that Jessica Urbano Ramirez died between 02.17 and 02.45 before suffering the direct effects of fire. Flat 202 97.131 Flat 202 on floor 23 had two bedrooms and was situated in the south-east corner of the tower. It was the home of Gimja Tekie, who was not present during the night of the fire. Gloria Trevisan and Marco Gottardi had been living in Flat 202 since April 2017.1486 97.132 By 02.10, Flat 202 had become affected by the spread of the fire on the outside of the building.1487 It spread across the east face of the kitchen and living room of Flat 202 from about 02.10. It moved across the south face of the living room between about 02.33 and 02.51 and had spread across the bedrooms by 02.55.1488 Those who sheltered in Flat 202 97.133 On the night of the fire, Majorie and Ernie Vital took shelter with Gloria Trevisan and Marco Gottardi. They had moved upstairs from their own flat on floor 19.1489 1482 Ramirez post-mortem report {COR00000770/3}. 1483 Purser, Phase 2 Report, Section 6 {DAPR0000006/13-17} paragraphs 36–58. 1484 Purser, Phase 2 Report, Section 6 {DAPR0000006/14} paragraph 48; Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser, Phase 2 Report, Section 6 {DAPR0000006/15} Figure 28; Purser {Day297/12:14-25}. 1485 Purser {Day297/13:4-18}. 1486 External Fire Spread Report {MET00012593/12}; Phase 1 Report Volume IV paragraph 32.50; Disaró {IWS00000543/3} page 3, paragraphs 8-9; External Fire Spread Report {MET00012593/12}; Tekie {IWS00000953/3} page 3, paragraph 16. 1487 Phase 1 Report Volume II paragraph 14.3. 1488 Purser, Phase 2 Report, Section 6 {DAPR0000006/18} paragraph 63. 1489 Phase 1 Report Volume II paragraphs 10.287 and 10.289 (g).

Part 9 | Chapter 97: Floor 23 183 Conditions and events on 14 June 2017 97.134 By approximately 01.25 the fire had reached the top of floor 19, where Flat 162, Majorie Vital’s home, was situated.1490 There is no evidence that Majorie or Ernie Vital made contact with the emergency services, members of their family or friends on the night of the fire. At about 01.30, they went upstairs to floor 23.1491 Fadumo Ahmed identified Ernie Vital as one of the people she had seen gathered inside or outside one of the flats on floor 23.1492 97.135 Ernie and Majorie Vital had knocked at the door and sought shelter in Flat 202. When Gloria Trevisan and Marco Gottardi opened the door, they found the lobby filled with a thick, dense smoke.1493 97.136 Gloria Trevisan’s parents were in Italy. Gloria called her mother, Emanuela Disaró, at 01.34 from Flat 202; the call lasted for just under 31 minutes. She told her mother that there were firefighters downstairs. She said they had been told to stay inside. It is not clear where that information came from. She said that they could not leave because of the smoke or go to the roof because the gate to the roof was locked. They made signs to attract attention.1494 97.137 Rania Ibrahim lived in Flat 203, a neighbouring flat on floor 23. At 01.38, she started to live stream on Facebook. A little over one minute into the recording, she opened her front door and called out into the lobby “Hello” and “Come here”. When Emanuela Disaró watched the video she thought that she could hear Marco Gottardi responding to Rania Ibrahim’s shouts, saying “We are here, we are inside my apartment.”1495 They remained in Flat 202. 97.138 Gloria Trevisan made a video call to her parents at 02.13. She said the fire was large and had reached floor 23. Black smoke was entering the flat through the living room windows. Emanuela Disaró could hear her daughter coughing. Gloria Trevisan was having difficulty breathing. Emanuela Disaró could hear Marco Gottardi speaking to Ernie Vital in the background. She heard Marco Gottardi ask whether there was anyone in another apartment and then say that he would go out to ask. Then Emanuela Disaró heard Marco Gottardi say in English “I tried but there’s too much smoke.”1496 97.139 At 02.45 Gloria Trevisan began her last call from Flat 202 to her parents. It lasted for almost 23 minutes, until 03.08. She told her mother that Majorie and Ernie Vital and Marco Gottardi were still with her. Marco was also speaking to his parents. Gloria said that smoke was coming from everywhere and that there was no way out. The flat was full of smoke. She could see the fire outside the window. They had shut the window because pieces of glass had been coming in. Gloria’s eyes and throat were burning and hurting. She was having difficulty breathing. She said that the fire had come through the window. That was the last contact she had with either of her parents.1497 1490 Phase 1 Report Volume II paragraph 10.118. 1491 Phase 1 Report Volume II paragraphs 14.125 and 10.287-10.289; External Fire Spread Report {MET00012593/12}. 1492 Ahmed post-mortem report {MWP00000034/3}; Ahmed {COR00000103/1} page 1; Foley {COR00000304/1} page 1. 1493 Phase 1 Report Volume II paragraph 11.35. 1494 Phase 1 Report Volume II paragraphs 10.287-10.289, 11.35, 14.125 and 14.141; Disaró {IWS00000543/6} page 6, paragraphs 20-21. 1495 Phase 1 Report Volume II paragraphs 11.29-11.35; External Fire Spread Report {MET00012593/12}. 1496 Phase 1 Report Volume II paragraphs 14.142-14.143. 1497 Phase 1 Report Volume III paragraphs 16.21 and 16.23.

The Grenfell Tower Inquiry: Phase 2 Report 184 97.140 Marco Gottardi spoke to his father, Giannino Gottardi, at some point after 02.45. He told his father that they had not left the building because there was too much smoke and they had been told to stay put. He said he had filled the bath with water. The last call between Marco Gottardi and his father started at 03.15 and was brief.1498 That was the last known contact with anyone in Flat 202. Information at the incident ground 97.141 Emanuela Disaró asked Gloria Trevisan during their last conversation whether they had made others aware that they were in the flat. Gloria Trevisan said that she had, and she asked the others in the flat the same question. Emanuela Disaró could not hear their responses. There is no record of any calls to the emergency services from any of those trapped in Flat 202.1499 97.142 The LFB was aware of conditions on floor 23 in general. In response to information received from emergency calls about seven people unable to leave Flat 205 on floor 23 (among other flats on other floors), a message was sent by radio to command unit CU8 at 01.43. CU8 confirmed receipt of that message confirming “the 23rd floor” and “heavy smoke logging”.1500 97.143 Between 02.01 and 02.02, CROs Gotts and Howson received calls from members of the public saying that they could see people at the top of the tower waving and signalling for help. In one call people were said to be on top of the building. As a result, a service request was created at 02.05 saying “Reports of people on the roof of the building”. CRO Darby passed that message to the incident ground at 02.05.1501 Further calls were received until 03.11 from members of the public reporting seeing people on the top floor.1502 Gloria Trevisan and Marco Gottardi Gloria Trevisan Date of birth: 2 December 1990 (26 years old). Place of birth: Camposampiero, Italy. Gender:

Female. Occupation: Trainee Architect. Usual address: Flat 202, floor 23, Grenfell Tower, London. Place of death: Flat 202, floor 23, Grenfell Tower, London. Time of death: Between 03.15 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. 1498 Phase 1 Report Volume III paragraphs 16.25 and 17.30. 1499 Phase 1 Report Volume III paragraph 16.22. Calls to the emergency services were made by and on behalf of people trapped in Flats 201, 203, 204 and 205 on floor 23. Information about people trapped in all of these flats was recorded at the incident ground: Phase 1 Report Volume II Figure 12.3. 1500 LFB Control Room Report {LFB00004790/43-46}. 1501 Phase 1 Report Volume II paragraphs 14.235-14.236. 1502 LFB Control Room Report {LFB00004790/63-124}.

Part 9 | Chapter 97: Floor 23 185 Marco Gottardi Date of birth: 26 June 1989 (27 years old). Place of birth: Motta di Livenza, Italy. Gender:

Male. Occupation: Architect. Usual address: Flat 202, floor 23, Grenfell Tower, London. Place of death: Flat 202, floor 23, Grenfell Tower, London. Time of death: Between 03.15 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases; single vessel coronary artery atheroma. Background and composition of household 97.144 Gloria Trevisan was 26 years old, having been born on 2 December 1990 in Italy. Marco Gottardi was 27 years old, having been born on 26 June 1989 also in Italy. They met at university and graduated with degrees in architecture in 2016. Wanting to improve their English and develop their professional skills, they came together to London in March

1. Both found work with architectural practices in London. They moved into Flat 202

in April 2017.1503 Vulnerability 97.145 Gloria Trevisan and Marco Gottardi did not have known vulnerabilities. Events of 14 June 2017 97.146 Gloria Trevisan and Marco Gottardi returned to Grenfell Tower at around 19.47 on 13 June 2017.1504 They remained in Flat 202 thereafter. 97.147 At around 01.30, Ernie and Majorie Vital knocked on their front door, alerting them to the fire and joining them in Flat 202. 97.148 There is no evidence that Gloria Trevisan or Marco Gottardi made contact with the emergency services on the night of the fire, however they did call their families, as described above. Recovery and identification 97.149 The remains of Gloria Trevisan and Marco Gottardi were recovered from the hallway of Flat 202.1505 The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death.1506 1503 Phase 1 Report Volume IV paragraphs 32.545-32.54. 1504 O’Riordan {MET00013136/3}. 1505 Purser, Phase 2 Report, Section 6 {DAPR0000006/19} paragraph 71. 1506 Interim certificates of the fact of death for Gloria Trevisan and Marco Gottardi {MET00065586}; {MET00065617}.

The Grenfell Tower Inquiry: Phase 2 Report 186 Cause and time of death 97.150 We are satisfied that Gloria Trevisan and Marco Gottardi both died between about 03.15 and 03.30 before suffering the direct effects of fire.1507 97.151 Gloria Trevisan was found to have a blood carboxyhaemoglobin saturation of 78%.1508 The post-mortem recorded the cause of her death as “inhalation of products of combustion” but in the light of Professor Purser’s evidence we find that a more accurate description of the primary cause of death is inhalation of asphyxiant gases. 97.152 The post-mortem report on Marco Gottardi recorded the cause of death as “inhalation of products of combustion” and “single vessel coronary artery atheroma”. 97.153 Carboxyhaemoglobin was present in Marco Gottardi’s blood, but it was not possible to measure the levels.1509 The single vessel coronary atheroma put Marco Gottardi at risk of collapse and death at a lower carboxyhaemoglobin concentration than would otherwise have been the case.1510 97.154 Although we acknowledge the contribution of single vessel coronary atheroma, we consider that the primary cause of death was inhalation of asphyxiant gases. Majorie and Ernie Vital Majorie Vital Date of birth: 14 November 1948 (68 years old). Place of birth: Soufrière, Dominica. Gender:

Female. Occupation: Retired. Usual address: Flat 162, floor 19, Grenfell Tower, London. Place of death: Flat 202, floor 23, Grenfell Tower, London. Time of death: Between 03.15 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Ernie Vital Date of birth: 11 January 1967 (50 years old). Place of birth: London, UK. Gender:

Male. Occupation: Unemployed. Usual address: Amhurst Park, London N16. 1507 Purser, Phase 2 Report, Section 6 {DAPR0000006} Table 20; Purser {Day296/28:15}-{Day296/29;8}. 1508 Trevisan post-mortem report {COR00000546/9}. 1509 Gottardi post-mortem report {COR00000974/8}; Gottardi toxicology report {MET00007684/1}. 1510 Purser {Day297/33:4-20}.

Part 9 | Chapter 97: Floor 23 187 Place of death: Flat 202, floor 23, Grenfell Tower, London. Time of death: Between 03.15 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 97.155 Majorie Vital was a retired seamstress and had lived in Flat 162 on floor 19 of Grenfell Tower for nearly 40 years. It was there that she brought up her two sons. Ernie Vital was staying with her on the night of the fire.1511 Vulnerability 97.156 Majorie Vital’s mental health vulnerability was recorded by RBKC in 1987 and by the TMO in a memorandum on 14 July 2004.1512 Rydon sent an email to the TMO on 31 October 2014 saying that she had Parkinson’s Disease and needed support.1513 That information was also recorded in November 2014 during the survey of residents carried out by Rydon.1514 97.157 Majorie Vital had declared both a disability and mental health support needs in response to a TMO questionnaire on 17 March 2015.1515 She appeared in the TMO list of Grenfell Tower residents created by David Noble on 14 June 2017 from information held on the TMO’s Capita Insight system which recorded that she was in the age group “65 plus” and had some mental health problems.1516 Events of 14 June 2017 97.158 Majorie Vital returned to Grenfell Tower at around 15.14 on 13 June 2017. Ernie Vital entered the tower at around 19.07 on 13 June 2017.1517 97.159 Majorie and Ernie Vital had both moved from floor 19 up to floor 23 by around 01.30. They knocked on Flat 202 and sought shelter with the residents of that flat, Gloria Trevisan and Marco Gottardi. They remained in that flat thereafter. 97.160 There is no evidence that either Majorie or Ernie Vital contacted anybody outside the tower on the night of the fire. Recovery and identification 97.161 The remains of Majorie and Ernie Vital were recovered from the bathroom of Flat 202.1518 The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death.1519 1511 Tenancy Information Questionnaire for Flat 162 {TMOH00025319/3}; Phase 1 Report Volume IV paragraphs 32.176-32.182. 1512 RBKC letter dated 24 August 1987 {TMOH00025230}; TMO Memorandum {TMO00865242}. 1513 Email from Rydon dated 31 October 2014 {TMOH00025320}. 1514 Rydon Residents Survey {RYD00024466/14}. 1515 Tenancy Information Questionnaire for Flat 162 {TMOH00025319/9}. 1516 David Noble’s list {TMO00862588}. 1517 O’Riordan {MET00013136/2-3} pages 2-3. 1518 Purser, Phase 2 Report, Section 6 {DAPR0000006/19} paragraph 71. 1519 Interim certificate of the fact of death for Majorie and Ernie Vital {MET00065611}; {MET00065635};

The Grenfell Tower Inquiry: Phase 2 Report 188 Cause and time of death 97.162 The post-mortem reports recorded the cause of death in the case of both Majorie Vital and Ernie Vital as “consistent with the effects of fire”.1520 In the light of more recent evidence we find that a more accurate description of the primary cause of death is inhalation of asphyxiant gases. 97.163 We are satisfied that Majorie Vital and Ernie Vital died between about 03.15 and 03.30 before suffering the direct effects of fire.1521 Flat 203 97.164 Flat 203 on floor 23 had two bedrooms and was situated in the south-west corner of the tower. It was the home of Rania Ibrahim, her husband, Hassan Awadh Hassan (who was abroad at the time of the fire), and their two daughters, Fethia Hassan and Hania Hassan.1522 The south-west corner of the tower was farthest from where the fire had started.1523 97.165 Smoke began to enter Flat 203 by 02.05, although at that stage not through the windows.1524 From about 02.40 smoke increasingly affected the south facing wall of the tower, spreading towards Flat 203.1525 97.166 Flat 203 was the last of those on floor 23 to be affected by the spread of fire on the outside of the building. By about 03.11 the fire had reached the area between Flats 202 and 203 and continued to move in a westerly direction across Flat 203. By 03.43 Flat 203 was fully affected by the fire.1526 97.167 The fire reached the south-west corner of the tower at the level of floor 23 by 03.58. From 04.07 onwards, there was a rapid deterioration of the conditions in the living room of Flat 203.1527 97.168 The adult occupants of Flat 203 are likely to have become comatose from the inhalation of asphyxiant gases by about 04.13, and to have inhaled a lethal dose of asphyxiant gases by about 04.17.1528 For the children, these events are likely to have happened sooner.1529 Those who sheltered in Flat 203 97.169 Rania Ibrahim gave shelter in her home to people who had fled from elsewhere in the tower. Those who went to Flat 203 seeking refuge were Fathia Ahmed Elsanousi, Isra Ibrahim, Abufras Ibrahim and Gary Maunders.1530 1520 Majorie Vital post-mortem report {COR00000934/6}; Ernie Vital post-mortem Report {COR00000309/4}. 1521 Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser {Day296/28:15}-{Day296/29;8}. 1522 External Fire Spread Report {MET00012593/12}; Phase 1 Report Volume IV paragraph 32.34. 1523 Phase 1 Report Volume II paragraph 14.145. 1524 Phase 1 Report Volume II paragraph 14.146. 1525 Purser, Phase 2 Report, Section 6 {DAPR0000006/35} paragraph 159. 1526 Lane, Phase 1 Supplemental Report, Section 12 {BLAS0000012/11}; Phase 1 Report Volume III paragraph 18.5; Purser, Phase 2 Report, Section 6 {DAPR0000006/35} paragraph 162. 1527 Phase 1 Report Volume III paragraph 18.4; Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 165. 1528 Purser, Phase 2 Report, Section 6 {DAPR0000006/38} Figure 34. 1529 Purser, Phase 2 Report, Section 6 {DAPR0000006/54} paragraph 253; Purser {Day297/65:3-8}. 1530 Phase 1 Report Volume II paragraph 14.125.

Part 9 | Chapter 97: Floor 23 189 97.170 Fathia Ahmed Elsanousi lived in Flat 206 on floor 23 with her daughter, Isra Ibrahim. Abufras Ibrahim, the son of Fathia Ahmed Elsanousi, had been visiting his mother and sister on 14 June 2017.1531 97.171 Gary Maunders did not live in Grenfell Tower. He had been visiting Debbie Lamprell from Flat 161 on floor 19. They went up to floor 23 and initially took shelter in Flat 201 at about 01.30. Gary Maunders then moved to Flat 203 at about 01.39.1532 97.172 All those who were in Flat 203 died. Rania Ibrahim, Fethia Hassan, Hania Hassan, Isra Ibrahim, Fathia Ahmed Elsanousi and Gary Maunders all died there. Abufras Ibrahim fell from the tower and his body was recovered from outside the south side.1533 Events in Flat 203 97.173 By 01.30 the outside of Flat 206, in the north-east corner of the tower (home to Fathia Ahmed Elsanousi and Isra Ibrahim), had become enveloped by flames.1534 Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim must have left it at an early stage. The precise time of their arrival at Flat 203 is not known but they must have reached it before 01.38 when Rania Ibrahim began to live-stream a video to Facebook. The female voice heard on the video telling Rania Ibrahim not to open the door was probably that of Isra Ibrahim. Abufras Ibrahim also appears in the video and can be heard telling Rania Ibrahim to close the door as she was letting smoke in.1535 97.174 At about 01.39 Rania Ibrahim can be seen opening the front door. Gary Maunders can be seen entering the flat when invited to do so. The video shows that the lobby on floor 23 was dark with smoke at the time.1536 Shortly afterwards, Rania Ibrahim went out into the lobby where she was able to breathe, speak and stand, at least for a short period. She shouted “Hello” and “Come here”. It was probably Marco Gottardi from Flat 202 who responded by saying “We are here. I am inside our apartment”.1537 97.175 At around 01.43, a voice can be heard coming from outside the building shouting, “This is the fire service. If you are able, exit the building”. That was probably FF Patrick Murray.1538 97.176 FF Mandeep Singh arrived at the tower at 01.35 and was instructed to pass FSG information from the command unit to the bridgehead. He recalled being handed telephones and speaking to residents inside the tower. During one such call, FF Singh spoke to a female occupant of the tower who gave a location of the “23rd floor, doors 205 and 201”. She said that she had brought all of the occupants of floor 23 into her flat. FF Singh advised her to stay put.1539 A page from his notebook contains the following entry “23rd FLOOR ALL OCCUPANTS 205/201 [illegible] WM BRIAN O’KEITH WM (Illegible)”.1540 In his witness statement FF Singh said that he thought the woman he had spoken to 1531 Phase 1 Report Volume IV paragraph 32.7. 1532 Phase 1 Report Volume II paragraphs 10.259-10.260, 10.287-10.289 and 11.30-11.31. 1533 Phase 1 Report Volume III paragraph 18.22; Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraphs 166-167. 1534 Phase 1 Report Volume II paragraphs 10.118 and 10.122; External Fire Spread Report {MET00012593/12}. 1535 Phase 1 Report Volume II paragraphs 11.30-11.31. 1536 Phase 1 Report Volume II paragraph 11.32 and Figure 11.9. 1537 Phase 1 Report Volume II paragraphs 11.33 and 11.35. 1538 Phase 1 Report Volume II paragraph 11.34. 1539 Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17; 1540 Singh Exhibit MS/1 - pages from notebook {MET00013089/2}.

The Grenfell Tower Inquiry: Phase 2 Report 190 was the same person who can be heard in a video recording, saying that she will let people in. This was probably Rania Ibrahim, who was in fact in Flat 203, and not in Flat 201 or Flat 205.1541 97.177 At 01.57 CRO Heidi Fox answered an emergency call from a member of Rania Ibrahim’s family.1542 That was the first call relating to Flat 203. As a result, she created a service request at 01.59 in relation to “a person with two children” trapped in Flat 203 on floor

1. CRO Darby passed the information to CU8 by radio a few seconds later.1543 At 02.00,

CRO Darby marked the service request as completed.1544 That was the only service request created in relation to Flat 203.1545 97.178 The second emergency call about Flat 203 was made at 02.05 by Isra Ibrahim. She told CRO Howson that there were five adults and two children in Flat 203. They were in the living room and kitchen area. Smoke was coming into the flat, but they were keeping the doors closed. No smoke was coming through the windows. Isra Ibrahim had smoke around her nose. CRO Howson advised her to remain in the flat.1546 97.179 At 02.21, Isra Ibrahim spoke to CRO Gotts. She reported that the occupants of the flat were stuck and the flat next door (probably Flat 202) was on fire. She gave her location as Flat 203 on floor 23. CRO Gotts advised her to try to block the doors and to stay away from the side of the flat on fire. Isra Ibrahim asked for someone to come to the flat immediately and whether helicopters could assist. CRO Gotts explained that firefighters were on the lower floors but were on their way up to floor 23. She said that the helicopter was being sent up so that they could see the fire from the air. At the very end of the call, CRO Gotts said “22nd floor, Flat 192. All right?”. That was not the location Isra Ibrahim had given, but the call ended before she could respond.1547 97.180 CRO Gotts passed the information orally to CRO Darby who sent a message to command unit CU7 at 02.26 about persons in Flat 192 on floor 22 who had said that the fire was in the flat next door to them. No service request was created by CRO Gotts in relation to either Flat 203 or Flat 192.1548 97.181 At 02.35, the “stay put” advice was revoked in the control room, but it took some time for all the control room operators to be told and for them to begin giving fresh advice.1549 97.182 At 02.42, Isra Ibrahim spoke to CRO Howson from Flat 203 and reported five adults and two children in the flat. That was the fourth emergency call relating to Flat 203. She said that the amount of smoke in the flat was increasing and that the flat next door (again, probably Flat 202) was on fire. CRO Howson advised Isra Ibrahim to block out the smoke, told her that firefighters were making their way to her and said that, as long as there were no flames, the flat was the safest place to be “because you don’t know what’s going on outside”.1550 1541 Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17. 1542 LFB Control Room Report {LFB00004790/57}. 1543 Phase 1 Report Volume II paragraph 13.105. 1544 LFB Short Incident Log {MET00013830/21}. 1545 LFB Short Incident Log {MET00013830}. 1546 Phase 1 Report Volume II paragraph 14.146. 1547 Phase 1 Report Volume II paragraph 14.147; 999 call transcript {LFB00000663/1-5}. The first image of the fire taken by the National Police Air Support (“NPAS”) helicopter was taken at 01.43, therefore it had reached the tower sometime before or around this time: Phase 1 Report Volume II paragraph 12.104 and Figure 12.8. 1548 Phase 1 Report Volume III paragraph 15.144. 1549 Phase 1 Report Volume III paragraph 15.168. 1550 Phase 1 Report Volume III paragraph 15.73.

Part 9 | Chapter 97: Floor 23 191 97.183 At 02.58, an unidentified male caller spoke to CRO Howson. That was the fifth and final call relating to Flat 203. He told her that the police would not let him into the tower and had told him to call the emergency services. The caller said that he had just spoken to someone in Flat 203 with two children. CRO Howson told him that they needed to try to get out of the building and that she would pass on the information that people were still in the flat. The caller must have been referring to Rania Ibrahim. It is not known if he was able to speak to her again to pass on CRO Howson’s advice.1551 That was the first time those in Flat 203 were advised to leave the building. 97.184 Rania Ibrahim appears to have thought that the “stay put” policy was still in place at that time. Munira Mahmud, a close friend who had earlier left floor 5, called her at about 03.00. Rania Ibrahim was coughing a lot and Munira Mahmud could tell that she was finding it difficult to breathe. Munira Mahmud tried to persuade her to leave. Rania Ibrahim said she had called the emergency services and that whoever had answered the call had told her to stay inside and wait for help. She also said that the roof door was locked but that they were sending help, as she could see a helicopter. Munira Mahmud continued to tell Rania Ibrahim that she should try to leave. That was the last conversation she had with Rania Ibrahim; she was unable to reach her by telephone again.1552 97.185 Sayeda Ibrahim spoke to her sister Rania Ibrahim at 01.00, 02.50 and 03.00. The call at 03.00 was the last known contact with anyone in Flat 203.1553 Attempts by a friend of Munira Mahmud to call Rania Ibrahim from about 03.15 were unsuccessful. 97.186 Information about those needing to be rescued from Flat 203 was recorded at various places at the incident ground. 97.187 The information from the first emergency call relating to Flat 203 at 01.57 was passed by radio to CU8 at 02.00.1554 97.188 We have seen no evidence of messages passed to the incident ground in response to the second call made by Isra Ibrahim at 02.05.1555 However, from 02.06, SM Oliff in the LFB control room was passing information to WM Meyrick in CU8 using his personal mobile telephone. The calls were not recorded and there is no record of the information he passed on.1556 97.189 The bridgehead was maintained on floor 2 from the beginning of the incident until about 02.17.1557 CM Charles Batterbee copied information from a forward information board at the bridgehead into his own notebook. There is no reference to Flat 203 in that notebook,1558 so it appears that the radio message about Flat 203 sent at 02.00 went astray and did not reach the bridgehead. 97.190 From 02.17 until about 03.08 the bridgehead was located on floor 3.1559 During that period the third, fourth and fifth emergency calls were made in relation to Flat 203. 1551 Phase 1 Report Volume III paragraphs 16.27-16.28. 1552 Phase 1 Report Volume III paragraph 16.29. 1553 Phase 1 Report Volume III paragraphs 16.30-16.31; Mahmud {MET00080727/18-19} pages 18-19. 1554 LFB Control Room Report {LFB00004790/58}. 1555 LFB Control Room Report {LFB00004790}. 1556 Phase 1 Report Volume II paragraph 14.243. 1557 Phase 1 Report Volume IV paragraphs 28.84(b) and 28.86. 1558 Phase 1 Report Volume II paragraph 14.73 and Figure 14.4. 1559 Phase 1 Report Volume III paragraph 17.11; Phase 1 Report Volume IV paragraph 28.86.

The Grenfell Tower Inquiry: Phase 2 Report 192 97.191 At 02.21, when the third call made by Isra Ibrahim came to an end, CRO Gotts misunderstood the caller’s location as being in Flat 192 on floor 22 and the radio message sent to command unit CU7 at 02.26 referred to persons in Flat 192 on floor 22. No other messages appear to have been passed to the incident ground in relation to Flat 203 as a result of that call.1560 97.192 The fourth and fifth emergency calls relating to Flat 203 were made at 02.42 and 02.58. 97.193 SM Oliff recorded information in the control room on two whiteboards from around 02.33. In a photograph taken at the end of the incident the first whiteboard shows the notation “Flat 203 23rd fl – 5 adults 2 children – smoke logging”.1561 It is possible that SM Oliff passed information about Flat 203 to WM Meyrick in CU8 using his mobile phone. 97.194 Messages about Flat 203 did reach command unit CU7. Between about 02.00 and 03.00, a white laminated sheet was being used in CU7 to record information about people needing to be rescued. The laminated sheet recorded “Flat 203 Floor 23 5 adults 2 children” as can be seen in a photograph taken at 02.59.1562 97.195 Messages about Flat 203 were also inscribed on a wall of the lobby on the ground floor. WM Glynn Williams started to record information on the wall of the lobby on the ground floor at 02.15. He said the information came from CU7. A photograph of the wall taken much later in the incident includes the notation “203 23 5A 2C”.1563 97.196 After 03.00, the laminated sheet in CU7 was replaced by a whiteboard bearing a grid. A photograph taken of the whiteboard much later in the morning shows Flat 203 and the annotation “5 2 P”. The “5” is in green indicating five adults, the “2” is in black indicating two children, and the “P” is in red and is circled, indicating a priority.1564 97.197 Given that no firefighters were sent to Flat 203 before 03.08, when the bridgehead was moved from floor 3 to the ground floor, it appears that messages relating to Flat 203 did not reach the bridgehead while it was on floor 3. However, after the bridgehead had moved to the ground floor firefighters were sent to Flat 203, which suggests that information from at least one of the emergency calls relating to Flat 203 was passed to the bridgehead after 03.08. 97.198 FFs Matthew Harold, David Friend and Richard Peacock were initially sent to Flat 203 but at the last minute their instructions were changed and they were sent to carry out search and rescue operations on floors 4 and 5. They tallied out between 03.31 and 03.32.1565 97.199 None of the other firefighting crews sent to floor 23 succeeded in reaching it. 1560 LFB Control Room Report {LFB00004790/81}. 1561 Phase 1 Report Volume III paragraphs 15.139-15.140 and Figure 15.8. 1562 Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3. 1563 Phase 1 Report Volume II paragraphs 14.103-14.104 and Figure 14.5. 1564 Phase 1 Report Volume III paragraph 16.12 and Figure 16.5; Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1} 1565 Phase 1 Report Volume III paragraph 18.15(b).

Part 9 | Chapter 97: Floor 23 193 Rania Ibrahim, Fethia Hassan and Hania Hassan Rania Ibrahim Date of birth: 3 March 1986 (31 years old). Place of birth: Aswan, Egypt. Gender:

Female. Occupation: Carer for children. Usual address: Flat 203, floor 23, Grenfell Tower, London. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Between 03.55 and 04.05 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Fethia Hassan Date of birth: 5 October 2012 (4 years old). Place of birth: Chelsea, London. Gender:

Female. Occupation: N/A. Usual address: Flat 203, floor 23, Grenfell Tower, London. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Between 03.55 and 04.05 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Hania Hassan Date of birth: 4 June 2014 (3 years old). Place of birth: Chelsea, London. Gender:

Female. Occupation: N/A. Usual address: Flat 203, floor 23, Grenfell Tower, London. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Between 03.55 and 04.05 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

The Grenfell Tower Inquiry: Phase 2 Report 194 Background and composition of household 97.200 Rania Ibrahim lived in Flat 203 with her husband, Hassan Awadh Hassan, and their two daughters, Fethia and Hania. Hassan Awadh Hassan was away at the time of the fire. Rania Ibrahim and her family moved into Flat 203 in 2016.1566 97.201 Born in Aswan, Egypt on 3 March 1986, Rania Ibrahim was 31 years old when she died. She had a place to study law in Cairo but had come to London to help her sister, who was unwell. She had met Hassan in London in 2010 and they got married. Fethia was born on 5 October 2012 and Hania on 4 June 2014. They were four and three years old respectively when they died.1567 Vulnerability 97.202 The family appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system. The ages of Fethia and Hania were respectively recorded as “5” and “3”. No other vulnerabilities were noted.1568 Events of 14 June 2017 97.203 Rania Ibrahim, Fethia Hassan and Hania Hassan had all returned to Grenfell Tower for the last time by 18.09 on 13 June 2017.1569 97.204 On the evening of 13 June 2017, Rania Ibrahim and her daughters spent time with a close friend, Munira Mahmud, who lived in Flat 25 on floor 5 of Grenfell Tower. Munira Mahmud’s children played with Fethia and Hania and ate dinner. After Rania Ibrahim and her daughters had returned to Flat 203, at about 21.30 Munia Mahmud brought Rania Ibrahim food for the iftar meal ending the Ramadan fast.1570 97.205 Rania Ibrahim did not make any emergency calls herself. However, she appears to have given her mobile telephone to Isra Ibrahim, who made a number of emergency calls as described above.1571 Calls were also made on behalf of Rania Ibrahim and her daughters by people outside the tower. Recovery and identification 97.206 The remains of Rania Ibrahim, Fethia Hassan and Hania Hassan were all recovered from the bathroom of Flat 203.1572 The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death.1573 1566 Tenancy Agreement for Hassan Awadh Hassan {TMOH00010399}; Presentations relating to Rania Ibrahim, Fethia Hassan and Hania Hassan {Day299/52:1-22}. 1567 Phase 1 Report Volume IV paragraphs 32.34-32.43. 1568 David Noble’s list {TMO00862588}. 1569 O’Riordan {MET00013136/3} page 3. 1570 Mahmud {IWS00000776/1-4} pages 1-4, paragraphs 3, 15, 16; Presentations relating to Rania Ibrahim, Fethia Hassan and Hania Hassan {Day299/54:10-15}. 1571 Presentations relating to Rania Ibrahim, Fethia Hassan and Hania Hassan {Day299/58:15-19}. 1572 Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167. 1573 Interim certificate of the fact of death for Rania Ibrahim, Fethia Hassan and Hania Hassan {MET00065635}; {MET00065604}; {MET00065636}.

Part 9 | Chapter 97: Floor 23 195 Cause and time of death 97.207 Toxicology testing for Rania Ibrahim and her daughters was not possible.1574 The post- mortem reports on Rania Ibrahim, Fethia Hassan and Hania Hassan recorded their cause of death as “consistent with the effects of fire”.1575 In the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”. 97.208 Given the lack of response to calls made to Rania Ibrahim’s telephone after 03.00, we consider it likely that Rania Ibrahim, Fethia Hassan and Hania Hassan had lost consciousness by that time. We are satisfied that they all died between 03.55 and 04.05 before suffering the direct effects of fire.1576 Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim Fathia Ahmed Elsanousi Date of birth: 1 January 1940 (77 years old). Place of birth: Al Nuhood, West Kordofan province, Sudan. Gender:

Female. Occupation: Retired. Usual address: Flat 206, floor 23, Grenfell Tower, London. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Between 04.20 and 04.40 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Isra Ibrahim Date of birth: 8 August 1983 (33 years old). Place of birth: Khartoum, Sudan. Gender:

Female. Occupation: Care worker and sales assistant. Usual address: Flat 206, floor 23, Grenfell Tower, London. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Between 04.20 and 04.40 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. 1574 Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167. 1575 Rania Ibrahim post-mortem report {COR00000444/3}; Fethia Hassan post-mortem report {COR00001724/3}; Hania Hassan post-mortem report {COR00001723/3}. 1576 Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser {Day296/28:15}-{Day296/29:8}.

The Grenfell Tower Inquiry: Phase 2 Report 196 Abufras Ibrahim Date of birth: 8 January 1978 (39 years old) . Place of birth: Khartoum, Sudan. Gender:

Male. Occupation: Fishmonger and sales assistant. Usual address: Queensgate, London SW7. Place of death: Outside Grenfell Tower, London. Time of death: Between 03.50 and 03.55 on 14 June 2017. Cause of death: Multiple injuries (consistent with a fall from height). Background and composition of household 97.209 Fathia Ahmed Elsanousi was born in 1940 in Al Nuhood, Sudan and was 77 years old in

1. She had been a headteacher in Sudan and had moved to the UK to escape the civil

war there.1577 Her daughter, Isra Ibrahim, was born on 8 August 1983 and was 33 years old. She and her mother had been tenants of Flat 206 since 2008.1578 Abufras Ibrahim was born on 8 January 1978 and was 39 years old. He did not live in Grenfell Tower but was visiting his mother and sister on 14 June 2017.1579 Vulnerability 97.210 Fathia Ahmed Elsanousi suffered from serious health problems that had been recorded in her housing file since 2000. She had breathing problems which required her to use a portable oxygen machine. Her mobility was impaired as a result of a stroke in 2006. She had been unable to manage stairs easily since January 2007.1580 Isra Ibrahim did not have any known vulnerabilities. Neither she nor her mother were identified as vulnerable in the spreadsheet of vulnerable tower residents created by David Noble on 14 June 2017.1581 Events of 14 June 2017 97.211 Fathia Ahmed Elsanousi last entered Grenfell Tower on 9 June 2017. Isra Ibrahim and Abufras Ibrahim entered Grenfell Tower in the evening of 13 June 2017.1582 97.212 The Neda family lived in Flat 205. At about 01.25, Farhad Neda and his mother, Flora Neda, looked out into the lobby of floor 23. Flora Neda saw Isra Ibrahim from Flat 206 start running down the stairs. Fathia Ahmed Elsanousi was behind her, walking slowly. That was at about the time that the fire reached the outside of floor 23.1583 By 01.30 the flames had enveloped all the “Flat 6s”, including Flat 206.1584 1577 Phase 1 Report Volume IV paragraphs 32.8-32.12. 1578 Presentations relating to Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim {Day307/96:7-10}. 1579 Phase 1 Report Volume IV paragraph 32.7. 1580 Presentations relating to Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim {Day307/99:5-13}; Health Assessment Form {BSR00000110}. 1581 David Noble’s list {TMO00862588}. 1582 O’Riordan {MET00013136/2-4} pages 2-4. 1583 Phase 1 Report Volume II paragraphs 10.283 and 10.118; Farhad Neda {Day61/37:1-25}; Neda {IWS00000887/7} page 7, paragraph 33; Flora Neda {Day61/130:12-18}. 1584 Phase 1 Report Volume II paragraph 10.122.

Part 9 | Chapter 97: Floor 23 197 97.213 By about 01.30, several occupants had reached floor 23, having come upstairs from lower floors. At about the same time, Fathia Ahmed Elsanousi and Isra Ibrahim returned to floor 23. By 01.38 they and Abufras Ibrahim were already sheltering with Rania Ibrahim and her children in Flat 203 when Rania Ibrahim began her live-stream video to Facebook.1585 97.214 Isra Ibrahim made three emergency calls from Flat 203, at 02.05, 02.21 and 02.42 as described above. 97.215 At about 03.50 Abufras Ibrahim fell from the tower. He fell first onto the canopy over the door to the main entrance of the tower on the south side. His body then landed on the south side of the tower close to the walkway connecting it to Grenfell Walk. His body was subsequently moved to a sheltered area by firefighters.1586 He was pronounced dead at 06.05 on 14 June 2017 outside the tower.1587 Recovery and identification 97.216 The remains of Fathia Ahmed Elsanousi and Isra Ibrahim were both recovered from the bathroom in Flat 203.1588 Abufras Ibrahim’s body was recovered from outside the tower. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death for each member of the family.1589 Cause and time of death 97.217 Toxicological testing for Abufras Ibrahim showed that the level of carboxyhaemoglobin in his blood was 20%, which is significant but not incapacitating. His body showed slight soot stains to the skin and nostrils but no burns. Despite a long period of slow smoke infiltration from the lobby and 40 minutes of serious smoke penetration of the bedrooms, he had been able to limit his exposure until the fire spread to the outside of the room in which he had taken refuge.1590 97.218 The post-mortem report for Abufras Ibrahim recorded the cause of death as “Multiple injuries (consistent with fall from height)”. We are satisfied that Abufras Ibrahim died between 03.50 and 03.55, either instantly when he landed outside the tower or very shortly afterwards. 97.219 The post-mortem reports on Fathia Ahmed Elsanousi and Isra Ibrahim recorded the cause of death as “consistent with the effects of a fire”1591 but in the light of Professor Purser’s evidence we consider that a more accurate description is “inhalation of asphyxiant gases”. 97.220 We are satisfied that Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim all died before suffering the direct effects of fire. 97.221 Fathia Ahmed Elsanousi and Isra Ibrahim died from inhalation of asphyxiant gases between 04.20 and 04.40.1592 1585 Phase 1 Report Volume II paragraphs 10.289 and 11.29-11.30. 1586 Phase 1 Report Volume III paragraph 18.22; Moore {MET00010819/10} page 10; Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 166. 1587 Abufras Ibrahim post-mortem report {COR00000049/3}. 1588 Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167. 1589 Interim certificate of the fact of death for Fathia Ahmed Elsanousi; Isra Ibrahim and Abufras Ibrahim {MET00065632}; {MET00065593}; {MET00065614}. 1590 Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 166. 1591 Elsanousi post-mortem report {COR00000443/3}; Isra Ibrahim post-mortem report {COR00000448/5-6}. 1592 Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20.

The Grenfell Tower Inquiry: Phase 2 Report 198 Gary Maunders Date of birth: 4 January 1960 (57 years). Place of birth: Hammersmith, London. Gender:

Male. Occupation: Painter and decorator. Usual address: Lancaster Road, London W11. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Approximately 04.20 – 04.40 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 97.222 Gary Maunders was born in London on 4 January 1960; in 2017 he was 57 years old. He was the father of two children. A talented footballer in his youth, Gary worked as a painter and decorator.1593 On the night of the fire he was visiting Debbie Lamprell at her home in Flat 161 on floor 19 of the tower. Events of 14 June 2017 97.223 Gary Maunders was one of those who went up to floor 23 to take shelter. He probably reached it by about 01.30.1594 He initially went into Flat 201, the home of Raymond (Moses) Bernard. 97.224 Fadumo Ahmed, Debbie Lamprell’s neighbour, left her flat at 01.20 and saw Debbie Lamprell near the lifts. She gained the impression that she had been told to go upstairs. They both walked up the stairs to floor 23. There was only a little bit of smoke in the stairwell at that time. Fadumo Ahmed said she did not see anyone else in the stairwell, but Debbie Lamprell later told CRO Jabin that she and her friend had come up together, which suggests that Gary Maunders may have also climbed the stairs with them.1595 Fadumo Ahmed saw people at the door to Flat 201 and joined a group in the hallway that included Gary Maunders and Debbie Lamprell.1596 97.225 The occupants of Flat 201 were soon having difficulty breathing. The fire was at the window and then entered the living room.1597 97.226 We do not know how Gary Maunders and Debbie Lamprell became separated. Nor do we know at what time he left Flat 201. He entered Flat 203 at about 01.39,1598 which coincides with Debbie Lamprell’s emergency call from Flat 201, during which she was shouting for “Gary”. That suggests she may already have lost contact with him.1599 1593 Phase 1 Report Volume IV paragraphs 32.191-32.196. 1594 Phase 1 Report Volume II paragraphs 14.125 and 10.287-10.289; External Fire Spread Report {MET00012593/12}. 1595 999 call transcript {LFB00055500/29}. 1596 Phase 1 Report Volume II paragraphs 10.259-10.260. 1597 Phase 1 Report Volume II paragraphs 10.289 (d), 11.25 and 11.28. 1598 Phase 1 Report Volume II paragraphs 11.29-11.30. 1599 999 call transcript {COR00000269}. Debbie Lamprell remained in Flat 201 and at 02.05 during a 999 call she referred to having lost her friend, saying they had come up together, but he had gone: 999 call transcript {LFB00055500/26-29}.

Part 9 | Chapter 97: Floor 23 199 97.227 Gary Maunders made no calls to the emergency services on the night of the fire. Recovery and identification 97.228 Gary Maunders’ remains were recovered from the bathroom of Flat 203. Toxicological testing was not possible.1600 The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.1601 Cause and time of death 97.229 The post-mortem report on Gary Maunders recorded the cause of death as “consistent with the effects of a fire”1602 but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”. 97.230 We are satisfied that Gary Maunders died between 04.20 and 04.40.1603 Flat 204 Hesham Rahman Date of birth: 30 January 1960 (57 years old). Place of birth: Cairo, Egypt. Gender:

Male. Occupation: Retired. Usual address: Flat 204, floor 23, Grenfell Tower, London. Place of death: Flat 204, floor 23, Grenfell Tower, London. Time of death: Between 03.45 and 04.00 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 97.231 Hesham Rahman was born on 30 January 1950 in Egypt and was 57 years old in 2017. He was a retired hairdresser.1604 Flat 204 had been his home since August 2012. He lived there alone.1605 Vulnerability 97.232 Hesham Rahman had diabetes and associated serious mobility problems which pre-dated his move to Grenfell Tower. His cousin said that his health had deteriorated after 2012. He had difficulty using stairs and relied on the lifts at Grenfell Tower. He had a disability blue badge for his car and a parking space at the tower for drivers with disabilities.1606 1600 Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167. 1601 Interim certificate of the fact of death for Gary Maunders {MET00065624}. 1602 Maunders post-mortem report {COR00000521/3}. 1603 Purser, Phase 2 Report, Section 6 {DAPR0000006/1} Table 20. 1604 Phase 1 Report Volume IV paragraphs 32.29-32.32. 1605 Tenancy Agreement {TMOH00013384/6-7}. 1606 El-Baghdady {IWS00001535/2-4} pages 2-4, paragraphs 7-14.

The Grenfell Tower Inquiry: Phase 2 Report 200 97.233 RBKC was aware of Hesham Rahman’s health conditions and mobility difficulties. RBKC’s assessments of 19 December 2006, August 2009 and 7 December 2010 all recorded his difficulty in managing stairs.1607 The assessment dated 7 December 2010 noted the contents of a letter from a consultant confirming his diagnoses and their interference with his ability to walk. He recommended an upper or lower ground floor property with no more than six steps to obtain access to the premises or a property up to fourth floor level with lift access.1608 97.234 A housing officer visited Hesham Rahman on 9 October 2012 and 28 June 2013 and on both occasions recorded that he had problems with mobility. A question whether any signs of a need for support had not been picked up when he was signed up for a tenancy was not completed in relation to the first visit and answered “No” in relation to the second.1609 97.235 Hesham Rahman was not identified as vulnerable in the spreadsheet of tower residents created by David Noble on 14 June 2017.1610 Events of 14 June 2017 97.236 Hesham Rahman returned to Grenfell Tower at 20.54 on 13 June 2017.1611 97.237 At about 01.20, Anna Krivsoun, the daughter of Hesham Rahman’s former partner, called to tell him that the tower was on fire and that he should leave. He agreed and said he would get dressed.1612 97.238 At some point before 01.30, Farhad Neda from Flat 205 saw smoke entering the lobby on floor 23 through the smoke extraction system vents. He also saw Hesham Rahman open and close the door to Flat 204.1613 That was the last contact anyone in the tower had with Hesham Rahman; no one else took shelter in Flat 204. 97.239 Hesham Rahman spoke to the emergency services on five occasions during the fire. He made his first call at 01.39 and spoke to OM Norman. He reported that a little smoke was coming into his flat and that he could smell it. He said that he could not see outside at all.1614 97.240 When Hesham Rahman received a call from OM Norman at 01.46, he said the fire had not reached his flat but was next door. The flats immediately next door to his were Flats 203 and 205. OM Norman said the fire was on floor 4 and he replied, “I think it’s gone upstairs”. OM Norman advised him to stay put, saying firefighter crews would get to him.1615 97.241 Although no service requests were created in response to Hesham Rahman’s first two emergency calls, it appears that information about a person needing to be rescued from Flat 204 was passed by telephone to command vehicle CU8 by OM Norman at 1607 {BSR00000133/3-5}; {BSR00000130/3-5}; {BSR00000131/3-4}. 1608 {BSR00000131/2-3}. 1609 {TMOH00013422/1}; {TMOH00013423/1-2}. 1610 David Noble’s list {TMO00862588}. 1611 O’Riordan {MET00013136/3} page 3. 1612 Krivsoun {MET00039926/1} page 1. 1613 Phase 1 Report Volume II paragraphs 10.149 and 10.283-10.286. 1614 Phase 1 Report Volume II paragraph 11.36. 1615 Phase 1 Report Volume II paragraph 12.68; External Fire Spread Report {MET00012593/12}. Of the two neighbouring flats, the exterior fire affected Flat 205 first, by 02.09-02.10: Lane, Phase 1 Supplemental Report, Section 12 {BLAS0000012/9-11}.

Part 9 | Chapter 97: Floor 23 201 01.47. OM Norman recorded the message in the incident log afterwards at 02.01.1616 That is the first record of Hesham Rahman’s situation and location being passed to the incident ground. 97.242 CRO Russell took Hesham Rahman’s third emergency call at 02.36. He reported smoke coming into his flat and said that he was finding it difficult to breathe. CRO Russell advised him to try to make his way out of the building. He told her that he had a disability and needed assistance. No service request was created in response to his call, but a note of his disability was added to a whiteboard in the control room. By the time she took that call CRO Russell had received the instruction from SOM Smith to change the “stay put” advice. She recalled that the new advice had been for people to cover themselves, not to breathe in the smoke and to make their way down the stairs.1617 97.243 Hesham Rahman’s fourth call to the emergency services was taken by CRO Russell at 03.10. He was then in the living room of his flat. He had blocked the front door but a lot of smoke was still coming in. He was advised to leave but said that he could not do so because he could not walk properly due to his disability. He told CRO Russell that he was lying on the floor with a wet cloth over his nose and that his windows were shut. CRO Russell told him that the crews were coming up to him. No service request appears to have been created in response to that call.1618 97.244 At 03.16, a person who identified herself as Hesham Rahman’s daughter spoke to CRO Yvonne Adams. When told to call him back and tell him that he needed to leave, the caller explained that he could not leave because of his disabilities.1619 97.245 Hesham Rahman’s fifth and final emergency call at 03.20 was also taken by CRO Adams. It lasted 2 minutes and 38 seconds. By that time the flat was full of black smoke and he could not see anything. The fire was coming into his flat. No service request was created in response to the call.1620 97.246 Anna Krivsoun made emergency calls on Hesham Rahman’s behalf from outside the tower, probably including calls made at 03.38 and 04.01. It was reported to CRO Gotts during the call at 03.38 that he had not been able to leave his flat and was struggling to breathe. At 04.01 the caller told CRO Russell that he was no longer responding and that it had been clear that he was struggling to breathe.1621 97.247 Anna Krivsoun had last spoken to Hesham Rahman by telephone at 03.43. She could hear him coughing and struggling to breathe.1622 That appears to be the last contact Hesham Rahman had with anyone outside the tower. 97.248 At the incident ground, there were references to Hesham Rahman and Flat 204 in various places. WM Meyrick in command unit CU8 was receiving information by radio from the control room which he was passing to WM Kentfield.1623 At some point between 01.40 and 1616 Phase 1 Report Volume II paragraph 12.76; LFB Short Incident Log {MET00013830/21}; LFB Control Room Report {LFB00004790/50}. 1617 Phase 1 Report Volume III paragraph 15.169; LFB Short Incident Log Report {MET00013830}. 1618 Phase 1 Report Volume III paragraph 17.26; LFB Short Incident Log Report {MET00013830}. 1619 Phase 1 Report Volume III paragraph 17.28. 1620 Phase 1 Report Volume III paragraphs 17.27 and 18.21; LFB Short Incident Log Report {MET00013830}. 1621 Phase 1 Report Volume III paragraph 18.21. 1622 Phase 1 Report Volume III paragraph 18.21. 1623 Phase 1 Report Volume II paragraph 11.5.

The Grenfell Tower Inquiry: Phase 2 Report 202 01.49 SM Loft received a piece of paper from WM Kentfield on which messages had been recorded. That piece of paper later became known as “Sadler’s Envelope”. One of the notes recorded on the paper was “FLAT 204 23 FLOOR”.1624 97.249 Between about 02.00 and 03.00, a white laminated sheet was being used on CU7 to record emergency calls.1625 It contained the notation “FLAT 204 FLOOR 23 1 PERSON disabled light smoke”.1626 97.250 At about 02.17, CM Batterbee went to the bridgehead on floor 2. He made a note of the entries on a forward information board, which included the note “204 (tick) 21st”.1627 (Flat 204 was in fact on floor 23.) 97.251 WM Glynn Williams started to record information on the wall of the lobby on the ground floor at 02.15. A photograph of the lobby wall taken much later on in the incident shows the notation “204 21” with “21” circled.1628 That is another example of inaccurate recording of the location of Flat 204. 97.252 Between about 02.20 and 03.08, WM Louisa De Silvo recorded information about people needing to be rescued on the wall of the lobby of floor 3 when the bridgehead had been re-located on that floor. A photograph of that wall from later in the incident shows the notation “EUSTON – 23 205 204” with 204 circled and ticked. The writing also included the expression “21 (tick) 204”.1629 A tick against a particular flat indicated that a crew had been sent there and a circle indicated that further information had been received, by runner, by radio or from returning crews.1630 The floor on which Hesham Rahman’s flat was situated seems to appear both correctly and incorrectly on the wall. 97.253 WM Sadler described being given an “envelope” (“Sadler’s Envelope”), which was in fact an A4-size piece of paper. He immediately photographed it, at 02.19.1631 As noted above, that piece of paper had written on it “FLAT 204 23 FLOOR”. 97.254 From about 02.33 SM Oliff recorded information in the control room on two whiteboards.1632 Following Hesham Rahman’s call to CRO Russell at 02.36, to the first whiteboard he added the details “1 disabled male” to the entry “204 23 flr”.1633 97.255 After 03.00, the laminated sheet used on command unit CU7 was replaced by a whiteboard with a grid. Flat 204 was annotated with “1 disabled P” with “1 disabled” in green and “P” in red and circled.1634 97.256 FFs Pole, Mitchell, Cheesman and Bate from Euston Fire Station were sent to floor 23, probably to Flats 204 (where Hesham Rahman lived) and 205. A photograph of the wall on floor 3 where the bridgehead was by then positioned shows that the word “Euston” had been written against Flats 204 and 205 on floor 23. In the bottom right-hand corner of 1624 Phase 1 Report Volume II paragraphs 12.18-12.19 and Figure 12.4. 1625 Phase 1 Report Volume IV paragraph 28.85(d). 1626 Phase 1 Report Volume IV paragraph 28.102(f); {MET00015930}. 1627 Phase 1 Report Volume II paragraph 14.73 and Figure 14.4. 1628 Phase 1 Report Volume II paragraphs 14.103-14.104 and Figure 14.5. 1629 Phase 1 Report Volume II paragraph 14.108; Phase 1 Report Volume III paragraph 15.23 and Figure 15.7 1630 De Silvo {Day30/14:18}-{Day30/15:15}. 1631 Phase 1 Report Volume II paragraph 14.71. 1632 Phase 1 Report Volume III paragraph 15.139. 1633 Phase 1 Report Volume III paragraph 15.169. 1634 Phase 1 Report Volume IV paragraph 28.85 (d); {MET00015924}.

Part 9 | Chapter 97: Floor 23 203 the photograph can be seen the words “23rd Euston 204 205”.1635 We therefore conclude that the emergency calls by and on behalf of Hesham Rahman did lead to an attempt to reach his flat. 97.257 The crew tallied out by 02.53. They came across another crew at about floor 12 and FF Bate was handed a child casualty, whom he decided to take out of the tower. FFs Mitchell, Pole and Cheesman continued upwards and reached what they thought was floor 18. There they realised that they did not have enough air to reach floor 23 and get back down again; they therefore helped to rescue seven residents from that floor. FF Mitchell recalled telling WM De Silvo that they had not reached floor 23. The crew’s “end of wear times” were between 03.15 and 03.17.1636 97.258 Flat 204 on floor 23 faced west and had one bedroom.1637 The exterior fire spread to the outside of the bedroom of Flat 204 by 03.20 and to the outside of the living room by 03.34. By 03.42 it was spreading to the column between Flats 204 and 203 and affecting Flat 203 next door.1638 Recovery and identification 97.259 The remains of Hesham Rahman were recovered from a partitioned area, which may have been a cupboard, in the living room of Flat 204.1639 The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.1640 Cause and time of death 97.260 Hesham Rahman was exposed to a slow increase in smoke and asphyxiant gases from about 01.29, followed by a more rapid increase after about 03.20 as the fire spread past his bedroom. The increase was even more rapid after the fire reached his living room.1641 97.261 Hesham Rahman is likely to have lost consciousness at about 03.43, which was the time of the last reported communication with him. He died at some point between about 03.45 and 04.001642 from the inhalation of asphyxiant gases and before suffering the direct effects of fire.1643 97.262 The post-mortem report on Hesham Rahman recorded the cause of death as “consistent with the effects of fire,1644 but in light of Professor Purser’s evidence we find a more accurate description to be “inhalation of asphyxiant gases”. The latest time at which he could have been rescued successfully was 03.15. 1635 Phase 1 Report Volume III paragraph 16.15 and Figure 16.6. 1636 Phase 1 Report Volume III paragraphs 16.15-16.20. 1637 External Fire Spread Report {MET00012593/12}. 1638 Purser, Phase 2 Report, Section 6 {DAPR0000006/24} paragraph 93 and {DAPR0000006/32} paragraph 139. 1639 Purser, Phase 2 Report, Section 6 {DAPR0000006/33} paragraph 143. 1640 Interim certificate of the fact of death for Hesham Rehman {MET00065606}. 1641 Purser, Phase 2 Report, Section 6 {DAPR0000006/33} paragraph 145. 1642 Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20. 1643 Purser, Phase 2 Report, Section 6 {DAPR0000006/33-34} paragraphs 146-147 and 153. 1644 Rahman post-mortem report {COR00001718/4}.

The Grenfell Tower Inquiry: Phase 2 Report 204 Flat 205 Mohammed Amied (Saber) Neda Date of birth: 3 May 1960 (57 years). Place of birth: Afghanistan. Gender:

Male. Occupation: Chauffeur. Usual address: Flat 205, floor 23, Grenfell Tower, London. Place of death: West Side of Grenfell Tower, London. Time of death: 02.41 on 14 June 2017. Cause of death: Multiple injuries (consistent with a fall from height). Background and composition of household 97.263 Mohammed Amied (Saber) Neda lived in Flat 205 with his wife, Shakila (Flora) Neda, and his son, Shekeb (Farhad) Neda. His family and friends knew him as Saber.1645 97.264 Saber Neda was born on 3 May 1960 in Afghanistan. In 2017 he was 57 years old. One of 10 children, he grew up in Afghanistan where he met his wife, Flora, in 1989. They married in 1991 in Kabul. The family moved to the UK in 1998 with their young son, Farhad. The family moved into Flat 205 in 1999.1646 Saber Neda established his own chauffeur business, which by 2017 he had operated for 10 years.1647 Vulnerability 97.265 Saber Neda did not have any known vulnerabilities. Events of 14 June 2017 97.266 Saber Neda returned home with his wife and son at 00.52 on 14 June 2017. On reaching floor 23 they noticed that a noise was coming from the vents of the extractor fans located in the lobby. Farhad Neda called the TMO at 01.10 to report it and also reported that there was an electrical burning smell. The call responder told him that they had received a call about the fire alarms and that the fire brigade was on its way.1648 97.267 At the time the lobby was clear of smoke.1649 About 15 minutes later the family decided to leave the tower. Saber Neda had looked out the window and thought there was a fire downstairs. A burning smell was still detectable in the lobby. Visibility in the lobby was still clear when the Neda family tried to leave but Farhad Neda saw black smoke coming into the lobby from the smoke extraction vents.1650 1645 Phase 1 Report Volume IV paragraph 32.22. 1646 Phase 1 Report Volume IV paragraphs 32.22–32.27. 1647 Phase 1 Report Volume IV paragraphs 32.22–32.27. 1648 Phase 1 Report Volume II paragraph 10.148. 1649 Phase 1 Report Volume II paragraph 10.150. 1650 Phase 1 Report Volume II paragraph 10.283.

Part 9 | Chapter 97: Floor 23 205 97.268 The family reached the stairwell but were prevented from going down the stairs by people coming up from the lower floors.1651 Among those coming up were Mariem and Eslah Elgwahry from floor 22 and Sakina Afrasehabi and Fatemeh Afrasiabi from floor 18. The Neda family returned to their flat and took in the Elgwahrys and Sakina Afrasehabi and Fatemeh Afrasiabi shortly before 01.30.1652 97.269 The Neda family took them into the living room. Black smoke slowly began to enter the flat underneath the front door. Within 10 to 15 minutes there were black marks around people’s noses due to the smoke.1653 97.270 Saber Neda did not make any calls to the emergency services on 14 June 2017, but Mariem Elgwahry made a number of calls from Flat 205. Her first two calls were made at 01.301654 and 01.38.1655 As a result, a message about persons trapped in Flat 205 on floor 23 was passed to the incident ground.1656 SM Loft was in front of the tower passing information he had received from WM Kentfield on command unit CU7 to the bridgehead, probably by radio.1657 He said that the first message he had received related to Flat 205. He passed it to the bridgehead at about 01.40.1658 Flat 205 and floor 23 were recorded on the forward information board used to record information about people needing to be rescued while the bridgehead was located on floor 2.1659 97.271 Although information about Flat 205 reached the bridgehead soon after 01.40, firefighters were not sent to floor 23 until 02.08.1660 FFs Zade Alassad, Scott Bell and John Wright tallied out between 02.08 and 02.10 to go to Flats 201 and 205 on floor 23.1661 Their names were written next to a circled note on a wall of floor 2 which read “Wandswor 23rd flts 201 205.”1662 However, the crew did not reach floor 23 because they stopped to help other firefighters take down casualties found on floor 10.1663 FF Bell said that he had told someone that they had not reached floor 23 but he could not remember to whom he had spoken or what that person did with the information.1664 Contact with others outside the tower 97.272 Farhad Neda was in contact with friends outside the tower who were able to speak to firefighters and pass advice back to him. He also spoke directly with a firefighter who gave him advice. The collective advice was for those in Flat 205 to cover their faces with wet towels, wet the carpets, put wet towels against the doors and remain in the flat until firefighters came.1665 The Nedas filled buckets with water which they threw on the carpets and soaked towels to cover their mouths when they saw smoke coming into the flat.1666 1651 Phase 1 Report Volume II paragraph 10.284. 1652 Phase 1 Report Volume II paragraph 10.284. 1653 Phase 1 Report Volume II paragraph 13.79. 1654 Phase 1 Report Volume II paragraph 10.289 (a). 1655 Phase 1 Report Volume II paragraphs 11.27 and 11.163. 1656 LFB Short Incident Log Report {MET00013830/19}; Phase 1 Report Volume II paragraphs 12.72 and 12.73 (b). 1657 Phase 1 Report Volume II paragraph 12.18. 1658 Phase 1 Report Volume II paragraph 12.19. 1659 Phase 1 Report Volume II paragraph 14.73 and Figure 14.4. 1660 Phase 1 Report Volume IV paragraph 28.101. 1661 Phase 1 Report Volume II paragraph 14.117. 1662 Phase 1 Report Volume II Figure 13.2 and paragraph 14.117; Phase 1 Report Volume IV paragraph 28.101. 1663 Phase 1 Report Volume II paragraph 14.117. 1664 Phase 1 Report Volume II paragraph 14.117. 1665 Phase 1 Report Volume II paragraph 13.81. 1666 Phase 1 Report Volume II paragraph 13.80.

The Grenfell Tower Inquiry: Phase 2 Report 206 97.273 Mariem Elgwahry made a third emergency call from Flat 205 at 01.54 and spoke to CRO Gotts.1667 At 01.57 CRO Darby sent a message to the incident ground about a caller in Flat 205 on floor 23 who had reported the fire coming up to the flat.1668 97.274 When Saber Neda saw that the fire had reached the bedroom in Flat 205 he closed the door and told everyone not to enter it.1669 At around 02.15 Farhad Neda decided that they needed to leave. He seized his mother and shouted for his father to follow.1670 Saber Neda agreed and said he would be behind them. He handed out wet towels to Eslah and Mariem Elgwahry and sisters Sakina Afrasehabi and Fatemeh Afrasiabi in preparation for them all to leave.1671 Farhad Neda and Flora Neda then left the flat thinking that the others would follow them. 97.275 However, Saber Neda did not follow his family out but remained in Flat 205 with Fatemeh Afrasiabi, Sakina Afrasehabi and Mariem and Eslah Elgwahry.1672 Further deployment to Floor 23 97.276 In a further emergency call at 02.25, Mariem Elgwahry described the conditions in the flat as having deteriorated significantly.1673 She said that they were running out of air and the whole flat was black.1674 The fire had reached the bedroom and the door to that room had been closed. Mariem Elgwahry said that they had tried to leave but it was totally black outside the front door.1675 97.277 CRO Adams called CU8 at 02.28 to pass on a message about that call. She was unaware of a request that all information about people needing to be rescued should now be sent to CU7. We do not know whether a message was sent to the bridgehead from CU7.1676 97.278 In any event, a message reached the bridgehead sometime after 02.17 when it had moved to floor 3, since Flat 205 was included in the information on the wall on that floor.1677 As a result CM Richard Evans and FF Gemma Bloxham were sent to Flat 205 on floor 23 after 02.24.1678 97.279 CM Evans and FF Bloxham had reached floor 20 when they came across Farhad and Flora Neda, whom they then helped to leave the tower.1679 Farhad Neda told the firefighters that his father and four others were trapped in Flat 205, which one of them recorded in a notebook. As they left the main entrance Farhad Neda told the firefighters again that there were still people in the flat. CCTV shows him and his mother leaving the tower between 02.42 and 02.43.1680 1667 Phase 1 Report Volume II paragraphs 13.78 and 13.98. 1668 Phase 1 Report Volume II paragraph 13.98. 1669 Phase 1 Report Volume III paragraph 15.64. 1670 Phase 1 Report Volume III paragraph 15.64. 1671 Phase 1 Report Volume III paragraph 15.64. 1672 Phase 1 Report Volume III paragraph 15.65. 1673 Phase 1 Report Volume III paragraph 15.143 1674 Phase 1 Report Volume III paragraph 15.61. 1675 Phase 1 Report Volume III paragraph 15.61. 1676 Phase 1 Report Volume III paragraph 15.147. 1677 Phase 1 Report Volume III Figure 15.7. 1678 Phase 1 Report Volume III paragraph 15.54. 1679 Phase 1 Report Volume III paragraphs 15.54-15.56; Phase 1 Report Volume IV paragraph 28.101. 1680 Phase 1 Report Volume III paragraphs 15.66-15.67.

Part 9 | Chapter 97: Floor 23 207 97.280 CM Evans returned to the bridgehead and told the officer in charge that they had not reached Flat 205 but that they had brought two people down.1681 That report may have led to a further deployment of firefighters to the top floor. At 02.51, FFs Niki Mitchell, Jessamine Bate, Michael Pole and Chris Cheesman from Euston Fire Station were sent to floor 23.1682 On the wall of the bridgehead, then on floor 3, was written the word “Euston” against Flats 204 and 205 on floor 23.1683 The notation was repeated further down where the words “23rd Euston 204 205” can be seen. The firefighters did not reach floor 23 but helped casualties escape from Flat 153 on floor 18.1684 FF Mitchell recalled telling WM Louisa De Silvo that they had not reached floor 23 but had got fairly high up the tower and had rescued a family of seven. The crew’s end of wear times were between 03.15 and 03.17.1685 Although they did not reach floor 23, their deployment was too late for them to have had any prospect of rescuing Saber Neda. 97.281 No firefighter successfully reached floor 23 on 14 June 2017.1686 Last contact with Saber Neda 97.282 At 02.37, Saber Neda called his nephew Lotfrahman (Massi) Abdulrahman. He was still in Flat 205 at the time and asked why no one had come to help. Massi Abdulrahman could hear female voices in the background. After the call ended he tried to call his uncle back, but without success. 97.283 At 02.40, Saber Neda left a message for his brother-in-law, Habibirahman Abdulrahman. He said: “Goodbye. We are now leaving this world, goodbye. I hope I haven’t disappointed you. Goodbye to all.” There was no further contact with Saber Neda. Recovery and identification 97.284 At 02.41, the body of Saber Neda was found in the children’s playground on the west side of the tower. He had fallen from the tower.1687 A paramedic formally pronounced him dead at 02.50.1688 The coroner was satisfied about the identification of his remains and therefore issued an interim certificate of the fact of death.1689 Cause and time of death 97.285 The post-mortem on Saber Neda recorded the cause of death as multiple traumatic injuries consistent with a fall from a significant height. The injuries were unsurvivable and death, which occurred at or just before 02.41, was instantaneous.1690 The level of carboxyhaemoglobin in his blood was 20%, significantly lower than the level associated with death from carbon monoxide poisoning.1691 1681 Phase 1 Report Volume III paragraph 15.56. 1682 Phase 1 Report Volume IV paragraph 28.101. 1683 Phase 1 Report Volume III paragraph 16.15 and Figure 16.6. 1684 Phase 1 Report Volume III paragraphs 16.17-16.20; Phase 1 Report Volume IV paragraph 28.101. 1685 Phase 1 Report Volume III paragraphs 16.17-16.20. 1686 Phase 1 Report Volume IV paragraph 28.101. 1687 Phase 1 Report Volume III paragraph 15.70. 1688 Matthews {COR00001112/5} page 5. 1689 Interim certificate of the fact of death for Saber Neda {MET00065621}. 1690 Neda post-mortem report {COR00001210/15}. 1691 Neda post-mortem report {COR00001210/14}.

The Grenfell Tower Inquiry: Phase 2 Report 208 Eslah Elgwahry and Mariem Elgwahry Eslah Elgwahry Date of birth: 1 December 1952 (64 years). Place of birth: Alexandria, Egypt. Gender:

Female. Occupation: Retired. Usual address: Flat 196, floor 22, Grenfell Tower, London. Place of death: Flat 205, floor 23, Grenfell Tower, London. Time of death: Between 02.50 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Mariem Elgwahry Date of birth: 11 April 1990 (27 years). Place of birth: London, United Kingdom. Gender:

Female. Occupation: Marketing Manager. Usual address: Flat 196, floor 22, Grenfell Tower, London. Place of death: Flat 205, floor 23, Grenfell Tower, London. Time of death: 02.50 to 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Background and composition of household 97.286 Eslah Elgwahry lived in Flat 196 on floor 22 with her daughter Mariem. She was born on 1 December 1952 in Alexandria, Egypt and was 64 years old. Her daughter, Mariem was born on 11 April 1990 in London. She was 27 years old.1692 97.287 Eslah Elgwahry had lived in Grenfell Tower for 34 years. She raised her two children, Mariem and her older brother, Ahmed, alone after their father died when they were young. She instilled in them a strong bond.1693 Eslah Elgwahry had retired by the time of the fire. Mariem Elgwahry graduated from Roehampton University and had established a successful career as a marketing manager.1694 1692 Phase 1 Report Volume IV paragraphs 32.61-32.63. 1693 Phase 1 Report Volume IV paragraphs 32.61-32.63. 1694 Phase 1 Report Volume IV paragraphs 32.64-32.65.

Part 9 | Chapter 97: Floor 23 209 Vulnerability 97.288 Eslah Elgwahry had a complex range of health problems which resulted in her having difficulty walking.1695 She was not able to climb many stairs without assistance. Mariem Elgwahry had no known vulnerabilities. She was Eslah Elgwahry’s carer.1696 97.289 Rydon’s survey of residents, prepared in November 2014 and provided to the TMO, recorded that Eslah Elgwahry had mental health problems and high blood pressure.1697 On 24 June 2015, she completed a TMO Tenancy Information Form as part of a tenancy audit on Flat 196, in which she reported that she considered herself to have a physical disability and to need the support of a carer.1698 97.290 Both Eslah and Mariem Elgwahry were recorded as residents in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system. Eslah Elgwahry was identified as being over 65 but there was no record of her vulnerabilities.1699 Events of 14 June 2017 97.291 Eslah Elgwahry was alone in Flat 196 on 13 June 2017 until 22.14 when Mariem Elgwahry returned to the tower.1700 It is not clear when they first became aware of the fire but its rapid spread up the “Flat 6s” prompted them to leave their home. (The fire on the outside of the building had passed Flat 196 by 01.26.)1701 Movement to Flat 205 97.292 Mariem Elgwahry and Eslah Elgwahry left Flat 196 at about 01.25.1702 Naomi Li, who lived in Flat 195, met them in the lobby of floor 22. Mariem told Naomi that the fire was already in their kitchen. Naomi said that they had closed the door to Flat 196 and Mariem Elgwahry was locking it before they left through the stairwell door.1703 97.293 Mariem Elgwahry and Eslah Elgwahry were prevented from going down the stairs by a group of other people going up.1704 They went up to floor 23 instead.1705 Together with Sakina Afrasehabi and Fatemeh Afrasiabi, who had come up from Flat 151 on floor 18, Eslah and Mariem Elgwahry were able to shelter in Flat 205, the home of the Neda family.1706 1695 Elgwahry {IWS00001757/7} page 7, paragraph 19. 1696 Elgwahry {IWS00001757/7} page 7, paragraph 19. 1697 Rydon Residents Survey {RYD00024466/6}. 1698 Tenancy Audit Form for Flat 196 {IWS00001778}. 1699 Noble spreadsheet {TMO00866002}. 1700 O’Riordan {MET00013136/3} page 3. Eslah Elgwahry was seen on CCTV in the lift lobby of the tower at 15.21. O’Riordan {MET00013136/2} page 2. 1701 Phase 1 Report Volume II paragraph 10.118. 1702 Phase 1 Report Volume II paragraph 10.277. 1703 Phase 1 Report Volume II paragraphs 10.277 and 10.281. 1704 Phase 1 Report Volume II paragraph 10.282. 1705 Phase 1 Report Volume II paragraph 10.284. 1706 Phase 1 Report Volume II paragraphs 10.284 and 10.288-10.289.

The Grenfell Tower Inquiry: Phase 2 Report 210 The first emergency messages from Flat 205 97.294 At 01.30, Mariem Elgwahry made her first call to the emergency services. She spoke to CRO Peter Duddy in the LFB control room1707 and told him that she was with others on floor 23. Mariem Elgwahry said that the fire had broken into her flat on floor 22 and that they had been forced to run to a neighbour’s flat. She said there was smoke everywhere. The call was cut off before CRO Duddy could give her any advice.1708 97.295 Mariem Elgwahry’s second emergency call followed shortly afterwards at 01.38, when she spoke to CRO Fox in the LFB control room.1709 She said that there was no smoke coming into Flat 205 and that there were seven people in the flat. CRO Fox told her to “put things on the door” and to keep the windows closed if smoke started to come in.1710 97.296 CRO Fox then created a service request which read, “Seven people in flat 205 on 23rd floor; persons unable to leave property.”1711 CRO Darby passed the information to WM Meyrick in CU8 at 01.43.1712 She then marked the service request as completed.1713 97.297 WM Kentfield was passing messages received by WM Meyrick in command unit CU8 to SM Loft, who was in front of the tower passing information to the bridgehead, probably by radio.1714 He said that the first message he had received related to Flat 205.1715 97.298 Flat 205 and floor 23 appeared on the forward information board used to record information about people needing to be rescued while the bridgehead was located on floor 2.1716 97.299 Although information about Flat 205 reached the bridgehead soon after 01.40, firefighters were not sent to floor 23 until 02.08.1717 Further emergency messages from Flat 205 97.300 At 01.54, Mariem Elgwahry made a third call to the emergency services and spoke to CRO Gotts. She reported that she was one of seven people in Flat 205. She said that the flat was full of smoke and that the fire was approaching; they could see the flames outside the window. CRO Gotts told her that the firefighters were trying to send people up and that she would make them aware of their location and the urgency of the situation.1718 97.301 After the call had ended, CRO Gotts went to check that the earlier message about Flat 205 had been sent to the incident ground. Although she did not create a service request, CRO Darby sent a radio message at 01.57 saying that the caller in Flat 205 on floor 23 had reported that the fire was coming right up to her flat.1719 We cannot say whether that further message reached the bridgehead or, if it did, whether it added to the information about Flat 205 already held there. 1707 Phase 1 Report Volume II paragraph 10.289 (a). 1708 Phase 1 Report Volume II paragraph 11.141. 1709 Phase 1 Report Volume II paragraphs 11.27 and 11.163. 1710 Phase 1 Report Volume II paragraphs 11.163-11.164. 1711 LFB Short Incident Log {MET00013830/19}. 1712 Phase 1 Report Volume II paragraphs 12.72 and 12.73 (b). 1713 LFB Short Incident Log {MET00013830/19}. 1714 Phase 1 Report Volume II paragraph 12.18. 1715 Phase 1 Report Volume II paragraph 12.19. 1716 Phase 1 Report Volume II paragraph 14.73 and Figure 14.4. 1717 Phase 1 Report Volume IV paragraph 28.101. 1718 Phase 1 Report Volume II paragraphs 13.78 and 13.98. 1719 Phase 1 Report Volume II paragraph 13.98.

Part 9 | Chapter 97: Floor 23 211 The first deployments to floor 23 97.302 FFs Zade Alassad, Scott Bell and John Wright were sent by WM Watson to two flats on floor 23.1720 They tallied out at between 02.08 to 02.10. Their names were written next to a circled note on the wall of floor 2 which read “Wandswor 23rd flts 201 205.”1721 It is likely that they were sent to Flats 201 and 205.1722 97.303 FFs Alassad, Bell and Wright did not reach floor 23. They stopped at floor 10 and helped to carry down casualties found on that floor.1723 FF Bell said that he told someone they had not reached floor 23 but he could not remember to whom he had spoken or what that person did with that information.1724 Contact with others outside the tower 97.304 Mariem Elgwahry spoke to her brother, Ahmed Elgwahry, at about 01.43. She told him that there was a fire in the kitchen and that she was with their mother. Ahmed Elgwahry told her to get out of the building. He then left his home and went to the tower.1725 97.305 Mariem Elgwahry called Ahmed Elgwahry again at 01.48 and then 01.49. She told him that they had tried to go down the stairs but could not do so as others had been coming up and telling her to go back. She explained that she was now in Flat 205 after a neighbour had let them into his flat.1726 97.306 Mariem Elgwahry spoke to her sister-in-law, Ferzana Elgwahry, at 01.56. She was distressed and crying and coughed a lot during the call. She confirmed that they had already covered their mouths with damp towels.1727 97.307 Mariem Elgwahry was also in contact with her close friend, Lucy Ho. At about 02.00, Lucy Ho called her and tried to persuade her to leave. She told Lucy Ho that the emergency services knew where they were and would come for them. Lucy Ho went to find a firefighter who told her to speak to a police officer. She told the police officer that her friend, her mother and four others were in Flat 205.1728 It has not been possible to identify that police officer. 97.308 Ahmed Elgwahry arrived at the tower at about 02.13 and then called Mariem Elgwahry. A police officer took Ahmed Elgwahry to a command unit, where a firefighter told Mariem Elgwahry to lie low and breathe through the drain in the bathroom and block out smoke using wet towels. The firefighter then told her to call the emergency services. The firefighter has not been identified.1729 1720 Phase 1 Report Volume II paragraph 14.117. 1721 Phase 1 Report Volume II Figure 13.2 and paragraph 14.117; Phase 1 Report Volume IV paragraph 28.101. 1722 Phase 1 Report Volume II Figure 13.2 and paragraph 14.117, Phase 1 Report Volume IV paragraph 28.101. 1723 Phase 1 Report Volume II paragraph 14.117. 1724 Phase 1 Report Volume II paragraph 14.117. 1725 Ahmed Elgwahry {IWS00000988/2} page 2, paragraphs 5 and 6. 1726 Ahmed Elgwahry {IWS00000988/3} page 3, paragraph 9. 1727 Ferzana Elgwahry {IWS00000995/3} page 2, paragraph 10. 1728 Phase 1 Report Volume II paragraph 14.149. 1729 Phase 1 Report Volume II paragraph 14.150.

The Grenfell Tower Inquiry: Phase 2 Report 212 Farhad and Flora Neda evacuate Flat 205 97.309 Saber Neda saw that the fire had reached the bedroom in Flat 205 and closed the door. He then told everyone not to enter it.1730 Farhad Neda decided that they needed to leave at around 02.15 and grabbed his mother and shouted for his father to follow.1731 Saber Neda agreed and said he would be behind them. Saber Neda handed out wet towels to Eslah and Mariem Elgwahry and sisters Sakina Afrasehabi and Fatemeh Afrasiabi in preparation to leave.1732 Farhad and Flora Neda then left the flat at this time believing that the others would follow them. 97.310 Eslah Elgwahry and Mariem Elgwahry remained in the flat with Saber Neda, Sakina Afrasehabi and Fatemeh Afrasiabi.1733 Final FSG message from Flat 205 97.311 Mariem Elgwahry’s last call to the LFB was connected to CRO Howson at 02.25.1734 Mariem Elgwahry said she was one of seven adults who were sheltering in the kitchen. They were running out of air and the whole flat was black.1735 She said that she was with her mother, who was diabetic and had asthma. The fire had reached the bedroom and the door to that room had been closed. CRO Howson advised her to leave, if necessary. Mariem Elgwahry told her that they had tried to leave but that it was totally black outside the front door.1736 Ahmed Elgwahry tried to call her while she was still speaking to CRO Howson.1737 97.312 CRO Adams called CU8 at 02.28 to pass on the information she had received from Mariem Elgwahry. She was not aware that a message from CU7 recorded in the incident log a few minutes earlier had asked for all information about people needing to be rescued to be sent to CU7 instead of CU8.1738 97.313 Mariem Elgwahry called Ahmed Elgwahry again at 02.31. She told him that she was with six or seven people in the kitchen of the flat. She said they could not leave because the lobby was full of black smoke and it was impossible to see.1739 The second deployment to Flat 205 97.314 The next deployments to floor 23 were after 02.24. CM Richard Evans and FF Gemma Bloxham were sent to Flat 205 on floor 23. They had reached floor 20 when they came across Farhad and Flora Neda on their way down. CM Evans and FF Bloxham stopped to help them out of the tower, not knowing that they had left the flat that they had been sent to.1740 Farhad Neda told the firefighters that his father and four others were trapped in Flat 205, which was recorded by one of the firefighters in a notebook. As they left the main entrance, Farhad Neda told the firefighters again that there were still people in the flat. They are recorded on CCTV leaving the tower between 02.42 and 02.43.1741 1730 Phase 1 Report Volume III paragraph 15.64. 1731 Phase 1 Report Volume III paragraph 15.64. 1732 Phase 1 Report Volume III paragraph 15.64. 1733 Phase 1 Report Volume III paragraph 15.65. 1734 Phase 1 Report Volume III paragraph 15.143 1735 Phase 1 Report Volume III paragraph 15.61. 1736 Phase 1 Report Volume III paragraph 15.61. 1737 Phase 1 Report Volume III paragraph 15.62. 1738 Phase 1 Report Volume III paragraph 15.147. 1739 Phase 1 Report Volume III paragraph 15.62. 1740 Phase 1 Report Volume III paragraphs 15.54-15.56; Phase 1 Report Volume IV paragraph 28.101. 1741 Phase 1 Report Volume III paragraphs 15.66-15.67.

Part 9 | Chapter 97: Floor 23 213 97.315 The crew’s end of wear time was 02.42, which must have been at about the time that CM Evans told the officer in charge at the bridgehead that they had not reached Flat 205.1742 97.316 CM Evan’s message to the bridgehead may have led to a further deployment of firefighters to the top floor. At 02.51, FFs Niki Mitchell, Jessamine Bate, Michael Pole and Chris Cheesman from Euston Fire Station were sent to floor 23.1743 At the bridgehead, then on floor 3, the word “Euston” had been written on the wall against Flats 204 and 205 on floor 23.1744 The message was repeated further down. That crew did not reach floor 23 but helped casualties evacuate from Flat 153 on floor 18.1745 FF Mitchell recalled telling WM Louisa De Silvo that they had not reached floor 23 but had got fairly high up the tower and had rescued a family of seven. The crew’s end of wear times were between 03.15 and 03.17.1746 97.317 No firefighter reached floor 23 on 14 June 2017.1747 Last contact with Mariem Elgwahry 97.318 The last telephone call between Ahmed Elgwahry and Mariem Elgwahry began at 02.33 and ended at 04.27. Ahmed Elgwahry said that there had been no background noise in the flat. He could hear coughing and his sister’s coughing increased. He tried to encourage her to leave but she said she could not leave as the landing was filled with thick black smoke. Ahmed Elgwahry believed that his sister did not want to leave their mother behind.1748 97.319 Ahmed Elgwahry could see that the kitchen of Flat 205 was the last room to be affected by the fire on the outside of the building. He heard Mariem Elgwahry begin to panic. She started mumbling and making a deep humming sound. She was initially able to make banging sounds in response to requests from her brother but stopped responding soon after. Ahmed Elgwahry then heard his mother say in Arabic, “I can’t breathe.” He thought that that was at about 03.10. He did not hear from them again. Five to ten minutes later he could hear the sound of glass windows breaking and the fire entering the flat. He kept the line open until 04.27, long after he had ceased to hear from them.1749 97.320 The fire reached the west face of Flat 205 by around 03.14.1750 By 03.33, there was evidence of a large fire throughout Flat 205.1751 Recovery and identification 97.321 The remains of Eslah and Mariem Elgwahry were recovered from the kitchen area of Flat 205.1752 The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for Eslah and Mariem Elgwahry.1753 1742 Phase 1 Report Volume III paragraph 15.56. 1743 Phase 1 Report Volume IV paragraph 28.101. 1744 Phase 1 Report Volume III paragraph 16.15 and Figure 16.6. 1745 Phase 1 Report Volume III paragraphs 16.17-16.20; Phase 1 Report Volume IV paragraph 28.101. 1746 Phase 1 Report Volume III paragraphs 16.17-16.20. 1747 Phase 1 Report Volume IV paragraph 28.101. 1748 Phase 1 Report Volume III paragraph 17.21. 1749 Phase 1 Report Volume III paragraphs 17.23-17.24. 1750 Bisby, Supplemental Phase 1 Expert Report {LBYS0000001/221} paragraph 1043; Purser, Phase 2 Report, Section 6 {DAPR0000006/29} paragraph 119. 1751 Phase 1 Report Volume III paragraph 17.4 and Figures 17.3 and 17.4; Purser, Phase 2 Report, Section 6 {DAPR0000006/29} paragraph 120. 1752 Purser, Phase 2 Report, Section 6 {DAPR0000006/24} paragraph 100 1753 Interim certificate of the fact of death for Eslah and Mariem Elgwahry {MET00065607}; {MET00065615}.

The Grenfell Tower Inquiry: Phase 2 Report 214 Cause and time of death 97.322 The pathologist who carried out the post-mortems on Eslah and Mariem Elgwahry attributed their deaths to the effects of fire but could not be more precise.1754 However, in the light of the evidence as a whole, including that of Professor Purser, we are satisfied that they died from the inhalation of asphyxiant gases. 97.323 It is likely that they had lost consciousness by 02.50 and that the concentration of asphyxiant gases in their blood had exceeded the lethal threshold a few minutes later.1755 97.324 We are satisfied that Eslah and Mariem Elgwahry died between 02.50 and 03.30 before suffering the direct effects of fire. Sakina Afrasehabi Date of birth: 4 April 1952. Place of birth: Abadan, Iran. Gender:

Female. Occupation: Homemaker. Usual address: Flat 151, floor 18, Grenfell Tower, London. Place of death: Flat 205, floor 23, Grenfell Tower, London. Time of death: Between 02.50 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. Fatemeh Afrasiabi Date of birth: 15 November 1957. Place of birth: Abadan, Iran. Gender:

Female. Occupation: Homemaker. Usual address: Martin Close, Edmonton, London, N9. Place of death: Flat 205, floor 23, Grenfell Tower, London. Time of death: Between 02.50 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases. 1754 Eslah Elgwahry post-mortem {COR00001002/4}; Mariem Elgwahry post-mortem {COR00000337/3}. 1755 Purser, Phase 2 Report, Section 6 {DAPR0000006/28} paragraph 117; Purser Summary table of toxicity endpoints in each 23rd floor flat {DAPR0000013}.

Part 9 | Chapter 97: Floor 23 215 Background and composition of household 97.325 Sakina Afrasehabi was born on 4 April 1952 in Abadan, Iran. She was 65 years old in June 2017.1756 She was the sole tenant of Flat 151 and had lived there since February 2016.1757 Her younger sister Fatemeh Afrasiabi was born on 15 November 1957 in Abadan, Iran. She was 59 years old in June 2017. Fatemeh Afrasiabi was staying with her sister on the night of 13 June 2017.1758 97.326 Sakina Afrasehabi and Fatemeh Afrasiabi grew up in Iran with four other siblings. They had a happy childhood before living through the revolution and the Iran-Iraq war. They moved to the UK from Iran and were very close. Vulnerability 97.327 Sakina Afrasehabi suffered from diabetes, high blood pressure and arthritis. Due to an accident in Iran, she could walk only with the aid of a walker. It was difficult for her to walk a short distance without assistance.1759 97.328 Sakina Afrasehabi was recorded as a resident in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system. She was identified as being over 65 and as vulnerable because of her mental and physical health.1760 Events of 14 June 2017 97.329 Fatemeh Afrasiabi and Sakina Afrasehabi spent the evening of 13 June 2017 in Flat 151 with family. Their other relatives left before 22.00 but Fatemeh Afrasiabi stayed the night with her sister.1761 97.330 Sakina Afrasehabi was first alerted to the fire by her neighbours from Flat 156, Shahid and Sayeda Ahmed. They had evacuated their flat after the fire broke into their kitchen at around 01.27 and had then knocked on the doors of all the other flats on that floor, including Flat 151.1762 97.331 Sakina Afrasehabi and Fatemeh Afrasiabi left their flat and were told by others they met on the stairs to go up to floor 23.1763 There the Neda family invited them to shelter in their home, Flat 205. Mariem and Eslah Elgwahry, who had also come up to floor 23, joined them in Flat 205. By 01.30 there were seven people in Flat 205.1764 97.332 Neither Sakina Afrasehabi nor Fatemeh Afrasiabi themselves called the emergency services on 14 June 2017, but nonetheless a message was passed by the LFB control room to the incident ground about persons trapped in Flat 205.1765 That was in response to calls 1756 Phase 1 Report Volume IV paragraphs 32.218–32.227. 1757 Aghlani {IWS00000774/1} page 1, paragraph 3. 1758 Phase 1 Report Volume IV paragraphs 32.218–32.227. 1759 Aghlani {IWS00000774/1-2} pages 1-2, paragraphs 5-6. 1760 Spreadsheet of residents {TMO00866002}. 1761 Sattar {IWS00000769/2} page 2, paragraph 7; Afrasehabi {IWS00000767/2} page 2, paragraph 7. 1762 Phase 1 Report Volume II paragraphs 10.249-10.250. 1763 Phase 1 Report Volume II paragraph 10.289 (c). 1764 Phase 1 Report Volume II paragraphs 10.284 and 10.288-10.289. 1765 Phase 1 Report Volume II paragraphs 12.18-12.19, 12.72 and 12.73 (b); LFB Short Incident Log Report {MET00013830/19}. Phase 1 Report Volume II paragraphs 12.72 and 12.73 (b). Phase 1 Report Volume II paragraphs 12.18-12.19.

The Grenfell Tower Inquiry: Phase 2 Report 216 received from Mariem Elgwahry at 01.301766 and 01.38.1767 The fact that there were people trapped in Flat 205 was communicated to the bridgehead on floor 2 and recorded there on a forward information board.1768 97.333 The first team of firefighters sent to floor 23 in response to those messages set out between 02.08 and 02.10. FFs Zade Alassad, Scott Bell and John Wright were sent to Flats 201 and 205 on floor 23.1769 A photograph taken of the wall on floor 2 shows writing which reads “Wandswor 23rd flts 201 205.” Next to this are the names of Alassad, Bell and Wright.1770 FFs Alassad, Bell and Wright did not reach floor 23. They stopped at floor 10 and helped to carry down casualties found on that floor.1771 FF Bell said that he told someone they had not reached floor 23 but he could not remember to whom he had spoken or what that person did with the information.1772 Conditions in Flat 205 97.334 Farhad Neda said that conditions in Flat 205 had changed rapidly.1773 He saw black smoke beginning to enter the flat beneath the front door. Within 10 to 15 minutes of the sisters’ coming into the flat there were black marks around people’s noses from the smoke.1774 Contact with others outside the tower 97.335 Solmaz Sattar, the niece of Fatemeh Afrasiabi, had several telephone conversations with her aunt during the night. In a call which occurred after Solmaz Sattar had reached the tower, Fatemeh Afrasiabi said they were in Flat 205. Solmaz Sattar passed the information to a police officer and a firefighter standing nearby. The firefighter advised that they should remain in the flat and that they should make everything wet, including themselves. The Nedas had filled buckets with water which they threw on the carpets and soaked towels to cover their mouths when they saw smoke coming into the flat.1775 Later, Fatemeh Afrasiabi told her niece that the water had stopped.1776 97.336 Fatemeh Afrasiabi and Sakina Afrasehabi were also in contact with Sharokh Aghlani, Sakina Afrasehabi’s son. Fatemeh Afrasiabi first called him around 01.20 to tell him of the fire. He went to the tower and told police officers there that his mother and aunt were on floor 23.1777 (It has not been possible to identify with any confidence which officer Sharokh Aghlani and Solmaz Sattar spoke to.) It is possible that his message was passed to the bridgehead. At the same time, Mariem Elgwahry in Flat 205 had made further calls to the LFB control room at 01.541778 and 02.25.1779 The information from both calls was passed to the incident ground at 01.571780 and 02.28 respectively.1781 1766 Phase 1 Report Volume II paragraph 10.289 (a) . 1767 Phase 1 Report Volume II paragraphs 11.27 and 11.163. 1768 Phase 1 Report Volume II paragraph 14.73 and Figure 14.4. 1769 Phase 1 Report Volume II paragraph 14.117; Phase 1 Report Volume II Figure 13.2 and paragraph 14.117; Phase 1 Report Volume IV paragraph 28.101. 1770 Phase 1 Report Volume II Figure 13.2. 1771 Phase 1 Report Volume II paragraph 14.117. 1772 Phase 1 Report Volume II paragraph 14.117. 1773 Phase 1 Report Volume IV paragraph 25.17. By 01.54, Mariem Elgwahry described Flat 205 as full of smoke in a 999 call. 1774 Phase 1 Report Volume II paragraph 13.79. 1775 Phase 1 Report Volume II paragraph 13.80. 1776 Phase 1 Report Volume II paragraph 13.82. 1777 Phase 1 Report Volume III paragraph 17.25. 1778 Phase 1 Report Volume II paragraphs 13.78 and 13.98. 1779 Phase 1 Report Volume III paragraph 15.143 1780 Phase 1 Report Volume II paragraph 13.98. 1781 Phase 1 Report Volume III paragraph 15.147.

Part 9 | Chapter 97: Floor 23 217 97.337 At least one of the messages about Flat 205 reached the bridgehead while it was still on floor 3 (between 02.17 and 03.10). That led to a further deployment of firefighters. At 02.24 CM Richard Evans and FF Gemma Bloxham set out to go to Flat 205.1782 97.338 Shortly before that, Saber Neda had seen that the fire had reached the bedroom of Flat 205. He closed the door and told everyone not to enter it.1783 At about 02.15 Farhad Neda decided that it was time to leave. He seized his mother and shouted for his father to follow.1784 Saber Neda agreed and said he would be behind them. He gave wet towels to Sakina Afrasehabi and Fatemeh Afrasiabi in preparation to leave.1785 Farhad and Flora Neda then left the flat thinking that the others would follow them. Instead, Sakina Afrasehabi and Fatemeh Afrasiabi remained in the flat with Saber Neda and Mariem and Eslah Elgwahry.1786 97.339 CM Evans and FF Bloxham had reached floor 20 when they came across Farhad and Flora Neda. CM Evans and FF Bloxham stopped to help them out of the tower.1787 Farhad Neda told the firefighters that his father and four others were trapped in Flat 205, which was recorded by one of the firefighters in a notebook. As they left the main entrance between 02.42 and 02.43, Farhad Neda told the firefighters again that people were still in the flat.1788 97.340 At about 02.42 CM Evans told the officer in charge at the bridgehead that they had not reached Flat 205 but that they had brought two people down.1789 That may have led to a further deployment of firefighters to the top floor. 97.341 At 02.51, FFs Niki Mitchell, Jessamine Bate, Michael Pole and Chris Cheesman from Euston Fire Station were sent to floor 23.1790 The wall of the bridgehead, then on floor 3, shows that the word “Euston” had been written against Flats 204 and 205 on floor 23.1791 The message was repeated on the lower right hand corner of the photograph where the words “23rd Euston 204 205” can be seen. They did not reach floor 23 but helped casualties evacuate from Flat 153 on floor 18.1792 FF Mitchell recalled telling WM De Silvo that they had not reached floor 23 but had got fairly high up the tower and they had rescued a family of seven. The crew’s end of wear times were between 03.15 and 03.17.1793 97.342 No firefighter successfully reached floor 23 on 14 June 2017.1794 1782 Phase 1 Report Volume III paragraph 15.54. 1783 Phase 1 Report Volume III paragraph 15.64. 1784 Phase 1 Report Volume III paragraph 15.64. 1785 Phase 1 Report Volume III paragraph 15.64. 1786 Phase 1 Report Volume III paragraph 15.65. 1787 Phase 1 Report Volume III paragraphs 15.54-15.56; Phase 1 Report Volume IV paragraph 28.101. 1788 Phase 1 Report Volume III paragraphs 15.66-15.67. 1789 Phase 1 Report Volume III paragraph 15.56. 1790 Phase 1 Report Volume IV paragraph 28.101. 1791 Phase 1 Report Volume III paragraph 16.15 and Figure 16.6. 1792 Phase 1 Report Volume III paragraph 16.17-16.20; Phase 1 Report Volume IV paragraph 28.101. 1793 Phase 1 Report Volume III paragraphs 16.17-16.20. 1794 Phase 1 Report Volume IV paragraph 28.101.

The Grenfell Tower Inquiry: Phase 2 Report 218 Last contact with Fatemeh Afrasiabi and Sakina Afrasehabi 97.343 Shahrokh Aghlani spoke to his mother, Sakina Afrasehabi, and his aunt, Fatemeh Afrasiabi, several times in the early hours of 14 June 2017. During his last call he could hear them wheezing. He heard his aunt say “forgive us” before the line was disconnected. About 50 seconds before that he heard the sound of an explosion. It is difficult to determine when that conversation took place.1795 97.344 Ahmed Elgwahry was on the telephone to Mariem Elgwahry from 02.33 until 04.27. He said that he had last heard Mariem and Eslah Elgwahry respond to him at between 03.10 and 03.15. He also heard the sound of windows breaking about 5 to 10 minutes later. 97.345 Sakina Afrasehabi and Fatemeh Afrasiabi are likely to have become unconscious from the effects of asphyxiant gases at about the same time as Eslah and Mariem Elgwahry, given their close proximity to each other in the kitchen of Flat 205. Recovery and identification 97.346 The remains of Sakina Afrasehabi and Fatemeh Afrasiabi were recovered from the kitchen area of Flat 205.1796 The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for Sakina Afrasehabi and Fatemeh Afrasiabi.1797 Cause and time of death 97.347 The pathologist who carried out the post-mortems on Sakina Afrasehabi and Fatemeh Afrasiabi attributed their deaths to the effects of fire but could not be more precise.1798 However, in the light of the evidence as a whole, including that of Professor Purser, we are satisfied that they died from the inhalation of asphyxiant gases. 97.348 It is likely that Sakina Afrasehabi and Fatemeh Afrasiabi lost consciousness at about 02.50 and died at some time between 02.50 and 03.30 before suffering the direct effects of fire. 1795 Phase 1 Report Volume III paragraph 17.25. 1796 Purser, Phase 2 Report, Section 6 {DAPR0000006/24} paragraph 94. 1797 Interim certificate of the fact of death for Sakina Afrasehabi and Fatemeh Afrasiabi {MET00065598}; {MET00065612}. 1798 Afrasehabi post-mortem report {COR00000425/5}; Afrasiabi post-mortem report {COR00001380/5}.

ISBN 978-1-5286-5080-9 (Volume 6 of 7) 7 volumes not available separately

FD05978 ｜ 2019_英国_UK_2019_London_Fire_Brigade_Grenfell_Preliminary_Report.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2019 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Grenfell Tower Fire Preliminary Report

Head of Grenfell Tower Investigation and Review Team OFFICIAL 2nd April 2019

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Page 2 of 101 2nd April 2019

Chapter 1 – Introduction

3 Background to Brigade’s investigation and team

3 Grenfell Tower Investigation and Review Team: Terms of reference

4 Investigation methodology

6 Scope of preliminary report

7 Chapter 2 – Summary timeline of events

9 Chapter 3 – Preliminary observations

12 Theme 1 – Observed failures of the building and its fire safety measures

12 Theme 2 – Operational pre-planning

21 Theme 3 – Command and control

31 Theme 4 – Operations

41 Theme 5 – Brigade Control

62 Theme 6 – Communications

78 Theme 7 – Operational equipment

89 Chapter 4 – Summary of key observations

94 Chapter 5 – Summary of recommendations

98 Chapter 6 – Appendices

100

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Page 3 of 101 2nd April 2019 Chapter 1 – Introduction Background to the Brigade’s investigation and review 1 The fire at Grenfell Tower on 14th June 2017 took the lives of 71 people, with a further fatality on 29th January 2018, and left hundreds more with both physical and psychological injuries. Whilst fire and rescue services are trained to respond to fires in residential high rise buildings, the incident on the 14th June 2017 was of a scale and rapidity that was exceptional; preceded and precipitated by a complete failure of the building’s fire safety measures to perform effectively. Those failures created a set of conditions not previously experienced by the Brigade and provided a unique challenge for the Brigade and its partner emergency services who responded on the night. 2 There is much to be commended in the multi-agency emergency response, and many emergency service personnel demonstrated bravery and selflessness during the night in the pursuance of preserving life. There can be little doubt that every member of the Brigade and those from the other agencies who attended, did so with the express aim of saving life and protecting property. 3 The courage of the residents, who, on the night had to endure punishing and terrifying conditions to escape the building as it became engulfed in fire is recognised and cannot fail to be admired by all. Similarly, the ongoing fortitude of the families and friends of those residents who were unable to escape and perished during or shortly after the fire is to be commended. 4 Like all incidents, large and small, there will be learning to be identified and it is acknowledged that any lessons to be learned and any good practice identified will undoubtedly apply not just to the London Fire Brigade, but nationally and possibly internationally. 5 The office of the London Fire Commissioner has a statutory duty to review the performance of the organisation and ensure all learning from incidents is identified, disseminated, and acted upon where appropriate. 6 This report is a product of the Brigade’s investigation and review but should be considered a preliminary output only as there is a need for the Brigade and others to conduct further investigations, in order to achieve a full understanding and reach conclusions. 7 Such was the scale of the incident at Grenfell Tower, a dedicated team within the Brigade, the Grenfell Tower Investigation and Review Team (GTIRT), was established to understand the circumstances of the incident and what happened on the night, identify lessons to be learnt, and

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Page 4 of 101 2nd April 2019 when all the evidence is available, provide an unfettered and comprehensive evaluation of the Brigade’s response to this unprecedented incident. This investigation has and will continue to work alongside the statutory processes being undertaken by the Grenfell Tower Inquiry and Metropolitan Police Service (MPS), whilst acknowledging the primacy of those processes. 8 GTIRT reserves the right to amend any information contained within this report if further evidence becomes available. 9 The Brigade has sought to support the aim of the Inquiry and MPS in placing the bereaved, survivors, and residents at the heart of their investigations through the provision of relevant information, including the products of its own investigations, to ensure the fullest understanding of the events of the night is achieved for those most directly affected. The internal investigation team also recognises the traumatic experiences of the Brigade’s staff and their need to understand the events of the night, and has sought to ensure its own activities and that of other statutory processes have due regard to the wellbeing of staff. 10 Eighty-three Brigade staff and five staff from other fire and rescue services provided oral evidence during the Inquiry’s Phase 1 hearings and more than 650 staff have provided voluntary witness statements to the MPS. Grenfell Tower Investigation and Review Team: Terms of reference 11 This section sets out the terms of reference and investigation methodology already known to Brigade’s principal officers to reflect the likely wider interest in the Brigade’s internal investigation and its outputs. Aim 12 Develop the fullest possible understanding of the circumstances of the Grenfell Tower fire to support the identification of lessons to be learnt, and evaluate the adequacy and effectiveness of the Brigade’s emergency response on the 14th June 2017. Rationale 13 In order to meet its statutory duties under Health and Safety legislation, the Brigade investigates all accidents and near misses (collectively known as safety events). The fire at Grenfell Tower on 14th June 2017 was unique in its scale, rapidity and loss of life and as such justified the formation of a dedicated team to ensure these duties were carried out effectively and efficiently, and support the Inquiry and MPS investigations.

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Page 5 of 101 2nd April 2019 14 Objectives  To set-up robust systems to capture all relevant information (documents, witness statements, emails, images, etc.) and any physical evidence associated with Grenfell Tower and Brigade’s response to the fire.  To develop and implement a storage and indexing solution for all the information relating to the Grenfell Tower investigation.  In conjunction with the General Counsel’s Department support the Brigade’s participation in the Inquiry and establish a ‘disclosure’ management protocol to support the evidence submissions.  To analyse all relevant and available information to develop a clear understanding of the Brigade’s involvement with Grenfell Tower prior to the major fire that occurred on 14 June 2017.  To investigate and establish the most likely cause of the fire and the factors that influenced the rapid fire spread in conjunction with external advisors.  To undertake a comprehensive review of the Brigade’s operational response to the incident including all the relevant aspects of the operational support and strategic co-ordination arrangements.  To undertake a comprehensive review of Brigade Control’s response to the incident.  To undertake an assurance review covering all the actions taken by the Brigade in responding to the Lakanal House fire which occurred on 3 July 2009, including those instigated in response to the Rule 43 recommendations arising from the Coroner’s Inquest.  To carry out and maintain effective governance and relationships with all relevant external partners and agencies through the use of Memorandums of Understanding and Working Protocols.  To work closely with all appropriate Brigade departments to develop an organisational action plan relating to any lessons learnt arising from the investigation or from recommendations delivered by the Inquiry N.B. The report addressing the objective to undertake an assurance review of the actions taken by the Brigade in response to the Lakanal House fire has been completed and is appended to this report. Out of scope 15 The investigation or its outputs will not seek to examine or reach conclusions in relation to the following:

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Page 6 of 101 2nd April 2019  The cause of death of the people who died and any question of the potential survivability from the injuries of those who died.  Any matters in relation to civil or criminal liability.  Why the building became so vulnerable to the fire that occurred on 14th June 2017, save to use the conclusions reached by the Inquiry’s experts where they provide context to actions or decisions taken by the Brigade on the 14th June 2017.  The activities or response of other agencies, save where they impact on the Brigade’s response. Relationship with formal statutory processes 16 The Brigade’s internal investigation is being undertaken whilst the Inquiry and MPS investigations are ongoing. In addition, the Coroner has opened and adjourned inquests into the deaths resulting from the fire and it is anticipated that the Inquiry will attempt to address the matters normally dealt with by the Coroner in the course of the Inquiry’s proceedings. 17 The Brigade has engaged extensively to ensure its actions do not in any way undermine or prejudice the other statutory processes. In respect of the MPS investigations, ways of working have been formalised through a Memorandum of Understanding and an Information Sharing Protocol. The Inquiry has published a number of documents setting out how its terms of reference will be delivered and as a Core Participant, the Brigade is bound by and adheres to these protocols. Investigation methodology 18 The Brigade’s internal ‘safety and learning’ investigation is being carried out in three stages; 19 Stage one is being carried out in two parts, the first being the gathering of information which has included the copying, recording and referencing of information relating to the incident. The second part is the use of the Sequential Time Event Plotting (STEP) process to record a timeline of the actions undertaken at the incident and remotely at Brigade Control. 20 The second stage of the investigation is running concurrently with stage one, and involves the investigation team building an understanding of what happened at the incident and how it happened. This understanding of the first seven hours of the incident has developed into the factual narratives presented in the ‘Operational Response Report Volume 1’ and the ‘Actions by Brigade Control Report’. Both documents are appended to this report.

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Page 7 of 101 2nd April 2019 21 The third stage is an analysis to identify those areas that do not align with the expectations of policy, national guidance and / or training and determine the immediate and underlying reasons for this, to support improvements and / or avoid a reoccurrence. It is intended to undertake the majority of stage three of the investigation prior to and during phase 2 of the Inquiry and present internal findings on the adequacy and effectiveness of the Brigade’s response at the end of the Inquiry proceedings, once all evidence is available. 22 However, as the internal investigation progresses, where a significant issue or concern is identified and verified which impacts on public or firefighter safety, and in the opinion of the investigation team requires action that cannot reasonably wait until the publication of reports, then these are communicated to the responsible department for consideration. The Brigade tracks and records any resulting actions taken through its Operational Improvement Process. 23 It is noted that the Brigade has also implemented a Grenfell Tower Fire Improvement Board to corporately consider operational learning identified by its internal investigation and recommendations arising from the Inquiry. The Board will direct the implementation of any improvement actions and assure the effective delivery and embedding of those actions. Scope of this preliminary report 24 This preliminary report predominantly covers the first seven hours of the incident up to 08:00hrs; the period of life saving activity and the focus of the Inquiry during its Phase 1 proceedings. The report also notes historical actions that are considered relevant or provide context to the actions / decisions taken on the night of the fire. In addition, observations that do not directly relate to the response on the night of the fire, but may be relevant when the Brigade is considering improvement measures, have been included to support continuous improvement. 25 The analysis to identify those actions or decisions or outcomes which are not aligned to the expectations of policy, national guidance and will take some time to complete. It will identify key lines of enquiry to be investigated to determine the immediate and underlying reasons for such discrepancies. 26 It follows that much of the work to identify, in particular, underlying reasons will lean heavily on examining the broader issues of policy and training, and identifying and understanding the systems and processes used by the Brigade to deliver its statutory functions. 27 In addition, there is a requirement to understand the events that led to Grenfell Tower becoming so vulnerable to the building wide fire that occurred on the 14th June 2017 in order to provide the

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Page 8 of 101 2nd April 2019 context for the actions and decisions of those who responded to this incident. These are areas that the Inquiry will examine during its Phase 2 proceedings and the MPS will also examine as part of its own ongoing investigation. 28 However, there is learning that can and has been identified, acknowledged, and acted upon from the evidence available to date, even without fully identifying or understanding the underlying reason. 29 This report identifies those areas of operational learning within themes and are presented to the London Fire Commissioner and the Grenfell Tower Fire Improvement Board so that the Brigade can consider and implement any agreed corrective measures, if it has not already done so. 30 Recommendations that point to matters that the Brigade may wish to consider are provided to support its decision making have been included in this report.

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Page 9 of 101 2nd April 2019 Chapter 2 - Summary timeline of events 31 This chapter provides a timeline of key events in the first seven hours of the incident. A minute by minute factual narrative of the events between 00:54:29hrs and 08:11:00hrs provided in the Operational Response Report Volume One and the Actions by Brigade Control reports (attached as Appendices A and B respectively). The entries presented below in italics denote messages. 00:54:29 Initial call to fire in flat 16, Grenfell Tower received 00:59:24 First appliance (G272) books ‘in attendance’ at Grenfell Tower 00:59:28 Second appliance (G271) books ‘in attendance’ at Grenfell Tower and Watch Manager (WM) Dowden assumes role as Incident Commander (IC 1) 01:00:28 H41S paged as Remote Monitoring Officer 01:07:21 Breathing Apparatus (BA) team One make first entry into flat 16 on fourth floor 01:08:06 Fire begins to break out of the kitchen window of flat 16 on east elevation 01:12:59 Make Pumps 6, 1 Hydraulic Platform (amended to 1 Aerial at 01:13:41) 01:14:21 From G272, residential block of flats of 20 floors, 25 metres x 25 metres, five roomed flat on fourth floor, 75 per cent alight, high rise procedure implemented MDT in use, tactical mode Oscar 01:16:05 G272 designated Initial Command Pump (ICP) 01:19:08 Make pumps 8 01:21:15 BA team One confirm fire is extinguished in flat 16 01:21:21 Fire has spread up external cladding to eleventh floor 01:21:24 First 999 call received from a resident inside Grenfell Tower (flat 195, 22nd floor) 01:24:09 Make pumps 10 01:24:33 From G271, can we request attendance of the police for crowd control 01:27:26 Make pumps 15, Aerial Ladder Platforms 2 01:28:12 From G271, this is a persons reported fire

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Page 10 of 101 2nd April 2019 01:29:11 Make pumps 20, Fire Rescue Units 2 01:30

Fire in external cladding reaches top of the building and begins to spread laterally 01:30:48 First Command Unit (CU8) books ‘in attendance’ 01:31:30 Make pumps 25 01:32:08 First Station Manager (SM) (G22S) books ‘in attendance’ 01:33

G22S meets with IC 1 and takes over management of Fire Survival Guidance calls 01:36

First aerial appliance (A213) arrives on scene 01:40 H41S arrives at Grenfell Tower and takes over as IC 2 at around 01:50 01:54:30 First Deputy Assistant Commissioner (DAC) (E6) arrives at Grenfell Tower and takes over as IC 3 from H41S around 01:59 01:57:21 First Group Manager (GM) (E109) books ‘in attendance’ and proceeds to CU8 where he is informed he is the senior officer on scene and assumes command 02:03:13 Make pumps 40 02:06:03 Major incident declared by Brigade 02:11

IC 3 moves to CU8 and appoints E109 as Fire Sector Commander 02:15:49 Make Fire Rescue Units 10 02:34:03 40th pumping appliance now in attendance 02:35 Brigade Control Senior Operations Manager informs Control Room Operators (CRO) to begin advising callers to leave the building. 02:39:17 From CU8, fire on all floors, from 2nd to 27th floor. Large number of persons involved. FSG calls being dealt with. Major incident declared. High rise procedure implemented, TL, ALP, EDBA, Main control, FSG, ground monitor, five jets, safety cordon in place. Tactical mode Oscar. 02:43:51 First Assistant Commissioner (AC) (BM8) on scene assumes command as IC 4. 02:47

Decision to alter FSG advice from ‘stay put’ to ‘get out’ recorded in decision log.

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Page 11 of 101 2nd April 2019 02:50:48 London Fire Commissioner (BM 1) books ‘in attendance’ as Monitoring Officer. 03:08

Bridgehead relocated to ground floor lobby due to deteriorating conditions. 04:03 External flame fronts converge at the south west corner of the building, totalling engulfing the building. 08:11 Last surviving resident (Mr Bonifacio) located in the Grenfell Tower is rescued from the 11th floor.

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Page 12 of 101 2nd April 2019 Chapter 3 - Preliminary observations 32 This chapter presents observations themed into seven key areas following a review of the evidence held by the Brigade and that provided during the Phase 1 proceedings of the Inquiry. Each key observation is followed by the rationale for its inclusion in this report, together with any context provided by policy positions or historical actions. 33 The actions the Brigade has completed or are progressing in response to the learning identified to date are also presented at the conclusion of each key observation or at the end of the section. 34 Recommendations that point to matters that the Brigade may wish to consider are provided to support its decision making. Theme 1 – Observed failures of the building and its fire safety measures 35 This section of the report provides a summary of what GTIRT currently understands about Grenfell Tower, the fire safety provisions within the premises, the apparent failure of those provisions, and their impact on the residents and the Brigade’s operational response. 36 It draws heavily on the Inquiry’s expert witness reports, particularly that of Dr Barbara Lane, all of whom have undertaken a significant amount of work to identify how the building impacted on the events of the 14th June 2017. The expert witness reports provide significant context to the Brigade’s operational response and the challenges it faced to deliver its key aims to save life, protect property, and protect the environment. 37 This report provides only a summary of those expert findings. The investigation will consider all the expert reports in detail during its analysis of the Brigade’s operational response. 38 Grenfell Tower was a 25 storey (including basement and plant room) residential premises built in the 1970’s. The premises is located on the Lancaster West estate within the Royal Borough of Kensington and Chelsea. The block originally contained 120 flats over 20 floors with the Ground and first three levels assigned to non-residential purposes. 39 During the refurbishment undertaken between 2012 and 2016, an additional nine flats were added within levels one to three, bringing the total number of residential units to 129. This refurbishment also included the installation of an external rain screen cladding system and works to the gas supply within the building.

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Page 13 of 101 2nd April 2019 40 There is also evidence that lift replacement works were undertaken in 2005 and a flat front door replacement programme was completed between 2011 and 2012. 41 On the 14th June 2017, the fire started in the kitchen of flat 16, on the fourth floor of Grenfell Tower. The flat is located on the north east corner with the kitchen window projecting onto the east elevation of the building. 42 The fire was discovered by the resident of the flat, Mr Behailu Kebede, in the corner of the kitchen adjacent to the east facing window. A fridge freezer was located in this area and the Brigade’s fire investigation officers believe the fire most likely started in this appliance. Key observation 1.1 : The external cladding system installed on Grenfell Tower was not compliant with Regulation B4(1), contributing to the observed failure of the fire safety measures provided within the premises. Rain screen cladding system 43 Dr Barbara Lane states in her report, dated 5th November 2018 that ‘The rain screen system, installed during the refurbishment in 2012 – 2016, was non-compliant with the functional requirement of the Building Regulations.’ 44 Dr Lane further states in her report that ‘the rain screen cladding assembly together with the insulation fitted to the existing external wall and the missing or defective barriers became part of successful combustion process. This created a condition (in the event of an internal fire, cavity fire or external fire) which connected every flat on a storey; and every storey from level three to the roof, which supported the spread of external fire back into the building , through windows, and created a series of internal fire events’. 45 She concludes in her report ‘I do not consider it reasonable that in the event of the installation of a combustible rain screen on a high rise building, the fire brigade should be expected to fully mitigate any resulting fire event. That is particularly so in circumstances where the fire brigade had never been informed that a combustible rain screen system had been installed in the first place.’ 46 Dr Lane noted in her report that she had found no evidence that the Brigade had been informed that a combustible rain screen cladding system had been fitted to Grenfell Tower and therefore had not had the opportunity to consider the appropriateness of its operational procedures in the event of a fire at the Tower.

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Page 14 of 101 2nd April 2019 Fire safety measures 47 Grenfell Tower was provided with a number of active and passive fire safety measures which were intended to create a layered safety system. They were intended to provide the means for early internal firefighting. This is achieved by providing the means to limit fire and smoke spread from a dwelling fire and create the high degree of compartmentation necessary to support the building owner’s/Responsible Person’s ‘Stay Put’ strategy, which was designated for this particular high rise residential premises. 48 Dr Lane in her report, dated 5th November 2018, states ‘The high degree of compartmentation had suffered its primary failure, caused by the fire spreading through the rain screen system’. She goes on to state ‘The remaining active and passive fire protection measures within the Tower were required to mitigate the effects of the resulting fire and smoke spread from that rain screen system fire. These measures were required to mitigate those effects on many floors.’ Evacuation strategy 49 The current statutory guidance does not require a residential high rise premises to be provided with an interlinked fire alarm system, as the guidance assumes that any fire will be confined to one flat. The guidance is Approved Document B 2013 states: “The provisions for the means of escape for flats are based on the assumption that: a. the fire is generally in a flat; b. there is no reliance on external rescue; c. measures in Section 8 (B3) provide a high degree of compartmentation and therefore a low probability of fire spread beyond the flat of origin, so that simultaneous evacuation of the building is likely to be necessary; and d. although fire may occur in the common parts of the building, the materials and construction used there should prevent the fabric from being involved beyond the immediate vicinity (although in some cases communal facilities exist which require additional measures to be taken).” 50 The definition of ‘stay put’ from BS 9991:2015 assumes the same; ‘when a fire occurs in a flat or maisonette, the occupants of that dwelling evacuate, but occupants of all other dwellings can safely remain in their dwellings unless affected by heat or smoke or directed to leave by the fire and rescue service.’

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Page 15 of 101 2nd April 2019 51 Dr Lane concludes that the guidance in the UK does not require there to be any system or process to either automatically sound a fire alarm in every flat or to sound an alarm in the common lobbies outside each flat. Therefore, unless a resident communicates with the emergency services by calling ‘999’, there is no other automatic or expedient means for operational staff attending an emergency incident to communicate with residents within the building. Protected lobbies and stair 52 The means of escape to the final exit at Grenfell Tower was a single staircase provided with a protected lobby at every storey. A smoke control system, an active fire safety measure, was provided to protect each lobby and in doing so protect the single escape stair. 53 Professor Torero notes in his report, dated 23rd May 2018; ‘In the Building Regulations and guidelines applicable to Grenfell Tower there is no requirement for provisions that allow the occupants of more than the flat of fire origin to evacuate (Section 5.1.7[1]’ 54 The evidence from witnesses and the Inquiry’s experts indicate that the lobbies and stairwell failed to perform on the night of the fire and became compromised by heat and smoke from some time between 01:21 and 01:40hrs. This created challenging conditions for firefighters and the residents seeking to self evacuate from the building. 55 There is evidence that heat conditions above 150 degrees centigrade were present in the stairwell between floors 13 – 16, probably some time around 02:00 – 02:30hrs. This is likely to have caused a physical and psychological barrier for those above 11th floor to escape around these times. It is conceivable that these heat conditions were, in part, a consequence of the lack of firefighting due to the finite limitations of the dry rising main (DRM) capacity. This may have enabled the fire to spread internally unchecked by firefighting activities that would be undertaken at a high rise incident that didn’t involve this level of rapid fire spread. 56 Evidence available to date indicates there is a close correlation between the progress of the vertical fire spread and the presence of smoke in lobbies. Smoke is reported in 13 of 20 lobbies between 01:19 and 01:38hrs, increasing to 15 out of 20 lobbies by 01:58hrs. By 02:38hrs, smoke is reported in 19 out of 20 lobbies with severe temperatures on floors six to 10. 57 The failure of the protected lobbies is attributed by Dr Lane to flat front doors failing to control the spread of fire and smoke from flats into the lobbies and vice versa. This is attributed to a lack of performance, initially identified by a fire resistance test undertaken by BRE Global, on behalf of the MPS, on a sample door of the type fitted to the majority of flats within Grenfell Tower.

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Page 16 of 101 2nd April 2019 58 Flat entrance front doors are considered an important element of the lobby enclosure as they provide protection to the lobby acting as a means of escape to occupants from a fire in an adjacent flat. All flat entrance doors are required to be fitted with self closing devices to ensure the door is closed after a person leaves their flat. Dr Lane was unable to confirm whether these devices performed as intended, but many witnesses stated in oral evidence that the self closer fitted to their flat did not work or was missing. 59 In regard to the protected stairs, Dr Lane has noted in her report, dated 5th November 2018, the following function described in BS9991:2015 ‘Whilst a simultaneous evacuation is normally not necessary, there will be some occasions where operational conditions are such that the fire and rescue service decide to evacuate the building. In these situations, the occupants of the building will need to use the common stair, sometimes whilst firefighting is in progress. As such, the measures in this British Standard for the protection of common stair are designed to ensure that they are available for use over an extended period.’ 60 Dr Lane further noted in her report in relation to the stair doors; ‘I observed no fire damage in the stairs consistent with the total failure of a stair door, allowing fire spread onto the stairs’ but does note ‘the non-compliances I have identified would have contributed to the failure to prevent the spread of smoke to the stair’. Mechanical Smoke Control system 61 A replacement mechanical smoke control system was installed in Grenfell Tower during the 2012- 2016 refurbishment, its purpose being to control the amount of smoke entering a lobby and therefore reducing the risk of smoke spread to the protected stair. 62 The smoke control system was intended to operate on one floor only, as per the requirements of Approved Document B, and was not expected or designed to operate on multiple floors simultaneously. 63 A smoke detector was present outside flat 16, the fire compartment of origin, and this detector should have activated the smoke control system on the fourth floor. There are no reports of smoke in any other lobby at this time. Evidence from residents report thick black smoke entering the stairs from the lobby on the fourth floor around 01:20hrs indicating the smoke control system was not operating as designed. 64 The smoke control system was installed with an override control located in the ground floor lobby. The control panel enabled the system to shut down or the floor on which the system was

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Page 17 of 101 2nd April 2019 operating could be controlled. Photographic evidence indicates that the override switch had been turned from ‘Auto’ to ‘On’, enabling manual control of the system. 65 The smoke control system could also be operated on each floor using a key switch located in each lobby, enabling the system to operate on that floor. There is no evidence at the time of writing that any of the lobby key switches were operated successfully during the fire. Fire lifts 66 Evidence available to date indicates the lifts provided with Grenfell Tower were consistent with the requirements of a ‘fire lift’ as described in the original design guidance at the time of construction, rather than a ‘firefighting lift’ as described in Approved Document B. 67 A ‘fire control switch’ was provided at ground level and CCTV footage confirms that Brigade personnel attempted to secure the lift using this fire control switch but the switch failed to engage. This resulted in the lifts continuing to operate as normal lifts but not under Brigade control. Dry rising main 68 Grenfell Tower was provided with a DRM to support internal firefighting operations. It is noted that this does not comply with the current guidance which includes for the provision of a Wet Rising Main in buildings over 50 metres. Prior to 2006, only buildings above 60 metres were required to have a wet rising main. 69 Dr Lane has stated in her report, dated 5th November 2018, that she believes the DRM was non- compliant with the original design guidance due to the building height of 67.30 metres. It is believed the original guidance allowing for a DRM in buildings under 60 metres measured the height of a building from the DRM inlet to the top of the building. There were no dry rising outlets on the second and third floors but these were added during the refurbishment when residential units were added to these levels. 70 However, Dr Lane notes that to comply with the guidance available (Approved Document B) at the time of the refurbishment, Grenfell Tower would have required the provision of a wet rising main. In her report, she notes the mechanical and electrical sub contractors stated in correspondence to RBKC; ‘We are not increasing the high [sic] of the existing riser but we are adding two additional floors at low level which were previously walkways. We understand the existing riser is above the current permitted height of 50m, we would therefore need to discuss

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Page 18 of 101 2nd April 2019 the proposed modification and what measures we need to take to gain approval for the new system’. 71 RBKC Building Control responded by advising; ‘Essentially the building regulations cannot require you to improve the existing floors above 50 metres. The regulations only apply to the work being carried out and additionally you must not adversely affect the existing building’. 72 Dr Lane, therefore, concludes that no works were undertaken as part of the refurbishment to upgrade the rising main from a dry system to a wet system. 73 Evidence to date indicates that the DRM failed to provide a sufficient number of firefighting jets to combat the fires present across multiple floors, and the jets established failed to provide sufficient pressure and flow, presumably because the number of jets connected to the dry rising main exceeded the capacity of the main. 74 Professor Jose Torero in his expert report, dated 23rd May 2018, states ‘Firefighting protocols for response to high rise building fires are intimately linked to a single floor fire. Furthermore, for residential buildings, the firefighters should find, on arrival, a single unit fire’. Professor Torero goes on to state ‘Fighting provisions, such as water supply, are also dimensioned under the expectation of a certain magnitude event. If vertical flame spread occurs this will require the drastic modification of firefighting protocols and advance planning’. 75 Further investigation of the non-compliances identified within Grenfell Tower by the Inquiry’s experts and the impact they had on the spread of fire and the operational response will be undertaken by the Inquiry’s expert witnesses in phase 2. Sprinklers 76 Grenfell Tower was not provided with any fire suppression system such as sprinklers but it is recognised that there is currently no regulatory requirement for such provision in a building of this type and age. Recommendation 1 - The Brigade should continue to work with all stakeholders to identify and deliver improvements to the regulatory regime to prevent a re-occurrence of the Grenfell Tower fire and increase the safety of the public and firefighters. Recommendation 2 - The Brigade should continue to campaign vigorously for the provision of sprinklers in residential high rise and other types of buildings in order to improve public safety.

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Page 19 of 101 2nd April 2019 Actions by the Brigade since the fire 77 In the week after the Grenfell Tower fire the Brigade’s Fire Safety Regulation (FSR) department established a High Rise Task Force (HRTF) to review the risks associated with high rise residential premises within the Brigade’s area. 78 The Brigade’s FSR department has responsibility for both the delivery of the regulatory fire safety function and community safety activities. 79 Through an on-going proactive programme of prevention activity targeting and supporting the most vulnerable members of society, it leads the Brigade’s aim to continue reducing the number of people who are injured or die in fires. 80 The department’s Fire Safety Inspecting Officers (FSIO) carry out risk based, targeted audits and inspections of premises under the Regulatory Reform (Fire Safety) Order 2005. Where non- compliance by the person responsible for the premises is identified appropriate enforcement action can be taken to ensure any fire safety deficiencies are addressed. 81 FSIOs also respond to consultations from building control bodies under the Building Regulations. They also provide general fire safety advice as required under the Fire and Rescue Services Act 2004. 82 This team has conducted in excess of 1,500 activities related to residential high rise premises, including providing reassurance at residents meetings, co-ordinated visits with fire station based staff and the completion of over 1,100 premises visits. 83 Since the fire, the Brigade’s officers have also consistently engaged with local councils via the London Councils Fire Safety Group forum. This has enabled the Brigade to share information, advice and good practice on a range of issues such as Aluminium Composite Material (ACM) cladding, fire doors and buildings designed on the basis of a ‘Stay Put’ strategy. This engagement has enabled a consistent fire safety message and helped to maintain links between local councils and the Brigade’s Fire Safety Teams and Borough Commanders. In addition it has helped the Brigade to provide community re-assurance, particularly to those people living in residential high rise buildings. The relationship between the Housing Act, the Housing Health and Safety Rating System (HHSRS) and the Regulatory Reform (Fire Safety) Order 2005 (RRO) have also been discussed at this forum, as have topics such as Person Centred Fire Risk Assessments and Personal Emergency Evacuation Plans.

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Page 20 of 101 2nd April 2019 84 A number of additional FSR posts have been established as a result of the funding secured from the Mayor of London, following the Grenfell Tower fire, to enhance the Brigade’s inspection regime. This has included development officers, quality assurance officers and the re- engagement of previously retired Inspecting Officers to create a new ‘Specific Projects Group’. This new group is tasked to focus on high risk property types and complete a more thorough inspection as a result of the learning from the HRTF inspections. 85 The Brigade’s FSR department has also undertaken the following:  led on assisting the Ministry for Housing, Communities and Local Government (MHCLG) in producing guidance for buildings that have partial cladding;  provided subject matter expertise to assist Home Office and MHCLG in implementing the Dame Judith Hackitt recommendations. The Brigade’s officers hold prominent positions on all the working groups established to deliver the Hackitt recommendations;  designated a Brigade officer to lead the work on reviewing the competency of Brigade’s Fire Safety Enforcing Officers;  embedded a Brigade officer as a part of the Ministerial task force dealing with remediation of private tower blocks;  provided, through the FSR Fire Engineering team, assistance to several other fire and rescue services to help them deal with ACM clad buildings (peer review);  provided, and are continuing to offer, expertise to Home Office, MHCLG, the Expert Panel and the Dame Judith Hackitt review workstreams. This includes the additional engagement following the concerns raised over fire doors since it was reported that a door from the Grenfell Tower block failed the fire spread test;  providing advice and support to London local authorities through regular monthly meetings of the London Councils Fire Safety sub group. One of the outcomes for which has been a proposal with the Local Government Association (LGA) and London Councils for a joint inspection team to deal with uncooperative landlords. Theme 2 – Operational pre-planning Identification of risks 86 A range of legislation, including the Health and Safety at Work etc Act 1974 and the regulations made under that Act, place responsibilities on employers to ensure the health and safety of staff and others and involves obligations to identify and assess risks arising from work activities and to take all reasonably practicable measures to manage them.

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Page 21 of 101 2nd April 2019 87 The Fire and Rescue Service Act 2004 places a duty on the Fire Authority (in London the Fire Authority is the London Fire Commissioner) to make arrangements for obtaining information to make provision in respect of firefighting, road traffic accidents and other emergencies. 88 The Fire and Rescue National Framework for England places a duty on fire and rescue authorities to identify and assess the full range of foreseeable fire and rescue related risks their areas face, make provision for prevention and protection activities and respond to incidents appropriately. 89 The Framework does not provide any further definition to ‘foreseeable’ but directs authorities to consider its Local Resilience Forum Community Risk Register and any other local analyses to ensure all foreseeable fire and rescue related risks are identified and included in their integrated risk management plan. The Brigade delivers its responsibilities for an integrated risk management plan through the publication of its London Safety Plan. 90 To determine the foreseeability of an event, it is necessary, as described in the National Framework, for a fire and rescue service to identify the risks in its local area and assess the likelihood of those identified risks materialising and the severity of the consequences. Those events which are deemed to be reasonably foreseeable are those which the fire and rescue service must adequately plan, train and equip to respond to. 91 Having identified a range of risks, the assessment of likelihood invariably involves considering the regulatory controls undertaken or administered by others which impact on the scale and likelihood of any event occurring. Building regulations are an effective example of this in regard to buildings, whether in the context of fire or any other matter which may impact on their safety. Similarly, Department of Transport regulatory rules are provided to control the safety of the country’s transport network and these serve to reduce the risk of an incident or limit the scale of an incident. 92 One of the key factors which fire and rescue services must consider when assessing and identifying risk in the built environment is the extent to which statutory controls are already in place to regulate the risk. Fire and rescue services necessarily rely on the existence of such controls when making provision for the carrying out of their functions1.

1 Part 2 of the Fire and Rescue Services Act 2004 ss 6-20

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Page 22 of 101 2nd April 2019 Key observation 2.1 : Any knowledge concerning the risks associated with cladding systems may not been recognised and communicated effectively across the Brigade. 93 Evidence adduced in Phase 1 of the Grenfell Tower Inquiry, such as that contained in the ‘Tall Buildings’ presentation2 suggests that the knowledge cladding systems may have presented a risk was fixed, if not completely understood, within some sections of the Brigade. 94 The risks identified in the presentations were not solely focussed on the combustibility of cladding systems but also addressed the impact that such systems might have on fire behaviour, including elongation of flames behind rain screen systems and / or unseen fire spread in any cavities behind or within the cladding system. Similar information is contained within the BRE Global publication ‘BR 135’, issued in March 2013, which also discusses the fire performance of external thermal insulation for walls in multi-storey buildings. 95 The knowledge contained within the ‘Tall Buildings’ presentation was developed and used within the Brigade to educate Fire Safety Inspecting Officers, Fire Engineering staff and operational Senior Fire Safety Officers (SFSOs). 96 Fire Safety Inspecting officers are responsible for the Brigade’s fire safety enforcement duties, primarily in respect of the Regulatory Reform (Fire Safety) Order 2005 (RRO), seeking guidance when necessary. They carry out fire safety inspections/re-inspections and audits of all premises types to assess the risks and the adequacy of their fire precautionary arrangements. 97 LFB Fire Engineers undertake casework on projects where fire engineering has been utilised as either part of the design for new/refurbished buildings or existing solutions for a building. Their primary role is to review fire engineering design submissions received as part of the Building Regulations consultation process. Through this role they provide technical support to area fire safety teams, Fire Engineering Liaison Officers (FELOs) and act as subject matter experts at internal and external meetings. They may provide representation of technical opinion through committee representation for fire safety engineering technical documents such as new and revised British Standards, Approved Documents, Industry guidance and Codes of Practice. 98 SFSOs provide an emergency response role. They are mobilised in line with Policy Note (PN) 412 Mobilising policy. Their role includes a range of advice and support to Incident Commanders

2 LFB00003521

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Page 23 of 101 2nd April 2019 during the response phase of an incident. They can advise on what passive and active fire safety facilities might be in a building and how these may assist with operations. 99 It is clear from evidence provided to the Inquiry by Brigade witnesses and the Brigade’s internal investigation that information such as that contained within the ‘Tall Buildings’ presentation and BR 135 was not communicated effectively to those concerned with the development of operational policy and training. 100 Cladding is mentioned in both the 2014 and the earlier 2008 version of Generic Risk Assessment (GRA) 3.2 ‘Firefighting in high rise buildings’ which informed the Brigade’s local high rise firefighting policy, PN 633, and in both documents, cladding is mentioned in the ‘Planning’ section, as an example of a building construction feature that should be included as part of the information a fire and rescue should gather about high rise buildings. 101 The Brigade had a significant role in reviewing GRA 3.2 as it had identified and was in the process of implementing a number of lessons learnt from the high rise fire which had occurred at Lakanal House in July 2009. This incident had led to a significant loss of life and a range of learning had been identified through the Coroner’s Inquest and the internal investigations which had preceded it. The Brigade’s learning from this fire was incorporated into the Lakanal House Case Study, which was implemented as mandatory training for all operational staff in 2014. 102 The Brigade’s recent report3 into national guidance and local policy for high rise firefighting, commissioned by the Operational Policy and Assurance (OPA) department following the Grenfell Tower fire states the use of the phrase ‘such as’ in 2014 version was intentional and indicative of the fact that the building features listed were not meant to be either definitive or prescriptive, but were offered as a guide to the kind of information fire and rescue services should consider gathering about high rise buildings. 103 The report noted that cladding is not identified as a specific hazard in the ‘Hazard and risk’ section of either version of GRA 3.2 and reflects on the fact that no reference was made to cladding in the responses that were made by any of the consultees who offered feedback regarding the development of the 2014 version of GRA 3.2. The report details that cladding was included within ‘Planning’ because, as an outer layer on one or more faces of a high rise building, it was understood that the use of this material would create a void which had the potential to promote an abnormal degree of external spread of fire or smoke, as referenced in BRE 135 and

3 GTIRT19-000737

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Page 24 of 101 2nd April 2019 the ‘Tall Buildings’ presentation. As such, cladding was noted alongside timber-framing, surface- mounted trunking and voids as an example of a building construction feature that should be recorded within the information to be gathered by fire and rescue services in relation to high rise premises. 104 The Brigade’s PN 633, reviewed in 2015 following the publication of the 2014 version of the GRA, does not include cladding as one of the eight examples of building construction features that may be found in a high rise building but it is noted that neither GRA 3.2 or PN 633 purported to list all of the building construction features that may be found in a high rise building and may be relevant to high rise firefighting. 105 More recently, the Brigade responded to a fire at Shepherd’s Court in Shepherds Bush in August 2016 which originated in a two bedroom flat located on the seventh floor of the 20 storey purpose built block. The fire was of particular interest to the Inquiry due to the external fire spread which spread vertically from the seventh floor, after breaching a window, to the 12th floor and penetrated back into the building. It is noted, however, that the characteristics of the building were significantly different to Grenfell Tower. It did not have a rain screen cladding system fitted and the compartmentation within the building was maintained to a satisfactory standard, enabling the Brigade to deploy resources to contain and extinguish the fire on each floor. 106 The Brigade’s fire investigation into Shepherd’s Court determined that the external fire spread involved external panels fitted directly under and above the windows. Further investigation identified the panels were constructed with a plywood backing and an 1mm metal face, sandwiching a polystyrene foam. The investigation concluded that the fire attack on the panels, arising from flames breaching the window initially, was likely to have assisted the fire in spreading up the outside of the building. 107 It is noted that the result of this investigation was communicated to Hammersmith & Fulham Council and raised by letter with other borough councils and registered landlords to inform them of the potential risk and request that they include consideration of that risk in their fire risk assessment for premises within their respective property portfolios. 108 At this time, there is no evidence that the issue with the infill panels identified by the Shepherd’s Court fire was communicated to those departments responsible for operational policy or training.

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Page 25 of 101 2nd April 2019 Other UK fires involving cladding 109 There have been other fires in the United Kingdom such as the fire at Garnock Court in Scotland in 1999, which led to the introduction of the Building (Scotland) Regulations 2004 which came into force on 1 May 2005. It contains the mandatory regulation: ‘Every building must be designed and constructed in such a way that in the event of an outbreak of fire within the building, or from an external source, the spread of fire on the external walls of the building is inhibited.’ 110 At Westminster, the Select Committee on Environment, Transport and Regional Affairs examined the issue of fire spread in buildings via external cladding systems following the Garnock Court fire and concluded in December 1999; ‘The evidence we have received during this inquiry does not suggest that the majority of the external cladding systems currently in use in the UK poses a serious threat to life or property in the event of fire. There have been few recorded incidents involving external cladding, and, although in our view any loss of life in incidents such as these should be prevented if at all possible, neither have there been many deaths (indeed, it is uncertain whether any of the deaths in the fires of which we have been informed can be directly attributed to excessive fire spread via the external cladding). Furthermore, the responsible attitude taken by the major cladding manufacturers towards minimising the risks of excessive fire spread has been impressed upon us throughout this inquiry.’ 4 111 Historically, fire and rescue services have been provided with national guidance, in addition to the Generic Risk Assessments, through the following publications:  Fire Service Circulars, issued by HM Government and replaced by Fire and Rescue Bulletins from August 2010  Dear Chief Officer Letters, issued by HM Inspectorate of Fire Services up to June 2004  Fire Service Manuals, issued by HM Government  Manuals of Firemanship, issued by Home Office and replaced by the aforementioned Fire Service Manuals 112 The information provided by these publications was broad in scope, ranging from operational guidance, training requirements to notification of events or lessons learned that may impact on fire service operations or the safety of personnel, both nationally and internationally. It is noted

4 https://publications.parliament.uk/pa/cm199900/cmselect/cmenvtra/109/10907.htm

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Page 26 of 101 2nd April 2019 that the different regulatory environments that exist in other countries often impact on the usefulness of any analysis of international fire events. 113 Since 2018, the function of capturing operational learning from UK fire and rescue services and the wider international fire and rescue sector has been undertaken by the National Operational Learning (NOL) secretariat. Learning events are collated and analysed by the NOL secretariat, in partnership with experts across the fire sector and academia to check it against the guidance framework of hazards, control measures, strategic and tactical actions. The secretariat propose any recommended changes to guidance to the National Operational Learning User Group (NOLUG) who decide on the required actions. 114 NOLUG is a national group formed of strategic leads from across UK fire services, multi agency partners and representative bodies. It is the decision making body of national learning and sits within the National Operational Effectiveness Working Group. Operational Risk Information 115 The Brigade’s PN 800 ‘Management of operational risk information’ provides the policy framework and guidance for personnel on the Brigade’s risk based approach to identifying, gathering and disseminating operationally important site risk information and recording it on the Operational Risk Database (ORD). 116 In April 2012, the Department for Communities and Local Government (DCLG) and the Chief Fire and Rescue Advisor’s Unit (CFRAU) published the Fire and Rescue Service Operational Guidance - Operational Risk Information. The purpose of the guidance is explained as “…robust yet flexible guidance on developing and maintaining a consistent approach to managing, processing and using strategic and tactical operational risk information that can be adapted to the nature, scale and requirements of the individual Fire and Rescue Service.” and “… to provide consistency of approach that forms the basis for common operational practices, supporting interoperability between Fire and Rescue Services and other emergency responders … to support safe systems of work … and enhance national resilience.” 117 Following publication of this national guidance, the Brigade’s Strategy and Risk department undertook a gap analysis to determine the extent to which the Brigade was compliant with the published guidance. The outcomes were presented to the Corporate Management Board on 6th

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Page 27 of 101 2nd April 2019 March 20135 and noted that the Brigade’s system was robust and largely compliant with national guidance. 118 The Brigade’s ORD replaced the previous Central Risk Register (CRR) in April 2011 and is the main database which holds location-based operational risk information. The primary purpose of the ORD is to record significant hazards and risks, including any less obvious hazards and any unique control measures in place, as well as any particular tactical plans or command and control procedures required. Appropriate information and a tactical plan, when required, is added to the ORD by station personnel via the Station Diary application and assured by Station Commanders. 119 The information held in the ORD is made available to crews via icons on maps displayed on appliance Mobile Data Terminals (MDTs) and can also be accessed by the subsequent ICs through the systems available on the CUs. Key observation 2.2 : The Operational Risk Database entry for Grenfell Tower was not populated in accordance with PN 800. 120 Evidence provided during Phase 1 of the Inquiry indicated that the ORD entry for Grenfell Tower did not provide all of the information that may have been relevant to the premises, and provided some information that was inaccurate. This included the absence of an electronic Premises Information Plate (ePIP) which may have provided information to assist crews including dimensions and the basic layout of the premises, number of floors, details of available hydrants and the rising main, together with the locations of lifts. Key observation 2.3 : There is a lack of consistency in the standard of premises risk information held on the Operational Risk Database. 121 Further investigations by GTIRT and the Operations Directorate have ascertained the lack of quality identified in the Grenfell Tower risk information is an issue replicated more widely in the location-based operational risk information held by the Brigade. This can include but is not limited to inaccurate information, incomplete tactical plans, and the absence of an ePIP for the premises.

5 13-CMB043 Operational risk information – LFB response to national operational guidance

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Page 28 of 101 2nd April 2019 Key observation 2.4: The Brigade has not undertaken Premises Risk Assessments for all residential high rise premises to determine the level of risk associated with these premises. 122 The Lakanal House Incident Assurance Review report (Appendix D) identified the Brigade’s intention, following the Lakanal House incident, to undertake a premises risk assessment (PRA) on all residential high rise premises to determine the level of risk associated with those premises. 123 A PRA is normally carried out by the operational staff in whose area the premises is located. In almost every case a site visit is required and the template provided in PN 800 ‘Management of operational risk information’ assists in this process by identifying potential hazards and applying a score to that hazard. The template also identifies controls that reduce the risk such as the presence of a dry or wet rising main. 124 Using the identified areas of hazard on the PRA template, the visiting operational staff apply a risk assessment to the hazards and in conjunction with the local SM decide the level of risk within the premises and the resulting action to be taken. 125 The level of risk is applied to a risk grading matrix, which determines how often the premises should be visited, whether it requires an on site exercise, and whether hazard information or a full tactical plan needs to be recorded. It is noted that premises will not all meet the risk threshold to justify inclusion on the ORD, due to the absence of any premises based risks that may impact on a safe and effective operational response. 126 There are approximately 6900 residential high rise premises in London and it is noted that some boroughs have a disproportionately high number of high rise residential buildings and other premises that may require inclusion on the ORD. It is recognised that this presents a challenge for the Brigade to balance fulfilling the gathering of operational risk information in these areas with ongoing activities undertaken by crews in relation to community safety and training, in addition to providing a response to operational incidents. 127 Premises which meet the risk threshold to require inclusion on the ORD are then subject to a requirement for periodic 7(2)d visits, at a frequency determined by the risk rating applied to the premises as indicated by the PRA. The primary aim of 7(2)d visits is to assist crews to remain familiar with any specific risks associated with the premises and any unusual control measures not generally covered in policy and update or confirm any existing risk information. They are not the primary mechanism to initially identify the level of risk associated with a premises.

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Page 29 of 101 2nd April 2019 Key observation 2.5 : There is an inconsistent level of knowledge and understanding amongst operational staff in relation to undertaking 7(2)d visits. 128 A number of Brigade witnesses provided oral evidence to the Inquiry that demonstrated a good knowledge of the ORD and the purpose of 7(2)d visits, however this was not replicated by all witnesses suggesting there is an inconsistent level of knowledge and understanding amongst staff, despite the current training and guidance available. 129 Section 7(2)d of the Fire and Rescue Services Act 2004 places a responsibility on the Fire and Rescue Authority to make arrangements for obtaining information needed for the purpose of extinguishing fires in its area, protecting life and property in the event of fires in its area, rescuing and protecting people in the event of a road traffic accident, and rescuing and protecting people in the event of emergencies. 130 A Watch based training package on conducting 7(2)d visits was included as mandatory training in Operational News 24, issued in March 2013 and has been refreshed through station based training periodically. Operational risk information and 7(2)d visits are also addressed in the Lakanal House Case Study, issued as mandatory training for all operational staff in 2014. 131 In addition, there are a number of documents available on the Brigade’s intranet providing guidance to staff on outside duties, including 7(2)d visits, and the ORD, together with advice for SMs on quality assuring ORD entries. 132 However, it has been observed that the information provided in the Brigade’s policies and associated training packages in relation to undertaking 7(2)d visits is not completely aligned. PN 800 directs operational staff to pay particular attention to nine areas, whilst PN 633 Appendix 1 provides a list of 22 items for crews to consider and ensure they are familiar with. 133 The Fire and Rescue Service Operational Guidance – Operational risk information, provides no practical guidance on undertaking 7(2)d visits and focusses on the process for identifying premises which may become subject to 7(2)d visits. Recommendation 3 – The Brigade should consider reviewing its policies and training packages relevant to 7(2)d visits to ensure consistent guidance is provided to operational personnel.

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Page 30 of 101 2nd April 2019 Key observation 2.6 : There is no established means for crews providing an emergency response to premises outside of their own station areas to be aware of any fire safety deficiencies that may have been identified. 134 The Brigade has an established process to ensure that local crews are notified when a premises in their own station area has been issued with a Notice of Deficiencies or an Enforcement Notice following a fire safety audit or notification of an Alleged Fire Risk6. This is to ensure crews are aware of any issues that may impact on firefighting operations and / or increase the risk to firefighters or members of the public. 135 During further investigation into the area of operational risk information, it is noted that the Brigade, necessarily, has a pan London approach to fire cover which on occasion may lead to non- local crews being the first attendance to a fire or other incident type. Currently there is no system to ensure information about any identified deficiencies in the fire safety provisions in a premises are available to all operational crews that may be required to provide an operational response. Recommendation 4 – The Brigade should consider how to ensure information relating to identified fire safety deficiencies in a premises is available to all operational crews. Actions by the Brigade since the fire 136 The Brigade has instigated a corporate project to review and, where necessary, improve its system for the gathering, recording and dissemination of operational risk information. The objectives for the project are identified as:  Review and rationalise current risk information systems to evaluate the current entries and carry out the necessary interventions to increase the underpinning knowledge and understanding of staff with these systems.  To create a policy that encompasses understanding and identifying risk and provides a uniform approach to gathering, recording, prioritising and sharing of operational risk information.  The relevant risk information will be easily available to the right people at the right time in a form that is easy to understand and use.  Staff will have a better understanding of their role whilst assessing risks with regards to reducing the risks to firefighters and the risks to the public.

6 An Alleged Fire Risk (AFR) is a notification from an individual to the Brigade reporting their concerns about the fire safety arrangements at a particular premises.

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Page 31 of 101 2nd April 2019  To ensure staff have a better knowledge and understanding of risk and their responsibilities of ensuring the data collected and entered is relevant and accurate. 137 The project will link to and complement planned Information Technology (IT) system rebuilds, which aim to provide the data management framework and portal for an integrated approach to risk recording and notification across all the areas of service delivery. Theme 3 – Command and Control Incident Command 138 The Brigade sets out its incident command framework through a series of policies owned by the OPA department. Those policies are broadly but not fully aligned to National Operational Guidance (NOG). The key difference is the Brigade currently continues to operate the Decision Making Model (DMM) it has used successfully for many years and has not adopted the Decision Control Process (DCP) included within NOG – Incident Command, published in 2016. 139 The DMM was included in the ‘Incident Command, Fire and Rescue Service Manual’7 to support commanders during their operational decision making. The model is a simple flow diagram which guides users through the decision making process in an organised way. The process aims to reduce the potential for information to be missed and requires objectives to be set and implemented. The DMM provides the framework to support Incident Commanders (IC) to manage operational incidents effectively and bring them to a safe satisfactory conclusion. A diagram is provided below for illustrative purposes.

7 HM Government publication superseded by National Operational Guidance – Incident Command in January 2016

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Page 32 of 101 2nd April 2019 140 The DMM is formed around two main activities, Deciding and Acting. Each stage identified in the model falls into one of these activities.  Deciding - gathering and thinking about all available information; identifying appropriate objectives; defining a plan; and considering the results of evaluations.  Acting - communicating the objectives and tactical plan; controlling the activity; and evaluating the outcome of the plan. 141 The model also serves as a golden thread through the Brigade’s operational review and debriefing framework, including the Performance Review of Command (PRC) process. Recommendation 5 - It is recommended that the Brigade determines whether to retain the DMM or move to the DCP. It is acknowledged the Brigade needs to consider the challenges and benefits of implementing such a wider ranging and fundamental change to its incident command framework, at a time of significant organisational change and other improvement programmes. Human factors impacting on command and control 142 The following paragraphs provide a summary of information set out within NOG in relation to the impact of human factors on incident command and their relationship to the events observed during the Grenfell Tower fire. It notes that the influence of human factors on behaviour and performance at incidents should not be underestimated or overlooked when evaluating performance or effectiveness. 143 Human behaviour will influence individual activities in the operational environment of an incident in complex and significant ways. Whilst characteristics such as personality are fixed, others such as competence, skills, attitudes and beliefs can be enhanced, influenced and changed. 144 The guidance states that although personality, situation, and environment play an important role in behaviour, an individual level of risk acceptance dictates what this behaviour will be. Individuals subconsciously accept the level of risk they are comfortable with. In the operational environment of an incident, individual influences on behaviour will include issues such as personality, their attitude to safety and their risk perception. 145 NOG observes that stress will also adversely affect an individual’s behaviour. Acute stress is a reaction to sudden, unexpected events such as those that may be experienced when working in a dynamic, high-risk environment when commanding an incident. Such stress will involve

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Page 33 of 101 2nd April 2019 significant physiological and psychological effects akin to the fight, flight or freeze responses observed in animals. 146 There can be little doubt the personnel who attended the Grenfell Tower fire would have experienced acute stress to a greater or lesser degree, particularly those making risk critical decisions and those who entered the building to undertake firefighting, search and rescue operations. Many of those who attended the incident required counselling support afterwards and for some that support is ongoing, demonstrating the stress and trauma experienced on the night. 147 The guidance states that acute stress can adversely impact on incident command in a number of ways. It can impair situational awareness and decision making leading to a decline in individual and team performance. 148 Stress and anxiety take up part of a person's mental processing capacity and can distract attention from the situation and reduce available capacity to focus on and understand information. Failing to recognise important information or not processing it properly may lead to an inaccurate mental picture of the situation. Recommendation 6 - The Brigade should consider the extent to which human factors affecting command and control are addressed in policy and training. Key Observation 3.1 : The scale and rapidity of the incident, combined with human factors, impacted on the ability to maintain situational awareness. 149 From approximately 01:20hrs on the night of the fire, as the incident began to develop rapidly, situational awareness amongst those in command roles became reduced in relation to what was happening within the building in regard to internal fires and the resulting conditions. From around this time, the situation escalated with a rapidity and scale not previously experienced by the Brigade, placing those in key roles under stress. 150 Brigade witnesses who performed command roles describe in their evidence the difficulties of gaining a clear understanding of the developing situation within the building. Around this time, it is evident that radio communications started to become problematic as discussed later in this chapter (Theme 6 refers). In addition, fire survival guidance (FSG) calls started to be received from 01:21hrs by Brigade Control and a large volume of information had to be transferred to and processed on the incident ground.

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Page 34 of 101 2nd April 2019 151 The rapidly developing situation and the resulting human factors identified in the preceding paragraphs may have contributed to challenges in maintaining effective situational awareness. It is necessary to gather further information and review that evidence to develop a fuller understanding and reach a conclusion. 152 It is clear that reduced situational awareness can have a number of potential impacts on the command and control of an incident. The ability to identify and prioritise objectives and develop a tactical plan can be compromised by reduced situational awareness. 153 Effective incident command, particularly at large and complex incidents, requires the delegation of responsibility and authority through the process of sectorisation to limit the spans of control of one individual. NOG notes that excessive spans of control have the potential to adversely impact on the ability of an individual to manage an area of responsibility effectively. 154 Officers tasked with managing an operational or functional sector must be briefed so they fully understand their objectives, how these objectives fit into the tactical plan, and the parameters of their responsibility and authority. The evidence from many witnesses suggests that briefings included minimal information about the developing situation, hazards, risks, objectives, and priorities. It is likely those providing the briefings did not have the time or sufficient situational awareness to conduct a detailed briefing and therefore officers nominated for command and functional roles were often reliant on building their understanding on arrival at their respective scene of operations. 155 During the Grenfell Tower fire, the breadth and volume of information, even in the early stages, that needed to be understood by commanders to gain and maintain situational awareness was considerable. It included rapid external fire spread, fire penetration back into the building, the effectiveness of the internal compartmentation and its effect on internal fire spread, the ongoing self evacuation by residents and the FSG call information relating to those still located within the premises. 156 The scale of this challenge should not be underestimated, particularly in the context of an incident that was unprecedented in the experience of those attending the incident and it is also necessary to acknowledge the human factors described earlier. 157 NOG observes that human perceptual and memory systems are not infallible. A strong focus on one part of the situation, or element of the environment, can lead to other sources of information being neglected or missed resulting in reduced situational awareness. Impaired communication

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Page 35 of 101 2nd April 2019 resulting from stress is likely to affect teamwork, leading to a lack of shared understanding about the situation, objectives and plan. Task focus 158 Analysis of the evidence suggests that many officers became, understandably, task focussed at stages during the incident. Becoming task focussed can lead to becoming unduly fixed on some elements of an incident, rather than looking at the incident or their area of operations as a whole. 159 In evidence many officers stated that they had often made assumptions that processes were working effectively and information was being communicated to those that needed to be updated. A number of witnesses described not having the time to assure themselves that things were being done effectively and stated they trusted subordinates were undertaking their roles and any actions effectively. Extended period undertaking tasks 160 A number of supervisory officers also provided evidence that they were overwhelmed by the scale of the tasks for which they were responsible. In some cases, these supervisory officers were not provided with further support or assistance and were often performing those roles for many hours. 161 In addition to welfare concerns related to undertaking an extended period in a dynamic and stressful role, NOG notes that ICs should be aware of the effects of fatigue on themselves and others, and ensure people are relieved appropriately. It also states that actions should be taken before fatigue begins to reduce performance. Actions by the Brigade since the fire Briefings 162 The Brigade has included an article on briefings at incidents in its latest Operational News publication (Ops News, Issue 36), published in February 2019. The article highlights the DMM (PN 341 refers) as the preferred tool to inform effective briefings. 163 Operational News is a six monthly publication provided to all operational LFB staff. It is one of Brigade’s key mechanisms to raise awareness of good practice and areas for development, and are supported by links to training materials. The training that is attached to each subject area is categorised as either; mandatory for all operational staff, mandatory for specific staff groups, or to be delivered at the discretion of the WM dependant on current development needs. The training

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Page 36 of 101 2nd April 2019 is completed by staff in accordance with the categorisation of the training intervention and recorded in the Station Diary8. New technology to support situational awareness 164 The Brigade has recognised that drones may provide officers on the incident ground a range of new capabilities that have the potential to improve situational awareness and decision-making at incidents. It commenced an operational trial in October 2018 to evaluate two different drones for a six month period. Each drone is operated by a minimum of two operational staff, one who pilots the drone and one who operates its on-board cameras. The two members of staff will operate from a Brigade vehicle in a safe area and will cordon off a small area to operate the equipment. 165 The drone team will attend a range of different incident types during the trial to establish exactly how drones can best serve the Brigade in future. The trial will assist to answer a number of questions, such as many drones are required to provide pan-London cover, call out times, which incidents to deploy them to, and many other practical considerations. 166 In addition to improving firefighter safety, the obvious benefit is that drones will provide an aerial view of an incident without reliance on imagery from an partner agency such as NPAS whose assets may be employed at another location. 167 The Brigade anticipates drones to be more useful at some incidents than others, such as large warehouse fires when observation by firefighters at ground level or from aerials is difficult or hazardous, or grass fires over a large area that may develop spontaneously in new locations. 168 The trial will evaluate the usefulness and effectiveness of the drones at residential high rise fires during the six month period but it is anticipated they will provide a useful tactical option in both the response and recovery phases. The Brigade has received permission from the Civil Aviation Authority to fly a drone throughout most of London at low altitudes and close to buildings. 169 The drone can remain in flight for up to one hour and has two cameras, a heat-sensitive camera that can 'see' through thick smoke and detect hot spots, such as the seat of a fire and members of the public who may be trapped by a developing fire. The second camera has 30x magnification and can read a number plate from some distance away, up to half a kilometre. The drones can

8 Station Diary is a software application provided to enable the effective management and recording of the activities of station based staff.

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Page 37 of 101 2nd April 2019 also fly up to seven kilometres from the pilot, although it is noted that tall buildings may limit the distance in practice. 170 The footage shot by each camera is stored on a memory card that can be removed and the footage stored after each incident to assist with any post incident review. Key observation 3.2 : The rapid escalation of the incident impacted to a limited extent on command handovers. 171 It is noted that the initial IC, a WM, was in charge of the incident from 01:00hrs until approx. 01:50hrs when the role was taken over by one of the two SMs mobilised at 01:15hrs on receipt of the ‘make pumps six’ message. Further SMs were mobilised to perform the roles of Press Liaison Officer (PLO) and SFSO, together with a GM. These mobilisations were all in accordance with the requirements of the Brigade’s mobilising policy, PN 412. 172 Additional officers, including a DAC, were mobilised in accordance with PN 412 at 01:20hrs and 01:26hrs following the ‘make pumps eight’ and ‘make pumps 10’ assistance messages. This was followed by further officers, including an AC, following ‘make pumps 15’. 173 The attendance times following mobilisation for all officers assigned to Grenfell Tower was broadly compliant with Brigade expectations i.e. SM on scene in 20 minutes after mobilisation, GM on scene in 30 minutes and DACs and above on scene in 60 minutes after mobilisation. The exception was the GM first mobilised, who was off duty, and had been mobilised in error and therefore understandably did not respond to his pager. The failure to respond by contacting Brigade Control was not noted by Control staff who were, at that time, inundated by emergency calls and did not follow up the ‘failure to respond’ or mobilise a replacement GM. 174 In the context of the rapid escalation of the incident from the predetermined (PDA) to ‘make pumps 25’ in less than 30 minutes, it is not surprising that a WM remained as the IC during this period and beyond. 175 There was an opportunity at around 01:40hrs for the first SM on scene to take over the incident but this was jointly rejected in favour of the SM taking over the coordination of the FSG calls being received, knowing that a second SM was en route and would arrive shortly. This decision suggests both officers considered that the FSG calls represented the greatest opportunity to save life. 176 The rapidity and scale of the incident also created a situation that led to two officers simultaneously performing the IC role for a short period, one located by the Tower and the

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Page 38 of 101 2nd April 2019 second officer located in CU 8. This situation developed due to their different arrival points at the incident, with the first having to pass the current IC located on the south east corner of the Tower and leading him to immediately taking command of the incident. The second officer approached from a different direction and passed CU 8 and was informed he was the most senior officer in attendance and therefore took command. There is no evidence at this stage that this inadvertent situation had any adverse consequences on the command and control of the incident. 177 It is noted that the process of command handovers is often challenging during incidents that escalate very quickly, as identified by Her Honour Frances Kirkham during the Lakanal House Inquest. Following the Inquest, a Rule 43 recommendation was directed at the Brigade noting ‘It is recommended that the Brigade review its policy and procedures concerning incident command, having regard to whether it is effective for the choice of IC to be tied closely to the number or type of appliances attending an incident and the effectiveness of a policy which may result in rapid and frequent changes of IC’. 178 In response, the Brigade implemented changes to its incident command thresholds to reduce the number of handovers required, as part of series of measures to improve the delivery of effective incident command. Key observation 3.3 : Effective early information gathering enabled the ‘on arrival’ tactics and actions identified in PN 633 to be implemented effectively by the crews who formed the pre-determined attendance for the incident. 179 Information was gathered effectively by the initial IC in the early stages of the incident and used to select and implement a safe system of work to deliver the ‘on arrival’ tactics and actions detailed in the Brigade’s high rise firefighting policy. Experts have surmised that these actions resulted in the extinguishment of the fire in the kitchen of flat 16 within 21 minutes of arrival on scene, but not before the fire had breached the window and ignited materials contained within the combustible rain screen cladding system fitted to the exterior of the building. 180 It is recognised that crews had to overcome a number of issues in delivering the ‘on arrival’ actions including accessing the building and the failure of the lift to respond to the fire control switch.

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Page 39 of 101 2nd April 2019 Key observation 3.4 : There was effective early recognition of resourcing requirements by incident commanders. 181 There was a necessary and effective focus on identifying resource requirements as the fire breached the kitchen window of flat 16 and ignited materials in the cladding system, particularly by the initial IC who sent a number of ‘assistance’ messages up to ‘make pumps 25’. This escalation of resources was reinforced by subsequent ICs who ordered further pumping and specialist appliances resulting in the attendance of:  40 pumping appliances  14 Fire Rescue Units  4 aerial appliances  7 Command Units  6 Operational Support Units  24 senior operational officers. Key observation 3.5 : Recording of decisions, rationale, objectives and tactical plans were in some regards ineffective. 182 A number of witnesses discussed their objectives and tactical planning during their evidence to the Inquiry. One Brigade witness described in oral evidence their thinking around the evacuation of the building. The witness described his thoughts as prioritising those making FSG calls and those residents located in the immediate vicinity of the fire, followed by a systematic search beginning on the upper floors of the building. 183 However, there is little evidence that decisions and the rationale for them, objectives and tactical plans were effectively recorded during the incident. The recording of ‘key decisions’ such as the application of operational discretion is discussed in more detail below (Key observation 3.7 refers). 184 The recording of objectives and tactical plans are crucial to support effective communication with others within the command team to achieve a shared understanding and to enable the command team to control the incident through sectorisation and clear, visible lines of command. In addition, the recording of such information facilitates effective post incident review, whether by internal debrief processes or wider external scrutiny, such as that currently being undertaken by the Grenfell Tower Inquiry.

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Page 40 of 101 2nd April 2019 185 It is noted that the Grenfell Tower fire was beyond the experience of those who attended the incident. Such was the extremely dynamic nature of the incident, it is likely this impacted on the recording of decisions, objectives and the tactical plan that might ordinarily be expected at an incident. In addition, the reported inoperability of the Command Support System (CSS) during the incident may have been an additional factor in the absence of effective recording. Recommendation 7 - The Brigade should consider how it can most effectively raise awareness of and reinforce the requirements of PN 828 ‘Recording decisions at incidents’. Key observation 3.6 : Difficulty in confirming who was being rescued or self evacuating from the building and from where created difficulty in maintaining accurate records to inform the search and rescue operation. 186 Many witnesses working at the Bridgehead described in evidence the challenge of accurately gathering information about persons self evacuating or being rescued from Grenfell Tower. A number of factors appear to have impacted on the ability to gather this information, including casualties suffering physical or psychological trauma and communication issues. 187 Lack of information about where a casualty had been rescued or self evacuated from impacts on maintaining a search and rescue plan that reflects the changing circumstances and priorities of the incident. Similarly it can impact on wider situational awareness and the ability to evaluate progress of search and rescue operations and subsequent reporting on progress to others. 188 At the Grenfell Tower fire, it is observed that these challenges, combined with the movement of residents within the building, created circumstances that made it extremely difficult to ascertain which flats identified in FSG calls were actually clear of occupants because either, the occupants had self evacuated, had moved to a different location or had been rescued from elsewhere in the building. These challenges could have potentially led to taskings to individual flats being duplicated, impacting on resource utilisation or crews not being tasked to a flat because inaccurate information suggested the occupants had been rescued or self evacuated. Actions by the Brigade since the fire 189 It is noted that the Brigade has been reviewing PN 790 ‘Fire survival guidance’ and other associated policies and evaluating procedures with Brigade Control and operational staff to deliver effective service improvements in this area. Further details of this work are provided in paragraphs 275 – 277.

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Page 41 of 101 2nd April 2019 Recommendation 8 – Whilst it is recognised that the volume of FSG calls experienced during the Grenfell Tower fire and the information associated with those calls was unprecedented, it is recommended the Brigade considers the issues carefully to ascertain if any measures can be implemented to address this matter. Key observation 3.7 : Operational Discretion was adopted for the incident but it was not formally recorded in accordance with Brigade policy. 190 Due to the fast-moving and varied nature of fire service operations, it is not possible for the Brigade to provide explicit guidance that will satisfactorily cover all situations. On the rare occasion that operational guidance does not meet the needs of the incident, ICs can adapt or move away from an operational policy where this is necessary and justifiable in terms of risk versus benefit. The decision to move away from operational policy is known as ‘operational discretion’ and should be based on ‘professional judgement’ enabling the IC to make calculated decisions about the course of action appropriate in the circumstances. 191 The use of operational discretion must be recorded as soon as practicable at stated in PN 828 – ‘Recording decisions at incidents’. The policy states that where a decision is made to carry out actions that amend or change a current operational procedure, this needs to be recorded in a Key Decision Log (KDL) and a risk assessment of the proposed activity needs to be undertaken and recorded. The risk assessment must show the additional hazards and the associated risks that have been identified and that appropriate control measures are being implemented before any action is taken. This can be recorded on either the CSS or, if not available, on a KDL pad which are provided on all CUs. 192 Two training packages covering ‘Recording decisions at incidents’ are available on the London Fire Brigade / Babcock Training ‘Big Learning’ portal. One is aimed at station based personnel and the other at senior officers. 193 The dynamic nature of some incidents may mean that it is not possible for a decision log to be started immediately. However, key decisions are to be recorded as soon as reasonably practicable using the KDL form, or on the logging facility within CSS. 194 As discussed under key observation 3.5 there was no decision log started for the incident until 02:47hrs although the incident was necessarily operating outside of the Brigade’s policy framework, an example being crews deployed above a known fire situation without firefighting media.

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Page 42 of 101 2nd April 2019 195 Once the decision log is started it records a number of decisions that move outside of policy but there is no evidence, at the time of writing, that a risk assessment identifying the additional hazards and associated risks or the appropriate control measures is recorded. 196 See recommendation 7. Theme 4 – Operations Key observation 4.1: The Brigade had limited means to fight an external façade fire resulting from the non compliance of the installed external cladding system with the requirements of Regulation B4(1). 197 The response to fires in high rise premises is predicated on internal firefighting and supported by building regulations which provide for firefighting facilities within such buildings, including protected shafts, firefighting lifts, dry rising mains and internal compartmentation. 198 In his expert report for the Inquiry, dated March 2018, Mr Colin Todd noted that building regulations state ‘the external walls of a building shall adequately resist the spread of fire over the walls and from one building to another, having regard to its height, use and position of the building’. Mr Todd goes on to observe ‘that whilst the dynamics of fire, can potentially, result in the external spread of fire from one flat to the flat immediately above, fire spread significant beyond such an extent would demonstrate a failure to comply with Requirement B4(1) of Approved Document B’. 199 In respect of external firefighting capability, the Brigade has 11 frontline aerial appliances, which consist of three different types of vehicle: All three vehicle types have varying functions / capabilities and achieve a range of heights from 22 to 32 metres. In optimum conditions the turntable ladder has the maximum height reach of 32 metres, which is equivalent to the 10th floor of a typical high rise premises and it is likely, in most circumstances, that a firefighting jet can be applied as high as the 14th floor. 200 These vehicles were originally chosen, taking in to account factors such as the technology available at the time of purchase, the ability to locate the vehicles within the Brigade’s fire station estate, their operational capability and vehicular access in London’s streets. 201 In advance of the arrival of an aerial appliance or if there is insufficient access to deploy an aerial appliance, handheld jets and / or ground monitors can be deployed to provide an external

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Page 43 of 101 2nd April 2019 firefighting capability. However the reach of any such firefighting jet is limited by a number of factors, including but not limited to water flow, pressure, proximity to the fire. 202 Grenfell Tower did not have an aerial appliance included on the PDA for the premises at the time of the fire. The nearest aerial appliance to Grenfell Tower is located at Paddington fire station and it is noted this was the appliance (A213) mobilised in response to the first request for an aerial appliance. 203 Having examined the incident log and noted a travel time of 12 minutes from Paddington to Grenfell Tower and assumed a minimum of 15 minutes to get the appliance sited and working, it is likely that even if A213 had been mobilised at 00:55hrs as part of the PDA for the premises, the external fire would have been near if not past the reach of the appliance’s water monitor. 204 It is notable that access issues meant that no aerial appliance was able to operate on the north or west elevations of Grenfell Tower. Operations on the south elevation were restricted by the Grenfell walkway and the grassed area on the east elevation was not identified as suitable for positioning a large aerial appliance albeit a aerial appliance was set up on this area after the crew risk assessed that the recent period of hot weather had resulted in the ground being firm enough to support the weight of the aerial appliance. 205 It is clear from documentary evidence that a water jet was directed intermittently at the east elevation of Grenfell Tower between 01:15 and 01:25hrs before the crew ceased this activity and returned to their appliance to rig in BA sets at around 01:28hrs. Attempts at external firefighting were also made from the kitchen window of flat 16 once the original fire had been extinguished. This was undertaken at significant risk by crews leaning out of the window space and directing the jet at the flames above. Ultimately this initial external firefighting was not successful and flames had reached the 23rd floor by 01:30hrs. Dr Lane concluded that it was not possible for any handheld jet to reach beyond the 7th floor. 206 Further external firefighting was carried out on the east elevation from around 01:43hrs by a ground monitor and by a turntable ladder, A213, until 02:07hrs when it was housed and re- located due to falling debris. It was re-pitched and recommenced firefighting operations until 02:18hrs when it was again housed and moved under the Grenfell walkway due to falling and burning debris. 207 Whilst external firefighting operations were improvised on all four elevations of Grenfell Tower and Dr Lane noted there is a strong correlation between the floors to which water was applied and the lack of external fire damage to these floors, it is recognised that the Brigade did not have

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Page 44 of 101 2nd April 2019 the capability to apply water effectively to the exterior of the building above the 14th floor. It is also noted that due to access restrictions, an aerial was unable to operate on the north and west elevations and therefore water could only be applied up to the seventh floor on these elevations. 208 Dr Lane provided an opinion in her 5th November 2018 report that ‘it is not acceptable to expect the fire and rescue service to mitigate the risk posed by combustible external wall construction in high rise residential buildings, as there are so many reasons why that is not feasible’. Actions by the Brigade since the fire Aerial appliances 209 At the time of the fire, the Brigade was finalising the procurement of 15 state of the art articulating head 32m turntable ladders to replace its existing aerial fleet. Partially in response to the Grenfell Tower fire and the new risk presented by clad buildings, the Brigade modified its procurement plan to incorporate three 64 metre turntable ladders. These extended reach aerial appliances will be strategically located across London to complement the standard aerial fleet. Deliveries of new fleet of aerial appliances, built by Emergency One Limited, are scheduled to commence in January 2020 for the 32 metre variant and in July 2020 in respect of the 64 metre model. Pre Determined Attendance (PDA) 210 As a result of the Grenfell Tower fire, and whilst awaiting the outcome of the MHCLG work into cladding on high rise buildings, the Brigade implemented an interim change to the PDA to all high rise buildings. This revision took effect from 22nd June 2017 with five fire engines, one aerial appliance and the standard officer complement for a five pump fire being mobilised to any high rise fire related incident. 211 In addition to the above, and as a result of the findings from the Government’s series of fire safety tests of cladding and insulation combinations undertaken by the Building Research Establishment, the Brigade made a further interim revision to the high rise PDA starting from 10th August 2017. From this date when Brigade Control receives multiple calls (four calls or more) to a residential high rise premise the PDA now includes eight fire engines and one aerial appliance. Where the fire is reported to Brigade Control as involving the outside of a clad building the PDA is further increased to ten fire engines and one aerial appliance (if the aerial appliance hasn’t

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Page 45 of 101 2nd April 2019 already been despatched). When this increase in resources is made the standard officer complement for an eight and ten pump fire is also mobilised. Key observation 4.2 : Extensive breaches of compartmentation resulted in simultaneous serious fires on multiple floors, impacting on the Brigade’s operational response. 212 The external fire experienced at Grenfell Tower was significant in terms of its scale and by the rapidity of the spread and precipitated fires internally on multiple floors. 213 The premises was provided with a number of active and passive fire safety measures which were intended to create a layered safety system intended to provide the means for an early internal firefighting intervention. This is achieved by providing the means to limit fire and smoke spread from a dwelling fire and create the high degree of compartmentation necessary to support the ‘Stay Put’ strategy in a high rise residential premises. 214 Once the fire was established within the rain screen cladding system the fire safety measures provided within Grenfell Tower were required to perform during an event not considered by Building Regulations – a multi storey fire. 215 Dr Lane in her report, dated 5th November 2018, concluded that ‘The high degree of compartmentation had suffered its primary failure, caused by the fire spreading through the rain screen system’. 216 Professor Jose Torero in his expert report, dated 23rd May 2018, states ‘Firefighting protocols for response to high rise building fires are intimately linked to a single floor fire. Furthermore, for residential buildings, the firefighters should find, on arrival, a single unit fire’. 217 In practical terms, the failure of the compartmentation resulted in the Brigade facing and being required to mitigate a number of significant and linked fire events, spread across multiple floors. As described by Professor Torero, the firefighting provisions do not anticipate fire spread affecting multiple floors and as such the water supply provided through the dry rising main is predicated on a single unit fire event and, and as such, is only required to provide two or three firefighting jets. 218 The impact of this was that the Brigade was unable to undertake simultaneous firefighting on multiple floors to extinguish or control the fires. The deteriorating conditions within the lobbies and stairwell resulting from these fires affected the ability of residents to self evacuate from the building and hindered the Brigade’s attempts to effect rescues.

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Page 46 of 101 2nd April 2019 219 In order to progress the search and rescue operations, it was necessary to deviate from Brigade’s operational policy and commit firefighters above fire situations and into hazardous environments without firefighting media. 220 Compliance with the Brigade’s operational policy would have resulted in a limited or no search and rescue operation above the fourth floor, so commanders took what must have been a difficult decision to continue operations by applying operational discretion. Actions by the Brigade since the fire Provision of water 221 The Brigade is currently reviewing existing solutions and undertaking further research into the practical water pressures and flow rates that can be achieved at the maximum height of dry rising mains, particularly those premises built when dry rising mains were permissible up to 60 metres. This work is aimed at identifying if the Brigade’s current hose equipment and pumping capabilities are able to provide optimum fire fighting jets at the maximum height of a dry rising main. This research will involve practical testing at a number of residential high rise premises with similar characteristics to Grenfell Tower. High rise firefighting policy (PN 633) 222 PN 633 ‘High rise firefighting’ and the associated training materials have been the subject of an extensive review by the Brigade’s OPA department. The revised policy is currently out for consultation with the Brigade’s Heads of Service. It is also being extensively consulted on with the two main Representative Bodies; the Fire Brigades Union (FBU) and Fire Officers Association (FOA). National Operational Guidance 223 The Brigade is also supporting the development of NOG for high rise fire fighting following the Grenfell Tower fire. Two immediate issues were identified by the Grenfell Tower fire ‘safety and learning’ investigation;  rapid fire spread taking place at the early stages of an incident and well before the expectation of when compartmentation of a building would normally be compromised, and  how Fire Survival Guidance (FSG) calls are managed nationally when this type of call is passed to another fire and rescue Control.

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Page 47 of 101 2nd April 2019 224 Both issues have been communicated to the Fire Central Programme Office, where the Brigade have worked closely with the NOL Secretariat. This has produced a series of recommendations. NOLUG 225 These recommendations have resulted in a number of national ‘Action Notes’ being published through the NOLUG forum. These include:  An Action Note sent to ‘Skills for Justice’ (the sector skills council for the fire and rescue service) with a recommendation for the review of the National Occupational Standards (NOS), with a purpose of ensuring relevant knowledge and understanding of building construction, fixed installations, fire science and fire engineered solutions that complement NOG – ‘Fires in buildings’;  An Action Note to all fire and rescue services in the UK highlighting the existing requirements under the NOG control measures: 'Produce a risk management plan' and ‘Site Specific Risk Information (SSRI)’, in reference to high-rise premises designed or constructed in a way that may result in rapid fire spread. The note states that the National Fire Chiefs Council (NFCC) support the approach of fire and rescue services determining their PDA for specific incident types on the basis of their own operational risk assessment (ORA). Each ORA will be cognisant of the need to achieve the appropriate speed and weight of attack;  An Action Note to NOG recommending a number of hazard and control measures relating to rapid fire spread and appropriate provision for fire survival guidance has also been issued. NFCC Simultaneous evacuation guidance 226 The Brigade also provided significant support to produce the NFCC publication ‘Guidance: To support a temporary change to simultaneous evacuation strategy in purpose-built blocks of flats’9 for owners and persons / organisations responsible for buildings fitted with Aluminium Composite Material cladding. This guidance was published in May 2018 and superseded an earlier version published in October 2017. The guidance has been appended to this report as Appendix F.

9 https://www.nationalfirechiefs.org.uk/Simultaneous-evacuation-guidance

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Page 48 of 101 2nd April 2019 Key observation 4.3 : The building behaved in an unpredictable manner beyond the experience of the Brigade. 227 The fire at Grenfell Tower originated in flat 16 on the fourth floor having started in an electrical appliance. The evidence of the Inquiry experts identified that the building owners, Royal Borough of Kensington and Chelsea (RBKC), had declared a ‘stay put’ strategy for the building which was confirmed in its most recent fire risk assessment. 228 The ‘stay put’ strategy documented in guidance has been a principle of building design since the 1960s and works on the assumption that residents are safe to stay in their flats unless directly affected by fire, heat or smoke whilst the fire service extinguishes the fire. That principle is founded on the building being constructed to provide a series of fire resistant compartments (the flats), one or more protected means of escape, and fire safety measures to support internal firefighting to ensure the fire in the compartment of origin can be extinguished before it spreads beyond that compartment. Behaviour of the external fire 229 The fire in the compartment of origin was extinguished at 01:21hrs but had breached the kitchen window on the east elevation of Grenfell Tower. This, in itself, is not an usual event and the Brigade and its operational personnel have experience of this situation. More unusually, the fire emanating from the window ignited materials within the rain screen cladding system installed on the original external walls of the premises and proceeded to spread vertically. 230 The Inquiry expert, Mr Colin Todd states in his report, dated March 2018 ‘whilst the dynamics of fire, can potentially, result in the external spread of fire from one flat to the flat immediately above, fire spread significant beyond such an extent would demonstrate a failure to comply with Requirement B4(1) of Approved Document B’. 231 The resulting fire continued to spread vertically, reaching the top of the building by 01:30hrs. The fire then proceeded to spread laterally in both directions, assisted by the presence of an architectural crown, whilst causing burning droplets to create further fires within the cladding below, resulting in what appeared to be a diagonal fire front burning laterally in both directions on the east elevation. 232 At 01:42hrs, the fire had reached the north east corner of the building and proceeded to continue to spread laterally across the north elevation. At 02:25hrs, the second flame front had reached the south elevation and continued to spread. At 02:51hrs the first flame front had

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Page 49 of 101 2nd April 2019 reached the west elevation and by 04:44hrs, all four elevations of the building were fully involved in the external fire. Training on high rise external fires 233 A number of Brigade witnesses stated they had no specific training on fires in cladding. Many witnesses explained that it was their expectation that exterior of a building could not burn in the way experienced at Grenfell Tower but did demonstrate an understanding of the ‘coanda’ effect referenced in GRA 3.2 and PN 633. 234 A number of witnesses provided evidence that their experience and expectations of external fires on high rise buildings involved fires in netting provided for safety purposes on scaffolding around buildings under construction or refurbishment, or involved fires on the balconies of such premises . Penetration of the fire internally 235 Internal penetration of the fire through open or failing windows subsequently caused internal fires on multiple floors which in turn spread further as a result of compartmentation issues. 236 Evidence from witnesses suggested that the extent of any internal fires was not clear to command officers until some time after 02:15hrs, although some witnesses acknowledged the likely presence of smoke within the building as indicated by the FSG calls. GRA 3.2 and PN 633 237 Following the Lakanal House fire and a number of other significant fires in high rise premises, GRA 3.2 was reviewed and 15 new hazards were incorporated and others were enhanced with additional information in the 2014 version. The new hazards included make explicit reference to the fact that fire and smoke can spread in an upward, downward and horizontal direction and in ways that can be less predictable than in other building types. A new hazard was identified with regard to the risk of fires occurring simultaneously on multiple floors and explicit reference is made to the fact that falling debris has the potential to cut hose lines and interrupt water supplies during firefighting. 238 The Brigade’s PN 633 was reviewed following the publication of the revised GRA 3.2 and generally reflects the information contained within the GRA. Notably PN 633 makes reference to the fact that fire and smoke can travel in any direction and the downward travel, in particular, can

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Page 50 of 101 2nd April 2019 have an adverse impact on fire service operations. It also notes the potential for fires on more than one floor. 239 A full explanation of the development of both documents, their relationship and any differences is set out in the Brigade report ‘National guidance and London Fire Brigade operational policy for fighting fires in high rise buildings’ is appended to this report as Appendix E. 240 The Brigade has previously addressed unusual fire spread in two training interventions, specifically, the Lakanal House case study in 2014 and the High Street, Barkingside case study in 2012, completion of which were mandatory for all operational personnel. Additionally, unusual fire spread was addressed in two issues of Operational News, issues 20 and 28, dated November 2011 and December 2014 respectively. 241 The extent to which, and when, the Brigade’s officers recognised the significance of and the potential consequences of the external fire and the unexpected fire and smoke spread within the building will be a key area of investigation in Phase 2 of the Inquiry. 242 An effective recognition of both matters was inextricably linked to any consideration of the requirement for a full simultaneous evacuation of the building. Actions by the Brigade since the fire 243 It is noted that the Brigade has commissioned a comprehensive review of its training provision following the major incidents that the Brigade responded to in 2017. It is being undertaken by an independent consultancy company, Ribband Star Limited, and is expected to take six months to complete. 244 The purpose of the review is to provide an objective baseline of organisational awareness of operational training including Control training and support key organisational priorities and provide an evidence base for continuous improvement. 245 The review will examine four key areas:  Acquisition of Skills/Knowledge o An assessment of the effectiveness of all operational training provided by the Brigade’s third party contractor, Babcock Training Limited.

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Page 51 of 101 2nd April 2019 o An assessment of the effectiveness of Brigade Control training provided by the Brigade’s Control training team.  Maintenance of Skills o To review systems in place – and those proposed for Developing and Maintaining Operational Professionalism (DAMOP) – to ensure that maintenance of skills activities are undertaken at all operational levels including Control training and that assurance mechanisms are in place to evidence that the service is maintaining an operational readiness to an appropriate professional standard.  Routine testing/quality assurance o To provide an assessment of quality assurance processes in place within the Brigade and Babcock Training Limited ensuring that assurance processes are fit for purpose.  Future proofing o To analyse whether the current training provision (acquisition and maintenance) is risk based and is adaptive to future demands. Recommendation 9 - The Brigade should consider to what extent recognition that a building is behaving unpredictably in fire is addressed in policy and training. Key observation 4.4 : The building’s single escape route was significantly compromised by the products of combustion from an early stage of the incident. Protected lobbies and stairs 246 The means of escape to the final exit at Grenfell Tower was a single staircase provided with a protected lobby at every storey. A smoke control system, an active measure, was provided to protect each lobby and in doing so protect the single escape stair. 247 The evidence from witnesses and the Inquiry’s experts indicate that the active and passive fire protection measures in the lobbies and stairwell failed to perform adequately on the night of the fire and became compromised by heat and smoke from some time between 01:21 and 01:40hrs. 248 The failure of the protected lobbies is attributed by Dr Lane to flat front doors failing to control the spread of fire and smoke from flats into the lobbies and vice versa. This is attributed to a lack

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Page 52 of 101 2nd April 2019 of performance, initially identified by a fire resistance test undertaken by BRE Global, on behalf of the MPS, on a sample door of the type fitted to the majority of flats within Grenfell Tower. 249 Evidence available to date indicates there is a close correlation between the progress of the vertical fire spread and the presence of smoke in lobbies. For example, smoke is reported in 13 of 20 lobbies between 01:19 and 01:38hrs, increasing to 15 out of 20 lobbies by 01:58hrs. By 02:38hrs, smoke is reported in 19 out of 20 lobbies with severe temperatures on floors six to 10. 250 British Standard 9991:2015 states ‘Whilst a simultaneous evacuation is normally not necessary, there will be some occasions where operational conditions are such that the fire and rescue service decide to evacuate the building. In these situations, the occupants of the building will need to use the common stair, sometimes whilst firefighting is in progress. As such, the measures in this British Standard for the protection of common stair are designed to ensure that they are available for use over an extended period.’ 251 Dr Lane has further noted in her report in relation to the stair doors ‘I observed no fire damage in the stairs consistent with the total failure of a stair door, allowing fire spread onto the stairs’ but does note ‘the non-compliances I have identified would have contributed to the failure to prevent the spread of smoke to the stair’. Mechanical smoke control system 252 A replacement mechanical smoke control system was installed in Grenfell Tower during the 2012-2016 refurbishment, its purpose being to control the amount of smoke entering a lobby and therefore reducing the risk of smoke spread to the protected stair. The smoke control system was intended to operate on one floor only, as per the requirements of Approved Document B, and was not expected or designed to operate on multiple floors simultaneously. 253 A smoke detector was present outside flat 16, the fire compartment of origin, and this detector should have activated the smoke control system on the fourth floor. There are no reports of smoke in any other lobby at this time. Evidence from residents report thick black smoke entering the stairs from the lobby on the fourth floor, indicating the smoke control system was not operating as designed. 254 As detailed in paragraph 249, the failure of the mechanical smoke control system to operate as designed contributed to the extensive spread of smoke into a number of lobbies and the protected stair as the fire developed.

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Page 53 of 101 2nd April 2019 Positive Pressure Ventilation 255 The Brigade has a limited Positive Pressure Ventilation (PPV) capability incorporated within its Special Operations capabilities but it is not, at present, a frontline capability. PPV can be utilised to undertake the planned and systematic removal of heat and smoke from the structure on fire, and their replacement with a supply of fresher air in order to facilitate other firefighting priorities and is used extensively by other UK fire and rescue services. 256 The IC requested PPV at 02:57hrs and it arrived on scene at around 04:00hrs. An attempt to use the PPV at around 05:00hrs to improve conditions in the ground floor lobby was unsuccessful and actually worsens the conditions, so its use was discontinued. Challenges presented by the conditions 257 The circumstances described above created challenging conditions for anyone seeking to evacuate from the building and for firefighters attempting to rescue those trapped within the building. In some instances firefighters were forced to make decisions, having reached a resident/s, as to the viability of moving a person through conditions that may have been considered untenable in terms of saving life and were often changing second by second. 258 In some cases, firefighters opted to leave residents in situ or move them to safer areas to avoid the risks presented by the untenable conditions. On one occasion around 02:00hrs, a crew utilised spare firefighter BA sets, obtained from the bridgehead, to rescue a mother and daughter from ninth floor. This improvised method of rescue was not replicated during the remainder of the incident but remains a commendable example of the ingenuity of firefighters. 259 Those conditions described above may have impacted on the feasibility and potential success of any full evacuation from the building, owing the very real but unquantified danger that those evacuating may have been overcome by the conditions encountered in the lobbies and stairwell, assuming that residents could have been contacted to advise on evacuation. It is noted that there was no central alarm system fitted to Grenfell Tower, nor was there any regulatory requirement for such a system. Actions by the Brigade since the fire 260 Recognising the challenges that Brigade officers faced in respect to the catastrophic failure of the Grenfell Tower building, in particular that associated with the protected single staircase which became compromised by heat, smoke and fire at a very early stage of the incident, the Brigade

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Page 54 of 101 2nd April 2019 has undertaken research and procured fire escape hoods (also commonly referred to as smoke hoods). Fire escape hoods 261 Fire escape hoods are designed to be used easily by members of the public where they need rescuing through smoke filled environments, such as those experienced at Grenfell Tower. They provide members of the public with up to 15 minutes of protection from four of the main fire gases and can be worn by conscious and unconscious persons. If more than 15 minutes of protection is required then another hood can be given to each wearer. Firefighters will be able to offer a hood to those being rescued and they can also be used to protect those who are not able to escape easily, such as the elderly or those with limited mobility. 262 The fire escape hoods have been issued to all frontline appliances across the Brigade and are carried on the Brigade’s standard and extended duration BA sets. This provides a total of 649 hoods on frontline appliances and gives firefighters and officers a new tactical option should a similar building failure occur in the future. 263 Since their introduction and at the time of writing, the fire escape hoods have been used on 8 occasions to protect 16 members of the public from hazardous conditions created by the products of combustion. PPV and PN 833 – Tactical ventilation 264 The Brigade has extensively reviewed PN 883, Tactical Ventilation as of the 4 April 2018, reiterating that the PPV equipment and capability is currently under evaluation. They have also added Appendix 1 to PN 883,which explains the functionality and capabilities of PPV. 265 In addition, the OPA department has recently initiated a PPV project group. The aim of this group is to deliver level 1, defensive ventilation, which is carried out away from the fire, or after the fire is extinguished, to remove heat and smoke, particularly to improve access and escape routes in areas of the building not directly affected by fire. The aspiration in phase one of the project is to place 10 PPV into operational service at 10 strategic locations to provide the Brigade with a defensive ventilation operational capability. The Brigade has allocated £350k to evaluate and deliver this part of the project. 266 The Brigade still retains two sets of PPV reserved specifically for its Special Operations capabilities and this equipment is now available on two specialist vehicles; one for responding to terrorist incidents and the other on a vehicle carrying an ultra high pressure lance used to

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Page 55 of 101 2nd April 2019 suppress fire conditions, particularly in situations when it not possible to enter a compartment on fire. Future firefighting technology 267 The Brigade is also evaluating the introduction of other new firefighting technologies for frontline appliances including the ultra high pressure lance and misting systems. Both have identifiable benefits for firefighter and public safety in many operational scenarios. Key observation 4.5 : Number of FSG calls and the resulting volume of information significantly exceeded the expectations of Brigade policy and training. 268 Following the Lakanal House fire in 2009, the Brigade reviewed its procedures for managing fire survival guidance calls and introduced PN 790. In addition, it introduced Forward Information Boards to record key information at a range of different incident types and PN 820 to support their use. At the Lakanal House fire, crews recorded FSG information on walls at the Bridgehead and it was identified that this risk critical information could be lost if the Bridgehead was forced to relocate due to deteriorating conditions. 269 The first of 152 calls from persons located within Grenfell Tower was received by Brigade Control at 01:21hrs and the volume increased exponentially to an extent that British Telecom began transferring calls to other fire and rescue service Control rooms, namely North West Fire Control, Essex FRS, Merseyside FRS, Surrey FRS, and Kent FRS. There is also evidence that calls were received by other agencies during the course of the night including the MPS and London Ambulance Service (LAS). The last call received from someone inside Grenfell Tower was received at 04:33hrs. 270 The evidence adduced in Phase 1 of the Inquiry suggests that there were a number of communication channels for FSG information established from Brigade Control to the incident ground during the first two hours of the incident. 271 On the incident ground as the volume of FSG calls intensified, the process of transferring information to the Bridgehead became more complex as additional officers and communication systems were introduced incrementally into the system. Evidence from witnesses indicated that various elements were working independently without knowledge of the other. 272 Around 02:00hrs, an FSG coordinator was appointed to manage the information and allocated CU7 for this purpose. All FSG information held on CU8 was transferred to CU7. Once CU7 was

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Page 56 of 101 2nd April 2019 set up and established, a message was sent to Brigade Control at 02:22hrs advising that all FSG information should be passed to CU7. 273 In the fire sector, crews, as they had at the Lakanal House fire, resorted to recording FSG information on walls in all three locations where the Bridgehead was set up. It is not clear if the use of multiple Forward Information Boards (FIB) was considered to manage the volume of information. Information was photographed on a mobile phone when the Bridgehead was relocated to ensure it was captured and re-recorded in the new Bridgehead location. 274 It is clear that the Brigade’s policies and training did not anticipate the volume of the FSG information and the rapidity with which it was received. Evidence from witnesses suggest that incidents or exercises involving more than three or four FSG calls are extremely rare. Actions by the Brigade since the fire 275 The Brigade’s OPA department is currently reviewing PN 790 and the extant processes used to manage FSG calls to identify improvement. To date, five exercises have been conducted with Brigade Control to identify any resourcing difficulties and the interface between Brigade Control, CU, and the Bridgehead. The exercise used was based on a high rise incident with FSG phone calls into Brigade Control from members of the public (role played by firefighters). 276 Any identified improvements arising from an evaluation of these exercises will necessitate further testing and consultation with Representative Bodies before they can be incorporated into policy and training solutions identified and implemented. This is likely to take some months and no clear outcomes are expected before the end of the summer 2019. 277 The Brigade’s CU replacement programme may also offer a longer term technical solution which delivers further improvements. Key observation 4.6 : Operational personnel were required by circumstances to provide fire survival guidance to residents, a task not anticipated by policy or training. 278 During the course of the Grenfell Tower fire, firefighters were required to provide fire survival guidance to members of the public in a number of ways. 279 There are a number of instances where BA crews, having reached the location they were tasked to, had to make calculated decisions on the tenability of conditions within the building that were often changing by the second, to determine whether it was feasible to evacuate the persons trapped. Crews would have had minimal situational awareness of conditions away from their

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Page 57 of 101 2nd April 2019 immediate location and radio communications issues meant they could not seek information on conditions from others. Similarly, issues with radio communications resulted in crews being unable to seek advice or support from others on the most effective course of action. 280 When crews determined the risk arising from an attempted evacuation was too great, they were then required to provide instructions and advice to keep residents safe until a subsequent rescue attempt could be made. 281 Outside Grenfell Tower, there were a number of occasions where firefighters and officers were required to talk to trapped residents directly on the phone or indirectly through family or friends. On some occasions, residents were encouraged to ring 999 to ensure their information was recorded accurately and transferred effectively. 282 On other occasions, firefighters felt a moral duty to help and engaged to provide advice and support directly to residents on the phone. In one instance, a firefighter stayed on the phone for a considerable length of time until the call dropped out when the resident is likely to have become overcome by smoke. 283 The issues described above are not anticipated by policy and firefighters and officers have received no specific training in relation to this situation, other than the more general knowledge and understanding of fire survival guidance and the ‘stay put’ strategy. Actions by the Brigade since the fire 284 The Brigade’s OPA department are considering this issue within its wider review work around PN 790 and the systems and processes related to FSG calls, as detailed in paragraphs 275 – 277. Key observation 4.7 : Operational crews had problems physically identifying floor numbers in the stairwell. 285 Many Brigade witnesses involved in the search and rescue operation noted that it was difficult to establish what floor they were on due to the lack of suitably visible markings in the stairwell indicating the floor number. This may have created delays to the search and rescue operations as crews had to periodically enter lobbies to identify on which floor they were located by checking numbers of flat front doors. 286 In addition to potential delays in getting to the floor or flat that they had been tasked to, this issue resulted in crews having to enter lobbies unnecessarily, in order to identify which floor they were on. Often, these lobbies were significantly involved in fire and / or heavily smoke logged

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Page 58 of 101 2nd April 2019 and many of those crews did not have firefighting media available to them, owing to water supply issues arising from the capacity of the DRM. This placed them at greater risk than was entirely necessary. Actions by the Brigade since the fire 287 The Brigade has suggested the requirement for adequate markings within buildings to indicate floor levels should be more effectively addressed in building regulations as part of its comprehensive response to the government’s consultation on the technical review of Approved Document B (ADB). Key observation 4.8 : Some elements of the BA operations during the Grenfell Tower fire were not fully aligned to the Brigade’s operational procedures set out in PN 466. 288 The Brigade’s BA operations are governed by a procedural framework set out in PN 466 ‘Respiratory protective equipment (RPE) – BA operational procedures’. This PN is supported by nine additional PNs addressing technical specifications, BA operations for specific incident types, ancillary equipment, personal protective equipment and radio communications equipment. 289 The purpose of BA and associated control procedures is to reduce the risk of respiratory discomfort or injury to personnel and provide safe systems of work when BA is used. It is important that personnel who may be required to wear BA or undertake entry control duties understand and properly implement these procedures at all times. 290 At any incident, the IC is responsible for ensuring that RPE is worn whenever there is a risk of personnel suffering respiratory discomfort or injury. Where any doubt exists as to the presence of a respiratory risk, the IC will give instructions for RPE to be used. BA is the default level of respiratory protection for fires and other incidents presenting an acute respiratory hazard. 291 PN 466 has been produced with regard to the following RPE legislation and approved codes of practice as well as other health and safety legislation:  National Operational Guidance Programme – Foundation for Breathing Apparatus.  National Operational Guidance – Breathing Apparatus Training Specification.  Control of Substances Hazardous to Health Regulations: 2002.  Ionising Radiations Regulations: 1999.  Control of Lead at Work Regulations: 2002.  Control of Asbestos Regulations: 2012.

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Page 59 of 101 2nd April 2019  Dangerous Substances and Explosive Atmospheres Regulations: 2002.  Confined Spaces Regulations: 1997.  Reporting of Injuries, Diseases and Dangerous Occurrences Regulations: 2013. 292 BA operations are identified as a core skill for firefighters and as such wearers are subject to regular maintenance of competence checks undertaken on station, known as ‘Best Practice Assessments’. 293 In addition, firefighters have to complete BA refresher training provided by Babcock Training annually at one of its Centres of Excellence. 294 The Babcock Training / London Fire Brigade learning portal also provides seven online training packages covering all elements of BA equipment and operations. 295 It is not intended to cover each occurrence in full within this preliminary report as investigations are ongoing but a summary of each issue is provided below, together with information, where appropriate, for the Brigade to reflect on when determining its response to this operational learning. 296 The Health and Safety Executive (HSE) has acknowledged in its publication ‘Striking the Balance’ that the application of health and safety law is challenging for fire and rescue services in relation to some operational activities. It notes the following points which are considered relevant and should be reflected on by the Brigade:  they have to send firefighters into dangerous situations in order to save lives when anyone else would be seeking to get away from the danger;  there is often an unrealistic public expectation that firefighters will put themselves at risk even when such risks outweigh any potential benefits to be gained;  many incidents firefighters face can develop at speed, some can develop in unexpected ways – and firefighters may, from time to time, be confronted with situations outside their experience;  they have to prepare individual employees to be able to make decisions in dangerous, fast- moving, emotionally charged and pressurised situations, even when there may sometimes be incomplete or inaccurate information about the incident;

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Page 60 of 101 2nd April 2019  they have to respond to dangerous situations which are not of their own making - this is different to most other sectors where it is the employer’s own business that creates the hazards; and  they may not be able to control or mitigate some aspects of the working environment. 297 No BA emergency teams were formally established as detailed in PN 466 but the Brigade should consider this in the context of the large number of BA wearers who were rigged and ready for deployment in Grenfell Tower throughout the incident. 298 PN 466 states that wearers must withdraw from the hazard if both radio communications and telemetry are lost between the Entry Control Point (ECP) and the BA team. Whilst there is evidence that there were sustained radio communications issues and sporadic telemetry signal issues, it is not clear at the time of writing if and when this occurred simultaneously and investigations are ongoing. From the available evidence it is known that no personnel were withdrawn from the hazard area by commanders as a result of radio and telemetry issues and no BA team elected to withdraw for this reason. 299 A relatively small number of personnel were recommitted to the incident when there were additional firefighters on scene who had not previously worn and were available for deployment. It is not clear at the time of writing if those previously recommitted into the hazard area had the sufficient rest and recovery periods detailed in PN 466. The policy states that rest and recovery periods will only be shortened in exceptional circumstances i.e. to save a saveable life when no fresh wearers are available. 300 Whilst it is apparent that fresh wearers were available, the dynamic nature of the incident, the need to save life, and the individual responsibilities of personnel should be taken into account by the Brigade when considering their response to this operational learning. 301 It has been identified that the maximum number of wearers for one Entry Control Board (ECB) was exceeded during the early stages of the incident, meaning appropriate entry control procedures and the recording of briefs, locations and actions, alongside the use of telemetry were not always achieved. 302 Following the revision to the maximum number of wearers permitted under Stage 1 entry control procedures to six wearers, this will increase the likelihood of exceeding the facilities of one ECB and resources that will be required to establish Stage 2 entry control procedures earlier in an incident where higher number of BA wearers are required.

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Page 61 of 101 2nd April 2019 303 A number of firefighters booked into the ECP in accordance with PN 466 but did not don their facemasks and ‘go under air’ until they reached a point in the hazard area that respiratory protection became an absolute necessity. PN 466 makes clear that all personnel passing through the ECP must be ‘under air’. 304 Despite BA Main Control being established, the majority of the BA teams that exited the building did not return to BA Main Control for further instruction. The Brigade’s policy requires the role of BA Main Control Officer, now a BA Sector Commander under the revised policy, to be undertaken by a minimum role of a SM. The training requirements for the role of a BA Sector Commander are not identified in any training framework for the role of a SM or above. 305 A number of firefighters exited the hazard zone past their ‘time of whistle’ and therefore without the required safety margin of air remaining in their cylinders. There is one instance of a firefighter leaving the hazard zone without his BA facemask and helmet, having abandoned both after completely exhausting his air supply during his attempts to rescue a casualty from the building. 306 There is no evidence that emergency exchange of air procedures were adopted to support firefighters who were low on air whilst still in the hazard area. 307 Evidence has identified that there were occasions where briefs and debriefs lacked detail, which led to areas of the building being searched on more than one occasion. Information such as, areas that had been searched and numbers of people rescued from specific flats were not accurately relayed. This was also compounded by residents and occupants of the building moving to different flats and floors or attempting to self-evacuate following fire survival guidance. 308 A clear degradation factor that contributed to a lack of detail for some briefings was the amount of information that was being communicated under high pressure conditions, which led to some key information not being recorded appropriately, leading to tasks that were allocated to subsequent BA teams being less effective. Accurate recording of briefs and debriefing would have assisted subsequent allocation of tasks and identification of hazards. The Brigade had previously published an article and associated training in its Operational News publication in January 2012 covering the briefing and debriefing of BA teams. 309 A dedicated BA Comms Operative was not established until 04:00hrs although sufficient resources were available. It is suggested that the Brigade reflect that there were radio communications issues, most likely as a result of demand exceeding capacity, and therefore the

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Page 62 of 101 2nd April 2019 ability for BA teams to communicate with the ECP was limited in any event. This is addressed in more detail in Theme 6 – Communications. 310 ECB tripods were not used until approx. 06:00hrs. It is known that placing the ECB in the provided tripod stand increases telemetry signal propagation. 311 A number of BA log books had been completed incorrectly on station and are illegible, impacting on the post incident review. This issue is described more fully under key observation 7.3. 312 Evidence has identified that the deployment of working radio repeater and telemetry repeaters was unsuccessful. The ultimate reason cannot be confirmed as to why they did not perform as expected but it is evident that personnel’s knowledge and understanding of their deployment is inconsistent. Currently only extended duration BA wearers are trained in the deployment of radio repeaters, which is delivered on refresher training courses only. Recommendation 10 - It is suggested the Brigade considers the extent to which policy, training and human factors played a role in the control measure degradation identified in the preceding paragraphs. Actions by the Brigade since the fire Data retrieval and analysis 313 Immediately following the fire, the Brigade downloaded the data from over 1200 BA sets and 100 telemetry boards to ensure it had captured all data that might be relevant to the incident. A number of telemetry boards suffered extensive heat and water damage and were returned to the manufacturer who were able to retrieve the required data. 314 The only data believed to have been lost is that where the electronic memory of a board was overwritten due to insufficient capacity. This learning was communicated to the manufacturer who has now increased the memory capacity of its telemetry boards to prevent a reoccurrence. 315 The data retrieved from both the BA sets and telemetry boards is complex and not easily understood without the correct knowledge. The Deputy Head of the PEG has been seconded to GTIRT since June 2017 to ensure all data is collated and analysed effectively to support the internal investigation and assist external investigations by the Inquiry and the MPS.

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Page 63 of 101 2nd April 2019 National Operational Guidance 316 The Brigade has engaged extensively with NOL Secretariat to reinforce its own understanding of the observations identified above and to support the identification of degradation factors which may cause control measures not to perform as expected. A report by the Secretariat outlining findings and making recommendations for revisions to the Foundation for BA guidance has been finalised and will be presented to NOLUG for consideration. Respiratory health monitoring 317 The Brigade is currently working with University College Hospital to scope an independent long term respiratory health study for staff who attended the incident to support those staff and build a greater understanding of the long term impact of firefighting operations on respiratory health. Theme 5 – Brigade Control Key observation 5.1 : The facilities at the Brigade’s fallback Control, located in Stratford, did not fully replicate those at the primary Control in Merton. 318 The Brigade’s primary Control is located at Merton and it operates a secondary or fallback Control, located at Stratford fire station to provide resilience to its control and mobilising function. 319 The Stratford facility is generally used during planned maintenance to the systems at the primary location but can be stood up at short notice if the primary site is not able to operate for any reason. The Brigade has established and well practiced procedures to fall back to the secondary Control when required. 320 On the 14th June 2017, Brigade Control was operating at Stratford due to planned maintenance at the Merton site. The secondary Control at Stratford is smaller than the primary site and images illustrating the difference are contained within the report appended as Appendix B. 321 In general, the facilities at Stratford replicate those at Merton with the same integrated mobilising and communications systems provided at both locations. On the night of the Grenfell Tower fire the main differences were that the Stratford site did not have the facility to access the Brigade’s Dynamic Cover Tool (DCT) or access the National Police Air Service (NPAS) downlink imagery via the ‘heli tele’ system. 322 The DCT is a computer software application designed to assist Brigade Control to manage the movement of appliances between locations during large incidents or periods of peak demand, in

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Page 64 of 101 2nd April 2019 order to maintain operational cover across the geographical area the Brigade is responsible for. The non-availability of the DCT on the night of the fire required an Assistant Operations Manager (AOM) to manually manage the movement of appliances to maintain pan London fire cover. This was a complex task, given the number of appliance movements required as the incident at Grenfell Tower escalated, and it is testament to the knowledge and experience of the AOM responsible that operational cover was maintained effectively. 323 The Brigade is unique in having a fixed ‘heli tele’ downlink and this is a legacy of its relationship with the MPS Air Support Unit before it transitioned to NPAS. The fixed downlink is provided to increase situational awareness and is available at the primary Control, Brigade Headquarters, and on the CUs. 324 Whilst the facility was not provided at Stratford, it is noted from evidence, during Phase 1 of the Inquiry, that on the night of the fire, the downlink had been withdrawn from external agencies by NPAS and so CROs would have been unable to view in any event. Actions by the Brigade since the fire DCT and Heli-Tele 325 The DCT software application has now been installed at the Stratford site and is fully functioning to assist staff to manage operational cover requirements when Brigade Control is operating from the secondary facility. The heli – tele downlink is also now available at the Stratford site. 326 As referenced in paragraph 164, the Brigade is also undertaking an operational trial of drone technology to increase situational awareness during and reduce its reliance on support from external partners such as NPAS. Key observation 5.2 : FSG call information was not gathered and communicated in accordance with PN 539, Appendix 3. 327 PN 539 states ‘The Brigade defines a Fire Survival Guidance (FSG) call as being a call to Brigade Control where the caller believes that they are unable to leave their premises due to the effects of fire, and where the Control Room Operator (CRO) remains on the line providing appropriate advice until either the caller is able to leave by their own means, is rescued by the Brigade, or the line is cleared’.

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Page 65 of 101 2nd April 2019 328 There is specific guidance for CROs to follow when taking calls to fire situations in domestic accommodation, where callers have indicated they are unable to leave their premises. This guidance follows national guidance and employs the principles of Escape, Assist, Protect and Rescue. 329 The following text is the relevant extract from Appendix 3 of PN 539: Brigade Control advise callers to ‘Get out and Stay out’, however if a call is received from a High rise building where Fire, Heat and Smoke are not affecting the caller, LFB would advise that: You are usually safest to remain in your premises unless affected by fire, heat or smoke. If the situation changes, you should leave your premises and dial 999, if you need further assistance.’ Should the caller be unable to escape, a RIF10 containing prompts are in place on the computer- aided mobilising system to assist the CRO in:  Providing guidance to assist the caller to safety.  Provide timely and relevant information to the attending resources.  Provide reassurance to the caller that help and assistance is forthcoming. The CRO will ascertain through initial questioning, the type of premises the caller is in and use the link on the Reference Information File to take them to the appropriate area of information to use, to assist the caller. CROs will always use the four principles of Escape, Assess, Protect and Rescue to provide guidance to these callers. Firstly by assisting the caller to help identify a safe, alternative ESCAPE route for them to leave their premises. If this is not possible, then CROs are directed to ASSESS the situation by asking the caller direct questions: Example questions are:  Do you know where the fire is?  What room are you in?  Is anyone with you? CROs will begin to PROTECT the caller by providing current fire safety advice to attempt to keep the caller safe. They are directed to reassure the caller and REASSESS the callers situation: Example questions are:

10 Reference Information File

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Page 66 of 101 2nd April 2019  Has that stopped the smoke coming in?  Let me know if the smoke gets thicker?  What’s happening now?

CROs will remain on the telephone with the caller and assist with RESCUE. Other CROs and supervisory staff will assist the CRO carrying out the Fire Survival Guidance call by ensuring all relevant information regarding the caller’s situation is passed via both the airwave radio and via telephone when a CU is in attendance. Relevant information to be passed to the incident ground includes:  Number of persons involved  Names if known (by telephone only, not by radio)  Condition of their location i.e. heavy smoke, thick smoke  Location of caller within premises  Callers proximity to fire  Latest FSG advice given by Control  Time of FSG call 330 From the evidence adduced in Phase 1 of the Inquiry, it is apparent that during a number of FSG calls arising from the Grenfell Tower fire there were no proactive attempts to identify a safe alternative escape route with the caller. During questioning on this matter by Counsel to the Inquiry, one witness explained they would be expect persons living in residential high rise blocks with a single stair would be familiar with their escape route. Another witness described the volume of calls as being a factor and the need to prevent a queue of calls from building. 331 Counsel to the Inquiry also asked Brigade Control witnesses about efforts to assist callers with assessing the situation. Those witnesses explained that their own situational awareness is limited as they are remote from the incident and the callers themselves are generally best placed to assess the conditions affecting them. 332 Witnesses also provided oral evidence that expressed the difficulties and risks associated with directing those trapped to follow particular instructions like opening doors to check escape routes, which may only serve to further deteriorate conditions in the location where persons are sheltering. 333 It is noted that many residents expressed a reluctance to leave their properties even when instructed to do so, because of the conditions outside of their flats. Control witnesses said that in

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Page 67 of 101 2nd April 2019 those circumstances you have to believe the caller, who is best placed to observe the conditions they are experiencing and assess the conditions they face if they attempt to leave their place of relative safety. 334 This is reinforced by the evidence of one resident ultimately rescued by the Brigade but who had earlier resisted all attempts by CROs to persuade him to evacuate the building. When questioned by the Inquiry on why he had ignored the instructions from the Brigade, the witness stated “Well ... I would have assessed again if I was in the condition to go out. But obviously she would've taken a big responsibility to do so on her behalf, because she wouldn't know how bad the conditions outside were. I knew, she didn't. She wouldn't know”. 335 He went on to state “Now let's say I would be convinced by this person to go out, and if something had happened to me, how would that person feel if I had not made it out, basically? So that's why I said, you know, I don't want to think of someone thinking, "Oh, because I gave him that advice, look what happened to him". How would that person then live for the rest of their life?” 336 This graphically illustrates the dilemma which CROs face in circumstances such as those experienced at Grenfell Tower that even if they seek to explore with a caller the conditions immediately outside their flats, they cannot know what the conditions may be beyond the immediate vicinity when considering whether to advise residents to leave their flats. There always remains a risk that they will be directing them into dangerous and potentially lethal conditions. There were numerous examples in the evidence of rapidly changing conditions within the building, by which smoke, toxicity and visibility changed minute by minute and often, second by second. 337 There, of course, may come a time when the situation has deteriorated to such an extent that escape remains the only viable option, whatever the risks involved. In those circumstances, it is necessary for CROs to make every effort to encourage or even coerce callers into attempting to escape. Evidence adduced in Phase 1 established that one CRO, during a particular FSG call, very forcefully sought to persuade the caller to leave their flat, even graphically describing the potential consequences if they did not. 338 It is noted from evidence that PN 539 directs CROs to stay on the line with callers until they are rescued by the Brigade. Such was the volume of calls related to Grenfell Tower, CROs felt unable to stay on the line in most instances due to the need to reduce the number of calls queuing in the system, many of whom would have also been from residents trapped in the Tower.

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Page 68 of 101 2nd April 2019 339 There are exceptions when CROs stayed on the call until the call dropped out which included one call which lasted just under an hour and these calls proved to be particularly harrowing for the CROs concerned. This is discussed in more detail under key observation 5.8. 340 Evidence from witnesses during Phase 1 demonstrated that the way CROs handled FSG calls and provided advice to callers was predicated on the assumption that they would be rescued. The Lakanal House fire in 2009 tragically demonstrated this is not always the case and prompted the need for CROs to engage more fully in active listening to build a more complete picture of the circumstances facing the caller. 341 A number of calls were received by Brigade Control in the early stages of the incident where the callers, located on the upper floors of Grenfell Tower state there is smoke in their flats and / or fire at the window. However the significance of this information is not recognised by the CROs and with limited situational awareness, they did not reconcile the information to their understanding of the incident. 342 One Brigade witness gave oral evidence to the Inquiry describing how they were unable to comprehend that a caller from an upper floor was describing smoke, and even fire, in their vicinity, when the fire was on the fourth floor. 343 The RIF details the information that should be recorded and communicated to the incident ground. One notable omission from nearly all FSG information received by the incident ground is the time the FSG call was received. This information is significant, particularly in circumstances where the IC or responsible officer may need to prioritise the individual calls. 344 There were also limited examples where other important information, such as the caller’s name, the conditions i.e. heavy or thick smoke, the location of the caller within the premises, their proximity to the fire and the latest FSG advice given by Control to the caller, was communicated to the incident. 345 The Lakanal House Incident Assurance Review commissioned by GTIRT to support its investigation noted in its report, dated 7th August 2018, that training records show that fire survival guidance refresher training has not been completed by all Control staff on an annual basis in accordance with national guidance (Fire Service Circular 10/1993 ‘Training of Fire Control Staff’ and Brigade expectations as set out in its pre-Inquest actions (identified as Action 12 of the Pre- Inquest actions within the report) following the Lakanal House fire.

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Page 69 of 101 2nd April 2019 346 As part of the refresher training referred to above, the Brigade identified an action (Action 8 of Pre-Inquest Actions) following the Lakanal House fire to include an input from Fire Safety Officers in Control FSG training to comply with the requirements of Fire Service Circular 10/93. The Lakanal House Incident Assurance Review report notes that ‘Whilst Fire Safety Officers were involved in developing the building structure / fire safety issues content for the fire survival guidance training and they have delivered the content on initial training, they have not consistently delivered that content in refresher training’. 347 It is appropriate to acknowledge the extraordinary challenge that handling FSG calls presents in normal circumstances, let alone in the extreme situation presented by the Grenfell Tower fire, in that they are required to provide appropriate advice to persons, who are often in danger and acute distress. This has to be undertaken from a remote position and with limited situational awareness. The circumstances of the Grenfell Tower fire increased those challenges exponentially. 348 It should also be noted that PN 539 anticipates that a CRO handling a FSG call will be supported and assisted by supervisors and other CROs. The circumstances of the Grenfell Tower fire meant that such support was not available due to the volume of calls being received. Actions by the Brigade since the fire 349 All Brigade Control staff have undertaken FSG refresher training during 2018 and further training will be undertaken this year once the revisions to PN 790 are published. At the time of writing, five of the six Brigade Control Watches have taken part in the exercises that are informing the revision of PN 790 and the associated procedures with the sixth Watch due to participate in the final exercise shortly. 350 A competency framework for all levels of Brigade Control staff identifying core skills and frequency of training to support maintenance of competence is currently being developed. 351 A new IT solution was implemented towards the end of 2018 to support the planning, delivery and recording of Brigade Control training. The new solution ensures that training activities are automatically recorded within Individual Training Records. 352 A facilitated discussion with Control staff around the challenges presented by the Grenfell Tower fire has been led by Control senior managers, supported by the Operational Support Team (OST) to ensure that all staff are aware of the ad hoc actions taken on the night where these were considered effective. Where actions taken on the night were identified as not being effective,

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Page 70 of 101 2nd April 2019 staff are discussing the situation which precipitated the original action and seeking to agree possible improvements. It is recognised this training is an interim measure prior to the implementation of revised policies, technological and training solutions that will be associated with the updated PN 790. Key observation 5.3 : There was no established or tested method to maintain an overview of the FSG call information being received by Brigade. 353 Brigade Control received a total of 408 ‘999’ calls from 0054hrs up to 0800hrs related to Grenfell Tower, and also handled 212 similarly related admin calls in this period. This volume is completely unprecedented in the collective memory of the Brigade and does not include calls related to other incidents ongoing in London during this period. On duty staff were also dealing with the large volume of appliance mobilisations and notification protocols associated with the fire, whilst attempting to manage the incoming calls and the transfer of risk critical information to the incident. 354 The first of 152 calls from persons located within Grenfell Tower was received by Brigade Control at 01:21hrs and the volume increased exponentially to an extent that British Telecom began transferring calls to other fire and rescue service Control rooms, namely North West Fire Control, Essex FRS, Surrey FRS, and Kent FRS. There is also evidence that calls were received by other agencies during the course of the night such as the MPS and LAS. 355 Such was the intensity of the calls being received by Brigade Control, a queue quickly built up within the system, impacting on the ability to maintain an adequate degree of situational awareness in regard to the rapidly developing situation at Grenfell Tower. This situation was alleviated to an extent by the arrival of the Brigade Control Duty Senior Manager who arrived at Stratford at approx. 02:15hrs. 356 A white board system was then implemented to display FSG call information to provide shared situational awareness in the room and enable CROs to correlate information, should any further calls come in from the same flats or floors. The white board system was not a recognised or tested procedure but an ad hoc measure established to ensure information was immediately available and could be utilised by CROs handling calls and providing advice to callers. The information was also available to the Brigade Coordination Centre (BCC) which had been set up at Stratford in response to the major incident.

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Page 71 of 101 2nd April 2019 Actions by the Brigade since the fire 357 A large wall screen has been fitted at the primary Control facility at Merton to increase shared situational awareness amongst Control staff. The screen is able to display the DCT, the heli-tele downlink feed, and information sourced from the Vision mobilising system including incidents in progress. In addition, the screen is able to display television broadcasts. As yet there are no plans to provide a similar system at the fall back location in Stratford although it is noted that all such information is available at individual CRO work stations. Recommendation 11 - It is suggested the Brigade considers how shared situational awareness within the Control room might be achieved in similar circumstances and whether a more sophisticated system than the whiteboards used on the 14th June should be developed and implemented as an established Control protocol. Key observation 5.4 : The ‘Vision’ mobilising system does not support the identification of telephone numbers to enable call backs, and the Brigade does not have a clear policy position on re-contacting callers. 358 PN 539 and the associated RIF requires that CROs maintain contact with callers being provided with fire survival guidance until they are rescued or are able to self evacuate. As detailed earlier in this report, the volume of calls and the rapidity with which they were received resulted in CROs not keeping calls open with those located in the building, in order to reduce the queue that had built up in the system. 359 The Brigade does not have a policy regarding re-contacting callers as the requirement to re- contact was not envisaged. Callers on 14th June were provided with guidance and advised to call ‘999’ again if the situation changed or deteriorated and the CRO ended the call in order to answer the next call. CROs had no means to know, before answering, if calls queuing in the system were from residents at risk in the building or from those reporting the fire from outside and not in danger. 360 Evidence demonstrates that callers did re-contact Brigade Control on many occasions during the course of the night and some residents made a number of ‘999’ calls as conditions deteriorated and their situation got worse. It is unlikely that residents making repeat calls would have spoken with the same CRO.

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Page 72 of 101 2nd April 2019 361 For those residents who called ‘999’ after the decision to advise all persons to leave the building whatever the dangers they faced, CROs were able to provide instructions to evacuate the building using wet towels to protect themselves. 362 For residents who did not or could not call after this time, this presented a serious situation, in that the Brigade had no means to advise them to leave their flat unless an individual made a further emergency call. 363 When questioned by Counsel to the Inquiry on this subject, one Brigade witness explained that such a situation was beyond the experience of the Brigade and described how it would have been very difficult to recontact callers as Brigade Control was inundated with emergency calls at that time, with many calls held in a queue. The witness went on to describe how it would have been very time consuming to search through call records to find the correct telephone number to recontact the caller. 364 When asked how previous FSG callers would know that the advice had changed, the witness reiterated that it was very difficult situation and such were the circumstances on the night that there was a reliance on those trapped calling ‘999’ again, in which case they would be provided with the appropriate advice. 365 In addition to the resourcing issues associated with attempting to recontact callers, it is noted that the Vision mobilising system does not have a facility that makes the identification of previous callers and their phone numbers easy or timely. This is, perhaps, not unsurprising as it was not anticipated that such a situation would occur and such a facility would be required. As a result, this was not included in the technical specification for the current mobilising system. Actions by the Brigade since the fire 366 The Brigade’s OPA department have been asked to consider this issue in the review of PN 790 and FSG procedures. However, it is noted that any changes to the current mobilising system in this respect are probably not achievable and would have to be included in the specification for any future replacement mobilising system.

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Page 73 of 101 2nd April 2019 Key observation 5.5 : There are no national standards for passing and receiving FSG call information between Fire and Rescue Service Control rooms handling calls related to the same incident. 367 The Brigade, like all emergency services have established mutual aid arrangements in place with other Control rooms to answer and handle ‘999’ calls including FSG calls should its own capacity be exceeded as a result of a major incident or spate conditions such as widespread flooding. 368 On the 14th June 2017, five fire and rescue service Controls, North West, Essex, Surrey, Merseyside and Kent provided mutual aid support to the Brigade by handling overflow calls, many of which were Grenfell Tower FSG calls. All fire and rescue services use the Escape, Assess, Protect and Rescue protocol for handling FSG calls so callers directed to these supporting Controls received fire survival guidance based on the same principles used by Brigade Control. 369 However, it is noted that the sharing of information in a timely and effective manner between the supporting Controls and Brigade Control was problematic. The sharing of FSG information being received by the supporting Controls was affected by the volume of calls being received in Brigade Control resulting in limited capacity to answer calls from the supporting Controls. Similarly Brigade Control found it challenging, in resource terms, to pass information to the supporting Controls to ensure shared situational awareness. 370 It is observed that there are no national standards for passing and receiving information between Control rooms handling FSG calls arising from the same incident to support the existing mutual aid arrangements. 371 It is further noted that much of the specific guidance available to fire and rescue services is historic. Fire Service Circular 10/1993 ‘Training of Fire Control Staff’ is a relevant example of this. NOG provides information on control and mobilising functions across its suite of guidance, however there is no specific ‘one stop’ guidance provided for fire and rescue services addressing the delivery of the relevant statutory duties required under the Fire and Rescue Service Act 2004. Actions by the Brigade since the fire 372 Brigade Control senior managers are engaging with the NFCC Mobilising Officers Group (MOG) to discuss how to improve the communication of information between Controls involved in taking overflow calls under the established mutual aid arrangements.

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Page 74 of 101 2nd April 2019 373 The group is carefully considering the Grenfell Tower fire and the challenges presented by a number of Controls simultaneously handling calls relating to the same incident. The group considers the establishment of a dedicated national Airwave talk group for Fire Controls could enable the affected Control to simultaneously broadcast information to all Controls handling overflow calls and ensure supporting Controls can communicate information to the affected Control. 374 This proposal, if confirmed by the NFCC MOG, will need to be presented to the NFCC Operations Committee for approval. 375 The NOL Secretariat has also been contacted regarding this issue and is examining the issue to identify improvements which could be made to national guidance. Key observation 5.6 : There is no automated system to link NICE voice records to Vision call records, impacting on any post incident review. 376 The Brigade’s call management system is made of four key components, one of which is the NICE11 voice recording system. The recording system for all incoming ‘999’ calls and the administration lines is stand alone and does not create a unique reference that aligns to the Vision mobilising system call records or the BOSS desk top incident viewer12. 377 When a 999 call is connected to the call handling system by the BT operator, the system immediately starts to record and includes the period whilst the call is waiting to be answered by Brigade Control. Once answered, the recording continues until the CRO ends the call, the caller hangs up or the call drops out because of a loss of signal or a malfunction. 378 The system captures all voice interaction on the line which includes the BT operator passing the call to the CRO. If the caller drops off the line or the call is cut off before being answered the recording will continue, this allows for the capture of any conversation with the BT Operator. 379 This system is not linked to other components in the system and as a result, when collating call data for review the voice records have to be manually cross referenced against the incident records on the BOSS desk top viewer application.

11 NICE is the name of the company that make the software package installed on a stand alone computer. 12 BOSS is a software application used to present incident information to Brigade personnel without the need to access the Vision mobilising system.

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Page 75 of 101 2nd April 2019 380 It was identified that times presented in the BOSS desktop viewer do not align with the call times associated with the audio recording because the BOSS application includes the ring time before the call is answered. The BOSS application also uses the ‘created time’ as the call time which is subject to variation depending on the call handling time and the selection of the ‘create record’ action. 381 During the exercise to gather information for the Actions by Brigade Control report, appended as Appendix B, voice recordings were found to be referenced against the wrong incident record i.e. the phone number did not correspond to the NICE record, effectively meaning that call information was held against the record of another call. There were also examples of voice call records not allocated to a incident record at all resulting in new records being created several months after the event. 382 Whilst these issues did not impact on the night, the reconciliation of call data presented a significant challenge for GTIRT who worked collaboratively with the Inquiry and MPS to ensure an accurate record of all calls related to the Grenfell Tower fire was adduced into evidence. Actions by the Brigade since the fire 383 It is acknowledged that overcoming these issues requires a significant change to the Brigade’s communications and mobilising systems and it not feasible until the future replacement of those systems. 384 These issues will also be captured as learning in a future guidance document to be produced as an appendix to PN 920 ‘Major incidents investigation’ to ensure future investigations are sighted on the issues identified during the Grenfell Tower safety and learning investigation. A new working group will convene in April 2019 to scope out work required to produce effective guidance to support future investigations. Key observation 5.7 : The ‘Vision’ mobilising system ‘call collection form’ can be overwritten if a new call is taken before it is added to the incident log. 385 During the collation of call data it became apparent that audio records of 999 calls had been captured on the NICE recording system that were not recorded against an incident record. 386 When a CRO answers a ‘999’ call on the Integrated Control and Communications System (ICCS), a ‘call collection form’ automatically opens on the Vision mobilising system. Some details of the call are automatically populated and the CRO is required to gather and enter other data

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Page 76 of 101 2nd April 2019 manually by asking the caller questions. When the CRO has reached the point that they are satisfied they have gathered all relevant information, an incident record is created and, where appropriate, the required resources are mobilised. 387 When large numbers of calls are received to the same incident the mobilising system provides the facility to ‘duplicate’ calls when a CRO determines the incident being reported is the same as an incident already being attended by the Brigade. In this event, a copy of the incident record is created and becomes a duplicate. The duplicate has a separate incident number but is linked to the original record created for the incident. This process assists the Brigade in managing call volumes and avoids unnecessary mobilisation of resources. 388 During the Brigade’s investigation a review of the NICE recording system was undertaken to ensure all audio records had been captured. It was identified that several ‘999’ call records were captured which were not assigned to an incident record. It was also observed that is some cases two phone numbers were captured in the same incident record. On further investigation it was apparent that it is possible to answer a ‘999’ call through the ICCS system with the previous call collection form still open, resulting in the new call number becoming embedded in the previous incident record. 389 Following any incident the collation of call data forms an important part of the evidence required to provide assurance to the organisation. The issue identified as key observation 5.6 results in investigators having to listen to the audio file for each call and manually cross reference these to incident logs to ensure all evidence is captured and is accurate. 390 While the issues identified above did not impact on the night of the fire, it did result in considerable delay in identifying all incident records to support the post incident investigation and review activities related to the Grenfell Tower fire. Actions by the Brigade since the fire 391 This issue has been communicated to Brigade Control senior managers and has been addressed during the facilitated discussions (paragraph 352 refers) to ensure Control staff are fully aware of the issue and take active measures to prevent a re-occurrence during future incidents involving large numbers of incoming calls.

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Page 77 of 101 2nd April 2019 Key observation 5.8 : There is potential for Brigade Control personnel to experience secondary trauma following a traumatic incident. 392 Following the Grenfell Tower fire there were a significant number of counselling referrals from Brigade Control staff and high levels of sickness absence were recorded, mostly related to stress, anxiety and depression (SAD). 393 Sickness arising from participating in the Grenfell Tower fire response and the public inquiry continues to contribute to sickness absence. The increasing number of episodes of sickness absence due to SAD, combined with the fact that episodes of SAD absence usually last longer than other causes of sickness absence, continues to drive up headline absence rates. The Brigade’s target for sickness absence for Brigade Control staff is 4.7% of working days lost, but has remained consistently above this figure since the Grenfell Tower fire and peaked at 9.06%. 394 On the night of the fire the Counselling and Welfare Services (CWS) duty counsellor was contacted by Brigade Control at approximately 03:00hrs on the day of the fire. A request was made to provide a counsellor to go to Brigade Control at Stratford to support CROs and managers. The Head of CWS was notified of this request and decided to go to Stratford as she was the nearest counsellor and arrived at Brigade Control approximately two hours after the initial call. 395 In Brigade Control, the Head of CWS met with managers and all the No. 2 Watch CROs involved in dealing with the calls from residents and other people close to the Grenfell Tower. At the end of their shift the CROs were provided with psychological first aid and support prior to them leaving to go home. 396 It is noted that one month after the fire, 19% of Brigade Control staff involved in the incident had been referred to CWS, this compares with 20% of firefighters involved in rescue operations. Actions by the Brigade since the fire 397 The Head of GTIRT recently commissioned an independent study of the Brigade’s counselling and trauma service provision during and following the Grenfell Tower fire by Dr Noreen Tehrani, Past Chair of the Crisis, Disaster and Trauma Section of the British Psychological Society and a member of the Crisis, Disaster and Trauma Standing Committee for the European Federation of Psychological Associations. 398 Dr Tehrani made the following recommendations in her report in March 2019:

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Page 78 of 101 2nd April 2019  Firefighters and others in high risk roles such as Brigade Control staff should be submitted to regular psychological surveillance, to manage the risk of psychological health in the same way that physical health is managed.  Following a major incident, the use of ‘screen and treat’ for all involved personnel would help to identify those likely to develop trauma related conditions. 399 Dr Tehrani also suggested the following changes be considered by the Brigade:  Introduction of trained peer trauma support volunteers  Increased mandatory/routine psychological screening of those involved  Additional psychosocial support for Brigade Control personnel  Increased support for senior officers 400 The report will be considered by the Brigade in April 2019 to determine its response to Dr Tehrani’s recommendations. Theme 6 – Communications Key observation 6.1: The volume of hand held radio traffic exceeded the capacity of both the breathing apparatus and command channel. 401 A number of witnesses stated in oral evidence that they had difficulty in communicating on the fire ground using their hand held radios and in the building using BARIE13 sets. Other witnesses said that the hand held radios were not working. The Brigade employs two main forms of communication equipment. A digital national radio system, ‘Airwave’ for wide area communications (Brigade Control to appliances) and a system of personal issue analogue ‘fireground’ radios for local use at incidents. 402 The Brigade’s hand held radios (Entel HX-480/1) are issued to all operational staff and are programmed with 10 separate channels. These are detailed below:  Channels 1 and 2 - General Incident and Command channels  Channel 3 - Used under direction of the IC / sector commander for firefighter communications during specific tasks  Channel 4 - To be used only under direction of the duty radio officer

13 Breathing Apparatus Radio Interface Equipment

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Page 79 of 101 2nd April 2019  Channel 5 - For communications (including BA) where a leaky feeder or base station equipment is installed  Channel 6 - BA  Channel 7 - To be used only under the direction of the duty radio officer  Channel 8 - For communications in specific buildings where leaky feeder or appropriate base station equipment is installed  Channel 10 - For use by the CU staff 403 An intrinsically safe variant, the Entel HT981 is used within the BARIE system (PN 592 refers). Intrinsic safety is achieved by capping output at one watt. 404 It should be noted that channels 2, 5 and 8 are duplex14 and will only work in conjunction with a repeater set available when a CU is in attendance or a base station is fitted in the premises, e.g. London Underground stations. 405 Channel 1 is reserved for all initial incident command communications. It remains the primary command channel until the circumstances of the incident dictate or the IC decides that additional command and control radio capacity is required. 406 Once a CU is in attendance the CU communications operator will advise the IC that channel 2 is available to be introduced as the command channel if required. 407 Channel 6 is the default channel for BA communications unless the premises involved has a base station and leaky feeder installed, such as London Underground stations. In this case Channel 5 will be used for BA Communications. During the Grenfell Tower fire only Channel 1 was utilised for command communications and Channel 6 was primarily used for BA communications. 408 In the aftermath of the fire the Brigade undertook a number of controlled radio signal propagation tests in and around Grenfell Tower testing both the hand held radios, BARIE system, and telemetry equipment. Tests on all floors and throughout the inner stair case on Channels 6 and 2 utilised a standard HX480 radio at the BA control board locations and BARIE variant at remote locations within the building.

14 Duplex channel radio systems describe the use of two frequency channels, usually in the same band spectrum, which allows simultaneous communication between two stations.

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Page 80 of 101 2nd April 2019 409 It is noted that when these tests were undertaken the fabric of the building was substantially altered from the night of the fire. The results of the tests are detailed below: TEST 1. - Channel 1 within inner cordon. Channel 1 transmissions and reception were clear during all tests. Within all areas of the inner cordon and the atrium of Grenfell Tower radio messages were clearly audible without signal loss. TEST 2. Channel 1 at original CU location. Channel 1 transmission and reception clear during all test calls. Within all areas of the inner cordon and the atrium of Grenfell Tower it was possible to transmit to and receive messages from a radio placed at the original CU location. With the Channel 2 repeater deployed at the original CU location Tests 1 and 2 were repeated. Channel 2 transmissions and reception were clear during all tests. From the original CU location to all areas of the inner cordon and atrium test messages were clearly audible without signal loss. TEST 3. Channel 1 at Bridge Head locations to and from all floors. Channel 1 transmissions on all floors from all bridgehead locations (floors 0,2,3 and 7) clearly audible without signal loss with the following exceptions:  Floor 7 (bridgehead at floor 0) - Slight background noise within lift lobby, but message still audible and understood.  Floor 10 (Bridgehead at floor 0) - missed number during test count, repeated clearly received.  Floor 23 (bridgehead at floor 0) - slight clipping of received signal, message audible when repeated.  Roof level (bridgehead at floor 0) - transmission from West side of roof area broken and inaudible when receiving at floor 0 (atrium). Channel 6 BA radio test. Bridge Head BA entry control locations to and from BA wearers on all floors.  Channel 6 BA transmissions on all floors from all bridge head locations (floors 0,2,4,7) clearly audible without signal loss with the following exceptions.  Floor 13 (bridgehead at floor 0) - 1-2 second loss on transmission from BA wearer within lobby area.  Floor 16 (bridgehead at floor 0) - slight signal loss within flat 1 regained clear transmission from lobby.  Roof level - Not tested by BA wearers.

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Page 81 of 101 2nd April 2019 Channel 2 (repeater at original CU location) to and from all floors.  Channel 2 transmission and reception was intermittent when leaving the atrium and proceeding within the central stairwell of the building up until reaching floor 3. From floor 3 communication was possible from within flats but broken within the central stair core of the building.  From floor 7 communication on channel 2 improved but was still breaking at times.  On floor 17 difficulties were experienced with interference. It was found that when transmitting on Channel 6 a whine was experienced on equipment monitoring channel 2 rendering reception of the test message inaudible. 410 Recognising the potential for signals to be reflected from surrounding buildings back into Grenfell Tower a further test was carried out within the central core of the building on upper floors to assist in ruling out the scenario. A radio operator on channel 1 was placed at floor 11 (above the level of any surrounding buildings) and test calls were then made to a radio operator ascending the building floors 12 to roof. Test messages were clearly received on all floors from 12 to roof level. 411 The Grenfell Tower fire was one of the largest and most complex incident communication challenges the Brigade has ever experienced. At the height of the response phase of the fire there was in excess of over 300 hand held radios available and potentially in use at the incident. 412 Given this fact and taking into consideration the radio propagation test results the most likely cause of the radio communication issues is the sheer volume of radio traffic being generated. This situation would have also been exacerbated by the unprecedented volume of BA crews deployed to undertake search, rescue and firefighting operations during this incident. Actions by the Brigade since the fire 413 The Brigade is reviewing its handheld radio capability and is in the process of tendering for a replacement radio handset. The Brigade officers involved in the radio replacement project have been made aware of the issues experienced at the Grenfell Tower fire and will, if the technology exists, select a replacement hand held radio that may mitigate some of these capacity challenges. It is anticipated that the replacement of the BARIE and the standard handheld radios will be completed in the 2019/20 financial period. 414 In addition to replacing the hand held radios the Brigade’s OPA department are reviewing the current guidance that is available to staff in respect to radio protocol. It is acknowledged that at

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Page 82 of 101 2nd April 2019 large scale and complex incidents where a significant number of hand held radios could be potentially used that operational staff may need to exercise more radio discipline in terms of generating radio traffic so as not too overrun the capacity of the available radio channels. Key observation 6.2: There is evidence of a lack of knowledge and understanding of the potential tactics and associated equipment that may have mitigated radio communication issues. 415 Evidence from Brigade staff points to a lack of knowledge and understanding of the equipment available to potentially mitigate the radio communication issues experienced during the incident. As can be seen in the findings detailed above, the requirement to deploy the Brigade’s radio repeater and leaky feeder capability probably wasn’t required at this incident as the radio communication issues experienced at the Grenfell Tower fire were primarily caused by the sheer volume of radio traffic being generated. Actions by the Brigade since the fire 416 To address the knowledge and understanding issue, two mandatory communications training packages, one of which specifically covers the capability and deployment of the Brigade’s radio repeater and leaky feeder equipment have been made available to all operational staff as part of the Operational News publication (Ops News 36, February 2019). Key observation 6.3: Senior officers were unable to book in attendance at the incident due to the high volume of radio traffic on the Airwave main scheme radio. 417 In reviewing the available data from the ‘Vision’ mobilising log it has been identified that a number of officers (and appliances) did not book in attendance with Brigade Control when they arrived at the incident as required by PN 23815 and PN 16216. Booking in attendance with Brigade Control is required to confirm that the asset has arrived safely at the incident they were mobilised to. 418 Booking in attendance provides a date and time stamp, which is used to measure attendance times for pumping appliances, which is one of the Brigade’s key performance indicators. This date and time stamp data can also be used for post incident review and investigation and greatly assists in producing a detailed timeline of incident, if required.

15 Incident command procedures 16 Officer responsibilities at incidents

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Page 83 of 101 2nd April 2019 419 In producing the STEP timeline of activities the GTIRT has overcome this issue by cross referencing other data sources and the available Global Positioning System (GPS) information, mobile phone footage and CCTV imagery. This has enabled GTIRT to place officers and other resources at the incident with a reasonable degree of accuracy. Actions by the Brigade since the fire 420 In an attempt to overcome this issue the Brigade has reviewed the capability of the ‘Airwave’ hand held radios to establish if the equipment will allow an officer to book in attendance with Brigade Control without recourse to sending an oral message, i.e. will the equipment and the mobilising system allow for a data message to be sent and acknowledged. 421 This review confirmed that while the ‘Airwave’ hand held radios have this functionality the Brigade’s mobilising system is not currently set up to process text data received from the ‘Airwave’ handset. Capita, the company that supplied and maintains the Brigade’s mobilising system, is currently scoping the work and associated costs involved in adding this capability to the Brigade’s mobilising system. Key observation 6.4: There was a lack of information provided to Brigade Control on progress with search and rescue operations. 422 As previously covered in this report (Theme 5 refers) the sheer scale and unprecedented number of calls, both emergency and FSG, overwhelmed the capacity of the CROs who, understandably, were trying to answer as many of the ‘999’ calls as possible. 423 At the incident the same problem occurred as the command structure, the Fire Sector and FSG CU in particular, became overwhelmed with the volume of information that they had to process and disseminate. This led to a lack of situational awareness in Brigade Control who were advising residents and providing fire survival guidance to callers over a protracted period. 424 PN 790 states that once a FSG Coordinator is appointed at the incident this officer should make contact with a supervisor in Brigade Control. This contact is to keep Brigade Control appraised of developments and progress relating to the search and rescue of those residents involved in FSG calls. 425 The evidence shows that the sheer volume of information coming into the FSG CU left them little, if any, opportunity to contact a supervisor in Brigade Control. It is also clear that all the supervisory managers in Brigade Control were fully engaged in call handling and mobilising

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Page 84 of 101 2nd April 2019 activities for an extended period of time so no-one would have been available to communicate with the FSG Coordinator, even had this officer attempted to make contact with Brigade Control. Actions by the Brigade since the fire 426 As a result of these findings the Brigade has initiated a comprehensive review of its FSG policy and procedures which has included undertaking a range of exercises to establish at what point, in terms of the number of FSG calls, does Brigade Control and the FSG CU functions, as detailed in current policy become overwhelmed. The findings from these exercises will be incorporated into updated FSG procedures. Key observation 6.5: Dissemination of FSG call information between the CU and the Bridgehead was delivered via multiple communication channels as the volume and sources of information increased. 427 There is evidence that multiple information exchange processes were established at the incident for the dissemination of FSG call information between the FSG CU and the Bridgehead. Some information was passed by hand held radio communications while at other times ‘runners’ were used. These communication channels were implemented incrementally as the volume of FSG calls and information increased. 428 It is also evident that as the incident developed, and the various FSG call communications channels were implemented, there was minimal shared situational awareness of the process for disseminating and exchanging this information. 429 There is also evidence that the officers deployed on the FSG CU did not consistently use the ‘Control Information’ forms, which are available on all front line fire engines. These forms are carbonated so that the casualty information can be shared at the incident with one copy being retained by the CU staff for post incident analysis. There is evidence that other forms of paper records were used to pass some FSG call information and at times this was passed via a number of officers before it reached the Bridgehead. Actions by the Brigade since the fire 430 Improvements to this area form part of the review work currently being undertaken to update the Brigade’s FSG policy, which will be published later this year.

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Page 85 of 101 2nd April 2019 Key observations 6.6: There was limited practical means to communicate with all the residents in the building to provide advice and/or instruct an evacuation. 431 During Phase 1 of the Inquiry there has been a considerable focus on why the Brigade did not initiate a full evacuation of the Grenfell Tower during the early stages of the incident when it was first recognised that the fire was spreading rapidly beyond the flat of origin. While this is an understandable line of enquiry the Brigade has repeatedly, both in oral evidence and in its ‘Opening’ and ‘Closing’ statements, explained that the full evacuation of a residential high rise premises, with the building design of Grenfell Tower, is a complex challenge. 432 As stated earlier in this report, Grenfell Tower was not fitted with a building wide communications system that could have been utilised by the Brigade to alert residents to evacuate the building. 433 Without any integral communications systems, the Brigade is left with very limited options to initiate an effective and efficient full evacuation of this type of premises during a major fire. In a single staircase residential high rise building, such as Grenfell Tower, this problem is further exacerbated as a full evacuation would greatly impact on the fire and rescue service undertaking its firefighting, search and rescue operations. This could place residents at additional risk especially when the fire is spreading rapidly and the Brigade is hampered in its firefighting operation. 434 The Brigade does have some limited capability, such as loudhailers, that can be used to communicate with residents from a distance. However, while there is evidence that loudhailers were employed to a limited extent by Brigade at the Grenfell Tower fire it is unlikely to be an effective way of communicating with residents located on the upper floors of a residential high rise building. 435 As such, the only way that the Brigade can fully evacuate a building is to commit large numbers of firefighters in BA into the building to knock and potentially force entry to every flat. This is both very arduous, due to the poor conditions in the staircase and lobbies, and inefficient in terms of being able to evacuate the whole block quickly. Such a decision would require the IC to operate outside of agreed operational policy as it would require firefighters to go above the known fire floors without any firefighting media, placing firefighters in significant danger.

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Page 86 of 101 2nd April 2019 Actions by the Brigade since the fire 436 The Brigade recognises the importance of evacuation procedures and the means to implement such procedures is to the bereaved, survivors and residents but it also believes it is not something the Brigade can resolve on its own. Grenfell Tower was not originally designed to support a full evacuation of residents and as such the building did not contain the means with which to alert residents or coordinate a full evacuation. 437 The Brigade will continue to work with all stakeholders to identify and deliver improvements to the regulatory regime to prevent a re-occurrence of the Grenfell Tower fire and increase the safety of the public and firefighters. 438 The Brigade’s OPA department also continues to review PN 633 and work with other fire and rescue services to identify solutions to mitigate the issues described above, until changes to the regulatory regime, such as those recommended by the Hackitt Review, are implemented. However the challenge of identifying workable and safe procedures to overcome the fundamental design principles of buildings described above is significant and practically difficult. 439 For those buildings identified as being fitted with ACM cladding similar to that installed at Grenfell Tower and until the cladding is removed, the NFCC simultaneous evacuation guidance should be applied by the responsible person and requires, either, the installation of a central alarm system or the provision of a waking watch to alert residents to a fire and initiate an evacuation. Key observation 6.7: There was no declaration of a ‘Firefighter Emergency’ to Brigade Control in accordance with Policy Note 496. 440 From reviewing the Brigade’s witness statements it has been identified that there were three Firefighter Emergency (FFE) events during the incident that were not formally declared in a message to Brigade Control, as required by PN 49617. In policy the term FFE applies whenever operational staff, or persons working under the control of the Brigade, are unaccounted for and/or in need of rescue. 441 If it is established or there is strong evidence to suggest that one or more firefighters or personnel working under the control of the Brigade are unaccounted for and/or in need of rescue the IC will immediately send the following priority message:

17 Tactical withdrawal, emergency evacuation and firefighter emergency

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Page 87 of 101 2nd April 2019 “From (Name of IC) at (address of incident), Firefighter Emergency, Tactical Mode Oscar”. 442 The FFE message will prompt Brigade Control to mobilise the following resources:  Six Pumping appliances  Two Fire Rescue Units  Fire Investigation Unit  Command Unit  An ambulance  Press Liaison Officer  Senior Fire Safety Officer  Three Station Manager  Group Manager  Deputy Assistant Commissioner  Senior Accident Investigator (SAI). 443 PN 496 directs that this attendance will be mobilised in full, regardless of the resources in attendance or en route. If the size of the incident is subsequently increased, the mobilising system will not include the resources ordered for 'FFE' when calculating the additional attendance required. 444 Through further investigation of this issue it has been confirmed that while the FFE messages were not sent to Brigade Control, the Brigade did respond appropriately to these safety events by diverting resources to deal with the situation as a priority. 445 It has also been established that a conscious decision was made not to initiate the FFE message as they were aware that Brigade Control were already dealing with an unprecedented number of 999 and FSG calls and the further mobilisations required by the policy would create additional pressure and work for Brigade Control. 446 Evidence provided by witnesses also suggest the situation was assessed and it was determined the Brigade had sufficient resources in attendance at the time the events occurred to respond effectively to each FFE and the automatic mobilisation of the FFE PDA would further deplete the Brigade available operational resources. Recommendation 12 - The Brigade should consider whether any improvement measures are necessary in relation to policy and training, noting the context provided in the preceding paragraphs.

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Page 88 of 101 2nd April 2019 Key Observation 6.8: From 02:06hrs FSG call information was passed from Brigade Control to the incident by a mobile phone to a mobile phone link resulting in a lack of evidence to support the post incident review and investigation. 447 Evidence provided during Phase 1 of the Inquiry illustrates the transfer of FSG call information from Brigade Control to the incident did not follow the guidance contained in policy. PN 790 states that if there are a large number of FSG calls in progress and Brigade Control has sufficient resources then main scheme channel 118 can be used to avoid impacting on the main scheme radio channel in use. 448 Brigade Control also has a ‘CU critical’ phone line which has a higher priority than calls to the Officer of the Watch (OOW), which is the role normally undertaken by the on duty OM in Brigade Control. This number is programmed into CU phones and is used for passing life critical information securely. Both of these systems for passing FSG information are recorded. 449 During the Grenfell Tower fire mobile phones were used to pass FSG information from Brigade Control to the incident. The evidence suggests that this was done as a result of the high volume of FSG calls being taken and to keep the main scheme radio channel clear to send and receive ‘Assistance’ and ‘Informative’ messages relating to the Grenfell Tower fire and other incidents and enable CROs to focus on answering emergency calls. 450 The main issue arising from this situation is that the Brigade has no voice recordings relating to the FSG call information sent by this method. This has made tracking the FSG call information as part of the safety and learning investigation more difficult. Actions by the Brigade since the fire 451 This issue is currently being considered as part of the review of the Brigade’s FSG policy and procedures being undertaken by the Brigade’s OPA department, who have been working closely with GTIRT to fully understand the challenges and issues that arose during the Grenfell Tower fire in respect to the handling and management of FSG calls. The lessons learnt from the incident will be captured and reflected in the revised FSG policy guidance and the associated training solution(s) that will be developed.

18 M2FH FLON-OPS-01

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Page 89 of 101 2nd April 2019 Theme 7 – Operational Equipment Key Observations 7.1: The Command Support System was unreliable during the incident. 452 On the night of the Grenfell Tower fire it was stated in evidence by several CU operatives that the CSS did not work. 453 A Brigade witness when asked about the CSS on CU8 stated in oral evidence that on arrival at the incident around 02:20hrs that the CSS failed to start up, despite repeated attempts. The decision log maintained on CU8 after 02:47hrs notes at 04:03hrs that ‘Command Support System has gone down’. 454 However, another Brigade witness when questioned about whether there were any problems with the CSS on CU8 that night responded by stating that he could not remember any issues with the system but further noted that he had little involvement with the CSS during the night. This is supported by another witness who noted in his voluntary police statement that the CSS was working when he arrived on CU8 just before 04:00hrs and even took a photo of the command structure illustrated on the system. 455 Historically the problems with CSS at incidents are well documented and these issues were referred to a number of times in oral and written evidence. In these circumstances, officers and CU staff use alternative equipment provided on the CUs to manually record the same information that would ordinarily be populated on the CSS. This alternative equipment includes blank whiteboards and the ‘headline board’19 provided to record the incident command structure. 456 The CSS can provide a useful overview of the incident structure and as identified earlier in the report be used to record key decisions. 457 It is noted that whilst there are acknowledged issues with the reliability of the CSS, the Brigade has tried and tested methods to adapt and overcome these issues at operational incidents. Actions by the Brigade since the fire 458 The Brigade is currently in the process of delivering the CU replacement vehicle project, which aims to incorporate the latest technology to support its command, control and communications functions to support operational incidents.

19 Board incorporating a template which can be annotated with information to illustrate the command structure being employed at the incident.

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Page 90 of 101 2nd April 2019 459 The commencement of this project pre-dates the Grenfell Tower fire and demonstrates that the Brigade had already recognised the need to continually improve the functions delivered by CSS and actively review the new equipment and software technologies now available. 460 In January 2019, and ahead of the delivery of the CU replacement project, scheduled for 2020, the Brigade has rolled out two Windows 10, 4G enabled laptops to all seven CUs. This is to build resilience in the systems and to ensure that even if the main computer on the CUs aren’t working effectively or if a CU is unable to attend an incident the Brigade is still able to utilise the CSS remotely. As part of the rollout of this new equipment the CSS software has been updated from Version 1.0 to Version 1.7, which provides a more stable platform and is compatible with the latest versions of the Windows 10 operating system. 461 The new software was tested for three months in the last quarter of the calendar year on various CUs and training was provided for CU operatives. The CUs are currently being further upgraded with new IT hardware which will allow the CSS to be used as originally intended on the Units, i.e., on a large, dedicated display terminal. Once the upgrade is complete the laptops will remain on the CUs to provide further resilience. Key Observation 7.2: There was no mobilising protocol for the Brigade’s limited Positive Pressure Ventilation capability. 462 The Brigade only had a limited PPV capability at the time of the Grenfell Tower fire. It was not well known throughout the Brigade that this capability was under evaluation and available, as its primary purpose is to assist the Brigade’s response to a Marauding Terrorist Firearms Attack (MTFA) where fire may have been used as part of the deliberate attack. 463 Evidence shows that at 02:57hrs the Brigade’s IC requests, via the Duty DAC, the attendance of Positive Pressure Ventilation (PPV). This request is made via a mobile phone call to Brigade Control. 464 The Brigade has an established method of mobilising the majority of equipment/resources to incidents, which is covered in PN 41220. However, as the PPV equipment currently only forms part of a specialist response capability to a specific incident type it is not in general use. This is why these vehicles and associated PPV equipment do not appear on the Pre Determined Attendances (PDAs) on the ‘Vision’ mobilising system.

20 Mobilising policy

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Page 91 of 101 2nd April 2019 465 This resulted in the PPV equipment, when requested, needed to be mobilised manually. This was done by a SM who was located at the BCC, who instructed a WM, also at the BCC, to collect the specialist vehicle carrying the two sets of PPV from the Brigade’s headquarters. The PPV capability arrived on scene just after 04:00hrs and is seen at 05:03:20hrs being brought into the Grenfell Tower ground floor lobby. Actions by the Brigade since the fire 466 The Brigade has introduced a new mobilising protocol for the existing Special Operations PPV equipment, which is now identified as an ‘attribute’ on the ‘Vision’ mobilising system. In March 2018 a new RIF was produced to support PPV mobilisations. These system changes enable PPV to be mobilised either by the Duty National Interagency Liaison Officer (NILO) or in response to a request from an incident. When PPV is requested from a routine fire incident the mobilisation must be sanctioned by the Duty NILO and the Duty AC. Recommendation 13 - It is suggested that the Brigade considers whether it needs to make operational staff more aware of the currently available PPV capability and its uses. Key Observation 7.3: A number of Breathing Apparatus sets were used more than once by different wearers and there was no means to record the test or subsequent wearer. 467 Traditionally when firefighters report for duty they are required to do a test of their BA sets. This is normally done at the beginning of the shift. Once the test is complete, whether the BA set has passed or failed the firefighter will, as soon as practicably possible, fill out the corresponding BA log book. 468 These BA log books are kept at the home station, enabling supervisory officers to check and confirm all BA sets have been allocated and tested. To support the Brigade’s investigation and the identification of BA teams, all log books were scanned to record their contents. This exercise identified that some log books were not completed correctly and a small number had not completed at all. 469 The log books remain on the station all the time the BA set is allocated to that station. The only time the BA log book should be removed is when the equipment is sent to PEG for periodic testing or when the equipment is defective. The log books are not carried on appliances with their respective BA sets.

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Page 92 of 101 2nd April 2019 470 At the Grenfell Tower fire between 01:04hrs and 08:11hrs there were 217 BA sets used by firefighters. Between 08:11hrs and 20:00hrs, a further 169 BA sets were worn. 471 The Brigade still have 58 BA sets that are known to have been used during the fire after 08:00hrs which have not been attributed to an individual firefighter, i.e. the Brigade has been able to confirm that the set was used during the fire, but is unable to identify by whom. 472 When firefighters exited Grenfell Tower some returned to their fire engine and performed a fire ground ‘A’ Test. This is a basic test of the set to ensure it is safe to be used again. As the incident escalated a specific area was established to service the sets and enable BA wearers to rest and recover. There was no facility at this area to record the testing of sets as all BA log books were at their respective fire stations. 473 The RPE Logistics Officers (RPELO) carry temporary log sheets that can be utilised on scene. The duty RPELO arrived on scene at 04:45hrs and the temporary log sheets were utilised from 10:30hrs. Reserve Extended Duration BA sets were mobilised to the incident from PEG with the accompanying log books but these were not used to record acceptance or fireground ‘A’ tests. 474 Whist there was no impact on the availability or usability of BA sets on the night of the Grenfell Tower fire. The poor records in BA log books made it difficult to identify wearers, the sets those wearers used and how those wearers were organised into teams when they entered the hazard area. Actions by the Brigade since the fire 475 The issues described above have been communicated to the RPE policy team and PEG for consideration. Key Observations 7.4: Time stamp on the Thermal Image Cameras were not aligned to Greenwich Mean Time. 476 As part of the Brigade’s investigation and evidence gathering in the recovery phase of the incident, the Brigade’s Fire Investigation (FI) officers undertook the task of identifying all of the Thermal Image Cameras (TICs) used during the fire. The FI officers reviewed the footage captured by the TICs as part of their own investigation as to the likely cause of the fire and downloaded approximately 60 hours of footage from 22 cameras. This footage was uploaded onto the Brigade’s Grenfell Tower image library.

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Page 93 of 101 2nd April 2019 477 The footage was reviewed by GTIRT to identify which TIC belonged to which station, who recorded the images and at what time, to corroborate the actions of firefighters, fire spread, smoke movement and identification of residents inside Grenfell Tower. 478 It was observed that there were a number of inconsistencies with time stamps on the images reviewed. Further investigation revealed that the TIC’s do not have an auto update feature which automatically updates the time on the equipment to align with Greenwich Mean Time (GMT) and British Summer Time (BST) as this requirement was not included in the procurement specification. 479 The TICs do not provide a time indication whilst the equipment is being operated so any inaccuracies are not apparent to the equipment user. As there is no automatic update facility on this equipment the time has to be changed manually, which is normally only done once a year by an external contractor during the equipment’s scheduled service. As a consequence it is highly probable the time stored within the Brigade’s TICs will often be inaccurate. 480 All the TICs were subsequently examined by the Brigade and a retrospective calculation was used to establish the time difference against the GMT. From this, GTIRT were able to establish an approximate time for the majority of the TIC footage reviewed, which has been used to inform its timeline and associated reports. Actions by the Brigade since the fire 481 The issue described above was communicated to the TIC manufacturer and supplier in July 2017 by the Brigade’s Technical and Commercial department to enable a solution to overcome the time stamp issue to be identified. The development of an approved solution is still being progressed.

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Page 94 of 101 2nd April 2019 Chapter 4 - Summary of key observations Theme 1 - Observed failures of the building and its fire safety measures Key observation 1.1 : The external cladding system installed on Grenfell Tower was not compliant with Regulation B4(1), contributing to the observed failure of the fire safety measures provided within the premises. Theme 2 – Operational pre-planning Key observation 2.1 : Any knowledge concerning the risks associated with cladding systems may not been recognised and communicated effectively across the Brigade. Key observation 2.2 : The Operational Risk Database entry for Grenfell Tower was not populated in accordance with PN 800. Key observation 2.3 : There is a lack of consistency in the standard of premises risk information held on the Operational Risk Database. Key observation 2.4: The Brigade has not undertaken Premises Risk Assessments for all residential high rise premises to determine the level of risk associated with these premises. Key observation 2.5 : There may be an inconsistent level of knowledge and understanding amongst operational staff in relation to 7(2)d visits. Key observation 2.6 : There is no established means for crews providing an emergency response to premises outside of their own station areas to be aware of any fire safety deficiencies that may have been identified. Theme 3 – Command and Control Key Observation 3.1 : The scale and rapidity of the incident, combined with human factors, impacted on the ability to maintain situational awareness. Key observation 3.2 : The rapid escalation of the incident impacted to a limited extent on command handovers. Key observation 3.3 : Effective early information gathering enabled the ‘on arrival’ tactics and actions identified in PN 633 to be implemented effectively by the crews who formed the pre-determined attendance for the incident.

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Page 95 of 101 2nd April 2019 Key observation 3.4 : There was effective early recognition of resourcing requirements by ICs. Key observation 3.5 : Recording of decisions, rationale, objectives and tactical plans was in some regards ineffective. Key observation 3.6 : Difficulty in confirming who was being rescued or self evacuating from the building and from where created difficulty in maintaining accurate records to inform the search and rescue operation. Key observation 3.7 : Operational Discretion was adopted for the incident but it was not formally recorded in accordance with Brigade policy. Theme 4 – Operations Key observation 4.1: The Brigade had limited means to fight an external façade fire resulting from the non compliance of the installed external cladding system with the requirements of Regulation B4(1). Key observation 4. 2 : Extensive breaches of compartmentation resulted in simultaneous serious fires on multiple floors. Key observation 4.3 : The building behaved in an unpredictable manner beyond the experience of the Brigade. Key observation 4.4 : The building’s single escape route was significantly compromised by the products of combustion from an early stage of the incident. Key observation 4.5 : Number of FSG calls and the resulting volume of information significantly exceeded the expectations of Brigade policy and training. Key observation 4.6 : Operational personnel were required by circumstances to provide fire survival guidance to residents, a task not anticipated by policy or training. Key observation 4.7 : Operational crews had problems physically identifying floor numbers in the stairwell. Key observation 4.8 : Some elements of the BA operations during the Grenfell Tower fire were not fully aligned to the Brigade’s operational procedures set out in PN 466.

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Page 96 of 101 2nd April 2019 Theme 5 – Brigade Control Key observation 5.1 : The facilities at the Brigade’s fallback Control, located in Stratford, did not fully replicate those at the primary Control in Merton. Key observation 5.2 : FSG call information was not gathered and communicated in accordance with PN 539, Appendix 3. Key observation 5.3 : There was no established or tested method to maintain an overview of the FSG call information being received by Brigade. Key observation 5.4 : The ‘Vision’ mobilising system does not support the identification of telephone numbers to enable call backs, and the Brigade does not have a clear policy position on re-contacting callers. Key observation 5.5 : There are no national standards for passing and receiving FSG call information between Fire and Rescue Service Control rooms handling calls related to the same incident. Key observation 5.6 : There is no automated system to link NICE voice records to Vision call records, impacting on any post incident review. Key observation 5.7 : The ‘Vision’ mobilising system ‘call collection form’ can be overwritten if a new call is taken before it is added to the incident log. Key observation 5.8 : There is potential for Brigade Control personnel to experience secondary trauma following a traumatic incident. Theme 6 - Communications Key observation 6.1 : The volume of radio traffic exceeded the capacity of both the BA and command channels. Key observation 6.2 : There is evidence of a lack of knowledge and understanding of the potential tactics and associated equipment that may have mitigated radio communication issues. Key observation 6.3: Senior officers were unable to book in attendance at the incident due to the high volume of radio traffic on the Airwave main scheme radio. Key observation 6.4 : There was a lack of information provided to Brigade Control on progress with search and rescue operations.

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Page 97 of 101 2nd April 2019 Key observation 6.5 : Dissemination of FSG information between the CU and the Bridgehead was delivered via multiple channels as the volume and sources of information increased. Key observation 6.6 : There was limited practical means to communicate with all residents in the building to provide advice and / or support. Key observation 6.7 : There was no declaration of a Firefighter Emergency to Brigade Control in accordance with Policy Note 496. Key observation 6.8 : From 0300hrs, FSG information was passed from Brigade Control to the incident by a mobile to mobile communication link, resulting in a lack of evidence to support a post incident review. Theme 7 - Equipment Key observation 7.1 : The Command Support System was unreliable during the incident. Key observation 7.2 : There was no mobilising protocol for the Brigade’s limited Positive Pressure Ventilation capability. Key observation 7.3 : A number of BA sets were used more than once by different wearers and there was no means to record the test or the subsequent wearer. Key observation 7.4 : Time stamp on Thermal Image Cameras is not aligned to Greenwich Mean Time.

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Page 98 of 101 2nd April 2019 Chapter 5 – Summary of recommendations Recommendation 1 - The Brigade should continue to work with all stakeholders to identify and deliver improvements to the regulatory regime to prevent a re-occurrence of the Grenfell Tower fire and increase the safety of the public and firefighters. Recommendation 2 - The Brigade should continue to campaign vigorously for the provision of sprinklers in residential high rise and other types of buildings in order to improve public safety. Recommendation 3 – The Brigade should consider reviewing its policies and training packages relevant to 7(2)d visits to ensure consistent guidance is provided to operational personnel. Recommendation 4 – The Brigade should consider how to ensure information relating to identified fire safety deficiencies in a premises is available to all operational crews. Recommendation 5 - It is recommended that the Brigade determines whether to retain the DMM or move to the DCP. It is acknowledged the Brigade needs to consider the challenges and benefits of implementing such a wider ranging and fundamental change to its incident command framework, at a time of significant organisational change and other improvement programmes. Recommendation 6 - The Brigade should consider the extent to which human factors affecting command and control are addressed in policy and training. Recommendation 7 - The Brigade should consider how it can most effectively raise awareness of and reinforce the requirements of PN 828 ‘Recording decision at incidents’. Recommendation 8 – Whilst it is recognised that the volume of FSG calls experienced during the Grenfell Tower fire and the information associated with those calls was unprecedented, it is recommended the Brigade considers the issues carefully to ascertain if any measures can be implemented to address this matter. Recommendation 9 - The Brigade should consider to what extent recognition that a building is behaving unpredictably in fire is addressed in policy and training. Recommendation 10 - It is suggested the Brigade considers the extent to which policy, training and human factors played a role in the control measure degradation identified. Recommendation 11 - It is suggested the Brigade considers how shared situational awareness within the Control room might be achieved in similar circumstances and whether a more

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Page 99 of 101 2nd April 2019 sophisticated system than the whiteboards used on the 14th June should be developed and implemented as an established Control protocol. Recommendation 12 - The Brigade should consider whether any improvement measures are necessary in relation to FFE policy and / or training. Recommendation 13 - It is suggested that the Brigade considers whether it needs to make operational staff more aware of the current available PPV capability and its uses.

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Page 100 of 101 2nd April 2019 Chapter 6 - Appendices Appendix A – Operational Response Report Volume One Brigade reference: GTIRT19-00152 Inquiry reference: LFB 00032988 Appendix B – Actions by Brigade Control Brigade reference: GTIRT18-03448 Inquiry reference: LFB 00004790 Appendix C – Organisational Overview Brigade reference: GTIRT18-02288 Inquiry reference: LFB 00001905 Appendix D – Lakanal House Incident Assurance Review, August 2018 Brigade reference: GTIRT18_03758 Inquiry reference: Not applicable Appendix E - National guidance and London Fire Brigade operational policy for fighting fires in high rise buildings Brigade reference: GTIRT19-00737 Inquiry reference: Not applicable Appendix F – NFCC ‘Guidance to support a temporary change to a simultaneous evacuation strategy in purpose-built block of flats’ Brigade reference: GTIRT18-02260 Inquiry reference: LFB 00024392 or HOM 00045969

FD05979 ｜ 1962_沙特阿拉伯阿·美石油火灾_8·4_火灾_调查报告.md

分类：06_境外及港澳台调查报告 ｜ 年份：1962 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：md

一、事故概况及经过

1962年8月4日，沙特阿拉伯的阿拉伯·美利坚石油公司冷冻罐发生火灾，造成1人死亡，6人受伤，经济损失4亿5千万日元。

该公司冷冻罐区有4座贮罐，分别贮存丙烷和丁烷气体。贮罐为单壳式，外包隔热泡沫玻璃纤维，最外层有沥青隔湿。容量为12700立方米，直径约32米，高约15米，拱顶结构，最大允许工作压力为O．07kg／m2。火灾发生在A罐，引燃B、C罐。

事故当天，冷冻罐循环压缩机发生故障，为抑制罐内压力上升，从排气管释放气体(据事后查明，压缩机停机2小时后，A罐压力为0．07kg／cm2，4小时后升为0．1kg／cm2，但工人未采取任何措施便交接班)。

交接班后，刚上班的工人登上B罐顶预查压力升高的原因时，A罐破裂，顶与壳接合部出现约二分之一圆周长的裂缝，气体外溢，随即着火。火焰引着B罐和C罐安全阀喷出的气体，B罐的镀铝安全阀熔化。

当时采取的紧急措施是向罐内吹入惰性气体，使罐压上升，把罐内贮存物移送到船上后(回收约80％)，在喷水掩护下关闭阀门，扑灭火。把B罐的丙烷用泵抽入燃烧坑内让其燃烧(约6天)。破裂的A罐任其燃烧。

二、事故原因分析

1．C罐底部连接冷却器的管道控制阀6B由于弹簧上有油漆和铁锈未能关紧，丁烷气体顺着临时安装的4B清洗管流入放气管。

2．放气管在进入顶出桶之前有6米的升高部分，丁烷在管内受阻，各罐气孔排出的气体不能从喇叭通风管释放，致使罐内压力逐渐上升。

3．着火原因可能是冷冻罐仪表照明灯引起，也可能是由于气体喷出时产生静电，或罐破裂时摩擦火花引起。

FD05980 ｜ 2010_瑞典_赫尔辛堡_安养院火灾调查_火灾报告.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2010 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

HELSINGBORGS STAD Brandförsvaret 2010-01-11

Sammanfattning efter brand på i Helsingborg Onsdagen den 6 januari 2010 fick räddningstjänsten i Helsingborg ett larm om brand i byggnad på i Helsingborg.

är ett trygghetsboende, vilket innebär att det är ett boende för äldre med viss extra service (gemensam matsal och värdinna). Boendet skall dock inte förväxlas med ett vårdboende. De krav som ställs på ett trygghetsboende enligt Boverkets byggregler är de samma som för vilket boende som helst, det vill säga det finns inga lagkrav att det ska finnas automatiskt brandlarm installerat.

Larmet kom in strax innan åtta på morgonen och väl framme på platsen mötte personal upp och visade vägen till den aktuella lägenheten. På golvet inne i lägenheten hittades den boende med svåra brännskador.

Den troliga orsaken till branden är att den boende har tänt ljus och i samband med detta har personens kläder fattat eld. Den boende har inte haft någon möjlighet att släcka branden i kläderna. Skadorna blev så omfattande att personen senare avled.

Det fanns ingenting som personalen hade kunnat göra annorlunda för att rädda den boende. I lägenheten fanns en brandvarnare som fungerade och personalen hade dessutom minskat rökspridningen till intilliggande utrymmen genom att stänga lägenhetsdörren.

Det har spekulerats i huruvida det borde finnas automatiskt brandlarm och eventuellt även boendesprinkler i bostäder för äldre, men oavsett om boendet hade varit utrustat med automatiskt brandlarm eller boendesprinkler så hade det inte påverkat utgången i detta fallet. Det enda som eventuellt hade kunnat rädda den boende hade varit ett förbud för levande ljus i bostaden.

Däremot kan det vid andra typer av bränder finnas ett mervärde i att utrusta trygghetsboende med automatiskt brandlarm och eventuellt boendesprinkler. Både vad gäller säkerheten för de boende i brandlägenheten men även för boende i intilliggande lägenheter.

Lasse Bengtsson, Anna Brand och Johan Lindström Olycksutredare Helsingborgs brandförsvar

FD05981 ｜ 2011_瑞典_赫尔辛堡_休闲中心火灾调查_火灾报告.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2011 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Olycksundersökning Nivå 2b Brand på fritidsgård, Södra Hunnetorpsvägen 49

Juni 2010

Anledning till utredningen: Brand på fritidsgård i Helsingborg på Södra Hunnetorpsvägen 49, 2010-06-09.

Uppdrag: Utvärdera genomförd insats på ovanstående objekt samt föra tillbaka erfarenheter till berörda inom organisationen på kommande lagträffar.

Anna Brand Helsingborgs brandförsvar HELSINGBORG

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INNEHÅLLSFÖRTECKNING

1 INLEDNING ................................................................................................................................................ 3 1.1 BAKGRUND ................................................................................................................................................ 3 1.2 SYFTE ........................................................................................................................................................ 3 1.3 METOD ...................................................................................................................................................... 3 1.4 AVGRÄNSNINGAR ...................................................................................................................................... 3 2 INSATS......................................................................................................................................................... 3 3 UTVÄRDERING AV INSATSEN ............................................................................................................. 3 3.1 TGI ........................................................................................................................................................... 3 3.2 INSATSORGANISATION PÅ SKADEPLATS ..................................................................................................... 4 3.3 METODVAL ................................................................................................................................................ 4 3.4 KOMMUNIKATION ..................................................................................................................................... 5 3.5 SAMVERKAN MED ANDRA ORGANISATIONER ............................................................................................. 5 4 ÖVRIGT ....................................................................................................................................................... 5 5 SLUTSATSER ............................................................................................................................................. 5

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1 Inledning 1.1 Bakgrund Den 9 juni 2010 fick räddningstjänsten ett nivå 3 larm om en brand på en fritidsgård på Södra Hunnetorpsvägen 49 i Helsingborg. I inledningsskedet var det oklart om det var brand i byggnaden eller om det var brand i den byggnadsställning som vid tillfället var placerad runt fritidsgården.

Enligt 10§ 3 kap Lag (SFS 2003:778) om skydd mot olyckor ska kommunen se till att olyckor undersöks för att i skälig omfattning klarlägga orsakerna till olyckan, olycksförloppet och hur insatsen har genomförts. 1.2 Syfte Syfte med denna utredning är att utvärdera genomförd insats och föra tillbaka erfarenheter till alla i organisationen. Syftet är inte att diskutera huruvida någon eller några har gjort något fel, utan att identifiera eventuella organisatoriska brister inom vår organisation eller i vårt samarbete med andra organisationer. 1.3 Metod Undersökningen fokuseras på viktiga slutsatser, som baseras på intervjuer med den operativa personalen (JJ, Nn), samt information från den efterföljande lagträff som hölls den 16 juni. Platsen har besökts den 9 juni efter avslutad insats. Information har även hämtats från insatsrapporten. Utredningen har utförts av Anna Brand och granskats av Lasse Bengtsson.

Själva händelseförloppet beskrivs endast kortfattat. 1.4 Avgränsningar I denna rapport utreds räddningstjänstens insats från och med att första styrkan larmades ut fram till dess att räddningstjänsten avslutades. 2 Insats Larmcentralens ärendenummer: 20.1744365.2 Start: 01:45.18 Avslut: 04:25.00 Händelsetyp och ledningsnivå: Brand i byggnad nivå 3 Adress: Södra Hunnetorpsvägen 49

Utalarmerade styrkor och fordon (lag A): Gåsebäck, Bårslöv, insatsledare och vakthavande brandingenjör

Förstärkande och avlösande enheter: Berga och Vallåkra 3 Utvärdering av insatsen 3.1 TGI Den taktiska grundinriktningen sattes till att tillintetgöra branden. Detta skulle säkerställas genom att ta upp en begränsningslinje på taket genom friläggning av en del av takkonstruktionen.

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1. 2

Insatsorganisation på skadeplats Skadeplatsen delades in i två sektorer där Gåsebäck hade hand om den invändiga rökdykningen och Berga och Bårslöv hade hand om håltagningen på taket.

Efter en knapp timmes insats (02:40) kommer Vallåkra till platsen för att lösa av Gåsebäck. 3.3 Metodval Redan vid framkörningen till objektet beslutade sig befälet på 1210 att stanna på gatan utanför fritidsgården. Detta för att lämna plats till hävaren inne på gårdsplanen framför fritidsgården.

Det uppstod inga problem vid uppkoppling till brandpost, utan det fanns en brandpost lätt tillgänglig på Södra Hunnetorpsvägen utanför byggnaden. Brandpostens placering var dessutom känd i och med att styrkan haft ett annat larm vid lastbryggan till den intilliggande mataffären tidigare samma natt.

Bild 1. Fritidsgården på Adolfsberg. De röda fyrkanterna visar brandposterna i närområdet.

Styrkan från Gåsebäck inledde med att koppla upp konventionell slang från släckbil och påbörjade utvändig släckning. Därefter gjordes en inbrytning via huvudentrén. I detta läget syntes ingen brand vare sig inne i entrén eller i takkonstruktionen. Mängden brandgaser i byggnaden var inte mer än att styrkan kunde se ett par meter framför sig. För att ventilera ut brandgaserna öppnades ett parfönster på baksidan av byggnaden och därefter sattes en övertrycksfläkt vid entrén för att förbättra sikten i byggnaden. Efter ett par minuter observerades dock att detta ledde till att brandförloppet accelererade i takkonstruktionen varför fläkten plockades bort igen.

Håltagningsarbetet utfördes framförallt från hävaren (1130) av personal från Berga men även från den byggnadsställning som vid tillfället för branden fanns runt byggnaden (personal från Gåsebäck). Metodiken för arbete på hög höjd användes med undantag för sågbyxorna som aldrig användes. Orsaken till att dessa aldrig användes var enligt uppgifter från styrkan att det upplevs som att det tar alldeles för lång tid att ta på sig byxorna samt att rörligheten blir starkt begränsad. Det var

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problem att få till någon riktig begränsningslinje på taket på grund av den komplicerade konstruktionen (balkar i vägen). Efter ett tag fick man dock till ett par hål i konstruktionen. Detta i kombination med rivning av innerväggar inifrån och släckning både inifrån och utifrån ledde till att branden till slut kunde släckas.

I inledningsskedet befarades att håltagningen inte skulle räcka för att få grepp om branden. Dimspik förbereddes som en eventuell omfallstaktik i kombination med rivning av innertak. 3.4 Kommunikation Kommunikationen skedde i huvudsak utan radio men den kommunikation som genomfördes med RAKEL fungerade utan problem. 3.5 Samverkan med andra organisationer Samverkan med polis och ambulans fungerade utan problem. Polisen lämnade dock platsen ganska omgående för att bevaka vilka personer som rörde sig i området. 4 Övrigt Ett kombinerat inbrotts- och brandlarm fanns i byggnaden. Enligt SOS-rapporten fick vaktbolaget larmet samtidigt som räddningstjänsten fick det (01:45) och en väktare var framme på plats klockan 01:50.

Även natten innan, den åttonde juni klockan 00:41, fick räddningstjänsten ett larm om brand på samma adress denna natten var det en moped som hade satts i brand utanför entrén. Vid detta tillfället begränsades dock brandskadorna till enbart den överbyggda huvudingången. Även vid detta tillfället har vaktbolaget fått larmet fast denna gången lite innan räddningstjänsten (klockan 00:34). En vakt var på plats redan klockan 00:38 och hade hunnit dämpa branden med en handbrandsläckare innan räddningstjänsten var på plats.

En fråga som dök upp dagen efter den inträffade branden är hur vi från räddningstjänstens sida skall lösa problematiken med att kunna svara på bland annat medias frågor. Detta då personerna som var involverade vid insatsen hade hunnit gå av sitt skift när media sökte kompletterande information om händelsen. 5 Slutsatser  Komplicerad takkonstruktion med ett flertal hålrum i där en brand lätt kan sprida sig. Kräver att utrymmena öppnas upp för att komma åt branden så att den inte kan sprida sig vidare.  Bra beslut av primärstyrkan att inte köra in till byggnaden utan lämna plats till 1130.  Värt att observera att vi kan få problem att kunna öppna/krossa rutor utifrån för att ventilera ut brandgaser efter hand som allt fler kommunala byggnader på grund av skadegörelse byter ut det yttersta fönsterglaset mot okrossbar polykarbonat. Denna fönstertyp deltar också i branden.  Viktigt att vatten till invändig rökdykning prioriteras innan vatten är säkrat från brandpost.

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 Trots komplicerad takkonstruktion har man lyckats släcka branden i ett så tidigt skede att det mesta av byggnaden räddats.  Ännu en gång arbetar man enligt metodiken för arbete på hög höjd med håltagning men använder sig inte av sågbyxor. Bör föras en diskussion om konsekvenserna om någon skulle skada sig.  Användning av övertrycksventilering är komplicerat. Risker bör bedömas från fall till fall.  Viktigt att minimera mängden brännbart material i närområdet. Tillsyn har redan varit ute och pratat med ägaren till den affär i närområdet vars kartonger det var som sattes i brand utanför fritidsgården vid det andra brandtillfället.  Den inträffade händelsen den åttonde juni visar på vilken resurs det kan vara med utbildade väktare som i vissa fall har möjlighet att begränsa brandspridningen i ett tidigt skede.  Hur skall vi lösa informationsproblematiken när media eller dylikt vill ha kompletterande information dagen efter en inträffad händelse? Skall information överlämnas till pågående skift för att kunna svara på medias eller andra förvaltningar/verksamheters frågor? Om inte hur skall denna informationskedja se ut?

FD05982 ｜ 2011_瑞典_赫尔辛堡_幼儿园火灾调查_火灾报告.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2011 ｜ 地域： ｜ 严重程度： ｜ 场所：学校/幼儿园 ｜ 起火原因： ｜ 来源格式：pdf

Snöbollsgatan 8 i Ödåkra Olycksundersökning nivå 3 Februari 2010

Anledning till utredningen: Brand i en förskola på Snöbollsgatan 8 i Ödåkra, Helsingborg, 2010-02-14.

Ansvarig utredare/analysgrupp: Anna Brand, Jerker Svensson och Lasse Bengtsson.

Uppdrag: Utvärdera genomförd insats på ovanstående objekt samt föra tillbaka erfarenheter till berörda såväl inom som utanför organisationen.

Återföring: Genomförd utvärdering skall återföras till berörda inom Helsingborgs brandförsvar, Kärnfastigheter, verksamheten på Snöbollsgatan samt till övriga som Säkerhet och Beredskap bedömer berörda inom Helsingborgs stad.

Anna Brand Helsingborgs brandförsvar HELSINGBORG

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INNEHÅLLSFÖRTECKNING

1 INLEDNING ................................................................................................................................................ 3 1.1 BAKGRUND ................................................................................................................................................ 3 1.2 SYFTE ........................................................................................................................................................ 3 1.3 METOD ...................................................................................................................................................... 3 1.4 AVGRÄNSNINGAR ...................................................................................................................................... 3 2 INSATS......................................................................................................................................................... 3 2.1 OMFATTNING VID ANKOMST ...................................................................................................................... 3 2.2 RÄDDNINGSTJÄNSTENS ÅTGÄRDER ........................................................................................................... 4 2.3 SKADEOMFATTNING .................................................................................................................................. 5 3 UTVÄRDERING AV INSATSEN ............................................................................................................. 5 3.1 TGI ........................................................................................................................................................... 5 3.2 INSATSORGANISATION PÅ SKADEPLATS ..................................................................................................... 5 3.3 METODVAL ................................................................................................................................................ 5 3.4 FORDONSPLACERING ................................................................................................................................. 5 3.5 KOMMUNIKATION ..................................................................................................................................... 5 3.6 SAMVERKAN MED ANDRA ORGANISATIONER ............................................................................................. 6 3.7 SAMVERKAN MED DRABBAD VERKSAMHET ............................................................................................... 6 4 ÖVRIGA FRÅGOR .................................................................................................................................... 6 4.1 INBROTTSLARM ......................................................................................................................................... 6 4.2 BRANDCELLSINDELNING ........................................................................................................................... 7 4.3 BRANDLARM ............................................................................................................................................. 7 5 SLUTSATSER ............................................................................................................................................. 7 5.1 RÄDDNINGSTJÄNSTEN ............................................................................................................................... 7 5.2 VERKSAMHETEN/KÄRNFASTIGHETER ........................................................................................................ 8

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1 Inledning 1.1 Bakgrund Den 14 Februari 2010 genomfördes en insats på Snöbollsgatan 8 i Ödåkra, Helsingborg med anledning av en brand i en förskolebyggnad.

Enligt 10§ 3 kap Lag (SFS 2003:778) om skydd mot olyckor ska kommunen se till att olyckor undersöks för att i skälig omfattning klarlägga orsakerna till olyckan, olycksförloppet och hur insatsen har genomförts. 1.2 Syfte Syfte med denna utredning är att utvärdera genomförd insats och föra tillbaka erfarenheter till alla i organisationen. Syftet är inte att diskutera huruvida någon eller några har gjort något fel, utan att identifiera eventuella organisatoriska brister inom vår organisation eller i vårt samarbete med andra organisationer. 1.3 Metod Faktainsamling har skett genom den återkoppling med insatta styrkor som genomfördes tisdagen den 16 februari. Information har även hämtats från insatsrapporten, fotografier och SOS ärenderapport. Utredningen har utförts av Anna Brand och granskats av en analysgrupp bestående av Kim Nydahl, Jerker Svensson och Lasse Bengtsson.

Platsen har besökts av brandförsvarets olycksutredare måndagen den 15 februari. Någon teknisk brandplatsundersökning har dock inte genomförts utan detta sköttes av polisens tekniker. 1.4 Avgränsningar I denna rapport utreds räddningstjänstens insats från det att larmet kom in till SOS och fram till dess att räddningstjänsten avslutades. 2 Insats Larmcentralens ärendenummer: 20-1581262-2 Larm till räddningstjänst: 01:59.16 Avslut av räddningstjänst: 04:42.46 Händelsetyp och ledningsnivå: Ursprungligen brand ute men klassas om till brand i byggnad, ledningsnivå 3. Adress: Snöbollsgatan 8 Utalarmerade styrkor och fordon: Station Berga, Station Bårslöv, insatsledare och VBI (01:59)

Förstärkande och avlösande enheter: Station Gåsebäck (02:03), Tankenhet (02:07), Höganäs Depå (02:23), restvärdesledare (03:19), Vallåkra (04:09), Allerum (04:57), RCB 2.1 Omfattning vid ankomst Redan vid Väla såg första styrkan från Berga rökpelaren från förskolan. Väl framme såg styrkan att det var kraftig rökutveckling från takskägg och ventilationsgaller runt hela byggnaden. Då brandpersonal gick runt gaveln på den närmsta längan

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observerades att alla fönsterrutorna i den sammanbindande korridoren var sönder och det var fullt utvecklad brand i korridoren. 2.2 Räddningstjänstens åtgärder Via det mobila insatsstödet hade första styrkan från Berga redan före framkomst till skadeplatsen lokaliserat var närmsta brandpost fanns, se bild 1. Väl framme inriktades första insatsen på rökdykning och att släcka branden.

Bild 1. Brandpost som användes vid insatsen, inringad på bilden.

När insatsledaren var på plats cirka sex minuter senare tog han över som räddningsledare och skadeplatsen delades in i tre sektorer där Berga hade sektor 1 (korridoren), Bårslöv hade sektor 2 (huvudentrén och flygeln till höger om entrén) och Gåsebäck hade hand om övertrycksventileringen; se bild 2.

Bild 2. Planritning över Snöbollsgatans förskola. Den röda delen var sektor 1 där röd pil anger angreppsväg, blåa delen sektor 2 där blå pil anger angreppsväg (huvudentrén). De två gröna fyrkanterna representerar placeringen för övertrycksfläktarna som Gåsebäck skötte.

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Restvärdesledare kallades in och Allerum fick i uppgift att sköta restvärdesuppdraget. 2.3 Skadeomfattning Hela byggnaden fick rökskador av varierande grad medan de centrala delarna blev totalskadade. 3 Utvärdering av insatsen För att föra tillbaka erfarenheter från den insats som genomförts vid branden på Snöbollsgatan 8 har en insatsutvärdering genomförts. 3.1 TGI Då larmet om branden på förskolan kom in på natten mellan lördag och söndag sattes den taktiska grundinriktningen till att släcka branden. 3.2 Insatsorganisation på skadeplats Larmet kom in som ett nivå 3 larm men då vakthavande brandingenjör har beredskap i hemmet på helgen, dröjde det över en halvtimme från första enhet var på plats till det att vakthavande brandingenjör var framme. Detta ledde till att det blev problematiskt för nivå 2 befälet att kunna ha koll på och samordna alla tre styrkorna samtidigt som han skulle ha hand om kommunikationen bakåt med stabsbrandmästaren samt med övriga samverkande. 3.3 Metodval För att släcka branden kopplades högtrycksslang upp från släckbil och brandpost. Brandposten fick dock kopplas ner då fler fordon kom fram eftersom brandposten var placerad på ett sådant sätt att den förhindrade framkörning, se bild 1 ovan.

Då Bergas och Bårslövs rökdykare var inne och släckte branden fick Gåsebäck i uppgift att sätta övertrycksfläktar på de två flyglarna till vänster om huvudentrén. Detta för att förhindra brandgaser att spridas in i dessa delar av byggnaden. 3.4 Fordonsplacering På grund av brandens omfattning då första styrkan kom fram till platsen blev inte fordonsplaceringen optimal. Detta i kombination med brandpostens placering och det faktum att det inte gick att köra runt byggnaden gjorde att det blev väldigt trångt framför byggnaden. I efterhand kan det konstateras att om det hade förelegat ett behov att använda höjdfordon så hade insatsen fördröjts avsevärt då flertalet fordon hade behövt flyttas. 3.5 Kommunikation Redan efter cirka 5 minuter på skadeplatsen sattes skadeplatskanalen till kanal 61. Kommunikationen fungerade överlag bra men som vid tidigare insatser upplevs att radioapparaterna laddas ur väldigt fort.

RAKEL användes mellan skadeplatsen och stabsbrandmästaren. Detta fungerade bra.

Ingen kommunikation mellan rökdykarna förekom då de hade olika kanaler.

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1. 6

Samverkan med andra organisationer Polis, ambulans, miljökontor, länsstyrelse, andra räddningstjänster etc. 3.7 Samverkan med drabbad verksamhet Samverkan med verksamheten fungerade bra. Det upplevdes dock som svårt att få kontakt med representanter från Kärnfastigheter. Ett problem är att brandförsvaret har kontaktpersonerna på ett papper och inte i databasen Daedalos. En annan sak som behöver utredas är vilka som behöver kontaktas vid en brand i vissa fall kanske det räcker att man får tag i den entreprenör som enligt avtal sköter service och underhåll etc. 4 Övriga frågor 4.1 Inbrottslarm Det fanns vid tillfället för branden ett nyinsatt inbrottslarm på Snöbollsgatans förskola. Larmet består av rörelsesensorer som aktiverar inbrottslarmet vid rörelse i byggnaden. Enligt larmloggen har det kommit in ett inbrottslarm redan klockan 01:21.57 i sektion 04 som täcker korridoren där brandskadan blev som störst. Strax därefter klockan 01:27.46 har larmet löst i sektion 1, 5 och 6 och klockan 01:28.03 i sektion 2 och 3. Sektionerna visas på bild 3 nedan.

Bild 3. En del av inbrottslarmets sektioner.

Inget ärende har dock skapats av dessa inbrottslarm. Enligt de första uppgifterna verkar det som att det har blivit en miss efter att det nya inbrottslarmet installerats och provats av. Efter godkänd provning har inte anläggningen gått över i skarp drift. Denna fråga är numera utredd och rutinerna har ändrats.

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1. 2

Brandcellsindelning Då skadorna på byggnaden blev omfattande kommer den sammanlänkande korridoren att behövas byggas upp på nytt. För att få en byggnad som har ett bättre skydd mot brand- och brandgasspridning rekommenderas att korridoren uppförs som en egen brandcell där respektive av de fyra flyglarna på byggnaden kommer att vara en egen brandcell. 4.3 Brandlarm I förskolor finns det inget krav på att det ska finnas ett automatiskt brandlarm och på grund av de kostnader som en installation för med sig väljs oftast det billigare alternativet med batteridrivna brandvarnare.

Det bör utredas vilka andra alternativ för att upptäcka en brand i ett tidigt skede som finns tillgängliga för den här typen av verksamheter. Detta är något som bör ses över och beslutas om centralt i Helsingborgs stad. 5 Slutsatser 5.1 Räddningstjänsten Det är viktigt att den som är räddningsledare har en överblick över hela insatsen. I detta fallet har nivå 2 befälet varit ensam på platsen under en stor del av insatsen på grund av att vakthavande brandingenjör har beredskap i hemmet på helgerna. Detta har lett till svårigheter att få den överblicken. Det är av största vikt att ingen fattar egna beslut utan följer de instruktioner och beslut som fattats av räddningsledaren. Det är annars en stor risk att de egna initiativen leder till att motverka det syfte som räddningsledaren satt upp, till exempel vid övertrycksventilering. Det är räddningsledaren på plats som har ansvar för de resurser som är insatta, inga resurser kan plockas bort från insatsen utan en dialog med räddningsledaren. Viktigt att alltid tänka framåt vid fordonsplaceringen. Kommer det att finnas behov av till exempel stegbil i nästa fas måste det finnas utrymme för den. När det nya höjdfordonet är i drift kommer det att behöva backas in. Då inte vattentillgången är säkrad ska rökdykarna prioriteras. Viktigt att tänka på slangdragningen från brandpost så att eventuella tryckstötar inte medför att brandposten lossnar från infästningen. Bra släckinsats – minimala vattenskador och mycket av byggnaden räddad trots omfattningen på branden samt det faktum att byggnaden saknade brandcellsgränser. En erfarenhet som kan dras är att det till viss del hjälper med stängda dörrar i verksamheten trots att det inte är brandcellsavskiljande dörrar. Problem med kommunikation mellan rökdykargrupper då de har olika rökdykarkanaler. Ett alternativ skulle vara att ligga på samma kanal, men då blir det istället problem med att rökdykargrupperna stör varandra. Kommunikation kan istället vid behov gå via styrkeledarna. Bra att gå över till skadeplatskanal tidigt för att slippa störningar i kommunikationen. Viktigt för räddningsledaren att planera för avlösning av enheter. Vid behov av extra resurs för rökdykning är det viktigt att stabsbrandmästaren är medveten om i vilken utsträckning som Vallåkra får rökdyka.

8

Finns ett behov att se över möjligheterna att få ut mat till insatser som pågår under en längre tid. En rutin bör tas fram för hur det ska fungera. Bra att utse en depåplats för att undvika att blanda nya och gamla flaskpaket. Ta fram checklista/rutin för vilka funktioner som skall kontaktas vid en brand/olycka både inom egen organisation och inom Kärnfastigheter. Ett problem som uppmärksammades var att det fanns en skylt om att det fanns gasflaskor på förskolan, men dessa påträffades inte under insatsen. Det framkom även att inte alla styrkor var medvetna om att det skulle finnas gasflaskor i byggnaden. Det är viktigt att räddningsledaren gör en riskbedömning innan rökdykning påbörjas. Vid utredningen efter branden framkom det att det hade funnits syrgas till ett av barnen i flygeln längst ifrån huvudentrén. Ett förslag till komplement av skyltningen skulle vara att skylten kompletterades med en planskiss där det utrymmet där gasen förvaras är markerat. 5.2 Verksamheten/Kärnfastigheter Ett problem som uppmärksammades var att det fanns en skylt om att det fanns gasflaskor på förskolan, men dessa påträffades inte under insatsen. Ett förslag till komplement av skyltningen skulle vara att skylten kompletterades med en planskiss där det utrymmet där gasen förvaras är markerat. Det bör utredas vilka andra alternativ för att upptäcka en brand i ett tidigt skede, förutom en automatisk brandlarmsanläggning, som finns tillgängliga för den här typen av verksamheter. Detta är något som bör ses över och beslutas om centralt i Helsingborgs stad. För att få en byggnad som har ett bättre skydd mot brand- och brandgasspridning rekommenderas att korridoren uppförs som en egen brandcell vid återuppbyggnaden, där respektive av de fyra flyglarna på byggnaden kommer att vara en egen brandcell. Ta fram checklista/rutin för vilka funktioner som skall kontaktas vid en brand/olycka inom Kärnfastigheters lokaler.

FD05983 ｜ 2012_瑞典_赫尔辛堡_印刷厂火灾调查_火灾报告.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2012 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

HELSINGBORGS STAD BRANDFÖRSVARET

2010-09-27

HELSINGBORG

Olycksundersökning – Nivå 3 Brand på JMS Rulloffset, Ängelholmsvägen 27 17 april 2010

Anledning till undersökningen: Brand på JMS Rulloffset på Ängelholmsvägen 27 i Helsingborg den 17 april 2010.

Uppdrag: Att utreda hur brandförsvarets insats genomfördes samt vilka faktorer som påverkade insatsen med syftet att föra tillbaka erfarenheter till inblandade parter.

Inblandade styrkor: I huvudsak lag D och lag C

Olycksundersökningen är genomförd av: Anna Brand, brandingenjör, Helsingborgs brandförsvar

Bilagor: Fotobilaga och STEP-analys.

INNEHÅLLSFÖRTECKNING

1 BAKGRUND ................................................................................................................................................ 3 2 SYFTE .......................................................................................................................................................... 4 3 METOD ........................................................................................................................................................ 4 3.1 AVGRÄNSNINGAR ...................................................................................................................................... 4 4 OLYCKSPLATS ......................................................................................................................................... 4 4.1 PLATSBESKRIVNING .................................................................................................................................. 6 4.2 BRANDSKYDD............................................................................................................................................ 6 5 BRANDFÖRLOPP ...................................................................................................................................... 6 5.1 OMFATTNING VID ANKOMST ...................................................................................................................... 6 5.2 SKADEOMFATTNING .................................................................................................................................. 6 5.3 PRIMÄRBRAND .......................................................................................................................................... 6 5.4 BRANDORSAK ............................................................................................................................................ 6 5.5 SPRIDNINGSRISKER .................................................................................................................................... 7 6 BESKRIVNING AV INSATSEN ............................................................................................................... 7 6.1 UTLARMNING ............................................................................................................................................ 7 6.2 TAKTISK GRUNDINRIKTNING (TGI) ........................................................................................................... 7 6.3 INSATSORGANISATION PÅ SKADEPLATS ..................................................................................................... 7 6.4 METODVAL ................................................................................................................................................ 9 6.5 KOMMUNIKATION ................................................................................................................................... 10 6.6 SAMVERKAN MED ANDRA ORGANISATIONER ........................................................................................... 10 6.7 SAMVERKAN MED DRABBAD VERKSAMHET ............................................................................................. 10 7 STEPANALYS ........................................................................................................................................... 11 7.1 IDENTIFIERADE FÖRBÄTTRINGSOMRÅDEN ............................................................................................... 11 7.2 RESONEMANG OCH SLUTSATSER STEP-ANALYS ..................................................................................... 11

1 Bakgrund Lördagen den 17 april klockan 06:53 inkom ett samtal till SOS angående brand på JMS Rulloffset på Ängelholmsvägen 27 i Helsingborg. Helsingborgs brandförsvar fick larmet klockan 06:54. Av den första utlarmningen framgick det att det var rökutveckling från ett industritak. Ärendebeskrivningen visas i bild 1 nedan. Adressangivelsen var Grenadjärsgatan i Helsingborg.

Bild 1. Del av SOS ärendekopia från branden på JMS.

2 Syfte Syftet med den genomförda utredningen är framför allt att utvärdera räddningsinsatsen för att dra lärdom av det inträffade. 3 Metod Faktainsamling har skett genom intervjuer med personal från JMS som jobbade den dagen då det började brinna samt med ett antal personer som är insatta i tryckeriprocessen. Intervjuer med personal från Helsingborgs brandförsvar som arbetade under olyckan genomfördes i huvudsak veckorna efter branden. Platsen har besökts torsdagen den 22 april.

Information har även samlats in från insatsrapport, fotografier från insatsen och SOS- protokoll.

Olycksförloppet har analyserats med hjälp av en STEP-analys (Sequential Timed Events Plotting). Metoden går ut på att de ingående aktörerna identifieras och att de olika aktörernas agerande dokumenteras. Såväl önskade som oönskade ageranden beskrivs i modellen. När alla aktörer och deras handlande är dokumenterat är nästa steg att identifiera förbättringsområden. Slutligen presenteras förslag till åtgärder för att kunna hantera en liknande händelse på ett bättre sätt.

Utredningen har utförts av Anna Brand och granskats av en analysgrupp bestående av Peter Wikeborg och Lasse Bengtsson. 3.1 Avgränsningar Denna utredning begränsas till den tidpunkt då branden startade till dess att räddningstjänst avslutades.

Endast personal från Helsingborgs brandförsvar har intervjuats. Detta leder till att den STEP-analys som beskrivs i bilaga 2 inte är heltäckande. Det är dessutom endast en liten del av de uppgifter som utfördes som finns med i tidslinjen.

Brandorsaken har inte undersökts. 4 Olycksplats Adressen för fastigheten där det brann var Ängelholmsvägen 27 medan adressen som angavs vid utlarmningen var Grenadjärgatan, se bild 2.

Bild 2. Adressangivelsen som angavs vid utlarmningen var JMS media system på Grenadjärgatan. Pilen på bilden visar vindriktningen vid brandtillfället.

Fastigheten består ett antal olika verksamheter som är egna brandceller men där byggnaderna hänger ihop, se bild 3. Sammansättningen av olika verksamheter medförde att det var svårt att få grepp om omfattningen på lokalen där det brann samt även att få en överblick över var möjliga angreppsvägar fanns. Det var dock aldrig något problem att lokalisera var brandposter i området fanns. Brandpostnätet runt byggnaden visas i bild 3.

Bild 3. Brandpostnät runt om byggnaden. Brandposten som är inringad är den som är placerad utanför den angreppsväg som användes vid insatsen. Tryckerilokal Lager Kontor Musikaffär Zoégas

1. 1

Platsbeskrivning Lokalen som JMS Rulloffset nyttjade bestod av en kontorsdel, tryckeridelen med två tryckpressar samt av en lagerdel. 4.2 Brandskydd Byggnaden där branden startade var inte utrustad med automatiskt brandlarm utan larmet kom in till SOS via ett telefonsamtal från en av de anställda. JMS utrymmen var delade i två olika brandceller, en för lagerdelen och en för tryckerilokalen.

Övriga verksamheter i intilliggande byggnader var egna brandceller. 5 Brandförlopp Tryckerilokalen där branden startade var efter branden avspärrad på grund av rasrisk. I och med detta har inte brandorsaken undersökts. 5.1 Omfattning vid ankomst Vid räddningstjänstens ankomst till platsen observerades omfattande rökutveckling. Väl framme vid JMS svängde primärstyrkan in mellan Zoégas och JMS där de passerade tre personer som inte gav sig till känna. Primärstyrkan fortsatte då runt till Grenadjärgatan bakom JMS, men insåg ganska omgående att angreppsvägen var från Ängelholmsvägen. Styrkeledaren Berga kallade då upp styrkeledaren från Gåsebäck och meddelade att angreppsvägen var från Ängelholmsvägen. Därefter vände Berga styrkan och stannade på Grenadjärgatan mellan Zoégas och JMS. 5.2 Skadeomfattning Skadorna begränsades i huvudsak till JMS produktionslokal som blev totalskadad. Lagerenheten klarade sig bättre tack vare att det var utformat som en egen brandcell. Det blev dock både rök- och vattenskador i lagerdelen.

Av de intilliggande verksamheterna fick Black and White Music AB och Västra Berga Bygg AB rökskador av sådan omfattning att sanering med hjälp av rökätare krävdes. Övriga verksamheter i området klarade sig utan skador. Detta mycket tack vare övertrycksventilering av intilliggande lokaler samt en gynnsam vindriktning (ca 3 m/s), se bild 2. 5.3 Primärbrand Enligt uppgifter av personal som var på plats vid tidpunkten då branden startade ska branden ha startat i det mittersta tryckverket av fem i den tryckpress som var placerad närmst Ängelholmsvägen. Branden skall inte ha föregåtts av någon glödbrand utan från att allt varit normalt har, enligt personalen, en cirka fyra meter lång flamma uppstått under det mittersta tryckverket.

Personalen har enligt uppgift därefter hämtat två handbrandsläckare medan en av dem ringde SOS, men bedömde snabbt att de inte klarade att släcka den uppkomna branden. De tre anställda som befann sig på JMS när branden startade beslutade sig istället för att utrymma. 5.4 Brandorsak Då ingen brandteknisk undersökning har kunnat genomföras på grund av rasrisk, har inte heller brandorsaken undersökts.

1. 5

Spridningsrisker Det har förelegat spridningsrisk till framförallt Black and White Music AB och Västra Berga Bygg AB. Hade vinden legat på åt andra hållet hade även Zoégas legat i farozonen framförallt vad gäller rökskador. 6 Beskrivning av insatsen I detta kapitel redovisas bland annat vilka uppgifter som räddningstjänsten fick vid utlarmning samt hur räddningsinsatsen gick till. 6.1 Utlarmning Larmcentralens ärendenummer: 20-1663338-2 Larm till räddningstjänsten: 06:54.30 Räddningstjänst avslutas: 15:00.00 Händelsetyp och ledningsnivå: Brand i byggnad, nivå 3. Adress: Grenadjärgatan, JMS media system

Utalarmerade styrkor och fordon: 1110, 1210, 1230, 1080 och 1180

Förstärkande och avlösande enheter: 1010, 1030, 1610 (Allerum), 2010 (Landskrona), 8010, 8040 (Bjuv), Höganäs (depåcontainer), ledningsbuss, 3080 (Ängelholm), Åstorp (passning egen station) samt Vallåkra för passning på Gåsebäck. 6.2 Taktisk grundinriktning (TGI) Inledningsvis var den taktiska grundinriktningen satt till släckning av branden i hög riskmiljö med hjälp av konventionell slangdragning. Efter att ett par explosioner hörts inne i lokalen beslutades dock att inga rökdykare skulle skickas in på grund av rasrisken. Detta medförde att den taktiska grundinriktningen ändrades till att begränsa branden till tryckerilokalen. 6.3 Insatsorganisation på skadeplats Ledningsnivån under insatsen var nivå 3. Under insatsen kallades dessutom stabsnivå 1 Skåne (insatsledare från Ängelholm) och ledningsbuss från Höör in.

Brytpunkt sattes till Ängelholmsvägen.

Inledningsvis hade Berga hand om rökdykning via lagret samt i ett senare skede begränsning via taket. Gåsebäck tillsammans med Bårslöv hade hand om rökdykning i hög riskmiljö i tryckerilokalen med angreppsväg från Ängelholmsvägen och Landskrona blev tilldelade kontorsdelen, se bild 4.

Bild 4. Sektorsindelning vid rökdykningen i inledningsskedet.

Efter explosionerna, som inträffade strax innan klockan åtta, beslutades det om att avbryta all rökdykning i tryckerilokalen och den taktiska grundinriktningen sattes till att förhindra brandspridningen till intilliggande delar (musikaffär, lager mm). Sektorsindelningen blev då enligt följande (se bild 5): Sektor tak (Gåsebäck och Bjuv) – hindra branden från att spridas via tak eller vägg till musikaffären. Sektor norr (Berga) – slå ner branden från brandport i norra delen av byggnaden (mellan lager och tryckeri). Sektor söder (Berga) – Slå ner branden från två brandportar i södra delen av byggnaden (mellan lager och tryckeri). Sektor kontor (Landskrona) – hindra branden från att ta sig in till kontorsdelen.

Landskrona Gåsebäck och Bårslöv

Bild 5. Sektorsindelning efter explosionerna. 6.4 Metodval Rökdykning genomfördes enligt metodiken för hög riskmiljö fram till dess att två explosioner hördes inifrån byggnaden, därefter bedömdes rasrisken för hög för att skicka in rökdykare i byggnaden. Brandsläckning genomfördes med konventionell slangdragning, brandpost fanns placerad precis utanför angreppsvägen från Ängelholmsvägen (Se bild 3).

Lättskumsaggregat användes men avbröts efter ett tag då inget skumtäcke byggdes upp och det bedömdes som att metoden inte fungerade. För placering se bild 6.

För att begränsa och förhindra brandspridningen från tryckerilokalen användes övertrycksfläktar. Landskrona satte en från ingången in till kontorsdelen, Berga satte en på baksidan in på lagret och Gåsebäck satte en från sidoingången till musikaffären. För placering se bild 6.

Landskrona Gåsebäck och Bjuv Berga

Bild 6. Placering av övertrycksfläktar (gröna kryss) och lättskumsaggregat (rött kryss).

Trafikdirigering och avspärrning ansvarade polisen för. 6.5 Kommunikation Ett flertal brandmän och styrkeledare upplevde att det var en oklar struktur på skadeplatsen. Det upplevdes som otydligt vem som ansvarade för vad.

Den allmänna uppfattningen var att det fanns för många befäl på platsen samt att räddningsledaren sprang runt för mycket på platsen och inte tog det steg tillbaka som man normalt är van vid.

Vid branden på JMS var ännu inte RAKEL i drift utan radiokommunikationen sköttes via det gamla analoga systemet (B96). Skadeplatskanal 61 användes vid insatsen. 6.6 Samverkan med andra organisationer Samverkan förekom bland annat med polis, ambulans, miljökontor, länsstyrelse, andra räddningstjänster i Skåne nordväst och NSR. Inga synpunkter har framkommit att samverkan med andra organisationer inte skulle ha fungerat. 6.7 Samverkan med drabbad verksamhet Inledningsvis ingen samverkan då personal som utrymt inte gav sig till känna. Men vid den fortsatta insatsen fungerade samarbetet bra.

7 Stepanalys Räddningstjänstens insats från och med utlarmning till och med räddningstjänsten avslutades har utvärderats bland annat med hjälp av en STEP-analys (Sequential Timed Events Plotting), se bilaga 2. Metoden går ut på att de ingående aktörerna identifieras och att de olika aktörernas agerande dokumenteras. Såväl önskade som oönskade ageranden beskrivs i modellen. När alla aktörer och deras handlande är dokumenterat är nästa steg att identifiera förbättringsområden. Slutligen presenteras förslag till åtgärder för att kunna hantera en liknande händelse på ett bättre sätt. 7.1 Identifierade förbättringsområden När händelseförloppet vid branden på JMS klarlagts så långt det var möjligt, identifierades förbättringar som behöver genomföras för att räddningstjänsten skall kunna genomföra en liknande insats på ett effektivare sätt i framtiden. De identifierade förbättringsområdena presenteras i STEP-analysen i form av röda trianglar som är länkade till en eller flera händelser under insatsen. Varje triangel är numrerad och i kommande resonemang beskrivs vad som behöver förbättras. 7.2 Resonemang och slutsatser STEP-analys 7.2.1 Vägledning Vid ankomsten till JMS morgonen den 17 april fanns tre personer från företaget på plats men ingen gav sig till känna. Detta ledde till att den första styrkan på plats körde runt till baksidan av byggnaderna på Grenadjärgatan innan de insåg att angreppsvägen måste vara från Ängelholmsvägen.

Slutsats: Det är viktigt att företag har rutiner för hur personalen ska agera vid en brand. Dessa rutiner bör informeras och övas regelbundet så att personalen vid en eventuell händelse vet hur de ska agera. I detta fallet har personalen agerat helt rätt genom att se till att alla kom ut, ringa SOS samt övervägt möjligheterna att släcka branden själva. Det som missades var att möta upp brandförsvaret vilket hade gjort att första styrkan hade stannat vid Ängelholmsvägen istället för som nu kört runt byggnaden och tillbaka. 7.2.2 Information om objektet På grund av att det inte fanns någon planritning att tillgå samt det faktum att räddningstjänstens personal inte lyckades skapa sig någon bra bild över var eventuella angreppsvägar fanns och hur byggnaden hängde ihop, fördröjdes släckningsarbetet. När man väl hittade angreppsvägarna från lagret mot tryckerilokalen var det redan för sent att rädda något i tryckeridelen. I stället fick insatsen inriktas på att förhindra att branden spred sig till lagret och musikaffären.

Slutsats: För att kunna genomföra en snabb och effektiv insats krävs det att räddningstjänsten har tillgång till någon form av underlag till hur byggnaden är uppbyggd. Det blir extra tydligt vid en så komplicerad byggnad som JMS lokal, där byggnaden hänger ihop med ett antal andra verksamheter. Hade personal från företaget haft tillgång till en planritning över byggnaden hade tiden till dess att angreppsvägen från lagret hittades 1 2

troligtvis minskat avsevärt. Nu dröjde det till cirka halv tio innan angreppsvägarna från lagerdelen hittades. För att underlätta och påskynda insatsen i inledningsskedet rekommenderas att företag har planritningar som är lätt tillgängliga vid en eventuell brand. Om möjligt är det bra om lämpliga angreppsvägar samt eventuella risker är utsatta på ritningarna. 7.2.3 Utlarmning av förstärkande enheter Då all information stabsbrandmästaren hade i inledningsskedet var att det kom rök från ett industritak inväntades mer information från primärstyrkan innan Bårslöv kallades ut som förstärkande enhet.

Slutsats: Vid detta tillfället hade stabsbrandmästaren i inledningsskedet inte information om att det var en konstaterad brand. Hade denna information kommit fram tidigare från SOS så hade troligtvis förstärkande enheter larmats i ett tidigare skede. 7.2.4 Avlösning av heltidsstationer Då det i inledningsskedet var en insats i hög riskmiljö var det inte aktuellt att Vallåkra löste av någon av heltidsstyrkorna. I ett senare skede efter explosionen övergick dock insatsen till att hålla begränsningslinjer mot intilliggande byggnader/lokaler. I detta läget hade Vallåkra med fördel kunnat lösa av någon av heltidsstyrkorna. Detta för att säkerställa att det fanns en styrka tillgänglig som kunde sättas in i vilken insats som helst.

Ett annat problem som uppstod var att kalla in mer personal. Det sms som skickades ut av stabsbrandmästaren till alla styrkeledare och alla brandmän genererade endast 5-10 personer. Räddningen i detta fallet blev att branden skedde i anslutning till ett skiftbyte där avgående personal stannade kvar samtidigt som avlösande personal gick på sitt skift.

Slutsats: Det faktum att ingen av heltidsstyrkorna löstes av ledde i förlängningen till att Vallåkra skickades på larm till Västhamnsverket. Ett objekt som även det kräver en styrka som är utbildad för att rökdyka i hög riskmiljö. Det är viktigt att både räddningsledaren på plats och stabsbrandmästaren hela tiden värderar om Vallåkra kan lösa av någon av heltidsstationerna. Detta då det finns begränsningar i vilka uppdrag som Vallåkra kan nyttjas till. Ett sätt att komma undan problemet skulle vara att utbilda Vallåkra så att de kan nyttjas vid hög riskmiljö. Det bör utvärderas om sms-inkallning är ett bra sätt att få in personal särskilt när insatsen sker på nätter/tidiga morgnar. I detta fallet löste det sig mycket tack vare att branden skedde i anslutning till ett skiftbyte. Ett förslag skulle vara att man kallar in en person som ansvarar för att kalla in personal via telefon. 3 4

1. 2.5

Slangbrott vid rökdykning Under rökdykningen inträffade ett flertal slangbrott som gjorde att rökdykningen fick avbrytas för att slangar skulle bytas. Slangbrotten skedde både på grov- och smalslang.

Slutsats: Det bör undersökas om slangbrotten var en tillfällighet eller om det kan bero på bristande underhåll alternativt ett ändrat användande av det konventionella slangsystemet i och med att användandet av högtryckssystemet ökar. 7.2.6 Beställning av ledningsbuss och stabsnivå 1 Rutinerna för vad som ingår i stabsnivåerna är inte tillräckligt kända. Vid beställningen av ledningsbussen medföljer två personer från Höör. Dessa personer är dock inte bemanning till bussen utan är endast med för att köra ut bussen och starta upp utrustningen. För att få bemanning till bussen krävs det att stabsnivå 2 aktiveras. Stabsnivå 2 innebär att tre personer från räddningstjänsten syd kommer ut på skadeplatsen för att bemanna ledningsbussen. Stabsnivå 1 som beställdes i detta fallet innebär att insatsledare från Ängelholm kommer ut för att stötta räddningsledaren på skadeplatsen.

I detta fallet har det skett ett missförstånd då stabsbrandmästaren informerade via SOS att insatsledaren från Ängelholm som kom som stabsnivå 1 skulle bemanna stabsbussen.

Slutsats: Det bör förtydligas vad som gäller vid de olika stabsnivåerna samt vad som ingår när ledningsbussen från Höör beställs. Det bör även kontrolleras så att alla som kan kallas ut som stabsnivå 1 har erforderlig utbildning. 7.2.7 Ostrukturerad avlösning Vid avlösning av styrkor uppstod problem då avlösande styrkor sökte upp ”sin” station direkt och löste av dem utan att kontakta staben först för att dels meddela att de var framme och dels få reda på vilken styrka det var tänkt att de skulle avlösa samt vilka uppgifter de skulle sköta.

Slutsats: För att få bättre struktur och större koll på vilka styrkor som är på plats bör det finnas en uttalad plats dit avlösande styrkor anmäler sig innan de löser av en avgående styrka. På denna brytpunkt skall det även finnas ett brytpunktsbefäl. En ytterligare vinst förutom att staben får bättre koll på de olika styrkorna och deras arbetsuppgifter är att de styrkor som ska avlösa kan få en snabb information om vilka sektorer som finns på plats och vilka parallella arbetsuppgifter som utförs på skadeplatsen. 7.2.8 Användning av lättskumsaggregat I ett senare skede av insatsen gjordes ett försök att släcka branden med hjälp av lättskum. Aggregatet placerades vid angreppsvägen på byggnadens södra sida (mot Ängelholmsvägen). Detta försök gav dock ingen effekt utan man lyckades inte bygga upp något skumtäcke och släckförsöket avbröts.

5 6 7 8

Vid tillfället då släckförsöket med lättskumsaggregatet genomfördes fanns inte de beställda lättskumsaggregaten från Landskrona och Åstorp på plats.

I de efterföljande intervjuerna/diskussionerna har det framkommit att personalen känner att de inte har tillräcklig kunskap om lättskumsaggregaten och mer praktiska övningar efterfrågas.

Slutsats: Det behövs utbildning och övning på lättskumsaggregaten för att säkerställa att de används på optimalt sätt vid en insats. Detta då det inte går att bygga upp ett lättskumstäcke mot vinden och/eller mot en övertrycksfläkt. Det är också viktigt att säkerställa att det finns tillräckliga resurser framme innan ett släckförsök med lättskum påbörjas. Dimensionering av lättskumsaggregat är en fråga som utreds vidare. 7.2.9 Felmärkt skumvätska De dunkar med skumvätska som användes vid insatsen på JMS ska enligt uppgifter från insatt personal ha varit märkta som mellan- och tungskum. Det skall dock ha varit lättskumsvätska i dunkarna. Den missvisande märkningen i kombination med att det inte byggdes upp något skumtäcke, ledde till att personal som nyttjade lättskumsaggregatet blev tveksamma till om det verkligen var lättskumsvätska i dunkarna.

Slutsats: Det är viktigt att all utrustning som används är rätt utmärkt. I detta fallet ledde de felmärkta skumvätskedunkarna till extra osäkerhet vid användandet av lättskumsaggregatet. 7.2.10 Kommunikation på skadeplats Kommunikationen ut till de olika sektorerna vid en större insats behöver bli tydligare. För att inte en sektor ska ta egna initiativ som i sin tur kanske motverkar den uppgift en annan sektor har fått behöver de olika sektorerna få en bild över vem som gör vad. Ett förslag skulle kunna vara att all personal får ut information om vad som händer via radio med jämna mellanrum. Detta skulle kunna säkerställa att all personal får samma information samt att informationen blir uppdaterad efter hand som insatsen fortskrider. 7.2.11 Information Räddningstjänsten fick i efterhand kritik från kommunpolitikerna för bristande information i samband med insatsen på JMS. Från kommunpolitikernas håll fick man reda på branden via media och inte via räddningstjänsten. Kritik för informationshanteringen kom även från Martin Arkel. Han pekade på att Krisinfo kontaktades för sent och att han själv (i form av krisinfochef) fick vetskap om branden via text-tv och inte via räddningstjänsten. Dessutom var det vid händelsen stora svårigheter att komma fram på telefonnumret till Bårslöv då det oftast var upptaget. Ett sätt att lösa problematiken vid en kommande händelse skulle kunna vara att RCB har i uppgift att meddela krisinfo som i sin tur har till uppgift att, då behov föreligger, informera kommunpolitikerna. 9

Räddningstjänsten bör vid större händelser rutinmässigt kalla in en funktion som har till uppgift att sätta ihop information från räddningstjänsten. Detta underlag kan sedan skickas över till krisinfo som i sin tur lägger ut det på Helsingborgs hemsida. 7.2.12 Möjlighet att stänga ventilation Ett problem som uppmärksammades var att en del fastigheter inte hade möjlighet att stänga av ventilationen alternativt att det inte fanns framtagna rutiner för det förfarandet. Det bör påtalas till fastighetsägare i Helsingborg om vikten av att se över sina möjligheter till att stänga ventilationen samt att se över vilka rutiner som finns. 7.2.13 Övriga synpunkter Ett antal personer från företaget fick möjlighet att gå in i lagerdelen (som var fri från brand och rök på grund av vindriktningen) och plocka ut det redan upptryckta materialet som gick att rädda. Utöver dessa personer observerades dock att ett antal personer (troligtvis från företaget) gick in i lagerdelen endast för att se hur det såg ut. Vid kontakt med till exempel NSR gäller det att vara medveten om att våra nummer oftast visas som dolt nummer. Det kan därför vara bra att skicka ett SMS om den sökta personen inte svarar. Detta då inte alla svarar på sin jobbtelefon på helger och ledig tid och framförallt inte om det är ett dolt nummer som visas. En fråga som dök upp efter insatsen på JMS var hur pågående insatsledare alternativt VBI kan nyttjas då de inte har tillgång till vare sig larmtelefon eller utrustat fordon. Detta är en fråga som är under utredning. Det bör finnas framtagna riktlinjer för hur länge en ledningsfunktion får arbeta innan han eller hon ska avlösas. Extra personal bör vid behov kallas in för att ta hand om förbrukat material under pågående insats för att minska tiden för respektive styrka att komma tillbaka i beredskap igen efter avslutad insats. En rutin för detta bör upprättas. Depåcontainern kom ut på plats men funktionerna har inte fungerat framför allt vad gäller förplägnad. Som sammanfattning kan sägas att trots den omfattande branden, den brist på kommunikation som funnits på skadeplatsen och problemen som uppstod i och med att räddningstjänsten inte fick någon bra bild över hur byggnaderna hängde ihop och var lämpliga angreppsvägar fanns, så blev resultatet av insatsen bra. Även om angreppsvägarna från lagret hade hittats i ett tidigare skede är det inte säkert att resultatet av insatsen hade blivit annorlunda. Det var ett bra beslut att ta ut resurser från byggnaden och ändra TGI från att släcka branden till att begränsa branden från att sprida sig. Insatsen förhindrade, delvis med hjälp av den gynnsamma vindriktningen, att branden spreds till intilliggande byggnader samt det intilliggande lagret.

BILAGA 1 Foto från branden.

Bild 1. Rökutveckling vid pågående släckning. Bild 2. Brandcellsgräns mellan tryckeri- och lagerdel.

Bild 3. Det inrasade taket. Bild 4. En av de bärande balkarna.

Bild 5. Tryckpressen som branden startade i (närmst Ängelholmsvägen). Bild 6. Angreppsväg från väster (via lagerdelen).

Bild 7. Angreppsväg från söder (mot Ängelholmsvägen).

BILAGA 2

Lördag 17 april P3 JMS Berga P2 JMS P1 JMS Aktörer Gåsebäck Bårslöv Depå- container VBI Insatsledare Landskrona Stabsnivå 1/ ledningsbuss Nivå 2 befäl L300 RCB Brand vid tryckpress Hämtar två pulversläckare Utrymmer Larmar 112 06:50 06:53 07:28 08:00 09:00 10:00 12:00 4 Utrymmer Utrymmer SBM Allerum Bjuv Vallåkra Tar över som RL 06:54 Utlarmning Utlarmning Utlarmning Utlarmning 07:00 Framme på plats (7.00) Framme på plats (7.01) Utlarmning (7.02) Framme på plats (7.06) Framme på plats (7.11) Framme på plats (7.13) Utlarmning Utlarmning (7.15) Utlarmning (7.16) På plats på Gåsebäck (7.30) Utlarmning (7.33) Framme på plats (7.38) Framme på plats (7.38) Utlarmning (7.39) Framme på plats (7.59) Bårslöv (8.05) Utlarmning av RVL (9.37) Framme på plats (10.11) Larmar ut enligt larmplan 3 Rökdykning plan 2 Angrepp tak Yttre släckning Ä-holmsvägen Rökdykning tryckeri – hög riskmiljö (7.20) Rd skyddsgrupp tryckeri – hög riskmiljö Avlösning (ca 7.40) A Alla styrkor ut Alla styrkor ut Alla styrkor ut Kallar ut styr- kor på radio Vent. + plockar ut instrument Vent. Intill- liggande utr T A K E T

R A S A R

I N B 15:00 Påbörjar släck- försök med lättskum från söder. Släckförsök ger ingen verkan och avbryts. 8 9 Order till rd om att stänga naturgasen Larm passning Gåsebäck (7.06) 2 1 R Ä D D N I N G S T J Ä N S T

A V S L U T A S Vent. + plockar ut instrument 5 7 6

= explosioner i tryckeridelen

= taket rasar in Händelser A B Framme på plats (8.54)

FD05984 ｜ 2013_瑞典_赫尔辛堡_生物燃气公交车火灾调查_火灾报告.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2013 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因：燃气/爆炸 ｜ 来源格式：pdf

helsingborg.se Olycksundersökning – Nivå 3 Brand i biogasbussar Brand i biogasbussar 2012-02-14

Anledning till undersökningen: Kollision med efterföljande brand i två biogasbussar på Ättekullagatan 2 i Helsingborg, 2012-02-14.

Uppdrag: Utreda händelseförlopp och utvärdera räddningstjänstens insats samt föra tillbaka erfarenheter till berörda.

Uppdragsgivare: Jörgen Hallberg, räddningschef Helsingborgs brandförsvar

Olycksundersökningen är genomförd av: Anna Brand, brandingenjör, Helsingborgs brandförsvar. Har arbetat med olycksundersökningar sedan 2007 och har genomgått Räddningsverkets kurs i olycksundersökning.

Analysgrupp: Lars-Göran Bengtsson, brandingenjör, Helsingborgs brandförsvar Gert Linderos, insatsledare, Helsingborgs brandförsvar

Bilagor: Insatsmetodik, Instruktion – Anmälan vid skador på miljön i samband med räddningsinsats och STEP-analys

Bussbranden på Ättekulla i Helsingborg i februari 2012 ledde till att två stadsbussar blev helt utbrända. I det stora hela fungerade insatsen från Helsingborgs brandförsvar bra. När den första styrkan kom på plats fanns det inte så mycket mer att göra än att se till att branden inte spred sig till den intilliggande rastlokalen. Trots att brandförloppet blev väldigt snabbt och intensivt kom inga personer till skada. Några rekommendationer för att förbättra räddningstjänstens förutsättningar vid kommande insatser finns dock.  Se över insatsstödet för brand i biogasbussar. Vilket är riskavståndet vid en bussbrand där temperatursäkringarna inte har löst ut och hur bör vi från räddningstjänsten agera då vi kommer fram till en brand i en biogasbuss där tankarna på taket är påverkade av en lokal brand? Vi behöver även fundera över hur vi inom räddningstjänsten gör riskbedömningar vid bränder i ”vanliga” bilar. Detta eftersom fler och fler fordon körs på alternativa bränslen. Problemet med kärlsprängning är därför inte bara relaterat till bussar utan kan lika gärna inträffa vid en vanlig bilbrand. Hur ska vi som räddningstjänst hålla oss uppdaterade på de olika alternativa bränslen som finns samt hur vi skall agera vid en insats beroende på bränsletyp?  Tydliggöra när räddningschef i beredskap bör kontaktas av stabsbrandmästaren.  Se över vilket stöd stabsbrandmästaren har till förfogande för att kunna förutsäga om en händelse/insats kan komma att påverka miljön. Det bör även kontrolleras om det går att förtydliga stabsbrandmästarens instruktion över vilka myndigheter som skall kontaktas vid misstanke om miljöpåverkan. Det efterföljande saneringsarbetet påbörjades inte förrän vid kvart i sex på kvällen. Det bör därför diskuteras vad det var som gjorde att saneringsarbetet inte kom igång. Vid denna diskussion bör alla berörda myndigheter/funktioner medverka.

INNEHÅLLSFÖRTECKNING

SAMMANFATTNING ........................................................................................................ 3 BAKGRUND ........................................................................................................................ 7 SYFTE ................................................................................................................................... 7 METOD................................................................................................................................. 7 AVGRÄNSNINGAR .............................................................................................................. 7 OLYCKSPLATS .................................................................................................................. 8 PLATSBESKRIVNING ........................................................................................................... 8 BESKRIVNING AV BUSSARNA .............................................................................................. 9 DRIVMEDEL ....................................................................................................................... 9 HÖGTRYCKSKÄRL .............................................................................................................. 9 HÄNDELSEFÖRLOPP ....................................................................................................... 9 BESKRIVNING AV RÄDDNINGSTJÄNSTENS INSATS ........................................... 10 UTLARMNING ................................................................................................................... 10 OMFATTNING VID ANKOMST ............................................................................................ 11 MÅLET MED INSATSEN (MMI) ......................................................................................... 11 INSATSORGANISATION PÅ SKADEPLATS ........................................................................... 11 METODVAL ...................................................................................................................... 11 K OMMUNIKATION ............................................................................................................. 12 SAMVERKAN MED ANDRA ORGANISATIONER ................................................................... 12 SKADEOMFATTNING ......................................................................................................... 12 S PRIDNINGSRISKER .......................................................................................................... 13 STEP-ANALYS .................................................................................................................. 13 AKTÖRER ......................................................................................................................... 13 IDENTIFIERADE FÖRBÄTTRINGSOMRÅDEN ........................................................................ 13 RESONEMANG STEP-ANALYS ......................................................................................... 14 SLUTSATSER OCH FÖRSLAG TILL ÅTGÄRDER ................................................... 15

BILAGOR Bilaga 1 – Insatsmetodik, brand i gasbuss 19 Bilaga 2 – Instruktion, Anmälan vid skador på miljön i samband med räddningsinsats 23 Bilaga 3 – STEP-analys 25

Tisdagen den 14 februari klockan 09:30 inkom ett samtal till SOS angående brand i två bussar på Ättekullavägen 2 i Helsingborg. Helsingborgs brandförsvar fick larmet klockan 09:32. Av utlarmningen framgick det att det var två bussar som brann och att det var oklart om det fanns personer kvar i bussarna. Syfte Syfte med denna utredning är att utvärdera genomförd insats och föra tillbaka erfarenheter till berörda såväl inom som utanför den egna organisationen. Syftet är inte att diskutera huruvida någon eller några har gjort något fel, utan att identifiera eventuella organisatoriska brister inom vår organisation eller i vårt samarbete med andra organisationer. Meto d Faktainsamling har skett genom intervjuer med personal från brandförsvaret som arbetade under olyckan. Intervjuerna genomfördes veckorna efter branden. En vecka efter händelsen intervjuades dessutom personal från bussbolaget Arriva.

Information har även samlats in från insatsrapport, fotografier från insatsen, SOS-protokoll, ljudupptagningar från radio- och telefontrafik samt från miljörestvärdesräddare (M-RVL), stadsbyggnadsförvaltningen och miljöförvaltningen.

Olycksförloppet har analyserats med hjälp av en STEP-analys, Sequential Timed Events Plotting. Metoden går ut på att de ingående aktörerna identifieras och att de olika aktörernas agerande dokumenteras. Såväl önskade som oönskade ageranden beskrivs i modellen. När alla aktörer och deras handlande är dokumenterat är nästa steg att identifiera förbättringsområden. Slutligen presenteras förslag till åtgärder för att kunna hantera en liknande händelse på ett bättre sätt. Avgränsningar Denna utredning begränsas till den tidpunkt då den bakre bussen (Volvon) körde in i den främre på busshållplatsen till dess sanering av skum- och släckvatten påbörjades på kvällen samma dag som olyckan inträffade.

Orsaken till att bussarna kolliderade och därefter började brinna analyseras inte utan för svar på dessa frågor hänvisas till Statens haverikommissions utredning. Olycksplats Adressen för platsen där de två biogasbussarna kolliderade och började brinna var på Ättekullagatan 2, se bild 1.

Bild 1. Adressangivelsen som angavs vid utlarmningen. Platsbeskrivning Platsen där branden startade är en busshållsplats i stadsdelen Ättekulla i Helsingborg. Bussarnas placering visas i bild 2 nedan. Vid sidan av busshållsplatsen fanns det även en rastlokal för Arrivas personal. Vindriktningen var den aktuella dagen nordlig.

Bild 2. Plats där de båda bussarna kolliderade och därefter började brinna. De två bussarnas placering på busshållsplatsen. Placering av Arrivas rastlokal. Vindriktning

eskrivning av bussarna

De båda bussarna som var involverade i olyckan var biogasdrivna stadsbussar. Den främre bussen var en MAN buss med stålkaross och den bakre var en Volvo med aluminiumkaross. Drivmedel Bussarna som var inblandade i branden drevs båda två med biogas. Den biogas som framställs i Sverige består av metan till cirka 98%, resten är i stort sett endast koldioxid. Högtryckskärl Kärlen som används som bränsletankar är placerade på bussarnas tak och utgörs av två olika typer, stålkärl och kompositkärl.

Kompositkärlet är godkänt för ett maximalt tryck på 250 bar. Vid sprängprov brister kärlen vid cirka 1000 bars tryck. Stålkärlen är godkända för ett maxtryck på 200 bar (Carlson, 2006).

Kärlen är försedda med temperatursäkringar som skall lösa ut vid cirka 110 grader. De tester som genomförs på dessa kärl omfattar dock endast bränder som påverkar hela kärlet inklusive temperatursäkringen och inte lokal brand där temperatursäkringen inte påverkas. Detta innebär att det saknas underlag för hur ett kärl står emot en brand där temperatursäkringen inte är involverad (Lönnermark, 2010). Händelseförlopp Den aktuella morgonen står MAN-bussen längst fram vid hållplatsen på Ättekulla med motorn avstängd. På MAN-bussen finns det en chaufför (C1) och fyra passagerare (tre vuxna och ett barn).

Volvon som inte har några passagerare kommer körande söderifrån på Ättekullagatan och chauffören (C2) stannar till ett tag strax innan infarten till busshållplatsen för att ringa sin dotter. Efter samtalet startar C2 bussen och kör i låg hastighet in bakom MAN-bussen. C2 Främre buss MAN, Regnr: SHD 931, internt nr: 6538

Bakre buss Volvo, Regnr: XDC 066, internt nr: 6547

trampar på bromsen men upplever att inget händer. C2 trampar därefter ner bromsen flera gånger men utan att få stopp på bussen. Bussen kör in i den stillastående MAN-bussen i låg hastighet.

Precis efter att den bakre bussen kört in i den främre ser C2 hur en låga slår upp över framrutan precis framför förarsätet. C2 som var chockad över branden försökte öppna framdörren med hjälp av ett vred som var placerat till vänster om förarsätet. Till en början händer ingenting men efter att ha tryckt ett antal gånger öppnas dörren där framme.

I den intilliggande rastlokalen väntar en annan av Arrivas chaufförer på den buss som han skall köra. Chauffören har blivit avsläppt vid kvart över nio och då bussen som han skall ta över brukar komma in vid halvtio så tittar han ut ur rastlokalen vid denna tid. När chauffören tittar ut ur rastlokalens dörr ser han hur Volvon kör in i MAN-bussen och fattar eld. Han plockar åt sig en pulversläckare från lokalen och genomför ett släckförsök men utan att lyckas. Chauffören ser då istället till att få med sig C2 från Volvon eftersom C2 chockad står kvar utanför bussdörren. Samtidigt som han drar med sig C2 plockar han upp sin mobiltelefon och ringer SOS.

C1 i den främre bussen känner kollisionen och ser direkt till att bussen utryms. B eskrivning av rädd ningstjänstens insats I detta kapitel redovisas bland annat vilka uppgifter som räddningstjänsten fick vid utlarmning samt hur räddningsinsatsen gick till. Utlarmning Larmcentralens ärendenummer: 20.2556640.2 Start: 09:32.41 Avslut: 11:45.00 Händelsetyp och ledningsnivå: Inledningsvis nivå 1 men höjdes upptill nivå 3 på grund av att flera personer ringde in. Adress: Ättekullagatan 2, Helsingborg

Utalarmerade styrkor och fordon: Nivå 1 – Berga (1110 och 1140) Nivå 3 – Insatsledare (1080), vakthavande brandingenjör (1180), stabsbrandmästare (SBM) och förstärkande enhet Bårslöv (1010)

Resurser som skulle larmats enligt larmplan: Brand ute/ avgränsat objekt – fordon/buss/övrigt Område: M20T Resurser enligt larmplan: Bårslöv primär – släckenhet (1010), Gåsebäck förstärkande – släckenhet (1210) samt eventuellt extra fordon. Utöver detta larmas även resurser i form av stabsbrandmästare, insatsledare samt vakthavande brandingenjör. Omfattning vid ankomst Redan på väg fram till olycksplatsen observerade räddningstjänsten en kraftig rökutveckling. Väl framme på plats såg personalen att det var två stadsbussar som var övertända. Målet med insatsen ( MM I) Då det snabbt stod klart att det inte fanns några personer kvar i bussarna inriktades räddningstjänstens arbete till att förhindra spridning samt till att släcka branden. Insatsorganisation på skadeplats Då vakthavande brandingenjör inte bedömde att det fanns något behov av en utökad ledningsnivå tog vakthavande brandingenjör aldrig över som räddningsledare utan insatsen leddes av insatsledaren som nivå 2 befäl.

Arbetet bestod i inledningsskedet av att släcka branden i bussarna. Denna uppgift stod Berga för (1110 och 1140). Men när det upptäcktes att branden var på väg att sprida sig till Arrivas lokal tilldelades Bårslöv uppgiften att förhindra spridning till rastlokalen. Metodval I inledningsskedet av insatsen fick räddningsledaren, 1080 information av stabsbrandmästaren (SBM) angående insatsmetodiken för brand i biogasbussar, se bilaga 1. Eftersom de två bussarna redan var helt övertända vid Helsingborgs brandförsvars ankomst och räddningsledaren fick information om att båda bussarna var tomma inriktades insatsen i inledningsskedet på att dämpa branden. Detta för att kunna urskilja om alla temperatursäkringarna på gasflaskorna på den främre bussen hade löst ut. Med hjälp av vattenkanonen från tankbilen lyckades personalen dämpa branden så mycket att de kunde se att alla temperatursäkringarna hade löst ut.

Då den bakre bussen var av aluminium hade redan taket med de ovanliggande gastankarna rasat in och tankarna låg i den brinnande

bussen. Aluminium har en smältpunkt på 650°C och temperatursäkringarna på gasflaskorna ska brista vid en temperatur strax över 100°C. I och med detta är det högst sannolikt att även temperatursäkringarna på den bakre bussens gasflaskor löst ut redan innan Helsingborgs brandförsvar varit framme på plats.

När detta väl var konstaterat inriktades arbetet på att släcka branden i bussarna. Vid släckningen användes inledningsvis vatten men efter ett tag övergick man till att använda mellanskum.

Stabsbrandmästaren kontaktade strax efter klockan tio Örbyverket enligt en framtagen instruktion för anmälan vid skador på miljön vid räddningsinsats, se bilaga 2. Detta då stabsbrandmästaren bedömde att det kunde föreligga fara för miljön med tanke på skumsläckningen. Kommunikation Kommunikationen fördes över RAPS 49 på stabsbrandmästarens initiativ. Samverkan med andra organisationer Efter att branden i bussarna var släckt dröjde det ända till klockan 17.45 innan sanering av släckrester på olycksplatsen samt dammarna vid Stenbrogården påbörjades.

Polisens avspärrningar hölls inte som de skulle, utan bilar tilläts att passera in i området kring bussarna som brann.

Helsingborgs brandförsvar fick i ett tidigt skede tag på en representant från den drabbade verksamheten, bussbolaget Arriva. Skadeomfattning Skadorna begränsades till de båda biogasbussarna som blev totalt utbrända. Även en byggnad intill busshållplatsen fick brandskador dock i mindre omfattning, se bild 3.

Bild 3. De två utbrända bussarna samt den intilliggande byggnaden som brandskadades. Spridningsrisker Det fanns brandspridningsrisk till den intilliggande byggnaden där Arrivas personal har möjlighet att uppehålla sig vid fikaraster alternativt i väntan på en annan buss. I övrigt fanns inga andra byggnader så nära att branden hotade att sprida sig vidare. S TEP

• analys

Insatsen har analyserats med hjälp av en STEP-analys. Resultatet redovisas i kronologisk ordning. För en översikt av den genomförda STEP-analysen, se Bilaga 3. Aktörer För att kunna genomföra STEP-analysen behövde först alla aktörer som agerat eller på annat sätt påverkat förloppet identifieras. De identifierade aktörerna redovisas i STEP-analysen i Bilaga 3.

Efter att alla aktörer identifierats genomfördes intervjuer med flertalet av de olika personer/verksamheter som var inblandade vid insatsen. Identifierade förbättringsområden När alla intervjuer hade genomförts påbörjades STEP-analysen av räddningstjänstens insats samt det efterföljande arbetet fram tills sanering påbörjades. När händelseförloppet klarlagts identifierades möjliga förbättringar som behöver genomföras för att räddningstjänsten och övriga myndigheter skall kunna genomföra en liknande insats på ett effektivare sätt i framtiden.

De identifierade förbättringsområdena presenteras i STEP-analysen i form av röda trianglar som är länkade till en eller flera händelser under insatsen. Varje triangel är numrerad och i kommande resonemang beskrivs vad som behöver förbättras inför en eventuell ny insats. Resonemang STEP

• analys

Kan ej öppna främre bussdörren När busschauffören i den bakre bussen försökte öppna de främre dörrarna i bussen öppnades inte dörren vid den första knapptryckningen. Enligt uppgifter från chauffören var det först efter ett antal knapptryckningar som dörren öppnades.

I denna utredning har inget fokus lagts på varför dörren inte öppnades i inledningsskedet. Men för att underlätta för chaufförerna vid en olycka rekommenderas att bussbolaget tar fram åtgärdskort/checklistor som med fördel kan finnas placerade i bussarna. Korten är tänkta att vara ett stöd vid en olycka där chauffören ska följa de instruktioner som finns på kortet. Till exempel bör där finnas en kort beskrivning av vilka knappar/vred etcetera som skall manövreras i inledningsskedet för att öppna dörrar så att eventuella passagerare kan utrymma. På korten bör det även finnas med vilka moment som chauffören bör genomföra för att så långt som möjligt undvika att biogastankarna blir involverade i en brand.

Alla chaufförer går visserligen igenom vilka rutiner som gäller både för dörröppning och för vilka vred som skall stängas vid en olycka, men då det förekommer olika modeller på bussar kan det vara en fördel att ha åtgärdskort/checklista som stöd vid en stressad situation. Utlarmade resurser Vid tillfället för bussbranden hölls en utbildning i hot- och våld på Brandorama (vid station Berga). Detta medförde att det fanns en täckstyrka på station Gåsebäck som hade Bergas fordon med sig. Normalt sett tar täckstyrkan bara med sig släck- och höjdenhet (1110 och 1130) vid flytt till annan station. Men just denna dag ville stabsbrandmästaren att även tankbilen (1140) skulle plockas med.

Normalt sett finns det tankbil på Berga och på Bårslöv men inte på Gåsebäck. Hade larmet gått enligt larmplan så hade Bårslöv åkt som primärstyrka med släckenhet och Gåsebäck hade gått som 2 1

sekundärstyrka. Detta innebär att det inte hade kommit med något tankfordon i inledningsskedet.

Då det vid utlarmningen framgick att det var två stadsbussar som brann beslutade sig styrkeledaren för att ta med tankbil. S tabsbrandmästaren (SBM) kont aktar Örbyverket Efter cirka en halvtimmes insats kontaktade stabsbrandmästaren Örbyverket för att meddela att det förelåg risk för att släckvatten och skum skulle kunna förorena dagvattnet.

Personen som tog emot samtalet skulle kontakta reningsverket för att se vilka åtgärder som behövde företas. Räddningschef i beredskap (RCB) Räddningschef i beredskap kontaktades aldrig vid insatsen. Istället uppmärksammade RCB olyckan av en slump via internet.

En fråga som bör diskuteras är i vilka fall räddningschef i beredskap skall kontaktas. Vid händelser med ett stort mediatryck och/eller i fall där det kan komma att bli ett stort medialt intresse även efter räddningstjänstens insats är avslutad kan det vara bra att räddningschef i beredskap är informerad om händelsen. Kontakt med miljörestvärdesledare ( M

• RVL

) Miljörestvärdesledaren kontaktades i ett senare skede på eftermiddagen då räddningsinsatsen redan var avslutad. Anledningen till att miljörestvärdesledaren kontaktades var att en miljöinspektör i Helsingborg hade kontaktat stabsbrandmästaren och påtalat att miljörestvärdesledaren borde larmas då det förelåg spridningsrisk till Råån. Kontakt med Nordvästra Skånes Vatten och Avlopp ( NSVA ) Under eftermiddagen försökte miljörestvärdesledaren i omgångar få tag på någon ansvarig på NSVA men blev hänvisad fram och tillbaka i organisationen. Först efter nästan en timme fick miljörestvärdesledaren klarhet i att det var PEAB som var underentreprenör till NSVA som skulle ta hand om saneringen. Slutsatser och förslag till åtgärder Med de förutsättningar som rådde vid räddningstjänsthändelsen och med de resurser som mobiliserades, blev resultatet av den akuta insatsen bra.

3 5 6 4

För att förbättra räddningstjänstens och andra inblandade organisationers möjligheter att utföra en bra insats vid liknande händelser föreslås dock följande åtgärder:

Arriva  För att underlätta för de busschaufförer som arbetar på Arriva rekommenderas att åtgärdskort/checklistor för hur chauffören ska agera vid en olycka tas fram. På kortet/checklistan bör det framgå hur och i vilken ordning olika moment ska genomföras till exempel vid dörröppning och vid avstängning av gassystemet.

Då det kan finnas skillnader i hur olika moment skall utföras beroende på bussmodell rekommenderas att de åtgärdskort/checklistor som tas fram är placerade i respektive fordon. Detta för att det alltid skall finnas ett åtgärdskort/en checklista som är aktuell för det fordon som busschauffören arbetar i. Stab- och ledning  I detta fall användes i stort sett inte den insatsmetodik som tagits fram för bränder i biogasbussar. Detta eftersom förloppet var så snabbt att biogastankarna hade löst ut på båda bussarna redan när brandförsvaret var på plats. Frågan är om den insatsmetodik som finns framtagen är rätt utformad eller om den behöver kompletteras med ytterligare information om hur man bör agera beroende på hur brandförloppet ser ut vid framkomst samt vilket riskavstånd som är aktuellt. Detta då det finns fall från bland annat USA där temperatursäkringarna inte har löst på grund av en lokal brand vilket i sin tur har lett till kärlsprängning (Perrette L., 2007).

 Vid insatsen kontaktade stabsbrandmästaren Örbyverket enligt den instruktion som fanns framtagen. Enligt den rutin som finns framtagen skulle även miljöförvaltningen och länsstyrelsen ha kontaktats via fax. Detta gjordes dock aldrig.

Vid olyckor som leder till skador på miljön där det krävs en aktiv åtgärd skall enligt instruktionen dessutom även M-RVL kontaktas. I detta fall kontaktades M-RVL i ett senare skede på initiativ av miljöinspektören. Detta var efter att räddningstjänsten avslutats.

Rutinen för vem som skall kontaktas och på vilket sätt vid skador på miljön i samband med en räddningsinsats behöver förtydligas och informeras till de funktioner som är berörda. Det förelåg även oklarheter i vilka nummer som skulle användas för att komma i kontakt med Örbyverket/VA-jouren vid olyckstillfället. Rutinen har

reviderats vad gäller de telefonnummer som skall användas vid en skada på miljön. Det bör funderas över om det går att göra instruktionen ännu tydligare, till exempel genom att lägga till en kort checklista.

 En annan sak som behöver diskuteras är när stabsbrandmästaren bör kontakta räddningschef i beredskap (RCB). I detta fall blev RCB aldrig kontaktad av stabsbrandmästaren, utan istället fick RCB reda på bussolyckan via nätet vid halvtolv-tiden. RCB ringde då upp stabsbrandmästaren för att kontrollera om det fanns något behov av hans hjälp. Stabsbrandmästaren meddelade att läget var under kontroll och att räddningsinsatsen i princip var avslutad.

Med tanke på det mediatryck som var under olyckan men som även höll i sig under de efterföljande dagarna hade det varit bra om RCB hade blivit inkopplad. En diskussion bör föras kring vilka kriterier som skall leda till att RCB kallas in.

NSVA  Vid insatsen kontaktade miljörestvärdesledaren NSVA i omgångar men blev bara runtskickad mellan olika personer innan han slutligen efter nästan en timmes tid fick reda på att det var PEAB som var driftansvariga. Det finns därför ett behov att se över sina rutiner inom NSVA för att säkerställa att anställda inom NSVA vet vem de ska koppla dessa ärenden till. Berörda myndigheter vid en olycka med skador på miljön  Efter vad som har framkommit i denna olycksundersökning har arbetet med att förhindra att förorenat släckvatten och skum nått dammarna vid Stenbrogården inte påbörjats förrän sent på eftermiddagen samma dag.

För att undvika att det blir liknande förseningar vid kommande händelser bör representanter från Helsingborgs brandförsvar, stadsbyggnadsförvaltningen, miljöförvaltningen, Örbyverket, NSVA och miljörestvärdesledaren träffas och gå igenom de rutiner som finns inom respektive verksamhet/organisation. Detta för att säkerställa att ett eventuellt saneringsarbete påbörjas i ett tidigare skede vid nästa tillfälle.

Carlson, I. (2006). Alternativa drivmedel, Naturgas och Biogas. Oxie: Ingenjörsfirman Ingemar Carlson . Lönnermark, A. (2010). New Energy Carriers in Tunnels. Borås, Sweden: SP Technical Research Institute of Sweden. Perrette L., W. H. (2007). Safe Storage of Natural Gas on Urban Buses: Case Early Investigation and Learnings. Detroit, Michigan, USA: SAE World Congress 2007.

helsingborg.se

helsingborg.se

BILAGA 3

Tid 09:30 09:30 09:32 9:38 10: 08 11:30 11:45 Chaufför Volvo SOS Volvo MAN Aktörer SBM VBI IL Berga Chaufför + passagerare MAN Avlösande chaufför 09:34 Bårslöv Örbyverket RCB M-RVL 10: 03 Står still på busshållsplats med motorn avstängd Blir påkörd bakifrån av Volvo - brandstart Kör in till busshållsplats, får ej stopp på bussen Kör in i den stillastående MAN- bussen - brandstart Utrymmer MAN-bussen Misslyckat släckförsök med handbrand- släckare Befinner sig i rast- lokal vid hållplats Tittar ut och ser busskollision med efterföljande brand Får med sig Volvochaufför, ringer SOS Tar sig ut på trottoar utanför bussen Flyttas i säkerhet SOS får inringt larm Upptäcker att buss brinner Nivå 1 larm Nivå 3 larm - förstärkningslarm Utlarmning – nivå 3 Utlarmning – nivå 3 Utlarmning Fler uppringare Beslutar att ta med 1140 Räddningstjänst avslutad Initierar RAPS 49 Går över på RAPS 49 Går över på RAPS 49 Går över på RAPS 49 Går över på RAPS 49 Kontaktar Örbyverket Får info av SBM Upptäcker rastlokal Försöker öppna bussdörr Blir varse buss- olyckan via nätet Kontaktar SBM Meddelar RCB att det inte behövs några ytterligare resurser 4 2 3 1 Höjer upp till Nivå 3 larm

BILAGA 3 5 6 Får info om busskrocken Larmar M-RVL Meddelar att det föreligger spridningsrisk till Råån Informeras om spridningsrisk till Råån och uppmanas att kalla in M-RVL Får larm Ringer SBM Informerar M-RVL Ringer miljöinspektör Kontaktas av M-RVL Söker kontakt med ansvarig på NSVA Kontaktar M-RVL Får info om spridning samt åtgärder Får info om spridning samt åtgärder Får kontakt med NSVA/ info att PEAB är ansvariga Får kontakt med PEAB Får info om spridning samt åtgärder Kontaktar miljöinspek- tör för mer info Kontaktas av PEAB Bekräftelse att PEAB kommer att vidta åtgärder Kontaktar M-RVL Kontaktar M-RVL Info om att inga åtgärder påbörjats Kontaktar PEAB och miljöinspektör Ärendet avslutas Sanering påbörjas Tid 13:25 13:35 15:20 15:50 SOS Aktörer SBM 14:30 PEAB M-RVL 14: 40 Miljö- inspektör NSVA 13:40 14:05 14:10 14:45 SBF 16:00 17:45

FD05985 ｜ 2014_瑞典_赫尔辛堡_建筑火灾调查_火灾报告.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2014 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Sammanfattning av olycksundersökning Annan Brand i gryta

Sammanfattning av händelsen Lägenhetsbrand. Mindre brand på spis, branden var koncentrerad till en kastrull med matolja.

Innehåll i undersökning (undersökningens djup) Rapporten är en händelseberättelse, där delarna olycksförloppet, orsak till olyckan, insatsutvärdering, erfarenheter samt åtgärdstankar tas upp.

Direkta och bakomliggande orsaker till olyckan och olyckans förlopp Att spisen lämnats utan uppsikt och matoljan har självantänt på grund av ökad värme.

Insatsutvärdering Det blev ingen egentlig insats. Närmast drabbade ”utbildades” om hur man kan hantera mindre bränder och att aldrig lämna spisen när man värmer olja. Även uppträdandet hos person i närheten har noterats genom att beskriva vad en annan hyresgäst vidtog för åtgärder, genom att bege sig till den lägenhet där brandvarnaren larmade och vara behjälplig vid händelsen

Åtgärder som föreslås Inga åtgärder föreslås. Åtgärdstankar redovisas.

Landskrona Undersökningsprotokoll Datum 2006-10-24 Räddningstjänst Olycksundersökning Handläggare/TN/JS ID – Olycksundersökning 2006102454/TN/JS

Anledningen till undersökningen Tisdagen 2006-10-24 Brand i köksfläkt xxxxxxxxxxxxxxxxx i Landskrona 2006-10-24

Upplysningar om olyckan

Larmtid: tisdagen 2006-10-24 Adress: xxxxxxxxxxxxxxx Räddningsledare: BM/Insatsledare Janos Sari Larmnummer: 2006007046/2006000624

Olycksutredare:

__________________________ __________________________ Janos Sari Tommy Nilsson BM/Insatsledare Brandutredare

Olycksförlopp I samband med matlagning och uppvärmning av olja börjar det brinna i en gryta och lågorna slår upp mot köksfläkten. En kvinna som bor i huset höll på nere i tvättstugan ner hon hörde en brandvarnare som börja tjuta. Kvinnan sprang upp från källaren och hörde att larmet kom högre uppifrån i trapphuset. På tredje våningen såg hon att en dörr var öppen och hon kunde se lite rök komma ut. Inne i hallen stod kvinnan som bor i lgh med sina 3 små barn (0 - 7 år). Hon sa till dem att gå ut i trappan och gick själv in och såg att en del smält plast låg och rök på spisen. Spisens plattor var redan frånslagna. Hon tog bort plasten samt en gryta som hon lade i vasken. Hon öppnade även några fönster för att vädra ut den stickande röken. Efter det kallade man på L-a - hems gårdskarl som i sin tur ringde oss för att komma och kontrollera så inte det glödde någonstans.

Efter Räddningstjänstens ankomst I lägenheten, som fortfarande luktade lite bränd, satt mamman med sina 3 barn. Vi kontrollerade ventilationstrumman och skåpen runt fläkten utan att hitta några spår på brand. Med den lilla flickan som tolk försökte vi ha dialog med mamman. Mamman svarade inte utan bara nickade på den inf vi gav om bl.a. att ej använda vatten, som påstods att hon gjort, för att släcka den brinnande olja i grytan. Efter en liten stund kom en vuxen som tolkade men vi kunde inte heller då få reda på till 100 % vad som hänt när det började brinna i grytan och varför.

Olycksorsak Allt tyder på att man lämnat spisen utan uppsikt och matoljan har blivit så upphettad att den börjat brinna.

Utvärdering av insats Det blev ingen direkt insats av oss mer än en undersökning med bl.a. värmekamera i ventilationstrumman. Det viktigaste vi förhoppningsvis bidrog med, förutom lugna dem om att allt var släckt, var att vi kunde via tolken, som efter ett tag kom till platsen, ”utbilda” mamman om hur hon kan hantera en mindre brand lik denna på rätt sätt. Samt vikten av att aldrig lämna spisen när man värmer olja.

Erfarenheter Det är lätt att förstå vilka problem man kan få när det gäller att få viktig inf snabbt. Kvinnan i detta fall pratade bara något Afrikanskt språk och det var helt omöjligt att kommunicera med henne. Om fallet var så att man helt glömt grytan var det bra/tur att man hade brandvarnare.

Åtgärdstankar Pratade med tolken som kom från samma land ( och just själv gått brand utb.) om att det hade varit bra om man haft någon möjlighet att på något sätt utb./inf invandrargrupper som inte kommit ut i arbetslivet vad gäller brand och övrig säkerhet. Hur kan man nå dessa grupper på ett effektivt sätt? Skulle kanske vara en uppgift för fastighetsägarna att i sitt SBA ha att man på något sätt informerar sina boende, speciellt om de kommer från andra länder, om det mest elementära angående.

FD05986 ｜ 2016_瑞典_哥德堡_燃气公交车火灾事故调查_火灾报告.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2016 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因：燃气/爆炸 ｜ 来源格式：pdf

www.rsgbg.se

Olycksutredning Brand i gasbuss Gnistängstunneln, Göteborg 12 juli 2016

Diarienummer

0397/16

2016-12-06 Mikael Hagberg Johan Lindström Petter Backlund

Olycksutredning: Brand i gasbuss, Göteborg

RÄDDNINGSTJÄNSTEN STORGÖTEBORG

ii

Olycksutredning Brand i gasbuss Gnistängstunneln, Göteborg 12 juli 2016

Diarienummer: 0397/16

Referens insatsrapport: 2016004769

Uppdragsgivare: Anders Ekberg, Räddningschef.

Per Jarring, Funktionsansv. Olycksutredning & Analys.

Utredningen utförd av: Mikael Hagberg, Olycksutredare.

Johan Lindström, Enhetschef samhällsplanering.

Petter Backlund, Insatschef.

Kvalitetsgranskad av: Per Jarring, Räddningstjänsten Storgöteborg

Bilagor:

Bilaga 1: Tidslogg, räddningsinsatsens genomförande.

Bilaga 2: Förslag till åtgärder.

Olycksutredning: Brand i gasbuss, Göteborg

RÄDDNINGSTJÄNSTEN STORGÖTEBORG

iii

Sammanfattning Den 12 juli körde linjebuss 99 genom Gnistängstunneln i Göteborg och stannade cirka 100 meter efter tunneln i södergående riktning. Anledningen till stoppet är röklukt i bussen samt att plasten i innertaket börjar smälta. Busschauffören genomförde omgående en effektiv och säker utrymning av samtliga passagerare. Strax efter bussen stannat passerar en räddningsenhet i motsatta körfält (norrgående riktning) på väg mot ett automatlarm. Styrkeledaren noterade den rykande bussen och anropade då larm och ledningscentralen (LC) och beskrev vad de sett. Styrkan blev då omdirigerade direkt av LC. En insatsledare (IL) som befann sig i närheten hörde anropet från räddningsenheten. IL gjorde också ett anrop till LC och meddelade att han åkte till skadeplatsen.

Vid framkomst såg styrkeledaren omgående att det var en gasbuss som brann samt att alla passagerare var utrymda. Räddningspersonalen påbörjade omgående ett släckningsförsök av den då begränsade branden.

Trafikledningscentralen fick order av räddningsledaren att göra en ”akut avstängning” till tunneln för att få stopp på trafiken. Trafikledningscentralen påbörjade avstängning av tunneln, men trafiken fortsatte att rulla förbi skadeplatsen. Det ledde till köbildning och trafikanterna befann sig cirka 3,5 meter ifrån en brinnande gasbuss.

Branden visade sig vara svåråtkomlig och tilltog i intensitet. Olika släckmetoder testades för att få bättre effekt. Efter cirka 30 minuter avtog branden och bedömdes då vara under kontroll. Bland annat hade ett CAFS1-spett används på bussens tak för att skumfylla utrymmet där bussens gastankar låg. 38 minuter efter framkomst exploderade en av bussens gastankar. Två brandmän blev skadade och transporterades med ambulans till sjukhus för vård. En kunde lämna sjukhuset samma dag och den andra brandmannen blev utskriven dagen efter.

Den troliga orsaken till att gastanken exploderade var en kombination av högt tryck i tanken och en försvagad mantel. Gastankarnas smältsäkringar ska utlösa och hindra att för högt tryck uppstår. De hindrades från att utlösa genom att smältsäkringarna kyldes då CAFS-skum påfördes.

1 CAFS: Compressed air foam system

Olycksutredning: Brand i gasbuss, Göteborg

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Innehåll 1 Inledning ........................................................................................................................................................ 1 1.1 Bakgrund................................................................................................................................................ 1 1.2 Syfte ....................................................................................................................................................... 1 1.3 Frågeställningar ..................................................................................................................................... 1 1.4 Avgränsningar ........................................................................................................................................ 1 1.5 Redovisningsplan ................................................................................................................................... 1 2 Metod ............................................................................................................................................................ 2 3 Resultat .......................................................................................................................................................... 3 3.1 Beskrivning av olycksplatsen ................................................................................................................. 3 3.2 Beskrivning av aktuell busstyp .............................................................................................................. 3 3.3 Beskrivning av olycksförloppet .............................................................................................................. 5 3.4 Räddningsinsatsens genomförande ...................................................................................................... 6 3.5 Konsekvenser av olyckan ..................................................................................................................... 10 3.6 Olycksorsaker ...................................................................................................................................... 11 3.7 Förberedelser för räddningsinsats ...................................................................................................... 12 3.8 Riskbedömningar och påverkan på säkerhet ...................................................................................... 16 4 Diskussion .................................................................................................................................................... 18 5 Rekommendationer ..................................................................................................................................... 22 5.1 Vad har gjorts efter händelsen ............................................................................................................ 23 6 Referenser ................................................................................................................................................... 24 Bilagor .................................................................................................................................................................. 25

Olycksutredning: Brand i gasbuss, Göteborg

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1 Inledning 1.1 Bakgrund Tisdagen den 12 juli 2016 cirka klockan 18:00 startade en brand i en gasbuss. Bussen stannade strax efter Gnistängstunneln i södergående riktning. Styrkan från Frölunda var samtidigt på väg på ett automatlarm och passerar därför bussen i norrgående riktning. Styrkan blev omgående omdirigerad till den brinnande bussen och var därför framme i ett tidigt skede i händelseförloppet. På platsen konstateras att det var en gasbuss, att det brann genom taket och att samtliga passagerare var utrymda. Styrkan påbörjade omgående ett släckningsarbete. Klockan 18:46 exploderade en av bussens gastankar. 1.2 Syfte Syftet med utredningen är att dokumentera händelseförloppet, räddningsinsatsens genomförande och de erfarenheter och lärdomar som dras från detta. Detta underlag ska sedan användas till vidareutveckling av Räddningstjänsten Storgöteborgs (RSG:s) verksamhet och ge fördjupad kunskap inom ämnesområdet för att i en framtid kunna genomföra bättre och säkrare insatser som en lärande organisation. 1.3 Frågeställningar 1) Dokumentera händelseförloppet och räddningsinsatsens genomförande. 2) Beskriv aktuell busstyp, konstruktion med gastankar, etc. 3) Undersök behov av vidareutveckling av RSG:s larmrutiner/insatsplaner/teknikstöd i det tidiga skedet vid denna typ av händelse. 4) Vilka riskbedömningar gjordes och hur påverkade detta säkerheten vid insatsen? 5) Vilka erfarenheter kan dras från denna räddningsinsats för vidareutveckling av riskbedömningsarbete och arbetssätt vid brand i gasbussar? 6) Hur ser förberedelserna ut i organisationen med avseende på arbetssätt, dokument och insatsstöd samt hur användes detta under insatsen?

RSG:s personalenhet genomför en arbetsmiljöutredning parallellt med denna olycksutredning. 1.4 Avgränsningar Orsaken till branden (utredning görs av Transdev) och rutiner kopplade till trafikavstängning av Gnistängstunneln (utredning görs av Trafikverket) ingår ej i denna utredning. Fortlöpande dialog och utbyte av information sker dock med båda dessa externa utredningar. 1.5 Redovisningsplan Utredningen ska resultera i en skriftlig rapport till uppdragsgivarna senast den 9 december 2016. Utredningen ska också skickas till MSB och registreras i sökverktyget Erfaros.

Olycksutredning: Brand i gasbuss, Göteborg

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2 Metod Delar av datainsamlingen (intervjuer) har genomförts gemensamt med personalenheten. I övrigt har utredarna för arbetsmiljöutredningen samt denna olycksutredning arbetat självständigt med respektive frågeställning.

Analysmetod  AcciMap metoden, har använts för att kartlägga händelseförloppet samt att koppla ihop bakomliggande styrdokument, utbildningar, lagar samt förordningar som kan ha påverkat utfallet av olyckan.  STEP metoden, har använts för att kartlägga en tidslinje.

Individuella intervjuer har genomförts följande datum: 2016-07-13: Larmoperatör, larm och ledningscentralen. 2016-07-14: Styrkeledare, Frölunda brandstation. 2016-07-14: Chaufför vattenenhet, Frölunda brandstation. 2016-07-14: Rökdykare 2, Frölunda brandstation. 2016-07-14: Chaufför vattenenhet, Mölndal brandstation. 2016-07-14: Insatsledare. 2016-07-15: Funktionskoordinator (FK), Frölunda brandstation. 2016-07-15: Chaufför räddningsenhet, Frölunda brandstation. 2016-07-15: Rökdykare 1, Frölunda brandstation. 2016-07-15: Medåkare vattenenhet, Frölunda brandstation. 2016-07-15: Larmoperatör, larm och ledningscentralen. 2016-07-18: Stabschef.

Datainsamling och material  2016-07-14: Platsbesök med representanter Bussbolaget Transdev och busstillverkare Solaris.  2016-07-21: Möte med representanter från busstillverkare Solaris från Polen, Hexagon Composites Norge, Bussbolaget Transdev.  2016-08-30: Möte med Myndigheten för samhällsskydd och beredskap (MSB) (sakkunnig inom tryckkärl och olycksutredningar).  Händelserapport (2016004769).  Insamling av bilder från media och operativa bilder.  Polishelikopter filminspelning.  Trafikverkets övervakningsfilm.  Insatsplan Gnistängstunneln.  Rutinbeskrivning Tunnelrutin (Trafikverket).  Informationshämtning från liknande händelser (MSB).  MSB rapport om Gasdrivna fordon – händelser och standarder (ISBN978-91-7383-671-5).

Referenser redovisas löpande i texten med hänvisningsnummer [nr].

Olycksutredning: Brand i gasbuss, Göteborg

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3 Resultat 3.1 Beskrivning av olycksplatsen Olycksplatsen var på Västerleden i Göteborg, cirka 100 meter ifrån södra tunnelmynningen på Gnistängstunneln i södergående körfält.

Gnistängstunneln byggdes 1978 och har en längd på 712 meter. Konstruktionstypen är Bergtunnel. Tunneln har två separata rör med två körfält i båda körriktningarna. Trafikmängden är cirka 55,000 fordon per dygn och tunneln är klassad för farligt gods, enligt Trafikverket. (Bild 1)

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Beskrivning av aktuell busstyp Bussen som började brinna var av märket Solaris och modellen var Urbino 15LE CNG. Bussen tillverkades i Polen 2010, ägdes av Transdev och nyttjades av Västtrafik. Totalt antal passagerare kan i denna modell uppgå till 119 stycken, varav 48 sittande, 70 stående och 1 rullstolsburen. En identisk buss som den brandutsatta visas i Bild 2.

Denna bussmodell är märkt som gasbuss genom texten ”Gasbuss” över framdörren (Bild 2) samt över förarens fönster på bussens vänstra sida. Fram, bak samt på passagerardörrarna finns även märkningen CNG2, enligt Bild 3.

2 Compressed Natural Gas Bild 1 Aktuell olycksplats. (Källa www.eniro.se) Bild 2 Bussmodellen är 14,59 meter lång, 2,55 meter bred och 3,40 meter hög. Det finns tre dörrar för på- och avstigning, varav en enkeldörr (bakre) samt två dubbeldörrar. (Foto Räddningstjänsten Storgöteborg). Bild 3 CNG märkning (Foto Räddningstjänsten Storgöteborg).

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Den aktuella bussmodellen var utrustad med sju gastankar placerade på taket i bussens främre del mellan främre ingången samt mittendörren. Tankarna var placerade tvärs bussens färdriktning. (Bild 4, Bild 5)

Tankarna var konstruerade av kompositmaterial, de rymmer 214 liter styck och väger 75 kg tomma. Arbetstrycket i tankarna ligger på 200 bar. Tankarna är testade upp till 300 bar.

Varje tank var utrustad med en magnetventil som styr flödet på gasen. När fordonet görs strömlöst stängs dessa magnetventiler. Detta innebär att varje tank ska betraktas som en separat enhet vid en insats. Varje tank var utrustad med två smältsäkringar som ska tryckavlasta tankarna vid brand.

Antalet tankar, placering, material samt utformningen av smältsäkringar kan variera mellan olika modeller. EU regelverket ECE R110 [27] är styrande för tankarnas utformning. Sverige har inte antagit de frivilliga reglerna om regelbunden kontroll av tankarnas skick.

Gastankarnas smältsäkringar är konstruerade likt ett vanligt sprinklerhuvud för att utlösa vid en specifik temperatur. Utlösningstemperaturen på de aktuella smältsäkringarna var satt till 110 ˚C.

Detta ventilhus innehåller dels magnetventilen som stänger gasflödet från tanken när strömmen bryts, smältsäkringen som löser ut vid 110 ˚C samt tömningsröret för evakuering av gas om smältsäkringen löser ut. Den röda pilen visar riktningen på utströmmande gas om smältsäkringen löser. Denna riktning är ca 45˚ snett ned och bakåt i Bild 4 Visar en skiss på bussens högra sida i bussens färdriktning. Bild 5 Visar att varje tank var utrustad med en magnetventil. Bild 6 Visar ventilhuset på en av tankarna. (foto Räddningstjänsten Storgöteborg)

Olycksutredning: Brand i gasbuss, Göteborg

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bussens längdriktning. Grovt sett träffar utströmmande gas kanten på bussens tak i riktning mot bussens mittendörr. (Bild 6)

Smältsäkringen på bussens vänstra sida i bussens färdriktning. Denna pekar vinkelrätt ut från bussen. (Bild 7)

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Beskrivning av olycksförloppet Linjebuss 99 avgick klockan 17:38 enligt tidtabell från Hjalmar Brantingsplats mot Frölunda Torg. (Bild 8)

Busschauffören uppmärksammade inget ovanligt med bussen inför avfärden. Bussföraren hade cirka 20 - 25 passagerare med sig.

Strax innan klockan sex körde bussen in i Gnistängstunneln. Passagerare uppmärksammade då busschauffören att det luktade bränt samt att det kom lite rök från taket vid barnvagnsplatsen, mitt i bussen.

Busschauffören uppmärksammade detta och stannade några sekunder i tunneln, för att undersöka vad det kunde vara. Chauffören beslöt att köra ut ur tunneln så snabbt som möjligt, trots att flera passagerare i bussen försökte övertala honom att stanna kvar i tunneln.

Busschauffören ville absolut inte stanna i tunneln för att utrymma bussen. Det skulle vara för stora risker att släppa ut passagerare i den trafikerade tunneln samt att en brand i en tunnel inte skulle vara bra.

När bussen hade kommit ut ur tunneln var klockan 18:01. Busschauffören körde in till vägkanten direkt och stannade. Busschauffören öppnade samtliga dörrar och bussen utrymdes omgående. Passagerarna samlades cirka 50 – 70 meter framför bussen. Bild 7 Smältsäkring, bussens vänstra sida (foto Räddningstjänsten Storgöteborg). Bild 8 Linjekarta (Källa Västtrafik).

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Busschauffören stängde av motorn och anropade trafikledningen att det var rökutveckling i bussen. Busschauffören försökte sedan att släcka branden med den tillgängliga handbrandsläckaren (pulversläckare ABC). Branden som var i taket tilltog allt mer trots försöket med handbrandsläckaren. Busschauffören använde en pulversläckare av två som fanns att tillgå i bussen, enligt Transdev utredningsrapport [1].

1. 4

Räddningsinsatsens genomförande Följande beskrivning är en summering av räddningsinsatsens genomförande. Det finns en tidslogg på räddningsinsatsens genomförande samt tillhörande bilder i bilaga 1.

Strax efter bussen stannat passerar Frölundas räddningsenhet i motsatta körfält (norrgående riktning) på väg mot ett automatlarm. Styrkeledaren noterade den rykande bussen och anropade då LC och beskrev vad de sett. Styrkan blev då omdirigerade direkt av LC. En insatsledare (IL) som befann sig i närheten hörde anropet från räddningsenheten. IL gjorde också ett anrop till LC och meddelade att han åker till skadeplatsen.

Vid framkomst fick styrkeledaren (Räddningsledare) information från busschauffören att det inte fanns några passagerare kvar i bussen. Samtliga i räddningsenheten noterade att det var en gasbuss och att det brann genom bussens tak. (Bild 9)

Brandmännen påbörjade omgående en släckinsats. Valda metoder fick begränsad effekt på branden. Känslan var att det var svårt att komma åt branden i innertaket. Ganska snart tog branden fart och det började brinna även inne i bussen.

LC gav förslag till räddningsledaren att stänga av södergående tunnelrör genom Gnistängstunneln. Räddningsledaren tyckte att det var en bra idé. LC kontaktade trafikledningscentralen och de bekräftade att de hade påbörjat avstängning av vägen. Brandmännen försökte släcka från olika håll för att bättre nå branden. Branden dämpades småningom inne i bussen. Det brann dock fortfarande i bussens innertak. De klättrade upp på taket och gjorde ett hål i takkåpan som täckte gastankarna. Där sprutade de in CAFS. Det blev en god effekt och branden började avta.

Bild 9 Visar vart branden var vid framkomst. (Foto Räddningstjänsten Storgöteborg.)

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Vid en händelse i Holland var det en bussbrand där en säkerhetsventil utlöste och det uppstod en jetflamma på cirka 15

• 20 meter då utströmmande gas

antände. Skulle samma scenario ha inträffat på denna händelse skulle fordon som passerade troligtvis ha blivit träffade av en jetflamma. (Bild 10)

Insatsledaren (IL) hade ”Hollandscenariot” i sina tankar från en utbildningsdag där denna händelse hade visats. IL blev frustrerad att fordonen körde igenom tunneln, fast de hade påpekat att tunnelröret skulle stängas. Trafikledningscentralen informerade inte IL att de hade tekniska problem med avstängningen. Det tog cirka 25 minuter att stänga av det ena tunnelröret helt för trafikledningscentralen. Över 200 fordon passerade skadeplatsen i gångfart efter räddningstjänstens ankomst, med ett avstånd på cirka 3,5 meter ifrån den brinnande gasbussen. Polisen stängde av motsatta körfält på cirka 10 minuter efter Räddningsledarens (RL) begäran.

Enligt insatsplan Gnistängstunneln finns det ett mynningsskåp vid båda tunnelmynningarna. På insatskortet [3] finns det en beskrivning på mynningsskåpets olika funktioner. Det står inget i insatskortet [3] eller utbildningsmaterialet [4] att Räddningsledaren kan ta över trafikledningscentralens styrning över de brandtekniska installationerna för tunneln. (Det har informerats muntligt att detta kan göras.) Det vill säga att Räddningsledaren själv skulle kunna fälla ner bommarna manuellt. Räddningsledaren öppnade mynningsskåpet, men genom att räddningsledaren fick bekräftelse att bommarna skulle fällas och att det inte fanns några tekniska problem gjordes det inga manuella åtgärder.

Det finns olika uppfattningar vad ”Akut avstängning” innebär. Räddningstjänsten uppfattning var att bommen fälls direkt även om bommen skulle träffa ett fordon. Trafikledningscentralen har en annan bild i Göteborg. Bommen fälls inte direkt utan en process som ska genomföras tar längre tid än att bommen bara fälls. Trafikverket i Stockholm fäller bommen direkt. Trafikverket i Göteborg har påbörjat ett arbete att se över denna rutin samt vad det tekniska felet berodde på.

Trafikverket påbörjade sin avstängning av Södra tunnelröret genom att ändra de variabla hastighetsskyltarna till avstängt körfält med ett ”kryss” i det högra körfältet. I det vänstra körfältet reducerades hastigheten. När trafikanterna kom ur tunneln var de variabla hastighetsskyltarna satta till 70 i båda körfälten. Trafikledningscentralen behöver lägga ut ”kryssmarkering” manuellt efter tunneln och detta gjordes inte av okänd anledning

Bild 10 Visar jetflamman från Holland. (Källa YouTube [2])

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Räddningspersonalen blev oskyddade de första tre minuterna då ena körfältet inte hade något ”buffertfordon” att ta skydd bakom. När Insatsledaren kom och gjorde sin fordonsplacering inledningsvis bakom bussen, så fungerade det som en mindre barriär. När vattenenheten kom, gjordes det en fordonsplacering bakom Insatsledaren, men hade inte fått uppgiften att vara en ”barriär” utan avvaktade på vad de skulle göra.

När det blev dålig miljö vid tunnelmynningen på grund av rök valde Insatsledaren och vattenenheten att lämna platsen. Insatsledaren körde fram till mynningsskåpet som var cirka 70 meter framför bussen för att få en bättre ledningsplats och tog då även över som räddningsledare. Styrkeledaren som var räddningsledare blev sektorchef. Räddningsenheten behövde vatten och det blev också en anledning till att vattenenheten flyttade på sig. Nu fanns det ingen barriär kvar som skyddade personalen som arbetade på vägen.

Chauffören på vattenenheten gjorde sin fordonsplacering väldigt tajt mot vägräcket. Detta gjordes för att tvinga fordonen att sänka farten genom skadeplatsen för att inte någon av räddningspersonalen skulle bli påkörda. Detta ledde till att trafiken stannades upp ytterligare. Det blev trångt för fordon att passera skadeplatsen vilket innebar att exponeringstiden intill den brinnande gasbussen ökade för de fordonen som passerade.

Trafiken blev ett stresspåslag för räddningsstyrkan. Målet med insatsen var att branden skulle släckas så att det inte kom mer rök mot tunneln samt att en jetflamma inte skulle uppstå på vänster sida i bussens färdriktning och träffa de fordon som passerade. Att spärra av vägen helt, med exempelvis vattenenheten, gjordes inte då räddningsledaren fick bekräftelse att bommen skulle fällas.

Vid intervjuerna framkom det att flera i räddningspersonalen hade uppfattningen att säkerhetsventilerna alltid är på vänster sida i bussens färdriktning. Trafiken passerade på denna sida i cirka 25 minuter efter räddningstjänstens framkomst.

Bussens konstruktion gjorde det svårt att nå branden. Genom att det var cellplastisolering mellan innertak och yttertak så droppade smält cellplast ner in i kupén som i sin tur spred branden vidare.

Det gjordes släckförsök genom att gå högre upp i sluttningen bredvid bussen. Brandmännen gjorde även släckförsök uppe på bussens tak, totalt fyra gånger under insatsen. Vid sista släckförsöket på taket bedömde sektorchefen att arbetet på bussens tak inte var säkert och beordrade ner brandmannen. Detta skedde fyra minuter innan en av bussens gastankar exploderade.

Olycksutredning: Brand i gasbuss, Göteborg

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Att kunna nå gastankarna under pågående brand är svårt då berörd bussmodell har satt fast takkåpan med fyra stycken bultar, enligt bilden nedan (Bild 11).

När räddningsledaren upplevde att branden var under kontroll kom samtidigt representanter från bussbolaget fram till skadeplatsen. Strax där efter (klockan 18:44) gick några av dem fram till bussen för att stänga av gasen till motorutrymmet. När både personal från räddningsstyrkan och bussbolaget stod bredvid bussen (klockan 18:46), exploderade en av gastankarna. Det vill säga 38 minuter efter räddningstjänstens framkomst.

Vid explosionen åkte en gastank rakt ner i bussen. En flög upp i luften och landade mellan vägräcken. Den tredje landade i slänten bredvid bussen där personerna stod. Denna gastank läckte även ut gas. Två brandmän blev skadade. De blev omhändertagna och transporterades med ambulans till sjukhus. (Läs 3.5 Konsekvenser av olyckan)

Troligtvis blev effekten av tryckvågen att branden slocknade. Efter att ha stämt av skadeläget på personalen, påbörjades kylning på gastankarna. Detta utfördes från en vattenkanon.

Polisens helikopter hjälpte till med en avancerad kamerautrustning, både högupplöst zoom och värmedetekterande kamera. Polishelikoptern kunde lokalisera resterande gastankar. (Bild 12)

Bild 11 Visar kåpans bultfäste på berörd bussmodell. Bild 12 Visar en översiktsbild över skadeplastområdet

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Kylningen pågick i 20 minuter, sedan blev det ett uppehåll på 45 minuter då grovslang fick dras cirka 400 meter till en brandpost på Fågelvägen. Superbrandposten som fanns bredvid skadeplatsen fick de inte ut något vatten ifrån. De saknade koppling (övergångslock från 110 mm till 76mm) för att fästa grovslangen. De fick även information av trafikledningscentralen att det inte fanns något tryck i vattenledningen till superbrandposten. Det visade sig i efterhand att det fanns tillräckligt med tryck för att få en god vattenförsörjning. Det fanns en brandpost i tunnelmynningen som inte nyttjades på grund av att de inte ville passera bussen. Kylningen påbörjades igen och höll på i cirka 35 minuter till innan kylningen av gastankarna avslutades helt.

Räddningsledaren kunde se polishelikopterns bilder att de övriga fyra gastankarna var svagt värmepåverkade. Då risken för explosion ansågs låg, skickade räddningsledaren fram bärgningspersonal för att bedöma möjligheten att bärga bort bussen, vilket visade sig vara görligt. Räddningsledaren tillkallade ett möte med polisen, bärgare, trafikledare från Västtrafik samt servicechefen från bussbolaget för att få garantier att bussen kunde bärgas på ett tillfredsställande sätt till bussgaraget på Deltavägen i Göteborg. Efter att räddningsledaren hade fått de garantier som eftersöktes påbörjades bärgning, med tydliga order om att förvara bussen och gastankarna utomhus samt att det skulle bevakas.

Räddningsledaren avslutade räddningstjänst klockan 22:00. Bussen bärgades klockan 22:35 från platsen.

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Konsekvenser av olyckan Vid händelsen skadades ingen passagerare i bussen. Dock skadade sig två brandmän lindrigt vid släckningsarbetet då en av bussens gastankar exploderade. Båda brandmännen fick färdas med ambulans till sjukhus för vård.

En av brandmännen skadas av en tryckvåg som uppstod då gastanken exploderade. Den andra brandmannen skadade sig i samband med flykt för att ta skydd bakom en brandbil. Brandmannen sprang emot ett utdragsskåp på brandbilen, varvid han faller till marken och skadar sig i bakhuvudet samt i ena foten.

Brandmännen som blev utsatt för tryckvågen kunde lämna sjukhuset samma dag medans den andra brandmannen fick ligga kvar på sjukhuset över natten för observation. Genom att detta klassas som en arbetsplatsolycka så görs det även en arbetsmiljöutredning samtidigt som denna utredning.

Det har framkommit att explosionen skapat oro hos närboende eftersom de saknade information om orsaken till explosionen. Polisen presstalesman samt räddningstjänstens stabschef blev intervjuade av olika nyhetstidningar om händelsen. Räddningstjänsten Storgöteborg gjorde ingen ”pressmeddelande” på denna händelse.

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Enligt Transved utredningsrapport [1] så fick bussen omfattande skador av branden. Sammantaget blev bussen totalförstörd med undantag att delar från, motor, växellåda och drivlina kunde återvinnas.

Konsekvenser av avstängning av transportled har inte utretts.

1. 6

Olycksorsaker Brandorsaken var enligt Transdev:s utredning [1] ett elfel i bussens innertak. Detta elfel har orsakat en brand i innertakets cellplastisolering.

Hexagon Composites AS som tillverkade tankarna har utvärderat skicket på samtliga gastankar. Vid denna utvärdering konstaterades att det är bara den bakre tanken (närmast mittendörren) som har exploderat. Nästkommande två tankar har skadats vid explosionen och på grund av tryckvågen slitits loss från sina infästningar och lämnat bussen. Detta har även medfört att dessa två tankar har fått skador på ventilhusen vilket har lett till ett läckage av gas. Vid testerna genomfördes även provtryckning av respektive tank vilket visade på ett visst läckage av gas.

Hexagon som tillverkar tankarna har i efterhand låtit Emer (tillverkaren av smältsäkringarna) testa smältsäkringar från bussen. Emer har då säkerställt att testade smältsäkringar var hela samt att de vid testerna löste enligt de temperaturkrav som finns på smältsäkringarna. Enligt uppgift från Hexagon [6] har inte alla smältsäkringar testats.

Det är viktigt att poängtera att följande resonemang är att beakta som troliga orsaker till den inträffade explosionen. Det som ligger till grund för resonemanget är den fakta som inkommit i form av Trafikverkets övervakningsfilm från händelsen, intervjuer med RSG:s räddningspersonal, genomförd inspektion av gastankarna samt information från tillverkaren av gastankarna (Hexagon Composites AS).

De troliga orsakerna till att en av bussens gastankar exploderade under insatsen var följande:  Genom valda släckmetoder har gastankarnas smältsäkringar kylts med skum och på så vis aldrig nått aktiveringstemperaturen på 110 ˚C.  Gastankarna blev påverkade av branden vilket har lett till försvagningar i tankens kompositmaterial (mantel).  En pågående brand som kontinuerligt försvagar gastankens mantel. Denna brand består troligtvis av brinnande gas som läcker genom kompositmanteln.  Kombinationen av att smältsäkringarna kylts, att gastankens mantel försvagats av pågående brand samt det höga trycket i gastanken har lett till ett explosionsliknande förlopp när tanken brister.

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Fakta som går att knyta an till den inträffad explosion är följande:

Under insatsen har ett CAFS-spett använts för att skumfylla utrymmet där gastankarna låg.

Inspektionen av gastankarna som Hexagon Composites AS [6] genomfört visar på en kraftig värmepåverkan på tre av gastankarna. De gastankar som var värmepåverkade var de tre som låg närmast branden, tank 1, 2 och 3. (Bild 13)

Brandskadorna är på gastankarnas övre halvor, samt på deras högra sida, i bussens färdriktning. I området runt smältsäkringarna syns begränsade skador till följd av värme. Gastankarna 5, 6 och 7 var opåverkade och rena, det vill säga ej sotiga. Detta tyder på att påfört skum har täckt hela tankarna. (Bild 14)

Vid besiktningen av Hexagon [6] genomfördes trycktester av gastank nummer två. Detta trycktest påvisade ett läckage av gas genom manteln på grund av de skador gastanken fått till följd av värmepåverkan. (Bild 15)

1. 7

Förberedelser för räddningsinsats RSG har samlat styrande rutiner, instruktioner och planer i ”verksamhetshandboken” och därigenom gjort dokumentationen tillgänglig för all personal. Den styrande dokumentationen utrycker bl.a. förväntningar på organisationen vid räddningsinsatser och på funktionerna styrkeledare, insatsledare, insatschef och stabschef gällande insatsledning. RSG har ingen specifik insatsvägledning för hantering av räddningsinsatser då metangasdrivna fordon är inblandade. Däremot finns en särskild instruktion för hantering av räddningsinsatser då acetylengasflaskor är inblandade [7] samt insatsvägledningspärmen för CBRNE [8].

Bild 13 Visar skiss på gastankarnas placering samt brandens startplats. Bild 14 Visar gastankarna nummer 7,6 och 5 är opåverkade och rena efter branden. (Foto Hexagon) Bild 15 Visar gastank nummer två. (Foto Räddningstjänsten Storgöteborg)

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CBRNE-pärmen [8] är däremot inte upptagen i verksamhetshandboken. Istället är den utdelad i tryckta exemplar till alla stationer för att finnas tillgänglig i räddningsenheter (RE). Dessa instruktioner är endast i vissa delar användbara vid räddningsinsatser med fordonsgastankar och ger ingen vägledning kring de tekniska systemen förknippade med fordonsgastankar eller de specifika riskerna.

För insatser i tunnlar finns både en larmplan [14] samt en specifik insatsplan [3] för Gnistängstunneln.

I instruktionerna för introduktion till styrkeledare [9], insatsledare [10], insatschef [11] och stabschef [12] har RSG utryckt vilka förväntningar organisationen ställer på dessa.

 För styrkeledare [9] uttrycks ingen generell förväntan att känna till operativt styrande dokument förutom tre specifika instruktioner, enheter under utryckning, radiotrafik samt räddningsledare. Hantering av brandfarlig gas eller tryckkärl nämns inte. I introduktionen ingår en timme utbildning som syftar till att skapa förståelse för larmplaner.

 För insatsledare [10] uttrycks en generell förväntan att ha god kunskap i operativa instruktioner och larmplaner. Instruktionen acetylengasflaskor nämns specifikt. Dessutom ska insatsledaren ha insikt i hantering och läsning av insatsplaner.

 För insatschef [11] utrycks en förväntan på taktik, ledning och juridik kopplat till en lista med typhändelser, däribland insats i tunnlar och brand i gasflaskor. Dessutom nämns som litteraturstudier ”Skydd och insatser vid gasolyckor”, SP 1994:57 samt ”Utbildningspaket om naturgasbussar” (internt) bland flera.

 För stabschef [12] uttrycks en förväntan att själv kunna göra taktiska bedömningar och bland flera scenarier nämns specifikt brand med gasflaskor. Fokus från stabschefer är i detta avseende kopplat till att hantera en eventuell begäran om skyttar från SÄRF, både praktiskt och avtalsmässigt. I instruktionens anges litteratur som bör ingå i introduktionen och där listas bl.a. larmplaner, aktuella instruktioner och åtgärdsplaner och enheternas förmåga

I dokumentationen enheternas förmåga beskrivs förväntningar på respektive enhet uppdelat på typhändelser. Dokumentationen är detaljerad med mätbara mål. Den innehåller beskrivningar med tillhörande övningar och övningsplaner. Relevanta typhändelser är i detta fall Olycka med farliga ämnen CBRN [17], Trafikolycka [18] och Brand i brandfarliga vätska eller gas” [19].

Samtlig dokumentation kring enheternas förmåga finns i ”Verksamhetsboken”, samt på den lokala ”Insidan” under fliken internutbildning. Kvalitetsgranskade övningar ska finnas i verksamhetsstödet Daedalos. I Styrdokument för övning [16] med tillhörande bilaga [13] anges förväntningar på vilka övningar som ska

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genomföras och med vilka intervall. Övningar delas in i styrande övningar (”skall”‐övningar), tematiska centrala övningar (UA:s enhetsövningar, flerenhetsövningar etc.) och generella övningsmoment (vägledning för ”bör”‐ övningar under lokalt ansvar). Bilaga 1 [13] anger i en matris intervall för genomförande av styrande övningar i en femårscykel. För de aktuella typhändelserna saknas relevanta kvalitetsgranskade övningar.

 Enhetens förmåga ”Trafikolycka” [18] har kvalitetssäkrade övningar i Daedalos. Däremot ingår ingen övning som omfattar alternativa bränslen. Följande förväntningar ligger på enheterna vid trafikolycka:  RE Trafikolycka, nivå 1: ”Grundläggande kunskap om räddningsinsatser mot fordon med alternativa drivmedel, eldrift eller hybridfordon. Nyttja fläkt för att styra rökspridning.” och ”Stabilisering/säkring av fordon”  RE Trafikolycka, nivå 3: ”Vara väl förtrogna med IT-stöd för fordonsrelaterad räddningsinformation, t.ex. CRS – Crash Recovery System i syfte att ta fram information för hybridfordon och fordon med alternativa bränslen.” Värt att notera är att RSG i dagsläget inte har CRS eller annat motsvarande system. Det pågår ett arbete att införa ett system på räddningstjänstens ledningscentral.  Bära varselväst vid trafikolycka. Nämns i RSG:s kvalitetsgranskade övning 4108 [29].

 Enhetens förmåga ”Olycka med farliga ämnen CBRN” [17] saknar kvalitetsgranskade övningar. I listan över övningar står ”Inleda CBRNE- insats” [13] vilken ska genomföras 2ggr/år. Pärmen ”Inleda insatser med farliga ämnen CBRNE” [8] borde här kunna användas som en grund för genomförande av övning.

 Enhetens förmåga ”Brand i brandfarliga vätska eller gas” [19] saknar kvalitetsgranskade övningar.

Tanken är att styrkeledaren ska kunna gå in i Daedalos och hämta de kvalitetssäkrade övningarna och öva med sitt arbetslag. Sedan ska styrkeledaren notera vilka som har utfört övningen. Rent tekniskt går det att göra uppföljning i Daedalos. Styrkeledaren behöver notera vilket övningsnummer som är utfört. Om detta görs går det att kvalitetssäkra för närmaste chef att personalen har gjort de styrande övningarna. Utredningen har inte funnit att organisationen har gjort uppföljning över enheternas genomförda, styrande övningar.

För insats i tunnlar finns Larmplan 1 ”TUNNLAR - brand eller annat nödläge” [14] och tunnelspecifika insatsplaner. Syftet med larmplanen är att larma tillräckligt med resurser och vidta andra åtgärder för att möjliggöra effektiva räddningsinsatser i tunnlar. Syftet med insatsplanen [3] är att vägleda räddningspersonalen i att hantera de tekniska system som finns inbyggda i tunneln. Det handlar alltså till viss del om en i förväg planerad taktik samt en

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styrning i att säkerställa tillräckliga resurser. Larmplanen användes inte vid händelsen.

För insatser med farliga ämnen finns Larmplan 20 ” OLYCKA MED FARLIGA ÄMNEN (CBRN)” [15]. Larmplanen syftar till att möjliggöra effektiva och säkra räddningsinsatser vid händelser med farliga ämnen. Eftersom larmplanen dimensioneras för alla typer av ämnen är vissa resurser enligt larmplanen onödiga för denna typ av händelse, t.ex. saneringsresurs. Larmplanen innehåller uppgifter om externt expertstöd. För brandfarlig gas listas bland flera Gasjouren (Gbg Energi) och Gasakuten (Gasol). Larmplanen användes inte vid händelsen.

På varje räddningsenhet finns insatsstöd i form av pärmen ”Inleda insatser med farliga ämnen CBRNE” [8]. Den innehåller checklistor och vägledning som bl.a. syftar till att första insatserna ska genomföras med beaktande av risker för egen personal. Första uppslaget innehåller en generell uppmaning att göra fordonsplacering 300 meter från olyckan, om det farliga ämnet är en gas. Under flik 4, Åtgärder på skadeplats, finns två checklistor, en för ”Först på plats” och en för ”Fortsatt insats”. (Bild 16)

Under livräddning anges att livräddande åtgärder kan göras i skyddsnivån larmkläder och andningsskydd i de flesta situationer, dock ”…ej…vid brand i explosiva ämnen med risk för massexplosion…”.

Under identifiera faror och riskområde uppmanas att söka stöd i annat beslutsstöd samt att arbeta med marginaler – ”vid osäkerhet agera som om ämnet är farligt”

Under fortsatt insats listas bl.a. att skyddsutrustning ska fastställas och tändkällor undanröjas.

Under Flik 12 ”Åtgärdskort ämnesklasser” och under klass 2, brandfarliga gaser, finns dels ett åtgärdskort för brandfarliga gaser generellt men också ett åtgärdskort specifikt för gasflaskor. Båda anger riskområde till lägst 300 meter. Risker som anges för gasflaskor är tryckvåg och splitter. Under åtgärder på skadeplats listas två inriktningar: passiv och aktiv insats. Vid passiv insats kyls flaskorna från skyddad plats till de är kalla och vid aktiv insats flyttas flaskorna till säker plats, alternativt punkteras genom beskjutning.

Bild 16 Visar framsidan på insatsstödet.

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1. 8

Riskbedömningar och påverkan på säkerhet Följande dokumentation fanns tillgängligt som stöd vid riskbedömningar vid denna typ av händelse:

 Säkring av arbete på väg [21]. Instruktionen bygger på att utlarmning sker enligt larmplan 23 Trafikolycka [22]. Utlarmning skedde inte enligt larmplan 23 och av den anledningen saknades resurser att vidta säkerhetshöjande åtgärder enligt instruktionen. Dessutom fanns tunnelns tekniska system med tillgång till varningsskyltar och bommar vilket kan utgöra en ersättning för flera av instruktionens arbetsmoment.

Följande arbetsmoment följer av instruktionen Säkring av arbete på väg [21]:  Initialt helt avstängd väg. Detta genomfördes ej med egna fordon. Däremot begärdes helt avstängt tunnelrör vilket skulle fått samma effekt om det hade genomförts direkt.  Förfaringssätt med två tunga fordon som stannar och blockerar båda körriktningens filer så att varningstält kan placeras ut i säkerhet. Detta genomfördes ej. Första enhet körde förbi olyckan och stannar efter bussen. IL samt Vattenenhet placeras framför olyckan då de anländer men flyttas senare pga. röken från branden samt att IL ville ha en bättre ledningsplats och att räddningsenheten behövde vatten från vattenenheten.  Trafiken varnas med hjälp av varningstält med blinkande gula lampor. Detta genomfördes ej. Två varningstält placerades ut, men utan lampor. Värt att nämna är att instruktionen även anger att varningsbloss ska användas. Vid händelser med risk för utströmmande, brandfarlig gas är ett varningsbloss en tändkälla som inte är önskvärd.

 Pärmen ”Inleda insatser med farliga ämnen CBRNE” [8]. Pärmen ska finnas på varje Räddningsenhet inom RSG.  Fordonsplacering enligt pärmen bör vara 300 meter från olyckan. Räddningsenhetens fordonsplacering var under hela insatsen cirka 17 meter från bussen.  Pärmen listar uppgifterna för första anlända resurs. Utöver livräddande åtgärder ska första anlända enhet utrymma och spärra av. Vid insatsen fortsätter första enhet med släckning och kylning. Med en nivåindelning enligt pärmen stimuleras till nya och uppdaterade riskbedömningar.  Pärmen uppmanar att hantera ett ämne som farligt om osäkerhet råder. Vid insatsen saknades kunskap om riskerna med punktuppvärmning av tankarna och att tankarna inte är säkrade mot för högt tryck.  Enligt pärmen ska skyddsutrustning fastställas samt tändkällor undanröjas. Personlig skyddsutrustning saknades hos flera personer som rörde sig i bussens absoluta närhet, bl.a. busschaufför. Några minuter efter räddningstjänstens framkomst

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blev bussen strömlös, troligtvis p.g.a. branden. Inom 20 meter från bussen stod räddningsenhet och vattenenhet med motorn igång och utgjorde därigenom tändkälla.  I pärmens åtgärdskort för gasflaskor anges riskerna tryckvåg och splitter. Riskområde anges till 300 meter. Vid hela insatsen hölls inget riskområde kopplat till tryckvåg och splitter.

 Räddningsinsats där acetylengasflaskor är inblandade [7]. Instruktionen är inte upprättad för att använda vid händelser med gasdrivna fordon. Däremot kan vägledning för riskområden hämtas från denna instruktion. Angående konsekvenser av flasksprängning anger instruktionen:  10 meter risk för tryckskador  25 meter risk för brännskador  300 meter risk för splitterskador

Instruktionens checklista har två punkter markerade med fet stil  Risker för personalen ska vara rimliga med hänsyn till vad som står att uppnå med insatsen.  Enstaka personer vistas så kort tid som möjligt vid flaskan.

Bedömningen initialt var att gastankarna inte var direkt påverkade av branden. Riskbedömningen blev därför att arbete intill och på bussen var möjlig. Efter att IL kom fram till platsen bedömdes risken för jetflamma på bussens vänstra sida i bussens färdriktning som den dominerande risken och därför fokuserades arbetet på att minska exponeringen av trafikanter bredvid bussen. Brandmännen arbetade på bussens vänstra sida, även om det uttalades som en risk att jetflamman skulle komma på bussens vänstra sida. Under den tid då gastankarna var direkt utsatta för brand agerade personalen utan hänsyn till risken för explosion. Cirka 34 minuter efter framkomst omvärderades riskbedömningen och det ansågs inte längre vara säkert att arbeta på bussens tak. 4 minuter senare exploderade en av tankarna på taket.

Två felaktiga bedömningar gjordes som hade stor betydelse för riskbedömningen: Att gastankarna var säkrade mot övertryck och att eventuella jetflammor endast skulle riktats mot ett håll. Båda dessa bedömningar kräver kunskap om bussens tekniska system. RSG har ingen specifik insatsvägledning att använda vid brand i gasdrivet fordon som skulle kunnat underlätta denna bedömning. RSG har genomfört en 1-timmes utbildning kring gasbussar på styrkeledarträff 2014. Uppföljningsutbildning har inte genomförts och därför har inte all personal i ledningsfunktionerna genomgått utbildningen samt det saknas dokumentation vilka som har genomfört utbildningen.

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4 Diskussion Olyckor med metangasdrivna bussar är inte ovanliga. Många kör i linjetrafik inom RSG:s område och de är inblandade i trafikolyckor och bränder som alla andra fordon. Däremot är kärlsprängning ovanlig som konsekvens och få inom räddningstjänsten har personlig erfarenhet från liknande händelser. Enligt Sveriges Bussföretag 2016 [23] svarade över 90 % av svenska räddningstjänster att de inte har tillräckliga kunskaper för denna typ av händelse. Flera utredningar som exempelvis Brand i biogasbussar Helsingborg 2012 [24], Statens Haverikommission Slutrapport RO 2013:01[25], Klaratunneln 2013 [26], MSB Gasdrivna fordon händelser och standarder [27] och Fire risks related to the use of CNG buses [28] pekar också på att området är säkerhetsmässigt underreglerat och att räddningstjänster har mycket svåra förutsättningar att bedriva räddningsinsatser, särskilt på grund av risken för explosion.

För allvarliga och ovanliga scenarier som detta behöver organisationen ha arbetssätt som skapar förutsättningar att agera med marginaler mot en osäker händelseutveckling. Det behöver finnas resurser och kompetens i tillräcklig omfattning för att skapa handlingsutrymme och kraft att utvärdera olika handlingsalternativ. Till viss del kan en larmplan bidra till att resurstilldelningen blir tillräcklig under etableringsfasen. Till viss del kan insatsvägledning och beskrivningar av komplexa system bidra till mer korrekta bedömningar och bättre val av taktik och metod. Även snabb tillgång till expertstöd kan bidra till detta. Det är också viktigt att tidigt identifiera bränsletyp för att kunna vidta nödvändiga åtgärder. Detta behöver göras redan vid inkommande larm i intervjufasen.

Räddningstjänsten står regelbundet inför nya scenarier; en olycka ingen hade kunnat föreställa sig. Lyckligtvis innehåller många av dessa olyckor endast begränsade risker för egen personal. Det är kombinationen av okända och stora risker som blir extra svår att hantera i en räddningsinsats. Personalen som hanterar en sådan händelse behöver vara tillräckligt utbildad och övad i problemlösning för att analytiskt angripa ett för alla nytt scenario, men som i vissa delar liknar tidigare hanterade scenarier. Mängdövning på kända scenarier kan då skapa en falsk trygghet att falla tillbaka på. Vid denna insats har personalen delvis missbedömt riskerna och valt taktik och metod från tidigare bränder. Detta har bidragit till att personer som vistades i närområdet utsattes risker. Bedömningen försvåras alltså på grund av att olyckan liknar tidigare bussbränder men innehåller en allvarlig och tekniskt svårhanterad risk. Händelsen kan jämföras med en farligt-gods-skyltad lastbil med sju gasflaskor i lasten. Om den hade börjat brinna skulle troligtvis utlarmade resurser, taktik och riskbedömningar blivit annorlunda.

Senaste årens utbildningar och utveckling inom RSG har till stor del fokuserat på att använda ny teknik och nya metoder, men på välkända scenarier. Exempel på detta är att använda CAFS för att släcka bränder i dolda och svårnådda delar inuti konstruktioner i byggnader. Ett annat exempel är säkerhet vid arbete på väg som fokuserar på att minska risken att bli påkörd vid räddningsinsatser på våra trafikleder. Våra ledningsfunktioner borde i högre utsträckning än idag övas mot scenarier som ställer högre krav på analytiskt problemlösande.

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Generellt är händelser med farliga ämnen av den typen och tjänar därför som bra övningsscenarier.

Enheternas förmåga [16] utgör ett system för kvalitetssäkring och uppföljning. Strukturen för detta system finns på plats men genom att övningar saknas, fungerar inte systemet som det är tänkt. Organisationen ställer förväntningar på enhetsnivå att upprätthålla kompetensen inom angivna områden men tillhandahåller inte medlen för att det ska bli möjligt att genomföra. Systemet medger även dokumentation och uppföljning. Dokumentationen brister idag och av den anledningen har organisationen ingen rättvisande bild av kompetensläget på enhetsnivå. Ledningsenheter ingår inte i detta system varför uppföljning av kompetensnivån på dessa blir svår att genomföra.

Taktik och metodval har inte valts med hänsyn till den osäkra riskbilden eller enligt tillgängligt insatsstöd för farliga ämnen. En avvägning mellan de värden som stod att rädda och riskerna förknippade med en aktiv insats borde lett till beslut om en passiv insats med avspärrning och utrymning av riskområdet. För att göra korrekta bedömningar krävs kunskap och utbildning kring riskerna samt insatsstöd att använda i en stressad situation. Dessutom är ledningsfunktionernas analytiska kompetens avgörande för att kunna göra välavvägda riskbedömningar. Från ett Youtube-klipp [31] framgår det att styrkan omedelbart påbörjar slangutläggning och räddningsledaren mister därigenom valmöjligheten till taktiskt plan i inledningen av insatsen.

En grundläggande tanke kring riskbedömningar vid räddningsinsats är att varje tillkommande enhet eller ledningsfunktion omvärderar gjord riskbedömning. Vid denna händelse kom de två ledningsfunktionerna (StL och IL) ungefär samtidigt till platsen och nästa ledningsfunktion kom först efter att tanken exploderat, cirka 50 minuter efter larm. Därigenom uteblev den naturliga omvärdering av mål, inriktning och riskbedömning som följer med att en högre ledningsfunktion tar över ledningen av insatsen. Vid denna händelse hade det möjligtvis haft betydelse för utfallet om förstärkningar kommit i ett tidigare skede. Användandet av någon av larmplanerna 1 eller 20 [14] [15] skulle inneburit att resurser kommit tidigare till platsen. Särskilt användbara kompetenser för att omvärdera riskbedömning hade vid denna händelse varit Insatschef/Stabsenhet och Styrkeledare från någon av Nivå 3-stationerna3 för farliga ämnen. Även den andra tjänstgörande Insatsledare skulle kunnat nyttjas för riskbedömningar och för att bevaka säkerheten på skadeplatsen.

Förutsättningarna att bedriva en säker räddningsinsats var i denna insats relativt gynnsamma. Bussen stod så till att den på ett säkert sätt skulle kunna brinna ut, även om en tank skulle explodera. Flera scenarier är tänkbara med sämre förutsättningar. Det som ligger närmast till hands är att tänka sig att busschauffören hade stannat kvar i Gnistängstunneln och utrymt bussen där. Riskerna förknippade med brandutsatta gastankar, gående personer och andra fordon inuti tunneln hade varit mycket stora och de taktiska valmöjligheterna färre och med större risker för personalen.

3 Enligt Enhetens förmåga, RE farliga ämnen, Nivå 3.

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Ett scenario med brinnande gasbuss intill exempelvis en samlingslokal är en annan problematik. Eftersom säkerhetsventilernas riktning varierar blir konsekvensen av en jetflamma osäker och vald taktik måste ta höjd för värsta tänkbara scenario. Dessutom kan en räddningsledare behöva fatta ett svårt beslut mellan passiv och aktiv insats då risken för egen personal vid en eventuell tankexplosion måste vägas mot vad som står att rädda med en aktiv insats.

I detta fall bedömdes bussen som säker efter kylningen och bogserades från platsen till Deltavägen. Som underlag till denna bedömning nyttjades IR-bilder från polisens helikopter. Det visade sig vara värdefull information och gav räddningsledningen både en översiktsbild av olyckan och samtidigt detaljerade bilder på gastankarna och deras tillstånd.

Det visade sig i efterhand att kvarvarande tankar på bussens tak var skadade och att infästningen i konstruktionen skadats så pass att risken var överhängande att tappa tankar under bogseringen.

RSG har avtal med Södra Älvsborgs Räddningstjänstförbund (SÄRF) om beskjutning av gastankar [30]. Denna resurs kontaktades aldrig under eller efter pågående insats. Punktering genom skjutning hade kunnat vara en metod för att tömma tankarna och därigenom få en säker hantering av efterarbetet, bl.a. bogsering.

Om branden inte går att bekämpa effektivt eller om gastankarna är brandpåverkade är det bättre ur arbetsmiljösynpunkt att genomföra en passiv insats och låta säkerhetsventilerna lösa ut. Då information om bussens konstruktion inte finns tillgänglig är det omöjligt att säkerställa att samtliga säkerhetsventiler har löst ut vilket innebär att någon tank kan vara nära att explodera. Detta är en överhängande risk och val av metod bör alltid kompletteras med tömning av tankarna. Två tänkbara metoder finns för nödtömning, punktering genom skjutning eller avfackling. Flera fysiska förutsättningar måste vara uppfyllda för att punktering genom skjutning ska vara möjlig, varav en är att tankarna måste vara synliga utan takkåpa. Vad gäller avfackling saknas idag tekniska möjligheter för att genomföra detta fältmässigt.

Säkerhetsventilerna på just denna buss pekade snett neråt på höger sida och rakt ut på vänster sida. Detta går inte att utläsa eftersom gastankarna är täckta av en kåpa. Utformningen skiljer sig dessutom åt mellan olika bussmodeller. Detta innebär att riskområdet till följd av en jetflamma sträcker sig i alla riktningar.

Som tidigare beskrivits är gastankarna utrustade med smältsäkringar som skall lösa ut vid en temperatur av 110 ˚C. Enligt tanktillverkaren Hexagon finns det en teoretisk risk att gastankarna kan explodera till följd av en brand även med fullt fungerande (ej kylda) smältsäkringar. Denna risk baseras på att en begränsad låga som träffar en gastank kan skapa en försvagning av kompositmaterialet som leder till att gastanken brister på grund av det höga trycket i tanken. Detta kan ske innan smältsäkringarna hinner lösa ut. En av anledningarna till att

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denna försvagning kan ske så fort beror på att gastankarna är byggda i ett kompositmaterial som är dåligt på att leda vidare värmen. En följdeffekt på grund av detta är att ingen värme leds till smältsäkringen så att den uppnår 110 ˚C. En värmepåverkad ståltank hade ganska omgående blivit så pass varm att även smältsäkringarna hade nått en hög temperatur och då kunnat lösa ut. Risken med detta är således att gastankar som utsatts för en låga riskerar att explodera innan smältsäkringen hinner lösa ut och tryckavlasta gastanken. Enligt Hexagon kan denna typ av explosion ske redan efter ett fåtal minuters direktpåverkan av en låga.

Under insatsen arbetade brandmän uppe på busstaket vid fyra tillfällen. Vid det sista tillfället beordrades brandmannen att klättra ned från taket på grund av att det inte bedömdes som en säker arbetsmiljö. Detta skedde bara fyra minuter innan explosionen. Att klättra upp på busstaket var ett stort risktagande då de värmepåverkade gastankarna riskerade att explodera. Denna arbetsposition på busstaket innebar att brandmannen var helt oskyddad för tryckvåg, gastankar som flög iväg samt splitter.

Vid denna händelse exploderar tank nummer 1 och tank 2 och 3 slets loss från sina fästen och flög iväg. Det gasmoln som bildas från dessa tankar antände aldrig. Hade detta gasmoln antänts hade skadeläget på personerna i bussens närhet troligtvis blivit ännu värre. Det fanns tändkällor i bussens närhet, samt pågående brand i bussen, som hade kunnat antända gasen, men detta skedde aldrig.

Denna insats gällde en brand i en CNG buss. Fordon med andra alternativa bränslesystem är idag i drift inom RSG:s område. Kunskapsläget hos RSG:s befäl behöver höjas beträffande alternativa bränslen som idag är i trafik. En omvärldsbevakning behöver kontinuerligt göras för att följa utvecklingen av nya fordonstyper som är på ingång.

RSG:s möjligheter att direkt påverka regelverk och standarder för utformning av gasdrivna fordon är begränsad. Regelverk som gäller gasdrivna fordon är internationella. Däremot har RSG en god möjlighet att skapa opinion i frågan och därigenom påverka både industrin och beslutsfattare. Standarder som skapar förutsägbarhet ger mycket större möjligheter att planera taktik och metod för bränder i gasdrivna fordon. Därigenom skulle RSG kunna minska konsekvenserna och kostnaderna för samhället genom att med vetskap om riskerna, agera mer offensivt och t.ex. korta ner tiden för avstängda transportleder.

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5 Rekommendationer  Utveckla RSG:s bedömningsarbete vid räddningsinsatser med okända fysiska och kemiska risker (t.ex. genom att ta fram ett standardiserat arbetssätt). Bedömningar och skyddsåtgärder bör initialt utgå från den högsta risken då osäkerhet råder. Genom informationssökning kan olika risker därefter stegvis uteslutas och skyddsåtgärder minskas.

 Genomför ledningsövningar och öva komplexa scenarier i större utsträckning än idag. Detta för att öka ledningsfunktionernas förmåga till analytiskt problemlösande. Öva specifikt riskbedömning kopplat till insatsledning.

 Ta fram insatsvägledning för fordon med alternativa bränslen.

 Arbeta fram ett utbildnings- och övningspaket kring fordon med alternativa bränslen. Detta ska då innehålla fakta om tekniska system, metod- och teknikval samt underlag för riskbedömningar. Övningspaketet bör ingå som en del i enheternas förmåga, men bör även innefatta ledningsfunktioner och LC.

 Införa ett system som tidigt kan identifiera bränsletypen vid händelser med fordon. Exempelvis kan ”intervjustöd” på SOS innehålla frågor om bränsletyp och LC kan införa system för sökning på registreringsnummer.

 Larmplan 1 bör omformuleras så att händelser även utanför tunnlar, och då tunneln riskerar att påverkas, inkluderas.

 Insatsplan Gnistängstunneln behöver omarbetas så att det stämmer överens med Trafikverkets rutiner. Mynningsskåpets funktion behöver förtydligas.

 RSG:s utbildningsmaterial för ”Information om trafiktunnlar” behöver revideras så att utbildningsmaterialet överensstämmer med Trafikverkets rutinbeskrivning.

 Påverka huvudman för kollektivtrafik, Västtrafik, att ställa krav i upphandling av kollektivtrafik med gasdrivna fordon angående:  Förutsägbarhet, standardutformning, i tekniska säkerhetssystem.  Underlätta släckning och kylning.  Användandet av cellplast som isolering mellan inner och yttertak behöver ses över om det går att använda något material som inte är så brännbart.

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1. 1

Vad har gjorts efter händelsen Västtrafik ser över:  Möjligheten att kunna lossa takkåpan på ett enkelt sätt.  Bättre instruktioner till förare vid olycka: Dra handbroms, stänga av huvudströmbrytare. En åtgärdsplan är framtagen.  Möjligheterna att sätta dit märkning på bussarna var smältsäkringarna sitter samt vart en jetflamma går.  Rutinen för hur en skadad buss ska transporteras, var en brandpåverkad gasbuss ska ställas upp efter olycka och hur gastankarna ska hanteras. Detta för att en eventuell ytterligare kärlsprängning inte ska skada andra bussar eller dylikt.

Trafikverket ser över följande:  Ser över hur man kan släppa fram teknisk personal från bussbolagen, så att de kan stödja räddningstjänsten med teknisk kompetens.  Ser över sina rutiner för ”Akut avstängning” samt att deras rutinbeskrivning för tunnlar sträcker sig även en bit utanför tunneln.  Ser över sina tekniska system för stängning av tunnel.

Räddningstjänsten Storgöteborg:  Har medverkat för att ge förslag på åtgärder till Trafikverket samt Västtrafik.  Berörda chefer inom RSG har tagit del av olycksutredarnas rekommendationer och besvarat dessa. (Bilaga 2)

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6 Referenser [1] Utredningsrapport Bussbrand Diarienummer: SU-GBB-20160712-01. [2] Gasbuss i Holland https://www.youtube.com/watch?v=CX8RUR-WgAY. [3] Insatsplan Gnistängstunneln, 2014-03-26. [4] RSG:s utbildningsmaterial ”Information om trafiktunnlar”. [5] Trafikverket Tunnelrutin, 2010-04-23. [6] Hexagon Report – Solaris bus fire in Gothenburg, 2016-07-12. [7] Instruktion Räddningsinsats där acetylengasflaskor är inblandade, 2014-06- 01. [8] Insatsstöd: Inleda insatser med farliga ämnen CBRNE, 2013-06-04. [9] Rutin Introduktion styrkeledare heltid, 2009-04-01. [10] Introduktion Insatsledare, 2013-05-16. [11] Rutin Introduktion till Insatschef/avlösande Insatschef, 2016-02-17. [12] Introduktion till Stabschef, 2016-04-06. [13] Bilaga 1: Matris över styrande övningar i en femårscykel, 2013-10-28. [14] Larmplan 1 Tunnlar - brand eller annat nödläge, 2015-03-31. [15] Larmplan 20 Olyckor farligt ämne, 2015-10-31. [16] Enhetens förmåga Styrdokument för övning, 2013-10-28. [17] Enhetens förmåga Olycka med farliga ämnen CBRN, 2013-05-07. [18] Enhetens förmåga Trafikolycka, 2013-05-07. [19] Enhetens förmåga brand i brandfarliga vätska eller gas, 2013-05-07. [21] Instruktion Säkring av arbete på väg, 2012-02-17. [22] Larmplan 23 Trafikolycka, 2015-10-31. [23] Bussar och brandsäkerhet, Sveriges bussföretag, 2016. [24] Brand i biogasbussar Helsingborg, 2012-02-14. [25] Statens Haverikommission Slutrapport RO 2013:0, Dnr O-03/12. [26] Storstockholms brandförsvar, Gasutsläpp biogasbuss, Klaratunneln, 2013. [27] EU regelverket ECE R110 redovisas i MSB Gasdrivna fordon händelser och standarder 2016. [28] Fire risks related to the use of CNG buses, A technical overview, Victor Bjälke, Institution of Civil Environment and Natural Resources, Luleå University of Technology, 2013 [29] RSG Övn.nr 4108 Avspärrning Trafikolycka,2013-09-04. [30] Avtal om hjälp från SÄRF med beskjutning av gasflaskor, 2014-01-27. [31] Brinnande Västtrafiksbuss, https://www.youtube.com/watch?v=arNHYUEdUsU

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Bilagor

Bilaga 1 Tidslogg av räddningsinsatsens genomförande. Bilaga 2: Förslag till åtgärder

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Brand i gasbuss 2016-07-12

Räddningstjänsten Storgöteborg

Foto: Robert Nilsson Bilaga 1 Tidslogg av räddningsinsatsens genomförande

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Tidslogg på Räddningsinsatsens genomförande

Klockan: 18:01 fick Frölunda brandstation ett automatlarm. En räddningsenhet med en styrkeledare och fyra brandmän åkte ut mot automatlarmet. Klockan 18:06 såg berörd räddningsenhet under framkörning en samling med människor bredvid en buss som hade rökutveckling i motsatta körriktning. Styrkeledaren kontaktade räddningstjänstens Storgöteborgs larm och ledningscentral (LC) direkt. Styrkeledaren i räddningsenheten frågade om de skulle avbryta utryckningen mot automatlarmet för att påbörja räddningsinsats på bussen. LC gav klartecken direkt och skickade en annan räddningsenhet mot automatlarmet. Vid bekräftelsen från LC begärde styrkeledaren samtidigt ut en vattenenhet som förstärkning till bussbranden. En insatsledare (IL) som fanns i närheten hörde över rakelkanalen när räddningsenheten från Frölunda meddelade LC att det var en buss som brann. IL kontaktade LC och körde mot bussen. Frölunda räddningsenhet körde igenom Gnistängstunneln för att kunna vända. (Bild 1)

Bild 1: Visar en illustration över räddningsenhetens framkörning.

Klocka 18:08 kom Räddningsenheten fram till den brinnande bussen. De gjorde sin fordonsplacering cirka 17 meter framför bussen. (Bild 2)

Bild 2: Räddningsenhet från Frölunda anländer. (Källa YouTube)

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Vid framkomst fick styrkeledaren (Räddningsledare) information från busschauffören att det inte fanns några passagerare kvar i bussen. Brandmännen bar ut varningstält samt förberedde för släckinsats. Samtliga i räddningsenheten noterade att det var en gasbuss och att det brann uppe på busstaket. (Bild 3)

Bild 3: Visar öppna lågor på busstaket samt en brandman som bar ut en varningstriangel (foto RSG ).

Klockan 18:09:32 slocknade bussens vägdestinationsskylt av okänd anledning. Ingen stängde av huvudströmmen manuellt. Klockan 18:10 gjordes det första släckförsöket från bussens mittersta dörr. (Bild 4)

Bild 4: Visar vart det görs släckförsök. (Källa YouTube)

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Klockan 18:11 kom IL fram till skadeplatsen. IL spärrade av ena körfältet med sitt fordon cirka 50 meter bakom bussen. Pågående släckinsats fick ingen effekt och branden tilltog. Ett nytt släckförsök gjordes genom att gå upp i slänten för att nå branden på busstaket. (Bild 5)

Bild 5: Visar en översiktsbild över skadeplatsområdet. (Källa trafikledningscentralens övervakningskamera.)

Klockan 18:12 kontaktade LC Frölunda räddningsenhet och gav ett förslag att stänga av tunnelröret helt mot Frölunda hållet (Södra tunnelmynning). Styrkeledaren samt insatsledaren tyckte att det var ett bra förslag. Styrkeledare meddelar samtidigt till LC att det handlade om en gasbuss. LC kontaktade trafikledningscentralen strax efter för att begära om avstängning.

Klockan 18:13 körde en linjebuss förbi den brinnande bussen. Bussen stoppades av Räddningsledaren på plats. Passagerare från den brinnande bussen plockades upp och lämnade skadeplatsen.

Vattenbegjutningen från slänten gav inte önskad effekt på branden. En brandman klättrade upp på busstaket med hjälp av en stege och gjorde släckförsök därifrån.

Klockan 18:14 kom vattenenheten från Frölunda brandstation fram. De gjorde sin fordonsplacering inledningsvis bakom IL, strax utanför tunnelmynningen. (Bild 6)

Bild 6: Visar en översiktsbild över skadeplatsområdet. (Källa trafikledningscentralens övervakningskamera.)

Klockan 18:14 försökte IL få kontakt med trafikledningscentralen två gånger för att få bekräftelse på avstängningen av södra tunnelröret. IL fick ej kontakt och LC hjälpte då till med kontaktförbindelsen.

Klockan 18:15 påpekade LC till trafikledningscentralen att IL hade begärt ”akut avstängning” av tunneln. Bommen fälldes inte vilket medförde att fordon tilläts att köra igenom tunneln.

Klockan 18:15 kom en polispatrull och gjorde sin fordonsplacering i motsatt körriktning.

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Klockan 18:16 kontaktade IL LC och bekräftade att han tog över som Räddningsledare (RL). En till vattenenhet begärdes ut till skadeplatsen. Han körde fram till mynningskåpet som var cirka 70 meter framför bussen för att få en bättre ledningsplats. Styrkeledaren som var RL blev nu sektorchef.

Trafikledningscentralen bekräftade att de påbörjade en avstängning av södra tunnelröret. RL pratade med polisen på plats strax efter bekräftelsen. Polisen fick till uppgift att stänga av motsatt körriktning mot Gnistängstunneln norra tunnelmynning.

Klockan 18:19 behövde räddningsenheten vatten. Vattenenheten lämnade sin fordonsplacering från tunnelmynningen och åkte fram till räddningsenheten. Vattenenhetens chaufför gjorde fordonsplaceringen tajt emot vägräcket. Detta gjordes för att minska hastigheten på de fordon som kom ut genom tunneln. (Bild 7)

Bild 7: Visar en översiktsbild över skadeplatsområdet. (Källa trafikledningscentralens övervakningskamera.)

Klockan 18:20 klättrade brandman ner från busstaket.

De använde mellanskum och sedan CAFS4 från marken. Branden tilltog och strålföraren bytte sida (se röd ring på bilden).

Klockan 18:22 kom ambulansen till olycksplatsen. (Bild 8)

Bild 8: Visar en översiktsbild över skadeplatsområdet. (Källa trafikledningscentralens övervakningskamera.)

Klockan 18:23 begärde LC en lägesrapport av RL. Bussen var då helt övertänd och RL begärde ytligare en vattenenhet.

Klockan 18:27 blev polisens avspärrning på motsatta körfält klart.

4 CAFS: Compressed air foam system.

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Klockan 18:27 öppnade RL mynningsskåpet till tunneln. Strax efter öppning av skåpet blev RL uppropad av LC om någon representant från bussbolaget hade synts till på plats. RL hade ej sett någon representant från bussbolaget. (Ingen manuell övertagning av tunnels tekniska funktioner gjordes via mynningsskåpet, utan skåpet förblev öppet under insatsen.)

Klockan 18:29 bekräftade trafikledningscentralen att bommarna var nedfällda och att de ökade ventilationen inne i tunneln.

Vattenenheten som begärdes anländer till skadeplatsen via norrgående körfält. Uppgiften blev att säkra vattentillförseln.

En brandman klättrade upp på busstaket för att göra ett nytt släckförsök. Det gjordes ett hål igenom takkåpan som skyddar gastankarna. Detta hål gjordes för att få in ett CAFS – spett. (Bild 9)

Klockan 18:32 bekräftade Trafikledningscentralen att hela tunneln var tom på fordon.

Klockan 18:34 minskade brandens intensitet och brandmannen klättrade tillfälligt ner från busstaket.

Bild 9: Visar när en brandman klättrade upp med CAFS - spettet. (foto RSG)

Klockan: 18:37 klättrade en brandman upp på busstaket och fortsatte med släckningen. Släckinsats genomfördes även från marken.

Klockan 18:42 klättrade brandmannen ner från busstaket på sektorchefens order. Detta gjordes för att det inte kändes säkert att vistas på busstaket. (Bild 10)

Bild 10: Visar en översiktsbild över skadeplatsområdet. (Källa trafikledningscentralens övervakningskamera.)

Klockan 18:43 kom tre representanter från bussbolaget fram till räddningsledaren och sektorchefen. En av dem stannade kvar och pratade med busschauffören som var kvar på skadeplatsen. De andra två följde med sektorchefen och en brandman för att stänga av gasen i motorutrymmet. Vattenbegjutning skedde sporadiskt från marken.

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Klockan 18:44 valde Insatschefen (IC) med stabsenheten att åka till platsen i syfte att stötta RL, då brand inträffat på en hårt trafikerad led i anslutning till tunnel.

Klockan 18:46 stod två representanter från bussbolaget samt räddningspersonal och pratade bredvid bussen.

Räddningspersonalen befann sig mellan buss och räddningsenhet. En brandman stod vid vägräcket mellan vattenenhet och polisbilen.

Räddningsledaren, busschauffören, en representant från bussbolaget samt två poliser stod vid insatsledarbilen och pratade. (Bild 11)

Sektorchefen beordrar personalen att förflytta sig bort från bussen då han bedömer området som osäkert.

Bild 11: Visar en översiktsbild över skadeplatsområdet. (Källa trafikledningscentralens övervakningskamera.)

9 sekunder senare!

Klockan: 18:46:34 exploderade en av gastankarna.

Personerna som stod vid bussen hukade sig. De kände av tryckvågen från smällen. Brandmannen som stod högre upp i slänten föll omkull av tryckvågen. (Bild 12)

Bild 12: Visar en översiktsbild över skadeplatsområdet. (Källa trafikledningscentralens övervakningskamera.)

Vid explosionen åkte en gastank rakt ner i bussen (nr1). En flög upp i luften som visas på bilden ovan. Den landade mellan vägräcken (nr 2). Den tredje landade i slänten bredvid bussen där personerna stod (nr3). Denna gastank läckte även ut gas. (Bild 13)

Bild 13: Visar en översiktsbild över skadeplatsområdet. (Källa polishelikopter)

Olycksutredning: Brand i gasbuss, Göteborg

RÄDDNINGSTJÄNSTEN STORGÖTEBORG

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Efter expositionen tog samtliga personer skydd som var i närheten av bussen. En av brandmännen sprang då rakt in i ett utdragsskåp från räddningsenheten. Detta gjorde att brandmannen föll ner på asfalten och blev liggandes. (Bild 14)

Bild 14. Visar vart utdragsskåpet var (foto Robert Nilsson).

Ambulanspersonal kallades fram för att ta hand om brandmannen som föll ner på asfalten. De transporterade sedan brandmannen till sjukhuset. En gravid kvinna som uppgav sig att vara läkare släpptes innanför avspärrningarna av polisen. Hon tittade till den brandmannen som föll av tryckvågen. Sedan fick hon lämna platsen. Även denna brandman transporterades med ambulans in till sjukhuset.

En till räddningsenhet samt en vattenenhet anslöt till skadeplatsen. Troligtvis blev effekten av tryckvågen att branden slocknade. Efter explosionen gjordes riskbedömningen att ingen person fick vistas i utrymmet mellan buss och räddningsfordonen.

Klockan 18:56 påbörjades kylning av dem gastankarna som låg kvar på busstaket. Detta gjordes med hjälp av en vattenkanon från en av vattenenheterna. (Bild 15)

Bild 15. Visar kylning från en av vattenenheterna (foto Robert Nilsson).

Olycksutredning: Brand i gasbuss, Göteborg

RÄDDNINGSTJÄNSTEN STORGÖTEBORG

9

Klockan 18:58 kom Insatschefen (IC) med stabsenheten fram till skadeplatsen. IC tog över Räddningsledarskapet direkt. Ledningsplatsen upprättades cirka 180 meter ifrån skadeplatsen. Berörd IL som var RL blev avlöst och kunde lämna skadeplatsen. (Bild 16)

Klockan 19:14 upphörde kylningen då vattnet tog slut. Superbrandposten som fanns intill skadeplatsen fick de ej igång på grund av att det var 110 mm uttag. Varken räddningsenheterna eller vattenenheterna var utrustade med övergång från 110 mm till 76 mm. Samtidigt sa trafikledningscentralen också att det var tillfälligt dåligt tryck till superbrandposten. De beslöt att dra slang till en brandpost som fanns cirka 400 meter bort på Fågelvägen. Det fanns en brandpost i tunnelmynningen som inte nyttjades på grund av att de inte ville passera bussen.

Klockan 20:04 kunde de börja kyla igen efter att ha kopplat in sig till brandposten på Fågelvägen.

Polisens helikopter hjälpte till med en avancerad kamerautrustning, både högupplöst zoom och värmedetekterande kamera. De lokalisera resterande gastankar. Räddningsledaren kunde då se via deras bilder att de övriga fyra gastankar var svagt värmepåverkade. Denna information nyttjades som beslutsunderlag för fortsatt mål med insatsen.

Klockan 20:41 avlutades kylningen av gastankarna. Då risken för explosion ansågs låg, skickade räddningsledaren fram bärgningspersonal för att bedöma möjligheten att bärga bort bussen, vilket visade sig vara görligt.

Räddningsledaren tillkallade ett möte med polisen, bärgare, trafikledare från Västtrafik samt servicechefen från bussbolaget för att få garantier att bussen kunde bärgas på ett tillfredsställande sätt till bussgaraget på Deltavägen i Göteborg. Efter att räddningsledaren hade

Olycksutredning: Brand i gasbuss, Göteborg

RÄDDNINGSTJÄNSTEN STORGÖTEBORG

10

fått de garantier som eftersöktes påbörjades bärgning, med tydliga order om att förvara bussen och gastankarna utomhus samt att det skulle bevakas.

Klockan 22:00 Avslutade Räddningsledaren räddningstjänst.

Klockan 22:13 tog polisen bort avspärrningen i norrgående körriktning.

Klockan 22:35 bärgades bussen från platsen. Strax efter midnatt öppnades även södergående körriktning. (Bild 17)

Bild 17 Visar en översiktsbild över bärgningen. (Källa trafikledningscentralens övervakningskamera.)

Här slutar detaljbeskrivningen över räddningstjänstens genomförande. Diskussion och rekommendationer finns i olycksutredningens huvudrapport.

Olycksutredning: Brand i gasbuss, Göteborg

RÄDDNINGSTJÄNSTEN STORGÖTEBORG

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Bilaga 2: Förslag till åtgärder

Nedan redovisas åtgärder/kommentarer tillsammans med berörd avdelning/enhet/funktion. Olycksutredare Berörd avdelning/enhet Rekommendation Åtgärdsförslag/Kommentarer Avdelning/Slutdatum Utveckla RSG:s bedömningsarbete vid räddningsinsatser med okända fysiska och kemiska risker (t.ex. genom att ta fram ett standardiserat arbetssätt). Bedömningar och skyddsåtgärder bör initialt utgå från den högsta risken då osäkerhet råder. Genom informationssökning kan olika risker därefter stegvis uteslutas och skyddsåtgärder minskas. Åtgärd enligt rekommendation. Tydliggöra rollförväntan på ledningsfunktioner inklusive LC. OPL. Start Q1 2017. Avstämning Q4 2017. Genomför ledningsövningar och öva komplexa scenarier i större utsträckning än idag. Detta för att öka ledningsfunktionernas förmåga till analytiskt problemlösande. Öva specifikt riskbedömning kopplat till insatsledning. Fortsätta utveckla spelledarledda övningar i Firestudio för ledningsfunktioner inklusive LC.

UÖE. Fortsatt arbete under 2017. Ta fram insatsvägledning för fordon med alternativa bränslen. Åtgärdsbehov bedöms efter framtagande av utbildningspaket (enligt nedan). OPL. Arbeta fram ett utbildnings- och övningspaket kring fordon med alternativa bränslen. Detta ska då innehålla fakta om tekniska system, metod- och teknikval samt underlag för riskbedömningar. Övningspaketet bör ingå som en del i enheternas förmåga, men bör även innefatta ledningsfunktioner och LC. Åtgärd enligt rekommendation. I arbetet ska externt material och erfarenheter tas till vara. För arbetet ske en metodutvecklingsgrupp tillsättas. UÖE och OPL. NOT samordnar. Klart Q4 2017. Införa ett system som tidigt kan identifiera bränsletypen vid händelser med fordon. Exempelvis kan ”intervjustöd” på SOS innehålla frågor om bränsletyp och LC kan införa system för sökning på registreringsnummer.

Pågående arbete av tillsatt arbetsgrupp med att införa system för att identifiera fordons- och bränsletyp.

Införa rutin på LC om att efterfråga bränsletyp i intervjun. Påverka SOS Alarm att inför fråga om bränsletyp i intervjustöd. UÖE och OPL. NOT samordnar. Förslag Q2 2017. Implementering Q4 2017.

OPL/LC. Klart Q2 2017.

Olycksutredning: Brand i gasbuss, Göteborg

RÄDDNINGSTJÄNSTEN STORGÖTEBORG

2

Larmplan 1 bör omformuleras så att händelser även utanför tunnlar, och då tunneln riskerar att påverkas, inkluderas. Åtgärd enligt rekommendation. OPL. Klart Q2 2017. Insatsplan Gnistängstunneln behöver omarbetas så att det stämmer överens med Trafikverkets rutiner. Mynningsskåpets funktion behöver förtydligas. Åtgärd enligt rekommendation.

Uppföljning av Trafikverkets översyn av rutiner. OPL. Klart Q1 2017.

OPL. Klart Q2 2017. RSG:s utbildningsmaterial för ”Information om trafiktunnlar” behöver revideras så att utbildningsmaterialet överensstämmer med Trafikverkets rutinbeskrivning. Åtgärd enligt rekommendation. OPL och UÖE. OPL samordnar. Klart Q2 2017. Påverka huvudman för kollektivtrafik, Västtrafik, att ställa krav i upphandling av kollektivtrafik med gasdrivna fordon angående:  Förutsägbarhet, standardutformning i tekniska säkerhetssystem.  Underlätta släckning och kylning.  Minska användandet av mycket brännbart material i bussar, såsom cellplast. Åtgärd enligt rekommendation, genom att tillse skrivelse till Västtrafik och MSB. Ledningen och OPC. OPC samordnar. Klart Q1 2017. Eventuella ytterligare kommentarer från berörd avdelning/enhet Genomgång av utredningen för/vid:

• Inblandad personal

Presentationsmöte

Mötesplatsledning (vid behov)

Styrkeledarträffar.

IA och OPL. Klart Q1 2017. OPC. Klart Q1 2017. OPL. Klart Q1 2017. IA. Klart Q2 2017.

FD05987 ｜ 2023_瑞典_MSB_建筑火灾_火灾报告.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2023 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Storskadeproblematik – Brand i byggnad

Storskadeproblematik – Brand i byggnad

Storskadeproblematik – Brand i byggnad Myndigheten för samhällsskydd och beredskap (MSB) Göran Holmstedt & Nils Johansson Department of Fire Safety Engineering Lund University, Sweden Brandteknik, Lunds tekniska högskola Lunds universitet Stefan Särdqvist Swedish Civil Contingencies Agency Myndigheten för samhällsskydd och beredskap Lotta Vylund, Haukur Ingason & Johan Lindström SP Technical Research Institute of Sweden SP Sveriges Tekniska Forskningsinstitut Borås Krister Palmkvist Southern Älvsborg Rescue Association Södra Älvsborgs Räddningstjänstförbund Borås Bo Nystrand Brandingenjör, Booster Media Foto framsida: Patrick Persson Produktion: Advant Produktionsbyrå Tryck: DanagårdLiTHO Kontakt: Bo Andersson, 010-240 52 62 Publikationsnummer: MSB827 - augusti 2015 ISBN: 978-91-7383-550-3

Innehåll

Inledning..............................................................................11 1.1 Begränsningar.......................................................................................... 13

Tidigare forskning och utveckling........................................... 15

Beskrivning av den systematiska analysmetoden....................19 3.1 Val av objekt........................................................................................... 20 3.2 Tillämpning av analysmetoden på objekten............................................... 21

Resultat och diskussion kring alternativa metoder..................23 4.1 Flerbostadshus.........................................................................................24 4.2 Industri....................................................................................................29 4.3 Sammanbyggda lägre hus......................................................................... 31 4.4 Övriga.....................................................................................................33 4.5 Lärdomar.................................................................................................35

Slutsatser ........................................................................... 39 5.1 Agera istället för att reagera......................................................................39 5.2 Val av alternativ metod.............................................................................39 5.3 Kombination av olika metoder..................................................................42 5.4 Förebyggande..........................................................................................42

Referenser.......................................................................... 45 BILAGA 1 – Umeå Ålidshem 24-25/12 2008.................................... 49 BILAGA 2 – Potatisåkern, Malmö 27/11 2007..................................57 BILAGA 3 – Vindsbrand, Vindelgatan, Borås 16/4 2010................... 65 BILAGA 4 – Västerås 30/9 1991......................................................73 BILAGA 5 – Trandaredsgatan, 18-19/08 2008.................................79 BILAGA 6 – Södra Sandby Killebäcksskolan 5-6/1 2009...................87 BILAGA 7 – Partille, Hålegårdsvägen 4/2 2013............................... 93 BILAGA 8 – Linköping bibliotek 20-21/9 1996................................101 BILAGA 9 – Steglinge gård, Höganäs, 5/8 2012.............................109 BILAGA 10 – Övertryck i angränsande utrymmen...........................117 BILAGA 11 – Sammanställning av skärsläckarens egenskaper........... 125

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 7 Förord Projektet har genomförts på uppdrag av Myndigheten för Samhällsskydd och Beredskap (MSB). Dokumentationen och information från studerade bränder har hämtats från ett flertal publikationer och samtal. Utan den detaljerade informa­ tionen hade detta projekt inte kunnat fullföljas. Speciellt har informationen i ett tidigare projekt finansierat av BRANDFORSK [1] varit till stor nytta. Ett stort tack till Bo Andersson på MSB som har varit projektansvarig för MSB och har deltagit i projektmöten där inriktning och analyser av inträffade insatser har diskuterats. Sökord Stora bränder, analys, släcktaktik, släckmedel, trycksättning, vattendimma, termografi. Abstract Nine fires that occurred between 1991 and 2013 were used as case studies in this project. In several of these fires, the volumes and areas of the indoor fires were too large and difficult to access for internal firefighting measures, due to, for example, the risk of injury of rescue personnel. The most evident finding of the study was the difficulty of the rescue services in making an operational risk assessment that includes the most appropriate action upon arrival at the scene and, thus, an assessment of the most likely outcome in terms of damage. In light of the above, alternative extinguishing methods were assessed in order to inves­ tigate how they would have affected the fire developments. The methods consid­ ered in most cases were water mist, pressurization of the adjacent spaces, and IR cameras. The aim was to reduce the fire size and cool the combustion gases in order to create a safe indoor environment for internal firefighting operations. Keywords Major fires, analysis, firefighting tactics, extinguishing media, water mist, pressurizing, thermal imaging.

8 Sammanfattning Sammanfattning Svensk räddningstjänst är i stort behov av utveckling så att brandskyddet och brandsläckningsinsatserna svarar mot riskerna och de krav som rimligen bör ställas av samhället. För samtidigt som antalet bränder i Sverige har minskat så har kostnaderna för dem ökat. Skadekostnad vid varje enskild brand har därmed blivit större. Vid en insats använder räddningstjänsten sig ofta av konventionella metoder, d.v.s. offensiv invändig släckinsats av en rökdykargrupp utrustad med dimstrålrör på smalslang. Denna metod är beprövad och pålitlig och fungerar bra vid den mindre olyckan som t.ex. en lägenhetsbrand. Vid en mer komplex olycka så ökar dock behovet på den enskilda räddningsledaren att kunna leda och använda sig av alternativa taktik- och metodval. Förutom att skadekostna­ derna har ökat behöver alternativa metoder väljas för att få ner antalet svårt skadade och omkomna i bränder samt att förbättra arbetsmiljön för brandmän­ nen. Vidare så måste miljöskadorna till följd av t.ex. rök och spridning av farliga ämnen med släckvatten minskas. Till följd av de ovan nämnda faktorerna har Myndigheten för Samhällsskydd och Beredskap (MSB) initierat detta projekt. Syftet är att analysera det metodval och taktikupplägg som räddningstjänsten använt vid ett flertal stora bränder som inträffat i olika typer av objekt och bedöma om ett annat taktikupplägg eller metodval skulle förändrat slutresultatet av insatsen och dess konsekvenser. I projektet har nio bränder studerats som inträffade mellan 1991 – 2013. De valda objekten representerar en stor variation där utgångspunkten har varit att under­ söka hur alternativa metoder påverkar resultatet. Tre av bränderna inträffade i flerbostadshus, två i industrier, ett i radhus, en i skola, en i distributionscentral och en i bibliotek. De lärdomar som kan dras från de analyserade bränderna är att tiden för insats är en avgörande faktor för en framgångsrik insats då brand­ effekten ofta ökar exponentiellt med tiden. I samtliga fall var branden redan omfattande när räddningstjänsten larmades och det krävdes en snabb och effektiv insats för att stoppa den negativa skadeutvecklingen. Istället för att lyckas med att stoppa skadeutvecklingen fick räddningstjänsten i flera av insatserna jaga branden som spred sig okontrollerat. Faktorer som påverkade insatsen var bl.a. felaktig riskbedömning, ofullständig brandcellsindelningen, exceptionellt stor brandbelastning, problem med vattenförsörjning eller att man inte förstod konstruktionens egenskaper. Analyserna visar på vikten av att göra en total och korrekt riskbedömning av den taktik och de metoder som väljs vid en insats. Lika viktigt är det att hela tiden utvärdera den valda taktiken och de metoder som används för att snabbt kunna ändra arbetssättet om situationen kräver det. Genom uppföljning av den effekt som vald metod ger, går det att ligga steget före och snabbt kunna ändra arbets­ sättet för att optimera släckeffekten. Alla åtgärder som genomförs vid en insats syftar till att snabbt släcka branden, men det effektivaste sättet att släcka branden kanske inte är att inrikta sig på startbranden. Istället kan det effektivaste sättet vara att först förhindra sprid­ ningen av branden för att därefter nå startbrandrummet och släcka branden. Många av de alternativa metoder som nämns i rapporten handlar om att först stänga in branden för att möjliggöra släckning senare i insatsen. Rapporten bidrar till att öka förståelsen för vilka alternativa metoder som finns att tillgå i Sverige och hur de effektivast kan användas samt hur de olika meto­ derna kan kombineras för att ytterligare öka effekten.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 9 Summary There is considerable need within the Swedish Fire and Rescue Service for the development of fire protection and firefighting measures in order to meet the requirements that can reasonably be expected from today’s society. While the number of fires in Sweden has decreased, the cost of damage resulting from them has increased; in other words, the cost of damage caused by each fire has increased. Conventional firefighting measures, a BA team using a fog nozzle, are often used. This is a tried and tested method, which can be successful when dealing with smaller fires, such as those in apartments. However, in the case of larger, more serious fires, there is an increased need for incident commander to be able to instigate and direct other methods and tactics. Apart from reducing the cost of damage resulting from fires, there is also a need for alternative meth­ ods of firefighting to reduce the number of serious injuries and fatalities, and to improve the working environment of firefighters. Furthermore, the effects on the environment resulting from the spread of smoke and toxic compounds in the water used to extinguish fires must also be reduced. This project was initiated by the Swedish Civil Contingencies Agency (Myndig­ heten för Samhällsskydd och Beredskap, MSB) to address the factors discussed above. The aim was to analyse the choice of firefighting method and the tactics employed by the fire and rescue service in a number of extensive fires that occurred in various kinds of buildings, and to assess whether a different method or tactics would have led to other results and/or consequences. Nine fires that occurred between 1991 and 2013 were studied in this project. The objects represent a wide variety of building types were the focus in what way alternative methods could be applied. Three of the fires were in apartment build­ ings, two in industrial premises, one in a terraced house, one in a school, one in a distribution centre and one in a library. One of the most important lessons that can be learnt from the analysis of these fires is that the rapid instigation of firefighting measures is a decisive factor, as the effect of a fire often increases exponentially with time. In all the cases studied, the fire was already widespread when the emergency services were alerted, and rapid, effective measures were required to limit damage. Instead of minimizing the damage, firefighters were forced in several of the cases to pursue the fire as it spread uncontrollably. The factors affecting the firefighting measures included erroneous risk assessment, inadequate fire compartmentalization, exceptionally high fire loads, problems with water supplies, and lack of understanding of the construction of the build­ ing. The analysis highlights the importance of comprehensive and correct risk assessment with regard to the methods and tactics chosen in a particular case. It is also important to continuously evaluate the effects of the chosen measures, in order to be able to change them if and when the situation requires it. Continu­ ous assessment of the effects of the measures implemented allows firefighters to stay ahead of the situation so that they can quickly adapt their operation so as to optimize the extinguishing effects. All the measures taken during a firefighting operation are aimed at extinguish­ ing the fire as quickly as possible, but the most effective way of extinguishing a fire is perhaps not always to concentrate on the source of the fire. It may instead be better to concentrate on preventing the spread of the fire, and then turn to extinguishing the main fire. Many of the alternative methods discussed in the report are based on confining the fire before attempts are made to extinguish it. This report contributes to our understanding of the alternative methods of fire­ fighting that can be used in Sweden, and how they can best be used, and also shows how they can be combined in order to further improve firefighting efficiency.

Inledning

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 11

1. Inledning

Det finns ett stort behov att utveckla svensk räddningstjänst så att brandskyddet och brandsläckningsinsatser svarar mot riskerna och de krav som rimligen bör ställas av samhället. Den vardagliga olyckan som en mindre lägenhetsbrand är idag något som svensk räddningstjänst är duktiga på, men vid en komplex olycka så ökar kravet på den enskilda räddningsledarens förmåga att leda och utvärdera taktik- och metodval under en insats. Målsättningen med insatsen måste vara att begränsa skador som människor drabbas av genom att både förbättra brand­ skyddet och effektivisera insatser. Det kan göras på olika sätt, antingen genom konventionella metoder som är beprövade och pålitliga eller genom att införa nya tillgängliga metoder när så krävs av situationen. Det rådande regelverket för brandmännens arbetsmiljö AFS 2007:7 [2] har historiskt påverkat sättet insatser mot bränder i byggnader genomförs. Samhället förändras och därmed måste räddningstjänsten förändras och följa med i utvecklingen. Behovet av effektiva räddningsinsatser ökar på samma sätt. Försäkringsföretagens branschorganisation redovisar att samtidigt som antalet bränder minskat så har kostnaderna för dem ökat markant [3], vilket tyder på att skadorna vid varje enskild brand har blivit större. Bidragande orsak till detta kan vara förändringar i de inventarier som finns i våra bostäder. Erfarna insatsledare kan beskriva hur energiutvecklingen i branden är mycket större nu än för 25-30 år sedan. Även brandens tillväxthastighet har ökat vilket gör att tidsfaktorn vid insatsen är mer avgörande. Med andra ord brandförloppen har blivit snabbare och det blir vanligare med brandspridning mellan lägenheter. Snabbare brand­ förlopp kräver tidigare insatser för att stoppa den negativa spiralen som branden skapar. Detta betyder att både den enskilda medborgarens och räddningstjäns­ tens förmåga att agera måste bli effektivare. Tillgängligheten till släckutrustning och förmåga ska öka totalt i samhället till exempel genom att vaktbolag, skolper­ sonal, vårdpersonal utbildas och utrustas med lättare utrustning. Den enskilde medborgarens förmåga att agera kan förbättras samtidigt som räddningstjäns­ tens insatsförmåga förbättras genom utnyttjande av de nya släckningsmedel och utrustning som har utvecklats under senare år. Dessa tankegångar är en del av den framtida förmågan att skapa ett säkrare samhälle. En annan bidragande orsak till att brandskadekostnaderna ökat kan vara att flera komplexa byggnader uppförs där det inte går att få stopp på brandsprid­ ningen med konventionella metoder, d.v.s. offensiv invändig släckinsats av en rökdykargrupp utrustad med dimstrålrör på smalslang. Vid en sådan insats krävs det alternativa metoder. Med alternativa metoder åsyftas i denna rapport både nya och existerande metoder som ersätter eller kompletterar offensiv invändig släckinsats både nya och existerande metoder. Storleken på brand­ skadekostnaderna beror inte bara på renodlade brandskador utan användandet av stora mängder släckvatten kan bidra till en mer omfattande skada på bygg­ nader och miljö. För företag kan vatten- och rökskador innebära stora kostnader på grund av produktionsstopp och i värsta fall förlorad marknad. Det är inte bara på grund av skadekostnaderna som andra metoder bör väljas utan MSB:s målsättning är att minska antalet svårt skadade och omkomna i bränder kommer att kräva nya effektivare metoder. Detta kommer innebära att tillverkarna av släcksystem måste tänka nytt och utveckla sina system till att möta de nya behov som finns i samhället i form av nya byggnadskonstruktioner, byggnadsmaterial, etc. Nya moment i utbildningarna måste till för att täcka de nya behov som finns i samhälle. Som en viktig del i detta är nytänkande hos räddningsledare och att de vågar testa nya metoder och taktik. Även arbetsmiljön

12 Inledning för brandmän måste förbättras. Brandmännen som nu arbetar med hög risk för skador och försämrad hälsa inklusive risk för cancer [4] är nu en av de farligaste arbetsuppgifter som tillåts i Sverige inom ramen för Arbetsmiljöverkets före­ skrifter AFS 2007:7 [2], se t.ex. Figur 1. Slutligen så måste miljöskadorna till följd av rök och t.ex. spridning av farliga ämnen med släckvatten minskas. Figur 1. Räddningstjänstens arbetsmiljö kan i många fall vara riskfyllt. Bilden visar en utvändig insats mot en vindsbrand i en industrilokal i Borås. På grund av ovannämnda faktorer har projektet initierats av Myndigheten för Samhällsskydd och Beredskap (MSB). Syftet är att analysera det metodval och taktikupplägg som räddningstjänsten använt vid ett flertal stora bränder som inträffat i olika typer av objekt och bedöma om ett annat metodval och taktik­ upplägg skulle förändrat slutresultatet av insatsen och dess konsekvenser. En systematisk analys av antal storbränder där det finns tillräckligt mycket och säker information för att bedöma vilken typ av alternativt metodval till det räddningstjänsterna valt som skulle resultera i mindre risk för insatspersonal, personer i objektet och skador på egendom och miljö redovisas. I dagens diskussion kring olika släcksystem för räddningstjänsten fokuseras mycket på effekten av de olika alternativa metoderna på brandutvecklingen i jämförelse med konventionella metoder. För att kunna göra en sådan analys av inträffade bränder måste branddynamiken studeras i det enskilda fallet och förtydliga varför en viss metod släcker eller dämpar branden. Det är viktigt att sammanlänka det med brandens utveckling parallellt med det att insatsen genomförs. Det kan bli avgörande för utgången av insatsen. Syftet med projektet är att utvärdera de släckinsatser som användes vid ett antal stora bränder och visa om ett annat metodval och taktikupplägg skulle

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 13 haft möjlighet att förändra slutresultaten av insatserna och dess konsekvenser. I denna rapport ligger därför fokus på att öka förståelsen kring: • • Dynamiken i brandförloppet, detta för att kunna välja den effektivaste taktiken och metoden vid komplexa insatser. • • Klargöra vilka alternativa metoder som finns och hur de kan användas och förväntat resultat av användningen. • • Hur man kan kombinera olika metoder för att öka effektiviteten i en insats. En projektgrupp bestående av författarna och en representant från MSB har valt ut de objekt som har analyserats. Varje enskild objekt som har valts ut har genomgått en systematisk analys utifrån förutsättningar så som typ av verksam­ het, storlek på objektet och komplexitet. De enskilda analyserna redovisas i detalj i Bilagor 1 – 9. De valda objekten representerar en stor variation där utgångs­ punkten har varit att undersöka hur alternativa metoder påverkar resultatet. En sammanfattande analys och slutsatser ges i kapitel 4 och 5. Som komplement anges även en närmare beskrivning av erfarenheter från trycksättning i Bilaga 10 och skärsläckarens egenskaper i Bilaga 11. 1.1 Begränsningar I detta arbete har vi inte beaktat inverkan av: • • Olika tillsatser till släckvatten för att utvärdera varje ämnes hälsorisk för räddningstjänstpersonal och allmänhet och skada på miljö enligt ett antal kriterier. • • De organisatoriska, utbildnings- och utrustningsmässiga problem som måste lösas för att genomföra de alternativa släckinsatserna. • • Hur de alternativa släckinsatserna påverkar insatstiderna. • • Förebyggande arbeten i den mån de inte genom brister förvärrat brand­ förloppen.

Tidigare forskning och utveckling

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 15

1. Tidigare forskning och utveckling

Behovet av ny kunskap om hur olika tekniska system för räddningstjänsten fungerar är något som många efterfrågar. En ny kunskap kan tas fram genom forskning, genom erfarenhet från verkliga insatser eller genom utbyte med olika tillverkare av de tekniska systemen. Nivån på innehållet och fokus i de arbeten som har genomförts tidigare, och som fokuserar på att ta fram ny kunskap om olika tekniska hjälpmedel vid insatser, varierar kraftigt. Det brister ofta i doku­ mentationen från de försök som har genomförts genom åren. Utvecklingen och kunskapsnivån hos räddningstjänsterna har inte alltid hängt ihop, och beror väldigt mycket på den enskilda räddningstjänsten. Intresset för teknikutveckling och viljan att införa det i organisationen skiftar och har historiskt varierat. Under sjuttio- och åttiotalet inträffade flera allvarliga olyckor. Rökdykare omkom i byggnader på grund av att de överraskades av en övertändning. Undersökningar gjordes då som visade att det behövdes bättre förståelse hos insatspersonalen för att kunna förutse och motverka en övertändning. Efterföljande diskussion resulte­ rade i utveckling av utbildningsprogram i containers med övertändning. Förbätt­ rad skyddsutrustning med andningsapparater och textiler med flera skyddande lager gjorde att detta var möjligt. Förgrundspersoner till denna utveckling var Anders Lauren, Krister Giselsson och Mats Rosander. Tekniken kallades för offen­ siv brandsläckning. Den innebar att brandmän trängde in i byggnaden, pulserade med vattenstrålen för att kyla ner väggytan och brandgaserna. Målsättningen var att snabbt gå in och därmed förhindra övertändning av brandgaserna. När rök­dykargruppen trängde in stängde de till dörren med slangen genom dörren. Detta gjorde att man arbetade i dålig och osäker miljö, vilket har visat sig i stati­ stiken över antal arbetsrelaterade sjukdomar (cancerfall) [4] för brandmän. Sättet att träna och utbilda brandmän och förbättra släckningen spred sig snabbt i Sverige och övriga Norden. Det uppmärksammades även internationellt och görs fortfarande idag. Det blev vida känt att Sverige varit duktiga på brand­ dynamik och att kyla brandgaser med finfördelat vatten. Den svenska offen­ siva brandsläckningen blev ett känt begrepp inom räddningstjänstvärlden och träningsmodellen är känd som CFBT (Compartment Fire Behaviour Training). Redan i början på nittiotalet började det aktualiseras att brandpersonal utsätter sig för hög värme när de går in tidigt. Man hade utvecklat bra skyddskläder med 3-4 skikt, bra andningsskydd med övertryck för att minimera risk för läckage och handskar samt hjälmar som tålde värmen. Man började ifrågasätta detta angrepssätt och undrade om man kanske inte behöver utsatte personalen för alldeles för höga temperaturer i alla lägen. Frågan uppstod om man kanske borde minska riskerna. Det resulterade i att mellan 1992 och 1993 började Södra Älvs­ borgs Räddningstjänstförbund (SÄRF) att öva och experimentera med övertrycks­ fläktar. I dag är denna teknik fullt integrerad inom många räddningstjänster och ingår ofta som en standardrutin. Även skärsläckare och IR-kameror ingår idag som en del av utrustningsparken hos många räddningstjänster, se t.ex. Figur 2. Men innan man kom fram till användningen av dessa hjälpmedel genomfördes en hel del forskning och utveckling på olika håll. Det bestod både av litteratur­ sammanställningar och direkta brandförsök.

16 Tidigare forskning och utveckling Figur 2. IR-tekniken har blivit ett viktigt redskap för att kunna läsa av branddynamiken vid insatsen. Bilden är tagen i Borgstena utanför Borås av Krister Palmkvist, SÄRF. Den första kända rapporten kring övertrycksventilation publicerades 1994 av Räddningsverket [5]. Rapporten är skriven av Institutionen för Brandteknik vid Lunds Tekniska Högskola (LTH) och ger en bra översikt över den internationella kunskap (USA först och främst) som fanns på den tiden. Rapporten lade grunden till den efterföljande verksamheten kring övertrycksventilation i Sverige. LTH följde upp det arbetet med ytterligare rapport kring brandventilation i teori och praktik [6]. Det presenterades flertal arbeten och rapporter kring brandventila­ tion och insatser i byggnader under perioden 1994 – 1998 [7, 8]. Även förslag till övningsanläggning för insatser i het miljö presenterades [9]. Under perioden 1997 – 2002 genomförde SP Brandteknik och Södra Älvsborgs Räddningstjänst­ förbund (SÄRF) flertal forskningsprojekt kring övertrycksventilation. Resultatet och erfaren­heterna redovisar i referenserna [10-13]. Den kartläggning på teori och praktik som beskrivs i dessa rapporter ger en bra och positiv erfarenhet med denna teknik. Parallellt med forskningsarbetet infördes tekniken som rutin i SÄRF:s dagliga verksamhet. Arbetet kring övertrycksventilation kulminerade i en vetenskaplig tidskrift [14] där arbetet har förts vidare till internationell forskning. Arbetet med skärsläckaren i Sverige började i senare halvan av nittiotalet och presenterades i en Räddningsverksrapport år 2000 [15, 16]. Idén kom från det arbete som började 1996 med fokus på ventilering genom håltagning i tak. Den håltagningsmetod som togs fram vid detta tillfälle var sprängramen och vid genomförandet av projektet så kom Luleå räddningstjänst med ett förslag att använda vattenskärningsmetod istället för sprängram. Projektledaren för detta projekt Lennart Danielsson från Räddningsverket fick i uppdrag tillsammans med Bo Anderson att göra ett besök i Luleå. Syftet var att se möjligheten med Luleås förslag, vilket Räddningsverket i detta läge inte ansåg det vara anpassningsbart för räddningstjänsten och framförallt för komplicerad och dyrt. Efter hemkomst insåg Bo Andersson att detta kunde vara grunden till ett helt nytt släcksystem dock i en annan utformning. Ledningen för utvecklingsenheten ansåg att det var värt att gå vidare och en förstudie startades [17]. Under perioden 1996 till 2000 pågick utvecklingsarbetet från idé till färdig produkt. Det kulminerade i fullskale­ försök gjorda i en stor lokal i Oslo, och det blev startskottet till den användning som har skett inom svensk räddningstjänst med skärsläckaren [15, 16]. I början

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 17 var skärsläckare monterad på höjdfordon, men har sedan utvecklats till en färdig produkt som finns som standardutrustning på släckfordon. I början av 2001 genomförde SP och SÄRF ett forskningsprojekt kring kombinationen av över­ trycksventilation och skärsläckaren. Grundliga försök genomfördes under en period mellan 2001 – 2003 där skärsläckarens förmåga att kyla och släcka bränder i stora och små lokaler testades. Forskningsarbetet användes vid olika utbildningar genomförda av SÄRF under en längre period men publicerades i sammanfattnings­ rapporterna från MSB, 2010 [18] och SP rapporten från 2012 [19]. Det finns flertal forskningsarbeten genomförda i slutet av nittiotalet och början av tvåtusentalet som är av intresse för denna den analys som har genomförts i kapitel 4 och 5 samt bilagor 1-9. Till exempel rapporten kring rökdykning [20] som visar studier av människa och miljö och den om brandmännens fysiska förmåga [21]. I dessa arbeten har arbets- och den fysiska förmågan kartlagts. Arbete kring säkerhet vid rökdykning resulterade i ett antal rapporter. En av dessa är rapporten kring lokalisering av nödställd rökdykare [22] och försök med IR kamera vid rökdykning som publicerades 2004 [23]. Exempel på mål för den kommunala räddningstjänstens övningsverksamhet publicerades 1999 [24]. Under denna period genomfördes även släckförsök vid brand i stor lokal, som syftade på att jämföra släckförmågan hos släcksystem med högtryck respektive lågtryck mot bränder i större lokaler [25]. Under senare halvan av 2000-talet publicerades intressanta publikationer som berör ledning och taktik vid räddningsinsatser [26, 27]. På senare tid har ett fler­ tal rapporter som är av intresse för denna rapport skrivits och berör arbetet med de släcksystem som idag används bland Svensk Räddningstjänst. Det är rapporter som är direkta försöksrapporter [28], sammanställningsrapporter [29-30] eller examensarbeten [31-34]. Ett flertal akademiska avhandlingar och handböcker som berör rapporten har skrivits. Där bör man först och främst nämna de arbeten som Lars Bengtsson [35, 36], Stefan Särdqvist [37-38] och Stefan Svensson [39, 40] har genomfört. All den kunskap som finns i de rapporter och böcker som har presenterats ovan, har på direkt eller indirekt sätt varit till stöd för de analyser som har genomförts i denna rapport.

Beskrivning av den systematiska analysmetoden

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 19

1. Beskrivning av den systematiska

analysmetoden I följande kapitel ges förutsättningarna för vilka faktorer som beaktas vid analys­ erna av de olika objekten. För att kunna analysera utfallet av olika räddnings­ tjänstinsatser och utfallet av alternativa metodval behövs kunskap om: • • Förutsättningar innan antändning – beskrivning av olika förutsättningar som påverkade antändning, upptäckt och brandförlopp. • • Antändning – brandorsak och plats för brandens uppkomst är viktiga be­ grepp underantändningsfasen. Det är denna fas som behandlas i de flesta brand(orsaks)utredningar. • • Upptäckt – Beträffande brandens upptäckt väcks frågor angående olika typ av detektions- och larmsystem. Här kommer också problematiken in kring ”automatiska fellarm” och system som inte larmar när det verk­ ligen brinner. • • Brandförlopp – Brandens tillväxt och spridning är viktig att kunna bedöma, i synnerhet under insatsens inledningsskede. Det handlar om hur snabb spridning det är från det först antända föremålet till nästa, hur snabb över­ tändning sker och hur snabb spridning kan ske från ett rum till nästa. Hur stor branden maximalt kan bli är också en intressant fråga för bedömningen av risken för storskada. Även brandröken är ett problem som är väl värt att studera. Hur mycket rök producerades, hur snabbt skedde rökfyllnaden, vilka delar av byggnaden rökfylldes, m.m. • • Släckinsats – Släckinsatsen är den viktigaste och mest studerade parame­ tern i insatserna. De flesta släckinsatser i Sverige sker med konventionella metoder, d.v.s. offensiv invändig släckinsats av en rökdykargrupp utrustad med dimstrålrör på smalslang. Det finns även en rad andra metoder och tekniker tillgängliga. Till stor del är det objektet som avgör vilken metod som är bäst lämpad. Åtgärderna kan dessutom delas in i grupper efter syftet, om avsikten är att släcka det som brinner, att skydda mot antänd­ ning, att sänka temperaturen hos brandgaserna för att minska risken för övertändning, att skydda opåverkade utrymmen genom ventilering m.fl. Dessa fem parameterar har varit vägledande för att erhålla så rättvis och komplett bild av insatsen.

20 Beskrivning av den systematiska analysmetoden 3.1 Val av objekt Vid val av bränder eller objekt är det viktigt att beakta den insamlade informa­ tionens tillförlitlighet vilken varierar med informationens syfte och kompeten­ sen hos dess källa. Den information som krävts är bl.a. följande: • • Tidrapportering i form av automatlarmsrapport, larmlistor, insatslogg och insatsrapport där tiderna är väl dokumenterade. Detta krävs efter­ som just tiden är en av de två parametrar som analysmetoden bygger på. Vid en brand rör det sig dessutom om korta tider, vilket gör parametern extra känslig. • • Fotodokumentation, ritningsunderlag och beskrivning av byggnadens innehåll. Detta krävs för att kunna analysera hur branden utvecklas, men också för att kunna bedöma möjligheterna till alternativa släckmetoder. Det krävs också vittnesuppgifter från personer på platsen. • • Beskrivning av hur räddningstjänstens resurser varierar med tiden. Denna beskrivning krävs för att kunna modellera räddningstjänstens förmåga. Utöver kraven på tillgänglig information, kan dessutom ett antal ytterligare önske­ mål ställas upp. Detta projekt som har en inriktning mot bränder som är så stora att räddningstjänsten måste reflektera över vilken taktik och vilka metoder som kan användas vid insatsen. Den taktik och metod som används vid normalstora lägenhetsbränder skall alltså inte vara det självklara valet. Begränsad information är det största enskilda problemet som finns när analyser av den här typen skall göras. Det finns sällan särskilt mycket skriftligt material tillgängligt. Räddningstjänstens utredningar är med enstaka undantag sällan tillräckliga. Ofta är de inriktade mot en frågeställning, beroende på utredarens intresse. Ibland handlar det om en fullständig tidsredogörelse, ibland om en beskrivning av hur branden startade. Sällan görs någon reflektion över effekten av räddningstjänstens insats. För det andra är det sällan som någon har en klar bild över hela brandförloppet. Inte ens räddningsledaren har alltid överblick över hela insatsen, brandens orsaker m.m. En viktig aspekt beträffande den insamlade informationen är dess tillförlitlighet vilken varierar med informationens syfte och kompetensen hos dess upphovs­ man. Trovärdigheten hos en brandutredning ökar om det finns angivet varifrån data kommer, så att det i efterhand går att göra en bedömning av materialet. Detta gäller i synnerhet sammanställningar där vittnesuppgifter blandas med automatiskt klockade tider och tider som beräknats ur andra data. Material från flera olika källor ger generellt en högre trovärdighet eftersom subjektiviteten i individuella bedömningar kan värderas och olika betraktelser av samma förlopp kan ge en bättre förståelse. Mot hänsyn till dessa krav har nio objekt valts ut till denna studie, tre i fler­ bostadshus, två i industrier, två sammanbyggda lägre hus (en skola och ett radhus), en i ett bibliotek och en i en paketerings- och distributionscentral för frukt- och grönsaksdistribution. Bränderna inträffade mellan 1991-2013.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 21 3.2 Tillämpning av analysmetoden på objekten Beskrivningarna av de olika objekten innehåller: • • Beskrivning av objektets konstruktion, geometri och innehåll av brännbart material före branden. • • Incidenter som inträffat före branden. • • Beskrivning av brandens utveckling och räddningstjänstens insats. • • Beskrivning av brandskador efter det att insatsen avslutats. • • Analys av brandförloppet. • • Analys av brytpunkter för annat metodval. • • Referensförteckning.

Resultat och diskussion kring alternativa metoder

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 23

1. Resultat och diskussion kring

alternativa metoder I detta kapitel sammanfattas analyserna från de nio olika bränderna, analyserna i sin helhet finns i Bilaga 1 till 9. I sammanfattningen är bränderna uppdelade i fyra olika avsnitt utifrån gemensamma förutsättningar. Dessa avsnitt är: Flerbostadshus Tre stycken analyser har genomförts under rubriken flerbostadshus och förutom flerbostadshus är den gemensamma nämnaren att branden spridit sig eller börjat på vinden. En utförlig beskrivning av dessa bränder finns i Bilaga 1 – 3. I Bilaga 1 återfinns analysen från ett större flerbostadshus i Umeå, Ålidhem där branden totalförstörde tre sammanbyggda huskroppar. Bilaga 2 beskriver analysen från ytterligare ett större flerbostadshus med 6 – 7 våningar och 6 trappuppgångar i Malmö, Potatisåkern där hela vinden blev totalförstörd och byggnaderna fick avsevärda vattenskador. Sista branden som är sammanfattad under avsnittet flerbostadshus finns i detalj beskrivet i Bilaga 3 och är ett lite mindre flerbostads­ hus i Borås, Vindelgatan. Här användes flera alternativa metoder under insatsen vilket medförde att endast vinden fick brand- och rökskador men inga vattenskador och samtliga lägenhetsinnehavare kunde bo kvar. Bilaga 3 innehåller också ett avsnitt med insatsledarens egna reflektioner kring händelsen. Industri Under rubriken har två stycken bränder sammanfattats. Gemensamt för dem är stora volymer med mycket brännbart material samt risken för farliga ämnen. Denna ena industribranden är i Västerås, ASEA. I branden var bl.a. brännbara väskor inblandade. Detaljerad beskrivning av analysen finns i Bilaga 4. I Bilaga 5 återfinns en detaljerad beskrivning av en stor industribrand i Borås, Trandareds­ gatan som höll på i över 1,5 dygn. Branden är intressant då flera olika metoder användes i kombination med varandra. Sammanbyggda lägre hus I denna kategori finns samlat en skola och ett radhus. Gemensamt för båda bränderna är att räddningstjänsten hade svårt att identifiera hur och var bran­ den spred sig, samt svårt att identifiera brandcellsgränserna. I Bilaga 6 finns en detaljerade beskrivningen av en skola som bestod av flera kringbyggda och sam­ manbyggda atrier med en oinredd vind och i Bilaga 7 finns beskrivningen av en radhusbrand. Övrigt Under övrigt sammanfattas analyserna från en biblioteksbrand i Linköping och en brand i en paketerings- och distributionscentral i Höganäs. Gemensam nämnare är att båda hade mycket stor brandbelastning och att branden var anlagd vilket gav ett häftigt brandförlopp. Biblioteksbranden från Linköping finns beskrivet i Bilaga 8 och paketerings- och distributionscentralen (Steglinge gård, Höganäs) återfinns i Bilaga 9. Under varje avsnitt beskrivs först objektet och dess förutsättningar, sedan brand­ förloppet och släckinsatsen. Slutligen förs en diskussion om vilka alternativa metoder som hade kunnat användas.

24 Resultat och diskussion kring alternativa metoder 4.1 Flerbostadshus I kategorin flerbostadshus finns tre analyserade bränder, två större flerbostadshus med flera huskroppar (Ålidhem och Potatisåkern) och ett mindre flerbostadshus med 12 lägenheter (Vindelgatan). Gemensamt för de tre bränderna är att branden spridit sig till eller börjat på vinden. Vid branden på Vindelgatan har alternativa metoder används. En utförlig beskrivning av dessa bränder återfinns i Bilaga 1 -3. Bilaga 3 innehåller också ett kapitel med insatsledarens egna reflektioner kring händelsen. I Figur 3 visas en vindsbrand som inträffade i ett flerbostadshus i Borås. Figur 3. Vindsbrand i flervåningshus i Borås. Bild: Borås Tidning.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 25 4.1.1 Förutsättningar innan antändning Gemensamt för de studerade vindskonstruktionerna var stora osektionerade ytor med hög brandbelastning. Minst yta hade Vindelgatan med ca 400 m2 och störst hade Ålidhem, där på grund av dålig brandisolering mellan huskropparna, fanns en osektionerad yta på upp mot ca 1900 m2. Vindsutrymmet i Potatisåkern var uppdelad i sektioner om 400 m2, men konstruktionen mellan sektionerna var bristfällig. Den höga brandbelastningen medförde ett häftigt brandförlopp. På Vindelgatan och Potatisåkern användes vinden som förråd, medan vinden på Ålidhem var tom men isolationen nedåt bestod av ½ m sågspån. Särskilt vid branden i Ålidhem påverkade detta skadeutfallet eftersom räddningstjänsten förutsatte att brand­ belastningen var mycket lägre än vad den var. 4.1.2 Antändning/upptäckt Antändningen i de olika fallen såg lite annorlunda ut och detta påverkade rädd­ ningstjänstens riskbedömning. För Potatisåkerns del började det med att lägen­ hetsinnehavaren sent på kvällen upptäckte glöd vid taket kring rökkanalen från en kamin som det eldats i. Antagligen hade branden pågått en längre tid innan upptäckt. I Ålidhem var det en spisbrand som via ventilationssystemet spred sig upp till vinden. Räddningstjänsten släckte spisbranden och kontrollerade ventila­ tionssystemet med IR-kamera inifrån köket. Någon mer kontroll av ventila­ tionssystemet uppe på vinden genomfördes inte. Ventilationskanalen gjorde två 90-graders böjar innan den kom fram till vinden och därför kunde bara höga temperaturer ha upptäckts fram till första böjen. Eftersom vindsbränder i fler­ bostadshus länge varit ett problem [41] bör spridning till vinden alltid kontrolle­ ras. I detta fall spred sig branden upp till vinden och i flera timmar låg och pyrde innan den upptäcktes. På Vindelgatan har brandorsaken inte helt klarlagts, men även här såg det ut som att branden pågått en längre tid innan den upptäcktes. Det finns inga krav på branddetektion i vindsutrymmen på flerbostadshus, men det kan konstateras att ett detektionssystem på vinden hade i samtliga analyse­ rade fall minskat risken för omfattande skador. 4.1.3 Brandförlopp/släckinsats När räddningstjänsten kom på plats var branden i alla tre fallen omfattande. Vid branden i Potatisåkern brann det både på vinden och i yttertaket. Samtidigt som rökdykare gick in restes en hävare mot gavel där branden brunnit igenom yttertaket. Hävaren var försedd med skärsläckare, men vattenförsörjning dröjde och när väl vattenförsörjningen var ordnad hade branden spridit sig för långt bort från hävaren för att skärsläckaren skulle haft effekt. Liknande var det med de invändiga släckförsöken. Rökdykarna försökte stoppa branden vid varje vinds­ sektion genom att angripa branden via trapphusen, men branden hann alltid förbi dem och de fick omgruppera sig till nästa trapphus. En tidig inspektion av vindsektionerna via vindsdörrarna i trappuppgångarna hade underlättat val av angreppspunkt för insatsen samt identifierat risken för brandspridning mellan avskiljningarna. När nästan hela vinden var brandpåverkad togs beslutet att låta den brinna av eftersom betongbjälkaget hindrade branden från att sprida sig till lägenheterna under. Vid branden i Ålidhem var vindsbranden i första huskroppen redan omfattande när den upptäcktes mitt i natten. Inledande beslut blev att ta fram stegbilen för att påbörja släckning, men innan insatsen påbörjades hade branden spridit sig till andra huskroppen och strax därefter till tredje och sista huskroppen. Även i denna insats beslutades det att låta vinden brinna av efter att man konstaterat att

26 Resultat och diskussion kring alternativa metoder bjälklaget bestod av betong. Beslutet grundade sig på att man trodde att brand­ belastningen var låg och att man ville minska risken för vattenskador. Dessutom hade man otillräckliga resurser på plats för att släcka branden. I andra insatser har detta resulterat i att endast vinden blivit förstörd men att lägenheterna under klarat sig och metoden kan ibland vara att föredra ifall det inte finns resurser för att släcka och för att undvika vattenskador. I detta fall var dock inte vinden brandteknisk avskild utan branden kunde sprida sig nedåt via ytterväggarna. Det är alltså viktigt med god objektskännedom och att ta reda på hur de brandtek­ niska avskiljningarna fungerar och var de finns. Ett gediget utbildningsmaterial kring detta är det material som Räddningstjänsten Storgöteborg tagit fram [42]. På Vindelgatan gick det inte vid framkomst att avgöra källan till rökutveck­ lingen, men båda trapphusen var rökfyllda och vit rök syntes från takfoten och kring ventilationshuvarna samt taknock. Den första kritiska skadeplatsfaktorn var livräddning av personer i lägenheten närmast vinden och omedelbara åtgär­ der blev att evakuera dem med hjälp av räddningstjänstens stegbil. Detta beslut grundade sig på att lägenheten höll på att rökfyllas och att det skulle tagit längre tid att nå fram till lägenheten på fjärde våningen med rökdykare för att sedan livrädda med andningsmask. En annan riskbedömning som hade varit möjlig var att låta personerna vara kvar i lägenheten tills man hade kunnat evakuera dem via trapphuset. Risken hade dock varit att personerna hade hoppat från fönstret eftersom de var mycket uppstressade. Vidare fördröjde inte evakuering insatsen eftersom stegbilen hamnade på ett bra ställe för livräddning och att efter en livräddande insats påbörja dämpning av branden på vinden med hjälp av skär­ släckaren. Boenden som befanns sig i de andra lägenheterna uppmanades att stanna kvar. Denna riskbedömning grundade sig på att det brann på vinden och att utrymma genom rökfyllda trapphus var alltför riskfyllt. Längre in i insatsen säkrades utrymningsvägarna för de boende genom att först ventilera ut brandgaserna i trapphusen via fönster med hjälp av fläktar och sedan stänga fönstren och tryck­ sätta trapphusen. Boendena uppmanades dock att fortsätta stanna kvar i lägen­ heterna eftersom det snabbt hade gått att evakuera dem om situationen skulle försämrats. Vid riskbedömningen tog insatsledaren hjälp av IR-kamera och det kunde kon­ stateras att takytorna och taknocken var kraftigt värmepåverkade och att den högsta påverkan fanns i mitten av vinden. Den höga temperaturen och att inga synliga lågor fanns indikerade att branden var ventilationskontrollerad. Brandga­ serna på vinden behövde alltså kylas av snabbt utan att syre tillsattes och därför beslutades det att låta stegbilen som tidigare användes för livräddning kyla av brandgaserna via gavelspetsen med hjälp av skärsläckaren. Detta gav bra effekt men skärsläckaren fick byta position en gång för att komma åt att kyla ner hela vindsutrymmet. När brandgaserna var tillräckligt kylda kunde rökdykare gå in och eftersläcka via trapphusen. Kontroll av temperaturen genomfördes kontinu­ erligt med IR-kamera för att säkerställa önskvärd effekt av släckinsatsen. Efter avslutad släckinsats fanns det inga synliga tecken på släckvatten och endast en svag rök lukt kunde kännas i trapphusen. Efteråt kunde man konstatera att den rökpelare som uppmärksammades med IR-kameran från mitten av taket var början till en genombränning av yttertaket. Om inte en offensiv taktik med brandgas­ kylning via stegbil valts hade förmodligen branden snabbt utvecklats till en helt övertänd vind- och takbrand där släckresurserna på plats troligtvis inte varit till­ räckliga för att kontrollera och släcka branden med ett önskvärt resultat. Att inte öppna upp utrymmet där det brinner utan försöka behålla tillslutheten medan bandgaserna kyls ner med vatten är en etablerad arbetstaktik hos den aktuella räddningstjänsten vid insatsen på Vindelgatan. Först när kyleffekt har

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 27 uppnått så tillåts det att öppna upp objektet, såga upp, öppna dörrar etcetera. Att behålla ojämlikheten i brandtriangeln är ett sätt att skydda mot antändning av brandgaslagret. Se Bilaga 3 för en mer detaljerad beskrivning av arbetssättet. De visuella iakttagelserna som görs efter branden bekräftar tolkningar som skett med hjälp av IR-kameran före-under-efter insats. IR bilden fick en mycket stor betydelse vid val av taktik och metod samt igångsättande av omedelbara åtgärder i inledningen av insatsen. IR informationen gav också god hjälp att tolka effekten av insatta släckåtgärder. 4.1.4 Alternativ metod Det krävs en annan taktik och andra metoder för vindsbränder i stora nästan slutna utrymmen än vid vanliga lägenhetsbränder. Det går heller inte att förut­ sätta att de brandtekniska avskiljningarna är korrekt utförda, utan dessa måste valideras innan val av släckmetod tas. En alternativ metod vid branden i Ålidhem hade varit att inte ventilera vinden och istället försökt dämpa branden med hjälp av vattendimma. Genom att använda skärsläckare som lämpligen placerats vid husgavlarna för att kunna få tillräcklig kastlängd innan strålen bryts upp hade brandgaserna kunnat kylas och ett undertryck hade skapats i det nästan slutna utrymmet. Detta hade fördröjt brandspridningen mellan huskropparna och ner längs ytterväggarna och man hade haft tid på sig att besluta hur kvarvarande glödbränder skulle släckas. Eftersom vindsutrymmet var så pass stort hade det antagligen krävts två stycken skärsläckare, en på var gavel för att snabbt kyla branden (se Figur B 32 i Bilaga 11). Även vid branden i Potatisåkern hade ett annat användningssätt av skärsläckaren varit en alternativ metod som kunnat förändra skadeutfallet. Genom att placera flera skärsläckarinsatser på strategiskt valda positioner hade branden kunnat slås ner och hållas under kontroll till dess att temperaturen hade sänkts så pass mycket att en invändig insats med rökdykare hade varit möjlig. Lämpligen hade skärsläckarna satts in vid vindsdörrarna eller väggarna till de utsatta vindsektio­ nerna och vid gavlarna via hävaren för att få tillräcklig kastlängd innan strålen bryts upp. Att gå vertikalt igenom taket är olämpligt, då strålen inte hinner bryta upp innan den träffar bjälklaget. Branden på Vindelgatan är ett exempel där skärsläckaren användes med lyckat resultat. Skärsläckaren sattes in vid gaveln eftersom det var där det var störst chans att nå så stor del av vinden som möjligt utan att stöta på hinder. Brand­ männen vinklade skärsläckaren åt olika håll och ändrade placering på skärsläck­ aren medan befälet som höll i IR-kameran utvärderade vilken vinkel och placering som gav mest effekt. En tät kommunikation mellan brandmännen och befälet var mycket viktig i insatsen. Vinden hade bra förutsättningar för en lyckad insats med skärsläckaren. Den höga temperaturen bidrog till snabb förångning av vatten­ dimman vilket ger en effektiv kylning av brandgaser och konstruktion samt sänkt syrekoncentration (inertering) i utrymmet. Positivt var också att vinden var oventi­ lerad eftersom effekten av inerteringen då förstärktes. En lägre temperatur hade bidragit till ett mer utdraget förlopp på grund av att förångning inte hade skett lika snabbt och att effekten av inerteringen därmed minskat. Skärsläckaren kan dock vara effektiv även vid mindre optimala förhållanden. Vid en vindsbrand i Svenljunga (Figur 4) sattes skärsläckaren in vid ena gaveln. Trots att byggnaden var över 60 m lång och att temperaturen inte var lika hög syntes en effekt direkt. Brandgasernas intensitet minskade och färgen på brandgaserna övergick från svart till vit. Det tog dock längre tid för skärsläckaren att sänka temperaturen och den totala tiden för släckning var ungefär en timme då man arbetade med skärsläckaren i perioder från 10 upp till 50 sekunder. Skärsläckaren var som effektivast när en rak stråle fick arbeta långt in i vindsutrymmet.

28 Resultat och diskussion kring alternativa metoder Ett annat alternativ för att komma åt branden utan att tillsätta syre är att använda dimspik. För en vindsbrand med stora volymer krävs ganska många dimspikar för att täcka hela vindsvolymen då kastlängden bara är mellan fyra och tio mi sidled beroende på tryck. Vattendropparna är större för en dimspik än för en skärsläckare vilket bidrar till att förångningen blir sämre samtidigt som ytkyl­ ningen blir bättre än för skärsläckaren (se Bilaga 11). Positivt med dimspik är att det går att montera flera dimspikar som sedan sköts av en person. Risken för vattenskador ökar dock då tendensen är att man lämnar dimspiken på istället för att arbeta aktivt även med den. I flera fall kan monteringen av dimspik ta längre tid och vara mer riskfylld än att arbeta med skärsläckaren. Figur 4. Restvärdesarbete efter branden i Svenljunga. Bilden visar att trots byggnadens längd (över 60 meter) hade skärsläckaren bra effekt på branden. Bild: Krister Palmkvist, SÄRF. För att minska risken för brandspridning kan trycksättning av angränsande u­t­ rymmen vara en bra metod. Vid branden på Vindelgatan så förhindrades brand­ gaserna från att tränga ner i trapphusen medan brandgaskylning genomfördes. Detta skapade fria utrymningsvägar för de boende och därmed behövde de inte utrymma eftersom de snabbt skulle kunna utrymma om situationen skulle ändras. Detta gjorde att ett av de kringproblem som branden skapade försvann och resurser kunde användas till att sänka brandgastemperaturen istället. Även för Potatisåkerns del hade trycksättning av angränsande vindsutrymmen för­ dröjt brandspridning och säkrat utrymningsvägarna. Om övertryckfläktar hade placerats i varje trappuppgång och vindsdörrarna varit öppna hade snabbt ett övertryck alstrats på vinden (se Bilaga 10). Man bör dock observera skillnaden mellan att sätta ett utrymme utan brand under övertryck, vilket sällan leder till problem, men att ventilera en underventilerad brand leder alltid till en större effektutveckling och ofta större problem. Insatsen på Vindelgatan visar nyttan av att använda IR-kamera som hjälpmedel då det direkt gick att avgöra vilken effekt skärsläckaren hade. Skärsläckaren kunde

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 29 därmed användas på ett optimalt sätt vilket bidrog till minimala vatten och rökskador på vinden. Det är dock viktigt att vara medveten om hur IR-kameran fungerar och vilka begränsningar som den har. Vid branden i Ålidhem användes IR-kameran till exempel för att kontrollera brandspridningen efter att köksbran­ den var släckt, men eftersom IR-kameran endast kunde scanna temperaturen en bit in i kökskanalen så invaggades brandmännen i en falsk trygghet. Det finns också en tidsfördröjning för hur det går att avläsa på utsidan vad som händer på insidan. Olika material ger olika tidfördröjning [43]. Fler sätt som IR-tekniken kan användas som beslutstöd är att ta bilder från luften. Flera räddningstjänster i landet testar koncept med minihelikopter med video/bild­ tagning under insatser. Bilder som tas från luften över skadeområdet skickas till stabsfunktion via mobilnätet. 4.2 Industri Två bränder i industrier har analyserats och gemensamt för båda industrierna (Västerås och Trandaredsgatan) var stora rumsvolymer och risker med farliga ämnen. En utförlig beskrivning av bränderna återfinns i Bilaga 4 och 5. 4.2.1 Förutsättningar innan antändning Industribyggnaden i Västerås var ca 18 000 m2 och uppdelad i 12 olika sektioner (i utredningsmaterialet fanns inte brandsektioneringen mellan sektionerna dokumenterad). Det brann i två sektioner och brännbart material bestod bl.a. av maskiner och brandfarlig vätska. Byggnaden på Trandaredsgatan var ett industri­ hotell med ca 15 olika företag och med en sammanlagd yta på ca 10 000 m2. Den brandutsatta lokalen var ca 3000 m2 men hade en brandavskiljande vägg mitt i lokalen som dock tog slut vid innertaket. Lokalen angränsade också till övriga stora lagerlokaler men dessa var brandteknisk avskilda från varandra. Brandbelast­ ningen var mycket hög och bestod av pallställ fyllda med material. Taket ovanpå den brandutsatta lokalen hade också hög brandbelastning och på en del av taket satt en speciell takpapp med högre brandklass som stod emot en högre brandpå­ verkan utan att bränna igenom. Denna takpapp påverkade förloppet avsevärt. 4.2.2 Antändning/upptäckt Det finns två olika versioner av vad brandorsaken vid branden i Västerås var, antingen på grund av teknisk fel eller på grund av utrunnen brandfarlig vätska. Branden som uppstod sent på kvällen upptäcktes av det automatiska brandlarmet som larmade räddningstjänsten, men det är dock oklart hur lång tid det tog innan det automatiska brandlarmet aktiverade. När räddningstjänsten anlände var bran­ den mycket intensiv vilket kan berott på att det brann i brännbara vätskor eller att det tog lång tid för det automatiska brandlarmet att larma. Även vid Tran­ daredsgatan startade branden sent på kvällen och hade ett häftigt förlopp inled­ ningsvis, men detta hade dock andra orsaker än i Västerås. Branden var troligen anlagd och vid första styrkans ankomst brann det i tre bilar som stod parkerade nära byggnaden. Branden hade också spridit sig till byggnaden. Det fanns heller inget automatiskt brandlarm och branden upptäcktes av en granne som trodde att det brann i skogsbrynet intill industrin och inte i byggnaden. Detta i sin tur medförde att räddningstjänsten larmades ut till ett litet larm vilket fördröjde tiden till påbörjad insats.

30 Resultat och diskussion kring alternativa metoder 4.2.3 Brandförlopp/släckinsats När räddningstjänsten kom på plats till branden i Västerås brann det i två sektio­ ner och beslutet togs att göra en offensiv insats med flera rökdykargrupper med uppgift att släcka branden. Problem uppstår dock genom att vattenförsörjningen fördröjdes eftersom vattenposternas placering var okänd. Ett annat problem i början av insatsen var att rökdykarna trodde att det endast brann i en sektion. När väl branden var lokaliserad sattes rökdykargrupper in från olika håll samt att taket vattenbegjöts. Branden tryckavlastades också via brandventilatorer som hade öppnats automatiskt. Vattenbrist och okunskap om brandens läge fördröjde insatsen och gjorde att branden inte kunde släckas förrän hela bygg­ naden var rökskadad. Det som brann i Västerås var en blandning av material, bl.a. brännbara vätskor, vilket gör ren vattensläckning olämplig. Bättre hade varit att blanda in skumvätska i vattnet. Man borde också identifierat risken för spridning av brand och brandgaser utanför de två sektionerna som brann och därmed borde en metod valts som motverkar spridningen. Vid inledningsskedet i Trandaredsgatan brinner det på tre ställen, i person­ bilarna, inne i den brandutsatta lokalen samt i takfoten på den brandutsatta lokalen. Två av de intilliggande lokalerna var dessutom rökfyllda och det var stor risk att branden skulle sprida sig till dessa lokaler. Det brann alltför intensivt i den brandutsatta byggnaden för att kunna bekämpa branden där. Den taktiska planen blev därför att stoppa brand- och brandgasspridning till sidoutrymmena med hjälp av övertrycksventilering och kylning av brandgaser med skärsläckare. Taktiken med att stoppa spridningen av brandgaser till intilliggande lokaler lyckades och den offensiva delen av insatsen inriktade sig på att dämpa strålnings­ intensitetet från branden i taket som var mycket intensiv. Hela taket över brand­ utsatt lokal brann upp men man lyckades hålla nere strålningsintensitet genom olika metoder så att branden inte spred sig till intilliggande tak. Insatsen höll på i över 1,5 dygn och ca 100 personer från tolv olika brandstationer arbetade under insatsen. Vid den här typen av objekt finns det ofta brandgasventilatorer. Styrning av dessa måste man ta hänsyn till vid beslut om exempelvis övertryckssättning. I båda fallen hade en insatsplan eller åtminstone orienteringsritningar underlättat och gjort att insatsen kommit igång snabbare. 4.2.4 Alternativ metod En alternativ metod som hade kunnat användas i Västerås är trycksättning av angränsande lokaler för att förhindra brandsgasspridning. Samtidigt hade en första insats med vattendimma mot de brandutsatta lokalerna kunnat kyla brandgaserna och skapat ett undertryck vilket ytterligare hade minskat risken för brandgasspridning. Eftersom lokalerna var så pass stora hade det dock krävts stor kastlängd och flera angreppspunkter för att uppnå tillräcklig kyleffekt, se Bilaga 11. En uthållig insats med skärsläckare från flera håll hade sänkt tempera­ turen och minskat de giftiga brandgaserna så att rökdykare senare kunnat göra en invändig släckinsats utan att utsättas för alltför mycket giftiga brandgaser. Vid branden på Trandaredsgatan använde man sig just av övertrycksventilering för att förhindra brandgaserna från att sprida sig från den brandutsatta loka­ len till angränsande lokaler. Trots lokalernas storlek fungerade detta bra. Har trycket väl byggts upp så spelar inte lokalens storlek någon roll utan det som spelar roll är om byggnaden inte är tillräckligt tät, se Bilaga 10. Lärdomar från Trandaredsbranden är också hur viktigt det är att vara medveten om hur olika metoder påverkar varandra och välja de metoder som kompletterar varandra. Nedan följer ett utdrag från analysen av branden från Bilaga 5.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 31 Insatsen visar att olika metoder har olika egenskaper som kan nyttjas. Är det en stor samling av heta brandgaser, som i lokal E, måste en metod som kan nå långt in och kyla brandgaserna snabbt användas. Små droppar kyler brandgaser mer effektivt än större droppar. Dessutom följer små droppar lättare luftströmmen istället för att falla till golvet vilket betyder att dropparna har längre tid på sig att förångas än större droppar [Bilaga 11]. Problemet med små droppar är dock kastlängden, men då är skärsläckare ett alternativ eftersom strålen bryts upp först efter fem till sju meter vilket ger en kastlängd på upp till 15 meter [Bilaga 11]. Skärsläckare visade sig också vara en bra metod och brandgaserna försvann på under en timma. På vissa andra ställen ville man hellre kyla ner heta brand­ ytor och där var det mer effektivt att använda dimstrålrör som ger större droppar. Detta eftersom det i experiment visat sig att små droppar inte väter ytor lika bra som större droppar [Bilaga 11]. Ytterligare en metod som användes var övertrycks­ ventilering för att hindra spridning av brandgaser till intilliggande lokaler och en viktig lärdom är att det går att trycksätta stora lokaler. Det är också fullt tillräckligt med en fläkt för varje stor lokal, förutsätt att lokalen är relativt tät, se också Bilaga 10. Insatsen visar också på att det är viktigt att vara medveten om hur olika metoder påverkar varandra. Till exempel att övertrycksfläktarnas verkan var att tryck­ sätta intilliggande lokaler och få värmen att gå ut via taket, men när vattenkanon användes så tryckte den ner värmen så att fläktarnas effekt försämrades. Ett annat exempel på att man måste vara medveten om hur vald metod kan få påföljder är skumanvändning som kan ha medfört stora konsekvenser för miljön. 4.3 Sammanbyggda lägre hus En skola och ett radhus har analyserats i denna kategori och utförlig b­eskrivning av bränderna finns i Bilaga 6 och 7. Gemensamt för båda bränderna var svårig­ heten med att identifiera hur och var branden spred sig. I Figur 5 visas ett exempel från en icke analyserad radhusbrand. Figur 5. Exempel på brand i en radhuslänga i Trosa. Bild: Räddningstjänsten i Nyköping.

32 Resultat och diskussion kring alternativa metoder 4.3.1 Förutsättningar innan antändning Skolan bestod av fem kringbyggda och sammanbyggda atrier med en oinredd vind. Vinden var sektionerad i delar om 300 – 450 m2 och brandcellerna på bottenvåningen var sektionerade i mindre sektioner. Takfoten var ihålig och stack ut långt utanför byggnaden vilket gjorde den idealisk för brandspridning. Radhuslängan bestod av sju stycken tvåvåningslägenheter och bredvid fanns ett garage. Avståndet mellan garaget och radhuset var endast tre meter men radhuslängan var brandteknisk avskild med hjälp av en tegelmur förutom en utstickande del vid ett fönster och en altan med träpanel som antagligen inte varit där då byggnaden uppfördes. Taket på radhuslängan var plåttak med en smal luftspalt till innertaket utan någon brandavskiljande konstruktion mellan lägenheterna. 4.3.2 Antändning/upptäckt Branden i skolan startade på grund av en fyrverkeripjäs som antände brännbart material lagrat i ett växthus. Branden spred sig sedan via takfoten till vinden. Den upptäcktes först av förbipasserande och sedan detekterade det automatiska brandlarmet. När räddningstjänsten kom på plats brann det kraftigt i växthus och takfot. Radhusbranden startade i intilliggande garage och spred sig till rad­ huset via taknock och altan. Boende larmade räddningstjänsten när de väcktes av att det small från garaget. När räddningstjänsten kom på plats brann det kraftigt i garaget och branden hade börjat sprida sig till radhuset. 4.3.3 Brandförlopp och släckinsats På skolan var den inledande delen av insatsen effektiv då räddningstjänsten snabbt blev visad till rätt plats, men branden hann sprida sig upp till vinden ändå. När den väl spridit sig dit så var det under långa tider som räddningstjänsten inte visste var branden fanns. Ytterligare problem under insatsen var att man inte hade kunskap om hur man tog sig upp på vinden och hur den var sektionerad. Vatten­ försörjningen var också ett problem eftersom brandposter och slangsystem frös sönder. Flera metoder användes, till exempel håltagning, tvärsnittsventilation och dimspik. Skärsläckaren kunde inte användas för utvändig insats på grund av det kalla vädret. Tillslut revs en del av byggnaden med hjälp av frontlastare och de sista glödbränderna släcktes genom invändig insats. Den första åtgärden som görs när räddningstjänsten kommer fram till radhus­ branden var att försöka stoppa spridingen från garaget till radhuset. Problemet var att spridningen skedde via altanen som låg på baksidan av radhuset och räddningstjänsten kom inte åt den sidan. När väl branden spridit sig till rad­huset så fortsatte den sprida sig via inner- och ytterväggar, mellanbjälklag och tak. Brandmännen bekämpade branden utifrån genom frånluftöppningar i taket och dimspik. Inifrån bekämpade brandmännen branden med hjälp av skärsläckare som punkterade bjälklagen samt håltagning och friläggning. En begränsnings­ linje som bestod av dimspikar och ett 60 – 70 cm brett hål över hela taket och baksidan av huset stoppade tillslut branden vid tredje lägenheten. 4.3.4 Alternativ metod I båda fallen visste man inte brandens omfattning och spridning. Därför hade IR-kameran underlättat för att hitta branden och förstå hur den spred sig. Det fanns också viss tvekan om hur byggnaderna var konstruerade vilket försvårade valet av metod och taktik. För skolans del hade en bättre bild över hur branden spred sig bidragit till att man kunnat trycksätta intilliggande sektioner och därmed minskat röksskadorna. Geometrin på de olika vindsektionerna hade

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 33 varit mycket lämpliga för en skärsläckarinsats. En skärsläckare hade gett mindre vatten­skador än vad dimspikarna gav. Skärsläckaren är dock på grund av sina små dimensioner på hål och slangar mer känslig för stark kyla. I radhuslängan spred sig branden via ytter- och innerväggar och det fanns inga naturliga brandtekniska avskiljningar. Skärsläckaren användes under insatsen men hade haft större effekt om den skjutits in från sidan så att den får lång kastlängd och möjlighet att bryta upp strålen till vattendimma. Beslutet om var begränsningslinjen skulle gå var ett bra beslut eftersom begränsningslinjen hann byggas upp innan branden hann ikapp. Dimspikar är bra att använda vid upprättande av begränsningslinje och vid denna insats var det mycket tack vare dim­spikarna som branden stoppades. Risken för vattenskador är dock stor vid användning av dimspikar och det är bättre att låta dimspiken pulsera i korta intervall. Det krävs kännedom om storlek på brand och lokal för att kunna avgöra hur långa pulserna ska vara. Genom att arbeta i pulser så genereras vattenånga och vattendimma vilket sprider släckeffekten bättre inne i dolda konstruktioner. För mycket vatten lokalt sänker temperaturen i närområdet för snabbt vilket leder till att förångning- och släckprocessen avstannar och förhindrar spridning av släckeffekten i den dolda konstruktionen. Det vill säga branden kan fortsätta att sprida sig utanför dimspikens träffområde. 4.4 Övriga I kategorin övriga har ett bibliotek och en paketerings- och distributionscentral (Steglinge) analyserats och utförlig beskrivning av bränderna finns i Bilaga 8 och 9. Gemensam nämnare är att båda var anlagda och hade mycket stor brand­ belastning vilket resulterade i häftiga brandförlopp. 4.4.1 Förutsättningar innan antändning Biblioteksbyggnaden innehöll ett stort arkiv i källaren, en öppen bibliotekshall med suterrängvåning på över 3000 m2 samt kontorsbyggnader och en övre bibliotekshall. Brandbelastningen var exceptionellt hög på grund av dels alla inventarier och dels ytskiktet på väggar och tak som bl.a. bestod av tretexskivor. Räddningstjänsten borde ha riktat föreläggande mot denna brandbelastning eftersom de vid ett flertal tillfällen varit på platsen och känt till byggnaden då den hade en hotbild mot sig och flera incidenter hade hänt innan branden bl.a. anlagda bränder som släcktes. Steglinge gård bestod av flera stora lagerlokaler och utanför lagerlokalerna fanns det trälådor staplade på varandra. Trälådorna stod nära byggnaderna och mellan de olika högarna var det endast ca 6 m vilket medförde att branden kunde sprida sig. 4.4.2 Antändning/upptäckt Branden i biblioteket började i ett av kontorsrummen och detekterades snabbt av brandlarmet. Personalen gjorde en första insats som ej lyckades på grund av att de använde sig av fel brandpost vars räckvidd inte sträckte sig till kontoret. Dessutom lämnades kontorsdörren öppen och branden spreds till hallen som på grund av den höga brandbelastningen övertändes inom en halvtimma. Mycket folk befann sig i lokalerna men alla hade utrymt innan räddningstjänsten anlände. På Steglinge gård upptäcktes brandhärdar på tre olika ställen av personalen. Räddningstjänst larmades och var på plats drygt 10 minuter senare. Initialt hade personalen kunnat forsla bort de trälådor som låg närmast den första brandhärden vilket hade minskat risken för spridning.

34 Resultat och diskussion kring alternativa metoder 4.4.3 Brandförlopp och släckinsats När räddningstjänsten kommer på plats till biblioteksbranden går en rökdykar­ grupp in med en smalslang och försöker släcka branden som nu börjat sprida sig till hallen utanför kontoret. Detta misslyckades av flera anledningar. Dels var bibliotekshallen för stor för att ett enda strålrör skulle täcka hela ytan och dels var det framför allt de tvärställda brädorna i bibliotekshallens innertak som brann. Brädorna förhindrade antagligen att vattendropparna nådde brandgaserna som fanns mellan brädorna och betongtaket. Vattnet träffade heller inte baksidan av brädorna där det brann och därför hade rökdykarna ingen möjlighet att kyla brandgaserna och förhindra övertändning. Efter övertändning tog det bara 30 minuter innan taket rasade in och då begränsades branden. Vid räddningstjänstens ankomst till Steglinge gård brann det kraftigt i ena högen av trälådor och eftersom lokalen närmast var fylld med gödningsmedel bedömdes den branden som mest kritisk att släcka. Branden spred sig dock till den andra högen med trälådor och därefter ytterligare en byggnad. Den bygg­ naden var isolerad med någon slags cellplast som gjorde att när den antände så gick brandförloppet mycket snabbt. Brandposterna på gården var ur funktion så släckvatten var hela tiden en begränsande faktor. 4.4.4 Alternativ metod Den höga brandbelastning och det intensiva brandförloppet i de båda bränderna gjorde att räddningstjänsten när de kom på plats snabbt hade behövt bryta skade­ utvecklingen. Flera olika metoder i kombination med varandra hade kunnat bromsa förloppet och skapa en miljö som gjort det möjligt att släcka branden. Nedan finns urklipp från bilaga 8 respektive 9. Bibilioteksbranden, Bilaga 8: Då räddningstjänsten anlände hade branden spridit sig till taket utanför det primära brandrummet. Effektutvecklingen uppskattas då ha varit 5-10 MW. För att fördröja brandspridning skulle brandgaserna kunna kylas med en insats med vattendimma. Avstånden utifrån från taket på markplanet till det primära brandrummets dörr är ca 14 m. På baksidan av byggnaden kan man dessutom nå brandrummet utifrån från taket på markplanet. Den bästa möjlighet, med tanke på kastlängd, kylförmåga, vattenskador och tryckminskning (Bilaga 11) hade varit en kraftfull insats med 2-3 skärsläckare utifrån riktade mot både det initiala brandrummet och taket i den övre hallen. Då fasaden i hallen och det primära brandrummet hade fönster skulle insatsen snabbt kunnat komma igång och dess verkan bedömas. Med denna åtgärd hade brandspridningen möjligen stoppats och underlättat för en påföljande konventionell släckinsats med strålrör. I Bilaga 9 (Steglinge gård) diskuteras följande fyra alternativ som var för sig eller som kombination hade kunnat släcka branden. Den valda metoden att angripa trälådorna vid byggnad A med ett konventionellt lågtryckssystem lyckades tyvärr inte. För att få en ökad effekt av den valda in­ satsen hade olika tillsatsmedel till släckvattnet kunnat användas. Önskat mål med användandet av tillsatsmedel är att uppnå en effektivare släckning samt minska risken för återantändning. Med tillsatsmedel avses även premix av A-skum. På grund av den höga strålningsvärmen hade tungskum varit ett bra alternativ eftersom den ger lång kast längd. Det finns ett flertal system med huvudfunktion att skapa en dimridå av vatten för att minska strålningsintensiteten mot angränsande objekt. Exempel på dessa system är ridåmunstycke, vattenkanon med tallriksmunstycke, backupstrålrör med tallriksmunstycke och slangar som innehåller ett antal munstycken direkt monterade på brandslangen. Målet med att använda dessa system är att vatten­

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 35 ridån skall absorbera strålningen från branden så att angränsande objekt ej skall självantända. Dessa system har generellt hög vattenförbrukning, ofta över 1000 l/min vilket inte fanns att tillgå vid den faktiska insatsen på grund av bristerna i brandpostnätet. Tidigt bortforslande av trälådor hade kunnat ge stor effekt på både brandens omfattning samt minskad spridningsrisk. Initialt hade personal på gården kunnat påbörja denna åtgärd för att inte branden skulle växa till den omfattning som var då räddningstjänsten kom till platsen. För att förhindra att trälådorna antände utanför byggnad B kunde man tidigt i insatsen kylt dem med vatten. Troligtvis hade det gett en ännu högre effekt om tillsatsmedel, tryckskumsystem typ CAFs eller traditionellt tungskum hade använts. Genom att använda tillsatsmedel eller skum kan mängden vatten som används minimeras då detta var en begränsning vid insatsen. Viktigt är dock att beakta miljöeffekterna av tillsatsmedel innan det används vid en insats. 4.5 Lärdomar Nedan sammanfattas i punktform de lärdomar som kan dras från de analyse­ rade objekten. Förebyggande arbete • • I flera av fallen hade ett detektionssystem kunnat ge en tidigare upptäckt och således ett snabbare ingripande. • • Det byggnadstekniska brandskyddet var i flera fall bristfälligt och hade en avgörande betydelse för att skadan blev så omfattande. I flera av fallen hade också det byggnadstekniska brandskyddet försämrats under årets lopp på grund av tillbyggnad, nya ytskikt, försämrade brandväggar etc. • • Det organisatoriska brandskyddet hade också i flera fall kunnat förhindra att branden blev så omfattande. Till exempel placering av brännbart material, underhåll av brandposter, upprättande av orienteringsritning och kunskap om hur man bör agera vid brand. Riskbedömning • • Att vindsbränder i stora nästan slutna utrymmen kräver tillgång till annan släckutrustning än för vanliga lägenhetsbränder. • • Att i inledningsskedet ha god information om hur byggnaden är brand­ tekniskt sektionerad och dess brandbelastning. Men det går inte att för­ utsätta att brandsektioneringen är korrekt utförd utan att den valideras innan val av släckmetod tas. • • Att i inledningsskedet skaffa sig god information om hur långt branden spridit sig och hur den fortsatte spridningen kan tänkas ske. • • Att vara beredd på att snabbt ändra taktik och metod vid behov. • • Att noga undersöka spridning via tekniska installationer, t.ex. ventilations­ system och imkanal. • • Att inte bara se branden utan också se de kringproblem som branden skapar. • • Att vara medveten om hur olika metoder påverkar varandra och att välja de metoder som kompletterar varandra.

36 Resultat och diskussion kring alternativa metoder Alternativ till räddningstjänstens val av insatsmetodik • • Trycksättning av angränsande utrymmen minskar risken för brandsprid­ ning och kan hjälpa till med att säkra utrymningsvägar. • • För att uppnå en effektivare släckning samt minska risken för återantänd­ ning hade tillsatsmedel till släckvattnet kunna använts. Det är dock viktigt att ta hänsyn till den miljöpåverkan som tillsatsmedel kan ha innan den tillsätts i släckvattnet. • • Vanliga dimstrålrör har svårt att snabbt kyla brandgaser på längre avstånd och andelen vatten som förångas i brandgaserna är avsevärt mindre än för system med vattendimma. • • En insats med skärsläckare hade i flera av de analyserade bränderna varit effektiv då den snabbt kunnat sänka brandgastemperaturen och fördröja brandförloppet. För störst effekt behöver skärsläckaren ha möjlighet till lång kastlängd så att strålen hinner bryta upp innan den träffar någon konstruktion. • • Skärsläckare fungerar bra även i större lokaler, men vattnet behöver på­ föras under längre intervaller och det tar längre tid innan det går att se effekten av insatsen. • • Med hjälp av en vattenkon skapas omrörning och turbulens vilket ökar släckeffekten på distans. Skärsläckaren är ett exempel på en metod som kan skapa denna effekt. • • Det är viktigt att inte upprätta en begräsningslinje för nära branden utan att läsa in hur snabbt branden sprider sig och jämföra den med tiden det tar att upprätta begränsningslinjen. • • Dimspikar är bra att använda vid upprättande av begränsningslinje. Risken för vattenskador är dock stor vid användning av dimspikar och det är bättre att låta dimspiken arbeta i korta intervall. • • Avsaknad av gemensam rättvisande lägesbild har inneburit att åtgärder vidtagits utan att man egentligen haft kontroll över effekt/verkan. • • IR-teknik är ett bra hjälpmedel för att skapa en korrekt lägesbild. • • Dokumenterade värmebilder från en insats är bra att använda vid utvär­ deringen av en insats. Bilderna kan visa hur branddynamiken förändras under insatsen och vilken effekt olika metoder haft, se exempel på IR-bild i Figur 6.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 37 Figur 6. IR-bild som visar tydligt brandens placering i relation till räddningstjänstpersonalens position. Bild: Krister Palmkvist, SÄRF.

Slutsatser

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 39

1. Slutsatser

I de räddningstaktiska grunderna [44] ingår; ”1. Räddning av liv går före räddning av egendom. 2. Angrepp fordrar större krafter än skydd. 3. Begränsa först – släck sedan. 4. Ju tidigare insats desto bättre resultat.” I fall där det kan finnas männi­ skor kvar fördröjs därför släckinsatsen ofta eftersom den inte är prioriterad i början. Alla åtgärder som sedan genomförs vid en insats ska syfta till att snabbt släcka branden. Branden är ett problem som måste lösas men den behöver inte vara det största problemet utan den kan ha skapat många sekundära problem. Många av de alternativa metoder som nämns i rapporten handlar om att först stänga in branden för att möjliggöra släckning senare i insatsen. 5.1 Agera istället för att reagera I inledningskedet vid en insats gäller det att komma ifatt branden så att man kan börja agera istället för att reagera. I flera av insatserna har räddningspersonalen aldrig kommit ifatt olyckan utan endast kunnat reagera på brandens utveckling. Till exempel i Potatisåkern (Bilaga 2) där man hela tiden fick jaga branden utan resultat. Ibland kan det vara bättre att inte attackera branden direkt utan arbeta mer defensivt och på så sätt komma ikapp olyckan. Kanske måste branden dämpas innan det går att släcka den som i exempelvis Vindelgatan (Bilaga 3), där man genom att snabbt kyla brandgaserna och bromsa brandförloppet kunde börja agera istället för att reagera. I många bränder är förloppen ventilationskontrolle­ rade. I de fallen kommer brandförloppet att förvärras om ventilationsöppningar skapas, medvetet eller omedvetet. Snabba beslut är viktigt för att kunna hejda brandförloppet och därmed köpa sig tid, men det är lika viktigt att under insatsen ha en korrekt och snabb kom­ munikation mellan befäl och brandmän för att kunna avgöra om insatt metod fått avsedd effekt. Genom att kontrollera vilken effekt som vald metod har på branden går det att ligga steget före och snabbt kunna ändra arbetssättet för att optimera släckeffekten. Viktigt att tänka på är dock att vid stora volymer måste man vara uthållig eftersom det kan ta tid innan det går att avgöra om metoden gett effekt eller inte. Till exempel vid Trandaredsgatan (Bilaga 5), där det tog nästan en timma innan rökgaslagret hade försvunnit från sidoutrymmena. 5.2 Val av alternativ metod Olika metoder är bra att använda vid olika situationer och ofta måste man kombi­ nera olika metoder. Utifrån de analyserade bränderna så kan följande slutsatser dras när en viss alternativ metod kan användas: 5.2.1 Vattendimma I flera av de analyserade fallen så var branden mycket omfattande när räddnings­ tjänsten kom på plats. Stora volymer fyllda med brandgaser gjorde att invändig släckning inte var ett alternativ på grund av riskerna för personalen. Det behövdes alltså ett system med huvudsyfte att kyla och inertera brandgaserna på stora avstånd i både höjd och sidled. En släckmetod, vattendimma, skulle snabbt kunna kyla brandgaserna och alstra ett kraftigt undertryck och därmed minska och fördröja brandspridning. Olika system alstrar olika stora vattendroppar och droppens storlek har stor påverkan

40 Slutsatser på förångningshastighet, fallhastighet, uppbromsning samt kastlängd. Små droppar kyler brandgaser mer effektivt än större droppar vilket minskar risken för vattenskador. Dessutom följer små droppar lättare luftströmmen istället för att falla till golvet vilket betyder att dropparna har längre tid på sig att förångas än större droppar. Problemet med små droppar är dock kastlängden som kan bli mycket kort. Ett system som förmår producera små vattendroppar med lång räckvidd är skär­ släckaren (COBRA), se exempel i Figur 7. Detta system ger dessutom, på grund av det höga initialtrycket, mest omröringseffekt (en fläkt på 10-15 m3/s per påförd liter vatten per sekund) då vattendropparna bromsas upp av friktion mot luft och brandgaser. Möjligheten att med skärsläckaren snabbt ta sig igenom olika konstruktioner medför dessutom en snabbare insats. Det första tecknet på att vattendimma har effekt på branden är att brandgaser slutar läcka ut på grund av den trycksänkning som förångningen i brandgaserna medför (Figur B 31 i Bilaga 11). När gasmassans temperatur sjunker mer än vad pyrolysen kan upprätthålla följer nästa fas. Vattendimman når fram till heta pyrolyserande ytor, och därefter stiger produktionen av ånga/vattendimma en gasblandning som medför blockering av syretransporten in i brandrummet. Blandningen av vattendimma och kondenserad ånga expanderar i brandrummet vilket medför att tidigare process där brandgasen från startbrand trängt in verti­ kalt och horisontellt till sidoutrymmen nu följs av vattenånga och vattendimma (vit rök) till dessa sidoutrymmen. Den släckeffekt som uppnås i startbrandrum­ met kommer även att påverka sidoutrymmet på ett positivt sätt släckmässigt. Hela den process som uppstår när vattendimman tränger in i brandrummet sänker syrenivån (inertering) och därigenom försvårar lågande brands fortlevnad i startbrandrum och sidoutrymmen. Figur 7. Skärsläckare används mot en takbrand. Den lyckas dämpa förloppet kraftigt en kort stund efter att bilden är tagen.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 41 Optimalt förhållande för att få en bra och snabb effekt av en skärsläckarinsats är ett inte alltför stort oventilerat utrymme, gärna avlångt, med höga temperaturer (exempel Vindelgatan, Bilaga 3). Då rumsytorna och volymerna i brandrummen är stora finns behov av insats med flera skärsläckare från olika håll. Vid lägre temperatur blir det ett mer utdraget förlopp på grund av att förångningen inte sker lika snabbt och inerteringen genom sänkt partialtryck av syre inte är lika markant. Vid större volymer är det viktigt att arbeta med skärsläckaren under längre intervaller och under längre tid innan effekt kan mätas. Skärsläckaren behöver också ett avlångt utrymme utan hinder för bästa släck­ effekt eftersom strålen bryter upp till vattendimma först efter ca fem meter. På vindar är det säkraste alternativet att gå in via gaveln för att skärsläckaren ska kunna uppnå full effekt utan att stöta på hinder. Genom att variera tekniken (ändra vinklar, rotera med mera) går det att öka effekten även på korta avstånd. Problemet med skärsläckaren är att vattnet i skärsläckaren vid kraftig kyla lättare kan frysa till is än för konventionella system. Se också Bilaga 11 där man mer i detalj kan läsa om skärsläckarens egenskaper. 5.2.2 Dimspik Dimspikar kan vara en bra metod att använda vid upprättande av begränsnings­ linje och har ofta bra effekt i det korta närområdet. Men problemet med dimspik är att man efter monteringen sätter på dem och låter dem vara på vilket kan medföra omfattande vattenskador. Alternativet är att istället påföra vattnet i korta intervall. Vattnet hjälper då till att inertera hålrum och på så sätt går det att öka släckeffekten med mindre vattenåtgång. Se bilaga 6 och 7 för exempel där dimspik använts vid en insats. 5.2.3 Övertryckssättning En metod som är bra att använda för att minska risken för brandgaser är att med hjälp av fläkt ventilera ut brandgaserna och sedan trycksätta utrymmet. I branden på Trandaredsgatan (Bilaga 5) användes övertryckssättning för att hindra spridning av brandgaser till intilliggande lokaler och en viktig lärdom är att det går att tryck­ sätta stora lokaler. Det är också fullt tillräckligt med en fläkt för varje stor lokal, förutsätt att lokalen är relativt tät. Läs vidare om trycksättning i Bilaga 10. 5.2.4 IR-teknik IR-teknik är ett bra hjälpmedel för insatsledningen. Till exempel går det att ut­ över visuella observationer av flammor, läckage av brandgaser etc., att använda sig av IR-teknik för att avgöra var det brinner och hur långt branden spridit sig. Under insats kan man med hjälp av IR-tekniken utvärdera effekten av olika metoder så att man snabbt kan ändra metod om inte effekt uppnås. Andra sätt IR-tekniken kan hjälpa till med är att hitta i ett brandgasfyllt rum och i efter­ släckningsskedet. Det är dock mycket viktigt att veta teknikens förutsättningar och begränsningar. Det krävs t.ex. en högre prestanda och upplösning på kameran om den ska användas på längre avstånd. Vissa modeller fungerar bra när kam­ eran bara ska användas inomhus och kunna scanna kortare avstånd men har då inte tillräckligt bra upplösning för att få en rättvis bild när byggnaden scannas utifrån. Nyligen har en rapport om hur IR-teknik kan användas av räddnings­ tjänstens publicerats [43].

42 Slutsatser 5.2.5 Tillsatsmedel I vissa av de analyserade fallen hade tillsatsmedel kunnat effektivisera släck­ ningen av branden. Denna rapport har dock inte analyserat olika tillsatser till släckvatten för att utvärdera varje ämnes hälsorisk för räddningstjänstpersonal och allmänhet och skada på miljö. 5.2.6 Aerosol släckgranat En aerosol släckgranat är en cylinderformad behållare fylld med ett ämne som vid aktivering bildar en pyroteknisk genererad aerosol. Behållaren har en utlös­ ningsfunktion som utlöser aerosolen sex till åtta sekunder efter att sprinten dragits ur. Sen introduktionen för två – tre år sedan (2011 – 2012) har efterfrågan och användandet av aerosolgranater ökat kraftigt. Olika serviceorgan, t.ex. natt­ patruller, väktare, poliser med flera är grupper som idag är utrustade med dessa släckgranater. Flera räddningstjänster har sett nyttan med att använda det som en första åtgärd för att bromsa brandförloppet. Granaten är i första hand fram­ tagen för en första insats i slutna brinnande utrymmen. Inom några minuter kyler och släcker granaten branden i mindre utrymmen (20 – 30 m3). Beroende på brandens storlek krävs olika omfattning av eftersläckning. Oftast räcker det dock med en mindre eftersläckning, vilket reducerar skadorna på egendom och minskar saneringsbehovet. 5.3 Kombination av olika metoder Det är inte bara kunskap om hur olika metoder fungerar utan man måste kunna läsa av branddynamiken och förstå hur olika metodval eller en kombination av olika metoder samspelar med varandra. Vid de två bränder (Bilaga 3 och 5) där man lyckades begränsa skadorna till primärbrandrummet användes en kombi­ nation av olika metoder. I de fallen var metoderna vattendimma kombinerat med övertrycksventilation av angränsande brandceller i kombination med IR-teknik. IR-tekniken användes som övervakning av brandens potentiella utveckling och som stöd när beslut skulle tas om vilken släckmetod som skulle användas. Branden i Bilaga 5 visar också på hur olika metodval kan motverka varandra så att effekten av den ena metoden tar ut effekten av den andra metoden. Till exempel så mins­ kade användning av vattenkanoner mot taket effekten av övertrycksventilering i intilliggande lokaler. Att taktiskt använda en kombination av olika metoder som ska samspela med varandra kräver en bra ledningsstruktur och förmåga till snabba förändringar. Om någon av metoderna går fel kan hela taktiken lätt haverera. 5.4 Förebyggande Att analysera det förebyggande arbetet har inte varit syfte med rapporten men i flera av de analyserade bränderna hade ett förebyggande arbete kunnat minska skadorna drastiskt. Ett detektionssystem förkortar tid till insats avsevärt och hade kunnat förhindra omfattande skador på byggnaden. Brandavskiljande kon­ struktioner var i flera av fallen dåligt utförda eller ej existerande. I de flesta fall är det vid en brandavskiljande konstruktion som räddningstjänsten har möjlig­ het att stoppa en brand. Ovanligt hög brandbelastning i förhållande till brand­ skyddet avgjorde också skadeutfallet i flera av fallen. Till sist kan nämnas att ett bra organisatoriskt brandsarbete hade kunna ha en avgörande inverkan på hur omfattande branden blev.

Referenser

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 45 STORSKADEPROBLEMATIK – BRAND I BYGGNAD 45

1. Referenser

[1] Särdqvist, S., Djupanalys av tre storbränder, LUTVDG/TVBB 3096-SE, 1998. [2] AFS 2007:7 Rök- och kemdykning. Arbetsmiljöverkets föreskrifter om rök- och kemdykning samt allmänna råd om tillämpningen av föreskrifterna (Ändringar införda t.o.m. den 25 mars 2014). [3] http://www.svenskforsakring.se/Huvudmeny/Press-old/Undersidor/Pressmed­ delanden/Kategorier/2014/Kostnader-for-brander-okar-markant/ [4] http://ki.se/sites/default/files/brandman_och_cancer_carolina_bigert.pdf [5] Övertrycksventilation - Förstudie över brandventilation med mobila fläktar, FoU Rapport P21-092/94, Räddningsverket 1994. [6] Bengtsson, L., Karlsson, B., Särdqvist, S., Brandventilation i teori och praktik, R53-146/96, Rapport Räddningstjänstavdelningen, Räddningsverket 1996. [7] Svensson, S., Försök med sprängram samt övertrycksventilation, Rapport Räddningstjänstavdelningen R53-132/96, Räddningsverket 1996. [8] Svensson, S., Försök med brandgasventilation i en liten lägenhet, Rapport Räddningstjänstavdelningen R53-159/96, Räddningsverket 1996. [9] Carlson, D., Räddningsverkets anläggning för försök, utbildning/övning och forskning i het miljö, FoU Rapport P21-203/97, Räddningsverket 1997. [10] Ingason, H., Fallberg, R., Palmkvist, K., Gustavsson, S., Brandförsök med offensiv släckning kombinerat med övertryckningsventilering - Erfarenheter och mätresultat från försök i Svaneholm 5-6 nov 1997, SP AR 1998:08, Brand­ teknik, Borås 1998. [11] Ingason, H., Fallberg, R., Övertrycksventilation i medelstora lokaler, försök med mobila fläktar, SP Rapport 1998:41. [12] Fallberg, R., Ingason, H., Erfarenheter med övertrycksventilation, FoU Rapport P21 331/00, Räddningsverket 2000. [13] Ingason, H., Fallberg, R., Övertrycksventilation i medelstora lokaler – försök med rökdykare, FoU Rapport P21-397/02, Räddningsverket 2002. [14] Ingason, H., Fallberg, R., Positive Pressure Ventilation in Medium-Sized Premises, Fire Technology, v 38, 2002, pp. 213 – 230. [15] Skärsläckaren – tillkomst och utveckling, FoU Rapport P21-352/00 – Räddnings­ verket, Karlstad 2000. [16] Cutting extinguisher: concept and development, FoU Rapport PUBP21- 362 – Räddningsverket, Karlstad. [17] Andersson, B, Håltagning med vätskeskärning – Förstudie, R53 – 2239/96 – Räddningsverket, Karlstad 1996. [18] SÄRF och SP, Skärsläckarkonceptets operativa användande. MSB 0167-10, 2010. [19] Ingason, H., Fallberg, R., Palmkvist, K., Edholm, U., Övertrycksventilation kombinerad med skärsläckare, SP Rapport 2012:63. 2012. [20] Bergh, U., Danielsson, U., Bern, M., Rökdykning – Studier av Människa och Miljö – Metod och teknik, FoU Rapport P21-249/98, Räddningsverket 1998. [21] Gavhed, D., et al, Brandmännens fysiska förmåga – Delrapport 1 – Typinsatser, FoU Rapport P21-379/01, Räddningsverket 2001. [22] Nyman, H., Lokalisering av nödställd rökdykare – Del 2, FoU Rapport P21- 436/03, Räddningsverket 2003.

46 Referenser [23] Andersson, L., Försök med IR-kamera vid rökdykning – Erfarenheter från försök och övningar, FoU Rapport P21-444/04, Räddningsverket 2004. [24] Melin, G., Nyström, S., Björnberg, F., Exempel på mål för den kommunala räddningstjänstens övningsverksamhet, FoU Rapport P21-301/99, Räddnings­ verket 1999. [25] Lundström, S., Svensson, S., Särdkvist, S., Släckförsök vid brand i stor lokal, FoU Rapport P21-328/00, Räddningsverket 2000. [26] Svensson, S., Cedergårdh, E., Mårtensson, O., Taktik, ledning, ledarskap, MSB 0015-09, Myndigheten för Samhällsskydd och Beredskap, 2009. [27] Mattson, M, och Eriksson, L., Taktikhandboken, Informationsbolaget, 2010. [28] Försth, M., Ochoterena, R., Lindström, J., Spray characterization of the cutting extinguisher, SP, Arbetsrapport 2012:14, 2012, Borås. [29] Lindström, J., Appel, G., Palmkvist, K., Bialas, K.O., Förmåga och begränsningar av förekommande släcksystem vid brand i byggnad – fokus på miljöarbete, MSB rapport MSB618, Myndigheten för Samhällsskydd och Beredskap, 2013. [30] Cutting Extinguishing Concept – practical and operational use – MSB report 2010 - EU Project FIREFIGHT II, Myndigheten för Samhällsskydd och Beredskap. [31] Bjerregaard, J., Olsson, D., Skärsläckaren – experimentella försök och beräk­ ningar, LTH Brandteknik, http://lup.lub.lu.se/luur/download?func=download File&recordOId=1767600&fileOId=1769399. [32] Carlsén.T., Winkler, H., Skärsläckaren som röjnings och släckverktyg för fartyg av kolfiberkomposit, LTH Brandteknik, http://lup.lub.lu.se/luur/downl oad?func=downloadFile&recordOId=1767290&fileOId=1769920. [33] Larsson, M., och Westerlund, J., Högtrycksbrandsläckning – ett underlag för räddningstjänsten, LTH Brandteknik, http://lup.lub.lu.se/luur/download?func =downloadFile&recordOId=1320832&fileOId=1320833. [34] Lundgren, L., Håltagning för brandgasventilation i tak, Examensarbete 2008:03, Luleås Tekniska Universitet, http://epubl.ltu.se/1402-1552/2008/033/ LTU-DUPP-08033-SE.pdf. [35] Bengtsson, L-G. Övertändning, backdraft och brandgasexplosion sett ur räddningstjänstens perspektiv, Lic Thesis, report 1019, Institutionen för Brandteknik, 1999. [36] Bengtsson, L-G., Inomhusbrand, U30-611/01, Räddningsverket, Karlstad, 2001. [37] Särdqvist, S., Demand for Extinguishing Media in Manual Fire Fighting, Doctoral Thesis, report 1021, Lund University, 2000. [38] Särdqvist, S., Vatten och andra släckmedel, Räddningsverket, 2006. [39] Svensson, S., The operational Problem of Fire Control, Doctoral Thesis, report 1025, Lund University, 2002. [40] Svensson, S., Brandgasventilation, U30-602/06, Räddningsverket, 2006. [41] Johansson, N., van Hees. P., En studie av vindsbränder utifrån statistik och brandutredningar, Report 3152. Brandteknik, LTH 2010. [42] Så brinner husen, materialet är tillgängligt via www.rsgbg.se. [43] Gudmundsson, A., Studahl, P., IR-teknik som hjälpmedel vid brandbekämp­ ning Report 5490, Lund 2015, Brandteknik, LTH. [44] Fredholm, L., Utveckling av räddningstaktik, Analyser och metodförslag, Försvarets Forskningsanstalt, FOA-rapport E 50006-5.3, 1990.

BILAGA 1 Umeå Ålidshem 24-25/12 2008

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 49 BILAGA 1 Umeå Ålidshem 24-25/12 2008 B1.1 Objektbeskrivning Tapani [1] beskriver byggnaden: ”Byggnaden är uppförd i början av 70-talet. Byggnaden är en flerfamiljsbyggnad i fyra våningsplan med oinredd vindsplan. Byggnaden har nio trappuppgångar och är formad som ett U bestående av tre byggnadskroppar, se Figur B 1. Två av byggnadskropparna har måtten 50x12 m och en kropp har måtten 60x12 m. Byggnaden har stomme av betong med lägen­ hetsavskiljande betongväggar.” Vidare beskrivs att ”Taket är ett motfalls­tak med taktäckning av takpapp på rote av trä och på vindsbjälklaget finns isolering i form av sågspån” Det var helt öppet via en spalt ca 0.1x5 m mellan vindarna till de tre huskropparna på knappt 2000 m². Lundqvist [2] beskriver ytterväggarna: ”I bygg­ naden på Geografigränd var utfackningsväggar utförda i brännbart material. Konstruktionen i dessa väggar bestod från insidan av gips, isolering och asfaboard med reglar av trä. Mellan utfackningsväggen och fasadbeklädnaden i tegel fanns en luftspalt som passerade alla bjälklag. Det var via denna luftspalt, asfaboarden och träreglarna som branden spred sig nedåt i byggnaden.” U-format 4-våningshus, sammanbyggda c:a 4,5 m bl.a. osektionerat på vind. Anslutning från lägenhetens fläkt uppåt till ventilationsrör. Samlingslåda för ventilation. Rör täckta av sågspån. Sågspånsisolering på vind. Figur B 1. Byggnadens olika delar.

50 BILAGA 1 – Umeå Ålidshem 24-25/12 2008 B1.2 Incidenter före branden Det fanns inte någon historia från detta område som utmärkte sig från flertalet miljonprogramsområden i Sverige. Den inledande branden utmärkte sig inte heller, mer än så till vida att en köksbrand som startade i olja har större starteffekt än många andra. B1.3 Branden Branden kan delas in i två faser, med var sin räddningsinsats: En lägenhetsbrand beroende på antänd frityrolja på spis. Branden blev relativt liten med brandskador endast i köksskåp. Dock skedde vidare antändning av vindens sågspån via venti­ lationssystemet, vilket så småningom ledde till en totalskada av tre huskroppar. Figur B 2 visar området en tid efter branden, där den hästskoformade byggnadens tidigare läge framgår tydligt. Efter branden föddes idén om att bygga 137 nya lägenheter och omvandla området till Norrlands största lågenergihusbygge [3]. Inflyttning startade under 2011. Figur B 2. Flygfoto från Eniro.se från ca 2009 hämtat 2014-04-02.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 51 Beskrivningen nedan av branden och släckinsatsen bygger på uppgifter i utryck­ nings-/insatsrapporter och dagboksanteckningar [4-8]. BRANDFÖRLOPP RÄDDNINGSTJÄNSTINSATS 16:xx Kastrull med matolja antänds vid matlagning. Uppgång 2J, 3 vån.

Brandvarnare börjar tjuta, misslyckat släckförsök av lägenhetsinnehavare, larmar 112. 16:24 Larm kommer till brandförsvaret. 16:33 Brand i fläkt och köksskåp ovanför fläkt. Brandgaslager på 1,5 m höjd. 16:33 Räddningstjänsten på plats, snabb släckning. 16:43 Temperaturen på synliga delar i köket faller 15-20 grader under den tid IR-mätningar pågår. Samtidigt uppstår en glödbrand i sågspån på vind. 16:43 Rökfritt i lägenheten. Mätningar med IR-kamera. 17:50 Tillfälligt brandlarm monteras. Räddnings­ insats avslutas. 00:45+1 Larm kommer till räddningstjänsten om lägenhetsbrand uppgång 2H. 00:52+1 Kraftig brand på vinden ovanför 2J, 2H. 00:52+1 Räddningstjänsten på plats. 00:xx+1 Brandspridning till nästa hus. 00:xx+1 höjdfordon reses mot vind. Ca 01:07+1 Brand på vind i sista huset. Ca 01:07+1 Beslut om evakuering. 02:20+1 Brandspridning nedåt till hörnlägenheter. 02:20+1 Oklart för RTJ hur konstruktionen ser ut. 06:00+1 Branden kryper i ytterväggarna och sprider sig till fler lägenheter. 06:00-09:00+1 Aktiv släckning av brand i luftspalt i fasad. 09:00+1 Branden begränsad. 18:00+1 Vindsbranden under kontroll. Brandspridning ända ned till bottenvåning. 09:30+2 Genomgång av byggnaden. 11:00+2 Räddningsinsats avslutas. B1.4 Analys Lägenhetsbranden Den första fasen, köksbranden, kan beskrivas som mycket enkel, en i det när­ maste rutinmässig insats. Rökdykarledaren kan i sin orientering gå upp i trapp­ huset och in i den olåsta lägenheten och göra en genomsökning. Rökdykarledaren släcker till och med själv köksbranden, allt enligt insatsrapporten [4]. En under­ sökning gjordes för att undersöka om brandspridning förelåg. Vatten spolades in i en ventilationskanal där förhöjda temperaturer observerats med IR-kamera. Brandspridning till vinden De flammor som funnits i köksskåpet har sugits in av fläktsystemet, som varit igång enligt rapporten. Detta är skälet till förhöjda temperatur i kanalen. I en senare rapport [3] ges en klarsynt beskrivning. ”Det är rimligt att anta att mycket brandgaser har gått in i kanalen vid genomföringen i bjälklaget och att en stor del av förbränningen har skett där. Frisk luft till samlingslådan tillförs via kanaler från andra lägenheter och det kan antas att det bildas en brännbar blandning i

52 BILAGA 1 – Umeå Ålidshem 24-25/12 2008 samlingslåda och kanal. Denna brandbild talar för att en mer noggrann kontroll av spridning via ventilationen borde ha genomförts. Detta skulle kunna ha skett genom att följa kanalen upp mot vinden”. Om man studerar ventilationssystemets utformning i insatsrapportens bildbilaga [7] ser man att ventilationsröret gör två 90° böjar. Det innebär att man inte kan se längre in i kanalen med IR-kamera än till första böjen. Det innebär dessutom att vatten från ett vanligt dimstrålrör inte heller kommer särskilt mycket längre. Det kan vara så att just användandet av ny teknik i form av IR-kamera invaggar i en falsk säkerhet. Om glödbranden på vinden identifierats, skulle i stort sett samtliga tillgängliga system kunnat hantera den, inklusive skyffel och plåthink, men Hovrätten i övre Norrland konstaterar i sin dom 2013 att ”… möjligheter att förutse vindsbranden måste beskrivas som små, varför dess bedömning att inte undersöka vinden var rimlig”. Å ena sidan finns alltså ingen signal om att det faktiskt finns en brand att släcka. Å andra sidan hade samtliga tillgängliga släcksystem kunnat hantera den begynnande branden i sågspånet på vinden. Vindsbranden Den andra fasen handlar om att den första branden, där larm kom 16:24, antänt sågspån på vinden. Branden har vuxit under kvällen och nästa larm kom 00:45. Då brann det kraftigt från vinden i ena huskroppen. I rapporten beskrivs ”Det inledande beslutet var att få fram stegbilen för att påbörja släckning. Innan stegen var rest hade branden spridit sig till den intilliggande huskroppen och strax därefter brann även den sista huskroppen.” Man konstaterade att det var ett betongbjälklag och beslöt att låta taket brinna av. Man konstaterar också ”Detta beslut grundade sig delvis på att det inte fanns tillräckliga resurser för att genomföra en aktiv släckinsats mot vinden samtidigt som en aktiv släckinsats skulle ha medfört omfattande vattenskador…” [2]. Samtidigt konstateras att man inte varit medveten om att vinden varit isolerad med sågspån. Huskropparna var 50 alternativt 60 m långa och 12 m breda, vilket ger en total osektionerad vindsyta om 1920 m². Enligt Byggregler från denna tid [9] ställs i kap 37:251 krav på sektionering av vind till högst 400 m² men med undantag om vinden inte kan utnyttjas för förvaring. En ytan större än 1200 m² skulle alltid sektioneras. I det aktuella fallet fanns en helt öppen spalt ca 0.1x5 m mellan vindarna till de tre huskropparna på knappt 2000 m². I princip gäller samma krav i än idag. Storleken på vindarna var för sig är därmed rimlig, men det borde funnits brandvägg mellan varje byggnadskropp. Alternativet är att reflektera över orsaken till undantaget för vindar utan förvaring. Hade det med sannolik­ heten för antändning är det säkert rimligt, men om undantaget grundar sig på en bedömning av brandbelastning, borde kanske inte undantaget gälla om man har brännbar isolering i det aktuella faller ca en halv meter sågspån. Av faktaunderlaget framgår att det är osäkert hur stor branden är 00:45 och hur snabbt den utvecklar sig ytterligare. Då är frågan om det finns alternativ mot en kraftigt underventilerad vindsbrand om 600 m² eller till och med 1920 m². Brandspridning i yttervägg Ytterligare en komplikation är att branden spred sig ner i ytterväggen. Här kan konstateras att tidsfaktorn inte var lika avgörande. Eftersom brandsektionering saknades mellan huskropparna och eftersom kon­ struktionen inte förhindrade brandspridning ner i väggarna kan konstateras att brandens omfattning var givet redan när larmet kom 00:45.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 53 B1.5 Möjliga brytpunkter för annat metodval Nedan diskuteras möjliga brytpunkter i förloppet och hur andra metoder hade påverkat skadeutgången. Lägenhetsbranden En ordentlig riskbedömning hade identifierat risken för brandspridning via imkanalen till vinden. Det är rimligt att anta att mycket brandgaser har gått in i imkanalen vid genomföringen i bjälklaget och att en stor del av förbränningen har skett där. Frisk luft till samlingslådan tillförs via kanaler från andra lägen­ heter och det kan antas att det finns risk för att det bildas en brännbar blandning i samlingslåda och kanal. I flera kommuner har man vid dylika bränder valt att som rutin följa imkanalen upp på vinden för att försäkra sig om att brandsprid­ ning inte skett. I det aktuella fallet hade man då upptäckt att det fanns en iso­ lering av ca en halv meter sågspån på vinden. Genom att inspektera imkanalen sträckning till samlingslådan hade pyrande glödbrand tidigt kunna upptäckas och släckas. Vindsbranden En ordentlig riskbedömning hade omfattat en undersökning av vindens isole­ ring, sektionering mellan byggnaderna med mera innan beslut tagits om att låta taket brinna av. En släckmetod, vattendimma, skulle snabbt kunna kyla brandgaserna och alstra ett kraftigt undertryck i det nästan slutna vindsutrym­ met och därmed minska och fördröja brandspridning mellan huskropparna och neråt, längs asfaboarden i väggen. Med användning av några skärsläckare skulle branden på vinden kunnat slås ner och hållas underkontroll till dess man tagit beslut om hur kvarvarande glödbränder skulle släckas. Lämpligt är då att gå igenom tegelväggarna på husgavlarna för att kunna få tillräcklig kastlängd innan strålen bryts upp. Med tanke på husets längd, ca 50 m, och vindens volym 600 – 750 m3 krävs minst två skärsläckare, en på var gavel, i det hus där branden började (avsnitt 4 i Bilaga 11) för att snabbt få tillräcklig kylning i hela vinds­ volymen. Det första man ser när påföringen startar är att brandgaser slutar läcka ut vid takfoten på grund av den trycksänkning som förångningen i brandgaserna medför (Figur B 33 i Bilaga 11). Inom 5 – 10 minuter efter det att påföringen startar förångas huvuddelen av vattnet när det kyler brandgaserna till 200 – 300 ºC och vattnet genererar därför endast små vattenskador. När brandgaserna kylts tillräckligt kommer mer och mer vatten att förångas då det träffar varma ytor. Trycket i brandrummet börjar då öka och efter en stund kommer vattenånga (vit rök) att läcka ut vid takfoten. Att gå uppifrån är olämpligt, då strålen inte hinner bryta upp innan den träffar bjälklaget. Om branden spridit sig till nästa hus hade samma insats med skärsläckare behövt sättas in mot denna byggnad. Simuleringar av ett vindsutrymme som i storlek motsvarar vinden i flerbostads­ huset i Umeå är utförda med datorprogrammet PDS 6 av ass. professor Bjarne Husted vid avdelningen för brandteknik, LTH. Vid simuleringarna har man inte tagit hänsyn till dropparnas förångning. Av simuleringarna framgår att gashastig­ heterna i rummets längdriktning efter ca30 m blivit så små att vidare transport till längre avstånd av vattenånga, luft och små droppar som inte förångats eller fallit ut på golvet måste ske med brandinducerande flöden. Ett annat alternativ är att använda dimspik. För att täcka hela vindsvolymen hade man behövt slå in många dimspikar då de endast har en kort kastlängd. Arbetet med att montera dimspiken hade tagit mycket längre tid och varit risk­ fyllt för insatspersonalen. Vattenskadorna hade dessutom blivit avsevärt större än de man får med skärsläckare.

54 BILAGA 1 – Umeå Ålidshem 24-25/12 2008 Väggbranden En snabb insats med skärsläckare mot vindsbranden hade minskat strömmen av varma brandgaser ner mot asfaboarden och därmed minimerat risken för brand­ spridning neråt. Hade branden ändå börjat sprida sig nedåt i väggen hade en inspektion med IR-kamera kunnat upptäcka brandspridningen avsevärt tidigare än vad som skedde. B1.6 Referenser [1] Tapani, L., 2009, Brandutredning lägenhetsbrand Ålidhem, Umeå 2008-12-25. [2] Lundqvist, M., 2009, Fördjupad olycksundersökning, Brand i byggnad, Geografi­ gränd 2 A-J i Umeå 2008-12-24, Brandförsvarets insatsrapport 2008/888-889, Umeå kommun, dnr 200.2009.00005.23256. [3] http://www.hallbarastader.gov.se/Bazment/hallbarastader/sv/umea-kommun.aspx [4] Utryckningsrapport nr 2008X00888, Umeå brandförsvar. [5] Utryckningsrapport nr 2008X00889, Umeå brandförsvar. [6] Insatsrapport nr 2008X00888, Umeå brandförsvar. [7] Insatsrapport nr 2008X00889, Umeå brandförsvar. [8] Dagboksanteckningar Ålidhemsbranden, 25/12. [9] Svensk byggnorm 67, Föreskrifter, råd och anvisningar till byggnadsstadgan BABS 1967, Statens planverk, publikation nr 1.

BILAGA 2 Potatisåkern, Malmö 27/11 2007

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 57 BILAGA 2 Potatisåkern, Malmö 27/11 2007 B2.1 Objektsbeskrivning Flerfamiljshus byggt 1996 med 6 (delvis 7) våningar och 7 trapphus, se Figur B 3. Totalt fanns det 70 lägenheter i byggnaden. Stommen var av betong och en tak- och vindskonstruktion av trä- och stålbalkar. Översta delen av byggnaden hade en trästomme. Från plan 5 och uppåt var byggnaden klädd med zinkplåt. Varje lägenhet var utförd i klass EI60. På vindsutrymmet fanns det lägenhetsförråd och det var därför uppdelat i sektioner om 400 m2. Figur B 3. Schematisk layout av byggnaden, layouten är framtagen baserat på information i utredningar[1-3] och ritningar över hus J, som är en spegling av hus 3. B2.2 Incidenter före branden Bränder på vindar som har medfört stora skador är tyvärr inte ovanliga [4] och det är ett problem som har varit känt långt innan branden på Potatisåkern. Boverket har t.ex. informerat kring detta [5] och räddningsverket (nuvarande MSB) har gjort detaljerade utredningar på omfattande vindsbränder där brister i det byggnadstekniska brandskyddet framkommer. En taktik som räddnings­ tjänsten tillämpat ett tag är att låta vinden brinna av. I en genomförd fallstudie [4] har det visats att detta i flera fall varit en lyckad taktik. Det är dock viktigt att vindsbjälklaget är tillräckligt sektionerat och att det är möjligt att kontrollera branden.

58 BILAGA 2 – Potatisåkern, Malmö 27/11 2007 B2.3 Branden Beskrivningen av brandförloppet baseras på information från Räddningstjänsten Syds insatsrapport [1], Räddningstjänsten Syds olycksutredning och utvärde­ ringen av gjord av Södertörns brandförsvarsförbund [3]. Branden upptäcktes först i en lägenhet med två plan belägna på plan 5-6 i den nordvästradelen av byggnaden. Det hade eldats i kaminen på andra våningen i lägenheten tidigare under kvällen. Glöd kring rökkanalen vid anslutningen till genomgången av vindsbjälklaget upptäcktes efter 23:30. Branden hade troligen på gått på vinden ett tag vid denna tidpunkt. Lägenhetsinnehavaren och dennes son slog sönder gipsen kring kanalen och försökte släcka med vatten. Samtidigt larmades rädd­ ningstjänsten. Vid den tidpunkten brann det i yttertaket. Under kvällen blåste det i husets längdriktning (nordvästlig vind) med 15 m/s. Det fanns flera mindre ventilationsöppningar i takfoten och i taket vilket gjorde att branden välventi­ lerad initialt. Dessutom fanns det vindsförråd som var fyllda med brännbart material. Detta gjorde att branden fick ett snabbt förlopp. Vindsutrymmet där branden började hade en area som översteg 400 m2 och hade därför sektionerats med en vägg i klass B30. Det var dock oklart vid denna tidpunkt vilka brandtek­ niska avskiljningar som fanns på vinden.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 59 Beskrivningen nedan av branden och släckinsatsen bygger på uppgifter i utryck­ nings-/insatsrapporter och dagboksanteckningar [4-8]. BRANDFÖRLOPP RÄDDNINGSTJÄNSTINSATS Ca 23:30 Glödbrand kring en rökkanal upptäcks av boende. 23:39 Larm inkommer till räddningstjänsten. Ca 23:45 Boende öppnar hål i taket vid rökkanalen, ser glöd och försöker släcka med hinkar med vatten. De boende ser sedan att det brinner i taket genom en spegling i fönstret på bygganden på andra sidan av gatan. Släckning med vattenhink. 23:45 Räddningstjänsten anländer. Ca 23:50 Rökdykare kommer in i lägenheten, de noterar ett rökdis i lägenheten och ser, genom ett hål, att det brinner ovanför innertaket. Rökdykare tar sig upp på vinden. Ser att det är en fullt utvecklad brand på vinden och på börjar släckning. Brandmännen är tvungna att retirera och avslutar släckinsats. Istället hjälper de till med evakuering. Invändig släckning av rök­ dykare med vatten. Strålrör. Ungefär samtidigt reses höjdfordon (hävare) för utvändig släckning vid trapphus 3 A, vattenförsörjning till höjdfordonet försenas dock. Rädd­ ningsledningen tror fortfarande att det är en lägenhetsbrand eftersom det är etagevåning. Utvändig släckning med vatten­kanon från hävare. Taket på husgaveln har brunnit av. Taket till etagevåningen rasar in. Beslut om att översta våningar ska evakueras och genomsökas. 00:00 Oklart hur brandcellsindelning på vinden ser ut för räddnings­ tjänsten. Beslut om begränsningslinje mellan trapphus 3A och 3B av jourhavande brandingenjör, som då har tagit över som räddningsledare. 00:05-00:12+1 Höjdfordon med skärsläckare reses vid trapphus 3A och förses med vatten från en enhet som anländer 00:12. Tanken är att skärsläckaren ska förhindra brandspridning från den del vinden där branden startat. Vatten/skärsläckare. Försök görs med invändigt släckning vid trapphus 3B, men pga. hettan (200°C på vindsdörren) beslutar man att inte genomföra den. Personal går även in i trapphus 3C men inser att man inte hinner före branden och omgrupperar och går in i trapphus 3D. Rökdykare kan då gå in på vinden genom trapphus 3D, men efter en stund trycks en del av väggen mot 3C in och varma brandgaser gör att rökdykarna måste retirera. Utvändigt försöker personal på hävare och maskinstege dämpa branden. Utvändig släckning med vatten. 00:30+1 Beslut om att upprätta begränsningslinje mellan hus 3 och 5. 01:30 Sprider sig branden förbi begränsningslinjen mellan hus 3 och 5. 02:00 Försök att begränsa branden vid trapphus 5C. Överger taktiken att försöka släcka branden och låter vinden brinna av och lägger ny begränsningslinje att branden inte får gå ner mer än till översta våningsplanet. Kontrollerar brandspridning neråt i byggnaden. 06:15 Branden under kontroll.

60 BILAGA 2 – Potatisåkern, Malmö 27/11 2007 I följande bildserie, Figur B 4, återges hur branden spridits över vinden/översta planet vid olika tidpunkter. 23:30 Branden upptäcks. 23:50 Brand på vinden ovan etagelägenheter. Ca 00:15 Ca 00:30 Ca 02:00

02:00 Hela vinden involverade i branden.

Figur B 4. Uppskattad brandspridning vid olika tidpunkter. B2.4 Analys Brandens upptäcktes runt 23:30. Ett detektionssystem i vindsutrymmet hade inneburit att branden upptäckts tidigare och hade möjligen kunnat släckas i ett tidigare skede. Med tanke på att vindsutrymmet användes som förråd, med hög brandbelastning som följd och det faktum att vindsbränder kan ge förödande konsekvenser anses det motiverat att installera någon typ av detektionssystem. De boende i etagelägenheten använde hinkar med vatten för att försöka släcka den glödbrand som de såg i taket kring en rökkanal. Att släcka genom att kasta vatten från en hink uppåt bedöms vara svårt. Eftersom det förmodligen var svårt

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 61 att komma åt branden nerifrån lägenheten så hade man sannolikt inte kunnat släcka branden, men det är mycket möjligt att man skulle ha köpt tid i väntan på räddningstjänsten. Styrkorna larmades ut till en lägenhetsbrand och ganska långt in i förloppet uppfattades det som en lägenhetsbrand av insatsledningen. Det är oklart vilken information om objektet/branden som insatsledningen sökte under framkör­ ningen och det initiala skedet av branden. När räddningstjänsten är på plats undersöker rökdykare lägenheten och konstaterar att det brinner i utrymmet ovanför lägenheten. De gör något släckförsök men retirerar och blir sedan satta att hjälpa till med utrymningen. Enligt de genomförda utredningarna befann sig ett rökdykarpar bakom en brandtekniskavskiljning vid trapphus 3D runt 00:15. Som det framgår av utredningarna verkar det som att rökdykarna inte gjorde någon aktiv insats utan avvaktade. Hus 5 var en våning högre än hus 3 och den betongvägg som fanns mellan husen slutade vid taket i hus 3. Detta innebär att branden kunde spridas förbi betongväggen då den bröt igenom taket på hus

1. Det finns inget krav på brandmursavskiljning. Först när branden nått trapp­

hus 5C, d.v.s. hela vinden var nedbrunnen så fattades beslutet att låta vinden brinna. Den hårda vinden och svårigheten att ta sig runt huset med höjdfordon och svaga brandtekniska avskiljningar mellan vindsutrymmena är faktorer som påverkat insatsen. Detta är en vanligt förekommande avskiljning som räddnings­ tjänsten måste vara medvetna om. B2.5 Möjliga brytpunkter för annat metodval Nedan diskuteras möjliga brytpunkter i förloppet och hur andra metoder hade påverkat skadeutgången. Lägenhetsbranden En noggrann riskbedömning hade i ett tidigt skede identifierat risken för brand­ spridning i vinden och medfört att en annan släckutrustning som kunde alstra vattendimma medförts som första insats. Någon typ av varningsklocka bör ringa när det brinner på översta våningen i ett flerbostadshus, eftersom vindsbränder i flerbostadshus länge har varit ett problem och flera av dessa bränder leder till total förstörda byggnader varje år. Därför är det viktigt med god objektskunskap. Bland annat är det viktigt att ta reda på om och vart på vinden det finns brand­ tekniska avskiljningar. Vindsbranden En annan släckmetod med vattendimma och trycksättning skulle snabbt kunna kyla brandgaserna och alstra ett kraftigt undertryck i de vindssektioner där det brann och därmed minska och fördröja brandspridning mellan vindsektionerna. En tidig inspektion av vindssektionerna via vindsdörrarna i trappuppgångarna skulle underlätta val av angreppspunker för insatserna. Trycksättning av angrändande vindsutrymmen genom trapphusen och öppna vinds­ dörrar skulle snabbt alstra ett övertryck i trapphusen och vindssektionerna (Bilaga 10) och därmed minska risken för brandspridning och säkra utrymningsvägar. Genom att förbereda för flera skärsläckarinsatser via dörren till vindssektionerna i trapphusen och från hävare skulle branden på utsatta vindsektionen kunnat slås ner och hållas under kontroll till dess till dess att man skapat en säker arbetsmiljö för invändig insats i drabbade utrymmen. Lämpligt är då att gå igenom vinds­ dörrarna och väggarna på ställen där man kan få tillräcklig kastlängd innan strålen bryts upp. Med tanke på husets längd och vindens volym krävs minst två

62 BILAGA 2 – Potatisåkern, Malmö 27/11 2007 skärsläckare per vindsektion (avsnitt 4 i Bilaga 11) för att snabbt få tillräcklig kylning i hela vindsvolymen. Om branden spridit sig till nästa vindsektion hade samma insats med skärsläckare behövt sättas in mot denna sektion på ett likartat sätt som vid vindsbranden i Umeå (Bilaga 1). Ett annat alternativ är att använda dimspik för mer information om för- och nackdelar med båda arbetssätten. B2.6 Referenser [1] Insatsrapport Brand på Marietorpsallé 3-5, Malmö. Räddningstjänsten Syd. [2] Nilsson, B., (2008) Olycksundersökning Brand på Marietorpsallé 3-5, Malmö. Räddningstjänsten Syd. [3] Danielsson, S., Kjell, T., Winnberg T., (2008) Utvärdering av räddningsinsatsen vid vindsbranden på Marietorps Allé. Södertörns Brandförsvarsförbund. [4] Johansson, N., van Hees, P., En studie av vindsbränder utifrån statistik och brandutredningar, Report 3152. Brandteknik, LTH 2010. [5] Boverket (2003) Boverket informerar om brandspridning på vindar. Boverket informerar 2003:8. Räddningsverket. (2002) Brand i hyreshus i Karlstad december 2001. Karlstad.

BILAGA 3 Vindsbrand Vindelgatan, Borås 16/4 2010

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 65 BILAGA 3 Vindsbrand, Vindelgatan, Borås 16/4 2010 B3.1 Objektbeskrivning Flerfamiljshus från 50/60-tal med tre våningar, två trapphus och 14 lägenheter, se Figur B 5. Medräknat två lägenheter på vindsvåningen, en i var gavel. Trapp­ husen gick ända upp till vindsvåningen där dörr in till vind också fanns. Vinden var inte sektionerad utan sträckte sig mellan båda trapphusen. Byggnadens fasad var tegel och takbeklädnad av råspont, takläkt och taktegel [1, 2]. Figur B 5. Vindelgatan 46. Foto: Google. B3.2 Branden Larm till SOS inkom 22:53 om rökutveckling från taket på ett flerfamiljshus på Vindelgatan 46b den fjärde april 2010. Nedan berättar insatsledaren med egna ord sina upplevelser och reflektioner kring beslut om ledning, taktik och metodval. Jag började närma mig larmadressen när SOS meddelade att det fanns rök ute i trapphuset. Det skymde ute och huset bildade en mörk siluett där våningsplan, fönster och dörrar var svåra att urskilja. Jag fick möte ute på gatan av kvinnan som larmat, hon pekade mot taket på bostadshuset. Det gick att skönja en dimliknande vit rök utefter taksidan mot gatan, men det gick inte att avgöra källan till denna rökutveckling. Min blick svepte längs hus­ fasaden för att om möjligt urskilja om det fanns tecken på rök eller brand från någon av lägenheterna. Ingen synlig orsak kunde upptäckas. Övrig utrycknings­ styrka anlände nu till larmadressen och jag mötte upp styrkeledaren i första släckbilen samtidigt som jag hörde tydliga rop om hjälp från byggnadens gavel. Tillsammans med styrkeledare 1 sprang vi fram till gavelsidan och upptäckte att två yngre kvinnor hängde ut genom fönstret på vindsvåningens gavel. De påkal­ lade hjälp och sa att deras lägenhet håller på att rökfyllas. Samtidigt kontrolle­ rade styrkeledare 2 entredörrar i trapphusen och konstaterade att rök trängt ner ända till ytterdörrarna. Utifrån mina första intryck av skadeplatsen formulerade jag några omedelbara åtgärder.

66 BILAGA 3 – Vindsbrand, Vindelgatan, Borås 16/4 2010 Mina taktiskta beslut om omedelbara åtgärder: • • Livräddning av personerna som hänger ut genom fönstret via räddnings­ tjänstens skylift. • • Att ej välja livräddning via trapphus berodde på att trapphusen var rök­ fyllda vilket skulle medföra tidsfördröjning att nå fram till utsatt lägenhet på fjärde våningen och därefter livrädda med Revitox andningsmask. • • Samtidigt som livräddning sattes igång scannade jag takytorna och hus­ fasaden med hjälp av IR-kamera. Det framgick tydligt att takytorna och taknocken var kraftigt värmepåverkade och den högsta värmekoncentra­ tionen (500 – 650 °C) var i den mittersta delen av taket, men det var ingen onormal temperaturhöjning kring fönster och dörrar i fasaden. På grund av detta fick styrkeledare 1, som hade befälet över livräddning, komman­ dot att efter livräddning se till att skyliften går i position på gavelspetsen och förbereda för brandgaskylning av vindsutrymmet med hjälp av skär­ släckaren, samt hålla vindsutrymmet skall hållas tillslutet under brand­ gaskylningen. • • Nästa steg var att snabbt informera inre befäl om läge på plats och begära en maskinstege samt två släckenheter som förstärkning. Polis och ambulans hade nu kommit till platsen. • • Ledningsplats blev vid parkeringen utefter gatan. Efter att de omedelbara åtgärderna igångsatts genomfördes en orientering runt byggnaden och sedan samlade jag styrkeledare 1 och 2 för lägesgenomgång. De skadeplatsfaktorer som identifierats på skadeplatsen var: • • Flerbostadshus med misstänkt brand på vinden. • • Brandgaser ute i båda trapphusen. Rökfyllnad ner till trapphusentrén. • • Personer hänger ut genom gavelfönster. • • Livräddningsbehov omedelbart. • • Brandgasspridning från vind. • • Antändningsrisk och brandspridning. • • Boende i huset har rökfylld utrymningsväg. • • Tillgängliga resurser. Utifrån dessa skadeplatsfaktorer gjordes en riskbedömning och identifiering av möjliga åtgärder för fortsatt insats. Under tiden riskbedömningen pågick så gav sig boende tillkänna via fönster, men de uppmanades att stanna kvar i lägen­ heterna tills annat meddelats. Detta på grunda av att utrymma huset genom rökfyllda trapphus är riskfyllt och därför valdes denna åtgärd bort. Efter läges­ genomgång med styrkeledarna så togs besluts om följande mål med insatsen och taktisk plan: Mål Med Insats (MMI) Livräddning, brandgaskylning på vind, säkra trapphusen och slutför släckning samt kontroll av trapphusen. Taktisk plan:

1. Livräddning av personer vid gavellägenhet med hjälp av skylift.
2. Brandgaskylning av ansamlade brandgaser på vind, med skylift och skär­

släckare efter avslutad livräddning.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 67

1. Boende som öppnar fönstren uppmanas stanna kvar i lägenhet.
2. Genomsökning av trapphus 1 med hjälp av RD-grupp. På plats fanns endast

resurser för att genomsöka ett av trapphusen och trapphus 1 bedömdes som mest kritiskt eftersom det var vinden ovanför detta trapphus som var mest värmepåverkad.

1. Placera en övertrycksfläkt i vardera entrédörren i trapphusen. Töm därefter

trapphuset på rök och brandgaser via fönster våning för våning. Efter töm­ ning av brandgaser, trycksätt genom stängning av fönster.

1. RD-grupp i trapphus 1 går i position vid branddörr till vind på fjärde våningen,

sedan invänta klartecken under tiden som brandgaskylning med skärsläckare via skylift får avsedd effekt.

1. Säkerhet: Hög skyddsnivå på inledande brandgaskylning, genom yttre kylning.
2. När kylningen fått avsedd effekt kommunicerar styrkeledare 1 och 2

därefter skiftar insatsen över till invändig insats med hjälp av RD-gruppen. Trycksättning och samtida brandgasventilering avser att ge en säker insats och förbättrad arbetsmiljö inne i vindsutrymmet. Den fortsatta insatsen Jag samlade styrkeledare och genomförde snabba genomgångar var 10 – 15 min för att följa upp resultat av taktik och metodval. Polis och ambulanspersonal medverkade vid dessa och blir fortlöpande informerade om insatsen och hur de kunde samverka under insatsen. Ett flertal metoder användes nu i ett flöde vilket krävde tydlig information om metodval och vilken effekt som vi ville uppnå och vilka alternativa metoder som brandpersonalen kunde använda om omfall skulle bli nödvändigt. Tydlig kommu­ nikation var viktigt mellan insatspersonalen och alla måste ha klart för sig läges­ beskrivningen, möjliga metodval samt vad som skulle uppnås med insatsen. När insatsen övergått i att värdera resultatet av de första åtgärderna kunde vi konstatera att livräddningen snabbt genomförts som första åtgärd 4 – 6 minuter efter att räddningstjänsten anlänt. Därefter ventilerades trapphusen och säkrade utrymningsvägarna för boende i huset. Den rökpelare som uppmärksammades med hjälp av IR-kameran från mitten av taket visade sig vara början till en genombränning av yttertaket. Anländande höjdfordon nr 2 fick till uppgift att kontrollera taksektionen från ovansidan. Om inte en offensiv taktik med brandgaskylning via skylift valts hade förmodligen branden snabbt utvecklats till en helt övertänd vind och takbrand där släckresur­ serna på plats ej varit tillräckliga för att kontrollera och släcka branden. Konstaterade efter avslutad släckinsats att inga synliga tecken på släckvatten fanns på vindsplanet och endast en svag röklukt kändes i trapphusen. Boende i byggnaden valde att bo kvar i sina lägenheter efter branden. En kraftig djuplig­ gande förkolnad fanns på innertak och takstolar i den mittersta delen av vinden. De båda gavellägenheterna hade ett begränsat vindsutrymme ovanför vilket medförde att branden hade större spridning där vindsutrymmet omfattades av hela volymen från golv ända upp till taknock (se Figur B 6). De visuella iakttagelserna som gjordes efter branden bekräftade tolkningar som skett med hjälp av IR-kameran före-under-efter insats. IR bilden fick en mycket stor betydelse vid val av taktik och metod samt igångsättande av omedelbara åtgärder i inledningen av insatsen. IR informationen gav god hjälp att tolka effekten av insatta släckåtgärder.

68 BILAGA 3 – Vindsbrand, Vindelgatan, Borås 16/4 2010 Brandförloppet och räddningstjänstens insats sammanfattas nedan i tabellformat. Beskrivning bygger på uppgifter från insatsbeskrivning från SÄRF [1] och intervju med Krister Palmqvist [2]. BRANDFÖRLOPP RÄDDNINGSTJÄNSTINSATS 22:53 Larm inkommer till SOS om rökutveckling från tak. Framkörningstid ungefär 5-6 minuter. 23:00 Räddningstjänst anländer. Vit rök syns från takfot och kring ventilationshuvar och taknock, men det går inte att avgöra källan till rökutveck­ lingen. Trapphusen är rökfyllda. Två personer från vindvåning hänger ut genom ett gavelfönster och ropar på hjälp. Vindsbrand misstänks eftersom det vid utvändig inspektion inte finns tecken på brand i någon lägenhet. På grund av osäkerheten kring utveck­ lingen av brandförloppet är omedelbar åtgärd livräddning av personer i vindsvåning via skylift. Samtidigt trycksätts och ventileras trapphusen med två övertrycksfläktar. Övriga lägenheter evakueras inte eftersom branden inte hotar dessa och samtidigt som en snabb evakuering kan ske vid behov då övertrycksventileringen fungerar och trapphusen är rökfria. Via IR-kamera syns tydlig värmespridning på tak­ konstruktion samt värmeströmning ut från takfot till taknock. Mitten av vinden har högst tempera­ tur. Inga lågor syns men den höga temperaturen indikerar att antändning skett tidigare och att branden i detta skede är ventilationskontrollerad. Skärsläckare skjuts in vid gavelspetsen men på grund av tekniska problem med skärsläckaren sätts istället rökdykargrupp in i trapphus 1 för att kyla brandgaser via vindsdörr. Temperaturen är dock för hög så retirering sker tillbaka till trapphus. Tekniska problemen avklarade och kylning som planerat med skärsläckare och kyleffekt märks på närmare halva vinden. Via IR-kamera syns en tydlig lokal värmepunkt ovanför trapphus 2. Troligen är startbranden belägen där. För att få bättre effekt mot brandhärden flyttas skärsläckaren längs med taket mot mitten av vinden. Sedan riktas skärsläckaren diagonalt mot den andra gavelsidan, se också Figur B 6. Effekt syns nu på resten av vinden. Genombränning av taket sker ovanför trapphus 2 vilket medför att brandgaser och vattenånga strömmar ut med hög hastighet. Hastigheten på utströmmande brandgaser minskar på grund av ändrade tryckförhållanden på vinden när skärsläckaren används. Röken blir vit och IR-kameran visar en kraftig sänkning av temperaturen. Detta indikerar att skärsläckaren har bra effekt på branden. 23:30 Temperaturen på vinden har sänkts från ca 700 grader ner till ca 100 grader. 23:30 Skärsläckarinsats avslutas och rökdykar­ grupper från trapphus 1 och 2 går in på vinden och släcker resterande glödbränder. 00:15 Restvärdesräddning påbörjas. B3.4 Analys Ett detektionssystem på vinden och i trapphusen hade minskat tiden till upptäckt och skadorna hade blivit avsevärt mindre. Efter branden kunde det konstateras att branden antagligen pågått 30 – 60 minuter innan upptäckt [1]. Målet med insatsen var livräddning och aktiv släckning av branden. Den taktiska planen var inledningsvis utvändig evakuering via hävare eftersom en evakuering genom trapphusen skulle medföra en tidsfördröjning för att nå fram till den utsatta lägenheten. När sedan trapphusen blev rökfria, skulle evakuering av inneboende ske genom trapphus om så behövdes. På grund av den höga värmen och inga synliga lågor måste brandgaskylning ske snabbt för att undvika över­ tändning. Temperaturen och brandgaserna indikerade att branden var ventila­ tionskontrollerad och därför behövdes en metod som kunde kyla brandgaserna

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 69 utan att tillföra syre till branden. Valet föll på skärsläckaren eftersom den kan nå långt in i brandrummet med vattendimma utan att behöva öppna upp med risk för övertändning. Branden och den brandutsatta vinden hade optimalt förhållande för ett lyckat resultat med skärsläckaren. Genom att påföra vatten vid höga temperaturer sker en snabb förångning av vattendimman vilket leder till en effektiv kylning av brandgaser och konstruktion samt sänkt partialtryck av syre (inertering) i utrymmet. Om temperaturen varit lägre hade det blivit ett mer utdraget förlopp på grund av att förångningen inte sker lika snabbt och inerteringen genom sänkt partialtryck av syre inte blivit lika markant. Det var också positivt att vinden inte var ventilerat eftersom detta gjorde att effekten av inerteringen förstärktes. [3] Det är viktigt att läsa av branddynamiken och förstå hur branden påverkas av släckangreppen. Denna insats visar på nyttan med att följa utvecklingen med IR-kamera och utseendet på brandgaser så att man direkt kan se om skärsläckaren ger effekt eller om man behöver ändra vinkeln eller placeringen. När skärsläcka­ ren användes kunde man snabbt se att metodvalet var rätt och resultatet visade att det blev minimala vatten- och rökskador. Det konstaterades också att det bara brunnit i brandgaslagret men att övertändning varit nära. Alla boende kunde bo kvar och dagen efter var det endast en förnimmelse av röklukt i trapphusen. Hade enbart rökdykargrupp gått in genom trapphusen för släckning av vinds­ branden hade antagligen trapphusen blivit rökskadade och det hade behövts en kraftigare vattenpåföring vilket kunnat resultera i vattenskador. Vidare hade arbetsmiljön för rökdykarna varit betydligt sämre. Att blanda in tillsatsmedel i skärsläckaren hade antagligen ökat hastigheten på kylning och påföringstiden hade blivit kortare eftersom återantändningsskyddet hade blivit bättre. Det är dock viktigt att ta hänsyn till både kortvariga och lång­ variga konsekvenser av de tillsatsmedel man väljer att använda. Läs mer om olika tillsatsmedels påverkan på människa och miljö i MSB rapporten; Förmåga och begränsningar av förekommande släcksystem vid brand i byggnad – fokus på miljöarbete [4]. B3.5 Möjliga brytpunkter för annat metodval Nedan diskuteras möjliga brytpunkter i förloppet och hur andra metoder hade påverkat skadeutgången. Antändning Branden var sannolikt anlagd och möjliga åtgärder för att förebygga anlagd brand är att ha trapphus och vind låsta för obehöriga. Upptäckt Det fanns tydliga tecken på att branden hade pågått i 30 till 60 minuter innan den upptäcktes. Dels var det den extremt höga temperatur som upptäcktes med IR-kamera på utsidan av vinden och dels kunde man se det på förkolnaden av trästolarna efter branden. Ett detektionssystem på vinden och i trapphusen hade upptäckt branden tidigare, vilket hade inneburit tidigare insats och därmed mindre skador. Utrymning Dörrstängare och röktäta dörrar till vinden hade medfört att trapphusen inte blivit rökfyllda och personer i lägenheterna hade kunnat utrymma själva. Vinden var dessutom en genomgång mellan trapphusen vilket gjorde att båda trapphusen blev rökfyllda.

70 BILAGA 3 – Vindsbrand, Vindelgatan, Borås 16/4 2010 Vid räddningstjänstens ankomst gick det inte att lokalisera branden utan det man såg var att trapphusen var rökfyllda och att det inte fanns någonting som tydde på en lägenhetsbrand. Eftersom det var mycket osäkert läge om var branden var och hur branden skulle utvecklas var livräddning första prioritet. Omedelbar åtgärd blev yttre livräddning med hävaren av de två personerna som befann sig vid det öppna gavelfönstret och samtidigt övertrycksventilerades trapphusen. Eftersom detta gav bra effekt blev riskbedömning att övriga lägenheter inte behövde utrymmas då en snabb utrymning via de rökfria trapphusen kunde ske vid behov. Alternativet hade varit att inte utrymma personerna i vindslägenheten. Personerna i vindslägenheten var dock väldigt stressade och risken hade varit att de hoppat från fönstret med risk för skador. Vidare fördröjde inte evakueringen insatsen eftersom hävaren hamnade på ett bra ställe för livräddning och bekämpning av branden med hjälp av skärsläckaren. Släckangrepp 1 IR-kameran visade att det förkom hög temperatur på vinden och den högsta temperaturen var mitt på vinden. Beslut fattades därför att placera skärsläckaren vid ett hål på gavelspetsen. Två anledningar fanns till att gå in via gaveln. Första anledningen var att man inte visst hur vinden såg ut och att det var störst chans att nå så stor del av vinden som möjligt utan att stöta på hinder om skärsläckaren sköts in vid gavel. Skulle skärsläckaren skjutits in via vindsdörren så skulle risken för att stöta på hinder varit större. Andra anledningen var att hävaren var place­ rad vid gaveln så det var det snabbaste alternativet. Tyvärr fick skärsläckaren tekniska problem och insatsen blev fördröjd, därför gjordes ett försök att gå in med rökdykargrupp via trapphus 1. Detta misslycka­ des dock på grund av att värmestrålningen var extremt hög innanför vindsdörren. När skärsläckaren fungerade igen så mättes effekten av skärsläckaren hela tiden med hjälp av IR-kamera. Brandmännen provade att vinkla skärsläckaren åt olika håll och såg vad som gav mest effekt. En tydlig kylning av halva taket syntes i IR-kameran. Det man inte visste då var att det fanns ett murverk som begränsade vägen för vattenstrålen. Att gå in via gaveln har i andra insatser visat sig vara det säkraste alternativet för att skärsläckaren ska kunna uppnå full effekt utan att stöta på hinder. Ett exempel är en brand i Svenljunga där skärsläckaren sattes in vid ena gaveln och trots att byggnaden var 60 meter lång så syntes effekt direkt genom att intensiteten i brand­ gaserna avtog och färgen övergick från svart till vit. Uppskattningsvis var den totala tiden för släckning av skärsläckaren en timma och släckningen genomfördes i perioder från 10 upp till 50 sekunder. Bäst effekt var när en rak stråle fick arbeta och skapa lång effekt in i vindsutrymmet genom brandgaser och lågande brand. Hela tiden var det tät kommunikation mellan den som använde skärsläckaren och den som hade IR-kameran för att skärsläckaren skulle användes på bästa sätt [1]. Hade istället för skärsläckaren det ensidigt valts att gå in med rökdykargrupp hade arbetsmiljön för brandmännen varit sämre. Vid öppning av vindsdörren hade branden som var ventilationskontrollerad fått tillgång till mer syre, vilket kunnat resultera i högre risk för antändning med stor effektutveckling samt att mer rök hade kommit ut i trapphuset. Vid släckning med dimstrålrör hade det behövt kraftigare vattenpåföring [3] och det hade troligen resultera i vattenskador. Släckangrepp 2 Innan släckangrepp 2 hade en maskinstege kommit på plats och placerades vid trapphus 2 för att undersöka en rökpelare ovanför trapphuset. Nu kunde det med säkerhet konstateras att det var en vindsbrand och eftersom skärsläckaren endast kom åt halva taket togs beslutet att flytta positionen på skärsläckaren

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 71 närmare där högst temperatur påvisades enligt IR-kameran. Efter förflyttningen fick skärsläckaren full täckning på vinden och det gick att se på brandgasernas färg och turbulens att skärsläckaren träffade brandhärden i mitten på vinden. Om inte förflyttning av skärsläckaren hade gjorts skulle kyleffekten av skär­ släckaren varit begränsad och risken stor för fullt utvecklad vindsbrand. Figur B 6. Angreppspunkter med skärsläckare. Första försöket genom gavelspetsen av huset och andra försöket strax ovanför trapphus 1. Bild: Krister Palmqvist (SÄRF). Släckangrepp 3 Under tiden som skärsläckaren kylde brandgaserna stod två rökdykargrupper redo att gå in på vinden, en i varje trapphus. När temperaturen sjunkit ner till ca 100 grader gavs order om att avsluta skärsläckarinsatsen och låta rökdykar­ grupperna gå in och släcka de sista glödbränderna. Tack vare kylningen av brand­ gaserna var arbetsmiljön för rökdykargrupperna mycket bättre än tidigare och de kunde använda väldigt lite vatten för att släcka de sista brandhärdarna. Skärsläckarinsatsen avslutades när temperaturen hade sjunkit till ca 100 grader trots att IR-kameran visade att skärsläckren fortfarande hade effekt på branden då temperaturen fortsatte att sjunka. Alternativ metod hade varit att fortsätta arbeta med skärsläckaren och inte gå in med rökdykargrupp. Skärsläckaren är dock mest effektiv vid höga temperaturer eftersom den höga effekten kan utnyttjas till att förånga tillräckligt mycket vatten för att släcka branden genom inertering. Detta underlättas om utrymmet är tillräckligt tillslutet så att inte syre fritt kan tillföras [3]. Troligen hade behovet blivit att brandmän ändå behövt gå in för att kontrollera och släcka de sista glödbränderna. B.3.6 Referenser [1] Palmqvist, K. Södra Älvsborgs Räddningstjänst, intervju april 2014. [2] Insatsbeskrivning, Vindelgatan 46b, 2010-04-16, Södra Älvsborgs Räddningstjänstförbund. [3] SÄRF och SP (2010). Skärsläckarkonceptets operativa användande. Räddningsverket, 2010. [4] Lindström, J., Appel, G., Palmkvist, K., Bialas, K. (2013). Förmåga och begränsning av förekommande släcksystem vid brand i byggnad – fokus på miljöarbete. MSB, Karlstad.

BILAGA 4 Västerås 30/9 1991

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 73 BILAGA 4 Västerås 30/9 1991 B4.1 Objektbeskrivning Byggnaden som brann är byggd i ett plan med yttermåtten 109x168 m och en takhöjd mellan 6 och 7 m. Konstruktionen är baserad på pelare och balkar i betong. Avskiljande väggar består av gipsskivor på stålreglar och ytterväggarna av plåt och mineralull. Taket består inifrån räknat av plåt, isolering och papp­ täckning. Avvattning sker invändigt via avloppsrör i plast. Byggnadskonstruk­ tionen är alltså i stort sett obrännbar. [1] I branden deltog delar av två rum, betecknade med sektion 29 och 30 i Figur B 7. I sektion 29 fanns maskiner för lödning och tvättning av kretskort, sammanlänkade av ett transportband. Enheten hade en sammanlagd längd av 11.8 m och största bredd och höjd 1.0 resp. 1.4 m. Vid lödmaskinen förvarades en plastdunk med 15 l flussmedel (85 % isopropanol) och en plåtdunk med ca 20 l isopropanol. Ingen av denna vätska återfanns efter branden. I maskinen fanns en plastbehållare med isopropanol som förblev oskadad. Figur B 7. Ungefärlig plan över byggnaden, med nummer på brandlarmssektionerna. Ovanför maskinerna löpte kabelstegar som också deltog i branden. Där fanns också kanaler för processventilation som anslöt till både löd- och tvättmaskinen. I lokalen fanns också ett pallställ med lindningstråd. [1] I den del av sektion 30 som deltog i branden fanns fyra plåtskåp med brandfarlig vätska. Skåpen var 1.9 m höga och breda och 1.3 m djupa med plats för fat nertill och en hylla för mindre behållare upptill. I skåpen förvarades brandfarlig vara. Klass 1: isopropanol och flussmedel (100 l) samt bensin, aceton, skyddslack, (tillsammans 32 l). Klass 2: lacknafta (300 l). Av övriga vätskor kan nämnas metylenklorid (120 l), hydraul­ olja (ett fat) samt diverse smörjoljor m.m. Skåpen skyddades av en automatisk släckanläggning med 25 kg halon 1301. [1] Ovanpå skåpen fanns ett pallställ i två våningar med blandat gods på träpallar. Ovanför pallställen fanns en kabelstege.

74 BILAGA 4 – Västerås 30/9 1991 B4.2 Branden Branden uppstod sent på kvällen och räddningstjänsten larmades av det auto­ matiska brandlarmet. Brandorsaken var oklar, men det fanns inget som tyder på att branden var anlagd. Räddningstjänsten var, liksom personal från företaget, snabbt på plats. Den insats som gjordes bestod av parallella rökdykarinsatser som dock inte lyckades slå ner branden. När branden spred sig upp på taket påbörjades utvändig släckning med vattenkanoner. Beskrivningen nedan av branden och släckinsatsen bygger på uppgifter i två utredningar som gjorts [1, 2]. BRANDFÖRLOPP RÄDDNINGSTJÄNSTINSATS Två utredningar har gjorts [1, 2] om brandens uppkomst, vilka kom till helt olika slutsats och där ingen av utredningarna förklarar samtliga observa­ tioner. Det kan alltså konstateras att brandorsaken inte är till fullo klarlagd. Haverikommissionen anser i sin utredning att branden börjat i brandlarmssektion 29 i en tvättmaskin för tvättning av kretskort och att brandorsaken är slitage och oxidation i kontaktor till en huvudströmkrets. Detta har lett till att kon­ taktorn fastnar i slutet läge och att strömmen är påkopplad trots att alla signallampor är släckta. Strömmen ger överhettning med efterföljande antändning av brännbara delar i maskinen. I utredningen finns ingen förklaring till den snabba brandspridningen genom väggen och till den andra lokalen. [1] En oberoende utredare har kommit fram till ett annat inledande brandförlopp. Branden har istället börjat i sektion 30 på grund av att brandfarlig vätska (klass 1) runnit ut och att bränsleångor an­ tänts av termostaten på en varmvattenberedare. Denna förklaring motsägs av att varmvattenbere­ daren är placerad i den angränsande lokalen och att golvet, enligt haverikommissionens utredning, lutar åt andra hållet. [2] 22:45 Det automatiska brandlarmet detekterar branden. [2] Detektorerna är placerade ca 0.5 m under taket och takhöjden är mellan 6 och 7 m [1]. Detektionstiden kan därför förmodas vara relativt lång. Detektorernas placering i planet framgår inte. 22:49 Första släckbilen är framme, med två man. [2] 22:52 Genom fönstren på östra sidan ses en kraftig brand i sektion 30 över plåtskåpen för brandfarlig vara. (Vittnesuppgift) Brand kan ses genom fönstren även på västra sidan i sektion 29. (Uppgift från insatsstyrkan) Klocka nära lödmaskinen, ca 3 m över golvnivån stannar. (Vittnesuppgift) [2] 22:52 Huvudstyrkan, bestående av släckbil och stegbil med (1+1+6) man är framme vid ingången vid brandlarmscentralen. [2] 22:54 Deltidskår larmas (1+4). Nycklar finns tillgängliga. [2] 22:55 Omflyttning av huvudstyrkans fordon. [2] 22:57 Brandingenjören är på plats. [2] 22:58 Branden mycket intensiv i sektion 29 men ovanligt fri från rök i första skedet. Lågorna bredde ut sig som en solfjäder med klara färger mot den bakomliggande väggen. Kort därefter förmörkades lokalen av tjock rök och branden tilltog intensitet. Rökutvecklingen kom mycket hastigt. Ca 10 000 m² rökfyllda. (Uppgift från insatspersonal) [2] 22:58 Rökdykarinsats påbörjas genom huvud­ entrén på södra sidan, mot sektion 29. Insats­ styrkan är ej medveten om att det brinner även i sektion 30. [2]

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 75 23:00 Fellarm inkommer till Securitas, troligen orsakat av att halonanläggningen i skåpen för brandfarlig vara hade utlöst (Datalog). [2] 23:00 - ca 23:10 Andra rökdykargruppen går in genom fönster på östra sidan för att hämta gas­ flaskor. Gruppen återvänder och går in igen för att angripa branden, nu via samma väg som den första gruppen. Stegbilspersonalen reser stegen mot sydöstra hörnet av byggnaden för brandventilering och släckning. [2] Några brandventilatorer öppnar automatiskt och några öppnas av räddningstjänsten. (Tid okänd) 23:02 Deltidsbrandmän börjar anlända till den obemannade brandstationen. [2] 23:07 Fellarm inkommer till Securitas, troligen orsakat av en avbränd kabel. (Datalog) [2] 23:09 Deltidskår larmas (1+4). [2] 23:10 Befäl i beredskap anländer till brandstation. [2] 23:12 Deltidskår larmas (1+6). [2] Ca 23:15 En dov explosion hörs (Vittnesuppgift). Denna kan härröra från ett fat med lacknafta som sprängdes under branden. Fatet stod i ett av plåtskåpen. [2] Brandlarm inkommer till Securitas från ”simulatorrum”. [2] 23:18 Brandposternas läge blir kända på brand­ platsen [2]. De finns inte angivna på kommunens brandpostkarta. Ca 23:20 Rökdykarinsats påbörjas av första deltids­ kåren på plats, genom sektion 33 till 32. [2] 23:30 Hela byggnaden är rökfylld. [2] 23:30 Tankbil och släckbil ut från brandstation med (7) man. [2] Ca 23:45 Vattenkanon sätts in på taket. En tredje rökdykargrupp går in från östra sidan. [2] Ca 23:50 Ytterligare en slangledning dras upp på taket. Branden angrips från norra sidan. [2] 00:30 Svåra brandskador inom sektion 29, 30 och 32, totalt ca 200 m². Rökskador inom hela övriga byggnaden. [2] 00:30 Branden under kontroll. [2] 01:00 Restvärdesarbete utförs av 46 man. Svetskärror påträffas mellan sektion 21 och 29. [2] B4.3 Analys Eftersom det är oklart hur branden startade, är det osäkert hur lång tid det tog innan branden upptäcktes av det automatiska brandlarmet. Klart är att när rädd­ ningstjänsten är på plats, 7 minuter senare, hade spridning redan skett så att det brann både i sektion 29 och 30. Räddningstjänsten valde en offensiv insats med flera rökdykargrupper med uppgift att angripa branden. Det är dock oklart var rökdykarinsatserna gjordes. Förmodligen gjordes släckinsats inledningsvis endast i en av de två sektioner där det brann. I insatsens inledningsskede fanns inte kunskap om vattenpos­ ternas placering, vilket resulterade i vattenbrist. Detta gjorde att målet inte nåddes förrän i ett relativt sent skede av branden och då hade hela byggnaden redan blivit rökskadad. Den släckmetod som valdes var en traditionell offensiv

76 BILAGA 4 – Västerås 30/9 1991 rökdykarinsats, med ett par parallellarupper. Rökdykarinsatsen avbröts, oklart när, på grund av övertändningsrisken. Det som brann bestod av en blandning av material: pallställ med blandat gods, kablage m.m. En del av bränslet bestod av brännbara vätskor, några hundra liter. Brandposternas läge fanns inte angivna på räddningstjänstens brandpostkarta. Under den första halvtimmen under insatsen rådde alltså vattenbrist trots att både brandposter och en branddamm fanns i närheten. Orsaken var att brandposterna inte hörde till kommunens nät. B4.4 Möjliga brytpunkter för annat metodval En ordentlig operativ riskbedömning hade identifierat risken för spridning av brand och brandgaser utanför sektion 29 och 30. Trycksättning av angränsande sektioner med fläktar hade gått snabbt (Bilaga10) och medfört minskad risk för brandspridning och rökskador. En insats med vattendimma i sektion 29 och 30 skulle dessutom kunnat kyla brandgaserna och alstra ett undertryck i sektio­ nerna och därmed ytterligare minskat och fördröjt brand- och brandgasspridning till övriga sektioner. Då sektionernas yta (1500-1700 m2) och volym var mycket stora krävdes stora kastlängder och flera angreppspunkter för att uppnå tillräck­ lig kyleffekt. En uthållig insats med skärsläckare från flera håll (Bilaga 11) skulle kunnat skapa en arbetsmiljö för en invändig släckinsats. Närvaron av brännbara vätskor i sektionerna gjorde ren vattensläckning mindre lämplig och det hade alltså varit bättre att blanda skumvätska i släckvattnet. B4.5 Referenser [1] Statens Haverikommission, Brand den 30 november 1991 i ABB Relays AB:s lokaler i Västerås, U-län, O-09/91, Rapport O 1994:1. [2] Brandsjö, K., FRC, Branden inom ABB Relays i Västerås den 30 november 1991, 92-01-13. [3] Räddningstjänsten Västerås, Mobisol-logg. [4] Räddningstjänsten Västerås, Dagbesked, 91-11-30 - 91-12-01. [5] SOS Alarmering, SOS-Centralen Västmanland. [6] Vikner, P., Storskadan ett faktum redan vid brandstarten, Brand&Räddning 3/92 sid 30-32. [7] Vikner, P., Lördagsnatten när räddningstjänsten räddade fyra gånger sin egen budget, Sirenen 1/92 sid 8-9. [8] Diverse ritnings- och bildmaterial.

BILAGA 5 Trandaredsgatan 18-19/08 2008

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 79 BILAGA 5 Trandaredsgatan, 18-19/08 2008 B5.1 Objektsbeskrivning Byggnaden på Trandaredsgatan var ett industrihotell med ca 15 olika företag i flera sammanbyggda huskroppar och med en sammanlagd yta på ca 10 000 m2 [1], se Figur B 8. Den brandutsatta lokalen var 35x85 meter och innehöll stora mängder brännbart material. Mitt i lokalen fanns en brandmur som gick upp till innertaket men omfattade inte yttertaket. Taket ovanpå den brandutsatta loka­ len (A) och verkstaden (C) bestod av underliggande betongtak med en meter hög konstruktion innehållande råspont och takstolar av trä vilket innebar hög brand­ belastning på taket. En del av taket var dessutom täckt med en takpapp som var gjord av en brandhämmande produkt som ska förhindra brandspridning. Industrihotellet inrymde i övrigt bl.a. lokaler för posten (B), bageri (D) samt en stor lagerlokal (E) på ca 4500 m2 fylld med varor som skulle säljas inför jul. Från den brandutsatta byggnadsdelen fanns brandcellsgränser mot posten, verksta­ den och norrut mot den stora lokalen med pallstallage (E). Vid brandtillfället var dock initialt en dörr delvis öppen mellan brandrummet (A) och lagerlokalen (E). Industrihotellet var inte utrustad med automatiskt brandlarm eller automatiskt släcksystem [2]. Figur B 8. Översiktsbild på industrihotellet. Krysset visar var branden startade och linjerna visar brandteknisk avskiljning. Bild: flygfoto från maps.google.se, hämtat 2014-05-15.

80 BILAGA 5 – Trandaredsgatan, 18-19/08 2008 B5.2 Incidenter före branden Branden misstänktes vara anlagd på grund av att det hittades en bensindunk och flera brandhärdar. Vid första styrkans ankomst brann det i tre personbilar som stod i omedelbar närhet av industrihotellet [SÄRF, 2010]. Det hade tidigare före­ kommit liknande bränder i området. Innan branden hade polisen gjort razzia hos personer som bodde i närheten av industriområdet [2]. B5.3 Branden 2008-08-18, 02:23 inkom ett larm till räddningstjänsten om brand i skogsdunge. Det var en granne öster om industrigatan som hade sett flammor och trott att det brann i skogsdungen bredvid industrihotellet. Larmet utgick som litet larm vilket innebar att en brandbil med fem man (1+4) skickades till platsen. Vid ankomst upptäckte brandmännen att det brann i tre personbilar som stod intill industrihotellet. Branden hade även spridit sig in till byggnaden och taket. Branden begränsades till lokal A och taket över lokal A och C. Insatsen höll på i över 1,5 dygn, ca 100 personer från tolv brandstationer arbetade under insatsen och räddat värde beräknades till 100 miljoner kronor [3]. Beskrivningen nedan av branden och släckinsatsen bygger på uppgifter i insats­ rapporter och intervjuer [1, 2 och 3]. BRANDFÖRLOPP RÄDDNINGSTJÄNSTINSATS 02:19 Flammor upptäcks av boende öster om industrihotellet som tror att det brinner i skogs­ dungen bakom industrihotellet. Utlarmning; brand i terräng, litet larm som inne­ bär en släckbil med fem man (1+4). 02:24 Brinner i tre personbilar plus spridning till närliggande lokal med stora portar. Släckning av personbilar på utsidan av byggnaden påbörjas samt försök till att begränsa branden inne i byggnaden dock utan effekt. 02:29 Det brinner på tre ställen, bilarna, inne i lokalen samt i takfoten på brandutsatt lokal. Stor risk för spridning av brand till intilliggande lokaler. Ingen invändig släckning på grund av risk för gasflaskor och ras. Senare under insatsen fram­ kommer det att det inte fanns några gasflaskor i byggnaden. Vattenkanoner (1200 l/min) och dimstrålrör används mot branden men ger inte någon effekt och stoppas snabbt då vatten också är en begränsande faktor. 02:40 Intilliggande lager (E) har ett rökgaslager som når ner till huvudhöjd. Även B är rökfylld. Horisontell och vertikal brandspridning. Aktiv insats mot branden (A) med dimstrålrör och backuprör (1200 l/min). Baserat på information från IR-kamera blir MMI: Stoppa brandgas och brand­ spridning in till sidoutrymmen. Taktisk plan: Över­ trycksventilering samt kylning av brandgaser med skärsläckare. Temperaturscanning av takets ovansida med IR-kamera och hävare och sektorindelning. Personbilsbränderna har hejdats, se Figur B 9. 03:34 Det brinner i byggnad A samt i takkonstruk­ tion på baksidan av byggnad A. Det uppmärksam­ mas att takbranden inte tar sig igenom takpappen. 04:00 Brandspridning på taket sker långsamt eftersom branden inte öppnar upp taket och tryckavlastar brandrum. Detta på grund av den brandbeständiga takpappen som smälter och lägger sig som ett lock över branden. Brandgasspridning in till sidolokaler har förhind­ rats tack vare övertrycksventilering och brand­ gaskylning. En dörr mellan brandutsatt lokal och intilliggande lager som var öppen har stängts.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 81 05:45 Fortsatt brandspridning på taket och det brinner fortfarande i startutrymmet. Spridning mot lokaler mot gatan. Brandmän är uppställda på rad på taket över lokal B och E för att med hjälp av dimstrålrör se till att takbranden inte sprider sig till intilliggande tak. 06:30 Halva taket nerbränt. Försök görs att stoppa branden vid den invändiga brandcellsgränsen. Lokal C är inte brandutsatt så bedömning är att taket ovanför den lokalen håller. Brandmän formeras i halvmåne och utrustas med dimspik, skärsläckare och dimstrålrör i ett försök att hålla tillbaka branden på taket. 07:43 Endast glödbränder kvar inomhus i lokal A. Fortsatt övertrycksventilering av sidoutrymmen. Så fort släckning på tak upphör laddar brandgas­ tillväxten snabbt igen. Därför fortsätter bevakning och släckning med dimstrålrör och skärsläckare längs begränsningslinjerna. 09:35 Fortsatt brandspridning i hela taket över lokal A och C. Brandspridning mot sidolokaler i markplan och takkonstruktion har stoppats. 13:15 Taket ovanför lokal A och C brinner fortfarande. A-skum blandas in i släckvatten på de brandhärdar som fortfarande finns inne i det brandhärjade lagret. Ger effekt först men sen ökar intensitetet igen. Detergentskum (expansionsgrad mellan) läggs i det svårsläckta mellantaket i hörnet vid anslutningen mot lokal B. 21:00 till 16:00+1 Brandhärdar fortsätter flamma upp. Bevakning och släckning av brandhärdar. 16:00+1 Avslut av räddningsinsats. Figur B 9. Schematisk bild över den taktiska grundinriktningen.

82 BILAGA 5 – Trandaredsgatan, 18-19/08 2008 B5.4 Analys Flera förebyggande åtgärder hade kunnat genomföras för att minska skadans om­ fattning. Branden var antagligen anlagd vilket är svårt att förebygga men att inte placera brännbart material i närheten av byggnaden är ett sätt. Ett automatiskt brandlarm är ett annat sätt att minska tiden till påbörjad insats. Ytterligare så hade sprinkler kunnat begränsa branden och därmed minskat skadorna. Orienterings­ ritningar eller insatsplan hade också underlättat för en snabbare insats. Det är viktigt att kunna läsa av branddynamiken och förstå hur länge branden pågått, nuvarande förlopp och hur branden kommer utvecklas. Detta är viktigt för att kunna agera och inte bara behöva reagera. I industribranden fanns det många faktorer som påverkade vad målet med insatsen blev och hur den tak­ tiska planen formulerades. Branden var kraftig och flera olika sorters områden (bilar, stora lokaler, mindre lokaler, tak etc.) var drabbade. Det räckte alltså inte med att jobba traditionellt utan det gällde att skapa en uthållighet och tänka på hur insatsen bäst skulle byggas upp samt vilka metoder som skulle klara av uppgiften. Tidigt i insatsen insågs att branden hade spridit sig för långt för att kunna släckas i startutrymmet (lokal A) och därför blev målet med insatsen att begränsa brand och brandgas­ spridning till lokal A. Taktisk plan var att hindra brandgasspridning genom övertrycksventilering i intilliggande lokaler. Minska strålningsintensiteten genom kylning av tak­ branden med hjälp av höjdfordon, dimstrålrör och skärsläckare samt skydda brandspridning via taket med hjälp av brandmän som vaktade intilliggande tak och snabbt kunde släcka mindre bränder. IR kamera var ett bra hjälpmedel för insatsledningen. Insatsen visar att olika metoder har olika egenskaper som kan nyttjas. Är det en stor samling av heta brandgaser, som i lokal E, måste en metod som kan nå långt in och kyla brandgaserna snabbt användas. Små droppar kyler brandgaser mer effektivt än större droppar. Dessutom följer små droppar lättare luftströmmen istället för att falla till golvet vilket betyder att dropparna har längre tid på sig att förångas än större droppar. Problemet med små droppar är dock kastlängden, men då är skärsläckare ett alternativ eftersom strålen bryts upp först efter fem till sju meter vilket ger en kastlängd på upp till 15 meter [Bilaga 11]. Skärsläckare visade sig också vara en bra metod och brandgaserna försvann på under en timma. På vissa andra ställen ville man hellre kyla ner heta brandytor och där var det mer effektivt att använda dimstrålrör som ger större droppar. Detta eftersom det i experiment visat sig att små droppar inte väter ytor lika bra som större droppar [Bilaga 11]. Ytterligare en metod som användes var övertrycksventilering för att hindra spridning av brandgaser till intilliggande lokaler och en viktig lärdom är att det går att trycksätta stora lokaler. Det är också fullt tillräckligt med en fläkt för varje stor lokal, förutsätt att lokalen är relativt tät, se också Bilaga 10. Insatsen visar också på att det är viktigt att vara medveten om hur olika metoder påverkar varandra. Till exempel att övertrycksfläktarnas verkan var att tryck­ sätta intilliggande lokaler och få värmen att gå ut via taket, men när vattenkanon användes så tryckte den ner värmen så att fläktarnas effekt försämrades. Ett annat exempel på att man måste vara medveten om hur vald metod kan få påföljder är skumanvändning som kan ha medfört stora konsekvenser för miljön. Den brandbeständiga pappen påverkade förloppet genom att den gjorde det svårare att släcka men gjorde även att förloppet gick långsammare. Branden gick också i pulser på grund av pappen vilket gjorde det svårt att avgöra om insatserna hade någon effekt eller inte. Pappen stängde in branden vilket gjorde att man trodde att släckmetoden hade fått effekt, men sen helt plötsligt kunde branden flamma

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 83 upp igen. Det är dock svårt att avgöra hur brandförloppet hade sett ut utan brandpappen. Genom att den höll tillbaka branden fick räddningstjänsten mer tid till att bygga upp insatsen samtidigt som pappen gjorde det svårare att släcka. Om inte pappen funnits hade taket snabbt brunnit av vilket hade resulterat i hög strålningsintenitet mot intilliggande tak med risk för att det inte hade gått att stoppa brandspridningen. B5.5 Möjliga brytpunkter för annat metodval Det var oroligheter i området och incidenter i och omkring området hade hänt innan industribranden. Förebyggande åtgärder är bättre bevakning, att inte ha bilar eller brännbart material i anslutning till byggnader samt brottsföre­ byggande arbete. Branden startade sent på natten och eftersom det inte fanns automatiskt brand­ larm var det en fördröjning innan någon upptäckte branden. Att en boende upp­ täckte branden trots den sena timmen var tur och det gav Räddningstjänsten en chans att begränsa spridningen. Med tanke på brandgaslagret i intilliggande lager så hade scenariot blivit helt annorlunda om insatsen fördröjts bara några minuter. Hade branden upptäckts tidigare hade den kanske inte spridit sig till det svårsläckta taket utan kunnat begränsas till startutrymmet. En annan faktor som fördröjde insatsen var att det saknades orienteringsplan eller insatsplan. Genom att snabbt få en uppfattning om vilket brandskydd som byggnaden har kan MMI och taktisk plan utformas snabbare. De faktorer som påverkade brandens förlopp mest var: • • den sena upptäckten, vilket gjorde att branden spreds till takkonstruktionen • • användning av alternativa metoder (övertrycksventilering, skärsläckare), vilket gjorde att branden kunde begränsas till lokal A samt tak över lokal A och C • • den brandbeständiga takpappen som gjorde att det var svårt att släcka taket samtidigt som brandspridningen saktades ner. Nedan redovisas avgörande brytpunkter i brandförloppet. Släckangrepp Personbilar På grund av för liten första styrka på plats och risk för att det fanns gasflaskor i lokalen genomfördes en mer passiv insats initial. Inriktningen innan förstärk­ ning anlände blev att släcka branden i personbilarna vilken hotade sprida sig till fler bilar. Alternativ metod här hade varit att inrikta sig på att stoppa spridningen i taket. Det är dock svårt att avgöra om detta hade haft någon effekt eller om branden spridit sig alltför mycket redan. Försök till släckning av lokal A Branden i lokal A var intensiv samt eskalerande och höga ljud från fallande pallstallage hördes inifrån lokalen. På grund av detta gjordes bedömningen att risken för ras var för stor för invändig brandbekämpning. Ett försök gjordes med kylning in i lokalen från utsidan med dimstrålrör och backuprör (1200 l/min). Försöket misslyckades och efter ca 10 minuter utan effekt avbröts försöken och de begränsade resurserna på plats, personellt och vattenmässigt, omfördelades till att begränsa spridning till intilliggande lokaler och takbranden.

84 BILAGA 5 – Trandaredsgatan, 18-19/08 2008 På grund av brandens intensitet och begränsade resurser kunde inte tillgängliga resurser påverka förloppet. Fortsatta släckförsök hade bidragit till att resurserna inte hade satts in där de bäst gjort verkan med resultatet att branden kunnat sprida sig till intilliggande lokaler. Släckning av brandgaslagar i intilliggande lokal E På grund av att det satt varningsskyltar för gasflaskor i intilliggande lagerlokal E undersökte räddningsledaren situationen och fann ett tjock brandgaslager som var nere vid huvudhöjd. Han uppskattade byggnaden till ca 4500 m2 med en takhöjd på 6-8 meter. Byggnaden var dessutom fylld med pallstallage och därför förstod han att om brandgaslagret antänder kommer man inte kunna rädda byggnaden. Ståldörren mellan lokal A och E stod delvis öppen, vilket förklarar förekomsten av mängden brandgaslagret i lokal E. Temperaturen var fortfarande låg och därför ansågs risken för att eventuella gasflaskor skulle vara påverkade som liten. Till följd av den stora lokalen behövdes ett system med huvudsyfte att kyla och inertera brandgaserna på stora avstånd i både höjd och sidled. Begränsande var också att ingen invändig brandsläckning fick ske på grund av riskerna för ras och påverkade gasflaskor. Lösningen var skärsläckare som ger en finfördelad vatten­dimma som når långt in i brandrummet [1]. Skärsläckaren vinklades upp mot taket och samtidigt sattes en fläkt in för övertrycksventilering. Inom en timme var brandgaslagret borta och dörren mellan lokal A och E kunde stängas. Fortsatt övertrycksventilering höll tillbaka branden från lokal E. Om inte skärsläckare och övertrycksventilation hade använts kunde lagret snabbt blivit övertänt och sannolikt hade hela industrihotellet blivit totalförstört. Begränsa spridning till intilliggande lokaler via väggar. Ungefär samtidigt som skärsläckare och övertryckventilering sattes in mot lokal E så upptäcktes det att det fanns brandgaslager i lokal B. Med hjälp av övertrycks­ ventilering försvann brandgaserna på bara åtta minuter. När man märkte att övertrycksventilering fungerade så beslutades att så fort fler fläktar anlänt sätta in dessa i intilliggande lokaler (B, C, D och E), se Figur B 9. Trots storleken på vissa lokaler så fungerade övertrycksventilering bra. Har trycket byggts upp så spelar inte lokalens storlek någon roll utan det som spelar roll är om byggnaden är tillräckligt tät. Ett tydligt exempel på detta var när företrädare för olika företag kom på plats och gick in till sina lokaler och började öppna fönster för att vädra ut röklukt. Detta resulterade i att trycket sjönk och brand­ gaser började strömma in i lokalerna. En annan observation var att vattenkanonen när den användes mot taket förstörde övertrycksventileringen genom att vattnet tryckte värmen från taket ner till lokalen och vidare in till intilliggande lokaler. Utan övertrycksventilering hade brandgasspridning skett till intilliggande lokaler. Begränsning vid brandcellsgräns Det fanns en brandcellsgräns mitt i den brandutsatta lokalen (mellan A och C). Muren sträcktes sig upp till betongbjälklaget och begränsade branden till lokal A. Lokal C var inte brandutsatt och det bedömdes därför som säkert att gå på taket ovanför lokalen. Det beslutades att kraftsamla för att försöka stoppa brandfronten på taket vid den underliggande brandmuren. Tio till tolv brandmän utrustade med tio dimstrålrör, dimspik och skärsläckare formerade en halvmåne mot branden. Efter 15 till 20 minuter hade brandfronten tryckts tillbaka men så fort vattenbegjutningen slutade så ökade intensiteten i branden igen. Efter 45 minuter avslutades försöket med att stoppa branden och efter ytterligare 35 minuter hade brandfronten nått gaveln på andra sidan.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 85 Till följd av den brandbeständiga takpappen som la sig som ett lock över branden och att det fanns mycket brändbart material i taket var det svårt att komma åt branden. Alternativa släckmetoder hade varit skum. Mellanskum uteslöts på grund av intensitet av branden, skummet hade ”ätits upp” direkt utan att ge effekt. Vidare hade mellanskum med största sannolikhet inte fyllt upp utrymmet i mellantaket. Eftersom det var ett trämaterial som brann under takpappen skulle tillsatsmedel till skärsläckaren vara ett alternativ för att få vattnet att lättare tränga in i materialet och förbättra återantändningsskyddet. Begränsa branden till tak över lokal A och C Takbranden begjuts med vatten och brandmän med dimstrålrör vaktade taket över lokal B och E och släkte takpappen om den antände. På detta sätt lyckades branden begränsas till taket ovanpå lokal A och C. Det blev en del vattenskador och alternativet hade varit att inte försöka släcka branden på taket. Eftersom branden var så pass intensiv hade detta troligtvis resulterat i att strålningen antänt taket ovanpå lokal B och E. Användning av skum Att blanda in skum i släckvatten hade uteslutits på grund av intensiteten i bran­ den och att släckvattnet rinner av direkt ner till dagvattenbrunnar med risk för miljöskador. Ca elva timmar efter brandstart gjordes ett nytt beslut och ett skum påfördes med avsikt att minska punktbränderna. En till två dygn efter brand­ start brann det dock fortfarande på dessa ställen. Problemet med skum är att en intensiv brand kräver mycket kyleffekt för att minska, medan mellanskum inte har denna kyleffekt. B5.6 Referenser [1] SÄRF och SP, 2010, Skärsläckarkonceptets operativa användande. Räddnings­ verket, Publikationsnummer MSB 0167-10, Myndigheten för samhällsskydd och beredskap. [2] Palmqvist, K., Södra Älvsborgs Räddningstjänst, intervju april 2014. [3] Sandin, L-E., 2008 Undersökning av olyckor och räddningsinsatser, Brand i industri, Räddningstjänstens olycksutredning dnr 09/1023, Södra Älvsborgs Räddningstjänst. [4] Lindström, J., Appel, G., Palmkvist, K., Bialas, K., 2013, Förmåga och begräns­ ning av förekommande släcksystem vid brand i byggnad – fokus på miljö­ arbete. Publikationsnummer MSB618, Myndigheten för samhällsskydd och beredskap.

BILAGA 6 Södra Sandby, Killebäcksskolan 5-6/1 2009

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 87 BILAGA 6 Södra Sandby Killebäcksskolan 5-6/1 2009 B6.1 Objektbeskrivning Högstadieskolan, som ligger i Södra Sandby, ett litet samhälle med 7000 invånare knappt en mil öster om Lund, hade ca 50 anställda och ca 400 elever i årskur­ serna 6 till 9. Faktauppgifter nedan är hämtade ur fyra dokument från Räddningstjänsten syd och ett från Kommunassurans Syd som finns listade under referenser. Kille­ bäcksskolan var en enplansbyggnad från 1982, byggd i brandteknisk klass Br2 enligt SBN 1980. Den bestod av fem kringbyggda och sammanbyggda atrier, se Figur B 10. Stommen bestod av trä, utvändigt tegelklädd. Vinden var med undan­ tag från fläktrum oinredd med ett valmat tak, bestående av trätakstolar klädda med plastfolie och betongpannor på kraftig läkt. Takutsprånget på ca en meter var luftat och klätt med glespanel på undersidan. Vindsbjälklaget bestod av lim­ träbalkar med 400 mm lösull ovanpå plastfolie och dubbla gipsskivor. Vinden var sektionerad i delar om 300 – 450 m² av plåtregelväggar med en gipsskiva på var sida. Brandcellerna på bottenvåningen var mindre. Insatsstyrkan saknade tillgång till ritningar och hade inte kunskap om hur man tog sig upp och runt på vinden. B6.2 Incidenter före branden Det finns inte någon historia från denna skola som utmärker sig från flertalet förortsskolor i Sverige. Den inledande branden utmärker sig inte heller, en brand anlagd av ungdomar. Däremot finns det många parallellhändelser med bränder i offentliga enplansbyggnader av den här typen [1]. B6.3 Branden Branden inträffade under nattetid i januari. Byggnaden var relativt ensligt belägen, det var mörkt och dessutom blåste det från sydväst och var ca -10°C. Några ung­ domar satte med en fyrverkeripjäs (fontän) eld i ett växthus som användes som förråd. Växthuset var monterat på skolbyggnadens baksida under takutsprånget. ”Skolor som ligger avsides och med den här konstruktionen med utskjutande takfot brinner förr eller senare. Det har erfarenhet visat. Jag har själv sett flera exempel. Det är en högrisk­ konstruktion för anlagda bränder” enligt räddningsledaren.

88 BILAGA 6 – Södra Sandby Killebäcksskolan 5-6/1 2009

Figur B 10. Skolan innan branden, bild hämtad ur Olycksundersökningen [2]. Växthuset där branden startade är den lilla vita rektangeln i prånget på bygg­ nadens södersida. I bilden visas även räddningstjänstens sektorindelning fram- och baksida. Enligt Kommunassurans Syd uppskattades skadorna efter branden till ca 35–40 % av skolbyggnaden helt förstörd, ca 30 % vatten och rökskador och resterande relativt intakt. De skadade delarna visas i Figur B 11.

Figur B 11. Skadebild enligt Kommunassurans syd [3]. Obs bilden är vriden i förhållande till Figur B 10.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 89 Nedan beskrivs branden och räddningstjänstinsatsen [4-6]. Förloppet delas i olycksundersökningen in i tre huvudfaser: uppstartsskedet (ca 21:45-22:45), inledande insats (ca 22:45-01:30) samt fortsatt insats (ca 01:30-07:00). BRANDFÖRLOPP RÄDDNINGSTJÄNSTINSATS 21:xx Brand anläggs i växthuset med hjälp av fyrverkeripjäs. 21:44 Personer i intilliggande idrottshall larmar via 112. 21:50 Det automatiska brandlarmet aktiveras. 21:52 Kraftig brand i växthuset, brand i takfoten. 21:52 Insatschefen är först på plats och möts av vaktmästaren. 301 blir hänvisade direkt till platsen där branden startat. Initialt släckförsök. Vindsbrand med oklar lägesbild. 22:00-22:45 Sektor baksida gör ett försök till begränsning med dimspik och håltagning. Sektor fotbollsplan med uppgift att hålla begränsning med hjälp av höjdfordon. 00:50+1 Okontrollerad brandspridning i mitt­ delarna av skolbyggnaden. Bra begränsningar på baksidan. 22:45-01:30 Två sektorer med var sin begräns­ ningslinje. Många brandposter är frusna. 01:30+1-07:00+1 Två sektorer, fram respektive bak med uppgift att begränsa brandspridning. Senare en invändig sektor med uppgift att stoppa branden inne på vindarna. Insatsstyrkan har under stora delar av natten tvingats ”jaga” branden. 03:00+1 Fortfarande risk för brandspridning Håltagning på vindar utifrån. Tvärsnittsventila­ tion. Nästan allt släckningsarbete gjordes utifrån. Dimspik. Högtryckssystemet upplevdes ha för dålig kastlängd, så lågtryckssystem användes. Vatten­ systemet på en släckbil frös under natten. 09:30+1 Branden under kontroll men fortfarande glödbränder. Under dagen: Personal arbetar inne på vinden för att släcka småbränder, vilket fungerade bättre än att stå utifrån på stege. Rivning dämpar branden. 12:30+1 Rivning igång med hjälp av frontlastare. 19:18+1 Räddningsinsatsen avslutas. B6.4 Analys Inledningen av insatsen gick effektivt, då räddningstjänsten snabbt blev visad till rätt plats. Samtidigt var antändningskällan kraftig och brandspridningshastig­ heten snabb inledningsvis vilket gjorde att branden i alla fall spred sig upp på vinden genom den ventilerade takfoten. Ventilerad takfot är tillåtet i en sådan här byggnad, men en välkänd brandspridningsväg. När branden väl spridit sig upp på vinden, verkar det under långa tider som om ingen har kunskap om brandens läge och omfattning. Man arbetar till största delen utifrån men kommer inte åt branden. Den brand som man inte har lokali­ serat, kan man inte heller släcka. Mycket av arbetet och därmed mycket av risk­ erna handlade om kvalificerat takarbete med håltagning. Under delar av insatsen bedömdes till och med riskerna som mindre för personalen att arbeta inifrån än utifrån. Flera slutsatser dras i olycksundersökningen [2], bl.a. att det vid en insats är viktigt att tidigt få kännedom och kontroll på byggnadskonstruktionen så att lämplig metod kan väljas. Man konstaterar att en gemensam lägesbild för befäl har saknats. Avsaknad av gemensam rättvisande lägesbild har inneburit att åtgär­ der vidtagits utan att man egentligen haft kontroll över effekt/verkan.

90 BILAGA 6 – Södra Sandby Killebäcksskolan 5-6/1 2009 Man noterar också att dimspik hade god effekt, samtidigt som de i kontinuerlig drift genererar stora mängder vatten och därför bör användas endast med kortare duschningar. Med längre dimspik hade åtkomligheten blivit bättre. Skärsläckare fanns tillgänglig, men frös på grund av det kalla vädret och kunde inte användas. Även vattensystemet i en vanlig släckbil frös. Kort sagt testades flera olika släck­ redskap, men bortsett från frysningsproblematiken handlade bristande släck­ kapacitet nog framförallt på att släckmedlet inte applicerades där det faktiskt brann och hade därmed liten effekt. B6.5 Möjliga brytpunkter för annat metodval En noggrann riskbedömning hade i ett tidigt skede identifierat risken för brand­ spridning på vinden. En första insats i vindsutrymmet vid primärbranden med vattendimma alstrad av en skärsläckare skulle snabbt kunnat kyla brandgaserna och sänkt trycket (Bilaga 11) och därmed försena brandspridning till angräns­ ande vindsutrymme. Ett annat alternativ hade varit att använda dimspik. För att täcka det 300-450 m2 stora vindsutrymmet vid primärbranden hade man behövt slå in många dimspik då de endast har en kort kastlängd. Arbetet med att montera dimspiken hade tagit mycket längre tid och varit mycket riskfyllt för insatspersonalen. Vatten­ skadorna hade dessutom blivit avsevärt större än de man får med skärsläckare. Huvuduppgiften därefter hade varit att identifiera eventuell brandspridning till angränsande vindsutrymmen och förbereda för ytterligare insatser med skär­ släckare och trycksättning av delar av skolan för att undvika rökskador. Över­ vakning av taken med en högt placerad IR-kamera och utsläpp av brandgaser vid takfoten i de olika vindsektionerna hade underlättat valet av nya angrepps­ punkter med skärsläckare. B6.6 Referenser [1] Johansson, N., van Hees. P., En studie av vindsbränder utifrån statistik och brandutredningar, Report 3152. Brandteknik, LTH. [2] Åberg, Martin, m.fl., 2009, Olycksundersökning – utvärdering av insats, Brand i Killebäcksskolan, Södra Sandby 2009-01-05, Räddningstjänsten syd. [3] Kommunernas assurans Syd. [4] Nilsson, B., 2009, Olycksundersökning Brand på Killebäcksskolan, Södra Sandby 2009-01-05, Räddningstjänsten syd. [5] Bilaga 1, Byggnadstekniskt brandskydd, Lund 2009-03-12/JBD Killebäcks­ skolan, Räddningstjänsten syd. [6] Insatsrapport, Räddningstjänsten syd, Rtj ärendenummer 2009/00076.

BILAGA 7 Partille, Hålegårdsvägen 4/2 2013

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 93 BILAGA 7 Partille, Hålegårdsvägen 4/2 2013 B7.1 Objektbeskrivning Den drabbade radhuslängan bestod av sju stycken tvåvåningslägenheter och bredvid fanns det ett gemensamt garage med plats för nio bilar [1]. Fasaden på radhuset närmast garaget var av tegel förutom en utsickande del vid ett fönster som var beklätt med träpanel samt en altan. Garageväggarna var gjorda av plåt och det fanns fönsteröppningar som vette mot radhuslängan [2]. Avståndet mellan garaget och det drabbade radhuset var ca tre meter [3] och avståndet mellan garaget och den södra radhuslängan var ca sju meter [1], se Figur B 12. Taket på radhuslängan var plåttak med en smal luftspalt till innertaket och bjälklaget mellan över och undervåning gick i längsgående riktning vilket gjorde att det var få eller inga naturliga begränsningslinjer [2].

Figur B 12. Hålegårdsgatan. Branden startade i garaget och spred sig sedan till radhuslängan. Bild: Flygfoto från maps. google.se, hämtat 2014-05-15. B7.2 Incidenter före branden Det finns inga incidenter rapporterade i närområdet före branden. Radhusbränder är dock kända för att vara svåra att stoppa på grund av att det oftast inte finns någon sektionering av vinden mellan lägenheterna. B7.3 Branden Branden började i det närliggande garaget som hade plats för nio bilar, se Figur B 13. Människor vaknade av att det smällde kraftigt från garaget och larmade räddningstjänsten. När räddningstjänsten anlände var branden fullt utvecklad i garaget och hotade både den södra och östra radhuslängan. I Figur B 12 kan man se att den södra radhuslängan ligger parallellt med garagets längd­ riktning, och det östra (drabbat radhus) vinkelrätt mot garagets längdriktning.

94 BILAGA 7 – Partille, Hålegårdsvägen 4/2 2013 Den södra radhuslängan klarade sig men branden spred sig till den östra rad­ huslängan via gavelbeslag och altan. Branden fortsatte sprida sig via inner- och ytterväggar, mellanbjälklag och tak. Branden stoppades vid räddningstjänstens begränsningslinje mellan andra och tredje lägenheten. Konsekvenserna av branden blev ett nedbrunnet garage, två lägenheter med totalskada och en lägenhet med rök och vattenskada. De fyra resterande lägenheterna klarade sig och människor kunde bo kvar i dessa. Figur B 13. Garage och drabbad radhuslänga, rött kryss visar var branden startade. Begränsningslinje drogs vid andra stup­ röret. Bild: Street view från maps.google.se, hämtat 2014-05-15.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 95 Beskrivningen nedan av branden och släckinsatsen bygger på uppgifter i insats­ rapporter och olycksundersökningar som gjorts [1, 2 och 3]. BRANDFÖRLOPP RÄDDNINGSTJÄNSTINSATS 0x:xx Det börjar brinna i garaget.

Boende hör kraftiga smällar från garaget. 02:16 Larm inkommer till SOS om brand i garage och räddningstjänsten åker ut i tron att det brinner i ett fristående garage utan risk för spridning. 02:25 Garagelänga med nio portar är helt över­ tänd och branden hotar två radhuslängor, en öster och söder om garaget. 02:25 Räddningstjänsten på plats. Första styrkan inriktar sig på att försöka förhindra brandspridning till östra radhuslängan med hjälp av dimstrålrör. Andra styrkan inriktar sig på att skydda södra rad­ huslängen och dämpa garagebranden med hjälp av backupstrålrör (ca 1000 l/min) från tankbil och dimstrålrör från släckenhet, se Figur B 14. Skär­ släckarenhet och fler räddningsenheter beställs. 02:38 Södra radhuslängan räddad och garage­ branden är dämpad men branden har spridit sig vidare till östra radhuslängan via altanen vid första lägenheten och in i lägenheten samt brandsprid­ ning via ytterväggar och tak. 02:38 När garagebranden är dämpad går det att komma runt till baksidan på radhuset och först nu kunde man konstatera spridningen via altanen. In­ vändig släckning, skyddsnivå rökdykning påbörjas i första lägenheten. Håltagning i tak över lägenhet 1 påbörjas. 02:40 Resurserna prioriteras till östra radhus­ längan. Mål med insats formuleras: Dämpa och begränsa branden i första lägenheten, släck och hindra brandspridning i andra och stoppa brand­ spridning vid tredje lägenheten. 02:51 Brandens intensitet i radhuslängan ökar och branden sprider sig i mellanbjälklag, takbjälklag och luftspalt till yttervägg, se principskiss i Figur B 15. 02:xx Två sektorer bildas; tak och invändig släckning. Taksektionen arbetar med att göra frånluftsöppningar i syfte att ventilera ut varma brandgaser och komma åt vattnet med dimstrål­ rör och dimspikar. Begränsningslinjen vid tredje lägenheten, se Figur B 14, består av dimspikar och ett 60-70 cm brett hål över hela taket och baksidan av huset. Sektionen för invändig släck­ ning använder sig av skärsläckaren för att punktera taket och mellan­bjälklagen underifrån och komma åt branden därifrån. Detta kompletterades sedan med hål­tagning och friläggning inifrån. Släckarbetet är intensivt och brandmännen arbetar hårt för att inte branden ska fortsätta sprida sig. Så fort det blir någon fördröjning i bytet av personal flammar branden upp. Begränsningslinjen vid lägenhet tre håller. Beslut tas att lättskumfylla lägenhet 3. 07:00 Branden under kontroll. Intensiteten i släckningsarbetet avtar, men det tar ytterligare ett dygn innan räddningstjänst avslutas.

96 BILAGA 7 – Partille, Hålegårdsvägen 4/2 2013 Figur B 14. Bild över var de första åtgärderna sattes in. de olika tjocklekarna på pilarna visar skillnader i vattenmängd som användes på plats.Rött streck visar var begränsningslinjen drogs [1]. Figur B 15. Principskiss över bjälklagen i radhuset som gjorde att branden var svår att släcka. B7.4 Analys Spridning till radhus Det är inte fastställt hur branden startade, antingen var den anlagd eller något teknisk fel i någon av bilarna. Branden upptäcktes av att folk hörde smällar från garaget. Möjligheterna att upptäcka branden tidigare var liten. Vid framkomst var garaget redan övertänt och det fanns ingen möjlighet att stoppa branden i garaget utan det stora hotet var spridning till södra och östra radhuslängan. Första styrkan försökte minska risken för antändning av östra radhuslängan genom att kyla med dimstrålrör. På grund av det korta avståndet samt träpanelen och altanen var inte kylningen tillräcklig och branden spred sig till den östra radhuslängan. Ytterligare en anledning till spridningen var att det inte gick att komma åt baksidan av radhuset där altanen och träpanelen fanns

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 97 då branden i garaget stoppade räddningstjänsten från att gå runt. Eftersom det inte gick att komma åt branden mot baksidan hade det varit svårt att stoppa branden även med alternativa metoder. Andra styrkan som kommer strax efter första styrkan riktar in sig på att begränsa spridningen av branden så att inte södra radhuslängan ska börja brinna. De använ­ der sig av back-up stålrör som ger ungefär fyra gånger så mycket vatten som ett vanligt dimstrålrör och lyckas därför förhindra brandspridning till södra radhus­ längan. Med vanliga dimstrålrör släcker de även branden i den södra delen av garagelängan, se Figur B 14, för illustration över var de första åtgärderna sattes in. Radhusbranden När branden i garaget hade dämpats gick det att komma runt till baksidan av radhuset och då såg man att det brann i altanen och i kanten av taket. Branden hade också spridit sig in i första lägenheten. Rökdykning enligt AFS 2007:7 genomfördes som en första insats mot lägenhet 1 (gavellägenheten). Vid denna insats användes även skärsläckaren för att släcka branden inne i byggnadskonstruktionen. Det visade sig tidigt i insatsen att bran­ den spridit sig vidare till angränsande lägenhet via mellanbjälklagen och lägenhets­ skiljande vägg. Beslutet blev då att släppa första lägenheten för att prioritera in­satserna till andra lägenheten. Med skärsläckare och sågar försökte de komma åt branden i mellanbjälklaget, lägenhetsavskiljande vägg samt tak i lägenhet 2. Samtidigt tog det sig rejält i första lägenheten och personal fick i uppgift att dämpa branden genom invändig släckning i den första lägenheten. Största pro­ blemet var att branden spreds långsamt i golv, väggar och tak. Så fort ett stålrör slutade användas (t.ex. vid byte av personal) så flammade det upp igen. Tidigt i insatsen tas beslut om att lägga en begränsningslinje mellan lägenhet 2 och 3. Taket öppnades upp från takfot till takfot, även panelen på väggen togs bort. Dimspik sattes i taket och i väggen vilket medförde att både tak, ytterväg­ garna och isoleringen mellan lägenhet 2 och 3 översvämmades med vatten och därmed förhindrade vidare brandspridning. Hade inte begränsningslinjen hållit så hade hela radhuslängan brunnit ner. Eftersom branden under de första timmarna var så intensiv och spridningen svår att bedöma så beslutade räddningsledaren att lättskumfylla tredje lägenheten. Beslutet att lättskumfylla istället för att övertrycksventilera baserades på att man inte visste exakt var branden var. Senare visade sig dock att lättskumsfyll­ ningen inte hade någon påverkan på förloppet. Skärsläckaren användes i detta fall genom att placera den i undertaket och i mellan­bjälkslagren. Detta gör att vattenstrålen direkt stöter på hinder och därför inte kan sprida sig och bli dimma. Skärsläckaren behöver ett avlångt utrymme utan hinder för bästa släckeffekt eftersom strålen bryter upp till vattendimma först efter ca fem meter.

98 BILAGA 7 – Partille, Hålegårdsvägen 4/2 2013 B7.5 Möjliga brytpunkter för annat metodval Nedan diskuteras möjliga brytpunkter i förloppet och hur andra metoder hade påverkat skadeutgången. Spridning till radhus Spridningen till radhuset skedde via tak och altan och hade det funnits möjlig­ het att komma åt baksidan av huset direkt genom att t.ex. dra slangen via östra gångvägen så hade man också kommit åt branden bättre och därmed kanske kunnat stoppa branden vid garaget. Radhusbranden Det största problemet var att man inte visste var branden var och därför hade en tidig kännedom och kontroll på byggnadskonstruktionen varit viktig för att på så sätt kunna välja lämplig metod. Skärsläckaren som användes genom att placera den i undertak och mellanbjälks­ lagren hade kommit till större nytta vid annan placering. För att skärsläckaren ska få bästa möjliga kastlängd måste den placeras så att strålen följer de befintliga längsgående öppningarna. T.ex. hade man kunnat arbeta från taket och skjuta in skärsläckaren så att strålen följer luftspalten. I detta fall hade det kanske inte varit lämpligt att stå på taket på grund av risken för ras, men alternativet hade varit att arbeta från en hävare. Eventuell isolering i mellanbjälklag eller taknock kan också begränsa kastlängden för skärsläckaren. En lösning på detta problem kan vara att punktera isoleringen i cirkel runt branden och sedan succesivt minska cirkel, d.v.s. ringa in branden. Dimspik som användes vid begränsningslinjen har bra effekt i det korta närom­ rådet, men problemet med dimspik är att man efter monteringen sätter på dem och låter dem vara på vilket ofta medför omfattande vattenskador. Alternativet är att man istället påföra vattnet i korta intervall. Vattnet hjälper då till att inertera hålrum och på så sätt går det att öka släckeffekten med mindre vatten­ åtgång. Ett annat alternativ för att öka släckeffekten med mindre vatten är att blanda i tillsatsmedel till släckvattnet. Med tillsatsmedel så tränger vattnet djupare in i materialet vilket göra att konstruktionen torkar upp sämre. Detta är positivt ur återantändningsskydd men vid sanering av bostaden är det mycket viktigt att konstruktionen får torka ut ordentligt så att den inte möglar. B7.6 Referenser [1] Liljeqvist, R., (2013). Olycksutredning brand i byggnad, Hålegårdsvägen, Lexby, Partille, 2 februari 2013. Räddningstjänsten Storgöteborg. [2] Karlsson, M., Räddningstjänsten Storgöteborg, intervju 2014-05-28. [3] Insatsrapport, Brand i byggnad, Hålegårdsvägen 15, Partille, 2013-02-04, Räddningstjänsten Storgöteborg.

BILAGA 8 Linköping bibliotek 20-21/9 1996

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 101 BILAGA 8 Linköping bibliotek 20-21/9 1996 B8.1 Objektbeskrivning Stadsbiblioteket i Linköping byggdes 1972-1973, i en tidstypisk stil. Informa­ tionen om branden är till stor del hämtad från Referens 1. Byggnaden rymmer utöver stadsbibliotek också informationskontor och invandrarbyrå, se Figur B 16. Huvuddelen av byggnaden har tre våningar [2]: • • källare med arkiv, Ca 3200 m² • • souterrängplan med en stor, öppen bibliotekshall, ca 3200 m² • • entréplan med en mindre bibliotekshall och kontorslokaler, ca 920 m². Den mindre hallen ligger på en balkong, med en 52 m lång öppning (ca 200 m²) till den stora bibliotekshallen. Till biblioteksdelen är fogat en kontorsbyggnad med totalt fyra våningar, varav två under mark. De två byggnadsdelarna bildar tillsammans med en förbindelsegång en öppen innergård, mot vilket brandrum­ met vetter. Konstruktionen består av pelardäck med slakarmerade betongpelare och bjälklag av platsgjuten betong (250 mm, klass 1). Ytterväggarna består av tegelmur. [3] Figur B 16. Planskiss över bibliotekets två våningar [2].

102 BILAGA 8 – Linköping bibliotek 20-21/9 1996 Källarplanets bokmagasin var avskilt i klass EI60 och dess handskriftsmagasin i klass EI120. Bibliotekshallen med angränsande kontorsrum m.m. var en stor brandcell över två våningar. Det fanns mycket brännbart material i lokalerna. Ett hängande undertak bestod av 20*95 mm furuträ ställd på högkant. Det var byggt likt ett ”raster” om rutor 600x600 mm och hade en uppskattad totalvikt av 1-2 ton. I ”spaltöppningen” fanns ca 150 kvm ljudabsorberande skivor av tretex, d.v.s. porös board. Väggbeklädnaden i vissa rum på entresolplanet bestod av väggkork. På entresolplanet bestod korridorväggen utanför kontorsrummen av träpanel. Kontorsbyggnaden är avskild i klass E30. [2] Byggnaden utrustades vid byggnationen med ett automatiskt brandlarm med rök- och värmedetektorer. Ett utrymningslarm var kopplat till högtalarsystemet. Brandlarmet var dessutom direktkopplat till räddningstjänsten. Släckutrustning bestod av inomhusbrand­ poster och handbrandsläckare. Placering och funktion hos dessa visade sig vara av avgörande betydelse. Byggnaden var brandsynepliktigt och hade ett eget objektkort för insatsinformation. [4] B8.2 Incidenter före branden I mitten av 1990-talet flyttade informationskontoret in i huset på grund av sparskäl. In flyttade också invandrarbyrån som ger service och information till invandrare. Invandrarbyrån, med lokaler i byggnaden, hade under året vid flera tillfällen varit utsatt för hot med flera sabotage innan branden. Med facit i hand är det idag uppenbart att någon ville skrämma de anställda på invandrarbyrån, kablar till datorer och telefoner klipptes av, anteckningar med invandrarbyråns anställda hittades, lås bröts upp, hotbrev förekom, bombattrapper hittades etc. ”Ännu i dag kan jag tycka att det är obegripligt att ingen gripits för branden. Eller åtmins­ tone för någon av de 42 incidenter som föregick branden” [5]. Dessa hotelser ledde till att särskilda brandvakter utbildades, för att hjälpa till vid en eventuell utrym­ ning. Räddningstjänsten skaffade sig extra god lokalkännedom och tog larmet på största allvar. Detta illustreras av en mycket kort insatstid. De incidenter som inträffat under året inkluderar [3]: 9 juli: Försök till brand i källaren. 12 juli: Brand i förråd i kontorskorridor. 22 augusti: Hotbrev, intrång med skadegörelse. 12 september: Bombhot och utrymning. Hotbrev. 20 september: Byggnaden brinner ner. B8.3 Branden Branden anlades sent på kvällen i en fåtölj i ett av kontorsrummen och detekte­ rades snabbt av det automatiska brandlarmet som endast hördes av personalen. Personalen identifierade branden, en fåtölj brann i ett kontorsrum på övervå­ ningen och gjorde ett släckförsök som ej lyckades. Personalen lämnade därefter brandrummet med öppen dörr varefter en av personalen sände ut ett högta­ larmeddelande om utrymning, Brandrummet övertändes mycket snabbt och branden spred sig ut i bibliotekshallen ungefär samtidigt som räddningstjänsten var på plats. Hallen övertändes redan efter en halvtimme på grund av brännbart material innertaket och branden blev så intensiv att betongpelarna som bar upp taket ger vika. F.d. chefen för länskriminalen, Tommy Håkansson, hävdade att ”branden polisiärt är uppklarad men att bevis saknas för att gripa gärningsmannen som förmodligen var en av de anställda. Vi har inte suttit och spekulerat i vem av oss det kunde vara men förstår att misstankarna gått åt det hållet eftersom låsta utrymmen forcerades utan minsta spår” [3]. Skadekostnaderna uppgick till 103 millioner SEK.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 103 Beskrivningen nedan av branden och släckinsatsen bygger på uppgifter i insats­ rapporter och olycksundersökningar som gjorts [3, 5-8]. BRANDFÖRLOPP RÄDDNINGSTJÄNSTINSATS Räddningstjänstens utredning [2] om brandför­ loppet beskriver ingående brandens tidiga förlopp. Med utgångspunkt från denna kan brandens storlek vid olika tidpunkter uppskattas. Hur insatsen varierar med tiden kan beskrivas unge­fär som följer. Notera dock att de utrymnings­ tekniska delarna är utelämnade och att redogörel­ sen endast rör sig om själva släckinsatsen. 23:06 Branden får fäste i en fåtölj i ett av kontors­ rummen (beräknad tid) [2]. 23:08 Branden detekteras av en värmedetektor (datalog) [3]. Branden bedöms vara anlagd. Den startade i en skinnfåtölj i ett av kontorsrummen på invandrar­ byrån. Fåtöljen bestod av ca 2 kg polyuretanstopp­ ning på träram, överdragen med ett skinnliknande material. I fåtöljen låg ett paket eller papper. Detektorn ingår i ett automatiskt brandlarm som larmar inom byggnaden och till räddningstjäns­ ten. Aktiveringstiden har i efterhand beräknats till ca 2 minuter. 23:09 Dörren till brandrummet öppnas. Hela fåtöljen brinner och branden sprider sig till taket, vilket ökar effektutvecklingen (vittnesuppgift). Effektutvecklingen har i efterhand beräknats till ca 1 MW [2]. 23:09-23:10 Personal gör ett släckförsök med in­ omhusbrandporten i passagen till personalentrén (rum 319, vittnesuppgift). Släckinsatsen misslyckas då det blir problem med slangen och det inte kom­ mer något vatten. I efterhand kan konstateras att även om dessa problem uteblivit hade inte släck­ insatsen lyckats. Avståndet mellan brandpost och dörren till brandrummet är 26 m vilket är längre än slangen. Släckeffekten under detta försök är alltså noll. Avståndet till den närmaste brand­ posten är 16 m och om denna använts istället, hade resultatet blivit annorlunda [8]. 23:11 Branden i kontorsutrymmet når övertänd­ ning, blir ventilationskontrollerad och sprider sig ut i bibliotekshallen (uppgift från insatsperson.) Effekten beräknas till ca 1,8 MW [2]. 23:11-23:12 Då inte brandposten fungerar, görs ett försök att angripa branden med en handbrand­ släckare. Vid denna tidpunkt var det redan för varmt för att kunna komma tillräckligt nära bran­ den och även detta släckförsök måste avbrytas (vittnesuppgift) [2]. 23:11 Räddningstjänstens första resurser är på plats, två släckbilar och en stegbil med tillsam­ mans 1+1+9 man (datalog) [3]. 23:14 Brandingenjören är på plats (datalog) [4]. 23:15 Branden har fått ordentligt fäste i biblioteks­ hallens innertak (uppgift från insatspersonal) [3]. Brandeffekten kan nu uppskattas till 5-10 MW. 23:14 En rökdykarinsats görs via personal-entrén, men rökdykarna kommer knappt fram till den obrukbara brandposten [3]. Avståndet är ca 30 m till brandrummet. Rökdykarna har en smalslang och dimstrålrör med sig, vilket ger en kapacitet på 300 l/min. Värmen i bibliotekshallen tvingar rök­ dykarna att retirera utan att de nått det ursprung­ liga brandrummet. 23:16 Resurser från två deltidsstationer anländer, två släckbilar med (2+8) man [3]. 23:24-23:30 Bibliotekshallen övertänds (uppgift från insatspersonal) [3]. 23:20 Rökdykarinsats avbryts och den invändiga släckeffekten upphör [3]. 23:55 En stor del av byggnaden rasar in. Effekt­ utvecklingen minskar kraftigt, men fortfarande är mycket värme ackumulerad i betongen (uppgift från insatspersonal) [3]. 23:55 Begränsningslinje är klar mot Hunnebergs­ gatan efter beslut 23.30. I och med att taket rasar in begränsas branden [3]. Tankbil med en man anländer [3]. 00:15 Fridygnsledig personal börjar anlända [3].

104 BILAGA 8 – Linköping bibliotek 20-21/9 1996 Raset av ett plastgjutet betongpelardäck i två våningar inträffade i ett oväntat tidigt skede av branden eller ca 30 minuter efter övertändning trots att byggna­ den formellt var dimensionerad för åtminstone 60 minuters motståndsförmåga. Enligt en utredning [9] är det helt uppenbart att förutsättningarna för det tidiga raset av bibliotekets tvåvåningsdel, fram till denna byggnads dilatationsfog, varit spaltöppningen i mellanbjälklaget. I Figur B 17 visas den del av byggnaden som kollapsade och i Figur B 18 visas ett tvärsnitt av byggnaden vid spaltöppningen. Branden spred sig från den övre våningen via taket och spaltöppningen till den nedre våningen. Figur B 17. Byggnaden efter branden. Figur B 18. Brandspridningsväg från övre planet till det nedre.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 105 B8.4 Analys Byggnadens brandskydd Den första av de nyckelhändelser som ledde till storbranden, är antändning. Ett bibliotek innehåller alltid brännbart material. Därför blir detta en fråga om att undanröja tändkällor. Då branden var anlagd, handlar det om byggnadens säker­ hetsskydd: tillträde, bevakning, m.m. Rumsbranden Nästa kritiska länk i händelsekedjan blir den snabba brandtillväxten. Denna bygger dels på att fåtöljen gav en snabb initialbrand, och att innertaket i kontors­ rummet var brännbart. Dels blev branden intensiv, dels misslyckades de första två släckförsöken med vattenslang och handbrandsläckare som gjordes av perso­ nalen. Dessutom lämnades dörren till kontoret öppen efter släckförsöken. Hade dörren stängts hade räddningstjänsten, som anlände några minuter senare troligt­ vis kunnat begränsa branden till kontorsrummet. Utrymning Utrymning är definitivt en kritisk aspekt vid biblioteksbranden. Folket var på väg ut ur byggnaden då kvällens program var slut och utbildade brandskydds­ värdar hjälpte till under utrymningen. Ingen skadades därför trots att det be­ funnit sig mycket folk, ca 400 personer, i byggnaden strax före branden [2]. Med det snabba brandförloppet fanns potential för en brandkatastrof med ett större antal omkomna. Det kan konstateras att räddningstjänsten kom fram först efter utrymningen avslutats och den enda livräddningsinsats som gjordes var i form av eftersök av förmodat kvarvarande i lokalerna. Utrymningsproblematiken har därför inte granskats i denna studie. Branden i övre hallen Släckförsök utfördes av räddningstjänsten med strålrör. Man lyckades inte nå fram till brandrummet och släcka rumsbranden och takbranden i hallen då värme­strålningen blev alltför stor, man tvingades retirera. Branden spred sig snabbt då det fanns ca2 ton träreglar i taket i övre hallen monterade i rutor på 60x60 cm och dessutom fanns det porösboard i taket på den nedre hallen. Brand i hela byggnaden Räddningstjänsten bedömde byggnaden som förlorad och koncentrerade insats­ erna till att hindra brandspridning till andra byggnader vilket lyckades väl. B8.5 Möjliga brytpunkter för annat metodval Byggnadens brandskydd Stora brister i det förebyggande arbetet borde ha rättats till långt innan det att branden inträffade. Byggnaden hade en extrem brandbelastning som tilläts då den byggdes 1972-73. Vid den tiden fanns det i stort sett bara en begränsning av energiinnehållet per m2 i rådande byggstandard. Trots att räddningstjänsten efter ett flertal incidenser fått god kännedom om objektet var det ingen som rea­ gerade för den exceptionella brandbelastningen i bl.a. övre hallen. Trots att ett flertal incidenser inträffat tycks bibliotekets förebyggande arbete inte fungerat. T.ex. kände personalen inte till hur långt slangarna räckte från olika brandposter och dörren till brandrummet lämnades öppen.

106 BILAGA 8 – Linköping bibliotek 20-21/9 1996 Rumsbranden Branden skulle av personalen kunna begränsas till det primära brandrummet genom en insats med vatten från rätt brandpost eller genom att dörren till rum­ met stängts. Brandspridningen skulle då fördröjas till dess räddningstjänsten anlände med släckutrustning som kunde hantera rumsbranden. Branden i övre hallen Då räddningstjänsten anlände hade branden spridit sig till taket utanför det pri­ mära brandrummet. Effektutvecklingen uppskattas då ha varit 5 – 10 MW. För att fördröja brandspridning skulle brandgaserna kunna kylas med en insats med vattendimma. Avstånden utifrån från taket på markplanet till det primära brand­ rummets dörr är ca 14 m (Figur B 18). På baksidan av byggnaden kan man dess­ utom nå brandrummet utifrån från taket på markplanet. Den bästa möjlighet, med tanke på kastlängd, kylförmåga, vattenskador och tryckminskning (Bilaga 11) hade varit en kraftfull insats med flera skärsläckare utifrån riktade mot både det initiala brandrummet och taket i den övre hallen. Då fasaden i hallen och det primära brandrummet hade fönster skulle insatsen snabbt kunnat komma igång och dess verkan bedömas. Med denna åtgärd hade brandspridningen möjligen stoppats och underlättat för en påföljande konventionell släckinsats med strålrör. Ett annat alternativ är att använda dimspik. För att täcka hela den snabbt ökande brandytan hade man behövt slå in många dimspik då de endast har en kort kast­ längd. Arbetet med att montera dimspiken hade tagit mycket längre tid och varit riskfyllt för insatspersonalen. Vattenskadorna hade dessutom blivit avsevärt större än de man får med skärsläckare. B8.6 Referenser [1] Djupanalys av tre storbränder, Stefan S., ISSN 1102-8246 ISRN LUTVDG/ TVBB-3096-SE. [2] Hanning, R., Jansson, H., Petri, J., Brandförlopp biblioteksbranden 1996-09-20, Räddningstjänsten i Linköping, 1996-11-04. [3] Biblioteksbranden 1996-09-29 Tidrapport, samt diverse sammanställningar av information, Räddningstjänsten i Linköping. [4] Objektkort 61, Stadsbiblioteket, Räddningstjänsten i Linköping. [5] Biblioteksbladet 08:2006, Tidskrift för Svensk Biblioteksförening. [6] Kommenderingslista 96-09-29, Räddningstjänsten i Linköping. [7[ Insatsrapport, Ärendenummer 960920-00358, SOS-Centralen Östergötland. [8] Kvarteret Artemis 10, Linköping, Linköpings Stadsbibliotek, Skadeinvente­ ring och rivningsförslag av kvarvarande stomme efter brand, J&W Bygg & Anläggning AB. [9] Biblioteksbranden i Linköping den 21 september 1996, Yngve Anderberg FSD AB, K.G. Bernander, Prefabkonsult AB, Brandforskprojekt 272-941, Brandför­ svaret, m.fl. [10] Lindkvist, A., Information nr 2, Till all personal i Linköpings kommun med anledning av biblioteksbranden, Informationskontoret, Linköpings kontor, 1996-09-27. [11] Diverse handlingar i samband med bygglovsansökan 1971, Byggnadsnämn­ den, Stadsarkitektkontoret. [12] Diverse ritnings- och bildmaterial. [13] Biblioteksbranden i Linköping, Videofilm, Informationsbolaget.

BILAGA 9 Steglinge gård, Höganäs 5/8 2012

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 109 BILAGA 9 Steglinge gård, Höganäs, 5/8 2012 B9.1 Objektbeskrivning Steglinge gård fungerar som paketerings- och distributionscentral för frukt och grönsaksdistributörer i södra Sverige. Detta innebär att stora mängder frukt och grönt ankommer till Steglinge gård för att sedan distribueras vidare. Gården har även viss egen produktion. För att driva verksamheten på gården fanns det 35 anställda vid tidpunkten för branden. Ett flygfoto från maj 2009 visar Steglinge gård i sin helhet, se Figur B 19. Gårdens byggnader som var involverade i branden benämns A-F i Figur B 19. Samma benämningar har används i Räddningstjänsternas olycksutredningar [1 och 2]. Figur B 19. Flygfoto över Steglinge gård taget 2009-05-19. Kryssen visar brandhärdar. Bild: Länsförsäkringar. B9.2 Incidenter före branden Branden var troligen anlagd eftersom det upptäcktes tre olika brandhärdar, men inga incidenter före branden har rapporterats. B9.3 Branden Den 8 maj 2012 inträffade en brand på Steglinge gård i Höganäs kommun. All information från händelsen är hämtad från den olycksundersökning Räddnings­ tjänsten Skåne Nordväst [1] genomfört, samt den olycksundersökning Helsing­borgs Brandförsvar [2] gjort. Analysen fokuserar på första timmen efter räddnings­ tjänstens framkomst, eftersom det är under denna timme det finns möjlighet att begränsa brandens omfattning.

110 BILAGA 9 – Steglinge gård, Höganäs, 5/8 2012 Resursmässigt fanns det mer personal att tillgå på Höganäs brandstation än van­ ligt vid tidpunkten för olyckan. Detta berodde på att det var planerat en övnings­ dag för samtliga heltidsbrandmän samt styrkeledare. Detta innebar att det fanns 12 brandmän och styrkeledare att tillgå. Vilka resurser som larmats till Steglinge gård visas nedan. Initialt utlarmade styrkor och fordon • • Höganäs 4010 (släckfordon) • • Höganäs 4020 (släckfordon) • • Höganäs 4030 (höjdfordon) • • Höganäs 4040 (tankfordon) • • Höganäs Insatsledare 4080 • • Vakthavande Brandingenjör (VBI) 1180 • • Stabsbrandmästare (SBM) Förstärkande styrkor och fordon • • Höganäs 4410 (släckfordon) • • Ängelholm 3010 (släckfordon) • • Ängelholm 3040 (tankfordon) • • Helsingborg 1110 (släckfordon) • • Helsingborg 1130 (höjdfordon) • • Helsingborg 1140 (tankfordon) • • Helsingborg extra minibuss med personal • • Åstorp 8610 (släckfordon) • • Helsingborg extra minibuss med personal Klockan 12.10, den 8 maj upptäcktes tre brandhärdar på Steglinge gård. Dessa brandhärdar är markerade med svarta kryss i Figur B 19. Räddningstjänsten lar­ mades ut kl. 12.15 och var framme på Steglinge gård kl. 12.22. Brandens utveck­ ling vid byggnad A ett par minuter efter Räddningstjänstens framkost visas i Figur B 20 (ca kl. 12:25). Vid framkomst bedömdes branden i trälådorna utanför byggnad A som mest kritisk eftersom den hotade byggnad A där det förvarades stora mängder göd­ ningsmedel. Högen med trälådor bedömdes vara åtta meter bred, nio meter lång och fyra till fem trälådor var staplade på höjden. Även trälådorna som stod stap­ lade intill byggnad B var hotade av branden på grund av den höga strålningsnivån. Uppskattningsvis var det endast sex meter mellan trälådorna vid byggnad A till trälådorna vid byggnad B. Initialt fanns det stora problem att hitta fungerande brandposter. På grund av detta fanns det under stor del av insatsen en begränsning i tillgång till släck­ vatten. Vidare så kunde man strax innan byggnad B antänder konstatera att den var isolerad med någon form av skum. Detta bidrog med stor sannolikhet till det snabba förloppet i byggnad B när den väl antänt. Figur B 21 visar brandens storlek ca 12:59 då byggnad B antänder samt byggnad B endast ett par minuter senare. Räddningstjänsten avslutas kl. 21:00 och då har branden stoppats vid byggnad C. Byggnad D är ej allvarligt skadad.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 111 Beskrivning nedan av branden och släckinsatsen bygger på uppgifter i olika olycksundersökningar [1 och 2]. BRANDFÖRLOPP RÄDDNINGSTJÄNSTINSATS 12:10 Brandhärdar på tre platser upptäcks på gården. 12:13 Larm inkommer till SOS. 12:15 Räddningstjänsten får larm, brand i bygg­ nad, ladugård, Nivå 3. Tre separata brandhärdar. 12:22 Första anländande styrkor. 12:25 Trälådor utandför byggnad A brinner, se Figur B 20. 12:25 Höganäs 4010 får till uppgift att släcka trälådorna på utsidan av byggnad A då detta anses mest kritiskt. Genomförs med traditionellt lågtryckssystem. Vald släckmetod får ej avsedd effekt på branden och spridning sker till trä­ lådorna vid byggnad B. Övrig personal från Höganäs (4020) som kom fram samtidigt får till uppgift att släcka inne i bygg­ nad A. Det förvaras stora mängder gödningsmedel inne i byggnad A. Genomförs enligt AFS 2007:7 som invändig släckning genom rökdykning. 12:25 Trälådorna utanför byggnad B antänder pga. strålningsvärme. 12:39 Kraftig brand i trälådorna vid byggnad B. Vald släckmetod får ej avsedd effekt på branden och spridning sker till byggnad B. 12:39 Helsingborgs styrkor anländer. Helsingborgs styrkor får i uppgift att släcka branden i trälådorna utanför byggnad B. Genomförs med traditionellt lågtryckssystem. 12:59 Byggnad B antänder. 13:30 uttalas att beslut i stort är att stoppa brand­ spridningen vid utlastningsdelen (byggnad C). Insatsen lyckas och branden stoppas vid byggnad C. 21:00 Räddningstjänsten avslutas.

112 BILAGA 9 – Steglinge gård, Höganäs, 5/8 2012 Figur B 20. Brandens utveckling vid byggnad A ett par minuter efter Räddningstjänstens framkomst kl. 12:25. Foto: Länsförsäkringar.

Figur B 21. Vänstra bilden är tagen precis innan byggnad B antänder och den högra är tagen endast någon minut senare. Foto: Länsförsäkringar. B9.4 Analys Vid ett brandförlopp av den karaktär som initialt inträffade på Steglinge gård är det väldigt viktigt med en tidig insats. Någon typ av insats från personalen innan Räddningstjänsten anlände hade sannolikt ändrat förutsättningarna för rädd­ ningstjänsten att göra en lyckad insats. Vid insatser som denna tydliggörs det hur avgörande det är att det finns ett fung­ erande brandpostnät att tillgå då det krävs stora mängder vatten för att släcka och begränsa brandens spridning. För att få ökad effekt av det vatten som fanns att tillgå hade olika tillsatsmedel, CAFs-system eller tung/mellanskum kunnat öka effekten på släckvattnet samt minska risken för självantändning av de angränsande trälådorna. Det är dock vik­ tigt att ta hänsyn till miljöaspekterna innan tillsatsmedel tillsätts till släckvattnet.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 113 En dimridå mellan trälådorna vid byggnad A och B hade troligtvis minskat risken för att branden skulle spridit sig till Byggnad B och skadans omfattning hade stannat vid byggnad A och de antända trälådorna. B9.5 Möjliga brytpunkter för annat metodval Nedan diskuteras möjliga brytpunkter i förloppet och hur andra metoder even­ tuellt hade kunnat påverka händelseutvecklingen. Fokus i analysen ligger på den första timmen i brandutvecklingen, d.v.s. fram tills att branden sprider sig till byggnad B ca kl. 12.59. Förebyggande Placeringen och mängden trälådor är avgörande för brandens intensitet samt spridningsrisk till angränsande staplar och närstående byggnader. Även hur de staplas är avgörande för brandutvecklingen och hur hög brandeffekten slut­ ligen blir. Att ha så korta avstånd som 6m mellan trälådorna vid byggnad A och byggnad B innebär en stor risk för brandspridningen. Denna brandspridning sker i huvudsak via hög strålningsvärme. Branden i trälådorna vid byggnad A var vid framkomsten 12:22 redan fullt utvecklad och var då troligtvis större än vad Räddningstjänsten normalt klarar av. Brandposterna i anslutning till gården var trasiga samt övertäckta med jord vilket medförde att det inte fanns vatten att tillgå mer än vad som fanns på brandbil­ arna under stor del av insatsen. Detta medförde att Räddningstjänsten fick agera med utgångspunkt att de var tvungna att vara sparsamma med mängden vatten som de använde. Begränsning 1 – personalen på gården Enligt 2 kapitlet 2§ i Lag (2003:778) om skydd mot olyckor [3] har ägare eller nyttjanderättsinnehavare ett stort ansvar för att begränsa brandens omfattning: ”2 § Ägare eller nyttjanderättshavare till byggnader eller andra anläggningar skall i skälig omfattning hålla utrustning för släckning av brand och för livrädd­ ning vid brand eller annan olycka och i övrigt vidta de åtgärder som behövs för att förebygga brand och för att hindra eller begränsa skador till följd av brand.” Enligt uppgift från räddningstjänsten [1] arbetade det ca 35 personer på Steglinge gård och det fanns tillgång till olika lastmaskiner enligt de bilder som finns från branden. Personal på plats kunde påbörjat en första insats att släcka branden samt flytta trälådor för att ta bort så mycket brännbart material som möjligt från brandplatsen. En snabb insats av personal på plats hade kunnat begränsa brandens omfattning i trälådorna som antänts samt förhindrat spridning till angränsande trälådor vid byggnad B. Det finns även en branddamm att tillgå på gården som hade kunnat utnyttjas som en första insats av personal på gården. Släckangrepp 1 – Begränsning av brandspridning De styrkor som anlände först inriktade sig på att släcka branden i trälådorna utanför byggnad A. Detta genomfördes för att begränsa brandens spridning efter­ som denna brand hotade att spridas till angränsande byggnader och trälådor. Initialt ansågs det möjligt att vald metod var tillräcklig för att släcka trälådorna som brann, men den valda metoden (konventionellt lågtryck) gav ej avsedd effekt på branden. Tillgängliga filmer från insatsen indikerar att strålnings­ värmen från branden i trälådorna vid byggnad A måste ha varit mycket hög och personalen från Höganäs har svårt att arbeta så nära branden som krävdes från den valda angreppspunkten. På grund av strålningsvärmen går det också att se på filmen att trälådorna vid byggnad B börjar självantända samtidigt som insatsen

114 BILAGA 9 – Steglinge gård, Höganäs, 5/8 2012 mot trälådorna vid byggnad A påbörjas. Att insatsen inte lyckades kan med stor sannolikhet bero på att mängden släckvatten kraftigt var begränsat. Med utgångspunkt från de skadeplatsfaktorer som fanns vid Räddningstjänstens ankomst kl. 12:25, se Figur B 20, diskuteras fyra alternativ. De skall inte betraktas som att de var för sig är lösningen på problemen utan de är ofta en kombination av flera metodval som krävs för att lösa komplicerade insatser. Situationsanpas­ sade val som skall baseras på kritiska skadeplatsfaktorer (vilka faktorer är vikti­ gast att ta tag i först) för att bryta det negativa händelseförloppet. Det är viktigt att tidigt tydliggöra mål med insatsen och taktisk plan för genomförande. De fyra alternativen som diskuteras är följande: • • Släckning av trälådor vid byggnad A. • • Begränsningslinje mellan byggnad A och B för att minska strålningsnivån mot trälådorna vid byggnad B. • • Bortforslande av trälådor för att minska risken för brandspridning. • • Direktpåföring på trälådorna vid byggnad B för att förhindra antändning. Den valda metoden att angripa trälådorna vid byggnad A med ett konventionellt lågtryckssystem lyckades tyvärr inte. För att få en ökad effekt av den valda insat­ sen hade olika tillsatsmedel till släckvattnet kunnat användas. Önskat mål med användandet av tillsatsmedel är att uppnå en effektivare släckning samt minska risken för återantändning. Med tillsatsmedel avses även premix av A-skum. På grund av den höga strålningsvärmen hade tungskum varit ett bra alternativ eftersom den ger lång kast längd. Det är dock viktigt att ta hänsyn till miljö­ aspekterna innan tillsatsmedel tillsätts till släckvattnet. Det finns ett flertal system med huvudfunktion att skapa en dimridå av vatten för att minska strålningsintensiteten mot angränsande objekt. Exempel på dessa system är ridåmunstycke, vattenkanon med tallriksmunstycke, backupstrålrör med tallriksmunstycke samt TST Smart Hose, som innehåller ett antal mun­ stycken direkt monterade på brandslangen. Målet med att använda dessa system är att vattenridån skall absorbera strålningen från branden så att angränsande objekt ej skall självantända. Vissa av dess system kräver ett vattenflöde på drygt 1000l/min vilket inte fanns att tillgå vid den faktiska insatsen på grund av brist­ erna i brandpostnätet. Tidigt bortforslande av trälådor hade kunnat ge stor effekt på både brandens omfattning samt minskad spridningsrisk. Initialt hade personal på gården kunnat påbörja denna åtgärd för att inte branden skulle växa till den omfattning som var då räddningstjänsten kom till platsen. För att förhindra att trälådorna antände utanför byggnad B kunde man tidigt i insatsen kylt dem med vatten. Troligtvis hade det gett en ännu högre effekt om tillsatsmedel, tryckskumsystem typ CAFs eller traditionellt tungskum hade använts. Genom att använda tillsatsmedel eller skum kan mängden vatten som används minimeras då detta var en begränsning vid insatsen. B9.6 Referenser [1] Lag (2003:778) om skydd mot olyckor. [2] Olycksundersökning Nivå 2A, Steglingegård, 2012-05-08, Brandförlopps­ utredning, Nivå 2A, Helsingborgs Brandförsvar. [3] Olycksundersökning Nivå 3, Brand Steglingegård, 2012-05-08, Räddnings­ tjänsten Skåne Nordväst, Diarienr. KS 2012/719.

BILAGA 10 Övertryck i angränsande utrymmen

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 117 BILAGA 10 Övertryck i angränsande utrymmen Räddningstjänsten behöver ibland åstadkomma ett övertryck i en del av en byggnad för att hindra brandgasspridning till angränsande lokaler. För att åstadkomma ett högt övertryck kan man ställa fläkten nära tilluftsöppningen. För att höja effekten kan man minska höjden på tilluftsöppningen (ytterdörren) och placera fläkten nära dörröppningen. Det teoretiskt högsta trycket som kan uppnås är genom att ställa fläkten i ett hål som är lika stort som fläktens diameter. Med hjälp av de fläktar som testades, uppnås högsta trycket på 300 Pa genom att placera fläkten i ett hål i dörren som har samma diameter som fläkten. Det är dock praktiskt svårt att genomföra. Det finns ett alternativ; dörradapter som ansluter dörröppningen till fläktkåpan. En fläkt som placeras i ett fyrkantigt hål på ungefär 1 m2 kan ge ett övertryck på 100 Pa förutsatt att byggnaden är relativt tät. Om det inte finns någon möjlig­ het att använda dörradapter eller skivor kan fläkten placeras ungefär 0,5 m från dörröppningen. Övertrycket kan bli storleksordningen 40 – 50 Pa, förutsatt att byggnaden har liknande täthet som försökslokalen. En fläkt som ställs 0,5 m från en vanlig dörröppning bör uppnå ett tryck på 40 – 50 Pa inom 10 sekunder för flesta typer av byggnader där denna typ av fläk­ tar används. Det handlar om att omvandla hastighetstrycket i dörrinloppet till ett statiskt övertryck i lokalen. Det förutsätter att byggnaden är tät. Även en brand genererar ett tryck som fläkten måste övervinna. Vid en brand i ett stängt rum kommer ett övertryck att byggas upp till följd av att luften värms upp och expanderar. För små eller måttliga temperaturer blir övertrycket några Pa. När temperaturen i det brinnande rummet blir några hundra grader kan denna tryckuppbyggnad i rummet ha en avsevärd effekt, speciellt om branden utvecklas snabbt. Fönster kan ge vika och därmed sänka brandtrycket. Normalt finns dock ett visst luftläckage i brandrummet, t.ex. i form av komfortventila­ tion eller otätheter vid fönster och dörrar. Eftersom en brand i ett rum normalt är växande, kommer trycket på grund av otätheter och läckage att utjämnas efterhand. Tryckökningen blir normalt därför endast i storleksordningen någon eller några enstaka tiotal Pa. Försök i brandrum som blir övertända och där lägenhetsdörrar eller fönster är delvis öppna visa att brandtrycket blir i storleksordningen 5 – 10 Pa. Om en lägenhet är på väg att bli övertänd (temperaturen omkring 400 – 500 ºC), och dörrar och fönster är stängda, då kan ett brandtryck på 50 – 60 Pa uppmätas. När branden växer från noll till 600 ºC på mindre än en minut, så kan brand­ trycket växa till 200 Pa på väldigt kort tid, innan rutan spricker och trycket sjunker ner till några Pa. Detta är dock väldigt sällsynt fenomen då flesta bränder växer långsammare eller rutorna ger sig innan man uppnår detta brandtryck. De flesta bränder utvecklas betydligt lugnare och det mest sannolika trycket som finns i övertända rum ligger omkring 10 – 50 Pa. Det är detta tryck som fläkten måste övervinna för att undvika att brandgaserna sprids mellan rummen. För att undersöka detta gjordes ett antal försök i olika byggnader och vid olika förhållanden vid ytterdörren. Den första försöksserien genomfördes i ett betong­ hus och senare i ett stålhus som byggdes i SP:s brandhall. En kort sammanfatt­ ning finns nedan och ytterligare information från försöken finns i SP Rapport 2012:63 Ingason, Fallberg, Palmkvist och Edholm.

118 BILAGA 10 – Övertryck i angränsande utrymmen B10.1 Försök i betonghus utan frånluftsöppning Två försöksserier genomfördes med övertryck i betonghuset. Fönstren hade stängts med påspikade skivor på ingjutna fönsterramar. Fyra små öppningar med skjutluckor var stängda. I första försöksserien ställdes fläkten ungefär 1,8 m från en öppen ytterdörr (0,87 x 2,04 m). I den andra försöksserien placerades en spånskiva med ett utsågat hål som hade samma diameter som fläkten (0,6 m). Fläktkåpan placerades sedan i hålet. Två fläktar med olika motorstyrka, 5,5 respektive 6,5 hästkrafter (HP) och primär­ flöde 5 m3/s respektive 5,7 m3/s, men med samma diameter på kåpan 24” (0,6 m) användes i försöken. Det statiska övertrycket som fläktarna åstadkom i byggnaden uppmättes med tryckmätare på bägge våningsplanen. Dessa värden användes för jämförelse med beräkningar. MOT EN YTTERDÖRR 0,87 X 2,04 M NEDRE PLAN (Pa) ÖVRE PLAN (Pa) BERÄKNING (Pa) 5,5 HP - Qp=5 m3/s, D0=0,6 m, H=2,04 m, ρ0 =1,25 kg/m3 25 24 17 6,5 HP - Qp=5,7 m3/s, D0=0,6 m, H=2,04 m, ρ0 =1,25 kg/m3 34 27 22 MOT ETT HÅL I YTTERDÖRR 5,5 HP - Qp=5 m3/s, D0=0,6 m, H=2,04 m, ρ0 =1,25 kg/m3 188 185 195 6,5 HP - Qp=5,7 m3/s, D0=0,6 m, H=0,6 m, ρ0 =1,25 kg/m3 248 242 254 Tabell 1. Uppmätta och beräknade övertryck i betongbyggnaden vid olika placeringar av fläktarna, Qp=primärflöde, D0=diameter, H=dörrhöjd, ρ0 =luftdensitet. Försöken visar att motorstyrkan har en betydelse för hur högt övertrycket blir. Placeringen av fläkten är också viktig och hur dörren är täckt. Högsta trycket uppnås genom att placera fläktkåpan inne i ett hål i dörröppningen (dörren täckt med skiva med ett hål som har samma diameter som fläktkåpan). B10.2 Försök i stålbyggnad utan frånluftsöppning Försök för att mäta övertryck i en lokal utan frånluftsöppning genomfördes i en stålbyggnad vid SP Brandteknik. Stålbyggnaden hade måtten 12,5 m lång, 8 m bred och 5 m hög. En port med skjutdörr fanns i mitten på ena kortsidan. Öppningar med måtten 2,5 x 2,3 m2 (b*h) samt en vanlig dörr med måtten 0,9 m x 2,04 m användes. Mätningar som gjordes visade på att stålbyggnaden var relativt tät. Det uppmätta läckaget var 0,112 m3/s vid 50 Pa övertryck och 0,25 m3/s vid 100 Pa övertryck.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 119 I första försöksserien placerades fläkten på olika avstånd från dörren. 24” (0,6 m) fläktar med 5,5 HP respektive 6,5 HP användes vid försöken. Fläktarna placerades med ett jämt intervall på 0,25 m mellan 0 och 2,25 m från dörren. Syftet var att undersöka lämpligaste placering för att skapa ett övertryck i en lokal utan från­ luftsöppning där fläkten placeras utanför en vanlig dörr som inte är täckt på något sätt eller där man inte använder en dörradapter. Högsta trycket uppmättes på avståndet 0,5 m ifrån dörröppningen. Det är också tydligt att motorstyrkan har en betydelse för vilken nivå trycket hamnar på. Högsta trycket som upp­ mättes var på 52 Pa för 6,5-HP fläkten och 41 Pa för 5,5-HP fläkten. I detta fall så täcker inte luftkonen hela dörren, därför blir trycket högre. På ett avstånd som motsvarar dörrhöjden, och där man kan förvänta sig att luftkonen täcker hela dörren, d.v.s. omkring 2,04 m, ligger trycket runt 12 – 16 Pa, vilket avviker betydligt från högsta trycket. Detta överensstämmer dock ganska bra med beräk­ ningar som ger ungefär 20 Pa. Försök gjordes också där man delvis täckte dörren med en skiva, se Figur B 22. En öppning som var 0,9 m bred och 1,03 m hög användes. Två olika typer av fläktar användes där avståndet varierades. Tre olika avstånd användes: 0 m (d.v.s. strax intill tilluftsöppningen), 0,2 m och 0,45 m från tilluftsöppningen. Högsta trycket uppmättes när fläkten placerades i dörröppningen, ungefär 110 – 122 Pa, vilket är högre än vad de teoretiska beräkningarna förutsäger. Anledningen att det blir högre är att luftkonen när den står i dörröppningen inte täcker hela öppningen. Men om den står lite bakom den, så den täcker hela öppningen så hamnar trycket på 80 – 90 Pa. Trycket sjunker linjärt med avståndet upp till 0,45 m från öppningen, ner till ungefär 60 Pa. Detta samband förändras antagli­ gen beroende på hur luftkonen täcker in öppningen. Figur B 22. Försök med dörr som är delvis täckt. Öppningen är 0,9 m x 1,03 m.

120 BILAGA 10 – Övertryck i angränsande utrymmen Figur B 23. En fläkt placerade i en öppning som motsvarade fläktens kåpdiameter, 0.6 m. En fläkt placerade i en öppning som motsvarade fläktens kåpdiameter, se Figur B 22. Hålet sågades ut i en skiva som täckte dörröppningen. Fläktkåpan placerades sedan i hålet. I försöket med 5,5 HP fläkten så uppmättes ett övertryck på 284 Pa (medel under 2 minuter) och med 6,5 HP- fläkt så uppmättes ett övertryck på 303 Pa (medel 2,5 minuter). Eftersom stålbyggnaden är tätare än betonghuset så blir övertrycket högre i stålbyggnaden. I stålbyggnaden blev högsta trycket uppmätt till 303 Pa med 6,5 HP-fläkten och hål i skiva jämfört med 248 Pa i betonghuset. Fläktar placerades framför en port med måtten 2,5 m bred och 2,3 m hög på ett avstånd på 2,25 m. Fläktar med olika motorstyrka användes, 5,5 och 6,5 HP. Fläk­ tarna placerades antingen enskilt framför porten eller parallellt, se figur 3. Lut­ ningen på fläktkåpan varierades, d.v.s. vinkeln mellan vertikalplan och kåpan. Övertrycket i lokalen uppmättes och resultaten visas i Tabell 2. Tabellen visar ingen tydlig tryckökning i lokalen när två parallella fläktar används jämfört med när endast en fläkt används. Däremot tenderar man att få högre tryck med lägre lutning på fläktkåpan, men skillnaderna är små. Fläkt med högre motorstyrka tenderar att ge lite högre tryck.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 121 Figur B 24. Parallella fläktar framför porten till stålhuset. FLÄKT­ UPPSTÄLLNING AVSTÅND FRÅN PORTEN (M) MOTORSTYRKA (HP) LUTNING PÅ FLÄKT (O) ÖVERTRYCK (Pa) En fläkt 2,25 5,5 10 12,8 En fläkt 2,25 5,5 20 11,9 En fläkt 2,25 6,5 7 13,1 En fläkt 2,25 6,5 20 11,2 Parallella fläktar 2,25 5,5 10 11,9 Parallella fläktar 2,25 5,5 20 11,3 Tabell 2. Uppmätt övertryck med fläktar placerade 2,25 m från en port som har måtten 2,5 m x 2,3 m. Försöken visar att högsta uppmätta trycket uppnås genom att placera fläkten i ett hål i dörren. Ungefär samma effekt kan uppnås med hjälp av en dörradapter eftersom principen är den samma (hög inloppshastighet). En fläkt som placeras i ett fyrkantigt hål på ungefär 1 m2 kan ge ett övertryck på 100 Pa förutsatt att byggnaden är relativt tät. Om det inte finns någon möjlighet att använda dörr­ adapter eller skivor kan fläkten placeras ungefär 0,5 m från dörröppningen. Övertrycket kan bli storleksordningen 40 – 50 Pa, förutsatt att byggnaden har liknande täthet som försökslokalen.

122 BILAGA 10 – Övertryck i angränsande utrymmen B10.3 Hur lång tid tar det att uppnå fullt tryck Det genomfördes ett antal mätningar som beskriver tryckuppbyggnaden i lokalen som funktion av tid. I Figur B 25 visas en sådan mätning för försöket när hålet är lika stort som fläktens diameter. Det visar sig att det inte tar mer än tio sekunder innan tryckuppbyggnaden är uppnådd. Teoretiska maxvärdet är 245 Pa. I Figur B 26 visas uppmätt tryck från försök med en 5.5 HP, i en dörr på 2,04 m, där det upp­ mätta och beräknade hamnar på ungefär samma nivå, 16,5 Pa inom tio sekunder. Figur B 25. Den uppmätta tryckförändringen i stålbyggnaden där ingen frånluftsöppning finns. Öppningen var lika stor som fläktens diameter. Figur B 26. Den uppmätta tryckförändringen i stålbyggnaden där ingen frånluftsöppning finns. Öppningen var 0.9 m x 2.04 m, en 5.5 HP. Från Figur B 25 och Figur B 26 kan man utläsa att tryckuppbyggnaden är nästan momentan ( sec), vilket man kan förvänta sig då flödestrycket omvandlas direkt till statiskt tryck när lokalen inte har några frånluftsöppningar. De beräk­ nade värdena överensstämmer väldigt bra med de uppmätta.

BILAGA 11 Sammanställning av skärsläckarens egenskaper

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 125 BILAGA 11 Sammanställning av skärsläckarens egenskaper I Bilaga 11 är sammanfattningarna i avsnitt 1-8 utmärkta i faktarutor. För de som dessutom önskar information om de försök och publikationer som lett till sammanfattningarna rekommenderas avsnitten under faktarutorna. B11.1 Skärförmåga SAMMANFATTNING • Panelvägg, träbjälklag och industrivägg skärs igenom på några få sekunder. • Träregel skärs igenom inom 2 minuter. • Lättklinkerblock (250 mm) och mjukare material skärs snabbast igenom om man håller skär- släckaren på ett avstånd av ca 15-20 cm från blocket. Då går det på några få sekunder. Annars kan det ta upp till 3 minuter. • Betongblock (100 mm) skärs igenom inom 2 minuter om man rör munstycket upp och ner ca 1 cm. Om man håller munstycket stilla tar det längre tid ca 5 minuter. • Tjocka betongblock (190 mm) skärs igenom inom 4 minuter om man rör munstycket upp och ner ca 1 cm. Om man håller munstycket stilla tar det väsentligt längre tid. Skärsläckaren skärförmåga har testats och redovisats i flera publikationer [1-9]. Sammanfattningen bygger på information i rapporterna och erfarenhet från räddningstjänsten SÄRF. B11.2 Sprayens egenskaper nära munstycket efter genombrottet SAMMANFATTNING • På avstånd upp till 3 m kan strålen även utan abrasiv skära hål (inom 5 s) eller skada ytan på en 16 mm spånskiva och utgör därför ett allvarligt hot mot en människa som kommer i vägen för strålen. • På avstånd upp till 5-6 m kan strålen även utan abrasiv upplevas som smärtsam om den träffar en människa. • På avstånd över ca 7 m ger strålen ingen nämnvärd påverkan mot oskyddad hud. En spray från en skärsläckare som ger 50 – 70 l/min vidgas nära utsläppet lång­ samt de första 5-6 metrarna med huvuddelen av vattnet nära centrum av strålen, Figur B 27.

126 BILAGA 11 – Sammanställning av skärsläckarens egenskaper Figur B 27. Sprayen nära utsläppet upp till 4 m avstånd [1]. På korta avstånd från genombrottet har vattenstrålen fortfarande en betydande kraft som kan skära igenom material och skada människor. I tabell 1 redovisas kraften i strålen och skärförmågan på olika avstånd från genombrottet [2]. AVSTÅND M MN/M2 SKÄRFÖRMÅGA/SKYDDSAVSTÅND 0 47.7 med abrasiv, 0.4 m/min 2 mm dural (flygplansplåt). 1 0.85 2 0.21 Utan abrasiv, hål i 16 mm spånskiva efter 5 s. 3 0.094 Utan abrasiv, ytskada i spånskiva (knottrig yta). 4 0.053 5-6 Utan abrasiv, smärtsamt för hand klädd med diskhandske. 5-6 Utan abrasiv, smärtsamt för oskyddad hand. 7-14 Lätt dimma, ingen nämnvärd påverkan på oskyddad hand. Tabell 3. Skärförmåga och skyddsavstånd [2]. B11.3 Sprayens egenskaper efter uppbrottet SAMMANFATTNING • Vattendropparna i sprayen efter uppbrottet är så små (volymsmedeldiameter ca 0.1 mm) att de snabb bromsas upp av friktionen mot luften och antar efter en mycket kort sträcka samma hastighet som luften. • Vid inbromsning överförs dropparnas rörelsemängd till luften. En fläkt med en kapacitet av 10-15 m3/s har alstrats. • Man kan även generera ett tidigt uppbrott av strålen inne i brandrummet på kortare avstånd än 5-6 m. Det innebär att man arbetar med hålet i väggen. När man rör munstycket i hålet beter strålen sig som ett sprinklerhuvud. Vattendropparna träffar nära väggen och dropparna blir större. Efter 5-6 m bryter strålen upp och får en tvärsnittsyta på ca 1 m2 på 5 meters avstånd till 2.6 m2 på 8 m avstånd [2]. I Figur B 28 visas uppbrottet.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 127 Figur B 28. Sprayens form vid uppbrottet. Foto: Bo Nystrand. Samtidigt som sprayen bryter upp bildas små vattendroppar med en volyms­ medeldiameter på ca0.1 mm [3] som effektivt bromsas upp av luftmotståndet samtidigt som dropparnas rörelseenergi överförs till luften [4]. Vattendropparna kommer mycket snabbt att anta samma hastighet som den omgivande luften, i storleksordning 17-7 m/s för avstånd mellan 5 till 10 m [1,3,5]. Man kan med upp­ gift om tvärsnittsarea och lufthastighet uppskatta den totala fläktkapacitet som bildats vid uppbrottet av sprayen, Figur B 29. Figur B 29. Sprayens tvärsnittsarea på olika avstånd [1].

128 BILAGA 11 – Sammanställning av skärsläckarens egenskaper Med hjälp av gashastighet och tvärsnittsarea för sprayen kan man beräkna fläkt­ kapaciteten som redovisas i Figur B 30. Figur B 30. Volymsflöde alstrat då sprayen bryter upp [1]. B11.4 Sprayens verkan på längre avstånd i rum. SAMMANFATTNING • Efter ca 30 meter har gasernas hastighet i rummets längdled minskat så mycket att vidare transport av gaser och resterande vattendroppar bara kan ske med brandinducerade gasflöden. • I rumsstorlekar över ca 25-30 får man en effektivare insats om man bekämpar branden från olika håll. Efter 6-7 m har de små vattendropparna helt bromsats upp avfriktionen mot luft och brandgaser varvid luften sats i rörelse, en fläkt har bildats som visas i Figur B 30 ovan. I ett slutet rum kommer fläkten att orsaka en strömning i av vattendroppar, vattenånga och luft. För att avgöra hur långt denna fläkt kan transportera vattendroppar och ånga i längd- och sidriktning i brandrummet har några scenarier simulerats med datorprogrammet FDS.6 [5]. I Referens 5 redo­ visas simuleringar för tre olik rum, ett med lbh = 8 4.62.5 m (70 m3 volym), ett med lbh =11.84.62.8 m (151 m3) och ett med lbh =1765 m (510 m3 volym). Simuleringarna redovisar hur gasströmning, förångning av vattendroppar och rumstemperatur påverkar en rumsbrand när en skärsläckare sätts in. Även simu­ leringar av ett vindsutrymme som i storlek motsvarar vinden i flerbostadshuset i Umeå (bilaga 1) utförda med datorprogrammet PDS 6 där man inte tagit hänsyn till dropparnas förångning visar att gashastigheten i rummets längdriktning efter ca 30 m blivit så liten att vidare transport till längre avstånd av vattenånga, luft och små droppar som inte förångats eller fallit ut på golvet måste ske med brandinducerande flöden.

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 129 B11.5 Skärsläckarens bidrag till släckverkan och tryckförhållande i brandrum Vatten kan bidra till att släcka bränder på flera olika sätt, genom flamverkan, ytkylning och strålningsdämpning. • • Flamverkan: Dropparna kommer in i flammorna där de förångas och ångan hettas upp. Flammorna kyls då till en så låg temperatur att de inte längre kan existera. Flammorna slocknar. Om vattnets helt förångas motsvarar ett vattenflöde på 1 l/s en släckkapacitet på ca 10 MW. Övertändning i ett mindre rum med en dörr öppen sker vid ca 1 MW. Några minuter senare brinner stora flammor utanför dörren med en effekt i storleksordning 5-10 MW. Varma ytor fortsätter en tid att producera pyrolysgaser vilket kan medföra risk för återantändning. Den minskade återstrålningen från flammor medför att de varma ytorna kyls genom ledning och konvektion. • • Ytkylning: Dropparna träffar den brinnande ytan där de förångas och ångan hettas upp. Ytan kyls då ned till en så låg temperatur att den inte längre kan producera antändbara pyrolysgaser över ytan. Denna kylning av ytan går betydligt fortare vilket medför att återantändningsrisken minskar snabbare än vid flamkylning. • • Strålningsdämpning: Dropparna hindrar eller minskar återstrålning och därmed uppvärmning och pyrolys från angränsande ytor och värmestrål­ ning mot insatspersonal. B11.6 Flamverkan och tryckförhållande i brandrum SAMMANFATTNING • En jetbrand från ett läckande rör eller en slang är förhållandevis lätt att släcka. Rikta strålen från skärsläckaren mot bränsleöppningen varvid flammorna omedelbart slocknar. Det är mycket viktigt att stänga av gasflödet då man annars riskerar att bygga upp en ansamling av brännbara gaser med risk för en gasexplosion. Hotar inte jetflamman den närmaste omgivningen är det bättre att låta den brinna till dess man stängt av gasflödet. • En skärsläckare med ett vattenflöde på 1 l/s har en släckeffekt mot gasflammor motsvarande ca 10 MW. Övertändning i ett mindre rum med en dörr öppen sker vid ca 1 MW. Några minuter senare brinner stora flammor utanför dörren med en effekt i storleksordning 5-10 MW. • I ett brandrum bör jetstrålen riktas så den inte i närfältet (inom 8-10 m) träffar väggar, tak eller golv för att få stor kyleffekt på brandgaserna. • Beroende på rummets totala volym kommer kylningen av brandgaser att ta tid. Sluta inte att påföra förrän ni ser ett tydligt tecken på att brandgaserna kylts. • I rumsstorlekar över ca 25-30 m eller rumsvolymer över 600 m3 får man en effektivare insats om man bekämpar branden från olika håll med flera skärsläckare. • Det första tecknet man ser av insatsen är att tryckminskningen i rummet medför att brandgaser inte längre läcker ut ur rummet. • När brandgaserna kylts tillräckligt mycket minskar förångningen av vattendroppar i brandgaserna och ökar när dropparna träffar varma ytor. • Förångning av vatten mot varma ytor ökar gasvolymen och därmed trycket i brandrummet och efter en tid kommer vita gaser som innehåller mycket vattenånga att läcka ut ur brandrummet. En av de vanligaste tillämpningarna av skärsläckaren inom räddningstjänsten är som verktyg för att sänka temperaturen i brandrummet och därmed under­ lätta den fortsatta släckinsatsen. För att få en uppfattning om hur stor brand­ gasvolym skärsläckaren kan kyla och hur snabbt detta sker kan en energibalans ställas upp. När sprayen med en droppstorleks av ca 0.1 mm träffar varma brand­ gaser sker förångning och uppvärmning av vattenånga mycket snabbt, vid en

130 BILAGA 11 – Sammanställning av skärsläckarens egenskaper brandgastemperatur av 600 C kan tiden uppskattas till ca 75 millisekunder [4]. Energin som krävs for att förånga vattnet tas från brandgaserna och kommer att resultera i en temperatursänkning hos dessa. I Referens 5 redovisas temperatur­ sänkningen och förångningen för tre rumsgeometrier. Om rumstemperaturen är mellan 200-250 C redovisas en förångningsgrad på upp till 80 % d.v.s. litet nedfallet av droppar på golv och väggar. Om det antas att allt vatten förångas fås den teoretiskt maximala kyleffekten. I Figur B 31 redovisas den maximala volymen brandgaser som kan kylas per sekund som funktion av den initiala brandgastemperaturen. Figur B 31. Maximal volym brandgaser som kan kylas per sekund som funktion av initial brandgastemperatur [1]. Med hjälp av informationen i Figur B 31 kan man skatta hur länge man måste hålla på för att med skärsläckaren (påföring 60 l/min) sänka temperaturen över­ tändning i ett rum där brandgastemperaturen är 600 och 800 C, Figur B 32. Figur B 32. Uppskattad släcktid för att kyla ner en rumsvolym där gastemperaturen är 600 och 800 C med antagande att endast rumsgaserna kyls. Påföring 60 l/min [1]. Vid kylningen kommer sprayens fläktverkan på 10-15 m3/s att hjälpa till med att blanda gaserna i rummet. Förångning av vatten till vattenånga och kylning av brandgaserna kommer även att påverka trycket och gassammansättningen i brandrummet. Hur pass mycket beror på hur pass stängt rummet är. I ett helt stängt rum kan man uppskatta tryckförändringen med en enkel överslags­ beräkning [6]. I Figur B 33 visas hur tryckändringen i ett stängt rum påverkas av vattenförångning i det varma brandgaslagret. Det framgår att kylningen av rökgaserna minskar gasvolymen mer än ökningen på grund av förångning av vattendroppar. Trycket i rummet kommer att minska och luft kommer att sugas in genom rummets öppningar för att utjämna trycket. Tryckminskningen sker även om rummet har relativt stora öppningar. I Referens 5 registrerades experi­

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 131 mentellt en trycksänkning på ca 15 Pa i ett rum med 151 m3 volym som hade fyra öppningar med en sammanlagd yta på 3.6 m2. Samtidigt kommer gassam­ mansättningen i brandrummet att påverkas, halten vattenånga kommer att öka samtidigt som halten syrgas kommer att minska. En överslagsberäkning ger att halten vatten ånga i medeltal ökar med 15-20 vol. % när gaserna kylts till 200 C. I Referens 5 redovisas även den rumsliga fördelningen av vattenånga och syrgas före och efter det att en skärsläckare satts in. Förångning och fläktverkan med­ för att sammansättningen av gaser drastiskt förändras i brandrummet med en stor ökning av halten vattenånga och en stor minskning av halten syrgas. Vatten­ ångan och de kylda förbränningsgaserna (som innehåller pyrolysprodukter, vattenånga och koldioxid) kommer att bidra till släckprocessen [7]. Vid en släckinsats i ett rum med begränsade öppningar kommer man tydligt att se att brandgaser slutar läcka ut ur brandrummet en stund efter påföringen börjat. För nästen slutna rum är trycksänkningen dramatisk. När kylningen av rökgaserna gått så långt att det påförda vattnet inte förångas i brandgaserna kommer det att förångas då de träffar varma ytor. Detta tillskott av vattenånga ökar trycket i brandrummet och efter en stund kommer vit vattenånga att läcka ut ur brandrummet. Slutsatserna redovisade i kapitel 2-7 ovan stämmer väl överens med resultaten i rapporten om skärsläckaren i EU firefight-projektet [8]. Figur B 33. Rumstryck när brandgaserna kyls till olika temperaturer med vattendimma i ett slutet rum [6].

132 BILAGA 11 – Sammanställning av skärsläckarens egenskaper B11.7 Ytkylning SAMMANFATTNING • Ytkylning i närområdet innan sprayen bryter upp på 5-6 m avstånd är inte effektiv då påföringen och anslagskraften är för stora. I närområdet kommer en stor del av vattnet att studsa mot ytan och eventuellt göra hål i ytan. • Man kan generera ett tidigt uppbrott av strålen inne i brandrummet på kortare avstånd än 5-6 m och få en bättre ytkylning i närområdet av genombrottet. Det innebär att man arbetar med hålet i väggen. När man rör munstycket i hålet beter strålen sig som ett sprinklerhuvud. Vattendropparna träffar nära väggen och dropparna blir större. • För längre avstånd, 8-12 m, ger skärsläckaren en rimlig påföring på ytor upp till 3-10 m2. När skärslackaren används mot en brinnande bränsleyta beror kylverkan till stor del av avståndet mellan släckaren och ytan. I Figur B 34 visas påförings­ hastigheten i l/m2min som för skärsläckaren under förutsättning att inget vatten förångas, samt strålens tvarsnittsarea (m2) som funktion av avstånd från munstycket. Figur B 34. Påföringshastighet längs strålen och tvärsnittsarea hos strålen som funktion av avstånd från munstycke [1]. Vattenbehovet för att släcka en brand varierar mycket beroende av påförings­ metod och brandscenario [7]. Statistik från inträffade bränder visar att den påföringshastighet som ger den minsta totala vattenvolymen för släckning är i storleksordning 9-15 l/m2 * min. Motsvarande påföringshastighet från experi­ ment är en faktor tio mindre. Påföringshastigheten från skärsläckaren är mer än tillräcklig för släckning genom ytverkan vid vertikal användning, förutsatt att vattnet når bränsleytan. Av Figur B 34 framgår att strålens tvärsnittsarea är för­ hållandevis liten på korta avstånd från munstycket. Detta medför att strålen de första 5-6 metrarna kommer att ha svårigheter att täcka större bränsleytor. Den väl samlade strålen de första 5-6 metrarna medför att den kraft per ytenhet som överförs till bränsleytan kommer att vara påtaglig. Efter uppbrottet ger skär­ släckaren på 8 m avstånd från munstycket ca 20 l/m2* min på en yta av Ca 3 m2. Vatten har en relativt stor ytspänning vilket medför att kollisionen mellan vatten­ dropparna och den brinnande ytan kommer att ske vid relativt låga webertal (We = rwv2D/ds) där rw är vattnets densitet (1000 kg/m3, v vattnets hastighet, D droppens diameter och ds vattnets ytspänning (0.075 N/m). För droppar i storleks­ ordning 0.1 mm ed en hastighet av 10 m/s blir We = 130. Vid så låga tal studsar en del av vattnet mot väggen vilket medför att väggen kyls sämre. En tillsats av ytspänningsnedsättande medel kan öka webertalet och därmed kyleffekten mot

STORSKADEPROBLEMATIK – BRAND I BYGGNAD 133 ytor [6]. I en nyligen publicerad rapport [9] redovisas hur släckeffekten för vatten mot ett A-brandscenario kan förbättras genom tillsats av olika ytspänningsned­ sättande medel som finns på marknaden. ”En minskad ytspänning gör att vattnet får lättare att tränga ned i porösa material och på så vis åstadkommer släckning. Vid användning på vätskebränder bildar skummet en hinna som avskiljer bränslet från flammorna vilket bl.a. minskar värmeåterstrålningen.” Som bäst minskades släcktiden för det aktuella scenariot med en faktor 3-4. Det går inte att dra några slutsatser från den studien om hur en tillsats av ytspänningsnedsättande medel till skärsläckaren skulle påverka en skärsläckarinsats mot ett rumsbrandsscenario t.ex. ett större vindsutrymme. B11.8 Strålningsdämpning SAMMANFATTNING • De fina dropparna gör att strålningen dämpas en faktor 5-10 vid passage genom 3 m dimma på ett avstånd av 6-10 m från påföringsstället. Strålning från flammor, varma ytor och brandgaser dämpas när strålningen passerar vattendimma. Dämpningen minskar värmestrålningen mot räddnings­ personal och dämpar pyrolyshastigheten från brännbara ytor. Typiska vattentät­ heter för skärsläckaren efter uppbrottet för avstånd mellan 6-8 m är 100 - 70 g/m3 vilket motsvarar en vattenandel i sprayen på 7-10 vikts%. I Figur B 35 visas strål­ ningsdämpningen på olika avstånd från en 1000 C gradig varm yta (black body med en strålning av ca 150 kW/m2). Figur B 35. Strålningsdämpning 3 meter från källan [4]. Figur B 35 visar att strålningen efter 3 m passage i dimman med 0,1 mm droppar har dämpats 5-10 gånger.

134 BILAGA 11 – Sammanställning av skärsläckarens egenskaper B11.9 Referenser [1] Bjerregaard, J., Olsson, D., Skärsläckaren- experimentella försök och beräk­ ningar, Brandteknik, Lunds tekniska högskola, Report 5221, Lund 2007. [2] Fredäng, A., Hermansson, J., Pilotskydd vid brand- utredning och utveckling, Brandteknik, Lunds tekniska högskola, Report 5047, Lund 1999. [3] Försth, M., Ochoterena, R., Lindström, J., Spray characterization of the cutting extinguisher, SP Arbetsrapport 2012:14. [4] Hertzberg, T., (SP), Adam Hahne, Josefsson, C., (Göteborgs Universitet), Holmstedt, G., (LTH), Husted, B., (DIFT), Vattendimma: Teori, fysik, simule­ ring, Brandforsk projekt 514-021, SP Brandteknik RAPPORT 2004:15. [5] Svensson, R., Lindström, J., Ochoterena, R., Försth, M., CFD simulation of the Cutting extinguisher, SP-Report 2014:43. [6] Holmstedt; G., Kompendium i Släckmedel och Släckverkan Brandteknik LTH, 2000. [7] Särdqvist, S., Holmstedt, G., Water for Manual Fire Suppression, Journal of Fire Protection Engineering November 2001 11: 209-23. [8] Gsell, J., Fighting Compartment Fires with the Cutting Extinguisher 2010 http://www.eufirefight.com/documents/Fire_Suppression_Capabilities_of_ Water_Mist.pdf. [9] Hummelgård, M., Linde, R., Släckeffekt hos tillsatsmedel i släckvatten Brand­ teknik, Lunds tekniska högskola, Report 5452, Lund 20145.

Myndigheten för samhällsskydd och beredskap (MSB) 651 81 Karlstad Tel 0771-240 240 www.msb.se Publ.nr MSB827 - augusti 2015 ISBN 978-91-7383-550-3 i samarbete med

FD05988 ｜ 2025_瑞典_MSB_住宅火灾发展分析_火灾报告.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2025 ｜ 地域： ｜ 严重程度： ｜ 场所：住宅/民房 ｜ 起火原因： ｜ 来源格式：pdf

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Underlagsrapport Analys av utvecklingen inom bostadsbrand 2025 Målstyrning av brandsäkerhetsarbetet mot etappmålen 2030

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Analys av utvecklingen inom bostadsbrand 2025 Myndigheten för civilt försvar 651 81 Karlstad Sektion: Sektionen för lärande från olyckor Publikationsnummer: Myndigheten för civilt försvar MCF0158 – juni 2026 ISBN-nummer: 978-91-7927-762-8

Förord Detta är den andra uppföljningen av indikatorerna som togs fram för att långsiktigt följa utvecklingen inom den nationella strategin för att stärka brandskyddet för den enskilda människan. Rapporten redovisar och analyserar utvecklingen av antalet omkomna och allvarligt skadade samt för ett antal andra utpekade indikatorer. Syftet med arbetet är att underlätta uppföljning av det målstyrda arbetet och bidra till att sätta framtida mål inom brandområdet. Rapporten är framtagen av analytiker från Myndigheten för civilt försvar. Vi är också tacksamma för bidrag från kollegor på myndigheten samt externa kontakter. Den här rapporten finns också sammanfattad i ett faktablad ”Nationella brandstrategin – lägesrapport 2026”.1 Faktabladet innehåller samma information som finns i sammanfattningen i denna rapport. Karlstad, 2026-06-12

1 Faktablad: https://www.mcf.se/siteassets/dokument/amnesomraden/skydd-mot-olyckor- och-farliga-amnen/brandskydd/faktablad-nationella-brandstrateginlagesrapport-2026.pdf

Sammanfattning Aktörerna som samarbetar kring den svenska nationella strategin för att stärka brandskyddet för den enskilda människan har formulerat en nollvision: ”Ingen ska omkomma eller skadas allvarligt till följd av brand” (MSB 2010). Syftet med denna rapport är att bidra till ett systematiskt och målstyrt säkerhetsarbete med fokus på att minska antal bostadsbränder och konsekvensen av dessa. Målet är att redovisa och analysera nuläget i förhållande till de uppsatta målen till år 2030 för indikatorerna för ett stärkt brandskydd. I tabellen sammanfattas indikatorerna genom utgångsläget, nuläget, målet år 2030 samt en bedömning av möjligheten att nå målet. Grön färg betyder god möjlighet till måluppfyllnad, gul färg betyder viss möjlighet till måluppfyllnad och röd färg betyder liten möjlighet till måluppfyllnad. Mått på Indikator Utgångsläge2 Nuläge3 Mål 2030 Personskador Omkomna 107 79 Under 60 Personskador Avtransporterade till vårdenhet 640 629 Under 600 Personskador Slutenvårdade 628 365 Under 400 Egendomsskador Försäkringsutbetalning ar brand och åska 1870 mkr 1802 mkr Nedåt- gående trend Egendomsskador Insatser vid bostads- bränder med spridning från startobjektet 2252 2055 Under 2000 Skyddsåtgärder Fungerande brandvarnare 78 % 92 % Minst 95 % Skyddsåtgärder Handbrandsläckare 50 % 68 % Minst 80 % Skyddsåtgärder Brandfilt 15 % 58 % Minst 70 % Skyddsproduktion (prestation hos kommunen) Kommuner med utvecklat samarbete 45 % 56 % Ökning Skyddsproduktion (prestation hos kommunen) Kommuner som genomför hembesök 27 % 32 % Ökning

2 Utgångsläget skiljer sig åt för indikatorerna. I rapportens delkapitel framgår det avsedda året. 3 Nuläget är beroende av det sista tillgängliga året för datatidsserien. I rapportens delkapitel framgår om det är år 2024 eller 2025 som avses.

Personskador Antal omkomna i bostadsbränder och vårdboende har haft en gynnsam utveckling i en nedåtgående trend sett till perioden, 2008 till 2025. I form av ett rullande treårsmedelvärde har utfallet rört sig från en nivå om knappt 110 omkomna år 2010 till cirka 80 omkomna år 2025. Prognosen mot 2030 indikerar att målet har viss möjlighet att nås, där osäkerheten främst drivs av de äldre över 65 år som står för ungefär hälften av dödsfallen. Antal personer som den kommunala räddningstjänsten har rapporterat som avtransporterade till vårdenhet, efter en inträffad bostadsbrand, har en relativt kort tidsserie. Perioden 2018 till 2025 indikerar en väldigt svag men nedåtgående trend vilket gör att det finns en viss möjlighet att nå målet under 600 händelser enligt prognos. De allra äldsta över 80 år visar dock på en ökande trend, och står för cirka 10 % av antal händelser, en grupp som också växer befolkningsmässigt. Antal personer som vårdats i sluten sjukhusvård (inlagda på sjukhus) till följd av rök och öppen eld har under en längre tidsperiod utvecklats i positiv riktning. Från början av 2010-talet fram till 2025 har nivån på antalet händelser minskat från cirka 650 stycken till cirka 350 händelser uttryckt i form av ett rullande treårsmedelvärde. Indikatorn ligger i nuläget med marginal i paritet med målet. Egendomsskador Målet för försäkringsutbetalningar (indexerade) är att de ska följa en nedåtgående trend sett över hela perioden 2010 till 2030, det vill säga 20 år enligt måldefinitionen för indikatorn. Analys historiskt och prognostiserat framtida kostnadsutfall indikerar en kostnadsutveckling med svårbedömd trend enligt definition. Bedömningen är att målet är fullt möjligt att nå, men det kräver samtidigt några år av stabila och något minskade kostnader under prognosperioden. Antal bostadsbränder med spridning från startobjektet redovisat per miljon invånare har utvecklats i form av en svagt nedåtgående trend under 2010 till 2025. Målet bedöms ha viss möjlighet att nås men det bygger på en fortsatt positiv utveckling i form av ett rullande treårsmedelvärde som måste minska knappt 5 %. Skyddsåtgärder Utvecklingen av andel hushåll med fungerande brandvarnare har ökat från 63 % till 92 % mellan åren 1996 till 2025. Målet på 95 % är en hög och optimistisk målsättning som möjligen tangerar det maximala värde som är möjligt att uppnå utan ytterligare styrmedel. Vi kan se att skillnaderna mellan olika grupper i samhället har minskat över tid men trots det så ligger undergrupper som exempelvis boende i hyresrätter cirka 10 % under målet. Den samlade bedömningen är att det finns en liten möjlighet att målet kommer att nås.

Andel hushåll med tillgång till handbrandsläckare har ökat från 31 % till 68 % mellan åren 1996 till 2025. Det sker dock en stabilisering på runt 67–68 % mellan 2018 och 2025 som tyder på att en maximal nivå närmar sig. Målet på 80 % är en hög och optimistisk målsättning. Skillnaderna mellan olika grupper i samhället är stora och exempelvis ligger boende i flerbostadshus och hyresrätter cirka 40 procentenheter under målet. Den samlade bedömningen är att det finns en liten möjlighet att målet kommer att nås. Andel hushåll med tillgång till brandfilt har ökat från 5 % till 58 % mellan åren 2005 till 2025. Det sker dock en stabilisering på runt 56–58 % mellan 2022 till 2025 som tyder på att en maximal nivå närmar sig. Målet på 70 % är en hög och optimistisk målsättning. Skillnaderna mellan olika grupper i samhället är stora och exempelvis boende i flerbostadshus och hyresrätter ligger cirka 25 till 30 procentenheter under målet. Den samlade bedömningen är att det finns en liten möjlighet att målet kommer att nås. Skyddsproduktion (prestation hos kommunen) Kommuner med utvecklat samarbete kring individanpassat brandskydd har ökat från 45 % till 56 % mellan åren 2019 till 2024. Det är en kort mätperiod som dessutom har påverkats av pandemin. Äldreomsorg, kommunala fastighetsbolag, skola, rengöring och brandskyddskontroll samt kommunens hälso- och sjukvård är de vanligaste verksamhetsområdena som samverkan sker med. 26 % uppger att de inte har några formaliserade samarbeten alls inom området. Bedömningen är att det finns en viss möjlighet att nå målet. Andel kommuner som genomför minst 10 hembesök har minskat från 40 % till 32 % mellan åren 2010 till 2024. Även denna period är kort och åtgärden har påverkats av pandemin. Antalet hembesök är dock högre än före pandemin vilket innebär att fler hembesök genomförs i genomsnitt per organisation av de som utför hembesök. Bedömningen är att det finns en viss möjlighet att nå målet.

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Innehåll Förord ......................................................................................................................2 Sammanfattning ......................................................................................................3 1. Inledning ...................................................................................................9 1.1 Bakgrund ...................................................................................................9 1.2 Syfte och mål .............................................................................................9 1.3 Avgränsningar ...........................................................................................9 1.4 Utgångspunkter .......................................................................................10 2. Omvärldsfaktorer ...................................................................................12 2.1 Befolkningsstatistik - SCB .......................................................................12 2.2 Befolkningsutveckling ..............................................................................12 2.3 Covid-19-pandemin .................................................................................15 2.4 Övergripande utveckling i tidsserier kopplade indikatorer .......................16 3. Omkomna ...............................................................................................20 3.1 Bedömning av måluppfyllnad år 2030 .....................................................20 3.2 Nulägesbeskrivning – utveckling till år 2025 ............................................21 4. Avtransporterade till vård .....................................................................27 4.1 Bedömning av måluppfyllnad år 2030 .....................................................27 4.2 Nulägesbeskrivning - utveckling till år 2025 ............................................29 5. Slutenvårdade ........................................................................................34 5.1 Bedömning av måluppfyllnad år 2030 .....................................................34 5.2 Nulägesbeskrivning – utveckling till år 2024 ............................................36 6. Kostnad för egendomsskador ..............................................................41 6.1 Bedömning av måluppfyllnad år 2030 .....................................................42 6.2 Nulägesbeskrivning – utveckling till år 2024 ............................................44 6.3 Prognos och scenarion till år 2030 ..........................................................51 7. Egendomsskador – händelser .............................................................56 7.1 Utvecklade bränder .................................................................................56 7.2 Bostadsbränder med spridning från startobjektet ....................................58 8. Brandvarnare .........................................................................................63 8.1 Bedömning av måluppfyllnad år 2030 .....................................................64 8.2 Nulägesbeskrivning – utveckling till år 2025 ............................................65 9. Handbrandsläckare ...............................................................................71 9.1 Bedömning av måluppfyllnad år 2030 .....................................................71

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1. 2

Nulägesbeskrivning – utveckling till år 2025 ............................................72 10. Brandfilt ..................................................................................................77 10.1 Bedömning av måluppfyllnad år 2030 .....................................................77 10.2 Nulägesbeskrivning - utveckling till år 2025 ............................................78 11. Kommuner med utvecklat samarbete ..................................................82 11.1 Bedömning av måluppfyllnad år 2030 .....................................................83 11.2 Nulägesbeskrivning – utveckling till år 2025 ............................................84 12. Hembesök ..............................................................................................86 12.1 Bedömning av måluppfyllnad år 2030 .....................................................87 12.2 Nulägesbeskrivning – utveckling till år 2024 ............................................88 Referenser .............................................................................................................89 Appendix ...............................................................................................................90

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Inledning 1.1 Bakgrund Bränder i bostäder orsakar betydande samhällskostnader i form av hälsa (dödsfall och personskador), egendom och miljö. Nationellt finns en strategi för hur brandskyddet kan stärkas genom stöd till enskilda och inom ramen för arbetet har en vision för brandskyddsområdet formulerats (MSB 2010): Ingen ska omkomma eller skadas allvarligt till följd av brand. För att långsiktigt kunna följa upp utvecklingen av den nationella strategin har MSB tillsammans med andra aktörer tagit fram indikatorer och satt upp mål för dessa fram till år 2030 (MSB 2021). Förutom mål för omkomna och allvarligt skadade har också ett antal andra indikatorer tagits fram. Dessa innehåller mått på personskador, egendomsskador, skyddsåtgärder och skyddsproduktion (prestationer hos kommunerna). Sedan målen mot 2030 sattes har ingen fördjupad analys av utvecklingen skett. Denna analys beskriver hur nuläget ser ut med siffror fram till och med år 2025, alternativt senast publicerade data. Analysen innehåller även en bedömning av om målet till 2030 kommer nås. En förändring av indikatorn för egendomsskador – antal insatser vid utvecklade bostadsbränder till bostadsbränder med spridning från startobjektet sker inom ramen för arbetet. 1.2 Syfte och mål Syftet med analysen är att bidra till ett systematiskt och målstyrt säkerhetsarbete med fokus på att minska antal bostadsbränder och konsekvensen av dessa. Målet är att redovisa och analysera nuläget i förhållande till de uppsatta målen till år 2030 för indikatorerna för ett stärkt brandskydd. En av indikatorerna för egendomsskadorna, utvecklade bostadsbränder, förändras för att åstadkomma en bättre möjlighet att följa utvecklingen. 1.3 Avgränsningar Översyn av de prioriterade åtgärderna ingår inte. Analysrapporten avgränsas till de specificerade indikatorerna för ett stärkt brandskydd som tagits fram (MSB 2021). Förändring i omvärldsfaktorer är begränsat till SCB:s befolkningsstatistik på aggregerad riksnivå över kön och ålder. Utvecklingen inom olika sociodemografiska subgrupperingar, geografier eller annat som kan kopplas till 10

bostadsbrand som exempelvis alkohol, rökning, inkomst med mera ligger utanför denna analys. 1.4 Utgångspunkter 1.4.1 Begreppet bostad Begreppet bostad har olika avgränsningar i olika sammanhang och tidsperioder. Exempelvis finns skillnader mellan data från försäkringsbranschen och räddningsinsatser. I indikatorer baserade på räddningstjänsternas insatsstatistik så ingår ”boende och vård” och där har indelningen ändrats över tid och främst i skiftet mellan insatsrapporten (åren 1998–2017) och händelserapporten (år 2016 och framåt).4 Detta är viktigt att vara medveten om och för respektive indikator definieras vad som ingår och inte i begreppet bostad. Mer detaljer om skillnaderna i räddningstjänsternas insatsstatistik finns i en tidigare rapport (MSB 2019). 1.4.2 Indikatortyper och bedömningsmetodik Två typer av indikatorer ligger till grund för uppsatta mål. (1) Fem tidsserier som är baserade på inträffade skadehändelser. (2) Fem tidsserier som är baserade på uppgifter om skadeförebyggande åtgärder. Beträffande de händelsebaserade indikatorerna (1) så finns det en ”naturlig” variation i händelseutfallet mellan årgångarna i denna typ av stokastiska tidsserier. Utöver slumpmässiga tillfälligheter finns bakomliggande faktorer eller variabler som över tid har inverkan i olika grad på händelseutvecklingen. Faktorernas betydelse i en prognosmodell beror bland annat på hur de förändras över tid. Om ett exponeringsmått i form av antal invånare ökar markant under perioden kan det få inverkan på händelseutfallet över tid, vilket sannolikt kan bli tydligare i ett mindre regionalt område eller subgruppering där befolkningen kan förändras förhållandevis mycket. Dock är brandindikatorerna konstruerade på riksnivå och syftet här är att se över dessa övergripande nationella mål. När det gäller indikatorerna med koppling till skadeförebyggande aktivitet (2) så är tre av dem hämtade från myndighetens enkätundersökningar, genomförda med lite olika periodicitet och innehåll, där den senaste är från 2025. Två av indikatorerna bygger på uppgifter som tas fram i samband med årlig uppföljning av lagen om skydd mot olyckor (LSO).

4 En överlappning mellan de olika rapporteringsformaten skedde under åren 2016–2017 då olika räddningstjänstorganisationer skiftade vid olika tidpunkter.

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Målstyrningen för de fem indikatorerna som baseras på skadehändelser bygger sålunda på en önskan om en sjunkande utveckling i antal händelser och tillhörande kostnader. För de fem indikatorerna med koppling till brandskydd är det naturligtvis önskvärt med en ökande trend. Mot ovanstående skiljer därför metod och analysmodell, beroende på typ och karaktär hos respektive indikator. Kvalitet, volym och tidslängd på historiska data skiljer mellan tidsserierna vilket också får inverkan på metod och bedömning. Ansatsen i bedömningen stöttar sig mot både kvantitativ och kvalitativ analys, som beskrivs för respektive indikator. Varje indikator är bedömd i förmodad möjlighet att utvecklas på ett sådant sätt att

den kan nå målet år 2030 och är satt på en skala enligt:

Utvecklingen har god möjlighet till måluppfyllnad – indikatorn är

grönmarkerad.

Utvecklingen har viss möjlighet till måluppfyllnad, men är osäker vilket

framgår av analysunderlaget – indikatorn är gulmarkerad.

Utvecklingen har liten möjlighet till måluppfyllnad – indikatorn är rödmarkerad. Tabell 1. Färgmarkering med text för bedömning av måluppfyllnad God möjlighet till måluppfyllnad (grön) Viss möjlighet till måluppfyllnad (gul) Liten möjlighet till måluppfyllnad (röd)

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Omvärldsfaktorer 2.1 Befolkningsstatistik - SCB Uppgifter över befolkningsutveckling, framåt i tiden, är hämtade från SCB:s prognoser enligt ”Folkmängd 31 dec, antal efter ålder, kön och år.”5 Även historik, bakåt i tiden, är hämtad från SCB enligt ”Folkmängd, antal efter ålder, kön och år.”6 Uppgifterna har bearbetats och anpassats till myndigheten för civilt försvars statistik över historiskt händelseutfall, för att i en prognosmodell prediktera framtida händelser under perioden fram till och med 2030. Tanken är att nyttja befolkningsutvecklingen för att deskriptivt beskriva hur bakomliggande faktorer i form av kön och ålder utvecklats under perioden för tidsserieanalysen. Befolkningssammansättningen har indirekt inverkan på händelseutfallet. Vidare har befolkningsuppgiften använts i prognosmodellerna som ett exponeringsmått. 2.2 Befolkningsutveckling Uppgifterna nedan över perioden år 2025–2030 motsvarar SCB:s prognos. Diagram 1. Sveriges befolkningsutveckling, i miljoner, totalt år 2008–2030. Källa: SCB:s statistikdatabas Det framgår att befolkningen följer en kurva som under perioden cirka år 2008– 2019 haft en högre tillväxttakt med någon form av brytning cirka 2019–2021. 5https://www.statistikdatabasen.scb.se/pxweb/sv/ssd/START__BE__BE0401__BE0401A/Be folkprognRevNb/table/tableViewLayout1/ 6https://www.statistikdatabasen.scb.se/pxweb/sv/ssd/START__BE__BE0101__BE0101A/Be folkningR1860N/table/tableViewLayout1/

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Periodens prognoshorisont från cirka år 2025 och framåt följer en lägre tillväxttakt. Diagram 2. Befolkningsutveckling fördelat på kön, i miljoner, år 2008–2030. Observera att y-axeln börjar på 4 miljoner.

Källa: SCB:s statistikdatabas I fördelningen över kön finns en brytpunkt år 2014 där antalet män och kvinnor var samma. Från och med 2015 är antalet män något fler än antalet kvinnor. Förändringen på övergripande nivå under perioden är relativt sett både långsam och liten. En omfördelning i befolkningen av andelar mellan könen har skett med cirka 0,6 procentenheter under cirka 25 år, och får därför förhållandevis liten betydelse för utvecklingen av bostadsbränder. Delar vi upp befolkningen i tre ålderskategorier unga (–24 år), mellanåldrar (25–64 år) samt äldre (65 år–) så framgår att befolkningsutvecklingen ser olika ut i de tre kategorierna.

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Diagram 3. Befolkningsutveckling, i andelar, fördelat på åldersgrupperna unga, medel och gamla. År 2008–2030.

Källa: SCB:s statistikdatabas Gruppen av äldre ökar mest under redovisad period ovan, andelsmässigt motsvarande en ökning på knappt 5 procentenheter. Tillväxten i gruppen av unga är lägst och över tid minskar andelen unga i befolkningen. Den stora kategorin av mellanåldrarna är andelsmässigt mer stabil och den gruppen utgör här ungefär halva befolkningen. Antalsmässigt växer alla tre ålderskategorierna under perioden. Men tillväxttakten ser olika ut i kategorier av både ålder och kön, vilket beskrivs i tabellen nedan. Tabell 2. Befolkningstillväxt per tidsperiod fördelat på ålderskategorier och kön, år 2008–2030. Period Totalt Kvinna –24år Kvinna 25 – 64år Kvinna 65år– Man –24år Man 25 – 64år Man 65år– 2008–2024 14 % 8 % 10 % 28 % 9 % 12 % 42 % 2025–2030 1 % -3 % 0 % 6 % -3 % 0 % 8 % 2008–2030 15 % 5 % 10 % 37 % 5 % 12 % 56 % Källa: SCB:s statistikdatabas Enligt historik år 2008–2024 har befolkningen totalt, det vill säga i genomsnitt över alla underkategorier, ökat med 14 %. Det är en tydlig skillnad i procentuell ökning mellan unga och gamla. Gruppen av äldre män är den som procentuellt sett ökat mest. I prognostiserad framskrivning år 2025–2030 framgår att de äldre (65år–) fortsatt beräknas växa, medan utvecklingen i övriga befolkningen förväntas stanna av eller minska. Befolkningstillväxten beräknas totalt till 15 % över

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perioden 2008–2030, återspeglas i historisk utveckling och prognos per kategori enligt tabell 2. Diagram 4. Befolkningsutveckling åldrarna 80 år och uppåt, i miljoner, år 2008– 2030. Källa: SCB:s statistikdatabas Kurvan över utvecklingen för den allra äldsta delen av befolkningen, de över 80 år, skiljer sig väsentligt från kurvan över hela befolkningen. Andelen som är över 80 år beräknas öka med cirka 3 procentenheter under perioden 2020–2030, till att stå för cirka 8 % av befolkningen (0,8 miljoner). 2.3 Covid-19-pandemin Covid 19 pandemin i Sverige inleddes i början av 2020 och den mest intensiva pandemiperioden varade fram till början av 2022, då de flesta restriktioner avskaffades. MSB (2023a) analyserar och gör översiktliga bedömningar av pandemins möjliga effekter för räddningsinsatser och räddningstjänsternas brandförebyggande arbete. De trendbrott som identifieras i rapporten kategoriseras i sådana som sannolikt berodde på restriktionerna till följd av pandemin, förändringar i arbetssätt samt väder- och säsongsrelaterade. Av de samhälleliga förändringar som påverkar bostadsbränder gick det att se att antal insatser till spisbränder översteg det förväntade antalet under månader med hög smittspridning. Att fler var hemma och oftare lagade mat i boendemiljön är sannolikt förklaringen. När det gäller bränder i byggnader generellt så minskade bränder i allmänna byggnader samt automatlarm utan brandtillbud. Detta gällde främst allmänna verksamheter som skolor, restauranger och idrotts-, bad- och motionsanläggningar. Vårdsektorn hade ingen sådan minskning av antal bränder.

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När det gäller förändringar i arbetssätt så minskade kommunernas brandförebyggande arbete kraftigt i omfattning under pandemin. Utbildningar, hembesök och tillsynsbesök minskade alla som en följd av restriktionerna och för att minska risken för smitta. Det fanns även en tendens till att resurserna för tillsyn samt information och rådgivning minskat under år 2021. De brandförebyggande åtgärderna har återhämtat sig men tidsserierna för indikatorerna om kommunernas hembesök och utvecklade samarbeten är påverkade (kapitel 11–12). 2.4 Övergripande utveckling i tidsserier kopplade indikatorer Av de totalt tio indikatorer som ingår i målstyrningen är det tre som baseras på statistik från Myndigheten för civilt försvar. • Omkomna • Avtransporterade till vårdenhet • Bostadsbränder med spridning från startobjektet (ersätter den tidigare indikatorn för utvecklade bränder) Utöver dessa är ytterligare två knutna till skador rörande brand i bostad, men hämtade från annan källa än Myndigheten för civilt försvar. • Slutenvårdade till följd av rök och öppen eld enligt Socialstyrelsens patientregister (PAR) • Försäkringsutbetalningar för skadetyperna brand och åska (Svensk försäkring). Karaktären på de fem nämnda indikatorerna skiljer sig mot övriga fem, som är kopplade till brandskydd, då de är grundade på oönskade och slumpmässiga händelser. Antal allvarligt skadade mäts på två olika sätt: 1) avtransporterade till vårdenhet efter bostadsbrand och 2) slutenvårdade till följd av rök och öppen eld.

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Diagram 5. Utveckling och volymmässig överblick av indikatorer kopplade till händelser år 2008–2024.Skador från försäkringsbranschen är exkluderade i diagrammet då volymen är så mycket större Källa: Omkomna i bränder och Räddningstjänstens insatser, Myndigheten för civilt försvar. Socialstyrelsens patientregister – PAR Indikatorerna kopplade till skadehändelser har i sig både olika karaktär och volym. Tillgång till enhetliga historiska data skiljer sig delvis också. Vid skrivande av denna rapport är heller inte uppgift för 2025 tillgänglig alla tidsserier. För en fördjupad diskussion kring framtagandet av innevarande indikatorer, se föregående rapport från 2021.7 Totalt antal inrapporterade skador till svenska försäkringsföretag har av naturliga skäl en betydligt större volym, jämfört de övriga händelsebaserade indikatorerna.

7 Inriktning av nationell strategi förstärkt brandskydd, MSB 1687 (2021)

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Diagram 6. Antal händelser totalt brand och åska och totalt hem-, villahem- och fritidshusförsäkring. År 2010–2024

Källa: Svensk Försäkring I genomsnitt inrapporterades drygt 20 000 skador per år under perioden 2010– 2024, händelser som ligger bakom den skademassa vilket indikatorn för brand- och åskrelaterade egendomsskador i bostäder är ämnad att följa. Det föreligger dock vissa kvalitetsproblem i årgångarna 2014–2015 vilket diskuteras i nulägesbeskrivningen i avsnittet över kostnader för egendomsskador där även medelskade- och kostnadsutvecklingen tas upp. Diagram 7. Utveckling och volymmässig överblick av indikatorer med koppling brandskydd, år 1996–2024. Källa: MSB:s Trygghetsundersökningar. Årsuppföljning LSO

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De fem tidsserier som är kopplade till brandskydd bygger på andelar av hushållen som har respektive skydd och andelar av kommunerna som genomfört hembesök eller samarbetar i vissa frågor. Årgångar med ett års mellanrum är streckade, övriga endast punktmarkerade.

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Omkomna Faktaruta start Definition Antal omkomna i bostadsbränder och vårdboende baserat på ett rullande treårsmedelvärde Källa: Omkomna i bränder (Myndigheten för civilt försvar) Indikator Mätstart 2010 Nuläge 2025 Mål 2030 Bedömd utveckling mot målet Omkomna 107 79 Under 60 Viss möjlighet till måluppfyllnad Indikatorn baseras på statistik över omkomna vid brand i bostad och vårdboende. Måttet tas fram som ett treårsmedelvärde där åren 2008 till 2010 utgör startvärdet. 3.1 Bedömning av måluppfyllnad år 2030 Diagram 1. Prognostiserat antal händelser till och med år 2030. Baserat på observerade händelser perioden 2008–2025. Pi – prediktionsintervall (hi – övre gräns, lo – undre gräns). R3 – rullande medelvärde (3 år). Källa: Omkomna i bränder, Myndigheten för civilt försvar. SCB:s statistikdatabas (befolkningsutveckling) 21

Prognos över händelseutvecklingen från och med 2026 är beräknad i en regressionsmodell8. SCB:s prognos över befolkningsutveckling till och med 2030 ingår i modellen som ett exponeringsmått, som stöd för beräkning av antal dödsfall framåt i tiden. Bedömningen är att målet för år 2030 är möjligt att nå, men där osäkerheten är relativt stor, vilket bland annat framgår av prediktionsintervallen i diagram 1. Bedömningen bygger på en fortsatt avtagande trend i ett rullande treårsmedelvärde som måste minska cirka 25 % för att nå uppsatt mål, vilket är möjligt enligt regressionsmodellens prediktion. Bedömningen baseras också på en mer kvalitativt inriktad analys enligt nulägesbeskrivningen i nästa avsnitt och följande korta sammanfattning. Tidsserien har enligt ovan en avtagande trend på total nivå, och när den fördelas efter variablerna bostadstyp, kön och ålder är det ingen fördelning som uppvisar ett väsentligt avvikande mönster. Den avtagande trenden av dödsfall kvarstår i olika grad. I gruppen av personer äldre än 65 år avtar dödsfallen minst, och samtidigt står denna grupp för hälften av dödsfallen. Uttryckt som andel av befolkningen, som exponeringsmått, växer denna grupp mest under aktuell tidsperiod, både i historiskt data men också under prognosperioden framåt i tiden. Dock visar även utvecklingen av antal omkomna per miljon invånare på en avtagande trend, vilket gäller i båda grupperna 65–79 år och 80 år och uppåt. Osäkerheten i bedömningen är främst kopplad till den fortsatta utvecklingen hos de äldre över 65 år och speciellt de allra äldsta som är den del av befolkningen som växer snabbast. Se avsnitt 2.2 som tar upp befolkningstillväxten. 3.2 Nulägesbeskrivning – utveckling till år 2025 Under perioden från 2008 fram till idag kan observeras en svagt men tydligt avtagande trend i antalet omkomna i brand i bostad totalt sett. Delar vi grovt in perioden i en första och andra halva, så kan ett observerat medelvärde på drygt 90 omkomna per år till och med 2016 jämföras mot ett medelvärde på cirka 75 omkomna per år åren 2017–2025.

8 Se appendix för modelldata i programverktyget STATA.

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Diagram 2. Antal omkomna i bostadsbrand fördelat efter bostadstyp. År 2008– 2025. Källa: Omkomna i bränder, Myndigheten för civilt försvar. Delar vi upp antalet omkomna per boendetyp syns tydligt att merparten, cirka 85 %, av dödsfallen skett i de vanligast förekommande bostadstyperna, villa och flerbostadshus. Tidsserierna över dessa bostadstyper är relativt lika i utvecklingen både i antal och med en svagt avtagande trend. I övriga boendeformer har det över tid inträffat ett mindre antal händelser per år, knappt 5 per år i genomsnitt. Diagram 3. Antal omkomna i bostadsbrand fördelat över åldersgrupper, unga (–24 år), medel (25–64 år) och äldre/gamla (65 år–). År 2008–2025. Källa: Omkomna i bränder, Myndigheten för civilt försvar.

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Delar vi upp antalet omkomna per åldersgrupp syns tydligt att gruppen över 65 år står för den största andelen av händelserna över tid, cirka 50 %. Samtidigt utgör denna grupp endast cirka 20 % av befolkningen även om denna är växande över tid. En minskande trend i antal omkomna är tydligast i den största gruppen, åldrarna 25–65 år. Diagram 4. Antal omkomna i bostadsbrand i gruppen av de allra äldsta, 80 år och äldre. År 2008–2025. Linjär trendlinje och rullande treårsmedelvärde, r3. Källa: Omkomna i bränder, Myndigheten för civilt försvar. Andelen händelser hos de över 80 år utgör drygt 20 %, knappt 20 händelser i genomsnitt per år. Händelseutvecklingen är relativt stabil trots att det handlar om förhållandevis få händelser samt att gruppen enligt befolkningsstatistiken har växt relativt mycket de senaste åtta åren. Ett rullande medelvärde rör sig kring cirka 15– 25 händelser per år. År 2010 sticker ut med 33 omkomna i denna åldersgrupp.

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Diagram 5. Antal omkomna i bostadsbrand fördelat på kön. År 2008–2025. Linjära trendlinjer. Källa: Omkomna i bränder, Myndigheten för civilt försvar. Fördelar vi antal omkomna över kön ser vi att män i genomsnitt ligger på ett högre antal händelser per år än kvinnor. Sett över hela perioden skiljer cirka 20 händelser per år, men skillnaden har minskat något över tid enligt trenden i diagrammet. Mot beskrivningarna av både befolkningsutveckling och ovanstående över antal omkomna i bränder kan uppgifterna kombineras till antal händelser per miljon invånare, som ett mått på händelsefrekvens eller ”risk” över tid.

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Diagram 6. Utveckling av antal omkomna i bostadsbrand per miljon invånare (exkl. vårdboende). Uppdelat på unga (–24 år), medel (25–64 år) och äldre (65 år–). År 2008–2025. Linjär trendlinje per grupp. Källa: Omkomna i bränder, Myndigheten för civilt försvar. SCB:s statistikdatabas (befolkningsutveckling). När händelse- och befolkningsutveckling kombineras framgår en avtagande trend i de tre grupperna -24år, 25-64år och 65år-, men på tre skilda nivåer. Trenden för de

äldsta är något brantare.

Unga har en lägre nivå av antal omkomna, i genomsnitt 2 per miljon och år under perioden. Unga utgör cirka 30 % av befolkningen. Genomsnittlig

andel av antal händelser under perioden är cirka 5 %.

Medelålders följer ungefär snittfrekvensen för totalt antal omkomna, i genomsnitt cirka 9 per miljon och år under perioden. Medelålders utgör cirka 50 % av befolkningen. Genomsnittlig andel av antal händelser under

perioden är cirka 40 %.

Gruppen 65år-, har i genomsnitt 23 omkomna per miljon och år under perioden. De utgör cirka 20 % av befolkningen. Genomsnittlig andel av antal händelser under perioden är cirka 50 % i denna grupp. Delar vi till sist uppfrekvensen för de äldre i två åldersgrupper så följer även denna uppdelning ett liknande mönster hos frekvensutvecklingen.

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Diagram 7. Utveckling av antal omkomna i bostadsbrand per miljon invånare (exkl. vårdboende). Äldre personer över 64 år uppdelade i åldrar under och över 80 år. Linjär trendlinje per grupp. Källa: Omkomna i bränder, Myndigheten för civilt försvar. SCB:s statistikdatabas (befolkningsutveckling) De allra äldsta över 80 år uppvisar en liknade frekvensutveckling men på högst nivå av alla åldersgrupperingar i antal händelser per miljon invånare. Trenden under perioden är sålunda avtagande på ett liknande sätt som för grupperna i åldrarna 65–79 år, trots skillnad i befolkningsutveckling för de över 80 år. Variation i antal händelser och frekvens mellan åren är dock större i gruppen av de allra äldsta.

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Avtransporterade till vård Faktaruta start Definition Antal personer som den kommunala räddningstjänsten har rapporterat som avtransporterade till vårdenhet, efter en inträffad bostadsbrand. Målet baseras på ett rullande treårsmedelvärde. Källa: Räddningstjänstens insatser (Myndigheten för civilt försvar) Indikator Mätstart 2020 Nuläge 2025 Mål 2030 Bedömd utveckling mot målet Avtransporterade 640 629 Under 600 Viss möjlighet till måluppfyllnad 4.1 Bedömning av måluppfyllnad år 2030 Diagram 1. Prognostiserat antal händelser, avtransporterade, till och med 2030. Baserat på observerade händelser under perioden 2018–2025. Pi – prediktionsintervall (hi – övre gräns, lo – undre gräns). R3 – rullande medelvärde (3 år). Källa: Räddningstjänstens insatser, Myndigheten för civilt försvar. SCB:s statistikdatabas (befolkningsutveckling) 28

Prognos över händelseutvecklingen från och med 2025 är beräknad i en regressionsmodell9. SCB:s prognos över befolkningsutveckling till och med 2030 ingår i modellen som exponeringsmått och stöd för beräkning av antal händelser framåt i tiden. Observera att tidserien är relativt kort i relation till prognoshorisonten, vilket modellmässigt medför en större osäkerhet i skattningen. En längre tidsserie gynnar en stabilare modell med större precision i skattning, och därmed ett snävare prediktionsintervall. Bedömningen är att målet för år 2030 är möjligt att nå. Det innebär att det krävs en fortsatt avtagande utveckling, trend, i form av ett rullande treårsmedelvärde som måste minska ytterligare med ungefär 5 %. Prognosen kan inte tydligt visa på att så kommer att ske, men är försiktigt positiv i en svagt minskande utveckling av antal händelser mot uppsatt mål. En orsak är det låga utfallet med 600 avtransporterade personer år 2025 (tidsseriens lägsta). Tidsserien är kort med 8 års observationer, som stöd till en prognos 5 år framåt. Därför är prediktionsintervallen relativt breda och osäkerheten stor. Bedömningen baseras också på en mer kvalitativt inriktad analys enligt nulägesbeskrivningen i nästa avsnitt och följande korta sammanfattning. Händelseutvecklingen i tidsserien har en svagt men dock något avtagande trend. När den fördelas efter variablerna bostadstyp och kön är det ingen underliggande fördelning som uppvisar ett väsentligt avvikande mönster. Gällande händelseutvecklingen i olika åldersgrupper så är det hos den största gruppen i åldrarna 65–79 år vilken står för ungefär hälften av antalet avtransporterade personer, där det går att se en positivt minskande trend uttryckt i antal händelser. De allra äldsta över 80 år visar dock på en ökande trend, och står för cirka 10 % av antal händelser, en grupp som också växer befolkningsmässigt.

9 Se appendix för modelldata i programverktyget STATA.

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1. 2

Nulägesbeskrivning - utveckling till år 2025 Under perioden från 2018 fram till 2025 kan skönjas en svagt avtagande trend i antalet avtransporterade orsakat av brand i bostad, totalt sett. Diagram 2. Antal avtransporterade fördelat efter bostadstyp. Övrigt boende omfattar radhus, vårdboende m.m., det vill säga allt utöver Villa och Flerbostadshus. År 2018–2025. Källa: Räddningstjänstens insatser, Myndigheten för civilt försvar. Delar vi upp antalet avtransporterade personer i villa, flerbostadshus och alla övriga boenden, som tillsammans utgör en relativt sett liten andel, syns tydligt att merparten av händelserna skett i flerbostadshus. Det är också gruppen av flerbostadshus som driver den övergripande nedåtgående trenden.

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Diagram 3. Antal avtransporterade i bostadsbrand fördelat över åldersgrupper, – 24 år, 25–64 år och 65 år–. År 2008–2025. Källa: Räddningstjänstens insatser, Myndigheten för civilt försvar. Delar vi upp händelser per åldersgrupp syns tydligt att åldersgruppen 25–64 år står för den största andelen av händelserna över tid, cirka 50 %. Trenden i denna grupp är tydligt avtagande. Gruppen utgör också ungefär hälften av hela befolkningen. I gruppen av de äldsta åldrarna över 64 år är trenden något ökande, och där 2025 sticker ut något i seriens tydligt högsta antal händelser. I de yngsta åldrarna samt i gruppen där ålder är okänd framgår ingen tydlig trend med inverkan på totalt utfall. Diagram 4. Antal avtransporterade i bostadsbrand i gruppen av de allra äldsta, 80 år och äldre. År 2018–2025. Linjär trendlinje och rullande treårsmedelvärde, r3. Källa: Räddningstjänstens insatser, Myndigheten för civilt försvar.

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Andelen händelser hos de över 80 år utgör cirka 10 %. De senaste åren är utfallet knappt 70 händelser per år. Trots ett relativt litet antal händelser i denna åldersgrupp går det att observera en tydligt uppåtgående trend sedan 2018. Enligt befolkningsstatistiken har gruppen också växt relativt mycket de senaste åtta åren. I ett rullande medelvärde har antal händelser under sex år ökat från cirka 50 per år till en nivå kring knappt 70 per år, i gruppen av de allra äldsta. Diagram 5. Antal avtransporterade i bostadsbrand fördelat efter kön. År 2008–

1. Linjära trendlinjer.

Källa: Räddningstjänstens insatser, Myndigheten för civilt försvar. Fördelar vi antal händelser över kön ser vi att män i genomsnitt ligger på ett högre antal händelser per år än kvinnor. Sett över hela perioden skiljer knappt 70 händelser per år i genomsnitt. Knappt 7 % motsvarande drygt 40 avtransporterade personer per år är kodade som okänt kön. Sett till både befolkningsutveckling och händelseutveckling av avtransporterade kan serierna kombineras till ett antal avtransporterade personer per miljon invånare, som ett mått på frekvens eller ”risk” över tid.

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Diagram 6. Utveckling av antal avtransporterade i bostadsbrand per miljon invånare. År 2018–2025. Uppdelat på åldrar –24 år, 25–64 år och 65 år–. Linjär trendlinje per grupp. Källa: Räddningstjänstens insatser, Myndigheten för civilt försvar. SCB:s statistikdatabas (befolkningsutveckling) När antalet avtransporterade och befolkningsutvecklingen kombineras kan observeras en svagt avtagande trend i gruppen 25-64år och en växande trend i

gruppen 65 år och äldre.

Unga (–24 år) har en lägre nivå av antal avtransporterade, i genomsnitt cirka 30 per miljon och år under perioden. Unga utgör cirka 30 % av befolkningen. Genomsnittlig andel av antal avtransporterade personer

under perioden är cirka 15 %.

Åldrarna 25–64 år följer ungefär snittfrekvensen, motsvarande kurvan för totalt antal avtransporterade, i genomsnitt cirka 60 per miljon och år under perioden. Dessa åldrar utgör cirka 50 % av befolkningen och står även för cirka hälften av antalet händelser sett till hela perioden. I enlighet med

antalsutvecklingen dippar kurvan 2025.

Åldrarna 65 år och uppåt har högst nivå, i genomsnitt cirka 80 avtransporterade per miljon och år under perioden. De utgör cirka 20 % av befolkningen. Genomsnittlig andel av antal händelser under perioden är cirka 25 % i denna grupp. I enlighet med antalsutvecklingen har frekvensen dock ökat 2025. Delar vi till sist upp, differentierar, frekvensen för gruppen över 64 år i två åldersgrupper går det att notera två relativt svaga trender där gruppen 65–79 år tenderar att ha en något ökande frekvens under perioden. För de över 80 år är trenden mer stabil trots att gruppen växer något befolkningsmässigt.

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Diagram 7. Utveckling av antal avtransporterade i bostadsbrand per miljon invånare (exkl. vårdboende). Äldre personer uppdelade i åldrar under och över 80 år. Linjär trendlinje per grupp. Källa: Räddningstjänstens insatser, Myndigheten för civilt försvar. SCB:s statistikdatabas (befolkningsutveckling) Variationen i antal händelser och frekvens mellan åren är dock större i åldrarna 65–79 år.

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Slutenvårdade Faktaruta start Definition Antal personer som vårdats i sluten sjukhusvård (inlagda på sjukhus) till följd av rök och öppen eld. Baserat på ett rullande treårsmedelvärde. Källa: Patientregistret (Socialstyrelsen)10. Indikator Mätstart 2010 Nuläge 2024 Mål 2030 Bedömd utveckling mot målet Slutenvårdade 628 365 Under 400 Goda chanser till måluppfyllnad 5.1 Bedömning av måluppfyllnad år 2030 Diagram 1. Prognostiserat antal händelser, slutenvårdade, till och med 2030. Baserat på observerade händelser år 2008–2024. Pi – prediktionsintervall (hi – övre gräns, lo – undre gräns). R3 – rullande medelvärde (3 år). Källa: Patientregistret, Socialstyrelsen. Prognos över händelseutvecklingen från och med 2025 är beräknad i en regressionsmodell11. SCB:s prognos över befolkningsutveckling till och med 2030 10 Status för tillgänglig statistik är till och med år 2024 vid innevarande rapportering. 11 Se appendix för modelldata i programverktyget STATA.

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ingår i detta fall inte direkt i den slutliga beräkningsmodellen12, eftersom resultaten då inte blev signifikanta. Däremot nyttjas befolkningsutvecklingen som ett exponeringsmått i den kvalitativa analysen redovisad i nästa avsnitt, som stöd i beräkning och bedömning av antal händelser framåt i tiden. Vi kan konstatera att dagens rullande treårsmedelvärde är 365 händelser där någon person skadats så allvarligt att det lett till slutenvård. Uppsatt mål för år 2030 är ett motsvarande treårsmedelvärde ska ligga under 400 personer. Därmed ligger dagens nivå med marginal i paritet med målet. Prognosen pekar på en fortsatt avtagande trend vilket är positivt. Dock bör här noteras att uppgifter över åren 2022–2024 uppvisar ett ökande antal hädelser från cirka 340–390 händelser. Om denna ökning vilken syns som en ”puckel” i diagram 1 skulle vara någon form av trendbrott är svårt att bedöma, och som framgår av den historiska utvecklingen föreligger en viss variation över tid mellan årgångarna. Prognosmodellen baserad på historiken indikerar dock att det med hänsyn tagen till skattningens osäkerhet, prediktionsintervallet, är sannolikt att målet om en händelseutveckling på färre än 400 händelser per år kommer att uppnås till 2030. Bedömningen baseras också på en mer kvalitativt inriktad analys enligt nulägesbeskrivningen i nästa avsnitt och följande korta sammanfattning. Tidsserien har en tydligt avtagande trend och när den delas upp i fördelningar efter kön och ålder uppvisar inte någon underliggande tidsserie ett väsentligt avvikande mönster. Dock framgår att händelseutvecklingen i åldrarna 65 år och uppåt inte är lika tydligt avtagande jämfört yngre åldrar. Eftersom befolkningsutvecklingen jämförelsevis också sker något snabbare i nämnda grupp får det effekten i att händelseutvecklingen uttryckt som antal händelser per miljonen invånare inte sjunker lika starkt som i de yngre grupperna. Den framtida förhållandevis stora befolkningsutvecklingen i gruppen av de allra äldsta skulle kunna vara en möjlig orsak till en försämrad händelseutveckling på sikt. Speciellt gruppen av äldre män som har högst antal händelser per miljon invånare. Bedömningen är dock att det inte är någon av de underliggande tidserierna enligt nulägesbeskrivningen som idag bör pekas ut som ett direkt hot i att nå uppsatt mål.

12 Flera varianter av regressionsmodell har testats i sedvanlig analys. Varje tidsserie är unik och i detta fall bedöms befolkningsutvecklingen, med avtagande tillväxttakt på övergripande nivå, bidra till en framtida alltför starkt avtagande prognos. I den aspekten är den använda modellen något mer konservativ och försiktig i den framtida avtagande utvecklingen.

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1. 2

Nulägesbeskrivning – utveckling till år 2024 Totalt och sett till hela perioden från 2018 fram till 2024 framgår en tydligt avtagande trend i antalet allvarliga skadehändelser som krävt slutenvård och som är orsakade av brand i bostad. Dock med det lägsta observerade antalet år 2022 som ökat något därefter enligt tidigare kommentar. Diagram 2. Antal slutenvårdade vid bostadsbrand fördelat över åldersgrupper, unga (–24 år), medel (25 – 64år) och äldre (65 år–). År 2008–2024. Källa: Socialstyrelsen, Patientregistret. Delar vi upp slutenvårdade personer per åldersgrupp syns tydligt att åldersgruppen 25–64 år står för den största andelen av händelserna över tid, cirka 50 %, vilket också ligger i paritet med hur stor andel gruppen utgör av hela befolkningen. Denna grupp har också den mest avtagande trenden, och förklarar mest av utvecklingen totalt. Även i gruppen av unga, de under 25 år, syns en tydligt avtagande trend. Gruppen i åldrarna över 65 år har en mer oförändrad utveckling över tid, med effekten i att de i slutet av perioden utgör en större andel av totalt antal händelser, cirka 30 % år 2024 jämfört med 20 % år 2008. Någon form av omfördelning mellan åldersgrupperna har således skett över tid, där gruppen av äldre utvecklats minst gynnsamt sett till antal händelser som lett till slutenvård.

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Diagram 3. Antal slutenvårdade i bostadsbrand i grupper av åldrarna 65–79 år samt de allra äldsta, 80 år och äldre. År 2018–2024. Linjär trendlinje och rullande treårsmedelvärde, r3. Källa: Socialstyrelsen, Patientregistret. Delar vi upp de över 64 år i två delgrupper enligt diagram 3, så framgår att de trendmässigt sett inte avviker markant från varandra i utveckling över tidsperioden. I den befolkningsmässigt större åldersgruppen 65–79 år är volymen händelser ungefär dubbelt så många sett till hela perioden. Variationen över tid är också större i denna grupp. Vidare går det att observera en svagt avtagande trend i båda grupperna, men som inte är lika tydlig i jämförelse de under 65 år. Diagram 4. Antal slutenvårdade i bostadsbrand fördelat på kön. År 2008–2024. Linjära trendlinjer. Källa: Socialstyrelsen, Patientregistret.

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Fördelar vi antal händelser efter kön ser vi att män i genomsnitt ligger på ett högre antal händelser per år än kvinnor. Båda grupperna uppvisar en tydlig och likartad nedåtgående trend i enlighet med den som observeras totalt sett. Män står för ungefär två tredjedelar av händelserna sett över tid och de har under år 2023 och 2024 haft ett ökat antal händelser. Mot beskrivningarna av både befolkningsutveckling och antal slutenvårdade kan serierna kombineras till ett antal händelser per miljon invånare, som ett mått på hur händelsefrekvens eller ”risk” har utvecklats över tid. Diagram 5. Utveckling av antal slutenvårdade efter bostadsbrand per miljon invånare. År 2018–2024. Uppdelat på unga (–24 år), medel (25 – 64år) och äldre (65 år–). Linjär trendlinje per grupp. Källa: Socialstyrelsen, Patientregistret. SCB:s statistikdatabas (befolkningsutveckling) När händelse- och befolkningsutveckling kombineras observeras en tydlig avtagande trend i samtliga tre åldersgrupperingar enligt ovanstående diagram.

Dock är den avtagande trenden minst i den äldsta gruppen.

Unga under 25år utgör cirka 30 % av befolkningen och har det lägsta

antalet observerade händelser per miljon invånare.

Medelålders följer ungefär snittfrekvensen, motsvarande kurvan för totalt antal slutenvårdade, i genomsnitt cirka 50 per miljon och år totalt sett under hela perioden. De medelålders utgör cirka 50 % av befolkningen

och står även för cirka hälften av antalet händelser.

De äldre 65år och däröver, har högst nivå, i genomsnitt 70 slutenvårdade per miljon och år under perioden. Gruppen utgör cirka 20 % av befolkningen. Genomsnittlig andel av antal händelser under perioden är cirka 25 % i denna grupp.

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Delar vi upp, differentierar, frekvensen för de äldre i två åldersgrupper går det att notera två liknande och trender under perioden. Diagram 6. Utveckling av antal slutenvårdade i bostadsbrand per miljon invånare (exkl. vårdboende). Äldre personer uppdelade i åldrar under och över 80 år. Linjär trendlinje per grupp. Källa: Socialstyrelsen, Patientregistret. SCB:s statistikdatabas (befolkningsutveckling) Det framgår tydligt att det är i gruppen av de allra äldsta som har det högsta antalet händelser per miljon invånare sett över hela perioden. Delar vi till sist upp frekvensen på kvinnor och män går det även i denna uppdelning att observera två liknande och nedåtgående trender under perioden. Diagram 7. Utveckling av antal slutenvårdade i bostadsbrand per miljon invånare (exkl. vårdboende). Uppdelning efter kön. Linjär trendlinje per grupp. Källa: Socialstyrelsen, Patientregistret. SCB:s statistikdatabas (befolkningsutveckling)

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Det framgår tydligt att män är den grupp som har högst antal händelser per miljon invånare. Vidare kan det observeras att utvecklingen enligt frekvenskurvorna, antal händelser per miljon invånare, är snarlika kurvorna över antal händelser. Orsaken är att exponeringsmåttet i form av befolkningsutvecklingen är så förhållandevis lika under perioden. Befolkningsutvecklingen kopplat till olika åldersgrupper, enligt föregående redovisning, får en annan inverkan i utvecklingen av antal händelser per miljon invånare. Den avtagande frekvensutvecklingen i åldrarna över 65 år och uppåt är inte lika markant som händelseutvecklingen i denna grupp.

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Kostnad för egendomsskador Faktaruta start Definition Försäkringsutbetalningar från hem- (lägenhet), villahem- (egnahem, villor och radhus) och fritidshusförsäkringar för skadekategorin brand och åska. Källa: Svensk Försäkring Indikator Mätstart 2010 Nuläge 2024 Mål 2030 Bedömd utveckling mot målet Försäkringsutbetalningar brand och åska 1870 mkr 1802 mkr Nedåtgående trend Viss möjlighet till måluppfyllnad Målet är formulerat som att kostnaden för egendomsskador ska uppvisa en nedåtgående trend mellan åren 2010–2030.13 Indikatorn baseras på statistik avseende försäkringsutbetalningar från hem- (lägenhet), villahem- (egnahem, villor och radhus) och fritidshusförsäkringar för skadekategorin brand och åska. I ambition att göra kostnadsmassan jämförbar över tid (fasta priser) har konsumentprisindex (KPI) nyttjats (metodmässigt samma sätt som då indikatorn konstruerades). För en överblick redovisas en sammanställning över periodens sammantagna kostnader efter de största skadearterna, hämtat från Svensk Försäkring. 13 Data från Svensk Försäkring tillgänglig innevarande rapport är till och med år 2024. På grund av vissa kvalitetsbrister i historiska data får det inverkan på avstämning och bedömning av innevarande målformulering, vilket framgår av nulägesbeskrivningen i nästa avsnitt. Det är orsaken till att år 2014 och 2015 är modellmässigt särbehandlade i bedömningen vilket beskrivs i den fördjupade diskussionen.

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Diagram 1. Fördelning av totala kostnader efter skadeart. Sammantaget perioden 2010 - 2024. Totalt boende - hem-, villahem- och fritidshusförsäkring. Källa: Svensk Försäkring Total skadekostnad för brand- och åskskaderelaterade händelser i boendeförsäkring, vilka indikatorn baseras på, utgör under perioden cirka en femtedel (20 %) av försäkringsbranschens totala kostnadsmassa. Vattenskador i boendeförsäkring omfattar motsvarande knappt 30 % och driver sålunda något mer utgifter i försäkringsbranschen. 6.1 Bedömning av måluppfyllnad år 2030 Bedömningen baseras på fyra scenarion. I varje scenario beräknas kostnads- utvecklingen som antal händelser multiplicerat med en medelskada per år perioden 2025–2030. Dessa scenarion är skapade genom två prognoser över antal händelser till och med 2030 och två varianter på medelskadeutveckling. Genom att kombinera de fyra prognoserna har på så sätt fyra scenarion skapats över kostnadsutvecklingen, där två är något mer optimistiska och två scenarion är något mer konservativt försiktiga.

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Diagram 2. Kostnadsutveckling enligt scenarioanalys, övre och undre gräns (max- och min-scenario). Totalt brand och åska och totalt hem-, villahem- och fritidshusförsäkring År 2010–2024. Fasta priser. Källa: Svensk Försäkring Målet för indikatorn uppställt enligt en nedåtgående trend. Det vill säga lutningen hos en trendlinje sett över hela perioden 2010 – 2030 ska vara nedåtgående. Diagrammet ovan visar på att framtida rimliga varianter av prognostiserad kostnadsutveckling kan innebära både en uppåtgående eller nedåtgående trend, beroende på val av övre eller undre gräns för kostnadsutvecklingen framåt i tiden. Trenden är därför något av en ”gungbräda” som kan tippa både uppåt eller nedåt 2030 med startår 2010. Baserat på den senast publicerade statistiken (2024) är trenden fram till och med 2024 svagt uppåtgående, vilket framgår av nulägesbeskrivningen. Där nämns även avbrottet i tidserien år 2024–2015 som beror på kvaliteten i data. Villaförsäkring står för merparten 75 % av kostnaderna som hör till indikatorn och driver sålunda kostnadsutvecklingen under perioden. Åskskaderelaterade händelser är antalsmässigt relativt många men har samtidigt en låg medelskada vilket innebär att de utgör mindre än 5% av de totala kostnaderna. Utvecklingen av kostnader sett över hela perioden 2010–2030, det vill säga 20 år enligt måldefinitionen för indikatorn, kan inte med säkerhet sägas ha varken en positiv eller negativ trend. Detta bygger på analys av både historiskt och prognostiserat framtida kostnadsutfall. Sammantaget är bedömningen att målet för kostnadsutvecklingen är fullt möjligt att nå, men det kräver några år av stabila eller minskade kostnader under prognosperioden.

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1. 2

Nulägesbeskrivning – utveckling till år 2024 Diagram 3. Antal händelser totalt brand och åska och totalt hem-, villahem- och fritidshusförsäkring. År 2010–2024. Åska ingår i totalt antal och särredovisas från år 2017. Källa: Svensk Försäkring Målet för kostnadsutvecklingen fram till och med 2030 är knutet till en relativt sett lång tidsserie med koppling till ett i grunden slumpmässigt händelseutfall. Generellt sett, i likhet med andra längre tidsserier, kan det av naturliga skäl ofta uppstå förändringar och kvalitetsbrister i det data som följs och beskrivs över tid. Åskskadedata redovisas separat i denna statistik från år 2017. I ovanstående tidsserie över antalet händelser som ligger bakom aktuell kostnadsutveckling sticker årgångarna 2014 och 2015 ut i form av periodens både högsta respektive lägsta observation. I dialog med Svensk Försäkring kan konstateras att det skett en överrapportering 2014 respektive underrapportering

1. Storleken på kvalitetsbristen är svår att avgöra i efterhand men en del av

orsaken till det förmodade felet är dels en beståndsöverlåtelse mellan två försäkringsföretag och dels någon form av omläggning av statistiken. Tillhörande kostnader bedöms kunna få viss inverkan på beräkningen av trenden för indikatorn, speciellt påverkas medelskadan i nämnda årgångar. Exkluderar vi nämnda årgångar är genomsnittet i antal inrapporterade händelser enlig ovan grovt avrundat knappt 20 000 per år, vilket framgår i diagram 3.

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Diagram 4. Utvecklingen av konsumentprisindex, KPI, under perioden 2010–2024 Källa: SCB KPI-värdet mäter den procentuella förändringen av priserna jämfört med basåret

1. Om till exempel KPI för ett visst år är 300, så betyder det att priserna har

stigit med 200 procent jämfört med priserna 1980. Diagram 5. Löpande kostnadsutveckling samt i fasta priser (miljoner kr) med år 2018 som basår. Totalt brand och åska och totalt hem-, villahem- och fritidshusförsäkring. År 2010–2024. Åska ingår i totalt antal och särredovisas från år 2017. Källa: Svensk Försäkring, SCB Kostnadsutvecklingen i fasta priser baseras enligt diagrammet på KPI, men där år 2018 har räknats om till basår.14 Av diagrammen ovan framgår att prisutvecklingen har ökat rejält från cirka 2021. I föregående diagram över kostnadsutvecklingen

14 Även den förra rapporten nyttjade 2018 som basår, så för att underlätta jämförelser används samma basår i denna uppföljning MSB (2019). I nämnda rapport förs också en diskussion kring indexeringens för- och nackdelar.

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2010–2024 syns en nedgång, ”dipp”, 2015 som är en av de kvalitetsmässigt problematiska årgångarna beskrivna ovan. Undantar vi år 2014 och 2015 framgår en kurva som uppvisar en förhållandevis jämn kostnadsutveckling i en relativt stabil kurva under perioden uttryckt i fasta priser (2018 års priser). Diagram 6. Utveckling av skadekostnader (skk, miljoner kr) för hem-, villahem- och fritidshusförsäkring. 2018 års priser. År 2010–2024. Kvalitetsbrister i årgångarna 2014 och 2015. Källa: Svensk Försäkring Vidare framgår att kostnadsutvecklingen, uttryckt i fasta belopp, under perioden rört sig inom ett spann mellan 1,8 och 2 miljarder kronor i brandskadekostnad inom egendomsförsäkring. Trenden enligt diagram 6 är svagt uppåtgående under perioden 2010–2024. Det kan skönjas att år 2010–2017 har en något lägre kostnadsnivå än år 2018–2023, där 2024 åter är i nivå enligt seriens första halva. År 2017 har seriens lägsta observerade kostnad, undantaget år 2015 som noterats med kvalitetsproblem. Under 2020 genomfördes en översyn och genomlysning av indikatorer och mål i den nationella strategin för stärkt brandskydd. Då konstaterades en svagt nedåtgående trend år 2010–2018, vilket lade grund för ett mål i en då fortsatt nedåtgående kostnadsutveckling. Ett antal osäkerhetsfaktorer togs upp i föregående rapport15. Ser vi nu till perioden 2018–2024 så blir en beräknad trendlinje även den svagt nedåtgående.

15 Inriktning av nationell strategi förstärkt brandskydd, MSB 1687 (2021)

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Men trenden över hela perioden 2010 – 2024 är som nämnt svagt uppåtgående, och målet utgår också från startåret 2010. Diagram 7. Utveckling av skadekostnader (skk, miljoner kr) för hem-, villahem- och fritidshusförsäkring. 2018 års priser. År 2010–2024. Kvalitetsbrister i årgångarna 2014 och 2015. Källa: Svensk Försäkring Det framgår att skadekostnaden för villaförsäkringar står för merparten, cirka 75 %, av de totala kostnaderna knutna till denna indikator. Det går att notera en svag men uppåtgående trend i kostnaderna kopplat till villa medan fritidshus och hemförsäkring sammantaget har en mer oförändrad kostnadsutveckling, uttryckt i fasta priser (2018 års priser). Notera att 2023 års kostnad för ”villa” är periodens högsta med en påföljande dipp 2024, medans fritidshusen har ett omvänt mönster. Det framgår av diagram 8 att de åskskaderelaterade händelserna utgör en jämförelsevis liten andel, cirka 4 %, av total skademassa. Fördelar vi skadekostnad för åska hela perioden, 2017–2024, per försäkringsgren så står villahem för knappt 70 %, fritidshus för drygt 20 % och hem för knappt 10 %.

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Diagram 8. Utveckling av medelskada per händelse (tkr) totalt hem-, villahem- och fritidshusförsäkring. Fasta priser. År 2010–2024. Kvalitetsbrister i årgångarna 2014 och 2015. Åska ingår i totalt antal och särredovisas från år 2017.

Källa: Svensk Försäkring I jämförelse med kurvan över antal händelser per år så är den totala indexerade medelskadan uttryckt i fasta priser mer stabil. Genomsnittet är knappt 100 tkr sett över hela perioden, och vi kan notera en svagt uppåtgående trend i medelskada. Då åskskaderelaterade händelser utgör 18 % i genomsnitt av totalt antal händelser och endast 4 % av kostnaden under 2017–2024, blir medelskadan jämförelsevis låg, cirka 25 tkr i genomsnitt över perioden. Delar vi upp eller differentierar medelskadan för åska per försäkringsgren får vi i fallande ordning: fritidshus cirka 55 tkr, villahem cirka 29 tkr och hem knappt 8 tkr.

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Diagram 9. Utveckling av medelskada per händelse (tkr) totalt och för hem-, villahem- och fritidshusförsäkring. Fasta priser. År 2010–2024. Kvalitetsbrister i årgångarna 2014 och 2015. Källa: Svensk Försäkring Om total medelskada fördelas per boendetyp eller försäkringsgren så sticker fritidshusen ut med den högsta medelskadan i genomsnitt under perioden (diagram 9). Under perioden utgör fritidshusen cirka 7 % av antalet händelser och 12 % av total kostnadsmassa, vilket driver upp medelskadan. Den relativt höga medelskadan för de åskskaderelaterade händelserna för fritidshus bidrar i viss mån till den höga medelskadan totalt för dessa. Men som nämnts utgör skademassan för fritidshus kopplat till åska en väldigt liten andel av total skademassa, även om medelskadan för fritidshus är hög. Den jämförelsevis låga medelskadan i hemförsäkring har koppling till försäkringsgrenen som framför allt täcker lösöre i lägenheter och inte byggnaden som i en villaförsäkring. Notera att år 2023 var medelskadan för villa högre än för fritidshus. Kostnadsutfallet 2023 för villa är det högsta under redovisad period och det lägsta för fritidshus under perioden. Ett sätt att belysa utvecklingen över händelser och kostnader är att inkludera någon form av exponeringsmått som direkt eller indirekt kan tänkas bidra till utfallet. Befolkningens utveckling har modellmässigt använts i nästa avsnitt som exponeringsmått för att prognostisera händelseutvecklingen framåt i tiden. Att nyttja antalet försäkringar som ligger bakom kostnadsutfallet vore ett bättre mått över exponeringen. Dock finns inte dessa uppgifter tillgängliga som prognoser framåt i tiden i offentlig statistik.

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I statistik från Svensk Försäkrings databas över bostäder finns uppgifter att hämta om antal försäkringar, så kallat försäkringsbestånd. Diagram 10. Utveckling av försäkringsbestånd för hem-, villahem- och fritidshusförsäkring. Uppgifterna är ett genomsnitt per år (riskår, det vill säga antal försäkringar per kalenderår), framräknat med hjälp av uppgifter hämtade från Svensk Försäkring. Källa: Svensk Försäkring Det framgår att försäkringsbestånden i ovanstående försäkringsgrenar förändrats relativt lite under perioden. Lösöret i ”Hem” kan möjligen betraktas som något mer föränderligt16, men utgör samtidigt bara för cirka 15 % av den totala kostnaden. Som konstaterats inledningsvis i detta avsnitt är den totala kostnadsutvecklingen ganska jämn och förhållandevis konstant uttryckt i fasta priser, även nedbruten på de olika försäkringsgrenarna i området boende. En relativt jämn eller trögrörlig exponering i form av antal boendeförsäkringar kan snarast bidra till den förhållandevis stabila utvecklingen av fasta kostnader över tid. Framför allt är variationer i skadeutfallet mellan enskilda år inte kopplade till förändringar i exponering, utan är ett resultat av den stokastiska process som i grunden driver antal händelser och kostnaden för dessa i försäkringsbranschen.

16 Som nämnts tidigare i avsnittet men då i samband om uppgifter över kostnader, så kan det generellt sett av praktiska skäl uppstå olika typer av ”brott” i data och statistik över långa tidsserier. Svensk Försäkring tar upp något av detta i uppgifter kopplat försäkringsgrenen hem. Vi går inte in på detaljerna här då syftet ytterst är att lyfta möjligheten till att finna förklaringar eller samband mellan utvecklingen i beståndsexponering och utvecklingen av skador.

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Diagram 11. Utveckling av kostnad per försäkring för hem-, villahem- och fritidshusförsäkring. Uppgifterna är beräknade som treårsmedelvärden med hjälp av uppgifter hämtade från Svensk Försäkring. Kostnader i fasta priser (indexerade för jämförbarhet över tid). Kronor. Källa: Svensk Försäkring Utvecklingen av den totala kostnaden per försäkring, treårsmedelvärden, indikerar varken någon uppåt- eller nedåtgående trend under perioden 2018–2024. Delar vi upp denna per försäkringsgren framgår inte heller någon tydlig trend. Det framgår tydligt att försäkringsgren villa har den högsta kostnadsnivån och att ”Hem” genererar den lägsta kostnadsnivån, i kronor per försäkring. 6.3 Prognos och scenarion till år 2030 Det framgår att utvecklingen av kostnader över tid, omräknade till jämförbara priser över tid med hjälp av KPI – fasta priser (2018 års priser) – uppvisar en relativt jämn kurva. Dock med en svagt uppåtgående linjär trend år 2010–2024 där årgångarna 2014 och 2015 exkluderats på grund av kvalitetsbrister i data. Frågan att besvara enligt målformuleringen är om en linjär trend över kostnadsutvecklingen, hela perioden 2010–2030, kommer att vara nedåtgående om 6 år. Tillgängligt data från Svensk Försäkring i denna indikator är till och med 2024 vid avrapportering, så prognoshorisonten är därför sex år, 2025–2030. Tillvägagångssätt för att bedöma framtida kostnadsutveckling bygger på scenarioanalys, ett enklare binomialtest (teckentest) samt genomgång av historik.

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Skadekostnaden för ett enskilt år kan betraktas som produkten av medelskada och antal händelser. Om vi för varje prognostiserat år framåt i tiden låter: ant = antal händelser msk = medelskadan skk = skadekostnaden, där skk = ant * msk Vi har tillgång till känt historiskt data enligt föregående avsnitt och vill nu på ett enkelt men rimligt sätt skapa fyra scenarion baserade på två varianter av framtida utveckling av antal händelser och medelskada. Syftet är att åstadkomma en form av känslighetsanalys baserad på två rimliga varianter av antals- och motsvarande medelskadeutveckling: ant1 = händelseutveckling 2025–2030 enligt en realistisk prognos ant2 = händelseutveckling 2025–2030 enligt en realistisk prognos, något mer försiktig eller konservativ msk1 = medelskadeutveckling 2025–2030 enligt en realistisk prognos msk2 = medelskadeutveckling 2025–2030 enligt en realistisk prognos, något mer försiktig eller konservativ 6.3.1 Händelseutveckling enligt prognos (ant1) Diagram 12. Prognos över antal händelser enligt en enkel linjär trend, egendomsskador - hem-, villahem- och fritidshusförsäkring, till och med 2030. År 2010–2024. Kvalitetsbrister i årgångarna 2014 och 2015. Källa: Svensk Försäkring.

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Antalet händelser per år är cirka 20 000 som inrapporteras till Svensk Försäkring. Antalsutvecklingen uppvisar en svagt avtagande trend enligt historiken år 2010–

1. En linjär förlängning av observerad trend innebär att antalet händelser år

2030 prognostiseras till cirka 17 500st. 6.3.2 Händelseutveckling enligt prognos (ant2) Diagram 13. Prognostiserat antal händelser, egendomsskador - hem-, villahem- och fritidshusförsäkring, till och med 2030. Baserat på observerade händelser år 2010 - 2024. Kvalitetsbrister i årgångarna 2014 och 2015. Pi – prediktionsintervall (hi – övre gräns, lo – undre gräns). R3 – rullande medelvärde (3 år). Källa: Svensk Försäkring. Prognos över händelseutvecklingen från och med 2025 är beräknad i en regressionsmodell17. SCB:s framskrivning över befolkningsutvecklingen till och med 2030 ingår i modellen som ett exponeringsmått, som stöd för beräkning av antal händelser framåt i tiden. Regressionsmodellen är anpassad till något mer konservativa och därmed bredare prediktionsintervall enligt diagrammet. Prognostiserat antal händelser enligt modellen är cirka 16 900 år 2030. Övre respektive undre gräns i prediktionsintervallet 2030 är cirka 14 500–19 700 händelser (vilket också täcker det antal som använts som ant1).

17 Se appendix för modelldata i programverktyget STATA.

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1. 3.3

Medelskadeutveckling enligt prognos (msk1 och msk2) Diagram 14. Prognos över medelskada i kronor enligt en enkel linjär trend, egendomsskador - hem-, villahem- och fritidshusförsäkring, till och med 2030. Baserat på observerade händelser år 2010 - 2024. Kvalitetsbrister i årgångarna 2014 och 2015. Källa: Svensk Försäkring. Utvecklingen av medelskada enligt en enkel linjär trend baserad på perioden 2010– 2024 uppvisar en växande trend under perioden vilket beror på ett något minskande antal händelser över tid men där kostnaden samtidigt utvecklats relativt konstant. Prognos msk1 bygger på antagandet om en relativt försiktigt men fortsatt ökande medelskada baserad på historiken 2010–2024. Prognos msk2 baseras på motsvarande trend men har skalats ned med hjälp av medelskadan år 2016–2024. Utvecklingen fram till 2030 är sedan något mer optimistisk men fortsatt ökande men på en något lägre nivå. 6.3.4 Scenarion – fyra stycken Genom att kombinera ovanstående prognostiserad utveckling av antal händelser och medelskada kan vi skapa fyra scenarion över kostnadsutvecklingen enligt: Scenario1 = ant1*msk1 Scenario2 = ant1*msk2 Scenario3 = ant2*msk1 Scenario4 = ant2*msk2

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Diagram 15. Scenarioanalys över utvecklingen av skadekostnader (skk, miljoner kr) för hem-, villahem- och fritidshusförsäkring. 2018 års priser. År 2010–2024 men 2014 och 2015 är exkluderade på grund av. kvalitetsbrister. Observera att skalan börjar på 1,5 miljarder kronor i diagrammet. Källa: Svensk Försäkring Notera att skadekostnaden år 2024, faktiskt utfall, är den lägsta sedan 2017. Tanken är att alla fyra scenarion ska vara realistiska. Baserade på två komponenter eller faktorer som kombinerat ger fyra varianter av framtida kostnadsutveckling där två är något mer optimistiska och två något mer konservativt försiktiga. Syftet är att påvisa eller grovt ringa in någon form av brytpunkt för uppsatt trendmål, utan att ändra alltför ”mycket” på indata. Sammanfattningsvis pekar två scenarion på en något ökande trend över perioden, och två scenarion pekar en något avtagande trend. Den framtida variationen kommer ha inverkan i faktiskt utfall mot indikatormålet.18

18 Modellansats är regression till redovisad antalsprognos. Någon variant av ARIMA-modell hade nog genererat en något mer realistisk årlig utveckling med hänsyn tagit till variansen i tidsserien. Med syfte enligt indikatorns målformulering bör redovisad scenarioanalys och ett teckentest (appendix) vara ett tillräckligt bedömningsunderlag. Modellmässigt följer antalsskattningen de andra delarna i denna översyn.

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Egendomsskador – händelser 7.1 Utvecklade bränder Faktaruta start Definition Bränder i boende eller vård, som spridit sig utanför startföremålet eller som pågått vid räddningstjänstens ankomst. För soteldar och bränder i skorsten krävs dessutom att branden spridit sig utanför sotet respektive skorstenen. Baserat på ett rullande treårsmedelvärde. Indikator Mätstart 2010 Nuläge 2025 Mål 2030 Bedömd utveckling mot målet Utvecklade bränder 2 633 2 420 Under 2 500 Goda chanser till måluppfyllnad Denna indikator ersätts av indikatorn ”bostadsbränder med spridning från startobjektet”. Nästkommande avsnitt tar upp detta. Orsaken hänger samman med datakvalitet och tidsseriebrott i statistiken.

• År 2016–2017 skedde en övergång från vad som tidigare kallades

insatsrapport till nuvarande händelserapport.

• År 2022 skedde en versionsförändring i händelserapporten.

Båda dessa förändringar har inverkan i form av två trendbrott i statistiken och tidsserien över utvecklade bränder vilket framgår tydligt av diagrammet i nästa avsnitt. Innevarande mål för indikatorn togs fram i samband med en genomgång och analys av statistik med data till och med 2019, beskrivet i tillhörande rapport19. Det förändrade insamlingsförfarandet av data 2016, och påföljande trendbrott medförde att det också blev mer problematiskt att sätta upp ett rimligt, utmanande mål att nå år 2030. Påföljande versionsförändring av händelserapporten år 2022 har också haft inverkan för utvecklingen av statistiken. Noteras kan att utfall i rullande medelvärde som mått på indikatorn, är enligt nuläget 2 475 händelser, det vill säga i balans med målet. Detta garanterar inte i sig att utfallet 2030 är i balans. Det ska nog snarare ses som en konsekvens av problematiken med att sätt upp målet i sig. Det bör också nämnas att indikatordefinitionen av utvecklad brand jämfört med brand med spridning från startobjektet har gjort det svårare att fånga historiska 19 Inriktning av nationell strategi för stärkt brandskydd genom stöd till enskilda, MSB 2020.

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data på ett stringent sätt. Likaså är det i prognoshänseende ”besvärligare” att modellmässigt behöva hantera olika trendbrott, även om det är praktiskt möjligt. Indikatorn för bostadsbränder med spridning från startobjektet hanterar i huvudsak samma typ av händelser som indikatorn för utvecklad brand, men i en mer statistiskt stabil och förutsägbar tidsserie, vilket borde gynna diskussionen kring mål, prognos och förebyggande arbete. 7.1.1 Bedömning av måluppfyllnad år 2030 Diagram 1. Prognostiserat antal händelser, utvecklade bränder, till och med 2030. Baserat på observerade händelser perioden 2008–2024. Pi – prediktionsintervall (hi – övre gräns, lo – undre gräns). R3 – rullande medelvärde (3 år). Källa: Räddningstjänstens insatser, Myndigheten för civilt försvar. SCB:s statistikdatabas (befolkningsutveckling) Prognos över händelseutvecklingen från och med 2025 är beräknad i en regressionsmodell där hänsyn tagits till tidsseriens trendbrott20. Bedömningen är att det finns väldigt goda chanser att nå uppsatt mål år 2030, men med en viss kvarstående osäkerhet. Prediktionsintervallen indikerar dock att det är troligt att händelseutfallet kan hamna under 2 500, i paritet med målet. Tidseriens första år i perioden fram till 2015 är de år som framför allt ligger bakom den ursprungliga analysen och tankarna bakom målformuleringen. För övrig analys och diskussion kring utvecklingen av händelser som hör samman med egendomsskador hänvisas till avsnittet om bostadsbränder med spridning

20 Se appendix för modelldata i programverktyget STATA.

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från startobjektet, och avsnittet som tar upp kostnadsutvecklingen för egendomsskador. 7.2 Bostadsbränder med spridning från startobjektet Definition Bränder i boende och vård med spridning från det objekt som först antändes. Indikator Mätstart 2010 Nuläge 2025 Mål 2030 Bedömd utveckling mot målet Bostadsbränder med spridning från startobjektet 2 252 2 055 Under 2 000 Viss möjlighet till måluppfyllnad Denna indikator ersätter indikatorn utvecklade bränder. Se föregående avsnitt som tar upp utvecklade bränder. Orsaken hänger samman med tidsseriebrott och datafångst i sistnämnda indikator, beskrivet i föregående avsnitt. Nytt mål för år 2030 baseras på strategi och tankesätt för att sätta framtida mål beskrivet då den nationella strategin togs fram 201921. Ett mål på 2 000 händelser i form av ett rullande treårsmedelvärde stöder sig både på en kvantitativ och kvalitativ analys enligt följande två avsnitt. Vi har även beaktat tidigare mål och utveckling i indikatorn över utvecklad brand. Syftet är att målet ska vara utmanande men nåbart.

21 Se avsnitt 4 – ”Att sätta framtida mål” - Nationell strategi förstärkt brandskydd, MSB1362 (2019 )

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1. 2.1

Bedömning av måluppfyllnad år 2030 Diagram 2. Prognostiserat antal händelser, bostadsbränder med spridning från startobjektet, till och med 2030. Baserat på observerade händelser under perioden 2008–2025. Pi – prediktionsintervall (hi – övre gräns, lo – undre gräns). R3 – rullande medelvärde (3 år). Källa: Räddningstjänstens insatser, Myndigheten för civilt försvar. SCB:s statistikdatabas (befolkningsutveckling) Prognos över händelseutvecklingen från och med 2026 är beräknad i en regressionsmodell. SCB:s prognos över befolkningsutveckling till och med 2030 ingår i detta fall inte direkt i den slutliga beräkningsmodellen22. Däremot nyttjas befolkningsutvecklingen som ett exponeringsmått i den kvalitativa analysen redovisad i nästa avsnitt, som stöd i beräkning och bedömning av antal händelser framåt i tiden. Bedömningen är att målet för år 2030 är fullt rimligt att nå, men osäkerheten är trots det relativt stor. Prediktionsintervallen indikerar dock att det är fullt rimligt enligt modellantagande att händelseutfallet kan hamna under 2 000, i paritet med målet. Det innebär att det krävs en fortsatt avtagande utveckling i form av ett rullande treårsmedelvärde som måste minska knappt 5 % för att nå uppsatt mål, och som är helt möjligt enligt regressionsmodellens prediktion. Bedömningen baseras också på en kvalitativt analysen enligt nulägesbeskrivningen i nästa avsnitt och följande korta sammanfattning.

22Se appendix för modelldata i programverktyget STATA. Flera varianter av regressionsmodell har testats i sedvanlig analys. Varje tidsserie är unik och i detta fall bedöms den nedåtgående befolkningsutvecklingen på övergripande nivå bidra till en alltför starkt avtagande prognos. I den aspekten är den använda modellen något mer konservativ och försiktig i den framtida nedåtgående utvecklingen.

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Händelseutvecklingen per boendetyp indikerar att villa och flerbostadshus båda uppvisar en nedåtgående trend i antal händelser under perioden 2008–2025. Nämnda boendeformer täcker den absoluta merparten av periodens alla händelser. Trenden framträder inte lika tydligt de senaste åren, villabeståndet har haft en något bättre händelseutveckling än flerbostadshusen sett till hela perioden, år 2008–2025. I övriga typer av boenden, fritidshus m.m., är trenden otydlig och inte nedåtgående. Totalt antal bostadsbränder med spridning från startobjektet redovisat per miljon invånare har utvecklats i form av en svagt nedåtgående trend under hela perioden. Bränder med startutrymmet kök utgör drygt 25 % av samtliga bostadsbränder med spridning från startobjektet under perioden, och drygt 15 % har okänt startutrymme. 7.2.2 Nulägesbeskrivning – utveckling till år 2025 Under perioden från 2018 fram till 2025 framgår en svagt avtagande trend i antalet bostadsbränder med spridning från startobjektet, totalt sett. Antal händelser har minskat påtagligt både under 2024 och 2025. Diagram 3. Antal bostadsbränder med spridning från startobjektet fördelat efter bostadstyp. Övrigt boende omfattar radhus, vårdboende m.m., det vill säga allt utöver villa och flerbostadshus. År 2018–2025. Källa: Räddningstjänstens insatser, Myndigheten för civilt försvar. Fördelar vi alla händelser efter boendetyp villa, flerbostadshus och allt övrigt boende så framgår att förstnämnda kategorier tillsammans står för drygt 80 % av händelserna. Det framgår att händelser i villa har tydligast trend som är svagt avtagande, och har under perioden gått från en något högre nivå än händelser i

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flerbostadshus för att idag ligga på ungefär samma antal händelser, cirka 800 per år. Sett till bostadstyp är det därför villabränderna som främst förklarar den nedåtgående trenden i bostadsbränder med spridning från startobjektet. I den sammanslagna gruppen, övrigt boende, kan noteras en svagt ökande trend, och att någon form av nivåhöjning har skett under perioden 2014–2017. Diagram 4. Antal bostadsbränder med spridning från startobjektet i de bostadstyper som ingår i ”Övrigt boende”. År 2008–2025. Källa: Räddningstjänstens insatser, Myndigheten för civilt försvar. Delar vi upp ”övrigt boende” som utgör knappt 20 % av händelserna så framgår att bakomliggande utveckling kan beskrivas i tre tidsserier eller grupper med olika utveckling och karaktär. Det framgår tydligt att det skett en omfördelning år 2014– 2017 mellan fritidshus och andra typer av boendeformer, som beror på hur statistiken samlas in och redovisas23. Antal bostadsbränder med spridning från startobjektet per miljon invånare följer över hela perioden en nedåtgående trend.

23 Det har tidigare varit lättare att hitta ”Fritidshus” i den insatsrapporten som tidigare låg till grund för statistikinsamling. I nuvarande händelserapport måste man först välja ”Vanligt boende” för att få gå vidare och välja ”Fritidshus”, och alla befäl (rapportörer) ser inte fritidsboende som vanligt boende. I fritidshusstatistiken är det därför sämre kvalitet i händelserapporten än i insatsrapporten.

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Diagram 5. Utveckling av antal bostadsbränder med spridning från startobjektet per miljon invånare. Källa: Räddningstjänstens insatser, Myndigheten för civilt försvar. SCB:s statistikdatabas (befolkningsutveckling) Som framgått följer utvecklingen i antal bostadsbränder med spridning från startobjektet under samma period en svagt nedåtgående trend. Med hänsyn tagen till exponering i form av befolkningsutvecklingen blir effekten att antal bostadsbränder med spridning från startobjektet per miljon invånare, som ett frekvensmått, sett över perioden är tydligt nedåtgående. Sett till perioden 2008–2025 var befolkningstillväxten knappt 15%. Antal händelser har minskat med cirka 8 %, vilket resulterat i att antal händelser per miljon invånare minskat med cirka 20 %. Trots en växande befolkning har antal händelser minskat.

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Brandvarnare Faktaruta start Definition Andel hushåll med fungerande brandvarnare. Källa: Enkätundersökningar (Myndigheten för civilt försvar) Indikator Mätstart 2010 Nuläge 2025 Mål 2030 Bedömd utveckling mot målet Brandvarnare 78 % 92 % Minst 95 % Liten möjlighet till måluppfyllnad Andelen hushåll och individer med fungerande brandvarnare har med jämna mellanrum sedan år 1996 undersökts genom enkätundersökningar till allmänheten av Statistiska centralbyrån (SCB) på uppdrag av Myndigheten för civilt försvar.24 Undersökningarna har haft olika innehåll men brand och brandskydd har varit ett tema som bestått. I underlaget beräknar SCB vikter för olika grupper av hushåll eller individer beroende på svarsfrekvens.25 Därmed kan resultatet antas utgöra ett representativt urval av befolkningen. 24 Tidigare har Myndigheten för samhällsskydd och beredskap och Statens Räddningsverk beställt undersökningarna. 25 I denna rapport är samtliga siffror beräknade för objektet ”individ/person” och inte för objektet ”hushåll” om inte något annat anges. Därför skrivs ibland ”Andel individer med…” istället för ”Andel hushåll med…”. Läs mer om detta i MSB (2023b), kapitel 1.3.

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1. 1

Bedömning av måluppfyllnad år 2030 Diagram 1. Andel individer med fungerande brandvarnare år 1996–2025 med mål år 2030 och en logistisk trendlinje med mättnadsnivå på 97 %26 Källa: Enkätundersökningar (Myndigheten för civilt försvar) Trenden mellan år 1996 och 2025 är ökande. Prognosen över utvecklingen till år 2030 är baserad på en stigande trend med avtagande ökningstakt. Datamaterialet har relativt få mätpunkter under en lång tidsperiod vilket begränsar metodval och möjlighet till statistisk styrka. Eftersom andelen närmar sig taket på 100 % uppnås en viss mättnad där varje procentenhets ökning kräver allt större ansträngningar. Tillväxttakten per år bör därför fortsätta att avta i framtiden. Bedömningen är att målet för år 2030 inte kommer att nås. Prognosskattningarna för de scenariomodeller som bedöms som mest rimliga för utvecklingen landar på strax under 95 % (se appendix för mer underlag kring bedömningen). Om inte ytterligare styrmedel som nya regler, kampanjer eller incitament införs är det liten möjlighet att målet uppnås.

26 Mättnadsnivå innebär den realistiska andelen individer som någonsin kommer att ha skyddsutrustningen. Nivån på 97 % bedöms som mest sannolik utifrån en kvantitativ och kvalitativ analys (se appendix för ytterligare underlag).

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Bedömningen baseras också på en mer kvalitativt inriktad analys enligt nulägesbeskrivningen i nästa avsnitt och följande korta sammanfattning. Andel individer med fungerande brandvarnare ligger på en nivå i enkätsvaren där en tänkt maximal mättnadsnivå närmar sig. Målet på 95 % individer med fungerande brandvarnare är en hög målsättning som möjligen tangerar detta värde. Vi kan se att skillnaderna mellan olika grupper i samhället, särskilt när det gäller flerbostadshus och småhus samt ensamstående och sammanboende, har minskat över tid. Trots det så ser vi att undergrupper som exempelvis boende i hyresrätter ligger cirka 10 % under målet. 8.2 Nulägesbeskrivning – utveckling till år 2025 Det är rimligt att det maximala värdet för andelen individer med fungerande brandvarnare är lägre än 100 % av flera anledningar. För det första är innehav och funktion inte lagstiftat vilket ger utrymme för möjligheter att fastighetsägare och boende väljer bort antingen eller. För det andra är produkten kopplad till en viss kostnad och arbetsinsats när det gäller inköp och underhåll. För det tredje karaktäriseras de som saknar en brandvarnare av särskilda bakgrundsfaktorer: de är i mindre utsträckning oroliga för bränder, de anser sig ha mindre möjlighet att påverka sin brandsäkerhet, de känner i mindre grad ansvar för att säkerhetsåtgärder vidtas i hemmet, och de tar i mindre grad information om risk och säkerhet på allvar (MSB 2019). I det perspektivet är 95 % fungerande brandvarnare en hög målsättning som möjligen tangerar den maximala mättnadsnivån som går att uppnå.

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Diagram 2. Förekomst och funktion av brandvarnare år 1996–2025 Källa: Enkätundersökningar (Myndigheten för civilt försvar) Skillnaden mellan innehav och funktion av brandvarnare ser ut att ha minskat i de senaste undersökningarna (diagram 2). År 2025 var skillnaden 4 procentenheter medan den som mest var 14 procentenheter år 2010. En jämförelse mellan år 2010 och år 2025, bland de som har en brandvarnare, tyder på att fler kontrollerar brandvarnarens funktion oftare och det är färre som inte brukar kontrollera den alls (diagram 3). Detta kan förklara en del av minskningen. Diagram 3. Kontroll av brandvarnare år 2005–2025 Källa: Enkätundersökningar (Myndigheten för civilt försvar)

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De grupper i samhället som har en lägre andel fungerande brandvarnare karaktäriseras generellt som: ensamstående utan barn, boende i flerbostadshus, boende i hyresrätt, låg inkomst, boende i storstäder, ensamstående kvinnor med barn, boende i tätorter med över 100 000 invånare samt ensamstående utan barn i den yngsta åldersgruppen 18–29 år (MSB 2023). I andra undersökningar har även grupper som män, ogifta, skilda, födelseland utanför Norden/Europa samt arbetslösa funnits påverka förekomst av brandvarnare (Runefors 2022; MSB 2019; Bonander & Nilsson u.å.). Vissa grupper som unga, kvinnor, ensamstående utan barn, personer med låg inkomst och låg utbildningsnivå, invandrare och boende i storstäder har generellt låg skyddsnivå mot brand (Henrekson m.fl. 2025). Med låg skyddsnivå menas att de i högre utsträckning saknar fungerande brandvarnare, handbrandsläckare, brandfilt och/eller kontrollerar sin brandvarnare mer sällan än en gång per år. Diagram 4. Andel individer med fungerande brandvarnare år 1996–2025 efter bostadstyp Källa: Enkätundersökningar (Myndigheten för civilt försvar) Skillnaden i andel fungerade brandvarnare för individer boende i flerbostadshus och småhus har minskat (diagram 4). År 1996 var skillnaden 34 procentenheter medan den var 8 procentenheter år 2025. Ökningen för boende i flerbostadshus har varit drygt 40 procentenheter, vilket bidragit mycket till den övergripande trenden. När det gäller ägande av bostaden så finns inte lika långa dataserier. Att ha äganderätt till sin bostad innebär i genomsnitt en högre andel fungerande brandvarnare, följt av att inneha en bostadsrätt (se diagram 5). Hyresrätterna ligger ett antal procentandelar efter.

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Diagram 5. Andel individer med fungerande brandvarnare år 2014–2025 efter ägande Källa: Enkätundersökningar (Myndigheten för civilt försvar) Ett liknande mönster som för bostadstyperna kan ses för olika hushållstyper (diagram 6). Här var skillnaden mellan ensamstående och sammanboende 22 procentenheter år 1996 och 4 procentenheter år 2025. Ökningen för ensamstående har varit drygt 40 procentenheter, vilket bidragit mycket till den övergripande trenden. När det gäller om det finns barn i hushållet eller inte går det inte att se några större skillnader (diagram 7).

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Diagram 6. Andel individer med fungerande brandvarnare år 1996–2025 efter hushållstyp Källa: Enkätundersökningar (Myndigheten för civilt försvar) Diagram 7. Andel individer med fungerande brandvarnare år 1996–2025 efter barn eller inte barn i hushållet Källa: Enkätundersökningar (Myndigheten för civilt försvar) Andelen individer med fungerande brandvarnare ligger högst för hushåll med hög inkomst, följt av medelinkomst och låg inkomst (diagram 8). Ökningen sedan år 1996 har varit något större för individer med låg inkomst men samtliga tre inkomstgrupper har bidragit till den gemensamma trenden.

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Diagram 8. Andel individer med fungerande brandvarnare år 1996–2025 efter inkomst27 Källa: Enkätundersökningar (Myndigheten för civilt försvar)

27 För år 2010 finns inte uppgifter om inkomst på individnivå.

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Handbrandsläckare Definition Andel hushåll med tillgång till handbrandsläckare. Källa: Enkätundersökningar (Myndigheten för civilt försvar) Indikator Mätstart 2010 Nuläge 2025 Mål 2030 Bedömd utveckling mot målet Handbrandsläckare 50 % 68 % Minst 80 % Liten möjlighet till måluppfyllnad Andel hushåll med handbrandsläckare har skattats genom enkätundersökningar till allmänheten på samma sätt som för fungerande brandvarnare (kapitel 8). 9.1 Bedömning av måluppfyllnad år 2030 Diagram 1. Andel individer med tillgång till handbrandsläckare år 1996–2025 med mål år 2030 och en logistisk trendlinje med mättnadsnivå på 80 % 28,29 Källa: Enkätundersökningar (Myndigheten för civilt försvar) 28 Nivån på 80 % bedöms som mest sannolik utifrån en kvantitativ och kvalitativ analys (se appendix för ytterligare underlag). 29 År 2007 var frågeställningen inte helt identisk med övriga enkätundersökningar när det gäller brandvarnare och brandfilt. För handbrandsläckare är resultatet jämförbart.

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Trenden mellan år 1996 och 2025 är ökande. Det sker dock en stabilisering på runt 67–68 % mellan 2018 och 2025. Prognosen över utvecklingen till år 2030 är baserad på en stigande trend med avtagande ökningstakt. Datamaterialet har relativt få mätpunkter under en lång tidsperiod vilket begränsar metodval och möjlighet till statistisk styrka. Tillväxttakten per år bör vara avtagande i framtiden allt eftersom en tänkt maximal mättnadsnivå närmar sig. För handbrandsläckare är det rimligt att detta värde är lägre än 100 % eftersom innehav inte är lagstiftat och produkten är kopplad till en viss kostnad. Bedömningen är att målet för år 2030 inte kommer att nås. Prognosskattningarna för de scenariomodeller som bedöms som mest rimliga för utvecklingen landar på under 80 % (se appendix för mer underlag kring bedömningen). Om inte ytterligare styrmedel som nya regler, kampanjer eller incitament införs är det liten möjlighet att målet uppnås. Bedömningen baseras också på en mer kvalitativt inriktad analys enligt nulägesbeskrivningen i nästa avsnitt och följande korta sammanfattning. Andel individer med tillgång till handbrandsläckare ligger på en nivå i enkätsvaren som planat ut och där en tänkt maximal mättnadsnivå sannolikt närmar sig. Målet på 80 % handbrandsläckare är en hög målsättning som möjligen tangerar den maximala nivån som går att uppnå. Vi kan se att skillnaderna mellan olika grupper i samhället, särskilt när det gäller flerbostadshus och småhus samt äganderätt och hyresrätt, är stora och ser ut att öka över tid. Undergrupper som exempelvis boende i flerbostadshus och hyresrätter ligger cirka 40 procentenheter under målet. 9.2 Nulägesbeskrivning – utveckling till år 2025 Andel individer som innehar handbrandsläckare ligger på en nivå där ökningen ser ut att ha planat ut under de tre senaste undersökningarna. Ett liknande resonemang som för fungerande brandvarnare kan föras då en tänkt maximal nivå på 100 % inte är rimligt. Det finns ingen lagstiftning som säger att innehav är ett krav. I jämförelse med brandvarnare upplevs innehavet av handbrandsläckare som ännu mer ”frivilligt”, kräver mer kunskap/förmåga vid användning och dessutom till en högre inköpskostnad. I det perspektivet bör en tänkt mättnadsnivå för handbrandsläckare ligga lägre, kanske mellan 70 och 80 %, än motsvarande tak för brandvarnare. De hushåll som saknar tillgång till något släckredskap, det vill säga varken har handbrandsläckare, vattenslang, brandfilt eller annat, var 27 % år 2014 (MSB 2019). Denna grupp utmärker sig genom att de anser sig ha liten möjlighet att påverka sin egen säkerhet när det gäller brand, har lägre förtroende för

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räddningstjänst och i lägre grad känner ansvar för att säkerhetsåtgärder vidtas i hemmet De är dessutom i högre utsträckning är ensamboende, bor i lägenhet, hyr sin bostad, inte är pensionerade, och/eller är födda utomlands (ibid.). De grupper i samhället som har en lägre andel handbrandsläckare karaktäriseras generellt som: ensamstående utan/med barn (särskilt de med utländsk bakgrund och/eller de som är födda utanför Sverige), boende i flerbostadshus, boende i hyresrätt, låg inkomst samt boende i storstäder (MSB 2023). Diagram 2. Andel individer med tillgång till handbrandsläckare år 1996–2025 efter bostadstyp Källa: Enkätundersökningar (Myndigheten för civilt försvar) Skillnaden i andel individer med tillgång till handbrandsläckare mellan flerbostadshus och småhus är tydlig och ser ut att ha ökat över tid (diagram 2). År 1996 var skillnaden 35 procentenheter medan den var 46 procentenheter år 2025. Nivån för småhus ligger över målet på 80 % medan nivån för flerbostadshus ligger långt under målet. När det gäller ägande av bostaden så finns inte lika långa dataserier. Att ha äganderätt till sin bostad innebär i genomsnitt en högre andel handbrandsläckare, följt av att inneha en bostadsrätt (se diagram 3). Nivån för såväl bostadsrätter som hyresrätter ligger långt under målet.

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Diagram 3. Andel individer med tillgång till handbrandsläckare år 2014–2025 efter ägande

Källa: Enkätundersökningar (Myndigheten för civilt försvar) Ett liknande mönster som för bostadstyper kan ses för hushållstyper (diagram 4). Här var skillnaden mellan ensamstående och sammanboende 16 procentenheter år 1996 och 26 procentenheter år 2025. Ökningen för ensamstående har varit 30 procentenheter medan ökningen för sammanboende varit 40 procentenheter. Ingen av grupperna ligger över målet och nivån för de ensamstående ligger långt under målet. När det gäller om det finns barn i hushållet eller inte så är skillnaderna ungefär mellan 5–10 procentenheter (diagram 5). Diagram 4. Andel individer med tillgång till handbrandsläckare år 1996–2025 efter hushållstyp Källa: Enkätundersökningar (Myndigheten för civilt försvar)

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Diagram 5. Andel individer med tillgång till handbrandsläckare år 1996–2025 efter barn eller inte barn i hushållet

Källa: Enkätundersökningar (Myndigheten för civilt försvar) Andelen handbrandsläckare ligger högst för hushåll med hög inkomst, följt av medelinkomst och låg inkomst (diagram 6). Skillnaden mellan hushåll med hög inkomst och låg inkomst var 9 procentenheter år 1996 och 31 procentenheter år

1. Ökningen för de med låg inkomst har varit 21 procentenheter medan

ökningen för de med hög inkomst varit 43 procentenheter. Andelen för de med låg inkomst har dessutom minskat i de senaste undersökningarna. Ingen av grupperna ligger över målet och nivån för hushåll med låg inkomst är till och med minskande för de senaste undersökningarna och ligger relativt långt under målet.

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Diagram 6. Andel handbrandsläckare år 1996–2025 efter inkomst30 Källa: Enkätundersökningar (Myndigheten för civilt försvar)

30 För år 2010 finns inte uppgifter om inkomst på individnivå.

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Brandfilt Faktaruta start Definition Andel hushåll med tillgång till brandfilt. Källa: Enkätundersökningar (Myndigheten för civilt försvar) Indikator Mätstart 2010 Nuläge 2025 Mål 2030 Bedömd utveckling mot målet Brandfilt 15 % 58 % Minst 70 % Liten möjlighet till måluppfyllnad 10.1 Bedömning av måluppfyllnad år 2030 Diagram 1. Andel individer med tillgång till brandfilt år 2005–2025 med mål år 2030 och en logistisk trendlinje med mättnadsnivå på 70 % 31 Källa: Enkätundersökningar (Myndigheten för civilt försvar) Trenden mellan år 2005 och 2025 är ökande. Utvecklingen har varit i det närmaste linjär men mellan åren 2022 och 2025 ser det ut som att ökningstakten har avtagit. Prognosen över utvecklingen till år 2030 är baserad på en stigande trend med avtagande ökningstakt. Datamaterialet har relativt få mätpunkter under en lång tidsperiod vilket begränsar metodval och möjlighet till statistisk styrka. Tillväxttakten per år bör avta i framtiden allt eftersom en tänkt maximal 31 Nivån på 70 % bedöms som mest sannolik utifrån en kvantitativ och kvalitativ analys (se appendix för ytterligare underlag).

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mättnadsnivå närmar sig. För brandfilt är det rimligt att denna nivå är lägre än 100 % eftersom innehav inte är lagstiftat och produkten är kopplad till en viss kostnad. Bedömningen är att målet för år 2030 inte kommer att nås. Prognosskattningarna för de scenariomodeller som bedöms som mest rimliga för utvecklingen landar på strax under 70 % (se appendix för mer underlag kring bedömningen). Om inte ytterligare styrmedel som nya regler, kampanjer eller incitament införs är det liten möjlighet att målet uppnås. Bedömningen baseras också på en mer kvalitativt inriktad analys enligt nulägesbeskrivningen i nästa avsnitt och följande korta sammanfattning. Andel individer med brandfilt ligger på en nivå i enkätsvaren som planat ut i de två senaste undersökningarna och där en tänkt maximal mättnadsnivå sannolikt närmar sig. Målet på 70 % brandfilt är en hög målsättning som möjligen tangerar den maximala nivån som går att uppnå. Vi kan se att skillnaderna mellan olika grupper i samhället, särskilt när det gäller flerbostadshus och småhus, äganderätt och hyresrätt samt inkomstnivåer, är stora och ser ut att öka över tid. Undergrupper som exempelvis boende i flerbostadshus och hyresrätter ligger cirka 25–30 procentenheter under målet. 10.2 Nulägesbeskrivning - utveckling till år 2025 Andel individer som har tillgång till brandfilt ligger på en nivå där ökningen ser ut att ha planat ut under de två senaste undersökningarna. Resonemanget som förts om fungerande brandvarnare och handbrandsläckare om att en tänkt maximal mättnadsnivå på 100 % inte är rimlig gäller även för brandfilt. Sannolikt börjar andelen närma sig en tänkt maximal mättnadsnivå på kanske runt 70 %. I föregående kapitel såg vi vad som var utmärkande för de hushåll som saknar tillgång till något släckredskap generellt, bland annat brandfilt. De grupper i samhället som har en lägre andel av just brandfilt karaktäriseras generellt som: ensamstående (särskilt de med utländsk bakgrund och/eller födda utanför Sverige), hushåll utan barn, boende i flerbostadshus, boende i hyresrätt, låg inkomst samt boende i landsbygdskommun med besöksnäring eller storstad (MSB 2023).

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Diagram 2. Andel individer med tillgång till brandfilt år 2005–2025 efter bostadstyp Källa: Enkätundersökningar (Myndigheten för civilt försvar) Skillnaden i andel brandfilt mellan flerbostadshus och småhus är tydlig och ser ut att ha ökat över tid (diagram 2). År 2005 var skillnaden 5 procentenheter medan den var 25 procentenheter år 2025. Nivån för småhus ligger på målet på 70 procent medan nivån för flerbostadshus ligger långt under målet. När det gäller ägande av bostaden så finns inte lika många mätningar. Att ha äganderätt till sin bostad innebär i genomsnitt en högre andel brandfilt, följt av att inneha en bostadsrätt (se diagram 3). Nivån för såväl bostadsrätter som hyresrätter ligger ungefär mellan 15 och 30 procentenheter under målet. Diagram 3. Andel individer med tillgång till brandfilt år 2014–2025 efter ägande Källa: Enkätundersökningar (Myndigheten för civilt försvar)

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Ett liknande mönster som för bostadstyper kan ses för hushållstyper (diagram 4). Här var skillnaden mellan ensamstående och sammanboende 3 procentenheter år 2005 och 18 procentenheter år 2025. Ökningen för ensamstående har varit 44 procentenheter medan ökningen för sammanboende varit 59 procentenheter. Ingen av grupperna ligger över målet och nivån för de ensamstående ligger långt under målet. När det gäller om det finns barn i hushållet eller inte så är skillnaderna ungefär mellan 5–10 procentenheter (diagram 5). Diagram 4. Andel individer med tillgång till brandfilt år 2005–2025 efter hushållstyp Källa: Enkätundersökningar (Myndigheten för civilt försvar) Diagram 5. Andel individer med tillgång till brandfilt år 2005–2025 efter barn eller inte barn i hushållet Källa: Enkätundersökningar (Myndigheten för civilt försvar)

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Andelen brandfilt ligger högst för hushåll med hög inkomst, följt av medelinkomst och låg inkomst (diagram 6). Skillnaden mellan hushåll med hög inkomst och låg inkomst var 4 procentenheter år 2005 och 24 procentenheter år 2025. Ökningen för de med låg inkomst har varit 41 procentenheter medan ökningen för de med hög inkomst varit 61 procentenheter. Ingen av grupperna ligger över målet och nivån för hushåll med låg inkomst är konstant för de senaste två undersökningarna och ligger relativt långt under målet. Diagram 6. Andel individer med tillgång till brandfilt år 2005–2025 efter inkomst32 Källa: Enkätundersökningar (Myndigheten för civilt försvar)

32 För år 2010 finns inte uppgifter om inkomst på individnivå.

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Kommuner med utvecklat samarbete Definition Andel räddningstjänstorganisationer med formaliserat samarbete mellan (två eller fler) verksamhetsområden kring individanpassat brandskydd. Källa: Årsuppföljningen LSO (Myndigheten för civilt försvar) Indikator Mätstart 2019 Nuläge 2024 Mål 2030 Bedömd utveckling mot målet Kommuner med utvecklat samarbete 45 % 56 % Ökning Viss möjlighet till måluppfyllnad I indikatorarbetet för ett stärkt brandskydd (MSB 2017) föreslogs som mål: ”En över tid statistiskt säkerställd ökning av antalet formaliserade samarbeten i syfte att förebygga bostadsbränder med utgångspunkt i LSO”. Detta tillstånd mäts genom ”andel räddningstjänstorganisationer med formaliserat samarbete mellan (två eller fler) verksamhetsområden kring individanpassat brandskydd”.33 Andelen räknas exklusive själva räddningstjänstorganisationen och uppgiften hämtas från Årsuppföljningen LSO. Verksamhetsområdena kan vara andra förvaltningar inom kommunen men också till exempel regionala, privata eller ideella aktörer. Dataunderlaget var osäkert före år 2019 till följd av en otydlig frågeformulering. Eftersom den nya frågeställningen gällde från 2019 så sattes inga nya mål mot år 2030 i det arbete med inriktningen av brandstrategin som skedde då (MSB 2021). Dessutom ändrades definitionen av indikatorn från antal samarbeten till andel räddningstjänstorganisationer. Vi kan dock till viss del utvärdera utvecklingen mot den uttryckta ambitionen om en statistiskt säkerställd ökning. 33 Vi väljer att använda termen ”räddningstjänstorganisation” i stället för kommun. I detta sammanhang innefattar räddningstjänstorganisationer såväl kommunalförbund och gemensamma nämnder som enskilda kommuner. Detta beror på hur räddningstjänsten är organiserad. Antal räddningstjänstorganisationer minskar generellt och var 140 stycken under år 2024.

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Bedömning av måluppfyllnad år 2030 Diagram 1. Andel räddningstjänstorganisationer med formaliserat samarbete mellan två eller fler verksamhetsområden kring individanpassat brandskydd samt linjär trendlinje (utan år 2020–2021) Källa: Årsuppföljning LSO (Myndigheten för civilt försvar) Trenden mellan år 2019 och 2024 är sannolikt påverkad av pandemiåren 2020–

1. Datamaterialet har relativt få mätpunkter under en lång tidsperiod vilket

begränsar metodval och möjlighet till statistisk styrka. Resultatet av regressionsanalys och andra statistiska tester är beroende av om år 2020 och 2021 inkluderas (se appendix). Är hela tidsperioden med så resulterar testerna i att ingen signifikant ökning kan konstateras. Om pandemiåren utesluts så är resultaten blandade. Bedömningen är att det finns viss möjlighet att målet för år 2030 kommer att nås. Bedömningen tar fasta på att ökningen ska vara statistiskt säkerställd för att målet ska anses vara uppnått. Att andelen ska fortsätta öka med någon eller några procentenheter är sannolikt men vi ser också att andelen de senaste två åren är på samma nivå (56 %). Därför bedömer vi att det inte är givet att en marginell ökning i procenttalen kommer att resultera i en statistiskt signifikant ökning. Bedömningen baseras också på en kvalitativ analys av underlaget i nästa avsnitt. Där framgår bland annat att antalet samarbeten följer ett liknande mönster som andelen räddningstjänstorganisationer ovan. Det framgår också att ungefär en fjärdedel av organisationerna inte har några formaliserade samarbeten alls inom området.

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1. 2

Nulägesbeskrivning – utveckling till år 2025 Indikatorns definition var tidigare ”Antal samarbeten i syfte att förebygga bostadsbränder med utgångspunkt i LSO.” Det är intressant att följa även denna utveckling. I diagram 2 ser vi att mönstret är väldigt likt det vi ser ovan. Det har skett en ökning under pandemiåren 2020–2021, följt av en nedgång år 2022 och därefter en relativt stabil trend på en högre nivå än före pandemin. Diagram 2. Antal formaliserade samarbeten i syfte att förebygga bostadsbränder med utgångspunkt i LSO Källa: Årsuppföljning LSO (Myndigheten för civilt försvar) I diagram 3 ser vi vilka verksamhetsområden räddningstjänstorganisationerna uppger att de har formaliserade samarbeten med. Äldreomsorg, kommunala fastighetsbolag, skola, rengöring och brandskyddskontroll samt kommunens hälso- och sjukvård är de vanligaste. Samtidigt ser vi att 37 räddningstjänstorganisationer, motsvarande 26 %, uppger att de inte har några formaliserade samarbeten alls inom området. Under perioden 2019–2024 ser mönstret liknande ut vad gäller fördelningen mellan olika verksamhetsområden.

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Diagram 3. Antal formaliserade samarbeten i syfte att förebygga bostadsbränder med utgångspunkt i LSO inom olika verksamhetsområden år 202434 Källa: Årsuppföljning LSO (Myndigheten för civilt försvar)

34 Antal räddningstjänstorganisationer under år 2024 var 140.

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Hembesök Definition Andel av räddningstjänstorganisationerna som utfört minst tio hembesök per år. Källa: Årsuppföljningen LSO (Myndigheten för civilt försvar) Indikator Mätstart 2019 Nuläge 2024 Mål 2030 Bedömd utveckling mot målet Hembesök 40 % 32 % Ökning Viss möjlighet till måluppfyllnad I nationella strategin för att stärka brandskyddet (MSB 2010) anges som ett mål att: ”Medvetenheten hos enskilda om brandrisker och hur man ska agera i händelse av brand ska öka.” Målet var från början tänkt att mätas genom ”antal hushåll som fått information om brandrisker genom hembesök.” Under inriktningsarbetet år 2021 ändrades indikatorn till ”andel av räddningstjänstorganisationerna som utfört minst tio hembesök per år” (MSB 2021). Förutom ändringen i indikatorns definition så var dataunderlaget osäkert före år 2019 till följd av en otydlig frågeformulering. Eftersom den nya frågeställningen gällde från 2019 så sattes inga nya mål mot år 2030 i det arbete som skedde då (MSB 2021). Vi kan till viss del utvärdera utvecklingen mot målet, även om en ”ökning” är vagt formulerat. I detta fall är målet inte uttryckt som en statistiskt signifikant ökning. 87

1. 1

Bedömning av måluppfyllnad år 2030 Diagram 1. Andel av räddningstjänstorganisationerna som utfört minst tio hembesök per år samt linjär trendlinje (utan år 2020–2021) Källa: Årsuppföljning LSO (Myndigheten för civilt försvar) Trenden mellan år 2019 och 2024 är påverkad av pandemiåren 2020–2021. Efter dessa år har en viss återhämtning skett men andelen har inte nått upp till de 40 % av räddningstjänstorganisationerna som utfört minst 10 hembesök år 2019. Datamaterialet har relativt få mätpunkter under en lång tidsperiod vilket begränsar metodval och möjlighet till statistisk styrka. Resultatet av regressionsanalys och andra statistiska tester visar att inga signifikanta skillnader kan konstateras (se appendix). Detta gäller oberoende av vilka perioder som inkluderas, 2019–2024 eller 2022–2024, eller om år 2020 och 2021 inkluderas i hela tidsperioden. Begreppet ”ökning” måste dock inte innebära en statistisk signifikant ökning i detta fall. Bedömningen är att det finns viss möjlighet att målet för år 2030 kommer att nås. Bedömningen tar fasta på en generellt ökande linjär trend för att målet ska anses vara uppnått. Som målet är uttryckt är formuleringen vag och har inget tydligt kvantitativt mål för uppfyllnad. Ökningen behöver inte vara statistiskt signifikant i detta fall. För att lyckas måste dock andelen fortsätta öka med någon eller några procentenheter utifrån andelen de senaste två åren (32 %), vilket gör att det ändå krävs en ansträngning för att nå målsättningen. Bedömningen baseras också på en kvalitativ analys av underlaget i nästa avsnitt. Där framgår att antalet hembesök är ökande och därmed att fler hembesök genomförs i genomsnitt per organisation av de som utför hembesök.

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Nulägesbeskrivning – utveckling till år 2024 Indikatorns tidigare definition ”Antal hushåll som fått information om brandrisker genom hembesök” är också intressant att följa. I diagram 2 ser vi att pandemiåren 2020–2021 kraftigt påverkade antalet hembesök. Jämfört med år 2019 har dock antalet hembesök återhämtat sig snabbare än vad indikatorn gjort. Antalet är högre än före pandemin och trenden är ökande. Trots att relativt sett färre organisationer än år 2019 utför fler än tio hembesök så är det totala antalet hembesök högre. Detta innebär att fler hembesök genomförs i genomsnitt per organisation av de som utför hembesök. Diagram 2. Antal hembesök per år Källa: Årsuppföljning LSO (Myndigheten för civilt försvar)

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Referenser Bonander C & Nilson F, (u.å). Sociodemografiska skillnader i risken för bostadsbrand, prevalens av brandskydd i hemmet och hantering av bränder. https://www.diva-portal.org/smash/get/diva2:1174963/FULLTEXT01.pdf Henrekson E, Andersen R, Turesson K & Nilson F, (2025). Fire safety disparities in Sweden: sociodemographic influences and the impact of societal protection on personal fire prevention measures. Fire Technology, 61, 751–769, 2025. https://doi.org/10.1007/s10694-024-01638-1. MSB (2023a). Effekter på räddningsinsatser till följd av covid-19. Komplettering med åren 2021 och 2022. Publ nr: MSB2294 – december 2023. ISBN: 978-91- 7927-463-4. https://rib.msb.se/Filer/pdf/30548.pdf. MSB (2023b). Brand- och brandskyddsundersökningen 2022. Publ nr: MSB2246 – oktober 2023. ISBN: 978-91-7927-427-6. https://rib.msb.se/filer/pdf/30478.pdf MSB (2021). Ingen ska omkomma eller skadas allvarligt – Inriktning av den nationella strategin för att stärka brandskyddet för den enskilda människan. Publ nr: MSB1751 - maj 2021. ISBN: 978-91-7927-162-6. https://rib.msb.se/filer/pdf/29623.pdf MSB (2019). Analys av utvecklingen inom bostadsbrand 2018. Publ nr: MSB1359 – augusti 2019. ISBN: 978-91-7383-926-6. https://rib.msb.se/Filer/pdf/28904.pdf MSB (2017). Indikatorer för ett stärkt brandskydd. Slutrapport från delprojekt inom den nationella strategin för att stärka brandskyddet för den enskilda människan. Diarienummer 2013–4818. Reviderad version 170215. MSB (2014). Indikatorer för ett stärkt brandskydd. Slutrapport från delprojekt inom den nationella strategin för att stärka brandskyddet för den enskilda människan. Diarienummer 2013–4818. https://www.mcf.se/siteassets/dokument/amnesomraden/skydd-mot-olyckor- och-farliga-amnen/brandskydd/slutrapport-indikatorer-for-ett-starkt- brandskydd.pdf MSB (2010). En nationell strategi för att stärka brandskyddet genom stöd till enskilda. Redovisning av uppdrag (Fö2009/2196/SSK, 2009-11-05). Diarienummer 2009–14343. https://rib.msb.se/Filer/pdf/28823.pdf Runefors (2022). Residential Fire Safety – An Interdisciplinary Approach. Marcus Runefors, Ragnar Andersson, Mattias Delin & Thomas Gell (red.). Springer.

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Appendix Omkomna Uppgifterna hör samman med text och diagram i avsnitt 3. Figur A.1. Index över antal omkomna i bostadsbrand. Poissonregression utförd i programvaran STATA.

Källa: Räddningstjänsternas insatsstatistik, Myndigheten för civilt försvar.

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Allvarligt skadade – avtransporterade till vård Uppgifterna hör samman med text och diagram i avsnitt 4. Figur A.2. Index över antal avtransporterade till vård i bostadsbrand. Poissonregression utförd i programvaran STATA.

Källa: Räddningstjänsternas insatsstatistik, Myndigheten för civilt försvar.

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Allvarligt skadade – slutenvårdade Uppgifterna hör samman med text och diagram i avsnitt 5. Figur A.3. Index över antal avtransporterade till vård i bostadsbrand. Poissonregression utförd i programvaran STATA.

Källa: Socialstyrelsen, Patientregistret.

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Kostnad för egendomsskador Uppgifterna hör samman med text och diagram i avsnitt 6. Händelseutveckling –nummer 2 (ant2) Figur A.4. Prognostiserat antal händelser, egendomsskador - hem-, villahem- och fritidshusförsäkring. Poissonregression utförd i programvaran STATA.

Källa: Svensk försäkring. Teckentest – kostnadsutvecklingen 2010–2024 (avsnitt 6.1.4) Diagram 1. Årsvis förändring av skadekostnad (skk, miljoner kr) för hem-, villahem- och fritidshusförsäkring. 2018 års priser. År 2010–2024 men 2014 och 2015 är exkluderade pga. kvalitetsbrister.

Källa: Svensk Försäkring Diagrammet ovan visar hur mycket kostnaden för egendomsskador har förändrats årsvis under perioden 2010–2024. Det framgår exempelvis att förändringen i kostnadsutfall mellan åren 2010 och 2011 har sjunkit med cirka 40 miljoner kronor.

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Det har skett två fler nedgångar av de 12 förändringar som observerats mellan åren under en period av 13 år. Totalt sett har kostnaden rört sig från cirka 1,9 miljarder kronor 2010 till cirka 1,8 miljarder kronor år 2024. I ett binomialtest eller teckentest, kan det inte uteslutas att det förändrade kostnadsutfallet mellan åren beror på slumpen. Tillsammans med scenarioanalyserna tyder mycket på att kostnadsutvecklingen sett över hela perioden 2010–2030 enligt målet för indikatorn, inte kan sägas ha varken en stabil positiv eller negativ trend. Detta bygger på analys av både historiskt och prognostiserat framtida utfall. Notera att under olika delperioder kan observeras både en svag uppgång eller svag nedgång i utvecklingen beroende på val av tidsperiod.

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Utvecklad brand Uppgifterna hör samman med text och diagram i avsnitt 7.1. Figur A.5. Index över antal avtransporterade till vård i bostadsbrand. Poissonregression utförd i programvaran STATA.

Källa: Räddningstjänsternas insatsstatistik, Myndigheten för civilt försvar.

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Bostadsbränder med spridning från startobjektet Uppgifterna hör samman med text och diagram i avsnitt 7.2. Figur A.6. Index över antal avtransporterade till vård i bostadsbrand. Poissonregression utförd i programvaran STATA.

Källa: Räddningstjänsternas insatsstatistik, Myndigheten för civilt försvar.

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Skyddsåtgärder Bakgrundsdata till avsnitt 8–10. Gemensamt för hushåll med andel fungerande brandvarnare, andel handbrandsläckare och andel brandfilt är att det är ett litet datamaterial med gles tidsupplösning. Underlaget utgörs av enkätundersökningar som utförts ungefär vart fjärde år sedan år 1996. Andel hushåll med brandfilt har undersökts sedan år

1. Detta begränsar valet av metoder och ger ofta låg statistisk styrka. Analysen

baseras på följande steg samt en mer kvalitativ inriktad analys:

1. Visualisering – diagram över punktskattningarna visas i kapitlet
2. Trendanalys – logaritmisk trend visas i kapitlet
3. Jämförelse mellan perioder
4. Beräkna tillväxttakt
5. Statistiska tester

Brandvarnare Andel individer med fungerande brandvarnare har ökat från 63 % år 1996 till 92 % år 2025. Det motsvarar en ökning på 29 procentenheter på 29 år, eller i snitt cirka 1,00 procentenheter per år. Ökningen har varit högst i början av perioden. En prognos till år 2030 med genomsnittlig årlig ökning på en procentenhet över hela perioden skulle innebära en andel på cirka 97 % år 2030. En ökning baserad på perioden år 2018 till 2025 skulle innebära en andel på 95 % (0,57 procentenheter per år). Bedömningen är att det är mest sannolikt att den framtida ökningen blir ännu lägre och att målet på 95 % därför inte kommer att nås. Period Startvärde Slutvärde Antal år Årlig ökning (procentenheter per år) 1996–2025 63 92 29 1,00 1996–2010 63 78 14 1,07 2010–2025 78 92 15 0,93 1996–2005 63 81 9 2,00 2005–2014 81 85 9 0,44 2018–2025 88 92 7 0,57

98

I tabellen nedan visas prognosen för år 2030 baserat på en logistisk modell med olika mättnadsnivåer från 95–100 %.35 Inga mättnadsnivåer medför en andel på 95 % eller högre enligt prognosen för år 2030. Tillväxtmodellen med en mättnadsnivå på 97 % bedöms som mest realistisk (visas i avsnitt 8.1) och ger en prognos på 93 %. Mättnadsnivå (%) Prognos 2030 (%) 95 92,2 96 92,6 97 93,0 98 93,4 99 93,7 100 94,0 Handbrandsläckare Andel individer med tillgång till handbrandsläckare har ökat från 31 % år 1996 till 68 % år 2025. Det motsvarar en ökning på 37 procentenheter på 29 år, eller i snitt cirka 1,28 procentenheter per år. Ökningen har varit högst i mitten av perioden och under den sista tredjedelen, mellan år 2018 och 2025, har andelen inte ökat alls. En prognos till år 2030 med genomsnittlig ökning över hela perioden skulle innebära en andel på cirka 74 procent år 2030. Mest sannolikt är tillväxttakten lägre i framtiden. Period Startvärde Slutvärde Antal år Årlig ökning (procentenheter per år) 1996–2025 31 68 29 1,28 1996–2010 31 50 14 1,36 2010–2025 50 68 15 1,20 1996–2005 31 42 9 1,22 2007–2014 45 59 7 2,00 2018–2025 68 68 7 0,00

35 Mättnadsnivå innebär den realistiska andelen hushåll som någonsin kommer att ha skyddsutrustningen. Den logistiska modellen uppskattar denna nivå baserat på den historiska utvecklingen.

99

Den logistiska tillväxtmodellen som visas i avsnitt 9.1 ger också en prognos på cirka 73 % med en maximal mättnadsnivå på 80 procent. I tabellen nedan visas prognosen för år 2030 baserat på en logistisk modell med olika mättnadsnivåer från 70–100 procent. Ingen av nivåerna resulterar i en prognos som hamnar på målet 80 % eller högre. Mättnadsnivå (%) Prognos 2030 (%) 70 68,0 75 71,0 80 73,3 85 75,0 90 76,3 95 77,3 100 78,1 Brandfilt Andel individer med tillgång till brandfilt har ökat från 5 % år 2005 till 58 % år

1. Det motsvarar en ökning på 53 procentenheter på 20 år, eller i snitt cirka

2,65 procentenheter per år. Ökningen har varit högst i mitten av perioden och under de sista tre åren, mellan år 2022 och 2025, har andelen ökat med 0,67 procentenheter per år. En prognos till år 2030 med genomsnittlig ökning över hela perioden skulle innebära en andel på cirka 71 % år 2030. Mest sannolikt är tillväxttakten lägre i framtiden. En prognos baserad på tillväxten under perioden 2018–2025 hamnar på 68 % år 2030 och en prognos på perioden 2022–2025 hamnar på cirka 61 %. Period Startvärde Slutvärde Antal år Årlig ökning (procentenheter per år) 2005–2025 5 58 20 2,65 2005–2014 5 29 9 2,67 2018–2025 44 58 7 2,00 2005–2010 5 15 5 2,00 2014–2018 29 44 4 3,75 2022–2025 56 58 3 0,67

100

Den logistiska tillväxtmodellen som visas i avsnitt 10.1 ger en prognos på cirka 67 % med en maximal mättnadsnivå på 70 %. I tabellen nedan visas prognosen för år 2030 baserat på en logistisk modell med olika mättnadsnivåer från 65–100 procent. Nivån måste överstiga 75 % för att målet till år 2030 ska uppnås enligt prognosmodellen. Mättnadsnivå (%) Prognos 2030 (%) 65 63,3 70 66,7 75 69,4 80 71,7 85 73,6 90 75,3 95 76,7 100 77,9

101

Skyddsproduktion Bakgrundsdata till avsnitt 11–12. Utvecklat samarbete Scenario Mann-Kendall test Linjär regression Hela perioden (2019–2024) Ingen signifikans Ingen signifikans Utan 2021 Gränsfall ökande Ökande (cirka 2 % per år) Utan 2020–2021 Ingen signifikans Ökande (cirka 2 % per år) Hembesök Scenario Mann-Kendall test Linjär regression Hela perioden (2019–2024) Ingen signifikans Ingen signifikans Utan 2020–2021 Ingen signifikans Ingen signifikans 2022–2024 Ingen signifikans Ingen signifikans

102

Analys av utvecklingen inom bostadsbrand 2025

FD05989 ｜ 2014_德国_BEU_车辆火灾调查_Laurenburg_火灾报告.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2014 ｜ 地域： ｜ 严重程度： ｜ 场所：交通/车辆 ｜ 起火原因： ｜ 来源格式：pdf

Aktenzeichen: 60uu2014-09/010-3323 Stand: 28.01.2019 Version: 1.0 Gefährliches Ereignis im Eisenbahnbetrieb Ereignisart: Fahrzeugbrand Datum: 28.09.2014 Zeit: 18:18 Uhr Bahnhof: Laurenburg (Lahn) Gleis: 1 Kilometer: 67,275

Veröffentlicht durch: Bundesstelle für Eisenbahnunfalluntersuchung Heinemannstraße 6 53175 Bonn Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) Seite 2 von 21

Inhaltsverzeichnis: Seite 1 Zusammenfassung ............................................................................................6 1.1 Kurzbeschreibung des Ereignisses ......................................................................6 1.2 Folgen..................................................................................................................6 1.3 Ursachen .............................................................................................................6 2 Vorbemerkungen................................................................................................7 2.1 Organisatorischer Hinweis ...................................................................................7 2.2 Ziel der Eisenbahn-Unfalluntersuchung ...............................................................8 2.3 Mitwirkende..........................................................................................................8 3 Ereignis...............................................................................................................8 3.1 Hergang ...............................................................................................................8 3.2 Todesopfer, Verletzte und Sachschäden .............................................................9 3.3 Wetterbedingungen..............................................................................................9 4 Untersuchungsprotokoll....................................................................................9 4.1 Notfallmanagement..............................................................................................9 4.2 Untersuchung der Infrastruktur ..........................................................................10 4.3 Untersuchung der Leit- und Sicherungstechnik..................................................10 4.4 Untersuchung der betrieblichen Handlungen .....................................................10 4.5 Untersuchung von Fahrzeugen ..........................................................................10 4.5.1 Allgemeine Angaben zum Dieseltriebwagen ......................................................10 4.5.2 Untersuchung des Drehgestells und des betreffenden Radlagers......................11 4.5.3 Demontage des defekten Radlagers im Werk Limburg (Lahn)...........................11 4.5.4 Revisionsunterlagen Drehgestell und Radlager..................................................18 4.5.5 Radlager-Montageanleitung FAG.......................................................................18 4.6 Interpretation der Unfallspuren...........................................................................19 5 Auswertung und Schlussfolgerungen............................................................19 6 Bisher getroffene Maßnahmen........................................................................20

Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) Seite 3 von 21

Abbildungsverzeichnis:

Abb. 1: Lageplan ................................................................................................................... 9

Abb. 2: Revisionseintrag ......................................................................................................11

Abb. 3: schadhaftes Radlager ..............................................................................................12

Abb. 4: schadhaftes Radlager geöffnet ................................................................................12

Abb. 5: Innenansicht Lagerdeckel ........................................................................................13

Abb. 6: Innenansicht 1..........................................................................................................13

Abb. 7: Innenansicht 2..........................................................................................................14

Abb. 8: Befestigungsschrauben............................................................................................14

Abb. 9: Druckkappe..............................................................................................................15

Abb. 10: Abstandring............................................................................................................15

Abb. 11: Druckkappe............................................................................................................16

Abb. 12: Rollenlager.............................................................................................................16

Abb. 13: Radsatzwelle..........................................................................................................17

Abb. 14: Druckkappenschrauben .........................................................................................18

Abb. 15: Gültigkeit Montageanleitung...................................................................................18

Ä n d e r u ngsverzeichnis Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) Seite 4 von 21

Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn)

Seite 5 von 21 Abkürzungsverzeichnis AEG Allgemeines Eisenbahngesetz BEU Bundesstelle für Eisenbahnunfalluntersuchung BMVI Bundesministerium für Verkehr und digitale Infrastruktur BPol Bundespolizei BÜ Bahnübergang EBA Eisenbahn-Bundesamt EBL Eisenbahnbetriebsleiter EBO Eisenbahn- Bau- und Betriebsordnung EIU Eisenbahninfrastrukturunternehmen ERA Europäische Eisenbahn Agentur ESO Eisenbahnsignalordnung EUB Eisenbahn-Unfalluntersuchungsstelle des Bundes EUV Eisenbahn-Unfalluntersuchungsverordnung EVU Eisenbahnverkehrsunternehmen NE Nichtbundeseigene Eisenbahn Nmg Notfallmanager Ril Richtlinie SB Sicherheitsbehörde SMS Sicherheitsmanagementsystem VT Verbrennungstriebwagen

Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) 1 Zusammenfassung 1.1 Kurzbeschreibung des Ereignisses Am 28.09.2014 gegen 18:18 Uhr wurde der Zug DPN 25582 (Limburg (Lahn) – Koblenz Hbf) in Laurenburg (Lahn) (VzG-Strecke 3710 Wetzlar – Koblenz Hbf) mit dem Triebwagen VT 251 (Fahrzeugregisternummer 95 80 0648151-8) der Vectus Verkehrsgesellschaft mbH auf­ grund Rauchentwicklung am ersten Drehgestell gestellt. Bei näherer Untersuchung der Rau­ chentwicklung wurden Flammen unter dem Fahrzeug festgestellt und mit Handfeuerlöscher gelöscht. 1.2 Folgen Eine Weiterfahrt war wegen der blockierten Achse am führenden Drehgestell nicht möglich. Die Reisenden wurden evakuiert. Das Fahrzeug wurde umgehend aus dem Betrieb genom- men und konnte am Folgetag mittels Hilfsdrehgestell aus eigener Kraft nach Limburg (Lahn) fahren. Personen wurden nicht verletzt. Es entstanden nur Schäden am Fahrzeug. Der Sachschaden beträgt ca. 11.200 €. 1.3 Ursachen Als Auslöser konnte ein Lagerschaden am rechten Radsatzlager der zweiten Achse des füh­ renden Drehgestells festgestellt werden. Der Lagerschaden wurde offenbar durch sich nacheinander aus den Gewinden lösende Befestigungsschrauben der Druckkappe verur­ sacht. Grund für das Lösen der Schrauben war vermutlich ein sich verminderndes Anzugs- Drehmoment der Schrauben aufgrund eines Montagefehlers (verminderte Vorspannung der Druckkappe durch Nachsetzung der Lagerinnenschalen). Seite 6 von 21

Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) 2 Vorbemerkungen

1. 1 Organisatorischer Hinweis

Mit der Richtlinie 2004/49/EG zur Eisenbahnsicherheit in der Gemeinschaft (Eisenbahnsi- cherheitsrichtlinie) wurden die Mitgliedstaaten der Europäischen Union verpflichtet, unab- hängige Untersuchungsstellen für die Untersuchung bestimmter gefährlicher Ereignisse ein- zurichten. Diese Richtlinie wurde mit dem 5. Gesetz zur Änderung eisenbahnrechtlicher Vorschriften vom 16.04.2007 umgesetzt und die Eisenbahnunfalluntersuchungsstelle des Bundes (EUB) eingerichtet. Die weitere Umsetzung der Sicherheitsrichtlinie erfolgte durch die Eisenbahn- Unfalluntersuchungsverordnung (EUV) vom 05.07.2007.

Mit dem Gesetz zur Neuordnung der Eisenbahnunfalluntersuchung vom 27.06.2017 wurden die rechtlichen Grundlagen zur Errichtung der Bundesstelle für Eisenbahnunfalluntersuchung (BEU) geschaffen. Durch das Gesetz wurden das Allgemeine Eisenbahngesetz (AEG) und das Bundeseisenbahnverkehrsverwaltungsgesetz (BEVVG) geändert, wobei Zustän­ digkeiten und Kompetenzen auf die neue Behörde, die BEU, übertragen wurden. Mit Er­ richtung der BEU wurde die EUB, bestehend aus der Leitung der EUB im Bundesministeri­ um für Verkehr und digitale Infrastruktur (BMVI) und der Untersuchungszentrale der EUB im Eisenbahn-Bundesamt (EBA), aufgelöst. Mit dem Organisationserlass des Bundesministe­ riums für Verkehr und digitale Infrastruktur zur Errichtung der Bundesstelle für Eisenbahnun­ falluntersuchung vom 14.07.2017 wurde die BEU als selbstständige Bundesoberbehörde im Geschäftsbereich des BMVI zur Erfüllung der Aufgaben nach § 7 BEVVG errichtet. Die Aufgaben zur Untersuchung bestimmter gefährlicher Ereignisse im Eisenbahnbetrieb gingen dabei nahtlos von der EUB au

f die BEU über. Da das vorliegende Ereignis vor dem Tag der Errichtung der BEU am 14.07.2017 lag, wur­ den Aufgaben, wie die Untersuchung vor Ort, durch die EUB durchgeführt. Andere Arbeiten, wie bspw. die Erstellung dieses Untersuchungsberichts, erfolgten nach der Errichtung und wurden deshalb von der BEU übernommen. Aus diesem Grund wird im vorliegenden Bericht sowohl die Bezeichnung „EUB“ als auch „BEU“ verwendet. Näheres hierzu ist im Internet unter >> www.beu.bund.de << zu finden. Seite 7 von 21

Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn)

1. 2 Ziel der Eisenbahn-Unfalluntersuchung

Ziel und Zweck der Untersuchungen ist es, die Ursachen von gefährlichen Ereignissen auf­ zuklären und daraus Hinweise zur Verbesserung der Sicherheit abzuleiten. Untersuchungen der BEU dienen nicht dazu, ein Verschulden festzustellen oder Fragen der Haftung oder sonstiger zivilrechtlicher Ansprüche zu klären, und werden unabhängig von jeder gerichtli­ chen Untersuchung durchgeführt. Die Untersuchung umfasst die Sammlung und Auswertung von Informationen, die Erarbei­ tung von Schlussfolgerungen einschließlich der Feststellung der Ursachen und ggf. die Ab­ gabe von Sicherheitsempfehlungen. Die Vorschläge der Untersuchungsstelle zur Vermei­ dung von Unfällen und Verbesserung der Sicherheit im Eisenbahnverkehr werden der Si­ cherheitsbehörde und, soweit erforderlich, anderen Stellen und Behörden oder Mitglied staaten der EU in Form von Sicherheitsempfehlungen mitgeteilt.

1. 3 Mitwirkende

Im Rahmen der Sachverhaltsermittlung und Ursachenerforschung wurden folgende externe Stellen einbezogen:  Hessische Landesbahn GmbH (Eigentümerin der Vectus Verkehrsgesellschaft mbH)  Deutsche Bahn AG, Instandsetzungswerk Kassel 3 Ereignis

1. 1 Hergang

Am 28.09.2014 war der Triebwagen VT 251 (Fahrzeugregisternummer 95 80 0648151-8) der Vectus Verkehrsgesellschaft mbH als Zugfahrt DPN 25582 (Limburg (Lahn) – Koblenz Hbf) im Einsatz. Beim Verkehrshalt in Laurenburg (Lahn) (VzG-Strecke 3710 Wetzlar – Kob­ lenz Hbf) wurde wegen der Lage im Bogen die Überprüfung der Abfahrbereitschaft durch die diensthabende Blockwärterin unterstützt. Dabei beobachtete sie eine Rauchentwicklung am ersten Drehgestell und informierte den Triebfahrzeugführer (Tf). Bei der näheren Untersuchung der Rauchentwicklung wurden offene Flammen unter dem Zug festgestellt und umgehend mit dem in der Blockstelle vorhandenen Feuerlöscher be­ kämpft. Die Reisenden wurden evakuiert. ­ Seite 8 von 21

Das Drehgestell war durch den Schaden blockiert, eine Weiterfahrt des Fahrzeugs daher nicht möglich. Der Triebwagen konnte erst am Folgetag nach Anbringen eines Hilfsdrehge­ stells aus eigener Kraft (zweiter Powerblock) in die Werkstatt nach Limburg (Lahn) fahren. Der Lageplan stellt den Unfallort im Streckenband dar.

Abb. 1: Lageplan Quelle: IVL-Plan DB Netz AG bearbeitet durch EUB Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn)

1. 2

Todesopfer, Verletzte und Sachschäden Todesopfer oder Verletzte sind keine zu beklagen. Die Sachschäden setzen sich wie folgt zusammen:  Triebfahrzeug

ca. 11.200 €  Betriebserschwernisse keine Angaben

1. 3 Wetterbedingungen

Zu den Wetterbedingungen liegen keine Informationen vor. Nach derzeitigem Erkenntnis­ stand war das Wetter jedoch ohne Einfluss auf das Ereignis. 4 Untersuchungsprotokoll

1. 1 Notfallmanagement

Nach § 4 Abs. 3 Allgemeines Eisenbahngesetz (AEG) haben die Eisenbahnen die Verpflich- tung, an Maßnahmen des Brandschutzes und der technischen Hilfeleistung mitzuwirken. In einer Vereinbarung zwischen den Innenministerien der Länder und der DB AG hat man sich auf eine Verfahrensweise verständigt. Für die DB Netz AG gelten die entsprechenden Seite 9 von 21

Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) Brand- und Katastrophenschutzgesetze der Länder. Das Notfallmanagement der DB AG ist in der Richtlinie (Ril) 123 mit Präzisierung für die DB Netz AG in der Ril 423 näher beschrie­ ben und geregelt. Da bei diesem Ereignis weder Personen geschädigt wurden noch die Umwelt gefährdende Stoffe austraten, war ein dringender Einsatz von Rettungskräften nicht erforderlich. Auf eine Untersuchung der Handlungen im Zusammenhang mit dem Notfallmanagement wurde des­ halb verzichtet.

1. 2 Untersuchung der Infrastruktur

Der Haltepunkt Laurenburg (Lahn) Bahnhof liegt an der Strecke 3710 Wetzlar – Koblenz Hbf bei Strecken-km 67,3 im Linksbogen.

Die zugelassene Höchstgeschwindigkeit (Hg) beträgt in diesem Bereich 80 km/h. Die Stre­ cke ist mit einer punktförmigen Zugbeeinflussung (PZB) und Zugfunk ausgerüstet. Eisenbahn-Infrastrukturunternehmen für die Strecke ist die DB Netz AG. Die vorhandene Infrastruktur und ihr Zustand sind ohne Bedeutung für diesen fahrzeugtech­ nischen Schaden. Die Infrastruktur wurde durch das Schadensereignis nicht beschädigt. Auf tiefgreifende Untersuchungen der Infrastruktur wurde deshalb verzichtet.

1. 3 Untersuchung der Leit- und Sicherungstechnik

Die Leit- und Sicherungstechnik hat keine Bedeutung für diesen fahrzeugtechnischen Scha­ den. Auf tiefgreifende Untersuchungen der LST-Anlagen wurde deshalb verzichtet.

­ 4.4 Untersuchung der betrieblichen Handlungen Die betrieblichen Handlungen des Triebfahrzeugführers oder anderer an der Zugfahrt Betei ligter wurden nicht weiter untersucht, da sie nach derzeitigem Erkenntnisstand ohne Einfluss auf den fahrzeugtechnischen Schaden sind.

1. 5

Untersuchung von Fahrzeugen

1. 5.1

Allgemeine Angaben zum Dieseltriebwagen Der Dieseltriebwagen LINT41 der Baureihe 648 besteht aus zwei Wagenhälften, die sich in der Fahrzeugmitte auf ein Jakobs-Drehgestell stützen. Angetrieben werden sie von zwei 315 kW leistenden Dieselmotoren, die jeweils zwischen den Drehgestellen unterflur einge­ baut sind und von dort die Achsen des End- Drehgestells über Kardanwellen und Achsge- Seite 10 von 21

Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) triebe antreiben. Der Dieseltriebwagen hat eine Länge von 41,81 m bei einer Leermasse von 63,5 t. 4.5.2 Untersuchung des Drehgestells und des betreffenden Radlagers Die letzte Revision des betroffenen Fahrzeugs war am 11.08.2011. Im Rahmen der Revision wurden auch die Lager begutachtet. Die Laufleistung bis zum Schadensereignis betrug ca. 370.000 km (vorheriges Revisionsintervall 362.688 km).

Abb. 2: Revisionseintrag Nach den Vorgaben des Radlager-Herstellers FAG ist eine Begutachtung der Radlager spä­ testens nach 600.000 km bzw. 4 Jahren durchzuführen. Beide Fristen wurden unterschritten. 4.5.3 Demontage des defekten Radlagers im Werk Limburg (Lahn) Zur Untersuchung wurde das schadhafte Radlager in der Werkstatt Limburg am 01.10.2014 ausgebaut und zerlegt. Auf der folgenden Abbildung ist das schadhafte Radsatzlager der zweiten Radsatzwelle auf der rechten Seite des führenden Drehgestells zu erkennen. Seite 11 von 21

Abb. 3: schadhaftes Radlager

Nach der Demontage des Radsatzlagerdeckels wurde ersichtlich, dass das Lager beschä­ digt war. Die Abbildung 4 zeigt das geöffnete Radsatzlager. Der Lager-Innenring ist auf der Welle nach außen verschoben.

Abb. 4: schadhaftes Radlager geöffnet Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) Seite 12 von 21

In der Abbildung 5 ist der Radlagerdeckel mit der sich abgelösten Druckkappe zu erkennen.

Abb. 5: Innenansicht Lagerdeckel

Nach Öffnen des Radlagerdeckels wurde festgestellt, dass alle vier Befestigungsschrauben der Druckkappe aus ihren Gewinden gelöst waren. Die Schraubenköpfe wiesen Deformatio­ nen auf, die entstanden sind, als sie sich nach dem Lösen aus den Gewinden in den Lager­ deckel gefräst haben. Im Lagerdeckel ist eine eingefräste Nut in Verlängerung der Schrau­ ben sichtbar, die im unbeschädigten Deckel nicht vorhanden ist. Drei Schrauben waren voll­ ständig herausgelöst, die vierte bereits vollständig aus dem Gewinde gelöste Schraube brach beim Lösen der Druckkappe ab. Weiterhin ist zu bemerken, dass alle Lagerteile vor­ handen waren. Sie wiesen jedoch teilweise starke Deformationen auf. Brüche an den Lagerteilen wurden nicht vorgefunden. Hier ist der Unterschied zwischen einem unbeschädigten Lagerdeckel und dem beschädig­ ten Lagerdeckel mit Einfräsungen durch die Schrauben zu erkennen.

Abb. 6: Innenansicht 1 Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) Seite 13 von 21

Zu erkennen ist der Radlagerdeckel mit entfernter Druckscheibe. Im Fett sind die gelösten Schrauben sichtbar.

Abb. 7: Innenansicht 2 Dies sind die beschädigten und gereinigten Befestigungsschrauben der Druckkappe.

Abb. 8: Befestigungsschrauben

Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) Seite 14 von 21

Die folgende Abbildung zeigt die beschädigte und gereinigte Druckkappe.

Abb. 9: Druckkappe

Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) Zu sehen ist auf der Abbildung 10 der stark deformierte Abstandring (gereinigt) Abb. 10: Abstandring Seite 15 von 21

Unten abgebildet ist die beschädigte Druckkappe mit den von losen Schrauben verursachten Riefen zu sehen.

Abb. 11: Druckkappe

Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) Nach dem Öffnen des Rollenlagers wurden die aus Abbildung 12 ersichtlichen Schäden. Abb. 12: Rollenlager Seite 16 von 21

Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) Durch das Blockieren der Lagerrollen wurde auch die Laufbahn der Radsatzwelle beschä­ digt. Abb. 13: Radsatzwelle Eine Messung der Anzugdrehmomente an den Druckkappenschrauben des linken Lagers der Schadachse ergaben Anzugs-Drehmomente von 60, 60, 70 und 80 N/m. Eine Ver­ gleichsmessung an einem dritten Radsatzlager lieferte Werte von 80, 90, 90 und 110 N/m. Der ab Werk geforderte Wert für das Anzugs-Drehmoment beträgt 120 N/m. Trotz der zu geringen Anzugs-Drehmomente am zweiten Lager der Schadachse zeigten die Lackmarkierungen an den Schrauben keine Verdrehung.

Zu erkennen sind die Unbeschädigten Lackmarkierungen an den Druckkappenschrauben des zweiten Radlagers der Schadachse. Seite 17 von 21

Abb. 14: Druckkappenschrauben 4.5.4 Revisionsunterlagen Drehgestell und Radlager Durch das DB-Werk Kassel, das die Instandhaltungsarbeiten an den Drehgestellen durchge­ führt hat, wurden die Arbeitsprotokolle zur Verfügung gestellt. Daraus ergibt sich, dass die Verschraubung der Druckkappen korrekt durch zweistufiges Anziehen mit zunächst 75 N/m und anschließend mit 120 N/m durchgeführt wurde. 4.5.5 Radlager-Montageanleitung FAG Die in den Triebwagen der Baureihe 648 verbauten Radlager der Firma FAG sind nach der zum Zeitpunkt der Revision des VT 251 gültigen Montageanleitung, Ausgabe 2001 vom 22.02.2000, eingebaut worden.

Abb. 15: Gültigkeit Montageanleitung

Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) Die auf der Radsatzwelle zu montierenden Elemente werden vorgewärmt dabei in folgender Reihung montiert: Seite 18 von 21

Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) Zunächst wird der Labyrinthring satt an die Schulter der Achswelle gedrückt, nach dessen Abkühlung werden die beiden Lamellenringe montiert. Anschließend werden der innere In­ nenring, der Zwischenring und der äußere Innenring mit schraubenden Bewegungen auf die Welle montiert. Nach Abkühlung können die Elemente nur noch mit großem Kraftaufwand bewegt werden. Daher sollen die Teile rechtzeitig mittels Hammerschlägen auf eine Schlag­ kappe soweit zusammengedrückt werden, dass die Abstände untereinander unter 0,03 mm liegen. Die Druckkappe wird erst zum Schluss nach vollständiger Montage des gesamten Radlagers auf den Wellenkopf aufgeschraubt und hindert so die Innenschalen am Verschieben nach außen.

1. 6 Interpretation der Unfallspuren

Ausgelöst wurde der vorliegende Lagerschaden offenbar dadurch, dass sich die Befesti­ gungsschrauben der Druckkappe nacheinander aus den Gewinden gelöst hatten. Dies wur­ de möglich, da die Schrauben offensichtlich zu geringe Anzugs-Drehmomente aufwiesen, wie diese auch an den beiden ergänzend überprüften Lagern festgestellt wurden. Aufgrund der Untersuchungsergebnisse ist davon auszugehen, dass es sich um einen Mon­ tagefehler beim Zusammenbauen der Lager im Rahmen der Revision handelt (verminderte Vorspannung der Druckkappe durch Nachsetzung der Lagerinnenschalen). Vermutlich waren die Innenschalen nicht weit genug auf die Radsatzwelle nach innen ge­ presst, sodass sich die Druckkappe auf die zu weit herausstehenden Innenschalen abge­ stützt hat. Dadurch wurde die Vorspannung der Befestigungsschrauben der Druckkappe nicht aufrechterhalten, sodass sie sich nach dem Setzen des Innenrings lösen konnten. 5 Auswertung und Schlussfolgerungen Ausgelöst wurde der vorliegende Lagerschaden offenbar durch einen Montagefehler beim Zusammenbauen der Lager im Rahmen der Revision (unzureichende Vorspannung der Schrauben der Druckkappe). Vermutlich waren die Innenschalen des Lagers nicht weit ge­ nug auf die Radsatzwelle nach innen gepresst, sodass sich die Druckkappe auf die zu weit herausstehenden Innenschalen abgestützt hat. Dadurch wurde die Druckkappe nicht bündig mit dem Wellenkopf verschraubt. Durch das Nachsetzen der Lagerinnenschalen in die kor­ rekte Position konnte sich in der Folge die Druckkappe längs der Schrauben bewegen und die Schrauben verloren so die ursprünglich korrekte Vorspannung. Aufgrund der verminder­ ten Vorspannung war es in der Folge möglich, dass sich die Schrauben der Druckkappe Seite 19 von 21

6 Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) vollständig aus den Schraubenlöchern des Wellenkopfes lösen konnten. Durch den nun feh­ lenden Anschlag konnten sich die Lagerinnenschalen in der Folge nach außen bewegen (vgl. Abb.4), was zu weiteren Schäden an den Wälzkörpern des Lagers führte. Derartige Montagefehler sind dem Fahrzeughersteller ALSTOM seit 2012 bekannt, worauf­ hin die Flotte der LINT41-Unterbaureihen 648.3 und 648.4 werksseitig überprüft und ent­ sprechende Hinweise an andere Instandhaltungsbetriebe der Fahrzeugbaureihe herausge­ geben wurden. Es ist somit festzustellen, dass es hinsichtlich der Montage der Radlager ein wiederholtes Qualitätsproblem bei dieser Fahrzeugbaureihe gab. Der Montagefehler trat wahrscheinlich bei dem nachfolgend dargestellten Arbeitsschritt auf: Bisher getroffene Maßnahmen Wie bereits unter Punkt 5 beschrieben wurden die Fahrzeuge der Unterbaureihen 648.3 und 648.4 Mitte 2012 vom Hersteller überprüft und entsprechende Hinweise an die Instandhal­ tungswerke der LINT-Baureihen herausgegeben. Der VT 251 der Vectus Verkehrsgesell­ schaft war jedoch kurz vor diesem Zeitpunkt in der Revision und wurde noch nicht von dieser Maßnahme erfasst. Die Konstruktion der Lager mit Lagerinnenringen und Druckkappe auf der Achse bedarf einer exakten Montageanleitung unabhängig von Fahrzeugbaureihe und Lagertyp. Aufgrund einer Empfehlung des Herstellers wurde im August 2012 im DB-Werk Kassel, wel­ ches die Instandhaltungsarbeiten am Vectus-Triebwagen VT 251 durchführte, eine zusätzli­ che Maßnahme eingeführt, um dem Lösen der Druckkappenverschraubung entgegenzuwir­ ken. Die Lagerinnenringe werden nun bei der Montage nachgesetzt, um deren richtigen Sitz auf der Radsatzwelle sicher zu gewährleisten. Dadurch wird vermieden, dass sich die Druckkappe auf die Lagerinnenringe abstützt statt bündig mit der Radsatzwelle verschraubt zu werden. Somit wird verhindert, dass durch geringfügiges Nachsetzen der Lagerinnenringe die Vorspannung der Druckkappenverschraubung absinken kann. Seite 20 von 21

Untersuchungsbericht Fahrzeugbrand, 28.09.2014, Laurenburg (Lahn) Seit Einführung dieser Maßnahme sind an den entsprechend behandelten Fahrzeugen keine neuen Fälle mit gelösten Druckkappenverschraubungen aufgetreten. Die letzte Revision des Vectus-VT 251 lag jedoch vor diesem Einführungsdatum. Das ursächliche Problem, das zu diesem Montagefehler und anderen ähnlichen Fällen führ­ te, wurde 2012 erkannt. Der Fahrzeughersteller Alstom hat daraufhin zum August 2012 ent­ sprechende Empfehlungen herausgegeben. Die Aufarbeitung der hier betroffenen Achse fand aber bereits am 11.08.2011 statt, so dass die Empfehlung, die Lagerinnenringe nach­ zudrücken, noch keine Berücksichtigung finden konnte. Seit Einführung des Nachdrückens zum August 2012 der Lagerinnenringe sind an den betroffenen Fahrzeugen keine weiteren Probleme mehr aufgetreten. Seite 21 von 21

FD05990 ｜ 2016_德国_DGUV_涂装设备防火技术指南_火灾报告.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2016 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Brandschutz an Lackieranlagen – Leitfaden für Planung, Herstellung und Betrieb Juni 2017 DGUV Information 209-087 209-087

Impressum Herausgeber: Deutsche Gesetzliche Unfallversicherung e.V. (DGUV) Glinkastraße 40 10117 Berlin Tel.: 030 288763800 Fax: 030 288763808 E-Mail: info@dguv.de Internet: www.dguv.de Sachgebiet „Oberflächentechnik und Schweißen“ des Fachbereichs „Holz und Metall“ der DGUV Ausgabe: Juni 2017 DGUV Information 209-087 zu beziehen bei Ihrem zuständigen Unfallversicherungsträger oder unter www.dguv.de/publikationen

Brandschutz an Lackieranlagen – Leitfaden für Planung, Herstellung und Betrieb DGUV Information 209-087  Juni 2017

Anhang 1 Brandschutzrelevante Planungs-Kenngrößen einer Lackieranlage............................................................... 27 Anhang 2 Brandszenarien und abgeleitete Schutzmaßnahmen............. 28 Anhang 3 Ablauf Baugenehmigung....................................................... 29 Anhang 4 Ablauf Genehmigung nach dem Bundesimmissionsschutzgesetz........................................... 30 Anhang 5 Hilfestellung zur Anwendung der TRGS 800, Anlage 3 auf Lackieranlagen................................. 31 Anhang 6 Verzeichnis der Abkürzungen................................................. 33 Anhang 7 Literatur................................................................................ 34 Inhaltsverzeichnis Seite Seite 1 Anwendungsbereich.........................................5 1.1 Allgemeines......................................................5 1.2 Regelungsbereiche und Schutzziele..................5 2 Von der Idee zur Realisierung – Handlungsfelder des Brandschutzes in der Planung und Herstellung.........................7 3 Betriebliche Planung........................................8 3.1 Erstellung des Lastenhefts................................8 3.2 Integration einer Lackieranlage in ein Gebäude................................................11 3.3 Planung des Brandschutzes für das Gebäude –Brandschutzkonzept...................... 13 3.4 Auswahl der Brandschutz-Anlagentechnik....... 15 4 Genehmigungsverfahren................................ 17 5 Brandschutzaspekte bei Konstruktion und Verkauf von Lackieranlagen..................... 19 5.1 Brandschutztechnische Optimierung. ............. 19 5.2 Empfehlungen zur Bereitstellung von Lackieranlagen auf dem Markt.................. 21 6 Betrieblicher Brandschutz..............................22

1 Anwendungsbereich 1.1 Allgemeines Dieser Leitfaden beschreibt Brandschutzanforderungen für La­ ckieranlagen. Er soll Hersteller und Betreiber von Lackieranlagen bei der Auswahl geeigneter Brandschutzmaßnahmen unterstüt­ zen und die Zusammenarbeit aller Akteure mit Bezug zum Brandschutz – das sind zusätzlich Fachplaner/Fachplanerinnen, Versicherungen und zuständige Behörden – erleichtern. Hierbei werden Aspekte aus den folgenden Bereichen erläutert: • Baulicher und betrieblicher Brandschutz • Arbeitssicherheit und Gesundheitsschutz • Sachwertschutz • Umweltschutz In diesem Leitfaden nicht vollständig behandelt sind Aspekte • des Explosionsschutzes, • der Lagerung entzündbarer und/oder wassergefährdender Flüssigkeiten, • der Lagerung brennbarer und/oder wassergefährdender Stoffe. Lackieranlagen sind Arbeitsmittel. Für Arbeitsmittel sind die Auswirkungen der am Arbeitsplatz gegebenen Bedingungen auf die Sicherheit und den Gesundheitsschutz im Rahmen einer Gefährdungsbeurteilung zu ermitteln (§ 3 BetrSichV). Um falsche Beschaffungsentscheidungen zu vermeiden, sollte die Gefähr­ dungsbeurteilung bereits während der Planungsphase begon­ nen werden. Hinsichtlich der brandschutztechnischen Anforde­ rungen ist dabei ein abgestimmtes Zusammenwirken aller Akteure erforderlich. Abb. 1: Layout einer verketten Lackieranlage Tagesbedarfslager Prozess-Steuerung Automatik-Spritzkabine 1 Automatik-Spritzkabine 2 Aufgabe Abnahme Automatik-Pulverkabine Abdunstzone 2 Abdunstzone Kühlzone Kühlzone Kühlzone Blaszone Hafwassertrockner 11 Zonen Vorbehandlungsanlage Pulvereinbrennofen (220°C) Lacktrockner(200°C) Spritzkabine 1 Spritzkabine 2 Kontrollraum 5

Lackieranlagen können bestehen aus Einrichtungen (Abbil­- dung 1) • zur Reinigung und Vorbehandlung, • zum Lackieren/Beschichten unter Verwendung organischer Beschichtungsstoffe (z. B. Kabinen, Applikationstechnik, Tauchbäder), • zum Abdunsten und Trocknen organischer Beschichtungsstoffe, • zur Versorgung mit Beschichtungs- und Reinigungsstoffen, • zum Fördern und Handhaben von Werkstücken, • zur Entsorgung. Diese Broschüre ist für alle genannten Einrichtungen grundsätz­ lich anwendbar. Schwerpunkt ist jedoch die Spritzapplikation von Flüssiglack. Diese DGUV Information unterstützt die verantwortlichen Perso­ nen bei der Erfüllung der brandschutztechnischen Anforderun­ gen der BetrSichV, der GefStoffV und der TRGS 800. 1.2 Regelungsbereiche und Schutzziele Brandschutzmaßnahmen resultieren aus unterschiedlichen Rechtsbereichen (Produktsicherheit, Arbeitsschutzrecht, Bau­ recht, Umweltrecht) und weiteren Regelungen (z. B. Anforderun­ gen der Sachversicherungen). Die Erfüllung aller Anforderungen des Brandschutzes macht eine frühzeitige Kommunikation der Beteiligten sowohl bei der Erstel­ lung von Neuanlagen als auch bei der Änderung bestehender Anlagen notwendig. Konkrete Schutzmaßnahmen können häufig mehrere Schut­z- ziele abdecken. Beispiel: Eine automatische Löscheinrichtung, die in eine Lackierkabine eingebaut worden ist, dient dem Sachwertschutz, kann aber indirekt auch dem Personenschutz dienen. Konkrete Schutzmaßnahmen müssen im Einzelfall, unter Beach­ tung mehrerer Regelungsbereiche, festgelegt werden. Beispiel: Fluchtwege müssen dem Arbeitsstättenrecht, zugleich aber auch dem Baurecht und dem Maschinenrecht entsprechen. 6 Anwendungsbereich

2 Von der Idee zur Realisierung – Handlungsfelder des Brandschutzes in der Planung und Herstellung Bis zur Inbetriebnahme einer Lackieranlage bedarf es einer Viel­ zahl von Entscheidungen und Festlegungen; Informationen müs­ sen ausgetauscht und Abstimmungen getroffen werden. Tabelle 1 zeigt einen Überblick über Handlungsfelder und die jeweils verantwortlichen und beteiligten Parteien. Die Hand­ lungsfelder „Betriebliche Planung“ und „Genehmigungsverfah­ ren“ werden in den Abschnitten 3 und 4 ausführlich behandelt. Im Rahmen der Realisierung werden alle brandschutzrelevanten Informationen zwischen den Beteiligten verbindlich ausge­ tauscht und die Lackieranlage entsprechend konzipiert und konstruiert. Tab. 1: Handlungsfelder des Brandschutzes bei der Realisierung von Lackieranlagen Genehmigungs- behörden Sach- versicherung Hersteller Lackieranlagen Hersteller Brandschutz- anlagen Betreiber Betriebliche Planung Erstellung des Lastenhefts ggf. beteiligt ggf. beteiligt verantwortlich Integration der Lackieranlage in ein Gebäude ggf. beteiligt ggf. beteiligt beteiligt ggf. beteiligt verantwortlich Planung Brandschutz für das Gebäude – Brandschutzkonzept beteiligt ggf. beteiligt ggf. beteiligt beteiligt verantwortlich Auslegung der Brandschutz-Anlagentechnik ggf. beteiligt ggf. beteiligt verantwortlich beteiligt Genehmigungsverfahren Vorgespräch/Voranfrage beteiligt ggf. beteiligt verantwortlich Baugenehmigung bzw. Genehmigung nach BImSchG oder Anzeige für Verfahren verantwortlich beteiligt ggf. beteiligt für Antrag- stellung verantwortlich Prüfungen & Abnahme vor Ort beteiligt ggf. beteiligt beteiligt beteiligt verantwortlich Realisierung Mitteilung der brandschutztechnischen Anforde­ rungen und Schnittstellen an die Anlagenhersteller ggf. beteiligt beteiligt beteiligt verantwortlich Konstruktion und Herstellung (Brandschutz nach Maschinenrichtlinie) verantwortlich beteiligt beteiligt 7

3 Betriebliche Planung 3.1 Erstellung des Lastenhefts Generell sind bei der Planung der Lackieranlage zunächst fol­ gende Aspekte zu prüfen: • Die Möglichkeit der Substitution der brennbaren oder oxidie­ renden Gefahrstoffe (s. TRGS 600 „Substitution“) • Die Möglichkeit einer Verfahrensänderung im Verarbeitungs­ prozess in Richtung geringerer Gefährdung Erster Schritt der betrieblichen Planung ist die Erstellung des Lastenhefts (Abb. 2). Auf der Grundlage der technischen Para­ meter kann die Gefährdungsbeurteilung nach Vorgaben der TRGS 800 durchgeführt werden. Zunächst sind alle für die Pro­ duktion relevanten Kenngrößen zu ermitteln (Anhang 1). Anhand dieser Kenngrößen können die Anlagenparameter als Bestand­ teil des Lastenhefts abgeleitet werden (Tab. 2). Im nächsten Schritt erfolgt die Zuordnung der Brandgefährdung für die einzelnen Bereiche der Lackieranlage. In der Tabelle 3 sind die Merkmale für die Höhe der Brandgefährdung entspre­ chend der TRGS 800 wiedergegeben und Beispiele aufgeführt, welche Brandgefährdung einzelnen Bereichen einer Lackieranla­ ge typischerweise zuzuordnen ist. Ergänzend sind Brandschutz­ maßnahmen dargestellt, die, abhängig von der Höhe der Brand­ gefährdung, zu berücksichtigen sind. In Anhang 2 sind typische Brandszenarien, deren Bewertung sowie geeignete Schutzmaß­ nahmen gelistet. Die Überprüfung der Plausibilität der Brand­ schutzmaßnahmen erfolgt nach TRGS 800 Anlage 3, Hilfestel­ lung dazu beinhaltet Anhang 5. Abb. 2: Lastenheft Produkt- übersicht Funktionale Anforderungen Nicht- funktionale Anforderungen Ausgangs- situation & Zielsetzung Produkt- einsatz Abnahme- kriterien Lieferumfang Lastenhef 8

Tab. 2: Anlagenparameter zur Erstellung des Lastenhefts Aufgabenstellung/Ablauf Beteiligung Konkrete Anforderung Beispiele Bemerkung 1 Verfahrensbeschreibung 1.1 Eingesetzte Stoffe Lieferant der eingesetzten Stoffe Sicherheitsdatenblätter technische Datenblätter Insbesondere Kapitel 2, 3, 9, 11 des Sicherheitsdatenblatts 1.2 Eingesetzte Stoffmengen Gefahrstoffverzeichnis Auch relevant für die Größe der Lagerräume 1.3 Zu erwartende Folgen im Brandfall Rauchgase, Brandrückstände, Löschwasserrückhaltung 1.4 Anlagenbeschreibung Lieferant der Anlage Beschreibung des vorgesehenen Beschichtungsprozesses Zulässig ist eine getrennte Betrach- tung einzelner Verfahrensschritte. Dabei ist jedoch eine gegensei- tige Beeinflussung durch den Grad der Verkettung und die örtliche Nähe zu berücksichtigen. 1.5 vorgesehene Betriebsweisen Lieferant der Anlage Nutzungshäufigkeit, Schichtbetrieb 1.6 bauliche und örtliche Gegebenheiten Siehe Abschnitt 3.2 Relevant bei Änderung des Prozesses oder bei Umbau vorhandener Anlagen 1.7 mögliche Wechselwirkungen Brandgefährdungen durch benach­ barte Gewerke 2 Besondere Betriebszustände Beschreibung erst nach Beauftragung 2.1 An- und Abfahrbetrieb Lieferant der Anlage 2.2 vorhersehbare Störungen Lieferant der Anlage Materialaustritt durch Schlauchplat­ zer oder unsachgemäße Einbindung 2.3 vorhersehbarer nicht bestimmungs- gemäßer Betrieb Lieferant der Anlage Überladene Abluftfilter 2.4 Instandhaltung (Reinigung, War­ tung, Inspektion, Instandsetzung) Lieferant der Anlage 2.5 In- und Außerbetriebnahme einzel­ ner Sicherheitseinrichtungen Hersteller der Brandschutzanlage Versichernde Informationen zur Außer- betriebnahme der Brandschutzanlage 3 weitere Aspekte 3.2 Anzahl der Beschäftigten und anderer Personen (z. B. Instand- haltungspersonal) 3.2 Zugänglichkeit für nicht berechtigte Personen (Besucher/ Besucherinnen) Lieferant der Anlage Zutritt für nicht berechtigte Perso­ nen ist auszuschließen oder im Sicherheitskonzept zu berücksichtigen 3.3 besondere Arbeitsbedingungen (lange oder unübersichtliche Fluchtwege, Arbeiten auf Gerüsten) Abgleich mit Flucht- und Rettungsplan ASR A 2.3 3.4 Hilfsfrist und vorhandene Ausrüstung der Feuerwehr Feuerwehr/für Brand­ schutz zuständige Behörde Abgleich mit Brandschutzkonzept, siehe Abschnitt 3.3 4 Beurteilung der Brandgefährdung (Zuordnung zu einer Brandgefähr­ dungsstufe nach TRGS 800), siehe Tabelle 3 Zu berücksichtigen sind Brandlas­ ten der Anlage selbst und der einge­ setzten Stoffe 9 Betriebliche Planung

Tab. 3: Beispiele für die Einordnung in Brandgefährdungsstufen nach TRGS 800 Höhe der Brand- gefährdung Merkmale Brandschutzmaßnahmen/ organisatorische Maßnahmen Beispiele normal • Anlagen (-teile), die nur geringe Brandlast aufweisen/beinhalten • Aufbau der Anlage in einzelnen Stationen, die nicht oder nur förder­ technisch verbunden sind • Werkstücke, die nicht brennbar sind oder nur geringe Brandlast aufweisen/ beinhalten und • geringe Wahrscheinlichkeit, dass Zündquellen wirksam werden • Anforderungen aus dem Baurecht und dem Arbeitsschutz sind eingehalten Beispiele: Feuerlöscher, Fluchtwege, Sicherheitsbeleuchtung, Unterweisung • Vorbehandlungsanlagen, die mit nichtbrennbaren Stoffen betrieben werden (z. B. Wasser, CO2) • Aufgabe-/Abnahmestationen, Demaskier- und Maskierstationen, Abblasstationen • im Inneren zündquellenfreie Trockner, in denen sich keine brennbaren Stoffe ansammeln, ablagern oder freigesetzt werden erhöht • ein Merkmal der normalen Brand­ gefährdung ist nicht erfüllt oder • nicht alle Merkmale für die hohe Brandgefährdung sind erfüllt zusätzlich • bauliche Abtrennung • Verkürzung der Fluchtwege entsprechend ASR A 2.3 • geeignete Branderkennung („Branderkennung“ durch Bedienperson zulässig) • organisatorische Kompensations- maßnahmen sind zulässig • Trockner, in denen sich keine brennbaren Stoffe ansammeln oder ablagern • manuell bediente Spritzkabine, kombinierte Spritz- und Trocknungs­ kabine für Pkw-Reparatur • Anlagen zur Verarbeitung lösemittel­ armer Beschichtungsstoffe, Einsatz einer Nassauswaschung mit geringer Brandlast der Anlage hoch • brennbare oder oxidierende Gefahr­ stoffe sind nicht nur in geringer Menge vorhanden • es ist mit hoher Wahrscheinlichkeit mit einer Brandentstehung zu rechnen • eine schnelle und unkontrollierbare Brandausbreitung oder eine große Rauch- oder Wärmefreisetzung ist zu erwarten • Aufbau der Anlage in einzelnen Stationen, die direkt verbunden sind zusätzlich • bauliche Abtrennung • Verkürzung der Fluchtwege entsprechend ASR A 2.3 • automatische Brandmelde- und Alarmierungseinrichtung • automatische Löscheinrichtungen abhängig – von der Anlagen- oder Brandabschnittsgröße – von den Möglichkeiten der Personenrettung • kombinierte betriebliche Brandbekämpfungsmaßnahmen • Vorbehandlungsanlagen, die mit brennbaren Stoffen betrieben werden • Trockner, in denen sich brennbare Stoffe ansammeln oder ablagern • Lackversorgungsräume • automatische Spritzkabinen mit Ver- arbeitung organischer Lacksysteme, insbesondere bei elektrostatischer Applikation oder Trockenabscheidung mit speichernden Filtern • Beflämmeinrichtungen 10 Betriebliche Planung

1. 2

Integration einer Lackieranlage in ein Gebäude Ein Gebäude oder Gebäudeteil, in das eine Lackieranlage integ­ riert wird, stellt einen Sonderbau im Sinne der Musterbauord­ nung dar, weil diese Nutzung durch Verarbeitung oder Lagerung der erforderlichen Stoffe (z. B. Lack, Reinigungs- und Hilfsstoffe) zu Explosions- und/oder erhöhter Brandgefahr führt. Die Errichtung einer Lackieranlage in einem bestehenden Gebäude oder Gebäudeteil (Abb. 3) stellt baurechtlich grund­ sätzlich eine Nutzungsänderung dar. Über die gesamte Planungsphase ist eine intensive Kooperation zwischen dem Betreiber der Anlage, den Architekten und Archi­ tektinnen und den planenden Personen und gegebenenfalls den Behörden und dem Sachversicherer erforderlich. Die Führung des Verfahrens liegt dabei in der Verantwortung des Betreibers. Tabelle 4 beschreibt den Ablauf und die einzelnen Arbeitsschrit­ te zur Integration einer Lackieranlage in ein bereits bestehendes Gebäude. Abb. 3: Integration einer komplexen Lackieranlage in ein Gebäude 11 Betriebliche Planung

Tab. 4: Arbeitsschritte zur Integration einer Lackieranlage in ein Gebäude Detaillierter Ablauf/ Detaillierte Aufgaben Ausführung Beteiligung Beispiele für konkrete Anforderung Rechtsgrundlage 1 Anlagenbetrieb/ Anlagenplanung Architekt/Architektin Statikerin/Statiker Betreiber Verantwortliche für Anlagenplanung ggf. Behörde und Sachversichernde Nutzung für Lackieranlage muss genehmigt sein MBO, BImSchG, WHG 2 Lackieranlagenplanung Verantwortliche für Anlagenplanung Betreiber 3 Planung aller erforderlichen Anlagenanschlüsse Verantwortliche für Anlagenplanung Betreiber Anschlusswerte können stark von tatsächlichen Verbräuchen abweichen; Gasfließdruck und Druck­ luftqualität müssen fest­ gelegt werden 3.1 TGA (technische Gebäude- ausrüstung): Versorgungs- leitungen und ggf. Entsorgungsleitungen für alle Medien Fachplaner/Fachplanerin Verantwortliche für Anlagenbau und Anlagen­ planung, Betreiber, Architekt/ Architektin Leitungen für elektrischen Strom, IT, Lüftung, Wasser (inkl. Löschanlage), Gas, Öl, Fernwärme, Druckluft WHG, AwSV 4 Planung der Prozess- materialsysteme 4.1 Lackversorgung Verantwortliche für Anlagenbau und Anlagenplanung Betreiber Auffangraum WHG, AwSV 4.2 Lackschlammentsorgung Verantwortliche für Anlagenbau und Anlagenplanung Betreiber Auffangraum WHG, AwSV 4.3 Chemikalien für Prozess- materialbehandlung Verantwortliche für Anlagenbau und Anlagenplanung Betreiber Auffangraum WHG, AwSV 4.4 Filtermedien (z. B. Steinmehl) Verantwortliche für Anlagenbau und Anlagenplanung Betreiber 5 Verknüpfung des Gebäude- brandschutzes mit dem anlagebezogenen Brandschutz Fachplaner/Fachplanerin, Architekt/Architektin Verantwortliche für Anlagenbau und Anlagen­ planung, Betreiber Gemeinsame Sprinkleran­ lage, gemeinsame BMA, Brandabschnittsbildung Notabschaltungen für Lackieranlage, Strom, Gas, Druckluft MIndBauRl, VdS-Regelwerk 12 Betriebliche Planung

1. 3

Planung des Brandschutzes für das Gebäude – Brandschutzkonzept Alle brandschutztechnischen Anforderungen werden im bau­ rechtlichen Verfahren in einem Brandschutzkonzept beschrie­ ben, das in der Regel nur baurechtliche Belange zum Inhalt hat. Arbeitsrechtliche, versicherungs- und anlagentechnische Belange können über die baurechtlichen Anforderungen hinaus­ gehen und müssen in die Planung einfließen. Abweichungen können z. B. bei der Auslegung der Flucht- und Rettungswege (Abb. 4), der Größe von Brandabschnitten, der Sicherheits­ beleuchtung oder der Auslegung von anlagetechnischen Brand­ schutzmaßnahmen bestehen. Das Brandschutzkonzept ist Teil des Bauantrags. Es beschreibt den ganzheitlichen Brandschutz eines Gebäudes und wird im­ mer individuell an ein Gebäude angepasst. Brandschutzkonzep­ te werden bei Sonderbauten in der Regel baurechtlich gefordert. Ein Muster-Brandschutzkonzept, wie für eine Lackieranlage, kann nicht erstellt werden, da dieses immer abhängig von der Gebäudegeometrie und den weiteren gebäudetechnischen Randbedingungen ist. Brandschutzkonzepte für das baurechtliche Genehmigungsver­ fahren müssen von Brandschutzsachverständigen erstellt wer­ den, die eine Zulassung in dem jeweiligen Bundesland haben. Die Inhalte eines Brandschutzkonzepts regelt zum einen die vfdb-Richtlinie 01/01, zum anderen gibt es auch in einigen Bun­ desländern Anforderungsregeln für Brandschutzkonzepte, zum Beispiel: • § 9 der Bauprüfverordnung (BauPrüfVO) des Landes Nordrhein-Westfalen • Die Verwaltungsvorschrift des Ministeriums für Verkehr und Infrastruktur über die brandschutztechnische Prüfung im baurechtlichen Verfahren (VwV Brandschutzprüfung) des Landes Baden-Württemberg Eine Übersicht zu den in einzelnen Bundesländern erlassenen Richtlinien ist im Internet verfügbar: www.is-argebau.de. Um die Belange des Brandschutzes bei der Planung einer La­ ckieranlage umfänglich zu berücksichtigen, ist es wichtig, den Brandschutzsachverständigen oder die Brandschutzsachver­ ständige frühzeitig in die Planungen einzubeziehen. 13 Betriebliche Planung Die Industriebaurichtlinie des jeweiligen Bundeslandes ist Grundlage für die Erstellung des Brandschutzkonzeptes. Als Sonderbauverordnung basiert sie weitestgehend auf der Muster-Industriebaurichtlinie (MIndBauRL) der ARGEBAU und regelt den Brandschutz in Industriebauten. Ziel dieser Richtlinie ist es, die Mindestanforderungen an den Brandschutz für Indust­ riebauten zu regeln. Insbesondere die Mindestanforderungen an: • die Feuerwiderstandsfähigkeit der Bauteile • die Brennbarkeit der Baustoffe • die Größe der Brandabschnitte bzw. Brandbekämpfungsabschnitte • die Anordnung, Lage und Länge der Rettungswege Um die Schutzziele zu erreichen, sind in der MIndBauRL bezie­ hungsweise in den IndBauRL der Bundesländer Regelungen beschrieben, die zunächst allgemeine Anforderungen enthalten, zum Beispiel: • Löschwasserversorgung • Zugänglichkeit für die Feuerwehr • Anforderungen an Rettungswege • Anforderungen an die Rauchableitung • anlagentechnische Brandschutzmaßnahmen • organisatorische Brandschutzmaßnahmen Die beiden im Folgenden beschriebenen Verfahren (MIndBauRL) umfassen jeweils die Aspekte, wie eine zulässige Brand­ abschnittsfläche erreicht wird und welche brandschutztech­ nischen Anforderungen an Bauteile gestellt werden. • Im vereinfachten Verfahren nach Abschnitt 6 werden anhand einer Tabelle die beschriebenen Anforderungen festgelegt. Die maßgebenden Einflussfaktoren sind die Größe des Brand­ abschnitts, die Feuerwiderstandsfähigkeit der Bauteile und die brandschutztechnische Infrastruktur. Zu einer brandschutz- technischen Infrastruktur gehören z. B. eine Brandmelde­ anlage, eine Werkfeuerwehr oder eine automatische Lösch­- anlage. • Das Nachweisverfahren nach Abschnitt 7 erfolgt auf der Grundlage einer Brandlastberechnung nach dem Rechen­ verfahren der DIN 18230-1. Ergebnis der Berechnungen sind dann, auf Grundlage der vorhandenen Brandlast, die zulässige Größe eines Brand­ abschnitts, die Anforderungen an den Feuerwiderstand der Bauteile und das Erfordernis einer brandschutztechnischen Infrastruktur (vgl. Flucht- und Rettungsplan auf Seite 14).

• In Anlehnung an die Technische Regel für Arbeitsstätten „Sicherheits- und Gesundheitsschutzkennzeichnung“ ASR A1.3, Anhang 3

Flucht- und Rettungsplan Verhalten im Brandfall Ruhe bewahren

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Schaulustige entfernen Standort Übersichtsplan Parkplatz B Legende Standort Feuerlöscher Fluchtweg Wandhydrant/Löschschlauch Notausgang mit Richtungspfeil Brandmelder Notruftelefon Brandmeldetelefon Erste Hilfe Aufzug Sammelstelle Treppe Erdgeschoss .......... .......... .......... .......... Name des Gebäudes Labor Toiletten Ausstellungsraum Empfang Abb. 4: Flucht- und Rettungsplan 14 Betriebliche Planung

1. 4

Auswahl der Brandschutz-Anlagentechnik Für die Auswahl der Brandschutz-Anlagentechnik müssen alle Schutzziele definiert sein. Anforderungen an den Brandschutz in einer geplanten Lackieranlage sind in unterschiedlichen Regel­ werken enthalten: • in baurechtlichen Regelungen (im Brandschutzkonzept festgelegt) • in europäischen Maschinensicherheitsnormen • im Regelwerk der Sachversicherer (z. B. VdS) • in nationalen Arbeitsschutzregelungen (z. B. technische Regeln) • im firmeninternen Risiko-Management Brandschutzanlagen bestehen grundsätzlich aus Brandmelde­ anlagen, Rauch- und Wärmeabzugsanlagen und Löschanlagen. 15 Betriebliche Planung Brandmeldeanlagen Brandmeldeanlagen (Abb. 5) können auch ohne Löschanlagen eingesetzt werden. Sie dienen der Alarmierung der Beschäftig­ ten der Feuerwehr, den Beschäftigten einer dritten Partei oder/ und lösen zum Beispiel die Abschaltung der Lackieranlage aus. Die Auswahl der Brandmeldetechnik erfolgt durch einen Fach­ planer oder eine Fachplanerin, der nach DIN 14675 zertifiziert ist. Bei der Auswahl von Brandmeldern, die das Innere von Lackier­ anlagen überwachen, sind die besonderen Bedingungen des Verfahrens (Aerosol, Stäube, Verschmutzungen, Temperatur) zu berücksichtigen (siehe DIN VDE 0833-2). Abb. 5: Brandmelder in einer Lackierkabine

Löschanlagen Löschanlagen werden entweder automatisch oder manuell aus­ gelöst. Sprinkleranlagen werden selbsttätig durch Wärme aus­ gelöst. Eine Gegenüberstellung der wichtigsten Löschanlagen­ arten für Lackieranlagen zeigt Tabelle 5. Objektschutzanlagen Stationäre Objektschutzanlagen werden manuell oder automa­ tisch ausgelöst und können durch gezielte Löschmittelabgabe den erkannten Brand einer einzelnen Einrichtung oder eines Objekts löschen. Raumschutzanlagen Stationäre Raumschutzanlagen können manuell oder automa­ tisch ausgelöst werden und löschen durch gezielte Löschmittel­ abgabe den erkannten Brand innerhalb einer Maschine, einer Kabine oder eines Raums. Eine Brandausbreitung auf angren­ zende Bereiche außerhalb des Raums soll verhindert werden. Örtlich wirkende Löschanlage Eine örtlich wirkende Löschanlage schützt den besonders ge­ fährdeten Bereich zwischen elektrostatischem Sprühsystem und Werkstück. Tab. 5: Löschanlagen für Lackieranlagen Anlageart Vorteile Nachteile Typische Anwendung Besonderheiten Sprinkleranlage keine Gefährdung für Personen hohe Kosten, Folgeschäden durch Löschwasser möglich Gebäudeschutzanlage Objektschutzanlage umfangreiche Lösch­ wasserbevorratung erforderlich Sprühflutanlage s.o. kein Gebäudeschutz Objektschutzanlage kaum Anwendung in Lackieranlagen bei sehr schneller Brand- ausbreitung der Sprinkler- anlage vorzuziehen Feinsprüh-Sprühflutanlage s.o. sehr geringer Löschwasserbedarf kein Gebäudeschutz Objektschutzanlage Anwendung in Lackieranlagen Hoch- und Niederdruckanlagen Gaslöschanlage geringer Raumbedarf, keine Folgeschäden Personengefährdung, Erstickungsgefahr, räumliche Begrenzung erforderlich, bei Arbeiten im Schutz­ bereich muss die Lösch­ anlage u. U. außer Betrieb genommen werden Objektschutzanlage, örtlich wirkende Löschanlage Speziallösung für automatische elektro­ statische Sprühsysteme 16 Betriebliche Planung

4 Genehmigungsverfahren Die Genehmigungsbedürftigkeit der Lackieranlagen basiert auf baurechtlichen und immissionsschutzrechtlichen Anforderun­ gen. Das immissionsschutzrechtliche Genehmigungsverfahren schließt alle anderen Genehmigungsverfahren (z. B. die Bauge­ nehmigung) mit ein. Der Bau und der Betrieb von Lackieranlagen sind grundsätz­- lich genehmigungsbedürftig. In Abhängigkeit vom geplanten Beschichtungsverfahren und den eingesetzten Stoffen bezieht sich die Genehmigung nicht nur auf die Gebäudenutzung, son­ dern auch auf Teile der geplanten Beschichtungsanlage bis hin zur gesamten Anlage inklusive der Nebenanlagen und der Gebäude. Der prinzipielle Ablauf des Baugenehmigungsverfahrens ist in Anhang 3 dargestellt. Eine Pulverbeschichtungsanlage ist zwar, insbesondere wegen der in der Regel nur geringen Umweltauswirkungen, nicht geneh­ migungsbedürftig nach BImSchG, aber die eingesetzten Pulver­ lacke können gefährliche explosionsfähige Atmosphären erzeu­ gen. Auch in diesem Fall stellt das Gebäude einen Sonderbau im Sinne der Musterbauordnung dar. An Sonderbauten können besondere Anforderungen gestellt, aber auch Erleichterungen gestattet werden. Anforderungen und Erleichterungen werden im Brandschutzkonzept beschrieben. Eine Nasslackieranlage, in der lösemittelhaltige Lacke einge­ setzt werden, kann hingegen erhebliche Umweltauswirkungen haben und ist deshalb genehmigungsbedürftig nach BImSchG. In Abhängigkeit vom Verbrauch organischer Lösemittel ist das Genehmigungsverfahren in Anhang 4 aufgeführt. Vorbehandlungsanlagen, in denen Werkstücke für die nachfol­ gende Beschichtung nasschemisch behandelt werden, unterlie­ gen mindestens wasserrechtlichen Anforderungen. Bei einem Wirkbadvolumen über 30 m³ in Summe ist eine Genehmigung nach BImSchG erforderlich. Wenn in solchen Anlagen Abwasser zur Einleitung in die öffentliche Kanalisation anfällt, sind die entsprechenden Genehmigungen ebenfalls zu beantragen. In besonderen Fällen werden Beschichtungsanlagen auch als Nebenanlagen (z. B. von Gießereien) genehmigungsbedürftig nach BImSchG. In Abhängigkeit der Festlegungen und Anforderungen im Geneh­ migungsbescheid schließt das Verfahren messtechnische Nach­ weise ein und endet mit den Abnahmen und der Inbetriebnahme. Tabelle 6 gibt einen Überblick über die relevanten Arbeitsschrit­ te innerhalb der Genehmigungsverfahren. 17

Tab. 6: Arbeitsschritte bei Genehmigungsverfahren für Lackieranlagen Aufgabe Verantwortung Beteiligung Schnittstellen zum Brandschutz Beteiligung Brandschutz Aufgabe Brandschutz

1. Anlagenparameter

definieren Betreiber Verantwortliche für Anlagenbau und Anlagenplanung Ohne Berücksichtigung

1. Genehmigungs-

bedürftigkeit feststellen Betreiber Verantwortliche für Anlagenbau und Anlagenplanung Behörde Ohne Berücksichtigung

1. Erstellung des

Anlagenlayouts Verantwortliche für Anlagenbau und Anlagenplanung Betreiber Wechselwirkung mit baulichem Brandschutz sachverständige Person für Brandschutz Sachversicherung Beratung

1. Antragskonferenz

Betreiber Fachplaner/ Fachplanerin Verantwortliche für Anlagenbau Behörde(n) Baulicher Brandschutz Objektschutz Arbeitsschutz ggf. sachverständige Person für Brandschutz ggf. Sachversicherung Beratung

1. Unterlagen-

erstellung Betreiber Fachplaner/ Fachplanerin Verantwortliche für Anlagenbau Behörde Fachgutachten Brandschutzkonzept Beschreibung Objektschutz Explosionsschutz- konzept sachverständige Person für Brandschutz Sachversicherung Verantwortliche für Anlagenbau Brandschutzkonzept erstellen Explosionsschutz- konzept erstellen Beratung im Hinblick auf Brandrisiko- minderung

1. Abstimmung

von Auflagen Behörde Betreiber Verantwortliche für Anlagenbau und Anlagenplanung Brandschutzkonzept Arbeitsschutz sachverständige Person für Brandschutz Sachversicherung Beratung über die Konzepte Überarbeitung der Konzepte

1. Gebäude errichten/

umbauen Bauunternehmen Betreiber Fachplaner/ Fachplanerin Umsetzung Brandschutzkonzept

1. Anlagenaufbau

Verantwortliche für Anlagenbau Betreiber Fachplaner/ Fachplanerin Umsetzung Objektschutz

1. Abnahme (-n)

Betreiber Verantwortliche für Anlagenbau Sachverständige und befähigte Personen Behörden Baulicher Brandschutz Objektschutz sachverständige Person für Brandschutz Sachversicherung Feststellung der Überein­stimmung Soll/Ist

1. Inbetriebnahme

Betreiber Verantwortliche für Anlagenbau 18 Genehmigungsverfahren

5 Brandschutzaspekte bei Konstruktion und Verkauf von Lackieranlagen 19 5.1 Brandschutztechnische Optimierung Konstruktion der Anlage Grundlegende Anforderungen an Werkstoffe und Bauelemente von Lackieranlagen enthalten die Europäischen Sicherheitsnor­ men (siehe Anhang 6). Die für den Bau einer Lackieranlage eingesetzten Werkstoffe und Bauelemente beeinflussen deren Brandlast. Daher lässt sich durch Verwendung ausschließlich nichtbrennbarer Werkstoffe und Bauteile die Brandlast einer Lackieranlage reduzieren. Bei der Festlegung der brandschutztechnischen Auflagen wird aller­ dings häufig auf Literaturwerte bezüglich der flächenbezogenen Brandlast (siehe Anhang zu DIN 18230-1) zurückgegriffen. Abscheider, Filtersysteme, Entsorgung Filtersysteme liefern, abhängig von der eingesetzten Abscheide­ technik, häufig den größten Anteil an der Gesamtbrandlast einer Lackieranlage. Trockenfilter-Systeme großer Anlagen können viele Hundert Kilogramm Lackmaterial aufnehmen. Zur Verringe­ rung der Brandlast wird empfohlen, Filtereinsätze mit hoher Aufnahmekapazität (Abb. 6, 7), häufiger als aus strömungstech­ nischen Gründen erforderlich, zu wechseln oder grundsätzlich Filter mit geringerer Kapazität zu verwenden. Abb. 6: Trockenfilterwand, teilmontiert Abb. 7 Trockenfilterwand vollständig montiert

Auch Rotationsbürstenfilter (Abb. 8) reduzieren die Brandlast in der Abscheidung, weil der abgeschiedene Lack in kurzen Inter­ vallen aus der Anlage entfernt wird. Die Abscheidung des Lack­ oversprays auf Steinmehl führt zu einer Reduzierung der Brand­ last, da das mit Lack beladene Steinmehl als nicht brennbar eingestuft wird. Bauartbedingt sind die Brandlasten bei Einsatz der Nassauswa­ schung (Abb. 9) geringer. Vorteilhaft ist, dass sich das Overspray zunächst in einem Wasserbehälter ansammelt und erst später, nach Koagulation, Abscheidung und Trocknung, einen Beitrag zur Brandlast darstellt. Aber auch in Nassauswaschungen kön­ nen sich erhebliche Brandlasten durch Ablagerungen bilden. Vergleichbare Brandlasten ergeben sich beim Einsatz von Elektrofiltern. Abb. 9: Nassabscheidung mit Roboterapplikation 20 Brandschutzaspekte bei Konstruktion und Verkauf von Lackieranlagen Abb. 8: Trockenabscheidung mit Rotationsbürsten In jedem Fall muss die Lagerung beladener Filtermedien und anfallender Lackschlämme/Lackreste über ein betriebliches Entsorgungskonzept geregelt sein. Geeignet ist die Lagerung zum Beispiel in geschlossenen Metallbehältern oder Silos (Steinmehl). Lackmaterial, Farbversorgung, Lagerung Nahezu alle Lackmaterialien bestehen zum erheblichen Teil aus organischen und daher brennbaren Stoffen. Das gilt auch bei wasserbasierten Lacken. Eine Reduzierung der Brandlast ist durch Verringerung des Oversprays möglich. Dies kann zum Beispiel durch ein anderes Auftragsverfahren (z. B. Tauchen statt Spritzen) oder den Einsatz elektrostatischer Sprühverfahren, einschließlich der Pulverbeschichtung, erreicht werden. In einem Farbversorgungsraum (Abb. 10) kann die Brandlast durch Verringerung der in der Anlage vorgehaltenen Lackmenge (Größe und Anzahl der Vorratsbehälter, Länge der Schläuche und Leitungen) reduziert werden. Das Lacklager muss räumlich/ baulich getrennt von der Lackieranlage und anderen Nutzungs­ bereichen angeordnet werden. Auch hier lässt sich die Brandlast reduzieren, zum Beispiel durch „just-in-time“-Lieferung der Lack­- materialien.

Abb. 10: Farbversorgungsraum Reinigung Durch regelmäßige Reinigung der Anlage sind Brandlasten zu minimieren. Deshalb müssen Anhaftungen von Overspray in der gesamten Kabine und insbesondere in Abscheidern und abluft­ führenden Leitungen der Technischen Lüftung entfernt werden. Wichtig ist in diesem Zusammenhang, die mit Reinigungsarbei­ ten verbundenen zusätzlichen Brandgefährdungen bei Beurtei­ lung und Ableitung von Maßnahmen zu berücksichtigen. In ei­ nem Konzept muss festgelegt werden, welche Reinigungs- und Hilfsstoffe verwendet werden dürfen, welche Maschinen und Geräte zugelassen sind und ob während dieser Arbeiten die technische Lüftungsanlage und eine vorhandene Brandschutz­ anlage eingeschaltet bleiben dürfen. Brandgefährdungen kön­ nen zum Beispiel durch den Einsatz moderner Reinigungsverfah­ ren, wie das CO2-Strahlen (Abb. 11), reduziert werden. 5.2 Empfehlungen zur Bereitstellung von Lackieranlagen auf dem Markt Die Europäischen Sicherheitsnormen für Lackieranlagen (z. B. DIN EN 12215, DIN EN 13355, DIN EN 50176) enthalten Anforde­ rungen an die Brandschutztechnik. Es handelt sich dabei um Brandmeldeeinrichtungen und, je nach Ausführung, um manuelle oder automatische Löschsysteme. Bei elektrostatisch unterstützten Verfahren werden außerdem örtlich wirkende Löscheinrichtungen eingesetzt. In der Praxis einigen sich die Hersteller und die Betreiber in vielen Fällen darauf, dass im Lieferumfang die erforderliche Brandschutztechnik nicht oder zumindest nicht vollständig ent- halten ist. Auf diese Weise lassen sich zum Beispiel Schwierig­ keiten bei der Verknüpfung mit bereits bestehenden Brand­ schutzsystemen oder solchen, die für den Gebäudeschutz erfor­ derlich sind, vermeiden. Es wird folgende Vorgehensweise empfohlen:

1. In der Planung einer Lackieranlage wird grundsätzlich im

Brandschutzkonzept und in der Gefährdungsbeurteilung festgelegt und abgestimmt, welche Brandschutzeinrichtun­ gen erforderlich sind und wie diese an betriebliche oder gebäudebezogene Brandschutzeinrichtungen gekoppelt werden.

1. Vor der Realisierung ist eine verantwortliche Person für die

EG-Konformitätsbewertung auf der Basis der Risikobeurtei­ lung(en) festzulegen.

1. Die Lackieranlage wird installiert.
2. Die Lackieranlage wird unter Verantwortung der Hersteller in

Betrieb genommen (Probebetrieb).

1. Der oder die Verantwortliche erstellt die EG-Konformitäts­

erklärung und bringt die CE-Kennzeichnung an. Die EG- Konformitäts­erklärung schließt anlagenbezogene Brand­ schutzeinrichtungen (wie in den Normen gefordert) ein.

1. Die Lackieranlage, einschließlich der Brandschutzeinrich­

tungen, wird, zum Zeitpunkt des Gefahrenübergangs vom Hersteller auf den Betreiber, der „Prüfung vor erstmaliger Inbetriebnahme“ nach BetrSichV unterzogen. In dieser Prü­ fung werden auch die sicherheitstechnisch relevanten Ver­ knüpfungen der Lackieranlage mit der gesamten Brand­ schutzanlage geprüft. Die Durchführung der Prüfung liegt in der Verantwortung des Betreibers. Abb. 11: Werkstückreinigung mit CO2 21 Brandschutzaspekte bei Konstruktion und Verkauf von Lackieranlagen

6 Betrieblicher Brandschutz Brandschutzmaßnahmen sind nicht nur während des Betriebs von Lackieranlagen relevant. Bereits vor oder während der Inbe­ triebnahme sind eine Reihe vorwiegend organisatorischer Maß­ nahmen zu treffen (im Wesentlichen): • Erstellung der für den betrieblichen Brandschutz erforder­ lichen Dokumentation (inklusive Gefährdungsbeurteilung) • Unterweisung der Beschäftigten • Prüfung aller Brandschutzeinrichtungen Zu den technischen Anforderungen gehört insbesondere die Auswahl der Geräte, Maschinen und Fahrzeuge, die für den Ein­ satz in brandgefährdeten Bereichen geeignet sind. Maßnahmen vor und während der Inbetriebnahme führen die Tabellen 7 und 8 auf. Die Maßnahmen während des Betriebs (siehe Tab. 9) haben schwerpunktmäßig das Ziel, • Brandlasten zu verringern oder zu vermeiden, • brandschutztechnische Maßnahmen hinsichtlich ihrer Wirk­ samkeit zu kontrollieren und • brandschutzrelevante Veränderungen zu erkennen und zu berücksichtigen. Ein weiterer, wichtiger Aspekt während des Betriebs ist die wie­ derkehrende Unterweisung der Beschäftigten. Tab. 7: Organisatorische Brandschutzmaßnahmen zur Inbetriebnahme Maßnahme Umsetzung Regelwerke Bemerkungen 1 Gefährdungsbeurteilung einschließlich Brand- und Explosionsschutz vor Inbetriebnahme • Gefährdungsbeurteilung gemäß ArbSchG/ BetrSichV/GefStoffV/ArbStättV • Erstellung eines Explosionsschutzdokuments BetrSichV GefStoffV Unterstützung/Durchführung durch Externe (FASI, Inge­ nieurbüros, Herstellfirmen) 2 Pläne Erstellung von • Ex-Zonenplan • Flucht- und Rettungsplan • Feuerwehrplan ArbSchG ArbStättV, DIN 4844-3 MIndBauRL, DIN 14095 3 Anweisungen Erstellung von • Betriebsanweisungen auf Grundlage der Gefährdungsbeurteilung • Alarmplan • Brandschutzordnung GefStoffV MIndBauRL DIN 14096 Herstellerangaben, z. B. in der Betriebsanleitung der Anlage, sind zu berücksichtigen 4 Rauchverbot • Für gesamte Lackieranlage einschließlich Peri­ pherie (z. B. Lacklager, Farbmischraum…) Rauch­ verbot aussprechen • Raucherbereiche nur außerhalb der o. g. Bereiche einrichten Grenzen diese unmittelbar an, feuer­ beständig abtrennen – kein unmittelbarer Zu­ gang zum Gefahrenbereich Entsorgung von Ziga­ rettenresten nur in nicht brennbare Behältnisse, getrennt von sonstigen Abfällen/Materialien ASF / VdS 2038 5 Erstunterweisung • Erstunterweisung der im Bereich der Anlage beschäftigten Mitarbeiter und Mitarbeiterinnen auf Basis der Gefährdungsbeurteilung sowie der Pläne und Anweisungen ArbSchG DGUV Vorschrift 1 6 Kennzeichnungen Kennzeichnung der • Ex-Bereiche gemäß Explosionsschutzdokument • Flucht- und Rettungswege • Brandschutzeinrichtungen BetrSichV ASR A 1.3 7 Schulung/Folgeunterweisung • Schulung der im Bereich der Anlage beschäftig­ ten Mitarbeiterinnen und Mitarbeiter ArbSchG DGUV Vorschrift 1 Ggf. mit Unterstützung durch den Hersteller 8 Erstabnahme der elektrischen Anlage DIN EN 60204-1 9 Freihalten von Feuerlösch- und Erste-Hilfe-Einrichtungen • Brandschutz- und Erste-Hilfe-Einrichtungen müssen dauerhaft frei zugänglich sein 22

Tab. 8: Maßnahmen zur Vermeidung von Zündquellen zur Inbetriebnahme Maßnahme Umsetzung Regelwerke Bemerkungen 1 Ortsveränderliche elektri­ sche Betriebsmittel • für Betrieb und Instandhaltung der Lackieranla­ ge notwendige ortsveränderliche elektrische Betriebsmittel in gefährdeten Bereichen nur mit entsprechender Schutzart bzw. Gerätekategorie betreiben • zuvor genannte Geräte regelmäßig prüfen • ortsveränderliche elektrische Betriebsmittel, die für den unmittelbaren Lackierbetrieb nicht notwendig sind (z. B. Kaffeemaschinen, Wasser­ kocher) ausschließlich in baulich oder räumlich getrennten, brandlastfreien Bereichen betreiben. BetrSichV DGUV Vorschrift 3 und DGUV Vorschrift 4 2 Einsatz mobiler IR-Strahler • Bei Einsatz von Geräten, die als wirksame Zünd- quelle einzustufen sind (z. B. mobile IR-Strah­ ler), auf brennbare Abdeckungen (Maskierun­ gen) verzichten • Kann auf brennbare Abdeckungen (Maskierun­ gen) nicht verzichtet werden, Trocknungsbe­ reich dauerhaft mit automatischer Brandmelde­ technik überwachen VdS 2279 IR-Strahler nicht explizit in 2279 genannt, aber Inhalte sind übertragbar 3 Flurförderzeuge (FFZ) • In Ex-Zonen nur explosionsgeschützte FFZ oder Stapleranbaugeräte einsetzen VdS 2259 Betrieb nicht explosions- geschützter FFZ ist möglich, wenn währenddessen Bildung einer Ex-Atmosphäre ausgeschlossen 4 Nicht explosionsgeschütz­ te Geräte (z. B. Batterie- ladegeräte) • Geräte sind außerhalb des Ex-Bereichs zu betreiben • Abstand zu brennbaren Materialien beträgt mind. 2,5 m VdS 2259 5 Explosionsgeschützte Elektroinstallationen • In Ex-Zonen dürfen nur explosionsgeschützte Elektroinstallationen eingesetzt werden BetrSichV 6 Explosionsgeschützte Werkzeuge • In Bereichen der Zonen 0, 1, 20, 21 nur explosionsgeschützte Werkzeuge einsetzen TRBS 1112-1 Verwendung nicht explosi­ onsgeschützter Werkzeuge ist möglich, wenn während­ dessen Bildung einer Ex- Atmosphäre ausgeschlossen ist 7 Erdung • Sämtliche Behälter, Leitungen und Armaturen bei Befüll- oder Umfüllvorgängen mit brenn­ baren Flüssigkeiten erden TRGS 727 Erdungseinrichtungen regel­ mäßig visuell und messtech­ nisch auf ausreichende Leitfähigkeit prüfen 8 Durchführung feuergefähr­ licher Arbeiten • Innerhalb der feuer- und explosionsgefährdeten Bereiche feuergefährliche Arbeiten nur durch­ führen, wenn geeignete Schutzmaßnahmen getroffen und in einem Erlaubnisschein doku­ mentiert sind VdS 2008 VdS 2038 DGUV Regel 100-500 DGUV Information 205-002 DGUV Information 209-046 TRGS 720 TRBS 1112-1 Erlaubnisschein bei Arbeiten sowohl durch Fremdfirmen als auch durch betriebseige­ nes Personal anwenden 23 Betrieblicher Brandschutz

Tab. 9: Maßnahmen während des Betriebs Maßnahme Umsetzung Regelwerke Bemerkungen 1 Bereitstellung und Nutzung von PSA • PSA auf Grundlage der Gefährdungsbeurtei­ lung bereitstellen und deren Nutzung überwachen ArbSchG BetrSichV DGUV Regel 109-013 ArbSchG DGUV Vorschrift 1 Schutzschuhe und Schutzhandschuhe müs­ sen ableitfähig sein 2 Folgeunterweisung 3 Regelmäßige Reinigung (Boden, Anlagenteile, Erdungsklemmen) • Reinigungsintervalle individuell festlegen • möglichst keine Lösemittel anwenden • bei Abdeckung der Böden je nach Ex-Zone Ableitfähigkeit berücksichtigen TRGS 727 Vorgaben der Hersteller sind zu beachten 4 Regelmäßige Instandhaltung • Instandhaltungsintervalle individuell festlegen, z. B. für Brenner, Filtertechnik, Brandschutz- einrichtungen BetrSichV TRBS 1112 Vorgaben der Hersteller sind zu beachten 5 Brandlastreduzierung auf Schichtbedarf • Brennbare und sonstige Gefahrstoffe aus­ schließlich in Sicherheitsschränken Gefahrstofflagerräumen bereitstellen TRGS 510 ASF / VdS 2038 6 Regelmäßige Kontrolle des Lackierbereichs • Lackierbereich täglich hinsichtlich brand­ schutztechnisch kritischer Zustände kontrollieren ASF / VdS 2038 7 Abfallentsorgung • Abfälle nach Bedarf, mindestens arbeitstäg­ lich, in vorgesehene Behältnisse außerhalb der Lackiererei/Gebäude entsorgen ASF / VdS 2038 8 Freihalten der Feuerlösch- und Erste-Hilfe-Einrichtungen • Brandschutz- und Erste-Hilfe-Einrichtungen dauerhaft frei zugänglich halten ASR 2.2 9 Revision der elektrischen Anlagen • ortsfeste elektrische Anlagen (gebäude- und anlagebezogen) und ortsveränderliche elektrische Geräte regelmäßig prüfen BetrSichV DGUV Vorschrift 3 und DGUV Vorschrift 4 10 Kein Festsetzen der Feuerschutzabschlüsse • sämtliche Feuerschutzabschlüsse dauerhaft geschlossen halten; falls aus betrieblichen Gründen nicht möglich, bauaufsichtlich zuge­ lassene Feststellanlagen installieren und Türen nach Betriebsende schließen VdS 2234 ASF / VdS 2038 11 Management of Change/ erneute Gefährdungs- beurteilung bei techni­ schen, baulichen oder organisatorischen Änderungen • bei Änderungen an Lackier-, Brandschutz- anlagen, Gebäudelayout und Organisation alle relevanten Unterlagen überarbeiten BetrSichV 12 Keine Überbrückung oder Abschaltung der Brandschutzeinrichtungen • sämtliche Brandschutzeinrichtungen müssen während des Betriebs in Funktion sein BetrSichV 13 Bewertung neuer Betriebs- und Hilfsstoffe • vor Einsatz neuer oder geänderter Hilfs- und Betriebsstoffe prüfen, ob alle Brandschutz­ maßnahmen auch für diese Stoffe ausreichen GefStoffV 24 Betrieblicher Brandschutz

Die Tabellen 10 bis 12 führen Brandschutzmaßnahmen bei Instandhaltungsarbeiten und Betriebsstörungen auf. Auf die Instandhaltung der Lackieranlage ist besonderes Augenmerk zu legen, weil die meisten Brände während solcher Tätig- keiten ausgelöst werden. Dies liegt einerseits an der Einbindung von Fremdfirmen als Auftragnehmer, die häufig unzureichend über die betrieblichen Anforderungen und Maßnahmen des Brandschutzes informiert werden. Andererseits ist es gerade wäh- rend vieler Instandhaltungsarbeiten erforderlich, brennbare Stoffe (z. B. Reinigungsmittel) zu verwenden, Brandschutzanla- gen (z. B. CO2-Löschanlagen) außer Betrieb zu nehmen und Arbeiten mit Zündgefahren (z. B. Schleifen, Schweißen) durchzuführen. 25 Betrieblicher Brandschutz Tab. 10: Maßnahmen vor Beginn der Instandhaltungsarbeiten Maßnahme Umsetzung Regelwerke Bemerkungen 1 Definition der durch- zuführenden Arbeiten • Gefährdungsbeurteilung unter Berücksichtigung aller zu erwar­ tenden Arbeiten erstellen bei möglicher wechselseitiger Gefähr­ dung, Koordinator/Koordinatorin einsetzen TRBS 1112 ggf. Beteiligung der Auftrag nehmenden Partei, Fremdfirmen 2 Explosionsschutz • z.B. durch ausreichende Lüftung   sicherstellen, dass sich keine Ex-Atmosphäre im Arbeitsbereich befindet TRBS 1112-1 3 Reinigung • Ex-Schutzmaßnahmen bei Verwen­ dung von Lösemitteln/brennbaren Reinigungsstoffen treffen ggf. Beteiligung der Auftrag nehmenden Partei, Fremdfirmen 4 Außerbetriebnahme der Brandschutztechnik • Brandschutzanlagen abschalten, die zu einer Gefährdung führen, z.B. CO   2-Löschanlagen Instandhaltungsarbeiten sind häufig Ursache für Brände in Lackieranlagen: deshalb auf Außerbetrieb­ nahme der Löschanlage möglichst verzichten; falls Außerbetriebnahme der Löschanlage notwendig, in Abhängigkeit von Lackieranlagengröße Kompensation durch Brandwache mit Löschgeräten gewährleisten 5 Unterweisung der Fremdfirmen • Unterweisung der im Bereich der Anlage Beschäftigten auf Basis der Gefährdungsbeurteilung Herstellerinformationen und Betriebsanweisungen sind einzubeziehen

Tab. 11: Maßnahmen während Instandhaltungsarbeiten Maßnahme Umsetzung Regelwerke Bemerkungen 1 Durchführung der feuer- gefährlichen Arbeiten • Gefährdungsbeurteilung • konsequente Anwendung eines Erlaubnis­ scheins für feuergefährliche Arbeiten, dies beinhaltet u. A.: – Definition des Arbeitsbereichs – Beseitigung der Brandlasten – Stellen einer Brandwache – Bereitstellung von Löschgeräten – Nachkontrolle des Arbeitsbereichs BetrSichV TRBS 1112 DGUV Regel 100-500, DGUV Information 205-002 VdS 2008 VdS 2038 Checkliste als Hilfe für Gefährdungsbeurteilung ggf. Beteiligung der Auftrag nehmenden Partei, Fremdfirmen 2 Lagerung von brennbaren Materialien, die im Rahmen der Instand- haltung benötigt werden • Begrenzung auf Schichtbedarf • konsequentes Verschließen der Gefahrstoffgebinde • kein Umfüllen brennbarer Flüssigkeiten TRGS 510 TRGS 400 3 Reinigung • Ex-Schutzmaßnahmen bei Verwendung von Lösemitteln/brennbaren Reinigungsstoffen • Nutzung von Dosierhilfen/zugelassenen Sicherheitsbehältern BetrSichV ggf. Beteiligung der Auftrag nehmenden Partei, Fremdfirmen 4 Regelmäßige Kontrolle des Arbeitsbereichs • Erfassung potentieller Zündquellen • Erfassung der Brandlasten • Einstellung der Arbeiten bei Verstößen gegen Sicherheitsvorkehrungen, z. B. bei Nichtbeachtung des Rauchverbots oder Schweißen ohne Genehmigung Kontrolle mindestens einmal pro Schicht Tab. 12: Maßnahmen nach Beendigung der Instandhaltungsarbeiten Maßnahme Umsetzung Regelwerke Bemerkungen 1 Vorbereitung der Wiederinbetriebnahme • Entfernung aller Materialien, die für Instand- haltung notwendig (z. B. Werkzeuge, brennbare Materialien) BetrSichV 2 Prüfung der Elektroinstallationen • Prüfung der elektrischen Anlage (nur nach maßgeblicher Arbeit an dieser Anlage) BetrSichV unabhängig von Ex-Zonen 3 Wiederinbetriebnahme der Brandschutzanlagen • Wiederinbetriebnahme aller Lösch- und Alarmierungseinrichtungen, Entfernen der Staubschutzkappen an Brandmeldern BetrSichV 4 Prüfung der Brandschutz- anlagen nach Veränderung • erneute Prüfung der Löschanlage nach Umbau­ maßnahmen an Löschanlage BetrSichV Bestätigung durch Installations- firma oder Abnahme durch SV-Organisation 26 Betrieblicher Brandschutz

Anhang 1 Brandschutzrelevante Planungs-Kenngrößen einer Lackieranlage Kenngröße Aufstellort Werkstückeigenschaften Masse/Werkstoff Oberfläche Abmessungen Werkstück/Werkstückträger Prozessstoffe Beschichtungsstoff(e) Vorbehandlungschemikalien Prozess Reinigung/Vorbehandlung Beschichtung Trocknung Mengengerüst/Durchsatz pro Zeit für Referenz, Minimal & Maximal Werkstück für Masse Beschichtungsstoffe für Masse Lösemittel (VOC/ Wasser/…) Losgrößen/Teilemixbetrieb Betriebszeitmodell Schichten/Tag Tage/Woche Jahresbetriebsstundenzahl 27

Anhang 2 Brandszenarien und abgeleitete Schutzmaßnahmen 28 Nr. Brandszenario Bewertung Maßnahmen 1 elektrische Zündquelle (z.B.   Kurzschluss, Überhitzung) verursacht Kabelbrand • Zündquelle ist nur selten wirksam • Auswirkungen des Brands auf umgebende Kabel beschränkt • Installation nach DIN EN 60204 • Installation nach VDE 0100-482 • Kontrolle ordnungsgemäßer Verlegung während Montage und im Reparaturfall • Prüfungen nach BetrSichV, TRBS 1201, VDMA 24387 2 feuergefährliche Arbeiten entzünden die in der Spritz- kabine vorhandenen Brand- lasten (z.B. Verunreinigungen,   beladene Filter) • Totalverlust der Kabine • entfernen der Brandlast durch Reinigen, Filterwechsel wiederkehrend, insbesondere vor Beginn der Arbeiten • Feuergefährliche Arbeiten nur mit Erlaubnisschein durchführen • Genehmigungsverfahren z. B. nach VdS 2036 unter Beachtung von VdS 2008 und VdS 2047 etablieren und kontrollieren 3 überhitzter Ventilator-Motor verursacht Feuer in Ab- oder Umluftkanal • lokaler Brand am betroffenen Motor zu erwarten • bei brennbaren Ablagerungen Brand­ ausbreitung bis zum Kamin/bis in die Kabine • ungeschützte Motoren in gefährdeten Lüftungskanälen sind unzulässig (z.B. DIN EN 13355, Abschnitt 5.8.2.3.2)   • Brandmelde- und Löscheinrichtung 4 Blitzschlag verursacht Feuer in Abluftrohrleitung oder in anderen Teilen der Lackieranlage • Brandentstehung nur bei erheb- lichen Ablagerungen zu erwarten • Installation einer Blitzschutzanlage oder Anschluss an eine vorhandene Blitzschutzanlage, wenn Lackieranlage durch Blitzeinschlag gefährdet ist • regelmäßige Reinigung (auch Abluftkanäle), um Ablagerungen zu vermeiden (Frage: Kann regelmäßige Reinigung den Verzicht auf die Blitzschutzanlage recht­ fertigen? Nein!) • Risikoabschätzung nach DIN EN 62305-2 • Revision der Blitzschutzanlage nach DIN EN 62305-3 5 ESTA-Applikation: Funkenüberschlag verursacht Entzündung des Spritznebels, in Folge entstehen Verpuffung und Brand in der Kabine • Totalverlust der Kabine • Folge: Rest der Anlage durch Brand­ gase unbrauchbar • Brandmeldeanlage (DIN EN 12215, Abschnitt 5.7.1) • Objektschutzanlage (örtlich wirkende Löschanlage), die Funken/Flammen sofort löscht, ggf. in Kombination mit Raumlöschanlage (DIN EN 50176, insb. Tabelle 2) • alle installierten Brandschutzanlagen regelmäßig warten • Aufschaltung der Alarmmeldung auf übergeordnete BMZ (soweit vorhanden) erforderlich 6 Lackleitungen unter Hoch- spannung verursachen Funken gegen geerdete Metallteile; dadurch Zündung der G. e. A in der Umgebung; Folge: Explosion und Feuer • signifikant, da durch Lackierprozess sowohl brennbare Flüssigkeiten als auch Hochspannung als potenzielle Zündquelle vorliegen • Totalverlust der Kabine • Folge: Rest der Anlage durch Brandgase unbrauchbar • weitgehend sichtbare Verlegung aller Leitungen für brennbare Flüssigkeiten und regelmäßige visuelle Dichtheitskontrolle • Verhinderung automatischer Nachförderung im Leckage­ fall in Leitungen für brennbare Flüssigkeiten (siehe DIN EN 50176, Abschnitt 5.8/DIN EN 50348 Abschnitt 5.7) • Lackversorgung sollte durch Brandschutzanlage geschützt werden • nur Arbeitsbehälter („Tagesbedarf“) für Lackversorgung in unmittelbarer Nähe der Kabinen installieren 7 mit Lack beladene Filtermedien durch äußere Zündquellen oder Selbstentzündung in Brand gesetzt; Brand kann umgebende brennbare Materialien erfassen • Funkenreißen durch defekten Abluftventilator 8 Brand des Isoliermaterials in Konstruktionselementen der Kabine als Folge eines bestehen­ den Brandes • keine Zündquelle innerhalb der Maschine vorhanden • bis sich Isoliermaterial entzündet, muss metallische Ummantelung erheblich geschädigt sein • keine 9 Brand des Isoliermaterials von Lüftungsleitungen als Folge eines bestehenden Brands • Zündquelle innerhalb der Maschine vorhanden • je nach Masse, erheblicher Beitrag zur Brandlast • Metallkaschierung der Isolierung • alternativ: Kompensation durch aktiven Brandschutz

Anhang 3 Ablauf Baugenehmigung Beteiligte Bauherrin/Bauherr Architekt/Architektin Verantwortliche für die Entwurfserstellung Verantwortliche für Fachplanung Brandschutz Brandschutz- Dienststelle (Behörde) Genehmigungsbehörde Bau einer Lackieranlage Abgestimmte Bauplanung Baugenehmigung prüfen Baubeginn Bauplanung Erstellung Entwurfskonzept Machbarkeitsstudie Brandschutz Erstellung Brandschutz- Konzept Abstimmung Brandschutz- Planung Baugenehmigung ausgestellt Hauptprozessschritte Unterstützungs- und Abstimmungsprozesse Einreichung Bau- genehmigung 29

Anhang 4 Ablauf Genehmigung nach dem Bundesimmissionsschutzgesetz Beteiligte Bauherr/Bauherrin Verantwortliche für die Anlagenplanung Verantwortliche für die Fachplanung Blm SchG Genehmigungs- behörde Sachverständige Architektin/Architekt Verantwortliche für die Entwurfserstellung Fachbehörden Bau einer Lackieranlage Abgestimmter Antrag Baubeginn Anlagenplanung Erstellung Entwurfskonzept Einreichung Antrag Genehmigung prüfen Prüfung Genehmigungsbedürfigkeit Erstellung Antrags- konzept Antrags- konferenz Blm SchG Genehmigung ausgestellt Erstellung Fachgutachten z. B. Brandschutz, Lärm, Boden Bauplanung Erstellung Entwurfskonzept Abgestimmte Bauplanung Abstimmung Fachplanung Hauptprozessschritte Unterstützungs- und Abstimmungsprozesse 30

Anhang 5 Hilfestellung zur Anwendung der TRGS 800, Anlage 3 auf Lackieranlagen 31 Die folgenden Fragen dienen einer strukturierten Überprüfung auf Plausibilität von Schutzmaßnahmen entsprechend TRGS 800 Nummer 5 Abs. 2 bei einer erhöhten oder hohen Brandgefährdung in einer Lackieranlage. Die Detaillierungstiefe der erforderlichen Informationen hängt vom Einzelfall ab.

1. Liegt eine Beschreibung der Tätigkeit bzw. Anlage und der

örtlichen Situation vor? Grundlagen dafür sind insbesondere: –– die Gefährdungsbeurteilung (Explosionsschutzkonzept/ Explosionsschutzdokument) –– Betriebsanleitungen –– Betriebsanweisungen

1. Sind alle zu erwartenden Betriebszustände beurteilt?

Dazu gehören neben dem Normalbetrieb: –– Reinigungs- Wartungs- und Reparaturarbeiten –– Stillstandszeiten –– In- und Außerbetriebnahme

1. Sind Art, Menge und Verwendung der brennbaren Gefahr­

stoffe beschrieben? Brennbare Gefahrstoffe an Lackieranlagen sind insbesondere: –– Beschichtungsstoffe (Flüssigkeiten, Pulver, Flock) –– Reinigungsstoffe (Flüssigkeiten) –– Hilfsstoffe Arten der Verwendung sind insbesondere: –– Lagern –– Anmischen/Verdünnen –– Fördern/Pumpen –– Versprühen –– Auftragen auf Werkstücke –– Ansammeln/Speichern in Filtern

1. Ist der zu beurteilende Bereich genau definiert (Abgrenzung

zu anderen Bereichen)? Betrachtung kann basieren auf: –– der Einteilung der Brandabschnitte oder –– auf Nutzungseinheiten (z. B. Lackierkabine, Trockner)

1. Stimmt die Nutzung des Raumes/Gebäudes mit der

baurechtlich genehmigten Nutzung überein? –– Bauart des Gebäudes –– Baugenehmigung –– Brandschutzkonzept –– BImSchG-Genehmigungsbescheid –– Unterlagen des Anlagenherstellers –– Flucht-/Rettungswegeplan Gegebenenfalls ist die Beantragung einer Nutzungsände­ rung erforderlich.

1. Ist die Anzahl der Beschäftigten oder anderer Personen

bekannt? Der Personenkreis umfasst: –– regelmäßig an der Lackieranlage Beschäftigte –– andere Beschäftigte im nach Nr. 4 definierten Bereich –– Personal für Wartung, Instandhaltung, Reinigung – darunter –– eigenes und fremdes Personal

1. Sind alle wirksamen Zündquellen ermittelt und bewertet?

Zündquellen an Lackieranlagen können sein: –– technisch bedingte Zündquellen (Risikobeurteilung) –– personenverursachte Zündquellen (Fehlverhalten)

1. Ist die Möglichkeit des Ersatzes für brennbaren Gefahrstoff

geprüft worden (Substitution)? Eine Substitution durch einen nichtbrennbaren Stoff ist bei den üblichen Anwendungen der Lackapplikation nicht möglich.

1. Ist der brennbare Gefahrstoff nur in der erforderlichen

Menge vorhanden? Die Grenze für die erforderliche Menge definiert sich an Lackieranlagen (Beschichtungsbereich) durch den Tagesbedarf. Für Lacklager müssen maximale Lagermengen festgelegt und deren Einhaltung regelmäßig geprüft werden. Nicht für das Verfahren erforderliche brennbare Stoffe sind aus dem Gefahrenbereich (feuergefährdeter Bereich) fernzuhalten.

1. Sind die Flucht- und Rettungswege (Länge, Anzahl) im Hin­

blick auf eine sichere Nutzung und eine Alarmierung zur Gebäuderäumung bewertet worden? Bewertungsgrundlagen für Flucht- und Rettungswege sind: –– ASR A2.3 –– Baurecht (insb. Industriebaurichtlinie)

–– Brandschutzkonzept –– ggf. DGUV Information 209-046 Bewertungsgrundlagen für Alarmierung sind: –– ArbSchG –– §13 GefStoffV –– DIN 33404-3

1. Sind zusätzliche Maßnahmen (z. B. Zugänglichkeit für die

Feuerwehr, Löschmittelversorgung) für eine wirksame Brand­ bekämpfung erforderlich? Maßnahmen sind abzuleiten und/oder zu bewerten auf der Grundlage folgender Regelwerke: –– Zugänglichkeit: DIN 14095 „Zufahrts- und Aufstellflächen für die Feuerwehr“ –– Löschmittelversorgung: DVGW Blatt W 405 –– Löschwasserversorgung (Industriebaurichtlinie)

1. Sind aufgrund einer hohen Brandgefährdung zusätzlich

Brandmeldeanlagen bzw. Löschanlagen erforderlich? Dieses Erfordernis kann sich z. B. aus festgestellten Defiziten ergeben.

1. Sind aufgrund einer hohen Brandgefährdung zusätzliche

Maßnahmen (z. B. Notstromversorgung) erforderlich? Eine unterbrechungsfreie Stromversorgung kann z. B. erfor­ derlich sein für –– Notbeleuchtung –– Freifahren von Brandabschnittsdurchdringungen –– Auslösen von Feuerschutzabschlüssen –– Öffnen von Rauch- und Wärmeabzügen 32 Anhang 5

1. Ist die Notwendigkeit zusätzlicher Qualifikationen und

Unterweisungen für Mitarbeiterinnen und Mitarbeiter geprüft worden? Zusätzliche Unterweisungen können z. B. erforderlich sein für: –– Verwendung von Barrieren zur Löschwasserrückhaltung –– Lage und Benutzung zentraler Absperrorgane für Versor­ gungsmedien (Druckluft, Gas, etc.)

1. Ist die Notwendigkeit einer Zugangsbeschränkung für den

beurteilten Bereich geprüft worden? Beispiele für relevante Bereiche sind: –– Lackierkabine –– Lacklager –– Misch-/Bereitstellungsräume –– Abdunsträume

1. Ist die Notwendigkeit spezieller Arbeitskleidung geprüft

worden? Zur Verminderung der Brandgefährdungen wird die Verwen­ dung nichtbrennbarer oder zumindest schwer entflammba­ rer Arbeitskleidung empfohlen.

Anhang 6 Verzeichnis der Abkürzungen 33 ArbSchG Arbeitsschutzgesetz ArbStättV Arbeitsstättenverordnung ARGEBAU Bauministerkonferenz (Arbeitsgemeinschaft der für Städtebau, Bau- und Wohnungswesen zuständigen Minister und Senatoren der Länder der Bundesrepublik Deutschland) ASF Allgemeine Sicherheitsvorschriften der Feuerversicherer ASR Technische Regeln für Arbeitsstätten BauPrüfVO Bauprüfverordnung BetrSichV Betriebssicherheitsverordnung BGI Berufsgenossenschaftliche Information BGR Berufsgenossenschaftliche Regel BImSchG Bundes-Immissionsschutzgesetz BMZ Betriebsmittelzentrale FASI Fachkraft für Arbeitssicherheit FFZ Flurförderfahrzeug G.e.A.     gefährliche explosionsfähige Atmosphäre GefStoffV Gefahrstoffverordnung IR infrarot MBO Musterbauordnung MIndBauRl Muster-Industriebaurichtlinie PSA persönliche Schutzausrüstung TRBS Technische Regeln für Betriebssicherheit TRGS Technische Regeln für Gefahrstoffe AwSV Verordnung über Anlagen zum Umgang mit wassergefährdenden Stoffen VdS VdS Schadenverhütung GmbH VDE Verband der Elektrotechnik Elektronik Informationstechnik e.V. VDMA Verband Deutscher Maschinen- und Anlagenbau e.V. vfdb Vereinigung zur Förderung des Deutschen Brandschutzes e.V. VOC flüchtige organische Verbindungen (volatile organic compounds) VwV Verwaltungsvorschrift WHG Wasserhaushaltsgesetz

Anhang 7 Literatur 34 Gesetze und Verordnungen: ArbSchG Gesetz zur Umsetzung der EG-Rahmenrichtlinie - Arbeitsschutz und weiterer Arbeitsschutz-Richtlinien; Artikel 1 Gesetz über die Durchführung von Maßnahmen des Arbeitsschutzes zur Verbesserung der Sicherheit und des Gesundheitsschutzes der Beschäftigten bei der Arbeit (Arbeitsschutzgesetz) ArbStättV Verordnung über Arbeitsstätten (Arbeitsstättenverordnung) BauPrüfVO Verordnung über die bautechnische Prüfung von Baumaßnahmen (Bautechnische Prüfungsverordnung) BetrSichV Verordnung zur Neuregelung der Anforderungen an den Arbeitsschutz bei der Verwendung von Arbeits­ mitteln und Gefahrstoffen (Betriebssicherheitsverordnung) BImSchG Gesetz zum Schutz vor schädlichen Umwelteinwirkungen durch Luftverunreinigungen, Geräusche, Er­ schütterungen und ähnliche Vorgänge (Bundes-Immissionsschutzgesetz) GefStoffV Verordnung zur Neufassung der Gefahrstoffverordnung und zur Änderung sprengstoffrechtlicher Verord­ nungen (Artikel 1 Verordnung zum Schutz vor Gefahrstoffen (Gefahrstoffverordnung) AwSV Verordnung über Anlagen zum Umgang mit wassergefährdenden Stoffen (Anlagenverordnung) WHG Gesetz zur Neuregelung des Wasserrechts (Artikel 1 Gesetz zur Ordnung des Wasserhaushalts (Wasserhaushaltsgesetz) Normen: DIN 14675:2003-11 Brandmeldeanlagen - Aufbau und Betrieb DIN 14095:2007-05 Feuerwehrpläne für bauliche Anlagen DIN 14096:2014-05 Brandschutzordnung - Regeln für das Erstellen und das Aushängen DIN 18230-1:2010-09 Baulicher Brandschutz im Industriebau - Teil 1: Rechnerisch erforderliche Feuerwiderstandsdauer DIN EN 12215:2010-06 Beschichtungsanlagen - Spritzkabinen für flüssige organische Beschichtungsstoffe

• Sicherheitsanforderungen

DIN EN 12981:2009-04 Beschichtungsanlagen – Spritzkabinen für organische Pulverlacke - Sicherheitsanforderungen DIN EN 13355:2010-06 Beschichtungsanlagen - Kombinierte Spritz- und Trocknungskabinen - Sicherheitsanforderungen DIN EN 50176 VDE 0147-101:2010-04 Stationäre Ausrüstung zum elektrostatischen Beschichten mit entzündbaren flüssigen Beschichtungs­ stoffen - Sicherheitsanforderungen DIN EN 50348 VDE 0147-200:2010-08 Stationäre Ausrüstung zum elektrostatischen Beschichten mit nichtentzündbaren flüssigen Beschich­ tungsstoffen - Sicherheitsanforderungen DIN EN 60204 VDE 0113-1:2014-10 Sicherheit von Maschinen - Elektrische Ausrüstung von Maschinen - Teil 1: Allgemeine Anforderungen DIN EN 62305-2 VDE 0185-305-2:2015-12 Blitzschutz - Teil 2: Risiko-Management DIN EN 62305-3 VDE 0185-305-3:2016-04 Blitzschutz - Teil 3: Schutz von baulichen Anlagen und Personen (IEC 62305-3:2010, modifiziert); DIN ISO 23601:2010-12 Sicherheitskennzeichnung - Flucht- und Rettungspläne (ISO 23601:2009) VDE-Bestimmungen: DIN VDE 0100-420:2016-02 Errichten von Niederspannungsanlagen - Teil 4-42: Schutzmaßnahmen - Schutz gegen thermische Aus­ wirkungen (IEC 60364-4-42:2010, modifiziert) DIN VDE 0100-520:2013-06 Errichten von Niederspannungsanlagen - Teil 5-52: Auswahl und Errichtung elektrischer Betriebsmittel

• Kabel- und Leitungsanlagen (IEC 60364-5-52:2009, modifiziert)

DIN VDE 0833-2:2015-11 Gefahrenmeldeanlagen für Brand, Einbruch und Überfall - Teil 2: Festlegungen für Brandmeldeanlagen

VdS-Bestimmungen: VdS 2008 Feuergefährliche Arbeiten - Richtlinien für den Brandschutz VdS 2033 Elektrische Anlagen in feuergefährdete Betriebsstätten und diesen gleichzustellende Risiken VdS 2036 Erlaubnisschein für Schweiß-, Schneid-, Löt-, Auftau- und Trennschleifarbeiten VdS 2038 Allgemeine Sicherheitsvorschriften der Feuerversicherer für Fabriken und gewerbliche Anlagen (ASF) VdS 2047 Sicherheitsvorschriften für feuergefährliche Arbeiten VdS 2093 CO2- Feuerlöschanlagen – Planung und Einbau VdS 2234 Brand- und Komplextrennwände - Merkblatt für die Anordnung und Ausführung VdS 2259 Richtlinien zur Schadenverhütung - Batterieladeanlagen für Elektrofahrzeuge VdS 2279 Elektrowärmegeräte und Elektroheizungsanlagen - Richtlinien zur Schadenverhütung VdS 3188 Wassernebel-Sprinkleranlagen und Wassernebel-Löschanlagen (Hochdruck-Systeme), Planung und Einbau Berufsgenossenschaftliche Informationen, Regeln und Vorschriften: DGUV Information 205-002 (bisher BGI 563) Brandschutz bei feuergefährlichen Arbeiten DGUV Information 209-046 (bisher BGI 740) Lackierräume und -einrichtungen für flüssige Beschichtungsstoffe - Bauliche Einrichtungen, Brand- und Explosionsschutz, Betrieb DGUV Regel 100-500 (bisher BGR 500) Betreiben von Arbeitsmitteln DGUV Regel 109-013 (bisher BGR 231) Schutzmaßnahmenkonzept für Spritzlackierarbeiten - Lackaerosole DGUV Vorschrift 1 Unfallverhütungsvorschrift - Grundsätze der Prävention DGUV Vorschrift 3 und 4 (bisher BGV A3 und GUV-V A3) Elektrische Anlagen und Betriebsmittel Technische Regeln für Betriebssicherheit: TRBS 1112 Technische Regeln für Betriebssicherheit - Instandhaltung Technische Regeln für Gefahrstoffe: TRGS 400 Gefährdungsbeurteilung für Tätigkeiten mit Gefahrstoffen TRGS 510 Lagerung von Gefahrstoffen in ortsbeweglichen Behältern TRGS 720 Technische Regeln für Betriebssicherheit - Technische Regeln für Gefahrstoffe - Gefährliche explosions­ fähige Atmosphäre - Allgemeines TRGS 800 Brandschutzmaßnahmen VDMA Einheitsblätter: VDMA 24387 Sicherheitsrelevante Steuerungen für Anlagen der Oberflächentechnik Anhang 7 35

Berufsgenossenschaft Holz und Metall Internet: www.bghm.de Kostenfreie Servicehotline: 0800 9990080-0

FD05991 ｜ 2017_德国_DGUV_大型容器点火温度爆炸研究_火灾报告.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2017 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因：燃气/爆炸 ｜ 来源格式：pdf

ZÜNDTEMPERATUREN IN GROßEN BEHÄLTERN

Projekt – Volumina bis 20 l Laufzeit: 01.02 2013 bis 31.0101. 2015 Projekt – Volumina bis 0,5 m³ (DGUV 617.0 – FP363) Laufzeit: 01.08.2014 bis 31.05.2017

Gemeinsamer Abschlussbericht

E. Brandes, W. Hirsch, PTB Braunschweig, September 2017

Forschungsbeirat: Gesa Gosda COVESTRO AG, Leverkusen Dr. Ute Hesener DEKRA EXAM GmbH, Bochum Dr. Michael Beyer PTB, Braunschweig Dr. Wolfgang Borchers BAYER AG, Leverkusen Dr. Jürgen Franke Consilab Ges. für Anlagensicherheit mbH, Frankfurt Dr. Markus Gödde BASF SE, Ludwigshafen Dr. Martin Gosewinkel Inburex Consulting GmbH, Hamm Dr. Joachim Herrmann DGUV, Berlin Dr. Lothar Neumeister BGETEM, Augsburg Björn Poga BGRCI, Heidelberg Dr. Volkmar Schröder BAM; Berlin Dr. Klaus-Werner Stahmer DGUV (IFA), St. Augustin Dr. Thomas Zimmermann Merck KGaA, Darmstadt Die Verfasser danken der DGUV und der BGRCI für die finanzielle Unterstützung, Inburex Consulting GmbH, Hamm für die Leihgabe des 0,5 m³-Behälters und den Mitgliedern des Forschungsbegleitkreises für die fachliche Beratung und Begleitung.

INHALTSVERZEICHNIS Kurzfassung deutsch Kurzfassung englisch 1 Einleitung und Problemstellung ................................................................................................................. 1 2 Ausgangssituation ..................................................................................................................................... 2 2.1 Forschungsziel ................................................................................................................................... 4 3 Methodik .................................................................................................................................................... 5 3.1 Untersuchte Substanzen ................................................................................................................... 5 3.2 Allgemeine Verfahrensweise ............................................................................................................. 8 3.2.1 Durchführung ............................................................................................................................. 9 3.2.2 Modifizierte Durchführung zur Untersuchung "homogener" Gemische ................................... 10 3.2.3 Datenerfassung........................................................................................................................ 10 3.2.4 Meßdatenauswertung .............................................................................................................. 11 3.2.5 Messreihen .............................................................................................................................. 11 3.3 0,005 m³-Gefäß (5l-Erlenmeyerkolben) ........................................................................................... 11 3.3.1 Versuchsaufbau ....................................................................................................................... 11 3.3.2 Durchführung ........................................................................................................................... 12 3.3.3 Allgemeine Beobachtungen ..................................................................................................... 12 3.3.4 Spezielle Phänomene .............................................................................................................. 14 3.3.5 Messergebnisse ....................................................................................................................... 16 3.4 0,02 m³-Gefäß ................................................................................................................................. 22 3.4.1 Versuchsaufbau ....................................................................................................................... 22 3.4.2 Durchführung ........................................................................................................................... 23 3.4.3 Ergebnisse ............................................................................................................................... 23 3.5 0,16m³-Gefäß .................................................................................................................................. 24 3.5.1 Versuchsaufbau ....................................................................................................................... 24 3.5.2 Durchführung ........................................................................................................................... 25 3.5.3 Ergebnisse ............................................................................................................................... 25 3.6 0,5m³-Gefäß..................................................................................................................................... 26 3.6.1 Versuchsaufbau ....................................................................................................................... 26 3.6.2 Durchführung ........................................................................................................................... 27 3.6.3 Ergebnisse ............................................................................................................................... 27 3.7 Versuchsreihen in Gefäßen mit kleineren Volumina ....................................................................... 27 3.8 Versuchsreihen in "homogenen" Gemischen .................................................................................. 28 3.8.1 Versuchsaufbau und -durchführung ........................................................................................ 28 3.8.2 Ergebnisse ............................................................................................................................... 28 4 Ergebnis - Volumenabhängigkeit der Zündtemperatur ............................................................................ 29 4.1 Theoretische Überlegungen ............................................................................................................ 29

1. 2

Auswertung ...................................................................................................................................... 29 4.2.1 Vergleich mit Beerbower- und Semenoff-Beziehung............................................................... 29 4.2.2 "Scheinbare Normzündtemperatur" ......................................................................................... 33 4.3 Zündverzugszeiten .......................................................................................................................... 36 4.3.1 Versuchsdurchführung ............................................................................................................. 36 4.3.2 Zündverzugszeiten bei der Zündtemperatur ............................................................................ 37 4.3.3 Ermittlung der scheinbaren Aktivierungsenergie ..................................................................... 38 4.3.4 Vergleich mit Aktivierungsenergien aus der Druckabhängigkeit ............................................. 40 4.4 Sicherheitstechnische Schlussfolgerungen ..................................................................................... 41 5 relevante Veröffentlichungen ................................................................................................................... 42 W. Hirsch, E. Brandes, T. Stolz: Zündtemperaturen in großen Behältern Tech.Sich. 7 (2017) Nr. 9, 24 ....... 42 W. Hirsch, E. Brandes: Zündtemperaturen in großen Behältern Beitrag für 13. Fachtagung ‚Anlagen-, Arbeits- und Umwelttechnik‘ Köthen angenommen ........................................................................................ 42 6 Bewertung der Ergebnisse hinsichtlich des Forschungszwecks/-ziels, Schlussfolgerungen .................. 42 7 Aktueller Umsetzungs- und Verwertungsplan ......................................................................................... 42 Anhang: Bestimmung von kalten Flammen ....................................................................................................... 45

Kurzfassung deutsch Die Normzündtemperatur Tz, eine der fundamentalen sicherheitstechnischen Kenngrößen, wird in einem offenen 0,2 l-Gefäß ermittelt (IEC 60079-20-1 und DIN 51794: 0,2 l Erlenmey- erkolben; ASTM E 659: 0,2 l Rundkolben). Ältere Beobachtungen in Volumina bis 20 l zeigen jedoch, dass die Zündtemperatur in größeren Gefäßen sinken kann. In der Literatur wird diese Reduzierung der Zündtemperatur durch folgenden Zusammenhang beschrieben: [ ])2,0 lg 12 /( ) lg 12 ( ) 75 ( 75 2 2 ,0 2 − − ⋅ −

+

V T T Z ZV . Mit Tz V2: Zündtemperatur im Volumen 2 TzV1: Zündtemperatur im Volumen 1 V1: Volumen 1 V2: Volumen 2 Dieser Zusammenhang wurde für reine Substanzen und binäre Substanzgemische systema- tisch in Gefäßen bis zu 0,5 m³ Rauminhalt untersucht. Im Ergebnis lassen sich folgende Fälle

unterscheiden:

Substanzen, die in der Normapparatur keine oder nur in einem engen Bereich unterhalb der Normzündtemperatur kalte Flammen bilden: Solche Substanzen zeigen eine logarithmische Abnahme der Zündtemperatur mit dem Volumen ähnlich dem in der Literatur beschriebenen Zusammenhang.

Das gleiche gilt für Gemische aus solchen Substanzen.

Substanzen, die deutlich unterhalb der Normzündtemperatur kalte Flammen bilden: Bereits bei geringer Erhöhung der Gefäßvolumina nimmt die Zündtemperatur stark (> 100 K) ab und folgt erst ab einem Volumen von ca. 1 l -5 l (je nach Substanz) einer vergleichbaren logarithmischen Beziehung. Wird an Stelle der Normzündtemperatur die ‚Kaltflammentemperatur nach Norm‘ herangezogen, so folgt die Volumenabhängigkeit der Zündtemperatur der aus der Literatur bekannten Korrelation.

Das gleiche gilt für Gemische aus solchen Substanzen

Gemische aus Substanzen mit deutlich unterhalb der Normzündtemperatur liegende ‚Kalt- flammentemperaturen‘ und Substanzen deren ‚Kaltflammentemperatur‘ sich nur gering oder gar nicht von der Normzündtemperatur unterscheiden zeigen kein einheitliches Ver- halten. Abhängig vom Anteil im Substanzgemisch kann die eine wie die andere Komponente die Volumenabhängigkeit der Zündtemperatur überwiegend beeinflussen. Es ist dann deren ‚Kaltflammentemperatur oder Normzündtemperatur für die Abschätzung heranzuziehen. Die Ergebnisse der durchgeführten Untersuchungen erlauben es somit, die Zündtemperatur in großen Volumina aus Messungen in kleineren Gefäßen abzuschätzen. Ein Sicherheits- zuschlag zur sicheren Seite (Abschlag) ist jedoch in allen Fällen erforderlich. Gleichzeitig mit der Erniedrigung der Zündtemperaturen kann es zu deutlich erhöhten Zündverzugszeiten kommen.

Kurzfassung englisch The standardised methods for determining the auto ignition temperature AIT– one of the fun- damental safety characteristics – use open 0.2 l vessels (IEC 60079-20-1 and DIN 51794: 0,2 l Erlenmeyer flask; ASTM E 659: 0,2 l round bottom flask). From prior observations in volumes up to 20 l it is obvious that the auto ignition temperature may decrease in larger volumes. Literature knows the following correlation to describe this effect:

[ ])2,0 lg 12 /( ) lg 12 ( ) 75 ( 75 2 2 ,0 2 − − ⋅ −

+

V T T Z Z V

where Tz V2: Autoignition temperature in volume 2 TzV1: Autoignition temperature in volume 1 V1: Volume 1 V2: Volume 2 This correlation was investigated systematically with pure substances and binary mixtures of

substances in volumes up to 0.5 m³. The following cases can be distinguished:

Substances showing no cool flames, or cool flames only within a narrow range below the

auto ignition temperature according a standard:

The auto ignition temperature of such substances follows a logarithmic decrease with increasing volume, comparable to the above mentioned correlation known from literature.

The same is valid for mixtures of such substances

Substances showing cool flames well below the auto ignition temperature according a standard: Even a small increase in the volume decreases the auto ignition temperature remarkably (> 100 K). Only in volumes larger than 1l - 5 l (depending on substance) it follows a logarithmic correlation. If, however, the ‘cool flame temperature’ is used as reference temperature, the volume dependence of the auto ignition temperature can be described by a correlation similar that known from literature.

The same is valid for mixtures of such substances

Mixtures of substances with ‘cool flame temperatures’ well below the auto ignition tem- perature according a standard and substances showing no or only a slightly lower ‘cool flame temperature’ behave inconsistent. Depending on the amount of the respective substance in the mixture the one or the other component will predominant the influence on the autoignition temperature. Following its ‚cool flame temperature‘ or its autoignition temperature has to be used for the estimation. The results of the investigations carried out allow to estimate the auto ignition temperature in larger volumes from that determined in standard vessels. A safety margin is however necessary in every case. The decreasing auto ignition temperature can be accompanied by a remarkably increase in ignition delay time.

1

1 EINLEITUNG UND PROBLEMSTELLUNG Viele chemische Verfahren, technische Prozesse oder Reinigungsvorgänge erfordern für ihre Durchführung erhöhte Temperaturen. Sind dabei explosionsfähige Gemische vorhanden oder können solche zumindest bei Betriebsstörungen entstehen, stellen vor allem heiße Oberflächen potentielle Zündquellen dar. Bei Umgebungsdruck ist die Zündquelle ‚heiße Oberfläche‘ charakterisiert durch die Zünd- temperatur bestimmt nach DIN 51794 [1], IEC 60079-20-1 [2], EN 14522 [3] und im außer- europäischen Raum bestimmt nach ASTM E 659 [4]. Die so bestimmte Zündtemperatur ist Grundlage für die Einteilung der brennbaren Gase und Flüssigkeiten und der explosionsge- schützten Geräte in Temperaturklassen. Obwohl die eigentliche Intention dieses Bestim- mungsverfahrens somit auf ein Ranking der Geräte zum Einsatz in explosionsfähiger Atmo- sphäre sowie der brennbaren Substanzen, die explosionsfähige Atmosphäre bilden können, abzielt, wird sie vielfach in der industriellen Praxis als ‚Leitgröße‘ herangezogen. Die Zündtemperatur ist jedoch wie die meisten anderen sicherheitstechnischen Kenngrößen von der Geometrie der Versuchsapparatur abhängig. Das Volumen des Zündgefäßes zur Bestimmung der Zündtemperatur nach DIN 51794 [1], IEC 60079-20-1 [2], EN 14522 [3] sowie ASTM E 659 [4] beträgt 0,2 l. Aus der Literatur bekannte Messungen [6, 7, 8, 9] in zur Umgebung offenen Volumina bis zu 20 l zeigen jedoch eine Reduzierung der Zündtemperatur mit zunehmendem Volumen der Versuchsapparatur. Gleichzeitig mit der Abnahme der Entzündungstemperatur wird in der Regel eine Zunahme der Zündverzugszeit beobachtet [6, 7]. Ergebnisse aus dem BGRCI-Projekt ‚Einfluss der Behältergröße auf die Schutzmaßnahmen im Innern von Behältern die explosionsfähige Gemische enthalten‘ bestätigen einen solchen Einfluss des Volumens auch für Entzündungstemperaturen und Zündverzugszeiten im geschlossenen Gefäß bis zu einem Volumen von 1 l. Da die Zündtemperatur bei technischen Prozessen oft als ‚Leitgröße‘ für die maximal zulässige Temperatur von heißen Oberflächen und von Gas/Dampf-Luft-Gemischen herangezogen wird, ergeben sich unter sicherheitstechnischen Aspekten aus dieser Volumenabhängigkeit Konsequenzen für Art und Umfang der Explosionsschutzmaßnahmen. Sowohl die TRBS 2152 Teil 3 als auch das Regelwerk der Berufsgenossenschaften, das gerade den klein- und mittelständischen Unternehmen eine große Hilfestellung bietet und im Rahmen der Prävention von Explosionsereignissen große Erfolge zu verzeichnen hat, weisen in der Explosionsschutz-Regel (EX-RL) DGUV Regel 113-001auf diesen Sachverhalt hin. Bei der Beurteilung der Zündquelle „heiße Oberfläche“ zeigt sich jedoch an Hand der Bemer- kung 1 zu TRBS 2152, Teil 3, Nr. 5.2.1, dass die Hinweise zu Zündtemperaturen in Behältern mit größeren Volumina notgedrungen sehr kurz und allgemein gehalten sind, da die notwendigen Informationen hierzu bisher nicht vorliegen.

2

Zitat aus TRBS 2152, Teil 3:

1. 2 Heiße Oberflächen

Ziel der Schutzmaßnahmen ist die Verhinderung der Entzündung explosionsfähiger Atmosphäre durch das Wirksamwerden einer heißen Oberfläche als Zündquelle. 5.2.1 Hinweise für die Gefährdungsbeurteilung (1) Kommt explosionsfähige Atmosphäre mit heißen Oberflächen (heiße Rohrleitungen, Heizkessel usw.) in Berührung, kann es zu einer Entzündung kommen. (2) Grundlage der Bewertung ist die genormte Zündtemperatur der die explosionsfähige Atmosphäre bildenden Stoffe. Es ist jedoch zu berücksichtigen, dass die Zündfähigkeit einer heißen Oberfläche u. a. von der Art und der Konzentration des jeweiligen Stoffes im Gemisch mit Luft, von Größe und Gestalt des heißen Körpers und vom Wandmaterial abhängt. Bemerkung 1: Explosionsfähige Atmosphäre kann z. B. im Inneren größerer erhitzter Räume durch heiße Wände mit deutlich niedrigerer Temperatur als die der Norm- Zündtemperatur des Brennstoffs entzündet werden. 2 AUSGANGSSITUATION Die Bestimmungsverfahren nach ASTM E 659 [4] und nach IEC 60079-20-1 [2]1 berücksich- tigen die Volumenabhängigkeit der Zündtemperatur. IEC 60079-20-1 ‚Wenn die Notwendigkeit besteht, den Einfluss des Volumens auf die Zündungstemperatur genau zu kennen, können zusätzliche Versuche in größeren (oder kleineren) Volumina der gleichen Form und aus dem gleichen Werkstoff durchgeführt werden. Daten aus der Literatur zeigen eine Abnahme der Zündungstemperatur mit zunehmendem Volumen, wobei gleichzeitig die Zündverzugszeit zunimmt. ASTM E 659 X2. EFFECT OF VOLUME ON AIT (Auto Ignition Temperature) X2.1 Numerous investigators have noted that the larger the test vessel the lower is the autoignition temperature. Thus, caution is indicated in applying the temperatures derived by this method to practical situations. X2.2 The determination of the vessel volume effect involves repeating these procedures in three or more test volumes, such as 250, 500, 1000 and 5000 ml, of the same geometry. A plot of autoignition temperature versus logarithm of the vessel volume can be helpful in estimating the AITs at other volumes. Dies ist jedoch recht zeitaufwändig und für Volumina über 0,02 m³ nicht praktikabel. Tabelle 1 und Abbildung 1 fassen die bislang vorhandenen Literaturdaten [6, 7, 8, 9] zusammen.

1 Neuausgabe wird unter der Nummer ISO IEC 80079-20-1 erscheinen.

3

Tab. 1: Volumenabhängigkeit der Zündtemperatur nach [6, 7, 8, 9] 0,008 0,035 0,2 0,5 1 2 5 12 20 Benzol 668 619 570 559 Toluol 649 584 538 519 482 Aceton 676 570 519 491 467 Essigsäure 611 544 505 488 464 Methanol 498 473 441 428 386 Ethanol 495 443 402 388 391 363 Butandiol 505 447 398 Isobutyrsäureanhydrid 362 345 337 330 323 Cyclohexan 271 266 265 n-Pentan 295 273 261 250 252 242 Diethylether 212 197 180 170 160 CS2 151 127 120 110 90 Octan 209 205 203 192 Decan 204 200 199 185 Harz 253 239 250 252 Kerosin 282 264 227 220 203 205 Substanz Gefäßvolumen /l Zündtemperatur °C

Abb. 1: Literaturwerte zur Volumenabhängigkeit der Zündtemperatur Für diese Messreihen wurden zur Umgebung offene Gefäße verwendet, denn der Großteil dieser Messreihen [6] wurde im Zusammenhang mit der Erarbeitung der heute genormten Bestimmungsverfahren der Zündtemperatur bei Umgebungsbedingungen durchgeführt. Deutlich erkennbar ist der Einfluss vor allem bei Volumina kleiner 0,2 l. Dies ist der Grund dafür, dass die genormten Bestimmungsverfahren als (Mindest-)Volumen für das Prüfgefäß 0,2 l vorschreiben. 0 2 4 0 100 200 300 400 500 600 700 Entzündungstemperatur / °C

log (V/ml) Aceton [6] Benzen [6] Toluen [6] Essigsäure [6] Ethylglycol [6] Methanol [6] Ethanol [6] Pentan [6] Diethylether [6] CS2 [6]

Cyclohexan [7]

Isobuttersäureanhydrid [8] Kerosin [9] Decan [9] Harz [9] Octan [9] 200 ml

4

Da bei diesen Versuchsreihen zum Teil andere Gefäßformen als in den genormten Verfahren verwendet wurden, unterscheiden sich die in der Spalte `0,2‘ der Tabelle 1 angegebenen Entzündungstemperaturen trotz gleichen Behältervolumens teilweise von den tabellierten Werten [10]. Die logarithmische Darstellung der Literaturdaten [6, 7, 8, 9] erlaubt eine lineare Korrelation (Abb. 1). Die Steigung der einzelnen Geraden (absolut oder prozentual) ist allerdings nicht identisch. Tabelle 2 zeigt beispielhaft, dass es eine vergleichbare Volumenabhängigkeit auch für Entzündungstemperaturen im geschlossenen Gefäß (untersuchte Volumina 0,3 l und 1 l) gibt. Tab. 2: Volumenabhängigkeit der Zündtemperatur; geschlossenes Gefäß [11]. 0,3 1 n-Propylpropionat 312 277 n-Heptan 220 207 n-Butylacetat 265 248 Hexanon-2 214 201 Heptanon-3 207 183 Heptanon-2 215 187 Ethylhexanoat 245 222 Cyclohexan 270 239 Dioxan-1,4 230 212 Substanz Gefäßvolumen /l Zündtemperatur °C

Beerbower [5] schlägt, basierend auf den experimentellen Daten aus den Messreihen von Setchkin [6], eine Extrapolation für große, in der Industrie übliche Volumina nach folgendem Zusammenhang vor:

    − − −

+

1 log 12 2 log 12 ) 75 ( 75 10 10 1 2 V V Tz Tz V V

Gl. 1 Mit Tz V2: Zündtemperatur im Volumen 2 TzV1: Zündtemperatur im Volumen 1 V1: Volumen 1 V2: Volumen 2 Mit diesem logarithmischen Zusammenhang erhält man konvergierende Geraden unter- schiedlicher Steigung, die bei 75°C zusammenlaufen. Sie sind naturgemäß umso steiler, je höher die Entzündungstemperatur in kleinen Gefäßen ist. Da diese Beerbower-Korrelation durch keinerlei Messungen in Volumina größer als 20 l belegt ist, greift die TRBS 2152, Teil 3 [12] in Kapitel 5 ‚Vermeiden des Wirksamwerdens von Zündquellen‘ auch nicht darauf zurück, um Grenzwerte für sichere Temperaturen großer Behälter abzuschätzen. 2.1 Forschungsziel Das Ziel dieser Projekte (BGRCI-Forschungsvorhaben ‚Zündtemperaturen in großen Behältern; Projekt – Volumina bis 20 l‘ und DGUV-Forschungsvorhaben ‚Zündtemperaturen in

5

großen Behältern; Projekt – Volumina bis 0,5 m³‘) ist es, eine Basis für die Beurteilung zu erhalten, in wieweit Extrapolationen (zum Teil aus der Literatur bekannt) von Zündtempera- turdaten die in kleinen Volumina bestimmt wurden, auf größere Volumina sicherheitstechnisch vertretbar sind. Ziel ist es, mit den experimentell ermittelten Daten aus beiden in direktem Zusammenhang stehenden Projekten sowohl das Ausmaß der Erniedrigung der Entzündungstemperatur als auch das Ausmaß der Verlängerung der Zündverzugszeit in Abhängigkeit des Behälter- volumens zu beurteilen und Abschätzverfahren für diese beiden Aspekte zu erarbeiten bzw. existierende Abschätzverfahren zu überprüfen und gegebenenfalls zu modifizieren. Darüber hinaus wäre auch eine Konkretisierung der Bemerkung 1 zu 5.2 Heiße Oberflächen der TRBS 2152, Teil 3 möglich. 3 METHODIK Als Methodik wurde gewählt die Ergebnisse der in diesem Forschungsprojekt durchgeführten exemplarischen experimentellen Untersuchungen mit berechneten/abgeschätzten Werten zu vergleichen. In Rahmen des BGRCI-Forschungsvorhabens ‚Zündtemperaturen in großen Behältern; Pro- jekt – Volumina bis 20 l‘ wurden an Substanzen und binären Substanzgemischen exemplarische Messungen in Volumina von 0,005 m³ und 0,02 m³ durchgeführt. Im Rahmen des DGUV-For- schungsvorhabens ‚Zündtemperaturen in großen Behältern; Projekt – Volumina bis 0,5 m³‘ wurden an Reinstoffen exemplarische Messreihen in Volumina von 0,16 m³ und 0,5 m³ durch- geführt. Die untersuchten Substanzen und Substanzgemische waren nach Möglichkeit für beide Forschungsvorhaben identisch. Die erhalten experimentellen Daten wurden verglichen mit Daten, die mit Hilfe aus der Literatur bekannter Korrelationen aus den tabellierten Zündtempe- raturen abgeschätzt wurden. 3.1 Untersuchte Substanzen Die zu untersuchenden Substanzen und binären Substanzgemische wurden nach Rück- sprache mit dem Forschungsbegleitkreis und unter Berücksichtigung der apparativen Rand- bedingungen ausgewählt. Für die in Tabelle 3 aufgeführten Substanzen wurden Messreihen in Gefäßen mit 0,005 m³, 0,02 m³, 0,16 m³ und 0,5 m³ durchgeführt, wobei aufgrund der apparativen Gegebenheiten nicht alle Substanzen in allen Volumina untersucht werden konnten. Außerdem wurden für folgende exemplarische Gemische brennbarer Substanzen bei unter- schiedlicher Zusammensetzung Messreihen im 0,005 m³-Gefäß durchgeführt: n-Hexan + Hexanol-1 n-Hexan + n-Butylacetat n-Hexan + Cyclohexanon n-Hexan + Butanon-2 n-Hexan + p-Xylol n-Heptan + Methylpropionat Octanol-1 + n-Pentylacetat n-Propanal + Propionsäure Dioxan-1,4 + Wasser n-Butylamin + Wasser

6 Tab. 3:Untersuchte Reinstoffe Substanz Tz nach Norm Untersuchte Volumina m³

°C 0,005 0,02 0,16 0,5 Kohlenwasserstoffe Cyclopentan 320 X

Penten-1 280 X

n-Pentan 260 X

Cyclopenten 309 X

Cyclohexan 260 X X

X n-Hexan 230 X X X X Methylcyclopentan 315 X

n-Heptan 220 X X X

n-Octan 205 X

Cyclooctan 250 X

Octadien-1,7 249 X

Octin-1 236 X

n-Decan 200 X

n-Dodecan 200 X X X X Decalin (cis,trans) 235 X X X

Alkohole n-Butanol 325 X X

n-Pentanol 320 X X X

i-Pentanol 340 X

4-Methylpentanol-2 335 X

n-Hexanol 280 X

n-Heptanol 275 X

n-Octanol 245 X X

X Ethoxyethanol 235 X

Butoxyethanol 240 X

Aldehyde n-Propanal 190 X

n-Butanal 190 X

n-Pentanal 205 X

Benzaldehyd 190 X

Ether Dioxan-1,4 375 X X X X Dioxolan-1,3 245 X X X

Diethoxyethan 175 X

Diethylether

X Diisopropylether 405 X

Dipentylether 180 X

Tetrahydrofuran 230 X X X X

7 Substanz Tz nach Norm Untersuchte Volumina m³

°C 0,005 0,02 0,16 0,5 2-Methyltetrahydrofuran 270 X

X

2,4,6-Trimethyltrioxan- 1,3,5 (Paraldehyd) 204 X

Dipropylenglykoldimethyl- ether (Isomerengem.) 159 X X

X 2H-3,4-Dihydropyran 245 X

Ketone Pentanon-2 445 X

Pentanon-3 455 X

Hexanon-2 420 X

Heptanon-2 305 X

Heptanon-3 410 X X

Heptanon-4 420 X

Octanon-2 295 X

Nonanon-2 240 X

Nonanon-5 330 X

Acetylaceton 340 X X X

Ester Butylformiat 265 X

n-Butylacetat 395 X X X X n-Pentylacetat 350 X X X X i-Pentylacetat 380 X X

Hexylacetat 265 X

Cyclohexylacetat 334 X

Butylbutyrat 395 X

n-Butylpropionat 405 X

Ethylvalerat 400 X

Ethylhexanoat 395 X X X X 2-Butoxyethylacetat 350 X

2-(2-Butoxyethoxy)-ethyl- acetat 295 X

Methylacetoacetat 280 X

Carbonsäuren Octansäure 245 X

Heptansäure 255 X

Stickstoffhaltige n-Butylamin 310 X

Morpholin 275 X X

N-Methylpyrrolidon-2 265 X

8 3.2 Allgemeine Verfahrensweise Nachfolgend sind die für alle durchgeführten Versuchsreihen einheitlichen Aspekte (Durchführung, Datenerfassung, Auswertung) beschrieben. Individuelle apparatur- spezifische Aspekte sind bei den jeweiligen Versuchseinrichtungen beschrieben.

Abb. 2: Größenvergleich der verwendeten Gefäße: 1: 0,2 l-Erlenmeyerkolben (Normgefäß); 2: 5 l-Erlenmeyerkolben, 3: 20 l-Gefäß; 4: 160 l-Gefäß; 5: 0,5 m³-Gefäß

1 4 3 2 1 5

9 3.2.1 Durchführung Vor jedem Versuch wurde das Versuchsgefäß mehrfach mit Druckluft gespült. Ruß- ablagerungen wurden nur bei Bedarf entfernt. Lediglich der 5 l-Erlenmeyerkolben wurde regelmäßig gereinigt, wenn die sich an der Innenoberfäche bildende Rußschicht die Sicht auf die Flamme behinderte. Aufgrund der Temperaturträgheit der großen Gefäße aus Stahl (0,02 m³, 0,16 m³, 0,5 m³) war es nicht möglich, Zündtemperaturen in diesen Gefäßen- wie in den genormten Verfahren gefordert - auf 2 K genau zu bestimmen. Die Schrittweite bei den Versuchs- reihen in diesen Gefäßen betrug 4 K- 5 K. Infolge der niedrigen Versuchs- und Zündtemperaturen war bis zu einer Zündung häufig viel mehr Zeit als die in den Normverfahren vorgeschriebenen 5 min erforderlich. Falls keine Zündung auftrat, wurde ein Versuch daher nicht nach einer vorgegebenen Zeit beendet. Vielmehr wurde abgewartet, bis der durch stille Oxydationsreaktionen verursachte Temperaturanstieg beendet war (Abb. 3). In Einzelfällen konnte dies zu einer Versuchsdauer von über einer Stunde führen. Aus diesen Gründen wurden keine Wiederholungsmessungen durchgeführt.

Abb. 3: Beendigung eines Versuchs:

1. nach Auftreten einer kalten Flamme (rote Linie)
2. nach Ende einer stillen Oxydationsreaktion (schwarze Linie).

Beispiel: Cyclohexan bei 230°C im 5l-Kolben, unterschiedliche Brennstoffmengen

Für die Versuchsreihen wurden keine vorgemischten Brennstoff/Luft-Gemische ein- gesetzt. Bei allen Versuchsreihen wurde der Brennstoff kalt und in flüssiger Form in diskreten Portionen in das Versuchsgefäß dosiert. Dies entspricht (bis auf die längere Zeitdauer) der Vorgehensweise wie sie in den Normverfahren beschrieben ist. Dabei wird zumindest anfänglich eine inhomogene Verteilung des Brennstoffs im Gefäß erzeugt. Der 0 100 200 300 400 500 600 700 800 900 1000 1100 1200 220 230 240 250 260 270 280 290 Temperatur oberes Thermoelement [°C] Zeit [s] Dosis: 3ml: keine Zündung Dosis: 3,5ml: kalte Flamme

10 vor dem Einsetzen der eigentlichen Zündung gemessene Temperaturanstieg war daher für jedes Thermoelement unterschiedlich (am schwächsten meist am oberen). Sofern "Brennstoffkonzentrationen" bei den Versuchen in geschlossenen Gefäßen angegeben sind, sind dies Nominalwerte, die nicht auf eine homogene Verteilung des Brennstoffes im Explosionsgefäß schließen lassen. Da zum einen aus den Versuchsreihen in offenen Gefäßen nicht auf die kritische Konzentration bei der die Zündung bei der niedrigsten Temperatur eintritt, geschlossen werden kann, und zum Anderen nicht davon ausgegangen werden kann, dass diese ‚kritische‘ Konzentration unabhängig vom Gefäßvolumen ist, wurden bei jeder Temperatur mehrere Versuche mit unterschiedlichen nominalen Brennstoffkonzentrationen durchgeführt. Begonnen wurde jeweils mit der Nominalkonzentration des nächstkleineren Gefäßes. Die Versuchsreihen wurden teilweise bis zu Nominalkonzentrationen von 60 Vol.-% ausgedehnt. Das Abgas wird über Filter geführt, um den größten Teil der Reaktionsprodukte / des unverbrannten Gemisches abzuscheiden. Die Steuerung der Versuchseinrichtung und des Versuchsablaufs bei den Gefäßvolumina 0,02 m³, 0,16 m³ und 0,5 m³ erfolgt aus Sicherheitsgründen aus einem Nebenraum 3.2.2 Modifizierte Durchführung zur Untersuchung "homogener" Gemische Im 0,02 m³- und 0,16 m³-Gefäß wurden für einige Stoffe Versuchsreihen durch- geführt, bei denen die Gemischherstellung zu Beginn des Versuches verändert wurde, um ein möglichst homogenes Gemisch zu erhalten und damit einen möglichen Einfluß der Gemischhomogenität auf die Zündtemperatur feststellen zu können. Hierzu wurde in das bis auf einen Restdruck (0,01 bar - 0,03 bar) evakuierte Reak- tionsgefäß zunächst die brennbare Flüssigkeit eingespritzt. Nach ihrer vollständigen Verdampfung wurde dann Luft rasch bis zum Normaldruck eingelassen. Durch die Verwendung eines Düsenkopfes wurde die schnelle Durchmischung weiter gefördert. Dieses Verfahren garantiert zwar auch keine vollständige Homogenität der Atmos- phäre zu Versuchsbeginn, die Konzentrationsunterschiede sollten aber wesentlich kleiner als bei dem Standardverfahren sein.

1. 2.3 Datenerfassung

Da bei den großen Gefäßen aus Stahl eine visuelle Beobachtung der Entzündung nicht möglich war, waren alle für die Versuchsreihen eingesetzten Gefäße mit jeweils 3 Ni-CrNi- Thermoelementen ausgestattet. Sie waren im Gefäß in unterschiedlichen Höhen angebracht. Die bei den Gefäßvolumina 0,005 m³, 0,02 m³ und 0,16 m³ verwendeten Mantelthermoelemente mit 0,5 mm Durchmesser geben dabei den Temperaturverlauf nahezu unverzerrt wieder, sodass die Angabe von Maximaltemperaturen und der maximalen Temperaturanstiegsgeschwindigkeiten während einer Zündung möglich ist. Für das 0,5 m³-Gefäß wurden Thermoelemente mit einem Durchmesser von 3 mm verwendet, da Thermoelemente mit geringerem Durchmesser bei Zündung beschädigt werden. Damit war nur die Messung der Starttemperatur sinnvoll. Maximaltemperaturen maximalen Temperaturanstiegsgeschwindigkeiten während einer Zündung konnten damit

11 nicht ermittelt werden, wohl aber konnte eine Zündung qualitativ registriert werden. In geschlossenen Gefäßen wurden ferner piezoresistive Druckaufnehmer eingesetzt, die eine für die untersuchten Reaktionen ausreichend kleine Zeitkonstante aufweisen. Bei den Gefäßvolumina 0,005 m³, 0,02 m³ und 0,16 m³ war teilweise über einen Lichtleiter eine Photodiode angeschlossen. Sie wurde entweder direkt oder über einen Transimpedanzverstärker ausgelesen. In beiden Fällen spricht die Photodiode bei kalten Flammen praktisch nicht an, was u.a. als Unterscheidungsmerkmal zwischen kalten und heißen Flammen verwendet werden kann. Eventuelle Rußablagerungen auf dem Lichtleiterende hatten auf das Diodensignal nur einen geringen Einfluss. 3.2.4 Meßdatenauswertung Die Datenerfassung erfolgte elektronisch mittels der Software LABVIEW (Ausnahme: 0,5 m³-Gefäß), die Auswertung mittels der Software ORIGIN. Die Erfassungsrate betrug 10 Werte/s für die Temperatur und 100 Werte/s für die Druck- und Photodiodensignale. Als Starttemperatur wurde der Mittelwert der Temperaturen an den beiden unteren Thermoelementen vor Beginn der Probenzugabe gewertet Diese Temperaturen unter- schieden sich meist um weniger als 1 K. Für jedes Thermoelement wurde der maximale Temperaturanstieg ∆T und die maximale Temperaturanstiegsgeschwindigkeit dT/dtmax berechnet. Analog wurde mit dem Drucksignal verfahren. Falls vorhanden, wurde das Photodiodensignal mit herangezogen. 3.2.5 Messreihen Aufgrund der verwendeten Apparaturen konnten nur solche Stoffe untersucht werden, deren Zündtemperatur in diesen Apparaturen 350 °C oder weniger betrug. Es können aber viele Stoffe mit einer Normzündtemperatur deutlich über 350°C vermessen werden, da ihre Zündtemperatur in größeren Gefäßen niedriger liegt (z. B Butanon-2: Tz: 475 °C). Auf die Untersuchung von bekanntermaßen stark rußenden Stoffen wie Aromaten wurde verzichtet, da Probleme mit Rußablagerungen erwartet wurden. Ebenso wurden keine Versuche mit halogen- oder schwefelhaltigen Verbindungen durchgeführt. 3.3 0,005 m³-Gefäß (5l-Erlenmeyerkolben) 3.3.1 Versuchsaufbau Zur Beurteilung des Volumeneinflusses ist es besonders wünschenswert, den Ver- suchsaufbau der Normzündtemperatur mit einem größeren Zündgefäß möglichst genau zu replizieren. Zu diesem Zweck wurden umfangreiche Versuche in einem 5 l- Erlenmeyerkolben, der sich in einem Wärmeschrank (Abb. 4) befand, durchgeführt. Der Hals des Kolbens reichte durch die obere Öffnung des Wärmeschranks bis zu dessen oberer Kante. Die drei Ni-CrNi-Themoelemente (Durchmesser: 0,5 mm) sowie ein Rohr, über das der Kolben nach jedem Versuch mit Druckluft gereinigt werden konnte, waren über die Öffnung des Kolbenhalses in den Erlenmeyerkolben eingeführt. Die Thermoelemente endeten 1 cm über dem Boden, auf halber Höhe des Kolbens und 5 cm unterhalb des Kolbenhalses. Bei den meisten Versuchen wurde darüber hinaus die

12 Flammenerscheinung mittels einer Photodiode registriert. Der verwendete Diodentyp (BPX60) zeichnet sich durch eine relativ hohe Empfindlichkeit auch im blauen Bereich des Spektrums (lt. Datenblatt bei 400 nm noch 40% der Maximalempfindlichkeit) aus. Durch ein Fenster im Wärmeschrank konnten die Vorgänge im Kolben außerdem visuell verfolgt werden. Bei entsprechender Abdunkelung konnten auch kalte Flammen mit bloßem Auge beobachtet werden. Diese Beobachtungen wurden als Text in der Datei des Versuchs mit aufgezeichnet. Der Versuchsaufbau konnte bis zu Temperaturen von 295 °C eingesetzt werden.

Abb. 4: Versuchsaufbau 5l-Erlenmeyer 3.3.2 Durchführung Der zu untersuchende Stoff wurde mittels einer Dosierpumpe mit einer Rate von ca.2 l/h dosiert. Dies entspricht den Vorgaben der standardisierten Prüfverfahren. Dosiervorgänge dauerten daher bis zu 15 s. 3.3.3 Allgemeine Beobachtungen Durch die Möglichkeit der visuellen Beobachtung konnte in jedem Falle zwischen heißen und den häufig auftretenden kalten Flammen [13] unterschieden werden. Während heiße Flammen helle, gelbe Lichterscheinungen ergaben (häufig von einem mehr oder weniger lauten Knall begleitet), waren kalte Flammen dunkelblau und nur (nach Adaption des Auges) im Dunkeln sichtbar. Besonders bei höheren Brennstoffkonzentrationen wurden bei "heißen" Zündungen oft Nachbrände im Kolben oder auch oberhalb des Halses beobachtet, die einige Sekunden andauern konnten. An der Photodiode ergaben nur heiße Flammen ein deutliches Signal. Bei Verwendung des Transimpedanzverstärkers wurden Ströme von mindestens 1 µA - meistens mehr als 10 µA – gemessen. Das Signal kalter Flammen lag meistens unterhalb der Nachweisgrenze (ca. 0,1 nA), in seltenen Fällen konnten schwache Signale < 1 nA detektiert werden (Abb. 5).

13 Der Temperaturanstieg konnte ebenfalls mit den visuellen Beobachtungen korreliert werden (Abb. 5). Aufgrund der Temperaturdaten wurden kalte und heiße Flammen wie folgt unterschieden: heiße Flamme: ∆T > 200 K und (dT/dt) > 200 K/s; kalte Flamme: 50K < ∆T < 150 K und 20 K/s< (dT/dt) < 150 K/s.

Abb. 5: Temperatur- (halbe Höhe) und Photodiodensignal bei heißen und kalten Flammen Beispiel: Nonanon-5 bei 234°C und zwei unterschiedlichen Konzentrationen Die bei heißen Flammen gemessenen Werte liegen dabei weit von diesen Grenzen entfernt, sodass eine eindeutige Zuordnung möglich ist. Bei heißen Flammen wurden absolute Temperaturanstiege von über 400 K und Temperaturanstiegsgeschwindigkeiten von mehr als 1000 K/s gemessen. Bei allen untersuchten Stoffen waren folgende Tendenzen zu beobachten:  Bei konstanter Temperatur war die Zündung umso heftiger, je niedriger die Brennstoffkonzentration war (die nominelle Konzentration lag stets im fetten Bereich). Bei hohen Konzentrationen wurden daher meist nur kalte Flammen beobachtet. Aber  Je niedriger die Temperatur war, umso höher mußte die Brennstoffkonzen- tration sein, bei der überhaupt noch eine Zündung auftrat. Neigt die Substanz zur Ausbildung kalter Flammen, konnte auch das Phänomen des ‚negativen Temperaturkoeffizienten‘ – die beiden Entzündungsregime ‚heiße Flamme‘ und ‚kalte Flamme‘ sind durch ein Temperaturminimum (siehe ∆T / t-Diagramm Abb. 6) klar voneinander getrennt [14] - beobachtet werden. Ein Beispiel zeigt Abb. 6. Zwischen 225 °C und 220 °C nehmen der absolute Temperaturanstieg und die Temperaturanstiegs-ge- schwindigkeit stark ab. Weitere Abnahme der Ausgangstemperatur führt jedoch zunächst wieder zu (leicht) erhöhten Temperaturanstiegen und Temperaturanstiegsgeschwindig- keiten (die Flamme bleibt jedoch ‚kalt‘), bis die Signale bei 170 °C schließlich fast verschwinden. Das Verschwinden des Photodiodensignals sowie visuelle Beobachtungen zeigen den Übergang von heißer zu kalter Flamme an. 0 5 10 15 20 25 30 220 260 300 340 380 420 460 500 540 580 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 Photodiodensignal heiße Flamme kalte Flamme t / s T / °C Temperaturverlauf heiße Flamme kalte Flamme IPhotodiode / nA

14

Abb. 6: Negativer Temperaturkoeffizient (Nonanon-5) im 5 l-Erlenmeyerkolben 3.3.4 Spezielle Phänomene Bei einigen Stoffen kommt es jedoch bei bestimmten Temperaturen zu Zwischenzustän- den zwischen kalter und heißer Flamme. Ein Beispiel zeigt Abb. 7. Am Rand einer kalten Flamme bildet sich ein gelber "Hut". Die Photodiode zeigt in solchen Fällen nur ein Signal von wenigen nA, Temperaturanstieg und maximale Temperaturanstiegsgeschwindigkeit liegen im Grenzbereich zwischen kalter und heißer Flamme. Solche Phänomene werden als heiße Flamme gewertet. Bei den Versuchen konnten zwei in der Literatur häufig erwähnte, aber meist nur durch Temperatur- oder Druckkurven verifizierte Phänomene direkt beobachtet werden.

Abb. 7: Zündung von Octanon-2 bei 215 °C: Kalte Flamme mit gelbem Rand

Regelmäßig beobachtet wurden Zweistufenzündungen [13], bei denen sich zunächst eine kalte Flamme ausbildet, die dann in eine heiße Flamme umschlägt (Abb. 8). In einigen Fällen lag zwischen dem Auftreten der kalten Flamme und der heißen Flamme ein ausreichender Zeitraum, sodass trotz der Lichtschwäche der kalten Flammen der Verlauf der Zündung photographisch dokumentiert werden konnte. Wie Abb. 8 zeigt, vergehen vom Erscheinen der kalten Flamme bis zum Umschlag in eine heiße Flamme mehr als 2 s. Besonders am mittleren der drei Thermoelemente ist ein deutlicher Absatz 160 180 200 220 240 260 0 100 200 300 400 500 heiße Flamme: Thermoelement Unterkante Hals Thermoelement halbe Höhe Thermoelement halbe Höhe Diodensignal kalte Flamme Thermoelement Unterkante Hals Thermoelement halbe Höhe Thermoelement halbe Höhe Diodensignal Nichtzündung Thermoelement Unterkante Hals Thermoelement halbe Höhe TGefäß / °C ∆Tmax / K 0 200 400 600 800 1000 (dT/dt)max / K/s 0,2 1 10 100 1000 10000 IPhotodiode / nA

15 bei ca. 100 K Temperaturerhöhung erkennbar. Erst wenn die Temperatur weiter steigt, spricht auch die Photodiode an.

Abb. 8: Temperaturverlauf und Photodiodensignal beim Umschlag einer kalten Flamme in eine heiße (Cyclohexylacetat bei 294 °C) Die optische Beobachtung (Abb. 9) entspricht diesem Ergebnis. Mehr als zwei Sekunden wabert eine schwache blaue Flamme im Kolben, bis sie dann plötzlich in eine sehr viel hellere gelbe Flamme umschlägt.

Abb. 9: Verlauf einer Zweistufenzündung (Cyclohexylacetat bei 294 °C) Abstand der Bilder: ca. 0,5 s In seltenen Fällen (z.B. Heptanon-3) konnten repetierende kalte Flammen beobachtet werden. Möglicherweise treten solche Flammen häufiger auf, wurden aber nicht beobachtet, da die Versuche normalerweise nach dem Erlöschen der ersten Flamme beendet wurden. Das Temperaturdiagramm weist elf Maxima auf (Abb. 10), die den mit bloßem Auge beobachteten elf kalten Flammen entsprechen.

20 21 22 23 24 25 26 27 28 29 30 280 300 320 340 360 380 400 420 440 460 480 500 Temperatur am Hals Temperatur Mitte Photodiode (gegl.) t / s T in °C 0 2 4 6 8 10 IPhotodiode Einsatz der kalten Flamme Umschlag in heiße Flamme

16

Abb. 10: Repetierende kalte Flammen: Heptanon-3 bei 272 °C 3.3.5 Messergebnisse Die im 5l-Erlenmeyerkolben erhaltenen Zündtemperaturen (Tz 0,005) sind in Tab. 4 zusammengefasst. Tz0,005 liegt stets unter der jeweiligen Normzündtemperatur (Tz). Falls es unterhalb Tz0,005 noch einen größeren Temperaturbereich gibt, in dem kalte Flammen beobachtet wurden, ist die untere Grenze dieses Bereiches als "Kaltflammentemperatur" TkF 0,005 mit aufgeführt. Tab. 4: Im 0,005 m³-Gefäß untersuchte Reinstoffe: Vergleich von Tz 0,005 mit Tz.

Substanz TZ °C Tz 0,005 °C TKF 0,005 °C Tz 0,005 - TZ K Kohlenwasserstoffe n-Heptan 220 206 -14 Cyclohexan 260 231 -29 Cyclopentan 320 219 -101 Decalin (cis,trans) 235 213 -22 n-Hexan 230 206 -24 Methylcyclopentan 315

<-81 n-Octan 205 190 -15 Octadien-1,7 249 239 -10 Octin-1 236 215 -21 Penten-1 280 <=246 <-34 n-Pentan 260 249 239 -11 Cyclopenten 309 257 -52 Cyclooctan 250 229 -21 n-Decan 200 190 185 -10 n-Dodecan 200 187 13 Ether 1,4-Dioxan 375 198 188 -177 Dioxolan-1,3 245 218 -27 0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 250 260 270 280 290 300 310 320 330 340 350 360 370 380

T / °C t / s Unterkante Hals halbe Höhe unten

17 Substanz TZ °C Tz 0,005 °C TKF 0,005 °C Tz 0,005 - TZ K Diethoxyethan 175 157 -18 Diisopropylether 405

300

145

105

2-Methyltetrahydrofuran 270 224 205 46 Tetrahydrofuran (THF) 230 225 220 -5 2,4,6-Trimethyltrioxan-1,3,5 (Paraldehyd) 204 168 -36 2H-3,4-Dihydropyran 245 222 -23 Diamylether 180 168 -12 Dipropylenglykoldimethylether (Isomerengem.) 159 146 143 -13 Alkohole n-Butanol 325

300

271

-25

Ethoxyethanol 235 212 -23 Butoxyethanol 240 218 -22 n-Heptanol 275 257 -18 n-Hexanol 280 261 -19 i-Pentanol 340

300

272

-40

n-Octanol 245 244 -1 n-Pentanol 320 271 261 -49 4-Methylpentanol-2 335 292 258 -43 Triethylenglykol 370 263 234 -107 Ester n-Butylacetat 395

300

242

-95

n-Pentylacetat 350 237 226 -113 Ethylhexanoat 395 238 213 -137 n-Butylbutyrat 395 257 239 -138 n-Butylformiat 265 259 245 -6 n-Butylpropionat 405

300

241

-105

Cyclohexylacetat 334 278 232 -56 Ethylpentanoat 400

300

239

-100

n-Hexylacetat 265 228 219 -37 i-Pentylacetat 380 285 254 -95 2-Butoxyethylacetat 350 198 188 -152 2-(2-Butoxyethoxy)ethylacetat 295 188 -107 Methylacetoacetat 280 249 -31 Ketone Hexan-2-on 420

300

209

-120

Heptan-3-on 410

300

175

-110

Heptan-2-on 305 260 175 -45 Acetylaceton 340

300

263

-40

Nonanon-5 330 225 169 -105 Heptanon-4 420

300

187

-120

Octanon-2 295 221 180 -74 Nonanon-2 240 206 183 -34 Pentanon-2 445

300

247

-145

Pentanon-3 455

300

228

-155

18 Substanz TZ °C Tz 0,005 °C TKF 0,005 °C Tz 0,005 - TZ K Aldehyde Benzaldehyd 190 179 -11 n-Butanal 190 185 -5 n-Pentanal 205 191 -14 Propanal 190 189 -1 Carbonsäuren Octansäure 245 229 213 -16 Heptansäure 255 244 223 -11 Stickstoffhaltige Verbindungen n-Butylamin 310 279 -31 Morpholin 275 266 -9 N-Methylpyrrolidon-2 265 220 -45

Dies ist jedoch nicht bei allen untersuchten Substanzklassen zu beobachten. Reine Koh- lenwasserstoffe zeigen Kaltflammentemperaturen die nur geringfügig unter Tz0,005. Der Volumeneinfluss auf die Zündtemperatur bei einem Volumen von 0,005 m³ (Tz0,005) ist, mit Ausnahmen von Cyclopentan und Cyclopenten gering. Dagegen gibt es bei Estern und Ketonen sehr häufig große Unterschiede zwischen der Normzündtemperatur und Tz0,005 und/oder der Normzündtemperatur und der Kaltflammentemperatur im 5l-Erlenmeyerkol- ben. Der erste Effekt kann nicht immer ausreichend quantifiziert werden, da die Zündtem- peratur oft auch im 5l-Erlenmeyerkolben noch über 295 °C liegt. Dagegen wird der zweite Effekt in dieser Substanzklasse fast durchgängig beobachtet. Bei Ethern und Aldehyden werden beide Effekte nur bei Diisopropylether und 1,4-Dioxan und in geringerem Maße bei Methyltetrahydrofuran und Paraldehyd (Trimethyltrioxan) beobachtet. Letzteres ist die einzige untersuchte Substanz mit einer Normzündtemperatur unter 250 °C, bei der eine deutlich tiefere Zündtemperatur (168 °C) im 5l- Erlenmeyerkolben gefunden wurde. Aus der Beerbower-Beziehung ergibt sich zwischen beiden Zündtemperaturen (Normzündtemperatur TZ und der Zündtemperatur im 5L-Erlenmeyerkoben TZ 0,005) folgende Abhängigkeit:

b T T Z Z +

⋅

89 ,0 005 ,0 mit b = 8,26 °C Gl. 2 Bis zu einer Normzündtemperatur von ca. 320 °C liegen die gemessenen Tz0,005 für die meisten untersuchten Stoffe in Nähe der durch Gl. 2 beschriebenen Geraden. In Abb. 11 ist diese Gerade gestrichelt dargestellt. Alternativ kann eine Ausgleichsgerade berechnet werden (durchgezogene Linie). Für ihre Berechnung wurden Stoffe mit einer Normzünd- temperatur von mehr als 320 °C nicht berücksichtigt, da dann die Zündtemperatur im 5l- Erlenmeyerkolben nur, wenn sie viel tiefer als die Normzündtemperatur lag, bestimmt werden konnte (orange Punkte in Abb. 11). Ebenso wurden einige "Ausreißer" nicht berücksichtigt. Es ergibt sich dann folgende Beziehung:

) 94 ,0 ( ) 04 ,0 ( 78 ,0 005 ,0 ≈ + ⋅

±

r d T T Z Z

Gl. 3. mit d = 32 ± 11 °C

19

Abb. 11: Zündtemperaturen von Reinstoffen: Vergleich Tz 0,005 mit Tz Nach Abb. 11 kann für die meisten Stoffe mit einer Normzündtemperatur Tz unterhalb von 300°C die Volumenabhängigkeit der Zündtemperatur näherungsweise mit Gl. 2 oder Gl. 3 beschrieben werden. Dies gilt nicht für Stoffe mit einer Normzündtemperatur von mehr als 300°C, da deren Zündtemperatur im 5 l-Gefäß häufig weit von den berechneten Werten zur unsicheren Seite abweicht. Neben Reinstoffen wurden auch Gemische untersucht, um den Einfluss der Gemischzu- sammensetzung zu verfolgen. Wenn für beide Gemischkomponenten die Beerbower- Beziehung anwendbar ist, so folgen auch deren Gemische dieser Korrelation (Abb. 12).

Abb. 12: n-Hexan+Hexanol-1: Vergleich der experimentellen Werte Tz, Tz 0,005 und der nach Beerbower berechneten Zündtemperatur für V= 0,005 m³

Ist eine Berechnung der Zündtemperatur bei beiden Gemischkomponenten nach Beerbower nicht möglich, ist dies auch für ihre Gemische nicht der Fall. Interessant ist der Fall, bei dem die Beerbower-Beziehung nur für eine der beiden Komponenten gültig ist. 150 170 190 210 230 250 270 290 310 330 350 370 390 410 140 160 180 200 220 240 260 280 300 nach Gl. 2 berechnete Zündtemperatur

Stoffe mit |Tgemessen Z0,005

• Tberechnet

Z0,005

| < 0,15·TZ Ausgleichsgerade dieser Stoffe

Stoffe mit |Tgemessen Z0,005

• Tberechnet

Z0,005

| ≥ 0,15·TZ TZ0,005 /°C TZ / °C 0 20 40 60 80 100 0 23 44 64 83 100 200 220 240 260 280 300 320 340 360 380 400 xHexan / % TZ TZ0,005 TZ0,005 aus TZ berechnet TZV / °C ωHexan / %

20

Abb. 13: n-Hexan+n-Butylacetat-Gemische: Vergleich der experimentellen Werte Tz, Tz 0,005 und der nach Beerbower berechneten Zündtemperatur für V= 0,005 m³ Das Beispiel von Butylactat+n-Hexan (Abb. 13) zeigt, dass unter Normbedingungen bei Masseanteilen von n-Hexan.> 40 % die Zündtemperatur des Gemisches durch die Zündtemperatur von n-Hexan bestimmt ist. In diesem Bereich erfüllt auch Tz0,005 die Beerbower-Korrelation. Bei geringeren Hexananteilen überwiegt der Einfluss des Esters, und da dessen Zündtemperaturen nicht nach Beerbower abschätzbar sind, versagt die Beziehung hier auch bei den Gemischen. Abb. 14 vergleicht alle gemessenen und nach Beerbower abgeschätzten Zündtempe- raturen der untersuchten Gemische.

Abb. 14: Zündtemperaturen von Gemischen: Vergleich Tz0,005 mit Tz Unterhalb von 300 °C liegen alle Meßwerte auf der Beerbower-Geraden (Gl. 2) bzw. der für die Reinstoffe berechneten Ausgleichsgeraden (Gl. 3). Zahlreiche Gemische mit 0 20 40 60 80 100 0 25 47 67 84 100 200 220 240 260 280 300 320 340 360 380 400 TZ TZ0,005 TZ0,005 aus TZ berechnet TkF0,005 xHexan / % TZV /°C ωHexan / % 100 150 200 250 300 350 400 450 500 100 150 200 250 300 350 400 450 500 nach Gl. 2 berechnete Zündtemperatur Ausgleichsgerade der Reinstoffe (Gl. 3)

Gemische mit |Tberechnet Z0,005

• Tgemessen

z0,005

| < 0,15·TZ

Gemische mit |Tberechnet Z0,005

• Tgemessen

z0,005

| > 0,15·TZ Tz0,005 / °C Tz / °C

21 Normzündtemperaturen über 300 °C zeigen Zündtemperatur im 5l-Kolben weit unterhalb der nach Gl. 2 oder Gl. 3 zu erwartenden Werte. Gemische verhalten sich demnach ähn- lich wie Reinstoffe. Tabelle 5 vergleicht die Ergebnisse mit der jeweiligen Normzündtem- peratur [10, 15]. Tab. 5: Im 0,005 m³-Gefäß untersuchte Gemische: Vergleich von Tz 0,005 mit Tz Komponente 1 Komponente 2 Tz Tz 0,005 Masseanteil in % °C °C Propionsäure Propanal

80 20 450 236 70 30 360 205 50 50 210 195 20 80 209 192 n-Hexan Cyclohexanon

75 25 250 230 50 50 295 252 40 60

266 n-Hexan n-Butylacetat

80 20 240 216 50 50 260 230 40 60 255 231 30 70 370 236 20 80 385 245 10 90

256 5 95

280 n-Hexan Butanon-2

80 20 245 224 50 50 280 251 40 60 380 264 20 80 425

300

n-Hexan n-Hexanol

90 10 235 228 80 20 250 233 50 50 265 246 20 80 280 257 n-Hexan p-Xylol

80 20 230 237 50 50 295 266 30 70 410

300

n-Heptan Methylpropionat

80 20 220 208 50 50 385 243 30 70 4152 280 n-Octanol n-Pentylacetat

90 10 265 244 67 33 270 243

2 Interpolierter Wert

22 Komponente 1 Komponente 2 Tz Tz 0,005 Masseanteil in % °C °C 50 50 270 246 33 67 265 248 1,4-Dioxan H2O

90 10 385 198 80 20 395

300

n-Butylamin H2O

80 20 335 293

1. 4 0,02 m³-Gefäß
2. 4.1 Versuchsaufbau

Bei größeren Volumina stößt die Durchführung der Versuche in einer hinsichtlich der geometrischen Form und des isochoren Bestimmungsverfahrens skalierten Normzünd- temperaturapparatur auf große Schwierigkeiten. Daher wurden die Versuche ab einem Gefäßvolumen von 0,02 m³ in einem geschlossenen Gefäß, das zusätzlich mit einem pie- zo-resistiven Druckaufnehmer bestückt war, durchgeführt (Abb. 15). Der druckfeste kugel- förmige Behälter war ausgerüstet mit einem Druckaufnehmer, drei Thermoelementen und einer Photodiode zur Detektion einer Entzündung sowie mit Zuleitungen für die Dosierung des Brennstoffes, der Gemischkomponente Luft und für die Spülluft, einer Ableitung für die unverbrannten/verbrannten Gemische und die Spülluft sowie einer Vakuumpumpe (Abb. 15). Die 3 Ni-CrNi-Thermoelemente endeten 2 cm von unten, auf halber Höhe des Gefäßes und 2 cm von oben. Die Einstellung der jeweils gewünschten Versuchstempe- ratur erfolgte mit Hilfe eines bis 400 °C beheizbaren Wärmeschranks. .

,

Abb. 15: Versuchsaufbau 0,02 m³-Gefäß

23 3.4.2 Durchführung Alle Versuche wurden bei einem Ausgangsdruck von ca. 1 bar durchgeführt. Dazu wurde zunächst die Luft bis zu dem, der gewünschten Brennstoffkonzentration entsprechenden Anteil abgepumpt (z.B. auf 0,7 bar für eine Brennstoffkonzentration von 30 Vol.- %) und anschließend die berechnete Menge Brennstoff mittels einer Dosierpumpe dosiert. Dieser Vorgang konnte in einigen Fällen bis zu 1 min dauern. Nach jedem Versuch wurde der Behälter zunächst mit Druckluft gespült, dann auf weniger als 50 mbar evakuiert. Aufgrund des Versuchsaufbaus war eine visuelle Beobachtung der Zündvorgänge nicht möglich. Bei diesen Experimenten zeigte ein Vergleich des Photodiodensignals mit den Anzeigen der Thermoelemente und des Druckaufnehmers, dass eine heiße Flamme gekennzeichnet war durch eine Temperaturanstiegsgeschwindigkeit von mindestens 150 K/s und einem Druckanstieg von mehr als 0,5 bar. Deutliche Temperatur- und Druckreaktionen mit geringeren Werten als 150 K/s und 0,5 bar Überdruck oder weniger wurden daher als kalte Flammen gewertet. 3.4.3 Ergebnisse Die im 0,02m³-Gefäß gemessenen Zündtemperaturen sind in Tab. 6 im Vergleich zu den entsprechenden Normzündtemperaturen aufgeführt.

Tab. 6: Im 0,02 m³-Gefäß untersuchte Reinstoffe: Vergleich von Tz 0,02 mit Tz Substanz Tz °C Tz 0,02 °C TKF 0,02 °C Tz 0,02-Tz K n-Hexan 230 213 -17 Cyclohexan 260 234 -26 n-Heptan 220 191 -29 Decalin (cis,trans) 235 214 -21 n-Dodecan 200 206 6 n-Propanol 385 276 -109 n-Butanol 325 273 265 -52 n-Pentanol 320 268 -52 n-Octanol 245 252 244 7 n-Butylacetat 395 234 -161 n-Pentylacetat 350 220 -130 i-Pentylacetat 380 254 242 -126 Ethylhexanoat 395 211

-184 Butanon-2 475 271 258 -204 Acetylaceton 340 268 -72 Cyclohexanon 430 293 273 -137 Heptanon-3 410 172

-238 Tetrahydrofuran 230 216 211 -14 Dioxolan-1,3 245 217 -28 Dioxan-1,4 375 197

-178 Dipropylenglykoldimethylether (Isomerengem.) 159 151

-8 Morpholin 275 259 -16

24 Gegenüber den Versuchsreihen im 0,005 m³-Gefäß ergaben sich bei vergleichbaren Bedingungen meist höhere maximale Temperaturanstiege (in Einzelfällen über 500 K) und höhere Temperaturanstiegsgeschwindigkeiten (z.T. mehr als 2000 K/s). Der Explosions- druck kann bereits wenige Grad oberhalb der Zündtemperatur erheblich sein: Für Butyl- acetat wurde bei 245 °C, d.h. 12 K über der Zündtemperatur ein Explosionsdruck von 4,2 bar beim (nominellen) stöchiometrischen Verhältnis ϕ ≈ 4 gemessen. Dagegen war die maximal gefundene Druckanstiegsgeschwindigkeit dp/dt = 43 bar/s (entspricht einem KG,ex-Wert von 12 bar·m/s) viel niedriger als die maximal möglichen Werte (KG-Werte bei Dämpfen typischerweise > 50 bar·m/s). Ferner ist allgemein eine weitere Absenkung der Zündtemperatur festzustellen. Bei Sub- stanzen, deren Zündtemperatur im 0,005 m³-Gefäß nur mäßig gegenüber der Normzünd- temperatur abgesenkt ist, fällt die Zündtemperatur gleichmäßig weiter ab. Es wurden keine Stoffe gefunden, bei denen die Zündtemperatur nach Norm und Tz 0,005 nur wenig, dann aber beim Übergang zu 0,02 m³-Gefäß stark abnimmt. Bei Stoffen, die zwischen der Normzündtemperatur und Tz 0,005 eine starke Abnahme zeigen (z.B. n-Pentylacetat), ver- ringert sich die Zündtemperatur beim Übergang auf das 0,02 m³-Gefäß weniger stark. Wie im 0,005m³-Gefäß können auch im 0,02 m³-Gefäß kalte Flammen auftreten. Die Tempe- raturbereiche, in denen nur kalte, aber keine heißen Flammen auftreten, sind jedoch sehr viel schmaler als im 5 l-Erlenmeyerkolben.

1. 5 0,16 m³-Gefäß
2. 5.1 Versuchsaufbau

Weitere Versuche wurden in einem aufrecht stehenden druckfesten Zylinder von ca. 0,16 m³- Rauminhalt (l/d-Verhältnis: ≈ 1,1) durchgeführt (Abb. 16):

Abb. 16: Versuchsaufbau 0,16 m²-Gefäß

25 Konzeption und Versuchsaufbau entsprachen im Wesentlichen den Versuchsreihen mit dem 0,02 m³-Gefäßes. Lediglich die Dosiervorrichtung war aufgrund der zu dosierenden großen Flüssigkeitsmengen verändert: Die Flüssigkeit wurde mittels ca. 4 bar Druck aus dem Vorratsgefäß über eine Kapillare in das Versuchsgefäß gegeben. Die dosierte Menge wurde über die Gewichtsabnahme gravimetrisch bestimmt. Ferner hatte das untere Thermoelement aus mechanischen Gründen einen Durchmesser von 1 mm und reagierte daher träger. Die beiden anderen Thermoelemente hatten einen Durchmesser von 0,5 mm. Die 3 Ni-CrNi-Thermoelemente endeten 2 cm von unten, auf halber Höhe des Gefäßes und 2 cm von oben. Der Versuchsaufbau konnte bis ca. 300 °C eingesetzt werden. 3.5.2 Durchführung Die Durchführung entsprach dem Vorgehen bei den Messreihen im 0,02 m³-Gefäß. Wegen des großen Verbrauchs an Substanzen wurden im 0,16 m³-Gefäß weniger Ver- suche im Vergleich zu den kleineren Gefäßen durchgeführt. Die maximale Beobachtungs- dauer betrug 85 min. 3.5.3 Ergebnisse Entzündungen bei Temperaturen oberhalb der Zündtemperatur verliefen unter sonst gleichen Bedingungen (Konzentration, Temperatur) im 0,16 m³-Gefäß heftiger als im 0,02 m³-Gefäß. Dies gilt für alle betrachteten Parameter. Als Beispiel zeigt Tab. 7 die Tem- peratur-anstiegsgeschwindigkeiten einiger Brennstoff/Luft-Gemische in beiden Gefäßen. Tab. 7: Maximale Temperaturanstiegsgeschwindigkeiten im 0,02 m³- und im 0,16 m³-Gefäß3 Substanz und Versuchsbedingung (dT/dt)max K/s 0,02m³-Gefäß (dT/dt)max K/s 0,16m³-Gefäß n-Butylacetat 20 Vol-%; 237°C 700 1290 n-Butylacetat 20 Vol-%; 232°C 263 746 Butan-2-on 20 Vol-%; 300°C 177 280 n-Butanol 25 Vol-%; 273°C 124 197 Ethylhexanoat 15 Vol-%; 210°C 1150 1370 n-Heptan 15 Vol-%; 204°C 724 1230

Entzündungen führten etwa 10 K oberhalb der Zündtemperatur bereits zu Explosions- drücken zwischen 2,1 bar und 4,4 bar. Überdrücke von mehr als 1 bar wurden stets als "heiße" Zündung gewertet. Erwartungsgemäß wurden niedrigere Zündtemperaturen (Tz0,16) gefunden. Die Ergeb- nisse sind im Vergleich mit der Normzündtemperatur in Tab. 8 zusammengefasst. Kalte Flammen treten, wenn überhaupt, nur in einem schmalen Temperaturbereich knapp unterhalb der heißen Flammen auf.

3 Die Bennstoffkonzentrationen liegen aufgrund der Temperaturabhängigkeit der OEG (starke Aufweitung) im Explosionsbereich

26 Tab. 8: Im 0,16 m³-Gefäß untersuchte Gemische: Vergleich von Tz 0,16 mit Tz Substanz Tz °C Tz0,16 °C TkF0,16 °C n-Heptan 220 182 177 n-Butylacetat 395 228 224 n-Pentylacetat 350 217 Ethylhexanoat 395 199 Dioxan-1,4 375 183 n-Butanol 325 268 253 Butanon-2 475 244 234 Cyclohexanon 430 284 262 Dioxan-1,4 375 183 Dioxolan-1,3 245 206 i-Pentylacetat 380 233 227 Tetrahydrofuran 230 202 197 2-Methyltetrahydrofuran 270 199 187 n-Pentanol 320 253 248

1. 6 0,5 m³-Gefäß

Das größte im Versuchsprogramm untersuchte Volumen war ca. 0,5 m³. 3.6.1 Versuchsaufbau Abb. 17 zeigt den Aufbau dieser Versuchsapparatur.

Abb. 17: Versuchsaufbau 0,5 m³-Gefäß Das Versuchsgefäß, ein aufrecht stehender Zylinder (l/d ≈ 4/3), wurde über einen Heiz- mantel mit Thermalöl beheizt Damit konnten Temperaturen bis zu 250 °C realisiert werden. Da der obere Abschlussflansch nicht beheizt war, war die Temperatur im Deckelbereich um 5 -10 K niedriger. Die Flüssigkeit wurde mittels ca. 4 bar Druck aus dem Vorratsgefäß über zwei Automobil-Einspritzdüsen dosiert, wobei die eingespritzte Menge über die Gewichtsabnahme des Vorratsgefäßes kontrolliert wurde. Zu Beginn eines Versuches

27 wurde der Luftdruck zunächst so reduziert, dass nach dem Dosieren und Verdampfen der Probe der Gesamtdruck 1 bar betrug. Die Temperatur wurde über drei in unterschiedlichen Höhen (15 cm von unten, auf halber Höhe, 20 cm von oben) befindliche Thermoelemente gemessen, die jedoch wegen ihres größeren Durchmessers (φ: 3 mm) nicht zur Anzeige einer Zündung geeignet waren. Die Druckmessung erfolgte mit einem piezoresistiven Druckaufnehmer.Um unzulässig hohe Drücke zu verhindern, war der Behälter mit einer Platzmembran versehen, die bei einem raschen Druckanstieg bei ca. 1,2 bar ansprach. In einigen Fällen war die Reaktion jedoch relativ langsam und erreichte 1,5 bar, ohne dass die Membran aufriss. Auch diese Fälle wurden als Zündung gewertet. Möglicherweise handelt es sich in solchen Fällen um kalte Flammen. Durch diesen Aufbau war es nicht möglich, im Falle einer Zündung diese - abgesehen von der Verzugszeit - näher zu charakterisieren 3.6.2 Durchführung Die Durchführung entsprach dem Vorgehen bei den Messreihen im 0,02 m³-Gefäß. Wegen des großen Substanzbedarfs wurden weniger Versuche durchgeführt. Die maximale Beobachtungsdauer betrug 81 min. 3.6.3 Ergebnisse In Vergleich zu den Messreihen im 0,16 m³-Gefäß fällt die Zündtemperatur im 0,5 m³- Gefäß (Tz0,5) weiter ab. Diese Abnahme ist jedoch verglichen mit den Veränderungen bei kleineren Volumina relativ gering. Starke Abweichungen von TZ 0,5 von der Normzündtem- peratur weisen daher nur solche Stoffe auf, bei denen dies bereits bei kleineren Volumina der Fall ist (Tab. 9). Tab. 9: Im 0,5 m³-Gefäß untersuchte Reinstoffe: Vergleich von Tz 0,5 mit Tz

1. 7 Versuchsreihen in Gefäßen mit kleineren Volumina

Zur Ermittlung der Volumenabhängigkeit der Zündtemperaturen wurden neben den vor- genannten Ergebnissen auch Resultate mit herangezogen, die bei früheren Projekten in Edelstahlgefäßen von 0,3 l, 0,5 l und 1 l Rauminhalt erzielt worden waren. Wegen des ungünstigen l/d-Verhältnisses des 0,3 l-Autoklaven von 5 können die dort gewonnenen Ergebnisse nur mit Einschränkungen mitverwendet werden. Diese Gefäße waren außer Substanz Tz °C Tz0,5 °C Tz0,5-Tz K n-Butylacetat 395 229 -166 n-Pentylacetat 350 217 -133 Ethylhexanoat 395 198 -197 Cyclohexan 260 224 -36 Dioxan-1,4 375 197 -178 n-Hexan 230 201 -29 n-Octanol 245 241 -4 Tetrahydrofuran 230 213 -17 n-Dodecan 200 170 -30 Diethylether 175 165 -10 Dipropylenglykoldimethylether (Isomerengemisch) 159 138 -21

28 mit einem Druckaufnehmer nur mit zwei Thermoelementen (z.T. von 1 mm Durchmesser) ausgerüstet. Eine optische Beobachtung fand nicht statt. In den kleineren Gefäßen waren aufgrund des geringeren Volumens, sowohl die Temperatur- als auch die Druckreaktion bei Zündung erheblich schwächer. Dies gilt insbe- sonders für die jeweiligen Anstiegsgeschwindigkeiten. Aus diesem Grunde wurde in den kleinen Gefäßen bereits ein Temperaturanstieg von 50 K als Zündung und zwischen 20 K und 50 K als kalte Flamme gewertet. 3.8 Versuchsreihen in "homogenen" Gemischen 3.8.1 Versuchsaufbau und -durchführung Für diese Versuche wurden die Versuchsaufbauten des 0,02 m³-Gefäßes (Abb. 15) und des 0,16 m³-Gefäßes (Abb. 16) weitgehend unverändert übernommen, lediglich der Luft- einlass war mit Düsen versehen. Die Photodiode konnte bei allen Versuchen eingesetzt werden. Die Versuchsdurchführung wurde, wie in Abschnitt 3.2.2 beschrieben, modifiziert. Da die Dauer eines einzelnen Versuchs ähnlich lang war wie beim Standardverfahren, wurden nur wenige repräsentative Substanzen untersucht. 3.8.2 Ergebnisse Die Ergebnisse sind in Tabelle 10 zusammengefasst. Tab. 10: Vergleich der Zündtemperaturen im 0,02 m³- und 0,16 m³-Gefäß bei homogenen und inhomogenen Gemischen ∆T(0,02m³) ∆T(0,16m³) inhomogen homogen K inhomogen homogen K n-Heptan 194 202 8 182 194 12 n-Dodecan 206 195 -11 180 186 6 n-Pentanol 268 273 5 253 262 9 Tetrahydrofuran 216 220 4 0 2-Methyltetrahydrofuran 199 211 12 Cyclohexanon 293 292 -1 284 285 1 n-Butylacetat 234 234 0 228 232 4 n-Pentylacetat 220 220 0 217 216 -1 Tz0,16 °C Stoff Tz0,02 °C

Die Zündtemperaturen in den homogenen Gemischen weisen nur geringe Abweichungen (maximal 12 K) zu den Zündtemperaturen inhomogenen Gemischen auf. Ursache hierfür könnte sein, dass infolge der langen Zündverzugszeiten auch bei den ‚inhomogenen‘ Gemischen eine weitgehende Homogenisierung eintritt. Zumeist waren die Brennstoffkonzentrationen, bei denen die niedrigste Zündtemperatur auftrat, jedoch bei den homogenen etwas niedriger als bei den inhomogenen Gemischen.

29 4 ERGEBNIS - VOLUMENABHÄNGIGKEIT DER ZÜNDTEMPERATUR 4.1 Theoretische Überlegungen Da Voraussetzung für eine Explosion ist, dass die Wärmeproduktion im Reaktions- volumen die Wärmeabfuhr (über die Wandung) übersteigt, ist unmittelbar verständlich, dass aufgrund des niedrigeren Oberfläche/Volumenverhältnis S/V in größeren Volumina Explosionen bei niedrigeren Temperaturen stattfinden können als in kleineren. Einen einfachen quantitativen Ansatz bietet die Theorie der Wärmeexplosion von Semenoff [16], nach der sich die Abhängigkeit der Zündtemperatur TZ vom Druck p und dem Oberfläche/Volumenverhältnis S/V wie folgt beschreiben lässt:

) 2 exp( ) 2 exp( 6 2 Z A Z A Z RT E V t cons RT E V S const T p

′

⋅

Gl. 4 Bei p = 1 bar gilt für zwei verschiedenen Volumina V1 und V2:

     

′

      ′ 2 2 1 1 2 exp 2 exp 6 2 2 6 1 2 V V V V Z A Z Z A Z RT E V t cons T RT E V t cons T

Gl. 5 oder:

2 1 1 2 ln 3 2 ln 3 1 1 2 1 V V V V Z Z A A Z Z T T E R V V E R T T +

−

Gl. 6 Setzt man auf der rechten Seite zunächst 2 1 V V Z Z T T ≈ , so kann hiermit die Zündtemperatur TZ,V2 beim Volumen V2 aus der Normzündtemperatur berechnet werden, vorausgesetzt, dass die (scheinbare) Aktivierungsenergie EA bekannt ist (z.B. über die Temperaturabhän- gigkeit der Zündverzugszeiten, siehe 4.3.3). Da dies häufig nicht der Fall ist, werden in der Praxis Zündtemperaturen in großen Volumina meist über die von Beerbower [5] ange- gebene empirische Beziehung abgeschätzt:

    − − ⋅ −

+

1 10 2 10 1 2 log 12 log 12 ) 75 ( 75 V V Tz Tz V V

Gl. 1 Diese Beziehung nimmt eine stoffunabhängige Volumenabhängigkeit an, die dazu führt, dass alle Substanzen in einem hypothetischen Gefäß von 1 km³ Größe eine Zünd- temperatur von 75°C aufweisen würden. 4.2 Auswertung 4.2.1 Vergleich mit Beerbower- und Semenoff-Beziehung Von 23 Reinstoffen konnte bei hinreichend vielen Gefäßgrößen die Zündtemperatur bestimmt werden, um eine Aussage über die Volumenabhängigkeit treffen zu können. Abb. 18 bis Abb. 22 zeigen die Ergebnisse zusammengefasst nach Substanzklassen. In die Abbildungen sind auch die aus der jeweiligen Normzündtemperatur sich erge- bende Temperaturabhängigkeit nach Beerbower eingetragen. Ebenfalls eingezeichnet ist

30 der Verlauf der Zündtemperatur, wie er sich aus der Semenoff-Theorie nach Gl. 5 ergibt. Die hierfür notwendigen scheinbaren Aktivierungsenergien wurden aus der Temperatur- abhängigkeit der Zündverzugszeit berechnet (siehe 4.3.3). Die in beiden Modellen beschriebene logarithmische Abhängigkeit der Zündtemperatur vom Volumen des Gefäßes wird durch die experimentellen Ergebnisse bestätigt. Beide Gleichungen schätzen die Zündtemperatur in größeren Gefäßen jedoch nicht immer zur sicheren Seite hin ab. Es ergibt sich jedoch kein einheitliches substanzklassenunabhängiges Bild. Kohlenwasserstoffe Für die untersuchten Stoffe gibt die Beerbower-Korrelation die Volumenab-hängigkeit zufriedenstellend wieder (Abb. 18). Die maximale Abweichung des für 0,5 m³ nach Beerbower berechneten Wertes beträgt -12 K.

Abb. 18:Volumenabhängigkeit der Zündtemperatur der untersuchten Kohlenwasserstoffe

Ether Bei den untersuchten Ethern ergibt sich ein ähnliches Bild wie bei den Kohlen- wasserstoffen (Abb. 19).

Abb. 19: Volumenabhängigkeit der Zündtemperatur der untersuchten Ether 0,1 1 10 100 1000 150 175 200 225 250 275 300

Tzv / °C VBehälter / l 0,1 1 10 100 1000 125 150 175 200 225 250 275 300 325 350 375 400 Tetrahydrofuran Dipropylenglykoldimethylether Dioxolan-1,3 Dioxan Morpholin 2-Methyltetrahydrofuran TZV /°C VBehälter / l

Volumenabhängigkeit nach Gl. 1 0 5 10 15 20 25 30 35 100 150 400 600 800 1000 125 150 175 200 225 250 275 300 325 350 375 400 Tetrahydrofuran Dipropylenglykoldimethylether Dioxolan-1,3 Dioxan Morpholin 2-Methyltetrahydrofuran Diethylether

TZV / °C VBehälter / l

31 Eine Ausnahme bildet Dioxan-1,4. Selbst mit der nach dem ASTM-Verfahren gemessenen Zündtemperatur (TzASTM: 266°C) ergibt sich keine befriedigende Kurve. Ansonsten beträgt die maximale Abweichung des für 0,5 m³ nach Beerbower berechneten Wertes -14 K.

Ester Für alle untersuchten Ester liegen die gemessenen Zündtemperaturen weit (z.T. über 100 K) unter den nach der Beerbower-Beziehung zu erwartenden Werten (Abb. 20). Die Abweichungen zu mit der Semenoff-Korrelation ermittelten Werten sind noch größer.

Abb. 20: Volumenabhängigkeit der Zündtemperatur der untersuchten Ester

Ketone Die untersuchten Ketone zeigen ein den untersuchten Estern vergleichbares Bild. Auch liegen die gemessenen Zündtemperaturen weit (z.T. über 100 K) unter den nach der Beerbower-Beziehung zu erwartenden Werten (Abb. 21). Die Abweichungen zu mit der Semenoff-Korrelation ermittelten Werten sind noch größer.

Abb. 21: Volumenabhängigkeit der Zündtemperatur der untersuchten Ketone 0,1 1 10 100 1000 150 175 200 225 250 275 300 325 350 375 400 425 450 Butylacetat Pentylacetat i-Pentylacetat Ethylhexanoat

Beerbower

Semenoff TZV / °C VBehälter / l 0 10 20 30100 150 400 600 800 1000 150 175 200 225 250 275 300 325 350 375 400 425 450 Butylacetat Pentylacetat i-Pentylacetat Ethylhexanoat

TZV / °C VBehälter / l 0 10 20 30 100 150 400 600 800 1000 150 175 200 225 250 275 300 325 350 375 400 425 450 475 500 Butanon-2 Acetylaceton Cyclohexanon Heptanon-3

TZV / °C VBehälter / l 0,1 1 10 100 1000 150 175 200 225 250 275 300 325 350 375 400 425 450 475 500 Butanon-2 Acetylaceton Cyclohexanon Heptanon-3

Volumenabhängigkeit nach Gl. 1 TZV / °C VBehälter / l

32 Alkohole Bei den untersuchten Alkoholen gibt es sowohl Stoffe, die die Beerbower-Beziehung erfüllen als auch solche, die starke Abweichungen zur unsicheren Seite zeigen (Abb. 22).

Abb. 22: Volumenabhängigkeit der Zündtemperatur der untersuchten Alkohole

Vergleich Gl. 1 (Beerbower) scheint die Resultate besser wiederzugeben als die kompliziertere Gl. 5 (Semenoff). Daher werden die Meßwerte im Folgenden nur mit der empirischen Beerbower-Beziehung verglichen. Die Unterschiede zwischen der nach Beerbower zu erwartenden Zündtemperatur und dem tatsächlich gemessenen Wert sind für die Substanzen die im 0,02 m³-Gefäß und im 0,16 m³-Gefäß vermessen wurden, in Abb. 23 dargestellt.

Abb. 23: Vergleich von Tz0,02 und Tz0,16 sowie von Literaturwerten im 0,012 m³-Gefäß [6] mit nach Beerbower berechneten Wert Die Stoffe mit einer Normzündtemperatur von weniger als 300 °C befolgen die Beerbower-Beziehung weitgehend. Häufig liegt der experimentell bestimmte Wert sogar 10 K - 20 K über dem berechneten. 0,1 1 10 100 1000 200 225 250 275 300 325 350 375 400 n-Propanol n-Butanol n-Pentanol n-Oktanol

Beerbower

Semenoff TZV / °C VBehälter / l 0 10 20 30 120 160 400 600 800 1000 200 225 250 275 300 325 350 375 400

n-Propanol n-Butanol n-Pentanol n-Oktanol TZV / °C VBehälter / l 100 150 200 250 300 350 400 450 500 550 600 -200 -150 -100 -50 0 50

Substanzklasse: 0,02m³ 0,16m³ 0,012m³/0,02 m³ [Lit]

Kohlenwasserstoffe und Ether:

Ester und Ketone:

Alkohole:

Essigsäure: CS2:

Meßunsicherheit nach IEC 60079-20-1 T ZV - T Zber / K TZ / °C

33 Bei Substanzen mit Zündtemperaturen höher als 300 °C weichen die abgeschätzten Werte der untersuchten Substanzen stärker von den experimentellen ab. Allerdings handelt es sich bei den untersuchten Stoffen mit Normzündtemperaturen unter 300 °C fast ausschließlich um Kohlenwasserstoffe und Ether, während die Stoffe mit höheren Norm- zündtemperaturen Ester, Ketone und Alkohole waren. Ein Vergleich mit Literaturdaten [6] zeigt jedoch, dass es auch oberhalb von 300 °C Normzündtemperatur Stoffe gibt, die Gl. 1 befolgen. 4.2.2 "Scheinbare Normzündtemperatur" Wie Abb. 17 – Abb. 21 zeigen, weichen die nach Beerbower erwarteten Temperaturen nicht völlig unsystematisch von den Messwerten ab. Falls in den größeren Volumina viel tiefere Zündtemperaturen gemessen wurden als durch Extrapolation aus der Normzünd- temperatur zu erwarten, erfolgt immer ein starker Abwärtssprung in den Temperaturen zwischen dem nach Norm bestimmten Wert und dem Wert im nächstgrößeren (untersuch- ten) Gefäß. Die Temperaturabnahme bei weiterer Volumenvergrößerung ist weit geringer und verläuft in etwa parallel der Beerbower-Korrelation. Wendet man für solche Substan- zen die Beerbower-Korrelation auf den im 0,001 m³-Gefäß oder 5-l-Erlenmeyerkolben ermittelten Wert an, ergibt sich eine weit bessere Übereinstimmung mit den in den größe- ren Volumina experimentell ermittelten Daten. Das Gleiche gilt für eine Ausgleichskurve durch alle Messwerte außer der Normzündtemperatur unter Benutzung der Beerbower- Gleichung, mit der Normzündtemperatur als freiem Parameter. Beides erlaubt eine ‚scheinbare Zündtemperatur‘ zu berechnen. In Abb. 24 ist dies am Beispiel des Butyl- acetats dargestellt:

Abb. 24: Experimentelle und berechnete Zündtemperaturen: Beispiel des Butylacetats Die in großen Volumina gemessenen Zündtemperaturen lassen sich sehr gut durch die Beerbower-Beziehung ausgleichen (Korrelationskoeffizient: 0,94). Durch Extrapolation dieser Kurve auf V=0,2 l lässt sich eine "scheinbare Zündtemperatur" berechnen. Für Butylacetat liegt dieser Wert bei 272 °C, d.h. mehr als 120 K unter dem tatsächlich nach Norm gemessenen Wert. Diese "scheinbare Normzündtemperatur" von Butylacetat liegt in der Nähe seiner unter Normbedingungen (0,2 l-Erlenmeyerkolben) ermittelten Kaltflammentemperatur TKF = 290°C [17]. 0,1 1 10 100 1000 100 125 150 175 200 225 250 275 300 325 350 375 400 425 450 475 500 TzV extrapolierte "scheinbare Normzündtemperatur" Kaltflammentemperatur in der Normapparatur TzV / °C VBehälter / l Volumenabhängigkeit nach Beerbower Volumenabhängigkeit nach Semenoff Ausgleichsgerade OHNE Tz

34 Tab. 11 fasst solche „scheinbaren Normzündtemperaturen“ aller untersuchten Substan- zen zusammen und vergleicht sie mit den Zündtemperaturen nach Norm Tz und den ‚Kalt- flammentemperaturen TKF [17] bestimmt im 0,2 l-Erlenmeyerkolben. Tab. 11: Vergleich der "scheinbaren Normzündtemperatur" mit Normzündtemperatur und Kalt- flammentemperatur Substanz Tz °C "scheinbare Normzündtemperatur" °C TKF °C (IEC 60079-20-1) Ausgleichsgerade Beerbower bezüglich. 0,005 m³ oder 0,001 m³ n-Hexan 235 230

Cyclohexan 260 263 250 n-Heptan 220 219 222 218 n-Dodecan 200 205

Decalin (cis,trans) 240 237

240 n-Propanol 385 323 314

n-Butanol 325 313 307 n-Pentanol 320 300 295 296 n-Octanol 245 278 265

Dioxolan-1,3 245 248 231

Dioxan-1,4 375 223 201 217 232 Tetrahydrofuran 230 244

229 Dipropylenglykol- diethylether 160 159

2-Methyltetrahydrofuran 270 234

Morpholin 275 294 290 Acetylaceton 340 315

Butanon-2 475 311 307 335 Heptanon-3 410 209 197 207 Cyclohexanon 430 329 325 349

n-Butylacetat 395 272 272 290 n-Pentylacetat 350 261 276 257 265 i-Pentylacetat 380 306

Ethylhexanoat 395 244 240 258 232 Diethylether 175 188

Aus Tab. 11 ist ersichtlich, dass in allen Fällen, in denen die "scheinbare Normzündtemperatur " weit unter der Normzündtemperatur liegt, auch kalte Flammen weit unterhalb der Normzündtemperatur auftreten. Die "scheinbare Normzündtemperatur" liegt dann in der Nähe der Kaltflammentemperatur. Dies ist vor allem bei Estern und Ketonen der Fall. Stoffe wie Alkane, Ether und Alkohole, die keinen oder nur einen kleinen Kaltflammenbereich aufweisen, haben dagegen "scheinbare Normzündtemperaturen" in der Nähe der tatsächlichen Werte. Eine Erklärung wäre, dass kleine Gefäße den Umschlag einer kalten in eine heiße Flamme (Zweistufenzündung) erschweren und dadurch die Zündtemperatur in der Normapparatur stark heraufsetzen können. Tabelle 12 zeigt die aus den im 5 l-Erlenmeyerkolben erhaltenen Werten berechneten

35 "scheinbaren Normzündtemperaturen" weiterer Stoffe, für die noch keine Kaltflammen- temperaturen bestimmt wurden und für die auch keine Ausgleichsgerade berechnet werden konnte. Zu den Stoffen mit einer großen Differenz zwischen „scheinbarer“ und wirklicher Normzündtemperatur zählen auch hier vor allem Ester und Ketone, aber auch einige andere Stoffe mit TZ(Norm) > 300 °C. Tab. 12: Aus den Zündtemperaturen im 0,005 m³-Erlenmeyerkolben zurückgerechnete "scheinbare Normzündtemperaturen". Substanz Tz °C TzR zurückgerechnet aus Tz0,005 °C TzR - Tz K Kohlenwasserstoffe Cyclopentan 320 237 -83 n-Octan 205 204 -1 Octadien-1,7 249 259 10 Octin-1 236 232 -4 n-Pentan 260 271 11 Cyclopenten 309 280 -29 Cyclooctan 250 248 -2 n-Decan 200 204 4 Ether Diethoxyethan 175 167 -8 2,4,6-Trimethyltrioxan-1,3,5 (Paraldehyd) 204 180 -24 2H-3,4-Dihydropyran 245 240 -5 Dipentylether 180 180 0 Alkohole Ethoxyethanol 235 229 -6 Butoxyethanol 240 236 -4 n-Heptanol 275 280 5 n-Hexanol 280 284 4 4-Methylpentanol-2 335 319 -16 Triethylenglykol 370 286 -84 Ester n-Butylbutyrat 395 280 -115 n-Butylformiat 265 282 17 Cyclohexylacetat 334 303 -31 n-Hexylacetat 265 247 -18 2-Butoxyethylacetat 350 213 -137 2-(2-Butoxyethoxy)ethylacetat 295 202 -93 Methylacetoacetat 280 271 -9 Ketone Heptanon-2 305 283 -22 Nonanon-5 330 244 -86 Octanon-2 295 239 -56 Nonanon-2 240 222 -18

36 Substanz Tz °C TzR zurückgerechnet aus Tz0,005 °C TzR - Tz K Aldehyde Benzaldehyd 190 192 2 n-Butanal 190 199 9 n-Pentanal 205 205 0 Propanal 190 203 13 Carbonsäuren Octansäure 245 248 3 Heptansäure 255 265 10 Stickstoffhaltige Verbindungen n-Butylamin 310 304 -6 N-Methylpyrrolidon-2 265 238 -27

1. 3 Zündverzugszeiten

Die Abnahme der Zündtemperatur mit der Gefäßgröße hat zur Folge, dass die Zeit zwi- schen dem Entstehen eines Gemisches und der Zündung, d.h. die Zündverzugszeit, an der Zündtemperatur stark zunehmen kann. Es ist daher wünschenswert, eine Beziehung zu finden, die die maximal zu erwartende Verzugszeit für einen Stoff bei einer bestimmten Gefäßgröße abschätzt. Aus diesem Grunde wurden neben den Zündtemperaturen auch die beobachteten Verzugszeiten ausgewertet. Durch Beschreibung der Temperaturabhän- gigkeit der Zündverzugszeiten durch eine Arrhenius-Beziehung mit einer scheinbaren Aktivierungsenergie EA ist es möglich, die Verzugszeiten, die bei den niedrigen Zündtem- peraturen in großen Volumina auftreten können, durch Extrapolation abzuschätzen. 4.3.1 Versuchsdurchführung Zur Ermittlung der Zündverzugszeiten wurden die Temperatur-Zeit-Diagramme der Ver- suche herangezogen. Als Zeitpunkt der Zündung wurde der Punkt des maximalen Temperaturanstiegs am mittleren oder oberen Thermoelement oder - im Falle des 0,5 m³- Behälters - das Aufreißen der Platzmembran angenommen. Beim offenen 5 l-Erlen- meyerkolben sowie beim 0,5 m³-Behälter galt das Temperaturminimum am untersten Thermoelement als Nullpunkt. Bei den 0,02 m³- und 0,16 m³-Gefäß wurde der Punkt, bei dem 60 % der eingespritzten Brennstoffmenge verdampft waren (zu erkennen am Druck- anstieg), als Nullpunkt angenommen. Aufgrund dieser Definitionen können Zündverzugs- zeiten nur dann sinnvoll ausgewertet werden, wenn sie deutlich größer als 1 s sind. Dies war in den allermeisten Experimenten der Fall. Falls vorhanden, können alternativ auch die Druck- und Lichtsignale als Signal für den Zündzeitpunkt herangezogen werden. Bei ausgeprägten heißen Flammen sind die auf diese Weise ermittelten Verzugszeiten praktisch identisch mit den Verzugszeiten aus der Temperaturmessung. Bei schwachen heißen Flammen und insbesondere bei kalten Flam- men können sich dagegen zwischen den einzelnen Sensoren Unterschiede im Bereich einiger Sekunden ergeben. Da die Zündverzugszeit in diesen Fällen jedoch schon sehr

37 lang ist, ist dies wegen der exponentiellen Temperaturabhängigkeit der Zündverzugszeit meist unerheblich. 4.3.2 Zündverzugszeiten bei der Zündtemperatur In Tab. 13 sind für alle Stoffe, die in mindestens zwei Gefäßen untersucht worden sind, die bei der jeweiligen Zündtemperatur beobachteten Zündverzugszeiten zusammen- gefasst. Im allgemeinen nimmt dieser Wert mit zunehmendem Volumen zu, da die Zündtemperatur abnimmt. Da im Rahmen dieser Arbeit jedoch nicht versucht wurde, minimale Zündverzugszeiten zu ermitteln, gibt es in Tab. 13 zahlreiche Ausnahmen. In Einzelfällen können die Verzugszeiten in den großen Behältern sehr lang werden (3000 s entspricht 50 min). Die Zunahme der Zündverzugszeit scheint jedoch substanzspezifisch zu sein, wie die Zündverzugszeit beim Normverfahren auch. Im gleichen Gefäß kann die Zündverzugszeit für die verschiedenen Substanzen um mehr als eine Größenordnung differieren. Daher ist es nicht möglich, für ein Gefäß eine maximale Zeit anzugeben, oberhalb derer es nicht mehr zu Zündungen kommen kann.

Tab. 13: Zündverzugszeiten nahe der Zündtemperatur für unterschiedliche Volumina Substanz Zündverzugszeit bei Gefäßgröße s 0,32 l/0,5 l 0,001 m³ 0,005 m³ 0,02 m³ 0,16 m³ 0,5 m³

n-Pentan

60

340

Penten-1

32 44

n-Hexan

32 430 340 1550

700

Cyclohexan 76 880 770 840

2600 Methylcyclopentan 28 191 1030

n-Heptan 107 183 290 350

2300 n-Octan

86 430

Octadien-1,7

39 91

Dodecan

410 300 700 710 Decalin (cis,trans) 64 78

630 1930

n-Pentanal

32 90

Benzaldehyd 21

60

Heptansäure

48 145

Octansäure

80 330

n-Propanol -- 313

302

n-Butanol 60 260 1250 360 3150

Pentanol

103 1530 560 3000

3-Methylbutanol

95 650

n-Hexanol

154 520

n-Heptanol

46 450

n-Octanol

179 590 630

1420 2-Ethoxyethanol 8 11 17

Mehyl-tert.-Butylether 14 52

Dipropylenglykol- dimethylether

920

650 Tetrahydrofuran 23 65 139 129 540 190 38 Substanz Zündverzugszeit bei Gefäßgröße s 0,32 l/0,5 l 0,001 m³ 0,005 m³ 0,02 m³ 0,16 m³ 0,5 m³

2-Methyltetrahydrofuran

146

330

1410

Dioxan 70 113 960 490 2600 4604 Trioxan-1,3,5 18 75

190

Dihydropyran

35 150

Morpholin

10 21 58

n-Butylformiat

84 89

n-Pentylformiat 15 71

n-Butylacetat

13 58 50 60 60 n-Pentylacetat

28 118 45 62 n-Hexylacetat

23 49

Methylacetoacetat

20 36

n-Butylpropionat

56 102

n-Butylbutyrat

78 135

Ethylpentanoat

58 32

Ethylhexanoat 6 81 41 320 520

Butanon-2

72

320 1390

Pentanon-2

66 136

Pentanon-3

61 70

Pentadion-2,4 163 2300 175 3100

Cyclohexanon

36 134 101 290

Heptanon-2 14 64

91

Heptanon-3

40 65 98

Heptanon-4 23 24 75

Octanon-2 53

146

Nonanon-2 21 56 242

2-Methylpyrrolidon 28 114 175 4.3.3 Ermittlung der scheinbaren Aktivierungsenergie Die Temperaturabhängigkeit der Zündverzugszeit tZV kann durch die "scheinbare" Aktivierungsenrgie EA in einer Arrhenius-Beziehung charakterisiert werden [7]. Um die Ergebnisse älterer Arbeiten, bei denen auch bei erhöhtem Druck gemessen wurde, mit in die Auswertung integrieren zu können, wurde eine Abhängigkeit 1. Ordnung vom Ausgangsdruck p angenommen:

   −

⋅

RT E p K t A ZV exp

Gl. 7. In Gl. 7 muss die Konstante K nicht unabhängig von der Gefäßgröße und -form sein. So kann sie z.B. vom Oberfläche/Volumen-Verhältnis beeinflusst sein. Ferner sollte K konzentrationsabhängig sein. Wurden bei einer Temperatur mehrere Versuche mit unterschiedlichen Konzentrationen durchgeführt, so wurde die kürzeste gefundene

4 Bei Dioxan wurde im 500l-Gefäß eine höhere Zündtemperatur als bei 160 l gefunden (siehe auch Abb. 19)

39 Verzugszeit zur Auswertung herangezogen, d.h. bei unterschiedlichen Temperaturen konnte die ausgewertete Verzugszeit durchaus bei unterschiedlichen Brennstoffkon- zentrationen gemessen worden sein. Es zeigte sich jedoch, dass die Zündverzugszeit nur geringfügig abhängig von der eingespritzten Brennstoffmenge ist, lediglich an den Rändern des zündfähigen Konzentrationsbereichs ist sie signifikant höher. Wegen der oft nur geringen Anzahl an Messpunkten und der durch die Versuchs- durchführung bedingten Streuung wurde die Temperaturabhängigkeit der Zündver- zugszeit stets durch eine einzige (scheinbare) Aktivierungsenergie EA beschrieben, eine mögliche Änderung von EA durch einen Wechsel des Reaktionsmechanismus - etwa beim Übergang von heißen zu kalten Flammen - wurde nicht berücksichtigt.

Abb. 25: Temperaturabhängigkeit der Zündverzugszeiten von Cyclohexan in unterschiedlichen Volumina bei Drücken von 1 bar - 10 bar Als Beispiel wird in Abb. 25 die Temperatur- (und Druck-)abhängigkeit der Zündver- zugszeit von Cyclohexan gezeigt. In der Arrhenius-Darstellung wird die Abhängigkeit von logtzv.p von T näherungsweise durch eine Gerade beschrieben, insbesondere stimmen bei niedrigen Temperaturen die bei 10 bar in einem kleinen Autoklaven und die bei Normaldruck im 500 l-Zylinder gemessenen Werte befriedigend überein. Auch einige in einer früheren Arbeit ermittelte Verzugszeiten [15] können in die Auswertung integriert werden. Die auf diese Weise gefundene Aktivierungsenergie beträgt 156 kJ/mol. Betrachtet man die verschiedenen Meßreihen jeweils für sich allein (vgl. die unterschiedlichen Symbole in Abb. 25), so kann man erkennen, dass sie im Arrhenius- Diagramm auf nahezu parallelen, aber gegeneinander verschobenen Geraden liegen, d.h. EA ist unabhängig vom Gefäß, nicht aber K. Abb. 26 zeigt ferner, wie lange man bei den tiefen Temperaturen, die in großen Gefäßen noch zur Zündung führen, unter Umständen auf eine Zündung warten muss. Im 500 l- Gefäß kam es im vorliegenden Fall erst nach ca. 2600 s, d.h. nach 43 min zu einer Zündung. Während des größten Teils dieser Verzugszeit betrug die mittlere Tempe- raturanstiegsrate weniger als 0,05 K/s, so dass man bei flüchtiger Betrachtung leicht zu dem falschen Ergebnis "Nichtzündung" gelangen kann. 200 210 220 230 240 250 260 270 280 290 300 310 320 10 100 1000 p·tZV / bar·s TZ / °C =0,5l-Autoklav (bis 10 bar) =1l-Autoklav (bis 5 bar) =Meßwerte Snee gr. Gefäße (bis 20l) =5l Erlenmeyerkolben =20l-Kugelautoklav =500l-Autoklav

40

Abb. 26: Zündverzugszeiten von Ethylhexanoat in unterschiedlichen Gefäßen: gleiche Akti- vierungsenergien, aber unterschiedliche Frequenzfaktoren Häufig war es jedoch nicht möglich, die in unterschiedlichen Gefäßen bestimmten Verzugszeiten durch eine einzige Arrhenius-Kurve wiederzugeben. Man konnte jedoch oft bei der Berechnung der Ausgleichskurven fordern, dass die Aktivierungsenergie für alle Gefäße die gleiche ist. In der Arrhenius-Darstellung ergeben sich dann parallele Geraden (Abb. 26). Da der Frequenzfaktor K auch das Oberfläche/Volumen-Verhältnis enthält, ist dieses Verhalten verständlich. Es gibt allerdings auch Fälle, in denen sich nicht nur die Frequenzfaktoren, sondern auch die Aktivierungsenergien in den einzelnen Gefäßen stark unterscheiden. Ein Beispiel ist n-Hexan. Die Gründe hierfür sind nicht bekannt. Für die meisten untersuchten Stoffe liegen die gemessenen Aktivierungsenergien im Bereich von 100 kJ/mol - 250 kJ/mol. 4.3.4 Vergleich mit Aktivierungsenergien aus der Druckabhängigkeit Die z.T. in früheren Arbeiten in 0,5 l- und 1 l-Autoklaven [15, 18] ermittelten Werte sind in Abb. 27 den Aktivierungsenergien aus der Verzugszeit gegenübergestellt.

Abb. 27: Vergleich der Aktivierungsenergien aus der Zündverzugszeit mit Aktivierungsenergien aus der Druckabhängigkeit der Zündtemperatur 190 200 210 220 230 240 250 260 270 280 1 10 100 1000 p·tZV / bar·s T / °C

0,32l-Gefäß

1l-Autoklav

5l-Erlenmeyerkolben

20l-Autoklav

150l- und 500l-Gefäß 50 100 150 200 250 300 350 400 450 500 50 100 150 200 250 300 350 400 450 500

Ether Ketone Ester Alkohole Kohlenwasserstoffe Carbonsäuren Ausgleichsgerade Prognoseband E A Zündverzugszeit / kJ EASemenoff / kJ

41 Bei den gemessenen Aktivierungsenergien handelt es sich um scheinbare Werte, die neben reaktionskinetischen Faktoren z.B. auch Einflüsse durch den Verdampfungs- vorgang aufweisen. Aktivierungsenergien können jedoch auch aus der Druckabhängigkeit der Zündtemperatur (z.B. über die Semenoff-Beziehung) ermittelt werden. Die Ergebnisse sind stark korreliert, ein Zeichen, dass die gemessenen Werte hauptsächlich durch Eigenschaften des Stoffes und der Reaktion beeinflußt sind. Allerdings sind die aus der Zündverzugszeit ermittelten Aktivierungsenergien meist etwas niedriger als die aus der Druckabhängigkeit von TZ bestimmten. Die in Abb. 27 eingezeichnete Ausgleichsgerade hat daher eine Steigung von 0,8 und nicht 1.

1. 4 Sicherheitstechnische Schlussfolgerungen

Die vorstehenden Untersuchungen ermöglichen es, die Zündtemperatur in großen Volumina aus Messungen in kleineren Gefäßen abzuschätzen. In der vorliegenden Arbeit wurden für zahlreiche Substanzen die Zündtemperaturen in Gefäßen, die größer als die Normapparaturen sind, ermittelt. Für 23 Stoffe konnte diese Untersuchung auf Gefäßvolumina von bis zu 0,16 m³ beziehungsweise 0,5 m³ ausgedehnt werden. Dabei zeigte sich, dass  die Zündtemperatur, wie aus der Literatur bekannt, mit zunehmender Gefäßgröße monoton abnimmt;  die Abnahme der Zündtemperatur, wie aus der Wärmeexplosionstheorie von Semenoff ableitbar und in der Beerbower-Korrelation impliziert, mit dem Logarithmus des Volumens korreliert ist;  jedoch häufig die logarithmische Abhängigkeit der Zündtemperatur vom Volumen erst ab Gefäßgrößen gültig ist, die größer als die Normapparatur sind. Dies ist regelmäßig der Fall bei Substanzen, die zur Ausbildung kalter Flammen weit unterhalb der Normzündtemperatur neigen;  die Beerbower-Korrelation die Volumenabhängigkeit der Zündtemperatur befriedigend wiedergibt, bei Substanzen, die zur Ausbildung kalter Flammen neigen, jedoch nur, wenn als Bezug an Stelle der Normzündtemperatur die ‚Kaltflammentemperatur nach Norm‘ (s. Anhang) herangezogen wird;  es bei der Ermittlung der Zündtemperatur unerheblich ist, ob man bei der Herstellung des Brennstoff/Luft-Gemischs auf dessen weitgehende Homogenisierung achtet oder nicht;  bei einigen Stoffen durch die Abnahme der Zündtemperatur in großen Volumina sehr lange Zündverzugszeiten von mehr als 30 min Dauer auftreten können. Eine Abschätzung aus Zündverzugszeiten bei höheren Temperaturen über eine Arrhenius- Beziehung ist häufig möglich. Eine Sicherheitsabschlag ist jedoch in allen Fällen erforderlich.

42 5 RELEVANTE VERÖFFENTLICHUNGEN W. Hirsch, E. Brandes, T. Stolz: Zündtemperaturen in großen Behältern Tech. Sich. 7 (2017) Nr. 9, 24 W. Hirsch, E. Brandes: Zündtemperaturen in großen Behältern Beitrag für 13. Fachtagung ‚Anlagen-, Arbeits- und Umwelttechnik‘ Köthen angenommen

6 BEWERTUNG DER ERGEBNISSE HINSICHTLICH DES FORSCHUNGS- ZWECKS/-ZIELS, SCHLUSSFOLGERUNGEN Da die Zündtemperatur bei technischen Prozessen oft als ‚Leitgröße‘ für die maximal zulässige Temperatur von heißen Oberflächen und von Gas/Dampf-Luft-Gemischen her- angezogen wird, ergeben sich unter sicherheitstechnischen Aspekten aus dieser Volu- menabhängigkeit Konsequenzen für Art und Umfang der Explosionsschutzmaßnahmen. Das Ziel dieser Forschungsvorhaben (BGRCI-Forschungsvorhaben ‚Zündtemperaturen in großen Behältern; Projekt – Volumina bis 20 l‘ und DGUV-Forschungsvorhaben ‚Zünd- temperaturen in großen Behältern; Projekt – Volumina bis 0,5 m³‘) eine Basis für die Beurteilung zu erhalten, in wieweit Extrapolationen von Zündtemperaturdaten, die in klei- nen Volumina bestimmt wurden, auf größere Volumina sicherheitstechnisch vertretbar sind, ist erreicht worden. Aufgrund der erarbeiteten Datenbasis ist es möglich, sowohl das Ausmaß der Erniedri- gung der Zündtemperatur als auch das Ausmaß der Verlängerung der Zündverzugszeit in Abhängigkeit des Behältervolumens aus der Normzündtemperatur bzw. der Kaltflammen- temperatur nach Norm abzuschätzen und zu beurteilen. 7 AKTUELLER UMSETZUNGS- UND VERWERTUNGSPLAN Aufgrund der erhaltenen Ergebnisse des Forschungsvorhabens ist eine Konkretisie- rung das Regelwerk der Berufsgenossenschaften (Explosionsschutz-Regeln (EX-RL) DGUV Regel 113-001) hinsichtlich der Beurteilung der Zündquelle ‚heiße Oberfläche‘ bzw. eine Konkretisierung der Bemerkung 1 zu 5.2 Heiße Oberflächen der TRBS 2152, Teil 3 „5.2 Heiße Oberflächen Ziel der Schutzmaßnahmen ist die Verhinderung der Entzündung explosionsfähiger Atmosphäre durch das Wirksamwerden einer heißen Oberfläche als Zündquelle. 5.2.1 Hinweise für die Gefährdungsbeurteilung (1) Kommt explosionsfähige Atmosphäre mit heißen Oberflächen (heiße Rohr- leitungen, Heizkessel usw.) in Berührung, kann es zu einer Entzündung kom- men. (2) Grundlage der Bewertung ist die genormte Zündtemperatur der die

43 explosionsfähige Atmosphäre bildenden Stoffe. Es ist jedoch zu berücksichtigen, dass die Zündfähigkeit einer heißen Oberfläche u. a. von der Art und der Konzentration des jeweiligen Stoffes im Gemisch mit Luft, von Größe und Gestalt des heißen Körpers und vom Wandmaterial abhängt. Bemerkung 1: Explosionsfähige Atmosphäre kann z. B. im Inneren größerer erhitzter Räume durch heiße Wände mit deutlich niedrigerer Temperatur als die der Norm-Zündtemperatur des Brennstoffs entzündet werden.“

möglich. Beispielsweise könnten Experten der PG „Überarbeitung der EX-RL – Beispielsammlung“ des SG Explosionsschutz im Fachbereich Rohstoffe und chemische Industrie der DGUV über einen entsprechenden AK des AGS UA II einen Vorschlag zur Änderung dieser Bemerkung einbringen

8 LITERATUR [1] DIN 51794: Prüfung von Mineralölkohlenwasserstoffen - Bestimmung der Zünd- temperatur, 2003 [2] IEC 60079: Explosive atmospheres part 20-1: Material Characteristics for Gas and Vapour Classification - Test Methods and Data; 2010 [3] DIN EN 14522: Bestimmung der Zündtemperatur von Gasen und Dämpfen; 2005 [4] ASTM E 659: Standard Test Method for Autoignition Temperature of Liquid Chemicals; 2005 [5] A. Beerbower: privat communication, zitiert n. Coffee [8] [6] N.P. Setchkin: Self-Ignition Temperatures of Combustible Liquids; J.Res.NBS 53 (1954), 49 [7] T.J. Snee, J.F. Griffiths: Criteria for Spontaneous Ignition in Exothermic, Auto- catalytic Reactions: Chain-Branching and Self-Heating in the Oxidation of Cyclohexane in Closed Vessels; Comb.Flame 75 (1989), 381 [8] R.D. Coffee: Cool Flames and Autoignitions: Two Oxidation Processes; 13th Loss.Prev.Symp.AIChE (1979), 74 [9] T.J. Snee: Auto-Ignition, Slow Combustion and the Variation of Minimum Ignition Temperature with Vessel Size, HSE Res.Lab.Div.; Buxton Loss Prev.Bull. 081 (1988), 25 [10] E. Brandes, W. Möller: Safety Characteristic Data Vol.1, Flammable Liquids and Gases; Wirtschaftverlag NW Verlag für neue Wissenschaft Bremerhaven 2008 [11] E. Brandes, Ch. Papp: Vorbereitende Untersuchungen, um praktische Konse- quenzen aus der Absenkung der Zündtemperatur in Behältern ziehen zu können Abschlußbericht zum BGRCI-Forschungsvorhaben 2011

44 [12] TRBS 2152 Teil 3: Gefährliche explosinsfähige Atmosphäre- vermeidung der Entzündung gefährlicher explosionsfähiger Atmosphären, GMBl. 77, No. 2009, S.1583 [13] J. Griffiths: Cool Flames, a Hot Prospect?; Proc. 4th Europ.Comb.Meeting, Louvain- la-Neuve 2005 [14] J. Barnard, A. Watts: Cool Flame Oxidation of Ketones, 12th Symp.(Int.) on Combustion (1969), 365 [15] W. Hirsch, E. Brandes: Zündtemperaturen binärer Gemische bei erhöhten Ausgangsdrücken; Abschlußbericht zum Forschungsvorhaben, Physikalisch- Technische Bundesanstalt Braunschweig, 2005 [16] N.N. Semenoff: Zur Theorie des Verbrennungsprozesses, Z. Phys. 48(1928), 571 [17] C. Papp, E. Brandes, W. Hirsch, M. Marx: Autoignition Temperatures of Flammable Liquids in Closed Vessels; 9th Int. Symp. on Haz. Prev. Mitigation of Ind. Expl., Cracow 2012 [18] M.Gödde: Zündtemperaturen organischer Verbindungen in Abhängigkeit von chemi- scher Struktur und Druck; PTB-Bericht ThEx-8, Wirtschaftverlag NW Verlag für neue Wissenschaft Bremerhaven 1998

45 ANHANG: BESTIMMUNG VON KALTEN FLAMMEN ISO IEC DIS 80079-20-1

Anhang C (informativ) Nicht autorisierte Übersetzung

Bestimmung von kalten Flammen Dieser Anhang befasst sich mit einem Screening-Verfahren zur Identifizierung von Stoffen, die in einem geschlossenen Gefäß deutlich niedrigere Entzündungstemperatur zeigen. Einige Stoffe, hauptsächlich kurzkettige Ester, Ketone und einige Ether zeigen einen signifikanten Unterschied (bis zu 200 K) zwischen der Tz nach dem in 7.4 beschriebenen Verfahren, bestimmt im offenen Erlenmeyerkolben bei Umgebungsdrücken (zwischen etwa 98 kPa und 103 kPa), und der in einem geschlossenen Gefäß von vergleichbarem Volumen bei vergleichbarem Druck (1 bar) gemessenen Zündtemperatur. Experimentelle Untersuchungen zeigten, dass bei solchen Stoffen sehr blasse blaue Flammen, begleitet von einem mäßig steilen Temperaturanstieg von nicht mehr als 150 K (kalte Flammen), im offenen Erlenmeyerkolben bei Temperaturen auftreten, die mit den Entzündungstemperaturen in einem geschlossenen Gefäß vergleichbar sind. Solche Stoffe können nach folgendem Verfahren identifiziert werden: Der Erlenmeyer-kolben wird mit einem zusätzlichen Thermoelement von 0,5 mm Durchmesser (T2 in Bild C.1) und einer Aufzeichnungseinheit für die laufende Aufzeichnung der Temperaturentwicklung während der Prüfung ausgestattet. Dieses Thermoelement sollte Nahe am Rand der Öffnung des Erlenmeyerkolbens angeordnet sein und etwa 10 mm über dessen Boden enden. Nach Durchführung der Schritte 7.4.3.4 bis 7.4.3.8 wird die Temperatur der Heizeinrichtung in Schritten von 10 K bis 20 K abgesenkt, bis entweder eine Differenz von 250 °C zu der AIT, die in 7.4 ermittelt wurde, oder eine Kolbentemperatur von etwa 85 °C erreicht ist. Bei jedem Temperaturschritt wird die Menge des Stoffes nach 7.4.3.6 variiert. Die von T2 registrierte Temperatur wird während dieser zusätzlichen Schritte aufgezeichnet. Eine Temperaturerhöhung zwischen 50 K und 150 K mit einer Temperaturanstiegs- geschwindigkeit zwischen 20 K/s und 30 K/s ist ein Hinweis auf kalte Flammen. Bei der Durchfüh rung der zusätzlichen Schritte über den gesamten Temperaturbereich ist darauf zu achten, die Kaltflammentemperatur (Bereich der Kaltflammentemperatur) nicht zu verpassen, da einige Stoffe einen so genannten „negativen Temperatur-koeffizient“ (Bild C.2) aufweisen.

Bild C.1

Bild C.2

Kaltflammentemperatur T Erlenmeyerkolben in °C ∆T bei Tz in °C Tz

FD05992 ｜ 2020_德国_IFS_IFS_Report_2020_4.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2020 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

• Jahrgang

Dezember 2020 Eine Information des Institutes für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. P hotovoltaikanlagen sind Teil der Energiewende und des Zeit- geistes; Solarmodule sind auf einer wachsenden Zahl von Dächern zu sehen. Für die gewonnene Energie bedarf es eines Energiespeichersystems für den Haushalt, eines sogenannten Heimspeichers, und die arbeiten in den meisten Fällen mit Lithium-Ionen-Akkus. Das IFS hat in den vergangen Monaten mehrere Brände an Heimspeichern von LG Chem untersucht. Bei allen betroffenen Anlagen war es innerhalb des Akkuteils zur Brandentstehung gekommen, in dem nach Angabe des südkoreanischen Herstellers jeweils Lithium-Ionen-Akkus aus dem gleichen Produktionszeitraum verbaut waren. Sie sind bei den verschiedenen Modellen allerdings unterschiedlich geschaltet. Betroffen sein können laut Her- steller Heimspeicher, die unter den Produktnamen RESU10, RESU Für die Speicherung von Solarstrom werden oft Lithium-Ionen-Akkus eingesetzt. Brände an Heimspeichern von LG Chem Der Hersteller tauscht Akkus einiger Modelle wegen Überhitzungs-/Brandgefahr aus Wie Schimmel in Wohn- räumen vermieden werden kann, lesen Sie auf ⟶ S. 3 Foto: Adobe Stock 7H Type-R, RESU10H Type-R und RESU10H Type-C vermarktet wurden sowie einige modulare Speicherein- heiten. Der Produktionszeitraum der betroffenen Akkuzellen liegt nach Herstellerangabe im Jahr 2017. Das IFS hat allerdings auch brand- betroffene Anlagen untersucht, deren Akkus nicht in die erwähnte Gruppe gehören. Für die vom Hersteller genannten Speicher hat das Unter- nehmen ein Austauschprogramm gestartet, das noch in diesem Jahr weitgehend abgeschlossen werden soll. Man bemühe sich, die Kunden über die Händler zu erreichen und über die Austauschmaßnahme zu informieren, so LG Chem. Die Speicher werden von zahlreichen Fachhändlern und auch auf Online-Marktplätzen angeboten. Der Hersteller bewertet die ihm vorliegenden Informationen so, dass Kunden ihre Speicher nicht abschalten müssen. Das IFS ist an der Untersuchung weiterer betroffener Speicher interessiert und bittet beim Auftreten von Bränden an Heim- speichern um eine kurze Mitteilung per E-Mail an info@ifs-ev.org. Ein generelles Überhitzungs-/Brandrisiko Mit Lithium-Ionen-Akkus geht ein generelles Risiko einher, das sich mittlerweile zu einer der typischen Brandursachen im Alltag entwickelt hat, wie die IFS-Statistiken zeigen. Betroffen ist eine breite Produkt- palette von der E-Zigarette bis zum Elektrofahrzeug. Informationen zu den technischen Hintergründen und die wichtigsten Tipps zur Schadenver- hütung haben wir auf unserer Inter- netseite zusammengestellt: www.ifs-ev.org/lithium-akkus 2 IFS-Report  4/2020 Fragen Sie Ihren Schornsteinfeger Für Brände durch Kamin- und Kachelöfen gibt es zwei typische Ursachen. Außerdem müssen einige Anlagen diesen Winter stillgelegt werden F ür die eigentliche Beheizung sind Kamin- und Kachelöfen heute meist nicht von großer Bedeutung. Und doch gibt es in Deutschland rund elf Millionen sogenannte Einzelraum- feuerstätten für feste Brennstoffe, wie der Bundesverband des Schornstein- fegerhandwerks weiß. Das Knistern des Feuers und die direkte Wärme schaffen eine gemütliche Atmosphäre an grauen Tagen und langen Winterabenden. Allerdings ist die Strahlungswärme auch genau das, was zum Problem wird, wenn man sie unterschätzt. Ein Schadenszenario, dem die Brand- ursachenermittler des IFS häufig begegnen, ist der Korb mit Brennholz, der zu nah am Ofen gestanden hat. Auch Polstermöbel werden manchmal nicht weit genug vom Kaminofen aufgestellt. Wie groß der Abstand mindestens sein muss, variiert stark von Anlage zu Anlage und steht in der Bedienungsanleitung. Dort beschreiben die Hersteller außerdem die korrekte Befeuerung. Um eine Brandent- stehung zu vermeiden, müssen auch diese Hinweise unbedingt befolgt werden. Wird ein Ofen falsch befeuert, so kann die Nennwärmeleistung erheblich überschritten werden. „Dann steigt auch die Strahlungs- wärme und damit die Gefahr, dass Gegenstände in der Nähe entzündet werden“, erklärt IFS-Geschäftsfüh- rer Dr. Hans-Hermann Drews. Brandausbruch mit Zeitverzögerung Die zweite typische Brandursache im Zusammenhang mit Kamin- und Kachel- öfen entsteht schon bei der Montage eines Ofens und der Installation der Abgasanlage. Denn oft werden dabei die Mindestabstände nicht eingehalten. Nach der Inbetriebnahme können durchaus Jahre mit scheinbar problem- loser Nutzung vergehen, bevor es zu Überhitzungen an Bauteilen kommt. Wie viel Raum zwischen dem Ofenrohr und brennbaren Baustoffen liegen muss, hängt ebenfalls von der Anlage ab. Die Angaben sind in den Feuerungs- verordnungen der Bundesländer festgelegt. Ob sie eingehalten wurden, prüft der Schornsteinfeger bei der Abnahme des Ofens. Die Betriebs- und Brandsicherheit muss vom Fachmann darüber hinaus zweimal innerhalb von sieben Jahren bei der sogenannten Feuerstättenschau überprüft werden. „Am besten sollte man den Schornstein- feger fragen, was für den jeweiligen Kamin oder Ofen notwendig ist“, rät Drews. „Eine falsch installierte Anlage oder nicht gekehrte Abgaswege bedeuten eine erhebliche Brandgefahr“. Neuer Gutachter für das IFS in Stuttgart Arne Lehmann IFS Stuttgart Tel. +49 711 380426080 lehmann@ifs-ev.org Das IFS begrüßt einen neuen Kollegen: Arne Lehmann ist Maschinenbauingenieur und erweitert das Gutachterteam des IFS in Stuttgart. Der erfahrene Schadenanalytiker wird für das Institut Brandursachen ermitteln und Leitungswasserschäden untersuchen. Anlagen, die zwischen 1985 und 1994 erstellt wurden, müssen übrigens bis spätestens Ende des Jahres stillgelegt werden. Grund ist eine Verschärfung der Emissionswerte, die am 1. Januar 2021 in Kraft tritt. Eigentümer sollten von ihrem Schornsteinfeger rechtzeitig einen Hinweis auf die Neuregelung erhalten haben. Die Grenzwerte sind der BImSchV (Verordnung zur Durch- führung des Bundes-Immissionsschutz- gesetzes) festgelegt. Sie sieht eine weitere Verschärfung der Emissions- werte mit Beginn des Jahres 2025 vor. Bis dahin müssen auch Einzelraumfeuer- stätten stillgelegt werden, die bis ein- schließlich 21.03.2010 erstellt wurden. Wenn der Korb mit dem Brennholz zu nah am Ofen steht, kann es gefährlich werden.

IFS-Report  4/2020 3 S chimmelpilzsporen sind sowohl draußen als auch in Gebäuden allgegenwärtig und zumeist kein Problem. Damit es in Wohnräumen zum Schimmelbefall kommt, benötigen diese Lebensformen, die weder ins Tier- noch ins Pflanzenreich gehören, nämlich ein feuchtes Raumklima. Wenn sich an Wänden und rund um die Fens- ter schwarze Spuren bilden, beginnt darum die Suche nach der Ursache der Feuchtigkeit. Diese kann in baulichen Mängeln liegen, und dann können auch nur bauliche Veränderungen das Problem nachhaltig beseitigen. Häufig werden jedoch insbesondere im Winter durch falsches oder ungenügendes Lüften und Heizen die Bedingungen für ein Schimmelpilzwachstum geschaffen, weil sich dadurch an kalten Oberflächen Kondenswasser niederschlagen kann. Kondenswasserbildung vermeiden Will man die Bildung von Kondens- wasser vermeiden, ist die relative Luftfeuchtigkeit die entscheidende Größe, die man im Auge behalten sollte. „Am besten wäre es, in jedem Raum ein Hygrometer zu haben“, empfiehlt Dr. Stefan Schallmoser. Die relative Luftfeuchtigkeit gibt an, zu welchem Anteil die Luft mit Wasser gesättigt ist. Sie wird aus der absoluten Richtiges Lüften und Heizen im Winter Wie Schimmel in Wohnräumen entsteht und wie er vermieden werden kann Am kalten Fenster kondensiert die Feuchtigkeit aus der Raumluft. Feuchtigkeitsmenge pro Kubikmeter und der Temperatur berechnet. Denn wieviel Wasser die Luft aufnehmen kann ohne Nebeltröpfchen zu bilden, hängt stark davon ab, wie warm sie ist. „Als Richtwert sollte man darauf achten, dass die relative Luftfeuchtig- keit im Winter bei angenehmen Wohn- temperaturen zwischen 50 und 60 Pro- zent liegt“, erklärt der IFS-Gutachter. Der Wert sollte auf jeden Fall immer deutlich unter 70 Prozent bleiben. Den Wert regulieren Wenn die relative Luftfeuchtigkeit zu hoch ist, kann an kalten Oberflächen wie Außenwänden oder Fenstern der Taupunkt erreicht werden. Das ist die Temperatur, bei der die Luft zu 100 Prozent gesättigt ist und die Feuchtig- keit kondensiert. Um den Wert zu regulieren, gibt es zwei Stellschrauben, an denen man drehen kann: die Wassermenge und die Temperatur. Beim Lüften strömt feuchte Raumluft raus und trockenere Außenluft ins Zimmer. Das gelingt am besten mit Entschlossenheit: „Stoßlüften mit weit geöffneten Fenstern ist wesentlich effektiver, als die Fenster dauerhaft zu kippen“, weiß Schallmoser. Übrigens enthält die kalte Winterluft selbst an verregneten Tagen mit hoher relativer Luftfeuchtigkeit weniger Feuchtig- keit als die warme Raumluft, weil die kalte Luft viel weniger Wasser aufnehmen kann. Werden die Fenster wieder geschlossen, erwärmt sich die Luft, kann mehr Wasser aufnehmen, und die relative Luftfeuchtigkeit sinkt weiter ab. „Um diesen Effekt zu unterstützen, ist es allerdings wichtig, die Räume nicht nur zu lüften, son- dern anschließend auch ausreichend zu beheizen“, sagt der Gutachter. Die Feuchtigkeitsquellen Feuchtigkeitseintrag von vornherein zu vermeiden, ist keine Alternative. Schon durch unser normales Wohn- verhalten treiben wir die Luftfeuchtig- keit in die Höhe. Zum Beispiel beim Duschen, Kochen, Wäschewaschen und -trockner gelangt Wasser in die Raum- luft. Dafür genügt sogar unsere bloße Anwesenheit: Ein schlafender Mensch gibt über den Atem und die Körper- oberfläche etwa 30 Gramm Wasser pro Stunde an die Umgebung ab. Wenn er sich bewegt, steigt die Menge. Je mehr Menschen sich in einem Raum aufhalten, desto mehr Wasser in Form von Wasserdampf gelangt in die Raumluft. Bei einem Drei-Personen- Haushalt addiert sich all das durch- schnittlich auf zwölf Liter pro Tag. Wer gern kühl schläft und darum das Schlafzimmer nur wenig beheizt, sollte die Schlafzimmertür tagsüber geschlossen halten, um den Luft- austausch mit den anderen Wohn- räumen zu reduzieren. Ein bisschen Wärme braucht allerdings auch das tagsüber ungenutzte Schlaf- zimmer, damit die Wände nicht zu sehr auskühlen. Um eine gute Luft- zirkulation zu ermöglichen, sollten Möbel außerdem immer etwas von den Wänden abgerückt aufgestellt werden. Das betrifft alle Räume und insbesondere die Außenwände, die zwangsläufig immer etwas kälter sind. Fotos: Adobe Stock

Herausgeber: Institut für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. Preetzer Straße 75, 24143 Kiel Tel. +49 431 775 78  0 mail@ifs-ev.org www.ifs-ev.org Redaktion, Layout: Ina Schmiedeberg Tel. +49 431 775 78 10 schmiedeberg@ifs-ev.org Druck: Carius Druck Kiel GmbH Boninstraße 25, 24114 Kiel Tel. +49 431 624 46 Aufkeimende Zweifel Der Keimhemmer Chlorpropham darf in der EU nicht mehr eingesetzt werden. Doch die Nachfolger sind brennbar B ei der Lagerung von großen Mengen Kartoffeln wird die Keimung mit einem Wachstums- regulator verhindert. Dafür wurde in der Vergangenheit Chlorpropham eingesetzt. Weil diese chemische Verbindung gesundheitsschädlich ist und im Verdacht steht, krebsauslösend zu wirken, ist sie in der EU seit Ende Juli 2019 als Keimhemmer nicht mehr zugelassen. Am 8. Oktober dieses Jahres endete auch die Aufbrauchfrist. Eine Alternative schien mit 1,4 Dimethyl- naphthalin gefunden zu sein, das unter dem Handelsnamen 1,4SIGHT vertrieben wird und in Deutschland seit 2018 als Pflanzenschutzmittel zugelassen ist. Doch Brandfälle lassen nun Zweifel an dem Nachfolger aufkommen. Denn während Chlorpropham als nichtbrenn- bare Lösung angewendet wurde, han- delt es sich bei 1,4 Dimethylnaphthalin um eine reine Kohlenwasserstoffver- bindung. Im Sicherheitsdatenblatt des Herstellers wird der Flammpunkt mit 122 °C angegeben. Damit ist 1,4SIGHT im gefahrstoffrechtlichen Sinne keine entzündliche Flüssigkeit, allerdings ist sie durchaus brennbar. Zudem ist das Brandverhalten einer Flüssigkeit im Kanister anders als im vernebelten Zustand, und der Keimhemmer wird als Heißnebel auf den Kartoffeln ver- teilt. In einem kürzlich vom IFS unter- suchten Fall kam es dabei in einem Lager für mehrere tausend Tonnen Kartoffeln zum Brandausbruch. Bei Brandversuchen im IFS ließ sich die Substanz als Flüssigkeit in einem offenen Gefäß erst im erwärmten Zustand entzünden. Als Sprüh- nebel konnte sie jedoch schon bei abgesenkter Raumtemperatur sowohl an einer offenen Flamme als auch durch elektrische Entladung ent- zündet werden. Bei der Behandlung im Kartoffellager kommen diverse Zünd- quellen für den Heißnebel in Frage. Der Hersteller des Nebelgerätes warnt in der Bedienungsanleitung: "Die Vernebelung von brennbaren Flüssig- keiten in geschlossenen Räumen ist absolut verboten." Außer 1,4SIGHT werden als Keimhemmer, die im Heiß- vernebelungsverfahren verwendet werden, derzeit Minzöl und Orangenöl eingesetzt. Auch dabei handelt es sich jedoch um brennbare Flüssigkeiten. Das IFS hat einen weiteren Brandfall untersucht, bei dem Orangenöl in einem Kartoffellager heißvernebelt wurde. Fotos: Adobe Stock Fröhliche Weihnachten Alle Jahre wieder steigen im Dezember die Schadenzahlen. Lokale Frost- perioden bringen Wasserleitungen in Abseiten zum Bersten oder erinnern daran, dass man den Gartenschlauch am Außenwasserhahn vergessen hat. Wo an Ihrem Haus mögliche Schwach- stellen liegen, zeigt der IFS-Winter- check. Wenn das Wasser aus dem einem Keller gepumpt ist, startet die Feuer- wehr zum nächsten Haus, wo sich gera- de Adventskerzen und Tannenzweige zu nah gekommen sind. Hauptsache, am Ende gerät nicht auch noch der Christ- baum in Brand, wie in unserem Video. Auf unserer frisch umgestalteten Inter- netseite haben wir Tipps und Hinter- gründe zu den typischen Winterschäden zusammengestellt. Besuchen Sie uns unter www.ifs-ev.org. Das Team des IFS wünscht allen Kunden, Partnern und Freunden ein besinnliches Weihnachtsfest und einen fröhlichen Start in das neue Jahr. Unbehandelt keimen Kartoffeln rasch.

FD05993 ｜ 2021_德国_IFS_ifs_report_2021_1.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2021 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

• Jahrgang

März 2021 Eine Information des Institutes für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. E in ungewöhnliches Geräusch weckte eine Frau in der Nacht. Dann hörte sie ihren Mann rufen, dass es brenne. Als sie die Treppe vom Schlafzimmer heruntereilte, sah sie, wie er mit einem Teppich ein Feuer im Wohnungsflur ausschlug – was glücklicherweise gelang. Der Mann war aufgestanden, um etwas zu trinken. Dabei hatte er zufällig das entstehende Feuer bemerkt. Auf einer Ablage im Flur hatte die Ladeschale für ein Klapphandy gestanden. Das Gerät befand sich im Ladevorgang, als der Akku thermisch durchging und den Brand verursachte. In dem zwei Jahre alten Mobiltelefon hatte sich der original Akku befunden, und es hatte zuvor keine Auffälligkeiten gegeben. Von Lithium-Ionen-Akkus, die in Mobiltelefonen in der Regel genutzt werden, geht ein generelles, wenn auch nach Einschätzung des IFS kein Bei beiden Telefonen ist der Akku thermisch durchgegangen. Wenn die Telefone heiß laufen Bei Mobiltelefonen sollte man einen Blick auf den Ladevorgang und auf Rückrufe haben Einen häufigen Fehler bei der Installation von Verbund- rohren finden Sie auf ⟶ S. 3 Fotos: IFS unverhältnismäßig hohes Brandrisiko aus. Die meisten Brände entstehen in der Ladephase. Darum empfehlen wir, die Akkus in einem Raum mit Rauchmelder und nicht inmitten brennbarer Materialien zu laden. Bei einem anderen kürzlich unter- suchten Schaden war der Akku eines Smartphones durchgegangen, das zu diesem Zeitpunkt ohne Anschluss ans Ladegerät auf dem Esstisch lag. Aller- dings war der Akku kurz zuvor geladen worden. Auch hier befand sich der erste original Energiespeicher im Telefon, und in diesem Fall war wahrscheinlich genau das das Problem: Es handelte ich um ein Samsung Galaxy S4. Bei diesen Geräten hatte der Hersteller 2013 einen kosten- freien Austausch der Akkus angeboten, nachdem sich Berichte über sich ausdehnende Akkus und „Explosionen“ derselben gehäuft hatten. Diese Aktion hatte der Besitzer des Smartphones offenbar nicht mitbekommen und es noch Jahre ohne Probleme benutzt. Da es im Zusammenhang mit Lithium- Ionen-Akkus immer wieder Austausch- und Rückrufaktionen gibt, lohnt sich ab und zu eine kurze Internet-Recherche. Ob eines der eigenen Geräte von einem bekannten Serienproblem betroffen ist, lässt sich in der Regel schnell heraus- finden. Das IFS empfiehlt, Akkus, die seitens des Herstellers ausgetauscht werden sollen, nicht mehr zu benutzen und vor allem nicht erneut zu laden. Wenn ein Lithium-Ionen-Akku sicht- lich beschädigt ist oder sich aufbläht, besteht die akute Gefahr eines Brand- ausbruchs. Was passiert, wenn ein solcher Akku thermisch durchgeht, zeigen wir in einer Reihe von Video- beiträgen. Dort finden Sie auch Hin- weise zur Schadenverhütung. Besuchen Sie unseren Youtube-Kanal. 2 IFS-Report  1/2021 B randgeruch sorgte am frühen Abend für Sorge in einem Wohn- haus. Kurz darauf entdeckte einer der Bewohner Rauchentwicklung, die von der Waschmaschine ausging. Das Gerät wurde später im IFS unter- sucht. Dabei zeigte sich ein bekanntes Schadenbild: Das Feuer war an der Bedieneinheit der Waschmaschine entstanden, bei der es sich um das Modell HW-C 1460TVE des chinesischen Herstellers Haier handelte. Bereits 2016 berichteten wir im IFS-Report über eine Schadenauffälligkeit, zu der es zunächst nur einen Eintrag bei Rapex, dem Schnellwarnsystem der EU für Verbraucherschutz, gab, der sich aus- schließlich auf Großbritannien bezog. 2019 veröffentlichte Haier auch für Deutschland Sicherheitshinweise wegen einer möglichen Brandgefahr. Betroffen sind demnach Waschmaschinen mit den Modellbezeichnungen HW-C 1460TVE und HW-C 1470TVE sowie ProSport 1260 und ProSport 1460. Brandgefahr besteht außerdem bei den Waschtrocknern HWD70-1482 und HWD80-1482. Wie der eingangs geschilderte Fall zeigt, können Brände auch nach vielen Jahren des problemlosen Betriebes auftreten. Der Hersteller bietet betroffenen Kunden den kostenfreien Austausch der möglicherweise fehlerhaften Komponenten an. Die Sicherheits- hinweise haben wir in einem Beitrag auf unserer Internetseite verlinkt. Besuchen Sie uns unter www.ifs-ev.org/haier Das Typenschild mit der Modellnummer ist bei geöffneter Trommel zu sehen. Gefährliche Manipulation Wenn technische Sicherheitseinrichtungen absichtlich überbrückt werden, wird es riskant E in Anwohner alarmierte mitten in der Nacht die Feuerwehr, denn in dem Schnellrestaurant, über dem er wohnte, war ein Brand ausgebrochen, und die Flammen breiteten sich schon auf die oberen Gebäudeteile aus. Erst eine gute Stunde zuvor war Betriebsschluss gewesen. Bei der Untersuchung der Brandstelle stellte ein IFS-Gutachter später fest, dass der Brand in der Fritteuse und dort im linken der beiden Frittierbecken entstanden war. Dort wurde Fett so weit erhitzt, dass es sich entzündet hatte. Über die Abluftanlage bahnten sich die Flammen ihren Weg ins Dach- geschoss. Bei der Laboruntersuchung der Fritteuse zeigte sich, wie es zu dem Schaden kommen konnte: Am linken Frittierbecken hatte jemand den Schutztemperaturbegrenzer (STB) überbrückt. Dessen Aufgabe ist es, die Beheizung zu unterbrechen, falls am Regelthermostat ein Fehler auf- tritt und dieser die Temperatur nicht begrenzt. Schon vor dem Schaden muss ein Defekt am Regelthermostat dazu geführt haben, dass die Heizung des linken Beckens durchheizte und das Fett soweit erhitzt wurde, dass der STB auslöste. Eine Reparatur wäre not- wendig gewesen. Stattdessen wurde die Sicherheitseinrichtung überbrückt, um die Fritteuse weiter nutzen zu können. Das IFS hat schon häufiger Brände in der Gastronomie untersucht, die auf die gleiche Weise entstanden sind. Blick auf die elektrotechnischen Komponenten: Der Schutztemperatur­ begrenzer ist im rechten Frittierbecken korrekt angeschlossen (oberes Bild), im linken Frittierbecken wurde das gleiche Bauteil überbrückt. Brände an Waschmaschinen Noch immer sind Geräte des chinesischen Herstellers „Haier“ im Einsatz, die von einem Rückruf betroffen sind

IFS-Report  1/2021 3 D urch einen Rohrbruch in einem neu gebauten Studenten- wohnheim wurden sieben Wohnungen geflutet und zunächst unbewohnbar. Die Leckagestelle befand sich an einem Mehrschichtverbund- rohr in der Leichtbauwand hinter einer Dusche. Der Installateur hatte das Rohr direkt hinter der Presshülse gebogen, um den vorgesehenen Leitungsverlauf Kannste knicken Wenn Verbundrohre unmittelbar am Verbinder gebogen werden, ist ein Schaden programmiert Unmittelbar hinter den Presshülsen wurden die Rohre geknickt. herzustellen. Für solche Belastungen sind Verbundrohre allerdings nicht geeignet. Bei der Druckprüfung zeigten sich zwar noch keine Undichtigkeiten, doch der Schaden war programmiert und trat unter gewöhnlichen Betriebs- belastungen nach kurzer Zeit auf: Das Rohr riss unmittelbar hinter der Press- hülse auf, wie die technische Unter- suchung im Labor des IFS später zeigte. Der beschriebene Installationsfehler kommt immer wieder vor. In den Unterlagen zu dem Presssystem wies der Markenhersteller sogar ausdrück- lich darauf hin, die Rohre nicht am Verbinder zu biegen, weil dies zum Knicken führt. Und ein Knick im Ver- bundrohr ist ein initiierter Schaden. Das Problem hatte in diesem Fall schon mit der Auswahl der Kompo- nenten begonnen. Der Installateur hatte eine Doppelwandscheibe mit zwei im 90°-Winkel angeordneten Abgängen verwendet. Um die beiden Anschlussrohre wie vorgesehen parallel zu führen, musste der Handwerker sie biegen. Dabei hat der Hersteller auch Doppelwandscheiben mit par- allel angeordneten Abgängen im Programm. Damit wäre die Installa- tion problemlos möglich gewesen. In dem Studentenwohnheim war es mit der Reparatur der einen Lecka- gestelle und der Sanierung der in der Folge aufgetretenen Feuchteschäden nicht getan. In mehr als 150 weiteren Duschen waren die gleichen Kom- ponenten auf die beschriebene Art installiert worden. Alle betroffenen Verbindungen lagen in Leichtbau- wänden, die zur Vermeidung weiterer Schäden geöffnet werden mussten. Fotos: IFS Gebrochene Geräte-Ventile Im Werk des Herstellers Benkiser wurden Geräte- Schrägsitzventile falsch montiert D as IFS hat eine Reihe von Leitungswasserschäden unter- sucht, die durch gebrochene Anschlussventile der Benkiser Armaturenwerke verursacht wurden. Bei den begutachteten Bauteilen war jeweils das Ventilkopfstück abgebrochen. Der Schädigung lag in allen Fällen eine Krafteinwirkung bei der Montage der Ventile während des Herstellungsprozesses zu Grunde. Diese zeigte sich bei den Untersuchungen in Form von ungleichmäßigen Abdrücken auf Werkzeugaufnahmeflächen, die ausschließlich während der Ferti- gung der Bauteile zugänglich sind. Durch die Krafteinwirkung wurden Zugspannungen und in der Folge Spannungsrisskorrosion im Messing- werkstoff der Ventile initiiert. Benkiser gibt Geräte-Schrägsitzventile des Modells PRIMA 1/2" mit Rückfluss- verhinderer und Belüftung sowie der Bezeichnung PRIMAGAVS15B als betroffen an und bittet darum, diese auf seine Kosten auszutauschen. Dieser Hinweis des Herstellers ist von

1. In dem Jahr wurde vom IFS das

erste gebrochene Ventil untersucht. Die jüngsten Schäden liegen weni- ge Monate zurück. Zwischen einer initiierten Spannungsrisskorrosion und dem in der Folge auftretenden Bauteilbruch können Jahre liegen. Das Ventilkopfstück ist abgebrochen.

Herausgeber: Institut für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. Preetzer Straße 75, 24143 Kiel Tel. +49 431 775 78  0 mail@ifs-ev.org www.ifs-ev.org Redaktion, Layout: Ina Schmiedeberg Tel. +49 431 775 78 10 schmiedeberg@ifs-ev.org Druck: Carius Druck Kiel GmbH Boninstraße 25, 24114 Kiel Tel. +49 431 624 46 „Solche Einsätze haben wir täglich“ Der Herd wird als Ausgangspunkt für Wohnungsbrände unterschätzt W ährend manche Risiken leicht überschätzt werden – weil sie zum Beispiel große Schlag- zeilen bekommen oder besonders furchteinflößend klingen –, werden Alltagsrisiken häufig unterschätzt. Eine Recherche in der Schadendatenbank des IFS ergab, dass jeder fünfte Wohnungs- brand auf dem Küchenherd beginnt. Der Herd erscheint uns vollkommen kontrollierbar. Gleichwohl ist er die moderne Feuerstelle, und wenn damit etwas schief geht, eskaliert die Situation meist so schnell, dass man sie nicht mehr allein unter Kontrolle bringen kann. Feuerwehren im ganzen Land können das bestätigen: „Wir werden täglich zu Einsätzen mit Herdbränden gerufen“, sagt Fabian Walheim von der Pressestelle der Feuerwehr Ham- burg. Eine typische Situation ist, dass jemand vergisst, den Herd nach dem Kochen auszustellen und anschließend das Haus verlässt. Dann brutzeln die Essensreste vor sich hin, es kommt zu einer starken Rauchentwicklung, und der Rauchwarnmelder alarmiert die Nachbarn. Häufig müssen die Einsatz- kräfte dann lediglich die Wohnung lüften. Allerdings müssen sie sich vorher natürlich Zutritt verschaffen. „Schlimmer ist es, wenn brennbare Gegenstände auf dem Kochfeld liegen und es zu einem Feuer mit offener Flammenbildung kommt“, so Walheim. Das passiert nach Erfahrung des IFS häufig: In zwei von drei Herdbrand- Fällen wird das Kochfeld aus Versehen eingeschaltet, zeigen unsere Daten. Gerade in kleinen Küchen ist jede zusätzliche Stellfläche willkommen, Foto IFS Besuchen Sie unser virtuelles Brandlabor unter www.gefahr-erkannt.de und da bleibt für die neue Kaffeepad- maschine manchmal nur das Ceran- kochfeld. Herdabdeckplatten aus Holz sind sogar dafür vorgesehen, den Herd in Abstellfläche zu verwandeln. Was passiert, wenn Gegenstände auf dem eingeschalteten Herd in Brand geraten, kann man in unserem virtuellen Brandlabor ausprobieren unter www.gefahr-erkannt.de. Ebenso wie die Wahrscheinlichkeit, dass man aus Versehen und ohne es zu merken, den Herd einschaltet, wird auch die Zeit unterschätzt, in der Fett sich so weit erhitzt, dass es zur Brand- entstehung kommt. In einem kürzlich vom IFS untersuchten Fall hielt sich eine Frau gerade im Arbeitszimmer auf, als der Rauchmelder Alarm schlug. In der Küche war ein Topf mit Fett für Schmalzgebäck in Brand geraten. Bei dem Versuch, das Feuer im Topf abzulöschen, zog sich ein Hausbe- wohner schwere Verletzungen zu. „Vom Einschalten des Kochfeldes bis zur Entzündung dauert es manchmal nur wenige Minuten“, sagt IFS-Gutachter Dr. Stefan Schallmoser. Die Zeit hängt vom Herd und der gewählten Einstellung, vom Kochgeschirr und der „Brandlast“ ab. Ein eingeschalteter Herd sollte darum nicht allein gelassen werden, auch nicht, um nur schnell ein Paket anzunehmen oder etwas aus einem anderen Raum zu holen. Denn auch hier ist unser Zeitgefühl kein gutes Maß. Gerade wenn wir, etwa durch ein Tele- fonat, abgelenkt sind, unterschätzen wir die Zeitspanne der Abwesenheit.

FD05994 ｜ 2021_德国_IFS_ifs_report_2021_2.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2021 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

• Jahrgang

Juni 2021 Eine Information des Institutes für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. E ine gute Stunde nachdem die jugendliche Tochter das Haus verlassen hatte, alarmierte der Rauchmelder im Obergeschoss die Eltern. Für eigene Löschversuche war es wegen der starken Rauchentwicklung bereits zu spät, doch die Feuerwehr konnte den Brand auf einen relativ kleinen Bereich im Jugendzimmer eingrenzen. Die intensiven Brandver- schmutzungen richteten allerdings einen umfangreichen Schaden an. In den Fokus der Brandursachen- ermittlung rückte bald ein Gerät, das hierzulande noch vor ein paar Jahren kaum von Bedeutung war und sich allmählich einen festen Platz in der Schadendatenbank des IFS sichert: der Shisha-Kohleanzünder. Zum Rauchen einer Wasserpfeife oder Shisha benötigt man glühende Kohle, und um die Kohle zum Glühen Der Kohleanzünder aus dem Brandfall und ein Vergleichsgerät werden im Labor untersucht. Feueralarm im Jugendzimmer Warum bei Shisha-Kohleanzündern häufig das Umfeld der kritische Punkt ist Warum es wichtig ist, Absperrventile regelmäßig zu betätigen ⟶ S. 3 Foto: IFS zu bringen, ist der Anzünder not- wendig. Die Geräte gibt es kosten- günstig im Onlinehandel und auch in manchen Supermärkten. Sie sind in flacher Bauweise erhältlich, die im Wesentlichen aus einer Bodenplatte mit elektrischer Heizspirale besteht, oder in einer höheren Bauform, wie sie auf dem Foto zu sehen ist. Ein untypischer Gerätetyp Im geschilderten Fall waren Materialien durch die Hitze des Kohleanzünders in Brand geraten. In unmittelbarer Nähe hatten sich Papier, Pappe und Vorhang- stoff befunden. Das Gerät stand vor der geöffneten Balkontür. Vielleicht hatte die Tochter vergessen es aus- zuschalten. Möglicherweise wurde es auch durch die Tür umgestoßen und dabei eingeschaltet. Bei Brand- versuchen konnte das schon mit sehr geringem Kraftaufwand geschehen. Die höchste Temperatur am Anzünder maß die IFS-Gutachterin, die den Fall untersuchte, am oberen Korb, in den die Kohle gelegt wird. Hier konnten auch Materialien wie Baumwolle – Zündtemperatur 450 °C – in Brand geraten. Auch außen am Korb genügte die Hitze, um Pappe zu entzünden. In einem weiteren vom IFS untersuchten Fall geriet in einem Jugendzimmer das Bett in Brand, nachdem ein Kohle- anzünder – ebenfalls versehentlich ein- geschaltet – darunter geschoben wurde. Mit Shisha-Kohleanzündern hält ein Gerätetyp, den man eher in der Küche verorten würde, Einzug ins Jugend- zimmer. Dort hat er in der Regel weder einen festen Aufstellplatz, noch trifft er auf das Risikobewusstsein, das beim Umgang mit elektrotechnischen Geräten, die betriebsbedingt starke Hitze entwickeln, angebracht ist. Ein brenzliges Lifestyle-Spielzeug. 2 IFS-Report  2/2021 Roller-Rückruf von „unu“ Hersteller und Kraftfahrt-Bundesamt weisen auf mögliche Brände an den Akkus der Elektroroller hin S eit drei Tagen war eine Familie im Urlaub, als Nachbarn einen Feuerschein hinter dem Wohn- zimmerfenster des Hauses bemerkten. Drinnen hatten die Akkupacks eines Elektrorollers zu brennen begonnen, wie die spätere Ursachenermittlung ergab. Es handelte sich dabei um die Lithium-Ionen-Akkus eines Fahr- zeuges der Berliner unu GmbH. Für unu-Roller „Classic“ aus den Bau- jahren 2018 und 2019 hat das Kraft- fahrt-Bundesamt im vergangenen Sommer einen Rückruf veröffentlicht mit Hinweis auf eine mögliche Brand- gefahr. Demnach ist eine Überprüfung der Akkumulatoren erforderlich und eine Anpassung der Rekuperation, das heißt der Schaltung, die – ähnlich wie bei einem Dynamo – das Laden des Akkus während der Fahrt beim Bremsen ermöglicht. Zu dem Produkt gibt es auch eine Meldung bei Rapex, dem Schnellwarnsystem der EU für Verbraucherschutz. Darin heißt es, hohe Ladeströme, die während der Rekuperation zeitweise auftreten, können zu Bränden am Akku führen. Das IFS hat bereits eine Reihe von brandbetroffenen unu-Akkus unter- sucht. Dabei kam es in einigen Fällen zum Brandausbruch, während sich die Akkus am abgestellten Fahrzeug befanden, in anderen Fällen gerieten sie in der Wohnung der Halter in Brand. Die etwa schuhkartongroßen Akkupacks sind im Betrieb unter dem Sitz des Rollers untergebracht und werden zum Laden herausgenommen. Wie im eingangs geschilderten Fall befanden sich allerdings auch die Energiespeicher, bei denen es in Wohnräumen zum Brandausbruch kam, nicht alle in der Ladephase. Der Hersteller hat im vergangenen Sommer Kunden über seine Rückruf- aktion informiert. Weil danach weitere „Vorfälle mit Batterien“ auftraten, die bereits auf ihre Sicherheit überprüft worden waren, richtete sich unu Ende des Jahres erneut an Besitzer des „unu Scooter Classic“ mit der Bitte, dem Unternehmen die Batterieserien- nummern mitzuteilen. Akkupacks aus bestimmten Produktionszeiträumen müssen „genauer angesehen“ wer- den, heißt es in der Mitteilung. In der online-Fassung dieses Beitrages ver- linken wir die Rückrufe sowie die Ser- vice-Seite, auf der Kunden ihre Batte- rienummern eingeben können. Besuchen Sie uns unter www.ifs-ev.org/unu Aktuelle Ursachen­ statistiken online Neuer Gutachter für das IFS in Stuttgart Dr. Jens Sorg IFS Stuttgart Tel. +49 711 380426070 sorg@ifs-ev.org Das IFS begrüßt einen neuen Kollegen: Dr. Jens Sorg ist Chemiker und wurde vom Institut für Anorganische Chemie der Uni- versität Würzburg promoviert. Für das IFS ermittelt er Brandursachen und untersucht Brandfolge- sowie Feuchteschäden. Ein UNU-Roller, dessen Akkus in der Wohnung des Betroffenen durchgegangen sind. Das kleine Bild zeigt die Akkus eines Rollers, der durch einen Defekt im Akku verbrannt ist. Die neuen Ursachenstatistiken sind jetzt auf unserer Internetseite abrufbar. Seit 2002 erfasst das IFS die Ergebnisse der eigenen Brand- ursachenermittlungen statistisch; die Erfassung der Ursachen von Leitungswasserschäden reicht bis ins Jahr 2003 zurück. Die Aus- wertungen des Jahres 2020 haben erneut die relativ stabile Verteilung der Schadenursachen bestätigt. So gibt es zum Beispiel im Fachbereich Leitungswasserschäden einen Schwerpunkt bei den Ausführungs- fehlern, die immer wieder einen Anteil von etwa 40 Prozent ausmachen. Die IFS-Statistiken können honorarfrei eingesehen und heruntergeladen werden. Besuchen Sie uns unter www.ifs-ev.org/ ursachenstatistiken

IFS-Report  2/2021 3 A ls die Küche einer frisch reno- vierten Eigentumswohnung beinahe fertiggestellt war, kam es zum Schaden: Vor der Mon- tage der Spülbeckenarmatur löste sich am Warmwassereckventil beim Schließen der Ventiloberkopf vom Gehäuse, und Wasser begann heraus- zuspritzen. Von der Küche aus ließ sich das Wasser nun nicht mehr abstellen. Die nächste Möglichkeit, die Schadenausweitung zu stoppen, lag im Keller. Doch bis das Absperrventil dort überhaupt gefunden wurde, war in der Wohnung bereits ein umfang- reicher Wasserschaden entstanden. Inspektion gehört zum Betrieb Um einen Leitungswasserschaden zu begrenzen, muss die Wasserzufuhr bei Weil jede Minute zählt Absperrventile müssen regelmäßig betätigt werden Diesem Absperrventil wurde schon länger keine Aufmerksamkeit gewidmet. Entdeckung der Leckage so schnell wie möglich abgestellt werden. Dafür ist es notwendig, dass die Absperr- ventile funktionstüchtig sind – und dass man überhaupt weiß, wo sich die entsprechende Armatur befindet. Hersteller weisen gewöhnlich in den Gebrauchsanleitungen darauf hin, jede Armatur regelmäßig zu betätigen und auf ihre Funktion zu prüfen. Auch in der hierfür gültigen Norm DIN EN 806- 5, „Technische Regeln für Trinkwasser- installationen: Wartung und Betrieb“, ist die regelmäßige Inspektion durch den Betreiber festgehalten. Was die Häufigkeit der Inspektion betrifft, gibt die Norm für die meisten Bestandteile der Trinkwasserinstallation ein Inter- vall von sechs Monaten oder einem Jahr vor. „In Regionen mit sehr hartem Wasser kann es allerdings sinnvoll sein, die Gängigkeit der Armaturen häufiger zu prüfen“, sagt Dr. Thorsten Pfullmann, der im IFS die Fachver- antwortung für die Untersuchung von Leitungswasserschäden trägt. Mit der Inspektion ist im Fall von Absperr- armaturen lediglich gemeint, sie ein- mal zu schließen und wieder zu öffnen, um zu sehen, ob die Armatur gängig ist. Sind Schäden erkennbar – zum Beispiel Korrosionsspuren oder Schwer- gängigkeit – sollte die Wartung durch eine Fachkraft veranlasst werden. Fotos: IFS (3), privat (1), saje - stock.adobe.com E ine unerfreuliche Entdeckung: Im Heizungskeller stand eines Tages Wasser auf dem Fußboden. Auf der Suche nach der Ursache stieß der Besitzer eines Einfamilienhauses zunächst auf stehendes Wasser in ande- ren Kellerräumen und schließlich auf die Leckage. Sie lag im Hausanschluss- raum, wo eine Regenwasserpumpe mit einer Regentonne verbunden war. An dem Gerät war eine Membran gerissen. Das Material war schlicht porös geworden, wie die spätere Untersuchung im IFS zeigte, und das konnte niemanden verwundern, denn die Pumpe hatte bereits 20 Betriebs- jahre hinter sich – ohne jede Wartung. Sogenannte Hauswasserwerke erlauben die Verwendung von Regen- und Brunnenwasser zum Beispiel für die Gartenbewässerung, aber auch im Haus – unter Beachtung der Trink- wasserverordnung – zur Nutzung für Toilettenspülungen. Sie bestehen in der Hauswasserwerke genau anschauen Regel aus einer Pumpe, der Steuerung und einem Druckbehälter. Besteht eine frostgefährdete Verbindung zur Wasserquelle im Freien, müssen die Anlagen im Winter außer Betrieb genommen und entleert werden. Oft kommen sie erst im Sommer wieder zum Einsatz, und wenn das Entleeren in der kalten Jahreszeit nicht ganz so ernst genommen wurde, offenbart der erste Betrieb möglicherweise Schäden. „Insbesondere vor und bei dem ersten Einschalten nach längerer Betriebs- pause sollte man das Gerät genau anschauen“, rät Dr. Thorsten Pfullmann. Gibt es Anzeichen für Schäden oder Undichtigkeiten, etwa Ablagerungen von Wasserinhaltsstoffen oder Korro- sion? Kondenswasser in den Anzeigen deutet darauf hin, dass Wasser in Bereiche gelangt ist, in die es nicht gehört. Ist das Betriebsgeräusch ungewöhnlich? Diese einfache Inspek- tion kann jeder durchführen, und sie gehört zur Pflicht des Betreibers. Was genau bei dem jeweils verwendeten Hauswasserwerk beachtet werden sollte und wofür es überhaupt ein- gesetzt werden darf, steht in der Betriebsanleitung des Herstellers. In der Schadendatenbank des IFS gibt es eine lange Reihe von Schäden durch Hauswasserwerke, wobei etwa ein Viertel davon Brandschäden sind. Ein Hauswasserwerk wartet auf die Laboruntersuchung: Bei diesem war nur eine Schraubverbindung undicht.

Herausgeber: Institut für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. Preetzer Straße 75, 24143 Kiel Tel. +49 431 775 78  0 mail@ifs-ev.org www.ifs-ev.org Redaktion, Layout: Ina Schmiedeberg Tel. +49 431 775 78 10 schmiedeberg@ifs-ev.org Druck: Carius Druck Kiel GmbH Boninstraße 25, 24114 Kiel Tel. +49 431 624 46 Glühzeiten werden stark unterschätzt Nach dem Grillen gehören Kohlereste und Asche in die Restmülltonne – allerdings erst nach drei Tagen Abkühlzeit, wie das IFS aus gutem Grund empfiehlt Z wei Nachbarn entdeckten am späten Abend den Brand am Dach eines Einfamilienhauses. Während einer die Familie weckte, alarmierte der andere die Feuerwehr. Verletzt wurde niemand, doch die Flammen hinterließen einen Total- schaden an dem in Holzrahmen- bauweise erstellen Gebäude. So schlimm der Tag endete, so nett hatte er begonnen: An jenem Sonntag im Frühling war Familienbesuch eingeladen. Auf der Terrasse hinter dem Haus hatte man am frühen Nachmittag gegrillt. Das lag bereits über vier Stunden zurück, als die Hauseigentümerin beim Aufräumen die Asche aus dem Holz- kohlegrill in eine Plastiktüte umfüllte und diese unter einem Pflanztisch aus Holz ablegte, der neben dem Grill direkt an der rückseitigen Hauswand stand. Diese Stelle war bei der späteren Ursachenermittlung unmissverständ- lich als Ausgangspunkt des Feuers zu erkennen. Von dem Tisch mit seinen zwei Ablageflächen war lediglich die metallene Abdeckplatte übrig geblieben. Ein Brandtrichter an der Hauswand zeichnete nach, wie die Flammen vom Tisch auf den darüber liegenden Dachüberstand geklettert waren. In der Grillasche hatte sich noch Glut befunden. Der Fehler, den die Hauseigen- tümerin gemacht hatte, passiert nach Erfahrung des IFS immer wieder: „Die Glühzeit wird oft stark unterschätzt“, weiß IFS-Geschäftsführer Dr. Hans-Her- mann Drews. Grillasche und Kohlereste können sehr lange eine so hohe Tem- peratur halten, dass dadurch andere Materialien in Brand geraten. Wie hoch die Temperatur steigt und wie lange es Foto: ©karepa - stock.adobe.com dauert, bis sie wieder auf ungefährliche Werte absinkt, hängt von verschiedenen Faktoren ab, wie dem Grill, der Kohle und der verwendeten Kohlemenge. Die Hauseigentümerin im beschriebenen Schadenfall war sich sicher, dass die Grillasche längst abgekühlt war. Ob sich in der Asche und den Kohleresten noch Glut befindet, ist auch beim Umfüllen nicht unbedingt zu erkennen. Darum sollten sie für eine Zeit lang in einem nicht brennbaren Behälter mit Deckel zwischengelagert werden, bevor sie in der Restmülltonne entsorgt werden dürfen. Ein Feuer, ausgehend von der Mülltonne, das mitten in der Nacht oder am frühen Morgen entdeckt wird, ist ein Klassiker der Brandursachen- ermittlung, denn es dauert häufig viele Stunden, bis sich aus einem Glimm- brand ein Flammenbrand entwickelt. „Um sicherzugehen, empfehlen wir nach dem Grillen eine Abkühlzeit von drei Tagen“, sagt Drews. Alternativ können Kohle und Asche auch mit reichlich Wasser abgelöscht werden. Konkret bedeutet das, das Material komplett mit Wasser zu durchtränken. Im Grill selbst ist die Asche nur auf den ersten Blick gut aufgehoben. Ein kräftiger Windstoß oder neugierige Tiere haben schon manchen Grill zu Fall gebracht. Wenn Glut dann auf Holzdielen, den Gartenmöbeln oder an der mit brennbaren Baustoffen verkleideten Wand landet, kann das Unglück genauso seinen Lauf nehmen wie im eingangs geschilderten Fall. Grillkohle und Asche können überraschend lange brandgefährlich sein.

FD05995 ｜ 2021_德国_IFS_ifs_report_2021_3.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2021 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

• Jahrgang

September 2021 Eine Information des Institutes für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. S ucht man in der Schadendaten­ bank des IFS nach Saunabränden, läuft eine bemerkenswert lange Liste über den Bildschirm. Meistens ist die Schadenursache, dass die Sauna im Laufe der Zeit zum Lagerraum und der unter lauter brennbaren Dingen vergrabene Ofen eines Tages aus Versehen eingeschaltet wurde. Doch es gibt eine weitere Ursache, die immer wieder vorkommt: Fehler von ambitionierten Hobbyhandwerkern. Ein Beispiel: Auf der Dachterrasse eines Wohnhauses kam es schon bei der ersten Benutzung einer neuen Sauna zum Brandausbruch. Der Eigentümer hatte die Sauna selbst gebaut und war dabei auch nach eigenen Plänen vorgegangen. So hatte er für die Befeuerung im Bau­ markt einen Kaminofen ausgesucht, der als Werkstattofen verkauft wurde. Für den Saunaaufguss stellte er einen Metallkorb mit Steinen darauf. Die Abgasführung bestand aus einwandigen Zu Sauna gehört oft eine Feuerstätte und damit auch ein Brandrisiko. Von Holz, Hitze und Heimwerkern Beim Selbstbau einer Sauna sollten im eigenen Sinne die Vorgaben beachtet werden Rückstauklappen schützen das Haus bei Starkregen vor Wasserschäden – wenn sie funktionieren ⟶ S. 3 Foto: kichigin19 - stock.adobe.com Blechrohren, die er durch die Wand der Holzkabine nach draußen führte. Das Spurenbild bei der späteren Ursachenermittlung ließ keinen Zweifel an einer Brandentstehung in der Sauna, wenn sich auch die genaue Ausbruchs­ stelle wegen der stark ausgeprägten Schäden nicht mehr lokalisieren ließ. Der Gutachter konnte aber den Auf­ bau der Sauna rekonstruieren. Dabei stelle sich heraus, dass die vom Her­ steller des Ofens geforderten Mindest­ abstände zu den Holzbauteilen der Kabine weit unterschritten wurden. Nach der Feuerungsverordnung des entsprechenden Bundeslandes hätte die Abgasführung außerdem an einen Schornstein angeschlossen werden müs­ sen und nicht einfach durch das Dach geführt werden dürfen. Nicht brennbare Materialien für diese Durchführung des einwandigen Abgasrohres waren im Brandschutt nicht zu finden, und auch der geforderte nicht brennbare Fuß­ bodenbelag wurde nicht entsprechend der Verordnung ausgeführt. Nicht zuletzt hatte der Bezirksschornstein­ feger keine Kenntnis von der Feuer­ stätte, obwohl er sie hätte abnehmen müssen. Diese Abnahme wäre mit dem Kaminofen anstelle eines Saunaofens ohnehin nicht geglückt, denn dafür war er überhaupt nicht zugelassen, wie ein Blick in die Bedienungsanleitung verriet. Der Hauseigentümer hatte also ein paar Vorschriften nicht beachtet, und in der Folge konnte es schon bei der ersten Befeuerung zur Überhitzung von Holzbauteilen kommen. Das Feuer griff von der Saunakabine auf die Holzüberdachung der Terrasse und die mit Holz verkleidete Giebel­ wand über, bevor es sich auch auf das Nachbargebäude ausweitete. Was nach einem kuriosen Sonderfall klingen mag, kommt nach unserer Erfahrung gar nicht so selten vor. 2 IFS-Report  3/2021 Wenn die Sanierung verzögert wird Feuchteschäden schaffen in Gebäuden ideale Bedingungen für Schimmelpilzbefall. Wenn dann noch ein Schwammbefall hinzukommt, kann die Beseitigung aufwendig werden. N achdem über einen Keller­ schacht Wasser ins Unter­ geschoss eines historischen Gebäudes gelangt war, wurde Schimmelbefall im Wandaufbau der Restaurantküche festgestellt, die sich dort befand. Das zumindest teilte man dem IFS mit, als es beauftragt wurde zu klären, ob neben dem Schimmel­ befall auch ein holzzerstörender Pilz, also ein Schwammbefall vorlag. Man befürchtete, den Echten Hausschwamm im Gebäude zu haben. Dieser richtet besonders große Schäden an, weil er nicht nur feuchtes Holz befällt, sondern auch auf trockene Bauteile übergreifen und sie zerstören kann. Entsprechend umfangreich ist in der Regel die Sanierung. In diesem Fall gab es in dieser Hinsicht jedoch Ent­ warnung: Genauere Untersuchungen zeigten eine massive Holzzerstörung durch den „Wilden Hausschwamm“, einen seltenen holzzerstörenden Pilz, der mit dem Echten Hausschwamm verwandt, aber nicht so aggressiv ist. Im Gegensatz zum Echten Hausschwamm, der ausschließlich in Gebäuden vor­ kommt, ist der Wilde Hausschwamm gewöhnlich in Wäldern auf den Stäm­ men umgestürzter Bäume zu Hause. In dem Restaurant hatte sich außerdem die Styropordämmung im Bodenaufbau mit Wasser vollgesogen – ein seltener Vorgang, der ebenso wie der Schwamm­ befall auf eine sehr lang andauernde Nässeeinwirkung hinweist. Als dann noch im Wandaufbau weitgehend intakte Holzbauteile neben bereits völlig zersetztem Holz gefunden wur­ den, war klar, dass hier ein Altschaden vorlag, bei dem bereits Reparatur­ versuche unternommen wurden. Bei einem Schwammbefall greift die sogenannte Schwammklausel. Der­ artige Schäden werden nicht durch die üblichen Gebäudeversicherungen reguliert. Es gibt also gute Gründe, diese Schäden zu vermeiden, und glücklicherweise gibt es auch Möglich­ keiten dazu: Zeigen sich Anzeichen von Feuchteschäden im Gebäude, sollte auf jeden Fall so schnell wie möglich nach der Quelle gesucht und diese selbst­ verständlich beseitigt werden. Auch der Feuchteschaden sollte durch eine komplette Trocknung so rasch wie mög­ lich beseitigt werden, damit es gar nicht erst zum Schimmel- oder gar Schwamm­ befall kommen kann. Im geschilderten Fall wurde die Sanierung so lange herausgezögert, dass sich ein holzzer­ störender Pilz ansiedeln konnte. Immer­ hin war es „nur“ der Wilde und nicht der Echte Hausschwamm. Trotzdem muss­ ten in großem Umfang tragende Bau­ teile und Wände zurückgebaut werden. Neue Mitarbeiter in Wiesbaden und Kiel Roman Münnich IFS Wiesbaden Tel. 06172 921399 - 26 muennich@ifs-ev.org Michael Deeg IFS Kiel Tel. 0431 77578 - 25 deeg@ifs-ev.org Unser Gutachterteam in Wiesbaden freut sich über Verstärkung: Roman Münnich hat an der Universität Kassel Nanostrukturwissenschaften studiert mit dem Schwerpunkt organische Chemie. Für das IFS wird der Berliner Brandursachen ermitteln sowie Brandfolgeschäden und Feuchte­ schäden untersuchen. Auch am Standort Kiel darf das IFS einen neuen Mitarbeiter begrüßen: Michael Deeg aus Kappeln ist gelernter Chemie­ laborant und wird vor allem Proben­ analysen für die Brandursachen­ ermittlung und im Rahmen der Untersuchung von Brandfolgeschäden durchführen. Zu seinen Aufgaben gehört außerdem die Vorbereitung und Durchführung von Brand­ versuchen. Ohne großen Kraftaufwand durchdringt die Messerklinge das durch Würfelbruch geschädigte Holz.

IFS-Report  3/2021 3 B ei Starkregen kann das Wasser in der Kanalisation bis zur Rückstau­ ebene ansteigen. Immobilien, die Abläufe unterhalb dieser Ebene haben, sollten darum durch Rück­ stausicherungen geschützt werden. In der Regel ist das auch der Fall, doch nicht immer sind die Eigentümer mit der Installation vertraut, wie dieser vom IFS untersuchte Schaden zeigt: Im Keller eines Einfamilienhauses kam es zum Rückstau von Abwasser, während die Eigentümer im Urlaub waren. Das Handwaschbecken in einem Kellerraum lief über, und der Raum stand schließlich mehrere Zentimeter unter Wasser. Ein Rückstau, aber von einem ungewöhnlichen Aus­ gangspunkt, wie sich herausstellte. Es gab eine Rückstausicherung, an die neben dem Waschbecken auch die Entwässerungsleitung für das Kondensatwasser eines Brennwertheiz­ gerätes angeschlossen war. Bei dem Rückstauverschluss handelte es sich um ein Gehäuse mit zwei eingesetzten Klappen. Über einen Hebel auf der Oberseite konnte man die Klappen festsetzen, also dauerhaft schließen. Diese Notsperre ist für Installations- oder Reparaturarbeiten vorgesehen. Vor dem Start in den Urlaub hatte Vorsicht: Rückstau! Rückstausicherungen verhindern – vor allem bei Starkregen – kostspielige Schäden. Allerdings muss man beizeiten ihre Funktion sicherstellen. Die Rückstausicherung aus dem zweiten unten geschilderten Fall besteht aus einem Grundkörper mit zwei eingesetzten Klappen und einem Deckel mit Notverschluss-Hebel (rot). Das rechte Bild lässt erahnen, dass sich der Deckel schwer einsetzen lässt. Der schwarze Schnellverschlusshebel ist jedoch weder dafür vorgesehen noch geeignet, einen schwergängigen Deckel in die richtige Position zu hebeln. der Eigentümer sie festgesetzt. Offen­ bar hatte er nicht verstanden, dass die Rückstauklappe das Eindringen von Wasser funktionsbedingt blockie­ ren würde und er mit dem zusätz­ lichen Verschließen nun auch das Abfließen von Wasser verhinderte. Das Kondensatwasser der Heiztherme füllte bald den Abwasserstrang, der sich gebäudeseitig hinter der Rück­ stausicherung befand und nur etwa 20 Liter Wasser aufnehmen konnte. In einem anderen Fall kam es in einem Geschäftsgebäude bei Starkregen zum Wasseraustritt aus einem Rück­ stauverschluss. Das Bauteil wurde zur Ermittlung der Schadenursache im IFS-Labor untersucht. Auch hier handel­ te es sich um ein Kunststoffgehäuse mit zwei eingesetzten Klappen. Auf dem Grundkörper befand sich ein Verriegelungsdeckel mit Schnellver­ schluss, und dieser war auf einer Seite abgebrochen. Die Bruchstelle offen­ barte Strukturen eines Gewaltbruchs. Der Deckel ließ sich nur schwer ein­ setzen. Mit etwas Gleitmittel auf der Dichtung funktionierte es allerdings problemlos. Ursache dieses Schadens war ein Montagefehler. Dem Spuren­ bild nach hatte man versucht, den Deckel mit dem Schnellverschlusshebel auf den Grundkörper zu drücken und ihn dabei an- bzw. abgebrochen. Die Folge war eine beschädigte Rückstau­ sicherung, die im Ernstfall versagte. Allerdings hätte das lange vor dem Schaden auffallen müssen. In der DIN 1986-3 und in der Einbau- und Betriebsanleitung des Herstellers wird eine monatliche Sichtprüfung auf Dichtheit und auf die Beweglichkeit des Notverschlusshebels gefordert. Zweimal jährlich muss die Rückstau­ sicherung demnach außerdem durch Fachpersonal gewartet werden. Weder das eine noch das andere war in diesem Fall geschehen. Mit zunehmender Häufigkeit von extremen Wetterereignissen gewin­ nen Rückstausicherungen bei vielen Gebäuden an Bedeutung. Wie bei allen Bestandteilen der wasserführenden Installation ist es unerlässlich, sie regelmäßig zu inspizieren und die vorgesehenen Wartungen durchführen zu lassen. Wer ein Bestandsgebäude kauft, sollte sich außerdem informie­ ren, ob und wo Rückstausicherungen vorhanden sind. Gibt es Abläufe, die nicht (mehr) genutzt werden, ist es sinnvoll, sie dauerhaft zu verschließen. Fotos: IFS (4), privat (1)

Herausgeber: Institut für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. Preetzer Straße 75, 24143 Kiel Tel. +49 (431) 775 78- 0 mail@ifs-ev.org www.ifs-ev.org Redaktion, Layout: Ina Schmiedeberg Tel. +49 (431) 775 78-10 schmiedeberg@ifs-ev.org Druck: Carius Druck Kiel GmbH Boninstraße 25, 24114 Kiel Tel. +49 (431) 624 46 Akkubrände: Feuer in einer Modellbauwerkstatt A ls er von einem Spaziergang nach Hause kam, sah ein Mann Rauch aus der Garage seines Hauses quellen, in der sich seine Modell­ bauwerkstatt befand. Noch ein paar Stunden zuvor hatte er dort an einem Modellauto gebastelt; nun konnte er den Raum wegen der starken Hitzeent­ wicklung nicht mehr betreten. Durch ein Fenster bemühte er sich, das Feuer mit einem Gartenschlauch zu löschen. Ein Nachbar, der durch einen Knall auf das Geschehen aufmerksam geworden war, hatte bereits die Feuerwehr alar­ miert. Erst die Einsatzkräfte konnten den Brand unter Kontrolle bringen. Die spätere Suche nach der Brand­ ursache führte den beauftragten IFS- Gutachter in der Garage zu dem Regal, in dem die Akkus für die Modellfahr­ zeuge gelagert wurden. Auch auf dem Fußboden davor lagen mehrere intensiv geschädigte Akkupacks verschiedener Bauformen. Auffällig waren vor allem die Lithium-Ionen-Akkus in der „Pouch- Zellen“-Form, die im Regal lagen. Diese leichte Bauform wird gern im Modellbau verwendet. Weil sie kein festes Gehäuse hat, ist sie jedoch mechanisch nicht sehr stabil. Die Pouch-Zellen in der Garage waren aufgeplatzt und hatten markante Schmelzspuren, wie sie beim thermi­ schen Durchgehen von Lithium-Ionen- Akkuzellen typischerweise entstehen. An welchem Akku das Feuer entstanden war und welche im Brandverlauf geschädigt wurden, ließ sich nicht mehr genau rekonstruieren. Das Spurenbild belegte jedoch eine Brandentstehung durch eine der Zellen. Alle anderen Ursa­ chen konnte der Gutachter im Zuge der weiteren Untersuchung ausschließen. Eine Pouch-Zelle aus dem geschilderten Fall Fotos: Olaf Schmidt, IFS Beispielfoto: Für die Stromversorgung von Modellbaufahrzeugen werden in der Regel Lithium-Ionen-Akkus verwendet. Brände durch Lithium-Ionen-Akkus sind mittlerweile eine typische Schaden­ ursache. In der Statistik des IFS werden sie zu den elektrotechnischen Brand­ ursachen gezählt. Etwa jeder dritte vom IFS untersuchte Brand entsteht durch Elektrizität. Der Anteil von Akku­ bränden liegt in dieser Kategorie seit ein paar Jahren bei etwa 15 Prozent.

Der Modellbau ist von Akkubränden in besonderer Weise betroffen, weil hier verschiedene Risiken aufeinandertreffen: In Modellfahrzeugen und -flugzeugen wird dem Akku mechanisch oft einiges abverlangt, und Lithium-Ionen-Akkus sind empfindlich gegen mechanische Beanspruchung. Zudem werden gern die erwähnten Pouch-Zellen eingesetzt. Eine Besonderheit im Modellbau ist außerdem, dass die Ladespannung an den Ladegeräten eingestellt werden kann bzw. muss. Die Fehlbedienung ist darum viel leichter möglich als bei anderen Geräten, die man höchstens ans falsche Ladegerät anschließen kann. Nicht zuletzt benötigen Modell­ bauer in der Regel relativ viele Akkus. Die wichtigsten Informationen zu Akkubränden und Hinweisen zur Schadenverhütung finden Sie auf unserer Internetseite. Besuchen Sie uns unter www.ifs-ev.org/lithium-akkus

FD05996 ｜ 2021_德国_IFS_ifs_report_2021_4.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2021 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

• Jahrgang

Dezember 2021 Eine Information des Institutes für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. Z uerst war ein knisterndes Geräusch, dann der Alarm des Rauchmelders aus dem Erd- geschoss zu hören. Ein junger Mann eilte die Treppe des Einfamilienhauses hinunter zu seiner Großmutter, die es sich in ihrem Schlafzimmer mit einem künstlichen Weihnachtsbaum und einer Krippe gemütlich gemacht hatte. Die beiden konnten das Haus unverletzt verlassen. Allerdings hinterließen die Flammen und die Feuerwehr ein Bild, das wenig weihnachtlich anmutete. Wie die Ursachenermittlung ergab, war das Feuer durch ein Teelicht ausgelöst worden, das inmitten von Moos zwischen den Krippenfiguren unter dem Baum gestanden hatte. Teelichter sind wesentlich brand- gefährlicher als sie erscheinen: Die Alubecher werden sehr heiß, wenn das Paraffin darin erst einmal flüssig ist. Eine nicht brennbare Unterlage und genügend Abstand zu brennbaren Was passiert, wenn der Weihnachtsbaum in Brand gerät, zeigt unser Video unter www.ifs-ev.org Kleine Lichter und hohe Flammen In der Weihnachtszeit brennen allzu häufig nicht nur die Kerzen. Mit ein paar einfachen Regeln kommen Sie auch ohne Feuerwehr durch den Advent Veränderungen der Gebäudenutzung können dem Frost die Tür öffnen ⟶ S. 3 Foto: Andrey Kuzmin - stock.adobe.com Gegenständen sind darum wichtig. Wenige Tage vor dem oben beschriebenen Fall hatte es im Wohnzimmer eines älteren Herren ebenfalls ein Feuer an einem künst- lichen Weihnachtsbaum gegeben. Hier war ein technischer Defekt an einer LED-Lichterkette die Ursache. Entgegen mancher Behauptung, können auch LED-Lichterketten Brände verursachen, wenn zum Beispiel die Isolation der Zuleitung beschädigt ist oder ein Defekt am Netzteil auftritt. Bei den älteren Lichterketten mit Glüh- birnchen kann ein Defekt im gesamten Leitungsverlauf zum Brandausbruch führen. Darum ist es wichtig, sich den Zustand der Lichterketten anzu- schauen, wenn man sie im Dezember vom Dachboden holt. Mit beschädigten Leitungsisolationen dürfen sie nicht angeschlossen werden. Fälle wie die oben beschriebenen untersucht das IFS jedes Jahr. Gleichwohl sind Lichterketten relativ sicher und am Weihnachtsbaum weit weniger brenzlig als echte Kerzen. Offene Flammen sind zwar stimmungs- voll, aber insbesondere in unmittelbarer Nähe von Nadelbäumen so riskant, dass man sie auf keinen Fall aus den Augen lassen sollte. Die Nadeln enthalten ätherische Öle, die den Baum zu einer beachtlichen Brandlast machen. Zudem werden die Pflanzen mit jedem Tag im Wohnzimmer trockener und geraten dadurch immer leichter in Brand. Wer sich für einen echten Baum mit tra- ditionellen Baumkerzen entscheidet, sollte darum immer ein Löschmittel griffbereit haben. Wird das Feuer nicht in der Entstehungsphase entdeckt und abgelöscht, bleibt nur ein Weihnachts- fest mit Feuerwehr. Glücklicherweise brennen in den meisten Wohnzimmern nur die Kerzen. Das IFS wünscht allen Kunden, Partnern und Freunden des Institutes ein frohes Weihnachtsfest. 2 IFS-Report  3/2021 Ein besonders tragischer Fall: Am Abend erhitzte ein Mann für seine Ehefrau ein mit Kirschkernen gefülltes Kissen im Mikrowellengerät. Er hatte es bereits die Treppe rauf ins Schlafzimmer getragen, als das Kissen unerwartet so heiß wurde, dass er es fallenließ. Daraufhin gab es eine Stichflamme, und ein Zimmerbrand begann. Die Eheleute retteten sich ins Freie und riefen die Feuerwehr. Doch anschließend lief der Mann noch ein- mal ins Haus zurück, um das Feuer zu löschen. Dabei erlitt er eine Rauchver- giftung und konnte von den Einsatz- kräften nur noch tot geborgen werden. Weil es unkompliziert ist und schnell geht, erwärmen viele Benutzer Körner- kissen in der Mikrowelle. Anders als im Backofen wird die Energie im Mikrowellenherd jedoch punktuell zugeführt. Auf diese Weise können allerdings lokale Überhitzungen in der Füllung des Kissens entstehen. Das ist ganz unabhängig davon, ob das Kissen mit Getreidekörnern oder Kirschkernen gefüllt ist. Da die Überhitzungen mitten in der Füllung liegen können, bemerkt man sie nicht unbedingt sofort, wie im oben geschilderten Fall. Das IFS hat weitere Brände untersucht, bei denen erst bemerkt wurde, dass etwas nicht stimmte, als das Kissen schon im Bett lag und dort das Bettzeug in Brand geriet. Wenn mitten im Kissen ein Glimmbrand entsteht, kann es unter Umständen mit einiger Zeitverzögerung zum Flammenbrand kommen. Körnerkissen werden ausdrücklich damit beworben, dass sie im Mikro- wellenherd erhitzt werden können. Gelegentlich findet sich der Hinweis, die Geräte dafür nicht auf die volle Leitung zu stellen und das Kissen nach dem Erwärmen durchzukneten. Das IFS rät hingegen, die sogenannten trockenen Wärmflaschen ausschließlich bei niedriger Temperatur im Küchen- herd zu erwärmen. Das Brandrisiko ist nach unserer Erfahrung zu hoch. Das IFS wächst weiter. Hier sind unsere Neuen Helge Marquardt IFS Kiel Tel. 0431 77578 - 84 marquardt@ifs-ev.org Dr. Katja Hauschildt IFS Kiel Tel. 0431 77578 - 85 hauschildt@ifs-ev.org Dr. Lina Mayr IFS Bamberg Tel. 0951 5098419 - 40 mayr@ifs-ev.org Dr. Mateus Dobecki IFS Berlin Tel. 030 2888498 - 93 dobecki@ifs-ev.org Mit zehn Standorten zwischen Kiel und München und fast 80 Mitarbeitern ist das IFS im gesamten Bundesgebiet präsent und einsatzbereit. In den zurückliegenden Monaten durften wir gleich mehrere neue Kollegen begrüßen: Dr. Lina Mayr verstärkt unser Team in Bamberg. Dort wird die promovierte Chemikerin Brand- ursachen ermitteln, Brandfolge- schäden und Feuchteschäden unter- suchen. Dr. Mateus Dobecki ist Werkstoffwissenschaftler und wurde von der Technischen Universität Berlin im Bereich der metallischen Werkstoffe promoviert. Der Berliner wird an unserem Standort in der Hauptstadt Brandursachen ermitteln und den Ursachen von Leitungswasserschäden auf den Grund gehen. Unser Kieler Team freut sich ebenfalls über eine neue Gutachterin: Dr. Katja Hau­ schildt hat an der Universität Kiel und am Helmholtz-Zentrum Geesthacht Physik studiert und wurde im Bereich der Festkörperphysik promoviert. Für das IFS wird sie Leitungswasserschäden untersuchen und Feuchteschäden bewerten. Weil mit unserer technisch- wissenschaftlichen Mannschaft und jedem neuen Tag auch unsere Daten- bestände wachsen, haben wir unsere IT weiter verstärkt. Helge Marquardt ist Diplom-Informatiker und wird sich vor allem um die Datenbanken des Institutes kümmern. Brandrisiko Körnerkissen

IFS-Report  3/2021 3 Z ufällig wurde der Schaden in einem Vereinsheim von einem Sportler entdeckt, der nach dem Training auf dem Außengelände die Sanitärräume betrat. Zu diesem Zeitpunkt waren bereits über 300 m3 Wasser ausgelaufen. Hätte der Mann nicht zufällig an einem Montag seine Runden um den Platz gedreht, wäre der Schaden noch wesentlich größer geworden. Die Schadenentstehung lag bereits ein paar Tage zurück. Die Leckageortung führte auf den ungedämmten Dachboden des Gebäudes, durch den die Trinkwasser- leitung verlief. An zwei Stellen waren die Kupferrohre geborsten. Ursache war eine starke Krafteinwirkung von innen, also ein massiver Druckanstieg – das charakteristische Bild einer Frostein- wirkung. Zwar waren die Rohre von einer Dämmhülse umschlossen und zusätzlich mit einer etwa zehn Zenti- meter dicken Mineralwolldämmung umwickelt, doch das bot keinen ausreichenden Schutz, als die Außen- temperatur um das Gebäude für einige Tage auf bis zu -12 °C fiel. „Wärme- dämmung allein kann das Auskühlen nur verzögern, aber nicht verhindern“, erklärt Dr. Thorsten Pfullmann, der im IFS die Fachverantwortung für die Nutzungsänderungen berücksichtigen Frostschäden treten vor allem in nicht oder nur teilweise genutzten Gebäuden auf. Vorsicht ist immer geboten, wenn sich das Nutzungsverhalten ändert Die Sportler halten sich warm, aber was ist mit dem Sportheim? Die Corona- Eindämmungsmaßnamen hatten zahlreiche Frostschäden zur Folge. Untersuchung von Leitungswasser- schäden trägt. Eine Rohrbegleithei- zung hätte die Trinkwasserleitung im ungedämmten Dachboden vor dem Einfrieren bewahrt. In den Jahren zuvor hatte die regelmäßige Nut- zung des Gebäudes die Entstehung von Frostschäden verhindert. Im Zuge der Corona-Eindämmungs- maßnahmen wurde das Vereins- leben weitgehend heruntergefahren. Darum wurde das Sportheim nur noch auf niedrigem Niveau beheizt, und vor allem gab es kaum noch Bewegung in den Wasserleitungen. Im vergangenen Winter hat das IFS auffällig viele Frostschäden an Gebäuden untersucht, die im Zuge des Lockdowns nicht oder selten genutzt wurden. Diese verbreitete und extre- me Veränderung verdeutlicht einen Zusammenhang, der in jedem Winter zu zahlreichen Schäden an Wasser- und Heizungsleitungen führt: „Wenn sich etwas an der Gebäudenutzung oder an der Installation ändert, müssen die Bedingungen im Hinblick auf mögliche Frostschäden überprüft werden“, sagt Pfullmann. Wenn ein Gebäude zum Beispiel wegen eines Eigentümer- oder Mieterwechsels zeitweise leersteht, müssen die Leitungen während dieser Zeit entweder entleert oder eine aus- reichende Beheizung sichergestellt werden. Wie stark das Gebäude beheizt werden muss, um Frostschäden auszu- schließen, ist von den Gegebenheiten abhängig und muss für jede Immobilie individuell beurteilt werden. Einfluss haben zum Beispiel die Wärme- dämmung und der Leitungsverlauf. Von Frostschäden sind zwar größten- teils, aber nicht ausschließlich ungenutzte Gebäude betroffen. Auch Änderungen an der Installation oder an der Wärmedämmung können zur Folge haben, dass Leitungen, die bisher durch die gewöhnlichen Nutzungs- bedingen geschützt waren, plötzlich einfrieren können. Ein Beispiel ist eine neue Heizung im Dachboden, die weniger Abwärme produziert und darum die Leitungen in der Umgebung nicht mehr warm genug hält. Oder eine neue Dämmschicht macht Abseiten, durch die Leitun- gen verlaufen, zu frostgefährdeten Bereichen. Wo mögliche Schwach- stellen liegen, haben wir in unserem Wintercheck zusammengestellt. Fotos: IFS (4), ©Dusan Kostic - stock.adobe.com (1); Illustration: Gerrit Hansen Zeit für den Wintercheck Prüfen Sie unkompliziert und kostenlos, ob Ihr Haus vor Frost- schäden sicher ist: www.ifs-ev.org/wintercheck

Herausgeber: Institut für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. Preetzer Straße 75, 24143 Kiel Tel. +49 (431) 775 78- 0 mail@ifs-ev.org www.ifs-ev.org Redaktion, Layout: Ina Schmiedeberg Tel. +49 (431) 775 78-10 schmiedeberg@ifs-ev.org Druck: Carius Druck Kiel GmbH Boninstraße 25, 24114 Kiel Tel. +49 (431) 624 46 Klimageräte zurückgerufen Brandgefahr durch Geräte von Midea und Comfee F euer im Serverraum eines IT- Unternehmens: Wegen der Wärmeentwicklung durch die Rechner lief in dem Kellerraum ein mobiles Klimagerät. Am Schadentag war es etwa zwei Stunden in Betrieb, bevor Mitarbeiter durch eine Rauchent- wicklung alarmiert wurden. Es gelang ihnen, den Brand selbst abzulöschen, bevor er sich über den Aufstellplatz des Gerätes hinaus ausbreiten konnte. Das Gerät war erst im Jahr 2019 produ- ziert worden. Es handelt sich um das Modell „Eco Friendly“ der Marke „Com- fee“. Bei der Laboruntersuchung stellte der IFS-Gutachter fest, dass es einen Kurzschluss zwischen dem Stroman- schluss des Klimakompressors und einer Kühlmittelleitung gegeben hatte. Die Leitung wurde dabei aufgeschmolzen, und das brennbare Kühlmittel konn- te austreten und sich entzünden. Besonders interessant an diesem Fall ist, dass der Hersteller, die Midea Europe GmbH, Klimageräte zurückruft. Es könne zur elektrischen Funkenbildung an einer Kupferleitung kommen, wodurch sich das Kältemittel und das Gerät selbst entzünden können. Betroffen sind demnach das portable Klimagerät „Mobile 35C“ der Marke Midea und das baugleiche „MPD1-12CRN7“ der Marke "Comfee". Die zurückgerufenen Geräte haben verschiedene Seriennummern und wurden im Jahr 2019 produziert. Der Hersteller bittet Kunden mit einem der von ihm genannten Geräte, die Nutzung unverzüglich einzustellen und sich mit dem Händler in Verbindung zu setzen. Das vom IFS untersuchte Gerät passt zum beschriebenen Fehlerbild, ist jedoch nicht in den Rückrufen aufgelistet. Einen Produktrückruf wegen des glei- chen Fehlerbildes hat auch die Imtron GmbH für das Klimagerät KAC 3352 der Marke KOENIC veröffentlicht. Für dieses Modell wird kein Produktions- zeitraum genannt. Es werden jedoch Seriennummer aufgelistet. Alle genannten Rückrufe sind in der Datenbank für gefährliche Produkte erfasst, die von der Bundesanstalt für Arbeitssicherheit betrieben wird. Die Meldungen der BAuA und die Rück- rufe der Hersteller verlinken wir in der Onlinefassung dieses Beitrages. Besuchen Sie uns unter www.ifs-ev.org/klimageraete Dichtung und Wahrheit Wasserschäden durch versprödete Rotex-Dichtungen D er Keller einer Doppelhaus- hälfte stand unter Wasser, weil am warmwasserseitigen Anschluss des Trinkwasserspeichers einer Luft-Wasser-Wärmepumpe eine Dichtung versagt hatte. Das Material war so intensiv versprödet, dass bei der Laboruntersuchung im IFS bereits Teile davon herausgebrochen waren. Dem beauftragten Gutachter fiel auf, dass es in der Schadendatenbank des Institutes weitere Fälle gab, bei denen es durch mangelhafte Dichtungen von Warmwassergeräten und -speichern des Herstellers „Rotex“ zu Wasserschäden gekommen war. Auch dem Hersteller ist eine Schadenhäufung durchaus bewusst, wie eine technische Informa- tion von Rotex belegt. Die Schäden seien regional konzentriert, so der Hersteller auf Nachfrage des Gutachters. Man gehe davon aus, dass die Ursache auf die Wasserqualität zurückzuführen sei. Allerdings ergab die Trinkwasser- analyse des Wasserversorgers zum Beispiel im eingangs geschilderten Fall keine auffälligen Werte, die auf eine außergewöhnliche Belastung des Materials hindeuten würden. Von den Schäden betroffen sind laut Rotex Wärme- und Warmwasserspeicher der Modelle „Sanicube“ und „Hybrid- Cube“, Luft-Wasser-Wärmepumpen mit den Bezeichnungen „HPSU compact“ und „monobloc compact“ sowie Gas-/ Brennwert-/Solarkombination des Modells „GCU compact“, die in den Jahren 2013 bis 2017 produziert wurden. Rotex gehört seit dem Jahr 2020 zur „Daikin“-Gruppe. Die meisten Produkte des Herstellers tragen mittlerweile den neuen Namen.

FD05997 ｜ 2022_德国_IFS_ifs_report_2022_1.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2022 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

• Jahrgang

März 2022 Eine Information des Institutes für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. K üchenbrand in einem 200 Jahre alten Haus. Die Flam- men können auf die Küche eingegrenzt werden, doch Ruß und Rauchgasniederschläge verunreinigen auch die anderen Räume. Nach einer umfangreichen Sanierung sind die gesundheitsgefährdenden Ver- schmutzungen nachweislich beseitigt, doch der Brand scheint noch immer in der Luft zu hängen. Ist da noch etwas? Unser Geruchssinn ist subjektiv, und wie alle Sinne ist er trügerisch. Um den Sanierungserfolg auch in dieser Hinsicht beurteilen zu können, ist eine objektive Größe notwendig, ein Messwert. Für das IFS sind Raumluftmessungen zur Erfolgskontrolle nach der Sanierung von Schimmelschäden ein übliches Vorgehen. Bisher gab es allerdings keine vergleichbare Methode für die Ein- ordnung von Brandgeruch. Ein solches Verfahren haben wir nun entwickelt. Geruchswahrnehmung ist zwar subjektiv, doch es gibt aussagekräftige Messwerte. Aus der Nase, aus dem Sinn Wie wir die subjektive Wahrnehmung von Brandgeruch objektivieren können Warum bei Schäden an Kunststoffrohren das Schadenumfeld betrachtet werden muss ⟶ S. 3 Fotos: stock.adobe.com Brandgeruch setzt sich aus etwa einem Dutzend chemischen Verbindungen zusammen. Schon wenige µg/m3 dieser Komponenten kann der mensch- liche Geruchssinn wahrnehmen. „Die Grenze zur Toxizität liegt um ein Vielfaches höher. Unsere Messungen orientieren sich jedoch an der unteren Geruchsschwelle“, erklärt Dr. Stefan Schallmoser. Der IFS-Gutachter ist federführend bei der Entwicklung und Einführung der neuen Methode. „Erst wenn der Summenwert aller relevanten Verbindungen unter ein µg/m3 liegt, gehen wir davon aus, dass keine brand- bedingten Geruchsbeeinträchtigungen mehr vorliegen“, so der Chemiker. Im eingangs geschilderten Beispiel lag der Summenwert leicht über der Geruchsschwelle. Die Brandrückstände hatten sich in den Fugen und Rissen der Sichtholzbalken des alten Gemäuers abgelagert. In solchen Fällen können die noch verbliebenen Verbindungen ausgeheizt werden. Dafür wird die Raumtemperatur auf bis zu 40 °C erhöht. Alternativ kann eine Ozon- behandlung durchgeführt werden, um die Restbelastung zu beseitigen. Bei der Messung von Brandgeruch steht nicht die Feststellung eines möglichen Gesundheitsrisikos im Vordergrund. Ein solches lässt sich mit der klassischen Probenahme identifizieren, die auch weiterhin als Standardverfahren ein- gesetzt wird. Die ergänzende Raumluft- messung geht einen entscheidenden Schritt weiter und berücksichtigt unsere Wahrnehmung. Erst wenn der Brand aus der Nase verschwunden ist, kann er auch aus dem Kopf verschwinden. Besonders relevant ist dieser Hygiene- grad in sensiblen Bereichen wie Kinder- tagesstätten, Schulen und Kranken- häusern. Das IFS bietet die Messung bundesweit über alle Standorte an. Brandfällen wurde ein ungeeignetes Ladegerät verwendet. Lesen Sie dazu auch unseren Beitrag auf Seite vier. Zur Elektro- und Mikromobili- tät gehören außer Pedelecs auch E-Scooter und Hoverboards. Letztere sind besonders häufig von Bränden betroffen, weil sehr viele Produkte auf dem Markt sind, bei denen der Preis im Vordergrund steht, und das manchmal zulasten der Produktsicherheit. Ein weiteres Gerät, das zwar nicht direkt zur Elektromobilität gehört, doch nach dem Winter wieder seine Runde zu drehen beginnt, ist der Mähroboter. Wo die Empfindlichkeiten von Lithium- Ionen-Akkus liegen, was bei einem Defekt geschieht sowie Tipps zur Hand- habung und Schadenverhütung finden Sie in unserem Akkudossier unter www.ifs-ev.org/lithium-akkus 2 IFS-Report  1/2022 G elegenheit macht Brandstifter, wie wir aus Erfahrung wissen. Oft steckt hinter einer willent- lichen Brandlegung kein ausgeklügelter Plan, sondern Frust und Unmut kombiniert mit der Möglichkeit zu zündeln. So sind ungenutzte Gebäude weit häufiger betroffen als genutzte. In den zurückliegenden zwei Jahren hat sich die Nutzung vieler Gewerbe- immobilien und öffentlicher Gebäude stark verändert. Das IFS hat zahlreiche Brandstiftungen an solchen Objekten untersucht. Das Beitragsfoto zeigt den Gastraum eines Restaurants, das über einen längeren Zeitraum geschlossen war. Brandstifter hatten sich Zugang zu dem verwaisten Gebäude verschafft und an mehreren Stellen Feuer gelegt. Besonders oft kam es zu Brand- stiftungen in und an Schulgebäuden. Die Zahl der Brandlegungen in Erziehungseinrichtungen hat in den zurückliegenden Jahren ohnehin zugenommen, wie die IFS-Statistik zeigt. In jüngster Vergangenheit hat sich der Trend weiter verschärft. Mit Sicher- heitstechnik und ein paar grundsätz- lichen Regeln können Immobilien nach unserer Einschätzung zumindest vor den Gelegenheitsbrandstiftern effektiv geschützt werden. So sollten keine leicht brennbaren Gegenstände direkt am Gebäude stehen. Insbesondere Mülltonnen sollten nicht frei zugäng- lich sein und außerdem so platziert werden, dass im Falle einer Brand- stiftung die Flammen nicht auf das Gebäude übergreifen können. Einbruch- sicherungen, Kameraüberwachung und Beleuchtung im Außenbereich helfen, potentielle Brandstifter abzuschrecken. Die Polsterbank vor dem Fenster ist bis auf das Metallgerüst verbrannt. Dahinter ist die Fensterscheibe durch die Brandhitze geplatzt. E-Mobilität nach dem Winter Was Sie nach der Nutzungspause beachten sollten M it dem Frühling kehrt das Leben nicht nur in die Natur, sondern auch auf die Rad- wege zurück. Immer mehr Radler sind mittlerweile mit einem unterstützenden Elektromotor unterwegs. Bei energie- hungrigen, mobilen Anwendungen wie Pedelecs kommen in der Regel Lithium- Ionen-Akkus zum Einsatz. Wegen des Brandrisikos, das mit der Lithium- technologie einhergeht, empfiehlt das IFS generell, solche Akkus nicht inmitten brennbarer Materialien und entweder beaufsichtigt oder zumindest in einem Raum mit Rauchmelder zu laden, denn die meisten Akku- brände entstehen in der Ladephase. Die erste Nutzung nach dem Winter ist besonders brisant. So manches Elektrofahrrad hat die dunkle Jahres- zeit vollkommen unbeachtet in der kalten Garage verbracht. Die niedrigen Temperaturen und die lange Ladepause können den Akku belasten. Das hat nicht nur Einfluss auf die Kapazität, sondern kann im schlimmsten Fall auch zum Defekt führen. Wurde ein Fehler initiiert, zeigt er sich gewöhn- lich bei den ersten Ladevorgängen. Diese sollten darum besonders auf- merksam begleitet werden. Vor allem weisen wir immer wieder darauf hin, die Herstellervorgaben zu beachten. In vielen vom IFS untersuchten Nichtnutzung lockt Brandstifter an Das IFS hat zahlreiche Brände an Gebäuden untersucht, deren Nutzung geändert wurde

IFS-Report  1/2022 3 K unststoff hat gegenüber Metal- len in Heizungs- und Trink- wasserinstallationen Vor- und Nachteile. Insbesondere der Wegfall des Korrosionsrisikos ist ein starkes Argu- ment für Kunststoff. Allerdings ist das Material empfindlicher gegen thermi- sche und mechanische Überlastungen. Ein Schadenbeispiel: Die Heizungs- anlage in einem Einfamilienhaus funk- tionierte vom ersten Tag an nicht so richtig. Darum installierte der Heizungs- bauer nachträglich einen Elektroheiz- stab im Pufferspeicher. Als die Anlage weiterhin nicht funktionierte, hatte der Hauseigentümer genug und beauf- tragte einen anderen Fachbetrieb, die störungsfreie Beheizung und Warm- wasserversorgung für das Gebäude herzustellen. Die zweite Firma instal- lierte eine neue Steuerung, an die unter anderem der Heizstab angeschlossen wurde. In der folgenden Zeit wurden nach und nach Leckagen an den im Fuß- bodenaufbau verlegten Warmwasser- leitungen gefunden. Der Hausherr war vom Regen in die Traufe geraten. Als Ursache für die Undichtigkeiten wurde eine Explosion in der Heizungs- anlage vermutet. Doch für eine Schä- digung durch eine Druckwelle gab es keine Anzeigen, als diverse Rohr- abschnitte und Verbindungsstücke aus Spezifische Schwachstellen Bei Trinkwasser- und Heizungsleitungen aus Kunststoff stehen Druck und Temperatur im Fokus der Installation im IFS untersucht wur- den. Vielmehr stellte der beauftragte Gutachter Undichtigkeiten an den Verbindern fest, die durch eine thermi- sche Überlastung entstanden waren. Bei der technischen Untersuchung von Leitungswasserschäden offenbaren die Asservate im Labor oft die Schaden- entstehung, zum Beispiel, wenn bei der Montage eine Verbindung zu fest angezogen oder ein ungeeignetes Werk- zeug benutzt wurde. Bei der thermi- schen oder mechanischen Schädigung von Kunststoffleitungen kann hingegen nur die Art der Schädigung ermittelt werden. Um deren Ursache zu finden, muss man das Umfeld betrachten. Im beschriebenen Fall stellte der Gutachter vor Ort fest, dass es in der Heizungs- anlage keinen Sicherheitstemperatur- begrenzer (STB) gab. Bei der ursprüng- lichen Installation war er nicht verbaut worden, und der zweite Fachbetrieb hatte ihn nicht nachgerüstet. Dass die vorgesehene Temperatur überschritten wurde, war ein Fehler der Steuerung. Doch solche Fehler können auftreten und müssen aufgefangen werden. Beide Handwerksbetriebe hätten das Fehlen des STB als Mangel erkennen müssen, denn nach der DIN EN 12828 ist er sicherheitsrelevant und sein Vor- handensein darum vorgeschrieben. Ein weiteres Beispiel: Als es an der Warmwasserleitung im Keller eines Mehrfamilienhauses zum zweiten Mal innerhalb weniger Tage zur Leckage kam, wurden die betroffenen Abschnitte ausgebaut und zur Untersuchung ins IFS geschickt. Man vermutete zu hohe Temperaturen in der wenige Jahre alten Anlage, deren Leitungen aus Mehrschichtverbundrohren bestanden. Der Rohrabschnitt, an dem die zweite Leckage entstanden war, zeigte jedoch die typischen Merkmale eines gewalt- samen Platzens wegen eines über- höhten Innendrucks. Warum der Druck derartig ansteigen konnte, musste der Gutachter vor Ort herausfinden... Als er im Keller die Isolierung des Wasserspeichers öffnete, kam ein tonnenförmig aufgeblähter Stahlinnen- behälter zum Vorschein, dessen äußere Beschichtung zum Teil abgeplatzt war. Doch die Schäden an der Anlage waren nicht durch ein einmaliges Ereignis ent- standen, sondern über einen längeren Zeitraum. Das hatten die Spuren an verschiedenen im Labor untersuchen Komponenten verraten. Der Aufbau der Installation löste das Rätsel: In der Kaltwasserzuleitung zum Speicher war in Fließrichtung hinter dem Sicher- heitsventil ein Rückflussverhinderer montiert. Dort hätte er sich nach der DIN EN 806-2 allerdings nicht befinden dürfen. Das Wasser im Speicher dehnt sich bei der Erwärmung aus. Es wird zum Teil in die Leitung zurückgedrückt, und über das Sicherheitsventil wird der Druck abgebaut. Doch der Rück- flussverhinderer versperrte hier den Weg zum Sicherheitsventil. Das Wasser wurde stattdessen ausschließlich in Richtung der Warmwasserleitung herausgedrückt. Deren Mehrschichtver- bundrohre wurden dabei wieder und wieder mit zu hohem Druck belastet, bis es schließlich zu Leckagen kam. Thermische und mechanische Über- lastungen von Mehrschichtverbund- rohren können auch in Kombination auftreten. Die Überlastung führt nicht zwangsläufig sofort zum Ver- sagen. In jedem Fall wird dadurch aber die „Lebensdauer“ verkürzt. Kommt es zum Schaden, so ist das Risiko für weitere Schäden erhöht. Fotos: IFS Beispielfotos: Das Rohr ist durch zu hohe Temperaturen aufgeweicht und von der Stützhülse gerutscht. Rechts: Das Rohr ist durch eine Krafteinwirkung von innen aufgeplatzt.

Herausgeber: Institut für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. Preetzer Straße 75, 24143 Kiel Tel. +49 431 775 78  0 mail@ifs-ev.org www.ifs-ev.org Redaktion, Layout: Ina Schmiedeberg Tel. +49 431 775 78 10 schmiedeberg@ifs-ev.org Druck: Carius Druck Kiel GmbH Boninstraße 25, 24114 Kiel Tel. +49 431 624 46 Gefährlicher Minimalismus ... bei Nachbauten von Ladegeräten für Werkzeuge E in Knallgeräusch aus dem Keller ließ eine Familie abends auf- schrecken. Während der Hausherr die Treppe herunterlief, hörte er einen weiteren Knall. Dann sah er Flammen im Heizungsraum. Keine Stunde zuvor hatte er dort den Akku für seinen Winkelschleifer von „Hilti“ zum Laden angeschlossen – allerdings nicht an das original Ladegerät des Herstellers, sondern an einen Nachbau, den er auf einem Online-Marktplatz gekauft hatte. Eine IFS-Gutachterin fand später im Keller ein Spurenbild vor, das unseren Brandursachenermittlern bereits ver- traut ist: Im Mittelpunkt standen mehrere aufgeplatzte Lithium-Ionen- Akkuzellen. Sie waren thermisch durchgegangen. Die Knallgeräusche, die die Familie gehört hatte, zeug- ten von der explosionsartigen Ent- ladung der gespeicherten Energie. Warum es in einer Akkuzelle zum Defekt kam, lässt sich nach einem solchen „thermal runaway“ kaum noch ermitteln. Die Zellen sind dann in der Regel aufgeplatzt und ihr Innenleben Fotos IFS Im Originalladegerät (1) führen fünf Leitungen zur Anschlussbuchse (2) für den Akku. Drei davon gehören zum Batteriemanagementsystem. Der Nachbau (3) hat lediglich die beiden Leitungen zum Laden (4). Auch ein Lüfter für die interne Kühlung (A) ist nur beim Original vorhanden und fehlt dem Nachbau. stark beschädigt oder vollständig zer- stört. In diesem Fall war die Ursache sehr wahrscheinlich eine Überladung oder Überhitzung, denn dem Ladegerät fehlten diverse sicherheitsrelevante Bauteile, wie sich bei der Untersuchung im Elektrolabor herausstellte. Anders als beim Original waren keine elektro- technischen Komponenten verbaut, um den Ladezustand und die Akkutemperatur zu überwachen. Auch die aktive Kühlvorrichtung war nicht vorhanden. Die Funktion des Gerätes beschränkte sich auf das reine Laden. In der Schadendatenbank des IFS fällt auf, dass Akkus von Werkzeugen relativ häufig von Bränden betroffen sind, und in den meisten Fällen handelt es sich dabei um Nachbauten des Lade- gerätes oder des Akkupacks selbst. Im Report 3/2020 berichteten wir über Brände durch Austauschakkus für „Makita“-Werkzeuge. Die technische Untersuchung hatte gezeigt, dass einige Nachbauten beim Laden nicht alle Zellen überwachten. Das Batterie- managementsystem unterschied sich darin vom Original. Selbstverständ- lich können und wollen wir nicht behaupten, dass Nachbauten generell den technischen Anforderungen nicht gerecht werden. Schließlich ist das IFS mit einer Auswahl von Produkten kon- frontiert, bei denen es zu einem Defekt kam. Bei unseren Untersuchungen sind wir jedoch wiederholt auf Nachbauten getroffen, die nicht den technischen Standard der Originalprodukte erfüllten. In den Bedienungsanleitungen wird außerdem häufig darauf hingewiesen, Originalakkus und -ladegeräte zu benutzen, weil der Hersteller nur dann die Sicherheit gewährleisten kann. 1 2 3 4 A

FD05998 ｜ 2022_德国_IFS_ifs_report_2022_2.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2022 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

• Jahrgang

Juni 2022 Eine Information des Institutes für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. D ie aktuelle Brandursachen- statistik des IFS zeigt: Kühl- geräte sind die neue Nummer eins. In unserem Ranking der häufigsten elektrotechnischen Brandverursacher im Haushalt verweisen sie erstmals den Wäschetrockner auf Platz zwei. Für Dr. Hans-Hermann Drews ist das keine Überraschung. „Wir erfassen die Ergebnisse unserer technischen Ursachenermittlungen seit über zwanzig Jahren. In den Daten können wir Ent- wicklungen deutlich erkennen“, so der Geschäftsführer des IFS. Wäschetrockner waren über viele Jahre die Geräte, die am meisten Brände verursachten. Dann führten technische Verbesserungen mit der Zeit zu mehr Produktsicher- heit. „Die Kurve fällt kontinuierlich; man sieht, wie sich die verbesserten Geräte verbreiten und weniger Schä- den entstehen", erklärt Drews. Dem IFS kommt dabei nicht nur eine beobachtende Rolle zu. Die Gutachter des Institutes unterstützen Gremien, Der Wäschetrockner rutscht auf Platz zwei und macht Platz für den Kühlschrank. Mehr IFS-Statistiken gibt's unter www.ifs-ev.org/statistik Unsere häufigsten Brandverursacher ... und warum Schadenforschung die Basis effektiver Schadenprävention ist Kleine Auffälligkeiten an der Wasserinstallation können wichtige Hinweise sein ⟶ S. 3 Illustration: Gerrit Hansen die das technische Regelwerk erarbeiten und aktualisieren. Bei Produktschäden steht das Institut außerdem häufig in Kontakt mit den Herstellern. Das Potential für die Schadenverhütung ist keinesfalls immer technisch. Elektrizi- tät ist mit rund einem Drittel kontinuier- lich die häufigste Brandursache in Gebäuden. Die sogenannte „weiße Ware“ steht bei der weiteren Analyse immer auf den oberen Plätzen. Das liegt zum einen daran, dass diese Geräte in jedem Haushalt stehen, und zum anderen an den hohen Belastungen, denen sie im Betrieb ausgesetzt sind. Allen voran trifft das auf Kühlgeräte zu. Sie befinden sich über viele Jahre im Dauerbetrieb. In unseren Statistiken belegen sie immer einen der vorderen Plätze unter den brandverursachenden Elektrogeräten. Sie sind demnach nicht die neue Nummer eins, weil sich ihre Bilanz ver- schlechtert, sondern weil das Brandrisiko durch Wäschetrockner gesunken ist. „Kühlgeräte können brennen – ‚brand- gefährlich‘ sind sie aber nicht“, resümiert Drews. Allerdings kann man die Wahr- scheinlichkeit für einen Kühlschrank- brand beeinflussen: Um die elektro- technischen Komponenten nicht über Gebühr zu strapazieren, sollte Eisbildung vermieden und das Gerät regelmäßig abgetaut werden. Außerdem muss genügend Platz für die Hinterlüftung da sein, und schließlich sollte auch ein Kühlgerät irgendwann ausgetauscht werden. In einem kürzlich untersuchten Fall ging der Brand von einem Kühl- schrank aus, der nach dem Küchen- dienst ein zweites Leben als Bierkühler auf dem Balkon bewältigen musste. Vor allem bei unserer Nummer drei, der Mehrfachsteckdose, ist Handhabung der Schlüssel zur Schadenverhütung. Eingequetschte oder unter Zug ste- hende Anschlussleitungen führen früher oder später zum Kurzschluss. Oft sind es einfache Änderungen, die zu mehr Sicherheit führen. 2 IFS-Report  2/2022 Sicherheitsgedanke mit Tücken Beim Anschluss von Gasflaschen kommt es immer wieder zu folgenschweren Fehlern K ulinarischer Genuss, Freizeitspaß, Philosophie – wir lieben das Grillen. Der Holzkohlegrill hat hierzulande nach wie vor die Nase vorn, doch auch der Gasgrill gewinnt immer mehr Freunde. Allerdings kommt es beim Anschluss der Gasflasche immer wieder zu Unfällen, wie dieser Fall zeigt: Ein Ehepaar hatte den neu gekauften Grill gerade zum zweiten Mal in Betrieb, als die Frau durch die Terrassentür Flammen unter dem Grill, direkt an der Gasflasche sah. Der Brand griff auf den Dachüberstand und die gedämmte Fas- sade des Einfamilienhauses über, bevor die Feuerwehr ihn löschen konnte. Bei der Brandursachenermittlung stellte unser Gutachter fest, dass der Druck- minderer nicht weit genug auf den Ventilanschluss der Flasche geschraubt wurde. Dieser Fehler passiert manch- mal, wenn das Gewinde fester gezogen werden soll und dann aus Versehen gelockert wird. Der Grund: Wir sind im Alltag ständig mit Rechtsgewinden konfrontiert; intuitiv schließen wir ein Ventil mit einer Rechtsdrehung. Flaschen mit brennbaren Gasen wie Propan und Butan sind jedoch nach der DIN EN 1117 mit Linksgewinden versehen. Das ist an sich eine sinnvolle Maßnahme zur Schadenprävention, denn damit wird verhindert, dass ungeeignete Adapter und Schläuche zum Anschluss verwendet werden können. Um nicht Opfer der eigenen Gewohnheit zu werden, aber auch um sicherzustellen, dass alle Kompo- nenten fehlerfrei sind, sollte die Ver- bindung nach dem Anschluss immer mit einem Lecksuchspray geprüft werden. Schlägt es Bläschen, ist die Verbindung nicht korrekt hergestellt oder möglicherweise eine Dichtung nicht in Ordnung. Auch das passiert manchmal, wenn das Gewinde über- eifrig mit einem Werkzeug festgezogen wird. Ein Gasgrill wird gewöhnlich mit einer 5- oder 11-kg-Gasflasche betrieben. Beim Anschluss genügt es, die Verbindung handfest anzuziehen. Neue Gutachter für Stuttgart und München Thomas Schäfer IFS Stuttgart Tel. 0711 3804260 - 40 tschaefer@ifs-ev.org Dr. Philipp Denk IFS München Tel. 089 6899988 - 16 pdenk@ifs-ev.org Das IFS in Stuttgart freut sich über einen neuen Gutachter: Thomas Schäfer ermittelt Brandursachen und untersucht Brandfolge- sowie Feuchte- schäden. Er hat an der Universität Würzburg ein Master-Studium der Chemie abgeschlossen und wird voraussichtlich in den nächsten Monaten von der Universität Gießen promoviert. Unser zweiter Neuzugang ist Dr. Philipp Denk. Der Lebensmittel- chemiker hat an der Universität Erlangen-Nürnberg studiert und an der Uni in Kooperation mit dem Fraunho- fer IVV in Freising promoviert. Er unterstützt das IFS München, wo auch er Brandursachenermittlungen durchführt, Brandfolgeschäden und Feuchteschäden untersucht. Das Beispielfoto ganz links zeigt den Anschluss einer Gasflasche mit Druckminderer und Schlauch. Rechts sind das Gewinde aus dem geschilderten Fall und ein Vergleichsbauteil zu sehen. Die Verfärbungen zeigen, wie weit die Verbindung eingeschraubt war (Pfeil).

IFS-Report  2/2022 3 W asserschäden bauen sich oft über einen langen Zeitraum auf, bevor sie bemerkt wer- den. In vielen Fällen gibt es Anzeichen für eine Leckage, doch diese Warn- signale werden allzu häufig ignoriert oder fehlinterpretiert. Ein Beispiel: In einem neu gebauten Einfamilienhaus ist kurze Zeit nach dem Einzug das Wasser, das aus der Küchenarmatur entnommen wird, bräunlich verfärbt. Die Installationsfirma hat den Wasser- versorger im Verdacht. Daraufhin lässt der Eigentümer hinter dem Haus- wasseranschluss einen zusätzlichen Feinfilter installieren – was die Situation allerdings nicht ändert. Viereinhalb Jahre vergehen, bis an den Wänden des nicht unterkellerten Gebäudes Feuchtigkeit aufsteigt. Die Suche nach der Ursache führt zu einer Leckage im Küchenfußboden an der Warmwasser- zuleitung zur Spültischarmatur. Eine IFS-Gutachterin asserviert an der Schadenstelle den betroffenen Abschnitt für eine Laboruntersuchung. Ein Rohrstück ist im Gegensatz zu den anderen Komponenten korrodiert. Die Elementanalyse im Elektronen- mikroskop belegt, dass es sich um ein an der Außenseite verzinktes C-Stahl- rohr handelt. Dieses Bauteil ist für Kleine Hinweise auf großen Ärger Schäden an der Trinkwasserinstallation beginnen häufig mit einer winzigen Leckage. Auffälligkeiten sollte man darum nicht einfach hinnehmen Links: Auch an einer Waschtischarmatur im Badezimmer kommt bräunlich verfärbtes Wasser aus der Leitung. Die Aufnahmen rechts und in der Mitte zeigen das Bidet im Gäste-Bad. Bei der Entnahme von Kaltwasser (rechts) ist die maximale Entnahmerate erheblich reduziert, während sie bei Entnahme von Warmwasser (Mitte) in vollem Umfang zur Verfügung steht. Heizungsinstallationen geeignet, aber nicht für Trinkwasserinstallationen. Der Sauerstoff in der Trinkwasserleitung führt zu Korrosion an diesem Material. Entsprechend ist die Innenseite des Rohres so stark geschädigt, dass die Rohrwand stellenweise durchbrochen wurde. Schon die bräunlichen Ver- färbungen, die Jahre zuvor festgestellt wurden, waren Korrosionsprodukte. Der Monteur hatte beim Erstellen der Trinkwasserinstallation aus Edelstahl versehentlich ein C-Stahlrohr ein- gebaut. Wenn C-Stahl verzinkt wird, ist er optisch kaum von Edelstahl zu unterscheiden. Der Hauswerker muss sich vor Ort darauf verlassen können, dass die Materialien im Teilelager nicht durcheinandergeraten sind. Die Verwechslung war dem Monteur in diesem Fall wahrscheinlich nicht nur an der Zuleitung zur Spültischarmatur in der Küche unterlaufen: An den Armaturen in beiden Badezimmern des Hauses fiel unserer Gutachterin auf, dass die Entnahmerate jeweils auf der Kaltwasserseite wesentlich geringer war als auf der Warmwasserseite. Das ist – wenn beide Eckventile gleich weit geöffnet sind – ein Hinweis darauf, dass Innenkorrosion möglicherweise den Rohrinnendurchmesser reduziert. Sie riet dringend, auf die Suche nach weiteren Fehlerstellen zu gehen. „Wenn es um Leitungswasser geht, sollten Sie das Gras wachsen hören“, sagt Dr. Thorsten Pfullmann, der im IFS die Fachverantwortung für die Untersuchung dieser Schäden trägt. Ein muffiger Geruch zum Beispiel hat einen Grund, und der kann durchaus eine Durchfeuchtung sein. „Wenn Sie etwas Ungewöhnliches oder auch einfach eine Veränderung feststellen, gehen sie dem auf den Grund“, rät der Gutachter. Nach der GDV-Statistik haben Leitungs- wasserschäden in Deutschland allein 2020 Kosten von über 3,3 Milliarden Euro verursacht. Diese Schäden las- sen sich nicht alle verhindern, denn Fehler passieren nun einmal. Viele ließen sich allergings in ihrem Ausmaß erheblich reduzieren. Leckageschutz- systeme können selbst Mikroleckagen detektieren. Bei Auffälligkeiten wird der Eigentümer auf ein mögliches Problem hingewiesen und kann – auch aus der Ferne per Smartphone – reagieren. Wird außergewöhnlich viel Wasser entnommen, kann die Zufuhr automatisch unterbrochen werden. Solche Leckageschutzsysteme gibt es in unterschiedlichen Ausführungen sowohl für große Anlagen als auch für die heimische Trinkwasserinstallation. Fotos: IFS (4), privat (2), stock.adobe.com (1)

Herausgeber: Institut für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. Preetzer Straße 75, 24143 Kiel Tel. +49 (431) 775 78- 0 mail@ifs-ev.org www.ifs-ev.org Redaktion, Layout: Ina Schmiedeberg Tel. +49 (431) 775 78-10 schmiedeberg@ifs-ev.org Druck: Carius Druck Kiel GmbH Boninstraße 25, 24114 Kiel Tel. +49 (431) 624 46 E in Mann ist im Badezimmer seines Einfamilienhauses, als eine Explosion das Gebäude erschüttert. Er bleibt unverletzt, doch die Dachkonstruktion wird durch die Druckwelle zerstört. Sie ging vom Heizungsraum im Keller aus. Dort ist eine Wand eingestürzt, und die Tür wurde samt Zarge nach außen gedrückt. Die spätere Ursachenermittlung durch das IFS führt zu einem Pelletheizkessel des österreichischen Herstellers „Bio- tech“, Modell PZ8RL, Baujahr 2006. In unserer Schadendatenbank fällt eine Reihe von Bränden und Explosionen durch Pelletkessel dieses Herstellers auf. Alle von uns untersuchten, betroffenen Geräte wurden in den Jahren 2004 bis 2006 produziert. Einige der Schä- den sind jedoch erst in diesem Jahr aufgetreten. Auf seiner Internetseite bewirbt Biotech seine Pelletkessel mit dem Hinweis auf „100 % Rück- brandsicherheit“. Dieses Versprechen erscheint etwas kühn, denn bei allen erwähnten Schäden ist es zum Rück- brand aus dem Brennraum gekommen. Bei der Konstruktion werden die Pellets über eine schräg nach oben verlaufende Förderschnecke aus dem Vorrats- behälter transportiert. Am oberen Ende fallen sie ein Stück und landen auf einer Rutsche, über die sie in den Brennraum gelangen. Der Weg ist durch die Fallstrecke also unterbrochen, was laut Hersteller Rückbrandsicherheit gewährleisten soll. Allerdings bildet der Schacht, in dem die Förder- oder Dosier- schnecke verläuft, eine unverschlossene Verbindung zwischen Brennraum und Fotos: IFS Der Pelletkessel aus dem geschilderten Explosionsschaden; das rechte Bild zeigt die ausgebaute Förderschnecke mit deutlichen Brandspuren. Vorratsbehälter. Eine Brandklappe ist nicht vorhanden. Die vom IFS unter- suchten Pelletkessel haben an der Förderschnecke einen Temperaturfühler, der diese bei zu hohen Werten in Gang setzt, um glühendes Material in Rich- tung Brennraum zu transportieren. Eine Löscheinrichtung gib es jedoch nicht. Ein generelles Brandrisiko Rückbrände sind ein generelles Risiko bei Pelletkesselheizungen. Effektiven Brandschutz bieten zum Beispiel Zellradschleusen, die den Brandweg verschließen. Sie werden in der Regel zwischen der Förderschnecke aus dem Vorratsbehälter und der Pellet­rutsche verbaut, die in den Brennraum führt. Auch beim Betrieb der Pelletheizung gibt es Faktoren, die das Brandrisiko beeinflussen: So sollte zum Beispiel die regelmäßige Reinigung auf keinen Fall vernachlässigt werden. Im Laufe der Zeit lagern sich Holzstäube unter anderem auf der Pelletrutsche ab, und dadurch wird die Wahrscheinlich- keit eines Rückbrandes vergrößert. Hier sollten Betreiber unbedingt die Herstellerangaben berücksichtigen. Zertifizierte Pellets helfen außerdem, Verunreinigungen zu reduzieren. Die EU-Norm 14961-2 definiert seit 2010 die Qualität von Holzpellets. Sie legt unter anderem den Mindestheizwert, die Abmessungen und den Schad- stoffgehalt fest. Qualitätsgeprüfte Pellets erkennen Verbraucher an den Prüfsiegeln „DINplus“ und „ENplus“. Rückbrände in Pelletkesselheizungen Das IFS hat eine Reihe von Schäden an Pelletkesseln von Biotech untersucht

FD05999 ｜ 2023_德国_IFS_ifs_report_2023_1.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2023 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

• Jahrgang

März 2023 Eine Information des Institutes für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. R auchen Sie noch oder dampfen Sie schon? Die E-Zigarette oder Vape ist gerade bei jungen Menschen eine beliebte Alternative zur herkömmlichen Zigarette. Die Verdampfer werden mit Lithium-Ionen- Akkus betrieben, sind also aufladbar. Mittlerweile erobert jedoch auch eine Einwegvariante den Markt. In Super- märkten und Tankstellenshops gibt es für ein paar Euro bunte Wegwerf- Vapes, die aussehen wie Textmarker. Die Hersteller versprechen 500 bis tausend Züge Dampferspaß. Dann landet das Produkt... ja, wo eigentlich? Der Hausmüll ist wegen der fest verbauten Batterie die falsche Wahl. Der bunte Verdampfer ist Sonder- müll und muss zu einer Sammelstelle gebracht werden, im Zweifelsfall zurück zum Händler. So gewissen- haft gehen aber nicht alle Benutzer damit um. Werden die Verdampfer E-Zigaretten gibt es auch als Einweg- Variante mit Batterie. Leider! Andere Zelle, gleiches Problem Auch als Einwegprodukt sind E-Zigaretten mit Lithiumtechnologie ausgestattet. Das wird spätestens bei der Entsorgung zur Herausforderung. Wo es im Winter besonders viele Schäden gab ⟶ S. 3 Foto: stock.adobe.com einfach in den Müll geworfen, landen sie samt Batterie in der Müllpresse und können dort Brände verursachen. Der Bundesverband der Deutschen Entsorgungswirtschaft klagt bereits über tägliche Brände an Anlagen, in Müllwagen und auch in Mülltonnen durch beschädigte Batterien. Über die Brandgefahr durch Lithium- Ionen-Akkus berichten wir regelmäßig, weil Akkudefekte mittlerweile zu den typischen und häufig vorkommenden Brandursachen zählen. Von Lithium- Batterien geht ein vergleichbares Risiko aus. Auch sie können im Falle eines Defektes thermisch durchgehen. Dabei wird die gespeicherte Energie explosionsartig entladen. Nach einem Feuer in einem Hochregallager loka- lisierte das IFS den Brandausbruch an einer Palette mit 9-V-Lithium-Batterien. Zu solchen Defekten kann es generell kommen. Das IFS schätzt das Risiko allerdings nicht als unverhältnismäßig hoch ein. Es steigt jedoch erheb- lich, wenn eine Lithium-Ionen-Zelle mechanisch oder thermisch strapa- ziert oder gar falsch geladen wird. Die meisten Brände an Lithium-Ionen- Akkus entstehen in der Ladephase. Bei Lithium-Batterien handelt es sich hingegen um Primärzellen, bei denen das erneute Aufladen überhaupt nicht vorgesehen ist. Das Problem: Dabei besteht das akute Risiko einer Brand- entstehung. Einweg-E-Zigaretten sind wesentlich preiswerter als die wieder- verwendbaren Ausführungen. Im Internet kursieren diverse Anleitungen, wie man die entladene Batterie des Wegwerfproduktes doch wieder auf- laden kann. Mancher Sparfuchs zahlt dafür allerdings einen hohen Preis. Bei der Brandursachenermittlung in einer Dachgeschosswohnung fand das IFS die Überreste eines solchen Versuchs. 2 IFS-Report  1/2023 Ein weiterer Standort und mehr Platz Klaudia Rückmann IFS Hannover Tel. 0511 8971822 - 40 rueckmann@ifs-ev.org Chiara Stöcker IFS Kiel Tel. 0431 77578 - 25 cstoecker@ifs-ev.org Vanessa Kamjunke IFS Kiel Tel. 0431 77578 - 13 vkamjunke@ifs-ev.org Johannes Moll IFS Wiesbaden Tel. 06127 921399 -29 jmoll@ifs-ev.org Hier sind unsere Neuen Mit einer neuen Dependance in Nord- hessen bauen wir unsere Präsenz im Bundesgebiet weiter aus. Kassel ist der elfte Standort des IFS. Mittlerweile haben wir ein Netz aufgebaut, das uns erlaubt, Schadenstellen überall im Land über relativ kurze Wege zu erreichen. In der Schadenverhütung und Schaden- forschung ist das IFS führend in Deutschland. Mit dem wachsenden Bewusstsein für die Endlichkeit von Ressourcen wächst auch das Interesse an diesen Themen. Das zeigt sich im kontinuierlichen Aufwärtstrend unserer Auftragszahlen. Um dieser Entwicklung gerecht zu werden, haben wir unsere Teams vergrößert. Mit mehr Personal platzte das IFS allerdings an mehreren Stellen aus den Nähten. In Berlin und Hannover konnten wir uns an den etab- lierten Standorten räumlich vergrößern. Die Kollegen in Bamberg und Münster hingegen sind umgezogen. Alle IFS- Adressen und weitere Kontaktdaten fin- den Sie auf unserer Internetseite unter

www.ifs-ev.org/standorte Auch personell ist das IFS weiterhin auf Expansionskurs, und wir dürfen ein paar neue Kollegen vorstellen: Unser Team in Wiesbaden hat Verstärkung bekommen von einem promovierten Chemiker. Dr. Johannes Moll ermittelt für das Institut Brandursachen, außerdem untersucht er Brandfolgeschäden und Feuchteschäden. Über Unterstützung freuen sich auch unsere Gutachter in Hannover: Klaudia Rückmann wird dort den Ursachen von Bränden und Leitungswasserschäden auf den Grund gehen. Die Physikerin, die sich in ihrem Studium auf Biophysik spezialisiert hat, wird voraussichtlich in diesem Frühjahr von der Universität Bremen promoviert. An unserem Hauptsitz in Kiel dürfen wir gleich zwei neue Kolleginnen begrüßen. Mit Vanessa Kamjunke haben wir eine neue Stimme für unsere Telefonzentrale gewonnen. Die gelernte Kauffrau für Büromanagement verstärkt die Verwaltung des IFS. An allen Standorten führen unsere Gutachter Laboruntersuchungen durch. Ein Herzstück unserer Arbeit sind jedoch unsere Labors in Kiel und das Brandversuchshaus. Auch dort gibt es ein neues Gesicht: Die gelernte chemisch-technische Assis- tentin Chiara Stöcker steht unserer Laborchefin Dana Wächter zur Seite.

IFS-Report  1/2023 3 G eplatze Heizkörper und Rohrleitungen, geborstene Armaturen, getrennte Press- verbindungen und herausgedrückte Perlatoren – in einem kommunalen Gebäude stießen IFS-Gutachter auf das gesamte Repertoire typischer Schaden- bilder, die durch Frosteinwirkung auf wasserführende Installationen ent- stehen. Schon vor dem Beginn des Winters war die Nutzung durch die Gemeinde ausgelaufen; das Haus stand leer. Offenbar gab es niemanden, der dafür zuständig war, das Gebäude zu kontrollieren. Als im Dezember eine strenge Frostperiode einsetzte, ent- standen umfangreiche Schäden, die zunächst nicht bemerkt wurden. Frostschäden entstehen vor allem in nicht oder nicht durchgehend genutzten Immobilien. In einem anderen Ort kam es zu erheblichen Schäden in einem Gebäude, das von der Gemeinde zur Unterbringung von Flüchtlingen angemietet wurde. Hier war alles vorbereitet worden, doch die angekündigten Bewohner waren noch nicht eingetroffen, als der Frost einsetzte. Der Schaden ist in einem solchen Fall nicht nur mit finanziellem, sondern auch mit einem enormen Eine frostige Schadenbilanz Im zurückliegenden Winter waren besonders viele Immobilien von Frostschäden betroffen. Wir werfen einen Blick auf die typischen Umstände dieser Ereignisse Aus dem Heizkörper (1) ist ein relativ großes Stück herausgebrochen. Der Perlator (2) wurde aus der Duscharmatur gedrückt. Die Bilder 3 und 4 zeigen getrenne Verbindungen. Alle Schäden wurden durch einen starken Innendruck verursacht und sind typische Frostfolgen. organisatorischen Aufwand verbunden, da das Gebäude häufig wochenlang nicht mehr genutzt werden kann. Im Hinblick auf Frosteinwirkung ist wich- tig, die Zuständigkeit für den Betrieb bzw. die Kontrolle einer Immobilie rechtzeitig zu klären. Das trifft keines- falls nur kommunale Gebäude, wie unser nächstes Beispiel zeigt: Während der Frostperiode im Dezem- ber kam es auch in einem Ferienhaus zu einem erheblichen Schaden. In der Küche einer Wohnung waren zwei Klemmringverbindungen auseinander- gedrückt worden. Das Haus hatte keine Wintergäste. Der Leerstand zwischen Oktober und April war bekannt. Der Eigentümer hatte eine Hausverwaltung damit beauftragt, nach der Immobilie zu sehen. Doch im Vertrag war die Kontrolle der Beheizung bzw. der Frost- sicherheit nicht vorgesehen. Darum wurde auch dieser Schaden erst einige Wochen nach seinem Eintritt bemerkt. Weitere typische Umstände für Frost- schäden sind Eigentümerwechsel. In einem kürzlich vom IFS untersuchten Fall war nach dem Tod eines Haus- eigentümers noch nicht geklärt, wer die Immobilie erben würde. In dem nicht beheizten Gebäude entstand im Dezember ein erheblicher Schaden. Wenn eine Immobilie längere Zeit nicht genutzt wird, sollten Heizun- gen und Trinkwasserinstallationen entleert werden. Oft erscheint diese Maßnahme der Schadenverhütung zu aufwendig. Dann sollte man das Schadenpotential immerhin begrenzen, und das gelingt mit einem Handgriff: „Durch das Zudrehen des Haupt- wasserhahns reduziert sich das Risiko, dass das Gebäude geradezu geflutet wird, auf einen ärgerlichen, aber lokal begrenzten Wasserschaden“, sagt IFS Gutachterin Dr. Meike Quitzau. Das ist auch in Sanierungsphasen einfach umzusetzen. Denn auch hier kommt es relativ häufig zu Frostschäden, wenn die Trinkwasserinstallation in Betrieb ist, aber die Heizung nicht oder nicht in allen Gebäudeteilen. Im vergangenen Winter trafen außer- dem überraschend niedrige Tempe- raturen auf hohe Energiepreise und knappe Ressourcen. Da ist der Wunsch zu Sparen nachvollziehbar. Dabei muss allerdings das Wetter berück- sichtigt und bei Frost die Beheizung angepasst oder die Immobilie ander- weitig frostsicher gemacht werden. Fotos: privat (4), IFS (4); 1 2 3 4

Herausgeber: Institut für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. Preetzer Straße 75, 24143 Kiel Tel. +49 (431) 775 78- 0 mail@ifs-ev.org www.ifs-ev.org Redaktion, Layout: Ina Schmiedeberg Tel. +49 (431) 775 78-10 schmiedeberg@ifs-ev.org Druck: Carius Druck Kiel GmbH Boninstraße 25, 24114 Kiel Tel. +49 (431) 624 46 Wenn Kaffeemaschinen wandern Für die Befestigung von Entwässerungsleitungen gibt es keine allgemeine technische Regel. Ein Grund mehr, sie im Auge zu behalten D urchfeuchtungsschaden in einem Restaurant: Wasser war unter den Tresen gelaufen und dort in den Fußboden eingedrungen. Die angrenzende Wand war von Schim- mel befallen. Das Wasser stammte aus der Abwasser- bzw. Überlaufleitung der Kaffeemaschine. Der Hersteller hatte das neue Gerät dort aufgestellt. Drei Monate später wurde durch einen Zufall der Schaden bemerkt. Man vermutete einen Installationsfehler. Zu der Kaffeemaschine hatte der Restaurantbetreiber vorab eine Planungsinformation bekommen: In die Arbeitsplatte, auf der das Gerät stehen sollte, musste eine Öffnung für die Zu- und Ablaufleitungen eingearbeitet und ein Trinkwasseranschluss bereitgestellt werden. Außerdem musste unter dem Aufstellplatz ein Trichtersiphon in die Abwasserleitung eingebaut werden. Diese Anweisungen wurden korrekt umgesetzt. Bei der Installa- tion wurde der geriffelte Abwasser- schlauch durch die Arbeitsplatte unter den Tresen geführt. Das Ende mündete lose in dem Trichtersiphon. Die Maschine funktionierte einwand- frei. Als jedoch ein Kühlschrank wegen einer Störung unter dem Tresen hervorgezogen wurde, entdeckte man, dass das Abwasser aus der Kaffee- maschine nicht in den Trichtersiphon, sondern daneben gelaufen war, und das offensichtlich schon eine ganze Weile. Allerdings hatte es diesen Fehler nicht von Anfang an gegeben, wie die Untersuchung zeigte. Die Maschine war irgendwann verschoben worden, weil man noch andere Dinge daneben stellen wollte. Dabei war der Ablauf- schlauch unbemerkt ein Stück heraus- gezogen worden. Beim Verschieben Die Kaffeemaschine und rechts der Blick unter den Tresen: Dort mündet der Abwasserschlauch in einem Trichtersiphon. hätte der Betreiber auf die Position des Schlauches achten müssen. Dieses Versäumnis wurde jedoch erst durch einen Montagefehler möglich: Der Schlauch hätte fixiert werden müssen, und zwar so, dass er nicht im Tichter- siphon endet, sondern darüber. Das ist aus hygienischen Gründen notwendig. Eine allgemeine technische Regel zur Ausführung und Befestigungen von Entwässerungsschläuchen gibt es nicht. Es ist üblich, dass die Her- steller in den Aufstell- und Montage- anleitungen Vorgaben zu den indivi- duellen Anforderungen machen. Der Hersteller hatte in diesem Fall sogar darauf hingewiesen, dass der Siphon und die Schläuche keinen Zugbe- lastungen ausgesetzt werden dürfen. Auf einer Abbildung war die Leitung oberhalb des Ablaufes fixiert, und das hätte den Schaden verhindert.

FD06000 ｜ 2023_德国_IFS_ifs_report_2023_2.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2023 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

• Jahrgang

Juni 2023 Eine Information des Institutes für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. M ehr als die Hälfte aller Brände in und an Gebäuden fallen in zwei Ursachenkategorien: Elektrizität und menschliches Fehl- verhalten. Daraus ergeben sich Chancen für die Schadenverhütung. Bei den Bränden durch menschliches Fehlverhalten fallen zahlreiche Küchen- brände auf, die entstehen, weil der Herd aus Versehen eingeschaltet wird, während etwas Brennbares auf dem Kochfeld liegt. Darum weisen wir immer wieder darauf hin, dass der Herd als Abstell- oder Arbeitsfläche tabu sein sollte. Brände durch den unachtsamen Umgang mit Zigarettenkippen bilden beim menschlichen Fehlverhalten einen weiteren Schwerpunkt. Beide genannten Brandursachen werden stark unterschätzt und als Risiko kaum wahr- genommen. Dabei sind es gerade diese scheinbar unspektakulären „Klassiker“, die unsere Feuerwehren auf Trab halten. Doch es gibt auch relativ neue Die Brandursachenstatistik 2002 - 2022. Alle IFS-Statistiken finden Sie unter www.ifs-ev.org/statistik Die häufigsten Brandursachen In der aktuellen IFS-Statistik zeigen sich klare Schwerpunkte bei den Brandrisiken Warum in Bauphasen oft Leitungswasserschäden entstehen ⟶ S. 3 Schadentrends, die sich in der Statistik deutlich zeigen. So haben Akkubrände mittlerweile einen erheblichen Anteil an den Schadenfeuern durch Elektrizi- tät. Grund ist nach Einschätzung des IFS vor allem die steigende Zahl der Geräte, die mit Lithium-Ionen-Akkus betrieben werden. Wegen der Brand- gefahr, die mit diesem Akkutyp ein- hergeht, ist es besonders wichtig, die Herstellerangaben bezüglich der Handhabung zu beachten und sichtbar beschädigte Akkus nicht zu benutzen. Bei den leitungsgebundenen Geräten gehört die sogenannte „weiße Ware“ zu den häufigsten Brandverursachern. Kühlschrank, Waschmaschine, Geschirr- spüler und Wäschetrockner stehen in nahezu jedem Haushalt und sind im Betrieb besonders starken Belastungen ausgesetzt. Brandauslösende Defekte sind im Vorfeld meist nicht erkennbar, und es gibt auch keine Möglichkeit, sie durch schadenverhütende Maßnahmen auszuschließen. Die Wahrscheinlich- keit für das Auftreten eines solchen Defektes lässt sich jedoch durchaus beeinflussen. So sollten zum Beispiel Kühlgeräte, die das Ende ihrer durch- schnittlichen Lebensdauer erreicht haben, beim Auftreten von technischen Problemen ausgetauscht werden. Für alle Elektrogeräte und -installa- tionen gilt: Leitungen dürfen nicht geknickt oder über scharfe Kanten geführt werden. Eine beschädigte Isolation führt zum Kurzschluss. Seit mehr als 20 Jahren erfasst das IFS alle untersuchten Schäden detail- liert für die statistische Auswertung. Anhand der Daten zeigen sich relevante Alltagsrisiken, Schadentrends und auch Serienfehler. Die Brandursachen- statistik hat sich zu einem zuverlässigen Kompass für die Schadenverhütung entwickelt. Alle IFS-Statistiken stehen der Öffentlichkeit frei zu Verfügung unter www.ifs-ev.org/statistik. Elektrizität Überhitzung Menschliches Fehlverhalten Offenes Feuer Selbstentzündung Feuergefährliche Arbeiten Brandstifung Explosion Sonstiges und unbekannt Brandursachen 32% 21% 9% 9% 3% 2% 3% 2% 19% 2 IFS-Report  2/2023 Schäden an Armaturen von Blanco Das IFS hat eine Reihe von Leitungswasserschäden mit gleicher Ursache untersucht E inige Monate nach dem Einbau einer neuer Küche kam es zum Wasserschaden in dem Wohnhaus. Die Ursache war schnell gefunden: Der drehbare Auslauf der Küchen- armatur war abgebrochen. Das defekte Bauteil wurde zur Ermittlung der Schadenursache an das IFS geschickt und war den Gutachtern dort nicht unbekannt: Das IFS hat bereits eine Reihe von ähnlichen Schadenfällen untersucht, bei denen es zu Brüchen an Küchenarmaturen der Serie „Blanco Antas HD“ gekommen ist. Die Labor- untersuchungen zeigen, dass mehrere Faktoren zu Spannungsrisskorrosion im Armaturengrundkörper führen: Der Messingwerkstoff weist eine erhöhte Härte auf, außerdem ist das Bauteil im Bruchbereich sehr dünn- wandig. Darüber hinaus gibt es bei den untersuchten Armaturen Werkzeug- spuren an einem Kartuschenhaltering, die auf einen unüblich hohen Kraftauf- wand bei der Endmontage im Werk des Herstellers hinweisen. Die genannten Faktoren können zu erhöhten Zug- spannungen im Armaturengrundkörper führen. Bei einem Messingbauteil, das mit Leitungswasser in Kontakt steht, sind damit alle Voraussetzungen für Spannungsrisskorrosion erfüllt. Die elektronenmikroskopische Untersuchung der Bruchflächen zeigt bei allen geschädigten Bau- teilen das charakteristische Bild dieser speziellen Korrosionsart. Alle betroffenen Armaturen, die das IFS untersucht hat, wurden laut Kenn- zeichnung im ersten und zweiten Quartal 2022 gefertigt. Bei fast allen handelt es sich um das eingangs erwähnte Modell Blanco Antas HD. Neue Gutachter für Hannover und Wiesbaden Thorsten Jeschke IFS Hannover Tel. 0511 8971822 - 50 tjeschke@ifs-ev.org Torben Deschauer IFS Wiesbaden Tel. 06127 921399 - 18 tdeschauer@ifs-ev.org Das IFS wächst weiter: Unser Team in Hannover freut sich über einen Spezialisten für elektrotechnische Untersuchungen. Thorsten Jeschke ist Diplom-Ingenieur für Mikrosystem- technik und bringt Berufserfahrung unter anderem aus der Raumfahrt mit. Für das IFS wird er Brandursachen ermitteln. Auch unseren Standort in Niedern- hausen bei Wiesbaden haben wir mit einem weiteren Gutachter verstärkt. Der Diplom-Chemiker Torben Deschauer geht dort den Ursachen von Bränden und Leitungswasser- schäden auf den Grund. Außerdem untersucht er Feuchte- und Schimmel- schäden. Die Armatur ist zwischen dem drehbaren Auslauf und dem Gehäuse für die Kartusche gebrochen. Die 7000-fach vergrößerte Bruchfläche (links) zeigt Strukturen von Spannungsrisskorrosion. Rechts sind Werkzeugspuren zu erkennen, die bei der Endmontage entstanden sind.

IFS-Report  2/2023 3 D ie Übergabe einer neu gebauten Seniorenwohnanlage stand kurz bevor, als ein umfangreicher Abwasserschaden den Zeitplan durch- kreuzte. Die Trinkwasserinstallation im Kellergeschoss des Gebäudes und die Hebeanlage, über die der Keller entwässert wurde, waren gerade in Betrieb genommen worden, als man eine Undichtigkeit an der Druck- leitung der Hebeanlage bemerkte. Um Reparaturarbeiten durchführen zu können, wurde die Anlage wieder außer Betrieb genommen. Früh am nächsten Morgen wurde der Scha- den festgestellt. Über Nacht waren 350 m3 Wasser aus einer geöffneten Wannenarmatur ausgetreten. Weil die Hebeanlage außer Betrieb war, konnte das Wasser nicht aus dem Gebäude geführt werden. Es staute sich in der Abwasserleitung, gelangte über die Bodenabläufe ins Gebäude und durchfeuchtete den Fußboden. Die Wannenarmatur funktionierte einwandfrei, wie das IFS feststellte. Irgendjemand hatte sie geöffnet und wahrscheinlich vergessen. Zu diesem Schaden konnte es kommen, weil die Trinkwasserinstallation in Betrieb war, während die Hebeanlage außer Betrieb war. Die Trinkwasserinstallation Betriebsbedingungen in Bauphasen Die Eigensicherheit von wasserführenden Installationen muss auch in Bauphasen gewährleistet sein. Dafür müssen die einzelnen Maßnahmen koordiniert werden Die Bilder illustrieren das zweite Schadenbeispiel: Der Thermostatkopf (roter Pfeil) wurde erst nach dem Schaden montiert. Vorher war auf dem Ventil nur eine zweiteilige Bauschutzkappe montiert (grüne Pfeile). Das rechte Bild zeigt den Stuck, der an dieser Stelle von der Decke fiel und die Kappe traf. Das Ventil wurde dabei geöffnet. ebenfalls abzusperren, wäre kein Problem gewesen, da das Gebäude noch nicht genutzt wurde. Ein Hand- griff hätte diesen Schaden verhindert. Doch die verschiedenen Maßnahmen wurden nicht abgestimmt. Die Bauleitung behält den Überblick In Bau- oder Umbauphasen ist es wichtig, den Überblick zu behalten. Wenn mehrere Handwerker oder sogar verschiedene Handwerksbetriebe in einem Objekt arbeiten, muss eine Bau- leitung alle Maßnahmen koordinieren. Diese Aufgabe obliegt entweder dem Eigentümer oder einer Bauleitung, die er beauftragt. Wichtig ist außerdem, dass die Betriebssicherheit auch wäh- rend der Bauphase gewährleistet ist, wie ein weiteres Beispiel verdeutlicht: Die umfangreiche Sanierung eines denkmalgeschützten Gebäudes zog sich über mehrere Jahre hin. Aus- gehend von einem Badezimmer im Obergeschoss kam es schließlich zu einem umfangreichen Wasserschaden. Das Badezimmer, die darunter liegen- de Küche und angrenzende Räume im Erdgeschoss waren wieder in den Rohbauzustand versetzt worden und die Trocknungsmaßnahmen liefen, als eine IFS-Gutachterin das Schaden- objekt untersuchte. Sie stieß auf ein einfaches Versäumnis und einen unglücklichen Treffer: Das Wasser war aus einem Heizkörperventil gelaufen. Der entsprechende Heizkörper im Badezimmer war zu diesem Zeit- punkt demontiert gewesen. Vor- und Rücklauf des Heizkörperanschlusses waren mit Pappringen und Klebe- band verschlossen worden, um sie vor Schmutz zu schützen. Das Ventil war lediglich mit einer provisorischen Bauschutzkappe verschlossen. Die Eigensicherheit gewährleisten Zu dem Schaden war es gekommen, als ein Stück Stuck von der Decke fiel. Der Stuck traf das Heizkörperventil, schlug die Bauschutzkappe ab, und das Ventil wurde dabei geöffnet. Nun konnte Wasser austreten, weil die Heizkörperanschlüsse nicht mit Blindkappen zugesetzt wurden. Der Schadenauslöser war hier ein unglück- licher Zufall. Die eigentliche Ursache war jedoch ein klares Versäumnis. Wenn ein Heizkörper bei laufender Heizung abgebaut wird, müssen die Anschlüsse mit Blindstopfen versehen werden, um die Eigensicherheit der Installation wieder herzustellen. Fotos: IFS (5), privat (2)

Herausgeber: Institut für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. Preetzer Straße 75, 24143 Kiel Tel. +49 (431) 775 78- 0 mail@ifs-ev.org www.ifs-ev.org Redaktion, Layout: Ina Schmiedeberg Tel. +49 (431) 775 78-10 schmiedeberg@ifs-ev.org Druck: Carius Druck Kiel GmbH Boninstraße 25, 24114 Kiel Tel. +49 (431) 624 46 B isher war es nur einem sehr begrenzten Personenkreis vorbehalten, die Situation an einer Schadenstelle zu betrachten. Die Fotodokumentation ist bei Ursachenermittlungen zwar Stan- dard, sie kann allerdings nur einen stark eingeschränkten Einblick geben. 3D-Scans bieten hier eine Vielzahl neuer Möglichkeiten. Mit einer Spezialkamera wird das Schadenobjekt aufgenommen. Im Abstand von einigen Metern werden 360°-Scans durchgeführt. Infrarot- sensoren nehmen die räumlichen Daten des Raumes und aller Gegenstände auf, die sich darin befinden. Es entsteht eine dreidimensionale Punktwolke, die die Basis ist für einen fotorealistischen Zwilling des aufgenommenen Objektes. Dieses digitale 3D-Modell ist eine maß- stabsgetreue Kopie des realen Raumes. Das IFS arbeitet bundesweit mit dieser Technologie, die zum Beispiel aus der Archäologie und dem Denkmalschutz bekannt ist und mittlerweile auch in der Immobilienwirtschaft gern eingesetzt wird. Im Zusammenhang mit Schaden- untersuchungen bietet sie eine ganze Reihe von Vorteilen. So können zum Beispiel komplexe Schadenbilder auch Laien verständlich erklärt werden. Doch auch für die Ursachenermittlung und die Beweissicherung ist die digitale Kopie des Schadenobjektes ein wert- volles Instrument. Bisher hatten in der Regel nur die Einsatzkräfte von Polizei und Feuerwehr und die ermittelnden 3D-Aufnahmen: IFS Nach einem Küchenbrand wurde die Schadenstelle gescannt. Der Brandausbruchsbereich kann virtuell betreten und aus unterschiedlichen Perspektiven betrachtet werden. Gutachter die Möglichkeit, sich an einer Schadenstelle umzusehen. Was bei diesen Ortsterminen nicht erkannt wurde, war später kaum noch nach- vollziehbar. Das virtuelle Modell ermög- licht es, das Schadenobjekt in dem Zustand, in dem es gescannt wurde, jederzeit wieder zu betreten, ohne dass weitere Ortstermine notwendig sind. Der digitale Zwilling ist immersiv, das heißt, der Betrachter kann in den detailliert erfassten Raum eintauchen. So können Schadenentstehungen und -abläufe rekapituliert und mit allen Beteiligten diskutiert werden. Die Daten ermöglichen es außer- dem, jederzeit Maße zu nehmen, da die Gebäudegeometrie maßstabs- getreu erfasst wird. Auch detaillierte Grundrisse stehen zur Verfügung. 3D-Aufnahmen an der Schadenstelle Der virtuelle Zwilling eines Schadenobjektes ist ein effektives Instrument der Ursachenermittlung und gewährt allen beteiligten Parteien Einblick in das Geschehen

FD06001 ｜ 2023_德国_IFS_ifs_report_2023_3.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2023 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

• Jahrgang

September 2023 Eine Information des Institutes für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. D ie mehrere hundert- oder tausendfache Vergrößerung einer Bruchfläche mit dem Elektronenmikroskop erzählt die Entstehungsgeschichte eines Leitungs- wasserschadens. Die gaschromato- graphische Analyse einer Brandschutt- probe belegt die Brandstiftung. Die meisten relevanten Informationen zum Geschehen verbergen sich im Schadenbild. Man muss sie nur finden und lesen können. Die beschriebenen Untersuchungsmethoden sind heute Standard im IFS. Derweil wachsen die technischen Möglichkeiten der Ursachenermittlung zusehends, und die interne, zum Teil staatlich geförderte Forschungsarbeit des Institutes gestaltet diese Entwicklung mit. Insbesondere der Bereich der Computer- simulation erweitert das Spektrum der vom Institut angebotenen Dienst- leistungen. Dazu zählten bisher vor Virtuelle 3D-Modelle erweitern die Möglichkeiten der Schadenbearbeitung und der Prävention. Wie wir in Zukunft Schäden verhindern Das IFS entwickelt neue Methoden für die Ursachenermittlung und Schadenprävention Viele Schäden der nächsten Monate können jetzt noch verhindert werden ⟶ S. 3 allem die Ursachenermittlung nach Brän- den und Leitungswasserschäden sowie die Beurteilung der daraus entstehenden Folgeschäden. Die 3D-Kameratechnik, mit der das IFS mittlerweile an der Schadenstelle arbeitet, ermöglicht es, weitergehende Fragen zu beantworten. Zum Beispiel: Wie hätte sich eine Brand- schutzmaßnahme oder die Einhaltung der Vorschriften auf einen bestimmten Schadenverlauf ausgewirkt? Einen kon- kreten Fall dazu finden Sie auf Seite 4. Die Simulationstechnik ergänzt nicht nur die klassische Ursachenermittlung um ein ressourcenschonendes Werk- zeug, sondern bietet darüber hinaus neue und wirtschaftliche Wege der Schadenprävention. Einmal erfasste Objektdaten stehen für Simulationen zu verschiedenen Fragestellungen zur Verfügung. Bereits vor einer potentiellen Schadenentstehung können wertvolle Informationen bereitgestellt werden. Im virtuellen Zwilling eines Gebäudes und im virtuellen 3D-Entwurf eines geplanten Gebäudes können auf Basis der Schadenerfahrung des IFS zum Beispiel realistische Brandszenarien und der Einfluss von Brandschutzmaß- nahmen durchgerechnet werden. So kann das Wissen aus der Ursachen- ermittlung in die Entwicklung optimaler Brandschutzkonzepte einfließen. Das Potential ist nicht auf den Bereich der Brandschäden beschränkt. Das IFS forscht auch zum Thema Frost- simulation. Auch hier können Risiken durch numerische Experimente auf neue Weise bewertet werden. Um die Methode zu verifizieren, werden in der Entwicklungsphase begleitend praktische Versuche zum Auskühlver- halten durchgeführt. Die vorgestellten Methoden werden vom IFS bereits eingesetzt. Parallel laufen Forschungs- projekte zur Weiterentwicklung. Matterport Frittierbecken war so niedrig gewesen, dass der Temperaturfühler nicht mit Öl bedeckt war. Er konnte demnach keine Überhitzung messen, und der Sicherheitstemperaturbegrenzer war dadurch ohne Funktion. Das Öl erreichte nicht einmal das Heizelement, sondern wurde von oben durch die Heizwendel erhitzt. Es kam zu einer starken Rauchentwicklung und schließ- lich zum Entzünden des Frittierfettes. Bevor Öl in Brand gerät, bildet sich schwarzer Rauch. Das ist die letzte Chance, einen Brand zu verhindern. Wäre der Restaurantbetreiber in der Nähe des Gerätes gewesen, hätte er eingreifen und die Fritteuse aus- schalten können. In den einschlägigen Regelwerken ist klar formuliert, dass Fritteusen, Fettbackgeräte und Woks im eingeschalteten Zustand nicht ohne Aufsicht betrieben werden dürfen. 2 IFS-Report  3/2023 A lle Werkstoffe haben Vor- und Nachteile. Um Schäden zu vermeiden, muss man die Schwächen von Materialien kennen und berücksichtigen. Polyphenylsulfon, kurz PPSU, gilt als Hochleistungswerkstoff, der hygienisch unbedenkliche Lösungen für die Trinkwasserinstallation bietet. Der Kunstsoff ist mechanisch sehr belastbar. Die chemische Beständig- keit, die dem Werkstoff zugeschrieben wird, hat allerdings Grenzen, die bei der Installation leicht überschritten werden können, wie eine Reihe von Leitungswasserschäden zeigen, die vom IFS untersucht wurden. Ein Beispiel: In einem neu gebauten Einfamilien- haus kam es knapp zwei Jahre nach der Inbetriebnahme der Trinkwasser- installation zu einem umfangreichen Wasserschaden durch ein undichtes T-Stück. Auf dem Bauteil befanden sich Reste von Montageschaum, und die Laboruntersuchung belegte, dass chemische Schädigungen zu Rissen im Werkstoff geführt hatten. Der Hersteller weist in seinen Montage- vorgaben darauf hin, PPSU-Fittings mit einer Umhüllung vor dem Kontakt mit Montageschäumen zu schützen und empfiehlt ein Schutzband aus der eigenen Produktpalette. In der Regel werden die Anfälligkeiten von Bau- teilen bzw. die sich daraus ergebenden Besonderheiten bei der Installation in den Herstellervorgaben beschrieben. Im Fall von PPSU empfehlen Hersteller neben dem Kontakt mit Montage- schäumen auch den Kontakt mit Mauerwerk, Zement, Gips, Schmutz und Bohrstaub zu vermeiden. Die weißen Ablagerungen auf dem T-Stück sind Reste von Montageschaum, der in diesem Fall Risse im Werkstoff verursacht hat. Gefährliche Bedienfehler Fritteusen dürfen nicht unbeaufsichtigt betrieben werden Z u den Geräten, die in den Asservatenkammern des IFS häufig zu finden sind, zählen Profi-Fritteusen aus Gastronomie- betrieben. Häufig führen Bedienfehler zu Bränden und auch zu schweren Verletzungen des Personals, denn Fettbrände sind besonders gefähr- lich. Ein Beispiel: Wie jeden Morgen schaltete ein Restaurantbetreiber die Fritteuse in seiner Küche ein. Das Gerät befand sich im von außen einsehbaren Bereich des Straßenverkaufs hinter einer Glasscheibe. Anschließend ging er in die Vorbereitungsküche, um Gemüse zu schneiden. Ein heftiges Klopfen an der Scheibe rief ihn wieder nach vorn zum Straßenverkauf. Ein Passant hatte Flammen gesehen und versuchte, das Küchenpersonal zu warnen. Zu diesem Zeitpunkt war die Rauchentwicklung bereits so stark, dass eigene Löschversuche nicht mehr in Frage kamen. Der Betreiber konnte sich noch ins Freie retten, und die Feuerwehr musste übernehmen. Der Brand war vom rechten der beiden Frittierbecken ausgegangen, stellte ein IFS-Gutachter später bei der Ursachenermittlung fest. Zwei Bedienfehler hatten zu den umfang- reichen Schäden in dem Restaurant geführt: Der Füllstand im rechten Die Werkstoffeigenschaften beachten Bauteile aus PPSU werden beim Kontakt mit Montageschaum chemisch angegriffen

IFS-Report  3/2023 3 D ie Tage werden merklich kürzer, die Nächte spürbar frischer. In der ersten Frostperiode der kommenden kalten Monate wird es zahlreiche Schäden an wasserführenden Installationen geben. Das geschieht auch in vergleichsweise milden Wintern. 2022 war nach Auskunft des DWD eines der wärmsten Jahre seit Beginn der Wetteraufzeichnungen, und noch am 31. Oktober wurde ein Sommertag gemessen. Zugleich begann die „Frost- saison“ für das IFS im Dezember mit einer unerwartet frühen und intensiven Phase, in der es bundesweit zu über- durchschnittlich vielen Schäden kam. Frostschäden entstehen meist in nicht oder nicht durchgehend genutzten Gebäuden. Vorsicht ist darum besonders bei Eigentümerwechseln oder in Sanierungsphasen geboten. Doch auch in Ferien- und Zweit- wohnungen stößt das IFS häufig auf die charakteristischen Schadenbilder, die Diese Schäden sind vermeidbar Der Herbst ist eine gute Zeit, um Immobilien auf die erste Frostperiode vorzubereiten durch das Einfrieren von Rohrleitungen entstehen. Ein Beispiel: Der Erbe eines Einfamilienhauses pendelte wegen sei- ner relativ weit entfernten Arbeitsstelle zwischen seiner bisherigen Wohnung und dem Haus, das er bald als Allein- wohnsitz beziehen wollte. Während sei- ner Abwesenheit kam es dort zu einem umfangreichen Wasserschaden. Die Immobilie sei durchgehend beheizt und nie eine volle Woche unbeaufsichtigt gewesen, erklärte er der IFS-Gutachte- rin, die die Schadenursache ermitteln sollte. Wasser war vom Obergeschoss durch das gesamte Gebäude gelaufen, und es gab typische Schadenbilder an diversen Stellen im Gebäude: Eine Spültischarmatur aus der Küche im Obergeschoss und eine Duscharmatur aus einem Badezimmer im Erdgeschoss waren durch einen starken Innendruck gebrochen. Auch an der Heizungs- installation gab es an verschiedenen Stellen Schäden durch einen starken Druckanstieg; mehrere Heizkörper waren aufgefroren. Das Gebäude war während der Frostperiode im Dezember nicht oder nicht ausreichend beheizt. Hier liegen die Schwachstellen Frostschäden können zuverlässig verhindert werden. Wird ein Gebäude absehbar längere Zeit nicht genutzt, sollten wasserführende Installationen außer Betrieb genommen und die Leitungen entleert werden. Schon das Absperren der Wasserzufuhr begrenzt immerhin einen möglichen Schaden auf die Wassermenge, die sich noch in den Leitungen befindet. Alle anderen Immobilien müssen durch ausreichende Beheizung geschützt werden. Was ausreichend ist, muss allerdings individuell beurteilt wer- den und ist zum Beispiel von der Wärmedämmung und dem Verlauf der wasserführenden Leitungen abhängig. Auch die Nutzung ist in diesem Zusammenhang relevant. Wenn Entnahmestellen regelmäßig genutzt werden, ist die Wahrscheinlichkeit eines Frostschadens wesentlich gerin- ger. Vorsicht ist also schon bei einem Winterurlaub geboten oder wenn zum Beispiel Bewohner ausziehen und Teile des Hauses unbewohnt sind. Auch eine neue Heizung, die effizienter arbeitet und weniger Abwärme pro- duziert, kann bedeuten, dass nun der Dachboden, auf dem sie aufgestellt ist, anders beheizt werden muss. Eine Kleinigkeit, die oft vergessen wird und zu Frostschäden an der Wasser- installation führen kann, ist der Außen- wasserhahn. Frostsichere Modelle entleeren sich automatisch, allerdings nur, wenn kein Gartenschlauch oder eine Schlauchtülle angeschossen ist. Wo mögliche Schwachstellen liegen und ob eine Immobilie fit ist für die kalte Jahreszeit, kann jeder kosten- frei und einfach prüfen: www.ifs-ev.org/wintercheck Fotos: IFS In dem Einfamilienhaus fand das IFS typische Frostschadenbilder: eine auseinandergedrückte Verbindung, eine gebrochene Armatur und ein aufgefrorener Heizkörper.

Herausgeber: Institut für Schadenverhütung und Schadenforschung der öffentlichen Versicherer e.V. Preetzer Straße 75, 24143 Kiel Tel. +49 431 775 78  0 mail@ifs-ev.org www.ifs-ev.org Redaktion, Layout: Ina Schmiedeberg Tel. +49 431 775 78 10 schmiedeberg@ifs-ev.org Druck: Carius Druck Kiel GmbH Boninstraße 25, 24114 Kiel Tel. +49 431 624 46 Rauchmelder retten Leben Computersimulationen belegen den Einfluss auf das Zeitfenster für die Selbstrettung im Brandfall A m Düsseldorfer Flughafen verursachten Schweißarbeiten am 11. April 1996 einen Schwel- brand in der Zwischendecke über der Ankunftsebene des Terminals A. 16 Men- schen erstickten an toxischen Rauch- gasen; ein weiteres Opfer erlag Wochen später seinen Verletzungen. Eine Folge dieser Katastrophe war die Einführung der Musterbauordnung im Jahre 2002. Sie gilt als Wendepunkt im Bereich des Brandschutzes. Die neueste Fassung, die 2022 veröffentlicht wurde, enthält erst- mals die Rauchwarnmelderpflicht für Schlafzimmer, Kinderzimmer und Flure, die zu Aufenthaltsräumen führen. Seit diesem Jahr ist die Rauchwarnmelder­ pflicht außerdem Teil aller Landesbau- ordnungen. Das IFS begrüßt diese Ent- wicklung. Rauchmelder retten Leben; die Brandsimulation untermauert diese These mit Daten. Ein Beispiel: In einer Einrichtung für betreutes Wohnen kam es nachts zu einem Schwelbrand an der Matratze eines Pflegebettes. Ein Rauchwarnmelder war zwar vor- handen, aber nicht korrekt platziert, so dass er den Brandausbruchsbereich nicht überwachen konnte. Außerdem gab es für die gesamte Wohneinheit nur einen einzigen Rauchwarnmelder. Als der Bewohner des Nebenzimmers durch den verspäteten Alarm und Brandgeräusche auf das Geschehen auf- merksam wurde, war die Rauchgasent- wicklung bereits so stark, dass er nicht mehr helfen konnte. Die betroffene, pflegebedürftige Person kam ums Leben; die übrigen Bewohner konnten sich retten. Hätte die vorschriftsmäßige Foto stock.adobe.com Alle Bundesländer haben mittlerweile die Rauchmelderpflicht für Neu- und Bestandsgebäude in die Landesbauordnung aufgenommen. Ausstattung der Wohnung mit Rauch- warnmeldern die Tragödie verhindert? Bei Bränden in bewohnten oder von Menschen genutzten Gebäuden ist der entscheidende Faktor, wie viel Zeit für die Rettung bzw. Selbstrettung bleibt. Das IFS hat im beschriebenen Fall nicht nur die Brandursachen- ermittlung, sondern auch eine Computersimulation durchgeführt: Wäre im Pflegezimmer ein Rauchwarn- melder korrekt angebracht gewesen, hätte er den Bewohner wenige Minuten nach der Brandentstehung geweckt. Funkvernetzte Rauchwarn- melder hätten zugleich die anderen Bewohner alarmiert und ihnen Zeit gegeben, der in ihrer Mobilität ein- geschränkten Person zu helfen. Schon die Einhaltung der Mindest- anforderungen der Landesbauordnung hätte hier ein Leben gerettet. Rauch- warnmelder vergrößern im Brandfall das Fluchtfenster. Beim Alarm bleiben durchschnittlich 120 Sekunden, um sich in Sicherheit zu bringen. Doch dieser Wert variiert stark, abhängig von der Brandentwicklung. Leit- parameter sind die Sichtweite, die Kohlenmonoxidkonzentration und die Temperatur. Pflegebedürftige Men- schen oder solche mit invididuellen Einschränkungen, deren Fähigkeit zur Selbstrettung beeinträchtigt sind, sind in besonderer Weise betroffen. Bei den bundesweiten Aktionen zum Rauch- meldertag am Freitag, 13. Oktober, wird darum dieses Jahr die Brandprä- vention für Senioren und Personen mit Einschränkungen im Mittelpunkt stehen. Informationen zur Rauch- melderpflicht, zur Installation und Wartung gibt es auf der Internetseite www.rauchmelder-lebensretter.de.

FD06002 ｜ 1942_美国国家消防协会_椰林_夜总会火灾调查报告（英文）.md

分类：06_境外及港澳台调查报告 ｜ 年份：1942 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因：燃气/爆炸;电气 ｜ 来源格式：md

一、基本情况

1942年11月28日，美国波士顿Cocoanut Grove夜总会发生火灾，造成492人死亡，是美国历史上最致命的夜总会火灾。当晚场内约聚集1,000人。

二、起火原因

起火点位于地下室Melody Lounge一处装饰性盆栽附近，具体点火源未最终确定，理论包括服务员火柴、电气故障，以及当时因战时氟利昂短缺而使用的甲基氯制冷剂泄漏。火灾以“违反常理”的速度沿吊顶与楼梯迅速蔓延至主层，木质家具、棕榈树等部分可燃物反而未燃尽。

三、责任与致灾因素

• 主入口为旋转门，人群涌出时卡死，大量遗体被发现于门口；
• 几乎所有出口都存在功能性缺陷；
• 严重超员；
• 内部装修可燃、火灾早期蔓延极快。

四、整改与教训

火灾直接推动建筑规范大修：出口、可燃材料、应急照明、自动喷淋等方面全面加严；夜总会等被明确归类为人员聚集场所；医疗领域也随之进步（烧伤治疗由鞣酸法改为纱布包扎，输血与呼吸管理改善）。该火灾成为后世研究人员行为与出口设计的经典案例。

FD06003 ｜ 1980_美国国家消防协会_酒店火灾调查报告（英文）.md

分类：06_境外及港澳台调查报告 ｜ 年份：1980 ｜ 地域： ｜ 严重程度： ｜ 场所：餐饮/酒店 ｜ 起火原因： ｜ 来源格式：md

一、基本情况

1980年7月26日深夜，美国一家酒店发生火灾。楼内当时共38人，其中24人遇难。住客多为认知障碍者或老年人。

二、起火原因

火灾很可能由接地故障引起：未接地导线接触AC铠装电缆的的金属外皮，引燃隐蔽空间（concealed space）内的可燃物，导致火情被发现前已延烧、延误人员察觉。

三、责任与致灾因素

• 缺乏早期预警探测系统，火在隐蔽空间阴燃后方被发觉；
• 二层、三层缺少第二逃生出口；
• 客房门上的百叶（louvers）使烟气渗入房间，扩大伤亡。

四、整改与教训

NFPA对此事件的调查指出：人员聚集住宿场所须配置早期火灾探测、保证至少两条独立逃生路径、并消除可能导致烟气横向蔓延的客房门构造缺陷（如百叶），尤其当住客为行动/认知受限人群时更须强化被动与主动防火措施。

FD06004 ｜ 1981_美国国家消防协会_住宅酒店火灾调查报告（英文）.md

分类：06_境外及港澳台调查报告 ｜ 年份：1981 ｜ 地域： ｜ 严重程度： ｜ 场所：住宅/民房;餐饮/酒店 ｜ 起火原因： ｜ 来源格式：md

一、基本情况

1981年3月14日凌晨，美国一栋4层住宅酒店（residential hotel）一层洗衣房区域起火，火势蔓至相邻楼梯间，困住楼内62名住客中的多人。火灾造成19名住客死亡，并导致建筑主体大面积坍塌。

二、起火与蔓延原因

起火于一层的洗衣房区域，并迅速侵入楼梯间。建筑结构缺陷既是火势蔓延也是伤亡放大的主因。

三、责任与致灾因素

• 危险区域（如洗衣房）缺乏适当防火保护；
• 走廊隔墙被楼板搁栅穿透，破坏防火分隔；
• 楼梯间未正确封闭；
• 楼梯构造可燃；
• 个别住户房间虽配独立电池烟感，但灾后检查发现部分探测器未装电池。

四、整改与教训

报告提示住宅型旅宿建筑须保证危险区域防火分隔、走廊与楼梯间完整封闭、采用不燃楼梯构造，并确保探测报警系统（含电池）始终有效；此类建筑应纳入更严格的消防设计与检查。

FD06005 ｜ 1991_US_NIST_NISTIR7179_WUI_Fire_Spread.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1991 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

NISTIR 7179

Physics-Based Modeling for WUI Fire Spread – Simplified Model Algorithm for Ignition of Structures by Burning Vegetation

David D. Evans Ronald G. Rehm Elisa S. Baker

Supported in part by funds provided by Pacific Southwest Research Station Forest Service U.S. Department of Agriculture

ii

NISTIR 7179

Physics-Based Modeling for WUI Fire Spread – Simplified Model Algorithm for Ignition of Structures by Burning Vegetation

David D. Evans Ronald G. Rehm Elisa S. Baker

Fire Research Division Building and Fire Research Laboratory National Institute of Standards and Technology Gaithersburg, MD 20899

October 2004

U.S. Department of Commerce Donald L. Evans, Secretary Technology Administration Phillip J. Bond, Under Secretary for Technology National Institute of Standards and Technology Arden L. Bement, Jr., Director U.S. Department of Agriculture Ann M. Veneman, Secretary Forest Service Dale N. Bosworth, Chief Pacific Southwest Research Station James Sedell, Director

ii

iii TABLE OF CONTENTS LIST OF FIGURES....................................................................................................................................IV LIST OF TABLES......................................................................................................................................IV 1.0 ABSTRACT ........................................................................................................................................... 1 2.0 INTRODUCTION................................................................................................................................. 1 3.0 BACKGROUND.................................................................................................................................... 2 3.1 PREVIOUS MODELING OF WILDLAND FUELS AND FIRES ............................................... 3 3.2 PREVIOUS MODELING OF WUI FIRES.................................................................................... 4 3.3 NIST RESEARCH CONTRIBUTION ............................................................................................ 4 4.0 BURNING CHARACTERISTICS OF DOUGLAS-FIR TREES ..................................................... 5 4.1 Experiments………………………………………………………………………………………....5 4.1.1 Tree Preparation.......................................................................................................................... 5 4.1.2 Large Fire Laboratory................................................................................................................. 7 4.1.3 Instrumentation............................................................................................................................ 7 4.2 MEASUREMENTS ........................................................................................................................... 8 4.2.1 Flame Heights............................................................................................................................ 11 4.2.2 Heat Release Rate and Mass Loss ............................................................................................. 12 4.2.3 Other Measurements................................................................................................................. 13 4.3 ANALYSIS....................................................................................................................................... 13 4.3.1 Flame Height ............................................................................................................................ 13 4.3.2 Heat Release Rate...................................................................................................................... 14 5.0 IGNITION OF STRUCTURES ALGORITHM FOR ECOSMART.............................................. 16 5.1 SIMPLE ALGORITHM FOR STRUCTURE IGNITION BY BURNING LANDSCAPE TREES.................................................................................................................................................... 17 5.1.1 Burnable Mass of the Tree......................................................................................................... 18 5.1.2 Flame Height ............................................................................................................................ 18 5.1.3 Peak Heat Release Rate............................................................................................................ 18 5.1.4 Radiative Fraction ..................................................................................................................... 19 5.1.5 Radiative Heat Flux ................................................................................................................... 19 5.1.6 Ignition Criteria......................................................................................................................... 19 6.0 IMPLEMENTATION OF THE ALGORITHM IN ECOSMART .................................................. 19 7.0 MODELING COMPLEX PHENOMENA........................................................................................ 20 8.0 RESEARCH NEEDS TO ADVANCE THE DEVELOPMENT OF PHYSICS-BASED MODELS FOR WUI AND RESIDENTIAL HOUSING COMMUNITY FIRES................................................... 22 9.0 NIST FIRE DYNAMIC SIMULATOR AND SMOKEVIEW MODELS ..................................... 22 10.0 ACKNOWLEDGEMENTS............................................................................................................... 23 11.0 REFERENCES ................................................................................................................................... 24 APPENDIX A………………………………………………………………………………………………29ERROR! BOOKMARK NOT DEFINED.

iv LIST OF FIGURES Figure 1 Crown height ....................................................................................................... 6 9Figure 2a. Pictures every 5 s of the Douglas-Fir-Tree Burns starting from the application of the igniter until 55 s after that…………………………………………………………..9 Figure 2b. Pictures of the Douglas-Fir-Tree Burns for times between 60 s and 110 s after application of the igniter…………………………………………………………………10 10Figure 3 Flame height.................................................................................................. 11 Figure 4 HRR as a function of time................................................................................. 12 Figure 5 Flame height data………………………………………………………………1313 Figure 6 Heat release rate curves aligned at their peak values ........................................ 14 Figure 7 Triangle approximation for the heat release rate of Douglas-fir crown fires..... 15 Figure 8 – Peak heat release rate from Douglas-fir trees as a function of moisture and mass........................................................................................................................... 16 Figure 9 Three caricatures of a house representing different levels of complexity for mathematical models ............................................................................................... 21

LIST OF TABLES

Table 1 Douglas-fir tree identifications and physical measurements ................................ 7 Table 2 Flame heights.................................................................................................. 1111 Table 3 Measured peak heat release rate and burned weight loss for tree....................... 12 Table 4 Tree height and flame height data....................................................................... 14

Physics-Based Modeling for WUI Fire Spread – Simplified Model Algorithm for Ignition of Structures by Burning Vegetation

David D. Evans, Ronald G. Rehm, and Elisa S. Baker Building and Fire Research Laboratory National Institute of Standards and Technology

1. 0 ABSTRACT

A simple physics-based mathematical algorithm is described for estimating the separation distances necessary to prevent radiative ignition of structures by burning vegetation. The algorithm is directed at use in applications such as the USDA Forest Service EcoSmart software suite of tools. The algorithm represents a first step in quantifying the fire spread phenomena involving both structures and vegetation typical of wildland-urban interface (WUI) areas and residential housing communities. Results of initial experiments to characterize the heat release rate (HRR), flame height, and duration of burning for individual Douglas-fir trees are provided. In addition, research required to understand better and quantify wildland-urban and residential community fires are discussed.

1. 0 INTRODUCTION

The Center for Urban Forest Research, the Pacific Southwest Research Center of the U.S. Department of Agriculture (USDA) Forest Service, together with other partners, is developing a web-based suite of software tools, called EcoSmart. EcoSmart is being developed for use by individual homeowners to provide guidance in assessing the contributions of landscape vegetation to home energy conservation, land hydrology, and fire spread. EcoSmart provides means to quantify the advantages and disadvantages of landscape vegetation relative to the costs.

As a partner in this effort, with partial support from the Pacific Southwest Research Station, the Fire Research Division of the Building and Fire Research Laboratory of the National Institute of Standards and Technology (NIST) developed a simple physics-based mathematical model for estimating whether a structure will be ignited by nearby tree crown fires. This model quantifies the burning of vegetation in a manner that has not been done before. The model developed treats each tree, shrub, and house as an individual fuel element. In order to predict fire spread from burning fuel elements by ignition of other fuel elements, the ignition and burning characteristics of each fuel element and the interactions between elements has to be defined or determined. This creates a need for ignition and burning data that has not been generally measured before for vegetation and structures. With this data and appropriate models, the importance of individual fuel elements in fire propagation can be assessed. Resolving individual fuel elements in a model is necessary in order to properly evaluate the WUI and residential

2 housing community fires. In these areas, structures are an important asset to be protected from fire, but can be an important source of fire spread if ignited. Fire spread in the WUI or residential housing communities cannot be characterized using the methods based on fuel bed classifications that are used widely to analyze the movement of fire fronts in forest fires. Regarding each structure as a fuel element, its likely fate in a fire can only be determined by examining its possible interactions with surrounding fuel elements that can, if burning, threaten the structure. The algorithm developed in this study is the first step in creating the foundation for a new method to analyze fire threat in WUI areas and residential communities.

Version 1.0 of the fire algorithm developed by NIST is available for and compatible with the level of detail in other portions of the EcoSmart software under development. The algorithm documented in this report represents a first step in quantifying fire spread phenomena involving both structures and vegetation typical of wildland-urban areas and residential community properties. The report provides new data on HRR, flame height, and duration of burning for individual Douglas-fir trees. In addition, it also contains a discussion of research necessary to better understand and quantify wildland-urban and residential community fire spread.

1. 0 BACKGROUND

The development of the EcoSmart suite of software tools began at the U.S. Department of Agriculture Forest Service, Pacific Southwest Research Station in 2002. There was a need to develop an algorithm that accounted for the increased risk for home destruction by fire due to the placement of trees and other ignitable vegetation close to the structure. This factor was in opposition to the benefits these plantings may have for energy conservation and soil hydrology. Development of the EcoSmart software suite of tools was undertaken to allow property owners to evaluate advantages and disadvantages, including fire safety and economics, of planting landscaping vegetation around homes.

NIST was asked by the Pacific Southwest Research Station to develop a physics-based algorithm for ignition of structures by landscape vegetation that could be programmed into the EcoSmart suite of software tools and would be consistent with level of information and desired speed of operation of all the other parts of EcoSmart. Very little information was found in the literature that could be used to construct a physics-based model for ignition of structures by burning vegetation of the type and arrangement that would be present on landscaped properties. Principally, there was a lack of data on burning characteristics for individual trees and shrubs.

Fire is an extremely complex natural phenomenon [1-10]. Decades of research to understand and quantify fire, together with revolutionary advances in computer technology and computational algorithms, have lead to the development of sophisticated mathematical models that can predict and visualize growth and spread of fire under a variety of conditions [11–16]. However, these models generally require substantial computational and data resources. Furthermore, since they have not been oriented toward

3 the prediction of WUI or residential community fires, they will not soon be available for application by end users without a substantial research investment over the next few years.

1. 1 PREVIOUS MODELING OF WILDLAND FUELS AND FIRES

Fires in the western U.S. have been headlines in the news for several recent years. Changes in the management of forested lands, the increasing intrusion of man into more remote areas and the cyclic dry periods produced by El Nino - La Nina have all increased the loss of man-made structures to fires. Wildland fires now often spread into the built environment causing injury, death and property damage. Concern about wildland fires and their effects on man and the built environment has generated increased interest recently, e.g., Livingston [17], Keller [18], Platt [19]. While the need to address fire spread in a mixed environment, containing both structures and wildland fuels, has been acknowledged, most research has continued to focus on wildland fires. Operational models that predict fire spread in wildland fuels are well developed and widely used, but do not yet address WUI fires.

For over thirty years, modeling of fire dynamics in wildland fuels has been an ongoing research and development activity [20-26]. It has lead to practical or “operational” models that are regularly used by land managers to predict fire growth and spread for both planned or “controlled” burns and unexpected wildland fires. These operational models have served land managers and firefighters well both for planning controlled burns and suppression of wildfires. In the United States, the mathematical models BEHAVE [11] and FARSITE [12] are two of the most widely used operational models.

Both are based upon the pioneering research of Rothermal [20, 21], who developed the framework for these models and determined many of the empirical relations used by it. In these models, wildland fuels are characterized by 13 standard fire behavior fuel types. These fuel characterizations and their behavior in wildland fires is the subject of several of the books cited above: Chandler et al [1], Chandler et al [2], Luke and McArthur [3], Pyne et al [4], and Brown and Davis [5] lists the 13 types and their characteristics.

The basic model regards all of the fuel to cover the land surface as though it were “painted” on; i.e., all of the combustible material resides in fuel beds that have no vertical extent, but are strictly two dimensional. Fire then spreads over these fuel beds as a contour which divides unburned fuel from burned fuel or combustion products. Fuel beds can be homogeneous or inhomogeneous, isotropic or anisotropic, and they can be composed of a single fuel type or a combination of fuel types. Furthermore, the land surface may be flat or may have significant topographical features, and all of these variations make for differences in how the fire line progresses.

Inclusion of improved descriptions of the physics in these models has progressed slowly in recent years and has not taken advantage of the revolution in computer hardware, and computational algorithms and software that has occurred over this same time frame.

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By comparison, over the past few decades, many of the physical and chemical processes occurring in fires have become much better understood, and physics-based mathematical and computational models have been developed to take advantage of this improved understanding. One such example is the work of Clark [27] and colleagues in which the coupling between large-scale wildland fires and the atmosphere has been studied. Another is modeling of the growth and spread of fires in structures, which has advanced dramatically using the methods of computational fluid dynamics (CFD) and, more generally, mathematical and computational methods that may be described as computational mechanics and computational combustion [28-31].

For models of combustion, the usual length scales of interest are measured in very small fractions of a meter (millimeters or less) to meters. Alternately, for problems related to computational mechanics or CFD, the length scales of interest can vary between meters and tens or even hundreds of meters. These scales should be contrasted with models for wildland fires, where the lengths are measured in kilometers or even hundreds of kilometers.

1. 2 PREVIOUS MODELING OF WUI FIRES

Very little progress has been made on understanding and predicting fire spread at the Wildland-Urban Interface (WUI), where both wildland fuels and man-made structures coexist. At the WUI, the length scales are intermediate to the wildland scales on the one hand and to those associated with individual structures on the other. As a result, a model for a WUI fire must describe individual structures and trees in some detail, and must be able to determine fire spread between these individual fuel sources, a much more challenging task! One of the few studies to attack this very difficult problem is the work of Maranghides [32], who concluded that there was an extreme lack of relevant data.

J. D. Cohen [33, 34] advocates the concept of a Home Ignition Zone, defined as the home and its surrounding area where heat transfer by radiation and/or convection from burning vegetation can ignite it. He is developing a model called the Structure Ignition Assessment Model (SIAM) to quantify this concept, which is being recognized as relevant to homeowners and firefighters. The model estimates conditions for home ignition. Once a home ignites in the calculation, it is considered lost. SIAM does not address the contribution of the burning structure to subsequent fire spread in the area. It therefore has limited application in the WUI, especially in cases of housing developments, where homes may be located within the Home Ignition Zone of its neighbors.

1. 3 NIST RESEARCH CONTRIBUTION

In order to understand better the burning of landscape trees, a series of burns was performed in the NIST large fire facility to measure the burning characteristics of individual Douglas-fir trees. The measured burning characteristics of the trees were used

5 as a basis for the construction of the algorithm for ignition of structures by burning vegetation.

During this research, three papers were prepared that provide background and discussion of fire spread in the wildland-urban interface and in residential housing communities [35- 37]. In recent WUI fire disasters, visual evidence suggests that fully involved burning houses contribute to fire spread and destruction. Examples are given to show that the long-duration and high-intensity burning of a structure can contribute to altering the fire- generated winds [36]. In addition, early implementations of the structure ignition algorithm in EcoSmart are illustrated [35].

1. 0 BURNING CHARACTERISTICS OF DOUGLAS-FIR TREES

Although landscaping trees and shrubs, if ignited, can endanger near-by structures, very little quantitative information exists about ignition and burning characteristics of landscape vegetation. Generally, experiments carried out to measure the HRR of trees have been conducted to assess the hazards of Christmas tree fires [38-40]. No information has been found to quantify how the HRR, burn duration, and flame height vary with the size of a tree or tree species. Two studies were found in which the burning characteristics of shrubs were measured [41, 42].

Previously, the HRR of dry Scotch Pine trees was measured using the instrumented hood in the Large Fire Laboratory at NIST [38]. However, the study included only one size tree. The same is true for the study of Douglas-fir tree burning carried out by Babrauskas [39]. To take advantage of existing data, in this study we continued to burn cut Douglas- fir trees. Three different commercial sizes were selected for the experiments. The height of the trees was limited by the HRR capacity of the Large Fire Laboratory exhaust hood. The tree burns provided important data for the algorithm development. Further experiments are needed to fully understand the burning characteristics. Data obtained from the burns provided information for the development of the algorithm that was not available from any other source.

1. 1 EXPERIMENTS

Prior to burning, the cut trees were allowed to dry for 17 days as discussed below. All tree burns were conducted during a single week in the Large Fire Laboratory. This included time needed for instrument set-up and mounting each tree for burning. During each burn, the HRR, mass loss, flame height, vertical temperature profiles and radiant heat flux emitted from the fire were measured.

1. 1.1 Tree Preparation

The Douglas-fir trees were purchased from a local nursery that grows Christmas trees. Three trees each with commercial sale heights of 1.2 m, 2.4 m, and 3.7 m (4 ft, 8 ft, and 12 ft) were cut on July 6, 2003. These trees were delivered to NIST the following day and weighed. As the trees are a large fuel load, for fire safety considerations, the trees

6 were dried on racks outside the Large Fire Laboratory. The racks were covered by tarps to shield the trees from rain. After 10 days, the trees were brought inside and weighed again to monitor the moisture lost to evaporation. Some of the trees had the base of the trunks trimmed to create a flat base for mounting on a stand that supported the tree upright for burning.

The trees were photographed and heights were measured (see Table 1). The crown height is the height from the bole (height of the first live branches) to the top branch as shown in Figure 1. This differs from the commercial height of the tree which is measured from the base to the tip of the stem. The crown height best represents the burnable fuel height by eliminating the top of the stem and base of the tree up to the bole height. The stem needle growth on the test Douglas-fir trees that was eliminated from the burnable mass by this definition extend 0.3 m above the highest branch in some cases, but only added a small amount to the burnable fuel mass.

Figure 1 Crown height

7 Tree

Test No. Crown Height (m) Bole Height (m) Total Height (m) Weight 7/7/03 (kg) Weight 7/17/03 (kg) Weight Pre-burn (kg) Weight Pre-burn Initial (7/7/03) 4-1 Test 1 1.37 0.08 1.45 5.16 3.014 2.85 0.55 4-2 Test 4 1.30 0.19 1.49 3.54 1.607 1.549 0.44 4-3 Test 7 1.42 0.22 1.64 8.4 4.515 4.372 0.52 8-1 Test 2 2.31 0.27 2.58 23.11 17.597 17.597 0.76 8-2 Test 5 2.62 0.43 3.05 24.4 18.103 17.637 0.72 8-3 Test 8 2.44 0.48 2.92 40.83 29.61 28.751 0.70 12-1 Test 3 3.10 0.69 3.78 38.17 30.116 29.92 0.78 12-2 Test 9 3.20 0.71 3.91 41.26 33.08 31.92 0.77 12-3 Test 6 3.33 0.50 3.82 38.34 29.345 29.14 0.76 Table 1 Douglas-fir tree identifications and physical measurements

1. 1.2 Large Fire Laboratory

The trees were burned in the NIST Large Fire Laboratory located on the NIST site in Gaithersburg, Maryland. The facility has several instrumented hoods that employ oxygen consumption calorimetry to measure the HRR. The largest calorimeter hood, which was used for the tree burns, has a design capacity for HRRs of 10000 kW. The hood measures 9 m x 12 m and the lower edge of the hood is 4.5 m above the floor level. At its highest, in the center of the hood, the clear space above the floor is 7.9 m. The products of combustion are collected by the hood and flow though ducts for measurement and then are exhausted from the test building. After leaving the building the fire products are treated by a pollution abatement system before being discharged into the atmosphere.

1. 1.3 Instrumentation

The experiments were video taped from three different perspectives, and still digital photographs were also taken. The tree and stand were on a platform supported by a load cell that measured the mass loss as a function of time. Additionally, a much larger platform underneath the first was supported by load cells at each of the four corners, to verify the accuracy of the first load cell, and serve as a backup.

Additional instrumentation included the following: Seven thermocouples were mounted on a 4.3 m (14 ft) vertical thermocouple support stand placed approximately a meter from each test tree. These thermocouples were mounted on horizontal arms at 0.61 m (2 ft) intervals, so that the sensing tips would be near the centerline of the tree crown in the buoyant gas nearest to the stem. The thermocouples were 3 mm diameter stainless steel sheathed, Type K Chomel-Alumel, 0.91 m (3 ft) long. Voltage output from the thermocouple array was recorded on the Large Fire Laboratory data acquisition system.

The first three tests had 4 water-cooled total-heat-flux gauges, which were mounted on a second 4.3 m (14 ft) vertical support located 3 m (9.8 ft) from the stem of the tree. The first gauge was located 0.61 m (2 ft) above the ground level, and the remaining three

8 gauges were spaced vertically every 1.22 m (4 ft). Additionally, two heat flux gauges were placed aiming upward at ground level 1.5 m (4.9 ft) and 3 m (9.8 ft) from the tree stem. For the fourth through ninth tests, a seventh heat flux gauge was added, 10 m (32.8 ft) away from tree stem. This gauge was angled at 20° to view the entire flame.

1. 2 MEASUREMENTS

Figure 2 presents a timeline of images from the video record of all Douglas-fir tree burns except Test 9 (tree 12-2) that was lost. Each tree was ignited at the base of the crown using a propane torch with two flames for simultaneous ignition of the crown on opposite sides of the stem. Depending on the moisture content, some trees required 5 s of torch application to ignite, others required 15 s. Once ignited, each tree was consumed by rapid burning in approximately 60 s.

All trees except Tree 12-1 behaved similarly in the burn tests. Tree 12-1 (Test 3) did not get fully involved, and required a re-ignition to sustain burning. Because of this unusual burning behavior the results for Test 3 are not included in the analysis. As there were two other trees of the same nominal size remaining in the data set, eliminating Test 3 from the analysis was regarded as not significant.

9

Figure 2a. Pictures every 5 s of the Douglas-Fir-Tree Burns starting from the application of the igniter until 55 s after that.

10

Figure 2b. Pictures of the Douglas-Fir-Tree Burns for times between 60 s and 110 s after application of the igniter.

11 4.2.1 Flame Heights

The mean flame height, Hflame was determined for each tree burn by analyzing video and still photos showing both the burning tree and the installed thermocouple supports. The flame height (see figure 3) was chosen to be the distance from the base of the flame near the tree bole (the lowest branch on the tree) to the top of the flame where the intermittency is 0.5. A flame intermittency of 0.5 means the visible flame is seen half of the time. For each burn, still photographs were used to determine the flame height, guided by the video record showing flame intermittency. The crown height, flame height and their ratio for each burn are shown in Table 2, and their use in the tree-burn model is presented in Sections 4.3.1 and 5.1.2.

Figure 3 Flame height

Tree Hcrown (m) Hflame (m) Hflame /Hcrown 4-1 1.37 4.2 3.06 4-2 1.30 3.47 2.68 4-3 1.42 4.36 3.07 8-1 2.31 4.61 1.99 8-2 2.62 5.05 1.93 8-3 2.44 5.61 2.30 12-1 3.10 N/A N/A 12-2 3.20 5.08 1.59 12-3 3.33 4.69 1.41 Table 2 Flame heights

12 4.2.2 Heat Release Rate and Mass Loss

Figure 4 shows a plot of the measured HRR for each of the tree-burns. The peak HRR occurs at different times in part because of variation in ignition times. Peak HRR and weight loss measured during the test are recorded in Table 3. The weight loss data in Table 3 are from the measurements made by the top load cell located directly under the tree.

0 1000 2000 3000 4000 5000 6000 0 30 60 90 120 time (s) HRR (kW) 12-3 12-2 8-3 8-2 8-1 4-3 4-2 4-1

Figure 4 HRR as a function of time

Tree

HRRpeak (kW) Tree Weight Pre-burn (kg) Weight Loss (kg) Weight loss / pre-burn weight 4-1 780 2.85 1.44 0.51 4-2 720 1.55 1.04 0.67 4-3 1660 4.37 2.67 0.61 8-1 3350 17.60 9.13 0.51 8-2 3400 17.64 8.6 0.49 8-3 5040 28.75 12.53 0.44 12-2 5000 31.92 13.49 0.42 12-3 4000 29.14 7.91 0.27

Table 3 Measured peak HRR and burned weight loss for tree

13 4.2.2 Other Measurements

As part of the large scale experiments, many measurements, not needed immediately for the formulation of the algorithm, were recorded. These included temperature measurements from an array of thermocouples within and above the crown of the tree, and radiant and total heat flux from the fire at various distances and heights. These data will be reduced and analyzed when additional resources become available.

1. 3 ANALYSIS

The series of tree-burn experiments provided initial data to start the formulation of the fire source portion of the algorithm to predict structural ignition from burning vegetation. Other observations from the data, not used directly in the development of the algorithm, are recorded in this section for possible use in other models for wildland-urban interface fires.

1. 3.1 Flame Height

The mean flame heights (Hflame) were compared to the crown height, Hcrown, to determine if there was a correlation between a tree’s height, and the resulting flame height. The results are shown in figure 5. Generally the larger trees produced a flame height twice the crown height. The smallest trees produced a flame three times the crown height. This data is also influenced by differences in initial moisture content. From the data in Table 1, the smallest trees lost about one-half of the initial weight before burning. The larger trees lost only one-fourth of the initial weight before burning. More experiments are needed to understand the effect of moisture and crown height on flame height. At this time, the best estimate of flame height for application to landscape trees is the data for the larger trees with greater moisture. That is Hflame / Hcrown = 2.0 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 H crown (m) H flame / H crown

Figure 5 Flame height data

14

Tree Hcrown (m) Hflame (m) Hflame/Hcrown 4-1 1.37 4.2 3.06 4-2 1.30 3.47 2.68 4-3 1.42 4.36 3.07 8-1 2.31 4.61 1.99 8-2 2.62 5.05 1.93 8-3 2.44 5.61 2.30 12-2 3.20 5.08 1.59 12-3 3.33 4.69 1.41 Table 4 Tree height and flame height data

1. 3.2 Heat Release Rate

NIST tree burn experiments demonstrated that there is a similarity in the growth curves to peak HRR amongst all the trees, regardless of size. The heat release data from the experiments shows wide variation in the time to peak HRR (Figure 3). The larger trees took longer to ignite, and have a steeper rate of increase, but once the fire was steadily increasing, peak HRR was obtained in approximately 30 s for all trees. Figure 6 shows the HRR curves aligned such that the peak values occur at 30 s. From this figure, it is apparent that the size of the tree plays a large role in determining the peak HRR, but has a relatively minor affect on the length of the burn.

Using 60 s as a common time interval for burning, the HRR of the burning Douglas-fir trees can be represented well by a simple isosceles triangle shape. In this case the base of the triangle is 60 s and the height is the peak HRR. Figure 7 HRR peaks 0 1000 2000 3000 4000 5000 0 10 20 30 40 50 60 delta t (s) HRR (kW) 12-3 12-2 8-3 8-2 8-1 4-3 4-2 4-1

Figure 6 Heat release rate curves aligned at their peak values.

shows this approximation as it applies to two of the measured HRR curves. This result is not used in the algorithm developed in this study, but may be an important and useful approximation in future modeling of crown fires.

15 0 1000 2000 3000 4000 5000 0 10 20 30 40 50 60 time (s) HRR (kW) 12-3 12-2 8-3 8-2 8-1 4-3 4-2 4-1 3.6 m 3.6 m 1.2 m 1.2 m 0 1000 2000 3000 4000 5000 0 10 20 30 40 50 60 time (s) HRR (kW) 12-3 12-2 8-3 8-2 8-1 4-3 4-2 4-1 0 1000 2000 3000 4000 5000 0 10 20 30 40 50 60 time (s) HRR (kW) 12-3 12-2 8-3 8-2 8-1 4-3 4-2 4-1 3.6 m 3.6 m 1.2 m 1.2 m Figure 7 Triangle approximation for the heat release rate of Douglas-fir crown fires.

The burning of Douglas-fir trees has also been studied to evaluate the hazards of Christmas trees in homes. In an extensive study of Christmas-tree burns by Babrauskas [39], peak HRR were correlated with total mass of the tree and the moisture content of the needles. A plot of the correlation and the curve-fit from the published results of that study are reproduced here as Figure 8 and Equation 1. . peak q /mass = e5.84-0.017M

(1)

Where, . peak q is the peak heat release rate [kW], mass is the total pre-burn mass of the tree [kg], M is the moisture of the needles [mass fraction or percent by weight].

Because these results contain a quantification of the effect of moisture on the peak HRR and the trees burned were similar to those burned in this study, the results published by Babrauskas will be used in the formulation of the algorithm. As Babrauakas normalized his peak HRR using the entire mass of the cut Douglas-fir tree, his formulation will need to be modified to work with the burnable mass of the tree estimated from experiments conducted in this study.

16

Figure 8 – Peak heat release rate from Douglas-fir trees as a function of moisture

and mass 39

1. 0 IGNITION OF STRUCTURES ALGORITHM FOR ECOSMART

In wildland-urban and residential community areas, fire can spread rapidly, often driven by wind, to threaten homes and other structures. There are several modes by which burning vegetation can threaten a home [1-8]. For example, flames from burning trees and shrubs close to a home can ignite combustible exteriors by direct contact. In addition, small fires in collected debris, such as dry leaves and needles dropped on and around the home, can start fires at corners and in small crevices of the structure. Furthermore, ground fires, which propagate in dead debris such as leaves or pine needles or in dry live fuels such as grasses, can ignite an exterior wall. All of these mechanisms depend essentially on direct contact (convection and/or conduction) for the heating and ignition of the combustible exterior materials of the structure. Alternately, hot brands from burning trees remote from the property can be carried by the wind and blown up-against the exterior or even into homes through small openings to ignite the structure. Or, finally, for large fires, thermal radiation emitted from the flames can be transported in line-of- sight directions across open spaces to be absorbed by and ignite the structure.

Of these possible modes of fire spread, the most quantitative understanding exists for fire spread by ignition from thermal radiation [9, 10, 43-47]. For example, radiative heating

17 of a surface is simply additive; therefore, the radiative heat flux at a position on the surface, from two identical non-interacting burning objects oriented similarly with respect to that position, is just twice that of one of them. In addition, radiation becomes a more dominant transport mechanism as fires become larger. Crown fires, which burn intensely and spread rapidly relative to other wildland fires, are well-known examples of fires where radiation is a dominant mode for fire spread. The fact that the heat transfer by radiation from burning trees to a structure could be quantified through knowledge of the geometric relationship between the two fuel elements, lead to the selection of this mode of ignition as to be the first to be quantified in EcoSmart [48-51]. This was done with full knowledge that more often structures are ignited by other means that are not well quantified as discussed above. A simple algorithm was constructed to determine the thermal radiation transport from trees to structures.

The fire spread algorithm can be used to examine many scenarios for fire spread from vegetation to structures. The algorithm provides means to calculate the radiative heat exposure to structures from burning trees with flames located at arbitrary positions in 3-dimensions relative to structural elements.

Although it is well known that piloted radiative ignition of combustible materials depends on both the magnitude and the duration of the incident radiative heat flux [48-51], the model described here introduces only a simple critical flux assumption for ignition. To be consistent with other capabilities of the initial version of EcoSmart, the burning duration was eliminated from the algorithm for the ignition model. Fire spread from vegetation to the structure is assumed to occur, therefore, if the value of the radiative flux exceeds a critical value for ignition. In Section 5.1.6, there is additional discussion of this assumption, and a value of this critical flux.

The computational relationships that form the basis for the initial fire spread model algorithm (version 1.0) for EcoSmart are summarized below.

1. 1 SIMPLE ALGORITHM FOR STRUCTURE IGNITION BY BURNING

LANDSCAPE TREES

The algorithm consists of six steps: 1) determine the burnable mass of the tree, 2) determine the flame height, 3) determine the peak HRR, 4) determine the fraction of the peak HRR emitted as radiative energy, 5) determine the fraction of the radiative flux emitted by the flame that impacts any part of the exterior surface, and 6) determine if the criteria for ignition of the exterior surface material is satisfied. The algorithm has been structured to utilize the burnable mass of the tree as a single parameter, to which burning properties are related. Future research may show that this single parameter can be used to generalize burning results between many different types of trees. As this study examined only one type of tree, however, experiments to determine additional data required for generalization of the results to other tree species, without generation of additional tree- burn experiments, is not recommended.

18 The measured mass loss during burning is used as the closest approximation to the burnable mass available for the trees burned in this study. The ratio of burnable mass for the trees to the pre-burn mass ranged from 0.27 to 0.65.

1. 1.1 Burnable Mass of the Tree

The burnable mass of the tree is an input to the algorithm. This is often referred to as the foliar mass( foliar m ) of the tree. This information is obtained from other sources within the EcoSmart software.

1. 1.2 Flame Height

The flame height at peak burning rate is related to the crown height of the tree as shown in Figure 5. This data is complicated by the fact that both the size and the moisture content of the trees varied. More data is needed to understand the best way to relate flame height to the tree properties. For the algorithm, a fixed ratio of flame height to crown height equal to 2.0 is used. This choice is supported by the limited data. Therefore:

Hflame = 2.0 Hcrown

(2)

where, Hflame [m], length of the flame above the bole of the tree, Hcrown [m], vertical distance from the bole to the highest branch.

1. 1.3 Peak Heat Release Rate

The peak HRR is well known to be strongly dependent on the moisture content of the burnable mass. In a study of 2 m Douglas-fir tree burning conducted by Babraukas [39] the ratio of peak HRR decreases exponentially with increasing moisture content of the needles over the range in which the tree could be ignited. The correlation developed by Babraukas relates the peak HRR of the burning tree to weight of the tree at ignition. For an algorithm to be used in EcoSmart, the data must be presented in terms of burnable mass. In the Douglas-fir trees burns conducted in this study, the pre-ignition tree weight was approximately twice the mass loss during burning (see Table 3). As this fraction of the initial tree mass lost during burning is the best approximation to the burnable mass ( foliar m ) available from measurement made in this study, the correlation published by Babraukas has been multiplied by the factor 2 to adjust for use with the burnable mass parameter. The peak HRR for the algorithm is:

M foliar peak e m q 017 .0 84 .5 . 2

−

(3)

where

19 . peak q is the peak heat release rate [kW] foliar m is the burnable mass of tree [kg] M is the moisture content of the needles [in percent of the needle mass]

1. 1.4 Radiative Fraction

The fraction of heat emitted from a fire as thermal radiation can vary widely (see Quintiere [10]). Here, it is chosen to be a mid-range value of 0.35 (pp. 58-59 of reference [10] and HUD Report [52]).

peak rad q q . . 35

.0

(4)

where, rad q . [kW] is the peak emitted thermal radiation from the flame

1. 1.5 Radiative Heat Flux

The heat flux at any part of the exterior surface of the structure is determined by a calculated view factor. The view factors are based on radiation from a vertical right cylinder body representing the flame orientated in 3-dimensions relative to the structure. The height of the cylinder is equal to the flame height (Hflame ), with the bottom of the cylinder position at the location of the bole of the tree. The calculation of view factors is given in Appendix A.

1. 1.6 Ignition Criterion

The ignition criterion for the structure is based on a critical radiant flux condition. There is no dependence on exposure time. A single value of 31.5 kW/m2 is used. This value is based on criteria developed by the Department of Housing and Urban Development for safe spacing of housing from potentially large fires [52, 53]. This value is relatively high compared to minimum heat flux values needed to ignite combustible exterior materials. However, without any time dependency for the ignition model in the algorithm and using only the peak radiant energy as exposure, this value is suitable for current use.

1. 0 IMPLEMENTATION OF THE ALGORITHM IN ECOSMART

The fire model algorithm was selected to be physics-based and to harmonize as much as practical with the other modules of EcoSmart. Many choices that were made in the development of the algorithm for ignition of structures by burning vegetation were made specifically to work within the limitations of the EcoSmart software design. There is a greater quantitative understanding of fire spread from vegetation to structures than is implemented in the software. Full and detailed models of fire development on landscaped properties have been performed with the NIST developed Fire Dynamics

20 Simulator (FDS) software [35-37]. Use of FDS directly in EcoSmart at this time is not practical because both the computational resources and the data requirements are too extensive. Using the algorithm developed where ignition of structures is based solely on fire radiant exposure should only be regarded as one indicator of fire spread potential from burning vegetation to structure.

As already discussed, the initial structure-ignition algorithm for EcoSmart does not account for many well known fire spread mechanisms that threaten houses. For example, the model algorithm does not contain any effect of wind. It is well known that fire spread and spread rate are enhanced by wind, see for example Chapter 5 of Quintiere [10]. Never-the-less as wind effects are not addressed in the first version of EcoSmart, they are not included in the structure-fire algorithm. Although many species of trees and shrubs will be available for use in the EcoSmart software, it was found that very little data is available that describes the burning of individual trees and shrubs in a form that is needed for the algorithm. As a result, new data was generated by NIST for burning Douglas-fir trees. As the vegetation burning portion of the algorithm was developed solely on data from Douglas-fir tree burns use of the Version 1.0 algorithm with other trees is not recommended. Additional research and data collection is needed to extend the algorithm to other tree species.

As many potentially important fire spread mechanisms have been omitted, conservative choices that favored structure ignition have been made for the fire scenarios. This is customary practice in safety analysis where considerable uncertainties exist. In the algorithm:

● All vegetation burns at the maximum burning rate. ● All surfaces ignite if exposed to a critical flux for ignition. ● Duration of burning for the sources of heat are not considered ● Duration of exposure for the materials being ignited are not considered

Since this version of EcoSmart has only implemented a model of structure ignition by thermal radiation, other important ignition threats to structures have been deferred for later development and implementation. For example, the initial version of the algorithm does not include the effects of ambient winds, burning brands and heat fluxes from nearby burning structures, for example. The determination of the relative importance of each of these effects is scenario dependent, and, therefore, inclusion of the effects will require additional research, data, and model development.

1. 0 MODELING COMPLEX PHENOMENA

A mathematical model of any phenomenon can be regarded as a caricature of that phenomenon. By its very nature, modeling is a creative venture. Just as a caricature depends on the artist for its rendition, so mathematical modeling depends on the modeler for its mathematical description. If a model is well crafted and efficient, it will capture

21 the important features of the phenomenon while ignoring less relevant ones and will produce results that are good representations of the phenomenon.

Our ability to construct effective mathematical models depends on our understanding of the phenomenon. If, for example, we do not understand a phenomenon conceptually, we will not be able to develop a mathematical representation of it. As an aside, however, any attempt to construct a mathematical model often leads to a much better understanding of research needs by focusing attention on developing relationships between variables and data some of which may not be available.

Mathematical models, even of the same phenomenon, can vary widely in complexity, as measured by several criteria: by the initial research and development effort required to construct the model, by the computational resources needed to use the model and by the data required for input and validation of the model. Using cost as the distinguishing feature, Figure 9 illustrates different classes of models by three caricatures of a house, ranging from most detailed on the left to the simplest on the right. We refer to the sketch on the left as a one-dollar model, the sketch on the right as a five cent model, and the center sketch as a 25 cent model. The price of each model is used here to convey the idea that greater model complexity generally leads to higher research and development costs, more extensive computer-resource requirements and greater data needs both for input and validation of the model. It also implies that greater model complexity usually yields a more faithful and easily understood representation of the phenomenon.

Complexity is neither a reliable gauge of model accuracy nor effectiveness. The goal of any mathematical model is to produce the simplest representation of that phenomenon consistent with user needs to understand and predict its behavior. It is generally true that representing a complex phenomenon, like fire, requires a complex model (a dollar model). For example, a simple (five cent) model, while often adequate to illustrate may be inadequate or misleading for evaluations of details.

$1

25¢

5¢

Complex Model:

Approximate Model: Large Computational

Small Computational and Data Needs

and Data Needs

Figure 9 Three caricatures of a house representing different levels of complexity for mathematical models.

22 The mathematical model algorithm for ignition of structures used in version 1.0 of Ecosmart is distinctly a 5-cent class model. As noted earlier, many choices were made throughout the development of the algorithm to simplify the model in order to approximate the ignition potential of a structure due to nearby burning vegetation, while requiring minimal computer resources and minimal input/validation data. During a review of a pre-release version of the fire portion of the EcoSmart software, many of the model limitations were identified by the reviewers. These limitations have served as the starting point for defining research needs to improve future versions of the software.

1. 0 RESEARCH NEEDS TO ADVANCE THE DEVELOPMENT OF PHYSICS-

BASED MODELS FOR WUI AND RESIDENTIAL HOUSING COMMUNITY FIRES

As discussed above, operational models are regularly used in practice by land-managers, and fire-prediction specialists, for example, to estimate the spread and spread rate of wildland fires. However, these models are limited, as noted above, and badly need updating to take into account of current mathematical modeling methodology and the revolutionary advances in computer technology over the past few decades. Since the wildland fuels simulated in the operational models have no vertical structure, the fire growth and spread are not governed by the conservation laws of physics. Therefore, there is no hope of generalizing these models to address the problem of fire spread to buildings, transitions from ground to crown fires, or fire spread from individual tree to tree. In other words, these models will never be able to model fires at the wildland-urban interface!

When, in addition, the built environment becomes involved in a fire, as in the Oakland and Berkeley Hills fire of October 21, 1991, or more recently the Los Alamos fires in May 2000, Summerhaven, AZ, fires in June 2003, and San Diego, CA fires in October- November, 2003 these models are ineffective. The operational models cannot predict the spread of fire because the fuel load from buildings needs to be treated as discrete and three-dimensional. Also, in many cases the fuel load from structures is much larger than the surrounding vegetation. In order to model WUI and housing community fires, buildings, as well as large individual trees, must be regarded as discrete fuel elements on the length scales of interest. At a fundamental level, the empirical correlations upon which the wildland-fire operational models have been developed are no longer valid. Predictive methods are needed to address the potential fate of housing communities and individual high valued structures threatened by fire. No validated predictive models of fires in an urban or urban/wildland setting exist. Research is needed to develop three- dimensional models of fire phenomena in WUI and housing communities. Measurement of three-dimensional burning characteristics of individual vegetation and man-made structure fuel elements are needed to support the model development.

1. 0 NIST FIRE DYNAMIC SIMULATOR AND SMOKEVIEW MODELS

Over the past 25 years, the Building and Fire Research Laboratory (BFRL) at the National Institute of Standards and Technology (NIST) has developed a physics-based mathematical and computational model, known as the Fire Dynamics Simulator (FDS), to

23 predict fire phenomena inside structures. Over time, this model has been used to predict outdoor buoyant plume behavior, outdoor fire spread from structure to structure, and, most recently, fire spread in both continuous and discrete wildland fuels. FDS, and a NIST-developed companion code for visualization called Smokeview have been well documented, validated using data from large-scale indoor and outdoor experiments, and are used by hundreds of fire protection engineers around the world. The model equations and their computational implementation in FDS have been carefully selected to be computationally efficient. Therefore, while FDS is both computationally and data intensive, simulations requiring on the order of a million or more computational cells generally require only a current high-end PC running overnight. Both codes and documentation can be downloaded free of cost from the URL: http://fire.nist.gov.

The generation of mathematical models represented by FDS is based on the methodology of Computational Fluid Dynamics (CFD), and takes advantage of the revolutionary advances in computer technology with correspondingly reduced costs that make effective fire modeling capabilities widely available. There is a parallel between the current operational models for wildland fires and the previous generation of fire models developed by NIST in the 1980’s. These “zone-models” were effective in computing fire phenomena in structures, but only as average conditions on a room-by-room basis. The need for engineers to resolve greater details within rooms forced a transition to the present generation of FDS fire modeling. To advance fire modeling of WUI and residential communities, a new generation fire modeling tools must be developed for general use by land managers, community authorities, and property owners.

At this time, there seems to be little to no research activity within the wildland-fire community directed at developing the next generation of three-dimensional fire models. NIST has begun to expand the capabilities of the FDS fire model and Smokeview fire visualization software to predict important fire phenomena occurring in the WUI and residential housing communities. This is a giant modeling undertaking. To estimate the order of magnitude of the research task to develop and validate a next-generation fire model, it has been estimated that NIST and its other agency partners have invested about 100 scientific staff-years in the development of the present FDS and Smokeview tools!

1. 0 ACKNOWLEDGEMENTS

The authors would like to thank Ms. Lisa Mabli for her enthusiastic support of this study with her insight into burning behavior and initial data on burning properties of vegetation. Initial data analysis and model development support was provided by Ms. Amaryllis Puig-Berrios. She served as a visiting scientist at NIST under the supervision of Dr. David Weiss from the Pacific Southwest Research Station. Development of new model representations for burning trees was contributed Dr. Sims Hostikka while at NIST as a visiting scientist from VTT in Finland. It was further refined by Dr. William Mell, formerly at the University of Utah, but now at NIST. Through the assistance of Mr. Alexander Maranghides and the operating technicians in the Large Fire Laboratory the tree burning experiments were conducted easily to produce the new data critical to the development of this model. Mr. Herbert Spitzer, Jr. contributed substantially in the

24 review of the implementation of the algorithm in a pre-release version of EcoSmart. His comments were an initial guide to the research needs for further development of the WUI models. This research was funded in part by the Center for Urban Forest Research, Pacific Southwest Research Station, U.S. Department of Agriculture Forest Service. Dr. E. Gregory McPherson provided continued encouragement and coordination in the development of the algorithm.

1. 0 REFERENCES

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Drysdale, Dougal. 1985. An Introduction to Fire Dynamics, Wiley-Interscience Publications, John Wiley and Sons, New York.

Quintiere, James G. 1998. Principles of Fire Behavior. Delmar Publishers, Albany, New York.

Andrews, P.L., and C.D. Bevins. 1999. “BEHAVE Fire Modeling System: Redesign and Expansion. Fire Management Notes. 59:16-19; Web site: http://fire.org/.

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McGrattan, K.B. and G.P. Forney. 2000. Fire Dynamics Simulator -- User's Manual. Nist Report NISTIR 6469, National Institute of Standards and Technology, Gaithersburg, Maryland.

Forney, G.P. and K.B. McGrattan. 2000. User's Guide for Smokeview Version 1.0 -- A Tool for Visualizing Fire Dynamics Simulation Data. NISTIR 6513, National Institute of Standards and Technology, Gaithersburg, Maryland..

Linn, R., J. Reisner, J. Colman, J. Winterkamp, 2002. Studying Wildfire Behavior using FIRETEK, International Journal of Wildland Fire, 11: 233-246.

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Rothermel, Richard C. 1983. How to Predict the Spread and Intensity of Forest and Range Fires. U.S. Intermountain Forest and Range Experiment Station, Ogden, Utah, Report PB 83-242289.

Albini, Frank A. 1985. A Model for Fire Spread in Wildland Fuels by Radiation. Combust. Sci. and Tech. 42:229-258; also, Albini, Frank A. 1986. “Wildland Fire Spread by Radiation - A Model Including Fuel Cooling by Natural Convection,” Combust. Sci. and Tech. 45:101-113.

Albini, Frank A. and Brian J. Stocks, “1986. Predicted and Observed Rates of Spread of Crown Fires in Immature Jack Pine,” Combust. Sci. and Tech. 48:65-76.

Albini, Frank A. 1997. “An Overview of Research on Wildland Fire.” Proceedings of the Fifth International Symposium on Fire Safety Science, Yuji Hasemi, editor.

Albini, F.A.. 1983. “Transport of Firebrands by Line Thermals,” Comb. Sci. & Tech.32:277-288.

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1. Albini, F.A.. 1981. Spot Fire Distance from Isolated Sources -- Extensions of a

Predictive Model. Research Note INT-309, Dept. of Agriculture, Forest Service, Intermountain Forest and Range Experiment Station, Ogden Utah

Clark, T.L., M.A. Jenkins, J. Coen and D. Packham. 1996. A Coupled Atmospheric-Fire Model: Convective Feedback on Fire-line Dynamics. J. Applied Meteorology 35:875-901.

Baum, H.R., K.B. McGrattan and R.G. Rehm. 1994. “Simulation of Smoke Plumes from Large Oil Fires.” Twenty-Fifth Symposium (International) on Combustion, The Combustion Institute 25:1463-1469.

Baum, H.R. 2000. “Large Eddy Simulations of Fire - from Concept to Computations.” Fire Protection Engineering 6:36-42.

Baum, H.R. 2000. “Modeling and Scaling Laws for Large Fires.” Proceedings of ISSM-III, Third International Symposium on Scale Modeling, Nagoya, Japan.

Baum, H.R., K.B. McGrattan and R.G. Rehm. 1994. “Mathematical Modeling and Computer Simulation of Fire Phenomena.” Theoretical and Computational Fluid Dynamics 6:125-139.

Maranghides, A., 1993. Wildland-Urban Interface Fire Models, MS Thesis to Worchester Polytechnic Institute, December 8, 1993, 139pp.

33 Cohen, J.D., 2000. Preventing Disasters, Home Ignitability in the Wildland-Urban Interface, Journal of Forestry, March 2000, pp15-21.

34 Cohen, J.D. and Butler, B.W., 1996. “Modeling Potential Structure Ignitions from Flame Radiation Exposure with Implications for Wildland/Urban Interface Fire Management,” 13th Fire and Forest Meteorology Conference, Lorne Australia, pp. 81-86.

Evans, D.D., R.G. Rehm, E.G. McPherson, Physics-based Modelling of Wildland- Urban Intermix Fires, Proceedings, Third International Wildland Fire Conference, October 3-6, 2003, Sydney, Australia, 2003

Rehm, R., D. Evans, W. Mell, S. Hostikka, K.McGrattan, G. Forney, C. Boulin, and E. Baker, Neighborhood-scale Fire Spread, Fifth Symposium on Fire and Forest Meteorology, 16-20 November, 2003, Orlando, Florida, 2003.

Evans, D.D., Rehm, R.G., Baker, E.S., McPherson, E.G., Wallace, J.B., 2004, Physics-based Modeling of Community Fires, Proceedings 10th International Fire Science and Engineering Conference (Interflam 2004), 5-7 July, 2004, Edinburgh, Scotland, Interscience Communications Ltd, London, United Kingdom.

27

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Tree Fire Tests. NIST Report of Test FR 4010, National Institute of Standards and Technology, Gaithersburg, Maryland.

Babrauskas, V., “Heat Release Rates”, The SFPE Handbook of Fire Protection Engineering (Third Edition), Section 3, Chapter 1, p 3-1, National Fire Protection Association, Quincy, Massachusetts 02269, 2002

Damant, G. and S. Nurbakhsh, “Christmas Trees – What Happens When They Ignite?” Fire and Materials, 18, PP 916, 1994.

Jennings, C.M., Development of Protocols for Testing the Exterior Components and Assemblies of Residential Structures Under Simulated Wildfire Conditions, MS Thesis in Wood Science and Technology, University of California, Forest Products Laboratory, Richmond, California, 2000.

Etlinger, M.G., Fire Performance of Landscape Plants, MS Thesis in Wood Science and Technology, University of California, Santa Barbara, Santa Rosa Spring 2000.

Hottel, H.C. and A.F. Sarofim, Radiative Transfer, 1967, McGraw-Hill Book Company, New York, New York.

Siegel, R. and Howell, J.R., Thermal Radiation Heat Transfer, Third Edition, Hemisphere Publishing Corporation, Washington DC, Chapters 6 and 7.

Howell, J.R., Website: http://www.me.utexas.edu/~Howell/

1. . Beyler, Craig L. (Task Group Chairman), Engineering Guide: Assessing Flame

Radiation to External Targets from Pool Fires, The SFPE Task Group on Engineering Practices, June 1999 (FRIS R0000329) National Fire Protection Association, Quincy, Mass.

Krishna S. Mudan and Paul A. Croce, Geometric View Factors, Fire Hazard Calculations for Large Open Hydrocarbon Fires, Section 2/Chapter 4, SFPE Handbook of Fire Protection Engineering, 2nd Edition; National Fire Protection Association, Quincy, Mass. 1995, p 2-57 to p 2-59.

Cohen, J.D. and Butler, B.W., “Modeling Potential Structure Ignitions from Flame Radiation Exposure with Implications for Wildland/Urban Interface Fire Management,” 13th Fire and Forest Meteorology Conference, Lorne Australia, 1996, pp. 81-86.

Cohen, J.D., 2000. Preventing Disasters, Home Ignitability in the Wildland-Urban Interface, Journal of Forestry, PP 15-21, March 2000.

Cohen, J.D., 2001. Wildland-urban fire--a different approach. In: Proceedings of the Firefighter Safety Summit, Nov. 6-8, 2001, Missoula, MT. Fairfax, VA: International Association of Wildland Fire. (www.umt.edu/ccesp/wfs/proceedings/Jack D. Cohen.doc)

28

Cohen, J.D., “What is the Wldland Fire Threat to Homes,” The Thompson Memorial Lecture, April 10, 2000, School of Forestry, Northern Arizona University, Flagstaff, Arizona.

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APPENDIX A Model Geometry Configuration Factor for the Cylindrical Flame of a Burning Conifer and an Element on the Target Structure. The radiation exchange between individual elements (structures, trees, shrubs, etc.) at the Wildland-Urban Interface (WUI) can be analyzed by the configuration-factor (CF) approach presented, for example, by Hottel and Sarofim [1] or by Siegel and Howell [2], among others. Such an approach has been used by the Society of Fire Protection Engineers (SFPE) [3], [4] to assess the thermal radiation to an external target from a pool fire. According to this analysis [3], three major steps are required:

1. Estimation of the characteristics of the pool fire, such as its radius, its flame height and its burning rate.
2. Estimation of the thermal radiation characteristics of the fire; e.g., its average emissive power, and
3. Calculation of the incident radiant flux at the target location.

Calculation of the incident radiant flux at a target structure can be accomplished by using the CF approach. In this approach, the radiative exchange from an elemental area of the flame to an elemental area on the target is the fraction of the total energy per unit time leaving the elemental flame area and incident upon elemental target area. This fraction depends upon the normal angles of the emitting and the receiving surfaces and the distance between the two surfaces. CF between a Finite-Length, Vertical Cylinder and a Differential Element on the Exterior of a Structure. Figure 1: Schematic diagrams show the geometrical relationship between a finite-length, vertical circular cylinder, rep- resentation of a flame and a horizontal or a vertical elemental area at ground level. Figure 1 shows a schematic diagram of a pool-fire flame modelled as a vertical, circular cylinder of height H and radius R. The radiation from this model flame impinges on a vertical rectangular element at ground level at a horizontal distance L from the axis of the cylindrical flame in the left diagram of Figure 1 and a horizontal rectangular element in the right diagram. The Configuration Factor (CF), or the view factor, determines the fraction of the radiation from the flame that is incident on each target element. F12,H is the CF for a horizontal target element and F12,V is the CF for a vertical element. Shokri and Beyler [3] present analytical expressions for these Configuration Factors as functions of the two parameters, s, the dimensionless horizontal distance of the target element from the centerline of the fire, and h, dimensionless cylindrical flame height: s = L R, h = H R , A = h2 +s2 +1 2s , B = s2 +1 2s The CF for the horizontal element is F12,H = B−1/s π √ B2 −1 tan−1 s (B+1)(s−1) (B−1)(s+1) −A−1/s π √ A2 −1 tan−1 s (A+1)(s−1) (A−1)(s+1) and the CF for the vertical element is F12,V = 1 πs tan−1

h √ s2 −1

−h πs tan−1 s (s−1) (s+1) + Ah πs √ A2 −1 tan−1 s (A+1)(s−1) (A−1)(s+1) 29

CF between a model crown fire and a Differential Element on the Exterior of a Structure. Now consider a crown fire in a single tree. As above, we will assume that flame can be modelled as a cylinder, and as- sume the top of the flame extends to height H above the ground, whereas the base of the flame is at the bole height, or the height of the base of the crown D. NIST experiments show that the flame height extends from the base of the bole to twice the crown height. Take the midpoint of the target element to be at height M above the ground and at a horizontal distance L from the centerline of the flame. The Configuration Factors are pictured schematically in Figure 2 and can be determined by the analytical expressions above of Shokri and Beyler [3] using techniques for addition of CFs [2]. Figure 2: Schematic diagrams showing a burning tree crown represented by a circular cylindrical flame (color red) starting at height D, the base of the crown or the top of bole, and extending to height H. NIST experiments show that the flame height extends from the base of the bole to twice the crown height. The Configu- ration Factor (CF) is calculated between the flame and differential vertical or horizontal elemental areas of height M above ground level and at horizontal distance L from the centerline of the flame. To model the CF between the crown fire and the vertical and horizontal elemental areas, we use the cylindrical-flame analysis presented above. First, take a cylinder of height H −M : s = L R, h = (H −M) R , A1 = h2 +s2 +1 2s , B = s2 +1 2s For this cylinder, the CF for the horizontal element is F12a,H = B−1/s π √ B2 −1 tan−1 s (B+1)(s−1) (B−1)(s+1) −A1 −1/s π q A2 1 −1 tan−1 s (A1 +1)(s−1) (A1 −1)(s+1) and for the vertical element is F12a,V = 1 πs tan−1

h √ s2 −1

−h πs tan−1 s (s−1) (s+1) + A1h πs q A2 1 −1 tan−1 s (A1 +1)(s−1) (A1 −1)(s+1) Next, take a cylinder of height D−M : s = L R, d = (D−M) R , A2 = d2 +s2 +1 2s , B = s2 +1 2s For this cylinder, the CF for the horizontal element is F12b,H = B−1/s π √ B2 −1 tan−1 s (B+1)(s−1) (B−1)(s+1) −A2 −1/s π q A2 2 −1 tan−1 s (A2 +1)(s−1) (A2 −1)(s+1) 30

and for the vertical element is F12b,V = 1 πs tan−1

d √ s2 −1

−d πs tan−1 s (s−1) (s+1) + A2d πs q A2 2 −1 tan−1 s (A2 +1)(s−1) (A2 −1)(s+1) The two CFs describing the crown fire should then be F12,H = F12a,H −F12b,H and F12,V = F12a,V −F12b,V. Written out fully, then: The CF from the crown fire to the horizontal element is F12,H = B−1/s π √ B2 −1 tan−1 s (B+1)(s−1) (B−1)(s+1) −A1 −1/s π q A2 1 −1 tan−1 s (A1 +1)(s−1) (A1 −1)(s+1) −  B−1/s π √ B2 −1 tan−1 s (B+1)(s−1) (B−1)(s+1) −A2 −1/s π q A2 2 −1 tan−1 s (A2 +1)(s−1) (A2 −1)(s+1)   A2 −1/s π q A2 2 −1 tan−1 s (A2 +1)(s−1) (A2 −1)(s+1) −A1 −1/s π q A2 1 −1 tan−1 s (A1 +1)(s−1) (A1 −1)(s+1) and for the vertical element is F12a,V = 1 πs tan−1

h √ s2 −1

−h πs tan−1 s (s−1) (s+1) + A1h πs q A2 1 −1 tan−1 s (A1 +1)(s−1) (A1 −1)(s+1) −  1 πs tan−1

b √ s2 −1

−b πs tan−1 s (s−1) (s+1) + A2b πs q A2 2 −1 tan−1 s (A2 +1)(s−1) (A2 −1)(s+1)   where, as before, s = L R, h = (H −D) R , b = (B−D) R A1 = h2 +s2 +1 2s , A2 = b2 +s2 +1 2s , B = s2 +1 2s CF Dependence on Angles The elemental area is regarded as part of the exterior wall of the target structure that is being irradiated by the cylindrical crown-fire flame. There is a second plane which contains the axis of the cylindrical flame and is perpendicular to the irradiated wall. This second plane contains lines perpendicular to the flame axis that determine the shortest distance between the flame and the irradiated plane or wall. Figure 3 shows a schematic diagram of the ”flame,” the ”wall,” and the other geometrical quantities discussed here. In this geometry, the ”flame” model, the ”wall” and two angles define the CF. The first, θ1, is an elevation angle from mid-height on the cylindrical flame surface to the center of the irradiated elemental area. This angle is in the vertical plane containing the axis of the cylindrical flame, which is perpendicular to the plane of the elemental area (the second plane defined above). This angle can be written as θ1 = arctan (D−M)+0.5(H −D) L−R

= arctan (d +0.5(h−d) s−1

The second angle, θ2, is a lateral angle which is determined by the distance along the irradiated wall of the elemental area from the normal plane (plane two above). If we define by X this lateral distance, and x as x = X/R, then this second angle θ2 can be written as θ2 = arctan

X L−R

= arctan

x s−1

Including the effects of the angles on the configuration factor, we have CFV = F12a,V cosθ1 cosθ2 31

Figure 3: Schematic diagram showing the geometry for a three-dimensional configuration factor (CF) between a burning tree crown represented by a circular cylindrical flame (color red) start- ing at height D, the base of the crown or the top of the bole, and extending to height H. NIST experiments show that the flame height extends from the base of the bole to twice the crown height. The Configu- ration Factor (CF) is calculated between the flame and the middle of a differential vertical element, which is of height 2 M. or, CFV/[cosθ1 cosθ2] = F12a,V Finally, substitute for F12a,V : CFV =  1 πs tan−1

h √ s2 −1

−h πs tan−1 s (s−1) (s+1) + A1h πs q A2 1 −1 tan−1 s (A1 +1)(s−1) (A1 −1)(s+1)  sinθ1 cosθ2 −  1 πs tan−1

d √ s2 −1

−d πs tan−1 s (s−1) (s+1) + A2d πs q A2 2 −1 tan−1 s (A2 +1)(s−1) (A2 −1)(s+1)  sinθ1 cosθ2 References [1] Hottel, H.C. and A.F. Sarofim, Radiative Transfer, 1967, McGraw-Hill Book Company. [2] Siegel, R. and Howell, J.R., Thermal Radiation Heat Transfer, Third Edition, Hemisphere Publishing Corporation, Wash- ington, Chapters 6 and 7. [3] Engineering Guide: Assessing Flame Radiation to External Targets from Pool Fires, The SFPE Task Group on Engineer- ing Practices, Craig L. Beyler, Chairman, June 1999 (FRIS R0000329). 32

[4] Krishna S. Mudan and Paul A. Croce, Geometric View Factors, Fire Hazard Calculations for Large Open Hydrocar- bon Fires, Section 2/Chapter 4, SFPE Handbook of Fire Protection Engineering, 2nd Edition; Natioinal Fire Protection Association, Quincy, Mass. 1995, p2-57 to p2-59. 33

FD06006 ｜ 1995_US_USFA_TR-105_Old_Buckingham_Station_Apartment_Fire_Investigation_Report.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1995 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Federal Emergency Management Agency Old Buckingham Station Chesterfield, Virginia Technical Report Series United States Fire Administration United States Fire Administration

UNITED STATES FIRE ADMINISTRATION FIRE INVESTIGATIONS PROGRAM The United States Fire Administration develops reports on selected mayor fires throughout the country. The fires usually involve multiple deaths or a large loss of property. But the primary criterion for deciding to do a report is whether it will result in significant lessons learned. In some cases these lessons bring to light new knowledge about fire — the effect of building construction or contents, human behav- ior in fire, etc. In other cases, the lessons are not new but are serious enough to highlight once again, with yet another fire tragedy report. The reports are sent to fire magazines and are distributed at national and regional fire meetings. The International Association of Fire Chiefs assists USFA in disseminating the findings throughout the fire service. On a continuing basis the reports are available on request from USFA; announcements of their availability are published widely in fire journals and newsletters This body of work provides detailed information on the nature of the fire problem for policy makers who must decide on allocations of resources between fire and other pressing problems, and within the fire service to improve codes and code enforcement, training, public fire education, building technol- ogy, and other related areas. The Fire Administration, which has no regulatory authority, sends an experienced fire inspector into a community after a major incident only after having conferred with the local fire authorities to insure that USFA’s assistance and presence would be supportive and would in no way interfere with any review of the incident they are themselves conducting. The intent is not to arrive during the event or even immediately after, but rather after the dust settles, so that a complete and objective review of all the important aspects of the inci- dent can be made. Local authorities review USFA’s report while it is in draft. The USFA investigator or team is available to local authorities should they wish to request technical assistance for their own investigation. This report and its recommendations were developed by USFA staff and by Varley-Campbell & Associates, Inc., Miami and Chicago, its staff and consultants who are under contract to assist the Fire Administration in carrying out the Fire Reports Program. The United States Fire Administration greatly appreciates the cooperation and information received from Chief Robert L. Eanes, C.E.M and Battalion Chief James E. Graham, Chesterfield Fire Department and William D. Dupler, County of Chesterfield, Virginia. For additional copies of this report write to the United States Fire Administration, National Fire Data Center, 16825 South Seton Avenue, Emmitsburg, Maryland 21727. For color copies of photographs, see USFA WEB Page at http://www.usfa.fema.gov/usfa.htmp.

Old Buckingham Station Chesterfield, Virginia Investigated by Thomas H. Miller, P.E. This is Report 105 of the Major Fires Investigation Project conducted by Varley-Campbell & Associates, Inc. under contract EMW-94-C-4423 to the United States Fire Administration, Federal Emergency Management Agency. Federal Emergency Management Agency United States Fire Administration

Old Buckingham Station 58 Unit Apartment Building May 19, 1995 Investigated by: Thomas H. Miller, P.E. Local Contacts : James E. Graham, Battalion Chief Chesterfield Fire Department Fire Department Headquarters P.O. Box 40 Chesterfield, VA 23832 William D. Dupler, Building Official County of Chesterfield Department of Building Inspections P.O. Box 40 Chesterfield, VA 23832 OVERVIEW On Friday, May 19, 1995 at 1:46 a.m., the Chesterfield County Emergency Communications Center received a 911 telephone report of a fire in the sprinklered Lodge Building at the Old Buckingham Station apartment complex. This X-shaped, three and four story, wood frame structure was the largest building in the complex and contained the management offices, social function room, and 58 apartments. All residential buildings in the complex were protected by an automatic sprinkler system. The system design basis was a modified version of NFPA Standard No. 13D, the Standard for Sprinkler Systems in One-and Two-Family Dwellings. The 13D Standard was not intended for use in multifamily dwellings and NFPA 13R, which applies to multifamily dwellings up to and including four stories high, was first pub- lished in February 1989, after the complex was constructed. Details on the automatic Report 105 Page 1

sprinkler protection are provided later in this report. The sprinkler systems were con- nected to the domestic water service and through a 1-1/2 inch water meter, as would have been appropiate, not a low friction loss fire type meter. Some water meters have significant pressure losses and the NFPA sprinkler installation standards indicate that these losses must be included on the design calculations. Special fire meters are used to minimize pressure losses, especially at high water flow rates. The first company on the scene found fire through the roof of the building’s cen- ter section with the fire spreading into all four building wings simultaneously. Fire department resources were divided between fire suppression and occupant search and rescue. Complicating the suppression effort was the location of the fire’s greatest involvement on the side of the building without direct street access, making rapid place- ment of hose streams directly on the fire more difficult. By the time the fire was declared under control at 4:53 a.m., more than 3 hours later, over 30 apartments were completely destroyed, another 12 sustained heavy dam- age and the balance suffered smoke and water damage. None of the apartments could be occupied after the fire. The Chesterfield Fire Department committed 13 engines, 2 trucks and 5 special service units staffed by 76 officers and firefighters to this incident. Estimates of the fire loss are 4.4 million dollars for the building and 1.1 million dollars for tenant property. Report 105 Page 2

Report 105 Page 3 Large Unsprinklered The lack of automatic sprinklers in substanital Combustible Spaces combustible spaces allowed a large fire to develop. The 1996 edition of NFPA 13R permits unsprinklered open baclconies, stairs and corridors, outside porches, attics and concealed spaces not intended for living purposes or storage. Inappropiate Sprinkler NFPA 13D is not intended for large structures or for Standard Used other than use in 1 and 2 family dwellings and mobile homes. Draft Stopping and The attic represented a substantial unprotected Tenant Fire Separations combustible space whose primary fire defense is the building code required draft stopping at tenant separation walls. Between effective draft stops, unimpeeded fire growth can be expected and, with typical attic ventilation, plenty of air will be available for this growth. Stopping the fire’s spread at this point will depend on the integrity of the draft stops, fire department intervention, and the failure time of the construction. In this structure, the location of draft stops may not have coincided with tenant separation walls in all locations. The fire may have traveled through apartments under the draft stops. Ventilation Openings Air vent openings at the building eaves permitted the into Attic fire to easily access the unprotected combustible attic space. Fire Spread The open combustible corridors and balconies and lightweight exterior wall finish supported rapid vertical and horizontal fire spread. KEY ISSUES Issues Comments

BUILDING HISTORY AND CONSTRUCTION The Old Buckingham Station apartment complex consisted of three and four story wood frame multi-family structures distributed over a wooded site with rolling hills. Buildings are grouped in clusters at different elevations. Vehicle access within the complex is provided by paved roadways and parking areas adjacent to the buildings. Two connection points provide access to the Midlothian Turnpike which passes on the south side of the complex. (See Appendix A for site plan.) According to Chesterfield County records, preliminary pre-design meetings with the developer and architect began in September 1986. While automatic sprinklers were not required by the building code, modified residential automatic sprinkler protection for the entire complex was discussed from the outset. These discussions related to the building code “modifications” that would be allowed based on the added protection provided by the sprinkler installation. (A description of the modifications granted is provided in the Building Code Section of this report.) Construction began in June 1987 and a certificate of occupancy was issued in January 1989. All of the buildings were protected by what local officials describe as a ìmodifiedî NFPA 13D residential style automatic sprinkler systems. Fire Building The Lodge Building was the largest building in the complex and contained 58 apartment units with over 57,000 square feet of occupied floor area. The building varied Report 105 Page 4 Delayed Fire Reporting The exterior point of origin and time of ignition combined to cause a long delay in the dicscovery and reporting of this fire. Access Limitation The main body of fire was on the side of the structure with restricted access. Swimming pool, fencing, and lack of roadways delayed the fire department’s attack on this side. KEY ISSUES (Continued) Issues Comments

Report 105 Page 5 from three to four stories in height. The building was “x” shaped with a four story cen- ter core area and four, three-story wings. (See Appendix B for drawing.) The core con- tained the complex’s management offices and social function room on the lower two floors and two apartments on each of the third and fourth floors. A single elevator in the core area served all four floors by means of open corridors. Two of the three-story wings had approximately 4,700 square feet of area on each floor divided into five apartments. These larger wings formed the east front of the building. The two rear wings were also three stories high but contained only four apart- ments and about 3,500 square feet per floor. The floor-to-floor height was approxi- mately 9.5 feet. A common, multiple level peaked roof with asphalt shingles covered the core area and the four wings. The exterior walls were load bearing wood stud construction covered with vinyl siding over Thermo-ply sheathing, a thin specialty construction material which has the visual appearance of pressed paper board covered with aluminum foil. These walls were insulated with fiberglass batts in the studs spaces, with a sheet plastic vapor barrier cov- ered by gypsum board on the inside. The interior walls were also of wood stud construc- tion covered with gypsum board. The floors were 2x4 parallel cord trusses 18 to 24-inches deep supporting a ply- wood subfloor that was topped with a thin (about 1-inch) layer of lightweight concrete. Gypsum board ceilings were attached directly to the bottom cords of the truss. The roof was constructed of a chip board deck over peaked wood trusses made from 2x4 and 2x6 members. The truss span was approximately 40 feet with a peak height of 13.5 feet and an 8/12 pitch. The roof contained a ridge vent and continuous soffit vents were provided around the perimeter of the building. (See Appendix C for soffit vent details.) The combustible attic space was divided by draft stops at intervals of every three or four apartment units depending on the wing of the building. The draft stop construc- tion was indicated as a single layer of 1/2-inch thick gypsum board attached to one side of the roof truss. The floor trusses were draft stopped at the separation walls between apartments. This was reportedly done by continuing the gypsum board wall covering to the floor deck above rather than stopping at the ceiling attached to the bottom truss cord. Each apartment entrance door opened directly to the outside. The first floor apartments were accessed via a covered concrete sidewalk. The upper floors had wooden covered walkways leading in two directions to open wood frame stairs one

located at the core and the other at the ends of the wings (See Appendix C for diagram). The walkways were of wood construction and contained small gaps between the deck boards to permit water to drain through. With the exception of horizontal sidewall auto- matic sprinkler heads that were located near the two core stairways, the covered walk- ways were not protected by automatic sprinklers. On the side of the apartment wings opposite the walkways, each unit had a cov- ered exterior balcony. On the first floor, the balconies were concrete on grade, while the upper floor balconies were wood frame construction very similar to the walkways. There was no automatic sprinkler protection for any of the balconies. BUILDING FIRE PROTECTION Automatic sprinklers were installed in all of the apartments, storage and other occupied spaces. The installation in the apartments followed a modified NFPA Standard No. 13D wet pipe automatic sprinkler design. This system was designed and installed before NFPA Standard No. 13R was adopted. (See Appendix D for an explanation of NFPA 13, 13D and 13R.) The residential sprinkler systems were supplied by a 1-1/2- inch metered domestic water connection into each of the four wings. Each wing had a separate, single 1-1/2-inch hose connection for the fire department to supplement the sprinkler water supply. These connections were located in the first floor walkway which surrounded the core area. There were no standpipes or hose valves connected to any of the automatic sprinkler systems. The sprinkler system used residential, quick-response sprinkler heads supplied by polybutylene piping in the apartments. The installation employed Underwriters Laboratories listed products and connection methods utilizing heat fusion rather than the mechanical type connections used with polybutylene plumbing. An NFPA Standard No. 13 compliant wet pipe automatic sprinkler system was installed in the core offices and social function room. Residential quick response heads were used in the third and fourth floor apartments; regular sprinkler heads sup- plied by steel piping were installed in the offices and social room. This system had a separate code-complying fire protection water supply connection with a fire depart- ment connection located at a pit in front of the building. This water supply was also connected to the residential sprinklers in the four apartments on the third and fourth floors of the core section. Report 105 Page 6

The combustible concealed spaces, including the attic, floor/ceiling space and vertical shafts were not protected by automatic sprinklers. The outside wooden walk- ways and balconies were also unprotected, except for some selected core areas. At these core areas, the two open stairways were protected by dry-type sidewall automatic sprin- kler heads located on the wall opposite the stairways. Evidence indicates that one of these sprinklers operated to extinguish the fire at the point of origin. However, by the time the sprinkler operated, the fire had spread beyond the sprinkler head’s reach. Each apartment was also provided with a hardwired single station smoke detec- tor located outside the sleeping areas. Alarm bells for occupant notification were oper- ated by water flow switches in the automatic sprinkler system. Manual pull stations were not provided. Automatic Sprinkler Water Supply The automatic sprinkler systems and fire hydrants in the Old Buckingham Station complex were supplied by an 8-inch ductile iron water main loop that was con- nected to a 12-inch circulating water main under Midlothian Turnpike. Because of the rolling type hills in the county, water system pressure varies significantly. Water flow test information from 1988 indicates that 1800 gpm was available at 20 psi in the area of the complex. Static water pressure for this test was recorded at 58 psi for a higher elevation. Adjusted to the Lodge Building elevation, this pressure would have been about 68 psi. The modified sprinkler system was tested after installation by flowing water from four remote heads. This test indicated that the supply met or exceeded NFPA requirements. (See Appendix D for requirements) THE FIRE Fire investigators determined that the fire began on the second floor in a covered walkway between the northeast wing and the center core, just outside of apartment 2J. (See Appendix B for location) The cause was identified as an exterior light fixture that had been inverted from its usual operating position by one of the occupants and then wrapped with a flannel shirt to reduce the light intensity into their bedroom. The fix- ture’s incandescent bulb was enclosed by a clear plastic globe. By inverting the fixture, the vent holes, which were intended to remove heat from the 60 watt bulb, were out of position and the plastic globe in combination with the flannel shirt held in the heat. This eventually resulted in the ignition of the shirt and the light fixture’s plastic globe. The fire spread to the vinyl plastic siding and to the wooden stairway. Report 105 Page 7

The siding fire quickly moved up the nearby open, wooden stairway before the sidewall sprinkler on the wall opposite the light fixture was able to operate. (See Appendix E for Section Drawing) The fire continued to burn upward until it reached the ceiling of the fourth floor open walkway. At this point it entered the combustible attic through a vent opening at the outside perimeter of the ceiling. The soffit vents in the fourth floor core area were located inside, rather than outside, the perimeter support beam for the roof. This design contained the heat and flames at the fourth floor ceiling and allowed them to pass through the vent into the unprotected combustible attic. Once in the attic, the fire was out of reach of the exterior sprinkler heads. As the fire burned in the unsprinklered attic, it was able to quickly travel hori- zontally to the fire/draft stops and then vertically up through the roof deck and down into the apartments. The fire consumed the structural supports for the roof, ceiling, and automatic sprinkler system. As these items failed, the fire moved past the fire/draft stops into the next attic section. The fire travel paths included burning across the combustible roof as fire/draft stops do not penetrate the roof deck. In addition, the fire may have also burned around the bottom of the draft stops as some of these stops may not have been placed in line with the separation walls between apartments. The fire also spread horizontally through the unprotected open wooden walkways around the building’s core.(See appendix D for a comparison of automatic sprinkler requirements.) This allowed the fire to spread to all four wings and all four floors through the core’s open stairways. The fire also began dropping down from the attic to involve the unprotected combustible balconies, which allowed the fire to spread into multiple apartments through the large glass doors which opened onto the balconies. By the time this fire encountered automatic sprinklers inside the apartment living areas, it had consid- erable momentum and was already attacking the sprinkler supporting elements. Fire Department Rescue and Suppression Activities Chesterfield’s 911 Emergency Center received a telephone report of the fire and, at 0147 hours, dispatched an initial assignment from Stations 4 and 5. Two engines from each station, Trucks 37 and 77 and the North Battalion Chief responded. Initial station alerts also provide firefighter, officer and equipment resources staffed by responding Report 105 Page 8

volunteer members. Station 5, about 0.8 mile from the apartment complex, was the clos- est station dispatched. Engine 53 with five firefighters was the first unit on the scene at 0153 hours, followed by Engine 54 with four firefighters. On arrival, the officer of Engine 53 reported fire showing from the roof over at least two third floor apartments adjacent to the core area and spreading rapidly horizon- tally and vertically. Incident Command was established and sectors identified using their standard procedure. The front (east) side of the building was designated as Sector A. The designations then proceed clockwise around the building: Sector B on the south, C on the west and D on the north. Each sector contained one side of two different wings plus part of the core area. (See Appendix F for drawing.) Incident Command passed from Engine 53’s officer (career) to the Assistant District Chief (volunteer) at 0156 hours and then to the area’s Battalion Chief, Battalion 3, (career) at 0200 hours. At the change in commands, Engine 53’s officer took charge of the Interior Sector. The initial strategic plan begun by Engine 53’s officer to search for and evacuate occupants and control fire spread was maintained throughout the incident. Because of the time of night, it was expected that most residents were home and asleep. Notification and evacuation of the occupants became the first priority of arriving companies. Crews of the initial units were split into two teams; about half of each crew was assigned to search and evacuation and the balance of each crew to fire suppression. The suppression effort of the first two engine companies, Engines 53 and 54, was to support the core section automatic sprinkler system and to operate a deluge set on Sector A (See Appendix F for drawing.) The core sprinkler system was charged through the siamese connection located at the pit in front of the building. There is no indication that any of the four wing fire department connections to the sprinkler systems were used. At 0156 hours, the Incident Commander reported “water on the fire” and directed incoming units to prepare for exterior master stream operations and to assist with search efforts. The first truck company, Truck 37, was positioned on the north side of Sector A to operate an elevated master stream. Engine 43 was directed to Sector D and to place into operation a portable deluge set at this sector’s west end. (See Appendix G for drawing.) Engine 44 was directed to assist Engine 43 with the deluge; both crews were split into search and suppression elements. As additional Station 5 volunteers arrived, they were primarily assigned to the search and evacuation of occupants. Truck Report 105 Page 9

77 was positioned at the east end of Sector D for the second elevated master stream. At this time, three master streams were operating and a fourth was being set up. Search and evacuation operations were underway in Sectors A and D. Around 0200 hours, the Incident Commander requested three additional engine companies to the scene. Other engine and truck companies were also being relocated from county fire stations away from the fire to cover nearby stations. These relocations were coordinated by the third on-duty battalion chief whose district was furthest from the fire. Special equipment such as the communications/command vehicle, air mask unit, and lighting were also dispatched during this time. At 0207 hours, the Interior Sector reported that the fire in the central core area had dropped from the third floor to the second floor and about 4 minutes later, the crew in Sector C reported fire now on all four floors and through the roof at the core. Search of this section was deemed impossible due to the intensely burning fire in this area and the beginning of structural collapse. Engine 93 was assigned to Sector D to lay a line from Truck 77 to the area of Engine 43 and to supply the line. Engine 102 was also assigned to this sector and con- nected into the two supply lines to the deluge set at the west end. These parallel lines exceeded 400 feet in length and Engine 102 relay pumped into the deluge. The crews from 93 and 102 were initially assigned to completing the search operation and then later to suppression operations in Sectors B and C. Chesterfield Fire Department does not routinely use large diameter hose (LDH) for water supply on its apparatus although it has several engines so equipped on an experimental basis. No LDH was used during this incident. The department’s usual water supply hose on engine companies is 3î diameter double jacket lined hose. Unless specially noted, supply lines from hydrants to the fire ground were 3î diameter. Engine 53 was moved from Sector A in front of the building to Sector B. It laid parallel supply lines from Engine 54 to its position in Sector B. This crew and a number of Station 5 volunteers operated a hand line on this side of the fire in addition to search- ing the apartments for occupants. Between 0200 hours and about 0225 hours, six engines, two trucks and the Station 5 volunteers who had responded directly to the scene were operating four master streams, two hand lines and were searching all of the building not presently involved. Report 105 Page 10

The “All Clear” signal for the primary search for Sector B was given at 0225 hours and for Sector D at 0232 hours. As the principal means of access to the apartments in all four wings were located in these two Sectors, this was also the all clear for the building. (See Appendix B) By about 0230 hours, the fire involved approximately 75% of the building’s entire roof, all of the fourth floor in the center core, about 60% of the building’s third floor and all of the first and second floors of the center core. Battalion B, Senior Battalion Chief, assumed Incident Command at 0240 hours after touring around building. Battalion 3 was designated as Operations Officer and the Assistant District Chief was designated the Incident Safety Officer. With the primary search completed, the Incident Commander directed all available resources to fire containment and suppression. At this time effort was made to increase the water supply being delivered to the fire ground. The two hydrants nearest the building were being fully utilized by apparatus and the next available hydrants were each over 700 feet away. Engines 103 and 106 com- bined together to lay a new supply line from Sector A to the hydrant at Buckingham Station Drive and East Coal Hopper Lane (See Appendix H). Engine 103 pumped from the hydrant to Engine 106 which supplied a line into Sector D. The crews initially oper- ated lines on the second floor of this Sector but this operation was later suspended because of the elevated master streams working on both sides of the building’s wing in this area. Engine 102 moved the portable deluge from Sector D into Sector C by extending the lines. The crew stretched a supply line from the engine into Sector C where it was wyed into two 1-3/4-inch handlines. These handlines were directed into this wing and also used to protect the building at 13201 Boggie Road West which was being affected by radiant heat. Engine 112 laid a second supply line from Engine 103 to Engine 54 and then into Sector B. Engine 112 directed used its mounted deluge, a 2-1/2-inch handline, and a second master stream onto the fire in Sector B. Engine 73 was also assigned to increase the water supply to Sector B. Two sup- ply lines were stretched from a hydrant at the rear of the Village Shopping Center to Engine 53. The placement of these lines involved a 600 foot long hand stretch through the woods. Once the lines were in place, the crew assisted with the placement and oper- ation of a deluge from the southwest corner of Sector C into the center of the building. Report 105 Page 11

By 0330 hours, ten engines were supplying water to two elevated master streams, seven additional master streams and six handlines of assorted diameters. By counting the master stream appliances and the number of handlines, fire officials esti- mated a peak fire flow of 5,500 gpm was being delivered to the fire. The spread of the fire was halted and the heavily involved areas began to darken down. The master streams continued to operate for the next 1-1/2 hours. During this time, crews were also performing secondary searches of apartments. Special emphasis was placed on those apartments where there was no account of the occupants’ location. A severe thunderstorm moved through the area after 0400 hours. The elevated master streams were shut down and the aerial apparatus lowered. Sector Officers were ordered to shelter all personnel in safe locations. The portable deluge sets and engine mounted deluges continued to operate unmanned during the storm. During the fire sup- pression effort, the Incident Commander twice requested all Sector Officers to report on Personnel Accountability. The first was at 0340 hours during the major assault on the fire. The second occurred at 0450 hours after the severe thunderstorm had subsided and crews were returning to the fire ground. At 0453 hours the fire was declared under control. The Operations Officer met with the Sector Officers to develop an overhaul plan. It was decided that only exterior suppression operations would be permitted until day break, when a full safety assess- ment of the building could be made. The Chesterfield County Building Officials Office was contacted to assist with the building’s structural assessment. Sections of the build- ing were identified where it was considered structurally safe to overhaul. Release of companies began at 0800 hours and a shift change for on scene com- panies was conducted between 0800 and 0845 hours. Overhaul and salvage operations continued all morning and into the evening. Five engines and two trucks remained on the scene for most of the day. An Occupant Services Sector under the command of a Department Captain was established by the Incident Commander during the morning. It was responsible for the coordination of resident access into their apartment to salvage and recover personal items from sections of the building identified as being safe. Residents were escorted into their units starting at about 1300 hours and access continued into the evening hours. Report 105 Page 12

Injuries The fire department reports indicate that there were no fatalities or injuries to apartment occupants. Two firefighters became ill and were transported to the hospital for observation; they were later released. There were no injuries to firefighters. BUILDING CODES At the time of design and construction of the Old Buckingham Station apart- ments, Chesterfield County was using the 1984 editions of the BOCA Basic National Building and Mechanical Codes. These documents did not require automatic sprinklers throughout any of the buildings planned for the complex. Negotiations between the developer and Chesterfield County officials produced an agreement requiring a modified NFPA Standard No. 13D automatic sprinkler system to be installed in all buildings. This agreement provided for the use of 1/2-inch type “C” gypsum board in place of 5/8-inch type “X” board except at common party walls and fireplace chases. The agreement also allowed that, subject to building separation distances, the exterior walls did not need to have a fire resistance rating and fire rated floor/ceiling assemblies would not be required, allowing the use of 1/2-inch dry wall. Allowable setback distances from streets and parking areas were also increased. Fire stop partitions in an attic are important to slow the fire’s spread throughout this large unsprinklered combustible concealed space. Their purpose in the building code is to provide a brief, rarely more than 20 minutes, period to hold the fire from spreading horizontally beyond the first compartment. Their successful function antici- pates that the fire department can be in place and attacking the fire within this time period. Even when constructed in accordance with building code requirements and well maintained (i.e., with no openings or holes around penetrations), they require timely fire department intervention to be effective. Firefighters with hose lines and tools will need to be dispatched to these locations early on the fire. These partitions also have to be located where the fire cannot easily travel around or under them. It is good practice to locate them in conjunction with the tenant separation walls as they are also required to have some resistance to fire spread. The developer requested that the attic firestops be provided on the basis of 3,000 square feet segments. In the requested attic firestop arrangement, the walls in the attic may not have been located at the same place as the tenant separation walls. According to April 28, 1987 correspondence, the County rejected the request. The tenant separation Report 105 Page 13

walls were to continue through the attic space to the underside of the combustible roof deck. Based upon the fire department’s investigation after the fire, the attic firestop walls were not in alignment with the tenant separation walls. FIRE DEPARTMENT AND EMERGENCY SERVICES The Chesterfield Fire Department is a combination career and volunteer depart- ment that operates from 15 stations. It is staffed by 325 career personnel and 350 volun- teers. Chesterfield County’s population is 233,000 and it measures approximately 446 square miles. In 1994, the fire department reported a total of 17,653 EMS, fire and other emergency calls. Out of the 15 stations, the department operates some 23 engines, 5 trucks, 4 tankers, 3 heavy duty rescue squads, an airport crash rescue vehicle and a number of specialty vehicles for hazmat, underwater dive rescue, brush, lighting and air mask sup- port. A combined fire and police mobile command vehicle is also available. The depart- ment continuously staffs four advanced life support (ALS) ambulances with career per- sonnel. An additional five ambulances are staffed during the daytime with career per- sonnel and at night with volunteer members. These five ambulances are typically ALS in the daytime and basic life support (BLS) at night. An additional four all volunteer rescue squads are provided in the county. Career personnel operate in a three platoon system of 24 hours on duty with 48 hours off. The county is geographically divided into three battalions with a career battal- ion chief on duty in each area. The senior battalion chief on duty is the overall shift commander and typically responds to the scene of any working fire in the county. The senior battalion chief in each platoon reports to the deputy chief of emergency opera- tions. The operations deputy also supervises the emergency medical and med-flight functions. A second deputy chief supervises support services including training and safety, fire prevention, maintenance and logistics, administrative services, and informa- tion services. The two deputy chiefs report to the chief of the department who is also the county’s coordinator of emergency services. Minimum staffing on both engines and trucks is three and many companies will typically have four personnel. Staffing is typically higher at nights when volunteers will sleep in the stations along with career staff. Two stations are staffed entirely with Report 105 Page 14

volunteers, five stations are staffed entirely with career personnel and eight stations are combination career and volunteer. In these combined stations, typically two separate engines are provided; one for the career staff and the other for volunteers. Fire hydrant location and spacing will depend upon the area of the county. Although water mains may be present, fire hydrants are installed only as the land is developed along the roadways. The location and spacing would be based on the size and occupancy of the development. Where new water mains are extended into developing land, hydrant location and spacing is usually reviewed with the fire prevention bureau. In this project, hydrant spacing adjustments were made to recognize that all of the apart- ment buildings were being protected by automatic sprinklers. As a result, the hydrant spacing in the complex exceeded the typical 300 to 500 feet spacing used for multifam- ily residential buildings. LESSONS LEARNED 1. Large unsprinklered spaces with exposed combustible construction can allow a fire to develop and spread beyond the control of automatic sprinklers in adjacent spaces. NFPA Standard Nos. 13D and 13R allow unsprinklered areas with exposed com- bustible construction such as attics. Once a fire enters such a space, it can spread beyond the reach of the automatic sprinklers protecting the living areas. It was recog- nized during the development of these standards that some residential fires, once they penetrate into an unprotected space, would not be controlled by automatic sprinkler sys- tems complying with the standards. In this incident, the fire started and grew to a significant size before the auto- matic sprinkler in the area of origin operated. The fire entered the unsprinklered com- bustible attic space and spread horizontally before dropping into the upper floor apart- ments. At this time, the fire size was beyond the control of the installed automatic sprin- klers. It also spread on the exterior of the structure by means of the combustible bal- conies, walkways and lightweight combustible siding. This avenue of travel allowed the fire to quickly enter the lower floor apartments through the glass balcony doors and exterior windows. Report 105 Page 15

The building construction used light weight combustible elements which allowed the fire to rapidly spread vertically and horizontally. The unprotected ventilation openings provided an avenue for the fire to readily penetrate into the unsprinklered combustible attic spaces. The fire quickly spread upwards on the exterior of the building, taking advantage of the lightweight plastic siding, an open wooden stairway and wooden balconies. The under-eave vents provided an easy path by which the fire and hot gases could enter the attic. Although the sidewall sprinkler head on the wall opposite the point of origin even- tually operated and controlled the fire at that point, the fire had already spread beyond the range of this head. The combustible construction materials and their arrangement allowed the fire to spread faster than the automatic sprinkler heads could respond. (Thermal lag of the sprinkler heads causes an operational delay, consisting of the time between heat first reaching the head until when the fusible element opens.) Location of vents should be coordinated with openings in exterior walls and balconies to minimize the potential for fire spread. Attic eave vents should not be located near windows, door- ways or vents which may allow fire extension to the attic. In addition to the automatic sprinklers, compartmentation is another means of controlling the speed and range of fire spread. To be effective, compartment construc- tion materials should have sufficient resistance to fire penetration and openings must be protected, eliminated completely or located out of predictable fire travel paths. 3. Draft stopping, fire separations, and tenant separations need to be coordinated into a sound compartmentation system that will slow the rate of fire spread through unsprinklered combustible spaces. Post fire investigation suggested that the location of attic draft stop partitions was not as noted on the building’s plans. Apparently the installed draft stops in the attic trusses did not coincide with the separation walls between apartments. Because the draft stops may have been located over apartments, as opposed to lining up with apartment separation walls, the compartmentation from the floor to the underside of the roof deck was not continuous. After the fire was established in an apartment a travel path around the draft stop and into the attic was provided. Attic draft stops are intended to slow the rate of a fire’s progression by providing a few minutes of delay. It is intended to provide a point where the fire department can take a Report 105 Page 16

defensive stand. A draft stop does not possess the same fire resistance as a fire partition or a fire wall, nor does it penetrate a roof, even when the roof is of combustible construction. It will not be an effective fire stop without fire department assistance and support. 4. The Lodge Building had five separate fire department connections to provide fire department support to the automatic sprinkler system. Each wing had a separate connection and the fifth siamese was at the pit in front of the building. Multiple connections are difficult to deal with even when grouped together and clearly marked as to their function or area protected. In this instance, one siamese con- nection was highlighted by being prominently located at a pit in the front of the building and was used by one of the two first-in companies. There were no reports of any of the other four connections being used. This could have resulted from the fire’s location in the core area making access to the other connections dangerous. Alternately, the lack of their use could be the result of confusion on the number of connections needed to sup- port the entire sprinkler system. Because of the extension of the fire into the unsprin- klered attic space early in the incident, it is doubtful that the use of the four additional fire department connections would have had any material effect on the end result. 5. Not all sides of this x-shaped structure were easily accessible for fire department apparatus. Sector C contained the pool and recreation area which was surrounded by an iron fence and did not have direct vehicle access. The restricted access to the sides of the building made it difficult to directly attack the initial fire. It also reduced the effectiveness of the initial hose streams because they were unable to reach the entire fire area. Large caliber fire streams could not be rapidly placed onto all sides of the main fire body to wet uninvolved areas of the struc- ture. Fire growth in Sector C constituted a problem that could not be completely resolved until more resources were available. Access to all sides of a building should be incorporated into the design and con- struction process. Proposed site drawings should indicate the location of fencing, land- scaping, walkways, and security features which may slow fire department access. Features, such as emergency access gates, wide sidewalks, fire lanes and reinforced all weather road beds, should be provided from the normal roadways into key locations. Report 105 Page 17

Callling for additional fire unites early in the incident is important to support first alarm units when faced with multiple tactical operations. Tactical plans involving fires in large residential occupancies continually balance resources between search and rescue and fire suppression. Both must be done simultane- ously because concentrating on one can result in neither being accomplished success- fully. To complete search and rescue, the fire spread must be slowed to allow companies the time to work. All residents immediately endangered by the fire must be quickly evacuated. Even residents remote from the actual fire can be overcome from the smoke and the large quantity of carbon monoxide generated during fire suppression. Additional fire companies were called prior to the arrival of the first due unit based on dispatch information and the fire officer's knowledge of this structure. After the arrival of the first in Battalion Chief, more fire units were dispatched to the incident. Additional units were dispatched to reinforce Sectors and proide relief crews for the Sectors. Because of the large area, irregular shaped buildings, and the large volume of fire some support functions were decentralized to the Sector level. Staging was not esta- bilshed because arriving units were immediately assigned to Sectors to perform tactical operations or provide relief crews. Rehab areas were established on the Sector level to provide services to fire companies in a more effective and efficient manner. 7. The extended detection time likely contributed to the difficulty in controlling the fire. Based upon the time of fire origin and its location on an outside walkway, it is believed that some delay occurred in detecting this fire. The nearest fire detection device to the fire’s point of origin was the sidewall style automatic sprinkler opposite the open stairway. By the time this head operated and the waterflow alarm registered the activa- tion, it is likely that the fire was already threatening the attic, if it was not already into the attic. The first fire department units on the scene reported a substantial fire in progress around the building’s center core area. Report 105 Page 18

This structure made use of light weight combustible surfaces and contained substantial unprotected combustible concealed spaces. These features provide for rapid fire spread and growth. Both officers and firefighters need to recognize and report on finding these items. This was the largest fire in a multi-family occupancy in the history of the Chesterfield Fire Department and it was successfully controlled without loss of life or significant injury to occupants or fire fighters. Yet the fire did substantial destruction and damage to the property. The speed of fire travel and the time needed to establish an effective suppression operation are elements that must be incorporated into the overall tactical plan. These two elements influence the placement of individual companies, loca- tion of master streams, and the time search operations will have available. Individual and multiple company drills can identify the amount of time and the effort required for specific fire ground operations. However, learning about and appreci- ating how fire spreads and how quickly it can expand is not easily done. This learning involves a combination of classroom theory, review of past fires, thorough post-incident critiques and actual experience. Each of these elements is different for firefighters, com- pany officers, and incident commanders. Report 105 Page 19

Appendix A Report 105 Page A

Appendix B Report 105 Page B

Appendix C Report 105 Page C

APPENDIX D NATIONAL FIRE PROTECTION ASSOCIATION RESIDENTIAL AUTOMATIC SPRINKLER REQUIREMENTS This section contains a summary of residential sprinkler system design criteria for three NFPA automatic sprinkler system standards. Two of the standards were pub- lished and effective at the time that Old Buckingham Station was being designed and constructed. The third standard was being developed during this period and was offi- cially published with an effective date of February 6, 1989. NFPA Standard No. 13, 1985 edition, Installation of Sprinkler Systems A new section in Chapter 7 on hydraulically designed systems provided the water supply requirements. This section applies to dwelling units where listed residential sprinklers are used. Other areas or the use of other types of automatic sprinkler heads would result in the application of other water supply requirements from the standard. Water supply requirements specify a minimum of 18 gpm for a single operating sprinkler head and 13 gpm per sprinkler head for multiple operating sprinkler heads. This is the same as NFPA 13D because the same fire test data and occupancy is used. All sprinkler heads in a compartment to a maximum of 4 heads shall be used in determining the total water supply amount. This represents two additional heads beyond that required by NFPA No. 13D. The typical water supply requirements would be about twice that for one-and two-family dwellings. This standard requires that automatic sprinklers be provided throughout all parts of the building. This would include combustible walkways, breezeways, and balconies. For unheated spaces, either dry systems, antifreeze systems, or special dry style sprin- kler heads would be required. In this building, automatic sprinklers would have been required in the attic, walkways and most likely the apartment balconies. The presence of automatic sprinklers in the attic would have likely reduced the extent of destruction. However, NFPA Standard No. 13R applied to the sprinkler instal- lation as the building was rebuilt and the attic was not protected. Report 105 Page D-1

Report 105 Page D-2 NFPA Standard No. 13D, 1984 edition, Installation of Sprinkler Systems in One- and Two-Family Dwellings and Mobile Homes. The installed automatic sprinkler system would use only new, listed or approved residential style automatic sprinkler heads. The response and water distribution charac- teristics of other automatic sprinkler heads might require different water supplies. Water supply requirements specify a minimum 18 gpm for a single operating sprinkler head and 13 gpm per sprinkler head for multiple operating sprinkler heads. All sprinkler heads in a compartment to a maximum of 2 heads shall be used in determining the total water supply amount. Essentially, this means that the typical fire protection water supply would be at least 26 gpm for the dwelling. The pressure required would have to meet the requirements of the sprinkler head listing. Automatic sprinklers may be omitted from typical bathroom and closets, open porches, garages, carports, and attics and crawl spaces which are not intended for living purposes or storage. The emphasis is to locate automatic sprinklers in the living area, heated utility areas, and unfinished storage areas. NFPA Standard No. 13R, 1989 edition, Installation of Sprinkler Systems in Residential Occupancies up to Four Stories in Height This is the first edition of the standard and represented a milestone in the design of automatic sprinkler systems for low rise multiple family swellings. This standard was published after the occupancy certificates for this property were issued. The water supply requirements are the same as NFPA Nos. 13 and 13D which specify 18 gpm for a single head and 13 gpm per head for multiple operating heads. Again, the same fire test data and occupancy are used for designing the protection. All sprinkler heads in a compartment to a maximum of 4 heads are used in deter- mining the total water supply amount. This is the same water supply as that required by NFPA No. 13. Unlike NFPA No. 13, this standard does not require all spaces in the structure to be protected by automatic sprinklers. Bathrooms, small clothes closets, attics, crawl spaces, elevator shafts and exterior balconies, corridors and porches are areas where automatic sprinklers can be omitted.

Report 105 Page E

Report 105 Page F Tactical Operations, Initial Appendix F

Report 105 Page G Tactical Operations, Search & Rescue Appendix G

Report 105 Page H Tactical Operations, Suppression Appendix H

Report 105 Page I-1 Appendix I PHOTOGRAPHS

Report 105 Page I-2

1. Site view of fire with north to the left. The shopping center and woods for the hand-stretched hose is on the left with Engine 73 still in position.

Report 105 Page I-3

1. View of building with units still operating to complete extinguishment. North is to the left.

Report 105 Page I-4

1. The rear or swimming pool side of the four story core building before the fire. The

fire started on a second floor breezeway on the left side of this photograph.

1. The main entrance to the building and the four story core building before the fire.

North is to the right.

Report 105 Page I-5

1. Fire involvement in Sector D (North side) as units were preparing to operate in this

sector. The fire was well-established in the attic, third floor walkway, and fourth floor.

1. Fire hydrant and core siamese connection used by Engine 54 on arrival. Repairs and recon-

struction are being made to the front wing; this side is the patio/balcony for each apartment.

Report 105 Page I-6

1. Reconstruction underway in Sector B, which is on the south side of the building. The

exterior walkways were on this side of the wings.

1. The remains of the front archway and the repairs and reconstruction underway for the

wing in Photograph 6. The attic trusses and exterior sheathing materials are illustrated.

Report 105 Page I-7

1. The exterior walkways in Sector D, with the stairway located at the left edge of the

photograph. The core is out of the picture to the right.

1. The stairway and exterior walkways used throughout the building. Note the gaps in the walk-

way to allow water to drain and the piece of thin exterior sheathing leaning against the stairway.

Report 105 Page I-8

1. The parallel cord wood floor trusses used in the original construction and a

polybutylene automatic sprinkler line.

1. Typical eve line vents installed around the perimeter of the building. The fire is

believed to have entered the attic through these vents.

FD06007 ｜ 1995_US_USFA_TR-108_St_George_Hotel_Complex_16_Alarm_Fire_Brooklyn_New_York_Investigation.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1995 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Federal Emergency Management Agency St. George Hotel Complex 16 Alarm Fire Brooklyn, New York Technical Report Series United States Fire Administration United States Fire Administration

UNITED STATES FIRE ADMINISTRATION FIRE INVESTIGATIONS PROGRAM The United States Fire Administration develops reports on selected mayor fires throughout the country. The fires usually involve multiple deaths or a large loss of property. But the primary criterion for deciding to do a report is whether it will result in significant lessons learned. In some cases these lessons bring to light new knowledge about fire — the effect of building construction or contents, human behav- ior in fire, etc. In other cases, the lessons are not new but are serious enough to highlight once again, with yet another fire tragedy report. The reports are sent to fire magazines and are distributed at national and regional fire meetings. The International Association of Fire Chiefs assists USFA in disseminating the findings throughout the fire service. On a continuing basis the reports are available on request from USFA; announcements of their availability are published widely in fire journals and newsletters This body of work provides detailed information on the nature of the fire problem for policy makers who must decide on allocations of resources between fire and other pressing problems, and within the fire service to improve codes and code enforcement, training, public fire education, building technol- ogy, and other related areas. The Fire Administration, which has no regulatory authority, sends an experienced fire inspector into a community after a major incident only after having conferred with the local fire authorities to insure that USFA’s assistance and presence would be supportive and would in no way interfere with any review of the incident they are themselves conducting. The intent is not to arrive during the event or even immediately after, but rather after the dust settles, so that a complete and objective review of all the important aspects of the inci- dent can be made. Local authorities review USFA’s report while it is in draft. The USFA investigator or team is available to local authorities should they wish to request technical assistance for their own investigation. This report and its recommendations were developed by USFA staff and by Varley-Campbell & Associates, Inc., Miami and Chicago, its staff and consultants who are under contract to assist the Fire Administration in carrying out the Fire Reports Program. The United States Fire Administration greatly appreciates the cooperation and information received from officials of the City of New York Fire Department, most particularly commissioner Howard Safir and Assistant to the Commissioner Tom Fitzpatrick. For additional copies of this report write to the United States Fire Administration, National Fire Data Center, 16825 South Seton Avenue, Emmitsburg, Maryland 21727. For color copies of photographs, see USFA WEB Page at http://www.usfa.fema.gov/usfa.htmp.

St. George Hotel Complex 16 Alarm Fire Brooklyn, New York Investigated by Scott M. Howell This is Report 108 of the Major Fires Investigation Project conducted by Varley-Campbell & Associates, Inc. under contract EMW-94-C-4423 to the United States Fire Administration, Federal Emergency Management Agency. Federal Emergency Management Agency United States Fire Administration

Report 108 Page d

St. George Hotel Complex 16 Alarm Fire Brooklyn, New York August 26, 1995 Investigated by: Scott M. Howell Edited by: Sheila-Faith Barry Local Contacts: (Former) Commissioner Howard Safir Tom Fitzpatrick, Assistant to the Commissioner Assistant Chief Edward Cunningham Deputy Assistant Chief Steven DeRosa Deputy Assistant Chief Thomas Lally Deputy Chief David Corcoran City of New York Fire Department 250 Livingston Street New York, New York 11201-5884 (718) 694-2056 OVERVIEW More than 700 firefighters operating over 100 pieces of firefighting apparatus were needed to control a fire that involved several large interconnected buildings in a Report 108 Page 1

crowded neighborhood in Brooklyn, New York on August 26, 1995. The complex of buildings was known as the St. George Hotel. It was the largest fire in New York City in more than twenty years, and one of the largest in the city’s history. The fire began in a vacant nine-story building and spread to several adjacent exposures, including an occupied 31-story apartment building. The fire was well devel- oped on the ninth floor by the time it was located by the first arriving companies due to a delay in reporting the fire and the initial dispatch to a different building. An interior attack was attempted, however, the standpipe in the fire building was not functional and the firefighters were forced to abandon their initial attack as the fire spread through the original fire building and into the exposures. The fire presented severe life safety and property exposure challenges on all four sides, in addition to generating a storm of fire brands that were carried by the wind and threatened an even larger area. Report 108 Page 2

Report 108 Page 3 Delay in Reporting A delay in discovery and reporting of the fire allowed the fire to spread to a larger area before firefighters arrived. Protection of Vacant The failure of the standpipe in the fire building Buildings compromised the initial attack and endangered personnel. Rigorous inspections and enforcement of codes requiring fire protection systems to be maintained and vacant buildings to be secured against vandalism could have prevented this situation. Need to call for Because of massive exposure problems this fire Resources Early required a tremendous commitment of resources. The Incident Commander’s decision to call for additional resources in anticipation of the need was a major factor in the successful outcome of this incident. Fire Risk of Vacant Vacant buildings and complexes in crowded Buildings neighborhoods present a large fire risk. Incident Command The Fire Department of New York City has a wealth System of experience in conducting major operations and has developed standardized procedures for implementing components of the Incident Command System. KEY ISSUES Issues Comments

Report 108 Page 4 THE FIRE AREA The St. George Hotel was the grandest of New York City’s hotels when it opened in 1926. Located in the Brooklyn Heights area of the city, it had a total of 2,632 guestrooms in a complex of eight buildings that occupied an entire city block. (Figure 1). Some of the original buildings dated back to 1885. All the buildings were intercon- nected at the basement level, and there were numerous connections on various floor lev- els among the different buildings. The complex was bordered by Pineapple Street to the north, Clark Street to the south, Hicks Street to the east and Henry Street on the west. Many streets in the Brooklyn Heights area are only 40 feet wide. Parking on the streets in front of the fire building further congested the area. Figure 1 shows the block and the relationships of the buildings to each other. Over the years, several of the buildings in the complex were vacated, while oth- ers were converted to residential apartment use. Only the original St. George Hotel building on the east end of the complex operated as a hotel at the time of the fire. The building of fire origin, known as the Clark Building, was located at 51 Clark Street. It was nine stores high, measured 75 feet wide by 90 feet deep, and had been vacant for at least seven years. The ten story Grill building was immediately west of the Clark Building on the corner of Clark and Hicks. Although the Grill Building was only 25 feet deep, it had 100 feet of frontage on Clark Street. At one time the Grill Building and the Clark Building had been connected at each floor level with overhead rolling fire doors at the openings. After the Clark Building was vacated the fire doors were closed and the open- ings were bricked over on the Grill Building side. The 31 story Tower Building ran nearly the length of the block on Hicks Street, between Clark and Pineapple Streets behind the Grill and Clark Buildings. The Tower building had 175 feet of frontage on Hicks Street and 150 feet on Pineapple Street. The main entrance was at 111 Hicks Street. The Tower Building was built in 1929 of pro- tected steel construction and was connected to the Grill Building at the basement level. The portion of the Tower Building that fronts on Pineapple Street was built as a free-

Report 108 Page 5 standing structure known as the St. George Apartments. In recent years the original Tower building, the old St. George Apartments and the Grill Building had all been com- bined into one residential building known as the Tower Building. East of the Tower Building were the six story Crosshall and the eight story Pineapple Buildings. The Crosshall building had a fifty-foot frontage on Pineapple Street, while the Pineapple Building at 60 Pineapple Street is 115 feet wide and, like Crosshall, is ninety feet deep. The building that was being operated as the St. George Hotel occupied the entire east end of the block. The section that faces Pineapple is eight stories tall, while the por- tion that faced Clark Street was 12 stories tall. There were entrances on Henry Street, which had more than 200 feet of frontage, and on Clark Street, which had 125 feet of frontage. The New York City Transit Authority operates a subway station under the St. George Hotel with direct access from the lobby to the station. The Weller Building, west of the St. George Hotel, was four stories in height with a 50 by 85 footprint. Between the Weller and the Clark Buildings was the 12 story Marquee Building, which had been vacant for several years. The Marquee Building was separated from the Weller Building by fire doors. The 50 by 85-foot Marquee Building was open to the Clark Building on all floor levels. A common one story covered courtyard occupied the remaining open area between the buildings at the west end of the block. All the buildings on the block, except the 31 story portions of the Tower Building, were of ordinary construction. The Clark and Marquee Buildings were both vacant at the time of the fire while all of the other buildings were being used as residential occupan- cies. The St. George Hotel had some permanent residents and was also being used by various city agencies to provide temporary housing for AIDS patients. Standpipe systems and partial sprinkler systems were present and functional in the occupied building. The vacant Clark Building had been legally and illegally scavenged. Large sec- tions of flooring were missing and the standpipe system was partially dismantled. Vagrants were known to frequent the building despite efforts to keep the building sealed as required by New York City codes.

THE FIRE The weather was warm in New York City in the early morning hours of August 26, 1995 and many of the occupants of the St. George Hotel and the surrounding buildings had their windows open for ventilation. Sometime close to 3:00 a.m. several occupants called down to the hotel desk to report a smell of smoke. The phones in the rooms did not have the capability to call outside the hotel itself. The hotel staff noted that the alarm sys- tem for the building was not indicating a problem so they did not call the fire department. At 3:31 a.m. the FDNY Brooklyn Communications Center received a call report- ing smoke in the area of the St. George Hotel on Henry Street. A first alarm response consisting of three engines, two trucks and a Battalion Chief was dispatched and were on the scene by 3:36 a.m. Upon entering they were told there was no problem in the hotel and that the fire alarm control panel showed no activation. The Battalion Chief (BC 31) asked the dispatcher to call back the person reporting the smoke to get a better location. The dispatcher’s call was answered by an answering machine, so no additional information was available. The units on the scene followed their Standard Operating Procedures, which included sending the “roofman” of the first due-in truck company to the roof. Once there he was able to see the glow of the fire, which was several buildings down the block. At about the same time a civilian reported light smoke visible above the buildings around the corner, on Clark Street, to the crews standing by. At 3:44 a.m. the Battalion Chief, BC-31, transmitted a radio report to confirm the presence of a fire. An additional Battalion Chief (BC-35) a fourth engine company and a squad company were dispatched. The crews on the scene repositioned their apparatus on Clark Street and investi- gated further, but the extent of the fire was not obvious from street level because of the narrow streets and the fire’s location in the upper floors at the rear of the ten-story build- ing. Entry was made to the ground floor of the building through a boarded-up doorway. The crews were familiar with the general building layout from past incidents and pre- fire plans but had trouble gaining access to the stairway because of trash piled up in front of the stairway opening. At 3:45 a.m. BC-31 transmitted an “all hands” signal which prompted dispatch- ers to assign a Deputy Chief, (DC-6), a rescue squad and a third truck company. A sec- ond alarm and a special call for an additional tower ladder were transmitted about five minutes later by BC-31 as the fire was growing in intensity and spreading rapidly. The Report 108 Page 6

Field Communications Unit and Maxi-Water system respond automatically on a second alarm, along with four engine companies and one truck company. The Citywide Tour Commander also responded on the second alarm. The two first alarm truck companies performed a primary search of the fire building. After making their way up the stairs to the eighth floor, the engine companies connected 2-1/2 inch hand lines to the standpipe and the order was given to charge the system. However, the standpipe had apparently been scavenged and sections of the pipe were missing. The 2-1/2 inch hand lines were then lowered out the windows, hooked up to an engine in front of the building and charged. At this point the command post was in the street in front of the building. BC-31 was Incident Commander. (Figure 2). The interior fire attack had to be terminated after a very short time when it was determined that the fire was spreading down to the lower floors via the elevator shaft and other openings in the floors. BC-35 gave the order to remove the attack crews from the interior of the building. The fire was spreading so rapidly that the standpipe packs were abandoned. At this time Tower Ladder 119 was setting up in front of the building in anticipa- tion of an exterior attack on the fire. TL-119 was ordered not to begin operating until all the members who had been working inside the Clark Building were outside. As the last of the firefighters were leaving the fire building, the fire dropped all the way down to the street level and flames were visible on all ten floors. There was heavy involvement of the eighth and ninth floors. The firefighters in TL-119’s basket were experiencing extreme radiant heat as they waited for the order to open up their master stream. At 4:06 the first arriving Deputy Chief, DC-6, ordered a third alarm and assumed incident command. (Figures 3 and 4) As the fire was beginning to spread to exposure 4, the Marquee Building. The third alarm brought in four engines, 2 trucks, the Air Mask Maintenance Unit and a Medical Command Unit. The fire quickly began to produce a huge volume of fire brands. Residents used gar- den hoses to protect their roofs as the brands landed on nearby structures. Brands floated through open windows into the taller adjacent buildings and ignited fires in apartments. The fire department hose lines on Clark Street had to be washed down for protection. Report 108 Page 7

The Incident Commander assigned BC-35 to Exposure 4 to stop the fire from spreading through the Marquee Building to the attached buildings on the east side. A primary search was performed in the Marquee Building, but due to its poor structural condition crews were instructed to attack that portion of the fire from the next building to the east, the Weller Building (exposure 4A). In essence the vacant Marquee Building was used as a buffer to protect the buildings to the east. As the additional companies from the “all hands” signal arrived they were assigned to the building with the greatest apparent life hazard, the Tower building. Some of the apartment windows in this building were less than thirty feet from the fully involved upper floors of the Clark Building. The standpipes in the Grill and the Tower buildings were charged while companies began the task of searching and evacuating the residents of the 31-story building. Many of the residents had been awakened by the noise of the incoming apparatus or the light of the flames and were self-evacuating. An additional Deputy Chief was requested to take charge of Exposure 3, the areas to the rear of the fire building on Pineapple Street. Several additional Battalion Chiefs were special called, as the need for more supervisory personnel became critical. The Citywide Tour Commander FC 1 requested a fourth alarm at 4:11 a.m. while he was still enroute. From the Brooklyn Bridge he had an excellent vantage point to size up the volume of fire and the obvious exposure challenges. By this time the interior por- tions of the upper floors of the Clark Building were beginning to collapse, adding to the storm of fire brands. (Figures 5 and 6) When FC-1 arrived on the scene at 4:18 a.m., he immediately called for a fifth alarm. The interior of the original fire building was well involved and the fire had spread to the upper floors of Exposure 4. A collapse zone was quickly established in front of the Clark and Marquee Buildings. The two tower ladders that had been set up in front of the buildings and the command post were repositioned out of the collapse zone. Battalion Chiefs were assigned to secure the collapse zone. (Figures 7 and 8) Directly across the street from the fire building at 52 Clark Street was Exposure 1, another high rise building in which many older and handicapped people lived. The only exit from this building was onto Clark Street directly across the street from the fire building. Evacuation would require the 450 residents to walk within 40 feet of the front wall of the ten-story fire building. With the risk of collapse and the intense radiant heat Report 108 Page 8

the decision was made to keep these residents in their building, but to move them to the rear apartments as far as possible from the danger and protect them in place. This was accomplished with the help of the Police Department. By this time the Incident Command System was well established. The Command Post was positioned on Clark Street east of the fire building. FC-1 was the Incident Commander, the first-in Deputy Chief DC-6 was the Operations Chief, and Deputy Chief DC-1 was in position on Pineapple Street to cover Exposure 3. Battalion Chiefs were assigned to both ends of the collapse zone to keep the danger area clear and to direct the tactical operations in their sector. Exposure 4 was a vacant building that was becoming involved in fire but was acting as a buffer for the occupied structures to the west. Exposures 1, 2 and 3, which were all occupied structures and significantly taller that the fire building, were all critical exposures. GREATER ALARMS It was obvious that the 31 story Tower Building that faced Pineapple Street was in immediate danger. The Incident Commander directed the fourth and fifth alarm com- panies to report to the Chief on exposure 3 to assist in evacuating and protecting the Tower Building. A Battalion Chief was assigned to conduct a survey of the entire block. It appeared from the street that the Grill, Tower and the St. George Apartments were sepa- rate buildings.1 However, the survey determined that the interior had been inter-con- nected to create one large structure. When the Incident Commander received this information he informed DC-1 of the building configuration and directed him to take charge of both Exposures 2 and 3 (Figure 9). The fireground was now divided into the Clark Street Branch, which included Exposures 1 and 2 and the fire building, and the Pineapple Street Branch, which included Exposures 2 and 3. Two Deputy Chiefs were assigned to direct opera- tions in the two branches, DC-6 on the Clark side and DC-1 on the Pineapple side. The Incident Commander directed DC-1 to initiate a separate incident and to communicate directly with Brooklyn Communications to request resources. Report 108 Page 9 1The landmark status of the area mandated that the exterior of the buildings remain basically the same as they had been before they were consolidated.

ADDITIONAL ALARMS A secondary Command Post was established at the corner of Hicks and Pineapple and a second alarm assignment was requested by DC-1 to report to the Pineapple Sector, which included the Pineapple and Crosshall Buildings. The equivalent of a third alarm was requested to assist the companies that were already operating in the Tower Building. (Figure 10) Additional alarms for the Clark Street side were transmitted as follows: the sixth at 5:06 a.m., the seventh at 5:09 a.m., the eighth at 5:28 a.m., the ninth at 6:15 a.m., the tenth at 7:17 a.m. and the eleventh at 7:20 a.m. The fire was declared under control at 7:09 a.m. (Figure 11) TOWER BUILDING A A primary search of the exposures was a major challenge due to the large number of living units exposed. Although most of the residents of the Tower Building self-evacu- ated, the concierge was receiving calls from numerous residents requesting help. Other residents called 9-1-1 and their locations were relayed to the command post by Brooklyn communications. The Sector Commander prioritized these requests and assigned compa- nies as they arrived or became available. Fires in several apartments had been ignited by the flying brands or radiant heat. In an effort to reach the areas most in need of interven- tion, apartment doors were forced open if heat was detected on the corridor side of the door. Entry ultimately had to be forced into 84 apartments in the Tower Building. As more Chief Officers arrived, the Tower Building was divided into sectors. Several floors and companies were assigned to each Battalion Chief. Some of the first companies into the Tower Building used the elevators to reach the upper floors. Some of the later arriving companies had to climb 20 to 25 stories to reach their assigned areas. The building’s two stairways became congested with hun- dreds of residents evacuating down while firefighters were advancing up the stairs, car- rying their equipment. Smoke in the corridors and stairways added to the confusion. A specially trained high rise crew was sent to retrieve the elevators from the upper floors and to assure their proper use. As more resources arrived and were assigned, a total occupant search was com- pleted and all of the apartment fires were extinguished. Sixteen 2-1/2 inch lines were Report 108 Page 10

stretched from the standpipes into apartments to directly attack the fire in the Clark Building. The radiant heat from so large a fire continued to present a major threat and to tax the resources on the scene. EXPOSURES The fire brand problem was multiplied as the floors of the Clark Building col- lapsed. Flaming brands found their way into the open or failed windows of apartments and landed on the rooftops of surrounding buildings. Exposed apartments had to be checked and rechecked to ensure that the contents did not ignite. Two companies and a Battalion Chief were assigned as a “Brand Patrol Group” for the rest of the neighborhood. Two apartments at 60 Pineapple Street were found in flames and were extinguished. After a search and evacuation of residents was accomplished, additional hose lines were operated from the roof of this building into the rear of the Clark and Marquee Buildings. Hose lines were also operated from the roof and from all floors of the Weller building into the Marquee Building on the Exposure 4 side. The fire doors between the two buildings held until the firefighters could evacuate the Weller Building and get their lines in place to attack the fire. A tower ladder was set up in the street in front of 60 Pineapple and operated over the rooftop into the fire building. Three additional tower ladders operated into the front of the Clark Building to extinguish the fire. The collapse zone was maintained and fortunately the fire building did not collapse significantly outside its footprint. CONTROL As the danger from the fire decreased, the residents of Exposure 1 at 52 Clark Street were removed to safety. This building suffered only slight water damage from the hose lines that were used to protect it from the radiant heat. The masonry bearing walls were all that remained of the original fire building. Virtually all combustible materials had been consumed. Residents of many of the sur- rounding buildings were not allowed back into their apartments until the walls were demolished due to the collapse danger. Fire companies remained on the scene for sev- eral days putting out spot fires. Report 108 Page 11

SPECIALIZED UNITS Communications The communication requirements for this Incident were a major challenge. The FDNY made extensive use of portable radios or handi-talkies (HT’s) to coordinate tacti- cal operations on the fireground. The HT’s are distributed as follows: 2 HT’s for each Deputy Chief and Battalion Chief 3 or 4 HT’s for each Ladder Company At least 2 HT’s for each Engine, Squad or Rescue Company At most multiple alarm incidents, the command officers use a Command Channel, while companies use a Tactical Channel. Battalion and Deputy Chiefs monitor and com- municate on the Command Channel while their aides monitor the Tactical Channel. The Field Communication Unit (Field Com) responded automatically on the sec- ond alarm. Battalion Chief 32 was assigned as communications coordinator at 4:25 a.m. with a listing of all units assigned to the incident up to that point in time. The Communications Coordinator ensures that all of the units already on the scene are on the proper Tactical and Command channels, then monitors the Tactical channel for urgent transmissions. The size of this incident required both of the tactical channels available in this area of the city. One tactical channel was used for the Clark Street Branch and the other for the Pineapple Street Branch. Only one Command Frequency is available in this area of Brooklyn, a second would have been useful if it had been available. The Communications Coordinator remains in close contact with the Incident Commander and maintains a status board which keeps record of the Branch and Sector assignments, the units operating in each area and the companies that are available in the staging area. The Command Control Chart is maintained at the Command Post in a graphic format for easy reference. The Computer Assisted Dispatch Operations (CADO) Unit also responds on the second alarm and reports to the Communications Coordinator. Report 108 Page 12

Water Supply The Maxi-Water System is dispatched on second alarms in this part of Brooklyn. The entire Maxi-Water System consists of six engine companies with 2000 gpm pumps, each of which has a hose wagon loaded with large diameter hose and appliances. Engine 207 is the primary Maxi-Water company and the officer of E-207 acts as the Water Resource Officer at major incidents. The five Satellite Units are assigned to other areas of the city. The normal response of the Maxi-Water System included Engine 207 as the Maxi-Water Unit and two of the Satellite Units. The 2000 gpm pumpers are directed to hydrants that can provide a strong water supply and deliver water through the large diameter hose to manifolds close to the fire. Due to the location of the fire, E-207 was one of the engines on the initial response and was assigned early in the fire incident. The Water Department was asked to open the grids to assure maximum water availability in the area. Manifolds were positioned on Clark Street, Pineapple Street and Hicks Street to supply both hand lines and heavy streams. Other Specialized Units One of the two Safety Operating Battalion Chiefs responds automatically on sec- ond alarms. He is responsible to survey the scene for safety practices and monitor radio traffic for emergency calls. SB-2 was assigned to this incident. The extra ladder company that is dispatched on an “all hands” fire is assigned as the Firefighter Assist and Search Team (FAST). The FAST reports to provide immediate assistance in the event that a company gets in trouble or cannot account for a firefighter. Due to the magnitude of this incident, several ladder companies were assigned as FAST companies for different areas. LESSONS LEARNED AND REINFORCED 1. Updated pre-fire plans provide critical information regarding the configuration and condition of buildings within a complex. Pre-fire Plans had been developed for this area in the past but may not have been up to date. The Incident Commander did not have the information that three buildings Report 108 Page 13

had been consolidated into one. This caused some confusion but did not significantly effect the outcome of the incident. The standpipe in the fire building was out of service. The Fire Department has a tagging system to indicate that a standpipe or sprinkler sys- tem is out of service. This system had been vandalized since the last inspection. 2. Walking all perimeters of the fire scene can provide information regarding exposures and conditions, and assist in the effective placement of firefighting resources. Because of the confusion about the configuration of the buildings in the com- plex, the Incident Commander sent a Battalion Chief to scout the area to obtain specific information. This put an end to the inconsistent reports the Command Post was receiv- ing and allowed confident placement of resources. 3. Aggressive resource staging can minimize the loss and assist with occupant location, evacuation and protection, as well as improving firefighter safety. The Incident Commander stated that whenever a problem came up he called an additional alarm. The outcome of the incident was much more positive because the Incident Commander readily brought additional personnel to the scene. Due to the size and location of the fire there was great potential for large loss of life and significantly more property damage than actually occurred. The initial Incident Commander had knowledge of what equipment was on the way as well as what equipment was needed. Making special calls for specific equipment, such as extra tower ladders, almost enabled extinguishment of the fire at the second alarm level. 4. Specialized units contribute to an effective fire attack. Many of the component parts of the Incident Command System were pre- assigned in this fire. Comcord, Maxi-Water and the Safety Battalion are examples of these components. These specialized units were trained to assume responsibility for a very focused and defined task. This well-defined area of responsibility was assigned to the specialized unit. The Incident Commander was confident that work expected from a unit was exactly the work the unit expected to perform. Report 108 Page 14

Pre-assigned radio frequencies and an orderly way to switch to them are vital to success. One of the biggest problems in a large incident is usually communications. By necessity, there is a sizable volume of radio traffic. Dispatch or main frequencies will quickly be overloaded if provisions are not made early in an incident to organize radio traffic. By promptly establishing two tactical and one command channel in addition to the dispatch frequency, the ComCord maintained control of communications. 6. Radio discipline, regardless of the number of fire ground radio channels available, should be emphasized by officers and companies. Operating 100 pieces of apparatus and 700 firefighting personnel, most of which had hand held radios, on two tactical channels and one command channel required disci- pline and vigilance. The command officers had aides able to monitor tactical radio com- munication. Companies kept their radio communications to a minimum so emergency traffic and important information could be passed on. 7. Gain control of the elevators early in the fire. Certain vital building systems need special attention to assure safe operation dur- ing a fire. Elevators are one of these systems. The elevators were abandoned on the upper floors of the Tower Building early on during the incident. As a result, subsequent companies had to climb the stairs to reach their operating areas. When the problem was relayed to a chief, a company was assigned to retrieve the elevator and operate it for the duration of the incident. If the elevators are controlled early, crews can safely use them for transportation and they will be less fatigued when they reach their operating areas. 8. Routine inspections and up-to-date pre-incident plans can identify compromised fire protection systems. A lot of time was spent by the first-in companies advancing to the fire floor believing they would be able to operate from the standpipe. If the inoperable state of the standpipe had been known, an alternative way of supplying water to the fire floor could have been employed, saving valuable time when it was most needed. The disabled standpipe may have been found during a routine inspection. A pre-incident plan must be continuously updated, as building conditions can change. Inspections should be per- formed on a regular basis so those changes can be reflected on the pre-incident plans. Report 108 Page 15

Using the Department’s Incident Command System (ICS) permitted this complex fire ground to be managed to a successful conclusion without loss of life or serious injury to civilians or firefighters. The first-in companies and battalion chief followed the Department’s Standard Operating Procedures. ICS was established from the beginning of the incident and func- tioned through command changes, command post relocation and separation of the fire ground into two branches, each with multiple sectors. The experience and familiarity of the command and company officers with ICS was evident during this incident. The large fire area and congested exposures required a concentrated and coordinated effort that effective ICS supports. Report 108 Page 16

APPENDIX A DIAGRAMS Report 108 Page A-1

Report 108 Page A-2 Figure 1

Report 108 Page A-3 Figure 2

Report 108 Page A-4 Figure 3

Report 108 Page A-5 Figure 4

Report 108 Page A-6 Figure 5

Report 108 Page A-7 Figure 6

Report 108 Page A-8 Figure 7

Report 108 Page A-9 Figure 8

Report 108 Page A-10 Figure 9

Report 108 Page A-11 Figure 10

Report 108 Page A-12 Figure 11

APPENDIX B Except for photograph No. 9, all of the photographs were captured from video tape of the fire and fire scene. The video tape was supplied by Eddie McDonald. Photograph No. 9 was supplied by F.D.N.Y. Forensic Unit and was taken by T. A. Strandberg. The video captured photographs are available in color from the USFA’s WEB page as part of the downloadable file. Report 108 Page B-1

• Later conditions on the front of the Clark building from street level.

Report 108 Page B-2

• Early conditions on the Clark Street (front) side of the Clark building with Truck 119

in position to operate its elevated master stream. Report 108 Page B-3

1. Illustrations of the fire brand conditions over the tops of the buildings.
2. Conditions from the street.

• Fire conditions at the center of the block behind the Clark Building. The Tower

building is in the background. Report 108 Page B-4

• The fire, brand, and energy plume from the now totally involved and collapsed Clark

Building silhouetted against the rest of the 31 story Tower building. Report 108 Page B-5

1. The Tower building and Grill Building with the 31 story Tower building in the

background.

1. The rear of the Clark building after the fire. The Tower Building and Gnill Building

is out of the picture to the right.

Report 108 Page B-6

1. Damage to exposures across Clark Street from the fire building.
2. The Clark building during demolition as viewed from the rear to the front.

FD06008 ｜ 1997_美国国家消防协会_布雷默顿_公寓楼火灾调查报告（英文）.md

分类：06_境外及港澳台调查报告 ｜ 年份：1997 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因：焊接/动火 ｜ 来源格式：md

一、基本情况

1997年11月13日约6:00，美国华盛顿州Bremerton一栋4层公寓楼发生火灾。该综合体共142个单元（约130个有人居住）。火灾造成4人死亡、12人受伤。

二、起火原因

火灾发生于西南角三层一处有人居住的公寓内。该住户当时不在家，火在独立式烟感报警前未被发现并增长；火势经由外墙未达耐火等级的胶合板覆面以及防火分隔墙上的开口向上层与相邻单元蔓延。

三、责任与致灾因素

• 整栋建筑未设自动喷淋系统；
• 仅配置单元内独立式烟感（报警声仅限于本单元），无楼栋级联动火灾报警；
• 唯一存续的防火分隔墙上存在未封堵的开口，导致火、烟突破防火分区。

四、整改与教训

报告强调：高层/密集型住宅应配置联动火灾报警与自动喷淋；外墙覆面与防火分隔须达到相应耐火等级并封堵所有贯穿开口；单元内独立烟感不足以防止火灾殃及邻户与竖向蔓延。

FD06009 ｜ 1999_美国国家标准与技术研究院_伍斯特_冷库仓库火灾调查报告（英文）.md

分类：06_境外及港澳台调查报告 ｜ 年份：1999 ｜ 地域： ｜ 严重程度： ｜ 场所：仓库/物流 ｜ 起火原因： ｜ 来源格式：md

一、基本情况

1999年12月3日18:13，美国马萨诸塞州伍斯特市（Worcester）Franklin街266号一座6层废弃冷库仓库（Worcester Cold Storage and Warehouse Co.）发生火灾。火灾导致6名职业消防员遇难（即“Worcester 6”），是当地36年来首次消防员殉职。

二、起火原因

火灾由两名滞留楼内的无家可归者不慎碰倒蜡烛意外引燃，二人未报警即逃离现场。建筑自1989年废弃，火在第二层阴燃30–90分钟未被发现，直至附近居民报警。

三、责任与致灾因素

• 建筑地面层以上无窗，无火灾探测与自动灭火（喷淋）系统；
• 内部由众多肉类冷藏间构成迷宫般布局，墙体与吊顶覆有软木、聚苯乙烯、喷涂聚氨酯泡沫等可燃保温层；
• 仅有一部从地下室通至屋顶的楼梯，且楼梯间门在火灾中反锁，消防员迷路后无法返回办公室侧；
• 消防员不熟悉建筑布局，在烟气中迷失，最终6人被困于楼层内遇难。

四、整改与教训（NIOSH 建议）

NIOSH F99-47提出13项建议：对闲置建筑开展巡查与预案（pre-fire planning），掌握结构材料与改建信息；全面落实事故指挥系统（ICS）；在大型/多警报火灾中任命独立于现场指挥的事故安全官；建立并前置快速干预小组（RIT）；在入口处固定导向绳/标记绳并布置高强度照明助逃生；严格人员清点；参照NFPA 1500建立健康安全计划；在闲置建筑入口加贴警示标识；研究热成像仪定位迷失人员等。

FD06010 ｜ 2001_US_NIST_NISTIR7412_PPV_HighRise.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2001 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

NISTIR 7412

Evaluating Positive Pressure Ventilation In Large Structures: High-Rise Pressure Experiments

Stephen Kerber Daniel Madrzykowski David Stroup

U.S. Department of Commerce Technology Administration Building and Fire Research Laboratory National Institute of Standards and Technology Gaithersburg, MD 20899

1

NISTIR 7412

Evaluating Positive Pressure Ventilation In Large Structures: High-Rise Pressure Experiments

Stephen Kerber Daniel Madrzykowski David Stroup

U.S. Department of Commerce Technology Administration Building and Fire Research Laboratory National Institute of Standards and Technology Gaithersburg, MD 20899

March 2007

Department of Homeland Security Michael Chertoff, Secretary Preparedness Directorate George W. Foresman, Under Secretary for Preparedness United States Fire Administration Charlie Dickinson, Acting Administrator U.S. Department of Commerce Carolos M. Gutierrez, Secretary Technology Administration Robert Cresanti, Under Secretary Of Commerce for Technology National Institute of Standards and Technology William Jeffrey, Director

iii Table of Contents

List of Tables ................................................................................................ iv List of Figures............................................................................................... iv 1.0 Introduction ........................................................................................ 7 2.0 Experimental Overview ................................................................... 10 2.1 Structure…………………………………………………………………………..11 2.2 Instrumentation…………………………………………………………………...15 3.0 Experimental Procedure.................................................................. 20 4.0 Results................................................................................................ 25 4.1 Stairwell Differential Pressure................................................................................ 25 4.1.1 Optimal fan placement at stairwell door (D2) ................................................ 25 4.1.2 Optimal fan placements at ground floor entrance (D1) .................................. 28 4.1.3 Multiple fans at ground floor entrance (D1)................................................... 30 4.1.4 Multiple fans at stairwell doorway (D2)......................................................... 33 4.1.5 Open doors in the stairwell ............................................................................. 35 4.1.6 Multiple fans at multiple ground level doors.................................................. 36 4.1.7 Fans located inside the building...................................................................... 37 4.1.8 1.2 m (46 in) trailer mounted fan at ground floor entrance ............................ 39 4.1.9 Further analysis of fans located inside the building........................................ 40 4.1.10 Fans at ground level and in the building with the bulkhead door open .................................................................................................................. 42 4.1.11 Fans at ground level and in the building with the roof hatch open............... 45 4.1.12 Ground level doorway sealed / Fan efficiency .............................................. 48 4.1.13 Other types of fans at the ground level stairwell door................................... 49 4.1.14 Fans and a hovercraft at ground floor entrances (D1 and D3)....................... 51 4.2 Stairwell Temperature....................................................................................... 53 4.3 Weather............................................................................................................. 54 4.4 Carbon Monoxide ............................................................................................. 57 4.5 Sound Levels..................................................................................................... 62 5.0 Uncertainty........................................................................................ 63 6.0 Discussion .......................................................................................... 65 7.0 Future Research................................................................................ 67 8.0 Conclusions........................................................................................ 68 9.0 References.......................................................................................... 70 10.0 Acknowledgments............................................................................. 72

iv List of Tables Table 1. NFPA 92A Minimum Design Pressure Differences Across Smoke Barriers...... 9 Table 2. Experimental overview description ................................................................... 10 Table 3. Door and hatch dimensions................................................................................ 12 Table 4. 0.4 m (16 in) fan setback/angle analysis at ground floor stairwell door............ 20 Table 5. 0.5 m (21 in) fan setback/angle analysis at ground floor stairwell door............ 21 Table 6. 0.7 m (27 in) fan setback/angle analysis at ground floor stairwell door........... 21 Table 7. Best setback/angles at ground floor entrance door............................................ 22 Table 8. Multiple fans at ground floor entrance door (series and parallel configurations).......................................................................................................... 22 Table 9. Multiple fans at stairwell door........................................................................... 22 Table 10. Stairwell door(s) open configuration(s)........................................................... 22 Table 11. Fans at multiple ground floor doors................................................................. 23 Table 12. Fans in the structure......................................................................................... 23 Table 13. 46” trailer mounted fan at ground floor entrances........................................... 23 Table 14. Fans in the structure setback configurations.................................................... 23 Table 15. Roof door ventilation through 29th floor.......................................................... 24 Table 16. Roof hatch ventilation through 29th floor ........................................................ 24 Table 17. Roof hatch ventilation through 28th floor ........................................................ 24 Table 18. Ground floor doorway sealed, Fan efficiency ................................................. 25 Table 19. Other fan types at ground floor stairwell door................................................. 25 Table 20. Hovercraft at ground floor entrance................................................................. 25 Table 21. Noise Scale ...................................................................................................... 63 Table 22. Uncertainty....................................................................................................... 64

List of Figures Figure 1. Two common PPV fans...................................................................................... 9 Figure 2. Conical air jet produced by PPV [14]............................................................... 10 Figure 3. Front (Side A) and left side (Side B) of the building (left photo) and rear (Side C)..................................................................................................................... 12 Figure 4. Ground Floor Plan............................................................................................ 13 Figure 5. Floors 2-13 floor plan....................................................................................... 13 Figure 6. Floor 14-28 floor plan. ..................................................................................... 14 Figure 7. Floor 29 and roof floor plan. ............................................................................ 14 Figure 8. Instrumentation layout diagram (P-pressure, T-temperature, CO-carbon monoxide,.................................................................................................................. 16 Figure 9. Differential pressure set-up .............................................................................. 17 Figure 10. Thermocouple location................................................................................... 17 Figure 11. Carbon monoxide meter ................................................................................. 18 Figure 12. Ground weather station................................................................................... 18 Figure 13. Roof weather station....................................................................................... 19 Figure 14. Sound meter.................................................................................................... 19 Figure 15. Fans placed at stairwell doorway, (a) 0.4 m (16 in), (b) 0.5 m (21 in), (c) 0.7 m (27 in) ....................................................................................................... 26 Figure 16. Stairwell pressures created by a 0.4 m (16 in) fan ......................................... 27 Figure 17. Stairwell pressures created by a 0.5 m (21 in) fan ......................................... 27 Figure 18. Stairwell pressures created by a 0.7 m (27 in) fan ......................................... 28 Figure 19. Fan placed at ground level doorway (D1)...................................................... 29

v Figure 20. Stairwell pressures from fans blowing into D1.............................................. 29 Figure 21. Fans placed at ground floor entrance (D1), a. 2 fans in series, b. 2 fans in V-shape, c. 2 fans in V-shape (top/bottom), d. 3 fans in V-shape w/center, e. 3 fans in series....................................................................................................... 31 Figure 22. Stairwell pressures from multiple 21 in. fans at D1....................................... 32 Figure 23. Stairwell pressures from multiple 27 in. fans at D1....................................... 32 Figure 24. Multiple fans in series at stairwell doorway, a. 1.2 m and 2.4 m, b. 1.2 m, 2.4 m and 3.7 m ......................................................................................... 33 Figure 25. Stairwell pressures from 0.5 m (21 in) fans in series at D2 ........................... 34 Figure 26. Stairwell pressures from 0.7 m (27 in) fans in series at D2 ........................... 34 Figure 27. Stairwell pressure with doors open................................................................. 35 Figure 28. Fans placed at multiple doors, a. Fans at D2 and D3, b. Fans at D1.............. 36 Figure 29. Stairwell pressures with multiple fans at multiple doors................................ 37 Figure 30. Fan positioned in the building........................................................................ 38 Figure 31. Stairwell pressures with fans inside the building ........................................... 38 Figure 32. Trailer mounted fan at stairwell door............................................................. 39 Figure 33. Stairwell pressures made by the 1.2 m (46 in) fan at the stairwell door. ....... 40 Figure 34. Fans locations in the stairwell ........................................................................ 41 Figure 35. Stairwell pressures created with fans at the 12th floor................................... 42 Figure 36. Stairwell pressures created by 0.5 m (21 in) fans with the 29th floor and bulkhead door open................................................................................................... 43 Figure 37. Stairwell pressures created by 0.7 m (27 in) fans at the ground level with the 29th floor and bulkhead door open. .................................................................... 44 Figure 38. Stairwell pressures created by 0.7 m (27 in) fans on the 12th floor with the 29th floor and bulkhead door open. .................................................................... 45 Figure 39. Stairwell pressures created by a single fan with the 28th floor and roof hatch open................................................................................................................. 46 Figure 40. Stairwell pressures created by multiple fans with the 28th floor and roof hatch open................................................................................................................. 47 Figure 41. Stairwell pressures created by fans in the building with the 28th floor and roof hatch open................................................................................................... 47 Figure 42. Stairwell pressures created by a 0.5 m (21 in) fan with the doorway sealed and with the fan setback................................................................................. 48 Figure 43. Other types of fans and configurations. (a) 2 – 21 in. fans side by side (b) 2 – 21 in. fans in series (c) 24 in. and 31 in. fans side by side (d) 21 in. Toledo truck fan........................................................................................................ 50 Figure 44. Pressures created by other manufacturer’s fans in various configurations .... 51 Figure 45. Hovercraft positioned at ground floor entrance (D3)..................................... 52 Figure 46. Stairwell pressures created by fans and hovercraft positioned at D1 and D3....................................................................................................................... 52 Figure 47. Stairwell temperatures.................................................................................... 53 Figure 48. Average temperatures..................................................................................... 55 Figure 49. Average wind speed. ...................................................................................... 55 Figure 50. Average wind direction. ................................................................................. 56 Figure 51. Relative humidity. .......................................................................................... 56 Figure 52. Barometric pressure........................................................................................ 57 Figure 53. Carbon monoxide levels for experiments 2 through 54. ................................ 59 Figure 54. Carbon monoxide levels for experiments 56 through 100. ............................ 60 Figure 55. Carbon monoxide levels for experiments 101 through 139. .......................... 61 Figure 56. Carbon monoxide levels for experiments 150 through 160. .......................... 62

6

Evaluating Positive Pressure Ventilation In Large Structures: High-rise Pressure Experiments

Stephen Kerber Daniel Madrzykowski David Stroup

Abstract

One hundred and sixty experiments were conducted in a thirty-story vacant office building in Toledo, Ohio to evaluate the ability of fire department positive pressure ventilation (PPV) fans to pressurize a stairwell in a high-rise structure in accordance with established performance metrics for fixed stairwell pressurization systems. Variables such as fan size, fan angle, setback distance, number of fans, orientation of fans, number of doors open and location of vents open were varied to examine capability and optimization of each. Fan size varied from 0.4 m (16 in) to 1.2 m (46 in). Fan angle ranged from 90o to 80o. The setback distance went from 0.6 m (2 ft) to 3.6 m (12 ft). One fan to as many as nine fans were used which were located at three different exterior locations and three different interior locations. Fans were oriented both in series and in parallel configurations. Doors throughout the building were opened and closed to evaluate the effects. Finally a door to the roof and a roof hatch were used as vent points. The measurements taken during the experiments included differential pressure, air temperature, carbon monoxide, metrological data and sound levels.

PPV fans utilized correctly can increase the effectiveness of fire fighters and survivability of occupants in high-rise buildings. In a high-rise building it is possible to increase the pressure of a stairwell to prevent the infiltration of smoke if fire crews configure the fans properly. Although many factors contribute and need to be considered for effective PPV operations, properly configured PPV can achieve stairwell pressures that are high enough to meet or exceed the performance metrics for fixed smoke control systems.

Disclaimer

Certain trade names and company products are mentioned in the text or identified in an illustration in order to specify adequately the experimental procedure and equipment used. In no case does such identification imply recommendation or endorsement by the National Institute of Standards and Technology, nor does it imply that the products are necessarily the best available for the purpose.

7 1.0 Introduction

According to the National Fire Protection Association (NFPA) Life Safety Code, a high rise building is “a building greater than 23 m (75 ft) in height measured from the lowest level of fire department vehicle access to the floor of highest occupiable story” [1]. In 1910, the New York City Fire Department Chief, Edward Croker informed the New York State Assembly that the fire department could not successfully combat a fire in a building greater than 7 stories tall. Three months later a fire in the Triangle Shirtwaist Company, which occupied the top three floors of a ten story building in New York City, resulted in the deaths of 146 people [2]. As a result of that fire, many improvements were made in the life safety of buildings.

Between 1985 and 2002 there have been approximately 385,000 fires in high-rise buildings greater than seven stories. These fires resulted in 1600 civilian deaths and more than 20,000 civilian injuries *[3]. Smoke is a major problem in high-rise fires as it travels to building locations remote from the fire and causes a serious life hazard. Stairwells may fill with smoke, hindering evacuation and enabling the spread of smoke to other floors of the building.

Fires in high-rise buildings can produce severe challenges for fire departments. Operations that are normally considered routine, such as fire attack, evacuating occupants and ventilation can become very difficult in high-rises. Smoke and hot gases in the stairwells and the corridors of high rise buildings complicate rescue and firefighting operations. Between 1977 and 2005, 20 fire fighters died from traumatic injuries suffered in high-rise fires in the United States *[4].

Fire fighters often rely upon built-in fire protection systems to help control a high-rise fire and protect building occupants. In many cases the buildings do not have the necessary systems or the systems fail to operate properly. This has created situations where even the most experienced and best equipped fire departments could not readily control the fire [5-8]. Many high-rise incidents have resulted in fire fighter fatalities due to disorientation, running out of air, or changes in wind conditions [7, 9-11].

An effective fire protection system for preventing major high-rise fires is an automatic sprinkler system. Not all high-rise buildings have automatic sprinkler systems and even when they function as intended there is still a serious life hazard created by smoke production and spread. In order to limit the smoke hazard, ventilation systems have been utilized. In particular, pressurization smoke control systems have been incorporated into high-rise buildings since the 1970s.

In 1972, the Brooklyn Polytechnic Institute collaborated with the Fire Department of New York City [12] to conduct a series of fire experiments in a 22 story office building to evaluate the effectiveness of pressurization smoke control. Materials representative of fuels that would be in an office building were burned and it was demonstrated that pressurization could maintain tenable exits during a large unsprinklered fire. Subsequent experiments have been done to

*Not including the World Trade Center losses of September 11, 2001.

8

examine the ability of pressurization to prevent smoke from entering paths of smoke spread such as stairwells, elevator shafts and areas outside of the fire origin. All of these experiments demonstrated that pressurization could control smoke from large unsprinklered fires.

In 1986, the NFPA began to provide guidance for smoke management systems. NFPA 92A [13] was developed to address smoke control utilizing barriers, airflows and pressure differences so as to confine the smoke of a fire to the zone of fire origin and thus maintain a tenable environment in other zones. Guidance for minimum pressures that are able to inhibit the flow of smoke into the stairwell is provided in Table 1. The values in the table for nonsprinklered buildings are minimum design pressures developed for gas temperatures of 927 oC (1700 oF) next to the smoke barrier with a 7.5 Pa (0.03 in. water) safety factor added. These criteria for fixed stairwell pressurization systems provides a metric to assess the ability of fire department positive pressure ventilation (PPV) fans to provide a smoke-free escape route for occupants and a smoke-free staging area for fire fighters.

NFPA 92A also states that a smoke control system should be designed to maintain the minimum design pressure differences under likely conditions of stack effect and wind. Pressure differences produced by smoke-control systems tend to fluctuate due to the wind, fan pulsations, door opening, doors closing, and other factors. Short-term deviations from the suggested minimum design pressure difference might not have serious effect on the protection provided by a smoke-control system. There is no clear-cut allowable value of this deviation. It depends on the tightness of doors, tightness of construction, airflow rates, and the volumes of spaces. Intermittent deviations up to 50 % of the suggested minimum design pressure difference are considered tolerable in most cases [13].

Positive pressure ventilation is a technique used by the fire service to remove smoke, heat and other combustion products from a structure. This allows the fire service to perform tasks in a more tenable environment. PPV fans are commonly powered with an electric or gasoline engine and range in diameter from 0.30 m to 0.91 m (12 in to 36 in) (Figure 1). More recently, fans up to 2.1 m (84 in) have been manufactured and mounted on trucks and trailers. Typically, a PPV fan is placed about 1.2 m to 3.0 m (4 ft to 10 ft) outside the doorway of the structure. It is positioned so that the conical jet of air produced by the fan extends beyond the boundaries of the opening (Figure 2). With the doorway within the air jet, pressure inside the structure increases. An exhaust opening in the structure, such as an opening in the roof or an open window, allows the air to escape due to the difference between the inside and outside air pressure. As a result of the introduced air, the smoke, heat and other combustion products are pushed out of the structure and replaced with ambient air.

Another use of PPV is to increase the pressure in a portion of a structure by not providing a vent location. This increase in pressure, if adequate, will prevent smoke flow to an area to be protected. This may be most useful in larger structures such as schools, hospitals and high-rise buildings. In a high-rise building it is possible to increase the pressure of a stairwell to prevent the infiltration of smoke if the fans are properly configured. This study evaluates the variables

9 associated with the fire department’s implementation of PPV fans to achieve stairwell pressurization using fixed smoke control performance metrics.

Table 1. NFPA 92A Minimum Design Pressure Differences Across Smoke Barriers Building Type Ceiling Height Design Pressure Difference

m (ft) Pa (in. water) Sprinklered Any 12.5 (0.05) Nonsprinklered 2.7 (9) 24.9 (0.1) Nonsprinklered 3.6 (11.7)* 28.6 (0.11)* Nonsprinklered 4.6 (15) 34.9 (0.14) Nonsprinklered 6.4 (21) 44.8 (0.18)

• Values for these experiments

Figure 1. Two common PPV fans

10

Figure 2. Conical air jet produced by PPV [14]

1. 0 Experimental Overview

One hundred and sixty experiments were conducted to evaluate the ability of fire department positive pressure ventilation fans to pressurize a stairwell in a high-rise structure. The stairwell was pressurized in accordance with performance metrics previously established for fixed stairwell pressurization systems. Table 2 displays a broad overview of experimental groups used to analyze the effectiveness of PPV fans. Variables such as fan size, fan angle, setback distance, number of fans, orientation of fans, number of doors open and location of vents open were varied to examine capability and optimization of each. Fan size varied from 0.4 m (16 in) to 1.2 m (46 in). The face of the fan was placed perpendicular to the ground and also tilted backward so that the face was at angles of 85 degrees and 80 degrees to the ground as the fan was tilted backward. The setback distance ranged from 0.6 m (2 ft) to 3.6 m (12 ft). Setback distance was measured from the exterior face of the doorway to the face of the fan. Between one and nine fans were used and fans were located at three different exterior locations and three different interior locations. Fans were oriented in both series and in parallel. Doors throughout the building were opened and closed to evaluate the pressure change. Finally a door to the roof and a roof hatch were used as vent points to evaluate the effects of vent size and location.

Table 2. Experimental overview description Experiments Overview Description 1-18 0.4 m (16 in) fan setback/angle analysis at ground floor stairwell door 19-36 0.5 m (21 in) fan setback/angle analysis at ground floor stairwell door 37-54 0.7 m (27 in) fan setback/angle analysis at ground floor stairwell door 56-61 Best setback/angles at ground floor entrance door 62-71 Multiple fans at ground floor entrance door (series and parallel configurations) 72-77 Multiple fans at stairwell door 78-84 Stairwell door(s) open configuration(s) 85-86 Fans at multiple ground floor doors 87-91 Fans in the structure 92-100 1.2 m (46 in) trailer mounted fan at ground floor entrances 101-109 Fans in the structure setback configurations

11 110-122 Roof door ventilation through 29th floor 123-127 Roof hatch ventilation through 29th floor 128-136 Roof hatch ventilation through 28th floor 137-139 Ground floor doorway sealed, Fan efficiency 150-159 Other fan types at ground floor stairwell door 160 Hovercraft at ground floor entrance

1. 1 Structure

These experiments were conducted in a thirty-story vacant office building in Toledo, Ohio. The building was constructed in 1969 with an overall height of 121.9 m (400 ft) and an overall floor area of 40,645 m2 (437,500 ft2). Each floor was approximately 48.8 m (160 ft) wide by 25.9 m (85 ft) deep with a ceiling height of 3.6 m (11.7 ft). The ground floor was taller and had a ceiling height of 6.3 m (20.7 ft). Figure 3 shows all four sides of the building. Two mechanical floors are located between floors 13 and 14.

Three exterior doors were utilized during the experiments, the single door directly into the stairwell (D2), the double door on the right side of Side A (D1), and the double door on the left side of Side A (D3) (figure 4). Door sizes are in Table 3. The rotary doors inside of D1 and D3 were open for the duration of the experiments. All other doors to the ground floor were closed at all times. The door to the stairwell on side A (S1) remained open during all of the experiments and led to the stairwell that was used for the experiments.

A square stairwell in center of side A opened to the basement and remained open during the experiments. The basement was 1540 m2 (16,570 ft2) with a 3.6 m (11.7 ft) ceiling. The second stair that accessed the basement was located near the rotary door on side C and was kept closed.

The building has twelve elevators, ten in the elevator lobby, one freight elevator next to D2i and one adjacent to the basement stair opening. Six of the ten main elevators access floors 1-28. The remaining four only access floors 1 to 13 (figures 5 and 6). The freight elevator extends from the basement to the 29th floor and the elevator adjacent to the basement stair opening only serves the basement to the fifth floor.

The stairwell used for the experiments was located near side A of the building and had a half story of steps that led to a landing that transitioned into the actual stair shaft. The stair shaft measured 2.44 m (8.0 ft) wide and 5.14 m (16.9 ft) long. There was a 0.1 m opening between the stair flights. The stairwell ended at the 29th floor with no access to the exterior of the building. The second stairwell in the building provided access to the roof and roof hatch but opened only to the exterior of the building at the ground floor without room to place a PPV fan (figure 4).

Floors 2 through 13 were similar with the exception of a few partition walls which had no impact on the experiments (figure 5). The two mechanical floors between floor 13 and

12 floor 14 remained closed and were not used during the experiments. Floors 14 through 28 were also similar and differed from the lower floors because of the elevators (figure 6). Floor 29 was not a complete floor and only had a mechanical room and access to the lower roof via the roof door (RD) in the stairwell. A ship ladder to the roof hatch (RH) provided the only access to the upper roof and was also located in the same stairwell as the lower roof door (figure 7).

Table 3. Door and hatch dimensions Door/Hatch Location Door Dimensions (Reference figures 4, 5, 6) Width (m) Height (m) D1 1.8 2.1 D1i 1.5 2.4 D2 1.1 2.4 D2i 1.1 2.4 D3 1.8 2.1 D3i 1.5 2.4 S1 0.9 2.4 S2-S29, S2-S29a 0.9 2.1 RD 0.9 2.4 Roof Hatch 0.8 0.9

Figure 3. Front (Side A) and left side (Side B) of the building (left photo) and rear (Side C) and right side (Side D) of the building (right photo)

13

Figure 5. Floors 2-13 floor plan.

Figure 4. Ground Floor Plan

Side C Side A Side B Side D Side C

14

Figure 6. Floor 14-28 floor plan.

Figure 7. Floor 29 and roof floor plan.

15 2.2 Instrumentation

The measurements taken during the experiments included differential pressure, air temperature, carbon monoxide, metrological data and sound levels. A differential pressure transducer and thermocouple were located on the door knob of every other floor (figure 8). A plastic tube was run under the door to the opposite door knob to reference the pressure readings to the floor side (figure 9). The thermocouples were bare-bead, type K, with a 0.5 mm (0.02 in) nominal diameter (figure 10).

Carbon monoxide was measured in the stairwell on floors 1, 14 and 28. Measurements were made using a chemical cell monitor with built-in sample pump (figure 11). The monitors were also located on the door handle on their respective floors.

Weather was monitored and recorded during each of the experiments using two portable weather stations. Temperature, relative humidity, average wind speed, average wind direction and barometric pressure were recorded continuously. One weather station was located 9.1 m (30 ft) from the centerline of D2 (figure 12). The second weather station was located on the lower roof outside RD (figure 13).

Sound measurements were taken with an analog sound meter and various locations including next to the fan and inside the structure. The meter had an operating range of 40 dBA to 120 dBA (figure 14).

16

Figure 8. Instrumentation layout diagram (P-pressure, T-temperature, CO-carbon monoxide,

DL-data logger)

17

Figure 9. Differential pressure set-up

Figure 10. Thermocouple location

18

Figure 11. Carbon monoxide meter

Figure 12. Ground weather station

19

Figure 13. Roof weather station

Figure 14. Sound meter

20 3.0 Experimental Procedure

Prior to each of the experiments the setup was configured according to the variables in tables 4-

1. Background measurements were recorded and the fan(s) were started and throttled to full

speed. The duration of each experiment was three minutes. At the completion of each experiment the fan was turned off, readings were allowed to return to ambient and the procedure was repeated.

Table 4. 0.4 m (16 in) fan setback/angle analysis at ground floor stairwell door. Experiment Fan Size Fan Angle Fan Setback Fan Location Doors Open Vents Open

(in) (degrees) (m)

1 16 90 0.6 D2 D2, S1 None 2 16 85 0.6 D2 D2, S1 None 3 16 80 0.6 D2 D2, S1 None 4 16 90 1.2 D2 D2, S1 None 5 16 85 1.2 D2 D2, S1 None 6 16 80 1.2 D2 D2, S1 None 7 16 90 1.8 D2 D2, S1 None 8 16 85 1.8 D2 D2, S1 None 9 16 80 1.8 D2 D2, S1 None 10 16 90 2.4 D2 D2, S1 None 11 16 85 2.4 D2 D2, S1 None 12 16 80 2.4 D2 D2, S1 None 13 16 90 3.0 D2 D2, S1 None 14 16 85 3.0 D2 D2, S1 None 15 16 80 3.0 D2 D2, S1 None 16 16 90 3.7 D2 D2, S1 None 17 16 85 3.7 D2 D2, S1 None 18 16 80 3.7 D2 D2, S1 None

21

Table 5. 0.5 m (21 in) fan setback/angle analysis at ground floor stairwell door. Experiment Fan Size Fan Angle Fan Setback Fan Location Doors Open Vents Open

(in) (degrees) (m)

19 21 90 0.6 D2 D2, S1 None 20 21 85 0.6 D2 D2, S1 None 21 21 80 0.6 D2 D2, S1 None 22 21 90 1.2 D2 D2, S1 None 23 21 85 1.2 D2 D2, S1 None 24 21 80 1.2 D2 D2, S1 None 25 21 90 1.8 D2 D2, S1 None 26 21 85 1.8 D2 D2, S1 None 27 21 80 1.8 D2 D2, S1 None 28 21 90 2.4 D2 D2, S1 None 29 21 85 2.4 D2 D2, S1 None 30 21 80 2.4 D2 D2, S1 None 31 21 90 3.0 D2 D2, S1 None 32 21 85 3.0 D2 D2, S1 None 33 21 80 3.0 D2 D2, S1 None 34 21 90 3.7 D2 D2, S1 None 35 21 85 3.7 D2 D2, S1 None 36 21 80 3.7 D2 D2, S1 None

Table 6. 0.7 m (27 in) fan setback/angle analysis at ground floor stairwell door. Experiment Fan Size Fan Angle Fan Setback Fan Location Doors Open Vents Open

(in) (degrees) (m)

37 27 90 0.6 D2 D2, S1 None 38 27 85 0.6 D2 D2, S1 None 39 27 80 0.6 D2 D2, S1 None 40 27 90 1.2 D2 D2, S1 None 41 27 85 1.2 D2 D2, S1 None 42 27 80 1.2 D2 D2, S1 None 43 27 90 1.8 D2 D2, S1 None 44 27 85 1.8 D2 D2, S1 None 45 27 80 1.8 D2 D2, S1 None 46 27 90 2.4 D2 D2, S1 None 47 27 85 2.4 D2 D2, S1 None 48 27 80 2.4 D2 D2, S1 None 49 27 90 3.0 D2 D2, S1 None 50 27 85 3.0 D2 D2, S1 None 51 27 80 3.0 D2 D2, S1 None 52 27 90 3.7 D2 D2, S1 None 53 27 85 3.7 D2 D2, S1 None 54 27 80 3.7 D2 D2, S1 None

22 Table 7. Best setback/angles at ground floor entrance door Experiment Fan Size Fan Angle Fan Setback Fan Location Doors Open Vents Open

(in) (degrees) (ft)

56 21 80 1.8 D1 D1, D2i, S1 None 57 21 85 2.4 D1 D1, D2i, S1 None 58 21 80 1.2 D1 D1, D2i, S1 None 59 27 85 1.2 D1 D1, D2i, S1 None 60 27 80 1.8 D1 D1, D2i, S1 None 61 27 80 1.2 D1 D1, D2i, S1 None

Table 8. Multiple fans at ground floor entrance door (series and parallel configurations) Experiment Fan Size Fan Angle Fan Setback Fan Location Fan Orientation Doors Open Vents Open

(in) (degrees) (m)

62 21 80 1.8, 3.0 D1 series D1, D2i, S1 None 63 21 80, 85 1.8, 1.8 D1 V D1, D2i, S1 None 64 21 80, 80 1.8, 1.8 D1 V D1, D2i, S1 None 65 21 75, 90 1.8, 1.8, 1.8 D1 V, w, center D1, D2i, S1 None 66 21 80, 80, 80 0.6, 1.8, 3.0 D1 series D1, D2i, S1 None 67 27 85, 85, 85 1.2, 2.4 D1 series D1, D2i, S1 None 68 27 80, 85 1.8, 1.8 D1 V D1, D2i, S1 None 69 27 80, 80 1.8, 1.8 D1 V D1, D2i, S1 None 70 27 80, 90 1.8, 1.8, 1.8 D1 V, w, center D1, D2i, S1 None 71 27, 21 80, 80, 80 1.8, 3.0 D1 V, w, center D1, D2i, S1 None

Table 9. Multiple fans at stairwell door Experiment Fan Size Fan Angle Fan Setback Fan Location Fan Orientation Doors Open Vents Open

(in) (degrees) (m)

72 21 80 1.8 D2 NA D2, S1 None 73 21 80, 85 1.8, 3.0 D2 series D2, S1 None 74 21 80, 80, 80 0.6, 1.8, 3.0 D2 series D2, S1 None 75 27 80 1.2 D2 NA D2, S1 None 76 27 80, 80 1.2, 2.4 D2 series D2, S1 None 77 27 80, 80, 80 1.2, 2.4, 3.7 D2 series D2, S1 None

Table 10. Stairwell door(s) open configuration(s) Experiment Fan Size Fan Angle Fan Setback Fan Location Fan Orientation Doors Open Vents Open

(in) (degrees) (m)

78 27 80, 80, 80 1.2, 2.4, 3.7 D2 series D2, S1, S2(2.5") None 79 27 80, 80, 80 1.2, 2.4, 3.7 D2 series D2, S1, S2 None 80 27 80, 80, 80 1.2, 2.4, 3.7 D2 series D2, S1, S10(2.5") None 81 27 80, 80, 80 1.2, 2.4, 3.7 D2 series D2, S1, S10 None 82 27 80, 80, 80 1.2, 2.4, 3.7 D2 series D2, S1, S20(2.5") None 83 27 80, 80, 80 1.2, 2.4, 3.7 D2 series D2, S1, S20 None 84 27 80, 80, 80 1.2, 2.4, 3.7 D2 series D2, S1, S10, S20 None

23 Table 11. Fans at multiple ground floor doors Experiment Fan Size Fan Angle Fan Location Fan Orientation Doors Open Vents Open

(in) (degrees)

85 27 All 80 D1, D2, D3 Series, V w/center D1, D2, D3, D2i, S1 None 86 27 All 80 D1, D3 V w/center D1, D3, D2i, S1 None

Table 12. Fans in the structure Experiment Fan Size Fan Angle Fan Setback Fan Location Doors Open Vents Open

(in) (degrees) (m)

87 27 80 1.2 D2 D2, S1 None 88 27 80, 80 1.2, 1.2 D2 D2, S1, S12 None 89 27 80, 80 1.2, 1.2 D2 D2, S1, S22 None 90 27 80, 80, 80 1.2, 1.2, 1.2 D2 D2, S1, S12, S22 None 91 27 80 1.2 D2 D2, S1, S12 None

Table 13. 46 in trailer mounted fan at ground floor entrances Experiment Fan Size Fan Angle Fan Setback Fan Location Doors Open Vents Open

(degrees) (m)

92 MVU (1000rpm) 90 10.0 D2 D2, S1 None 93 MVU (1500rpm) 90 10.0 D2 D2, S1 None 94 MVU (2000rpm) 90 10.0 D2 D2, S1 None 95 MVU (2500rpm) 90 10.0 D2 D2, S1 None 96 MVU (3000rpm) 90 10.0 D2 D2, S1 None 97 MVU (3500rpm) 90 10.0 D2 D2, S1 None 98 MVU (4000rpm) 90 10.0 D2 D2, S1 None 99 MVU (4500rpm) 90 10.0 D2 D2, S1 None 100 MVU (4500rpm) 90 10.0 D1 D1, D2i, S1 None

Table 14. Fans in the structure setback configurations Experiment Fan Size Fan Angle Fan Setback Fan Location Doors Open Vents Open

(in) (degrees) (m)

101 16 80 in stairwell NA S1 None 102 16 80 at S12 S12 S1, S12 None 103 16 80 1.2 m back from S12 S12 S1, S12 None 104 16 80 2.4 m back from S12 S12 S1, S12 None 105 27 80 in stairwell NA S1 None 106 27 80 at S12 S12 S1, S12 None 107 27 80 1.2 m back from S12 S12 S1, S12 None 108 27 80 2.4 m back from S12 S12 S1, S12 None 109 16, 27 80, 80 1.2 m, 2.4 m back from S12 S12 S1, S12 None

24 Table 15. Roof door ventilation through 29th floor Experiment Fan Size Fan Angle Fan Setbac k Fan Location Doors Open Vents Open

(in) (degrees) (m)

110 Natural NA NA NA S1, S29, S29a RD 111 Natural NA NA NA S1, S29, S29a, D2 RD 112 27 80 1.2 D2 S1, S29, S29a, D2 RD 113 27 80 1.8 D2 S1, S29, S29a, D2 RD 114 21 80 1.8 D2 S1, S29, S29a, D2 RD 115 21 80 2.4 D2 S1, S29, S29a, D2 RD 116 16 80 1.2 D2 S1, S29, S29a, D2 RD 117 27 80, 80 1.2, 2.4 D2 S1, S29, S29a, D2 RD 118 21 80, 80 1.2, 2.4 D2 S1, S29, S29a, D2 RD 119 27 80 1.2 S12 S1, S12, S29, S29a, D2 RD 120 27 80 1.2 S12 S1, S12, S29, S29a RD 121 27 80, 80 1.2, 1.2 D2, S12 S1, S12, S29, S29a, D2 RD 122 27 80, 80, 80 1.2, 1.2, 1.2 D2, S12, S22 S1, S12, S22, S29, S29a, D2 RD

Table 16. Roof hatch ventilation through 29th floor Experiment Fan Size Fan Angle Fan Setback Fan Location Doors Open Vents Open

(in) (degrees) (m)

123 27 80, 80, 80 1.2, 1.2, 1.2 D2, S12, S22 S1, S12, S22, S29, S29a, D2 RH 124 27 80, 80 1.2, 1.2 D2, S12 S1, S12, S29, S29a, D2 RH 125 27 80 1.2 D2 S1, S29, S29a, D2 RH 126 NA NA NA NA S1 RH 127 NA NA NA NA S1, D2 RH

Table 17. Roof hatch ventilation through 28th floor Experiment Fan Size Fan Angle Fan Setback Fan Location Doors Open Vents Open

(in) (degrees) (m)

128 16 85 1.2 D2 S1, D2, S28, S28a RH 129 21 80 1.8 D2 S1, D2, S28, S28a RH 130 27 80 1.2 D2 S1, D2, S28, S28a RH 131 27 80, 80 1.2, 2.4 D2 S1, D2, S28, S28a RH 132 27 80, 80, 80 1.2, 2.4, 3.7 D2 S1, D2, S28, S28a RH 133 21 80, 80 1.2, 2.4 D2 S1, D2, S28, S28a RH 134 27 80 1.2 D2 S1, S12, D2, S28, S28a RH 135 27 80 1.2 D2 S1, S12, S28, S28a RH 136 27 80, 80 1.2, 1.2 D2, S12 S1, S12, D2, S28, S28a RH

25 Table 18. Ground floor doorway sealed, Fan efficiency Experiment Fan Size Fan Angle Fan Setback Fan Location Doors Open Vents Open

(in) (degrees) (m)

137 Blower Door, 21 90 0 D2 S1 NA 138 Blower Door, 21 90 0 D2 S1 NA 139 Smoke Curtain, 27 90 0 D2 S1 NA

Table 19. Other fan types at ground floor stairwell door Experiment Fan Size Fan Angle Fan Setback Fan Location Fan Orientation Doors Open Vents Open

(in) (degrees) (m)

150 27 80 1.2 D2 NA D2, S1 NA 151 24 80 1.8 D2 NA D2, S1 NA 152 31 75 2.4 D2 NA D2, S1 NA 153 21 70 2.4 D2 NA D2, S1 NA 154 21 70 1.2 D2 NA D2, S1 NA 155 21 70, 90 1.5, 2.3 D2 V D2, S1 NA 156 21 70, 70 2.4, 2.4 D2 V D2, S1 NA 157 21 70, 70 1.2, 2.4 D2 series D2, S1 NA 158 21 85 1.8 D2 NA D2, S1 NA 159 31, 24 90, 70 2.7,3.0 D2 V D2, S1 NA

Table 20. Hovercraft at ground floor entrance Experiment Fan Size Fan Angle Fan Setback Fan Location Doors Open Vents Open

(gegrees) (m)

160 Hovercraft 90 3.7 D3 D3, D2i, S1 NA

1. 0 Results
2. 1 Stairwell Differential Pressure

1. 1.1 Optimal fan placement at stairwell door (D2)

Three fan sizes 0.4 m (16 in), 0.5 m (21 in) and 0.7 m (27 in) were used for this series (figure 15). Fan setback was varied from 0.6 m (2 ft) to 3.6 m (12 ft) and fan angle ranged from 90 degrees to 80 degrees to determine the optimal fan placement. The optimal placement is determined by the highest pressures created in the stairwell. Background pressures were recorded with D2 open.

The optimal placement for the 0.4 m (16 in), 5.5 hp fan was 1.2 m (4 ft) and 85 degrees (figure 16). A placement of 0.6 m (2 ft) and 85 degrees is the second most optimal position. These close distances suggest that there is a large amount of air entrained by the air flowing through the shroud of the fan in order to create the seal around the doorway by preventing backflow.

26 The least optimal placement was 3.0 m (10 ft) and 85 degrees, followed by 3.7 m (12 ft) and 80 degrees. Another least desired position was 1.2 m (4 ft) and 90 degrees. This suggests that the fan tilted to blow straight into the doorway does not create the desired airflow to seal the doorway and increase the pressure.

The 0.4 m (16 in) fan was not able to meet the 28.6 Pa thresholds (Table 1) to prevent smoke flow from unsprinklered buildings into the stairwell on any floor. The 12.5 Pa threshold for sprinklered buildings was achieved up to the third floor using the optimal placement. Many of the non-optimal placements do not meet the sprinklered threshold at any floor.

Increasing the fan size to 0.5 m (21 in) with a 6.5 hp engine resulted in slightly different optimal positions. The optimal placement was 1.8 m (6 ft) and 85 degrees (figure 17). The second most optimal placement was 1.8 m (6 ft) and 80 degrees. The least optimal placement was 3.0 m (10 ft) and 90 degrees. All three angles at 0.6 m (2 ft) and 90 degrees at 1.8 m (6 ft) produced poor results. These placements also reinforce that backflow from the doorway is important to avoid in order to create higher pressures.

The 0.5 m (21 in) fan was also not able to increase the pressure at any floor to 28.6 Pa. However the optimal placement was able to increase the pressure above 12.5 Pa up to the ninth floor. Similar to the 0.4 m (16 in) fan many of the non-optimal placements do not meet the 12.5 Pa sprinklered threshold (Table 1) at any floor.

The 0.7 m (27 in) fan with a 9.0 hp engine had an optimal placement of 1.2 m (4 ft) and 80 degrees (figure 18). The second most optimal placement was 1.8 m (6 ft) and 80 degrees. The least optimal placements were 3.0 m (10 ft) and 85 degrees, 3.0 m (10 ft) and 80 degrees, and 0.6 m (2 ft) and 90 degrees.

Only the optimal placement created pressures above 28.6 Pa for unsprinklered buildings. It achieved this pressure only on the first floor. This placement also created pressures above 12.5 Pa up to the thirteenth floor. All placements with the 0.7 m (27 in) fan were able to reach 12.5 Pa but most were only able to on the lower few floors.

Figure 15. Fans placed at stairwell doorway, (a) 0.4 m (16 in), (b) 0.5 m (21 in), (c) 0.7 m (27 in) (a) (b) (c)

27 0 5 10 15 20 25 30 0 5 10 15 20 Pressure (Pa) Floor Number 2 ft, 85 degrees 2 ft, 80 degrees 4 ft, 90 degrees 4 ft, 85 degrees 4 ft, 80 degrees 6 ft, 90 degrees 6 ft, 85 degrees 6 ft, 80 degrees 8 ft, 90 degrees 8 ft, 85 degrees 8 ft, 80 degrees 10 ft, 90 degrees 10 ft, 85 degrees 10 ft, 80 degrees 12 ft, 90 degrees 12 ft, 85 degrees 12 ft, 80 degrees Background

Figure 16. Stairwell pressures created by a 0.4 m (16 in) fan

0 5 10 15 20 25 30 0 5 10 15 20 25 30 Pressure (Pa) Floor Number 2 ft, 90 degrees 2 ft, 85 degrees 2 ft, 80 degrees 4 ft, 90 degrees 4 ft, 85 degrees 4 ft, 80 degrees 6 ft, 90 degrees 6 ft, 85 degrees 6 ft, 80 degrees 8 ft, 90 degrees 8 ft, 85 degrees 8 ft, 80 degrees 10 ft, 90 degrees 10 ft, 85 degrees 10 ft, 80 degrees 12 ft, 90 degrees 12 ft, 85 degrees 12 ft, 80 degrees Background

Figure 17. Stairwell pressures created by a 0.5 m (21 in) fan

28

0 5 10 15 20 25 30 0 5 10 15 20 25 30 35 Pressure (Pa) Floor Number 2 ft, 90 degrees 2 ft, 85 degrees 2 ft, 80 degrees 4 ft, 90 degrees 4 ft, 85 degrees 4 ft, 80 degrees 6 ft, 90 degrees 6 ft, 85 degrees 6 ft, 80 degrees 8 ft, 90 degrees 8 ft, 85 degrees 8 ft, 80 degrees 10 ft, 90 degrees 10 ft, 85 degrees 10 ft, 80 degrees 12 ft, 90 degrees 12 ft, 85 degrees 12 ft, 80 degrees Backgrond

Figure 18. Stairwell pressures created by a 0.7 m (27 in) fan

1. 1.2 Optimal fan placements at ground floor entrance (D1)

It is not always possible to place the fan to blow directly into the stairwell doorway. Many high-rise buildings only have stairwells that exit onto the ground floor and not directly to the outside. Experiments 56-61 examine the pressures created in the stairwell by the best placements determined in experiments 1- 54 at a ground floor entrance door remote from the stairwell (figure 19). This configuration requires the fan to pressurize the ground floor and a portion of the basement due to the open stairwell that connects the ground floor to the basement located near side A, adjacent to doorway D1.

The pressures created by a single fan located at its optimal locations are significantly less than those from the fan blowing directly into the stairwell door. At floor 5 the pressures created were approximately one-fourth of those obtained with a fan placed at the stairwell door (figure 20). Pressures were increased less than 2 Pa at all of the floors. This was expected due to the large volume that was added between the fan and the stairwell.

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Figure 19. Fan placed at ground level doorway (D1) 0 5 10 15 20 25 30 0 2 4 6 8 10 Pressure (Pa) Floor Number 21 in, 6 ft, 80 degrees 21 in, 8 ft, 85 degrees 21 in, 4 ft, 80 degrees 27 in, 4 ft, 85 degrees 27 in, 6 ft, 80 degrees 27 in, 4 ft, 80 degrees Background

Figure 20. Stairwell pressures from fans blowing into D1

30 4.1.3 Multiple fans at ground floor entrance (D1)

In order to get better performance fire departments often place more than one fan at a doorway. Two main questions were addressed with experiments 62 through 71. First, does adding a second and third fan double and triple the pressures in the stairwell and what is the best way to arrange the fans to achieve the best results?

Experiments 62 through 66 used 0.5 m (21 in) fans (figure 21). Figure 22 demonstrates using additional fans did not cause the pressures to reach the desired magnitudes. All of the floors remained below 10 Pa which would not prevent smoke infiltration into the stairwell. The orientation of the multiple fans also made a difference in the pressures. Placing the fans in a V-shape was more effective than placing them in series. Placing the fans in a V-shape with one angled at the top of the door and one at the bottom of the door was less effective than angling them both at the center of the door.

Experiments 67 through 70 used 0.7 m (27 in) fans and experiment 71 used a combination of the 0.5 m (21 in) and 0.7 m (27 in) fans. Pressures created by adding additional fans were slightly higher than the single fan but did not come close to creating adequate pressures, with the exception of floors three through seven when six fans were used (figure 23). All of the floors remained below 12.5 Pa, a pressure which would not prevent smoke infiltration into the stairwell. The orientation of the multiple fans also makes a difference in the pressures. Placing the fans in a V-shape is more effective than placing them in series. However with the 0.7 m (27 in) fans, placing the fans in a V- shape with one angled at the top of the door and one at the bottom of the door was more effective than angling them both at the center of the door, which is not consistent with the 0.5 m (21 in) fans.

31

Figure 21. Fans placed at ground floor entrance (D1), a. 2 fans in series, b. 2 fans in V-shape, c. 2 fans in V- shape (top/bottom), d. 3 fans in V-shape w/center, e. 3 fans in series (a) (b) (c) (d) (e)

32 0 5 10 15 20 25 30 0 5 10 15 Pressure (Pa) Floor Number 2 - 21 in. fans in series 2 - 21 in. fans in V-shape 2 - 21 in. fans in V-shape (top/bottom) 3 - 21 in. fans in V-shape w/center 3 - 21 in. fans in series Background

Figure 22. Stairwell pressures from multiple 21 in. fans at D1

0 5 10 15 20 25 30 0 5 10 15 Pressure (Pa) Floor Number 2 - 27 in. fans in series 2 - 27 in. fans in V-shape 2 - 27 in. fans in V-shape (top/bottom) 3 - 27 in. fans in V-shape w/ center 3 - 21 in. fans and 3 - 27 in. fans Background

Figure 23. Stairwell pressures from multiple 27 in. fans at D1

33 4.1.4 Multiple fans at stairwell doorway (D2)

A single fan at the base of the stairwell door (D2) was not able to adequately pressurize the stairwell, so, it was necessary to see if multiple fans would be more effective and how much more effective that adding one and two additional fans in series. The fans were not placed in a V-shape because sufficient space was not available in front of the doorway. The first fan was setback 1.2 m (4 ft) and additional fans were placed in 1.2 m (4 ft) increments. All fans were set at an 80 degree angle (figure 24).

A single 0.5 m (21 in) fan created pressures ranging from 26 Pa at the ground floor to approximately 8 Pa from the 15th floor to the roof (figure 25). Adding a second 0.5 m (21 in) fan in series increased the ground floor pressure to 27 Pa and created a pressure of 10 Pa from the 15th floor to the roof. Three fans increased the ground floor pressure to 31 Pa but did not increase the pressure on the floors above the 13th floor.

A single 0.7 m (27 in) fan created pressures ranging from 24 Pa at the ground floor to approximately 8 Pa from the 15th floor to the roof (figure 26). Adding a second 0.7 m (27 in) fan in series increased the ground floor pressure to 29 Pa and created a pressure of 10 Pa from the 15th floor to the roof. Three fans increased the ground floor pressure to 33 Pa and increased the pressure to 11 Pa on the upper floors.

Figure 24. Multiple fans in series at stairwell doorway, a. 1.2 m and 2.4 m, b. 1.2 m, 2.4 m and 3.7 m (a) (b)

34 0 5 10 15 20 25 30 0 10 20 30 40 Pressure (Pa) Floor Number 1.2 m (4 ft) 1.2 m (4 ft) and 2.4 m (8 ft) 1.2 m (4 ft), 2.4 m (8 ft) and 3.7 m (12 ft) Background

Figure 25. Stairwell pressures from 0.5 m (21 in) fans in series at D2

0 5 10 15 20 25 30 0 10 20 30 40 Pressure (Pa) Floor Number 1.2 m (4 ft) 1.2 m (4 ft) and 2.4 m (8 ft) 1.2 m (4 ft), 2.4 m (8 ft) and 3.7 m (12 ft) Background

Figure 26. Stairwell pressures from 0.7 m (27 in) fans in series at D2

35 4.1.5 Open doors in the stairwell

Open doors in the stairwell are an obvious concern due to the need for the fire department to access the floors and for occupants to exit the structure. The added volume of the large floors would certainly affect the pressures the fans were able to create in the stairwell. Doors were either opened 0.08 m (3 in) to simulate the minimum opening achievable by the fire department after stretching a hose line through the doorway or completely open to replicate the worst case scenario. The pressures were created with three 0.7 m (27 in) fans in series, identical to the configuration in the previous series.

Opening the doors 0.08 m (3 in) had little impact on the stairwell pressures (figure 27). Having the 10th floor slightly open allowed for the 28.6 Pa threshold to be met up to the 9th floor and the 12.5 Pa threshold to be met in the entire stairwell. With the 2nd floor and 20th floor slightly opened kept the pressure above 28.6 Pa up to the 5th floor and kept the pressure above 12.5 Pa up to the 15th floor.

Completely opening the doors had a major impact on the stairwell pressures. Having the 20th floor door open had the least impact on the stairwell pressures while the second floor door open had the largest impact. Having the door completely open essentially eliminates the effect of the fan in the stairwell on the floors above the open door and lowers the pressure of the floors below the floor of the open door as well. With the 20th floor door open the pressures still maintained the 28.6 Pa threshold up to the 5th floor and the 12.5 Pa threshold up to the 13th floor. With the 10th floor door open the pressures only maintained the 28.6 Pa threshold on the 1st floor and the 12.5 Pa threshold up to the 7th floor. With the 2nd floor door open only the 12.5 Pa threshold was met on the 1st floor.

0 5 10 15 20 25 30 0 10 20 30 40 50 Pressure (Pa) Floor Number 2nd Floor, 0.08 m (3 in) open 2nd Floor Open 10th Floor, 0.08 m (3 in) Open 10th Floor Open 20th Floor, 0.08 m (3 in) Open 20th Floor Open 10th and 20th Floor Open

Figure 27. Stairwell pressure with doors open

36 4.1.6 Multiple fans at multiple ground level doors

An effort was made to pressurize the stairwell from the ground level by utilizing multiple fans in various arrangements. In experiment 85, three 0.7 m (27 in) fans were placed in a V-shape at D1, three 0.5 m (21 in) fans were placed in a V-shape at D3 and three 0.4 m (16 in) fans were placed in series at D2 (figure 28). In experiment 86, three 0.7 m (27 in) fans were placed in a V-shape at D1 and three 0.5 m (21 in) fans were placed in a V- shape at D3, with no fans at D2 assuming that there was no access directly into the stairwell.

Even with nine fans at three different doors the pressure increase was minimal and did not even meet the lower threshold pressure at any floor (figure 29). Apparently the larger fans at D1 and D3 overpressurized or overwhelmed the smaller fans/open doorway at D2 and lower pressures resulted (figure 29). Once the smaller fans were removed and doorway D2 was closed, the larger fans at D1 and D3 provided higher pressures (figure 29). Even with the six fans running the lower sprinklered building threshold of 12.5 was met up to the ninth floor. Using the same six fans at two doors was more effective than using all six at one door as compared to experiment 71 in figure 20.

Figure 28. Fans placed at multiple doors, a. Fans at D2 and D3, b. Fans at D1 (a) (b)

37 0 5 10 15 20 25 30 0 5 10 15 20 Pressure (Pa) Floor Number D1, D2, D3 D1, D3 Background

Figure 29. Stairwell pressures with multiple fans at multiple doors

1. 1.7 Fans located inside the building

Placing fans at the ground level alone was not effective in meeting the pressure requirements necessary to prevent smoke from flowing into the stairwell. This series tried to replicate a multiple injection stairwell pressurization system that can be found in some buildings. Five different configurations were examined placing 0.7 m (27 in) fans on the ground floor, the 12th floor and the 22nd floor. The fans on the upper floors were setback and angled just as if they were blowing in from the outside, 1.2 m (4 ft) and 80 degrees (figure 30). There was no opening to the outside of the building on the 12th or 22nd floor so little make-up air was available.

The difference between placing a fan at the ground floor and the 12th floor was significant. The fan at the 12th floor created higher pressures from the 5th floor to the top floor (figure 31). The pressures from the 13th floor to the roof were more than double those from the fan on the ground floor. A single fan on the 12th floor created pressures throughout the stairwell that exceeded the 12.5 Pa threshold. Adding a fan at the 1st floor elevated the pressures above the 28.6 Pa threshold up to the 15th floor and adding a fan on the 22nd floor allowed for the 28.6 Pa threshold to be met on all floors with the exception of floors 21 and 27. The lower pressures on 27 appear to be consistent with decrease in pressure as one moves away from the fan.

38

Figure 30. Fan positioned in the building

0 5 10 15 20 25 30 0 10 20 30 40 Pressure (Pa) Floor Number Fan at floor 1 Fan at floor 1 and 12 Fan at floor 1 and 22 Fan at floor 12 Fan at floor 1, 12 and 22

Figure 31. Stairwell pressures with fans inside the building

39 4.1.8 1.2 m (46 in) trailer mounted fan at ground floor entrance

The smaller, compartment size fans were not effective from the ground so a larger trailer mounted fan was utilized for a series of experiments. The 1.2 m (46 in) fan was positioned 10.0 m (32.8 ft) from the stairwell doorway and was not angled (figure 32). The engine speed was increased by 500 rpm increments, up to 4500 rpm, and steady state pressures were recorded for each level. Experiments were stopped at 4500 rpm, close to the maximum output of the fan, due to concerns for glass breakage.

At 3500 rpm the fan was able to pressurize the entire stairwell to the 12.5 Pa sprinklered building minimum pressure (figure 33). When increased to 4500 rpm the stairwell pressures were above the 28.6 Pa unsprinklered pressure threshold. The highest steady state pressure, 103 Pa, was recorded on the 1st floor, with the fan set to 4500 rpm. Pressures of this magnitude border on the upper threshold which should not be exceeded if occupants are to readily open the doors to exit the building.

Figure 32. Trailer mounted fan at stairwell door.

40 0 5 10 15 20 25 30 0 20 40 60 80 100 120 Pressure (Pa) Floor Number 1000 rpm 1500 rpm 2000 rpm 2500 rpm 3000 rpm 3500 rpm 4000 rpm 4500 rpm

Figure 33. Stairwell pressures made by the 1.2 m (46 in) fan at the stairwell door. 4.1.9 Further analysis of fans located inside the building

Since elevated pressure results were successfully achieved in the previous series of experiments with fans located inside the building, additional configurations were analyzed. This series focused on the setback of the fan in the building at the 12th floor. Fans were placed in the stairwell with the stairwell door shut, at the stairwell door, setback 1.2 m (4 ft), setback 2.4 m (8 ft) and two fans in series at the stairwell doorway (figure 34).

The fans placed in the stairwell slightly increased the stairwell pressures above the 12th floor and decreased the pressures below the fan level (figure 35). This configuration was not effective and could actually draw flows downward in the building. The 0.4 m (16 in) fan was not able to increase the pressure on any floor above 10 Pa which does not meet either desirable pressure threshold. The 1.2 m (4 ft) setback with an angle of 80 degrees was more effective than the 2.4 m (8 ft) setback with an angle of 80 degrees and the fan positioned in the doorway.

The 0.7 m (27 in) fan was able to raise the pressure on all floors above the 12.5 Pa threshold with three different setbacks, in the doorway, 1.2 m (4 ft) back from the door and 2.4 m (8 ft) back from the door. The optimal setback was 1.2 m and 80 degrees. This placement created pressures above 19 Pa on every floor, with a maximum pressure of 28 Pa recorded on floor 13. This setback even outperformed both fans in series.

41

Figure 34. Fans locations in the stairwell

(a) (b) (c) (d)

42 0 5 10 15 20 25 30 0 10 20 30 40 Pressure (Pa) Floor Number 16 in. fan in stairwell 16 in. fan at stairwell door 16 in. fan 1.2 m (4 ft) setback 16 in. fan 2.4 m (8 ft) setback 27 in. fan in stairwell 27 in. fan at stairwell door 27 in. fan 1.2 m (4 ft) setback 27 in. fan 2.4 m (8 ft) setback 16 in. and 27 in. fan in series Background

Figure 35. Stairwell pressures created with fans at the 12th floor.

1. 1.10 Fans at ground level and in the building with the bulkhead

door open

A common tactic in venting a high-rise building is opening the bulkhead door at the top of the stairwell, if there is one. In this building the bulkhead door was in the second stairwell, therefore both doors to the 29th floor were opened so the flow would travel through the 29th floor into the other stairwell and out of the bulkhead door. This tactic often allows for smoke to escape and create more tenable conditions in the stairwell both for civilians attempting to exit and fire fighters. This series of experiments examined the pressure decrease in the stairwell when the 29th floor and the bulkhead door in the other stairwell were opened.

After completing this series of experiments it was noticed that there was an exhaust fan on the 29th floor that forced air to the outside. This is common on mechanical floors but changes the meaning of the pressures recorded for this series only. Pressures in the top of the stairwell were lower than expected because of the negative pressure created by the exhaust fan. The pressures can be treated as a worst case scenario as opposed to ideal which will be examined in a later series which uses the 28th floor as opposed to the 29th floor to eliminate the exhaust fan from the path to the vent locations (bulkhead door and roof hatch).

43

Background data was recorded to examine the pressures in the building with just the bulkhead door open and then with the stairwell door open. When the stairwell door was opened it induced pressures in the lower portion of the stairwell as high as 11 Pa at the ground floor. The pressure declined to approximately 0 Pa at floor 19 (figure 36).

Three different configurations were analyzed, 0.5 m (21 in) fans at ground level, 0.7 m (27 in) fans at ground level and 0.7 m (27 in) fans on the 12th floor. The pressures on the upper floor drop significantly when the 29th floor and the bulkhead doors were opened. The pressures above the 20th floor dropped from 9 Pa to 0 Pa with the 29th floor and bulkhead doors open. Two 0.5 m (21 in) fans were able to create pressures exceeding the 28.6 Pa threshold up to the 3rd floor and 12.5 Pa threshold up to the 11th floor.

A 0.7 m (27 in) fan located at the ground level created pressures of approximately 9 Pa above the 15th floor with all the stairwell doors closed (figure 37). Those pressures dropped to 0 Pa when the 29th floor and the bulkhead doors were opened. When two fans were used the 12.5 Pa thereshold was exceeded up to the 11th floor, even with the vents opened. When the fan was moved to the 12th floor the doors opened at the top and the bottom of the stairwell were analyzed (figure 38). With the 29th floor and bulkhead doors open, the pressures dropped as much as 21 Pa to 0 Pa at the 27th floor. The ground floor door open in addition to the 29th floor and bulkhead doors had little impact on the stairwell pressures.

0 5 10 15 20 25 30 0 10 20 30 40 Pressure (Pa) Floor Number BH open, Stairwell door closed BH open, Stairwell door open 21 in. fan, 1.8 m (6 ft) and 80 degrees 21 in. fan, 2.4 m (8 ft) and 85 degrees 2 - 21 in. fans, 1.2 m (4 ft) and 2.4 m (8 ft), both 80 degrees 21 in. fan, 1.8 m (6 ft) and 80 degrees, BH closed

Figure 36. Stairwell pressures created by 0.5 m (21 in) fans with the 29th floor and bulkhead door open.

44

0 5 10 15 20 25 30 0 10 20 30 40 50 Pressure (Pa) Floor Number BH open, Stairwell door closed BH open, Stairwell door open 27 in. fan, 1.2 m (4 ft) and 80 degrees 27 in. fan, 1.8 m (6 ft) and 80 degrees 2 - 27 in. fans, 1.2 m (4 ft) and 2.4 m (8 ft), both 80 degrees 27 in. fan, 1.2 m (4 ft) and 80 degrees, BH closed

Figure 37. Stairwell pressures created by 0.7 m (27 in) fans at the ground level with the 29th floor and bulkhead door open.

45 0 5 10 15 20 25 30 0 10 20 30 40 Pressure (Pa) Floor Number BH open, Stairwell door closed BH open,Stairwell door open 27 in. fan on 12th floor, Stairwell door closed 27 in. fan on 12th floor, Stairwell door open 27 in. fan on 12th floor, Stairwell door closed, BH closed

Figure 38. Stairwell pressures created by 0.7 m (27 in) fans on the 12th floor with the 29th floor and bulkhead door open. 4.1.11 Fans at ground level and in the building with the roof hatch open

Adjacent to the bulkhead door on the 29th floor was a ship-style ladder that led to a roof hatch. The roof hatch was the highest point of the building and the most remote ventilation location from the ground level entrances. In this series the exhaust fan on the 29th floor was removed from the flow path by opening both stairwell doors to the 28th floor and flowing through the 28th floor to the roof hatch. Configurations were run with single fans at ground level, multiple fans at ground level, and fans inside the building.

The series of experiments began with pressures recorded with just the roof hatch open. This did not provide any pressure above ambient (figure 39). The stairwell door was opened and pressures below the 15th floor increased. The 1st floor pressure increased to 7 Pa, decreasing down to 1 Pa at the 15th floor. The 0.4 m (16 in) fan was only able to increase pressures approximately 3 Pa and never exceeded 10 Pa. The 0.5 m (21 in) fan increased pressures on the first floor to 25 Pa and met the 12.5 Pa threshold to the 9th floor. Increasing the fan size to 0.7 m (27 in) increased the 1st floor pressure to 32 Pa. The 12.5 Pa threshold was exceeded up to the 11th floor. Without an exhaust fan in the flow path pressures were slightly increased up to the 25th floor whereas in the previous series the pressures were not increased above the 21st floor with single fans located at ground level.

46 Fans were added in series to try to increase the pressures in the stairwell. When a second 0.5 m (21 in) fan was added in series an increase of approximately 2 Pa was achieved throughout the stairwell (figure 40). This provided little benefit and increased the 12.5 Pa threshold from the 9th floor to the 10th floor. A second 0.7 m (27 in) fan in series increased pressures in the lower floors from approximately 4 to 6 Pa. The 12.5 Pa threshold was raised from the 11th to the 13th floor. Adding a third 0.7 m (27 in) fan in series provided very little benefit and raised stairwell pressures less than 2 Pa at all floors.

A single 0.7 m (27 in) fan was placed on the 12th floor positioned as previously described and the door at the base of the stairwell was placed in the open and closed position. Having the door closed created higher pressures below the 12th floor (figure 41). Closing the door increased the average 1st floor stairwell pressure from 10 Pa to 17 Pa. Above the 12th floor the position of the ground floor stairwell door was irrelevant. When a second 0.7 m (27 in) fan was added at ground level the pressures were increased close to the 28.6 Pa threshold up to the 13th floor. In all three configurations the 12.5 Pa threshold was reached up to the 13th floor. 0 5 10 15 20 25 30 0 10 20 30 40 50 Pressure (Pa) Floor Number RH open, Stairwell door closed RH open, Stairwell door open 16 in., 1.2 m (4 ft) and 85 degrees 21 in., 1.8 m (6 ft) and 80 degrees 27 in., 1.28 m (4 ft) and 80 degrees

Figure 39. Stairwell pressures created by a single fan with the 28th floor and roof hatch open.

47 0 5 10 15 20 25 30 0 10 20 30 40 50 Pressure (Pa) Floor Number RH open, Stairwell door closed RH open, Stairwell door open 2 - 21 in, 1.2 m (4ft) and 2.4 m (8 ft) 2 - 27 in, 1.2 m (4ft) and 2.4 m (8 ft) 3 - 27 in, 1.2 m (4ft) and 2.4 m (8 ft), 3.6 m (12 ft)

Figure 40. Stairwell pressures created by multiple fans with the 28th floor and roof hatch open. 0 5 10 15 20 25 30 0 10 20 30 40 50 Pressure (Pa) Floor Number RH open, Stairwell door closed RH open, Stairwell door open 27 in., 12th floor, RH open, Stairwell door open 27 in., 12th floor, RH open, Stairwell door closed 2 - 27 in., Ground floor and 12th floor

Figure 41. Stairwell pressures created by fans in the building with the 28th floor and roof hatch open.

48

1. 1.12 Ground level doorway sealed / Fan efficiency

Positive pressure ventilation fans setback from a doorway seal the doorway with a cone of air to increase the pressure. The distance the fan is from the doorway, or setback, can impact how effective a PPV “seals” the doorway. A fixed stairwell pressurization system usually has a fan, or multiple fans, that are connected directly to the stairwell with no setback and in turn should be 100 % efficient at using its flow to increase the pressure in the stairwell. In an attempt to recreate a similar situation, the ground floor doorway was sealed with an air infiltration door test frame and a 0.5 m (21 in) fan was placed in the hole to flow into the building with no air escaping because of a setback distance.

As compared to the optimal setback configuration determined in a previous series, sealing the door created higher pressure throughout the stairwell. Pressures increased as much as 8 Pa to 2 Pa at the ground level and at the 27th floor respectively (figure 42). Assuming the fan flowing with the sealed door is completely efficient, the fan setback at its optimal distance and angle is 80 % efficient. While sealing the door is more efficient it eliminates the ability for fire fighters to enter the stairwell from that doorway and for occupants to exit via that doorway.

0 5 10 15 20 25 30 0 10 20 30 40 Pressure (Pa) Floor Number 21 in. fan with sealed doorway 21 in. fan, 1.8 m (6 ft) and 85 degrees Background

Figure 42. Stairwell pressures created by a 0.5 m (21 in) fan with the doorway sealed and with the fan setback

49

1. 1.13 Other types of fans at the ground level stairwell door

PPV manufacturers and representatives were invited to take part in the experiments. Two additional manufacturers brought fans. The fans ranged in size from 0.5 m (21 in) to 0.8 m (31 in) with engines ranging in size from 5.5 hp to 12.0 hp. The fans were positioned at the ground level stairwell doorway and the stairwell was pressurized with all vents closed. The fans were initially setup at the doorway by the manufacturer’s representative. Additional configurations such as side by side and series were done for comparison (figure 43).

As expected, the larger the fan the higher the pressures created in the stairwell (figure 44). The 0.8 m (31 in) fan created pressures as high as 41 Pa at the ground floor. The 0.6 m (24 in) fan peaked at 30 Pa on the ground floor. The 0.5 m (21 in) fan reached 23 Pa and the Toledo truck fan (has been in service for over 10 years on a Toledo Fire Department truck company) only raised the first floor stairwell pressure to 8 Pa. The 0.8 m (31 in) fan was able to exceed the 12.5 Pa threshold in the entire stairwell while the smaller fans were effective for less than half of the stairwell height.

A few different configurations were experimented with the 0.5 m (21 in) fans, 1.2 m setback, 2.4 m setback, side by side (same angle, V), offset (top and bottom, R) and series (S). The 2.4 m setback with a 70 degree angle created higher pressures than the 1.2 m setback with a 70 degree angle. The offset fans with 70 degree and 90 degree angles created higher pressures than the side by side with the same angle which created higher pressures than the fans in series. Adding the 0.6 m (24 in) fan to the 0.8 m (31 in) raised pressures 8 Pa on the ground floor and approximately 1 Pa above the 17th floor. The old fan that was taken off of the Toledo ladder truck did not perform well, not coming close to achieving the 12.5 Pa threshold anywhere in the stairwell.

Different fans are constructed different ways and cannot always be compared directly due to different sized motors, shroud type and size and fan angle adjustments. However, common trends exist. Placing the fans next to each other as opposed to in series is more effective. It is possible to have a single fan achieve 12.5 Pa in the entire stairwell but that fan maybe large and may not fit in a truck compartment. PPV fans have improved greatly in the last 10 years and older fans should be checked for performance and replaced if necessary to allow for increased effectiveness. Different fan manufacturers have different optimal setbacks and angles due to many differences, such as shrouds and fan blades.

50

Figure 43. Other types of fans and configurations. (a) 2 – 21 in. fans side by side (b) 2 – 21 in. fans in series (c) 24 in. and 31 in. fans side by side (d) 21 in. Toledo truck fan (a) (b) (c) (d)

51 0 5 10 15 20 25 30 0 10 20 30 40 50 60 Pressure (Pa) Floor Number 24 in, 9.5 hp (R) 31 in, 12.0 hp (R) 21 in, 5.5 hp (R) 21 in, 5.5 hp (4 ft) 2 - 21 in, 5.5 hp (R) 2 - 21 in, 5.5 hp (V) 2 - 21 in, 5.5 hp (S) 21 in, 5.5 hp (Toledo Truck) 31 in, 12.0 hp and 24 in, 9.5 hp (R)

Figure 44. Pressures created by other manufacturer’s fans in various configurations

1. 1.14 Fans and a hovercraft at ground floor entrances (D1 and D3)

Many fire departments have been resourceful when they had to remove smoke from a large structure and have occasionally used a hovercraft or airboat. Oftentimes, a hovercraft is much more accessible than a large trailer mounted fan. A hovercraft was used in the experiments for comparison against a trailer mounted fan. The hovercraft was setback 3.7 m (12 ft) from the ground entrance door (D3) and was run at full throttle (figure 45).

The hovercraft was approximately as effective as a previous experiment where six fans were utilized (3 - 0.7 m (27 in) fans at D1 and 3 – 0.5 m (21 in) fans at D3) (figure 46). Pressures peaked at 15 Pa on the 5th floor and decreased to an average of 8 Pa in the upper half of the stairwell. The 1.2 m (46 in) trailer mounted fan positioned at D1 created much higher pressures, exceeding the 12.5 Pa threshold in the entire stairwell.

52

Figure 45. Hovercraft positioned at ground floor entrance (D3) 0 5 10 15 20 25 30 0 10 20 30 Pressure (Pa) Floor Number Hovercraft at D3 MVU at D1 3 Fans at D1 and D3

Figure 46. Stairwell pressures created by fans and hovercraft positioned at D1 and D3

53 4.2 Stairwell Temperature

Temperature was recorded on every other floor with bare-bead, type K thermocouples, with a 0.5 mm (0.02 in) nominal diameter. Thermocouples were located next to each of the differential pressure transducers. There was no temperature control in the building; therefore the stairwell temperatures were very similar to the outside temperatures. The temperature in the lower floors ranged between 19 oC (66 oF) in the morning hours to 23 oC (73 oF) in the afternoon. The temperature in the upper floors of the stairwell remained almost constant at about 25 oC (77 oF) to 26 oC (79 oF) independent of the day the experiments were done or of the time of day (figure 47). This small variation in temperature between the inside temperatures and the outside temperatures suggests the impact of stack effect in the stairwell was minimal

0 5 10 15 20 25 30 0 10 20 30 Temperature (oC) Floor Number Experiment 9 Experiment 27 Experiment 49 Experiment 63 Experiment 85 Experiment 95 Experiment 131 Experiment 154

Figure 47. Stairwell temperatures

54 4.3 Weather

Weather was monitored and recorded during each of the experiments using two portable weather stations. Temperature, relative humidity, average wind speed, average wind direction and barometric pressure were recorded continuously. One weather station was located 9.1 m (30 ft) from the centerline of D2 on ground level. The second weather station was located on the lower roof outside RD. Each day started at time zero and readings were captured every 30 seconds. Technical difficulties with the wireless link between the weather station and the data logger resulted in some data loss, but the trends of the data were captured.

The average air temperature was recorded over the course of the four days of experiments at the ground and the roof. The average temperatures remained fairly constant during all of the experiments. Temperatures ranged between 16 oC (61 oF) and 25 oC (77 oF) (figure 48). The morning temperatures were cooler than the afternoon temperatures but there was never an increase of more than 5 oC (9 oF) during the entire day.

Wind speed has the potential to greatly impact the effectiveness of PPV. Wind blowing against an exhaust vent could decrease the effectiveness of PPV. Wind blowing into an inlet could increase the air flow or increase pressurization of a building. The average wind speed mostly remained below 2 m/s (4.5 mph) (figure 49). The wind had little impact on the experimental results. If there was wind there were no gusts that would give one experiment an advantage or disadvantage from another experiment in the same series. The average wind direction was also examined to determine if the wind was into or out of one of the inlets or vents. The wind mainly impacted the building on side B and C, between zero and 140 degrees from north (figure 50). The north arrow can be referenced to the inlets and outlets in figure 4 and figure 7. Therefore the wind had no direct impact on the inlets on side A and little impact on the roof door on side C. A wind impacting the opposite side of the building from the inlets has the potential to lower the pressure on the leeward side of the building. This phenomenon did not play a role in these experiments due to the low magnitude of the wind speed. The stairwells were also interior to the building which lessened the impact of any wind.

The relative humidity and barometric pressure did not show any variations that may have affected the results. The relative humidity ranged between 20 % and 70 % (figure 51). The relative humidity decreased as it became later in the day. The barometric pressure on the roof was between 98 kPa and 99 kPa and between 99 kPa and 100 kPa at ground level (figure 52).

55 0 10 20 30 40 50 0 5000 10000 15000 20000 Experiment 2-54 Ground Experiment 56-100 Ground Experiment 56-100 Roof Experiment 101-149 Ground Experiment 101-149 Roof Experiment 150-160 Ground Experiment 150-160 Roof Average Temperature (oC) Time (s)

Figure 48. Average temperatures.

0 1 2 3 4 5 0 5000 10000 15000 20000 Experiment 2-54 Ground Experiment 56-100 Ground Experiment 56-100 Roof Experiment 101-149 Ground Experiment 101-149 Roof Experiment 150-160 Ground Experiment 150-160 Roof Average Wind Speed (m/s) Time (s)

Figure 49. Average wind speed.

56 0 60 120 180 240 300 360 0 5000 10000 15000 20000 Experiment 2-54 Ground Experiment 56-100 Ground Experiment 56-100 Roof Experiment 101-149 Ground Experiment 101-149 Roof Experiment 150-160 Ground Experiment 150-160 Roof Average Wind Direction (degrees from north) Time (s)

Figure 50. Average wind direction.

0 20 40 60 80 100 0 5000 10000 15000 20000 Experiment 2-54 Ground Experiment 56-100 Ground Experiment 56-100 Roof Experiment 101-149 Ground Experiment 101-149 Roof Experiment 150-160 Ground Experiment 150-160 Roof Relative Humidity (%) Time (s)

Figure 51. Relative humidity.

57 96 97 98 99 100 101 102 0 5000 10000 15000 20000 Experiment 2-54 Ground Experiment56-100 Ground Experiment 56-100 Roof Experiment 101-149 Ground Experiment 101-149 Roof Experiment 150-160 Ground Experiment 150-160 Roof Barometric Pressure (kPa) Time (s)

Figure 52. Barometric pressure.

1. 4 Carbon Monoxide

One of the main toxic gases in combustion is carbon monoxide (CO). When examining PPV and preventing smoke infiltration there are two types of combustion that are important, the fire creating the smoke and the internal combustion of the fan motor. Both sources of CO must be monitored to maintain a safe environment for victims as well as fire fighters.

A fire has the potential to produce a very large amount of CO. This amount could be on the order of 50,000 ppm in an under-ventilated fire [15]. Tenability limits for incapacitation and death for a 5 minute exposure are 6000 ppm (0.6 %) to 8000 ppm (0.8 %) and 12,000 ppm (1.2 %) to 16,000 ppm (1.6 %) respectively. CO is the major toxic gas in approximately 67 % of fatalities in structure fires [15]. Using PPV fans to keep the CO produced by the fire along with the other harmful combustion products out of the stairwells greatly increases the chances of safe evacuation.

The internal combustion fan motors also produce CO. While the levels are much lower than the fire they have to be analyzed. CO meters were placed at the bottom, middle and top of the stairwell to analyze this level. The National Institute for Occupational Safety and Health (NIOSH) has established a recommended exposure limit for CO of 35 ppm (0.0035 %) as an

58 8-hour time weighted average (TWA) and 200 ppm (0.02 %) as a ceiling exposure [16]. A reading of 1200 ppm (0.12 %) is considered immediately dangerous to life and health. The National Research Council (NRC) also defines emergency exposure guidance levels of, 1500 ppm ( 0.15 %) for 10 minutes, 800 ppm (0.08 %) for 30 minutes, 400 ppm (0.04 %) for 60 minutes and 50 ppm (0.005 %) for 24 hours [17].

CO levels for the four days of experiments are graphed in figures 53 through 56. The single fan at the ground floor stairwell created readings as high as 110 ppm (0.011 %) at the 1st floor with a 0.7 m (27 in) fan set back 0.6 m (2 ft) from the doorway. The reading decreased to 30 ppm (0.003 %) when the fan was run at 3.7 m (12 ft). The optimal fan placements for all three sizes of fans created CO readings of 50 ppm (0.005 %) to 80 ppm (0.008 %). The experiments were run one right after another with no venting of any openings between experiments. There was a break between fan sizes to allow for the CO readings to return to ambient.

Any number of fans placed at the ground level did not exceed readings of 100 ppm (0.01 %). Nine fans blowing into the building from three different ground level doorways did not raise the CO reading above 100 ppm (0.01 %). The 1.2 m (46 in) trailer mounted fan did not exceed 50 ppm (0.005 %) at any level in the stairwell.

The fire service becomes very concerned with the idea of taking gasoline powered fans into a structure. This was done multiple times to see the actual CO levels created. A single 0.7 m (27 in) fan set back from the 12th floor door did not exceed 100 ppm (0.01 %). With a 0.7 m (27 in) fan at the ground level in addition to the one on the 12th floor the CO readings peaked at 130 ppm (0.013 %). Adding another 0.7 m (27 in) fan to the 22nd floor increased the peak CO reading on the 14th floor to 140 ppm (0.014 %) but also increased the 28th floor CO level to 110 ppm (0.011 %). The only two experiments that caused the CO levels to exceed the NIOSH ceiling exposure value of 200 ppm (0.02 %) were when a fan was placed in the stairwell and the stairwell doors were closed. In these experiments the 0.4 m (16 in) fan created a peak CO reading of 210 ppm (0.021 %) in the stairwell at the 14th floor and the 0.7 m (27 in) fan had a peak reading of 360 ppm (0.036 %) in the same configuration.

Ultimately the CO produced by the PPV fans was at least one order of magnitude less than that created by a fire. As long as the PPV fans were not placed in the stairwell with the door shut, the NIOSH ceiling exposure was not exceeded and the TWA would not be exceeded for a long period of time. If CO readings are less than 50 ppm (0.005 %), it is not likely that a gasoline powered PPV fan would be effective in ventilating the area. In this case alternatives such as electric PPV fans or natural ventilation should be considered.

59

0 20 40 60 80 100 120 0 5000 10000 15000 20000 Floor 1 Floor 14 Floor 28 Carbon Monoxide (ppm) Time (s) Exp 2-18 Exp 19-36 Exp 37-54 Meters Off for Data Download

Figure 53. Carbon monoxide levels for experiments 2 through 54.

60 0 20 40 60 80 100 120 140 0 5000 10000 15000 20000 25000 30000 Floor 1 Floor 14 Floor 28 Carbon Monoxide (ppm) Time (s) Exp 56-71 Exp 92-100 Exp 87-91 Exp 72-86 Meters Off for Data Download

Figure 54. Carbon monoxide levels for experiments 56 through 100.

61 0 50 100 150 200 250 300 350 400 0 5000 10000 15000 20000 25000 Floor 1 Floor 14 Floor 28 Carbon Monoxide (ppm) Time (s) Exp 101-109 Exp 134-136 Exp 126-133 Exp 110-125 Exp 137-139 Meters Off for Data Download

Figure 55. Carbon monoxide levels for experiments 101 through 139.

62 0 10 20 30 40 50 60 70 0 2000 4000 6000 8000 10000 Floor 1 Floor 14 Floor 28 Carbon Monoxide (ppm) Time (s) Exp 150-159 Exp 160

Figure 56. Carbon monoxide levels for experiments 150 through 160.

1. 5 Sound Levels

Another concern with the use of PPV fans is the noise they create. Fans placed at the base of a stairwell can increase the ambient noise in the stairwell and may adversely affect the communications of the fire crews. Fans placed at lobby doors have the potential to affect command officers that may set up command posts in high-rise structures.

Noise levels were monitored in certain locations throughout the experimental series to estimate the level of impact to the fire crews and command officers. Ambient noise measurements were 60 to 65 dB. This value rose to 80 dB when traffic went past the building. Measurements next to the compartment size fans were approximately 100 dB to 110 dB depending on the size of the

63 fan. The noise value measured 3.0 m (10 ft) from the fans decreased to 90 to 100 dB. Table 21 has a number of common noise levels for comparison.

A 0.7 m (27 in) fan was placed 3.7 m (12 ft) from the stairwell doorway. Readings next to the fan were 105 dB with the fan at full throttle, directly inside the doorway with the door open were 104 dB. In the lobby with the door shut the readings decreased to 77 dB but increased to 95 dB when the door connecting the stairwell and lobby was opened. On the second floor landing, the reading decreased to 80 dB. Similar readings were obtained with a 0.5 m (21 in) fan placed at the same setback distance.

Table 21. Relative Noise Levels Source of Sound/Noise Sound Pressure Level (dB) Threshold of hearing 0 Quiet bedroom at night 30 Conversational speech 60 Curbside of busy roadway 80 Heavy Truck 90 Jackhammer 100 Chainsaw 110 Threshold of pain 130 Instant perforation of eardrum 160

1. 0 Uncertainty

There are different components of uncertainty in the length, differential pressure, gas temperature, metrological, and carbon monoxide data reported here. Uncertainties are grouped into two categories according to the method used to estimate them. Type A uncertainties are those which are evaluated by statistical methods, and Type B are those which are evaluated by other means [18]. Type B analysis of systematic uncertainties involves estimating the upper (+ a) and lower (- a) limits for the quantity in question such that the probability that the value would be in the interval (± a) is essentially 100 %. After estimating uncertainties by either Type A or B analysis, the uncertainties are combined in quadrature to yield the combined standard uncertainty. Multiplying the combined standard uncertainty by a coverage factor of two results in the expanded uncertainty which corresponds to a 95 % confidence interval (2σ). Components of uncertainty are tabulated in Table 22. Some of these components, such as the zero and calibration elements, are derived from instrument specifications. Other components, such as differential pressure, include past experience with the instruments.

Each length measurement was taken carefully. However due to some issues, such as obstructions and unlevel terrain there was a total expanded uncertainty of ± 6 % associated with the length measurements.

64 Differential pressure reading uncertainty components are derived from pressure transducer instrument specifications. The transducers were factory calibrated and the zero and span of each was checked in the laboratory prior to the experiments.

Gas temperature measurements were taken in a very low range of less than 30 oC. There were no temperature fluctuations of large magnitude and no radiative effects. Calibration data was obtained from the thermocouple manufacturer and the measurements appeared very repeatable.

Weather, carbon monoxide and sound measurement uncertainty was referenced to each of their published user’s manuals. Weather and CO instruments have calibration certificates that are traceable to NIST standards. The carbon monoxide meters were factory calibrated prior to the experiments. The sound meter had a self-calibration setting.

Table 22. Uncertainty

Component Standard Uncertainty Combined Standard Uncertainty

Total Expanded Uncertainty

Length Measurements Instrumentation Locations Fan Location Building Dimensions Repeatability1 Random1

± 1 % ± 1 % ± 1 % ± 2 % ± 2 %

± 3 %

± 6 %

Differential Pressure Calibration [19] Accuracy [19] Repeatability 1 Random 1

± 2 % ± 1 % ± 3 % ± 3 %

± 5 %

± 10 %

Gas Temperature Calibration[20] Repeatability1 Random1

± 0.75 % ± 1 % ± 1 %

± 1 %

± 2 %

Weather Measurements Temperature[21] Relative Humidity Average Wind Speed Wind Direction Barometric Pressure Repeatability1 Random1

± 2 % ± 2 % ± 1 % ± 1 % ± 0.003 % ± 1 % ± 1 %

± 3 %

± 6 %

65 Carbon Monoxide Measurements Calibration[22] Accuracy[22] Repeatability1 Random1

± 1 % ± 0.002 % ± 2 % ± 2 %

± 2 %

± 4 %

Sound Measurements Calibration[23] Accuracy[23] Repeatability1 Random1

± 1 % ± 3 % ± 2 % ± 2 %

± 4 %

± 8 %

Notes: 1. Random and repeatability evaluated as Type A, other components as Type B.

1. 0 Discussion

For this limited series of experiments, the fan setback distance and angle needed to be optimized in order to maximize the impact of the fan. The fans used in these experiments had optimal configurations of 1.2 m (4 ft) and 85 degrees for the 0.4 m (16 in) fan, 1.8 m (6 ft) and 85 degrees for the 0.5 m (21 in) fan, and 1.2 m (4 ft) and 80 degrees for the 0.7 m (27 in fan). The setback distances suggest that PPV fans rely on the air that is entrained around the shroud from air being pulled through the shroud to achieve the cone of air to seal the doorway. The fans positioned right in front of the doorway, which had limited air entrainment, were not able to raise the pressures in the stairwell as well as the fans set back from the doorway.

This set of full-scale experiments indicates that when possible the PPV fan should be placed at the stairwell doorway and not at another ground floor entrance. Adding the volume of the first floor makes any number of fans at the ground floor entrances ineffective, especially above the 10th floor. This may not hold for buildings with smaller lobbies or with first floors that can be sectioned off to limit the volume, but typically high-rise buildings have large open lobbies.

During these ambient temperature experiments, placing PPV fans in series was less effective than placing the fans in a V-shape. When the fans were in a V-shape it did not seem to make a large difference if the fans were at the same angle or if one was angled at the top and the other at the bottom of the doorway. If building geometry prevents the fans from being placed in a V- shape, adding a second fan in series only increases the pressure by approximately 25 % and a third fan an additional 10 %.

Similar to fixed smoke control systems, opening stairwell doors has a large impact on stairwell pressures. Opening a stairwell door reduces the pressure on floors above the open door to approximately ambient, eliminating the desired impact of the PPV fan. A significant increase in pressure could be achieved by closing the doorway to the width of a hoseline. If the fire crew closes the doorway on their hoseline instead of keeping the door completely open, the amount of smoke that infiltrates into the stairwell will be greatly reduced. This will be of significant benefit to the people exiting through this stairwell and fire crews operating above the fire floor.

66

Placing fans in the building was the only way to effectively pressurize the stairwell. In a 30- story stairwell a 0.7 m (27 in) fan placed at the ground floor and one 0.7 m (27 in) fan set back from the 12th floor stairwell doorway greatly increased the pressure in the entire stairwell. There was no make-up air provided to the fans set back in the building. This is not necessary as the fan recirculates the same air to the stairwell doorway maintaining the pressure on a continuous basis.

The fans positioned in the building were more effective when configured using the same optimal setback and angle described previously for fans at the ground floor stairwell doorway. Placing the fans in the doorway was ineffective because there was no cone of air to seal the doorway. Also, moving the fans back to 2.4 m (8 ft) was less effective. Fans should not be placed in the stairwell; this resulted in lower pressure differentials and generated significant amounts of CO in the stairwell.

Examining the effects of the fan on the 12th floor and the fan on the 22nd floor it may be most effective to place a 0.7 m (27 in) fan at the stairwell doorway 2 floors below the fire to get the desired pressures and reduce the impact of doors opening on any of the floors. This configuration also allows for ventilation in addition to pressurization. The smoke that has already infiltrated the stairwell could be vented out of the top of the stairwell while the localized pressure will prevent any additional smoke from entering the stairwell. The data suggest that this will work on sprinklered buildings even with the top and bottom of the stairwell open and the pressures are borderline to work on an unsprinklered building based on the threshold pressures required.

When venting the top of the stairwell and pressurizing the stairwell, a smaller vent such as a roof hatch should be considered rather than a bulkhead or roof door in order to maximize the potential pressure differential. A roof hatch is usually large enough to vent sufficient smoke while small enough to increase the pressure in the stairwell.

Fixed stairwell pressurization systems usually have at least one fan that is built into a wall or the top of the stairwell. The pressure loss due to the fire department fan being set back as opposed to sealed in the doorway yielded an 80 % efficiency based on the comparison of pressure differences. This setback allows access and egress from the fan inlet doorway which is essential for most fire department operations. The 20 % loss has little impact on the overall ability of the fans to pressurize the stairwell.

The large trailer-mounted fan was able to pressurize the stairwell to the NFPA 92A unsprinklered threshold in the entire stairwell when utilized on the stairwell doorway. It was also able to pressurize the stairwell to the unsprinklered threshold at the other ground floor entrance when it had to pressurize the entire first floor and basement in addition to the stairwell. Attention needs to be given to the maximum allowable pressure with these large fans in order to ensure that the pressure does not prevent the opening of doors into the stairwell. This value is specified in national codes such as NFPA 101 or in local codes and is a function of stairwell door size, handle location and door closer force. This value is often approximately 80 Pa to100 Pa which the large fans are capable of creating in the lower portions of the stairwell.

67 The hovercraft created stairwell pressures that were below the standards minimum. The hovercraft’s performance could be replicated by multiple compartment sized fans. If multiple compartment sized fans are not available the hovercraft may be a good choice to vent a large volume but not to pressurize a stairwell to a desired pressure differential.

There are multiple fan manufacturers and each of them has differences whether it is blade type, shroud size, engine power rating, etc. Not all PPV fans behave the same and it is important to utilize them optimally to get the desired performance. These results provide guidance to the important variables but may not be relevant to all fan types. As technology improves so will the ability of the fans to move air. The fans used in these experiments represent the best current technology available and the size and power rating of the fans may not be representative of older fans that may currently be on fire apparatus.

Temperature can be an important variable when pressurizing a stairwell. In these experiments the temperature in the stairwell was very similar to the outside temperature which minimized the impact of stack effect. In cases where the outside temperature is lower than the stairwell pressure there tends to be an upward movement of air in the stairwell. Air in the building is often warmer and therefore less dense than outside air causing it to rise in the stairwell. This causes smoke to accumulate on the upper floors and reinforces the need to ventilate along with pressurization.

The CO produced by the PPV fans was at least one order of magnitude less than that created by a fire. As long as the PPV fans were not placed in the stairwell with the door shut, the NIOSH ceiling exposure was not exceeded. However, CO readings less than 50 ppm are unlikely with a gasoline powered PPV fan. Electric PPV fans or natural ventilation should be considered if CO readings less than 50 ppm are desired.

The noise levels created by the fans reached as high as 110 dB next to the fan at full throttle. This is comparable to a chainsaw and can have an impact on communications on the fire ground. Attempting a conversation or radio transmission near the PPV fan was difficult both for the sender and receiver. Attention should be given to the location of the command post and potential for PPV fan usage locations.

1. 0 Future Research

The results of these experiments provide guidance for fan placement to be effective against smoke flow due to pressure differences. The performance metric was provided by NFPA 92A but needs to be tested in live fire experiments. The experiments should focus on realistic fire conditions in high-rise structures and integrate the use of the fans into fire department standard operating procedures to determine if conditions can in fact be improved for both the occupants exiting the building and for firefighters performing fire ground operations.

Additionally a standard test needs to be developed and followed to provide the fire service with a set of performance metrics such as flow capacity so that they may make educated decisions on which fans work for their needs. Currently the Air Movement and Control Association

68 International, Inc. (AMCA) has a standard entitled “Laboratory Method of Testing Positive Pressure Ventilators for Rating.” This standard is meant to establish a uniform method for laboratory testing of PPV fans in order to determine performance in terms of airflow rate, pressure, air density, and speed of rotation for rating or guarantee purposes.

Further testing should be done to determine the relevance of the current AMCA standard to fire fighting operations. If the standard were mandatory for all manufacturers the fire service would have a means to determine the effectiveness of a particular fan for a certain application. Currently the fire service has attributes such as fan size and motor power but that is not directly applicable to particular applications. It would be valuable to be able to label or certify a fan to be capable of generating a specified capacity of air allowing the fire fighter to determine if that flow capacity meets their needs for an incident. Formulas, like those for fire fighting flow rates, could be developed for positive pressure ventilation operations. The formula would incorporate the height of the building or the volume of the building to aid fan selection. Such a standard would require additional data gathered collaboratively with all affected parties.

1. 0 Conclusions

Positive pressure ventilation fans utilized correctly can increase the effectiveness of fire fighters and survivability of occupants in high-rise buildings. In a high-rise building it is possible to increase the pressure of a stairwell to prevent the infiltration of smoke if fire crews configure the fans properly. When configured properly PPV fans can meet or exceed previously established performance metrics for fixed smoke control systems. Proper configuration requires the user to consider a range of variables including, fan size, set back, and angle, fan position inside or outside of the building, and number and alignment of multiple fans.

The data collected during this limited set of full-scale experiments in a 30-story office building demonstrated that in order to maximize the capability of PPV fans the following guidelines should be followed:

• Regardless of size, portable PPV fans should be placed 1.2 m (4 ft) to 1.8 m (6ft) set back from the doorway and angled back at least 5 degrees. This maximizes the flow through the fan shroud and air entrainment around the fan shroud as it reaches the doorway. • Placing fans in a V-shape is more effective than placing them in series. • When attempting to pressurize a tall stairwell, portable fans at the base of the stairwell or at a ground floor entrance alone will not be effective. • Placing portable fans inside the building below the fire floor is a way to generate pressure differentials that exceed the NFPA 92A minimum requirements. For example, if the fire is on the 20th floor, placing at least one fan at the base of the stairwell and at least one near the 18th floor blowing air into the stairwell could meet the NFPA 92A minimum requirements. • Placing a large trailer mounted type fan at the base of the stairwell is another means of generating pressure differentials that exceed the NFPA 92A minimum requirements. • Fans used inside the building should be set back and angled just as if it were positioned at an outside doorway.

69

The experiments also document that PPV fans can be loud which may have an impact on fire ground and command post communications. Gasoline powered fans generate carbon monoxide but the magnitude has to be compared to that of the hazard created by the fire in the building. Overall, when properly setup and correctly operated, positive pressure ventilation is a tool which the fire service can use to improve the safety and effectiveness of fire ground operations.

70 9.0 References

NFPA 101, Life Safety Code. National Fire Protection Association, Quincy, MA., 2006.

Grant, Casey,C., Triangle Fire Stirs Outrage and Reform, NFPA Journal, May/June 1993, pp73-82.

Hall Jr., John. High-rise Building Fires. NFPA, Quincy, MA. August 2005.

Traumatic Firefighter Fatalities in High-rise Office Buildings in the United States 1977- Present, NFPA Database Search. National Fire Protection Association, Quincy, MA. January

Isner, Michael, S., Fire Investigation Report: High-Rise Office Building Fire, Alexis Nihon Plaza, Montreal, Canada, October 26, 1986. National Fire Protection Association, Quincy, MA.

Nelson, Harold, E., An Engineering View of the Fire of May 4, 1988 in the First Interstate Bank Building, Los Angeles, California. NISTIR 89-4061. National Institute of Standards and Technology, Gaithersburg, MD. March 1989.

Klem, Thomas J., Fire Investigation Report: One Meridian Plaza, Philadelphia, PA, February 23, 1991. National Fire Protection Association, Quincy, MA.

Madrzykowski, D., and Walton, W.D., Cook County Administration Building Fire, 69 West Washington, Chicago, Illinois, October 17, 2003: Heat Release Rate Experiments and FDS Simulations, NIST Special Publication, SP-1021. National Institute of Standards and Technology, Gaithersburg, MD. July 2004.

NIOSH ALERT:Preventing Injuries and Deaths of Fire Fighters. National Institute for Occupational Safety and Health (NIOSH), Morgantown, WV. September 1994.

Three Fire Fighters Die in a 10-Story High-Rise Apartment Building – New York. Fire Fighter Fatality Investigation Report F99-01. National Institute for Occupational Safety and Health (NIOSH), Morgantown, WV. August 1999.

High-Rise Apartment Fire Claims the Life of One Career Fire Fighter and Injures Another Career Fire Fighter – Texas. Fire Fatality Investigation Report F2001-33. National Institute for Occupational Safety and Health (NIOSH), Morgantown, WV. October 2002.

DeCicco, P.R., Cresci, R.J., and Correale, W. H., “Fire Tests, Analysis and Evaluation of Stair Pressurization and Exhaust in High-Rise Office Buildings”, New York: Polytechnic Institute of Brooklyn, 1972.

71

1. NFPA 92A. Standard for Smoke-Control Systems Utilizing Barriers and Pressure

Differences. 2006 Edition.

Tempest Technology Corporation, http://www.tempest-edge.com, January 2003.

Purser, David. “Toxicity Assessment of Combustion Products.” The SFPE Handbook of Fire Protection Engineering, National Fire Protection Association, Quincy, MA, Third Edition (2002).

NIOSH [1992]. Recommendations for occupational safety and health: Compendium of policy documents and statements. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health. DHHS (NIOSH) Publication No. 92-100.

NRC [1987]. Emergency and continuous exposure guidance levels for selected airborne contaminants. Vol. 7. Ammonia, hydrogen chloride, lithium bromide, and toluene. Washington, DC: National Academy Press, Committee on Toxicology, Board on Toxicology and Environmental Health Hazards, Commission on Life Sciences, National Research Council, pp. 17-38.

Taylor, B.N., and Kuyatt, C.E., Guidelines for Evaluating and Expressing the Uncertainty of NIST Measurement Results. NIST Technical Note 1297. National Institute of Standards and Technology, Gaithersburg, MD. January 1993.

Setra Systems, Inc., Installation Guide, Setra Systems Model 264 Differential Pressure Transducer. Boxborough, MA., 1999.

Omega Engineering Inc., The Temperature Handbook, Vol. MM, pages Z-39-40, Stamford, CT., 2004.

Weatherpak – 2000 User’s Manual. Coastal Environmental Systems. December 9, 1997.

Q-RAE Multi-gas Monitor. Operational and Maintenance Manual. Document No.:027- 4001-000, Rev. B. May 2005.

Sound Meter 84005 Instruction Manual. Sper Scientific Ltd. May 11, 2005.

72 10.0 Acknowledgments

The authors would like to thank Roy McLane and Ryan Travers of the Building and Fire Research Laboratory for their invaluable support during the preparation and implementation of the experimental series. The authors would also like to thank Chief John Coleman and the Toledo Fire Department for inviting NIST to participate and the endless support they provided. Special thanks to representatives from the Fire Department of New York and the Chicago Fire Department for their guidance and assistance during the experiments. Tempest, Euramco and SuperVac supplied resources and provided technical support in order to make the experiments possible. Finally, the authors express gratitude to the Department of Homeland Security, Mr. Randall Griffin and Mrs. Meredith Lawler for their sponsorship and support of this important and ongoing research.

FD06011 ｜ 2001_美国国家标准与技术研究院_世贸中心火灾结构调查调查报告（英文）.md

分类：06_境外及港澳台调查报告 ｜ 年份：2001 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：md

一、基本情况

2001年9月11日，劫持客机先后撞击纽约世贸中心（WTC）双塔，后续火灾导致WTC 1、WTC 2坍塌，当日晚些时候WTC 7亦因火灾坍塌。事件共造成2,749人死亡（含2,184名楼内人员、343名消防员、71名执法人员等）。 NIST根据《国家建筑安全团队法》（NCST Act）牵头技术调查，发布43份双塔报告（约10,000页，2005-10-26）及3份WTC 7报告（约1,000页，2008-11-25）。

二、坍塌原因

飞机撞击严重破坏两塔柱体与楼板，但单独撞击不足以致塌。真正原因是：撞击使结构防火隔热层脱落，航空燃油点燃并蔓延至多层火灾；自动喷淋因供水管线被撞毁而失效。WTC 1中受火 weakened 的楼板向内侧拉拽受热弱化的外围柱，柱相继失效后整体坍塌（历时102分钟）；WTC 2结构损伤更重，56分钟后坍塌。WTC 7被WTC 1坍塌碎屑击中并引燃至少10层火灾，约7小时后关键内柱屈曲导致整体坍塌。

三、责任与致灾因素

• 超高层建筑结构防火隔热设计不足以抵御长时间全面火灾；
• 喷淋供水管线抗撞毁冗余不足；
• 疏散与应急通信存在短板（消防员无线电互通性差、通道拥堵）；
• 部分逃生路线在撞击区以上被完全摧毁。

四、整改与教训（NIST 31项建议）

调查提出31项高层消防安全改进建议，已推动美国建筑与消防规范至少16处修订：结构构件耐火等级整体提高1小时；结构框架所有构件采用同等（或更高）耐火等级；防火涂层粘结强度提高3–7倍；每个喷淋分区至少两套相互远离的供水管；楼梯间封闭且间距加大；新增第三部楼梯、楼梯净宽提高50%；设置供应急疏散的专用电梯；中高层设置蓄光型疏散路径标识；加强应急通信室内覆盖等。

FD06012 ｜ 2002_US_NIST_NISTIR6891.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2002 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

NISTIR 6891 Community-Scale Fire Spread Ronald G. Rehm Anthony Hamins Howard R. Baum Kevin B. McGrattan David D. Evans

NISTIR 6891 Community-Scale Fire Spread Ronald G. Rehm Anthony Hamins Howard R. Baum Kevin B. McGrattan David D. Evans Fire Research Division Building and Fire Research Laboratory July 2002 U N I T E D S T A T E S O F A M E R I C A D E P A R T M E N T O F C O M M E R C E U.S. Department of Commerce Donald L. Evans, Secretary National Institute of Standards and Technology Arden L. Bement, Director

Community-Scale Fire Spread Ronald G. Rehm, Anthony Hamins, Howard R. Baum, Kevin B. McGrattan, David D. Evans Building and Fire Research Laboratory National Institute of Standards and Technology (NIST) Gaithersburg, Maryland, 20899, USA ABSTRACT This paper addresses community-scale fires, which have also been called urban/wildland interface or inter- mix fires. These fires arise when wildland fires invade the built environment and attack structures as well as wildland fuels. The prediction of the spread of wildland fires, such as those occurring out West during the summer of 2000, has been accomplished through ”operational” mathematical models. These models are based on empirical correlations for wildland fuels and have generally performed well. They fail, however, when the fire spreads to the built environment where the empirical correlations no longer apply and where there is greatly increased potential for property damage, injury and death. The Oakland and Berkeley Hills fire of October 21, 1991, and the Los Alamos fires of May 2000 are examples of community-scale fires. The potential fuel loadings for various land uses demonstrates that structures generally provide much higher loadings than wildlands do. While this comparison is useful, it could also be misleading since generally, not all of the potential fuel in either the wildland or the built environment will burn. Furthermore, often the time scales for ignition and the heat release rates for the wildland fuel and the fuel in the structures will be widely disparate, and these differences will influence both the spread rate of the fire and its persistence. Although the NIST computational model known as the Fire Dynamic Simulator (FDS) was developed to study build- ing fires, it is now being extended to study community-scale fires. These extensions require much higher resolution data on local topography, buildings, vegetation, and meteorological conditions. They also require additional research on the mechanisms by which fires spread in the built environment between discrete ele- ments, such as structures or structures and trees. This paper appeared as pp 126-139 in: Blonski, K.S., M.E. Morales and T.J. Morales, 2002. Proceedings of the California’s 2001 Wildfire Con- ference: Ten Years After the 1991 East Bay Hills Fire, 10-12 October 2001, Oakland California Technical Report 35.01.462. Richmond CA; University of California Forest Products Laboratory. Published by: University of California Agriculture & Natural Resources, Forest Products Laboratory, 1301 South 46th Street, Richmond CA 94804, www.ucfpl.ucop.edu.

Proceedings of the California’s 2001 Wildfire Conference:10 Years After the 1991 East Bay Hills Fire 1 COMMUNITY-SCALE FIRE SPREAD R.G. Rehm, A. Hamins, H.R. Baum, K.B. Mcgrattan and D.D. Evans, Building and Fire Research Laboratory, National Institute of Standards & Technology, Gaithersburg, MD 28099 Email: Ronald.Rehm@nist.gov ABSTRACT This paper addresses community-scale fires, which have also been called urban/wildland inter- face or intermix fires. These fires arise when wildland fires invade the built environment and attack structures as well as wildland fuels. The prediction of the spread of wildland fires, such as those occurring out West during the summer of 2000, has been accomplished through ”operational” mathematical models. These models are based on empirical correlations for wildland fuels and have generally performed well. They fail, however, when the fire spreads to the built environment where the empirical correlations no longer apply and where there is greatly increased potential for property damage, injury and death. The Oakland and Berkeley Hills fire of October 21, 1991, and the Los Alamos fires of May 2000 are examples of community-scale fires. The potential fuel loadings for various land uses demonstrates that structures generally provide much higher loadings than wildlands do. While this comparison is useful, it could also be misleading since generally, not all of the potential fuel in either the wildland or the built environment will burn. Furthermore, often the time scales for ignition and the heat release rates for the wildland fuel and the fuel in the structures will be widely disparate, and these differences will influence both the spread rate of the fire and its persistence. Although the NIST computational model known as the Fire Dy- namic Simulator (FDS) was developed to study building fires, it is now being extended to study community-scale fires. These extensions require much higher resolution data on local topography, buildings, vegetation, and meteorological conditions. They also require additional research on the mechanisms by which fires spread in the built environment between discrete elements, such as structures or structures and trees. Keywords: Wildland/Urban Interface Fires; Mathematical Models; Computational Fluid Dynam- ics; Potential Fuel Loads; INTRODUCTION Fires in the West have been headlines in the news for most of the summer of 2000. Changes in the management of forested lands, the increasing intrusion of man into more remote areas and the cyclic dry periods produced by El Nino - La Nina have all increased the destruction of man- made structures by fires. Wildland fires now often spread into the built environment causing injury, death and property damage. Concern about wildland fires and their effects on man and the built en- vironment has produced several recent conferences Livingston (2000), Keller (2000), Platt (2000). While these conferences acknowledge the need to address fire spread in a mixed environment con- taining both structures and wildland fuels, i.e., community-scale fires, they have continued to focus

Proceedings of the California’s 2001 Wildfire Conference:10 Years After the 1991 East Bay Hills Fire 2 on wildland fires where understanding and predictive models of the fire spread are well developed. Compared with wildland fires, those which impact the built environment are generally more costly, both in terms of loss of life and injury and also in terms of property damage. What char- acterizes fires in the built environment and how do they differ from wildland fires? By comparing and contrasting community fires and wildland fires, we hope to characterize conceptual differences between the two. Then, we suggest research areas needed to develop a mathematical model to de- scribe fire spread in the built environment, where both individual structures and wildland fuels – trees, shrubs and ground litter – compose the fuel inventory. Note first that the manner in which the fires are fought differs dramatically. Most communities have either professional or volunteer fire departments, which usually respond to individual struc- ture fires in the built environment. Wildland fires, on the other hand, usually occur in federal or state owned land and are therefore the responsibility of one or more government agencies. Both the training and the response of community fire departments are very different from units trained to fight wildland fires, and only in a few locations are firefighters given cross training to fight both types of fires. Furthermore, the scientific communities which study each type of fire and the cor- responding literatures are almost disjoint. In 1998 there were 1.75 million responses by local fire departments, with about a half million being structures (others involving vehicles, materials outside of structures, etc.) Karter (1999). Over 4000 civilian deaths and 17,000 injuries occurred as a result of these fires, and the cost of the fires was about $ 8.6 billion. Significantly, the number of fires in various categories together with associated losses have either remained the same or decreased since 1977, the first year that the NFPA (National Fire Protection Administration) conducted its survey using current methodology. In contrast, in the West during the summer of 2000, there were about 80,000 fires, which de- stroyed about 7 million acres and required about $ 1 billion in Federal funds for suppression costs. Expectations are that future wildland fires will continue at rates more like the summer of 2000 than those in recent summers past. The federal agencies responsible for control of these fires reside in the Department of Interior (DOI) and the Department of Agriculture. They are the National Park Service, the U.S. Geological Survey, the Bureau of Land Management, the Fish and Wildlife Ser- vice and the Bureau of Indian Affairs, all part of the DOI, and the Forest Service which is part of Agriculture. The acreage of wildland destroyed by fires has undergone considerable variation during the twentieth century, and this variation has lead to substantial changes in forest management strate- gies. Recently for example, fires in wooded areas have begun to be viewed in much more am- bivalent terms; it has been recognized that smaller and more frequent fires can clean out debris, thin woods and make them healthier and more resistant to large, catastrophic fires. The so-called “prescribed burn” has now become a tool by which wildlands are managed. In the next section, we characterize the fuel load by land use. First, a brief review of the lit- erature on the characterization of wildland fuels is presented. Then, we look at the corresponding literature concerning structural fires. In each case the emphasis is on the potential fuel loadings

Proceedings of the California’s 2001 Wildfire Conference:10 Years After the 1991 East Bay Hills Fire 3 available for burning in various settings. In the third section, we examine differences arising from attempts to mathematically model each type of fire. A brief discussion of wind-driven fire spread models in wildlands is presented, since these models are relatively well developed. Furthermore, they have been used extensively for research, training, planning (for prescribed fires for example), and to provide real-time emergency-response predictions to guide fire fighting operations. The corresponding models are not available for multiple-structure community fires. Finally, we discuss extensions to a computational model developed by NIST which could be used to address the prob- lem of predicting community-scale fire spread in areas containing both vegetation and structures (the so-called urban-wildland intermix). POTENTIAL FUEL LOADINGS The most basic characterization of land use relative to fire is the amount of fuel available on the land. Specifically, the potential fuel energy loading per unit area is a useful measure which allows a direct comparison between fuels in wildland settings and those in man-made structures. While this comparison is useful, it could also be misleading since generally, not all of the potential fuel in either the wildland or the built environment will burn. Furthermore, often the time scales for ignition and the heat release rates for the wildland fuel and the fuel in the man-made structures will be widely disparate, and these differences will influence both the spread rate of the fire and its persistence. Wildland Fuels Fuel characterization and fire behavior in wildlands is the subject of several books: Pyne et al (1996), Chandler et al (1983a), Chandler et al (1983b), Brown and Davis (1973) and Luke and McArthur (1973). Chandler et al (1983a) describe the total amount of plant material, both living and dead, but excluding roots and animal matter as phytomass. They state that the total phytomass on any site has a physiological upper limit: W = 23 √ A = (26 √ A), where W is the total phytomass in newtons/m2 (tons per hectare) and A is the stand age in years. The degree to which this limit is approached depends on the site quality, but is not dependent on the particular vegetation. Potential fuel loading is the maximum fuel available, or the amount of material that could be consumed in the most intense fire. Available fuel loading is the amount of fuel that is expected to burn under specified fire weather conditions, and is therefore widely used for planning prescribed fires where weather conditions are known in advance. Usually, foliage and small crown material (branches and twigs of 5 cm (2 inch) diameter or less) is what burns in tree crown fires. Wildfires have been characterized in terms of 13 standard fire behavior fuel models, whose properties are tabulated by Pyne et al (1996). All fuel loads are given in terms of fuel mass per area (tons/acre), with a footnote stating that, for all fuel models, the energy content per mass is 18.6 MegaJoules (MJ)/kg (8000 Btu/lb). The data for fuel loadings are restated in Table 1, first in units of kilograms per hectare, and then, in GigaJoules (GJ) per hectare. Wildland fuels are composed mostly of lignin and cellulose in both living (green) and dead

Proceedings of the California’s 2001 Wildfire Conference:10 Years After the 1991 East Bay Hills Fire 4 forms and vary widely in distribution, physical characteristics and their effect on fire behavior. Chandler et al (1983a) give the composition, heat of combustion, and moisture content of living tree material. This information plus the composition and heat of combustion for “an average tree” are presented in Table 2 below. From this chart, we infer that average wildland fuels yield about 15-20 MJ/kg, a value consistent with that stated above by Pyne et al (1996). Dry fuel characteristics for individual conifers can also be inferred from data in the NIST Report by D.W. Stroup et al. (1999) in which eight scotch pines were separately burned. Mea- surements included weight before and after each burn, height and width of each tree and moisture content before the test. During each burn, the oxygen consumption rate was inferred from cap- tured combustion gases. The oxygen consumption can be related to the heat release rate (HRR), using a factor which is approximately constant for all fuels (oxygen calorimetry). The mass loss determines the total energy released, and agrees approximately with the integral of the HRR with respect to time. The initial mass of these trees ranged between 9.5 kg to 28.1 kg, and the energy per unit mass for complete consumption of these partially dried conifers was found to be about 17 MJ/kg, again confirming the values stated above. Fuel Load Energy Load No. Complex kg/hectare GJ/hectare Grass & grass dominated 1 Short grass 1660 32 2 Timber (grass& understory) 1100-4400 21-84 3 Tall grass 6700 124 Chaparral & Shrubs 4 Chaparral 4400-11000 84-207 5 Brush 1100-2200 21-42 6 Dormant brush, wood slash 3500-5700 62-104 7 Southern rough 2400-4200 47-79 Timber litter 8 Closed timber litter 2400-5700 42-104 9 Hardwood litter 350-6400 6.2-120 10 Timber (litter & understory) 4400-11000 84-210 Slash 11 Light logging slash 3500-12400 62-230 12 Medium logging slash 8900-37000 168-690 13 Heavy logging slash 16000-62000 300-1100 Table 1: Potential mass and energy loading for the 13 standard fuel models, from Pyne et al. (1996).

Proceedings of the California’s 2001 Wildfire Conference:10 Years After the 1991 East Bay Hills Fire 5 Living Tree Fuel Hc Dry Weight Ave. Tree < Hc > J/g Composition Dry Weight J/g Cellulose 16170 50-75 % 65 % 10500 Hemicelluloses Lignin 24612 15-35 % 25 % 6200 Extractives 32424 .2-15 % 5 % 1600 Mineral 0 5-10 % 5 % 0 Total 18000 Moisture 2400 100-250 % 150 % -3600 (foliage,twigs) Table 2: Living tree fuel composition: in the first two columns are shown the heat of combustion and the dry weight percentage range by component. (The last two rows show the heat of evapo- ration and the moisture content range.) Values are taken from Chandler et al. (1983). The last two columns display for an “average tree,” a dry weight composition and the corresponding heat of combustion, with the moisture content and the heat of vaporization for this “average tree” being given in the last row. Fuel Loading from Structures Burning man-made fuels and fires in enclosures are the subject of books by Drysdale (1985) and Quintiere (1998). In addition, a review by Pitts (1991). deals with wind effects on urban mass fires. In the suburban and urban setting, the key quantity is the density of houses – together with the combustible material in these houses – in determining fuel loading and fire behavior. The density of trees, shrubs and ground cover (grass) may still be important for determination of the fire be- havior, but clearly house density is critical. An estimate of the energy release rate during a house fire in the Oakland and Berkeley Hills fires was made by Trelles (1995) and by Trelles and Pagni (1997). According to these estimates, a house burns at a peak rate of 45 MW for 1 h (yielding about 160 GJ), and then dies down over another 6 h period. The die-down of the fire is approximated as two steps, one 10 MW for 3 h and the last as 5 MW for 3 more h. The total burn time is 7 h, and the total energy released by the house is 324 GJ. If, as assumed also, there is brush around each house which releases another 5 MW for one h, then an additional 18 GJ of energy will be released. If the house is assumed to be 15 m by 15 m by 5 m, then we estimate the total potential fuel loading per unit area to be of order 1.44 GJ/m2, the peak HRR per unit area to be of order 0.2 MW/m2, and the volumetric heat release rate to be of order 0.04 MW/m3. For comparison, oil has an energy content of about 42 MJ/kg, and oil pool fires yield a heat release rate per unit area of approximately 2 MW/m2, see McGrattan et al. (1996), Baum et al. (1994) and Baum (1999). Furthermore, Chandler et al (1983b) describe the concept of an “ideal” burning rate, which was first introduced by Tewarson and Pion (1976), and they tabulate the ideal burning rates for several fuels. Liquid hydrocarbons have ideal heat release rates per unit

Proceedings of the California’s 2001 Wildfire Conference:10 Years After the 1991 East Bay Hills Fire 6 area ranging between 0.7 and 3.0 MW/m2. The corresponding rate for wood is about 0.26 MW/m2. Wildland and Urban Fuel Loading The only reference of which we are aware that discusses technical issues related to wildland and community fires is Chapter 8 of Chandler et al. (1983b). entitled, “Fire at the Urban-Forest Interface.” This chapter makes several very important observations. First, the authors note that fuel loadings in buildings are typically many times those in a forest: “the heaviest likely fuel load in the forest is less than the lightest load for a structure.” Next they observe that fuels in buildings include a variety of combustibles whereas forest fuels are exclusively cellulosic. The authors also point out several important differences between burning in a structure and burning forest fuels. Mois- ture, which is very important during burning, is controlled within a building, but is determined in wildlands by environmental factors such as the sun, wind and precipitation. Radiation from an indoor fire is trapped inside the building whereas most radiation in a wildland fire escapes. Simi- larly, most convective heat is trapped in an indoor fire whereas it is lofted into the atmosphere in a wildland fire. Finally, oxygen is severely limited in an indoor fire whereas it is virtually unlimited in a wildland fire. The first point concerning the potential fuel loading differences between structural fires and wildland fires is illustrated in Table 8.1 of Chapter 8 of Chandler et al. (1983b). This table shows the land use (or area) in one column and the corresponding mass loading of fuel in the second; it is reproduced below with the addition of columns showing the potential mass load in kilograms per acre and the corresponding potential energy load in GJ per hectare. (Some of the numbers in this table appear large compared to those reported here and elsewhere.) Area Fuel Type kg/hectare Fuel Load/hectare (GJ/hectare) Forest Grass & sward (Tasmania) 4900 94 Forest Heavy brush (Southern Cal.) 101,000 1680 Forest Maximum 27,000× √ A 490× √ A Urban Dwellings, offices, schools 202,000-504,000 3700-9400 Urban Apartments 490,000 ×N 8900 ×N Urban Shops 500,000-1,010,000 9400-18800 Urban Industrial & storage 300,000-3,000,000 or more 5,700-57,000 or more Table 3: Available Fuel Load (from “Fire at the Urban-Forest Interface,” Chapter 8, Volume II, Chandler et al. (1983). Here A is the age of the forest in years and N is the number of floors in a multistory building. Finally, the data from the past sections and the chart above are combined in Table 4, where the description of land use is presented with likely numbers of trees and houses per hectare. We have divided the description of the land use into four basic categories: wildland, rural, suburban and urban; and the wildland and rural categories have been further subdivided. This information can

Proceedings of the California’s 2001 Wildfire Conference:10 Years After the 1991 East Bay Hills Fire 7 also be plotted as shown in Figure 1. In this figure, the number of structures per hectare is plot- ted as the abscissa and the ratio of the vegetation energy load to the structure energy load is the ordinate. In this diagram, wildland covers the upper left corner of the diagram, where the num- ber of structures is small and the vegetation energy load is relatively high, whereas the urban area occupies the lower right corner. Also shown on this plot are several fires for which we estimated, from information available, the potential energy load per hectare where the fires did their greatest damage to the built environment, whether the fires began there or elsewhere. Note that the Oakland Hills Fire of 1991 and the Los Alamos/Cerro Grande Fire of 2000, fall directly in the category of suburban fires and are good examples of community-scale or urban-wildland interface fires. Description Tree Density House Density Tree Fuel Load House Fuel Load (Trees/ hectare) (Houses/hectare) GJ/hectare GJ/hectare Wildland 740-2200 0 37-111 0 Unhealthy Forest Nelson (2000) Wildland 49-124 Ponderosa 0 2.5-6.2 0 Healthy Forest Pines Nelson (2000) Rural Area 0-74 0-0.05 0-3.7 0-16 0-0.03 people/acre Grass & Brush 0-25 0-0.05 0-0.12 0-16 Forested 25-74 0-0.05 0.12-3.7 0-16. Suburban Area 25-74 2.5-9.9 1.2-3.7 815-3200 Urban Area ≈0 37-or more 0 12,000 or more Table 4: Land use described by tree and housing density (units/hectare). MODELING FIRE SPREAD Wildland Fires The types of wildfires, their spread rates and intensities were summarized in a review article by Albini (1984) and are presented in Table 5. The wildfire types are ground fires (which burn or smolder in the subsurface organic material at a very slow rate), surface fires (which are most common and variable, and which burn in the material on the ground surface, such as debris, grass or chaparral) and crown fires (which are relatively rare, but spectacular and highly dangerous). An additional column has been added to this table to show the energy density of the consumed fuel, which can be determined from the numbers given in by Albini: if I is the intensity of the fire, and v is the spread rate, then the energy density E = I/v.

Proceedings of the California’s 2001 Wildfire Conference:10 Years After the 1991 East Bay Hills Fire 8 Figure 1: Potential energy loading by land use. Also shown are six specific fires including the Oakland Hills fire of 1991 and the Los Alamos/Cerro Grande fire of 2000. Types of Wildfire Spread Rate ROS Intensity Fuel Energy Density (m/h) (m/s) (MW/m) (GJ/hectare) Ground Fire 0.00003 m/hr .0000083 0.00001 12 Surface Fires Marginal Conditions 0.01 0.003 1 3.7 “Good” Conditions 10 2.77 10 36 Grass Fires 20 5.54 1 1.8 Debris Fires 1 0.277 10 370 Crown Fires 3 0.833 10 121 Table 5: Types of Wildfires, Rate of Spread (ROS) and Intensities as reported by Albini (1984). Also shown are fuel energy density implied by these values. Fuel moisture and continuity are primary factors in the behavior of wildfires and in the diffi- culty of bringing them under control. Other fuel properties described by Chandler et al. (1983a) and by Pyne et al. (1996), which influence fire spread, are size and shape distribution, compact- ness and arrangement of the fuel. Wind conditions and topography are non-fuel-related factors

Proceedings of the California’s 2001 Wildfire Conference:10 Years After the 1991 East Bay Hills Fire 9 which also influence fire spread. Finally, spotting or branding of a fire is yet another factor which influences its spread Albini (1981), Albini (1983), Woycheese and Pagni (1999) and Woycheese et al. (1999). (Spotting or branding is airborn burning debris lofted by the fire and carried by both ambient and fire-induced winds to locations separate and often remote from the main flaming region; these brands generally ignite additional fires in the new locations.) For wildland fires, mathematical models are regularly used to predict the likely burn devel- opment for expected meteorological conditions. These models, which are known as operational models, have largely developed through empirical correlations over the past few decades. In the United States, they include the Rothermel model, Rothermel (1972), and models known as BE- HAVE, Andrews and Bevins (1999), and FARSITE, Finney and Andrews (1999), with the last one being the most recent and most highly developed. Generally, these operational models have served well as long as the fires are confined to wild- lands. They are based on the assumption that the fuels can be represented by continuum beds, which may be inhomogeneous and anisotropic, but nevertheless are continuous. They fail, how- ever, when conditions lie outside of those for which the empirical relations were developed, such as when fires become very intense and induce significant buoyant plumes with resulting atmospheric convection, Clark (1996). Fire Spread in the Built Environment These operational models regard the meteorological conditions as prescribed, and have not considered the winds generated by the fire itself. However, for large fires, the self-generated winds may be significant and can even dominate the fire-spread behavior Clark (1996), Baum (2000). Furthermore, to our knowledge, the only studies to consider the discrete nature of fuel elements are the study by Carrier et al. (1991), which examined the effects of discrete fuel elements in a wildland fire, and the study by Himoto and Tanaka (1997), which examined fire spread by radiation between structures in an urban setting. When the built environment becomes involved, as in the Oakland and Berkeley Hills fire of October 21, 1991, or more recently the Los Alamos fires of May 2000, these models are totally ineffective. They cannot predict the spread of fire because the building fuel loads are larger and discrete. In these community-scale fires, buildings, as well as large individual trees, must be re- garded as discrete fuel elements. At a fundamental level, the physical mechanisms controlling fire spread are very different than those in wildland fires. The empirical correlations upon which the wildland-fire models have been developed are no longer valid. No validated predictive models of fires in an urban or urban/wildland setting exist to our knowledge. The NIST computational code, known as the Fire Dynamics Simulator (FDS), was originally developed to predict fire spread within buildings. Over the past few years, it has also been used to predict smoke and hot gas plume behavior produced by outdoor fires. In addition, more recently, it has been used to predict wind fields in the built environment with one to ten meter resolution over regions measuring up to one kilometer or so on a side. All of these simulations require only a current high-end PC running overnight. The code can be downloaded free from the URL:

Proceedings of the California’s 2001 Wildfire Conference:10 Years After the 1991 East Bay Hills Fire 10 http://fire.nist.gov. It consists of two components, a computational fluid dynamics (CFD) code, called fds, written in Fortran 90 for computation of fire-driven flows, and an OpenGL graphics program known as smokeview for visualization of results, see McGrattan et al. (2000), McGrattan and Forney (2000), and Forney and McGrattan (2000). The model has now been applied to several specific sites, including the NIST campus and indi- vidual plots of land in a small community, each of which includes at least one structure and many trees. At this time, the trees participate in the flow dynamics by providing wind resistance to the ambient or fire-driven flows, see Rehm et al. (2000); however, there is no submodel yet for tree burning in these simulations. The combustion is calculated using a mixture-fraction formulation, and radiation transport is also included, see McGrattan et al. (2000). In the simulation, brands, shown as black spots, are produced and carried by the wind in a dynamically simple, but correct manner. However, at present, there is no mechanism for the brands to ignite combustible material downstream of the fire. Figure 2: Three frames of a simulation of fire spread on a parcel of land containing a house, trees and dry grasses. These frames are taken at different times during the fire progression, and are qual- itatively correct if the fire spread is primarily along the ground material. As noted in the body of this paper, several submodels must still be developed, tested experimentally and incorporated into these simulations. It is extremely important to note that the overall model must be able to describe the progression of a fire among discrete fuel elements, structures, trees and shrubs. Figure 2 shows a composite of three frames from a simulation of wind-blown fire spread on a parcel of land on which there is a structure and wildland fuels (trees and dry grass). In this simula- tion, the fire (shown as red “flames”) begins upwind of the building and progresses as a ground-fire toward the structure. The trees modify the incoming wind profile by providing drag, but, as noted above, the trees do not burn. The porch of the house is assumed to be made of easily ignitable material, while the house is not. Therefore, the porch, but not the house ignites. Submodels are still needed for burning of an individual tree, brand disributions produced by a tree or by a house, and brand spotting or ignition of downwind materials. All of these submodels must also be cali- brated and validated through laboratory experiments, and probably later by limited full-scale burns. Through these simulations, we are beginning to develop an understanding of the mechanisms by which fires progress in a community where both structures and wildland fuels coexist. Such

Proceedings of the California’s 2001 Wildfire Conference:10 Years After the 1991 East Bay Hills Fire 11 an understanding will lead to a predictive capability using a model such as the one presented here. Propagation of fire by radiation, natural and fire-induced winds, brands and ground spread must all be examined both theoretically and experimentally to develop a verifiable predictive capability. LITERATURE CITED Albini, Frank A. 1984. Wildland Fires, American Scientist 590-597. Albini, Frank A. 1985. A Model for Fire Spread in Wildland Fuels by Radiation. Combust. Sci. and Tech. 42:229-258. Albini, Frank A. 1986. Wildland Fire Spread by Radiation - A Model Including Fuel Cooling by Natural Convection. Combust. Sci. and Tech. 45:101-113. Albini, Frank A. and Brian J. Stocks. 1986. Predicted and Observed Rates of Spread of Crown Fires in Immature Jack Pine. Combust. Sci. and Tech. 48:65-76. Albini, Frank A. 1997. An Overview of Research on Wildland Fire. Proceedings of the Fifth International Symposium on Fire Safety Science, Yuji Hasemi, editor. Albini, F.A.. 1983. Transport of Firebrands by Line Thermals. Comb. Sci. & Tech. 32:277- 288. Albini, F.A.. 1981. Spot Fire Distance from Isolated Sources – Extensions of a Predictive Model. Research Note INT-309, Dept. of Agriculture, Forest Service, Intermountain Forest and Range Experiment Station. Andrews, P.L., and C.D. Bevins. 1999. BEHAVE Fire Modeling System: Redesign and Ex- pansion. Fire Management Notes. 59:16-19; Web site: http://fire.org/. Baum, H.R., K.B. McGrattan and R.G. Rehm. 1994. Simulation of Smoke Plumes from Large Oil Fires. Twenty-Fifth Symposium (International) on Combustion, The Combustion Institute 25:1463-1469. Baum, H.R. 2000. Large Eddy Simulations of Fire - from Concept to Computations. Fire Pro- tection Engineering 6:36-42. Baum, H.R. 2000. Modeling and Scaling Laws for Large Fires. Proceedings of ISSM-III, Third International Symposium on Scale Modeling, Nagoya, Japan. Baum, H.R., K.B. McGrattan and R.G. Rehm. 1994. athematical Modeling and Computer Simu- lation of Fire Phenomena. Theoretical and Computational Fluid Dynamics 6:125-139. Brown, Arthur A. and Kenneth P. Davis. 1973. Forest Fire Control and Use, second edition,

Proceedings of the California’s 2001 Wildfire Conference:10 Years After the 1991 East Bay Hills Fire 12 McGraw-Hill Book Company, New York. Carrier, G.F., F.E. Fendell, and M.F. Wolff. 1991. Wind-Aided Firespread across Arrays of Dis- crete Fuel Elements. I. Theory. Combust. Sci. and Tech. 75:31-51. Chandler, Craig, Philip Cheney, Philip Thomas, Louis Trabaud and Dave Williams. 1983. Fire in Forestry: Volume I Forest Fire Behavior and Effects, Wiley-Interscience, John Wiley and Sons, New York. Chandler, Craig, Philip Cheney, Philip Thomas, Louis Trabaud and Dave Williams. 1983. Fire in Forestry: Volume II Forest Fire Management, Wiley-Interscience, John Wiley and Sons, New York. Clark, T.L., M.A. Jenkins, J. Coen and D. Packham. 1996. A Coupled Atmospheric-Fire Model: Convective Feedback on Fire-line Dynamics. J. Applied Meteorology 35:875-901. Drysdale, Dougal. 1985. An Introduction to Fire Dynamics, Wiley-Interscience Publications, John Wiley and Sons, New York. De Mestre, N.J., Catchpole, E.A., Anderson, D.H. and Rothermel, R.C. 1989. Uniform Propa- gation of a Planar Fire Front Without Wind. Combust. Sci. and Tech. 65:231-244. Emmons, Howard. 1963. Fire in the Forest. Fire Research Abstracts and Reviews 5:163-178. Finney, M.A. and P.L. Andrews. 1999. FARSITE - A Program for Fire Growth Simulation. Fire Management Notes. 59:13-15; Web site: http://fire.org/. Forney, G.P. and K.B. McGrattan. 2000. User’s Guide for Smokeview Version 1.0 – A Tool for Visualizing Fire Dynamics Simulation Data. NISTIR 6513, National Institute of Standards and Technology. Himoto, K. and T. Tanaka. A Preliminary Model for Urban Fire Spread - Building Fire Behavior under the Influence of External Heat and Wind. Proceedings of Karter, Michael J. 1999. 1998 Fire Loss in the United States. NFPA Journal. Keller, C., Organizer. 2000. Integrating Research on Wildland Fuels and Fires. Los Alamos, New Mexico. Livingston, R., Organizer, 2000. Second USGS Fire Science Workshop. Los Alamos, New Mex- ico. Luke, R. Harry and A.G. McArthur. 1978. Bushfires in Australia. Australian Government Pub- lishing Service, Canberra.

Proceedings of the California’s 2001 Wildfire Conference:10 Years After the 1991 East Bay Hills Fire 13 McGrattan, K.B., H.R. Baum and R.G. Rehm, 1996. Numerical Simulation of Smoke Plumes from Large Oil Fires. Atmospheric Environment 30:4125-4136. McGrattan, K.B., H.R. Baum, R.G. Rehm, A. Hamins and G.P. Forney. 2000. Fire Dynamics Simulator - Technical Reference Manual. Nist Report NISTIR 6467, National Institute of Stan- dards and Technology. McGrattan, K.B. and G.P. Forney. 2000. Fire Dynamics Simulator – User’s Manual. Nist Re- port NISTIR 6469, National Institute of Standards and Technology. Nelson, Robert H. 2000. Fires by Design. August 8 Washington Post. Perry, G.L.W. 1998. Current Approaches to Modelling the Spread of Wildland Fire: a Review. Progress in Physical Geography. 22:222-245. Pitts, W.M. 1991. Wind Effects on Fires. Prog. Energy Combust. Sci. 17:83-134. Platt, R., Roundtable Chair 200. Natural Disasters Roundtable, Forum on Urban/Wildland Fire. 26 January,, National Academy of Sciences. Washington, D.C. Pyne, Stephen J., Patricia L. Andrew and Richard D. Laven, , 1996. Introduction to Wildland Fire, second edition, John Wiley & Sons, Inc. New York. Quintiere, James G. 1993. Canadian Mass Fire Experiments, J. of Fire Prot. Engr. 5:67-78. Quintiere, James G. 1998. Principles of Fire Behavior. Delmar Publishers, Albany, New York. Rehm, R.G., K.B. McGrattan and H.R. Baum. 2000. Large Eddy Simulation of Flow over a Wooded Building Complex. 3rd International Symposium on Computational Wind Engineering – CWE 2000. To appear in special CWE 2000 issue of the Wind and Structures Journal. Rothermel, Richard C. 1972. A Mathematical Model for Predicting Fire Spread in Wildland Fu- els. USDA Forest Service Research Paper INT-115, Intermountain Forest and Range Experiment Station. Rothermel, Richard C. 1983. How to Predict the Spread and Intensity of Forest and Range Fires. U.S. Intermountain Forest and Range Experiment Station, Ogden, UT, Report PB 83-242289. Stroup, D.W., L. DeLauter. J. Lee and G. Roadarmel. 1999. Scotch Pine Christmas Tree Fire Tests. NIST Report of Test FR 4010. Tewarson, A. and R.F. Pion. 1999. Flammability of Furnishings. Comb. and Flame 26:85-103. Trelles, Javier. 1995. Mass Fire Modeling of the 20 October 1991 Oakland Hills Fire. Ph.D. Thesis in Mechanical Engineering, University of California at Berkeley.

Proceedings of the California’s 2001 Wildfire Conference:10 Years After the 1991 East Bay Hills Fire 14 Trelles, Javier, and Patrick J. Pagni. 1997. Fire-Induced Winds in the 20 October 1991 Oakland Hills Fire. Fire Safety Science – Proceedings of the Fifth International Symposium, 3-7 March 1997, Melbourne, Australia, Yuji Hasemi, Editor. 911-922. Williams, Forman A. 1982. Urban and Wildland Fire Phenomenology. Prog. Energy Combust. Sci. 8:317-354. Woycheese, J.P. and P.J. Pagni. 1999. Combustion Models for Wooden Brands. Proc. 3rd In- ternational Conference on Fire Research and Engineering. 4-8 Oct. Soc. Fire Protect. Engs. Bethesda, MD. 53-71. Woycheese, J.P., P.J. Pagni and D. Liepmann. 1999. Brand Propagation from Large-Scale Fires. J. of Fire Prot. Engr.. 10:32-44.

FD06013 ｜ 2003_US_NIST_2003_Station_Nightclub_Fire_Technical_Investigation_Report.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2003 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

NIST NCSTAR 2: Vol. I

Report of the Technical Investigation of The Station Nightclub Fire

William Grosshandler Nelson Bryner Daniel Madrzykowski Kenneth Kuntz

Storage Area (Recessed) Drummer Alcove (Recessed)

NIST NCSTAR 2: Vol. I

Report of the Technical Investigation of The Station Nightclub Fire

William Grosshandler Nelson Bryner Daniel Madrzykowski Fire Research Division Building and Fire Research Laboratory National Institute of Standards and Technology

Kenneth Kuntz Federal Emergency Management Agency U.S. Department of Homeland Security

June 2005

U.S. Department of Commerce Carlos M. Gutierrez, Secretary

Technology Administration Michelle O’Neill, Acting Under Secretary for Technology

National Institute of Standards and Technology Hratch Semerjian, Acting Director

Disclaimer Certain commercial entities, equipment, products, or materials are identified in this document in order to describe a procedure or concept adequately or to trace the history of the procedures and practices used. Such identification is not intended to imply recommendation, endorsement, or implication that the entities, products, materials, or equipment are necessarily the best available for the purpose.

Disclaimer The policy of NIST is to use the International System of Units (metric units) in all publications. In this document, however, units are presented in metric units or the inch-pound system, whichever is prevalent to the discipline. Conversion tables are provided in this report.

Disclaimer The NIST-led investigation of The Station Nightclub fire was conducted during the same time period as civil and criminal legal actions involving the same incident, which limited the Team's access to physical evidence and limited the ability to interview many witnesses.

Use in Legal Proceedings No part of any report resulting from a NIST investigation can be used in any suit or action for damages arising out of any matter mentioned in such report (15 USC 281a; as amended by P.L. 107-231).

National Institute of Standards and Technology NCST Act Report (NCSTAR) 2: volume I Natl. Inst. of Std. NCST Act Rept. 2: v. I, 246 pages (June 2005) CODEN: NSPUE2

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ABSTRACT A fire occurred on the night of Feb. 20, 2003, in The Station nightclub at 211 Cowesett Avenue, West Warwick, Rhode Island. A band that was on the platform that night, during its performance, used pyrotechnics that ignited polyurethane foam insulation lining the walls and ceiling of the platform. The fire spread quickly along the walls and ceiling area over the dance floor. Smoke was visible in the exit doorways in a little more than one minute, and flames were observed breaking through a portion of the roof in less than five minutes. Egress from the nightclub, which was not equipped with sprinklers, was hampered by crowding at the main entrance to the building. One hundred people lost their lives in the fire. On Feb. 27, 2003, under the authority of the National Construction Safety Team (NCST) Act, the National Institute of Standards and Technology (NIST) established a National Construction Safety Team to determine the likely technical cause or causes of the building failure that led to the high number of casualties in that fire. This report documents the procedures, findings, and issues that were raised by the investigation. Volume I contains the main report and Volume II contains appendix material. The investigation concluded that strict adherence to 2003 model codes available at the time of the fire would go a long way to preventing similar tragedies in the future. Changes to the codes subsequent to the fire made them stronger. By making some additional changes – and state and local agencies adopting and enforcing them – we can strengthen occupant safety even further. Ten recommendations to improve model building and fire codes, standards and practices (as they existed in February 2003) resulted from the investigation, including (i) urging state and local jurisdictions to (a) adopt and update building and fire codes covering nightclubs based on one of the model codes and (b) enforce those codes aggressively; (ii) strengthening the requirements for the installation of automatic fire sprinklers; (iii) increasing the factor of safety on the time for occupants to egress; (iv) tightening the restriction on the use of flexible polyurethane foam -- and other materials that ignite as easily and propagate flames as rapidly as non-fire retarded foam -- as an interior finish product; (v) further limiting the use of pyrotechnics; and (vi) conducting research in specific areas to underpin the recommended changes.

Keywords: fire investigation, NCST, nightclub fire, sprinklers, egress, fire spread, polyurethane foam, fire modeling, pyrotechnics

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TABLE OF CONTENTS (VOL. I) Page Abstract........................................................................................................................................................iii List of Acronyms, Abbreviations, Units, and Conversion Factors ..............................................................ix Preface ......................................................................................................................................................xiiii Acknowledgment........................................................................................................................................ xv Executive Summary..................................................................................................................................xvii Chapter 1 Background 1.1 Introduction...................................................................................................................................1-1 1.2 Description of the Building and Site.............................................................................................1-2 1.3 History of the Building .................................................................................................................1-2 1.4 Previous Incidents at The Station .................................................................................................1-8 1.5 Jurisprudence ..............................................................................................................................1-10 1.6 References for Chapter 1 ............................................................................................................1-10 Chapter 2 Description and Timeline of the Incident 2.1 Introduction...................................................................................................................................2-1 2.2 Overview Narrative.......................................................................................................................2-1 2.3 Overall Incident Timeline.............................................................................................................2-2 2.4 Evacuation Timeline.....................................................................................................................2-8 2.5 References for Chapter 2 ............................................................................................................2-14 Chapter 3 The Emergency Incident Response 3.1 Introduction...................................................................................................................................3-1 3.2 The West Warwick Fire Department ...........................................................................................3-2 3.3 The Fire and Emergency Medical Services Response..................................................................3-3 3.4 Mutual Aid....................................................................................................................................3-9 3.5 Observations ...............................................................................................................................3-14 3.6 References for Chapter 3 ............................................................................................................3-14 Chapter 4 Materials Testing and Supporting Experiments 4.1 Introduction...................................................................................................................................4-1 4.2 Material Properties for Fire Models..............................................................................................4-3 v

1. 3 Polyurethane Foam .......................................................................................................................4-4
2. 4 Cone Calorimeter Measurements of Finish Materials ................................................................4-10
3. 5 Pyrotechnic Device Test Series ..................................................................................................4-15
4. 6 Fire Growth Measurements in Real-scale Platform Area Mockup.............................................4-26
5. 7 References for Chapter 4 ............................................................................................................4-47

Chapter 5 Computer Simulation of Fire and Smoke Spread 5.1 NIST Fire Dynamics Simulator ...................................................................................................5-1 5.2 FDS Simulations of the Full-scale Mock-up.................................................................................5-3 5.3 FDS Incident Simulation ............................................................................................................5-28 5.4 Summary.....................................................................................................................................5-60 5.5 References for Chapter 5 ............................................................................................................5-61 Chapter 6 Analysis of Building Egress 6.1 Introduction...................................................................................................................................6-1 6.2 Analysis of Evidence ....................................................................................................................6-1 6.3 Estimates of Occupant Load .......................................................................................................6-10 6.4 Life Safety Features....................................................................................................................6-12 6.5 Egress Pathways and the Location of Victims Recovered from the Scene.................................6-23 6.6 Alternative Simulations of Nightclub Evacuation Scenarios......................................................6-24 6.7 References for Chapter 6 ............................................................................................................6-29 Chapter 7 Model Codes, Standards and Practices 7.1 Introduction ................................................................................................................................7-1 7.2 Code History.................................................................................................................................7-1 7.3 Model Code Analysis...................................................................................................................7-3 7.4 References for Chapter 7 ............................................................................................................7-18 Chapter 8 Summary, Findings and Recommendations 8.1 Summary of Investigation.............................................................................................................8-1 8.2 Findings ........................................................................................................................................8-2 8.3 Recommendations for Improving Model Standards, Codes, and Practices..................................8-9 8.4 Actions Already Taken ..............................................................................................................8-13 8.5 Research Recommendations and Other Appropriate Actions.....................................................8-17 8.6 References for Chapter 8 ............................................................................................................8-20

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TABLE OF CONTENTS (VOL. II) Appendix A Large Format Evacuation Timeline Stills Appendix B Large Format Device Stills Appendix C Previous Egress Incident Accounts Appendix D Small Scale Laboratory Tests Appendix E Foam Covered Wall Panel Tests Appendix F Pyrotechnic Device Test Series Appendix G Real-scale Platform Area Mockup Experiments Appendix H Polyurethane Foam -- Chemistry Appendix I Pyrolysis of Polyurethane Foam Appendix J Hydrogen Cyanide Analysis Appendix K Code Comparison Tables Appendix L Computer Simulation Input Files

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LIST OF ACRONYMS, ABBREVIATIONS, UNITS, AND CONVERSION FACTORS AC

alternating current AG

Attorney General AHJ

Authority Having Jurisdiction AIA

American Insurance Association ALS

Advanced Life Support ANSI

American National Standards Institute ASCE

American Society of Civil Engineers ASME

American Society of Mechanical Engineers ASTM

American Society for Testing and Materials ATF

Bureau of Alcohol, Tobacco and Firearms BBC Basic Building Code BCMC Board for the Coordination of Model Codes BFPC Basic Fire Prevention Code BLS Basic Life Support BOCA Building Officials and Code Administrators (previously Building Officials Conference of America) BST barium strontium titanate CFD computational fluid dynamics, and Coventry Fire Department CF carpet flooring CT ceiling tile DC direct current DHS

Department of Homeland Security DSC

Differential Scanning Calorimetry EMS

Emergency Medical Services EMT

Emergency Medical Technician EMT-C

Emergency Medical Technician - Cardiac EST

Eastern Standard Time FDS

Fire Dynamics Simulator FEMA

Federal Emergency Management Agency ix

FIT

Flash Ignition Temperature FPC

Fire Prevention Code FR

fire retarded HRR

heat release rate IBC

International Building Code IC

Incident Command ICC

International Code Council IEBC

International Existing Building Code IFC

International Fire Code IR

infrared ISO

International Organization for Standardization LCL0

lethal concentration, low LSF

life safety feature MCI

Mass casualty incident NCST

National Construction Safety Team NBC

National Building Code NFC

National Fire Code NFPA

National Fire Protection Association NFR

non-fire retarded NIOSH

National Institute of Occupational Safety and Health NIST

National Institute of Standards and Technology ODP

Office of Domestic Preparedness OSHA

U.S. Occupational Safety and Health Administration PUF

polyurethane foam RI

Rhode Island RTI

response time index SBC

Standard Building Code SIT

Spontaneous Ignition Temperature SNEFEAP Southern New England Fire Emergency Assistance Plan t

time TC

thermocouple TGA

Thermal Gravimetric Analysis x

TIA

Tentative Interim Amendment UFC

Uniform Fire Code UL

Underwriters Laboratories USC

United States Code USFA

United States Fire Administration WFD

Warwick Fire Department WP

wood paneling WPD

Warwick Police Department WWFD

West Warwick Fire Department WWPD

West Warwick Police Department

Units °C

degrees Centigrade °F

degrees Fahrenheit ft

feet gpm

gallons/minute in

inch kg

kilogram kPa

kilopascal kW

kilowatt L

liter m

meter mm

millimeter min

minute MW

megawatt psi

pounds/in2 s

second W

Watt μm

micrometer

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Conversion Factors °F = 1.8 x °C + 32 1 m = 3.281 ft 1 mm = 0.03937 in 1 L = 0.2642 gal 1 kg = 2.204 lb (mass) 1 kg/m3 = 0.06243 lb/ft3 1 kPa = 0.1450 psi 1 kJ = 0.9479 Btu 1 kJ/kg = 0.4301 Btu/lb 1 kJ/kg-oC = 0.2389 Btu/lb-oF 1 kW = 3413 Btu/hr 1 kW/m2 = 317.1 Btu/hr/ft2 1 kW/m2-oC = 176.1 Btu/hr-ft2-oF 1 W/m-oC = 0.5778 Btu/hr-ft-oF 1 kg = 1000 g 1 m = 1000 mm 1 μm = 0.001 mm 1 MW = 1,000,000 W

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PREFACE On Feb. 27, 2003, under the authority of the National Construction Safety Team (NCST) Act, the National Institute of Standards and Technology (NIST) established a Team to determine the likely technical cause or causes of the building failure that led to a high number of casualties in The Station nightclub fire in West Warwick, Rhode Island on the night of Feb. 20, 2003. The investigation consisted of the following tasks: • identification of technical issues and hypotheses requiring investigation through consultations with experts in fire protection engineering, and emergency evacuation, and members of other teams investigating The Station fire; • data collection from local authorities, contractors and suppliers, building and fire protection design documents, records, plans, and specifications, video and photographic data, telephone and radio transmissions, field data, a limited number of interviews and other oral and written accounts from building occupants and emergency responders, and other witnesses as reported by the news media; • analysis and comparison of model building and fire codes and practices, as well as review and analysis of practices used in operation of the building; • simulation and analysis of phenomena (with associated uncertainties), including fire spread, smoke movement, tenability, occupant behavior and response, evacuation issues, and operation of active and passive fire protection systems; • testing to provide additional data and support computer predictions; and • preparation of the final report, following established NIST Editorial Review Board procedures, augmented by the NCST Advisory Committee. As required by the NCST Act and its implementing regulations, priority in the investigation was ceded to the local criminal investigation. No physical evidence was obtained from the scene and access to witnesses and local authorities was limited due to the criminal investigations and civil litigation. It is important to note that state and local building regulations -- rather than model codes -- govern building design, construction and operation. Comparisons of the building design and operation to provisions within model codes were done to assess possible improvements in public safety through revision of model codes, standards and practices. Many of the recommendations are directed toward the current national model codes maintained by the National Fire Protection Association (NFPA) and the International Code Council (ICC), the standards within those codes and elsewhere (e.g., ASTM International, and Underwriters Laboratories (UL)), and the practices associated with their adoption and implementation. Other recommendations are aimed at nightclub owners and managers, occupants, and state and local regulatory authorities and first responders. The NCST Act requires that at least one member of the Team be an employee of NIST, and that experts who are not employees of NIST shall also be appointed to the Team by the NIST Director. The members of the Team included the following: • William Grosshandler (Lead Investigator), NIST Building and Fire Research Laboratory

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• Nelson Bryner, NIST Building and Fire Research Laboratory • Daniel Madrzykowski, NIST Building and Fire Research Laboratory • Kenneth Kuntz, DHS/FEMA, US Fire Administration Koffel Associates, Inc., provided a review of model building and fire codes; Ove Arup & Partners Massachusetts, Inc., assisted with the analysis of the evacuation process. Portions of both contractor reports have been integrated into this final report.

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ACKNOWLEDGMENT The number of people from NIST assisting the investigation extended beyond the official team members. Of particular note is Stephen Kerber, who devoted a tremendous amount of time and energy to running the fire simulations. The assistance provided by William Walton and Kevin McGrattan in this effort is also acknowledged. Erica Kuligowski was responsible for the egress simulations and was consulted regarding the behavior of humans in fire. The foam panel and full-scale mock-up experiments were ably supported by David Stroup, Laurean DeLauter, Roy McLane, Jay McElroy, Jack Lee, Alex Maranghides, Ed Hnetkovsky, Caron Nyquist, Tim Strunk, Joseph Schuh, Daniel Schuh, and Mike Schaefer. Outside of NIST, the cooperation of the Bureau of Alcohol, Tobacco, and Firearms (Christopher Porreca in particular), and the assistance of the Army Research Laboratory (Steven Hoke) are acknowledged. Within the Department of Homeland Security, the Office of Domestic Preparedness coordinated its own investigation with NIST's work. The cooperation of the State of Rhode Island is acknowledged, in particular the Office of the State Fire Marshal and the Warwick field office of the Attorney General. WPRI-TV supplied the Team with the complete video taken on the night of the fire, and the Providence Journal provided NIST with information from their interviews with survivors of the incident. Both made invaluable contributions to the investigation. William Koffel and Eric Mayl of Koffel Associates, Inc. and Jeffrey Tubbs of Ove Arup & Partners Massachusetts provided outstanding contractor support in reviewing model building and fire codes and analysis of the evacuation process, respectively. xv

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EXECUTIVE SUMMARY Under the authority of the National Construction Safety Team Act, an investigation team was deployed by the NIST Director on Feb. 27, 2003 to investigate the failure seven days earlier of The Station nightclub in West Warwick, Rhode Island. The objectives of the investigation were: • to establish the likely technical cause or causes of the building failure; • to evaluate the technical aspects of evacuation and emergency response procedures; • to recommend, as necessary, specific improvements to building standards, codes, and practices based on the findings made pursuant to the duties listed above; and • to recommend any research and other appropriate actions needed to improve the structural safety of buildings, and improve evacuation and emergency response procedures, based upon the findings of the investigation. The NIST team met these objectives primarily by reviewing and analyzing model building and fire codes, public documents, photographic and video data, telephone and radio transmissions, published accounts, and discussions with local authorities and several witnesses, by simulating and analyzing the fire spread, smoke movement, tenability, occupant behavior and response, and the impact of fire sprinklers, and by testing representative materials (not obtained from the fire scene) to provide additional data and support the simulation predictions. The simulations and supporting fire tests were particularly important given that NIST was not able to obtain any physical evidence from the incident scene due to the ongoing criminal investigation and civil litigation. While the access to physical materials was denied to NIST, the Institute's investigators were provided extensive video tape footage taken before, during and after the fire. This report describes the methodology used to conduct the investigation, details what occurred on the night of Feb. 20, 2003, reviews the history of the building and the model codes and standards that would have applied to a building of this type, presents the results of testing and simulations, and includes recommendations to improve building safety, evacuation and emergency response procedures. It is important to note that state and local building regulations -- rather than model codes -- governed The Station nightclub. NIST's comparison of the nightclub with model codes has been done strictly to assess possible improvements in public safety through revision of model codes, standards and practices. The recommendations are directed toward the current model codes maintained by the National Fire Protection Association (NFPA) and the International Code Council (ICC), the standards within those codes and elsewhere (e.g., ASTM International, and Underwriters Laboratories (UL)), and the practices associated with their adoption and implementation. Other recommendations are aimed at nightclub owners and managers, occupants, and state and local regulatory authorities and first responders. FINDINGS The Station nightclub was a single-story wood frame building with a footprint of about 412 m (4484 ft ). A floor plan of the building is shown in the figure below. The main entrance on the north side, with double doors, led to a short hallway with a single interior door. In addition to the main entrance, there were doors leading directly to the outside adjacent to the platform (commonly, but less precisely, referred to as the stage) on the west end of the building, and at the side of the main bar at the east end of the building. The kitchen also had an exit door. There were windows along the north side of the building on 2 2

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Floor plan of The Station nightclub both sides of the main entrance. The fire began when pyrotechnics used during the performance of a band ignited polyurethane foam lining portions of the walls and ceiling of the platform, and spread quickly along the ceiling area over the dance floor. Smoke was visible in the exit doorways in a little more than one minute and flames were observed breaking through a portion of the roof in less than five minutes. Escape from the nightclub was hampered by the crowding at the main entrance to the building. One hundred people lost their lives in the fire. The direct contributors to this large loss of life were found to be (1) the hazardous mix of building contents, (2) the inadequate capability to suppress the fire during its early stage of growth, and (3) the inability of the exits to handle all of the occupants in the short time available for such a fast growing fire. Both of the 2003 editions of the major model building and fire codes (2003 International Building Code and NFPA 5000, Building Construction and Safety Code) have provisions that address these problems. Materials The hazard associated with the building contents was created by the close proximity of a high temperature source (a pyrotechnic device) and a substantial amount of material with a relatively low ignition energy and high flame spread rate (polyurethane foam). As could be seen in the WPRI video, flames spread rapidly over the foam, generating smoke and enough heat to ignite the wood paneling underneath and adjacent to the foam. The wood structure and paneling in the nightclub was estimated to contain over 95 percent of the fuel load, so that once most of the foam was consumed, the fire transitioned to a wood frame building fire.

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A non-fire retarded foam sample purchased by NIST ignited in less than 15 seconds when exposed to a pyrotechnic device in an arrangement shown in the adjacent photo, which was similar to the set up on the platform of the nightclub. When a fire retarded polyurethane foam purchased by NIST was exposed to a pyrotechnic source in the same manner, no ignition of the foam occurred, nor did the wood paneling ignite with no foam present.

In addition to the flexible polyurethane foam that was attached to the walls, a foam plastic thermal insulation, that had been installed in the stud space with no fire resistant barrier on the interior side of the walls of the drummer's alcove, contributed to the smoke and heat release from the fire. (Note that no foam samples from the walls nor the stud space in The Station were obtained by NIST for testing.) The platform area of the nightclub, including NIST- purchased flexible polyurethane foam on the walls, was reconstructed in the large fire laboratory at NIST to examine, in a controlled environment, how the fire may have spread in the full-scale nightclub, and to measure the temperature, heat flux, and gaseous products. In less than 90 seconds after ignition of foam at the corner of the reconstructed drummer's alcove, conditions in the middle of the room (5.5 m, or 18 ft, away) at head height (1.5 m, or 5 ft, above the floor) were found to be lethal. Pyrotechnic device impinging on non-fire retarded polyurethane foam panel Fire Protection Systems The capability to suppress this fire during its early stage of growth was insufficient primarily because automatic fire sprinklers were not installed in The Station. (Note that while the 2003 editions of the model codes would have required sprinklers to be installed for new construction, sprinklers would not have been required for an existing structure like The Station.) The building was equipped with hand-held fire extinguishers, although they were not located convenient to where the fire started; NIST found no indication that the employees of The Station were trained to use the hand-held extinguishers, and it is unclear if the extinguishers would have been effective in controlling this fire. Experiments conducted at NIST in a reconstruction of the platform area fire demonstrated that a water sprinkler system installed in the test room in accordance with NFPA 13 (Standard for the Installation of Sprinkler Systems) was able to control the fire initiated in non-fire retarded polyurethane foam panels and to maintain survivable conditions at head height in the test room for the duration (over five minutes) of the experiment. A computer simulation of the full nightclub with and without sprinklers led to a similar positive result for the sprinklered scenario. A heat detection/fire alarm system was installed in The Station Nightclub, which activated (sound and light strobe) 41 seconds after ignition of the polyurethane foam, by which time the crowd had already begun to move towards the exits.

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Remains of the platform area after the fire (left) and an image from the simulation of The Station fire had sprinklers been installed (right) Occupant Load and Egress The inability of the exits to handle all of the occupants in the short time available for this fast growing fire contributed directly to the large loss of life. The number of building occupants at the time of the fire was reported by the news media to range from 440 to 458; the occupant limit for a building similar to The Station nightclub would be around 420 persons according to the 2003 model codes. Three emergency exits were available: the front main entrance on the north (limited by the single door into the vestibule), the single door on the west near the performance platform, and the single door on the east side of the main bar. A fourth door in the kitchen was not considered accessible to the patrons. The first patrons recognized the fire danger about 24 seconds after ignition of the foam; the bulk of the crowd began to evacuate shortly after that, around the time the band stopped playing (30 seconds). The rate of egress from the main entrance at the front of the building was limited initially by the single doorway inside the vestibule, not the double doors visible from the outside. From 56 percent to 66 percent of the occupants appear to have attempted to leave through the single main entrance in t front of the building; many were unsuccessful. The windows in the main bar room and the sunroom became the secondary routes of escape once the main entrance became impassable, and, according to reports, they accounted for over 1/3 of the successful evacuations. Number of Occupants Out of the Club - buildingEXODUS Results 0 50 100 150 200 250 300 350 400 450 0 100 200 300 Evacuation time (s) Number of Occupants Out of the Club he Scenario 1 Scenario 2 Scenario 2* Scenario 3 Prior to 1-1/2 minutes into the fire, a crowd- crush occurred in the front vestibule which almost entirely disrupted the flow through the main exit. Many people became stuck in the prone position in the exterior double doors. Simulation of egress for different scenarios xx

The precise event which led to the crowd- crush likely was related to the arrangement of the single interior door with merging streams of traffic and the pressure to escape the rapidly deteriorating conditions in the main area of the nightclub. Measurements of temperature, heat flux and gas species in a reconstruction of the platform area fire at NIST and computer models of the NIST experiment and the full nightclub suggest that the conditions around the platform, dance floor, sunroom, and dart room would have l to severe incapacitation or death within abou 1-1/2 minutes after ignition of the foam for anyone remaining standing, and for not muc longer even for those occupants close to the floor. Temperatures 1.5 m (5 ft) above floor 90 seconds after ignition, calculated from computer simulation of full-scale nightclub fire. ed t h Emergency Response The first 911 call reporting a fire was before 11:09 p.m., less than 40 seconds after ignition of the foam; West Warwick police officers on the scene reported the fire about one minute after ignition of the foam, leading to the dispatch of four engine companies, a tower-ladder truck, a rescue unit, and a battalion chief. The first fire engine, staffed with one firefighter and a fire officer, was confirmed on-scene less than five minutes after the first 911 call was received. Given the hazardous mix of materials in The Station and the lack of installed sprinklers, nothing that the fire department could have done that night would have saved the building from the fast growing fire. To deal with the large number of victims, a mass casualty plan was implemented within about 10 minutes of arrival of the first engine on the scene. All occupants needing medical attention had been evacuated from the scene and transported to medical facilities within two hours of the start of the fire. Summary Finding The investigation concluded that strict adherence to 2003 model codes available at the time of the fire would go a long way to preventing similar tragedies in the future. Changes to the codes subsequent to the fire made them stronger. By making some additional changes – and state and local agencies adopting and enforcing them – we can strengthen occupant safety even further. RECOMMENDATIONS The findings presented above, and others that are documented in this report, raised a number of issues concerning model building codes and standards, and the practices surrounding their adoption, application, and enforcement. The specific sections of the current NFPA and ICC model codes that relate to these issues are identified in the report, as well as significant actions already taken by the state of Rhode Island and model code organizations in response to this tragedy. NIST has made ten recommendations, listed in the following Table, that (a) support actions already taken by the state and by the model code development organizations, (b) extend or further improve the model

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Table of Recommendations

1. Model Code Adoption and Enforcement: NIST recommends that all state and local jurisdictions

a) adopt a building and fire code covering nightclubs based on one of the model codes (as a minimum requirement) and update local codes as the model codes are revised; b) implement aggressive and effective fire inspection and enforcement programs that address: (i) all aspects of those codes; (ii) documentation of building permits and alterations; (iii) means of egress inspection and record keeping; (iv) frequency and rigor of fire inspections, including follow-up and auditing procedures; and (v) guidelines on recourse available to the inspector for identified deviations from code provisions; and c) ensure that enough fire inspectors and building plan examiners are on staff to do the job and that they are professionally qualified to a national standard such as NFPA 1031 (Professional Qualifications for Fire Inspector and Plan Examiner).

1. Sprinklers: NIST recommends that model codes require sprinkler systems according to NFPA 13

(Standard for the Installation of Sprinkler Systems), and that state and local authorities adopt and aggressively enforce this provision, a) for all new nightclubs regardless of size, and b) for existing nightclubs with an occupancy limit greater than 100 people.

1. Finish Materials and Building Contents: NIST recommends

a) that state and local authorities adopt and aggressively enforce the existing provisions of the model codes; b) that non-fire retarded flexible polyurethane foam, and other materials that ignite as easily and propagate flames as rapidly as non-fire retarded flexible polyurethane foam, (i) be clearly identifiable to building owners, operators, contractors, and authorities having jurisdiction (regulatory agencies); and (ii) be specifically forbidden, with no exceptions, as finish materials from all new and existing nightclubs; c) that NFPA 286 (Standard Methods of fire Tests for Evaluating Contribution of Wall and Ceiling Interior Finish to Room Fire Growth) be modified to provide more explicit guidance to building owners, operators, contractors, and authorities having jurisdiction for when large-scale tests that are covered in NFPA 286 are required to demonstrate that materials (other than those already forbidden in b above) do not pose an undue hazard for the use intended; and d) that ASTM E-84 (Standard Test Method for Surface Burning Characteristics of Building Materials), NFPA 255 (Standard Method of Test of Surface Burning Characteristics of Building Materials), and NFPA 286 be modified to ensure that product classification and the pass/fail criteria for flame spread tests and large-scale tests are established using the best measurement and prediction practices available.

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Table of Recommendations

1. Indoor Use of Pyrotechnics: NIST recommends that NFPA 1126 (Use of Pyrotechnics before a

Proximate Audience) be strengthened as described below, and that state and local authorities adopt and aggressively enforce the revised standard: a) Pyrotechnic devices should be banned from indoor use in new and existing nightclubs not equipped with an NFPA 13 compliant automatic sprinkler system. b) NFPA 1126 should be modified to include a minimum occupancy and/or area for a nightclub below which pyrotechnic devices should be banned from indoor use, irrespective of the installation of an automatic sprinkler system. c) Plans for the use of indoor pyrotechnics in new and existing nightclubs should be posted on site; and in addition to the items listed in para. 4.3.2 of NFPA 1126, should describe the measures that have been established to provide crowd management, security, fire protection, and other emergency services. d) Section 6.6.2 of NFPA 1126 should be modified to require the minimum clearance between (i) the nearest fixed or moveable contents, and (ii) any part or product (igniter, spark, projectile, or debris) of a pyrotechnic device permitted for indoor use in new and existing places of assembly, to be twice the designed projection of the device, until such time that studies show that a smaller minimum clearance can guarantee safe operation in spite of the possibility that building decorations or temporary features that greatly exceed flame spread or fire load provisions of the fire code may occur.

1. Occupancy Limits and Emergency Egress: NIST recommends that the factor of safety for

determining occupancy limits of all new and existing nightclubs be increased in the model codes in the following manner, and that state and local authorities adopt and aggressively enforce these provisions: a) Within the model codes, establish the threshold building area and occupant limits for egress provisions using best practices for estimating tenability and evacuation time; and, unless further studies indicate another value is more appropriate, use 1-1/2 minutes as the maximum permitted evacuation time for nightclubs similar to or smaller than The Station. b) Compute the number of required exits and the permitted occupant loads assuming at least one exit (including the main entrance) will be inaccessible in an emergency evacuation. c) For nightclubs with one clearly identifiable main entrance, increase the minimum capacity of the main entrance to accommodate 2/3 of the maximum permitted occupant level (based upon standing space or festival seating, if applicable) during an emergency. d) Eliminate trade-offs between sprinkler installation and factors that impact the time to evacuate buildings. e) Require staff training and evacuation plans for nightclubs that cannot be evacuated in less than 1- 1/2 minutes. f) Provide improved means for occupants to locate emergency routes -- such as explicit evacuation directions prior to the start of any public event, exit signs near the floor, and floor lighting -- for when standard exit signs become obscured by smoke.

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Table of Recommendations

1. Portable Fire Extinguishers: NIST recommends that a study be performed to determine the minimum

number and appropriate placement (based upon the time required for access and application in a fully occupied building) of portable fire extinguishers for use in new and existing nightclubs, and the level of staff training required to ensure their proper use.

1. Emergency Response: To ensure an effective response to a rapidly developing mass casualty event,

NIST recommends that state and local authorities adopt and adhere to existing model standards on communications, mutual aid, command structure and staffing, such as a) NFPA 1221, Standard for the Installation, Maintenance, and Use of Emergency Services

Communications Systems b) NFPA 1561, Standard on Emergency Services Incident Management Systems c) NFPA 1710, Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments d) NFPA 1720, Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Volunteer Fire Departments

1. Research on Human Behavior: NIST recommends that research be conducted to better understand

human behavior in emergency situations, and to predict the impact of building design on safe egress in fires and other emergencies (real or perceived), including the following: a) the impact of fire products (gases, heat, and obscuration) on occupant decisions and egress speeds; b) exit number, placement, size and signage; c) conditions leading to and mitigating crowd-crush; d) the role of crowd managers and group interactions; e) theoretical models of group behavior suitable for coupling to fire and smoke movement simulations; and f) the level of safety that model codes afford occupants of buildings.

1. Research on Fire Spread and Suppression: NIST recommends that research be conducted to

understand fire spread and suppression better in order to provide the tools needed by the design profession to address recommendations 2, 3, and 5, above. The following specific capabilities require research: a) prediction of flame spread over actual wall, ceiling and floor lining materials, and room furnishings; b) quantification of smoke and toxic gas production in realistic room fires; and c) development of generalized models for fire suppression with fixed sprinklers and for firefighter hose streams.

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Table of Recommendations

1. Research on Computer-aided Decision Tools: NIST recommends that research be conducted to:

a) refine computer-aided decision tools for determining the costs and benefits of alternative code changes and fire safety technologies, and b) develop computer models to assist communities in allocating resources (money and staff) to ensure that their response to an emergency with a large number of casualties is effective.

codes, standards, and practices, and (c) identify research necessary to underpin and provide additional technical justification for these actions. The first recommendation, to adopt and enforce a building and fire code for nightclubs based upon one of the model codes, is a prerequisite for the subsequent recommendations, and is strongly supported by the finding that provisions in the 2003 model codes, if they are adopted and enforced, will significantly improve the safety of structures and occupants, and may well eliminate tragedies such as this in the future. Recommendation 2, to increase the requirements for the installation of sprinklers, is equivalent to the Tentative Interim Amendment (TIA) already adopted by NFPA. The laboratory testing and simulations performed by NIST as part of this investigation provide additional reinforcement of the appropriateness of NFPA's action. Recommendation 3 recognizes the critical role that the non-fire retarded polyurethane foam played in the ignition and rapid flame spread process. While the use of foam plastics as exposed finish products is already inconsistent with current model codes, the standards development organizations such as ASTM and NFPA need to be enlisted to improve the technical basis for materials testing to ensure that the methods used to rate the flammability of finish materials and building products correlate with the actual fire hazard posed, even anticipating possible situations that may not be consistent with the building code. In addition, markings that are easily distinguishable by the contractor, building manager, and regulating authorities would decrease the possibility for the inappropriate use of these materials and products. To reduce the chance that a pyrotechnic device could be present in the event that unapproved materials are brought into a nightclub (which already is inconsistent with the provisions of NFPA 1126), recommendation 4 would make unequivocal those situations in which pyrotechnic devices are simply not permitted. Model codes need to be robust and more redundant to minimize the chances of loss of life caused by the failure of a building that is out compliance, with codes. Adequate performance of the structure should be ensured even when one of the protective systems is compromised by uncertain behaviors of the building owner or occupants, including the installation of building decorations or temporary features that greatly exceed flame spread or fire load provisions (as discussed in the previous paragraph), as well as exposing the building to strong ignition sources; exceeding the posted occupancy limits; temporarily blocking an exit; and disabling sprinklers or other life safety systems for maintenance. Adequate exits literally provide the lifelines for a building's occupants in the event of a fire. For this reason the safety factor for the number, size and location of exit paths must be large enough to account for the uncertainties in the structure caused by the conditions listed above and for the uncertainty in our

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ability to predict the time for complete egress during an emergency. Recommendation 5, on occupancy limits and emergency egress, acknowledges that uncertainty. Portable fire extinguishers, if readily available to someone properly trained, can be effective early in a fire and delay fire spread in the event the sprinkler system is not functioning. However, the type of training required, the importance of timing, and the limitations on the size of fire that can be safely attacked require additional study. Recommendation 6 is for such a study. Even though the first fire engine arrived expeditiously, the speed at which the fire engulfed The Station rendered it impossible for the fire department to save the structure or the lives of many victims. However, the importance of the role of fire prevention activities in avoiding a future tragedy was highlighted by this incident. As in all mass causality events, especially those where the window of opportunity for rescue is extremely limited, effective and efficient communication within and among the various responding agencies is imperative. Developing effective interoperable communications requires addressing numerous factors, including frequent test use of interoperable communications equipment and procedures, formal governance and collaboration, formal standard operating procedures, appropriate technology, and multi-agency training and exercises. Recommendation 7 identifies existing standards that address these issues. Tools and best practice models addressing many of these success factors, including a statewide communications interoperability planning methodology are available through the Department of Homeland Security’s SAFECOM Program. Based upon the findings of this investigation and the resultant recommendations presented above, additional research is recommended in three general areas: human behavior and people movement, material behavior and fire spread, and decision aids. Recommendation 8 addresses the first of these. There clearly is a need to understand better the behavior of people and crowds in emergency situations to pinpoint the factors that lead to crowd crush. This would enable sensible changes in building design to minimize the possibility of crowd crush, and improved ways to communicate to the crowd in emergency situations that go beyond the code, in direct support of recommendation 5. The time available for safe egress is influenced by the building geometry and ventilation system, the materials of construction and furnishings, and actions to suppress the fire. Predicting sprinkler activation and suppression and the influence of fire fighting activities on the spread of the fire is another aspect of the problem that can be done today only at the grossest level of precision. Implementation of recommendation 9 would move us to the level of precision needed in support of recommendations 2 and 3, as well as recommendation 5. Recommendation 10 recognizes the need for research into computer-aided decision tools specifically designed to deal with the costs and benefits of revisions to building and fire codes and standards, and to assist decision makers at the community level responsible for allocation of resources for public safety.

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Chapter 1 BACKGROUND 1.1 INTRODUCTION A fire occurred on the night of Feb. 20, 2003, in The Station nightclub at 211 Cowesett Avenue, West Warwick, Rhode Island. A band that was performing that night, during its performance, used pyrotechnics that ignited foam insulation lining the walls and ceiling of the platform being used as a stage. The fire spread quickly along the walls and ceiling area over the dance floor. Smoke was visible in the exit doorways in a little more than one minute, and flames were observed breaking through a portion of the roof in less than five minutes. Egress from the nightclub was hampered by crowding at the main entrance to the building. One hundred people lost their lives in the fire. The National Institute of Standards and Technology (NIST), under the authority of the National Construction Safety Team (NCST) Act [1], established a National Construction Safety Team (Team) on Feb. 27, 2003, to determine the likely technical causes of the building failure that led to the high number of casualties in that fire. The investigation included the following tasks: • identification of technical issues and major hypotheses requiring investigation through consultations with experts in fire protection engineering, and emergency evacuation, and members of other teams investigating The Station fire; • data collection from local authorities, contractors and suppliers, building and fire protection design documents, records, plans, specifications, video and photographic data, telephone and radio transmissions, field data, and a limited number of interviews and other oral and written accounts from building occupants and emergency responders, and other witnesses as reported by the news media; • analysis and comparison of building and fire codes and practices, and review and analysis of practices used in operation of the building; • simulation and analysis of phenomena (with associated uncertainties), including fire spread, smoke movement, tenability, occupant behavior and response, evacuation issues, and operation of active and passive fire protection systems; and • testing to provide additional data and support simulation predictions. This document constitutes the draft report of the NIST investigation into The Station fire. The building and surroundings as they were prior to the fire are described in the following section of this chapter. The general history of the building is reviewed here as well. Chapter 2 provides a timeline of the incident, including the ignition and spread of the fire, the evacuation process, and firefighting activities. The fire and emergency response and procedures are detailed in Chapter 3. Chapter 4 describes the testing and supporting experiments, and Chapter 5 provides background and results of the computer simulation of the fire and smoke movement. An analysis of the evacuation process is provided in Chapter 6. Chapter 7 reviews the model building and fire codes that are relevant to a structure like The Station. The report concludes with a summary of findings and recommendations in Chapter 8. There are a number of appendices that provide more detail, or information that is peripheral to the main objectives. NIST video recordings and animations are included in the DVD that accompanies this report.

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1. 2

DESCRIPTION OF THE BUILDING AND SITE The Station nightclub was located at 211 Cowesett Avenue, West Warwick, Rhode Island. It was a single-story wood frame building with a footprint of about 412 m (4484 ft ) and a small basement under the main bar room. Figure 1-1 is a photograph of the building on its lot. The north-facing front door of the nightclub was set back about 42 m (140 ft) from Cowesett Avenue, a three-lane, two way street that runs east-to-west. Kulas Road is two lanes wide and runs along the east side of the building, about 10 m (33 ft) east of the side bar exit. There was no direct street access to the building from either the west or south sides. Parking for over 100 cars was provided in the front and to the west side of the building. 2 2 A distant aerial view of the area, Figure 1-2, shows the nightclub in relation to the community. Note the location of Fire Station #4 at 110 Cowesett Avenue about 500 m (1650 ft) to the west of The Station. Figure 1-3 is a sketch showing the north side of the building approximately as it looked on February 20,

1. Note the windows on the left which are in the main bar area, the windows on the right in the

sunroom/poolroom, the ramp and stairs leading from the main entrance in front, and the stairways leading from side exits on the west and east of the building. Inside the double doors of the main entrance is a vestibule with a single doorway. Figures 1-4a and 1-4b are photographs of the north side and north west corner of the building as they looked within a year or two of the February 20, 2003 fire. The external walls were primarily covered with painted wood shingles or panels above a concrete foundation. The roof was flat with a wood shingle façade along the front and sides, as seen in the photographs. Figure 1-5 shows a plan view of the nightclub floor, a composite from multiple sources of information obtained during the investigation. Entering from the front through the double doors would have brought one into a short entrance hall with a single door at the far end that led to the ticket-taker area. To the right of the ticket taker was an assembly area containing the dance floor, sunroom (or poolroom), elevated dining area, and a platform (imprecisely referred to as a stage) with the drummer's alcove. A dressing room was situated in the northwest corner and an exit to the outside was located between the platform and dressing room. Except for the front of the sunroom, which was composed of darkened glass windows, there were no other windows in the right half of the nightclub. Turning left at the ticket-taker area would have brought one into the main (or horseshoe) bar room. An exit to the outside was located on the far left wall. There were no windows on that wall but windows lined most of the front of the main bar room. The kitchen separated the main bar room from a smaller assembly area (or dart room) and back bar. There was one door to the outside from within the kitchen. A storage area, office, and restrooms were located in the back of the nightclub. There were no additional exits leading directly to the outside from these rooms; any windows or exits that had been installed were covered with bars or paneling. Figures 1-6a and 1-6b show different views inside the nightclub, highlighting the exit doors next to the platform and the exit from the main bar area. 1.3 HISTORY OF THE BUILDING1 The Station nightclub was a single-story wood frame building, with a small basement. Over the years the building was sold multiple times and changed function, as shown in Table 1-1.

1 This section is taken from the contract report prepared by Koffel Associates, Inc. [11]

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Figure 1-1. General orientation of building and site [2]

Figure 1-2. Aerial photograph of the community around The Station nightclub [2] Cowesett Avenue Cowesett Inn Cowesett Avenue N

1-3

Storage Area (Recessed) Drummer Alcove (Recessed)

Figure 1-3. Sketch of the north side of The Station nightclub locating the main entrance, front stairway/ramp, windows in the main bar area (left), sunroom/pool room (right), and exit stairs from the east and west sides

1-4

Figure 1-4a. Front view of The Station nightclub showing the main entrance [3]

courtesy of Anthony Baldino III Figure 1-4b. View of the northwest corner showing the sunroom windows [3] courtesy of Anthony Baldino III

1-5

Figure 1-5. Plan view of The Station showing different rooms and exits.

1. 5 m

1. 5 m

OFFICE KITCHEN SUNROOM MAIN BAR FRONT REAR DANCE FLOOR 20.9 m 24.2 m 4.6 m 10.9 m 9.8 m 6.1 m 16.6 m RAISED PLATFORM Front Entrance Doors Platform Exit Door Main Ba Side Ex Door Kitchen Exit Door N r it DART ROOM

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1-7 Figure 1-6a. View of inside of nightclub showing exit sign above door near platform [13]

Figure 1-6b. View of inside of nightclub showing exit sign above door in main bar area [4] Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. photo courtesy of K. Corbin

On the night of the fire, The Station nightclub looked different from when it was built in 1946 [5]. While the club was still a single-story wood building with a small partial basement, it was modified numerous times over its 57 years [6, 7]. Although the original plans of the building were not located, several sources reported that the building was modified over the years. The modifications included small additions, multiple reconfigurations of the interior, rebuilding after a fire, and rebuilding after a car rammed the front of the building [5]. The original date of construction has been variously reported to be 1946 or 1950. The 1946 date is based on a Providence Journal article dated July 13, 2003 [5]. The article reports the land was purchased in 1945; the nightclub (originally named Casey's Inn) was constructed in 1946 and changed hands in 1947. The Town of West Warwick tax records, dated May 30, 2001, indicate that the building was constructed in 1950 [8]. West Warwick land records indicate the property changed hands in November 1945 and 1947, suggesting 946 as reported by the Providence Journal (W. Warwick Land Use Record undated, [5,9]). For the purposes of this report, the date of construction will be 1946. In an effort to document the original building construction date, construction permits were reviewed at the Town of West Warwick for 211 Cowesett Avenue. The permits document dates of construction and provide brief narratives of work to be completed. However, the details of the construction are not included in the permits. It is not possible to determine from the permits the extent of work completed, or i The building was damaged by fire in March 1972. T 2003 Providence Journal article reported the firefighters cut holes in the roof [5]. The contents of the building sustained fire and smoke damage, but the building structure remained. The first building permit issued after the fire was in November 1974. The permit paneling and ng remained In June 20 19, 2001 to repair the dam it indicates that a window and The Town of nt, 165 m2 (1794 ft2 of the building 1.4 At the time of the 197 5]. The ensuing fire alarm mes. They contained the determined ugh the ceiling and into the attic. No occupants were in the club at the ti e of the fire. No other significant fire incidents or egress difficulties were reported to have occurred in this building p

the construction took place in 1 f the work was completed in compliance with model codes of the time. he July makes no mention of roof fire damage repair. It simply states that the work included interior partitions. Workmen reported that smoke-stained and charred structural frami in the building continuously up until the February 2003 fire. 01, a car ran through the front of the building. A building permit was issued on June age [10]. The extent of the damage is not detailed; however, the perm a portion of the exterior wall adjacent to the window were replaced. West Warwick tax records indicate the building consisted of a small baseme ) in area, and a main level of 412 m2 (4484 ft2) [5]. The tax record depicts the general outline with dimensions, not including windows or doors. PREVIOUS INCIDENTS AT THE STATION2 2 fire mentioned above, the building housed a nightclub named Julio’s [ alerted responders; firefighters arrived to find the building engulfed in fla fire, but much of the interior of the club had been significantly damaged. Investigators that the fire started in the rear center of the building and worked up thro m rior to February 20, 2003.

2 This section taken from the contract report prepared by Ove Arup & Partners Massachusetts [12].

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Table 1-1. Time Line of Construction and Changes of Use Date Modification Extent of Construction Spring 1946 Original construction as a night club New construction June 1964 Change of ownership Converted to meeting house (same Use Group Unknown if any as restaurant) May 1967 Change of ownership and name Converted to night club See permit July 27, 1967 July 27, 1967 (building permit 6748)

Commercial alterations Paneling inside Rebuild two porches in front New sign outside 1968 Name change Unknown June 1969 Nightclub closed

April 1970 Change of ownership and name See permit May 18, 1970 Converted to restaurant and removed the bar May 18, 1970 (building permit 8018)

Alterations to Business Roofing, paneling etc. Fall 1970 Renamed Unspecified remodeling June 1971 Bank forecloses

Reopens as night club October 18, 1971 Alterations and remodeling

March 1972 Fire Club may have remained closed until 1974

June 1974 Change of ownership

November 15, 1974 Convert to restaurant Commercial alterations Interior paneling and partitions April 29, 1975 (building permit 10558) Commercial exterior alterations and renovations

July 1, 1975 (building permit 10641) Addition Addition 30.6 m2 (330 ft2) February 1985 Change of ownership Change of name

Converted to “pub” Feb 20, 1985

Remo ruary deling and renovations to existing (building permit 14930) restaurant Late 1980’s Pub closed

1991 Reopened as nightclub

January 1993 Change of ownership renamed

January 1995 Change of ownership

December 1999 Non-permitted work

March 2000 Change of ownership renamed

June 19, 2001 (building permit B01-1098) Repair damage from car ramming building Remove damaged window and replace size for size, replace damaged sill plate and reframe damaged exterior wall and interior wall and exterior siding

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1. 5

JURI Subsequent events of February ge number of publi be hey are outsi N Grand Jury has returned in nd a trial is pe ave been filed s; disputes have arisen involving Workers Compen itation which is presently being contested. NIST expresses no views o oceed In addition, these ongoing l ST's access to some physical evidence and limited the ab witnesses. 1.6 REFERENCES FOR CHAPTER 1 [1 National Construction Safety Team Act, Public Law 107-231 -- Oct. 1, 2002, Congress of the d States of Am [2 ased from Glo [3 thony Ba ino III (undated) [4 Brian, Video by WPRI, Channel 12, February [5] der July 13, 2003. [6] West Warwick App Permit Number 6748. July 27, 1967. [7 ick App it Numb r 8018. May 18, 1970. [8] West Warwick, Rh rial Property Record Card May 30, 2001 [9 Warwick, Rh Record. Unda d. [1 ppli ermit Number 01. [11 o 004. [1 im Egress through Doorwa s," Ove Arup & Massachusetts Inc., NIST contract report #32979, February 18, 2004. [13 ourtes

SPRUDENCE to the 20, 2003, a lar c and private legal actions have gun. While t de the scope of this investigation, IST notes that a dictments a nding; private suits h seeking damage sation; and OSHA has issued a c n the merits of any of these pr ings. egal actions limited NI ility to interview some ] Unite erica. ] purch beXplorer 2004 ] photograph by An ] Butler, ld 20, 2003.

Providence Journal, Zachary R. Mi lication for Building ] West Warw lication for Building Perm e ode Island Commercial /Indust ] West ode Island Land Use te 0] W. Warwick A cation for Building P B01-1098, June 19, 20 ] "Code Analysis of the Station Nightclub Warw City, MD, NIST c ick Rhode Island," ntract report # KA 03732-004, June 23, 2 Koffel Associates, Inc., Ellicott 2] "Evaluation of L Partners itations to ys in Emergency Situation ] photograph c y of K. Corbin

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Chapter 2 DESCRIPTION AND TIMELINE OF THE INCIDENT 2.1 INTRODUCTION A basic element of any fire investigation is the development of the timeline of events. Most of the deaths in The Station fire occurred during the evacuation process; hence, a focus of the NIST investigation was on documenting the egress event. Overlaying the progress of the fire, the movement of occupants, and the collapse of the building was the response to the emergency by the fire and police departments and EMS teams in West Warwick and surrounding regions. The intent of this review is to help understand the incident so that the details and occurrences that resulted in the large loss of life can be identified. The timelines generated in this chapter integrate information from a range of sources to identify the specific events that occurred starting just after 11:07 pm, Eastern Standard Time (EST), Feb. 20, 2003 as well as the order in which they transpired. The timeline is presented as a collection of overviews and snapshots. Overviews describe a series of significant events that occur on the time scale of hours, and serve to place the events in a broader framework. Snapshots focus on a shorter time period, and provide details resolved down to a few seconds. 2.2 OVERVIEW NARRATIVE About 11:07 pm, the lights were dimmed just prior to the band stepping onto the performance platform. Once the band was on the platform, a set of multi-colored lights were activated and four pyrotechnic devices (gerbs) were ignited to begin the show. The hot particulates which were part of the stream of white sparklers discharged by the gerbs struck both sides and the top of the opening to the alcove where the band’s drummer was situated. In a matter of seconds the hot particulates ignited the polyurethane foam on both sides of the platform. Eleven seconds after ignition, the band noticed the flames and the crowd soon began to realize that the fire was not an intentional part of the show. Within 25 seconds, the flames reached the ceiling on both sides of the platform. The fire spread very quickly across the polyurethane foam. The band stopped playing 30 seconds after the fire had started, and the bulk of the crowd began to evacuate. At approximately 41 seconds, the fire alarm sounded and the emergency strobe lights began to flash. In less than 60 seconds, the Rhode Island Emergency 911 Center began receiving calls from cell phones reporting a fire, and at about the same time, a West Warwick Police officer who was at the nightclub reported to the police dispatcher that there was a fire inside The Station on Cowesett Avenue. This information was immediately relayed to the West Warwick Fire Department (WWFD). The fire department assigned and dispatched Engine 4, Engine 1, Engine 2, Engine 3, Ladder 1, Rescue 1, and Battalion Chief 1 to the fire scene. Inside the nightclub, the fire continued to develop and in about 90 seconds, the thick black smoke layer appeared to have dropped to within 0.3 m (1 ft) of the main floor of the nightclub. Less than 100 seconds after ignition, the main front doorway became clogged with occupants trying to exit the main floor. Club patrons and staff were breaking windows on the front of the nightclub from the area of the main bar and sunroom and were exiting through the windows. Patrons who had escaped were attempting to extricate people who had been wedged in the front doorway. Shortly after 11:13 pm (5 minutes after ignition), flames were observed extending out of the windows and front doorway.

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A few seconds later, Engine 4 arrived at the nightclub and began to pull a hose line to near the front door. Water from the booster tank on Engine 4 was initiated at approximately 11:14 pm (about 6 min into the fire). Additional fire fighters arrived on Ladder 1, Engine 2 and Engine 3. Battalion 1 activated the Warwick Task Force which invoked a mutual aid agreement and dispatched seven additional engine/ladder companies from surrounding communities. Battalion 1 also requested 12 rescues (ambulance units). At approximately 11:22 pm, the West Warwick Fire Chief indicated that he was responding to the fire scene. As the chief was responding, he asked the fire dispatcher to contact Metro Fire Control and implement the Mass Casualty Plan. The Engine 3 officer had set up a triage area in the parking lot of and inside the Cowesett Inn. Engine 4 was applying water on the fire by about 11:24 pm, and at least three hose lines were being used to apply water to the area around the front door by 11:28 pm. Shortly after 11:32 pm, the fire chief asked the fire dispatcher to contact the State Fire Marshal’s Office and request a state fire marshal be sent to the scene. The fire dispatcher advised Triage that Kent County Hospital was overwhelmed with injured victims and that additional victims should be directed to Rhode Island Trauma Center, and Triage responded that the rescue units were using their own discretion as to which hospital the victims were being transported. At about 11:57 pm, a portion of the nightclub roof appeared to collapse. The fire chief ordered a roll call to account for all fire fighters on the fire ground. Around midnight the Warwick ladder unit raised its ladder, and began applying a master stream to the fire. Approximately ten minutes after the collapse of the main roof section, a portion of the roof around the sunroom collapsed. Sometime between 12:15 am and 1:00 am, February 21,the State Fire Marshal arrived on the fire scene, the incident commander asked the fire dispatcher to cancel additional rescue units, and Triage reported that all patients had been transported. An overview timeline is shown in Figures 2-1a and 2-1b. Detailed events are summarized in Table 2-1. 2.3 OVERALL INCIDENT TIMELINE The overall incident timeline was assembled from the video footage inside and outside The Station filmed by WPRI-TV [1], published interviews with occupants by the Providence Journal, a video taken by an amateur using a handheld camcorder [2], audio tapes, and fire department records. A high-quality digital version of the TV video was provided to NIST by WPRI. The amateur video [2] was retained as evidence by the Office of the Attorney General for Rhode Island. The Attorney General's staff permitted the NIST investigators to review the tape in the West Warwick Fire Investigation field office. Audio tapes from two sources were also retained by the Attorney General. The first audio set contained digital recordings of cellular phone calls to the Rhode Island Emergency (911) Center. The second audio set included cassette tapes of radio communications from the WWFD. The Attorney General's staff allowed investigation team members to listen to both the 911 and fire department recordings at the field office. In order to integrate the events on the two videos with the audio recordings, it was necessary to establish a common time reference. Each of the two videos was time-stamped by the camera/camcorder, but the two clocks were not synchronized. The 911 audio recordings were time-stamped, but it appeared that the 911 clock did not match either of the two video clocks. The fire department radio transmissions were not continuously time-stamped, but the central dispatch (fire alarm) periodically inserted a clock time either before or after a transmission. The fire department communication system did not record continuously, but instead recorded only when a radio transmission occurred. The result is that the dispatcher may have inserted a clock time twice in 5 minutes, but then not provided another clock time for 30 minutes.

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Figure 2-1a. Overview Timeline of The Station Nightclub Fire

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Figure 2-1b. Overview Timeline of The Station Nightclub Fire (cont.)

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Table 2-1. Summary of Incident Timeline. (Uncertainty is less than +/- 5 seconds for times showing seconds, and +/- 30 s for times without seconds.) EST Fire Time Description 11:08 pm 0:00:00 First flames on upper wall, left of platform

0:00:25 Flames touching ceiling on both sides of platform

0:00:30 Band stops playing, crowd begins to evacuate 11:09 0:00:36 Three Cell phone caller reports fire to 911

0:00:41 Fire alarm sounds and strobes begin to flash 11:09 0:00:59 Report received of fire at Station Nightclub- Police on Scene, 11:09 0:01:13 Fire alarm recorded at WWFD

0:01:30 Thick black smoke from pool room windows. Smoke appears to be at floor level inside.

0:01:42 People piled up in doorway. Smoke pouring out above people. 11:10 0:02:00 E-4, E-1, E-2, E-3, L-1, B-1assigned/dispatched

0:04:38 Smoke approximately 0.3 m above floor inside. Flames near door

0:05:12 First observation of flames out front of building 11:13 0:05:21 Engine 4 on scene. Fire department confirmed on scene, front of building

0:05:34 Fire Department commences running first hose line (1 ¾”). Flames (2.5 m to 3 m) extending from front exit

0:05:43 Flames extend from front windows 11:14 0:06 Engine 4 on scene reporting heavy fire

Water from 1 ¾” hose line directed to the main entrance

Battalion 1 – activate Warwick Task Force ( seven additional engines/ladders) Mutual Aid

Battalion 1 to Fire Alarm – request 12 rescue units

0:11 Engine 2 – monitor; knock it down, Master Stream from E-2 on fire at club entrance 11:22 0:14 Fire Chief responding

Fire Chief 1 to Fire Alarm- Metro Fire Control; Implement Mass Casualty Plan 11:24 0:16 Master Stream off Engine 4 operational – water on center of fire

any available rescue units, request 15 more

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EST Fire Time Description 11:28 0:20 Three hose streams, three hand lines streaming on front door area 11:32 0:24 Area/Roof over Main Bar appears down 11:33 0:25 Master Stream off Engine 4 still operating

Fire Chief 1 to Fire Alarm – need State Fire Marshal asap 11:40

Rescue 2 at Kent County Hospital

Command to Triage-Triage –need 10-24 stretchers

Fire Alarm to Triage – Kent County overwhelmed; send to RI Trauma

Engine 3 to Fire Alarm – repeat; rescues using own discretion; Engine 3 triaging out of here

Battalion 1- accountability Roll Call – roof down? 11:57 0:49 Middle of Accountability Check- Accountability –Fire Alarm to E-1,E-2,E-3,E-4, Rescue 1, FC, SH 11:58 0:50 Warwick Ladder platform water operating

Fire Alarm to Command – Kent filled to max; Rescue 1 – approaching scene with doctor from Kent Cty 12:09 am 1:01 Master stream off ladder platform still operating 12:15 1:07 Partial collapse of pool room area begins 12:16 1:08 Warble tone ----- partial collapse; all personnel out

Accountability Check – E-1, E-2, E-3, E-4, L-1, R-1, E-5, E-7, R-3 12:22 1:14 Master stream from ladder platform still operating 12:23 1:15 Streets appear clear and casualties gone 12:37 1:29 Narragansett Electric Power Truck visible on Cowesett

State Fire Marshal on scene; Narragansett responding

Command to Fire Alarm – notify chaplain; cancel additional rescues; cancel LifeFlight helicopter

Command to Fire Alarm – Chief Rock (Fire Chief 2) and State Fire Marshal meet in front of building

Safety – cancelled all Rescue, Triage to Fire Alarm – all patients transported 1:06

Rescue 1 clear 1:07

Fire Alarm – Power has been cut

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After careful review of the video and audio recordings, links were discovered which allowed all the recordings to be tied to a common clock. West Warwick Fire Department records indicated that the first unit, Engine 4, arrived on the scene at 23:13:22. Engine 4 also notified the WWFD dispatcher over the radio that they were on scene and the dispatcher inserted a clock time of 23:14. While it was not clear that the same clock was used to record the arrival and the dispatcher's time stamp of the radio transmission, the two clock times suggested that both clock times were relatively consistent. It was also possible that the same clock was used for both times and there was a short delay after Engine 4 arrived and their report of being on scene. For development of this timeline, it was assumed that the earlier time, 23:13:22, was the time of arrival of Engine 4. The arrival time of Engine 4 provided a link to the WPRI video because Engine 4 was visible in the video. A siren could be heard in the background of the WPRI video and seconds later, Engine 4 appeared on the video. The video did not actually show Engine 4 pulling into the parking lot of the nightclub. But 5 minutes 21 seconds after ignition, Engine 4 was shown to be in the parking lot of the nightclub. It was possible that Engine 4 arrived slightly earlier, but was simply not visible in the field of view of the WPRI camera. The arrival time from the fire department records, 23:13:22, was paired to the appearance of Engine 4 in the WPRI video at 5:21 after ignition. This link allowed the fire department records, fire department radio tapes, and the WPRI video to be tied to a common clock. The fire department radio tapes could be linked to the 911 audio tapes because one of the cell phone callers was relayed from the 911 center to the WWFD. Part of the communication between the cell caller and the WWFD could be overheard on the fire department radio transmissions. Unfortunately, the dispatcher did not insert a clock time on that specific radio transmission, but had inserted a clock time with a preceding transmission. Again, since the radio transmissions were only recorded during actual transmissions, it was not possible to ascertain how much time had passed between the previous clock time insertion and the cell call being transferred to the WWFD. Since each cell call to the 911 center was time stamped automatically, it was possible to link the fire department radio transmissions to the 911 calls. While the WPRI video captured the first 6 minutes of the fire, the amateur video tape was longer and recorded later in the evolution of the incident. A link between the two video times was found through common events captured on the amateur tape and fire department transmission records. During the fire department response and suppression operations, the WWFD conducted two roll calls of personnel on the fire ground. The first roll call appeared to be associated with the collapse of a significant portion of the nightclub roof. The second roll call was requested when part of the sunroom collapsed. The warble tones used by the fire department to signal a roll call could be heard on both the amateur video tape and the fire department radio transmissions. The fire dispatcher did insert a clock time on the radio transmission announcing the second roll-call. Comparing the time stamp on the amateur video with the fire department radio transmissions identified the amateur video clock to be 3:32 min behind the fire department clock. The amateur video times were adjusted by adding 3:32 min to each time mark. By linking the fire department radio transmissions to the WPRI video, the 911 cell calls, and the amateur video, all the events were placed on a common timeline. Combining this with the fire department incident record allowed the timeline to reference a single clock time. However, since most of the fire department radio transmissions did not have an inserted clock-time, the timeline shown in Figure 2-1 provides the order in which all of the events occurred, but not necessarily the specific times at which they occurred.

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1. 4

EVACUATION TIMELINE1 Three types of data were used to develop a reasonable and verified description of the evacuation: video footage, photographs and eyewitness statements from the Providence Journal. While many newspaper articles reported various details of the incident, the building, and the evacuation, no conclusions were drawn from such sources unless they could be independently verified through review of photographs, video footage, or eyewitness statements. Short of personal observation, visual evidence can provide investigators with the most reliable depiction of the events of an incident such as this. By considering visual evidence, the investigator does not rely upon the interpretations or views of other observers. Due to inherent inaccuracies involved with eyewitness accounts, visual evidence was given priority in developing the timeline. The evacuation timeline presented here was assembled with the assistance of Ove Arup & Partners Massachusetts, Inc. Their final report to NIST [3] is quoted freely in this chapter without further reference; however, any conclusions and findings that are presented are solely those of NIST. The timeline includes events specific to the evacuation of the building, as well as those specific to the development of the fire. Various sources were contacted as part of this effort. However, because litigation activities were underway, some potential sources were unable to provide us their information. The video footage recorded inside and outside of the club before and during the fire by WPRI-TV camera operator [1] was of great benefit to this task. This video showed various activities prior to the incident, as well as the initiation of the fire and portions of the ensuing evacuation. The television news crew’s video was used as the primary source of data for this task. Available photographs were used to confirm various details observed in the video, as well as to gain observations of different parts of the club, both before and during the fire. While eyewitness statements have some drawbacks, they can provide valuable insight, especially since video footage and photographs were not available for all aspects of this incident, or of areas and features of The Station nightclub. In this review, eyewitness statements, primarily as reported by the Providence Journal and the Boston Globe, were used to draw conclusions regarding occurrences outside of the view of the available visual evidence sources. Unless they could be disproved, eyewitness statements were assumed accurate based on the experience of the eyewitness; conclusions drawn from these were independently verified, where possible. NIST also provided an anonymous toll free hotline and an email address for voluntary input from the general public to generate additional communications, none of which contradicted the published accounts. Photographs used in this analysis were in digital form, and thus no software was necessary in their processing. The WPRI video was provided to NIST in digital form as well. In order to obtain still images from this video, the media editing software Pinnacle Studio SE, Version 7.15.1, was employed. This software allowed specific individual video frames to be extracted from the video while maintaining image quality. The timeline that resulted from this analysis, with reference to the still frames from which events were identified (refer to Appendix A for images), is provided in Figures 2-2a through 2-2d . The timeline indicates times in relation to the initiation of fire on the platform, estimated to occur at 11:08:01 pm EST (06:22 video time).

1 This section taken from the contract report prepared by Ove Arup & Partners Massachusetts [3].

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1 Min 2 Min 3 Min 4 Min 5 Min 6 Min START OF FIRE Timeline Part 1

00:00 00:09 -00:33 -00:14 -00:08 START OF FIRE Lights turned off for show.

Band takes stage. Pyrotechnic display initiated. Flames on upper wall, right of stage. First flames, upper wall, left of stage.

Figure 2-2a. Evacuation Timeline (33 seconds before to 10 seconds after ignition). Video stills copyright © 2003 TVL Broadcasting, Inc. All rights reserved.

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1 Min 2 Min 3 Min 4 Min 5 Min 6 Min START OF FIRE Timeline Part 2

Flames touching ceiling, both sides. Flames extend fully above stage. Flames reach ceiling, right of stage. Camera operator begins to evacuate. Band stops playing, begins to evacuate. Alarm sounds; strobes begin to flash. Band members first notice flames.

00:25 00:11 00:16 00:18 00:41 00:32 00:30

Figure 2-2b. Evacuation Timeline (10 seconds to 50 seconds after ignition). Video stills copyright © 2003 TVL Broadcasting, Inc. All rights reserved.

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1 Min 2 Min 3 Min 4 Min 5 Min 6 Min START OF FIRE Timeline Part 3

00:54 01:06 01:11 01:26 01:30 01:42 Smoke from stage exit, flames inside Smoke in exit lobby. Occupants jammed in doorway. Camera operator reaches exit lobby. Camera operator exits building. Smoke out of poolroom windows.

Figure 2-2c. Incident Timeline (50 seconds to 2 minutes after ignition). Video stills copyright © 2003 TVL Broadcasting, Inc. All rights reserved.

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1 Min 2 Min 3 Min 4 Min 5 Min 6 Min START OF FIRE Timeline Part 4

Flames extend from front windows. Fire department confirmed on scene. Flames near eave at rear of building. Fire department runs first hose line. Flames out front of building. Camera operator returns to stage door.

05:21 05:34 05:43 05:12 04:56 04:38

Figure 2-2d. Incident Timeline, Part 4 (2 minutes after ignition to 5:43). Video stills copyright © 2003 TVL Broadcasting, Inc. All rights reserved.

The focus was the time period beginning when portions of the club lights were shut down in preparation for the show, until the videographer placed the camera on the ground in the parking lot and significant flames were seen at the front of the building. The polyurethane foam along the vertical corners of the walls forming the drummers alcove ignited 8 seconds after the pyrotechnic display was initiated, as seen in Fig. 2-2a.. The videographer moved his camera aside 7 seconds later to view the growing fire along the wall better; the band members near the back of the platform noticed the flames 4 seconds later. (Refer to Fig. 2-2b.) The videographer swung his camera around and headed for the exit at the front of the building 18 seconds after ignition of the foam; the first patrons could be seen on the videotape to

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Table 2-2. Summary of Evacuation Timeline Developed from Video Analysis 1, 3

Video Time Fire Time Description 0:05:49

• 0:00:33

Platform lights turned off for beginning of show. 0:06:08

• 0:00:14

Band first shown on platform. 0:06:14

• 0:00:08

Pyrotechnic display initiated. 0:06:22 0:00:00 First flames on upper wall, left of platform. 0:06:31 0:00:09 Flames on upper wall, right of platform. Pyrotechnic display ends. 0:06:33 0:00:11 Band members first notice flames. 0:06:38 0:00:16 Flames reach ceiling to right of platform. 0:06:40 0:00:18 Camera operator begins to evacuate. 0:06:47 0:00:25 Flames touching ceiling on both sides of platform. 0:06:52 0:00:30 Band stops playing, begins to evacuate. 0:06:54 0:00:32 Flames extend fully across ceiling above platform. 0:07:03 0:00:41 Fire alarm sounds and strobes begin to flash. 0:07:16 0:00:54 Camera operator reaches exit lobby. 0:07:28 0:01:06 Smoke in outer exit lobby. 0:07:33 0:01:11 Camera operator exits building. 0:07:48 0:01:26 Smoke coming out of platform exit. Flames visible inside at this location. 0:07:52 0:01:30 Thick black smoke from pool room windows. Smoke appears to be at floor level inside. Occupants egressing through windows. 0:08:04 0:01:42 Camera operator returns to main exit. People piled up in doorway. Smoke pouring out above people. 0:10:30 0:04:08 Occupants still being assisted through main bar windows 0:11:00 0:04:38 Camera operator returns to platform exit. Smoke ~1 ft above floor inside. Flames near door. 0:11:18 0:04:56 Flames outside building at roof level in rear. 0:11:34 0:05:12 Flames first recorded out front of building. 0:11:43 0:05:21 Fire department confirmed on scene. 0:11:56 0:05:34 Fire department commences running first hose line. Flames extending from main exit ~2.5 to 3 m. 0:12:05 0:05:43 Flames extend from front windows.

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recognize the fire danger at 24 seconds. Around the time the band stopped playing (30 seconds fire time), the bulk of the crowd had begun the evacuation process. At 41 seconds the fire alarm could be heard and the strobe seen on the video. (See Fig. 2-2b.) The videographer made his way to the exit lobby while continuing to capture the movement of the crowd leaving the area around the dance floor. As seen in Fig. 2-2c, he exited the building at 1 minute 11 seconds (fire time) along with a steady stream of occupants. Sometime estimated to be around 1 minute 30 seconds after ignition of the foam, the front exit became blocked with people, and occupants could be seen breaking windows and escaping from the poolroom/sunroom. The result of the crowd crush at the front exit was captured on the video at 1 minute 42 seconds (Fig. 2-2c). The latest time recorded for an occupant escaping from inside the main bar (through a window) was at 4 minutes 8 seconds; however, people stuck in the front entrance are seen in the video to have escaped as late as 5-1/2 minutes into the fire, just before the fire department ran its first hose line (Fig. 2-2d). (One patron claimed to have been pulled from the bottom of the pile by a firefighter considerably later, but this has not been confirmed by the NIST investigation.) Table 2-2 provides a summary of the events making up the evacuation timeline. “Video Time” refers to the absolute counter time associated with the events as captured on the television crew video, while “Fire Time” refers to the time of events relative to the start of the fire. 2.5 REFERENCES FOR CHAPTER 2 [1] Butler, Brian, Video by WPRI, Channel 12, Feb. 20, 2003. [2] Personal communication between N. Bryner and M. Stone, Rhode Island Attorney General's office, West Warwick, June 2, 2004. [3] "Evaluation of Limitations to Egress through Doorways in Emergency Situations," Ove Arup & Partners Massachusetts Inc., NIST contract report #32979, Feb. 18, 2004.

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Chapter 3 THE EMERGENCY INCIDENT RESPONSE 3.1 INTRODUCTION Beginning late Thursday evening, Feb. 20, 2003, Rhode Island’s fire/rescue, emergency medical services and law enforcement agencies were challenged by the largest life loss fire incident in the state’s history. In a matter of minutes The Station nightclub became engulfed in flames, producing both a major mass fatality and mass casualty incident that drew upon the resources of virtually every fire and emergency medical services (EMS) provider in the State, a variety of law enforcement agencies and others. The fire and resulting structure loss was principally limited to the single story, wood framed, unsprinklered, public occupancy, commercial building of relatively modest size [approximately 412 m2 (4484 ft2)]. Several vehicles in the vicinity of the building were also lost or damaged by the fire. As described in Chapter 1, the structure stood facing north, at the left rear of a roughly rectangular corner lot at the southwest intersection of Cowesett Avenue and Kulas Road. The corner lot had been carved from a steeply graded hillside and then leveled and re-graded to provide relatively level access along the length of the Cowesett Avenue frontage, while on the Kulas Road (east) side, the grade rose away to the rear and southeast corner of the lot from Cowesett Avenue at a significant incline. The south or back line and the west side property line were covered by relatively heavy brush comprised of various small trees, bushes and ground cover and accumulated snow pack. The length of the rear property line was also contained and obstructed by a privacy style fence. The site’s contours maximized the Cowesett Avenue access and parking (north half of the lot) and placed the structure lower than adjacent perimeter grades at the rear on the east and south (back) sides. The structure’s proximity to the berm-like elevated boundary on the east and along the south/back side property line limited tactical operations at the rear and southeast corner of the building. This area also provided no personnel access/egress points to the structure on either side. The building’s placement on the lot and its irregular configuration, the higher graded perimeters, and the narrow distance between firefighters and the southeast side and south facing rear walls of the structure presented a risk to fire ground operations due to the rapidly deteriorating conditions, including the possibility the building would collapse. The east side of the lot along Kulas Road also presented an electrocution hazard risk to fire ground operations due to overhead electrical lines and a pole-mounted transformer at the service drop to the structure. The northeast front facing side, the full front (north facing) and west side of the structure each contained slightly elevated entrance ways into the building and were accessible from the relatively level parking areas extending from the building to the north and west. In other respects, the structure presented no obvious hazards beyond those normally associated with comparable occupancies nor were there any other nearby at-risk structural exposures. However, vehicle fire exposure risks filled the parking area, in the front of and extending from the structure to the west. This area contained numerous vehicles of various types including a tour bus, media van, cars and trucks, as well as residual snow banks/piles from previous plowing. Although the tour bus was removed during the early minutes of the fire, other vehicles parked near the northeast side (adjacent to the single door bar area exit) in the immediate proximity of the building were exposed to sufficient radiant heat to produce

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secondary ignitions, requiring extinguishment and producing additional vehicle fire losses from the incident. The human toll from the fire was far more devastating. Within only minutes of the pyrotechnic display ignitions, 96 people perished, unable to egress safely ahead of the intense and fast moving fire. Most of the fatalities occurred in the moments prior to the arrival of the first emergency services units. Three more died within days subsequent to hospitalization, followed by an additional death 70 days after the fire raising the final fatality count to 100. More than 200 other victims, many seriously hurt from burns, respiratory insult and physical trauma, were provided emergency care and triaged at the scene, then transported to hospitals in multiple states. This major mass casualty incident (MCI) effectively concluded its emergency on-scene and pre-hospital care operation (casualty collection, triage and transport) phase in less than two hours from the fire’s onset. The operation was accomplished expeditiously through the combined efforts of dozens of agencies (some 60 EMS units and untold number of individual care providers), notwithstanding the communications interoperability challenges experienced by many of the responding units. Subsequent to the fire’s suppression and once the scene was cleared of casualties, the next major phase began -- the recovery and identification of the fatality remains. These activities opened the opportunity for police, fire investigators and others to access the primary loss area to collect and document information in support of their investigations. The State Fire Marshal and Medical Examiner's personnel coordinated the recovery of the dead. Fire Department personnel were utilized to collect individuals' remains and to move them to a holding area at the northwest corner of the lot while awaiting transport. The respective investigative teams documented the fire scene and the body recoveries, attempting to identify the deceased as early on in the process as possible. This phase of the operation continued until the recovery and removal of the last victims by late afternoon, on Friday, Feb. 21. The scene had been secured with temporary fencing and site control was transferred to the law enforcement authorities conducting the follow on investigations. Fire department on-scene operations concluded with the last ‘stand-by’ engine company returning to quarters some 24 hours after the ignition of the pyrotechnics that came to produce the fourth deadliest nightclub fire loss in the Nation’s history. 3.2 THE WEST WARWICK FIRE DEPARTMENT The description of the West Warwick Fire Department (WWFD) provided in the DHS/ODP After-action Report (Annex A, p. A-1) [1] forms the basis of the information summarized here. The WWFD provided both emergency medical and fire suppression services to a community of approximately 30,000 people. West Warwick is situated geographically at about the center of the state, and comprises a primary response area of just under eight square miles. The Department operated from four stations with a combined response capability of four engine companies, one tower/ladder company, two rescue- ambulances and one special hazards unit or squad-type apparatus with a light tower. The Department’s 66 uniformed personnel were divided into four rotating platoons typically comprised of not less than one battalion chief and 12 other officers and firefighters per shift. An officer and firefighter each staffed Engines 1, 3 and 4. An officer and firefighter cross-staffed Ladder 1 and the special hazards unit and two firefighter/EMT-C’s cross-staffed Engine 2 and Rescue 2 (ambulance), while two firefighter/EMT-C’s staffed Rescue 1 (ambulance). (Note: cross staffing indicates the personnel responded on either of the indicated apparatus depending on the nature of the assignment.)

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At the time of the fire, the WWFD’s unit staffing (as noted above) was about half the minimum complement of engine and truck company personnel suggested in the applicable National Fire Protection Association (NFPA) Standards (1500 [4] and 1710 [5] respectively). The Standards advocate a minimum crew of four members operating from each type of apparatus. Unit staffing levels directly affect the firefighting crew’s tactical performance capabilities, the speed at and duration of which they can be relied upon to accomplish various tasks, such as establishing water supply, advancing hand lines, or effecting rescues, as well as the overall scope and effectiveness of the tactical intervention strategy being applied in a given situation. The WWFD routinely relied upon substantial mutual-aid augmentation [principally from the Warwick Fire Department (WFD) and the Coventry Fire Department (CFD)] to respond to its working structure fires due in large part to its below standard staffing levels. In general, the additional response times of mutual aid assets can delay the effective implementation of the Incident Command (IC) based strategies and tactics necessary to successfully mitigate significant incidents. In this case, however, the large loss of life was not connected to any delay in establishing the Incident Command. 3.3 THE FIRE AND EMERGENCY MEDICAL SERVICES RESPONSE A "structure fire with person(s) trapped" type incident by its nature produces a situation where occupant rescue and fire suppression activities are competing for immediate priority attention. The response to this incident involved major concurrent tactical challenges (the fire suppression, the mass casualty management, scene control and traffic management and the subsequent victim identification, community support, and incident investigation) requiring concurrent intervention activities by fire suppression, EMS, law enforcement personnel and others from a plethora of agencies. The following overview is intended to provide a general description of the incident’s progression noting key tactical challenges and how they were addressed. The overview timeline (Fig. 2-1a and 2-1b, and Table 2-1) summarize the sequence of events that are described in more detail in this chapter. Invaluable contributions were made by literally hundreds of service providers from a host of agencies working in common cause, even though there were problems in the response. 3.3.1 The Initial Alarm On Feb. 20, 2003, at approximately 11:09 p.m., the State’s 911 call center began to receive calls reporting a fire at the Station Nightclub and requesting that help be sent to the nightclub. Simultaneously, the West Warwick Police Department dispatcher received a radio call from a paid detail officer (police) at the scene also reporting a fire at a nightclub which was located at 211 Cowesett Avenue. Within seconds reports from both the 911center and police officer were relayed to West Warwick’s fire dispatcher who initiated a standard structure fire response at approximately 11:10 p.m. The duty chief, four engine companies, the tower/ladder company and a rescue-ambulance responded to the initial alarm. Calls continued to come in, indicating the extraordinary severity of the fire and that numerous people were trapped and injured, which prompted the assignment of additional rescue- ambulances and other assets from both the adjoining jurisdictions and across the state. At approximately six minutes into the fire, and within moments of his arrival, the WWFD’s on-duty chief (acting Battalion 1) requested the activation of a task force from the nearby Warwick Fire Department for mutual aid. Warwick Fire Department units monitoring the alarm traffic and anticipating the assignment went "in-route" when dispatched at approximately 11:14 p.m. The WFD response was comprised of an augmented task force including a chief officer, 3 engines, 1 truck and 2 rescue-ambulances. The WWFD

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on-duty chief then requested 12 rescue-ambulances to be dispatched in addition to those already responding. The dispatchers received multiple alarm/mutual aid requests as the incident progressed. 3.3.2 The Incident Command The initial Incident Command (IC) was established with the arrival of the WWFD on-duty Chief (acting Battalion 1) who positioned his command vehicle at the west end of the alarm assignment structure on Cowesett Avenue. From this location the IC had a fair view of the front of the burning structure, the large number of casualties dispersed among the crowds of other people in the parking area in front of The Station and along both sides of the roadway to the east, the Kulas Road intersection with Cowesett Avenue, and some of the area on the street in front of the Cowesett Inn. As one scanned from a southerly direction to the east the following could be seen: • directly south - o the immediate parking area in front of the building with numerous at-risk vehicle exposures, the at-risk structure with heavy fire showing, and the steep grade incline and wooded area to the rear of the lot • to the southeast – o at a distance, the rise of Kulas Road up-grade away from Cowesett Avenue with adjacent utility poles and overhead wires with a transformer o in the near ground, the approximate length and width of the parking area and vehicle loading • looking east - o on the right of Cowesett Avenue, the length of the street section in front of The Station o on the left, the area in front of and to the west side parking areas of the Cowesett Inn The fire ground scene was chaotic. The fire was rapidly enveloping the structure with a large collection of victims trapped at the main entrance and an unknown number still likely to be in the building. Dozens of victims with obvious injuries were scattered across the operational area, including the parking lot and along the street looking east toward the Inn. The concurrent and emerging operational objectives of rescuing victims, providing mass casualty care/transport and mounting an attack to extinguish the fire were apparent to the IC who immediately requested additional assistance. The IC directed WWFD’s Engine 2 to lay-in supply lines from the hydrant in front of the Cowesett Inn and to support the first due unit’s (Engine 4) suppression operations. During these initial activities, the primary command focus was to establish a water supply and accomplish as many victim rescues as possible given the rapidly deteriorating fire conditions. At 11:22 p.m., less than 14 minutes into the fire, WWFD’s Chief of the Department notified dispatch that he was responding. Moments later while in route, he ordered the formal activation of the Mass Casualty Incident (MCI) component of the mutual aid plan. Upon his arrival, approximately six minutes later, he conducted a brief assessment of the unfolding operations and moved the position of the IC forward of the original command location, in the parking lot

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at the front of the building. Also recognizing the magnitude of the incident’s casualties, the Chief immediately requested any available rescue-ambulance to respond. He specifically requested 15 additional units beyond those units previously deployed and those currently responding to the initial IC’s request for “any available unit.” Although the Chief did not formally announce his assumption of command or the new IC location his presence became obvious to the dispatchers and the personnel already engaged in rescue and suppression operations at the scene. The IC (WWFD Chief) was joined in short order by the department chiefs from the Warwick FD and the Cranston FD at the newly positioned IC area at the front of the building. From this vantage point the command group could better observe and direct the rescue efforts at the entranceway and the fire attack. The chiefs from the mutual aid departments functioned as a command group to support the IC and to direct the assignment of their respective department assets. Upon the arrival of the Chief from the Coventry FD the IC requested that the Coventry Chief assess and report on the unfolding EMS activities at and near the Cowesett Inn. In this role the Coventry Chief became the EMS liaison to the IC for the remainder of those operations. Although the IC group did not adopt a traditional IC structure or paradigm, it functioned in a fashion that was, in effect, driven by the unprecedented magnitude of the mutual aid response and the huge coordination challenge presented by the high volume of communications necessary for the multiple responding units. As discussed in the DHS/ODP After-action Report (Annex A, p. A-21) [1], the respective chiefs relayed commands to their dispatchers and arriving units on their respective radio channels, as no common channel was available to effectively handle the volume of radio traffic emanating from the scene. The resulting fragmentation of vital communications posed substantial challenges to area dispatchers who were trying to satisfy the numerous “any available unit” requests from their respective assets already at the scene. The generalized requests for “any available units” initiated to various dispatch centers by the mutual aid companies produced confusion regarding which units had already responded and which were still available. Since units were being self-deployed, dispatchers had to poll departments to see if they could respond rather than relying on the call-ups driven by the mutual aid system's resource cascade. The communications difficulties also led to Basic Life Support (BLS) patients being transported by Advanced Life Support (ALS) units on a first-come-first-served basis, which is a less effective use of resources. From a command/operations perspective the incident could have been better managed. In spite of this situation, all the critical requirements were achieved with the fire being extinguished in little over an hour and the evacuation of the last casualty in less than two hours from the initiation of the incident. At approximately 4 am the Command group met at the Cowesett Inn to plan the demobilization of the incident. This effort prioritized the actions necessary to close out the on-scene operations, identified the additional equipment and various staff resources needed to accomplish a wide range of related tasks both at the scene and elsewhere, and insured the necessary notification and coordination with other participating agency personnel. Principal among these activities was the effort to structure the process and staff the victim recovery activities that would conclude the fire ground operations. The absence of a centralized communications capability and record of the IC operations during this incident precludes a meaningful objective review of those activities. However, the assets needed, both personnel and apparatus, did materialize in a timely fashion. Given the time needed to collect, triage and care for the casualties, these services were capably provided by the initial mutual aid responders.

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1. 3.3

Fire Attack The first fire apparatus, WWFD Engine 4 and Tower/Ladder 1, were located about 500 m (0.3 mile) west of the nightclub on Cowesett Avenue and arrived on scene within three minutes of dispatch and approximately 5 ½ minutes into the fire. On arrival Engine 4 reported “heavy fire” conditions at the scene, as flames were visible at multiple locations and heavy volumes of thick black smoke were emanating from various points of the structure. Engine 4 was able to pull into the parking lot and positioned almost directly in front (the north side) of the building, a few meters west of the main entrance, while Tower/Ladder 1 passed the parking lot and turned south on Kulas Road to position on the upgrade, east side of the structure. The location of WWFD Tower/Ladder 1 was tactically compromised by pole mounted power lines extending parallel along Kulas Road between the blazing structure and the apparatus. Within moments of their arrival, Engine 4’s crew with assistance of Tower/Ladder 1’s personnel and bystanders, had extended a 1 ¾” hand line from the unit and advanced to the main entrance of the club. The fire conditions were deteriorating rapidly. Significant volumes of fire were enveloping the building and heavy smoke was billowing from the main entrance, secondary exits, and knocked out windows in the sunroom and main bar area on either side of the main entrance. At the same time, occupants were trying to escape through that main entrance, with tiers of entrapped victims stacked on top of one another in the doorway. As the crew approached, they utilized a 1 ¾” hand line, served by the unit’s on board water supply, to retard the fire at this principal egress point. This was to provide the entrapped victims a protective water curtain while units assisted individuals. (It has not been determined how many people may have been rescued during this phase, nor when they may have been removed from the front doorway; however, it was reported [2], without confirmation from the fire department, that one person was pulled from near the bottom of the pile as much as an hour after the fire department arrived on the scene.) Upon its arrival WWFD Engine 2 laid-in, providing two 3” water supply lines from the hydrant across the street at the corner of Cowesett Avenue and Coit Avenue adjacent to the southeast corner of the Cowesett Inn, to support Engine 4’s operations, which had exhausted its on board water supply. Engine 2 was able to enter the parking lot positioning a short distance behind Engine 4. The crew established a supply line to the first arriving unit (WWFD Engine 4) enabling that unit to recharge its previously deployed hand lines once the two supply lines from the hydrant were charged. WWFD personnel were also able to advance additional hand lines and initiate a master stream operation at the front of the structure utilizing Engine 4’s deck gun. When the WWFD Special Hazards unit arrived it was positioned at the northeast corner of the property facing south on Kulas Road directly behind WWFD Tower/Ladder 1 and raised the unit’s light mast to illuminate the scene. WWFD Engines 3 and 1 were not employed in the suppression operations but were positioned nearby on Cowesett Avenue across the street from the Inn. WFD Engine 1 laid-in, providing approximately 90 m (300 ft) of 4” supply line from a hydrant on the east side of Kulas Road above the fire ground. They positioned the apparatus facing down-grade (north) in the south bound lane of Kulas Road just above WWFD Tower/Ladder 1 and Special Hazards unit at the east side of the lot. The crew initiated a master stream operation with their deck gun from that position to attack the fire to the interior of the building near the main entrance area. WFD Ladder 1 was the last apparatus to be engaged in the suppression effort. It backed into the parking lot in front of the structure just to the west of the WWFD initial assignments (Engines 4 and 2). Although equipped with a 4” supply line, Ladder 1 did not have an on board pump capability and attempts to begin

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master stream operations were initially ineffective due to low water pressure. This operational challenge was overcome by re-routing the supply line to one of the WWFD’s engines which then provided the necessary water pressure to establish and maintain an effective master stream Figure 3-1 shows the layout of the fire ground during the fire attack and suppression activities. The initial attack was mounted by WWFD’s first unit, Engine 4, approximately 6 ½ minutes into the fire with the advance of a 1 ¾” line to the main entrance of the structure and the primary victim cache, and continued until the unit’s on board water supply was exhausted. While the two, 3” supply lines to the front of the structure were being laid and charged, rescue efforts continued along the building’s north face, through both the broken windows and exits. However, these efforts were pursued without the benefit of protective hose lines and were substantially hampered by the rapid fire propagation, radiant heat and heavy volumes of smoke discharge from the structure. Once the two 3” supply lines to Engine 4 were established approximately 10 minutes after their arrival, an apparatus mounted deck gun/master stream operation was initiated from WWFD’s Engine 2 and additional hand lines deployed at the front and to the west side of the structure. The frontal attack was almost immediately augmented with the arrival of WFD’s Engine 1, which had laid its own supply line. Once positioned, Engine 1 began a master stream operation from its deck gun on the east side of the structure and then extended hand lines down the grade to the east side front of the building. These attack lines were most effectively applied to suppress the multiple vehicle fires adjacent to the northeast corner of the structure. Less than 25 minutes into the incident, the structure was showing fire through the roof in the area of the main bar, which appeared to have substantially self-ventilated or partially collapsed. Shortly thereafter WFD’s Ladder 1 was backed into the west side of the parking lot. The unit was provided a 4” supply line from a hydrant located at 198 Narragansett Avenue by Cranston FD’s Engine 4. However, due to the extended length of the supply line and the hydrant pressure, this source was not sufficient to produce an effective flow. These efforts were suspended and the supply line was then repositioned to allow WWFD’s Engine 4 to initiate pumping operations in support of WFD Ladder 1’s elevated master stream operations. The major section of the main roof collapsed a little more than 45 minutes in to the fire, prompting the IC to initiate an accountability check of the suppression crews. The roll call produced no indication of missing personnel and suppression operations continued. The sunroom area at the front of the club included a window-wall approximately 9 m (29 ft) long just to the west of the main entrance facing the parking lot. The roofing and structural support for this element of the building’s façade collapsed a little more than an hour into the fire, which prompted the IC to initiate another personnel accountability check. After this second major element of the structure failed, little remained of the building except sections of the exterior walls at the front (primarily in the area of the main entrance which had been the focus of substantial suppression effort). The west and rear walls were heavily damaged, and elements of the nightclub’s storage area, food preparation and office areas to the southeast corner of the structure were

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(BC) (SH) (L) (E) West Warwick Fire Department (WWFD) Warwick Fire Department (WFD)

effectively destroyed although some components of interior compartment separations still remained standing at that end of the structure. The fire attack continued with the master stream operations knocking down the residual pockets of major fire in the remaining structure while hand lines were used to address areas that were difficult for the master streams to reach. With the structure now heavily damaged (essentially a total loss) and the fire effectively suppressed, the interior of the structure became accessible for the first time in the operation. No interior fire suppression attack had been possible at the outset of operations due to the untenable conditions and none was initiated until this final stage of the incident. Once able to get inside, suppression personnel checked the area for possible survivors, extinguished the last of the residual fires and wet down hot spots. At this point the fire suppression and rescue efforts were essentially terminated and operations at the building transitioned into a victim recovery and identification phase that continued until the last of the 96 fatality remains were removed from the structure and transported to the State Medical Examiner's facilities. The final body recovery efforts were completed by late afternoon on Friday, Feb. 21. No firefighter fatalities occurred during the extinguishment of this fire. Five firefighters were injured: one with a fractured ankle, and four with smoke inhalation, cuts and bruises. 3.3.4 The Water Supply The incident area had immediate access to a municipal hydrant system to support fire ground operations. Although positioned short distances away (see Figure 3-1), the incident site had expedient access to three hydrants, all of which were utilized. The first hydrant was located a few dozen meters northeast of the incident site on Cowesett Avenue near the corner of Coit Avenue and in front of the east side of the Cowesett Inn. That hydrant supported two, 3" supply lines to WWFD’s Engine 4 while that team attacked the fire from the front of the building in the parking lot a few meters west of the structure’s main entrance. The two other hydrants both provided 4" supply lines to the units they supported respectively. One, at the southeast corner of the site on the opposite side of the Kulas Road incline at about the crest of the grade, provided WFD Engine 1 supply for its master stream and hand line operations. The other was on the east side of Narragansett Avenue to the north and upgrade of the intersection with Cowesett Avenue some distance from the northwest corner of the site. That hydrant supported the master stream operations of WFD Ladder 1 positioned to the west of the two WWFD engines in the parking lot. The hydrants' proximity to the incident site’s northwest, northeast and southeast corners allowed apparatus to lay-in to the fire ground from all three directions. When supported by the pumping operations of the various engine assignments, the water system’s pressure and flow was sufficient to sustain the multiple master streams and the numerous hand lines utilized to extinguish the structure and the various vehicle fires. 3.4 MUTUAL AID Most emergency services providers, and fire departments in particular, develop and operate with the assistance of mutual aid compacts or agreements with neighboring departments to augment their capability to respond to incidents when their assets are committed or otherwise unable to satisfy the community’s emergency response requirements. Such compacts are typically designed to rapidly

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augment the department’s staffing or equipment during an emergency when needs exceed their capabilities. Mutual aid agreements vary widely in scope and content. Some agreements are designed to provide assets as specifically requested while others provide for the routine deployment of another department’s specialized assets such as hazardous materials units, advanced life support (ALS), bomb disposal units, water supply, aerial apparatus or other specialty units when an alarm is initially transmitted. In the latter situation, the mutual aid assets are in effect shared by signatories to the agreements, and are utilized independent of actual jurisdictional or organizational ownership. All agreements benefit the member agencies by providing emergency surge capabilities (staffing, equipment, etc.) from other agencies that would be prohibitively expensive to operate and maintain in each jurisdiction. While mutual aid arrangements have an obvious practical value, they also have limiting characteristics. Assets which are infrequently used by a department requesting the mutual aid from another may be in use by the department possessing the asset on a regular basis, and therefore unavailable when needed by others. In a wide scope event, there may be more departments in need of specific assets than are available within the member compact. Jurisdictional differences in equipment, tactics and communications systems may also present interoperability challenges to the effective use of mutual aid assets, as was the situation at this incident. Some agreements are relatively small in scope, limited for example, to nearby departments. Others may apply to all the departments in a county -- or as in the case with Rhode Island, cover a multi-state region. Most agreements center on strategic principles that assure that the specific mutual aid requested will normally come from the nearest jurisdiction with the assets available. Depending on the amount of aid needed (the number, magnitude and/or the diversity of the assets required) the aid is typically moved toward the incident in a fashion that first thins the assets of the area departments nearest the incident and then progressively back-fills or covers those departments providing the initial aid with units from departments further away, providing for successive concentric waves of resource augmentation. Mutual aid was provided to the West Warwick FD and the other fire departments throughout the state in conjunction with the Southern New England Fire Emergency Assistance Plan (SNEFEAP). The plan was designed to augment each department’s staffing and equipment capabilities through an anticipated incident severity progression of up to seven alarms beyond the initial assignments. This is designed to be achieved by providing both assets to the scene and back-fill /coverage for the departments providing emergency fire-EMS assistance to others. The mutual aid support provided to the respective major operational activities at The Station nightclub fire is summarized briefly in the following sections. These sections provide a general overview of the incident’s magnitude and complexity and are not intended to identify or chronicle all of the individual contributions that were made. 3.4.1 The Fire Suppression Operations The Station nightclub fire required only a relatively modest augmentation of the West Warwick Fire Department’s available suppression equipment resources to contain and extinguish. Beyond the WWFD’s response, this fire required only two additional apparatus from the Warwick Fire Department to augment the direct fire suppression operations at the scene (WFD Engine 1 and Ladder truck 1). The additional units from WFD that were utilized (one engine and one ladder truck) did not exceed WWFD’s equipment complement capabilities; WWFD’s own similar assets were deployed to the scene but were not utilized in the suppression effort.

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The initial WFD task force group dispatched had been supplemented with an additional engine company, rescue-ambulance and special hazards unit at the election of the responding department. Beyond WFD’s substantial response of equipment and personnel, Cranston FD and Coventry FD also provided numerous units and substantial staffing (including approximately 100 firefighters and command officers) to support on-scene operations and to cover WWFD’s stations and service area during the incident. During this stage of operations significant numbers of the officers and staff on the mutual aid units were also deployed to the scene but not involved in direct suppression support. These personnel were primarily employed to provide the critical on-site cadre necessary to effectively initiate and maintain the coordinated casualty collection, triage, pre-hospital victim care and survivor support operations. 3.4.2 The Mass Casualty Incident Operations In stark contrast to the suppression operation’s minimal equipment resource demand on the mutual aid system, the magnitude of the resulting EMS-fire casualty management operation drew upon substantial personnel and equipment resources from throughout in the state. The incident management also benefited from the mutual aid plan’s everyday use of fill-in/coverage assignments and direct incident support by and for the EMS units of various departments. This is done in essentially the same fashion as the deployment of the suppression units and other specialized assets. Initially, the incident site was strewn with numerous victims: many with obvious injuries were sitting on and in the surrounding cars, and some were on guard rails and snow banks, while others stood and milled about or lay on the ground. The immediate availability of shelter from the winter cold was afforded by the proximity of the Cowesett Inn just a few dozen meters across and down the street. Many of the uninjured survivors and walking-wounded migrated there spontaneously to flee the scene and seek/secure assistance. Given its on duty support staff, size, diverse facilities, configuration and cross-street location, the Inn readily became the primary triage and survivor assistance center at the scene. As this incident’s high casualty count became increasingly apparent, the mass casualty incident (MCI) operation began to unfold with dispatchers receiving multiple requests from the scene for “any available rescue” to respond. The casualty collection and care began with the first arriving rescue-ambulance units being besieged by those in need of care or requesting medical assistance for others. A number of these first-in units initially effectively served as field triage and care stations, transferring casualties to other units in and beyond the immediate fire ground congestion on Cowesett Avenue between The Station and the Cowesett Inn. Initial command of the EMS operations evolved quickly as personnel and equipment became available. As EMS units and company officers arrived they began organizing the chaotic scene. The triage and care efforts that were initially attended by the first arriving EMS providers wherever the units were positioned on-scene began to center on the Inn and its immediate area. For much of the incident’s duration, at least three distinct triage areas were operating simultaneously: one near The Station on Cowesett initiated by an officer and crew from Hopkins Hill FD from Coventry, one on the outside of the Inn at the front door established by a Cranston FD officer and crew, and another inside the Inn under the direction of a WFD officer. As additional chief officers and crews from Warwick, Cranston and Coventry fire departments began to arrive, the management of the EMS operations evolved significantly. The needs and activities of the respective triage sections were afforded greater command cognizance through the use of an EMS liaison to the IC, a role filled by the Coventry FD Chief.

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A Cranston FD deputy chief assumed the role of transportation coordinator and began staging units away from the immediate area of the Inn at a parking lot of a nearby restaurant. This action was initiated to reduce the congestion at the site and to better coordinate the loading and transfer of victims to regional hospitals. The effective coordination of both incoming unit staging and on-scene activities was significantly compromised due to non-interoperable radio equipment between command elements and responding units, as mentioned earlier [1]. The communications challenges also materially hampered direct coordination with regional hospitals. As a result, the transportation officer was, more often than not, unable to communicate directly with the hospitals to ascertain their status and capabilities -- and therefore unable to direct units to the most appropriate medical facilities. Less than two hours after the initial alarm, the MCI management effort had effectively organized multiple field triage and care locations as well as the in-door operations at the Cowesett Inn and the last of the casualties were transported. The wide scale ground transportation EMS evacuation of 186 casualties had been accomplished using nearly 40 fire department-based emergency medical services units, 20 private sector ambulances from a variety of commercial providers, and buses used to shelter and transport those with only minor injuries. More than 200 people may have been injured in the incident, most of whom were transported to medical facilities throughout the state by EMS providers and private vehicles. 3.4.3 The Law Enforcement Scene Security & Traffic Management Operations Beyond their immediate response and assistance at the scene, the West Warwick Police Department (WWPD), the Warwick Police Department, the Coventry Police Department and other local agencies including the Rhode Island State Police personnel played key roles in managing and supporting the incident security, access and traffic management efforts necessary to effectively access, stage, deploy and permit egress by the significant numbers of rescue/ambulances (about 60 units) and all the other fire apparatus and emergency services units that responded. Their collective efforts assured the volume of EMS units had effective access to the scene and its adjacent staging areas. They also assured that the traffic management effort provided for the safe exit of emergency vehicles once they were loaded with victims and enroute to area hospitals. 3.4.4 The Mass Fatality Recovery and Victim Identification Operations The impact and consequence of such a significant number of fire casualties (both injured and killed) extended beyond the fire service organizations involved to also challenge the area’s local law enforcement agencies, the State Police, the State Fire Marshal’s Office, the State Medical Examiner’s Office and other regulatory authorities. There were extraordinary informational, tactical and technical challenges requiring the coordination and contribution of virtually every agency involved. These included identifying uninjured survivors, those who had been EMS triaged and transported and to where, those who might still be missing, and those who were among the dead These operations generally required two concurrent efforts; one to physically recover and identify the remains on site, and the other -- accomplished off-site at facilities conducive to conducting confidential interviews -- was to collect victim identification profiles from friends and relatives of those still unaccounted for. The victim profiles included physical descriptions of the person such as sex, height, weight, hair and eye color etc., and any available information about what they had been wearing when last seen (such as clothing items and jewelry). This information was used to assist with subsequent identification efforts, including forensic examinations by the State Medical Examiner.

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Both of these activities were accomplished with a regard for the privacy and dignity of the victims and their survivors. During the recovery of the physical remains, efforts were made to avoid additional trauma to the deceased and to collect personal effects that might aid in the victim’s identification. These actions were accomplished while shielding the area from the view of bystanders. The collection of victim identification profiles was also handled discreetly, to the extent possible given the circumstances. Interviews were conducted in private and the information collected was treated as confidential. The victim identification processes, both investigatory and forensic, continued through the weekend and until the last fatality was positively identified on Tuesday evening, Feb. 25, 2003. Completion of the victim recovery and identification operation effectively brought a close to the response efforts, with the exception of the on-going fire investigation. 3.4.5 Post-fire Investigation Operations Major fires, especially those producing a significant number of injuries and/or fatalities, often involve concurrent investigations by various local and state law enforcement agencies and other regulatory authorities, as occurred in this case. By law, in most jurisdictions, fire losses in general -- and particularly those resulting in serious injuries and/or deaths -- are investigated to determine at the very least, the location of the origin of each fire and its cause (natural, accidental, criminal, etc.). Depending on a variety of other factors, they also may be the subject of other inquiries, reviews, or hearings by a range of regulatory/technical authorities. The sooner that relevant information regarding witnesses/persons involved and specific facts can be collected, the more effective the initial incident information management effort and subsequent investigations are likely to be. Law enforcement agencies typically play the key role in this aspect of overall incident management security and in supporting the public’s information needs. The RI State Fire Marshal was on the scene of this multiple fatality fire within an hour of the IC’s request for his assistance. Even though the origin and cause of this fire was known (actually captured on video- tape) the State Fire Marshal’s Office conducted an investigation to document the loss, and to determine the parties responsible for the catastrophic loss of life and injury. These efforts were conducted in conjunction with local authorities, primarily WWPD and WPD although other authorities (including the RI State Police) participated substantially. Owing to the magnitude of the incident, the State Attorney General’s Office oversaw and directed various aspects of the inquiry. The Warwick PD also played a key role by establishing and staffing an office dedicated to assembling investigative reports and related information. Post-incident investigation is part of the emergency response function. The subsequent investigative efforts are normally necessary to determine the origin and cause of the fire and to ascertain if the circumstances of the incident warrant the filing of criminal charges, the issuance of notice of regulatory violations, and legal actions (such as condemnation orders) to protect the public safety and to enforce laws and regulations. This typically involves local and state agencies working in collaboration with each other, as was the case in the investigation of The Station nightclub fire. A number of Federal agencies responded after the fact to The Station nightclub fire. At the request of the State's Attorney General, the Bureau of Alcohol, Tobacco, and Firearms (ATF) provided direct technical assistance to the AG's investigation. The U.S. Occupational Safety and Health Administration conducted its own investigation due to its jurisdiction over worker safety and health [3]. The Office of Domestic Preparedness in the Department of Homeland Security was interested in how the community responded to

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this mass casualty event [1]. The National Institute of Occupational Safety and Health was not involved because there were no firefighter deaths. 3.5 OBSERVATIONS The use of standard Incident Command structures and practices facilitated the concurrent fire suppression and mass casualty incident management operations. The early involvement of the EMS teams within the overall IC effort allowed the chief officers directing the EMS operation to focus on their casualty care and management challenges and to enable the fire suppression command forces to direct victim rescue and extinguishment efforts. As is common in wide-area mutual aid responses, various responding agencies/units were unable to establish or maintain effective voice communications with IC. The Incident Commander’s ability to effectively apply the available resources is critically dependent upon wireless voice communications with the responding units. The need for effective communication systems and equipment (e.g., interoperable with multiple common channels and the ability to handle a large amount of traffic) at large-scale events cannot be overstated. The arrival time of WWFD's first due units (Engine 4 & Ladder 1) of the initial response assignment was within the four minute objective specified in NFPA Standard 1710 [5]. The model standard further suggests that the remainder of the first full alarm assignment should arrive within eight minutes. The achievement of the latter objective could not be confirmed from the information available to this investigation. WWFD's fire apparatus staffing of the first full alarm assignment was half of the firefighter staffing recommended by NFPA Standard 1710, which suggests a minimum of four personnel on both engine and truck companies. Had WWFD apparatus staffing been consistent with the model standard at least ten additional firefighters would have been available to more expeditiously establish water supply to the suppression units, establish master stream operations from the first arriving ladder/truck company, and support victim rescue and casualty care operations.

1. 6

REFERENCES FOR CHAPTER 3 [1] "Rhode Island -- The Station Club Fire After-Action Report," Office of Domestic Preparedness, Department of Homeland Security, October 2004. [2] Crowley, C.F., The Station Nightclub Disaster - A survivor's story: Saved by a pileup; Providence Journal. Providence, R.I.: Mar 10, 2003. pg. A.01 [3] Occupational Safety and Health Administration Citation and Notification of Penalty, dated August 19, 2003 based on inspection # 304991086. [4] NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, National Fire Protection Association, Quincy, MA, 2002. [5] NFPA 1710, Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments, National Fire Protection Association, Quincy, MA, 2001.

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Chapter 4 MATERIALS TESTING AND SUPPORTING EXPERIMENTS 4.1 INTRODUCTION Combustible interior finishes, scenery, or decorations have played an unfortunate but significant role in fires that have occurred in places of assembly over the last 100 years. Often resulting in hundreds of fatalities, examples of these fires include the Iroquois Theatre (602 died, Chicago, IL, 1903), the Rhythm Club (207 fatalities, Natchez MS, 1940), and the Cocoanut Grove (492 died, Boston, MA, 1942) [1]. In each of these incidents, fire-related material properties, including ignitability, heat release rate, and rapid flame spread contributed significantly to fire growth that resulted in a tragic loss of life. In an effort to minimize the repetition of this type of fire, standard test methods for assessing the rate of flame spread, heat release rate, and ignitibility have been developed. Standard tests can generate critical fire-related material property data that can be a valuable resource for fire protection engineers, code officials, and code enforcement personnel. In the U.S., flammability and fire spread properties of materials are often evaluated using UL 94 –Standard for Tests for Flammability of Plastic Materials for Parts in Devices and Appliances [2] and ASTM E-84 – Standard Test Method for Surface Burning Characteristics of Building Materials [3]. The heat release rate properties of materials can be assessed using ASTM E-1354 – Standard Test Method for Heat and Visible Smoke Release Rates for Materials and Products Using an Oxygen Consumption Calorimeter [4]. Both the spontaneous ignition temperature (SIT) and flash ignition temperature (FIT) for plastics can be determined using ASTM D 1929 - Standard Test Method for Determining Ignition Temperatures of Plastics [5]. Standard tests have a limited ability to predict performance in real fire scenarios and no single standard tests should be used as the sole criterion to assess the total fire hazard. Under carefully controlled laboratory conditions, standard tests do allow comparisons such as, Will material “A” ignite more quickly than material “B”? or, Will material “A” contribute to more rapid flame spread than material “B”? Standard tests do allow the performance of different materials to be rated or compared, but the relationship between standard test performance and actual fire performance can be much more complicated. For example, while a standard test may provide a comparative measure of flame spread, it is difficult for the same standard test to predict the overall fire hazard because the standard test does not incorporate or measure important fire behavior properties including melting, ease of ignition, heat release rate, and products of combustion. Additional properties need to be included for a complete fire-hazard or fire-risk assessment of the materials or assemblies under fire actual conditions. 4.1.1 Standard Tests for Flammability and Fire Spread – UL 94 and E-84 UL 94 includes six different tests to compare the relative burning characteristics of different materials, or assessing any change in the burning characteristics prior to, or during, use. These tests include (1) Horizontal Burning Test –HB, (2) 20 mm Vertical Burning Test – V-0, V-1, or V-2, (3) 125 mm Vertical Burning Test – 5VA or 5VB, (4) Radiant Panel Flames Spread Test, (5) Thin Material Vertical Burning Test – VTM-0, VTM-1, or VTM-2, and (6) Horizontal Burning Foamed Material Test – HBF, HF-1, or HF-2. These test methods typically involve exposing small samples (less than 500 mm x 150 mm) to a flame or radiant panel for a specified period of time, then removing the heat source, and observing whether the sample continues to flame or glow. A burning rate with units of mm/min can be calculated

4-1

from the time required by the flame to burn a specific distance. Each test method includes criteria for classifying or rating the performance of each material. For example, an HF-1 rating could be achieved by a 150 mm x 40 mm sample of polyurethane foam if after exposure to a small flame source for 60 s (a) no more than four of five samples continued to flame for more than 2 s after the flame was removed and no more than one sample continued to flame for more than 10 s, (b) the foam did not continue to glow for more than 30 s after the flame was removed, and (c) the cotton indicator that was positioned below the test sample was not ignited by flaming particles or drops. While UL 94 does utilize both horizontal and vertical sample orientations, the impact of corner geometry, ventilation effects, and prolonged exposure to high thermal flux are not included in the test conditions. Ignition temperature, mass loss rate, and heat release rate data are also not recorded. The E-84 test method was developed with the anticipation that a large test would provide a more realistic environment for surface burning behavior of building materials. E-84 involves a much larger test specimen than UL 94, up to 0.610 m x 7.3 m, which is mounted on the ceiling of a 0.45 m wide x 0.32 m high x 7.6 m long “tunnel” apparatus. A natural gas fired burner, 88 kW, is positioned at one end of the test sample and the flames from the burner impinge on an approximately 3.25 m2 area of the sample. The specimen is exposed to the flames and hot gases of the burner for a 10 minute test period. The hot gases and combustion products flow along the unburned portion of the sample and are exhausted at the other end of the apparatus. The extension of the visible flames is recorded as a function of time and is used to determine a flame spread index, which is based upon the extent of burning that occurs with a red oak plank. Red oak is assigned a value of 100, and the flame spread index of other materials are normalized accordingly. For example, Douglas fir plywood, fire retardant treated Douglas fire plywood, and type X gypsum board are 91, 17, and 9, respectively. Loose-fill insulation, plastics, and wall coverings can be tested by using different sample mountings and support screens. The large specimen does allow for the development of physical and structural failure modes, such as cracking and buckling, which may not occur on smaller specimens. The openness of the tunnel design does allow for testing of composite assemblies, panels, and boards. Although plastics can be tested in the apparatus, thermoplastic materials can drip or fall to the floor of the apparatus and result in low values for flame spread index that do not relate to their true fire hazard potential. The test configuration is limited to a horizontal ceiling orientation. Vertical or corner configurations, different flame exposure periods, and different heat fluxes are not included in the test method. 4.1.2 Standard Tests for Heat Release Rate Properties of Materials – E-1354 The E-1354 test method utilizes a cone calorimeter to collect data on heat release rate, mass loss rate, optical density of smoke, and gas concentrations in combustion products. The cone calorimeter exposes relatively small samples (10 cm x 10 cm) to a uniform thermal flux. The thermal flux can be varied from 5 kW/m2 to 100 kW/m2 in either a horizontal or vertical sample orientation. An electric spark is used to ignite the combustible gases near the surface of the sample. The sample is positioned on a load cell to track mass loss rate throughout the burn. Additional instruments allow the optical density of the smoke and gas concentrations to be monitored continuously. While the cone calorimeter can provide heat release rate as a function of thermal flux, the impact of ventilation, corner geometries, and composite assemblies are difficult to characterize.

4-2

1. 1.3

Standard Test for Determining Ignition Temperature of Plastics – D 1929 The D-1929 test method utilizes a hot air furnace to determine the ignition temperatures for small samples of plastic materials. A specimen of a material, in pellet, powder, sheet, or foam form, and up to 3 g in mass or 20 mm x 20 mm x 50 mm in size is inserted into a pre-heated tube furnace. Air flows from the bottom up and out through the top of the vertically oriented tube at a velocity of 25 mm/s. After insertion, the sample remains inside the furnace for up to 10 minutes. At the end of 10 minutes, depending on whether ignition has or has not occurred, the temperature of the furnace is lowered or raised and repeated at the new temperature with a new specimen. The lowest air temperature at which ignition occurred is recorded as the ignition temperature. The Flash Ignition Temperature determination uses a pilot flame at the top of the furnace while the Spontaneous Ignition Temperature determination does not utilize a pilot flame. This test method is limited to a temperature of 400 oC, which is much lower than typical gas temperatures in the upper layer of a room fire (600 oC). The exposure time is limited to 10 minutes and the air flow is limited to a single velocity. 4.2 MATERIAL PROPERTIES FOR FIRE MODELS Computational fire models incorporate specific material properties in order to calculate fire development and growth for a given fire incident. These material properties, such as thermal conductivity, heat capacity, density, and heat of combustion are utilized by the model to predict if and when a component will ignite and how much energy or heat will be released as the component burns. The ignition and subsequent release of energy causes the fire to grow and spread throughout a structure. For common building materials including gypsum or pine paneling, these materials can be found in various handbooks [6,7,8] or in the combustion/fire literature 9,10,11. For less common building materials, such as flexible polyurethane foam, one can estimate a set of thermal properties from similar materials or one can characterize the properties by conducting tests on representative samples of the material. Since the quality of the model predictions is directly related to how accurately the material properties have been characterized, testing representative material samples provides more accurate properties. The properties in Table 4-1 were either measured in this investigation or taken from the literature. The type and composition of the materials that were identified as being present inside the nightclub were characterized generically as flexible polyurethane foam, ceiling tiles, wood paneling, carpet, and an industrial pyrotechnic device. This materials testing conducted by NIST and described in this chapter did not include any materials actually recovered from the nightclub. NIST was not able to determine whether the foam in the nightclub was (a) fire retardant, (b) non-fire retardant, or (c) a combination of fire retardant and non-fire retardant foams. Four test series were conducted and are described in this chapter or the appendices: 1) properties of polyurethane foam; 2) cone calorimeter heat release measurements of several polyurethane foams, plywood, carpet, and ceiling tile; 3) heat flux and temperature measurements of pyrotechnic devices impinging on surfaces; and 4) fire growth measurements in real-scale mockups of the platform, main floor, and alcove. Data from each of these test series provided insight into the material properties, fire spread, heat flux, and fire growth of the different materials. The properties of the polyurethane foam that were measured

4-3

included the density, ignition temperature, and heat of vaporization, all of which are required to accurately simulate fire spread. The cone calorimeter measurements established an appropriate range of heat release rates for those materials tested. (Note that both fire retardant and non-fire retardant foams ignited and burned when exposed to an external thermal flux in the cone calorimeter.) The experiments that involved discharging pyrotechnic devices against a foam-covered wall verified that non-fire retarded polyurethane foam could be ignited by a shower of sparks. (The fire retardant foam did not ignite in a similar test.) The real-scale mockups of the platform, main floor, and alcove provided data to evaluate the performance of the computer fire model. The information from all four test series led to an improved set of input data for the combustion model used in predicting the behavior of the fire (presented in Chapter 5), and allowed a better understanding of the parameters that affected the performance of the computer simulation of the entire nightclub. Table 4.1 Material Properties of Common Building Materials and Selected Plastics [4,5,6]

Material

Thermal conductivity W/m-oC

Density kg/m3

Heat capacity kJ/kg-oC

Heat of combustion MJ/kg Piloted ignition heat flux limit, kW/m2

Ignition temperature oC Heat of vapor- ization kJ/kg

Flame spread indexa Douglas Fir 0.11 420 2.72

70-100 Fiber Insulating Board 0.048 240

Fiber Board Medium Density

749

7 - 12 12 - 13

167

Gypsum 0.48 1440 0.84 3

10-15 Hardboard

27

< 200 Pine white yellow

1. 112
2. 147

430 640

1. 8

72-215 130-195 Plywood Panelling

29

< 200 Polystyrene Foam

1. 9

17 - 21 36 - 41

Polyurethane Foamb 0.034 22b 1.4 21 - 28b

370b 1000 - 1600b

a based upon ASTM E84 [3] b data from NIST investigation 4.3 POLYURETHANE FOAM 4.3.1 Background Polyurethane refers to a large category of materials including surface coatings, elastomers, and foams, rigid or flexible, and thermoplastic or thermosetting [12,13]. While large quantities of polyurethanes are used to manufacture adhesives and protective coatings, the foam type of polyurethane is widely used in

4-4

the production of upholstered furniture, bedding, sponges, toys, wearing apparel, and medical dressings. Rigid urethane foams are used for insulation in building constructions. Flexible polyurethane foams are used in packaging materials and acoustical insulation panels. The urethane linkage, which all polyurethanes have in common, involves the reaction of an isocyanate group with a hydroxyl-containing group. Common hydroxyl-bearing groups include polyether alcohols, polyester alcohols, carboxylic acids, and amines. If the hydroxyl-bearing group incorporates multiple ether groups, then the resulting polyurethane will have a number of ether linkages and is typically referred to as a polyether polyurethane. If the hydroxyl-bearing group incorporates multiple ester groups, then the resulting polyurethane will have a number of ester linkages and is termed as a polyester polyurethane foam. A more detailed description of urethane formation chemistry is in Appendix H. Both polyether and polyester formulations of polyurethane can be used as packaging materials. The polyurethane foam which is offered for packaging typically does not include any fire retardant additives or incorporate any fire retardant compounds into the urethane structure. As a packaging material, the polyurethane foam (ether and ester) is commercially available in a range of sizes including 1.22 m (4 ft) x 2.44 m (8 ft) sheets. The gray colored foam can be obtained in several geometries including solid blocks, uniform thickness sheets, and convoluted or “egg-crate” sheets. 4.3.2 Locations in Nightclub In The Station nightclub, polyurethane foam had been installed on the rear wall, platform wall, and in the alcove as a sound attenuation material (Figure 4.1). The foam was installed on the vertical surface of the platform wall from the raised floor of the platform to the raised ceiling. The ceiling over the dance floor, raised platform, and area between the dance floor and the sun room had been raised to 3.8 m (above the dance floor). The raised ceiling was fabricated out of gypsum board and a light rack had been suspended approximately 12 cm below the gypsum board. The vertical surface on the east side (side nearest kitchen) was also faced with gypsum board. The vertical surface on the north side (side nearest the sun room) was covered with wood paneling. The rear wall featured a vertical section and a sloped section. The vertical wall formed the rear wall of the nightclub and was vertical for approximately the first 2.5 m above the dance floor. At 2.5 m above the dance floor, the “ceiling” sloped and followed the angle of the roof. The sloped ceiling extended from the rear wall over the raised dining area to the raised gypsum ceiling. Wood paneling covered the lower portion, 0.8 m high, of the rear wall. The upper portion of the vertical wall and the sloped ceiling were covered with foam. A roll of gray convoluted foam was recovered by other investigators from the basement of the burned out nightclub one day after the fire and turned over to the West Warwick Police Department as evidence. That foam did not appear to have been painted or to have been mounted on any surface. Samples from this recovered foam were tested, upon the request of the state of Rhode Island, by the Bureau of Alcohol, Tobacco, and Firearms (ATF) in a cone calorimeter at the ATF Fire Laboratory in Maryland [24]. NIST had no access to the material examined by the ATF Fire Laboratory, and was not able to conduct a chemical analysis to determine if the foam contained fire retardants. (Note: The ignition behavior of the NIST non-fire retardant foam, described in Section 4.5.2, was consistent with the behavior exhibited by the foam on the walls of the nightclub as documented by the WPRI-TV video.) Photographs of the nightclub interior do not clearly demonstrate whether staples, nails, organic adhesive, or some combination of all three were used to mount the foam on the wall. The foam appeared to have been mounted over the top of the previous wall material, which, depending on the location was either wood paneling or gypsum board. In some areas, portions of the alcove in particular, the foam was

4-5

installed over rigid polystyrene foam thermal insulation laid between the wood studs. The foam was installed in either full 1.22 m x 2.44 m sheets or was trimmed to fit the geometry. The photographs of the nightclub interior do clearly show gaps where two sheets of foam meet. Gaps between the foam and the wall can also be observed at various locations, typically at external corners of the alcove. While the gray color of the foam can be observed in some photos of various bands that had performed at The Station, later photos show a darker color, indicating that the foam may have been sprayed with a black paint. The surface of the foam also had a glittery appearance that may have been a result of the wet paint being dusted with glitter or sparkle dust. Some of the glitter would have become partially embedded in the wet paint and would have provided the more sparkling appearance that was observed in some of the video of the nightclub interior. PLATFORM

Figure 4-1. Portion of Nightclub with Polyurethane Foam Mounted on Wall (shaded red section). 4.3.3 NIST Foam Samples After experiencing some difficulty, NIST was able to locate a source of non-fire retardant polyether polyurethane foam. Recent consolidations within the polyurethane foam manufacturing industry appear to have reduced the range of polyurethane foam products available to the public. The non-fire retardant polyurethane foam (ether) was purchased in two lots from a single distributor. Unfortunately, the distributor was not able to identify the manufacturer of the foam. Foam distributors typically purchase foam from a number of different sources based on price and availability. Foam arrives at distributor’s

4-6

warehouse in tractor-trailer sized lots. While bulk shipment may contain source information, stock is broken down into smaller units and source information is typically not maintained on each individual piece of foam. When foam arrives at a warehouse, new stock is intermingled with old stock. The foam was purchased in two lots as 1.22 m x 2.44 m sheets (flat or in rolls). The rear surface of each sheet was flat. The front side was convoluted, with a series of peaks and depressions that resembled the surface of a continuous egg crate. Lot A was nominally 40 mm thick measured from the back to the peak; lot B was nominally 30 mm thick. Peak-to-peak spacing, and valley to sheet back dimensions are described in Appendix D. NIST also purchased a number of 1.22 m (4 ft) x 2.44 m (8 ft) sheets of fire retardant polyester polyurethane foam from a commercial supplier in single lot. It is possible that the distributor had intermingled foam from different sources within a single purchase. Unfortunately, as with the purchase of the non-retardant polyether foam, the distributor was not able to identify the manufacturer of the foam for the same reasons. The fire retardant foam was measured at 0.03 m (1.5 in) and 0.010 m (0.4 in) at its thickest and thinnest dimensions, respectively (See Appendix D). 4.3.4 Heat of Vaporization and Ignition Temperature of Non-flame retarded Polyurethane Foam Polyurethane foams can be produced in numerous ways with different properties, and because the behavior of the polyurethane foam in the fire was critical to the incident, measurements were made on the NIST-purchased materials to confirm literature values, fill gaps in the data, or narrow uncertainties. The heat of vaporization is a measure of the amount of energy that is necessary to convert a material from a condensed to a vapor phase. Differential scanning calorimeter(DSC) and thermal gravimetric analysis (TGA) techniques were used by NIST to calculate the heat of vaporization for samples of non-fire retarded, flexible polyether polyurethane foam (lot B). These instruments yielded a range of heats of vaporization between 1000 and 1600 kJ/kg. The ignition temperature was determined by Southwest Research Institute using ASTM D 1929. As described in Appendix D, the piloted ignition temperature of non-fire retarded flexible polyurethane foam (lot B) was found to be 370 oC +/- 5 oC. 4.3.5 Heat Release Rate of Polyurethane Foams The cone calorimeter was used to determine the heat release rate of the NIST-purchased polyurethane foams. The test protocol detailed in ASTM E 1354 [14] was used for these experiments. Samples which measured 0.1 m x 0.1 m were cut from the larger sheets. These samples were then stored in a controlled humidity (50 % relative humidity) and temperature (23 oC) room for at least two weeks. Then each sample was wrapped in an aluminum foil, except for the exposed side, and positioned in the cone calorimeter. A test plus two replicates of each sample (total of three tests) were conducted with an external heat flux from 20 kW/m2 to 70 kW/m2. In all tests, the convoluted side was exposed to the thermal flux. Data from these tests (23 in all) are tabulated in Table 4-2. (Additional data and plots of the heat release rate for each sample versus time are in Appendix D.) Focusing on the last column of the table, one can see that the non-flame retarded NIST samples have a peak heat release rate of around 600 kW/m2 when exposed to an incident radiant flux of 35 kW/m2. This compares to a peak heat release rate of 453 kW/m2 for the flame retarded NIST sample at the same external flux, and less than 300 kW/m2 for the sample

4-7

tested by ATF. A plot of the peak heat release rate as a function of incident radiation is shown in Fig. 4- 2a, comparing the NIST results to the ATF measurements. As expected, the peak heat release rate increases about linearly with imposed heat flux. The time to sustained ignition is another measure of the fire hazard posed by a material. The times to ignition are shown in the third column in Table 4.2. Both lots A and B of the NIST non-fire retarded polyurethane foam needed 6 to 7 seconds for sustained ignition when exposed to 35 kW/m2 of radiant heat. The fire retarded NIST sample resisted ignition for 13 seconds, and the ATF sample ignited in 3 seconds at a slightly higher irradiance level (40 kW/m2). Figure 4-2b is a plot of the time to ignition (expressed as 1/t1/2) as a function of incident flux, comparing the NIST non-fire retarded polyurethane (lot B) to the cone calorimeter measurements made by ATF on their foam [24]. Table 4.2 Peak HRR, time to sustained Ignition, and time to Peak HRR

polyurethane foam sample ID

Time to Sustained Ignition, Average,* Time to Peak Heat Release, Average,* Peak Heat Release Rate, Average,* External Radiant Flux, kW/m2 seconds kW/m2

seconds NIST PUF-FR 35 13 36 453 PUF-NFR-A 35 7 30 605 20 14 45 450 35 6 30 586 40 4 29 820 60 3 24 1154 PUF-NFR-B

70 3 21 970 ATF [24] Polyether PUF 20 9 37 260 Polyether PUF 40 3 31 297 Polyether PUF 60 1 26 415

• Average values include all individual test runs at each specific external thermal flux. Data from

individual test runs are provided in Appendix A.

The time to ignition in the cone calorimeter is governed by the ignition temperature, the imposed radiant flux, and the effective thermal inertia, kρc, of the material, where k is the thermal conductivity, ρ is the density, and c is the specific heat averaged over the heating period. As explained in Appendix E, the time to ignition is inversely related to the square of the imposed radiant flux and directly related to the effective thermal inertia. From the measured ignition temperature# and ignition delay at 35 kW/m2, kρc is estimated to be about 0.075 (kW/m2-oC)2-s for the NIST (lot B) non-fire retarded polyurethane foam.

Measured here using ASTM D 1929. The ignition temperature can also be inferred from the limiting heat flux necessary for

piloted ignition in the cone calorimeter.

4-8

0 200 400 600 800 1000 1200 1400 0 20 40 60 80 100 NIST PUF-NFR ATF PUF-NFR Linear Fit y = 199 + 13x R= 0.90 Linear Fit y = 169 + 3.9x R= 0.96 Peak Heat Release Rate, kW/m2 External Heat Flux, kW/m2

Figure 4-2a. Peak heat release rate versus external heat flux for different polyurethane foams tested at NIST and ATF.

0 0.5 1 1.5 0 20 40 60 80 100 NIST PUF-NFR ATF PUF-NFR Linear Fit y = 0.192 + 0.0059x R= 0.91 Linear Fit y = 0.062 + 0.0135x R= 0.99 t ig -1/2, s -1/2 Radiant Heat Flux, kW/m2

Figure 4-2b. Time to sustained ignition versus external heat flux for different polyurethane foams tested at NIST and ATF.

4-9

The precise reasons why the polyether foam tested by ATF differed from the behavior of the foams tested by NIST are not clear. (NIST did not have access to the foam from the fire scene tested by ATF.) However, the shorter time necessary for ignition of the ATF foam suggests that the effective value of kρc was less. It is possible that the behaviors were influenced by the different molecular structure, additives, or manufacturing processes. It is also not clear under what conditions the foam had been stored in the basement of the nightclub or whether it had always been stored in the basement, nor what impact aging or water from fire fighting operations may have had on the foam. Using the properties of either foam, the fire is predicted to spread rapidly, with the foam acting as an ignition source for the wood layer underneath. The contribution from the foam to the total heat release in the fire was much less than from the wood, once the wood was ignited by the burning foam. 4.4 CONE CALORIMETER MEASUREMENTS OF FINISH MATERIALS Cone calorimeter experiments were conducted on four other common finish materials similar to those in the nightclub. Two external heat fluxes were examined to account for the changing conditions experienced by the materials in the actual fire. All of the cone calorimeter tests conducted on the materials representative of those in the nightclub (polyurethane foams, wood paneling, carpet flooring, and ceiling tiles) and the external fluxes that were imposed on the samples are summarized in Table 4.3. The complete data set (time to ignition, peak heat release rate, time to peak heat release rate, total heat release rate, specimen total mass loss, average mass loss rate, average effective heat of combustion, average smoke extinction area, average carbon dioxide yield, and average carbon monoxide yield) can be found in Appendix D for each of the 38 tests. Table 4.3 Cone Calorimeter Tests

External Flux Sample

kW/m2 Material Number Test ID Manufacturer Poly(ether) Polyurethane Foam, gray,

convoluted, non-fire retardant 35 3 PUF-NFR-A A Poly(ether) Polyurethane Foam, gray, 20, 35, 40,

convoluted, non-fire retardant 60, and 70 20 PUF-NFR-B B Poly(ester) Polyurethane Foam, gray,

convoluted, fire retardant 35 3 PUF-FR C Wood Paneling, 5 mm thick,

plywood substrate, birch finish 35 and 70 6 WP D

Carpet Flooring, 6.2 mm thick, polyester short nap, 100% filament olefin, ave. tufted face wt 39 oz, twist tough bind 14.00, beige color

35 and 70

6

CF E Ceiling Tile type 942B

610 mm x 1219 mm x 16 mm 35 and 70 6 CT (24 in x 48 in x 0.62 in) F

4-10

PLATFORM

1. 4.1

Acoustical Ceiling Tiles A suspended or dropped ceiling had been installed in the nightclub except for in the sunroom, the platform area, and the dance floor areas (Figure 4-3). Each 0.61 m (2 ft) x 1.22 m (4 ft) x .016 m (0.625 in) panel had been installed or dropped into a metal grid support system. Photographs of the nightclub interior clearly demonstrate that the ceiling tiles had been painted black. It was not clear from the photographs whether the paint had been applied by brush, roller, or spray can. The surface of the tiles also had a glittery appearance that may have been a result of the wet paint being dusted with glitter. Figure 4-3. Portion of Nightclub with Acoustical Tile Ceiling (shaded blue section). Labeling found on a surviving acoustical tile indicated that that the tile was a mineral fiber type of material, a 942 (residential coding) or 755 (commercial coding). Samples of 942B acoustical tiles were purchased from a local supplier for these cone calorimeter tests. The front side of each panel (see Appendix D) exhibited a factory-applied coat of white vinyl-latex paint while the rear side of each panel was unpainted. Samples that measured 0.1 m x 0.1 m were cut from the larger panels. These samples were then stored in a controlled humidity (50 % relative humidity) and temperature (23 oC) room for at least two weeks. Then each sample was wrapped in an aluminum foil, except for the exposed side, and positioned in the cone calorimeter. In all tests, the painted side was exposed to the thermal flux. When exposed to 35 kW/m2 of external heat flux, the ceiling tiles did not ignite. Ignition and peak heat release rate values (average) are tabulated in Table 4.4. Each test was terminated after 3 minutes of exposure when none of the three samples ignited. As the thermal flux was increased to 70 kW/m2,

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ignition did occur and the samples reached their peak heat release rate in approximately 20 seconds. The ceiling tiles demonstrated an average peak heat release rate of 57 kW/m2. Individual test data and plots of the heat release rate for each sample versus time are in Appendix D. Table 4.4 Cone Calorimeter Results for Ceiling Tile, Wood Panels, & Carpet Flooring

Sample ID External Thermal Flux, kW/m2 Time to Sustained Ignition, seconds Time to Peak Heat Release Rate, seconds

Peak Heat Release Rate kW/m2 35 Did not ignite Ceiling Tile (CT) 70 8 20 57

35 41 129 437 Wood Paneling (WP) 70 15 85 526

35 54 192 627 Carpet Flooring (CF) 70 20 78 1371 4.4.2 Wood Paneling Wood paneling had been installed in the nightclub around the platform area, around the sunroom, back bar area, and entry way (Figure 4-4). Interior photographs of the nightclub did not provide sufficient information to identify the specific brand or type of paneling. A veneer type paneling which utilizes a plywood substrate was selected as being representative of the fuel load contributed by the paneling. The wood paneling was purchased from a local retailer in 1.22 m (4 ft) x 2.44 m (8 ft) sheets. The 0.0003 m (0.0125 in) birch veneer was laminated to a 0.006 m (0.25 in) thick three-ply Luan mahogany backer layer. The front side of each panel (Appendix D) had a glossy coat of finish while the rear side of each panel was unfinished plywood. Samples that measured 0.1 m x 0.1 m were cut from the larger panels. These samples were then stored in a controlled humidity (50 % relative humidity) and temperature (23 oC) room for at least two weeks. Then, each sample was wrapped in an aluminum foil, except for the exposed side, and positioned in the cone calorimeter. In all tests, the veneer side was exposed to the thermal flux. When irradiated with 35 kW/m2 of external heat, the wood paneling reached its average peak heat release rate, 440 kW/m2 , in approximately 130 seconds. At the lower thermal flux, each sample required about 40 seconds to achieve sustained ignition. At the higher flux, 70 kW/m2, the wood panel samples required much less time to sustain ignition, resulted in a higher average peak heat release rate of 530 kW/m2, and required substantially less time, 85 seconds, to achieve the peak value. Individual test data and plots of the heat release rate for each sample versus time are in Appendix D. The heat release curves exhibited a two peak shape, with the second peak much greater than the first peak. Each wood panel sample charred significantly as it burned, and the char represented a greater fraction of the total available fuel than that which was burned early in the test. In the higher thermal flux exposure, the additional flux caused more of the fuel to be burned early in the test, so the two peaks were closer in value.

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Figure 4- 4. Portion of Nightclub with Wood Paneling (brown shaded sections).

1. 4.3

Carpet Flooring Carpet flooring had been installed in the nightclub on the elevated section along the rear wall and around the platform area. (Figure 4-5). Interior photographs of the nightclub did not provide sufficient information to identify the specific brand or type of carpeting. A closed-loop olefin carpet with a binding layer was selected as representing the fuel load contributed by the carpeting. The carpet was purchased from a local supplier in a 3.2 m (12 ft) wide x 15.7 m (50 ft) long continuous roll. The 0.006 m (0.25 in) nylon pile was embedded in a 0.002 m (0.1 in) thick binding layer. Samples that measured 0.1 m x 0.1 m were cut from the roll. These samples were then stored in a controlled humidity (50 % relative humidity) and temperature (23 oC) room for at least two weeks. Then each sample was wrapped in an aluminum foil, except for the exposed side, and positioned in the cone calorimeter. In all tests, the olefin pile side was exposed to the thermal flux. When exposed to 35 kW/m2 of external heat flux, the average peak heat release rate for the three carpet samples was 627 kW/m2. The carpet required about 54 seconds, on average, to achieve sustained ignition, and approximately 190 seconds to reach its peak heat release rate (Table 4.4). hen exposed to the higher external heat flux of 70 kW/m2, the carpeting reached its peak heat release rate in about half the time. Peak heat release rates for all three carpet samples averaged 1370 kW/m2. Individual test data and plots of the heat release rate for each sample versus time are in Appendix D.

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Figure 4-5. Portion of Nightclub with Carpeting. For the lower flux exposure, the heat release curve exhibited a relatively brief step at around 200 kW/m2 and then increased gradually to a single broad peak. As the carpet initially began to burn, some of the energy released was conducted into the olefin pile, but instead of producing a char, the polymer melted and formed a more uniform density fuel. As the burning continued, it increased at a relatively steady rate, reached its peak and decreased at a more rapid rate. At the higher flux exposure, the additional energy from the internal heating caused the melting to occur more rapidly, so the initial step seen at the lower flux was not observed. 4.4.4 Fuel Load Properties – I gnitability, Mass, and Location The contribution of assorted fuels to fire spread and total heat release rate can be very different. The cone calorimeter test data demonstrated that the polyurethane foam, both the fire retardant and non-fire retardant formulations, could ignite in less than 15 seconds of exposure to 20 kW/m2 of external heat flux. Once ignited, the polyurethane foam reached peak heat release rates ranging from 450 kW/m2 to1150 kW/m2 in less than 60 seconds. Both the wood paneling and carpet flooring required from 80 seconds to 200 seconds to reach peak heat release values which ranged from 440 kW/m2 to 1370 kW/m2. The polyurethane foam was a low density material and was quick to ignite, but the mass of the foam was consumed in a relatively short period of time. The foam would have contributed to a quick initial fire growth, but typically would not have had sufficient mass to carry the fire past the initial stages. Wood and the carpet flooring had greater mass and were a larger source of energy than the foam, although the wood and carpet required longer times to ignite. Once ignited, both the wood and carpet would provide a

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substantial amount of the energy released during a fire. The ceiling tiles would have released relatively little energy compared to the other fuel components. The contribution of a specific fuel is dependent on the relative amounts of the fuel and how quickly the fuel becomes involved in the fire. Wood is often found in flooring, wall paneling, and structural members such as studs, joists and rafters. Carpeting is typically used only as a floor covering. In a wood frame structure, the wood component of the fuel load may provide the bulk of the energy released. The location of the fuel can also impact when and how rapidly a specific fuel becomes a contributor to the heat release rate. For instance, wood paneling near the ceiling ordinarily would become involved more quickly than wood flooring. 4.5 PYROTECHNIC DEVICE TEST SERIES A series of full scale experiments was conducted to document the thermal characteristics of a discharging pyrotechnic device like those that were ignited in the nightclub on Feb. 20, 2003. At the beginning of the show, four separate pyrotechnic devices, or gerbs, were discharged on the platform in front of the alcove. Two gerbs, which had been positioned on the floor of the platform, discharged vertically along the centerline of the alcove opening (Figure 4-10). Two additional pyrotechnic gerbs, which were located near the other two gerbs on the platform floor, sprayed white "sparks" at a 45 degree angle to both the left and right sides of the alcove. The WPRI-TV video of the nightclub interior showed that glowing particles or “sparks” ignited the foam on both sides of the alcove in approximately 10 seconds. The throw, or distance the hot particles traveled, the period of "spark" discharge, and the white appearance of hot particles, were consistent with a pyrotechnic device called a Silver 15 x 15 Stage Gerb. Forty silver 15 x 15 gerbs were purchased from a commercial manufacturer of stage pyrotechnics. Appendix F provides a detailed description of the gerbs. For the NIST tests, each gerb or pair of gerbs was discharged either along or against a gypsum board wall or a foam covered gypsum board wall. The wall was painted black to enhance the contrast with the white sparks, and a grid of 0.3 m (1 ft) squares was painted on it. Gerbs were also discharged against the wall in a plane perpendicular to the wall (Figure 4-11). Heat flux gauges and thermocouples were embedded in the gypsum wall. The instrumentation was positioned so that the spark discharge was centered over the flux gauges and thermocouples. Examples of typical data, heat flux and gas temperature, are plotted versus time in Appendix F, and each discharge was video taped using a standard mini-DV digital video camera and an infrared camera. 4.5.1 Gypsum Wall Board The gerbs were ignited electrically. Each discharge was recorded using a standard video camera and an infrared camera. The infrared camera utilized a barium-strontium-titanate (BST) solid state detector with a spectral response of 8 μm to 14 μm. The IR camera was included in these experiments to provide a qualitative image of the hot gas plume as well as the spray of the white sparks. The visible images show that each gerb discharged a spray of white sparks for at least 14.5 seconds, but no more than 16 seconds. While most of the sparks were thrown less than 2.74 m (9 ft), a limited number of sparks traveled in excess of 4.6 m (15 ft) from the tip of the gerb. For the gerbs that were positioned at 45 o, the infrared images show a central core of hot gases, a plume of warm gases that does not travel as far as the hot metallic particles. The buoyant hot gases developed a vertical trajectory within 1.2 m (4 ft) of the gerb tip. For the gerbs that were positioned vertically, the infrared images again

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Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. PLATFORM PLATFORM

Figure 4-10. Pyrotechnics (15 x 15 gerbs) positioned on nightclub platform. Video image copyright © 2003 TVL Broadcasting, Inc. All rights reserved.

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Figure 4-11. Single Gerb at 45 degrees and in a Plane Perpendicular to Wall.

demonstrate a central core of hot gases; in this vertical configuration, the plume of combustion gases is aligned with the trajectory of the hot sparks. The measured heat fluxes from the gerbs impinging on the wall were less than 2.5 W/m2. Each total heat flux gauge monitored the heat flux over a fixed volume that was defined by the view angle of the gauge. The heat flux monitored by a gauge might result from multiple glowing particles, hot gases propelling the sparks, and/or the air entrained by the gerb discharge. 4.5.2 Foam Covered Wall The video recorded in the nightclub demonstrates that there were four gerbs positioned in front of the alcove. The two vertical gerbs were spaced about 0.1 m (4 in) apart and the two 45 degree gerbs were each positioned about 0.25 m (10 in) outside the vertical gerbs. This arrangement placed the tip of the 45 degree gerbs approximately 1.21 m (4 ft) from each of the side walls of the alcove. The spray of hot sparks would have impinged on a foam covered wall from about that distance. In order to simulate this arrangement, a single gerb which was angled at 45 degrees was discharged against (and in a plane perpendicular to) the wall from a distance of 1.22 m (4 ft). A single 1.22 m (4 ft) by 2.44 m (8 ft) sheet of non-fire retardant polyurethane foam (PUF-NFR-B) was stapled to the gypsum board wall. A single gerb was positioned at a 45 degree angle so that the tip of the gerb was 1.22 m (4 ft) from the wall surface. The tip of the gerb was located 0.3 m ( 1ft) above the floor. While temperature data were collected during the gerb discharge, the heat flux gauges were removed to prevent damage from dripping and burning plastic.

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Figure 4-12. Instrumentation Diagram for a Single Gerb at 45 degrees and in a Plane Perpendicular to Wall.

4-18

Still images were captured from the video recorded by the standard video and IR camera. For gerbs that were positioned at 45 degrees in a plane parallel to the wall, pairs of visible and infrared images are shown for times from 0 seconds to 30 seconds in Figure 4-13a through 4-13h. The visible images demonstrate that the gerb discharged a spray of white sparks for 15 seconds. The spray of hot sparks impacted the wall between 0.91 m (3 ft) and 1.5 m (5 ft) above the floor. Within 2 seconds after ignition, a thermal pattern (white area in IR image) developed on the wall. This area of increased temperature was oval in shape with a horizontal width of 0.3 m (1 ft) and a vertical dimension of 0.61 m (2ft). A similarly sized and positioned thermal pattern was also seen at 5 seconds into the discharge. The edges of the thermal pattern appeared fuzzy or diffuse. At 10 seconds after ignition, this thermal pattern had sharper edges and a black “haloing” appeared around the pattern. This haloing or shadowing has been observed under laboratory conditions in the presence of a significant thermal gradient. BST detectors measure relative levels of infrared radiation and are AC-coupled. The AC-coupling can cause a "black halo" or shadowing effect that increases as the relative radiation difference between an object and its surroundings increases unless a DC restoration process is included in the signal output circuitry. This would be consistent with the foam burning before t = 10 seconds. Although not clearly seen in the standard video camera, flames were observed on the right hand side of the hot spark pattern at 9 seconds. By 15 seconds a well defined and hot thermal plume was observed in the IR image. Gas temperatures are plotted versus time in Appendix F, Figs. F-16a and F-16b. The alcove in the nightclub was 2.0 m (6.5 ft) tall and the gerbs were positioned vertically at the center of the alcove opening. In the NIST tests, similar gerbs easily reached that height, as did the plume of hot gases. It can be seen from the WPRI video, however, that the pair of vertically-directed gerbs on the platform of the nightclub did not ignite the foam at the top of the alcove. The width of the alcove in the nightclub was 3.0 m (10 ft) and the end of each gerbs was offset from the center of the opening by about one foot. The NIST tests demonstrated that a 15 x 15 gerb which was angled at 45 degrees and discharged against (and in a plane perpendicular to) a wall from a distance of 1.22 m (4 ft) could ignite a sheet of polyurethane foam in approximately 10 seconds. This is similar to the ignition sequence observed in the WPRI video.

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Figure 4-13a. Standard and Infrared Video Images of Non-fire Retarded Polyurethane Foam on Gypsum Board Wall just before ignition at t = 0 seconds.

Figure 4-13b. Standard and Infrared Video Images of Gerb Discharge onto a Non-fire Retarded Polyurethane Foam Sheet on Gypsum Board Wall at t = 0.5 seconds.

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Figure 4-13c. Standard and Infrared Video Images of Gerb Discharge onto a Non-fire Retarded Polyurethane Foam Sheet on Gypsum Board Wall at t = 1 second.

Figure4-13d. Standard and Infrared Video Images of Gerb Discharge onto a Non-fire Retarded Polyurethane Foam Sheet on Gypsum Board Wall at t = 2 seconds.

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Figure 4-13e. Standard and Infrared Video Images of Gerb Discharge onto a Non-fire Retarded Polyurethane Foam Sheet on Gypsum Board Wall at t = 5 seconds.

Figure 4-13f. Standard and Infrared Video Images of Gerb Discharge onto a Non-fire Retarded Polyurethane Foam Sheet on Gypsum Board Wall at t = 10seconds.

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Figure 4-13g. Standard and Infrared Video Images of Gerb Discharge onto a Non-fire Retarded Polyurethane Foam Sheet on Gypsum Board Wall at t = 15 seconds.

Figure 4-13h. Standard and Infrared Video Images of Gerb Discharge onto a Non-fire Retarded Polyurethane Foam Sheet on Gypsum Board Wall at t = 30 seconds.

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1. 5.3

Impingement of Gerbs on Wood Paneling A test using an arrangement similar to the one above was conducted using a bare wood panel to determine if the wood could be ignited by a 15 x 15 gerb. A 1.22 m (4 ft) x 2.44 m (8 ft) panel of 6.4 mm (1/4 in) plywood with a birch veneer was mounted vertically 1.22 m (4 ft) from a gerb angled at 45 degrees from the floor. The plywood panel had been cut in two with the exposed surface of the upper portion offset about 1 - 2 mm back from the front surface of the lower portion, forming a small lip 1.22 m from the floor. The purpose of the lip was to capture hot sparks in an attempt to increase the likelihood that the gerb could cause ignition of the wood. Figure 4-14a shows the sparks from the gerb impinging on the wood panel about half way through the test. No ignition was observed. The hot sparks did create small black marks and craters in the finish of the panel, as can be seen in Figure 4-14b.

Figure 4-14b. Damage to wood panel following impingement by sparks from gerb. Lip on panel surface can be seen as line below mounting screws.

Figure 4-14a. Gerb impinging on wood panel.

1. 5.4

Impingement of Gerbs on Fire Retarded Polyurethane Foam A test using the arrangement similar to the one above was conducted with a piece of the fire retardant polyurethane (PUF-FR) attached to the wood panel to determine if the foam could be ignited by a 15 x 15 gerb. A 1.22 m (4 ft) x 2.44 m (8 ft) panel of 4.6 mm (0.18 in) thick plywood with a birch veneer was mounted vertically with a 0.71 m (28 in) high x 0.97 m (38 in) wide piece of foam centered on the panel as shown in Figure 4-15a. The foam was positioned 1.22 m (4 ft) from the gerb discharge tip. The gerb was angled 45 degrees above horizontal as in the previous experiments. The foam had been cut in two

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with the exposed surface of the upper portion offset from the front surface of the lower portion, forming a small gap and lip along the horizontal centerline of the foam. The purpose of the gap was to capture hot sparks in an attempt to increase the likelihood that the gerb could cause ignition of the foam. Figure 4-15a shows the sparks from the gerb impinging on the foam. No ignition was observed. The hot sparks did cause “pitting” in the foam. The pits are area where the sparks melted or burned away small amounts of foam, but the process did not propagate. Examples of the pitting can be seen in Figure 4-15b. The experiment was repeated with a new piece of foam. The lower piece of foam overlapped the upper piece of foam, creating a small ledge as shown in Figure 4-15c. The positioning of the gerb was the same. The results were similar to the previous experiment; i.e., no ignition, just minor scorching and small holes in the foam from some of the sparks (see Figures 4-15c and 4-15d). The temperatures in the plume as a function of time are plotted in Appendix F, Figs. F-24 and F-25.

(a)

(b)

(c)

(d)

Figure 4-15. Gerb impinging fire retardant polyurethane foam (a); evidence of pitting (b); horizontal ledge at mid-plane to catch sparks, and evidence of scorching in second sample (c); and close-up of scorched area (d).

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1. 6

FIRE GROWTH MEASUREMENTS IN REAL-SCALE PLATFORM AREA MOCKUP Real-scale platform area mockup experiments were conducted to characterize the fire growth and spread in the early stage of the fire. Approximately 20 % of the nightclub was reconstructed in real scale with polyurethane foam covered walls, a drummer’s alcove, a raised platform, carpeting, and wood paneling. Figure 4-16 shows the dimensions of the mock-up floor plan and compares the test compartment to a floor plan of the nightclub. Data collected on fire spread (gas temperatures, heat fluxes, and gas concentrations) allow the performance of the computer fire model to be assessed. The degree to which the computer fire model is able to mimic the fire growth for this real-scale mockup is indicative of the quality of the simulation of the fire in The Station presented in Chapter 5, within the limitations of uncertain materials and imprecise dimensions for the actual nightclub. Two real-scale tests were conducted: one without automatic sprinklers, and one with automatic sprinklers. By designing the real-scale mockup experiments carefully, in terms of controlling factors such as fuel and ventilation, the mockup tests provided a means to determine the benefit of automatic sprinklers in a fire similar to what occurred in The Station, and to gain insight as to conditions in the nightclub during the early fire growth and spread, in particular the levels of CO and HCN since these cannot be predicted by the computer fire model. 4.6.1 Test Configuration The physical mock-up was recreated in the NIST Large Fire Laboratory. The overall floor dimensions of the test room were 10.8 m by 7.0 m, and the ceiling height was 3.8 m. A single opening, 0.91 m wide and 2.0 m high was located in the wall opposite the alcove. An isometric view of the test compartment is shown in Figure 4-17. In order to allow the combustion gases to be exhausted into an instrumented hood, the full-scale mock-up experiments were conducted with the platform section oriented to the east of the dance floor. In the actual nightclub, the platform section was west of the dance floor. In order to be consistent, the mock-up data will be presented using the orientation of the actual nightclub. The test area was constructed with a structural steel frame, lined with two layers of 12 mm thick calcium silicate board, and covered with 12 mm thick gypsum board. The walls of the alcove and the raised floor area had 5.2 mm thick plywood paneling installed over the gypsum board. The paneling had a flame spread index of 200 or less per ASTM E-84 [15], according to the manufacturer. The plywood paneling extended 3.6 m from the raised floor along the rear wall of the test area.. The rear wall was adjacent to the platform on the right as one stands on the platform facing the audience (stage-right). A non-fire retarded, ether-based, polyurethane foam (PUF-NFR-B) was glued over the paneling in the alcove and along the walls on both sides of the alcove opening and to the rear wall, as shown in Figure 4-18. The polyether polyurethane foam was from the second lot of PUF-NFR-B foam tested and described earlier in this chapter. The flat side of the foam was mounted next to the plywood and the convoluted side was left exposed. The foam was installed from the top of the wall down to 1.35 m above the floor. It was also applied to the ceiling of the alcove and extended for 2.4 m from the raised floor along the rear wall. 4.6.2 Instrumentation The test room was equipped with thermocouples, video cameras, heat flux gauges, bi-directional probes, and gas extraction probes to measure carbon monoxide (CO), carbon dioxide (CO2), oxygen (O2), and hydrogen cyanide (HCN). In addition, fixed temperature and rate-of-rise heat detectors were installed, as

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Figure 4-16. Real-Scale Mockup Floor Plan versus Station Nightclub Floor Plan.

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7 m 3.8 m 2.28 m 3.8 m 1.1 m 0.4 m 0.74 m 1.56 m 5.94 m 2.44 m 2.4 m RAISED FLOOR ALCOVE MAIN FLOOR 2.7 m 3.1 m DOOR OPENING 0.91 m wide x 2 m high

Figure 4-17. Isometric view of the test compartment.

1. 44 m

WOOD PANELING POLYURETHANE FOAM NYLON CARPETING REMAINING FLOOR, WALLS, & CEILING LINED WITH GYPSUM BOARD Figure 4-18. Floor plan showing the test area and the fuel locations.

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Figure 4-19. Schematic floor plan with instrumentation positions. were sprinklers. In the unsprinklered experiment, standard response pendent sprinklers were installed without a water supply. The sprinklers were attached to a 150 mm (6 in) length of 19 mm (0.75 in) pipe that was filled with water and pressurized with air. In the sprinklered experiments, all sprinklers were connected to a single water supply. The sprinkler was monitored for time to activation with a pressure sensor that was attached to the short length of pipe. The only difference between the sprinklers installed in the unsprinklered experiment and the sprinklered experiment was the thermal element. In the sprinklered experiment, quick response sprinklers were used. Figure 4-19 is a schematic floor plan of the instrumentation positions. 4.6.3 Experimental Procedure Prior to ignition, each of the analyzers was zeroed and calibrated and the data acquisition system and videos were started to collect background data. Data for 194 channels were recorded at 1 second intervals. Ignition of the foam was initiated simultaneously with electric matches at two locations on the outer corners of the alcove, 1.66 m above the raised floor area. The fire gases that emerged from the open door on the south end of the test room were captured in the hood of the oxygen depletion calorimeter. The data were reduced and plotted versus time for each of the channels. The succession of video frames on the left of Fig. 4-20 show how rapidly the fire spreads during the first 50 seconds, compared to how quickly the fire is controlled with sprinklers in the frames along the right. The first sprinkler activates on the right of the platform 24 seconds after ignition. By 30 seconds the sprinkler above the platform on the left and the sprinkler in the alcove have activated.

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Figure 4-20. Still frames taken from video of full-scale mock-up experiments. Time after ignition is indicated in lower left of each frame. Left column: unsprinklered; right column: sprinklered (first head activates at 24 seconds)

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Figure 4-21. Schematic floor plan with thermocouple positions. 4.6.4 Temperature The temperatures were measured with 0.51 mm nominal diameter bare bead, type K thermocouples, distributed as shown in Fig. 4-21. The standard uncertainty in temperature of the wire itself is ± 2.2 °C at 277 °C and increases to ± 9.5 °C at 871 °C as determined by the wire manufacturer [16]. The uncertainty of the temperature in the environment surrounding the thermocouple is known to be much greater than that of the wire[17][18]. Temperatures were not corrected for radiation since the radiant environment was dynamic and the local velocity needed for such a correction was not measured. Radiation tends to increase thermocouple temperatures in cooler regions of the fire room and to decrease thermocouple temperatures in hotter regions. The thermocouple array over the platform floor area had a thermocouple located at 0.025 m, 0.30 m, 0.61 m, 0.91 m, 1.22 m, 1.52 m, 1.83 m, 2.13 m, 2.44 m, 2.74 m, 3.05 m, 3.35 m, 3.66 m below the ceiling. For the platform floor thermocouple array, the thermocouple that was located 3.66 m below the ceiling, was positioned on the platform floor. The two thermocouple arrays on the main floor also had a thermocouple located at 3.66 m below the ceiling, but in each case, the thermocouple was positioned 0.15 m above the main floor. Vertical thermocouple arrays were installed in the center of each wall of the alcove. Each array had a thermocouple located at 0.30 m, 0.61 m, 0.91 m, 1.22 m, 1.52 m, and 1.83 m below the ceiling of the alcove. A horizontal thermocouple array was installed 0.30 m below the ceiling. The array began at the centerline of the alcove opening and continued north along the rear wall, and then followed the platform wall west for 6.1 m. The thermocouples were spaced approximately 0.30 m apart. In addition, thermocouples were located adjacent to the sprinklers. Selected temperatures versus time are plotted in Fig. 4-22 through Fig. 4-24 for the unsprinklered experiment. Results for the sprinklered experiment, at the same locations in the test room, are provided in Fig. 4-25 through Fig. 4-27. Additional temperature plots are presented in Appendix G.

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0 200 400 600 800 1000 0 50 100 150 200 Ceiling 0.3 m below ceiling 0.6 m below ceiling 1.2 m below ceiling 1.8 m below ceiling 2.4 m below ceiling 3.0 m below ceiling 3.6 m below ceiling Gas Temperature (Co) Time (s)

Figure 4-22. Temperatures versus Time for Unsprinklered Mockup Test. Thermocouples positioned on Platform (Location B) from ceiling to platform floor.

0 200 400 600 800 1000 0 50 100 150 200 Ceiling 0.3 m below ceiling 0.6 m below ceiling 1.2 m below ceiling 1.8 m below ceiling 2.4 m below ceiling 3.0 m below ceiling 3.6 m below ceiling Gas Temperature (Co) Time (s)

Figure 4-23. Temperatures versus Time for Unsprinklered Mockup Test. Thermocouples positioned on Main Floor (Location C) from ceiling to floor.

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0 200 400 600 800 1000 0 50 100 150 200 Ceiling 0.3 m below ceiling 0.6 m below ceiling 12 m below ceiling 1.8 m below ceiling 2.4 m below ceiling 3.0 m below ceiling 3.6 m below ceiling Gas Temperature (Co) Time (s)

Figure 4-24. Temperatures versus Time for Unsprinklered Mockup Test. Thermocouples positioned on Main Floor (Location D) from ceiling to floor. For the unsprinklered case, the temperature at the ceiling measured at location B (Fig. 4-22) began to increase within 10 seconds of ignition and continued to increase to over 800 °C in approximately 50 seconds. In less than 60 seconds, the temperature exceeded 50 oC at 1.4 m (4.5 ft) above the floor (2.4 m below the ceiling). The hot gases began to form an upper layer and the layer began to descend; in just over 110 seconds, the temperature at the floor of the platform had increased to over 600 oC. The thermocouple array at location C was installed 6.7 m from the foam covered platform wall, 3 m further away from the platform wall than the thermocouples at location B. The temperatures required about 15 seconds longer to begin increasing than those measured at location B, and required approximately 70 seconds to reach peak temperatures of 800 oC. From Fig, 4-23 one can see that the temperatures at 3.6 m below the ceiling did not begin to increase until 60 seconds after ignition and then the temperatures reached peak values of approximately 100 oC in 90 s. The temperatures at location C exceeded 50 oC at the 1.4 m (4.5 ft) above the floor (2.4 m below the ceiling) elevation in less than 70 seconds. The thermocouple array at location D was installed 8.5 m from the foam covered platform wall, an additional 1.8 m further away from the platform wall than the thermocouples at location C. The temperatures began to rise in about 20 seconds (see Fig. 4-24), and required approximately 80 seconds to reach peak temperatures of 700 oC. The temperatures at 3.6 m below the ceiling did not begin to increase until 70 seconds after ignition and reached peak values of approximately 100 oC in 90 s. The temperatures near the floor at location D were about the same as the values recorded at the floor on the platform, Location C.

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0 100 200 300 400 500 0 50 100 150 200 Ceiling 0.3 m below ceiling 0.6 m below ceiling 1.2 m below ceiling 1.8 m below ceiling 2.4 m below ceiling 3.0 m below ceiling 3.6 m below ceiling Gas Temperature (Co) Time (s)

Figure 4-25. Temperatures versus Time for Sprinklered Mockup Test. Thermocouples positioned on Platform (Location B) from ceiling to platform floor.

0 100 200 300 400 500 0 50 100 150 200 Ceiling 0.3 m below ceiling 0.6 m below ceiling 1.2 m below ceiling 1.8 m below ceiling 2.4 m below ceiling 3.0 m below ceiling 3.6 m below ceiling Gas Temperature (Co) Time (s)

Figure 4- 26. Temperatures versus Time for Sprinklered Mockup Test. Thermocouples positioned on Main Floor (Location C) from ceiling to floor.

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0 100 200 300 400 500 0 50 100 150 200 Ceiling 0.3 m below ceiling 0.6 m below ceiling 1.2 m below ceiling 1.8 m below ceiling 2.4 m below ceiling 3.0 m below ceiling 3.6 m below ceiling Gas Temperature (Co) Time (s) Figure 4-27. Temperatures versus Time for Sprinklered Mockup Test. Thermocouples positioned on Main Floor (Location D) from ceiling to floor.

For the sprinklered test burn, the ceiling thermocouple at location B (on the platform) recorded a peak temperature of 380 oC about 20 seconds after ignition, as can be seen in Fig. 4-25. When the sprinkler activated, the ceiling temperature quickly decreased, dropping to about 20 oC within 40 seconds of ignition. The activation of the sprinklers caused the other thermocouples at lower elevations to record near ambient temperatures throughout the test burn. At location C (Fig. 4-26), the ceiling temperatures reached a peak temperature of 170 oC in about 20 seconds and declined to near ambient temperatures within 60 seconds. For location D (Fig. 4-27), the ceiling temperatures reached a peak temperature of 130 oC in about 20 seconds and declined to near ambient temperatures within 60 seconds. Thermocouples at lower elevations for both locations appeared to remain at near ambient temperatures throughout the test. The comparison between the temperatures at the ceiling and 1.4 m above the floor for the sprinklered and unsprinklered experimental data is striking, as demonstrated in Fig. 4-28a for location C and Fig. 4-28b for location D. At 25 seconds, the temperatures at the ceiling were about 175 ºC at location C and 125 ºC at location D for both experiments, indicative of the fire being properly replicated up to the point when the sprinkler activated. During the next 25 seconds the temperatures throughout the compartment returned to close to ambient conditions in the sprinklered compartment. This compared to a continuing rapid rise in temperatures for the unsprinklered compartment, which reached ceiling temperatures in excess of 300 ºC at 50 seconds, and peaks of 700 ºC plus in the following 25 seconds. Peak temperatures of 400 ºC to 500 ºC were reached 1.4 m above the floor for the unsprinklered test; temperatures did not rise at all for the sprinklered compartment at this location.

4-35

0 100 200 300 400 500 600 700 800 0 50 100 150 200 Temperature ( oC ) Time (s) Ceiling Un-sprinklered Ceiling Sprinklered 1.4 m above floor Un-sprinklered 1.4 m above floor Sprinklered

Figure 4-28a. Temperatures versus Time for Unsprinklered and Sprinklered Mockup Test. Thermocouples positioned on Main Floor (Location C) at ceiling and 1.4 m (4.5 ft) above floor. 0 100 200 300 400 500 600 700 800 0 50 100 150 200 Temperature ( oC ) Time (s) Ceiling Un-sprinklered Ceiling Sprinklered 1.4 m above floor Un-sprinklered 1.4 m above floor Sprinklered

Figure 4-28b. Temperatures versus Time for Unsprinklered and Sprinklered Mockup Test. Thermocouples positioned on Main Floor (Location D) at ceiling and 1.4 m (4.5 ft) above floor.

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Platform

Figure 4-29. Schematic floor plan with gas sampling locations. 4.6.5 Oxygen Depletion and Gas Volume Fractions For fires burning in the open under the laboratory hood, the chemical power measured by the oxygen depletion calorimeter is equal to the heat release rate from the fire as a function of time. However, for a fire within a room, the effluent from the enclosure is a mixed average of the upper layer gases, and does not represent the instantaneous heat release rate of the fire. With this limitation in mind, oxygen depletion rate was measured using the NIST 10 MW hood. The measurement system was calibrated with a gas burner placed directly under the hood (not in the enclosure) with heat release rates as high as 5 MW and an expanded uncertainty (95 % confidence level) of 11 % for fires larger than 400 kW. Bryant et al. [19] provide details on the operation and uncertainty in measurements associated with the oxygen depletion calorimeter. There was a significant time delay between ignition of the foam in the full-scale mock-up and the first indication in the oxygen depletion calorimeter that heat was being released by the fire. The fire gases generated inside the test room did not exit the door way and enter the calorimeter until about 70 seconds later, and by the time they were detected, the combustion products had mixed with fresh air in the room. The result was that the measured heat release represented an average over time. The measured peak for the unsprinklered test was 4.3 MW. A steady heat release rate of about 3.4 MW was reached after about 150 seconds. The sprinklered experiments yielded no heat release rate measurements since the sprinklers quickly suppressed the fire after 25 seconds, a time shorter than the time lag discussed above. Gas sample extraction probes 1.4 m above the floor were used to measure CO, CO2, O2 and HCN at the two locations shown in Fig, 4-29. The gases were pulled through 9.4 mm ID tubing to chemical analyzers

4-37

0 5 10 15 20 25 0 50 100 150 200 Oxygen (volume %) Time (s) 1.4 m above floor Un-sprinklered Sampling Location C

Figure 4- 30. Oxygen Volume Fraction vs Time for Unsprinklered and Sprinklered Mockup Test. Gas Sampling probe positioned on Main Floor (Location C) at 1.4 m (4.5 ft) above floor. 0 5 10 15 20 25 0 50 100 150 200 Oxygen (volume %) Time (s) 1.4 m above floor Un-sprinklered 1.4 m above floor Sprinklered Sampling Location D

Figure 4-31. Oxygen Volume Fraction vs Time for Unsprinklered Mockup Test. Gas Sampling probe positioned on Main Floor (Location D) at 1.4 m (4.5 ft) above floor.

4-38

0 1 2 3 4 5 6 0 50 100 150 200 Carbon Monoxide (volume %) Time (s) 1.4 m above floor Un-sprinklered Sampling Location C 1.4 m above floor Sprinklered Figure 4-32. Carbon Monoxide Volume Fraction vs Time for Unsp Mockup Test. Gas Sampling probe positioned on Main Floor (Location C) at 1.4 m (4.5 ft) above floor. rinklered and Sprinklered

rinklered and 0 1 2 3 4 5 6 0 50 100 150 200 Carbon Monoxide (volume %) Time (s) 1.4 m above floor Un-sprinklered Sampling Location D 1.4 m above floor Sprinklered Figure 4-33. Carbon Monoxide Volume Fraction vs Time for Unsp Sprinklered Mockup Test. Gas Sampling probe positioned on Main Floor (Location D) at 1.4 m (4.5 ft) above floor.

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rinklered and Sprinklered

Figure 4-35. Hydrogen Cyanide Volume Fraction vs Time for Unsprinklered and Sprinklered Mockup Test. Gas Sampling probe positioned on Main Floor (Location D) at 1.4 m (4.5 ft) above floor.

Figure 4-34. Hydrogen Cyanide Volume Fraction vs Time for Unsp Mockup Test. Gas Sampling probe positioned on Main Floor (Location C) at 1.4 m (4.5 ft) above floor. 0 0.05 0.1 0 50 100 150 200 Hydrogen Cyanide (vol 0.15 0.2 ) Time, s ume % 1.4 m above floor Un-sprinklered 1.4 m above floor Sprinklered 0 0.05 0.1 0.15 ume Un-sprinklered 0.2 0 50 100 150 200 Hydrogen Cyanide (vol %) Time, s 1.4 m above floor 1.4 m above floor Sprinklered

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after passing through moisture and particulate filters. Carbon monoxide and CO2 volume fractions were monitored using non-dispersive infrared gas analyzers while the oxygen volume fractions were measured using paramagnetic analyzers. Hydrogen cyanide concentrations were monitored using impingers and real-time gas analyzers with cyanide combination electrodes. Each impinger utilized 0.1 M KOH as the trapping solution and samples were analyzed according to NIOSH Method 7904 [20]. During the sampling process, the gas sample for the oxygen, carbon monoxide, and carbon dioxide analysis was drawn through a cold trap which removed the water vapor. The oxygen, carbon monoxide, and carbon dioxide concentrations were recorded by each analyzer on a dry basis, and later corrected for the water removed by assuming that for every mole of carbon dioxide or carbon monoxide generated, one mole of water was also generated. By adding the water vapor back into the gas sample, the concentrations of oxygen, carbon monoxide, and carbon dioxide decreased. The hydrogen cyanide sample gas utilized a different sampling train and did not pass through a cold trap. Gas volume fractions versus time are plotted for the unsprinklered and sprinklered tests in Figures 4-30 through 4-35 for O2, CO and HCN. (Additional gas volume fractions measurements are discussed in Appendix G.) At both locations C and D, oxygen volume fractions did not begin to drop at the 1.4 m elevation until 70 seconds to 80 seconds after ignition for the unsprinklered mock-up experiments. At both locations, the oxygen volume fractions descended to less than 4 % in less than 100 seconds, then fluctuated between 1 % and 4 % . During the sprinklered test burns, the oxygen mole fraction at location did not appear to drop much below ambient oxygen levels. (A malfunctioning oxygen analyzer preve ) increase until 70 seconds to 80 second lered mock-up experiments, but then s peak value of lume n B, ge with an upward

t-

ation

D nted the oxygen concentrations from being monitored at location D during the sprinklered burns. At both locations C and D, volume fractions of carbon monoxide at the 1.4 m elevation did not begin to s after ignition for the unsprink increased to 3 % in the next 20 seconds to 30 seconds and reached 4.5 % by 200 seconds after ignition. During the sprinklered test burns, the carbon monoxide concentration at neither location C nor location D appeared to increase much above ambient levels. The volume fractions of hydrogen cyanide at the 1.4 m elevation began to increase 60 seconds after ignition for the unsprinklered mockup experiments. At location C, the HCN reached it 0.13 % in 120 seconds. The HCN increased slightly faster at location D, where it reached a peak vo fraction of 0.17 % in about 90 s. During the sprinklered test burns, the hydrogen cyanide concentration at locations C and D were barely above the measurable limit. 4.6.6 Heat Flux and Heat Detectors Three elliptical radiometers were installed in the ceiling of the test cell viewing downward at locatio C, and D (Fig. 4-36). In addition to the radiometer at location B, a total heat flux gau view was installed flush with the platform floor. At locations C and D, two additional total heat flux gauges were installed 1.5 m above the floor. One total heat flux gauge was position to have an upward view, while the other gauge had a view of the alcove. The heat flux sensors were water cooled Schmid Boelter type transducers. For the unsprinklered compartment test, the output of the thermal radiation and total heat fluxes for the radiometer and heat flux gauges at locations C and D are shown in Fig. 4-37 and Fig 4-38. At location C, peak fluxes in excess of 50 kW/m2 were reached about 70 seconds after ignition. Peak fluxes at loc D were about 20 % lower than location C. At 100 seconds after ignition, radiation and heat flux at

4-41

Figure 4-36. Schematic floor plan with heat flux and heat detector locations.

main relatively kW/m2 before beco uch on and total heat flux Two ty perature of 93 ºC ature increase exceeded about 7 stalled on detectors was installed 4-39 and detectors acti temperature d 20 .6.7 Sprinkler Activation ive sprinkler heads were installed on a nominal 3.66 m spacing. One sprinkler was installed centered in e alcove, two were installed over the platform, and two over the main floor area. (See Figure 4-41.) The location C and the heat flux at location D decreased significantly to 20 kW/m2 and appeared to re constant at both locations. The radiometer in the ceiling at location D dropped to 10 ming relatively steady. (Additional plots of heat flux are shown and discussed in App. G.) In the sprinklered test at locations C and D, neither radiation nor total heat flux reached levels m above the background. Only on the platform at location B was there a slight increase in radiati , starting around 20 seconds after ignition. pes of heat detectors were also installed: fixed temperature models with an activation tem , and a rate of rise/fixed temperature model which activated when the rate of temper ºC /min or when the temperature reached 93 ºC. One pair of detectors was in the ceiling, adjacent to the thermocouple array on the raised floor, and the second pair of heat on the ceiling in the north-east corner of the alcove. The responses of rate of rise heat detectors and fixed temperature detectors are plotted in Fig. Fig. 4-40, respectively. For both unsprinklered and sprinklered test burns, each of the rate of rise vated in less than 20 seconds. Only in the unsprinklered experiments did the fixed etectors activate. The fixed temperature detector in the alcove activated in about seconds while the fixed temperature detector above the platform required almost 40 seconds to respond. 4 F th

4-42

Figure 4- 37. Heat Fluxes versus time for unsprinklered mockup test. Radiomet positioned flush with ceiling (3.8 m above floor); heat flux gauges facing up (1.44 m above floor), and facing alcove (1.44 m above floor) at sampling location C. er positioned flush with ceiling (3.8 m above floor); heat flux gauges facing up (1.44 m above floor), and facing alcove (1.44 m above floor) at sampling location D.

Figure 4- 38. Heat fluxes versus time for unsprinklered mockup test. Radiometer 0 10 20 30 40 50 60 0 50 100 150 200 Heat Flux (kW/m2) Time (s) Station D (Facing Up) (1.44 m above floor) Station D (3.8 m above floor) Station D (Facing Alcove) (1.44 m above floor) 0 10 0 50 100 20 Heat Flu 30 40 x (kW/m 50 60 150 200 2) Station c (3.8 m above floor) Station C (Facing Up) (1.44 m above floor) Station C (Facing Alcove) (1.44 m above floor) Time (s)

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versus Time for Unsprinklered Un . Figure 4- 39. Response of Rate of Rise Heat Detectors and Sprinklered Mockup. Detectors located in Alcove and at Location B.

Figure 4- 40. Response of Fixed Temperature Heat Detectors versus Time for sprinklered and Sprinklered Mockup. Detectors located in Alcove and at Location B Alcove - Sprinklered Raised Platform (B) - Sprinklered Alcove - Unsprinklered 0 20 40 60 80 100 Rate of Rise Heat Detectors Raised Platform (B) - Unsprinklered Heat Detector Response Time, s Alcove Sprinklered Raised Platform (B) - Sprinklered Alcove - Unsprinklered 0 20 40 60 80 100 Fixed Temperature Heat Detectors Raised Platform (B) - Unsprinklered Heat Detector Response Time, s

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F

igure 4- 41. Schematic Diagram of Sprinkler and Sprinkler Thermocouple Locations. 0 100 200 300 400 500 0 10 20 30 40 50 60 Gas Temp. Sprink. Head Stage Left Gas Temp. Sprink. Head Stage Right Gas Temperature Sprink. Head Alcove Temperature (Co) Time (s) Stage Left 23 s Stage Right 26 s Alcove Ceiling 27 s Sprinkler Activation Times

Figure 4- 42. Temperature versus Time for Sprinkler Thermocouples.

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Table 4.5 Time to Reach Untenability Criteria, or maximum deviation obtained

sprinkler installation and water supply were based on a light hazard classification in accordance with NFPA 13 [21]. For the sprinklered experiments, each of the five installed sprinklers was supplied via a common water source capable of providing approximately 4.1 mm/min water spray density if all heads were activated. The sprinklers used were commercially available pendent-type with a nominal 15 mm standard orifice. The listed activation temperature for all of the sprinklers used was 74 ºC and were of the quick response type. The temperatures monitored by a thermocouple that was positioned next to the sprinkler head are plotted versus time in Fig. 4-42. The first sprinkler, above the platform at stage-left, activated in 23 seconds. The sprinkler above the platform on stage-right was the next to activate at 26 seconds. One second later the sprinkler in the alcove activated. No other sprinkler was triggered. In the unsprinklered experiment, standard response pendent sprinklers were installed without a water suppl . The sprinklers were attached to a 150 mm (6 in) length of 19 mm (0.75 in) pipe that was filled with water and pressurized with air. The sprinkler was monitored for time to activation with a pressure sensor that was attached to the short length of pipe. The only difference between the sprinklers installed in the unsprinklered experiment and the sprinklered experiment was the thermal element. In the unsprinklered experiment, at 33 s after ignition, the sprinkler above the platform at stage left was the first standard response sprinkler to activate. 4.6.8 Tenability According to Purser [22] a room becomes untenable for people when any of the following occur: the temp ature exceeds 120 oC (250 oF), a heat flux exceeds 2.5 kW/m2, or the oxygen volume fraction drops below 12 %. These levels provide guidelines generally accepted by the fire protection engineering profession as leading to quick incapacitation, but may be tolerated for a short (unspecified) time. Hydrogen c t concentration of a material in air that has been reported to have caused death in humans is termed Lethal y er yanide and carbon monoxide also represent significant hazards to humans. The lowes

Temperature

120

oC

Heat Flux

2.5 kW/m2

Oxygen < 12 %

Hydrogen Cyanide

0.02 %

Carbon Monoxide

0.5 %

Sprinklered Location B

< 28 oC not measured not measured not measured not measured Location C < 24 oC < 0.32 kW/m2 not measured < 0.004 % < 0.002 % Location D < 24 oC < 0.21 kW/m2 > 20.6 % < 0.0006 % < 0.04 %

Unsprinklered Location B

71 seconds not measured not measured not measured not measured Location C 76 seconds 61 seconds 87 seconds 71 seconds 82 seconds Location D 71 seconds 61 seconds 85 seconds 75 seconds 92 seconds

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Concentration Low (LCLo). The LCLo (inhalation) for hydrogen cyanide is reported as 0.02 % for 5 minute The upper portion of Table 4-5 summarizes the temp atures, heat fluxes, oxygen volume fractions, CO olume fractions, and HCN volum ctions measured at locations B, C, and D at an elevation 1.4 m above the floor(appro -heig rinkler lso list nabi and LCLo levels. In the d test, id not e of the riteri oxygen volume fraction), or the LCLo volume fractions for either hy rbon monoxide during the entire duration of the test (> 200 seconds). The maximum values ure, heat flu en cya n m ll

were record the sp re ble. ith the unsp mock ature n be 4-5 een exceeded in less than 76 seconds at all three locations. The thermal flux exceeded 2.5 kW/m2 in s. At sampling location C and D, the oxygen concentration dropped below 12 % in less s. The anide ex Lo s de concentrations reache e tenabili not im or al ho a tha environment will succumb due to a particular limit exceeded. The length of time exposed, the rate of hange of the environmental conditions, possible antagonistic effects, and the susceptibility of the ible ther an occupant of The Station nightclub would have first fallen victim to the high heat flux, to the high temperature, to the lack of oxygen, or to the hydrogen cyanide, carbon monoxide or

s [23]. For carbon monoxide the LCLo (inhalation) is listed at 0.5 % for 5 minutes [23]. er v e fra ximately head

lity criteria a

sprinklere ht) for the sp conditions d ed test. A xceed any ed are the te tenability c

drogen (temperature, heat flux, or cyanide or ca for temperat x, hydrog nide and carbo onoxide as we as the minimum value for oxygen that ed during rinklered test a shown in the ta

In the test w rinklered -up, the temper criterion ca seen in Table to have b about 60 second nd than 87 seco hydrogen cy concentrations ceeded the LC in less than 75 econds and the carbon monoxi d its LCLo in less than 92 seconds. Exceeding th ty limit does ply that any l occupants w re present in t c individual all play a role. With this limited set of data from a single mockup experiment, it is not poss to determine whe smoke levels, or even to the crush of the crowd. (Note that NIST was unable to get access to the Rhode Island Medical Examiner's report due the ongoing criminal investigation, and was therefore unable to relate findings regarding the conditions in the nightclub to possible causes of death.) Given the rapid spread of the fire and combustion products, it is likely that the victims succumbed to multiple conditions. If conditions developed in The Station in the same manner as during this mock-up, most occupants likely would have had less than 90 seconds to escape under tenable conditions. 4.7 REFERENCES FOR CHAPTER 4

[1] Duval, R., “Fires in Places of Assembly”, presented at NFPA Fall Education Conference, Miami, FL November 14 – 17, 2004, National Fire Protection Association, Quincy, MA. [2] UL 94- Test for Flammability of Plastic Materials for Parts in Devices and Appliances, Fifth October 29, 1996, Underwriters Laboratories, Inc., Northbrook, IL, p. 34. [3] ASTM E84-04 – Standard Test Met , Edition, hod for Surface Burning Characteristics of Building Materials, merican Society for Testing and Materials, West 0- 1018.

M ASTM Fire Standards, Sixth Edition, A Conshohocken, PA, pp 100 [4] ASTM E 1354-04a, Standard Test Method for Heat and Visible Smoke Release Rates for Materials and Products Using an Oxygen Consumption Calorimeter, ASTM International, West Conshohocken, PA, 2004. [5] ASTM D 1929 - Standard Test Method for Determining Ignition Temperatures of Plastics, AST International, West Conshohocken, PA, 2004.

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n, P.J. nts of Ignition and Fire alorimeter Inter- March 13 7,

ls lding Materials, STM [16] Omega Engineering Inc., (2000) The Temperature Handbook, Vol. MM, pages Z-39-40, Stamford, [17 ent Fires", National ciety for eedings. ASTM STP 1427. December 3, 2001, Dallas, TX. ial Publication 1007, National Institute of Standards and Technology, Gaithersburg, MD, [6] Society of Fire Protection Engineers’ Handbook of Fire Protection Engineering, Third Editio DiNenno, Editor-in-Chief, Society of Fire Protection Engineers, Bethesda, MD, pp. A-32 - A-42, 2002. [7] Fire Protection Handbook, Nineteenth Edition, A.E. Cote, Editor-in-Chief, National Fire Protection Association, Quincy, MA, pp. 8-38 – 8-39, 2003. [8] Troitzsch, J., “The Burning of Plastics”, Chapter 4 in International Plastics Flammability Handbook, Second Edition, Hanser Publishers, New York, NY, 1983, pp 16 – 30. [9] Ma, S., Venart, J.E.S., and Sousa, A.C.M., “Cone Calorimeter Measureme Properties of Several Building Materials,” International Conference on Fire Science and Engineering, Hong Kong, March 15 – 16, 1995, pp. 629 –634. [10] ISO 1716, “Reaction to fire tests for building products-Determination of the heat of combustion,” ISO, Annex B, 2002. [11] Marchal, A., Yoshida, M., and Hasemi, Y., “Asia-Oceania ISO 5660 Cone C Laboratory Trials,” in Thirteenth Meeting of the UJNR Panel on Fire Research and Safety, – 20, 1996, NISTIR 6030, National Institute of Standards and Technology, Gaithersburg, MD, 199 pp. 173 – 214. [12] “Polyurethanes,” in Fire Retardant Materials, Edited by A.R. Horrocks and D. Price, Woodhead Publishing Limited, Cambridge England, 2001, pp.243-245. [13] Fire Protection Handbook, Seventeenth Edition, A.E. Cote, Editor-in-Chief, National Fire Protection Association, Quincy, MA, p. 3-111, 2001. [14] ASTM E 1354-04a, Standard Test Method for Heat and Visible Smoke Release Rates for Materia and Products Using an Oxygen Consumption Calorimeter, ASTM International, West Conshohocken, PA, 2004. [15] ASTM E84: Standard Test Method for Surface Burning Characteristics of Bui A International, West Conshohocken, PA, 2002. CT. ] Blevins, L.G., "Behavior of Bare and Aspirated Thermocouples in Compartm rd Heat Transfer Conference, 33 Proceedings. HTD99-280. August 15-17, 1999, Albuquerque, NM, 1999. [18] Pitts, W.M., E. Braun, R.D. Peacock, H.E. Mitler, E. L. Johnsson, P.A. Reneke, and L.G.Blevins, "Temperature Uncertainties for Bare-Bead and Aspirated Thermocouple Measurements in Fire Environments," Thermal Measurements: The Foundation of Fire Standards. American So Testing and Materials (ASTM). Proc [19] Bryant, R.A., Ohlemiller, T.J., Johnsson, E.L., Hamins, A.H., Grove, B.S., Guthrie, W.F., Maranghides, A., and Mulholland, G.W., The NIST 3 MW Quantitative Heat Release Rate Facility, NIST Spec 2003.

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[21 13 (2002), Standard for the Installation of Sprinkler Systems, National Fire Protection [22 n Products,” in Society of Fire Protection [24 se Analysis,

[20] "Cyanides, Aersol and Gas, Method 7904," NIOSH Manual of Analytical Methods, Fourth Edition, 8/15/94. ] NFPA Association, Quincy MA. ] Purser, D.A., “Toxicity Assessment of Combustio Engineers’ Handbook of Fire Protection Engineering, Third Edition, DiNenno,P.J., Editor-in-Chief, Society of Fire Protection Engineers, Bethesda, MD, 2002. [23] Lewis, R.J., Sax’s Dangerous Properties of Industrial Materials, Ninth Edition, Van Nostrand Reinhold, New York, NY, 1995. ] Zicherman, J.B., The Fire Incident at “The Station”, Report FCA NO 04-5667, Fire Cau 213 W. Cutting Blvd., Richmond, CA 94804, November 10, 2003.

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Chapter 1 Chapter 2 Chapter 3 Chapter 4

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Chapter 5 COMPUTER SIMULATION OF FIRE AND SMOKE SPREAD The WPRI-TV video tape provided information to the investigation of the start and spread of the fire that was almost unprecedented in fire forensics. Supplemented with first person interviews and examination of the scene after the fact, a clear overall picture of the event emerged rather quickly. However, a number of important details could not be gleaned from the evidence, nor was it possible to examine the impact of the fire on the occupants. Both would have helped to understand the fire's effect on the evacuation process and to determine the relative importance of different contributors to the building failure. Computer simulation has been demonstrated to be credible, when properly applied, as a tool to help fill in critical details of a fire incident and to demonstrate the value of alternative building designs and fire safety measures[1-14]. This chapter presents the results of numerical simulations and analyses of fire spread, smoke movement, tenability, and operation of fire protection systems that relate to the conditions in The Station on the night of Feb. 20, 2003. The numerical models used in this investigation were the NIST Fire Dynamics Simulator (FDS) [15] and Smokeview [16]. The essential fire properties of the materials needed as input to FDS were generated from the small scale and real scale measurements described in Chapter 4. The following sections provide an overview of the models, describe how the testing was used to add credence to the simulations, and present the results of the full nightclub simulations. 5.1 NIST FIRE DYNAMICS SIMULATOR The NIST Fire Dynamics Simulator is a computational fluid dynamics (CFD) model of fire-driven fluid flow. It solves numerically a form of the Navier-Stokes equations appropriate for low-speed, thermally driven flow with an emphasis on smoke and heat transport from fires [17]. Version 1 was publicly released in February 2000. The predictions performed here were made with the public pre-release version 4 of the model. Version 4 includes several new features, including multi-blocking, which were critical in performing the full nightclub simulations. A CFD model requires that the room or building of interest be divided into small three-dimensional rectangular control volumes or computational cells. The CFD model computes the density, velocity, temperature, pressure and species concentration of the gas in each cell as it steps through time. Based on the laws of conservation of mass, momentum, species, and energy, the model tracks the generation and movement of fire gases. Radiative heat transfer is included in the model via the solution of the radiation transport equation for a non-scattering gray gas. All solid surfaces are assigned thermal boundary conditions, plus information about their burning behavior. Heat and mass transfer to and from solid surfaces is usually handled with empirical correlations. FDS utilizes material properties of the furnishings, walls, floors, and ceilings to compute fire growth and spread. A complete description of the FDS model as well as the technical references which support the model are given in references [15,17]. Inputs required by FDS include the geometry of the structure, the computational cell size, the location of the ignition source, the energy release rate of the ignition source, thermal properties of walls, ceilings, floors, furnishings, and the size, location, and timing of door and window openings to the outside which critically influence fire growth and spread.

5-1

1. 1.1 Geometry

FDS approximates the governing equations on a rectilinear grid. This three-dimensional grid represents the volume modeled by FDS. The grid is isolated from the surroundings, that is, all the smoke and heat generated by the fire stays within the grid and the air does not enter the grid. The user may, however, prescribe vents that allow smoke and heat to leave and air to enter the grid area. The user prescribes rectangular obstructions that are forced to conform to the underlying grid. Multi-blocking is a term used to describe the use of more than one rectangular grid or mesh in a calculation. FDS predictions are sensitive to grid size; using a larger number of smaller cells will generally capture more features of the flow; however, the computation time increases more than linearly with the increase in number of grid cells. Computation times of one day on a fast computer are not uncommon but may increase to several months with a large number of grid cells. Therefore, it is important to use the smallest number of grid cells that still capture the important features of the fire. One way to reduce the number of grid cells is the use of multi-blocking. With multi-blocking, smaller grid cells that capture more detail are used near the fire and larger grid cells with less detail are used remote from the fire. Building items such as walls, floors, windows, doors and furniture are described in FDS as rectilinear blocks. These blocks must have sides that are either horizontal or vertical and no sloped or curved surfaces are allowed. The blocks may be colored for identification and may be assigned material properties. The blocks may be entered into the simulation with exact measurements from the building. However FDS can only work with items that fall exactly on grid cell boundaries. FDS takes the input blocks and adjusts them to match the grid cell boundaries. As a result, items may either grow or shrink to match the grid. In most cases this does not have a major impact on the calculations, although it can result in walls with no thickness or walls with gaps at intersections. Usually these issues are resolved by adjusting the size of the blocks slightly to produce the desired geometry that matches the grid size. 5.1.2 Materials When a wall, ceiling, floor, piece of furniture, or any other material is defined for use in the FDS model, it is given a set of physical and thermal properties that are used by the model. Some of these properties such as thermal diffusivity, thermal conductivity, density and thickness impact the heat transfer in the material. For materials that burn, additional parameters such as ignition temperature, heat of combustion, heat of vaporization and maximum burning rate are specified. The properties for the materials, to the extent they were available, were taken from standard references or fire experiments. The combustion process is handled in two ways within FDS. In one version, the fuel gasification rate is related to the radiant heat flux imposed from the fire onto the material. The mass burning rates of these same materials are measured in a cone calorimeter (or similar) apparatus; hence, the importance of collecting these data as described in Chapter 4. An alternative way to handle the gasification of fuel in FDS is to base the fuel generation rate on a measured heat of vaporization and ignition temperature. Both versions utilize a mixture fraction combustion model, in which burning occurs in regions where the fuel and air are in stoichiometric proportion. The second approach was used in FDS to model both the mock- up experiments and the full nightclub fire. The accuracy of either of these combustion models is related to the complexity of the fuel and the resolution of the numerical grid used during the simulation. A maximum burning rate is imposed to limit the amount of pyrolysis that can occur regardless of the amount of heat flux impinging on the surface of the fuel. To the extent that the heat release rates measured for the polyurethane foams by NIST and ATF differed, this had no effect on the calculations presented in this chapter since the same ignition

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temperature, heat of vaporization, and maximum burning rate were used for simulations of the experimental mock-up and the full nightclub fires. 5.1.3 Vents Vents in FDS are openings from the model to ambient conditions outside the computational domain. Vents allow smoke and heat to leave the grid area and air to enter. Vents may be either simple openings that allow natural flow to occur based on the buoyancy of the hot gases, or vents may use a specified or forced flow rate such as the flow from a fan. Vents can also be used to introduce heat into the modeling domain. In both the mock-up and the incident simulations, vents are used to represent the areas of the foam which were initially ignited. 5.1.4 Openings Within the Grid The placement of blocks within the grid forms the structure of the building and its contents. The hydrodynamic calculations performed by FDS allow air, hot gases, smoke and flames to flow through the simulated building. Thermal radiation travels by line-of-sight and may be intercepted by obstacles within the grid. Normal buildings may appear tightly constructed, but there are many small openings or leaks within a building that allow for the flow of air or combustion products. Since objects can only exist at grid boundaries, small leaks may be created by either using a very small grid size, or by representing many small leaks by fewer large leaks. During the course of a fire, some items within the building may be consumed by the fire or otherwise change position. FDS does not have the capability to calculate burn-through or collapse but the user can remove items during the course of the calculations. Items that are removed can represent objects that fall or are destroyed by fire, or objects that are changed by people such as doors or windows that are opened. 5.1.5 Smokeview Smokeview is a scientific visualization program that was developed to display the results of an FDS model computation [16]. Smokeview allows the viewing of FDS results in three-dimensional snapshots or animations. Smokeview can display contours of temperature, velocity and gas concentration in planar slices. It can also display properties with iso-surfaces that are three-dimensional versions of a constant value of the property. Iso-surfaces are most commonly used to provide a three-dimensional approximation of the flame surface where fuel and oxygen are present such that flames may exist. 5.2 FDS SIMULATIONS OF THE FULL-SCALE MOCK-UP The major objective of the mock-up experiments was to observe the primary mode of flame spread and smoke movement under fire conditions that were similar to what likely existed early in The Station fire on Feb. 20, 2003. Results from the experiment, which included video records, measurements of heat release rate, temperature, heat flux, oxygen volume fraction, and gas velocity, were used to compare with FDS results for this complex fire environment. The secondary objective was to examine the impact of automatic fire sprinklers under experimental conditions, again to provide a basis of comparison with FDS. In addition to using data from bench-scale experiments, input values to FDS were developed, as described in this section, based on comparisons with the full-scale mock-up experiments. The complete FDS input files are provided in Appendix L.

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1. 2.1 Computational Domain, Grid Size, Initial Conditions, and Boundary Conditions

Selecting the appropriate grid size required balancing the need to resolve critical dimensions and physical phenomena, and the need to budget enough time to perform the hundreds of computer runs necessary to assess the importance of different variables on the outcome. FDS was run on a Linux cluster with eight 3.2 MHz processors. To complete the estimated 100 simulations needed of 300 seconds actual time for the full nightclub fire in a six month window necessitated runs with a turn-around time of less than two days. Based upon the software needs and the hardware capabilities, this translated to a limit of about 2 million grid cells. The computational domain used to simulate the full nightclub measured about 22 m by 33 m by 4 m high, which led to a minimum computational grid size of about 145 mm. Grid size sensitivity has been examined in several studies as noted by McGrattan [17]. For full-scale experiments involving a small compartment, 2.4 m (8 ft) by 3.6 m (12 ft) by 2.4 m (8 ft) high, with fires ranging from 55 kW to 110 kW, 100 mm computational grids were found to provide temperatures within 15 percent of the measured values. Based upon that work and the imposed time constraints, 100 mm was selected as the baseline computational grid size, with computational time savings sought through multi- blocking and the physical evidence provided by the WPRI video and the full-scale mock-up experiments described in Chapter 4. The choice of computational grid size influenced the selection of the appropriate values for the initial conditions, boundary conditions and material properties, including the size and energy of the ignition source, heat transfer at the boundaries, and burning properties of the fuel. With all other inputs kept constant, doubling the grid size did not lead to the fast growing fires seen in the video or mock-up experiments; halving the grid size led to a fire growth rate that was faster than the evidence (and a single run-time of 10 days). Hence the simulations could not be shown to be grid size independent. This confirmed that if the mock-up experiments and mock-up simulations were to be used to develop input parameters for the full nightclub computer simulation, then the computational grid size needed to be consistent between the two simulation cases. With the grid size selected at 100 mm, the mock-up simulation computational domain required 319,000 grid cells. Approximately 17 hours were required to generate a 200 second simulation of a mock-up experiment. The FDS input parameters could be adjusted to the 100 mm grid by comparing the simulation results with the measured results from the full-scale mock-up experiments. The FDS inputs, described later in this section, were then applied to the full nightclub simulation, with the WPRI video serving as a source of comparison. For the full-scale mock-up, the platform area and the dance floor area to the west of the platform were located in a compartment that was 10.8 m east to west and 7.0 m north to south. The ceiling height over the dance floor was 3.8 m. The drummer’s alcove, located to the west of the platform, was 3.1 m wide, 2.4 m deep, and 1.96 m high. The height of the drummer’s alcove floor and ceiling relative to the dance floor were 0.74 m and 2.7 m respectively. The platform was 7.0 m wide and 2.4 m deep and 0.4 m high. Figures 5-1 shows the resulting FDS model in Smokeview based upon a 100 mm grid size. Refer to Fig. 4-16 through Fig. 4-18 for additional details on the mock-up design. The exposed interior finish materials used in the experiment consisted of convoluted polyurethane foam, plywood paneling, gypsum board, and carpeting. In Fig. 5-1a, the foam is shown as a dark gray surface, the paneling is depicted as the brown surface and the carpet is shown as a light blue surface. The remaining light gray surfaces are gypsum board. Foam, spruce, gypsum board and carpet material properties were used in conjunction with tabulated [15] and experimentally derived properties of polyurethane. The bottom of the domain was considered to be an inert, adiabatic solid.

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Figure 5-1a. FDS model of mock-up in Smokeview

The principal fuels in the mock-up were the convoluted polyurethane foam and plywood paneling. In the area of the platform and the drummer’s alcove, the foam was installed over the plywood paneling. The complexity of this arrangement limited the extent to which the burning composite fuel could be modeled a priori. Therefore, several simplifications and assumptions were made in order to generate model results that were representative of the experimental data. The thickness of the convoluted polyurethane foam varied significantly as shown in Figure 5-1b. Typical thickness variations ranged from 6 mm (0.24 in) valleys up to 30 mm (1.2 in) peaks in the “egg crate” configuration. Given that the thickness of two nested sheets was consistent at 36 mm (1.4 in), the foam was approximated as a uniform flat solid with an average thickness of 18 mm (0.7 in). The other material properties used to describe the foam are given in Table 5-1. All of the foam material properties were derived directly from the experiments that were documented in Chapter 4, with the exception of the maximum burning rate. Given the complex nature of the foam over plywood composite, it was difficult to determine when only the foam was pyrolyzing, when only the plywood was pyrolyzing and when they were pyrolyzing at the same time. Therefore a series of simulations was conducted to determine a representative maximum burning rate. The value of the maximum burning rate was varied from 0.004 kg/m2-s to 0.028 kg/m2-s. The maximum burning rate which yielded the heat release rate closest to the experimental results for the unsprinklered mock-up experiment was 0.008 kg/m2-s. The plywood paneling is based on the thermal properties of spruce [18] and is modeled as a charring material as described in [15]. The only modeled difference between the spruce material in the FDS

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Figure 5-1b. Photograph of the edge of two sheets of convoluted polyurethane foam.

Table 5-1. Polyurethane foam material properties used as FDS input. Property Value Thermal Conductivity 0.034 W/m ºC Specific Heat 1.4 kJ/kg ºC Thickness 18 mm Density 22 kg/m3 Ignition Temperature 370 ºC Heat of Vaporization 1350 kJ/kg Maximum Burning Rate 0.008 kg/m2-s

database and the paneling is in the thickness of the material; 5 mm (0.2 in ) was used to represent the paneling. The material properties of gypsum board and carpet were taken directly from the FDS 4 database with no changes [15]. Four heat producing vents were used to simulate the initial fire areas on both sides of the alcove. Two 100 mm (4 in) wide by 200 mm (8 in) tall vents, were located on the west side of the platform wall, at the north and south edge of the drummer’s alcove. Two more heat vents, 100 mm (4 in) square were located

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on the north and south walls of the drummer’s alcove adjacent to the vents of the platform wall. The lower edge of the vents was located 1.50 m (5 ft) above the platform floor. The vents had a defined heat release rate per unit area of 1500 kW/m2. These vents produced heat for the duration of the simulations. The size and location of the vents were based on the locations where the foam was ignited in the full-scale mock-up experiments and the approximate of area involved in fire within a few seconds after ignition. The heat release rate was determined after conducting a series of simulations to match the heat release rate per unit area needed to provide enough energy per unit volume (grid cell volume) to provide reasonable agreement with the results of the full-scale experiment The only opening within the grid of the model itself was the doorway in the east wall of the compartment, as shown in Figure 5-1a. The doorway was 0.9 m (3.0 ft) wide and 2 m (6.6 ft) high. The computational grid extended outside the door 1.2 m to allow unrestricted flow into and out of the doorway. Two simulations of the mock-up experiment are presented in the next section. The first simulation was unsprinklered. The second simulation examined the conditions resulting from the use of automatic fire sprinklers. The capability to model the sprinkler activation and the effects of suppression can not be done a priori. Several simulations were conducted by varying both the parameters that impacted the activation of the sprinklers and the parameters that impacted the suppression physics. The values that are presented in Table 5-2 provided the best fit to the data. Three parameters of the sprinkler are used in a lumped-mass model for the thermal element in the sprinkler: response time index (RTI), activation temperature, and conduction factor [19]. This lumped mass sub-model is used to calculate the time of sprinkler activation. However, the lumped mass model Table 5-2. Sprinkler Properties Used as FDS Input Property Value Sprinkler Type Pendant Operating Pressure 174 kPa (25 psi) K-factor 8.0 L/min/kPa1/2 (5.6 gpm/psi1/2) Response Time Index 16 m1/2 s1/2 (32.6 ft1/2 s1/2) C-Factor 0 Activation Temperature 74 ºC (165 ºF) Offset Distance 100 mm ( 3.9 in) Size Distribution Global Average Median Volumetric Diameter 675 μm (0.03 in) Minimum Spray Angle 75º Maximum Spray Angle 105º Speed 15 m/s (49 ft/s)

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does not account for radiative heat transfer, only conductive and convective heat transfer. In this incident given the location of the fire and the rapid flame spread, radiative heat transfer played a role. The activation temperature used was the listed temperature of the sprinkler from the experiment. No conductive losses were considered in order to eliminate another variable and simplify the determination of the “effective” RTI. The RTI was chosen based on matching the response time of the first sprinkler activated in the experiment. The other sprinklers were given the same RTI. The remaining sprinkler parameters describe how much water would be discharged, what the water droplet size distribution would be and the direction of the droplets discharge. The water flow rate is determined by the operating pressure and the discharge factor (or K-factor). As modeled, the water flow from each sprinkler was 94.6 L/min (28.0 gpm). This flow rate was determined from a series of simulations to develop suppression results that were representative of the full-scale mock-up experiment with sprinklers. The resulting flow rate and spray angle inputs are what was required to simulate the suppression in FDS. They are not a measure of the actual flow rate or spray angles from the experiment. In addition, the computational droplet tracking parameters; age, droplets per second, maximum number of droplets and drop vertical velocity were determined empirically from numerous computations. The water droplet size distribution is based on a median droplet diameter to which a size distribution is applied. A median droplet diameter of 675 μm (0.03 in) was used with the FDS default parameters of the Rosin-Rammler/log-normal distribution (γ= 2.4). [20, 15] The droplets were distributed uniformly in the conical spray pattern emanating from the sprinkler deflector. The spray pattern is defined by the minimum and maximum spray angles. Relative to a sphere that is centered on the sprinkler, with a radius equal to the offset distance, the spray pattern ranged from 75º north of the south pole to 15º above the equator. Further discussion of the sprinkler properties is provided in section 5.2.3. 5.2.2 FDS Full-scale Mock-up Simulation, Non-Sprinklered Results The results of the non-sprinklered simulation are compared with the video record of the experiment, and the measurements of temperature, oxygen volume fraction, heat flux, heat release rate and gas velocity. Visual comparisons of the experiment and simulation are shown in Figures 5-2 through 5-11. Quantitative comparisons between the experimental data and the model predictions are given in Figures 5-12 through 5-18.

Figure 5-2. Ignition at the corners of the drummer’s alcove, t = 0 second.

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Figure 5-3. Flames spreading toward ceiling, t = 10 seconds after ignition. (i) Visual Comparisons Figures 5-2 through 5-11 are composed of pairs of images. The still frames, captured from video tape, appear on the left. The images on the right are rendered from Smokeview. Both images represent the same time after ignition. The pairs of images begin at ignition, or t = 0 seconds, and continue at 10 seconds intervals until 90 seconds after ignition, when most of the visibility from the video is lost. Figure 5-2 shows the experiment and the simulation at the time of ignition. The video frame on the left shows the foam covered walls, the wood paneling, and the carpeted platform. Gypsum board covered the ceiling, floor and the remaining wall areas that were not covered with wood paneling or foam. Some of the instrumentation can be seen in the foreground of the video frame. In the image from the simulation, on the right, the comparable interior finishes can be seen. The instrumentation in the right figures is represented by colored dots. The thermocouples appear as yellow dots in evenly spaced arrays. The light gray blocks represent the locations of the heat flux sensors and the gas sampling locations, which were installed at approximately 1.5 m (5 ft) above the floor. Figure 5-3 compares the fire development at 10 seconds after ignition. A flame is shown on both corners where the platform wall intersects with the drummer’s alcove. In the case of FDS, the area that appears to be involved with flames is based on the stoichiometric mixture fraction, where there is the ideal mixture of fuel and oxygen for a robust flame to exist. The heat release rate per unit volume represented by the simulated flames is 285.5 kW/m3. The flames in the simulation appear wider due to the grid resolution, which is 100 mm (4 in) throughout the room. The video frame to the left in Figure 5-4 shows flames 20 seconds after ignition growing vertically and impinging on the ceiling. The simulated flames on the right, however, have not yet reached the ceiling. As noted above, the simulated flame is constrained to grow in 100 mm (4 in) increments, both vertically and laterally. This may account for the wider flame and the accompanying redistribution of energy that would reduce the propensity for rapid vertical flame spread. Light smoke can be seen in both images along the ceiling of the alcove, with light wisps of smoke along the ceiling above the platform.

5-9

Figure 5-4. Flames impinging on ceiling, t = 20 seconds after ignition.

Figure 5-5. Visible smoke spreading across ceiling, t = 30 seconds after ignition.

Figure 5-5 shows an increased amount of smoke flow across the ceiling at 30 seconds after ignition. The actual fire continues to grow at a faster rate than the simulated flames. In the video frame on the left the flames have formed twin V-patterns on each side of the alcove and the flames are spreading across the alcove ceiling. Notice the light smoke that is coming up from the carpeting below the two fire plumes. This is the result of foam melting and the burning foam droplets falling to the floor. This mode of flame spread is not accounted for within the FDS model. At 40 seconds after ignition, the video frame in Figure 5-6 shows areas of the foam on the platform wall have burned out (note the dark area directly above the point of ignition on the left side of the alcove). The actual flame fronts have continued to spread and into the alcove, where fire is visible on portions of the side walls and the ceiling of the alcove. The flames simulated with FDS have also grown, although at a slower rate. Both of the simulated flames have impinged on the ceiling.

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Figure 5-6. Flames continue to spread into alcove, t = 40 seconds after ignition.

Figure 5-7. Ceiling of alcove fully involved in fire, t = 50 seconds after ignition.

Figure 5-7, has images captured at 50 seconds after ignition. In the experiment, it appears that the entire ceiling of the alcove is burning, as well as the area of the platform wall above the opening to the alcove. There is also more smoke from drop-down of the burning foam onto the carpet, both in the alcove and on the platform. In the simulation, the flames have moved into the alcove and are spreading across the ceiling. In both images, the smoke or hot gas layer has developed across the ceiling of the enclosure. In Figure 5-8, the ceiling and the walls of the alcove have become fully involved with fire in both of the images. At 60 seconds after ignition, flashover has already occurred in the experiment and flashover is about to occur in the simulation. In both cases, flames are extending out of the alcove across the ceiling and the smoke layer has become thicker and darker.

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Figure 5-8. Flashover has occurred in alcove area, t = 60 seconds after ignition.

Figure 5-9. Smoke layer has dropped to 1.5 m above floor, t = 70 seconds after ignition.

The images in Figure 5-9 show a significant increase in the amount of the smoke in the enclosure. The smoke layer has descended to within 1.5 m (5 ft) of the floor. The flames have spread along the wall behind the platform and can be seen at the lower edge of the smoke layer in both the video frame and the image from the simulation. The smoke in the experiment appears lighter in color than it actually is due to light that is being reflected from floor level halogen lights that were used to improve the visibility for the video cameras. The fire continues to grow in both the experiment and the simulation as shown in Figure 5-10. The smoke layer has continued to descend. The interface height of the smoke layer is approximately 0.75 m (2.5 ft) above the floor at 80 seconds after ignition for both the experiment and the simulation. Both images also show the flame extension on the left wall of the enclosure. The upper portion of the left wall near the platform had foam installed over the paneling.

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Figure 5-10. Fire continues to spread, t = 80 seconds after ignition.

Figure 5-11. Visibility lost, t = 90 seconds after ignition.

The last set of images, Figure 5-11 demonstrate that most of the visibility in the enclosure has been lost due to smoke filling. A small layer of clear area can be seen near the floor in both the experiment and the simulation. This is due to fresh air being drawn into the fire enclosure through the open doorway. The image pairs show that the simulation is not exact with respect to time, in reproducing the development and growth of the fire, especially during the initial growth stages of the fire. Based on the images during the first 40 seconds of the fire FDS appears to lag behind in fire growth by approximately 10 to 20 seconds. As the fire reaches the transition point of flashover, the simulation has reduced the time lag significantly. Post-flashover, the appearance of the fire progression and the smoke development for both the experiment and the simulation are more closely synchronized with each other.

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(ii) Numerical Comparison In this section, measurements of power generated, temperature, heat flux, oxygen volume fraction, and gas velocity from the full-scale mock-up experiments described in Chapter 4 are compared with the values generated by the FDS simulation. The heat release rate of the fire is the source for the energy transfer that occurs throughout the fire environment. Heat release rate is critical in fire protection engineering for assessing the development of a hazard due to a fire within a building. In addition, the heat release rate is a function of oxygen depletion. Therefore, differences in the heat release rate comparison also impact the comparison of the temperature, heat flux, oxygen, and gas velocity measurements. Figure 5-12 compares the measured heat release rate leaving the door of the experiment (based upon oxygen consumption) to the heat release rate from the fire within the compartment as predicted by FDS. For fires burning in the open under the laboratory hood, the thermal power measured by the oxygen depletion calorimeter is equal to the heat release rate from the fire. However, for a fire within an enclosure, the effluent from the room is a mixed average of the upper layer gases, and does not represent the instantaneous heat release rate of the fire. Smoke did not exit the compartment doorway until approximately 60 seconds after ignition. This means that a direct comparison between the experimental measurements and the numerical predictions cannot be made because the oxygen depletion calorimeter does not respond to a fire within an enclosure until the combustion products have had time to exit the door and become entrained into the hood. The heat release rate predicted by FDS in Fig. 5-12 represents the instantaneous heat release throughout the room. The heat release rate reaches a peak of

0 1000 2000 3000 4000 5000 6000 7000 8000 0 50

Experiment

5-14 100 150 200 FDS HRR (kW) Ti e (s)

m

Figure 5-12. Power generated in experiment as measured outside of doorway, compared to FDS simulation of heat release rate from fire within compartment.

0 100 200 300 400 500 600 700 800 0 50 100 150 200 Experiment - Ceiling Experiment - 1.4 m FDS - Ceiling FDS - 1.4 m Temperature (oC) Time (s)

Figure 5-13. Temperature comparison between the un-sprinklered fire experiment and the FDS simulation at Station C. approximately 6 MW about 70 seconds into the simulation, 20 seconds prior to the peak in thermal power measured in the oxygen depletion calorimeter. Both curves approach 3000 kW ± 300 kW approximately 150 seconds into the fire, again consistent with a ventilation-limited condition. The heat release rates diverge at longer times as the model consumes the remaining interior finish fuels while the physical fire continues to burn at a reduced rate into the wood supporting the platform and walls. When the areas under the heat release rate curves were integrated, the resulting energies were found to agree within 10 %. Figure 5-13 is a comparison of the temperatures predicted and measured 25 mm below the ceiling and 1.4 m above the floor at the thermocouple array located at Station C (4.25 m west of the door opening or 1.7 m from the platform). The FDS output has been smoothed by applying a Stineman function (a geometric weight applied to the current point ±10 % of the data range). The temperature data show reasonable agreement with the predictions, including an overshoot followed by a leveling off as the fire reaches a ventilation limit. The temperatures near the ceiling increase faster in the test; conversely, the lower level temperatures increase at a slower rate in the test. Note that, unlike the heat release rate, the temperature measurements respond to the local environment within a second; hence, the experimental temperatures and FDS predictions can be compared directly. Initially, the experimental measurements near the ceiling increase more rapidly than predicted. This is probably due to the strong transverse temperature gradients associated with the ceiling jets created early in the fire (see Fig. 5-5), where small differences in position between the experiment and simulation can have a large change in temperature. The simulated thermocouple temperatures are temperatures averaged over the grid cell volume(s) that they are associated with, which results in differences in positions between the experimental point measurement and the FDS output. The peak temperatures for the experiment and the simulation occur within 5 seconds of each other.

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Figure 5-14 is a comparison of the temperatures predicted and measured 25 mm below the ceiling and 1.4 m above the floor at the thermocouple array located at Station D (2.35 m west of the door opening). Similar to the previous figure, the temperature data show reasonable agreement with the predictions. The trends are also similar and both of the measured temperatures and the predictions exhibit a reduction in peak temperatures relative to the values from Station C that is located approximately 2 m closer to the platform. Figures 5-15 and 5-16 present the heat flux measurements taken at Stations C and D respectively. There were three total heat flux sensors at each position: one installed at ceiling level with the sensor aimed at the floor; and two sensors installed at approximately 1.5 m (5 ft) above the floor with one aimed at the ceiling and the other aimed toward the platform end of the enclosure. In both cases, the predictions follow the trends of the measured heat flux. Better agreement in terms of magnitude occurs at the ceiling level. The predicted heat fluxes 1.5 m above the floor are low by almost 50 % when compared with three out of four measurements. Figures 5-17 and 5-18 represent the oxygen volume fraction comparisons between the measurements at Stations C and D and the predicted values from FDS. The measurements and the predictions were positioned at 1.5 m (5 ft) above the floor. The oxygen levels predicted by FDS dropped sooner but slightly less rapidly than the experimental measurements; both reached the same low value of about two percent, confirming that the fire was close to ventilation-limited at this point.

0 100 200 300 400 500 600 700 800 0 50 100 150 200 Experiment - Ceiling Experiment - 1.4 m FDS - Ceiling FDS - 1.4 m Temperature (oC) Time (s)

Figure 5-14. Temperature comparison between the un-sprinklered fire experiment and the FDS simulation at Station D.

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0 10 20 30 40 50 60 0 50 100 150 200 Experiment - Ceiling Experiment - Facing up Experiment - Facing Alcove FDS - Ceiling FDS - Facing Up FDS - Facing Alcove Heat Flux (kW/m2) Time (s)

Figure 5-15. Heat flux comparison between the un-sprinklered fire experiment and the FDS simulation at Station C

0 10 20 30 40 50 0 50 100 150 200 Experiment - Ceiling Experiment - Facing up Experiment - Facing Alcove FDS - Ceiling FDS - Facing up FDS - Facing Alcove Heat Flux (kW/m2) Time (s)

Figure 5-16. Heat flux comparison between the un-sprinklered fire experiment and the FDS simulation at Station D.

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0 5 10 15 20 25 0 50 1

Experiment Station C

5-18 00 150 200 FDS Station C Oxygen (Volume %) Tim (s)

e

Figure 5-17. Oxygen volume fraction comparison between the un-sprinklered fire experiment and the FDS model at approximately 1.5 m above the floor at Station C.

0 5 10 15 20 25 0 50 100 150 200 Experiment Station D FDS Station D Oxygen (Volume %) Time (s)

Figure 5-18. Oxygen volume fraction comparison between the un-sprinklered fire experiment and the FDS model at approximately 1.5 m above the floor at Station D.

(iii) Tenability Tenability limits based upon the work of Purser [21] were discussed in section 4.6.8. The time predicted by FDS to reach the limits of temperature, heat flux, and oxygen are summarized in the top portion of Table 5.3. The agreement between the simulation and experimental measurements at Location C is within eight percent, with both methods indicating the heat flux criteria is exceeded first, around one minute into the fire. Table 5.3 Time to reach untenability criteria at Location C, or maximum deviation obtained, in sprinklered and unsprinklered simulations, compared to experimental measurements

Temperature

120

oC Heat Flux

2.5 kW/m2

Oxygen < 12 %

Unsprinklered

Experiment

76 seconds 61 seconds 87 seconds FDS 72 seconds 57 seconds 80 seconds

Sprinklered

Experiment

< 24 oC < 0.32 kW/m2

20.6 %

FDS

< 22 oC 18.8 %

1. 2.3 FDS Full-scale mock-up Simulation, Sprinklered Results

The results of the sprinklered simulation are compared with the video record of the experiment, and the measurements of temperature and oxygen volume fraction. Visual comparisons of the experiment and simulation are shown in Figures 5-19 through 5-27. Quantitative comparisons between the experimental data and the model predictions are given in Figures 5-28 through 5-32. Given the limited growth of the fire during the experiment, the oxygen depletion calorimeter did not register a significant rate of heat release. The comparison of the sprinkler activation times from the sprinklered mock-up experiment and the FDS simulation of that experiment are given in Table 5-4. In FDS, the activation time of the first sprinkler was the result of adjusting the RTI in the simulation until the times were similar. The RTI that provided the best match, 16 m1/2 s1/2 (32.6 ft1/2 s1/2), was used as the RTI for the remaining sprinklers in both the mock- up and the full nightclub simulation. The order of sprinkler activation, and the number of sprinklers activated, were the same in the simulation and the experiment. The times to activation differed by no more than 6 seconds. (i) Visual Comparisons Figures 5-19 and 5-27 are composed of pairs of images. The still frames, captured from the video tape of the experiment, appear on the left. The images on the right are rendered from Smokeview. Both images represent the same time after ignition. The pairs of images begin at ignition or t = 0 seconds and continue at 10 second intervals until 60 seconds after ignition, when most of the fire in the experiment had been suppressed. Additional sets of images are included at 25 seconds after ignition to show the initial sprinkler just after activation and at 90 seconds to demonstrate the lack of significant fire spread after

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Table 5-4. Comparison of sprinkler activation times. Sprinkler Activation Times (seconds)

Sprinkler Location Experimental Fire Dynamic Simulator Northwest 24 23 Southwest 29 35 Alcove 30 36 Northeast Did Not Activate Did Not Activate Southeast Did Not Activate Did Not Activate

Figure 5-19. Ignition at the corners of the alcove, t = 0 seconds.

Figure 5-20. Flames spreading toward ceiling, t = 10 seconds after ignition.

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Figure 5-21. Flames impinging on ceiling, t = 20 seconds after ignition.

Figure 5-22. Initial sprinkler operating, t = 25 seconds after ignition.

Figure 5-23. Third sprinkler operating in experiment, t = 30 seconds after ignition.

5-21

Figure 5-24. Suppression with three sprinklers operating in each case, t = 40 seconds after ignition.

Figure 5-25. Fire suppression continues in both the experiment and the simulation, t = 50 seconds after ignition.

Figure 5-26. Fire controlled in both cases, t = 60 seconds after ignition.

5-22

Figure 5-27. Fire controlled in both cases, t = 90 seconds after ignition.

sprinkler activation. Figures 5-19 through 5-21 show a very similar progression in fire growth as the unsprinklered case for both the experiment and the FDS simulation between ignition and 20 seconds after ignition. Figure 5-22 was captured at 25 seconds after ignition, approximately 1 second after the first sprinkler activated in both the experiment and the simulation. With the experiment, the impact of the sprinkler can be seen as the fire on the right side of the platform wall is suppressed. In FDS the flame height on the right side of the alcove can be seen to be reduced. By 30 seconds (see Fig. 5-23) the effect of both of the sprinklers above the platform operating as well as the sprinkler in the alcove is apparent. Burning continues at the intersection of the platform wall and the ceiling. This area is above where the water spray is hitting the wall. Also notice the flames on the ceiling of the alcove. This area is shielded from the water spray of the two sprinklers. The smoke being pushed out of the alcove is due to the activation of the sprinkler on the ceiling of the alcove. In the simulation, only one sprinkler is operating at this time. The fire growth on the right side of the alcove has been limited by the single sprinkler. By 40 seconds after ignition, three sprinklers in the experiment and in the simulation have activated. The video frame in Figure 5-24 shows that the fire in the alcove has been suppressed and that the burning above the water line on the platform wall continues. With three sprinklers operating in FDS, the water spray is significantly reducing the visible flames. The flames on the platform wall have been suppressed. However, there are still flames visible at the intersections of the alcove ceiling and the alcove walls on both sides of the alcove. These areas are shielded from the water spray of the sprinklers over the platform and they are above the water impact line from the sprinkler in the alcove. Figures 5-25 through 5-27 show continued fire suppression for both the experiment and the simulation. In both cases some flames exist in the ceiling area of the alcove. But clearly the rate of fire growth and the resulting hazard development has been reduced significantly when compared with the unsprinklered case. Both the experiment and the computer model demonstrate that the sprinklers would prevent flashover and considerably mitigate the hazard from the fire. However, the degree to which the fire is controlled is different between the experiment and the model, since the simulation has more flame spread along the edges of the alcove ceiling after activation of the sprinklers.

5-23

(ii) Numerical Comparison In this section, measurements of heat release rate, temperature, heat flux, and oxygen volume fraction from the full-scale mock-up sprinklered experiments conducted in Chapter 4 are compared with values generated by the FDS simulation. Figure 5-28 shows the FDS predicted heat release rate for the sprinklered enclosure. The experiment failed to produce enough combustion gases for the oxygen depletion calorimeter to measure a heat release rate. This was due to the rapid sprinkler activation, the effective fire suppression and the large volume of the enclosure. This graph demonstrates that in the simulation the fire grew after the activation of the third sprinkler (all were operating by 36 seconds). The decrease in HRR at approximately 140 seconds is when the shielded (dry) foam on the alcove ceiling burns itself out. In the experiment, foam above the line of water impact on the walls and the ceiling continued to burn after sprinkler activation as was shown in Figures 5-24 through 5-26. The comparison of the temperatures at Stations C and D are shown in Figures 5-29 and 5-30. In both cases FDS under predicts the temperatures near the ceiling. The FDS predictions in these two graphs have not been smoothed in order to show that the peak values near the ceiling are very close to the sprinkler activation temperature of 74 ºC. Typically the temperature of the fire gases surrounding a sprinkler at the time of activation is approximately twice the listed temperature. Due to the continued burning of foam on the ceiling of the alcove prior to complete extinguishment, the temperature in the simulated enclosure increases over the experimental temperatures. However, at the 1.4 m level above the floor the temperature never exceeds 35 ºC (95 ºF). This is well within the temperature tenability range. 0 100 200 300 400 500 0 50 100 150 200 HRR Heat Release Rate (kW) Time (s) 3 sprinklers operating

Figure 5-28. FDS predicted heat release rate for the sprinklered case.

5-24

0 50 100 150 200 0 50 100 150 200 Experiment - Ceiling Experiment - 1.4 m FDS - Ceiling FDS - 1.4 m Temperature (oC) Time (s)

Figure 5-29. Temperature comparison between the sprinklered fire experiment and the FDS simulation at Station C.

0 20 40 60 80 100 120 140 0 50 100 150 200 Experiment - Ceiling Experiment - 1.4 m FDS - Ceiling FDS - 1.4 m Temperature (oC) Time (s)

Figure 5-30. Temperature comparison between the sprinklered fire experiment and the FDS simulation at Station D.

5-25

0 0.2 0.4 0.6 0.8 1 0 50 100 150 200 Experiment - Ceiling Experiment - Facing Up Experiment - Facing Alcove FDS - Ceiling FDS - Facing UP FDS - Facing Alcove Heat Flux (kW/m2) Time (s)

Figure 5-31. Heat flux comparison between the sprinklered fire experiment and the FDS simulation at Station C. The comparison of the measured heat flux with the calculated heat flux is shown in Figures 5-31 and 5-32. Due to the limited fire growth and significant cooling by the water all of the heat flux values are less than 1 kW/m2. One notable difference between the experiment and the simulation is after the sprinklers activate in the experiment, the measured heat flux goes to zero, while in the simulation small values heat flux energy continue to be shown. Figure 5-33 exhibits the comparison of the measured and predicted oxygen concentrations at Station C. The measured oxygen concentration shows only a slight decrease during the 200 seconds, while the simulation shows a decrease of approximately 2 percent. This may be due to the continued burning of the foam along the ceiling of the alcove that is taking place in the simulation of the experiment. (iii) Full-scale mock-up comparison - Summary The visual and numerical comparisons demonstrate that the effects of an automatic fire sprinkler system on a fire can be successfully modeled by FDS and visualized with Smokeview. Both the experiment and simulation demonstrate that the sprinklers would prevent flashover and considerably mitigate the hazard from the fire in the test enclosure. However, the degree to which the fire is controlled is different between the experiment and the model, since the simulation has more flame spread along the edges of the alcove ceiling after activation of the sprinklers. The temperature, heat flux, and the oxygen volume fraction comparisons show reasonable agreement between the experiments and the model in terms of both trends and range. Again some differences were caused by the increased burning after the start of suppression in the shielded areas, but that phenomenon has been documented in other experiments as well [22]. Tenability limits were predicted never to be exceeded using FDS, consistent with what was observed in the full-scale mock-up experiments. The lower portion of Table 5.3 compares the extreme values of heat flux, temperature, and oxygen volume fraction predicted in the simulation to the measured values.

5-26

0 0.2 0.4 0.6 0.8 1 0 50 100 150 200 Experiment - Ceiling Experiment - Facing Up Experiment - Facing Alcove FDS - Ceiling FDS - Facing Up FDS - Facing Alcove Heat Flux (kW/m2) Time (s)

Figure 5-32. Heat flux comparison between the sprinklered fire experiment and the FDS simulation at Station D.

0 5 10 15 20 25 0 50 100 150 200 Experiment - 1.5 m FDS - 1.5 m Oxygen (Volume %) Time (s)

Figure 33. Oxygen volume fraction comparison between the sprinklered fire experiment and the FDS simulation at approximately 1.5 m above the floor at Station C.

5-27

1. 3

FDS INCIDENT SIMULATION 5.3.1 Computational Domain and Materials The computational domain used for the incident simulation consisted of eight adjoining rectangular meshes. Figure 5-34 shows an isometric view and Figures 5-35 and 5-36 show two different external views of the building. Each mesh was 4.1 m (13.5 ft) wide and the lengths varied from 10.8 m (35.4 ft) to 21.6 m (70.9 ft) based on the size of the structure and vent location. Each computational (or grid) cell was 100 mm (3.9 in) on a side. The input geometry for the Station nightclub including all wall, door and window sizes and locations was modeled based on the documentation provided in Chapter 2. Figure 5-37 is a plan view, Figures 5-38 shows the grid spacing used for the foam on the platform, and Figure 5-39 is a view looking toward the horseshoe bar and side exit from the center of the nightclub. The interior finishes of the structure were simplified and modeled as five different materials: foam, wood, ceiling tile, gypsum board and carpet. The foam was prescribed with a wood backing due to the fact that the foam burns away leaving the wood paneling behind. Typically, FDS accounts for the burning of a single material; thus, the model was modified to allow the wood behind the foam to burn once the foam had burned away. The actual structure was lined with multiple types of wood such as paneling, wafer boards and bead board. In the simulation, all of these woods were prescribed with a single set of material properties. The ceiling tile, gypsum board and nylon carpet properties were based upon a combination of the cone calorimeter tests described in Chapter 4 and the FDS materials database. The view of the platform area seen in Figure 5-40 contains foam (grey), wood (brown and black), gypsum board (tan) and ceiling tile (tan). Table 5-5 lists the material properties used in the simulation of the full-scale nightclub. The only difference in the properties used in the full nightclub versus the mock-up simulation was the thickness of the foam and the paneling. Based on materials observed in the field, the foam recovered from the nightclub was thicker than the foam used in the mock-up; a value of 30 mm (1.2 in) was chosen. The paneling that remained in the nightclub was installed in two layers. Therefore the thickness of the paneling for the incident simulation was doubled relative to the mock-up. The ceiling tile, gypsum board, and carpet used the same values as the FDS database, which were the same values used in the mock-up simulation. The complete FDS input files are provided in Appendix L. Table 5-5. Simulation Material Properties

Material

Thickness (m) Ignition Temperature (oC) Heat of Vaporization (kJ/kg) Thermal Conductivity (W/m K)

Density (kg/m3) Foam 0.03 370 1350 0.034 22.0 Paneling 0.01 360 500 0.13-0.29 450 Ceiling Tile 0.016 NA NA 0.0611 NA Gypsum Board 0.013 400 NA 0.48 NA Carpet NA 280 3000 NA NA

5-28

Figure 5-34. FDS computational domain of full nightclub

Figure 5-35. External view of nightclub from northeast corner

Figure 5-36. External view of nightclub from northwest corner

5-29

Figure 5-37. View from above with structure sliced 2.5 m above floor

Figure 5-38. Numerical grid used for foam covered walls on platform. Red squares represent the points of ignition

5-30

Figure 5-39. View from center of nightclub toward horseshoe bar, with side exit and front windows in background

Figure 5-40. View of platform and dance floor showing different materials

5-31

1. 3.2 Vents and Openings

All four sides and the top of the computational domain were modeled as open to the environment outside of the domain to allow air to enter and combustion products to exit. The outside temperature was assumed to be the same as the initial temperature inside, and the wind was assumed to be calm1. The bottom of the domain was considered to be an inert, adiabatic solid. Four heat producing vents were modeled: two 200 mm (7.8 in) square vents on the front corner of the alcove, and two 100 mm (3.9 in) square vents located 100 mm (3.9 in) back from the corner, into the alcove. All of the heat producing vents were 1.24 m (4 ft) above the floor of the alcove. The vents have an energy flux of 1500 kW/m2 and emit energy for 35 seconds beginning at t = 0 seconds. The structure's doors and windows were opened during the simulation based on estimations from the WPRI video. The first door to open was the door adjacent to the platform. This door was observed opening in the video 29 seconds after ignition. The front double door was assumed to open shortly after the stage door at 30 seconds. This time was selected due to the crowd beginning to notice the fire and to move toward the front door. The side door near the main bar was opened at 45 seconds and the side door in the kitchen was opened at 60 seconds. These times were estimated by the crowd movement seen in the video and the remoteness of the doorways from the stage area. At 78 seconds, the lower portion of one of the bay windows was removed. This appeared to occur as the cameraman passes by on his way to the rear of the structure. Portions of the windows located on the front of the structure, left of the main entrance were removed at 80 seconds. This included the lower half of each of the matching windows next to the large window in the center, the entire large window in the center, all of the thin window to its left and the lower half of the thin window to its right. Finally, more sections of the bay window, surrounding the portion that was removed at 78 seconds, were removed between 100 and 130 seconds. The side bay window facing the main entrance was seen open in the WPRI video and the three other windows between the side window and the lower portion of the window were removed at 78 seconds based on the sounds heard in the video. Vent opening times are summarized in Table 5-6 and visualized in Figure 5-41. Table 5-6. Time of Openings for FDS Simulation Location of Opening Time of Opening (s) Stage Door 29 Front Double Door 30 Side Door (near main bar) 45 Side Door (kitchen) 60 Front Bay Window (lower portion) 78 Front Windows 80 Left Side Bay Window 100 Three Bay Windows 110, 120, 130

1 The temperatures recorded at T.F. Green Airport that night were in the high 20s (oF) and the winds were light.

5-32

30 s 80 s 78 s 100 s 110 s 120 s 130 s 45, 60 s 29 s Figure 5-41. Visualization of Opening Times 5.3.3 FDS Simulation Results The focus of this simulation was the examination of the conditions that may have been present in The Station nightclub during the early stages of the fire. Results from the bench-scale experiments and existing data were used to develop the input properties for the interior finish materials. The full-scale mockup results were used to compare against the FDS simulations to validate the implementation of the data in the model, and to determine the model’s capabilities for this fire incident. Further, the sprinklered mock-up results were used to develop a means to model the sprinkler in the full nightclub simulation. Images from the WPRI video were utilized to develop model input to establish the location of the different interior finishes within The Station nightclub as well as being used as a general resource for confirming the physical arrangement of the nightclub. The simulation was run for 300 seconds to examine the time period from ignition to the approximate time of application of water by the fire department. The computation included simulated fire and smoke spread, potential temperatures, oxygen concentrations and visibility that may have existed in the actual incident. Each of these was compared to published tenability criteria. In order to gauge the accuracy of the full nightclub simulation results, they were compared with the WPRI video record of the incident. In addition, analysis of the simulation considered published tenability criteria and the location of the victims within the nightclub. (i) Heat Release Rate The total heat released in the fire is plotted in Figure 5-42. The graph shows that after the alcove became fully involved with fire, at approximately 50 to 60 seconds, the heat release rate increased from approximately 2 MW to 54 MW in less than 50 seconds. Hence the rate of increase was more than 1 MW per second. As the fire spread throughout the structure and the fire became oxygen limited the heat release rate became steady at approximately 45 MW for approximately 150 seconds. After that time, the simulation began to deplete the fuel contained in the interior finish materials. The fire in the actual nightclub had spread into the structure and burned in and through areas of the roof and walls by this time. The simulation only provided fuel based on the interior finish and did not account for fuel being provided by structural elements and materials in building outer envelope.

5-33

0 10 20 30 40 50 0 50 100 150 200 250 HRR Heat Release Rate (MW) Time (s) 60

Figure 5-42. Total Heat Released in Building Fire Simulation as a Function of Time (ii) Fire Growth and Smoke Spread Images were selected from the WPRI video to compare with the FDS simulation results. Iso-surfaces of the heat release rate per unit volume and three-dimensional smoke density parameters are displayed in the Figures 5-43 through 5-53. It should be noted that the orange color in Smokeview tracked the location of stoichiometric fuel and air mixture. If the temperature were high, then the orange surface could be thought of as a flame; if the temperature were below a threshold value, then no flame was actually present, just a non-burning mixture of fuel and air. Qualitative agreement can be seen between the pairs of images from the video and the simulation for both the initial growth prior to the videographer leaving the structure, and the outside view as the videographer walked around the structure. This similarity helped the investigation draw conclusions as to the conditions inside the structure even though the video was no longer recording inside. Time “0” refers to the instant of ignition of the foam by the gerbs as documented in the WPRI video. All of the times that accompany the figures below are times after ignition. The times were chosen based on the image availability from the WPRI video. The images were chosen based on the visibility of the fire or the smoke from the fire. The last image set does not reflect the same time. The simulation stops at 300 seconds while the image from the video showing flames from the front of the nightclub was not recorded until 337 seconds after ignition. At this point in the fire, conditions were not changing as rapidly as during the fire development, so the comparison between the two images is reasonable. The images from the video in Figures 5-43 and 5-44 capture the initial state of the fires on each side of the platform shortly after the gerb discharge had stopped. At 10 seconds after ignition, the fire can be seen burning on two surfaces at each of the corners; this is also considered in the simulation with the placement of the ignition vents on both sides of the corner. In both the simulation and the actual incident the flames impinge on the ceiling within 20 seconds after ignition.

5-34

Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. Figure 5-43. Initial growth of fire on foam at corner of the alcove (10 seconds)

Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. Figure 5-44. Flames impinging on ceiling (19 seconds) At 23 seconds after ignition, Figure 5-45, the videographer has begun to move toward the exit as have many in the crowd. Notice that many people are still facing the platform. The fire continued to grow and smoke has collected in the raised ceiling area over the dance floor. The smoke filling can be seen in the image from the simulation. (Note the black rectangular image on the floor is representative of the speaker cabinet, whereas the boundaries of the smoke layer are irregular.) At 53 seconds after ignition, the flames have grown and spread along the platform wall and into the alcove as shown in video image in Figure 5-

1. In addition, the smoke is spreading across the lower level ceiling area toward the main exit. The

flames have spread in the simulation as well and smoke is beginning to spill over from the dance floor area towards the exits and the main bar room, although it takes a few more seconds into the simulation for this to occur. Again the black rectangular objects on the floor are representative of speaker cabinets (near the platform) and the sound and lighting board (left side). The videographer had exited the nightclub at approximately 70 seconds and headed toward the stage door. He then returns toward the main entrance and attempts to pass between the nightclub and the bus when he encounters a plume of black smoke pushing out of one of the window vents in the sunroom. The image from the simulation also shows a similar view. At approximately 110 seconds after ignition, smoke is flowing from the main entrance; the image from the simulation is given in Figure 5-48. The model did not account for people blocking the air flow into the doorway.

5-35

Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. Figure 5-45. Videographer backing away from platform (23 seconds)

Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. Figure 5-46. Smoke beginning to roll across ceiling (video 53 seconds, simulation 60 seconds)

Figure 5-47. Smoke billowing outside from broken sunroom window (100 seconds) Copyright © 2003 TVL Broadcasting, Inc. All rights reserved.

5-36

Figure 5-48. Light smoke emanating from front door of nightclub (110 seconds) The Smokeview image in Figure 5-49 shows the smoke flow from the front door at 160 seconds after ignition in the simulation. In Figure 5-50, the simulated smoke flow from the main bar room windows is shown. More smoke is coming from the center window than the two side windows because the upper and lower portions of the center window have been removed while only the lower portion of the side windows are open in the simulation. The videographer moves around to the stage door again. The view inside the open door at approximately 289 seconds after ignition is shown in Figure 5-51 The image from the simulation agrees with the video image on the level of combustion products in the doorway. However without a comparison to the temperature in the doorway, the mixture fraction alone would indicate that more flames are in the area of the stage doorway than can be seen in the video image. The videographer continues around to the backside of the nightclub, at 300 seconds after ignition flames are coming through a small portion of the back wall (south wall) of t ance floor area and smoke is leaking from the bat room hallway wall. The video area of the front door. It takes another 25 seconds before he is in a position to record the images of the flames he d h grapher moved toward the front of the nightclub again, at 309 seconds flames can be seen in the coming from the sunroom windows and the main door. The simulation stops at 300 seconds after ignition, short of the time that the entire nightclub reaches flashover conditions.

Figure 5-49. Heavy smoke leaving front door and open main bar window (160 seconds)

5-37

Figure 5-50. View of smoke plumes from front windows of horseshoe bar area (176 seconds)

Figure 5-51. Looking in oor exit (289 seconds)

to stage d

Figure 5-52. Flames breaking through front door and sunroom windows (337 seconds video, 300 seconds simulation) Copyri sting, Copy Inc. All Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. ght © 2003 TVL Broadca Inc. All rights reserved. right © 2003 TVL Broadcasting, rights reserved.

5-38

Smokeview images were rendered at certain time intervals from the view looking through the far side of the main bar to the platform area. (See Figures 5-53a,b.) This allowed for the conditions to be observed at several key locations: the platform area, the entrance to the main exit way and the main bar area. Many of the occupants traveled this path as either they were able to exit or were overcome by the conditions prior to being able to do so. The fire developed quickly in the platform area as the foam burned and resulted in the alcove becoming fully developed with fire. Once that occurred the flames involved the entire rear wall and spread toward the main entrance, generating large amounts of smoke. At 70 seconds after ignition, the smoke can be seen in the area of the main entrance to the nightclub. This is consistent with the WPRI video. As the videographer leaves the nightclub, at approximately 70 seconds after ignition, smoke is flowing over the heads of people in the main entry foyer. However, even 80 seconds after igni bar room. This changed suddenly as the smoke and hot ases that w w-filled raised ng above the dance floor quickly spread to the vi be seen in the last three images of ea began to burn. tion visibility remained high in the main ere spilling out of the no g ceili main bar room. Based on the FDS simulation, within another 20 seconds, 100 seconds after ignition sibility was impaired, and remained so throughout the rest of the 300 seconds simulation. Flames can Figure 5-53b as the surfaces in the main bar ar

ignition (0 seconds)

20 seconds

40 seconds

60 seconds Figure 5-53a. View of fire from beyond horseshoe bar, looking at platform (0 - 60 seconds)

5-39

70 seconds

80 seconds

85 seconds

100 seconds

200 seconds

250 seconds Figure 5-53b. View of fire from beyond horseshoe bar, looking at platform (85 - 250 seconds)

5-40

(iii) Temperature Temperature slices were examined to assess the tenability conditions that existed during the evolution of the fire. Horizontal slices were taken at both the 1.5 m (5 ft) and 0.6 m (2 ft) levels above the floor with the ceiling rendered transparent to examine the temperature distribution throughout structure as a whole. Vertical slices were used to analyze certain locations where groups of victims were located (See Figure 5- 54). These locations included the main entrance as seen through the front door, the area leading into the exit area from the dance floor, and the left side of the sunroom and the open area adjacent to the side bar and kitchen. This analysis utilized 120 ºC (248 ºF) as the temperature tenability threshold [6]

Figure 5-54. West Warwick Police Department Victim location diagram emperatures increase dramatically shortly after the alcove area reaches flashover conditions at ately 65 seconds and then the platform area becomes fully involved in flames. The first two ages in Figure 5-55 show the temperatures at 1.5 m (5 ft) above the floor at 80 and 85 seconds. Within at 5 second time interval the simulation predicts that dance floor area of the nightclub would have become untenable due to temperature. By 100 secon ulation shows a large portion of the structure had become untenable due to tempera e at the 1.5 m (5 ft) level. Figure 5-55 continues with the presentation of simulation temperature resul from 160 seconds to 250 seconds after ignition. During this time interval temperatures continue to remain in the untenable range throughout the simulated nightclub, with the exception of areas that are consid ed closed off from the hot gas flow such as the

T approxim im th ds after ignition, the sim tur ts er

5-41

bathrooms, office and storage areas. These areas we assumed to be separated from the rest of the nightclub by closed doors, so they were modeled without a path for the gases to enter the spaces, hence they appear to remain in the tenable range. The kitch n area has an open door from the dart room and a open door that exits to the outside. The hot gas flow from the dart room to the exit doorway. This leaves the kitchen at a cooler temperature than the surrounding rooms.

re e goes directly

Figure 5-55. Temperatures at 1.5 m (5 ft) above the floor, 80 seconds to 250 seconds

5-42

At the 0.6 m (2 ft) height above the floor conditions remain tenable for a longer period of time than at the higher elevation. Figure 5-56 contains images captured at the same time intervals as in the previous figure. One can see that the dance floor and adjacent areas reach untenable temperatures in the simulation within 90 seconds after ignition. The sunroom and dart room areas are predicted to reach untenable temperatures within another 10 seconds.

Figure 5-56. Temperatures at 0.6 m (2 ft) above the floor, 80 seconds to 250 seconds

5-43

The significant differences in temperature between the 1.5 m (5 ft) elevation and 0.6 m (2 ft) occur in the main bar room and the main entrance. This area remains tenable at the lower level due to the inflow of fresh air through the open windows and open doorways. The cooler temperatures toward the floor at both the front door and main bar area explain why occupants were seen in the WPRI video escaping from the windows and doorway later into incident. The temperatures in later images do not change significantly regarding areas that have untenable conditions versus areas that remain tenable based on temperature only. Figure 5-57 shows the temperature predictions for the plane of data that is centered along the axis of the entry foyer. Temperatures just inside the front door, near the floor remain below the tenable limit because of the fresh air being drawn in through the doorway. This region of tenability decreases in a triangular orientation as the entranceway goes into the structure and gets smaller as the simulation continues. This simulation does not account for the occupants that accumulated in the doorway. Thirty-one victims were located in this area. The area in the end of the sunroom adjacent to the entranceway was also a location that many victims were found. A vertical temperature slice through this area, shown Figures 5-58a and 5-58b, suggests that these victims did not have much time before the heat overcame them. Temperatures exceeded the 120 ºC (248 ºF) tenable threshold within 90 seconds after ignition. The simulation indicates that this change was rapid and extreme with temperatures in the upper portion of the space increasing from ambient conditions to flame temperatures on the order of 1000 ºC (1830 ºF) within 10 seconds. After the initial energy release due to the burning polyurethane foam (90 seconds), the predicted temperature decreased, but remained in the untenable range throughout the remainder of the simulation. Figure 5-58b shows that the temperatures increased again to 900 ºC (1650 ºF) at 250 seconds after ignition. The opening of portions of the bay windows between 78 seconds and 120 seconds after ignition had a minimal impact on reducing the temperatures in this part of the building. Eighteen victims were located in this area. Figure 5-59 depicts the temperatures in the approaches to the main entry foyer. The vertical temperature slices cover the area at the end of the entrance foyer and next to the ticket booth. The view is from the dance floor area looking toward the main entrance (front door). What appears to be a pillar in between the intersection of the two vertical slices is a portion of the wall that separates the sunroom from the main entry foyer. The images demonstrate that temperatures were untenable outside of the entranceway and that if the occupants were not able to make it into the area of cool air coming in from the front doorway, they did not have a chance of survival. Temperatures near the floor exceeded 400 ºC (750 ºF) within 100 seconds of ignition. Nine victims were located in this area. The area of the nightclub with the side bar and the dart room is shown in the simulated images with vertical temperature slices bounding the area to the north (toward the main entrance) and to the east (toward the storage/office area entrance). Figure 5 hows the rapid change in thermal conditions bet sig

-60 s As in ween 80 seconds and 90 seconds after ignition. other parts of the nightclub simulation this nificant increase in temperature was due to the burning of the polyurethane foam. Temperatures near the floor ranged from 200 ºC (390 ºF) to 600 ºC (1110 ºF) at 100 seconds. The figure indicates that the temperatures remained in the untenable range throughout the rest of the simulation. In the incident, nine victims were found in this area.

5-44

Figure 5-57. Temperature profile through the center of the entry foyer, 80 seconds to 250 seconds

5-45

Figure 5-58. Temperature profile through the center of the sunroom, 80 seconds to 250 seconds

5-46

Figure 5-59. Temperature profiles approaching main entry foyer, 80 seconds to 250 seconds

5-47

Figure 5-60. Temperature profiles in the dart room, 80 seconds to 250 seconds

5-48

(iv) Oxygen Oxygen volume fraction concentrations were also examined in the simulation to assess the tenability conditions that existed during the evolution of the fire. Horizontal slices were taken at both the 1.5 m (5 ft) and 0.6 m (2 ft) levels with the roof removed to examine the structure as a whole. This analysis will utilize a volume fraction of 12 % as the oxygen tenability threshold [6]. Based on that oxygen limit the following figures show that occupants would have had less than 100 seconds of tenable conditions. Just as the temperature levels rose rapidly after the platform area became fully involved in flames, the oxygen levels drop proportionally. As shown by the three dimensional smoke output in the previous section, the smoke spreads quickly through the structure. The first four images in Figure 5-61 range from 80 seconds after ignition to 100 seconds after ignition. This sequence has the most dramatic changes in oxygen concentration. Beyond 100 seconds the e ructure is untenable at the 1.5 m (5 ft) height. enability exists for the longest duration in the ma of the building, including the latform and dance floor areas, the dart room, the main entry foyer and the main bar room, is shown by the simulation to be significantly depleted of oxygen to less than two percent. Figure 5-62 shows the predicted oxygen volume fraction 0.6 m (2 ft) above the floor, beginning at 80 seconds after ignition through 250 seconds after ignition. At this lower level it is apparent that tenability is also not likely in any area other that the main bar area and the entranceway right inside the front door. The opening of the windows at the front of the main bar room creates a more tenable atmosphere, probably saving the lives of occupants as they can be seen being pulled from the windows in the WPRI video. Occupants that stayed low in the main bar area had a better chance of survival. The images in later in Figure 5-62, once again, show a rapid decrease in tenable conditions due to oxygen depletion throughout most of the simulated nightclub with the exception of the main bar room and the main entry foyer. Due to the open doors and windows in these areas, the simulation indicates that sufficient fresh air was drawn in to maintain a leve tenability with respect to oxygen in the areas djacent to the open windows and the main entry way. This trend is shown to continue through the end of mulation. In the WPRI video, the last person recorded being assisted through a window from the main bar room occurs at 250 seconds after ignition. This is consistent with the predicted oxygen concentrations near the windows.

ntire st in bar area. Most T p l of a the si

5-49

Figure 5-61. Oxygen volume fractions at 1.5 m (5 ft) above the floor, 80 seconds to 250 seconds

5-50

Figure 5-62. Oxygen volume fractions at 0.6 m (2 ft) above the floor, 80 seconds to 250 seconds

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1. 3.4 Simulation of full nightclub equipped with sprinklers

Another simulation of the full nightclub was completed in order to examine the effects that sprinklers may have had on the fire and the environment. The input from the FDS incident simulation was combined with the input from the FDS sprinklered full-scale mock-up simulation. Five sprinklers were placed in the simulation. One was located in the center of the alcove and the other four were placed using 3.6 m (12 ft) spacing. The west sprinklers were 1.8 m (6 ft) north and 1.8 m (6 ft) south of the alcove sprinkler and 1.8 m (6 ft) east of the platform wall. The east sprinklers were also 1.8 m (6 ft) north and 1.8 m (6 ft) south of the alcove sprinkler and 12 ft east of the west sprinklers. While the maximum allowable sprinkler spacing would have been 4..6 m (15 ft) throughout the main portion of the nightclub, the alcove would have required an individual sprinkler regardless of the sprinkler spacing used elsewhere in the nightclub. In the un-sprinklered cases, flashover of the alcove increased the rate of hazard development significantly. The single sprinkler in the alcove (w was full-scale) was shown to prevent flashover in oth the sprinklered experiments and the simulations, significantly mitigating the hazard. The sprinkler activation times from the sprinklered FDS simulation are given in Table 5-7. The sprinklers used in the FDS simulation are identical to those used in the full-scale mock-up FDS simulation. The properties of each sprinkler can be found in Table 5-2. Table 5-7. FDS Predicted Sprinkler Activation Times Sprinkler Location FDS Sprinkler Activation Times (seconds) hich b Southwest 20 Northwest 16 Alcove 29 Southeast Did Not Activate Northeast Did Not Activate (i) Visualization Figures 5-63a and 5-63b are rendered from Smokeview to examine the flame and smoke spread and the effect of the sprinklers. The images begin at ignition or t = 0 seconds and continue until 100 seconds after ignition. The first image in Figure 5-63a shows the two sprinklers over the platform area and the two sprinklers over the dance floor as small red dots along the ceiling. The larger red areas on the platform walls represent the location of the ignition burners. The sprinkler located on the ceiling of the alcove is hidden from view. The second image rendered at 20 seconds shows smoke being pushed away at the first sprinkler, which activated at 16 seconds after ignition. By 30 seconds after ignition, three of the sprinklers had been activated. This caused some of the smok e pushed down to the floor. The two sprinklers over the dance floor area did not activate during the s ulation. Figure 5-63b has images from 70 seconds to 150 seconds after ignition. o The smoke continued to spread and is diluted by fresh air entering the area. e to b im During this period the fire was significantly suppressed. The series f images show the smoke dispersing. The fire was extinguished fully at approximately 114 seconds.

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Figure 5-63a. Simulation of nightclub with sprinklers, 0 seconds to 60 seconds

5-53

th sprinklers, 70 seconds to 150 seconds

Figure 5-63b. Simulation of nightclub wi

5-54

Figure 5-64 provides another means of looking at the simulation. This image, rendered at 2 seconds after the first sprinkler activated, includes the visualization of the sprinkler droplets but does not include the visualization of the smoke. Notice that the activated sprinkler has changed color from red to green.

Figure 5-64. Simulation of northwest sprinkler activation 18 seconds after ignition, showing water flow with smoke "turned off."

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(ii) Numerical Output In this section, predictions of heat release rate, temperature, and oxygen volume fraction from the FDS sprinklered incident simulation are presented and compared to the non-sprinklered simulation and te

5-56 0 100 200 300 400 500 0 50 100 150 200 HRR Heat Release Rate (kW) Time (s) 3 sprinklers operating nability criteria. igure 5-65 shows the FDS predicted heat release rate for the sprinklered simulation. The heat release rate reached its maximum of approximately 220 kW at 20 seconds. This heat release rate quickly declined as the three sprinklers activated and suppressed the fire. Isothermal plots are shown in Figures 5-66a and 5-66b to assess the tenability conditions based on temperatures that were predicted during the simulation of the fire. The figures show horizontal isothermal images 1.5 m (5 ft) above the floor from the time of ignition (t = 0) to 100 seconds at 10 second intervals, and an image at 150 seconds. Due to the rapid activation of the sprinklers (three sprinklers were operating by 30 seconds after ignition), the temperatures at the 1.5 m (5 ft) level remain well below the temperature tenability threshold of 120 ºC (248 ºF) [6].

Figure 5-65. FDS predicted heat release rate for the sprinklered case. he comparison between the temperatures 1.5 m (5 ft) above the floor in the non-sprinklered simulation (Figure 5-55) and in the sprinklered configuration (F s. 5-66a and 5-66b) show dramatically different thermal conditions. (Note the large difference in color scales.) During the non-sprinklered simulation tem m they exceeded 500 ºC (930 , the temperature ceeds 25 oC at head height only near the platform; following sprinkler activation around 20 seconds, the ermal environment remains close to ambient up until the time the fire is fully extinguished at 120 seconds. Given the limited fire spread and the resulting tenable gas temperatures, the heat flux tenability criteria was never exceeded in the sprinklered case. F T ig peratures exceeded 1000 ºC (1830 ºF) in the platform and dance floor areas, and in the main bar roo ºF) within 100 seconds. In the sprinklered simulation ex th

Figure

5-66a. Temperatures at 1.5 m (5 ft) above the floor, 0 seconds to 50 seconds

5-57

Figure 5-66b. Temperatures at 1.5 m (5 ft) above the floor, 60 seconds and 100 seconds

(iii) Oxygen Oxygen volume fractions were also examined in the sprinklered simulation to assess the tenability conditions that existed during the evolution of the fire. Horizontal slices were taken at the 1.5 m (5 ft) level with the roof removed to examine the structure as a whole. The analysis utilized a volume fraction of 0.12 as the oxygen tenability threshold [6]. Based on that oxygen limit, Figures 5-67a and 5-67b demonstrate that the atmosphere remained tenable during the entire duration of the simulation. In contrast, the non-sprinklered simulation predicted oxygen levels below 0.12 at the 1.5 m (5 ft) elevation throughout the building at 100 seconds after ignition and then continuing at untenable concentrations during the remainder of the simulation.

Figure 5.67a. Oxygen volume fractions at 1.5 m (5 ft) above the floor, 0 seconds and 10 seconds

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Figure 5-67b. Oxygen volume fractions at 1.5 m (5 ft) above the floor, 20 to 100 seconds

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1. 4

SUMMARY Images from the WPRI video were utilized to develop model input to establish the location of the different interior finishes within The Station nightclub as well as used as a general resource for confirming the physical arrangement of the nightclub. The simulation was run for 300 seconds to examine the time period from ignition to the approximate time of flames throughout most of the nightclub as recorded by WPRI. The computation included simulated fire and smoke spread and potential temperatures, heat flux and oxygen concentrations that may have existed in the actual incident. Each of these parameters were compared to published tenability criteria. Results from some of the bench-scale experiments described in Chapter 4 and existing data were used to develop the input properties for the interior finish materials. The key parameters were the combustion properties of the foam/plywood wall; i.e., ignition temperature, heat of vaporization, and maximum burning rate. The results from the cone calorimeter tests of the polyurethane foam were not used directly in the simulation because of the composite nature e foam-plus-plywood fuel on the wall of the nightclub. (As a consequence, the differences in heat release rate of the polyurethane foam measured by NIST and ATF had no impact on the simulation results.) The visual and numerical comparisons between the experiments and the FDS simulations of the experiments demonstrated reasonable agreement. The visual comparisons indicated a lag in fire development in the simulation relative to the experiments, but once the simulated fire grew large enough the growth rate and smoke development were consistent with the experiments. The temperature, heat flux, and the oxygen concentration comparisons show reasonable agreement between the experiments and the model in terms of both trends and range. To gauge the accuracy of the full nightclub simulation results, they were compared with the WPRI video record of the incident and the map of victim locations. The FDS simulation predicted rapid fire growth due to the burning of the convoluted polyurethane foam. The simulation is consistent with the video record during the early stages of fire development. The conditions in the actual nightclub transitioned from a fire within a compartment to a fully involved wood structure fire burning in void spaces, the attic area, structural elements, and roofing materials. In the computer simulation, such regions and materials were not included, which led to a diminishing of the fire after 250 seconds as the fuel was consumed. According to the computer predictions, many of the occupants had less than 90 seconds after ignition to exit the structure. The quickly spreading fire and rapid production of smoke led to high temperatures and low oxygen levels throughout most of the simulated nightclub. The exceptions were a few areas near the open windows of the main bar room and the open doorway to the main entry foyer. In these areas air from outside the structure was being drawn in providing a more tenable environment and more time for escape. The effects of an automatic sprinkler system on a fire were modeled to a useful degree by FDS and visualized with Smokeview. Both the experiment and the FDS simulation demonstrate that the sprinklers would prevent flashover and considerably mitigate the hazard from the fire in the test enclosure. However, the degree to which the fire is controlled is different between the experiment and the model. The simulation has more flame spread along the edges of the alcove ceiling after activation of the sprinklers. While the ability of FDS to predict fire pression is simplified and cannot capture all of th hysics involved in the process, FDS is able to predict the trends in reasonable agreement with the m of th

sup e p easured temperatures, heat fluxes and oxygen volume fractions.

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In the simulation of the full nightclub equipped with sprinklers, examination of the predicted temperature the on. 97-3560, National Institute of ding,

17-131, 1992. uincy, MA, pp85-89, November/December 1995. nal y Duplex-Iowa, December 22, 1999.”, NISTIR 6854, National Institute of Standards and

and the oxygen volume fractions shows tenable conditions would have existed over the duration of simulation (300 seconds), as the fire was fully extinguished approximately 114 seconds after igniti 5.5 REFERENCES FOR CHAPTER 5

[1] Nelson, H.E., “An Engineering Analysis of he Early Stages of Fire Development- The Fire at the Dupont Plaza Hotel and Casino- December 31, 1986”, NBSIR Standards and Technology (formerly the National Bureau of Standards), Gaithersburg, MD, April 1987. [2] Nelson, H.E., “An Engineering View of the Fire of May 4, 1988 in the First Interstate Bank Buil Los Angeles, California”, NISTIR 89-4061, National Institute of Standards and Technology, Gaithersburg, MD, March 1989. [3] Bukowski, R.W., and Spetzler, R.C., “Analysis of the Happyland Social Club Fire with HAZARD I”, Journal of Fire Protection Engineering, Vol. 4, No. 4, pp1 [4 ] Nelson, H.E., “Fire Growth Analysis of the Fire of March 20, 1990, Pulaski Building, 20 Massachusetts Avenue, N.W., Washington, DC”, NISTIR 4489, National Institute of Standards and Technology, Gaithersburg, MD, June 1994. [5] Bukowski, R.W., “Modeling a Backdraft: The Fire at 62 Watts Street.”, NFPA Journal, Vol. 89, No. 6, National Fire Protection Association, Q [6] McGrattan, K.B., Hamins, A., and Evans, D.D., “Sprinklers, Vent and Draft Curtain Interaction – Modeling and Experiment”, Fire Suppression and Detection Research Application Symposium, Research and Practice: Bridging the Gap, February 25-27, 1998, Orlando, FL Proceedings. Natio Fire Protection Research Foundation, Quincy, MA, 1998. [7] McGrattan, K.B., and Forney, G.P., “Numerical Simulation of Sprinkler Performance”, Fire Suppression and Detection Research Application Symposium, Research and Practice: Bridging the Gap, February 24-26, 1999, Orlando, FL. Proceedings. National Fire Protection Research Foundation, Quincy, MA, pp. 79-85, 1999. [8] Madrzykowski, D., and Vettori, R.L., “Simulation of the Dynamics of the Fire at 3146 Cherry Road NE, Washington D.C., May 30, 1999.”, NISTIR 6510, National Institute of Standards and Technology, Gaithersburg, MD, April 2000. [9] Madrzykowski, D., Forney, G.P., and Walton, W.D., “Simulation of the Dynamics of a Fire in a Two- Stor Technology, Gaithersburg, MD, January 2002. [10] Sutula, J., “Applications of Fire Dynamics Simulator in Fire Protection Engineering Consulting”, Fire Protection Engineering, No. 14, Society of Fire Protection Engineers, Bethesda, MD, Spring 2002. [11] Rehm, R.G., Pitts, W.M., Baum, H.R., Evans, D.D., Prasad, K., McGrattan, K.B., and Forney, G.P., “Initial Model for Fires in the World Trade Center Towers”, NISTIR 6879, National Institute of Standards and Technology, Gaithersburg, MD, May, 2002.

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[12] Sutula, J., “Practical Applications of Fire Dynamics Simulator in Fire Protection Engineering Consulting”, Fire Protection Engineering, No. 15, Society of Fire Protection Engineers, Bethesda, MD, Summer 2002. [13] McGrattan, K.B., and Hamins, A., “Numerical Sim B re, Maryland, July 2001., NISTIR 6902, Na ulation of the Howard Street Tunnel Fire, altimo tional Institute of Standards and Technology, Gaithersburg, MD, August 2002.

[16 .B., "User's Guide for Smokeview Version 4 - A Tool for [18 FDS Simulation of Fire Spread – Comparison of Model [20 ational Institute of Standards and [21

[22 prinkler Fire Suppression Algorithm," Journal of Fire

[14] Vettori, R.L., Madrzykowski, D., and Walton, W.D., “Simulation of the Dynamics of a Fire in a One-Story Restaurant – Texas, February 14, 2000.”, NISTIR 6923, National Institute of Standards and Technology, Gaithersburg, MD, October 2002. [15] McGrattan, Kevin; Forney, Glenn; "Fire Dynamics Simulator (Version 4) – User’s Guide," National Institute of Standards and Technology, Gaithersburg, MD, NIST SP 1019, September 2004. ] Forney, G. P. and McGrattan, K Visualizing Fire Dynamics Simulation Data," NIST SP 1017, National Institute of Standards and Technology, Gaithersburg, MD, August 2004. [17] McGrattan, K., ed., "Fire Dynamics Simulator (Version 4), Technical Reference Guide," NIST SP 1018, National Institute of Standards and Technology, Gaithersburg, MD, September 2004. ] Hietaniemi, J., Hostikka, S., and Vaari, J. “ Results with Experimental Data”, Technical Report VTT Working Paper 4, VTT Building and Transport, Espoo, Finland, 2004. [19] Heskestad, G. and Bill, R.G., “Quantification of Thermal Responsiveness of Automatic Sprinklers Including Conduction Effects”. Fire Safety Journal, 14:113-125, 1988. ] Putorti, A.D., Belsinger, T.D., and Twilley, W.H., Determination of Water Spray Drop Size and Speed from a Standard Orifice, Pendant Spray Sprinkler, N Technology, Gaithersburg, MD., Report of Test FR4003, May 1999. ] Purser, D.A., "Toxicity Assessment of Combustion Products." SFPE Handbook of Fire Protection Engineering, 3rd ed. DiNenno, P.J., et. al. (eds). NFPA Quincy, MA, 2002. ] Madrzykowski, D., and Vettori, R.L., "A S Protection Engineering, Vol. 4, No. 4, 1992, pp 151-164.

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Chapter 6 ANALYSIS OF BUILDING EGRESS 6.1 INTRODUCTION Chapter 6 documents, to the extent possible, life safety egress features present in the building at the time of the fire on Feb. 20, 2003. A summary of previous incidents in which a significant number of lives have been lost is provided in Appendix C, as well as emergency evacuations that can be classified as successful. A contract was let to Ove Arup & Partners Massachusetts, Inc. to help document the egress process and life safety features in the building. This chapter is based upon portions of their final report [1], although any conclusions and findings that are presented are solely those of NIST. The analysis and observations presented depend primarily on the following sources: • Providence Journal – all pertinent published documents; • Boston Globe – all pertinent published documents; • Town of West Warwick, RI, Building Department – public information on file at the Office of the Town Clerk; • Town of West Warwick, RI, Fire Department – public information on file at the Office of the Town Clerk; • National Fire Protection Association (NFPA) – published fire investigations, and historical Life Safety Codes, code handbooks and commentaries; • International Code Council (ICC) – historical building codes and code commentaries; and • Rhode Island Attorney General’s Office – public information available regarding the indictments. Additional information was provided by individuals directly to NIST via email, mail, and telephone calls in response to an appeal to the public. 6.2 ANALYSIS OF EVIDENCE Chapter 2 of this report provides a timeline for the evacuation based upon the WPRI-TV video. Times taken from the video are accurate to within a few seconds, although some events being described had less specific starting or ending points. Additional photographic records, documents, and witness statements have been analyzed to gain a more complete picture of the egress process and associated activities. 6.2.1 Lighting While the camera operator was evacuating, the fluorescent “black lights” mounted on the ceiling of the club remain on, as do various other lights that are visible on the video. Thus, main power within the club was still on when the camera reached the exterior. The video did not provide evidence as to when the lights inside the club went out. This information would have aided in coordinating some of the eyewitness statements provided later in Chapter 6.

6-1

Lights mounted on the eaves outside of the building were seen to be illuminated throughout the duration of the video up until 0:12:36 video time (0:06:14 fire time). The video did not depict these as illuminated after 0:12:36 video time (0:06:14 fire time). It is not clear if the circuit powering these lights turned off, or if individual fixtures turned off as a direct result of the fire in their vicinity. 6.2.2 Occupant Tracking A great deal of analysis was carried out to attempt to track occupants as they evacuated the building. The goal was to determine if specific portions of the crowd were able to escape more readily than others and to gain insight as to the pile-up at the front door. The main sources for locating occupants within the building for this analysis were the WPRI video footage panning across the crowd facing the platform, video footage taken while the camera operator evacuated the facility, and video of occupants escaping through windows. Efforts were made to track individuals from their location in the club when the fire ignited until they had evacuated. One male occupant, shown facing the camera in Figure 6-1, was tracked through evacuation. The time of this still frame is 0:06:51 video time (0:00:29 fire time). The occupant’s face has been blurred in the figures below in order to preserve his anonymity; his facial features were not critical for the identification analysis. After the ignition of the fire, the camera operator began reacting before most other occupants did. The camera captured the occupant shown in Figure 6-1 29 seconds after the ignition of the fire turning and beginning to move toward the door. At this point, the camera was approximately two rows of people behind this man (between him and the main exit). This occupant can be seen reaching and crossing the main exit at 0:07:31 video time (0:01:09 fire time), 39 seconds later, in Figure 6-2. It appears that whether an occupant choosing to exit through the main exit was able to escape or not depended on a combination of two factors: (1) when the occupant decided to begin to evacuate, and (2) where the occupant was located when he/she decided to evacuate. Based on analysis of the video, it appears that the camera operator was located approximately three to six rows back from the platform, chose to evacuate 18 seconds after the ignition of the fire, and was able to exit safely 53 seconds later. The male occupant discussed above was farther away from the platform 29 seconds after the ignition. Because he was closer to the main exit at this point, he was able to complete his egress safely 39 seconds later. Clearly, the time to commence evacuation and the initial location at the beginning of one's evacuation effort both contribute to the outcome. A number of people were seen early in the video within the club and, after the ignition of the fire, at the exterior. However, based upon the limited video footage of the crowd facing the platform at the start of the concert and during the evacuation, attempting to track other occupants initially located further inside the club was unsuccessful. This is mainly due to the fact that many of the occupants exiting through the vestibule were not originally located in the view of the camera. 6.2.3 Interruption of Flow Through Front Door Although Figure 6-3 is of poor quality because the camera was in motion at the time, this video frame depicts a series of occupants evacuating through the main exit (note that the white surface at the lower right corner of the frame is one of the open exterior doors). The video time of this still frame is 0:07:33

6-2

Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. Figure 6-1. Occupant at Start of Evacuation [2]

Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. Figure 6-2. Occupant Exiting the Building [2]

Copyright © 2003 TVL Broadcasting, ights reserved. Inc. All r Copyright © 2003 TVL Broadcasting, Inc. All rights reserved.

Figure 6-3. Evacuating Occupants [2]

6-3

(0:01:11 fire time). A male and a female are visible near the center of the frame; however, occupants cannot be seen immediately behind them. It would be expected that the occupant density ahead of these individuals would be similar to the occupant density behind them, given that much of the crowd in the video frames leading up to this frame is noted to be moving towards this door. The lack of occupants visible behind these individuals suggests that some event may have occurred to slow or stop further egress. The camera angle shifts away from this door after 0:07:33 (0:01:11 fire time) and does not return to the front door until 0:08:04 (0:01:42 fire time). When the camera returns at 0:08:04 (0:01:42 fire time) a pile-up of occupants is visible. Details regarding how the pile-up occurred are not available from the WPRI-TV video; however, the interruption in flow of evacuating occupants apparent in Figure 6-3 supports the contention that the disruption may have initiated early during the 31 second period when the camera was pointed elsewhere. 6.2.4 Occupants Within Crowd-Crush Attempts were made to relate individuals observed in the build-up at the main exit door to their locations at the start of the evacuation for the purpose of gaining additional information regarding how and when the pile-up occurred. Due to the limited views afforded by the WPRI video, most individuals could not be tracked. However, the male occupant shown in Figure 6-4 (attempting to evacuate) was also seen in the video near the bottom of the pile-up of occupants shortly later. This occupant was identified by the color of his clothing, gold chain and hairstyle. It appears that this occupant waited at the sidelight of the interior vestibule door (see Figure 6-4), so it is unclear when he was able to join the stream of evacuating occupants. There appears to be one person below him in the pileup of people, implying that he was directly behind or close to the first occupants who tripped or otherwise fell to the ground. According to an interview conducted with the Providence Journal [23], the person who appeared to be this occupant "got into entry hall, it was chaotic with people coming from two directions into foyer, like a funnel. The smoke came in. [The occupant] started pushing and shoving his way to front; 'I could feel myself walking over' people; he could feel the heat on his back. Front doors were open. He was almost out when he tripped over someone who had fallen, and was laying perpendicular to front door. [The occupant] caught himself but as he was halfway up, people behind him fell on top of him. 30-35 people on him. Half his body was out of the door. His waist was where the door was. [He] felt himself being yanked back in. Grabbed bottom metal bar [outside the main entrance]... Finally, [on the] third or fourth pull, [the occupant's] other shoe popped off and he came sliding out." Forty-one seconds elapsed between Figure 6-4 (0:01:02 fire time) and when the occupant was first seen near the bottom of the pile. Because the camera operator moved to the side of the building immediately upon exiting through the main exit, it is not known when the individual shown in these figures reached the door and fell to that position. A second survivor of the crowd-crush gave the following account, as reported by the Providence Journal [41]: "As the mass followed the most direct route to the doors, [the survivor] detoured around a free- standing wall, and rejoined the river of people on the other side. The force of the crowd behind him was growing. He almost made it to the exit. He tried to stay upright by putting his hands on the person in front of him, but the pressure from behind overwhelmed him. He fell to the floor, two feet from the door. He rolled over to his side and curled up into the fetal position. 'People were piling up on top of me and I could feel the press of people,' he said…. He could breathe in cool, fresh air. He wasn't even hot. But he couldn't move. 'It felt like a football pileup,' he said…'I didn't want to move

6-4

Broadcasting, Inc. All rights reserved. Copyright © 2003 TVL Broadcasting, Inc. All rights reserved.

Figure 6-4 Occupant Attempting to Evacuate [2] because I didn't want the pile to topple on me,' he said. 'I had air and I didn't feel any heat. I wasn't crushed or feeling crushed. I was in a relaxed state. I just felt calm and focused… I knew it was bad because we were stuck there, but I didn't know how bad,' he said. Finally, he felt the load above him lighten as firefighters searched for survivors. He saw a firefighter's boot and reached for it. The firefighter gripped him and wouldn't let go… It took a couple of tugs and [he] was freed." 6.2.5 Eyewitness Statements Statements from approximately 30 individuals were reviewed for this analysis; those that are relevant to this project are summarized in the following sections. The accounts presented here are quoted from those compiled and published by the Providence Journal, Boston Globe, Associated Press, and various other sources. In addition, NIST provided an anonymous toll free hotline and an email address for voluntary input from the general public, which generated another 25 communications, none of which contradicted the published accounts. (i) General accounts of the fire The statements in this Section refer to the development of the fire and any occupant actions in response to the fire, other than evacuation. Paul Vanner – Club Employee [3] After the fire started on the sides of the stage, Vanner moved to the sound control booth towards the back of the concert space and picked up a fire extinguisher that was stored there: “I hit the pin, hit the trigger just to make sure I got something coming out of it. Then I’m heading for the stage. …a fire extinguisher has no chance against this. We’ve got to get out of here right now.” Vanner then exited via the kitchen exit, bringing several occupants along with him.

6-5

(Note: The Providence Journal reported that Kimberly Phillips, a club patron, recalls being hit on the leg by a fire extinguisher as a club employee carried it past her. It is not known if the employee was Vanner, but this confirms that at least one employee obtained a fire extinguisher and advanced towards the stage with it.) Mario Giamei, Jr. – Former Club Employee [4] Giamei described the actions of the club’s manager in attempting to re-enter the building to help occupants: “He tried to run back in but he couldn’t; he got knocked back with smoke.” Robert Riffe – Club Patron [5] Riffe was attending the concert with a friend on the night of the fire: “I believe I heard someone screaming fire, and I recall someone in the band throw a cup of water on the flames, which of course did nothing.” Riffe also described the development of the fire that he observed as he evacuated: “Within about 5 seconds of us heading to the door, the flames were already about half way through the first room, and the black smoke had filled the entire club.” It is expected that the “first room” Riffe refers to is the main event space where the stage is located. (ii) General accounts of the evacuation This section provides general eyewitness statements of the evacuation of The Station subsequent to the fire. The statements in this section do not refer to any specific portion of the building or its exit components. Christopher Travis – Club Patron [6] Travis was somewhere in the middle of the crowd when the fire started: “Nobody wanted to give up their spot. People felt like it would just be put out.” Travis did not start to evacuate until after the lights in the club had gone out. Andrea Stewart – Club Patron [7] Stewart was in the crowd about ten rows back from the stage when the fire started: “It happened so fast. I saw the top of the stage catch on fire… People started to run. All of a sudden, bam! People were pushing me so hard.” Stewart was knocked down and landed in the middle of a pile of people just before the lights in the club went out. Mark Knott – West Warwick, RI, Police Officer [8] Officer Knott was located near the club’s main entrance door when people began to evacuate. He was pushed out of the door by the evacuating occupants, and subsequently radioed to the police dispatcher: “Stampede.” (iii) Accounts of evacuation via the main exit Many of the occupants of The Station exited (or attempted to exit) through the main exit door at the front of the building. This Section provides several statements describing the evacuation at this location. The Providence Journal reported that 90 occupants exited through the main exit [9]. Robert Riffe – Club Patron [5]

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Riffe was attending the concert with a friend on the night of the fire. Upon noticing the growing fire, he and his friend began to evacuate: “We both turned and headed for the main door, which…was the only door we knew of.” They made their way to the main door: “Just as we reached the point where the two hallways came to one, the thick black smoke just completely filled the room. I couldn’t see, I couldn’t breathe… As I got within inches from the front door way, I just came to a complete stop.” Once out of the building, Riffe attempted to assist others in evacuating: “I tried pulling on one man and could not get him to even budge the tiniest bit. I grabbed onto a woman who was trapped at the bottom, and could not get her to budge either.” He eventually left the area of the main entrance and observed the scene from the parking lot: “…we could see people coming out of the windows…” Raul Michael Vargas – Club Patron [10] After deciding to evacuate the club, Vargas states that he encountered numerous people who were not moving and were still watching the stage: “I just picked people up as I went so I wouldn’t trip over them.” It is unclear if by “picked people up” Vargas means that he got people to evacuate along with him, or if he encountered people who had fallen and lifted them from the floor. (iv) Accounts of the evacuation via the exit by the main bar An exit was provided in the main bar area of the club. Numerous eyewitness statements are available describing evacuation efforts in this area, as provided below. The Providence Journal reported that 46 occupants exited through the exit by the main bar [9]. Deborah Lemay – Club Patron [11] Lemay had been in the club several times prior to the night of the fire, and knew of the exit door by the main bar. When the fire broke out, she decided to exit via this door. However, she claims to have experienced difficulty in opening this door. “There was no push bar and I’m looking for a handle and I remember there not being anything to open the door.” This is contrary to the statements of Robin Petrarca and the video taken inside the club before the fire. Robin Petrarca – Club Patron [12] Petrarca, who was a frequent patron of The Station, was located in the main bar area of the club when the fire started. She and a number of her friends escaped through the exit door near the main bar: “Only because we know where the door is…” Petrarca did not imply that her friend had any trouble in opening this door. Petrarca was pushed out of the door and fell down some stairs: “So many people were just pushing that bodies started coming down the stairs on top of me." Rick Sanetti – Club Patron [11] Sanetti was among the occupants who chose to exit through the door near the main bar area: “It was totally pitch black and you had about 20 of us pushing, and you’re in a state of panic pushing

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at that door, and it wouldn’t open. The door was functional, but whoever it was [trying to open it] was having a problem getting it open. The door was jammed with people. Had it opened, I assure you, had it opened easily, another 30 or 40 people would have gotten out that door.” Jason Williams – Band Member of Opening Band Trip [13] Upon noticing the fire, Williams, who had been near the main bar, moved towards the exit door in the main bar area. There, he encountered a crowd, and he attempted to calm people down: “I said something about Chicago, people getting trampled. People seemed to kind of relax for a second. Then, a flood of people came over the bar, flying toward me… the smoke came right behind them, just really fast.” In the above quote, Williams is referring to a February 18, 2003 incident in a Chicago nightclub in which 21 people were killed and 55 were injured attempting to evacuate through a single door. Just after the lights in the club went out, Williams decided to back away from the door where people were bunching up, and covered his mouth until he saw an opening to the outside: “As soon as I saw a little glimmer of light, I ran for the door and made it through.” (v) Accounts of evacuation via the platform exit A third exit door was located next to the performance platform in the club. The statements below describe evacuation efforts using this exit. The Providence Journal reported that 20 occupants exited through the platform exit [9]. Paul Vanner – Club Employee [3] Vanner had warned band personnel against placing objects in the path to the door by the stage: “…you’ve got to move this stuff. That’s a fire exit.” Walter Castle – Club Patron [11] Castle attempted to use the door by the stage early in the fire’s development. His statement indicates that he was told by a club employee that the exit was for band members only: “Come to find out it was a band exit....I ended up throwing him out of the way.” (vi) Accounts of evacuation via the kitchen exit While technically not an exit per code, a door to the exterior was available in the kitchen area of the club, and several occupants (mostly employees) utilized this door during the evacuation. The statement below describes this door. The Providence Journal reported that 12 occupants exited through the kitchen exit [9]. Mario Giamei, Jr. – Former Club Employee [11] Giamei described the exit located near the club’s kitchen: “It had an exit sign, but unless you’re back in that area, you wouldn’t know it. The way the club was shaped, it was out of the way.” (vii) Accounts of evacuation through windows Numerous eyewitness statements suggest that a significant number of occupants escaped through the club’s windows. The Providence Journal reported that 79 occupants exited through windows [9].

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Anthony Bettencourt – West Warwick, RI, Police Officer [8] Officer Bettencourt was pushed out of the main exit of the club by the initial rush of people. Once outside, he apparently heard people kicking at windows, and proceeded to break some of these windows with his baton. He and other officers helped numerous people, both conscious and unconscious, exit through the windows. Eventually, the officers could no longer reach people immediately inside the windows, and began to call for occupants: “Come to the window.” According to Bettencourt, one occupant ran through one of the windows: “He opened up a nice hole.” Robert Riffe – Club Patron [5] After being stopped at the main entrance by the build-up of people, he was able to struggle free from the pile and to get out of the building. He observed the scene from the parking lot. “…we could see people coming out of the windows, and people scattered throughout the parking lot. Some…were all bloodied from jumping out of the windows and onto the pavement.” Paul Vanner – Club Employee [3] After deciding against attempting to fight the fire with a fire extinguisher, Vanner evacuated through the kitchen door. He then moved around towards the front of the building. "All of a sudden, I heard smash-smash-smash, people kicking out the windows. It was like black oozing smoke when they started kicking those windows out." (viii) Accounts of when the lights failed Several accounts suggest that the lighting failed after the pile-up occurred. Andrea Stewart – Club Patron [7] Stewart was in the crowd about ten rows back from the stage when the fire started. Stewart was knocked down and landed in the middle of a pile of people just before the lights in the club went out. Deborah Lemay – Club Patron [11] Lemay had been in the club several times prior to the night of the fire, and knew of the exit door by the main bar. When the fire broke out, she decided to exit via this door. "When the lights went off. I was almost at the door. I remember turning around and seeing the black smoke rolling in. Then I became engulfed in smoke.” 6.2.6 Summary of Additional Evacuation Analysis Observations The analyses of the WPRI video and the available eyewitness statements have generated numerous observations in addition to the fire and evacuation timeline presented above. These are summarized below. • It is apparent that many people did not immediately move upon first noticing the flames. This may have occurred because people initially believed that it was “part of the show” or wished to maintain their locations within the crowd for the rest of the show. This may also have occurred

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because the occupants were apparently not instructed by the club’s staff to begin evacuation. People appear to have initially felt that the fire would be controlled. These factors caused a delay in the evacuation of many occupants which, for an ordinary fire, would not be considered excessive. • Some of the occupants knew of the existence of the side exit door near the main bar. The Providence Journal identified survivors of the February 20, 2003 fire at The Station [14]. According to this article, approximately 46 occupants used this exit. However, difficulty in opening this door, for unknown reasons, was reported by several survivors (but not all survivors that exited through this door reported difficulty). In the WPRI video, this door appears to have panic hardware and to swing in the direction of egress. Eyewitness statements confirm that occupants were able to evacuate through this door. • Some occupants who used the side exit near the main bar reported falling down a series of stairs immediately after passing through the door. Video footage or photographs of the evacuation efforts at this location are not available; however, this door exits onto a landing with steps to grade. • A small number of occupants (approximately 20 - mainly those associated with the band or the club, as reported by the Providence Journal [14] used the exit near the platform early in the fire. It is apparent from the WPRI video that this exit rapidly became impassable; the camera observed significant flames in the area of this door when the camera operator first made his way to the side of the building at 1 minute 25 seconds after the start of the fire. Thus, it is likely that smoke and flames blocked this exit within 1 minute 25 seconds of the start of the fire. At 4 minutes 30 seconds after the start of the fire, dense smoke and flames could be seen down to the floor level just inside of the platform exit. • Multiple survivors described the evacuation as “panicked” or likened it to a “stampede,” [6-8]; however, no evidence of panic was captured on the video. • Many survivors indicated that they were not aware of any exit doors other than the main front door. • Seventy-nine occupants exited the building through its windows. Many were assisted by individuals, including police officers, on the outside of the building. • Some attempts were made at initiating manual extinguishment of the fire. One band member attempted to douse the flames with a bottle of water, while another ran for a fire extinguisher (but never actuated it). Based upon eyewitness statements and observations from the WPRI-TV video regarding the fire growth, manual extinguishment efforts when initiated were ineffective against the fire. 6.3 ESTIMATES OF OCCUPANT LOAD Based upon the 2003 editions of the IBC and NFPA 5000 model building codes, the estimated permitted occupant load for a building similar to The Station in area and use varies (See Section 7.3.11), but is equal to 420 people when limited by egress from properly functioning doors at the main entrance, platform, and bar exits. (Refer to Figures 7-3 through 7-5 for the floor areas and to Table 7-6 for the door widths used to arrive at this estimated occupancy limit.)

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Several public documents from the Town of West Warwick were found that referred to occupant loads in The Station or its previous incarnations. One, dated Nov. 21, 1981 [16], was an Application for Variation under the Fire Safety Code to omit completely enclosing the boiler room, which identified an occupant load of 225 for the building as it was being used at the time. The West Warwick Fire Department, in a memorandum dated Dec. 30, 1999 [17], identified the occupant load as 253 occupants; however, an allowance was given to increase the occupancy to 317 by removing tables and chairs from three lounge areas and providing standing room only in those areas. No other distribution for the memorandum is indicated on the document. A third document was an unsigned memorandum on blank bond without letterhead from the West Warwick Fire Department, dated Mar. 2, 2000 [18], addressed to Chief Peter Brousseau. Again, no other distribution is shown. The memorandum identified the occupant load as 258 when tables and chairs were set up in the four designated seating areas; however, an allowance was given to increase the occupancy to 404 by removing all tables and chairs. The memorandum also stated that a uniformed firefighter should be on the premises if this higher occupancy were to be applied. No explanation has been obtained for why the memorandum was written, nor does NIST know if either of the memoranda was made available to the owners of the building. Published articles were reviewed in an attempt to develop estimates of the number of occupants at The Station during the incident. The Providence Journal identified the names of 100 people who died as well as the names of the survivors of the Feb. 20, 2003 fire at The Station [14]. Survivors are listed by source of identification. According to the Providence Journal, 208 survivors were interviewed; of those interviewed, 59 were identified by other survivors, 46 were identified by lawyers, 10 were identified by relatives, 5 were identified by hospital staff and two photographers were taking pictures in the club. The Providence Journal lists ages, town of residence, and state of residence for 274 of these people, list a total 430 occupants in October 2003 [14], 432 in December 2003 [9], and 440 in Feb. 2004 [40]. The Associated Press reported [42] that the Rhode Island Office of the Attorney General claimed that 458 people were inside the nightclub that evening. To the degree possible, the WPRI-TV video taken in The Station on the night of the incident [2] was used to provide an alternative estimate of the actual number of occupants within the club; however, several factors limited the accuracy and comprehensiveness of the count: • A camera has a limited view, or “cone of vision.” As the operator moved around, he was only able to capture occupants within the camera’s view; and thus, in many cases additional occupants at the periphery of the camera’s view were not recorded. • A single sequence in which the camera pans in a full circle and thus shows the entirety of the club at a given time was not available. Thus, at any given time, the camera is only showing the occupants of one portion of the club, and the occupant load conditions in the rest of the club are unknown. • The first part off the video was recorded over an unknown amount of time, and includes several “cuts” or stop points when the camera was turned off for an unknown portion of time. During such cuts, occupants were likely to have moved around the club, and new occupants likely entered. • The dark conditions of the club through most of the evening created shadows in areas distant from the light of the camera. Occupants located in these shadows were generally not visible. With the above limitations in mind, a series of still frames that provide a panning view of the club’s performance assembly area were obtained from the WPRI-TV video. These frames are shown in

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sequence in Figures 6-5 through 6-8 as the camera pans from right to left. The occupants shown in these still frames were counted in an effort to derive an approximate occupant load for the area shown. Orange dots have been used to represent counted occupants. The yellow lines in these Figures represent the boundaries where the frames overlap. A total of 144 occupants can be seen in these four figures. It is not clear at what time in relation to the start of the concert this video sequence was recorded. If it was recorded well before the main musical act, then it is likely that many occupants were located outside of the main platform viewing area at this time (i.e., many occupants may have been near one of the bars, in the pool room, or in the restrooms). Conversely, if this sequence was recorded immediately prior to the start of the primary musical act, then it is likely that the majority of the club’s occupants would have moved towards the platform and into the performance assembly area. For these reasons it is not possible to extrapolate to a total building occupant load from this analysis. However, these figures can be helpful in estimating possible ranges of the number of occupants that may have been within the main platform viewing area. 6.4 LIFE SAFETY FEATURES Multiple data sources were reviewed to assist in determining the life safety features present at The Station at the time of the fire on Feb. 20, 2003. The following section documents the results of this effort. The information is divided into three categories: • Public Documentation Evidence: This includes data from Fire Department Inspections, Fire Alarm Company Sketches and Reports, and other publicly available documentation. • Photographic Evidence: This includes information obtained from a review of the digital photographs and scanned images received from NIST. • Video Evidence: This includes information extracted from the WPRI video footage of the incident. 6.4.1 Floor Surfaces It has been claimed that floor surfaces in The Station were uneven [22]. NIST has no independent information to confirm or contradict this claim. 6.4.2 Exit Doors Egress through the main entrance to the building was limited by a single interior door (LSF 6 in Figure 6- 10) not the double doors that could be seen from outside the building. The West Warwick Fire Department Inspection Report dated Nov. 10, 2001, commented that the exit door near the platform cannot swing inward [24]. The building owner was instructed to call when ready for re-inspection. Note that these comments were checked and deemed “OK”; however, the re-inspection signature is blank. In a West Warwick Fire Department Inspection Report dated Nov. 20, 2002 [25], the following comments were made: • Platform exit door swings in the wrong direction; • Panic hardware on platform door is broken. The building owner was instructed to call when ready for re-inspection. These comments were checked and deemed “OK”; however, the re-inspection signature is blank.

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Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. Figure 6-5. Occupant Load Count, Part1 – 45 Occupants

Copyright © 2003 TVL Broadcasting, Inc. All rights reserved.

Figure 6-6. Occupant Load Count, Part 2 – 42 Occupants

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Copyright © 2003 TVL Broadcasting, Inc. All rights reserved.

Figure 6-7. Occupant Load Count, Part 3 – 37 Occupants

Copyright © 2003 TVL Broadcasting, Inc. All rights reserved.

Figure 6-8. Occupant Load Count, Part 4 – 20 Occupants

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1. 4.3

Exit Signs Numerous West Warwick Fire Department reports were issued to previous businesses on this site regarding the exit signs. In reports dated Sept. 25, 1993 [26], Nov. 17, 1994 [27], Oct. 2, 1995 [28], Sept. 25, 1996 [29], and Nov. 22, 1998 [30], the condition, arrangement, and operation of the exits signs were noted as “OK”. These reports did not require re-inspection. The West Warwick Fire Department Inspection Report dated Nov. 10, 2001 [24], commented that the exit sign near main entrance needs bulbs. The building owner was instructed to call when the building was ready for re-inspection. Note that this issue was checked and deemed “OK”, although re-inspection signature on the report is blank. The West Warwick Fire Department Inspection Report dated Nov. 20, 2002 commented that the exit signs were not working [25]. The building owner was again instructed to call when the building was ready for re-inspection. Note that these issues were checked and deemed “OK”, although the re- inspection signature is blank on this report as well. 6.4.4 Emergency Lighting The West Warwick Fire Department inspected the emergency lighting within the building under previous ownership on numerous occasions. In Inspection Reports dated Sept. 25, 1993 [26], Oct. 2, 1995 [28], Sept. 25, 1996 [29], and Nov. 22, 1998 [30], the condition and operation of the emergency lighting within the building were noted as “OK” and re-inspection was not called for. In a West Warwick Fire Department Inspection Report dated Nov. 17, 1994, the kitchen emergency lighting was noted as not working. The owner was instructed to notify the Fire Department when the repairs were completed; note that the re-inspection signature is blank [27]. The West Warwick Fire Department Inspection Report dated Nov. 10, 2001, commented that the emergency lighting units at main entrance and at platform were not working [24]. The building owner was instructed to call when the building was ready for re-inspection. These issues were rechecked and deemed “OK”, although the re-inspection signature on the report is blank. 6.4.5 Suppression The West Warwick Fire Department carried out numerous inspections of the manual suppression equipment in businesses at this site. The Fire Department issued reports on Sept. 25, 1993 [26], Nov. 17, 1994 [27], Oct. 2, 1995 [28], Sept. 25, 1996 [29], and Nov. 22, 1998 [30], deeming the condition and location of the existing fire extinguishers “OK”, and re-inspection was not required. The West Warwick Fire Department Inspection Report dated Nov. 10, 2001, commented that the fire extinguishers must be hung [24]. The building owner was instructed to call when the fire extinguishers were ready for re-inspection. This issue was rechecked and deemed “OK”, although the re-inspection signature on the report is blank. 6.4.6 Fire Alarm and Detection (i) Fire alarm company information An inspection report from RI-CONN Fire Systems, Inc. [31] verifies the testing of the following system components: • four heat detectors in the kitchen and basement;

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• two manual stations – one at the kitchen exit and one at the bar; • the kitchen hood suppression system was also tested. Fire alarm sketches prepared by New England Custom Alarms [32], indicate existing system devices and various device additions to upgrade the fire alarm system at The Station. This work was permitted on Mar.8, 2000; it appears that this work was completed. The existing drawings located the following life safety devices: • two heat detectors in the space between the Kitchen and the Employee Restroom Area; • one heat detector in the Employee Restroom; • an Ansul system in the kitchen (presumably protecting cooking appliances); • one alarm horn near the kitchen door adjacent to the large bar; • one alarm horn in the greenhouse near the pool tables; • one alarm horn adjacent to the platform exit door; • two heat detectors in the basement. The upgrades included on the Mar. 6, 2000, drawings resulted in the following: • a new Fire Alarm Control Panel inside the main entrance doors. • one existing heat detector in the space between the kitchen and the employee restroom/prep area (one of the heat detectors was to be removed); • one heat detector in the prep area (moved from the employee restroom); • an existing Ansul system in the kitchen (presumably protecting cooking appliances); • one new heat detector below the platform; • one new heat detector above the platform; • one new heat detector backstage; • one existing alarm horn near the kitchen door adjacent to the large bar; • one existing alarm horn in the greenhouse near the pool tables; • one existing alarm horn adjacent to the platform exit door; • one new alarm horn in the hallway to the restrooms. • four new manual pull stations (inside front door, at platform door, at left side bar area door, and at light/sound control area); • two existing heat detectors in the basement. An NFPA 72 Inspection and Testing form [33] lists the following fire alarm system components: • three manual stations; • six heat detectors; • one Ansul tie-in; • four horns;

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• five strobes; • one speaker. The device testing section of the same form [33] confirms that the following initiating and supervisory devices were inspected and tested: • one heat detector in the Kitchen; • one heat detector in the Prep Area; • one heat detector in the Dining Area; • one heat detector in the Employee Restroom; • two heat detectors in the Basement; • two pull stations (location is not specified); • Ansul system was visually inspection and its operation was simulated. 6.4.7 Interior Finish In letters dated May 22, 2003 [34] and May 23, 2003 [35], the West Warwick Fire Chief and the West Warwick Building Official, respectively, responded to the West Warwick Town Clerk regarding requests for permits or inspections from The Station for the use of decorative or acoustic materials. No information was found by either individual with regard to a request from The Station for permitting or inspection of decorative or acoustic material usage. 6.4.8 Identification of In-place Life Safety Features Table 6-1 summarizes all identified life safety features within The Station prior to the fire. Refer to Figure 6-9 for the locations of these features within the building. Specific devices and features are shown in Figures 6-10 and 6-11, taken from video stills or photographs taken at the site on Feb. 22, 2003. (Large format copies of the photos are included in Appendix B.) Additional details, such as manufacturer names, model numbers, or other descriptions of the devices were not available. Several additional observations were made regarding the main exit vestibule area and the exit door near the platform. Figure 6-12 provides an approximate representation of the orientation and layout of the main exit vestibule area. It also shows the video evidence that was used to formulate this representation. The notes provided with this Figure give some additional observations related to this exit. Figure 6-13 shows the exit door located in the vicinity of the platform. Based upon this video still and other frames from this portion of the WPRI video, it appears that this exit included two doors: • an exterior door, which swung outward, or with the direction of egress travel, and • an interior door, which swung inward, or against the direction of egress travel. The presence of the interior door is evident from the inward-swinging hinges seen on the doorframe. The edge of this door is visible as well. As can be seen in Figure 6-14 the exterior door was equipped with panic hardware. The hardware installed on the interior door is unclear. Additional examination of this figure reveals what appears to be adhesive on the inside of the exterior door.

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Table 6-1. Summary of Identified Life Safety Devices Image ID Description LSF 1. Main double doors with ramp and stairs. (Note that egress was limited by the single interior door (LSF 6), not the main double doors.) LSF 2. Exterior stairs from the left-side main bar area indicating location of exit door. LSF 3. Exterior stairs from the kitchen area indicating location of exit door. LSF 4. Exterior stairs from the platform area indicating the location of exit door. LSF 5. Site view indicating the location of the doorway from the main bar area to the ticket area. LSF 6. Door leading from the interior ticket area towards the outer vestibule. LSF 7. Exit door from the left side of the main bar area to the exterior concrete stairs. Panic hardware was provided on this door. LSF 8. Exit door adjacent to the platform to the exterior concrete stairs. Panic hardware was provided on this door. Note that it appears there was foam attached to this door and that there was an additional interior door that swung against the egress direction. LSF 9. Exit sign located near the rear bar; it appears to be pointing toward the kitchen exit door. LSF 10. Exit sign above the door that leads from the ticket area to the front vestibule. LSF 11. Exit sign above the platform door. Note that in this image the sign is clearly illuminated. LSF 12. Exit sign above the platform door on February 20, 2003. Note that in this image the sign does not appear to be illuminated. NOTE: This is a duplicate of LSF 12, but was included to show that the exit sign may not have always been illuminated. LSF 13. Two exit signs. One located in the main floor area with an arrow towards the ticket area and another above the ticket area doors leading to the front vestibule. LSF 14. Exit sign over the left side main bar area exit door. LSF 15. Exit sign located in the front vestibule above the main double exit doors. This location is based upon similar wall and ceiling features observed in the WPRI video. LSF 16. Emergency light located near the rear bar. LSF 17. Emergency light above and to the right of the platform exit door. LSF 18. Emergency light on the wall adjacent to the kitchen by the main bar facing into the main floor area. LSF 19. Emergency light above and to the right of the left side exit door from the main bar area. LSF 20. Fire extinguisher located behind the rear bar. LSF 21. Detector (heat) located above the lighting grid on the ceiling near the platform. LSF 22. Fire alarm strobe adjacent to the exit sign above the platform exit door. LSF 23. Fire alarm strobe on the ceiling to the left and in front of the platform. LSF 24. Fire alarm strobe on the wall adjacent to the exit sign in the main floor area pointing toward the ticket area.

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Figure 6-9. Locations of life safety features listed in Table 6-1.

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Left b b a a 6-11 d b a c Figure 6-10. Summary of Life Safety Features – Part 1 a - photo by NIST; b - Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. c - photo with permission of A. Baldino, III; d - photo with permission of K. Corbin

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b d b 6-11 b b b b Figure 6-11. Summary of Life Safety Features – Part 2 b - Copyright © 2003 TVL Broadcasting, Inc. All rights reserved; d - photo with permission of K. Corbin

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Video stills copyright © 2003 TVL Broadcasting, Inc. All rights reserved. Figure 6-12. Detail of Main Exit Vestibule Area (Video frames copyright © 2003 TVL Broadcasting, Inc. All rights reserved) Note A: The exact location of this exit sign above the secondary vestibule doorway was estimated from a reflection in the mirror behind the main bar observed in the WPRI video. Note B: The exact location and size of the secondary vestibule doorway was approximated based upon the video evidence available. Note C: The dimensions of the ticket counter were approximated based upon the video evidence available. Note D: The dimensions of the associated sidelights are not known, although the orientation shown here is accurate based upon video evidence. Note that the single inner door provides the limit to egress, not the exterior double doors. Note E: The diagram in Figure 6-12 is an approximation based upon the video available, and reflects approximate locations from where video was taken both before and during the fire. The video images in this Figure 6-12 were captured both before and during the fire. The uncertainty in the transverse position of the camera is estimated to be +/- 1 ft; it is not possible to estimate the uncertainty in position of the camera along the direction of the arrow since the zoom setting is unknown.

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Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. Figure 6-13. Exit Door Near Platform [2] 6.5 EGRESS PATHWAYS AND THE LOCATION OF VICTIMS RECOVERED FROM THE SCENE The Providence Journal, during interviews with some of the survivors and acquaintances of the occupants, was able to identify the exit path for 248 of the approximately 350 people who escaped from the building. Of the 169 occupants who indicated that they had escaped through a door (main, barroom, kitchen, and platform), 91 left through the main entrance in the front of the building. The windows in the main bar room and the sunroom appear to have become the secondary routes of escape once the main entrance became impassible, with 25 survivors escaping through the sunroom windows and 54 leaving through the windows in the main bar, accounting for 32 % of the successful evacuations documented. The Rhode Island Attorney General's office released a diagram of the approximate location where the rescuers recovered the 96 people who died at the scene of the fire 36; 58 of these were located in the main entryway, at the entrance to the main entryway, or trapped in the sunroom. Taken together with the 91 who escaped through the front door, this translates to 56 % of the occupants apparently selecting the main entrance as a route to safety. Including the people who chose the windows only after the main exit became impassable, one could argue that as many as 2/3 of the occupants attempted (at least initially) to leave through the main entrance in the front of the building. Only about 40% of those who successfully evacuated escaped through the main entrance.

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Figure 6-14. Location of Recovered People Who Died at Scene [36] The small number of victims shown in Figure 6-14 who were found in the main bar room suggests that the main bar room exit door and windows provided open routes to escape for a time period about as long as it took to reach untenable conditions in that area of the building. By contrast, the high number of victims found in the sunroom relatively close to the windows suggests that the environment there became untenable quickly, eliminating the option of a secondary route through the sunroom windows once the platform door and main entrance became unusable. Both of these conclusions are consistent with the environmental conditions predicted in the FDS simulations discussed in Chapter 5. Twenty-three victims were found in the dart room, storage area, and office, suggesting either that they were unfamiliar with the building and hoped to find a safe exit in that region, or that they became disoriented while heading for the side exit of the main bar room (or possibly the kitchen exit). It is unclear whether the seven people identified in Figure 6-14 as being recovered from the front of the building outside of the sunroom died as they escaped or were pulled from the sunroom by rescuers. 6.6 ALTERNATIVE SIMULATIONS OF NIGHTCLUB EVACUATION SCENARIOS The following questions were posed by the investigation team regarding the evacuation from the nightclub:

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• How long would it take to evacuate a building similar to The Station with no fire present

assuming exit numbers, exit widths, and occupancy limits were consistent with current national model building codes (see chapter 7 for details)?

• How long would it have taken to evacuate The Station assuming the platform door became

impassable in 30 seconds and the main entrance in front became blocked in 90 seconds?

• How long would it take to evacuate a building similar to The Station assuming that the doorway

near the ticket-taker was the same width as the double doors leading to the outside and that it did not become blocked, but that the platform door became impassable in 30 seconds? The first question is important to answer since it yields the minimum time that could be expected. The second question is a challenge to our ability to predict reality when it comes to an emergency evacuation. The third question provides insight into the effectiveness of a possible change in model code requirements. The Station had four exit paths: through the main entrance, the main barroom, the kitchen, and the platform area. Based upon current model codes, the kitchen door was not accessible to the patrons. As mentioned in Chapter 6.3 and discussed in more detail in Chapter 7.3, the occupancy limit based upon current model code provisions for safe egress from the building as it was used on Feb. 20, 2003, was calculated to be roughly 420. With these data as input, and the floor plan from Chapter 1, the evacuation time was estimated using two commercial software packages, Simulex [36, 37] and buildingEXODUS [38]. To run these models it was necessary to distribute the 420 occupants throughout the building. It was assumed that the dance floor and area around the platform were at the maximum density permitted by the current national model codes described in chapter 7, 2.17 persons/m2 (5 ft2/person), that the sunroom and raised area around the dance floor had a density of 1.56 persons/m2 (7 ft2/person), that the main barroom and back room were populated at 0.72 persons/m2 (15 ft2/person), and that the 36 remaining occupants were scattered about the kitchen, behind the bar, restrooms, storage area, dressing room, and corridor. Simulex and buildingEXODUS also needed to have a pre-movement time assigned as well as an algorithm for selecting exits. In a more conventional fire situation for a building of this type, pre- movement times can range from less than a minute to several minutes. For all cases examined here, for simplicity, the pre-movement time was assumed to be zero since the primary intent was only to examine the changes in egress time associated with different evacuation scenarios; as a result, the times calculated are non-conservative and shorter than what one would expect under even a non-emergency evacuation. The occupants were instructed to always select the closest exit. While there are other algorithms that could have been chosen, it was felt that this simple approach was sufficient to assess the differences in the evacuation scenarios. Building EXODUS is designed to handle open and closing of exits during the simulation; Simulex is not. For the scenarios that called for the platform area door to be closed 30 seconds into the simulation, we first calculated the number of occupants who would potentially leave through the platform door before 30 seconds, which totaled 39, and then instructed only these 39 simulated occupants that the platform door was a viable exit; this door was unavailable to the rest of the crowd. Table 6-2 summarizes the results of the simulations. (Refer to Appendix L for a complete listing of input data for both models and all scenarios examined.) The scenario number in column one corresponds to the questions posed above. The total times to evacuate and the number of people through each of the available doors are listed in the other columns, corresponding to the scenarios and the simulation model used in column 1. For a building meeting current national model code requirements at maximum 6-25

Table 6-2. Summary of calculated evacuation times* (seconds) and total occupants out each exit

Scenario Total Evacuation Time Occupants to Front Door Occupants to Platform Door Occupants to Kitchen Door Occupants to Main Bar Door Total Remaining at 90 s 1 (Simulex) 188 s 213 184 3 20 166 1 (EXODUS) 202 s 214 180 4 22 208 2 (EXODUS) 330 s 91 32 3 273 271 3 (Simulex) 198 s 358 39 3 20 173 3 (EXODUS) 194 s 363 33 4 20 201 2* (Simulex) 308 s 356 39 3 22 256 2* (EXODUS) 341 s 364 32 4 20 274

• Note that evacuation times are based upon instantaneous reaction of the occupants to the fire; an appropriate pre-

movement time must be included in a proper design calculation. occupant load (scenario 1), the time needed to evacuate with no fire or smoke present was calculated to be 195 seconds ± 7 seconds for the two simulations. The flow through the various exits was about the same for both calculation methods, with just over 50 % of the occupants evacuating through the front door. Only buildingEXODUS was used to evaluate the scenario in question 2, in which the platform door became impassable in 30 seconds and the front entrance became blocked at 90 seconds. (The technique described above for "closing" a door while using Simulex would not have worked for the front entrance because it was also necessary to trap the occupants in the vestibule once the front door was closed.) Scenario 2 was the closest to the condition that occurred on Feb. 20, recognizing that the simulations did not account for any impairment of movement associated with high temperatures, smoke and toxic gas levels that were produced in the actual fire. The time for total evacuation increased to 330 seconds, with the bulk of the people forced to evacuate through the only (known) exit in the main barroom. (No provision was made to allow escape through broken windows). In this case, only 91 people used the front entrance and 35 used either the platform door or the kitchen door, numbers that were consistent with those reported by the Providence Journal. The total number of people evacuated in this scenario was only 399 since it was assumed that the 21 occupants who were in the entrance corridor when it became blocked at 90 seconds were trapped. Scenario 3 investigated the impact of doubling the width of the most restrictive element at the front entrance. Figure 6-15 is one frame grabbed from the Simulex computer simulation indicating the initial population and distribution of patrons and employees. (This was typical of the initial conditions for all of the simulations.) The purpose was to see how this affected the evacuation time in the event that one of the other exits became blocked (e.g., due to construction, negligence or a criminal act). Simulex and

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Figure 6-15. Initial distribution of 420 simulated nightclub patrons and employees

buildingEXODUS calculated a total egress exit time of 196 seconds ± 2 seconds, almost identical to the baseline case in scenario 1. The main difference in the outcome for scenario 3 was the larger number of occupants using the front entrance to escape, about 87 % of the total. Assuming that doubling the width of the restrictive front entrance would also have reduced the possibility for a crowd crush to develop, this change would bring the level of safety equivalent to what was implied by the current model codes. The last row in Table 6-2 applies to a modified form of scenario 2 (Scenario 2), in which it was assumed that the main door did not become blocked by the crush of the crowd (in spite of the single door width at the entrance to the ticket taker area), and that the platform door became impassable after 30 seconds. (Because the front door did not close and trap the occupants, Simulex, as well as buildingEXODUS were capable of simulating Scenario 2.) It is interesting to see that while the distribution of occupants through the different doorways is essentially the same as was calculated for scenario 3, the total evacuation time increased to between 308 seconds and 341 seconds. This results from the decision algorithm that required occupants to choose the closest exit, even if the queue was long. One could argue that many of the people waiting to go out the front door would have chosen the barroom door (which remained clear for most of the evacuation period) as a logical alternative, even though it may have been a bit more distant. The counter argument is that the barroom exit sign could have been obscured by smoke, making that door a reasonable alternative only for those familiar with the nightclub.

6-27

Figures 6-16 and 6-17 compare the cumulative population that was evacuated as a function of time for the scenarios described above, based upon the results of buildingEXODUS [39] and Simulex [37, 38] respectively. If one draws a vertical line up from the time scale at 90 seconds, the total number of people who remained in the nightclub at that time can be determined. Ninety seconds had significance on Feb. 20 because that was about the time the front entrance became blocked and, according to the fire dynamics simulations, was a point where the conditions were becoming untenable throughout the building. The last column in Table 6-2 lists the population remaining for both the buildingEXODUS and Simulex simulations. Note that buildingEXODUS, when compared to Simulex, consistently provided a more conservative (i.e., a slower) rate of egress, which is consistent with the conservative flow rates chosen for the exit doors in buildingEXODUS. Somewhere between 166 and 208 people were calculated to remain in the building 90 seconds after the fire began for the scenario in which the building met current national model code requirements. This number jumped to 271 for scenario 2, with the platform door blocked (recall that the front door remained open during the first 90 seconds). Doubling the entrance door width in scenario 3 brought the number of people remaining in the building 90 seconds into the fire back down to the range calculated for scenario 1. Finally, since the crowd-crush had not occurred prior to 90 seconds, the calculation for the 2* scenario is essentially the same as for scenario 2.

Figure 6-16. Cumulative plot of evacuation from building for different scenarios calculated from buildingEXODUS [39]. (Note that a non-zero pre-movement time would shift the curves to right.)

Number of Occupants Out of the Club - buildingEXODUS Results 0 50 100 150 200 250 300 350 400 450 0 50 100 150 200 250 300 350 Evacuation time (s) Number of Occupants out of the Club Scenario 1 Scenario 2 Scenario 2* Scenario 3

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Number of Occupants Out of the Club - Simulex Results 0 50 100 150 200 250 300 350 400 450 0 50 100 150 200 250 300 350 Number of Occupants out of the Club Scenario 1 Scenario 2* Scenario 3 Evacuation time (s)

Figure 6-17. Cumulative plot of evacuation from building for different scenarios calculated from Simulex [37, 38]. (Note that a non-zero pre-movement time would shift the curves to right.)

1. 7

REFERENCES FOR CHAPTER 6 [1] "Evaluation of Limitations to Egress through Doorways in Emergency Situations," vol. 1, Ove Arup & Partners Massachusetts Inc., Job number 32979, Westborough MA, Feb. 18, 2004. [2] Butler, Brian, Video by WPRI-TV, Channel 12, Feb. 20, 2003. [3] Parker, P.E. and Anderson, E. “Stage manager: Pyrotechnics not unusual at club.” Providence Journal, Feb. 26, 2003. [4] Parker, P.E., Levitz, J., and Anderson, E. “Witness describes placement of fireworks just before blaze.” Providence Journal, Feb. 27, 2003. [5] Riffe, R. “A first-person account from a survivor.” Providence Journal, Feb. 24, 2003. [6] Patinkin, M. “You just make plans for the end.” Providence Journal, Feb. 23, 2003. [7] Carbone, G. “Survivor reflects on life: Tell those you love, I love you.” Providence Journal, Mar. 4, 2003. [8] Mooney, T. “Saving lives at the open gates of hell.” Providence Journal, Apr.13, 2003. [9] Corkery, M. and Parker, P.E. “Forged by Fire, Day 7: Life and Death.” Providence Journal, Dec. 21, 2003.

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[10] Crowley, C. “A survivor's story: Saved by a pileup.” Providence Journal, Mar. 10, 2003. Lev pe.” Providence Journal, May 5, 2003.

[13] [15] ing and Fire Codes and Practices," Koffel Associates, Inc., Ellicott City, [16] ty Code, submitted to the State of Rhode Island by Jan. 30,

[23] ed by Providence Journal, provided to NIST, Jan. 23, 2004. que. aroque. uellette. rt, dated Oct. 2, 1995, signed by BC R. Ouellette. [30] Inspection Report, dated Nov. 22, 1998. [33] ing Form, dated Mar. 3, 2000, [34] garding requests for permits or inspections for the use of [35] ctions for the use of s, [11] itz, J. and Breton, T. “No easy way to esca [12] Bramson, K. “Friends lost during frantic escape.” Providence Journal, Feb. 23, 2003. Anderson, E. “Opening band: A 'little button' set off sparks that started fire.” Providence Journal, Feb. 28, 2003. [14] Providence Journal, “In the Fire.” Oct. 5, 2003. "Analysis if Model Build MD, 2004. Application for Variation under the Fire Safe D. S. Kelly, Triton Industries, Inc. Nov. 21, 1981. [17] Larocque, D., letter to Chief P. Brousseau of West Warwick Police Department, dated 1999, signed by D. Larocque, West Warwick Fire Marshal. [18] Letter from West Warwick Fire Department to Chief P. Brousseau of West Warwick Police Department, dated Mar. 2, [22] Horgan, Daniel J., Ralph J. Monaco, John J. Nazzaro & Robert I. Reardon, Jr. United States District Court District of Connecticut, Civil Action Indictment. June 5, 2003. database compil [24] West Warwick Fire Department Inspection Report, dated Nov. 10, 2001, signed by D. Laro [25] West Warwick Fire Department Inspection Report, dated Nov. 20, 2002, signed by D. L [26] West Warwick Fire Department Inspection Report, dated Sept. 25, 1993, signed by R. O [27] West Warwick Fire Department Inspection Report, dated Nov. 17, 1994, signed by Capt R. Ouellette. [28] West Warwick Fire Department Inspection Repo [29] West Warwick Fire Department Inspection Report, dated Sept. 25, 1996, signed by R. Ouellette. West Warwick Fire Department [31] RI-CONN Fire Systems, Inc. Inspection Report, dated Apr. 3, 1991 by inspector #9776. [32] New England Custom Alarms, Fire Alarm Sketches, dated Mar. 6, 2000. New England Custom Alarms NFPA 72 Inspection and Test completed by J LaFontaine (License #BF 09863). West Warwick Fire Chief, letter re decorations or acoustic materials, dated May 22, 2003. West Warwick Building Official, letter regarding requests for permits or inspe decorations or acoustic materials, dated May 23, 2003. [36] Rhode Island Attorney General's Office, Aug. 2004. [37] IES, "Simulex User Manual, Evacuation modeling software," Integrated Environmental Solution Inc., Glasgow, UK, Mar. 2001.

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[38] IES, "Simulex Technical Reference, Evacuation modeling software," Integrated Environmental Solutions, Inc., Glasgow, UK, Nov. 2000. Galea, E.R [39] ., Gwynne, S., Lawrence, P.J., Filippidis, L., Blackshields, D., and Cooney, D., a pileup; "buildingEXODUS V4.0 User Guide and Technical Manual," Fire Safety Engineering Group, University of Greenwich, London, UK, 2004. [40] Providence Journal, “In the Fire,” p. B4, Feb. 20, 2004. [41] Crowley, C.F., The Station Nightclub Disaster - A survivor's story: Saved by Providence Journal. Providence, R.I.: Mar 10, 2003. pg. A.01 [42] Associated Press, March 28, 2005.

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6-32

Chapter 7 MODEL CODES, STANDARDS AND PRACTICES 7.1 INTRODUCTION A contract was issued to Koffel Associates, Inc. of Ellicott City, Maryland, to identify the current model building and fire codes that were available for application to a structure such as The Station nightclub, as well as to identify the model building codes in place at the time modifications were made to the structure. This chapter reproduces information supplied NIST by the contractor [1], much of it verbatim and without further attribution, although any conclusions and findings that are presented are solely those of NIST. 7.2 CODE HISTORY Since the 1946 original construction of the building at 211 Cowesett Avenue in West Warwick, RI, numerous model codes have come and gone. Prior to 2000, most model codes were limited to regional adoption. Tables 7-1 and 7-2 summarize the model fire and building codes that were relevant to the structure over its history. From the 1940’s through the 1960’s, the prevalent regional model building code in Rhode Island was the National Board of Fire Underwriters, later the American Insurance Association (AIA) National Building Code (NBC), last published in 1976. AIA also published the Fire Prevention Code (FPC), which was the prevalent model fire code in the region. From the 1970’s through the end of the century, the Building Officials and Code Administrators (BOCA) building code was the leading model code in the region. The BOCA fire code dominated during this period. The BOCA codes were originally named the Basic Building Code (BBC) and Basic Fire Prevention Code (BFPC). In the 1980’s, BOCA purchased the rights to the AIA codes. BOCA renamed their codes the National Building Code (NBC) and the National Fire Code (NFC). While the names were that of the AIA codes, the content was that of the BOCA documents. In 2000, the International Code Council (ICC) published the first International Building Code (IBC) and first International Fire Code (IFC), both now published in 2003 editions [2, 3]. The ICC was formed by the merger of the three regional code writing organizations. As such the IBC replaced the NBC and the IFC replaced the NFC. From 2000 until the appearance of the NFPA building code, the IBC was the only model building code that was being developed and maintained in the United States. The Life Safety Code, published by the National Fire Protection Association (NFPA) as NFPA 101 [7[, deals with the aspects of life safety from fire as would a model building code. This code, with its predecessor document dating back to 1913, addresses requirements for both new and existing construction. NFPA 101, unless amended when adopted, does not permit existing conditions that pose a serious safety risks to remain unabated. Typically, building codes only regulate conditions that came into existence after the code was adopted. NFPA 101 mandates a minimum level or standard of care for all buildings. In many cases, NFPA 101 will require improvements to existing buildings. NFPA has published a fire code since 1971 and began publishing a building code in 2003. The NFPA fire code, originally named the Fire Prevention Code, was renamed the Uniform Fire Code for the 2003 edition [4]. The NFPA building code, Building Construction and Safety Code, is a second model code

7-1

7-2 Bldg. Permit Date Description of Work BOCA: Fire Code NFPA 101 NFPA 1 July 27, 1967 Install paneling; rebuild two porches; install new sign Basic Fire Prevention Code 1965 Life Safety Code 1967 May 18, 1970 Roofing Paneling ect Basic Fire Prevention Code 1970 Life Safety Code 1970 October 18, 1971 Alterations and remodeling Basic Fire Prevention Code 1970 Life Safety Code 1970 November 15, 1974 Interior paneling and partitions Basic Fire Prevention Code 1970 Life Safety Code 1973 April 29, 1975 Exterior Alterations and Renovations Basic Fire Prevention Code 1975 Life Safety Code 1973 July 1, 1975 Addition 330ft2 Basic Fire Prevention Code 1975 Life Safety Code 1973 November 21, 1981 Request of Variation Under Building Code, not enclose stair to basement Basic Fire Prevention Code 1981 Life Safety Code 1981 Feburary 20, 1985 Remodel and renovation to existing restaurant Basic/National Fire Prevention Code 1984 Life Safety Code 1985 Fire Prevention Code 1982 December 9, 1999 Notice of Construction without a permit National Fire Prevention Code 1999 Life Safety Code 1997 Fire Prevention Code 1997 June 19, 2001 Repair front from car National Fire Prevention Code 1999 Life Safety Code 2000 Fire Prevention Code 2000 Table 7-1. Applicable Model Fire Code

Building Permits Dates Description of Work BOCA Building Code July 27, 1967 Install paneling; rebuild two porches; install new sign 1965 Basic Building Code May 18, 1970 Roofing Paneling ect 1970 Basic Building Code October 18, 1971 Alterations and remodeling 1970 Basic Building Code November 15, 1974 Interior paneling and partitions 1970 Basic Building Code April 29, 1975 Exterior Alterations and Renovations 1975 Basic Building Code July 1, 1975 Addition 330ft2 1975 Basic Building Code November 21, 1981 Request of Variation Under Building Code, not enclose stair to basement 1981 Basic Building Code Feburary 20, 1985 Remodel and renovation to existing restaurant 1984 Basic/National Building Code December 9, 1999 Notice of Construction without a permit 1999 National Building Code or IBC 2000 June 19, 2001 Repair front from car 1999 National Building Code or IBC 2000 Table 7-2. Applicable Model Building Code

developed and maintained in the United States. As such, it is included in the code analysis. The Building Construction and Safety Code is commonly known as NFPA 5000 [5]. The older editions of the BOCA building code treated restaurants and nightclubs differently. To many, a restaurant and a night club may seem to pose similar risks; however, prior to 2000, the codes viewed restaurants and night clubs differently. Even though the codes classified nightclubs and restaurants in different occupancies, it is not always easy to distinguish between restaurants and nightclubs. Below are BOCA definitions of class A-1 and class A-2 structures [6]: 303.3 Use Group A-2 structures: This use group includes all buildings and places of public assembly, without theatrical stage accessories, designed for occupancy as dance halls, nightclubs and for similar purposes, including all rooms, lobbies and other spaces connected thereto with a common means of egress and entrance. 303.4 Use Group A-3 structures: This use group includes all buildings with or without an auditorium in which persons assemble for amusement, entertainment or recreation purposes as well as incidental motion picture, dramatic or theatrical presentations, lectures or other similar purposes without theatrical stage other than a raised platform; and which are principally occupied without permanent seating facilities, including art galleries, exhibition halls, museums, lecture halls, libraries, restaurants other than nightclubs, and recreation centers; and buildings designed for similar assembly purposes, including passenger terminals. Facilities that have seating at tables and chairs for all patrons and serve food are typically considered as restaurants. Facilities that may have some seating and food service, but offer standing and gathering space are typically considered to be nightclubs. Either occupancy may have entertainment and a dance floor. As a tool to assist in determining if an establishment is a nightclub or restaurant, historically, local jurisdictions have compared amounts of food and alcohol served. The ratio of food to alcohol to be classified as one or the other varies between localities. Converting from one to the other would trigger the change of occupancy provisions of the codes. Historically, the change of occupancy provisions of the BOCA codes required that the building meet the intent of the code for the new occupancy and not pose a greater hazard. The 1955 National Building Code made no distinction between restaurants and nightclubs. The Code stated the following: "The provisions of this code based on occupancy also apply to conversions of existing buildings and structures or portions thereof from one occupancy classification to another, which would not apply to change from restaurant to nightclub." It is clear that the proper classification of The Station at the time of the fire was as a nightclub. However, as of the writing of this document, the Town of West Warwick has not made either the historical, or most current, use and occupancy permit for the bar available. It is not possible to determine how the facility was being regulated. Also, it is not possible to determine how the facility was classified when changes occurred to the building. Without accurate knowledge of how the building was classified, assumptions regarding occupancy classification could lead to incorrect conclusions. 7.3 MODEL CODE ANALYSIS The model code analysis was based upon the International Building Code (IBC) 2003 [2] edition and Building Construction and Safety Code (NFPA 5000) 2003 edition [5]. A comparison of the relevant

7-3

sections of these codes is included as Table K-1 in Appendix K. In areas were the codes had dissimilar requirements the impact of both requirements were evaluated. The Life Safety Code (NFPA 101) 2003 edition [7] is a code that addresses life safety issues primarily through regulation of egress and fire safety systems. The provisions of new construction in NFPA 101 aligned with the requirements of NFPA 5000. (Note that the analysis did not include a comparison to NFPA 101 for existing buildings) The International Fire Code (IFC) [3] and the Uniform Fire Code (NFPA 1) [4] are compared section by section in Appendix K, Table K-2. Details on the changes to NFPA 101, the Uniform Building Code, the Standard Building Code, and the BCMC over the life of The Station and its previous incarnations were also tabulated in the final report from Arup Fire [8]. NIST's technical investigation did not focus on compliance or non-compliance with the specific state or local regulations in effect at the time of the fire, nor did it seek to find fault. Rather, the focus was on model codes and standards and how the design and operation of The Station compared with the guidance provided within them. The findings and recommendations from the NIST investigation are expected to be useful across the nation. Relevant aspects of the national model building codes are discussed in this section, followed by comments (in italics) on the conditions in The Station that were documented during the analysis. It should be noted that the building code evaluation utilizes current building code requirements, which generally are not applied to existing buildings. 7.3.1 Administration IBC §105.1 mandates permits for enlarging, altering, repairing, or changing of the occupancy of any building. NFPA 5000 §1.7.6.1.1.1 maintains similar requirements. Comment: Over the life of this building, it was rehabilitated numerous times. A number of the projects were permitted. Typically, descriptions of work included on building permits included Roofing Paneling [9], Alterations and remodeling [10], Addition 30.6 m2 (330 ft2) [11] Both IBC §109.1 and NFPA 5000 §1.7.6.6.1.3 demand any work that is required to have a permit issued to be inspected. Comment: Limited inspection records for the building were available for review. The inspection records are of fire department inspections, not inspection records for the building department. The reports appear to be from inspections related to renewal of the bar’s liquor license. NFPA 5000 §1.7.6.6.4 requires the records be maintained for each inspection. IBC §104.7 also mandates that reports of inspections be maintained for the period of time required for public records by the local authority. 7.3.2 Occupancy Classification IBC §303.1 classifies the occupancy as a Group A-2. NFPA 5000 §3.3.371.1 classifies the space as an Assembly Occupancy. Comment: The use of The Station is consistent with the IBC and NFPA 5000 occupancy classifications of Group A-2 and Assembly, respectively.

7-4

1. 3.3

Construction Type IBC §602.5 classifies the building as Type VB construction. NFPA 5000 §7.2.6 classifies the building construction as Type V (000). Comment: The construction of the building was unprotected wood frame. The requirements, IBC Table 602 and NFPA 5000 Table 7.3.2.1, for fire resistance rating of exterior walls are consistent in both codes. In instances were the building is more than 3.05 m (10 ft) from the property line, exterior walls are not required to have a fire resistance rating. For a separation distance between the building and the property line of less than 3.05 m (10 ft), the codes require the exterior wall to have a 1-hour fire resistance rating. Comment: The building was more than 3 m (10 ft) from the property line. 7.3.4 General Building Heights and Area Both codes regulate the height and area of buildings based on occupancy of the building and construction type. IBC Table 503 limits the area of the Group A-2 Type VB buildings to 557 m2 (6000 ft2) and one story. NFPA 5000 Table 7.4.1 limits Assembly occupancies with occupant loads greater than 300 and less than 1000 persons of Type V (000) construction to 511 m2 (5500 ft2) and one story. Comment: West Warwick tax records indicate the main floor of the building was 416 m2 (4484 ft2) and the basement was 78 m2 (840 ft2) [12] Both codes allow an increase in the area based on open perimeter. The IBC also allows an increase in the height of the building based upon sprinkler protection. NFPA 5000 does not allow the increase in height for sprinklers in this instance. Comment: The building was not sprinkler protected. 7.3.5 Interior Finish Both model codes regulate interior finish materials based upon flame spread, smoke production, location in the building, and type of use or occupancy of the space. The IBC, Chapter 8 contains interior finish provisions; in NFPA 5000, they are contained in Chapter 10. ASTM E-84 13 is the principal test method used by both codes to characterize flame spread and smoke development. Both codes also allow for large scale testing of interior finishes in lieu of E-84. Tests such as NFPA 286 [15] meet the requirement for large scale testing. IBC Table 803.6 and NFPA 5000 §16.3.3.3 require interior finishes such as wood paneling, wood sheathing boards, and bead board to have a flame spread rating equal to or less than 75 and a smoke development index equal to or less than 450. In sprinkler protected buildings, both codes allow the flame spread index to go up to 200. In the IBC, plastics used as interior finish are regulated by IBC §2604. In NFPA 5000, cellular or foamed plastics used as interior finish are regulated by §10.4.3. The IBC requires foam plastics used as interior finish to be labeled, to have a flame spread index not to exceed 75, to have a smoke development index not to exceed 450, and to pass full scale testing. The large scale testing shall be related to the actual use configuration. NFPA 5000 §10.4.3.1 requires large scale fire tests for foam plastic insulation. The tests must be representative of actual use conditions.

7-5

In 1949, no combustible wall or ceiling finish was permitted in public buildings and places of assembly and exits there from that would “spread flame over its surface more rapidly than over one-inch (nominal) wood boards covered with ordinary paint or varnish.” This rather loose standard was replaced in the 1955 NBC by the E-84 test discussed above. The interior finish requirements have changed little since the 1955 edition. The most significant change in 1967 tightened a previous exception for business occupancies by reducing the allowable flame spread in rooms or spaces less than 139 m2 (1500 ft2). In 1976, the allowable flame spread of exits in assembly occupancies was reduced, and dwellings were regulated for the first time. A separate section was added on floor coverings based upon a “flame propagation index”. Neither smoke production nor toxicity has been regulated. Comment: As would be expected, the interior finish materials of the building varied greatly. The interior finish material was mapped and is shown in Figures 7-1 and 7-2. The interior wall finishes included wood paneling, bead board, painted gypsum, wafer board, and ceramic tile. Interior finishes were identified from photographic and video records. The finishes identified were estimates based on a video and photographs taken in the building. The finishes referred to as painted gypsum may be either gypsum wall board or plaster. Neither samples of products nor model and manufacture information were available. Accordingly, conclusions regarding flame spread ratings are based upon broad product categories. The ceramic tile and gypsum do not pose potential interior finish flame spread issues. It appears that there were multiple types of wood paneling installed in the building. Portions of the wood paneling and bead board were painted. Wood paneling is manufactured with different flame spread ratings ranging from Class A to Class C. Many wood panelings are plywoods. Flame spread indexes for plywood range from 70 to 160 [16, 17]. Without knowledge of the specific paneling installed, it is not possible to determine the interior finish classification of the wood paneling at its time of installation. The natural aging and surface treatments applied after installation can dramatically affect the flame spread index of products. The bead board is subject to the same variations in flame spread index due to aging and surface treatments. Without samples to test the class of the interior finish, the flame spread index cannot be definitively stated for either the bead board or paneling. Untreated red oak flooring has a Class C interior finish rating (100 flame spread index). The walls surrounding the platform and the wall to the left of the platform were covered in expanded foam plastic insulation. Additionally, a portion of the ceiling over the platform and the ceiling in front of the platform were covered with expanded foam plastic insulation. The model codes allow foam plastic installation as an interior finish only after large scale testing has been conducted and successfully completed. 7.3.6 Plastics IBC regulates plastics in Chapter 26. Chapter 26 has provisions that complement the interior finish provisions in Chapter 8. NFPA 5000 Chapter 48 regulates all plastic materials used in or on buildings. Comment: The tie between Chapters 48 and 10 is not as concise as with IBC. The provisions of IBC and NFPA 5000 are the same. The organization of these codes differ; however, the requirements are the same.

7-6

Office Rest Room Rest Room Side Bar Kitchen Main Bar Sunroom Drummers Box Building Front Building Rear Raised Dining Area Storage Dressing Room Stage Main Bar 1 1 UTD UTD UTD UTD 1 1 4 2 UTD UTD 3 20 20 7 4 13 10 19 16 14 1 1 X Legend Bibliography of Photos Indicates Ceiling Type* X * Refer to Appendix _ for details ** Blank Indicates No Wall Exists

UTD - Unable To Determine UTD Platform 1 Dance Floor & 2 Assembly Area Legend of Ceiling Types 1 Acoustical Ceiling Tile 2 Foam 3 Wood Lattice 4

2x4 Rafters

Figure 7-1. Station Night Club Ceiling Interior Finish

7-7

Office Rest Room Rest Room Side Bar Kitchen Main Bar Sunroom age Drummers Box Building Front Building Rear Raised Dining Area Storage in Bar Dressing Room St Ma UTD 4 4 7 6 2 1 1 1 1 5 5 5 5 UTD 1 7 UTD UTD UTD 3 3 3 3 UTD UTD 2 2 2 2 3 3 3 3 2 3 2 20 20 15 18 7 3 1 12 11 5 2 9 8 17 16 6 5 Legend Bibliography of Photos Indicates Wall Type* X X X Bottom portion of wall** Top portion of wall** * Refer to Appendix _ for details ** Blank Indicates No Wall Exists

UTD - Unable To Determine Platform Dance Floor & Assembly Area

Legend of Wall Types 1 Foam 2 Paneling 3 Gypsum 4 Waffer Boards 5 Ceramic Tile 6 Stucco 7 Bead Board

Figure 7-2. Station Night Club Wall Interior Finish

7-8

Foam plastic used as an interior finish shall be the tested in accordance with NFPA 286. During the NFPA 286 test, the room may not flashover nor may flames exit the enclosure. Additionally, total smoke production (a measure of the total surface area of the smoke particles per kg of fuel consumed) shall not exceed 1000 m2. In the IBC, the requirements for foam plastic to be used as an interior finish are found in §2604.1. §2604.1 requires testing in compliance with §2603.8. §2603.8 requires large scale testing and compliance with Chapter 8 flame spread provisions. NFPA 5000 §48.4.4 contains the same provisions as IBC §2603.8. Comment: The model codes prohibit the use of foam plastic insulation as an interior finish that does not pass a large scale test replicating end-use conditions. There is no indication that the foam used on the walls of The Station was tested. 7.3.7 Automatic Sprinkler System For new construction, IBC §903.2.1.2 requires Group A-2 uses to be protected by automatic sprinklers if any of the following are exceeded: • fire area > 1114 m2 (12,000 ft2) • occupant load > 300 persons • fire area located on other than the floor of exit discharge NFPA 5000 §16.3.5.1.1 mandates automatic sprinkler protection for assembly occupancy serving more than 300 persons. Several exceptions are allowed. None of the exceptions are relevant to The Station. Comment: The model codes trigger sprinkler protection for buildings based on a combination of factors including occupancy, building area, construction type, building height, location relative to exit discharge, and occupant load. For new construction of this type of building, the model codes require sprinklers for an occupant load. in excess of 300 persons. The building was not equipped with an automatic sprinkler system. The BOCA National Building Code would have required sprinkler protection (for new construction) based on the area and construction type of the building. The largest Type 5B Use Group A-2 building the BOCA National Building Code would have allowed is 390 m2 (4200 ft2), which is less than the area of The Station. 7.3.8 Fire Alarm IBC §907.2.1 requires manual fire alarm systems in Group A occupancies with occupant loads exceeding 300 persons. IBC §907.2.1.1 requires voice notification for Group A occupancies with occupant loads greater than 1000 persons. NFPA 5000 §16.3.4 requires manual fire alarms in Assembly occupancies with occupant loads exceeding 300 persons. The fire alarm shall be activated by manual pull station, smoke detectors, the sprinkler system, and heat detectors in hazardous locations. Comment: The building was equipped with a manual fire alarm. Manual pull stations were located adjacent to Door 3 and behind the main bar. Heat detectors were located in the area behind the kitchen. Heat detectors were present above and below the platform area. Fire alarm horns were located behind the main bar and in the front room near the pool tables.

7-9

1. 3.9

Festival Seating NFPA 5000 §3.3.474.1 defines "Festival Seating" as a form of audience/spectator accommodation in which no seating, other than a floor or ground surface, is provided for the audience/spectators gathered to observe a performance. NFPA 5000 §16.2.4.1 allows festival seating for assembly occupancies with less than 1000 occupants. IBC uses the term "standing room" rather than"festival seating." Comment: At the time of the fire, the nightclub was arranged for festival seating, permitting more occupants than had the building been arranged for fixed seating. 7.3.10 Exits There were four exit routes from the building, as numbered in Figure 7-5: (1) the front main exit, (2) the main bar exit on the side, (3) the kitchen exit, and (4) the platform exit. The model codes govern their number, size, placement, and other details of design, as discussed in this section (i) Doors Doors shall provide a clear opening of at least 0.81 m (32 in), IBC §1008.1.1 and NFPA 5000 §11.2.1.2.4. Doors shall swing in the direction of egress travel when serving spaces with more than 50 persons, IBC §1008.1.2 and NFPA 5000 §11.2.1.4.2. Comments: All doors exceeded the 0.81 m (32 in) minimum, and all door leaves swung in the direction of egress travel with the exception of the interior leaf at exit 4. (See Fig. 7-5.) (ii) Panic Hardware IBC §1008.1.9 and NFPA 5000 §16.2.2.2.3 mandate panic hardware on doors that have locks or latches in the means of egress for assembly occupancies with an occupant load greater than or equal to 100 persons. Comments: When viewed from the exterior, the right leaf of the front doors was not equipped with panic hardware. There was no visible hardware on either door. As of this writing, the type of hardware on the swinging door immediately inside the double exterior doors is undetermined. (See Fig. 7-5.) The door to exit 2 was equipped with panic hardware. As of this writing the type of hardware with which the door at exit 3 was equipped has not been determined. The inward swinging leaf of the door at exit 4 was fitted with standard knob style hardware. The outward swinging door was equipped with panic hardware. (iii) Floor Level and Landings IBC §1008.1.4 and NFPA 5000 §11.2.1.3 mandate that the floor level on both sides of a door shall be at the same level. IBC §1008.1.5 and NFPA 5000 §11.2.2.3.2 also requires that the landing be at least as wide as the stair or door being served and the door when fully open may not reduce the required width of the landing by more than 0.18 m (7 in). Comments: Based on photographic evidence and review of the video, the floor was level on both sides of the main door at exit 1. It could not be determined if the floor was level on both sides of the doors at exits 2 and 3. The floor was not level on both sides of door at exit 4. The first riser was in line with the plane of the closed door.

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There was not a landing at the exterior of exit 4. The photos of exit 2 indicate a landing outside the door, however, it cannot be determined if a step existed at the door. The photos indicate a stair at Door 3, but it could not be determined if a landing or risers were present at the door. (iv) Exit Signs Exit signs are required at exits other than obvious main exits, and at other locations where exit access is not obvious, per IBC §1011.1 and NFPA 5000 §11.10.1.4. Comments: The nightclub was equipped with exit signs over each of the four doorways. (v) Travel Distance Both IBC §1018.1 and NFPA 5000 §16.2.6 require the travel distance to exits (the maximum distance from any place in the building to an exit) not exceed 61 m (200 ft). In the 1955 NBC travel distance in assembly occupancies was increased to 45.7 m (150 ft), up from 30.5 m (100 ft). In 1967 it was changed back to 30.5 m (100 ft). Comment: The travel distance in this building was less than 61 m (200 ft). (vi) Common Path of Travel IBC §1013.3 states the common path of travel shall not exceed 22.8 m (75 ft). NFPA 5000 §16.2.5.1.2 limits the common path of travel to 6.1 m (20 ft) or less. Common path of travel is the portion of the means of egress that must be traversed until such a point that at least two independent means of egress to at least two exits are available. Comment: If all doors to the exterior were considered exits, all areas complied with the model codes' common path of travel provisions. If exit 4 is not considered an exit, over 50% of the sun room and dance floor area have a common path of travel greater than 6.1 m (20 ft). Not considering exit 3 as an exit does not create additional common path of travel issues. (vii) Exit Separation NFPA 5000 §11.5.1.4 and IBC §1014.2.1 requires the exits to be separated by at least one half the length of the maximum overall diagonal dimension of the building area served. Comments: The diagonal of the area served was 25.3 m (83 ft). The model codes require a separation of 12.6 m (41.5 ft). If all doors to the exterior were considered exits, the separation of exists in The Station would have been consistent with the model code provisions. Only Door 1 and Door 2 were consistent with the model code definition of an exit, and they were separated by 10.4 m (34 ft)t. Accordingly, when considering Doors 1 and 2 as the only exits the separation of exits was less than required in the model codes. (viii) Dead Ends IBC §1016.3 states that dead ends in relation to corridors shall not exceed 6.1 m (20 ft). NFPA 5000 §16.2.5.1.3 has the same limit.

7-11

While the passage way to the restrooms created a dead end 7.6 m (25 ft) long and the access aisle to the raised seating area was a dead end 7.3 m (24 ft) in length, neither were associated with corridors. No other dead ends existed. 7.3.11 Occupant Load Limits The model codes compute the occupant load limits in two ways: based upon area, and based upon egress capacity. If the occupant load calculated via area exceeds the capacity of the egress system, the codes require the egress system to be expanded. The egress capacity must always exceed the occupant load. (i) Area Basis Occupant load factors are expressed in terms of square meters (feet) per person. Dividing the area of the space by the occupant load factor yields the allowable occupant load. The model codes use occupant load factors to determine the allowable number of persons given an area. The relevant occupant load factors from IBC Table 1004.1.2 and NFPA 5000 Table 11.3.1.2 are detailed in the following table.

Table 7-3. Occupant Load Factors, m2/person (ft2/person) Occupancy/Use IBC Table 1004.1.2 Occupant load factor NFPA Table 11.3.1.2 Occupant load factor Assembly, Concentrated (chairs only not fixed) 0.65 (7) net 0.65 (7) net Assembly, Stand space 0.46 (5) net 0.65 (7) net Assembly, Unconcentrated (tables and chairs) 1.39 (15) net 1.39 (15) net Business area 9.28 (100) gross 9.28 (100) gross Kitchens commercial 18.6 (200) gross 9.28 (100) gross Stages and Platforms 1.39 (15) net 1.39 (15) net Warehouse 46.4 (500 ) gross based upon maximum probable number of occupants present

IBC §1004.2 allows the occupant load to be increased above the calculated number provided the other egress provisions are met and the occupant load does not exceed 0.46 m2/person (5 ft2/person). NFPA 5000 §11.3.1.3 and 16.1.6 contains similar provisions. Both model codes allow the occupant load to be based on capacity of the means of egress provided each person has 0.46 m2 (5 ft2) of floor space. NFPA 5000 §16.1.6 limits the increased occupant density to 0.46 m2/person (5 ft2/person) net floor space for buildings up to 930 m2 (10,000 ft2) and to 0.65 m2/person (7 ft2/person) net floor space for buildings that are larger.Note that net space excludes restrooms, passageways, and space assigned for other uses such as the space behind the bars and the kitchens. Comment: Refer to Figure 7-3 and Figure 7-4 for the use of spaces within the Station as defined by the model codes. Based upon those uses, the maximum load for each space is computed in Table 7-4. The total maximum occupancy of a building similar to The Station, according to IBC,

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Office Business Occupancy 162 Sq.Ft at 1 son 00 Sq.Ft/Per Rest Room Rest Room Kitchen Kitchen Occupancy 171 Sq.Ft at 0 Sq.Ft/Pers Main Bar Non-Simultaneous Use 137 Sq.F Sunroom Dressing Room Business Occupancy 108 Sq.Ft at 0 Sq.Ft/Pers Stage Occupancy 73 Sq.Ft at 5 Sq.Ft/Pers Drummers Box Building Front Building Rear Raised Dining Area Assembly Occupancy (Tables & Chairs) 161 Sq.Ft at 15 Sq.Ft/Person Non-Simultaneous Use 399 Sq.Ft Storage Storage Occupancy 690 Sq.Ft a 300 Sq.Ft/Per Assembly Occupancy (Concert Standing) 709 Sq.Ft at 7 Sq. t/Person (NFPA 00) Side Bar 20 on t 10 on Stage 3 1 on t son Main Bar 2 F 50 15 m2 (162 ft2) 9.28 m2 (100 ft2)/person 15 m2 (161 ft2), 1.39 m2 (15 ft2)/person 36.9 m2 (399 ft2) Platform 64 m2 (690 ft2) Dance Floor & Assembly Area 35 m2 (373 ft2) 1.39 m2 (15 ft2)/person 16 m2 (171 ft2) 9.28 m2 (100 ft2)/person 251 m2 (2709 ft2) 0.65 m2 (7 ft2)/person 12.7 m2 (137 ft2) 10 m2 (108 ft2) 9.28 m2 (100 ft2)/person

Figure 7-3. Station Nightclub (NFPA 5000) Use Area Designations

7-14 Office Business Occupancy 1 t 62 Sq.Ft a 0 Sq.Ft/Per Rest Room Rest Room Kitchen Kitchen Occupancy 171 Sq.Ft at 00 Sq.Ft/Per Main Bar Non-Simultaneous Use 37 Sq Stage Occupancy 373 Sq.Ft at 5 Sq.Ft/Perso Drummers Box Building Front Building Rear Raised Dining Area Assembly Occupancy (Tables & Chairs) 161 Sq.Ft at 15 Sq.Ft/Person Non-Simultaneous Use 399 Sq.Ft Storage Storage Occupancy 690 Sq.Ft at 0 Sq.Ft/Pers Assembly Occupancy (Concert Standing) 2709 Sq.Ft at .Ft/Person (I Sunroom Dressing Room Business Occupancy 108 Sq.Ft a 0 Sq.Ft/Pers 10 son Side Bar 2 son 1 .Ft Stage 1 n 30 on Main Bar 5 Sq BC) t 10 on 16 m2 (171 ft2) 18.6 m2 (200 ft2)/person 12.7 m2 (137 ft2) 15 m2 (162 ft2) 9.28 m2 (100 ft2)/person 36.9 m2 (399 ft2) 15 m2 (161 ft2), 1.39 m2 (15 ft2)/person Platform 64 m2 (690 ft2) 27.8 m2 (300 ft2)/person Dance Floor & Assembly Area 35 m2 (373 ft2) 1.39 m2 (15 ft2)/person 251 m2 (2709 ft2) 0.46 m2 (5 ft2)/person 10 m2 (108 ft2) m2 (100 ft2)/p 9.28 erson

Figure 7-4. Station Night Club Fire (IBC) Occupancy Area Designations

7-15 Office Rest Room Rest Room Side Bar Kitchen Main Bar Sunroom Drummers Box Building Front Building Rear Raised Dining Area Storage Stair Clear Width = 36" Stair Clear Width = 36 Door Clear Width = 36" Dressing Room Stage Main Bar " Egress Capacity = 120 persons y = 180 persons Egress Capacity = 120 persons Egress Capacit Door Clear Width = 36" Egress Capacity = 180 persons Platform

Figure 7-5. Station Nightclub Egress Capacity (Note that model codes exclude exiting through a kitchen when calculating occupancy limit.) Dance Floor & Assembly Area 1 4 3 2 Egress Capacity = 120 persons Stair Clear Width = .91 m (36") Stair Clear Width = .91 m (36") Stair Clear Width = .91 m (36") Door Clear Width = .91 m (36")

Table 7-4. Computed Occupant Loads Based Upon Model Codes and Areas Shown in Figures 7-3 and 7-4 Use Area, m2 (ft2) IBC capacity* NFPA 5000 capacity* Assembly Standing 251 (2709) 542 387 Business 25 (270) 3 3 Platform 35 (373) 25 25 Kitchen 16 (171) 1 1 Storage 64 (690) 3 3 Assembly T/C 15 (161) 11 11 Total 406 (4374) 585 430

• Note that conversion between metric and common units can lead to a variation of about 1 % in capacity

would have been 585 persons; a similar calculation based upon the NFPA 5000 occupant load factors yields a total maximum population of 430 persons. The significant differences arise from NFPA 5000 allowing the use of 0.65 m2/person (7 ft2/person) for concentrated assembly occupancy. IBC uses 0.46 m2/person (5 ft2/person) for standing assembly space. NFPA 5000 does have a provision that allows the occupant load to be increased to match the available egress capacity. Typically, the table value of 0.65 m2/person (7 ft2/person) is used. Both codes would allow these occupant loads, if the exit capacity were available. (ii) Egress Basis Egress capacity factors are related to the minimum clear width required for exit pathways in order to ensure timely egress, and are expressed in terms of mm/person (in/person). The egress capacity factors for level egress components and ramps are smaller than factors for stairways. The smaller this factor, the more occupants the egress component is given credit to manage. IBC Table 1005.1 and NFPA 5000 Table 11.3.3.1 contain the capacity factors for egress elements. Clear widths are divided by egress capacity factors to yield the maximum capacity for that particular egress element. The IBC reduces the required width when a building is fully sprinkler protected, as shown in Table 7-5. IBC and NFPA 5000

Table 7-5. Egress Capacity Factors Occupancy Without Sprinkler System, mm/person (in/person) With Sprinkler System, mm/person (in/person)

IBC Table 1005.1 NFPA 5000 Table 11.3.3.1 IBC Table 1005.1 NFPA 5000 Table 11.3.3.1 Level Components and Ramps 5.1 (0.2) 5.1 (0.2) 3.8 (0.15) 5.1 (0.2) Stairways 7.6 (0.3) 7.6 (0.3) 5.1 (0.2) 7.6 (0.3) a Dimensions estimated from photographs to the nearest 1/2 in (12 mm) b Model codes exclude exiting through a kitchen when computing occupancy limit c Small increases within the uncertainty of our estimates of the sizes of the clear width of the stairs and doors could increase the total capacity to 426.

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require the number of occupants to be less than the capacity of the available egress width, and both codes require two means of egress for buildings with a total occupant load of less than 501 persons. IBC §1008.1.2 and NFPA 5000 §11.2.1.4.2 contain requirements that doors swing in the direction of egress travel in the path of egress from assembly occupancies serving occupant loads of greater than 50 persons. Comments: The building was not sprinkler protected. See Table 7-6 and Figure 7-5 for capacities of each exit. As required by both model codes, the element with the smallest capacity in each path of egress was considered to be the limiting element. The limiting element dictated the capacity of each egress path. For the main entrance, exit 1, the interior 914 mm (36 in) door was the limiting element, resulting in a capacity of 180 persons for the main entrance exit. For exit 2, the side door out of the main bar area, the exterior stairs leading from the door were the limiting element, resulting in a capacity of 120 persons. Exit 3, from the kitchen, was also limited by an exterior stair; however, both codes prohibit egress by patrons through the kitchen (IBC §1013.2 and NFPA 5000 §11.5.2.1) Exit 4 adjacent to the platform had two doors installed on the same jam, one swinging in the direction of egress travel and one swinging opposing the direction of travel. Excluding the kitchen exit and including the exit adjacent to the platform, the occupancy limit based upon egress capacity would have been 420 according to both model codes. (See Table 7-6.) Table 7-6. Egress-limited Occupant Load Calculations (IBC and NFPA 5000) Element Width,a mm (in) Clear Width,a mm (in) Capacity Fac., mm/person (in/person) Capacityc, persons Limiting Element Exit 1 - main

Front Door 1829 (72) 1727 (68) 5.1 (0.2) 340 no Interior Door 914 (36) 914 (36) 5.1 (0.2) 180 yes Stairs (4 risers) 2540 (100) 2438 (96) 7.6 (0.3) 320 no Ramp 2540 (100) 2438 (96) 5.1 (0.2) 480 no Exit 2 - bar

Side Door 914 (36) 914 (36) 5.1 (0.2) 180 no Stairs (4 risers) 1016 (40) 914 (36) 7.6 (0.3) 120 yes Exit 3 - kitchenb

Side Door 914 (36) 914 (36) 5.1 (0.2) 180 no Stairs (4 risers) 1016 (40) 914 (36) 7.6 (0.3) 120b yes Exit 4 - platform

Side Door 914 (36) 914 (36) 5.1 (0.2) 180 no Stairs (4 risers) 965 (38) 914 (36) 7.6 (0.3) 120 yes total egress limit 420c

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1. 4

REFERENCES FOR CHAPTER 7 [1] "Code Analysis of the Station Nightclub," KA 03732-004, Koffel Associates, Inc., Ellicott City, MD, June, 2004. [2] 2003 International Building Code, International Code Council, Inc., Falls Church, VA. [3] 2003 International Fire Code, International Code Council, Inc., Falls Church, VA. [4] NFPA 1, Uniform Fire Code, National Fire Protection Association, Quincy, MA, 2003. [5] NFPA 5000, Building Construction and Safety Code, National Fire Protection Association, Quincy, MA, 2003. [6] The BOCA National Building Code/1993, Twelfth Ed., Building Officials and Code Administrators, Inc., Homewood, IL. [7] NFPA 101, Life Safety Code, National Fire Protection Association, Quincy, MA, 2003. [8] "Evaluation of Limitations to Egress through Doorways in Emergency Situations," vol. 2, Ove Arup & Partners Massachusetts Inc., Job number 32979, Westborough MA, Feb. 18, 2004. [9] West Warwick, Rhode Island, Building Permit May 18, 1970. [10] Building Permit October 18, 1971. [11] Building Permit July, 1, 1975. [12] West Warwick, Rhode Island Commercial /Industrial Property Record Card May 30, 2001. [13] ASTM E84-00a, Standard Test Method for Surface Burning Characteristics of Building Materials, American Society for Testing & Materials, West Conshohocken, PA, 2001. [14] NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, National Fire Protection Association, Quincy, MA, 2002. [15] NFPA 286, Standard Methods of fire Tests for Evaluating Contribution of Wall and Ceiling Interior Finish to Room Fire Growth, National Fire Protection Association, Quincy, MA, 2002. [16] American Wood Council. Design for Code Acceptance. awc.org/publications/dca/dca1/dca1.pdf [17] Canadian Wood Council. Cwc.ca/design/tech_topics/fire/spread_ratings.html

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Chapter 8 SUMMARY, FINDINGS AND RECOMMENDATIONS 8.1 SUMMARY OF INVESTIGATION Under the authority of the National Construction Safety Team Act, a team was formed by the NIST Director on Feb. 27, 2003 to investigate the failure seven days earlier of The Station nightclub in West Warwick, Rhode Island. The objectives of the investigation were the following: • to establish the likely technical cause or causes of the building failure; • to evaluate the technical aspects of evacuation and emergency response procedures; • to recommend, as necessary, specific improvements to building standards, codes, and practices based on the findings made pursuant to the duties listed above; and • to recommend any research and other appropriate actions needed to improve the structural safety of buildings, and improve evacuation and emergency response procedures, based upon the findings of the investigation. The following activities were undertaken by the team to reach the first two objectives and to establish the basis for the remaining two: • identification of technical issues and hypotheses requiring investigation through consultations with experts in fire protection engineering, emergency evacuation, and members of other teams investigating The Station fire; • data collection from local authorities, contractors and suppliers, building and fire protection design documents, records, plans, and specifications, video and photographic data, telephone and radio transmissions, field data, a limited number of interviews and other oral and written accounts from building occupants and emergency responders, and other witnesses as reported by the news media; • analysis and comparison of national model building and fire codes and practices, as well as review and analysis of practices used in operation of the building; • simulation and analysis of phenomena (with associated uncertainties), including fire spread, smoke movement, tenability, occupant behavior and response, evacuation issues, and operation of active and passive fire protection systems; and • testing to provide additional data and validate computer simulation predictions. The previous seven chapters of this final report describe the methodology used to conduct the investigation, detail what occurred on the night of Feb. 20, 2003, review the history of the building and the model codes and standards that would have applied to a building of this type, and present the results of testing and simulations. The key findings from the investigation are summarized in the following section. Recommendations for improving model building and fire standards, as well as codes, and practices are listed in Section 8.3; Section 8.4 describes actions already taken by local authorities and code making organizations. Research recommendations and other appropriate actions are provided in Section 8.5.

8-1

1. 2

FINDINGS During the course of the investigation NIST examined relevant model building and fire codes; previous incidents with some similar aspects that occurred in places of assembly; the life safety systems that were part of the building design; the materials used as part of the structure, as finish products and as building contents; the egress process; and the response of the fire department to the incident. NIST developed new information or confirmed published reports as to the initiating event, the reasons for the very rapid spread of fire and smoke, the difficulties encountered by the occupants during egress, and the mass casualty situation confronted by the fire department. Many of the findings summarized in this section had a direct bearing on the tragic outcome of this specific event (these are highlighted below in bold); others had a more peripheral role but are important to capture because of the potential to positively influence the outcome of future events. 8.2.1 Model Codes and Standards Appendix C recounts dozens of other tragedies in nightclubs and places of assembly where adherence to U.S. model building and fire codes could have prevented the failure of the building. Of most relevance to the current incident are the Happy Land Social Club fire [17], the Gothenburg Dance Hall fire [18], the Café de Hemel fire [19], and the E2 Nightclub crowd crush incident [20]. These events killed between 14 and 87 people each, with the root causes related to limitations on exits, overcrowding, an unanticipated initiating event, and (except for E2) building contents and materials -- all conditions that are inconsistent with the 2003 model building and fire codes. The following is the primary finding of the investigation regarding model codes and standards: • The investigation concluded that strict adherence to 2003 model codes available at the time of the fire would go a long way to preventing similar tragedies in the future. Changes to the codes subsequent to the fire made them stronger. By making some additional changes – and state and local agencies adopting and enforcing them – we can strengthen occupant safety even further. 8.2.2 Materials The hazardous mix of materials present in The Station were key contributors to the failure of the building. Specific findings regarding the foam on and in the walls and the pyrotechnics used in the performance are listed below: • A non-fire retarded foam sample purchased by NIST ignited within 10 seconds when exposed to a pyrotechnic device (15x15 gerb) in an arrangement similar to the set up on the platform of the nightclub. When a plywood panel with fire retarded polyurethane foam was exposed in a similar manner to a 15 x 15 gerb, no ignition of the panel occurred, nor did the plywood ignite with no foam present. • As could be seen in the WPRI video, flames spread rapidly over the foam in the nightclub, generating smoke and enough heat (estimated to be almost 60 MW at its peak) to ignite the wood paneling underneath and adjacent to the foam. The wood paneling in the nightclub was estimated to contain over 95 % of the fuel load, so that once most of the foam was consumed (estimated to be around two minutes after ignition of the foam), the fire transitioned to a wood frame building fire, with a steady heat release rate estimated to be around 45 MW.

8-2

• There was no fire resistant barrier between the interior of the nightclub and foam thermal insulation which had been installed in the stud space on the interior side of external walls of the drummer's alcove. • In the reconstruction of the platform area fire conducted at NIST, within 90 seconds after ignition of the non-fire retarded polyurethane foam conditions near the middle of the dance floor at head height (1.5 m, or 5 ft, above the floor) were lethal. (Temperature exceeded 460 oC (860 oF), carbon monoxide volume fractions reached 1 percent, hydrogen cyanide levels exceeded 0.07 percent, oxygen volume fraction fell to 9 percent, and radiant heat flux exceeded 40 kW/m2.) • NIST could not obtain samples of the foam that actually had been applied to the nightclub walls to conduct a chemical analysis to determine if the polyurethane material contained fire retardants; however, the ignition behavior of the foam exhibited on the WPRI video was consistent with the behavior observed in the NIST testing with a non- fire retardant foam. • Model codes require that foamed plastic material used as an interior finish pass large-scale fire tests that substantiate the combustibility characteristics of the material related to the actual end use. • Model codes permit the use of pyrotechnic devices in nightclubs if certain precautions are taken and with the approval of the authority having jurisdiction. • The average heat flux from the gerbs purchased by NIST impinging on a surface was determined to be much less than the average heat flux from the fire to the foam surface, once ignition of the foam had occurred. • The heat release rate from foam samples found at the site and representative materials purchased by NIST ranged between about 250 kW/m2 and 1100 kW/m2 when exposed to radiant fluxes between 20 kW/m2 and 70 kW/m2 in a cone calorimeter. • The carpet and furnishings contributed a relatively small amount to the fire, and the ceiling tiles a negligible amount. 8.2.3 Fire Protection Systems An inadequate capability to suppress the fire during its early stage of growth was another direct contributor to the large loss of life. The following was found regarding the installation and operation of fire suppression and other safety systems applicable to the building: • Experiments conducted at NIST in a reconstruction of the platform area fire demonstrated that a water sprinkler system installed in the test room in accordance with NFPA 13 [1] was able to control the fire initiated in non fire retarded polyurethane foam panels and maintain tenable (survivable) conditions at head height in the test room for the duration (over five minutes) of the experiment. This was in contrast to the reconstruction of the platform area fire with no sprinklers present, which led to likely fatal conditions at head height in the test room in about 1-1/2 minutes. A computer simulation of the full nightclub with and without sprinklers led to a similar positive result for the sprinklered scenario.

8-3

• Automatic fire sprinklers were not installed in The Station nightclub, nor were they required for such existing structures under the 2003 editions of the model codes. • A heat detection/fire alarm system was installed in The Station nightclub, which activated (sound and light strobe) 41 seconds after ignition of the polyurethane foam, by which time the crowd had already begun to move toward the exits. • Several hand-held fire extinguishers were located on the premises, at least one of which was used in an attempt to extinguish the fire on the platform. • Standard exit signs were located above each exit. • The building was equipped with emergency egress lighting. • The kitchen was equipped with a dry powder fire suppression system above the stove. 8.2.4 Occupant Load and Egress The inability of the exits to handle all of the occupants in the short time available for such a fast growing fire was the third major contributor to the substantial loss of life in The Station. Specific findings regarding the occupant load and egress process are presented here. • The first patrons recognized the fire danger about 24 seconds after ignition of the foam; the bulk of the crowd began to evacuate shortly after that, around the time the band stopped playing (30 seconds). • The rate of egress from the main entrance at the front of the building was limited by the single doorway inside the vestibule, not the double doors visible from the outside. • Between 56 percent and 66 percent of the occupants appear to have attempted to leave through the single main entrance in the front of the building; many were unsuccessful. • Prior to 1-1/2 minutes into the fire, a crowd-crush occurred in the front vestibule which almost entirely disrupted the flow through the front exit. The precise event which led to the crowd-crush likely was related to the arrangement of the single interior door with merging streams of traffic and the pressure to escape the rapidly deteriorating conditions in the main area of the nightclub. • Measurements of temperature, heat flux and gas species in a reconstruction of the platform area fire at NIST and computer models of the NIST experiment and the full nightclub suggest that the conditions around the platform, dance floor, sunroom, and dart room would have led to severe incapacitation or death within about 1-1/2 minutes after ignition of the foam for anyone remaining standing, and for not much longer even close to the floor. • The number of building occupants at the time of the fire was reported by the Providence Journal to be 440 [2]; as reported by the Associated Press [42], the prosecutor's office claimed that 458 occupants were present. • The Station had three doors suitable for exit by occupants. • The main area of the nightclub around the platform was open with very few chairs, stools or tables, consistent with a festival seating arrangement. Based upon the arrangement, number

8-4

and , geometry of the exits, the occupant limit for a similar building would be 420 persons according to both NFPA 5000 [3] and the International Building Code [4]. • For more than a minute into the fire, the crowd moved in an orderly fashion at an egress rate estimated to be a bit faster than 1 person/second through the main entrance of the building. • It was reported by the Providence Journal that a little over half of all people who successfully escaped via the doors (main entrance, main bar, kitchen and platform doors) exited via the main entrance. • The windows in the main bar room and the sunroom became the secondary routes of escape once the main entrance became impassible, and, according to reports, they accounted for over 1/3 of the successful evacuations. • The high number of victims found relatively close to the windows in the sunroom suggests that the environment became untenable more quickly than the victims were able to find a secondary route (e.g., through the sunroom windows) once the platform door and main entrance became unusable. • The small number of victims found in the main bar room suggests that the main bar room exit door and windows provided open routes of escape up to the point where conditions in that area of the building became untenable. • A computer model of The Station nightclub fire suggests that the conditions in the main bar area near the floor may have been survivable for more than three minutes after ignition, which is consistent with the WPRI video that showed people being assisted through the main bar windows up to 4 minutes after the start of the fire. • A significant number of victims were found in the dart room, storage area, and office near the back of the building, suggesting that they (1) were unfamiliar with the building and hoped to find a safe exit in that region, (2) did not realize that an exit existed inside the kitchen, or (3) became disoriented while heading for the side exit of the main bar room. • An interior door which opened inward was located at the platform exit, but the orientation of the door did not play a role in delaying the evacuation process since the rapid fire growth in that vicinity discouraged patrons from attempting to escape via the platform door exit. • A preexisting exit adjacent to the lavatories at the back of the structure had been eliminated during some previous construction. • The Team found no evidence of a written emergency action plan, a written fire prevention plan, or employee training to assist safe and orderly evacuation. • No evidence was found that a uniformed firefighter was on the premises at the start of the fire; however, two off-duty West Warwick police officers were known to be present, including one who called in the fire from within the building. 8.2.5 Emergency Response Given the hazardous mix of materials in The Station and the lack of installed sprinklers, nothing that the fire department could have done that night would have saved the building from the fast growing fire. Based upon the findings below, however, there are still things to learn from the incident regarding emergency response procedures:

8-5

• The first 911 call reporting a fire was before 11:09 pm, less than 40 seconds after ignition of the foam. • West Warwick police officers on the scene reported the fire about one minute after ignition of the foam, leading to the dispatch of four engines with six fire fighters and three fire officers, a tower-ladder truck with two fire fighters, a rescue unit with two attendants, and a battalion chief. • The first fire engine, staffed with one firefighter and a fire officer, was confirmed on- scene less than five minutes after the first 911 call was received, which was well within the limits of the NFPA standard [5] that states the fire department should be able to respond to a call within six minutes at least 90 percent of the time. • NFPA standards [5] recommend a minimum staffing level of four firefighters on both engine and truck companies, which was not achieved. Additional firefighters on scene at the crucial initial phase of the response would have benefited the rescue and firefighting efforts, although NIST is unable to say how the outcome might have been altered. • Rhode Island’s fire/rescue, emergency medical services and law enforcement agencies were confronted with the largest life loss fire incident in the State’s history. • Mutual aid agreements with neighboring jurisdictions were effective in bringing the necessary resources (equipment and emergency responders) to the scene of the incident. • A mass casualty plan was implemented capably within about 10 minutes of arrival of the first engine on the scene, such that within two hours of the start of the fire, all occupants needing medical attention had been evacuated from the scene and transported to medical facilities. • Because of the ongoing criminal investigation, the medical examiner's reports that may have revealed the likely causes of death of the 100 victims of the fire were not available to NIST. • Communications challenges resulting from limited radio equipment capabilities and the high volume of traffic substantially hampered the Incident Command's effective coordination of fire ground and triage operations, as well as the routing of responding EMS units to area hospitals. 8.2.6 Public Building Record-keeping Practices Inspections and record-keeping practices are an integral part of a community fire safety program. Findings related to this area that are relevant to The Station fire include the following: • Records were not found of the initial building design. Records of modifications -- when located -- lacked sufficient detail to track the changes to the structure. • Neither the historical nor most current use and occupancy permit for the building was located; however, the use of The Station was consistent with the IBC and NFPA 5000 occupancy classifications of "Group A-2" and "Assembly," respectively. • The main deficiencies of the building identified during the history of inspections by the Town of West Warwick related to the location of the fire extinguishers, non-functioning exit signs and emergency lights, broken panic hardware on an exit door, and the direction of swing of an exit door.

8-6

• On numerous reports, deficiencies identified by the inspectors were later annotated as "OK," but with no official re-inspection signature. • No Town of West Warwick or State of Rhode Island documents prior to Feb. 20, 2003, were located that mentioned foam materials on the walls of the nightclub, nor the use of pyrotechnics similar to those used on Feb. 20, 2003. 8.2.7 Referenced Codes and Standards Tables 8-1, 8-2, and 8-3 list, respectively, the model codes and standards in the areas of materials, fire protection systems, and occupant load and egress that relate to the findings of the NIST investigation team. Table 8-4 summarizes the issues surrounding applications of the code, and building and fire safety practices. References are to the appropriate sections/paragraphs in the current International Building Code [4], the Life Safety Code [7], NFPA 5000 [3], and the standards contained therein. (The relevant sections in the International Fire Code and the Uniform Fire Code can be linked to the corresponding sections in the International Building Code and NFPA 5000 through the Tables provided in Appendix K.) The last column indicates the relevance of the issue to the outcome on Feb. 20, 2003. Based upon the computer simulations and other findings from the investigation, an "H" was assigned to issues that, properly addressed, were highly relevant and would almost certainly have reduced substantially the loss of life (these are also highlighted in bold); an "L" implies a low likelihood that addressing the issue would have reduced the loss of life for this particular incident; and "M" implies moderate relevance to the specifics of this particular incident. Consideration by the model code organizations and the building and fire safety professions for those actions marked as "L," while not linked tightly to the outcome of The Station fire, is still warranted. In some cases, actions may be called for that are not even addressed in the model codes as currently written; the code sections identified in Tables 8-1 through 8-4 are not meant to be inclusive. Table 8-1 Findings Concerning Materials Relevant to Model Codes and Standards

Issue

References Relev. H M L ASTM E84 [9] X

NFPA 255 [11] X

NFPA 286 [10]

X

IBC:2604 [4]

X

Polyurethane foam used as sound insulation on platform and walls.

Foam thermal insulation unprotected in back platform wall. 5000:10.4.3.1 [3]

X

Pyrotechnic devices were used as part of the theatrics.

Little guidance provided to AHJ* regarding appropriate use of pyrotechnics. NFPA 1126 [12] X

IBC:803.6 [4]

X Unknown fire rating on wood paneling. 5000:16.3.3.3 [3]

X

• Authority Having Jurisdiction

8-7

Table 8-2 Findings Concerning Fire Protection Systems Relevant to Model Codes and Standards

Issue

References Relev. H M L 101:13.3.5.1 [7] X

5000:16.3.5.1.1 [3] X

IBC:903.2.1.2 [4] X

Automatic sprinklers not required for existing structures. 101.12.3.5.1 [7]

X IBC:907.2.1 [4] X

Fire alarm system unable to alert people to hazard quickly enough to avoid trapping occupants in building. 5000:16.3.4 [3] X

Portable fire extinguishers ineffective/not used early in fire. NFPA 10 [8] X

Table 8-3 Findings Concerning Occupant Load and Egress Relevant to Model Codes and Standards

Issue

References Relev. H M L Main entrance did not have capacity to handle 50% of the occupants on the night of the fire, and 50% would have been insufficient to safely evacuate all occupants in time (1- 1/2 minutes). IBC:1024.2 [4] 5000:16.2.3.3 [3] 101:12.2.3.3 [7] 101:13.2.3.3 [7] X

Festival seating overloaded the exit capacity. 5000:16.2.5.4.1 [3] 101:12.2.5.4.1 [7] 101:13.2.5.4.1 [7] 5000:16.2.4.1 [3] X X X X

Trained crowd managers not required for occupant loads < 1000. 101:12.7.5 [7] 101:13.7.5 [7]

X X

Higher occupant load factor permitted in IBC. IBC:1004.2 T [4] 5000:11.3.1.2 T [3]

X X

Lower egress capacity factor permitted in IBC if sprinklers are installed. IBC:1005.1 T [4] 5000:11.3.3.1 T [3]

X X

Location of alternative exits not obvious to patrons unfamiliar with nightclub, in spite of proper exit signs above doors. IBC:16.4.7.5 [4] 5000:11.10.1.4 [3]

X X

Longer common path of travel allowed in IBC. IBC:1013.3 [4] 5000:16.2.5.1.2 [3]

X X

Interior leaf of platform door did not swing in direction of egress. IBC:1008.1.1 [4] 5000:11.2.1.4.2 [3]

X X Stairs and landings at side exits may not have been at same level on both sides of doors. IBC:1008.1.4 [4] 5000:11.2.1.3 [3]

X X Main entrance double doors not equipped with panic hardware. IBC:1008.1.9 [4] 5000:16.2.2.2.3 [3]

X X

8-8

Table 8-4 Findings Relevant to National Practices

Issue

References Relev. H M L Automatic sprinklers not required in many existing structures. IBC:903.2.1.2 [4] 5000:16.3.5.1.1 [3] X X

Polyurethane foam used as sound insulation on platform and walls. education, practice X

Model codes can provide a meaningful level of safety only when adopted, practiced, and enforced by local jurisdictions. policy, practice X

Model codes attempt to deliver reasonable safety but do not guarantee safety of occupants in all anticipated situations. policy

X

Criteria for optimum allocation of resources among routine inspections, prevention programs, and emergency response not established. policy, practice, research

X

101:12.7.1 [7] 101:13.7.1 [7]

X X

Inspection reports not maintained. IBC:104.7 [4] 5000:1.7.6.6.4 [3]

X X Portable fire extinguishers ineffective/not used early in fire. training, practice

X Stairs and landings at side exits may not have been at same level on both sides of doors. IBC:1008.1.4 [4] 5000:11.2.1.3 [3]

X X Main entrance double doors not equipped with panic hardware. IBC:1008.1.9 [4] 5000:16.2.2.2.3 [3]

X X Details of work not included in permits, or permits not obtained. IBC:105.1 [4] 5000:1.7.6.1.1 [3]

X X No indication that building was inspected following completion of work. IBC:109.1 [4] 5000:1.7.6.6.1.3 [3]

X X

1. 3

RECOMMENDATIONS FOR IMPROVING MODEL STANDARDS, CODES, AND PRACTICES The general public expects that the model code upon which their community depends will protect them in public buildings from severe hazards (that can be anticipated). The investigation concluded that strict adherence to 2003 model codes available at the time of the fire would go a long way to preventing similar tragedies in the future. Changes to the codes subsequent to the fire made them stronger. By making some additional changes – and state and local agencies adopting and enforcing them – we can strengthen occupant safety even further. It is important to note that neither of the 2003 model codes were required to be followed at the time of The Station fire, and that NIST did not examine the code actually in force in West Warwick on Feb. 20, 2003, because the goal of the investigation was to understand how the incident happened, how it progressed, and how changes could be made in standards, codes and practices to avoid similar outcomes. Adoption of a model code, in and of itself, is not sufficient to guarantee the safety of a building, however, since the source of a building failure that leads to significant loss of life usually can be traced to a breakdown in one or more of the following key assumptions upon which the model codes are based:

8-9

(1) that the building designer, constructor, owner, operator, staff and patrons adhere to all applicable code provisions; (2) that the authorities having jurisdiction (AHJs) properly interpret and aggressively enforce the code provisions; and (3) that the historical record is a reliable predictor of worst case events. Recognizing this, model codes need to be robust and more redundant to minimize the chances of loss of life caused by the failure of a building that is out compliance, or is operating out of compliance, with code provisions. Adequate performance of the structure should be ensured even when one of the protective systems is compromised by uncertain behaviors of the building owner or occupants such as the following: a) installing building decorations or temporary features that greatly exceed flame spread or fire load provisions; b) exposing the building to strong ignition sources; c) exceeding the posted occupancy limits; d) temporarily blocking an exit; and e) disabling sprinklers or other life safety systems for maintenance. Recommendation 1 The findings presented above and the recommendations that follow raise a number of issues concerning model codes and standards, and the practices surrounding their adoption, application, and enforcement. NIST will work with the major organizations representing state and local officials – including mayors, state legislators, and county executives, as well as building and fire officials—to encourage them to seriously consider the recommendations of this report. As a starting point, state and local jurisdictions need to establish a sufficient building code infrastructure. NIST recommends that all state and local jurisdictions: a) adopt a building and fire code covering nightclubs based on one of the model codes (as a minimum requirement), and update local codes as the model codes are revised; b) implement aggressive and effective fire inspection and enforcement programs that address: (i) all aspects of those codes; (ii) documentation of building permits and alterations; (iii) means of egress inspection and record keeping; (iv) frequency and rigor of fire inspections, including follow- up and auditing procedures; (v) and guidelines on recourse available to the inspector for identified deviations from code provisions; and c) ensure that enough fire inspectors and building plan examiners are on staff to do the job and that they are professionally qualified to a national standard such as NFPA 1031 [14]. Recommendation 2 The results of the investigation clearly demonstrated the value of an NFPA 13 compliant automatic fire sprinkler system in extending the time the nightclub remained tenable. Recommendation 2 mirrors the action already taken by NFPA to strengthen the requirement for sprinklers in new and existing nightclubs and festival seating venues. NIST recommends that model codes require sprinkler systems, and that state and local authorities adopt and aggressively enforce this provision: a) for all new nightclubs regardless of size, and b) for existing nightclubs with an occupancy limit greater than 100 people.

8-10

Recommendation 3 Limitations on the flammability of materials used as finish products in nightclubs are included in both model codes, with specific references to NFPA 286, ASTM E-84, and/or NFPA 255. These standards and the sections of the codes that refer to them are the focus of recommendation 3. In relation to the fire performance of finish materials and building contents, NIST recommends: a) that state and local authorities adopt and aggressively enforce the existing provisions of the model codes; b) that non-fire retarded flexible polyurethane foam, and other materials that ignite as easily and propagate flames as rapidly as non-fire retarded flexible polyurethane foam, (i) be clearly identifiable to building owners, operators, contractors, and authorities having jurisdiction (regulatory agencies)I; and (ii) be specifically forbidden, with no exceptions, as finish materials from all new and existing nightclubs; c) that NFPA 286 be modified to provide more explicit guidance to building owners, operators, contractors, and authorities having jurisdiction for when large-scale tests that are covered in NFPA 286 are required to demonstrate that materials (other than those already forbidden in b above) do not pose an undue hazard for the use intended; and d) that ASTM E-84, NFPA 255, and NFPA 286 be modified to ensure that product classification and the pass/fail criteria for flame spread tests and large-scale tests are established using the best measurement and prediction practices available. Recommendation 4 Most pyrotechnic devices produce temperatures high enough to ignite certain materials, including non- fire retarded flexible polyurethane foam, if the device is in close proximity to the material. NFPA 1126, Use of Pyrotechnics before a Proximate Audience, is a model standard that provides "requirements for the protection of property, operators, performers, support personnel, and the viewing audiences where pyrotechnic effects are used…" [12] The provisions in NFPA 1126 are designed to prevent an incident such as the one that occurred in The Station nightclub on Feb. 20, 2003. Because it is not possible for the authority having jurisdiction to continuously monitor what materials are brought into a nightclub, and where they may be placed relative to a pyrotechnic device, the model code should be unequivocal on those situations in which pyrotechnic devices are simply not permitted. NIST recommends that NFPA 1126 be strengthened as described below, and that state and local authorities adopt and aggressively enforce the revised standard: a) Pyrotechnic devices should be banned from indoor use in new and existing nightclubs not equipped with an NFPA 13 compliant automatic sprinkler system. b) NFPA 1126 should be modified to include a minimum occupancy and/or area for a nightclub below which pyrotechnic devices should be banned from indoor use, irrespective of the installation of an automatic sprinkler system. c) Plans for the use of indoor pyrotechnics in new and existing nightclubs should be posted on site; and in addition to the items listed in para. 4.3.2 of NFPA 1126, should describe the

I For example – all non-fire retarded polyurethane foam could be formulated with bright red or orange coloring to indicate that it is not a fire retarded product and may ignite easily and propagate flames rapidly.

8-11

measures that have been established to provide crowd management, security, fire protection, and other emergency services. d) Section 6.6.2 of NFPA 1126 should be modified to require a minimum clearance between (1) the nearest fixed or moveable contents, and (2) any part or product (igniter, spark, projectile, or debris) of a pyrotechnic device permitted for indoor use in new and existing places of assembly, to be twice the designed projection of the device, until such time that studies show that a smaller minimum clearance can guarantee safe operation in spite of the possibility that building decorations or temporary features that greatly exceed flame spread or fire load provisions of the fire code may occur. Recommendation 5 The rationale for changes in egress provisions includes the realization that the impact of smoke, heat, and gases on human behavior during evacuation is not known; that mobility challenged persons take longer to evacuate; that other fire safety systems may be non-functional; and that threats other than fire can require rapid evacuation. Given the uncertainty in human behavior, and uncertainties in fire hazard calculations and egress analysis during an emergency, the code should ensure that the margin of safety on the time required to evacuate a nightclub accounts for the maximum reasonable uncertainty in these predictions. NIST found the conditions in The Station to be untenable in less than 1-1/2 minutes. NIST recommends that the factor of safety for determining occupancy limits of all new and existing nightclubs be increased in the model codes in the following manner, and that state and local authorities adopt and aggressively enforce these provisions: a) Within the model codes, establish the threshold building area and occupant limits for egress provisions using best practices for estimating tenability and evacuation time; and, unless further studies indicate another value is more appropriate, use 1-1/2 minutes as the maximum permitted evacuation time for nightclubs similar to or smaller than The Station. b) Compute the number of required exits and the permitted occupant loads assuming at least one exit (including the main entrance) will be inaccessible in an emergency evacuation. c) For nightclubs with one clearly identifiable main entrance, increase the minimum capacity of the main entrance to accommodate 2/3 of the maximum permitted occupant level (based upon standing space or festival seating, if applicable) during an emergency. d) Eliminate trade-offs between sprinkler installation and factors that impact the time to evacuate buildings. e) Require staff training and evacuation plans for all nightclubs that cannot be evacuated in less than 1-1/2 minutes. f) Provide improved means for occupants to locate emergency routes -- such as explicit evacuation directions prior to the start of any public event, exit signs near the floor, and floor lighting -- for when standard exit signs become obscured by smoke.

8-12

Recommendation 6 Portable fire extinguishers, if readily available to someone properly trained, can be effective early in a fire and delay fire spread in the event the sprinkler system is not functioning. NIST recommends that a study be performed to determine the minimum number and appropriate placement (based upon the time required for access and application in a fully occupied building) of portable fire extinguishers for use in new and existing nightclubs, and the level of staff training required to ensure their proper use. Recommendation 7 As in all mass causality events, especially those where the window of opportunity for rescue is extremely limited, effective and efficient communications within and among the various responding agencies is imperative. Developing effective interoperable communications requires addressing numerous factors, including frequent use of interoperable communications equipment and procedures, formal governance and collaboration, formal standard operating procedures, appropriate technology, and multi-agency training and exercises. Tools and best practice models addressing many of these success factors, including a statewide communications interoperability planning methodology, are available though the Department of Homeland Security's SAFECOM Program [24], and through model standards such as those listed below. To ensure an effective response to a rapidly developing mass casualty event, NIST recommends that state and local authorities adopt existing model standards on communications, mutual aid, command structure and staffing, such as: a) NFPA 1221, Standard for the Installation, Maintenance, and Use of Emergency Services

Communications Systems [15] b) NFPA 1561, Standard on Emergency Services Incident Management Systems [16] c) NFPA 1710, Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments [5] d) NFPA 1720, Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Volunteer Fire Departments [13] 8.4 ACTIONS ALREADY TAKEN The magnitude of the incident at West Warwick invoked a swift response by code developing organizations as well as by the State of Rhode Island. A number of the most critical recommendations from NIST presented above already have been enacted, either on a temporary emergency basis or as a permanent change to the codes. Some NIST recommendations have been addressed only partially, while aspects of others have been proposed and rejected by code bodies. Table 8-5 provides a cross-walk between the recommendations from NIST and the actions already taken that are discussed below. (i) National Fire Protection Association The Standards Council of NFPA held hearings to consider Tentative Interim Amendments (TIAs) to address certain life safety issues raised by The Station fire. The TIAs dealt with sprinklers, occupancy

8-13

levels, crowd management, and means of egress. The following TIAs, and the NFPA Code section to which they apply, were approved in July 2003: • Sprinkler existing nightclub type facilities and festival seating venues with occupant loads greater than 100 (TIA #739R, 101: 13.3.5.1 [7]) • Sprinkler new nightclub type facilities and festival seating venues (TIA #741R, 101:12.3.5.1 [7], and TIA #743R, 5000: 16.3.5.1.1 [3]) • Require trained crowed managers for existing and new assembly occupancies (TIA #738, 101:12.7.5 [7] and 101:13.7.5 [7]) • Restrict festival seating in new and existing facilities if occupant load is greater than 250 unless life-safety evaluation conducted (TIA #737R, 101:12.2.5.4.1 [7] and 101:13.2.5.4.1 [7]; and TIA #740R, 5000:16.2.5.4.1 [3]). • Require of owner means of egress inspection and record keeping (TIA #742R, 101:12.7.1 [7] and 101:13.7.1 [7]). (ii) International Code Council A number of proposals for code changes related to The Station fire incident were submitted to the ICC at its September 2003 public hearing. One proposal, to require foam plastics covered with a textile or vinyl facing to pass a flame spread test (proposal FS108-03/04) [4], was approved. Several proposals were aimed at increasing the capacity of the main entrance and the area requirement per occupant: • Proposal E101-03/04 to eliminate 300 occupant minimum before requiring 50% capacity for main entrance, and increasing capacity requirement to 67% • Proposals E102-03/04 and E103-03/04 to increase capacity of main entrance to 75% and 67%, respectively. • Proposal E11-03/04 to increase area required per occupant from 0.47 m2 (5 ft2) to 0.65 m2 (7 ft2) • Proposal E13-03/04 to eliminate sprinkler trade-offs with egress width requirement These proposals were disapproved, primarily due to lack of technical justification to substantiate the change. The recommendations for research presented later in this chapter were made to address this issue. (iii) State of Rhode Island The State of Rhode Island acted quickly to examine its own building and fire codes. A special legislative commission was formed, held hearings, and delivered its report to the governor on June 5, 2003 [21]. Quoting from the letter of transmittal, five actions were identified to improve building standards, codes, and practices: • "Require the use across the board of up-to-date fire safety codes -- this will require the elimination of the 'grandfather clause'-- and the coordinated administration of fire safety building codes.

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Table 8-5. Actions taken by model code bodies and State of Rhode Island

NIST Recommendation Related Action Taken Comments

1. Adopt and enforce model codes

RI adopted NFPA 1 and NFPA 101

NFPA TIA #742R NFPA action encompassed within broader NIST recommendation, needs formal proposal

RI strengthened fire marshal's enforcement power critical aspect of NIST recommendation NFPA TIA #739R NFPA TIA #743R NIST recommendation mirrors NFPA modification

1. Strengthen requirement for

sprinklers RI strengthened regulation requiring sprinklers based upon occupant load of 150 rather than 100, some exemptions

1. Strengthen restrictions on foam

plastic finish materials ICC FS108-03/04

ICC action deals with one aspect of foam plastic finish materials; NIST recommendation is broader, needs formal proposal

1. Strengthen restrictions on use of

pyrotechnics RI strengthened restrictions on pyrotechnics same objectives as NIST recommendation, needs formal proposal

1. Increase factor of safety on

egress NFPA TIA #737R NFPA TIA #738 NIST recommendation is broader, based upon egress time rather than occupant load; some research required before formal proposal is submitted

8-15

NIST Recommendation Related Action Taken Comments

1. Conduct portable fire

extinguisher study RI increased number required in stage areas Study needs to be conducted before formal proposal can be prepared

1. Adopt and practice

communication, response, command structures, and staffing guidelines already established no code modifications needed more local and state jurisdictions should consider adopting and practicing guidance already in model codes and standards

1. Conduct research to understand

human behavior better in emergency situations none multi-agency effort needed

1. Conduct research to understand

fire spread and suppression better none work ongoing at NIST and elsewhere

1. Conduct research to refine

computer-aided decision tools none work ongoing at NIST and elsewhere

8-16

• Prohibit the use of pyrotechnics in places of assembly such as nightclubs and strictly regulate their use in large venues…that can accommodate them safely. • Mandate sprinklers in nightclubs with an occupancy of 150 or greater and in all Class A and B places of assembly, except places of worship and state and municipal buildings used for government purposes and place other requirements on nightclubs as high risk places of assembly. • Provide greater enforcement powers to fire marshals to assure their ability: a) to make inspections, b) to require immediate abatement of conditions that pose an imminent threat to public safety or property and when necessary to order a premises vacated, and c) to inspect of nightclubs and other places of assembly during their actual hours of operation. • Establish comprehensive planning requirements to identify in the future the weaknesses in Rhode Island's approach to fire safety and to recommend actions needed to improve fire safety." The Fire Safety Code of the State of Rhode Island was amended significantly by The Comprehensive Fire Safety Act of 2003 [22] to address these five items and other issues discussed in the June 5 Report. Among the most significant changes was the adoption by Rhode Island of the Uniform Fire Code (NFPA 1) [5] and the Life Safety Code (NFPA 101) [7], which now includes the provisions of TIAs #737R, 738R, 739R, 740R, 741R, 742R, and 743R. All new and existing places of assembly in Rhode Island with a capacity greater than 300 will be required to be completely protected by an approved automatic sprinkler as of July 1, 2005. For new and existing buildings similar to The Station nightclub with occupancy less than 301 but greater than 150, the deadline for installing sprinklers is July 1, 2006. Additional provisions in The Comprehensive Fire Safety Act of 2003 include the requirement for two 20 pound fire extinguishers in stage areas and the strengthening of inspection authority for the Fire Marshal. 8.5 RESEARCH RECOMMENDATIONS AND OTHER APPROPRIATE ACTIONS This investigation focused on The Station nightclub. Several recommendations in this report relate directly to nightclub structures, and other recommendations apply more broadly. Model building code organizations as well as state and local regulatory authorities should review the results of this investigation and consider the findings regarding sprinklers, egress, and materials flammability as they make revisions to their codes. The acceptance by the model code and standards organizations of the recommendations being made by NIST and the adoption of modified provisions of the national model codes into the local code depend upon the strength of the technical evidence when weighed against the economic impact of implementing the change. There are a number of areas where the benefits may be obvious and the costs of implementation to the property owner and community can be computed easily. In those areas, to apply a particular provision of the code or not becomes a local policy decision that is not necessarily hindered by a lack of information available to the decision-maker. There are other areas in which the basis for making the change is unsupported by data or technical rigor. Research is often needed in order to gain new knowledge and collect the data necessary to ensure that such changes are adopted if justified, or rejected if not. Research results also serve as the basis for setting thresholds or pass/fail criteria.

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1. 5.1

Recommendations for Research NIST is required, under the NCST Act, to identify areas of research needed to support improvements to model building codes, standards and practices. Based upon the findings of this investigation and the resultant recommendations presented in section 8.3, additional research is recommended in three general areas: • human behavior and people movement, • material behavior and fire spread, and • decision aids. Recommendation 8 A basic tenet of our model codes is that public buildings should be designed and operated in a manner that assures there is enough time for occupants to evacuate safely for an anticipated worst case fire. In addition, we need to determine the desired behavior of occupants when faced with an unanticipated extreme event. Crowd-crush as observed in The Station fire also occurred in the E-2 [18] nightclub in Chicago the week prior to The Station incident, killing 21 people even though there was no fire, or even a real threat to the occupants. There is a need to understand better the behavior of people and crowds in emergency situations to pinpoint the factors that lead to crowd crush. This would enable sensible changes in building design to minimize the possibility of crowd crush, and improved ways to communicate to the crowd in emergency situations that go beyond the code, in direct support of recommendation 5. NIST recommends that research be conducted to better understand human behavior in emergency situations, and to predict the impact of building design on safe egress in fires and other emergencies (real or perceived), including the following: a) the impact of fire products (gases, heat, and obscuration) on occupant decisions and egress speeds; b) exit number, placement, size and signage; c) conditions leading to and mitigating crowd-crush; d) the role of crowd managers and group interactions; e) theoretical models of group behavior suitable for coupling to fire and smoke movement simulations; and f) the level of safety that model codes afford occupants of buildings. Recommendation 9 The behavior of people in a fire emergency and the time they have to escape depend upon the speed at which the fire spreads. Significant progress has been made in our ability to model the dynamics of a fire moving through a building, as evidenced by the simulations of The Station fire presented in this report. However, the state of the technology is insufficient to accurately model, in general, the spread of fire over common composite structures such as foam insulation on plywood, fabric covered foam furnishings, or gypsum covered wood frames. The detailed mechanisms for the formation of toxic products and smoke are extremely complex and are not amenable for inclusion in predictive fire models. Instead, it is necessary to rely on scientific experiments and real-scale fire testing of products and room geometries that are similar to what existed in the actual event to develop the empirical data required as input to

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computer fire models. This can be an impossible task for a fire that has occurred in a very large space, or when the fire totally destroys the structure along with the key evidence necessary for a reasonable recreation. The time available for safe egress is influenced by the building geometry and ventilation system, the materials of construction and furnishings, and actions to suppress the fire. Predicting sprinkler activation and suppression and the influence of fire fighting activities on the spread of the fire is another aspect of the problem that cannot be done today to any but the grossest level of precision. NIST recommends that research be conducted to understand fire spread and suppression better in order to provide the tools needed by the design profession to address recommendations 2, 3, and 5, above. The following specific capabilities require research: a) prediction of flame spread over actual wall, ceiling and floor lining materials, and room furnishings; b) quantification of smoke and toxic gas production in realistic room fires; and c) development of generalized models for fire suppression with fixed sprinklers and for firefighter hose streams. Recommendation 10 New knowledge, data, and predictive methods generated in the above research will lead to new technologies and improved fire standards. The selection among alternative fire safety technologies or building design options, and the setting of threshold values in the model codes, can have significant economic ramifications. New tools are needed that can be tailored to the individual stakeholder that rigorously account for cost in a manner transparent to competing interests. This research would be of particular value to implementing recommendations 1 and 7, above. NIST recommends that research be conducted to: a) refine computer-aided decision tools for determining the costs and benefits of alternative code changes and fire safety technologies, and b) develop computer models to assist communities in allocating resources (money and staff) to ensure that their response to an emergency with a large number of casualties is effective. 8.5.2 Impact of Research Completing the research recommended will put a sound technical foundation under the changes to codes, standards and practices that have already been made or are suggested. Specifically, a comprehensive research program would lead to an ability to: • evaluate the impact of changing egress capacity and occupant load factors on the minimum time available for safe evacuation; • quantify the value of increasing the size of the main entrance to handle a greater fraction of the occupant load; • determine the relationship between flame spread rating on finish materials and fire spread in actual buildings;

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• predict the smoke and toxic gas levels to a much greater level of precision, and the ramification of these fire products on occupant movement; • quantify the value of sprinklers in places of assembly with different occupant loads, and compare the performance of alternative designs; • investigate different strategies for managing crowds under various threat types and levels; • supplement training for firefighters, fire marshals, other emergency responders, code officials, and crowd managers; and • educate building owners, their employees and the general public on approaches to remain safe in places of assembly. 8.6 REFERENCES FOR CHAPTER 8 [1] NFPA 13, Standard for the Installation of Sprinkler Systems, National Fire Protection Association, Quincy, MA, 2002. [2] Providence Journal, “In the Fire,” p. B4, February 20, 2004. [3] NFPA 5000, Building Construction and Safety Code, National Fire Protection Association, Quincy, MA, 2002 [4] 2003 International Building Code, International Code Council, Inc., Country Club Hills, IL, 2002. [5] NFPA 1710, Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments, National Fire Protection Association, Quincy, MA, 2001. [6] NFPA 1, Uniform Fire Code, National Fire Protection Association, Quincy, MA, 2003. [7] NFPA 101, Life Safety Code, National Fire Protection Association, Quincy, MA, 2003. [8] NFPA 10, Standard for Portable Fire Extinguishers, National Fire Protection Association, Quincy, MA, 2002 [9] ASTM E84-00a, Standard Test Method for Surface Burning Characteristics of Building Materials, American Society for Testing & Materials, West Conshohocken, PA, 2001. [10] NFPA 286, Standard Methods of fire Tests for Evaluating Contribution of Wall and Ceiling Interior Finish to Room Fire Growth, National Fire Protection Association, Quincy, MA, 2002. [11] NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, National Fire Protection Association, Quincy, MA, 2002. [12] NFPA 1126, Use of Pyrotechnics before a Proximate Audience, National Fire Protection Association, Quincy, MA, 2002 [13] NFPA 1720, Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Volunteer Fire Departments, National Fire Protection Association, Quincy, MA, 2001. [14] NFPA 1031,Professional Qualifications for Fire Inspector and Plan Examiner, National Fire Protection Association, Quincy, MA, 2003.

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[15] NFPA 1221, Standard for the Installation, Maintenance, and Use of Emergency Services Communications Systems, National Fire Protection Association, Quincy, MA, 2002. [16] NFPA 1561, Standard on Emergency Services Incident Management Systems, National Fire Protection Association, Quincy, MA, 2002. [17] NFPA Alert Bulletin, “Social Club Fire Bronx, New York”. Number 90-2, May 1990. [18] NFPA Fire Investigation Report, Dance Hall Fire, Gothenburg, Sweden, National Fire Protection Association, Quincy, MA, 1998. [19] Lostetter, S.M.O., and Reijman, P.B., "Reconstruction of the Fire in 'de Hemel' in Volendam, New Years Eve 2000/2001," Interflam 2004. [20] Johnson, Mark, Chicago Club had been told to Close, Milwaukee Journal Sentinel, 18 Feb. 2003. [21] "Making Rhode Island the Safest State," Report to the Rhode Island General Assembly, June 5 2003. [22] Comprehensive Fire Safety Act of 2003, Chapter 23-28, Amendment to the General Laws, Health and Safety, SECTION 2. Title 23. [23] Associated Press, March 28, 2005. [24] http://www.safecomprogram.gov/SAFECOM/

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FD06014 ｜ 2003_US_NIST_NCSTAR2_Vol2_Station_Nightclub_Appendix.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2003 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

NAT'L INST. OF STAND & TECH AlllDt. M777TE iNIST PUBUCATIONS NIST NCSTAR 2: Vol. II Report of the Technical Investigation of The Station Nightclub Fire: Appendices William Grosshandler Nelson Bryner Daniel Madrzykowski Kenneth Kuntz storage Area (Recessed) EIIIIIKIlii i [ [ 1 [ 1 n ! [ [ Drummer Alcove (Recessed) TH VV3 V-2- Jisr 5^003 National Institute of Standards and Technology • Technolog)r Administration • U.S. Department of Commerce

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NISTNCSTAR2: Vol. Report of the Technical Investigation of The Station Nightclub Fire: Appendices William Grosshandler Nelson Bryner Daniel Madrzykowski Fire Research Division Buiiding and Fire Research Laboratory Nationai Institute of Standards and Technology Kenneth Kuntz Federal Emergency Management Agency U.S. Department of Homeland Security June 2005 U.S. Department of Commerce Carlos M. Gutierrez, Secretary Technology Administration Michelle O’Neill, Acting Under Secretary for Technology National Institute of Standards and Technology Hratch Semerjian, Acting Director

Disclaimer Certain commercial entities, equipment, products, or materials are identified in this document in order to describe a procedure or concept adequately or to trace the history of the procedures and practices used. Such identification is not intended to imply recommendation, endorsement, or implication that the entities, products, materials, or equipment are necessarily the best available for the purpose. Disclaimer The policy of NIST is to use the International System of Units (metric units) in all publications. In this document, however, units are presented in metric units or the inch-pound system, whichever is prevalent to the discipline. Conversion tables are provided in this report. Disclaimer The NIST-led investigation of The Station Nightclub fire was conducted during the same time period as civil and criminal legal actions involving the same incident, which limited the Team's access to physical evidence and limited the ability to interview many witnesses. Use in Legal Proceedings No part of any report resulting from a NIST investigation can be used in any suit or action for damages arising out of any matter mentioned in such report (15 USC 281a; as amended by P.L. 107-231). National Institute of Standards and Technology NCST Act Report (NCSTAR) 2: volume II Natl. Inst, of Std. NCST Act Rept. 2: v. II, 414 pages (June 2005) CODEN: NSPUE2 U.S. GOVERNMENT PRINTING OFFICE WASHINGTON: 2005 For sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov — Phone: (202) 512-1800 — Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001

Abstract A fire occurred on the night of Feb. 20, 2003, in The Station nightclub at 21 1 Cowesett Avenue, West Warwick, Rhode Island. A band that was on the platform that night, during its performance, used pyrotechnics that ignited polyurethane foam insulation lining the walls and ceiling of the platform. The fire spread quickly along the walls and ceiling area over the dance floor. Smoke was visible in the exit doorways in a little more than one minute, and flames were observed breaking through a portion of the roof in less than five minutes. Egress from the nightclub, which was not equipped with sprinklers, was hampered by crowding at the main entrance to the building. One hundred people lost their lives in the fire. On Feb. 27, 2003, under the authority of the National Construction Safety Team (NCST) Act, the National Institute of Standards and Technology (NIST) established a National Construction Safety Team to determine the likely technical cause or causes of the building failure that led to the high number of casualties in that fire. This report documents the procedures, findings, and issues that were raised by the investigation. Volume I contains the main report and Volume II contains appendix material. The investigation concluded that strict adherence to 2003 model codes available at the time of the fire would go a long way to preventing similar tragedies in the future. Changes to the codes subsequent to the fire made them stronger. By making some additional changes - and state and local agencies adopting and enforcing them - we can strengthen occupant safety even further. Ten recommendations to improve model building and fire codes, standards and practices (as they existed in February 2003) resulted from the investigation, including (i) urging state and local jurisdictions to (a) adopt and update building and fire codes covering nightclubs based on one of the model codes and (b) enforce those codes aggressively; (ii) strengthening the requirements for the installation of automatic fire sprinklers; (iii) increasing the factor of safety on the time for occupants to egress; (iv) tightening the restriction on the use of flexible polyurethane foam — and other materials that ignite as easily and propagate flames as rapidly as non-fire retarded foam — as an interior finish product; (v) further limiting the use of pyrotechnics; and (vi) conducting research in specific areas to underpin the recommended changes. Keywords: fire investigation, NCST, nightclub fire, sprinklers, egress, fire spread, polyurethane foam, fire modeling, pyrotechnics

Table of Contents (Vol. II) Page Abstract iii List of Acronyms, Abbreviations, Units, and Conversion Factors ix Preface xiiiiii Appendix A Large Format Evacuation Timeline Stills A. 1 Large Formate Evacuation Timeline Stills A- A.2 References for Appendix A A- 14 Appendix B Large Format Device Stills B . 1 Introduction B-1 B.2 Exit Doors B-1 B.3 Exit Signs B-5 B.4 Emergency Lighting B-9 B.5 Suppression B- 1 B.6 Fire Alarm and Detection B-1 B. 7 References for Appendix B B-1 Appendix C Previous Egress Incident Accounts C . 1 Introduction C - C.2 Summary of Past Evacuations C- C.3 Details of Unsuccessful Incidents C-2 C.4 Details of Successful Incidents C-34 C. 5 References for Appendix C C-39 Appendix D Small Scale Laboratory Tests D. l Introduction D-1 D.2 Test Series D-3 D.3 Summary Tables D-25 D.4 Ignition Temperature Results D-43 D.5 Summary of Small Scale Tests D-49 D.6 References for Appendix D D-49 V

Appendix E Foam Covered Wall Panel Tests E.l Geometry E-1 E.2 Description of the Fires and Heat Release Rates E-3 E.3 Flame Spread Rates E-8 E.4 Comparison of Results to Mock-up and Other Studies E.IO E. 5 References for Appendix E E- 1 3 Appendix F Pyrotechnic Device Test Series F. l Pyrotechnic Gerbs F-1 F.2 45 Degree Discharge Tests F-6 F. 3 90 Degree Discharge Test F-1 1 Appendix G Real-scale Platform Area Mockup Experiments G. 1 Instrumentation and Experimental Procedure G- 1 G.2 Temperature Measurements G-2 G.3 Gas Measurements G-9 G.4 Heat Flux Measurements and Heat Detector Response G-9 G-5 References for Appendix G G-17 Appendix H Polyurethane Foam - Chemistry H. 1 Polyurethane Plastics H- 1 H.2 Polyurethane Chemistry H- 1 H. 3 References for Appendix H H-7 Appendix I Pyrolysis of Polyurethane Foam I. 1 Faboratory Report Number 2004-CC-045 1-l 1.2 Analytical Method: Fourier Transform Infrared Spectroscopy with Brill Pyrolysis Cell 1-6 1.3 Sample Identification and Expected Products 1-7 1.4 Identification 1-8 1.5 Background Information 1-19 Appendix J Hydrogen Cyanide Analysis J. 1 Hydrogen Cyanide Report J-1 J. 2 NIOSH Pocket Guide to Chemical Analysis J-10 Appendix K Code Comparison Tables K. 1 Code Comparison of IBC and NFPA 5000 K- 1 VI

K.2 Code Comparisons of IFC and NFPA K-49 K. 3 References for Appendix K K-88 Appendix L Computer Simulation Input Files L. l Evacuation Simulations L-1 L.2 Fire Dynamic Simulator Version 4.0 L-8 vii

List of Acronyms, Abbreviations, Units, and Conversion Factors AC AG AHJ AlA ALS ANSI ASCE ASME ASTM ATE BBC BCMC BFPC BLS BOCA BST CFD CF CT DC DHS DSC EMS EMT EMT-C EST EDS FEMA alternating current Attorney General Authority Having Jurisdiction American Insurance Association Advanced Life Support American National Standards Institute American Society of Civil Engineers American Society of Mechanical Engineers American Society for Testing and Materials Bureau of Alcohol, Tobacco and Firearms Basic Building Code Board for the Coordination of Model Codes Basic Fire Prevention Code Basic Life Safety Building Officials and Code Administrators (previously Building Officials Conference of America) barium strontium titanate computational fluid dynamics, and Coventry Fire Department carpet flooring ceiling tile direct current Department of Homeland Security Differential Scanning Calorimetry Emergency Medical Services Emergency Medical Technician Emergency Medical Technician - Cardiac Eastern Standard Time Fire Dynamics Simulator Federal Emergency Management Agency IX

FIT Flash Ignition Temperature FPC Fire Prevention Code FR fire retarded HRR heat release rate IBC International Building Code IC Incident Command ICC International Code Council lEBC International Existing Building Code IFC International Fire Code IR infrared ISO International Organization for Standardization LCLo lethal concentration, low LSF life safety feature MCI Mass casualty incident NCST National Construction Safety Team NBC National Building Code NFC National Fire Code NFPA National Fire Protection Association NFR non-fire retarded NIOSH National Institute of Occupational Safety and Health NIST National Institute of Standards and Technology OOP Office of Domestic Preparedness OSHA U.S. Occupational Safety and Health Administration PUF polyurethane foam RI Rhode Island RTI response time index SBC Standard Building Code SIT Spontaneous Ignition Temperature SNEFEAP Southern New England Fire Emergency Assistance Plan t time TC thennocouple TGA Thermal Gravimetric Analysis

TIA Tentative Interim Amendment UFC Uniform Fire Code UL Underwriters Laboratories use United States Code USFA United States Fire Administration WFD Warwick Fire Department WP wood paneling WPD Warwick Police Department WWFD West Warwick Fire Department WWPD West Warwick Police Department Units °C degrees Centigrade op degrees Fahrenheit ft feet gpm gallons/minute in inch kg kilogram kPa kilopascal kW kilowatt L liter m meter mm millimeter min minute MW megawatt psi pounds/in“ s second W Watt pm micrometer XI

Conversion Factors °F= 1.8x°C + 32 1 m = 3.281 ft 1 mm = 0.03937 in 1 L = 0.2642 gal 1 kg = 2.204 lb (mass) 1 kg/m^ = 0.06243 Ib/ft^ 1 kPa = 0.1450 psi 1 kJ = 0.9479 Btu 1 kJ/kg = 0.4301 Btu/lb 1 kJ/kg-T = 0.2389 Btu/lb-°F 1 kW = 3413 Btu/hr 1 kW/m" = 317.1 Btu/hr/fr 1 kW/m“-°C =176.1 Btu/hr-ft--°F 1 W/m-°C = 0.5778 Btu/hr-ft-°F 1 kg = 1000 g 1 m = 1000 mm 1 pm = 0.001 mm 1 MW= 1,000,000 W

Preface On Feb. 27, 2003, under the authority of the National Construction Safety Team (NCST) Act, the National Institute of Standards and Technology (NIST) established a Team to determine the likely technical cause or causes of the building failure that led to a high number of casualties in The Station nightclub fire in West Warwick, Rhode Island on the night of Feb. 20, 2003. The investigation consisted of the following tasks: • identification of technical issues and hypotheses requiring investigation through consultations with experts in fire protection engineering, and emergency evacuation, and members of other teams investigating The Station fire; • data collection from local authorities, contractors and suppliers, building and fire protection design documents, records, plans, and specifications, video and photographic data, telephone and radio transmissions, field data, a limited number of interviews and other oral and written accounts from building occupants and emergency responders, and other witnesses as reported by the news media; • analysis and comparison of model building and fire codes and practices, as well as review and analysis of practices used in operation of the building; • simulation and analysis of phenomena (with associated uncertainties), including fire spread, smoke movement, tenability, occupant behavior and response, evacuation issues, and operation of active and passive fire protection systems; • testing to provide additional data and support computer predictions; and • preparation of the final report, following established NIST Editorial Review Board procedures, augmented by the NCST Advisory Committee. As required by the NCST Act and its implementing regulations, priority in the investigation was ceded to the local criminal investigation. No physical evidence was obtained from the scene and access to witnesses and local authorities was limited due to the criminal investigations and civil litigation. It is important to note that state and local building regulations — rather than model codes -- govern building design, construction and operation. Comparisons of the building design and operation to provisions within model codes were done to assess possible improvements in public safety through revision of model codes, standards and practices. Many of the recommendations are directed toward the current national model codes maintained by the National Fire Protection Association (NFPA) and the International Code Council (ICC), the standards within those codes and elsewhere (e.g., ASTM International, and Underwriters Laboratories (UL)), and the practices associated with their adoption and implementation. Other recommendations are aimed at nightclub owners and managers, occupants, and state and local regulatory authorities and first responders. The NCST Act requires that at least one member of the Team be an employee of NIST, and that experts who are not employees of NIST shall also be appointed to the Team by the NIST Director. The members of the Team included the following: • William Grosshandler (Lead Investigator), NIST Building and Fire Research Laboratory xiii

• Nelson Bryner, NIST Building and Fire Research Laboratory • Daniel Madrzykowski, NIST Building and Fire Research Laboratory • Kenneth Kuntz, DHS/FEMA, US Fire Administration Koffel Associates, Inc., provided a review of model building and fire codes; Ove Amp & Partners Massachusetts, Inc., assisted with the analysis of the evacuation process. Portions of both contractor reports have been integrated into this final report. xiv

Appendix A. Large Format Evacuation Timeline Stills A.1 large format evacuation timeline stills This Appendix, compiled by Amp [1] presents the still frame pictures taken from the WPRl-TV video of the incident at the Station nightclub on Febmary 20, 2003 [2]. The events comprising the incident timeline (see Chapter 2) were identified through these still frames. Each video frame includes a time bar representing the incident duration considered here with an indication of where the given event occurred in this time span. The analysis focused upon the time period beginning when the lights in the club were turned down in preparation for the show until the camera operator, in the parking lot, places the camera on the ground and significant flames are seen emanating from the front of the building. Beyond this time, the building is heavily engulfed by the fire and no additional events specifically significant to this analysis are shown on the video. The time bar provided above each still frame corresponds to the comprehensive timeline given in the main report. Note that “Video Time” refers to the absolute videotape co unter time associated with the events as captured on the television crew video, while “Fire Time” refers to the time of events relative to the start of the fire. Each frame also includes a location key showing where the camera was located (yellow dot) and in which direction it was pointing (green arrow) when the frame was recorded. The faces of occupants have been blurred to preserve anonymity. A-1

Figure A.1 Timeline Event 1 Video Time: 0:05:49 Fire Time: -0:00:33 Description: Stage lights turned down for beginning of show.

Loeation Key:

-K, START OF FIRE I 1 Min I 2 Min 3 Min I 4 Min I 5 Min _J ; '.-yf- 6 Minu Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. Figure A.2 Timeline Event 2 Video Time: 0:06:08 Fire Time: -0:00:14 Description: Band first shown on stage. Location Key: a START OF FIRE I 1 Min I 2 Min I 3 Min I 4 Min I 5 Min I 6 Min I *v V-'-- ^opyright © 2003 TVL Broadcasting, Inc. All rightsreserved. A-2

Figure A.3 Timeline Event 3 Video Time: 0:06:14 Fire Time; -0:00:08 Description; Pyrotechnic display initiated. START OF FIRE 1 Min 2 Min 3 Min 4 Min I 5 Min I 6 Min I Figure A.4 Timeline Event 4 Video Time: 0:06:22 Fire Time: 0:00:00 Description: First flames on upper wall, left of stage. Location Key: START OF FIRE 1 Min 2 Min 3 Min 4 Min 5 Min 6 Min J I I I I I L A-3

Figure A.5 Timeline Event 5 Video Time: Fire Time: Description: 0:06:31 0:00:09 START OF FIRE J 1 Min I 2 Min I 3 Min 4 Min 5 Min 6 Min Flames on upper wall, right of stage. Pyrotechnic display turned off. Location Key: Figure A.6 Timeline Event 6 Video Time: 0:06:33 Fire Time: 0:00:11 Description: Band members first notice flames. Location Key: START OF FIRE I 1 Min I 2 Min I 3 Min 4 Min 5 Min l_ 6 Min 1 -r-m A-4

Figure A.7 Timeline Event 7 Video Time: 0:06:38 Fire Time: 0:00:16 Description: Flames reach ceiling to right of stage. Location Key: START OF FIRE 1 Min 2 Min 3 Min 4 Min 5 Min I I I I I L_ 6 Min I Figure A.8 Timeline Event 8 Video Time: 0:06:40 Fire Time: 0:00:18 Description: Camera operator begins to evacuate. Location Key: START OF FIRE 1 Min 2 Min 3 Min 4 Min 5 Min 6 Min A-5

Figure A.9 Timeline Event 9 Video Time: 0:06:47 Fire Time: 0:00:25 Description: Flames touching ceiling on both sides of stage. START OF FIRE I 1 Min I 2 Min I 3 Min I 4 Min I 5 Min I 6 MinL Figure A. 10 Timeline Event 10 Video Time: 0:06:52 Fire Time: 0:00:30 Description: Band members begin to evacuate stage. Location Key: ia START OF FIRE 1 Min 2 Min 3 Min 4 Min 5 Min 6 Min I I I J I I ^ I A-6

Figure A.11 Timeline Event 11 Video Time: 0:06:54 Fire Time: 0:00:32 Description: Flames extend fully across ceiling above stage. Location Key: START OF FIRE 1 Min 2 Min 3 Min 4 Min 5 Min 6 Min I I I L I I L Figure A.12 Timeline Event 12 Video Time: 0:07:07 Fire Time: 0:00:41 Description: Fire alarm strobes begin to flash. Fire alarm can be heard. Location Key: START OF FIRE 1 Min 2 Min 3 Min 4 Min 5 Min I I I I I l 6 Min I. , A-7

Figure A.13 Timeline Event 13 Video Time: Fire Time: 0:07:16 0:00:54 START OF FIRE I 1 Min 2 Min l L 3 Min 4 Min 5 Min Description: Camera operator reaches exit lobby. Location Key: Figure A.14 Timeline Event 14 Video Time: 0:07:28 Fire Time: 0:01:06 Description: Smoke in outer exit lobby. Location Key; START OF FIRE 1 Min 2 Min 3 Min 4 Min 5 Min 6 Min A-8

Figure A.15 Timeline Event 15 Video Time: 0:07:33 Fire Time: 0:01:11 Description: Camera operator exits building. Location Key: START OF FIRE 1 Min 2 Min 3 Min 4 Min 5 Min 6 Min Figure A.16 Timeline Event 16 A-9

Figure A.17 Timeline Event 17 Video Time: 0;07;52 Fire Time: 0:01:30 Description: Thick black smoke from pool room windows. Smoke appears to be at floor level inside. Occupants egressing through windows. Location Key: START OF FIRE 1 Min 2 Min 3 Min 4 Min 5 Min 6 Min Figure A.18 Timeline Event 18 Video Time: 0:08:04 Fire Time: 0:01:42 Description: Camera operator returns to main exit. People piled up in doorway. Smoke pouring out above people. 1 Min 2 Min l l 3 Min 4 Min 5 Min 6 Min Loeation Key; A-10

Figure A.19 Timeline Event 19 Video Time: 0:11:00 Fire Time: 0:04:38 Description: Camera operator returns to stage exit. Smoke ~1 ft above floor inside. Flames near door. Loeation Key: START OF FIRE I 1 Min I 2 Min 3 Min 4 Min 5 Min —I I I l_ 6 Min __L Figure A.20 Timeline Event 20 A-ll

Figure A.21 Timeline Event 21 Figure A.22 Timeline Event 22 Video Time: 0:1 1 :43 Fire Time: 0:05:21 Description: Fire department confinned on scene. Location Key: START OF FIRE 1 Min 2 Min 3 Min 4 Min 5 Min 6 Min Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. A-12

Figure A.23 Timeline Event 23 Video Time: 0:11:56 Fire Time: 0:05:34 Description: Fire department commenees running first hose line. Flames extending from main exit -8-10 ft . Location Key: START OF FIRE 1 Min 2 Min 3 Min 4 Min 5 Min 6 Min I I I 1_L I I I Figure A.24 Timeline Event 24 Video Time: 0:12:05 Fire Time: 0:05:43 Description: Flames extend from front windows. Location Key: A-13

A.2 REFERENCES FOR APPENDIX A [1] "Evaluation of Limitations to Egress through Doorways in Emergency Situations," vol. 1, Ove Amp & Partners Massachusetts Inc., Job number 32979, Westborough MA, Febmary 18, 2004. [2] Butler, Brian, Video by WPRI-TV, Channel 12, Febmary 20, 2003. A-14

Appendix B. Large Format Device Stills B.1 INTRODUCTION This Appendix, compiled by Arup[l], provides large-format versions of the photographs and video still frames [2] used in the review of life safety features (see Chapter 6) in the Station nightclub prior to the fire on February 20, 2003. The photos and still frames are primarily organized based upon the type of life safety feature shown (i.e. exit doors, exit signs, emergency lighting, suppression, and fire alarm and detection). On a secondary level, the pictures are organized based upon their source (i.e. photographic or video evidence). Each picture includes a location key showing where the camera was located (yellow dot) and in which direction it was pointing (green arrow) when the photograph was taken or the video frame was recorded. The ID number provided with each picture can be used to locate the represented life safety feature on the map provided in Figure 6-10 of the main report. The faces of occupants have been blurred to preserve anonymity. B.2 EXIT DOORS B.2.1 Photograph Evidence: Exit Doors Figure B.1 Life Safety Feature 1 [3] Life Safety Feature ID: LSF 1 1 L— T — 1 1 Type:

Exit door / exterior stairs and ramp

ih Description: Main double doors with ramp and stairs i 1r courtesy of Anthony Baldino, III B-1

Figure B.2 Life Safety Feature 2 Life Safety Feature ID: LSF2 Type: Exit door / exterior stairs Description: Exterior stairs from Left-side front bar exit Figure B.3 Life Safety Feature 3 Life Safety Feature ID: LSF3 Type: Exit door / exterior stairs Description: Exterior stairs from kitchen B-2

Figure B.4 Life Safety Feature 4 Life Safety Feature ID: LSF4 Type; Exit door / exterior stairs Description: Exterior stairs from stage area Figure B.5 Life Safety Feature 5 B-3

Figure B.6 Life Safety Feature 6 [4] Life Safety Feature ID: LSF6 Type: Interior Door Description: Door leading from the interior ticket area towards the outer vestibule T TT B.2.2 Video Evidence: Exit Doors Figure B.7 Life Safety Feature 7 [2] Life Safety Feature ID: LSF 7 Device Type: Exit door with panic hardware Description: Exit door from left side of main bar to exterior concrete stairs. Panic hardware was provided on this door.

Figure B.8 Life Safety Feature 8 [2] Device Type: Life Safety Feature ID: Description: LSF 8 Exit door with panic hardware Exit door adjacent to stage to exterior concrete stairs. Panic hardware was provided on this door. Note that it appears there was foam attached to this door and that there was an additional interior door that swung against the egress direction. B.3 EXIT SIGNS B.3.1 Photograph Evidence: Exit Signs Figure B.9 Life Safety Feature 9 [4] Life Safety Feature ID: LSF 9 Device Type: Exit Sign Description: Located near the rear bar. The exit sign is pointing toward the kitchen exit door. li & photo courtesy of K. Corbin B-5

Figure B.10 Life Safety Feature 10 [4] Life Safety Feature ID: LSF 10 Device Type: Exit Sign Description: Exit sign above door from ticket area to front vestibule Figure B.11 Life Safety Feature 11 [4] Life Safety Feature ID: LSF 11 Device Type: Exit Sign Description: Exit sign above door to the right of the stage. Note that sign is clearly illuminated. B-6

B.3.2 Video Evidence: Exit Signs Figure B.12 Life Safety Feature 12 [2] Life Safety Feature ID:

LSF 12

1 1 -I ' 1 1 Device Type: Exit Sign Description: Exit sign above door to the right of the stage. Note that sign does not appear to be illuminated. ^ ^ U-i ^ Figure B.13 Life Safety Feature 13 [2] Life Safety Feature ID: Device Type: Description: LSF 13 Exit Signs Two visible. One located in the main fiCor area with an arrow towards ^he ticket area. One above the ticket area doors leading to the front vestibule. B-7

Figure B.14 Life Safety Feature 14 [2] Life Safety Feature ID: Device Type: Description: LSF 14 Exit Sign Exit sign over left side main bar area Figure B.15 Life Safety Feature 15 [2] Life Safety Feature ID: LSF 15 Device Type: Exit Sign Description: Located in front vestibule above main double exit doors. This location is based upon similar wall and ceiling features observed in the WPRI video. u: Copyright © 2003 TVL Broadcasting, Inc. All rights reserved. ^ . B-8

B.4 EMERGENCY LIGHTING B.4.1 Photograph Evidence: Emergency Lighting Figure B.16 Life Safety Feature 16 [4] Life Safety Feature ID; LSF 16 Device Type: Emergency Light Description: Located near the rear bar adjacent to exit sign. B.4.2 Video Evidence: Emergency Lighting Figure B.17 Life Safety Feature 17 [2] Life Safety Feature ID: LSF 17 Device Type: Emergency Light Description: Emergency light above and to the right of the stage exit door. B-9

Figure B.18 Life Safety Feature 18 [2] Life Safety Feature ID: LSF 18 Device Type: Emergency Light Description: Location on the wall adjacent to the kitchen by the main bar. Figure B.19 Life Safety Feature 19 [2] Life Safety Feature ID: LSF 19 1 1 -J ' 1 1 Device Type: Emergency Light Description: Emergency light above and to the right of the left side exit door in the main bar area. L^l

B.5 SUPPRESSION B.5.1 Video Evidence: Suppression Figure B.20 Life Safety Feature 20 [2] Life Safety Feature ID: LSF 20 Device Type: Fire Extinguisher Description: Located by the small bar. ^ , B.6 FIRE ALARM AND DETECTION B.6.1 Video Evidence: Fire Alarm and Detection Figure B.21 Life Safety Feature 21 [2] Life Safety Feature ID: LSF 21 Device Type: Detector Description: Located above lighting grid in the vicinity of the stage. B-ll

Figure B.22 Life Safety Feature 22 [2] Life Safety Feature ID: LSF 22 1 I"" T J ' 1 1 Device Type: Fire Alarm Strobe ^ Description: Adjacent to exit sign at stage exit door. L-i£_ Figure B.23 Life Safety Feature 23 [2] Life Safety Feature ID: LSF 23 Device Type: Fire Alarm Strobe Description: On ceiling to the left and in front of the stage B-12

Figure B.24 Life Safety Feature 24 [2] Life Safety Feature ID: LSF 24 Device Type: Fire Alarm Strobe Description: Located adjacent to exit sign in the main floor area. B.7 REFERENCES FOR APPENDIX B [1] "Evaluation of Limitations to Egress through Doorways in Emergency Situations," vol. 1, Ove Amp & Partners Massachusetts Inc., Job number 32979, Westborough MA, Febmary 18, 2004. [2] Butler, Brian, Video by WPRl, Channel 12, Febmary 20, 2003. [3] photograph by Anthony Baldino III (undated) [4] courtesy of K. Corbin B-13

B-14

phs. • Code change dates were matched to significant fire dates, and where possible, code changes precipitated by large life loss fires were identified. C.2.1 Unsuccessful Evacuation Table C-1 provides a summary of the unsuccessful incidents. The contributing factors listed in the table were identified as possible links to code changes that followed the incident. Contributing factors flagged were the following: delayed notification, combustible interior finishes, some exits blocked or not obvious, incorrect exit door swings, locked exit doors, inadequate exit capacity, barred or boarded windows, and crowd cmsh at exits. Delayed notification was considered a contributing factor if the incident reports specifically stated this fact. Combustible interior finishes were considered a contributing factor if it was mentioned in the sources that combustible finishes were located on the walls, ceilings, or stmcture. Combustible finishes were not considered a contributing factor if a large amount of combustibles were present, but finishes were noncombustible. Blocked or concealed exits were considered a contributing factor if it was found in C-1

the literature that the exits were blocked by fire, blocked by building contents, or if they were concealed or hidden by building contents, furnishings, or layout. If the literature stated that the building had incorrect exit door swings, this was considered a contributing factor. Locked exits were considered a factor if it was stated in the reports that doors were locked or were difficult to open to unfamiliar occupants. If the incident reports stated that there was inadequate exit capacity, or this could be inferred by the situation then this was considered a contributing factor. If a building was overcrowded and could otherwise accommodate the number of occupants specified by the building code, inadequate exit capacity was still considered a factor. If the reports stated that the windows were barred or boarded and the windows could otherwise be considered a means of escape, this was considered a contributing factor. If the incident accounts included descriptions of occupants piling- up at the exit doors, and thus hindering evacuation, crowd crush at the exits was considered a contributing factor. Table C-2 provides additional details regarding these incidents, as well as an overview of any regulatory changes brought about as a result and any efforts to analytically model each incident. Note that the regulatory changes listed in Table C-2 are not necessarily directly related to the specific incident, but rather, the changes listed indicate modifications to the subsequent revision of the particular regulation. C.2.2 Successful Evacuations Table C-3 is set up similarly to Table C-1, except that it lists factors that may have contributed to a successful evacuation. C.3 DETAILS OF UNSUCCESSFUL INCIDENTS C.3.1 Conway’s Theater Fire, Brooklyn, NY, 1876 On December 5, 1876, during the final act of the play The Two Orphans, a fire erupted in Conway’s Theater [1]. The theater seated 1700, but held 800 at the time of the fire. The rising velvet curtain created a draft that caught a gas jet flame. The flame ignited a flimsy drape and spread quickly. The audience saw the fire spreading out from around the stage before the actors on stage knew what was happening. A member of the company in the wings alerted the actors. Three actors stood at the front of the stage and told the audience to stay calm. Some people even sat back in their seats when they heard this. The theater construction included a cheap wooden bench gallery; this gallery collapsed, throwing 150 audience members into the fire below. This also led to further fire spread into the theater. Stagehands were trying to put out the fire with canvas, since there was no fire fighting equipment available. The stagehands stopped attempts to extinguish the fire after the collapse of the gallery. The stage manager ordered everyone on stage to save themselves; some actors escaped through the stage door to an adjoining alley or through the cellars under the stage, which opened through horizontal grates to the street. All of the people in the theater company escaped except for the three actors that stood at the front of the stage to calm the audience during the beginning stages of the fire. Many of the audience members were crushed to death in the obstructed, narrow, winding stairs of the main exit. In addition, many perished in the cellar. However, since the fire department had no way of knowing the occupant toad of the theater at the time of the fire, and since a significant number people made it out of the building safely, the firefighters thought that all had been saved and started trying to prevent the fire from spreading to other buildings. In all, 315 lives were lost in the Conway’s Theater fire. C-2

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The following details regarding this incident are of note: • The theater did not have the basic fire fighting equipment, including a hose or any water buckets, because it was believed that a brick building would not bum; • The wooden bench gallery collapsed, killing many audience members and spreading the fire beyond the stage; • The main exit was at the bottom of narrow, winding stairs, which were eventually blocked by bodies that had fallen in the evacuation push; • Fire fighters thought that everyone had made it safely out of the building and concentrated on saving the surrounding buildings. Impact on regulations or practices The NFPA Life Safety Code, the Board for the Coordination of Model Codes (BCMC), the Uniform Building Code (UBC), the BOCA Building Code (BOCA), and the Standard Building Code (SBC) had not yet been developed at the time of the fire. C.3.2 Iroquois Theater Fire, Chicago, Illinois, 1903 Less than one month after its grand opening, the Iroquois Theater in Chicago, Illinois suffered a fast- moving fire during a perfonnance [2,3]. At 3:15 PM, a hot light ignited highly combustible stage scenery items. The fire spread rapidly, and the efforts of the lone on-duty firefighter proved futile. Contrary to standard precautions in theaters at the time, the Iroquois Theater had no fire hoses or extinguishers and the standpipes on the stage were dry because the water supply system was not completed. Confident that the fire could be controlled, an actor urged the audience to remain seated. However, the fire rapidly escalated, and people eventually began moving. Numerous deaths occurred as people from the balcony level, the gallery level, and the main level converged in the exit stairway. Additionally, numerous people jumped from the upper levels as the stairway became blocked. All 602 deaths occurred within 15 minutes of the start of the fire. Most of the fatalities were in the third floor or gallery area. A draft caused by the stage exit doors being opened caused flames to rush to open vents above the gallery rather than to the stage vents, which were missing counterweights and were nailed shut. Upon arrival, fire department personnel were able to extinguish the fire within 30 minutes. The building was largely undamaged, and reopened within one year. The following details regarding this incident are of note: • The theater lacked fire hoses and extinguishers, so the on-duty firefighter was not able to fight the fire above his head; • The ushers and personnel received no instructions about what to do in the case of a fire; • The curtain designed to separate the stage area from the audience got caught before it could reach its full down position, and thus was unable to prevent fire spread from the stage. Later testimony revealed that the curtain may have been improperly installed, and also may not have been fireproof; C-10

• After the fire started, the audience was urged to stay in their seats and not to evacuate, and the orchestra continued playing; • Some exit doors had been covered by metal gates. Some of these were locked, and others had latches that were likely unfamiliar to occupants; • Exit paths from the balcony area and the main floor met in a single, common stairwell. Impact on Regulation or Practices The NFPA Life Safety Code, the Board for the Coordination of Model Codes (BCMC), the Uniform Building Code (UBC), the BOCA Building Code (BOCA), or the Standard Building Code (SBC) had not yet been developed at the time of the fire. C.3.3 Lakeview Elementary School Fire, Coiiinwood, Ohio, 1908 The Lakeview Elementary School fire was the worst disaster in Cleveland history with a toll of 172 children and two teachers [4]. The three-story school had a brick exterior, but the interior was all constructed of wood. It was theorized at the time that the fire was caused by an overheated steam pipe that ignited wood joists under the front stairs. The fire was discovered by a child who had gone down to the girls’ lavatory in the basement. The student told the janitor who then sounded the alarm and opened the front and rear doors. Students that attempted to escape using the front doors were pushed back by flames and smoke, so they ran to the back entrance. Someone fell at the back entrance and a blockage of people developed as many tried to force their way through. One of the exterior doors had blown shut and children became wedged in the narrow space. The pushing of the students trying to escape and the weakening of the structure by the fire below caused the floor to collapse, which plunged the crowd into the burning basement. Classes on upper floors fled using fire escapes and others jumped out of windows. The team of village horses used by the volunteer fire department was busy dragging a road scraper a mile away, so by the time they arrived little could be done. The following details regarding this incident are of note: • Wooden construction ignited under the front stairs, rendering them useless for evacuation; • The floor at the rear exit collapsed, throwing many occupants into the fire; • Stairways were not enclosed; • Exterior rear door blew shut; • The team of horses that normally pulled the fire engine were not readily available at the time of the fire and arrived late to the scene. Impact on regulations or practices The fire in Coiiinwood brought about laws requiring fire resistant construction, enclosed stairwells, and “panic bars” that trigger door latches when pushed from inside in schools. The NFPA 101 Life Safety Code, the Board for the Coordination of Model Codes (BCMC), the Uniform Building Code (UBC), the BOCA Building Code (BOCA), or the Standard Building Code (SBC) had not yet been developed at the time of the fire. C-11

C.3.4 Triangle Shirtwaist Company Fire, New York, New York, 1911 The fire at the Triangle Shirtwaist Company in New York in 1911 had possibly the greatest impact on modem fire and life safety codes of any historical fire. The business was located on the three topmost floors of a ten-story building. Fire initiated in a bin of rags on the lowest of the three floors, and quickly spread despite the efforts of employees to extinguish it using buckets of water [5]. Large amounts of fabric throughout the space contributed to rapid fire growth and spread. Initial evacuation was hampered by a locked exit door, which, when eventually unlocked, swung against the direction of egress travel, thus causing a cmsh of evacuating occupants. Even after the door was opened, some occupants tripped on the exit stairway and caused a further delay in the egress. Some occupants from the top floor escaped via the roof to an adjacent building. Occupants of the upper and lower floors never notified the middle floor occupants of the fire. Instead, occupants of this floor learned of the fire when flames extended through the windows. During the exiting of occupants from this floor, the fire escape collapsed. Some occupants tried to use the elevators, but they were already packed with occupants from other floors. As a last resort, some occupants jumped from the ninth-floor windows. A total of 147 people died in this incident. The following details regarding this incident are of note: • The building had wood floors, window frames, and trim. The New York City building codes of the time allowed this for structures less than 1 1 stories high; • Each of the two lower floors, where large numbers of employees worked, included vast amounts of cloth either piled on the floors, in bins or on tables, or hanging from lines. This contributed to rapid fire growth and spread on the floor of origin; • Numerous exit doors were locked in an effort to monitor employees and prevent theft; • The exit doors swung opposite the direction of egress travel; • The building had only two staircases. This violated New York City building codes of the time, which required three staircases per floor where the floor area of each floor exceeded 10,000 ff; • Elevators placed priority on the topmost floor, and thus were full when they stopped at the lower floors, where the danger was more imminent; • A lack of communication between the eighth and tenth floors and the ninth floor led to late notification of the occupants of the ninth floor; • The fire escape, when heated by the fire extending from the windows, could not support the large number of evacuating occupants and collapsed; • The New York City fire department did not have equipment that could fight fires higher then seven stories up in a given building. Impact on regulation or practices According to information in the Life Safety Code® Handbook: • Immediately after the incident. New York City residents formed the Committee on Safety, which worked to pass laws requiring greater safety in factory buildings; C-12

• The Governor of New York, in response to this ineident, created a Factory Investigating Commission within the state; • Later in the same year, a law was passed creating the New York City Fire Prevention Bureau (the first such bureau in the US). NFPA 101®: Life Safety Code® Again, according to the Life Safety Code Handbook, due to the severity of this incident, NFPA began to broaden its scope to include elements of life safety. The first such publication dealt with exit drills in factories, schools, department stores, and theaters. Two years later, an NFPA committee on Safety to Life, which was to study the current situation regarding life safety in buildings, was formed. This was the beginning of the NFPA Life Safety Code. In 1927, this work also resulted in the NFPA Building Exiting Code. Boardfor the Coordination ofModel Codes (BCMC) The earliest BCMC reports obtained were from 1977; therefore, information on changes prior to 1977 was not available. Uniform Building Code (UBC) The first edition of the UBC was not published until 1927. BOCA Building Code (BOCA) The first edition of the BOCA code was not published until 1950. Standard Building Code (SBC) The first edition of the SBC was not published until 1945. Details of proposed changes and committee reports were not available prior to 1977. C.3.5 Italian Hall Disaster, Calumet, Michigan, 1913 On Christmas Eve of 1913, a party was being held in an upstairs function room in the Italian Hall in Calumet, Michigan. The majority of the attendees were children. At some point during the party, something caused the occupants to initiate a mass evacuation. Reports of the cause of this vary, but no fire was found [5,6]. The evacuating occupants rushed down the main stairway and clogged in the exit doorway. The resulting crush of people in the stairwell led to the deaths of 72 people; all of these were either crushed or suffocated. Some reports indicate that intoxicated, disgruntled workers may have yelled ‘fire.’ It is unclear if this did occur. The following details regarding this incident are of note: • The function room was served by a single main exit stairway; • The exit doors at the bottom of the main stairwell opened inward; this resulted in a blockage as people rushed down the stairway before the first evacuating occupants could open the doors. Impact on regulation or practices NFPA 101®: Building Exits Code® NFPA 101 was not yet published; the incident occurred in 1913 while the first edition of the Building Exits Code was released in 1927. Boardfor the Coordination ofModel Codes (BCMC) C-13

The earliest BCMC reports obtained were from 1977; therefore, information on changes prior to 1977 was not available. Uniform Building Code (UBC) The first edition of the UBC was not published until 1927. BOCA Building Code (BOCA) The first edition of the BOCA code was not published until 1950. Standard Building Code (SBC) The first edition of the SBC was not published until 1945. Details of proposed changes and committee reports were not available prior to 1977. C.3.6 Clinic Fire, Cieveland, Ohio, 1929 On May 15*, 1929 a fire started at 1 1:25 AM in a basement room where 70,000 X-rays were stored [7,8]. The burning films released poisonous gases that traveled through the building’s ventilation system that was also located in the basement. A fire door was left open aiding in the movement of the poison gas. At 1 1:31 AM, an explosion rocked the building, spreading more poisonous gas and starting fires throughout the building. When the fire department arrived, the building was already shrouded in smoke. Soon after, another explosion shook the building. Patients ran for the exits, and many succumbed to the toxic gases while trapped in stairways and near the elevator. Many of the nurses and doctors died helping the patients. Some patients found their way out, but eyewitness accounts state that many of these perished as a result of their injuries or inhalation of smoke. The fires were extinguished, and the victims were removed from the building within two hours. The incident claimed 123 lives; 43 of these were doctors and nurses. Nearly all of the victims died of inhalation of poison gas. The following details regarding this incident are of note: • Contrary to American Hospital Association guidelines, the X-rays were stored in paper folders and some had been left outside the steel cabinets where they were supposed to be kept; • A fire door was open and allowed the gas to spread throughout the clinic; • The building was not equipped with a sprinkler system. Impact on regulation or practices The fire resulted in the development of new standards for the storage of hazardous materials, particularly X-ray film. Also, poisonous gases were recognized as a hazard and fire insurance companies began to develop and strictly enforce safety regulations. The impacts that this incident had on various regulations are discussed below. NFPA 101®: Building Exits Code While there do not appear to be any changes to NFPA 101 directly associated with this incident, the 1929 edition brought the first introduction of the “Assembly Occupancies” chapter. The 1934 edition expanded upon occupant loading, exit capacities, required number of exits, and travel distances. Boardfor the Coordination ofModel Codes (BCMC) C-14

The earliest BCMC reports obtained were from 1977; therefore, information on ehanges prior to 1977 was not available. Uniform Building Code (UBC) There do not appear to be any changes to the UBC directly related to this incident. BOCA Building Code (BOCA) The first edition of the BOCA code was not published until 1950. Standard Building Code (SBC) The first edition of the SBC was not published until 1945. Details of proposed changes and committee reports were not available prior to 1977. C.3.7 Rhythm Club Fire, Natchez, Mississippi, 1940 The Rhythm Club was a single-story dance hall in Natchez, Mississippi. It was a wood framed building with corrugated steel walls and roof. Several years before the fire, the ceiling joists of the building had been concealed by adding a layer of Spanish moss on top of a netting system. On the night of the fire, the moss was extremely dry; it is suspected that the heat from a grill located near the front of the building caused the moss to ignite. The fire spread rapidly across the dry moss [9]. The building was equipped with only one exit, which was located at the front of the building. When the fire began to grow, several occupants were able to exit through this door. However, the location of the ignition near the front of the building caused most of the occupants to move to the back into the building, where there were no additional exits. The main exit doors opened against the direction of egress travel, but since only a few people were able to reach this exit, it was not expected that this detail significantly contributed to the loss of life, and no fatalities occurred near these doors. The sides of the building were lined with numerous small windows, but all of these in the main open portion of the building had shutters, some of which were latched, but most of which were nailed closed. All of the shutters opened inward. As a last resort, occupants attempted to break through the corrugated steel walls of the building to reach the outside, but were unsuccessful. The majority of the 207 fatalities occurred at the very back of the building, at the opposite end from the only available exit. The following details regarding this incident are of note: • The tinder-dry Spanish moss layered below the ceiling joists led to extremely fast fire spread along the length of the building, and contributed to further fire spread by falling and igniting combustible items below; • The building was equipped with only one available exit door. The location of the fire in the front portion of the building prevented most occupants from accessing this exit; • None of the windows along the sides of the main portion of the building could be used as a means of escape, since they were very small and most were boarded up. One plain glass window was included in a subdivided portion at the front of the building, but occupants were not able to reach this area due to the location of the fire, and even if they had, the door to this room was locked; • At the time of the fire, more than 700 people were packed into the 120 ft by 38 ft structure; C-15

• There were no skylights or other windows to vent the heat or smoke, so the metal walls held the heat in like an oven. Impact on Regulation or Practices NFPA 101®: Building Exits Code® There do not appear to be any changes to NFPA 101 directly associated with this incident. Boardfor the Coordination ofModel Codes (BCMC) The earliest BCMC reports obtained were from 1977; therefore, information on changes prior to 1977 was not available. Uniform Building Code (UBC) There do not appear to be any changes to the UBC directly related to this incident. BOCA Building Code (BOCA) The first edition of the BOCA code was not published until 1950. Standard Building Code (SBC) The first edition of the SBC was not published until 1945. Details of proposed changes and committee reports were not available prior to 1977. C.3.8 Cocoanut Grove Nightclub Fire, Boston, Massachusetts, 1942 The Cocoanut Grove Nightclub was a single-story building with a finished basement. The basement contained an additional lounge and a kitchen. Technically, the capacity of the club was 600 occupants. On the night of November 28, 1942, when a fire broke out in some combustible decorations in the basement lounge, there were over 1000 occupants in the club [5,10]. From the portion of the building where the fire broke out, there was only one obvious exit, and this was up a set of stairs leading through an approved exit door to a hallway, and eventually to the main exit, which included a revolving door. This hallway also had a door exiting to the street, but this was locked at the time of the fire. Other means of egress existed, but were concealed behind decorations and false walls; some were locked. The fire spread rapidly across the underside of the false ceiling in the compartment of origin, and eventually went up the exit stairs and into the exit hallway and spread into the main dining room. The patrons in the main dining area knew of only one exit, the main exit with the revolving door. Other exits were not obvious or were hidden with decorations similar to the basement lounge. Some of the patrons stumbled upon these exits and escaped; however, some of the exits on the first floor were also locked trapping occupants. There was a second lounge area on the first floor down a narrow hallway from the dining area. The smoke spread into this area and people rushed for the only exit door, which opened inward. The push of the crowd jammed the door closed and many of the occupants within this area died. It is reported that the fire lasted less than an hour from ignition to extinguishment; 492 people died. Many of these deaths resulted from a bottleneck of evacuating occupants in the narrow exit hallway leading from the downstairs lounge. Many more people died when they got trapped behind the revolving door that served as the main exit from the lobby area. C-16

The following details regarding this incident are of note; • The night of the fire, the club was highly overcrowded (compared to its capacity according to the applicable codes); • The fire spread rapidly across combustible decorations throughout the club; • While numerous exits from the lower-floor lounge existed, only one was obvious and unlocked the night of the fire. Others were hidden by decorations or false walls, and many of these were locked. Only employees, and the few people the employees were able to assist, used these exits; • The main exit from the lower lounge required that occupants traverse a narrow hallway and enter the main lobby, where they would converge with occupants evacuating from other parts of the building. An additional exit door located in the narrow hall was locked; • Many of the patrons in the dining area only knew of the main exit, since many of the other exits were concealed or unmarked; • Some of the exits were locked; • The only exit in the smaller lounge off from the dining area opened inward and trapped patrons in the lounge; • A large number of people were trapped behind the revolving main entrance door, which became jammed with people early in the evacuation. Impact on Regulation or Practices NFPA 101®: Building Exits Code® According to information in the Life Safety Code® Handbook: • Subsequent to this incident, the NFPA Building Exits Code began to be accepted by more jurisdictions throughout the country; • At the 1945 NFPA Annual Meeting, the Committee on Safety to Life recommended changes to the prescribed method of egress capacity measurement, clarification of stairway enclosure requirements, changes to requirements regarding moveable chairs in nightclubs, and changes in exit lighting and signage requirements, as a result of this fire; • A caution was added to the Building Exits Code warning that, where combustible interior finishes exceeding the limitations of the Code were used, the provisions of the Code may not be sufficient to ensure life safety. Boardfor the Coordination ofModel Codes (BCMC) The earliest BCMC reports obtained were from 1977; therefore, information on changes prior to 1977 was not available. Uniform Building Code The 1943 edition of the UBC did not contain any significant changes from the previous edition; however, a number of changes were made between the 1943 and the 1946 editions. Though it is unclear if this incident had any direct impact, the following were changes incorporated into the 1 946 edition of the UBC: C-17

• Required egress width requirements ehanged to provide one foot of width for every 50 oecupants. The previous requirement provide for a varying number of inches of exit width per person based upon the total occupant load; • A main entrance/exit provision was added such that the main entrance/exit was now required to have a capacity not less than 50% of the design occupant load; • The number of required exits was changed such that 2 exits were required from 1 0-499 occupants; 3 exits for 500-999 occupants; and 4 exits for more than 1,000 occupants; • Panic hardware was now required for doors serving more than 50 occupants in assembly occupancies. BOCA Building Code (BOCA) The first edition of the BOCA code was not published until 1950. Standard Building Code (SBC) The first edition of the SBC was not published until 1945. Modeling Efforts In one study, the Cocoanut grove fire was the subject of a number of modeling efforts. Both CFAST and WPl/Fire were used to model fire effects within the building. FPETool was also used to estimate the evacuation time from the building and to estimate sprinkler activation time (had sprinklers been present). C.3.9 Winecoff Hotel Fire, Atlanta, Georgia, 1946 In the early morning hours of December 7, 1946 a fire occurred at the fifteen-story Winecoff Hotel in downtown Atlanta [1 1,12,13]. At the time the hotel had 280 guests in its 194 rooms and 1 19 of these guests died in the fire. The hotel was advertised as fireproof because of a brick exterior and concrete and steel construction. It was built in 1913 and did not have fire escapes or a sprinkler system because it was not required by code when it was built. The authorities believed that the fire began on the fourth or fifth floor. The fire was reported to the night auditor and as soon as he verified that there was a fire he sounded the alarm around 3:20am. However, the fire department records indicate that the first alarm came in by telephone at 3:42am. The night auditor then contacted as many rooms as possible before the switchboard stopped working telling the guests to keep their doors closed and to stay calm. However, only the rooms on the third through the sixth floors had heavy wooden doors and tightly sealed transoms. Above the sixth floor, the rooms did not have the thick doors and many of the transoms had been permanently opened allowing for smoke and flame to spread into these rooms. Also, the fire spread quickly because it was aided by the open narrow staircase that acted as a flue. The fire was ruled as an accident, caused by a burning cigarette on a mattress. However, there are some investigations that have pointed toward arson. The following details regarding this incident are of note: • There were no fire escapes or sprinklers in the hotel; • There was a twenty minute delay in reporting the fire to the fire department; • The main central staircase was open and allowed flame and smoke to spread floor to floor; • Fire rated doors were not used; C-18

• The transoms were not fire rated or sealed. Impact on Regulation or Practices The Winecoff fire led to a number of new fire regulations for Atlanta. The major change was to require the enclosing of stairwells with additional requirements for alarm systems and smoke detectors. The impacts that this incident had on various regulations are discussed below. NFPA 101®: Building Exits Code® There do not appear to be any changes to NFPA 101 directly associated with this incident. Boardfor the Coordination ofModel Codes (BCMC) The earliest BCMC reports obtained were from 1977; therefore, information on changes prior to 1977 was not available. Uniform Building Code (UBC) There do not appear to be any changes to the UBC directly related to this incident. BOCA Building Code (BOCA) The first edition of the BOCA code was not published until 1950. Standard Building Code (SBC) The first edition of the SBC was not published until 1945. Details of proposed changes and committee reports were not available prior to 1977. C.3.10 Our Lady of Angels School Fire, Chicago, Illinois, 1958 Inadequate exit components were blamed for the loss of 93 occupants in a fire that spread rapidly through the Our Lady of Angels School in Chicago in 1958 [5]. The school consisted of a pair of two-story brick buildings connected together. However, per the applicable code, the building was considered one fire area, since the masonry wall separating the two annexes did not have protected openings, and the majority of the stairways within the buildings were not enclosed. The actual origin of the fire is not known, but it was located in a rear unenclosed stairway. Combustible materials here, as well as in adjoining corridors, contributed to rapid spread from the stairway to other areas of the building. Additionally, combustible ceiling tiles in the classrooms likely added to fire growth and spread. After the fire was discovered and efforts were made to locate the school principal, the few teachers aware of the fire evacuated their own classes to another building. Only after returning did they activate the school’s fire alarm and initiate general evacuation. Because the fire had moved up the open stairway in which it initiated and was largely burning in the second floor corridor, the first floor occupants were able to evacuate through the five available exit stairs. Some of the upper level occupants were able to escape because someone closed the dividing door between the two annexes, thus largely confining the products of the fire to the North wing. However, occupants of the North wing could not use the corridor to escape because of smoke and heat, and thus were forced to jump from the second-story windows or to be rescued by fire fighters using ladders. The majority of the fatalities occurred in this area. The following details regarding this incident are of note: C-19

• Only two of the five available stairways were enclosed, and these had inadequate opening protection at their landings. At the time of the fire, the doors to these stairwells were propped open; • Combustible materials in the stairwell where the fire started, combustible wood trim in the main second-floor corridor, and combustible ceiling tiles in the classrooms all contributed to rapid and widespread fire impact on the second floor of the North annex; • Notification was delayed because teachers evacuated their own classes before sounding a general alarm. By the time a general evacuation was initiated, dense smoke and heat had reached the upper corridor through the open stairwell. This prevented occupants of the upper floor of the North annex from reaching the enclosed exit stairway at the North end of the corridor; • The opening protection between the two annexes was substandard, and the door in the upper corridor was propped open leading up to the fire. An occupant closed it during the fire, thus isolating the occupants of the second story portion of the South annex from the heat and smoke of the fire. Impact on Regulation or Practices Spurred by the Our Lady of Angels fire, the Los Angeles Fire Department conducted a series of tests designed to explore methods of protecting multistory school buildings containing open stairways. One of the major conclusions of these tests was that automatic sprinkler systems provided the best chance of occupant safety and egress. Generally speaking, the Our Lady of Angels fire awakened much of the US to hazards present in the country’s schools, and efforts were undertaken to improve conditions. One year after the fire, the NFPA polled fire departments regarding fire safety in schools, and it was found that the majority of communities had implemented better fire drill procedures, improved waste control measures, refined inspection requirements, and more appropriate storage of combustible goods; NFPA 101®: Building Exits Code® In response to the Our Lady of Angels fire and the Los Angeles fire tests, the NFPA reorganized its provisions for educational occupancies, which included requirements for sprinklers in school buildings of different types. Boardfor the Coordination ofModel Codes (BCMC) The earliest BCMC reports obtained were from 1977; therefore, information on changes prior to 1977 was not available. Uniform Building Code (UBC) There do not appear to be any changes to the UBC directly related to this incident. BOCA Building Code (BOCA) The 1960 edition of BOCA contained changes in the Interior Finish requirements which modifying how material combustibility was classified. It is uncertain if any changes occurred in the requirements for the types of materials allowed in various occupancies. Standard Building Code (SBC) C-20

The first edition of the SBC was not published until 1945. Details of proposed changes and committee reports were not available prior to 1977. C.3.11 Upstairs Lounge Fire, New Orleans, Louisiana, 1973 On June 24, 1973, an arson fire killed 32 patrons of the Upstairs Lounge in New Orleans, Louisiana [14]. The fire was started in the only staircase serving the upper floors of the three-story building. The second floor was the lounge, and the third floor included unoccupied apartments. At the time of the fire, there were 65 people in the lounge, which had a capacity of 1 10. Once established, the fire spread rapidly up the stairwell, fueled by combustible wood paneling and carpeting. The stairway was separated from the lounge on the second floor by a wood-framed partition with plaster-on-lath covering the studs. An approved fire door assembly was installed in this partition. However, on the night of the fire, a patron responding to repeated rings of the doorbell opened this door, and fire rushed into the lounge. The location of the fire in the exit staircase prevented occupants from evacuating down the main exit stairs. An alternate escape path, opening onto an adjacent building’s roof, was located in the back of the lounge, but was not marked as an exit. Also, the path to this door was obstructed by equipment on a stage, and the door had an improvised latch. The bartender attempted to lead people to this door, and was successful in evacuating several people in this fashion. However, on his second attempt to move people to the back door, he received no response, and evacuated, latching the fire door behind him. The final exit option was through the windows of the club. The building was equipped with a single fire escape, accessed through one of the windows. Many windows in the lounge were boarded up; other windows in the bar area were equipped with metal bars to prevent patrons from falling through. This proved to hamper escape efforts. Some occupants were able to squeeze through the bars and reach the outside, where they Jumped, slid down drainpipes and other building features, or utilized the fire escape. Many of the fatalities occurred in the bar area in the vicinity of the exterior windows. The following details regarding this incident are of note: • The fire spread rapidly up the only stairway in the building due to the combustible interior finishes within the stairwell; • The fire door at the top of the stairwell, which initially blocked the heat and smoke from the fire, was opened by a patron and, presumably, remained open for the duration of the fire. Smoke and flames entered the lounge immediately after this door was opened, and patrons had little time to react; • A rear door, which turned out to be the only safe exit, was not properly marked as an exit, and the path to it was hidden and obstructed by a stage and associated equipment. Also, it had an improvised latch, which may have been difficult to operate by those unfamiliar with it; • Numerous windows were boarded up, and the rest were equipped with steel bars to prevent people falling through the large glass panels. Many of these also had wooden shutters over their lower sections. Impact on Regulation or Practices NFPA 101®: Life Safety Code® There do not appear to be any changes to NFPA 101 directly associated with this incident. Boardfor the Coordination ofModel Codes (BCMC) C-21

The earliest BCMC reports obtained were from 1977; therefore, information on changes prior to 1977 was not available. Uniform Building Code (UBC) There do not appear to be any changes to the UBC directly related to this incident. BOCA Building Code (BOCA) While it is unclear if changes were perpetuated by this incident, a number of changes appear in the 1975 BOCA code. Due to the fact that these changes tend to make the Code more lenient, it is doubtful that they were in response to this incident. These include: • Increases in the egress capacities of doors and stairs as follows: o Unsprinklered

• 75 people per unit width for stairs and 100 people per unit width for

doors; o Sprinklered - 1 13 people per unit width for stairs and 150 people per unit width for doors; • Before the 1975 edition, the egress capacities for unsprinklered buildings was 60 people per unit exit width for stairs and 90 people per unit exit width for doors; • Travel distances were increased to 150 ft. for unsprinklered buildings and 200 ft for sprinklered buildings. Before the 1975 edition, the travel distance was 100 feet for all construction types; • Panic hardware was now required for all assembly occupancies with an occupant load greater than 100 persons; • Sprinkler systems were now more widely required for various assembly spaces; • Standpipes were more widely required for assembly spaces with more than 300 occupants. Standard Building Code (SBC) The first edition of the SBC was published in 1945. Details of proposed changes and committee reports were not available prior to 1977. C.3.12 Gulliver’s Discotheque Fire, Port Chester, NY, 1973 On June 30, 1974 a fire killed twenty-four people in a nightclub called Gulliver’s in Port Chester, New York [15]. Gulliver’s was part of a small shopping center on the Connecticut-New York border that also housed a bowling alley, a men’s clothing store, and a barbershop. It was a one-story building with a basement. The basement was used for storage, offices and a children’s playroom that the bowling alley rented. The fire started in the basement in a children’s playroom. The fire was deliberately set. The dance floor itself was five feet lower than the dining room and had two adjacent sets of stairs leading to the basement and to the dining room. These were the only exits from the dance floor. At approximately 1 :00 am people in the service bar area of the basement at the foot of the stairs to the dance floor noticed smoke. Someone called the fire department while someone else notified the bandleader who told people to leave the building. The evacuation was orderly, but within a minute heavy smoke started coming up the stairs from the basement to the dance floor. Smoke had traveled in the floor joist channels above the playroom into the service bar area below the dining area and then billowed up the stairs leading C-22

to the dance floor. Occupants were forced to leave by using the “up” stairs leading to the dining room adjacent to the basement stairs. Even though the stairs were 5 Vi feet wide there was not enough time for the crowd to evacuate and the twenty-four people that died did so of smoke inhalation. Once the crowd was warned to evacuate there was not enough time to complete evacuation before smoke exposure became a problem. Some of the reasons for the lack of evacuation time were: • Delayed discovery of the fire, since it originated in the unoccupied children’s play area in the basement; • Lack of a fire-rated wall between the discotheque and the rest of the shopping center; • Lack of a fire-rated door at the bottom of the stairs from the service bar to the dance floor; • Lack of occupant load restrictions; • Exits from the dance floor were not remote from each other. Impact on Regulation or Practices NFPA 101®: Life Safety Code® There do not appear to be any changes to the 1976 edition of NLPA 101 directly associated with this incident. However, this incident is specifically mentioned in a proposal to change the fire alarm / notification system requirement for the 1981 edition ofNFPA 101. The proposal as submitted was rejected, but the concepts were accepted toward creating a new requirement for fire alarm / notification systems in assembly spaces with an occupant load greater than 300 persons. Boardfor the Coordination ofModel Codes (BCMC) The earliest BCMC reports obtained were from 1977; therefore, information on changes prior to 1977 was not available. Uniform Building Code (UBC) There do not appear to be any changes to the UBC directly related to this incident. BOCA Building Code (BOCA) While it is unclear if changes were perpetuated by this incident, a number of changes appear in the 1975 BOCA code. Due to the fact that these changes tend to make the Code more lenient, it is doubtful that they were in response to this incident. These include: • Increases in the egress capacities of doors and stairs as follows: o Unsprinklered

• 75 people per unit width for stairs and 100 people per unit width for

doors; o Sprinklered - 1 13 people per unit width for stairs and 150 people per unit width for doors; • Travel distances were increased to 150 ft for unsprinklered buildings and 200 ft for sprinklered buildings; • Panic hardware was now required for all assembly occupancies with an occupant load greater than 100 persons; C-23

• Sprinkler systems were now more widely required for various assembly spaces; • Standpipes also more widely required for assembly spaces with more than 300 occupants. Standard Building Code (SBC) The first edition of the SBC was published in 1945. Details of proposed changes and committee reports were not available prior to 1977. C.3.13 Beverly Hills Supper Club Fire, Southgate, Kentucky, 1977 Few assembly occupancy fires have been investigated and documented as thoroughly as the one that occurred at the Beverly Hills Supper Club in Southgate, Kentucky, in 1977. This sprawling nightclub had multiple event rooms of varying sizes. On the day of the fire, multiple events were scheduled, including a wedding reception earlier in the afternoon, and a show was in progress when the fire broke out. In total, 2400 to 2800 people were in the building at this time, and 1200 to 1300 of these were in a single event room (the Cabaret Room). The fire initiation, assumed to be electrical in nature, occurred in an unoccupied room where an event had taken place earlier in the day [5,6]. Employees noticed the flames, and attempted to extinguish them using fire extinguishers. The fire was seated in a concealed space within the wall, and the employees’ extinguishment efforts were unsuccessful. Largely because of the unsuccessful efforts to extinguish the fire, approximately 1 5 minutes elapsed between the discovery of the fire and the general notification of the employees and occupants. Additionally, it is reported that some employees were not sure of evacuation procedures, and this may have further delayed notification. According to witness accounts, the initial evacuation of patrons followed an interesting trend. Employees tended to notify only those patrons for which they were responsible during the normal operations. In other words, a given waitperson might only have notified the people seated at the tables that that person served. This led to delayed notification of some guests in remote parts of the building. Unfortunately, during the performance in the Cabaret Room, the wait staff was isolated from the patrons so as not to interrupt the perfonnances, and thus employees did not instinctively notify occupants in the Cabaret Room. This led to delayed notification within the Cabaret Room; thus, almost all of the 1 64 fatalities occurred in the Cabaret Room. Many survivors of this fire owe their lives to a calm and quick-thinking busboy, who took the stage in the crowded Cabaret Room, pointed out the available exits, and asked people to leave. Some followed his advice, but many did not perceive the danger until smoke and heat reached the area outside of the Cabaret Room. At this point, occupants began to rush to the exits. Some tripped or were knocked down, and the exits became blocked. According to the busboy, one of the three available exit doors was locked, and he was unable to break it open. The following details regarding this incident are of note: • While the applicable codes of the time limited the occupancy of the club to 1511 based on its construction, more than 2400 occupants were inside at the time of the fire; • The Cabaret Room was vastly overcrowded, with tables pushed together and additional seating placed in the aisles, thus blocking egress movement. Based on the codes at the time the capacity of the Cabaret Room was just over 500, but there were over 1000 occupants in the room that evening [3]; • The exit capacity of the egress system was approximately 60% of the code-required capacity; C-24

• The Cabaret Room should have had four separate exits, but it only had three, and at least one was locked at the time of the fire. Some of these exits were poorly marked or intentionally masked; • There was no evacuation plan and personnel were not properly trained; • Once established in the compartment of origin, fire spread rapidly across combustible interior finish within the room of origin and the main corridor of the building; • Many occupants did not perceive the severity of the fire until it was too late, and few evacuated immediately upon being told to do so. No alarm system was installed within the building. Impact on Regulation or Practices NFPA 101®: Life Safety Code® According to information in the Life Safety Code® Handbook; • Previous to the Beverly Hills Supper Club fire, the NFPA 101 Life Safety Code required alarm systems in all occupancies except storage spaces and places of assembly. The reasoning for the latter was that it was felt that an alarm might cause panic. This fire showed the importance of rapid notification, and the next version of the Code, the 1981 edition, included a requirement for alarm systems in places of assembly. Additionally, a note was added requiring that notification of places of assembly be done through a voice alarm or a public address system. These requirements were implemented retroactively in existing buildings, as well; • The Life Safety Code historically only required sprinkler systems in assembly occupancies when those spaces were used as exhibit halls. After the Beverly Hills Supper Club incident, provisions were added to the 1981 edition of the code requiring sprinkler systems in different assembly occupancies based on the types of construction used. Some of these requirements were also issued retroactively. Boardfor the Coordination ofModel Codes There do not appear to be any recommended changes to the model building code from the BCMC as a result of this event. Uniform Building Code (UBC) There do not appear to be any changes to the UBC directly related to this incident. BOCA Building Code (BOCA) While unclear if changes were directly related to this incident, a few changes appear in the 1978 BOCA code. These include: • Panic hardware in all assemblies with 50 or more occupants. • Door swing in the direction of travel when serving 50 or more occupants. Standard Building Code (SBC) There do not appear to be any changes to the SBC directly related to this incident. C-25

Modeling Efforts In the early 1980s Emmons [44] attempted to estimate mathematically fire growing and fire gas spread rate in the Beverly Hills Summer Club fire. Using a resistor network diagram and mean flow volume equations this “educated guess” clearly showed that the act of opening doors to escape drew the fire into the escape routes. C.3.14 “The Who” Concert, Cincinnati, Ohio, 1979 The Who concert was a sold out show and many ticket holders had arrived to the Coliseum early and were waiting to be let into the venue to claim the best seats. There were over 18,000 general admission tickets sold and as many as 8,000 ticket holders waiting outside competing for the preferred general admission seating [3]. Two banks of eight doors were finally opened, but according to many in the crowd, not all of the doors were opened. The guards would let in people until the lobby was full and then they would temporarily close the doors. This resulted in the crowd pushing forward. Within an area outside one of the banks of doors, several people fell. The people behind those that had fallen were pushed forward by the crowd. The surge toward the Coliseum resulted in eleven people being crushed to death and approximately two-dozen more becoming injured from he incident [17]. Concertgoers told of only one or two doors being open out of a possible sixteen to process the incoming crowd. The following details regarding this incident are of note: • Poor crowd safety was the major cause of this tragedy; • Only a few doors out of a total of 16 were open to accommodate 8,000 people and when the lobby filled the guards closed the doors, which caused the crowd to become concerned about getting into the arena. Impact on Regulations or Practices This incident spurred the Cincinnati government to take action. By the end of the month the Mayor and City Council had passed legislation that banned festival seating and gave the police emergency on-the- scene authority at major public assembly venues. In addition, a full-scale investigation was conducted by an independent citizen’s task force called “The Task Force on Crowd Control and Safety”, which was established by the City Council. The Task Force released a report called Crowd Management in 1980 that offered 108 crowd safety recommendations. The report is now in its fourth printing and remains one of the important manuals on facility rock concert crowd management. NFPA 101®: Life Safety Code® A requirement regulating festival seating-type assembly areas was introduced into the code for the 1994 edition. Boardfor the Coordination ofModel Codes There do not appear to be any recommended changes to the model building code from the BCMC as a result of this event. Uniform Building Code (UBC) There do not appear to be any changes to the UBC directly related to this incident. BOCA Building Code (BOCA) There do not appear to be any changes to the BOCA code directly related to this incident. Standard Building Code (SBC) There do not appear to be any changes to the SBC directly related to this incident. C-26

C.3.15 Haunted Castle Amusement Facility Fire, Jackson Township, NJ, 1984 On May 1 1, 1984 a fire destroyed the “Haunted Castle” amusement at the Six Flags Great Adventure Park located in Jackson Township, New Jersey [18]. Eight young adults died as a result of smoke inhalation and carbon monoxide poisoning. The structure was composed of seventeen commercial trailers connected by plywood and wood framing. The interior of the amusement was constructed of plywood partitions creating a convoluted path 450 ft. long. Other materials used in the interior of the structure were synthetic foam, various fabrics and plastics, and tarpaper. The cause of the fire was the accidental ignition of a wall mounted, polyurethane foam pad by a cigarette lighter from a visitor trying to light their way through the dark path. The foam pad burned rapidly and fire spread down the corridor fueled by plywood construction of the ceiling, floor, and walls. The foam was not flame retardant and the plywood was untreated. At approximately 6:30 PM an employee in the Haunted Castle smelled smoke and went to investigate. Coming upon heavy smoke he went to the main gate to instruct employees to discontinue entry of visitors and then went to the control room inside the facility to call the park fire brigade. Meanwhile, a visitor in the amusement discovered the fire and alerted an employee. There was approximately a five-minute delay between the employee detecting the fire and alerting the fire brigade. There were a total of seven exits including the main entrance and fire protection features included emergency lighting and portable fire extinguishers. There were no automatic detection or sprinkler systems provided in the facility. The following details regarding this incident are of note: • The fire was not detected and suppressed in its incipient stage because of the lack of automatic detection and suppression systems; • There was a large amount of combustible material present including interior finishes such as foam and plywood; • The occupants had difficulty escaping due to fire conditions in the haunted house type of environment. Impact on Regulation or Practices NFPA 101®: Life Safety Code® Though unclear if directly related to this incident, the interior finish requirements were changed for the 1985 edition ofNFPA 101 so that rooms with an occupant load greater than 300 were limited to Class 11 interior finish materials. Class III materials were still allowed in rooms with less than 300 occupants. In direct response to the Haunted Castle amusement facility fire, NFPA added a new section on Special Amusement Buildings to the 1988 edition. This category of assemble occupancy use establishes criteria that are unique to an environment that may intentionally confuse or confound the occupants. Boardfor the Coordination ofModel Codes (BCMC) The BCMC report dated February 19, 1985 included recommendations for the size, location and illumination of exit signs. It is uncertain if these recommendations were directly related to this incident, but they certainly address the pertinent issue of the Haunted Castle fire. Uniform Building Code (UBC) C-27

Though unclear if directly related to this incident, the interior finish requirements were changed for the 1985 UBC so that rooms with an occupant load greater than 300 were limited to Class II interior finish materials. Class 111 materials were still allowed in rooms with less than 300 occupants. BOCA Building Code (BOCA) There do not appear to be any changes to BOCA directly related to this incident. Standard Building Code (SBC) While unclear if directly related to this event, the main exit provision was modified for the 1985 edition of the SBC. The new requirement called for 1/2 of the total egress capacity to be provided through the main exit and 2/3 of the total egress capacity to be provided by all other exits. C.3.16 Happy Land Social Club Fire, New York, New York, 1990 Early on the morning of March 25, 1990, numerous patrons were in the Happy Land Social Club in the Bronx borough of New York City [20,21]. It is suspected that an arsonist used an accelerant to ignite a fast-growing fire in the building’s main lobby, and that combustible interior finish contributed to the rapid growth of the fire. The ground floor of the building, which is where the lobby was located, had been left unsprinklered during a previous renovation, and thus the fire spread unimpeded. Coatroom employees discovered the fire, and alerted first floor occupants. Another employee went up to the second floor, where the majority of occupants were located, to alert patrons to the fire. Only two occupants from the second floor survived, although one of these sustained severe bums mnning through the lobby to the main exit; these individuals left the second floor immediately upon being informed of the fire. Fire damage was limited to the front portion of the building. A total of 87 people died in this fire, 18 on the first floor, and 69 on the second. The following details regarding this incident are of note: • At the time of the fire, the club was in violation of New York City building and fire code regulations, and had been ordered shut down, but was still in operation; • At some point in its history, the building had been converted from one story (high ceiling) to two, and the original sprinkler system was not extended to the first floor. Also, part of the sprinkler system on the second floor was not functional. The fire initiated in an unsprinklered area; • One of the two main exit doorways to the front exterior of the building was covered by an unlocked roll-down steel security door. The swinging doors here were locked, and the doorway was not marked from the inside as an exit. However, at some point during the evacuation, an employee unlocked this door, and it was used by several egressing occupants; • Four additional doors separated patron areas from an entrance lobby. All of these doors swung in the direction of egress travel, but three of the four were locked at the time of the fire; • The two available exit stairs were not enclosed. The stairway closer to the front exit was a steep “ships ladder” type stair. The primary stair access to the second floor, and the stairway labeled as the main exit, was at the back of the building. This stair had uneven risers, as well as a 90° bend and a width that varied down to 1 9 inches; C-28

• Combustible interior finishes in the lobby area, where the fire was ignited, led to rapid fire growth, thus blocking the only available exits from the building. impact on Regulation or Practices NFPA 101®: Life Safety Code® There do not appear to be any changes to NFPA 101 directly associated with this incident. Boardfor the Coordination ofModel Codes There do not appear to be any recommended changes to the model building code from the BCMC as a result of this event. Uniform Building Code (UBC) Though it is unsure if this incident had any direct impact, the following were changes incorporated into the 1991 edition of the UBC: • Required egress width requirements changed to provide 0.3 inches of stair width and 0.2 inches of door width for each occupant. The 1946 through 1988 editions of the UBC specified required exit width as the number of occupants divided by 50. However, in the 1943 version of the UBC required 0.24 inches per person for occupancies with 1 to 1000 occupants, which is greater than the width required in 1991; • A fire alarm / notification system was now required for assembly spaces with and occupant load greater than 300. BOCA Building Code (BOCA) The 1 993 edition of the BOCA code incorporated changes in the requirements for sprinkler and standpipe system, but it is unclear if there changes were related to this incident. Standard Building Code (SBC) There do not appear to be any changes to the SBC directly related to this incident. C.3.17 Indianapolis Athletic Club Fire, Indianapolis, Indiana, 1992 On February 5, 1992 a fire occurred at the Indianapolis Athletic Club that killed two fire fighters and one patron [22]. At 12:06am the Indianapolis Fire Department received a phone call reporting the fire. Upon their arrival, they could find no external evidence of fire in the high-rise building, but once inside they found heavy smoke in the first floor lobby. Investigating further, they discovered a room on the third floor that was fully involved in fire. During suppression operations on the third floor, a flashover occurred in the room adjacent to the room of fire origin. The sudden increase in the magnitude of the fire caused it to spread to other areas and resulted in the death of two fire fighters. Several other fire fighters were injured. A search of the building revealed that one patron died in the fire between the sixth and seventh floors. The fire department determined that the fire was accidental and caused by an electrical fault involving a refrigerator caused the ignition of wood paneling in a third-story bar. It was further detennined that the release of combustion gases which were trapped in a concealed space contributed to the flashover that killed and injured the fire fighters. After the flashover, the fire spread to other areas of the third floor and it also spread to the fourth floor via an open stairway. The HVAC systems also continued operation until electrical power was lost and contributed to the spread of smoke throughout the building. C-29

The following details regarding this incident are of note: • The lack of an approved automatic sprinkler contributed to the spread of the fire; • Unprotected penetrations in the wall and ceiling assemblies aided the fire spread; • Concealed spaces increased the hazard for fire suppression personnel; • Combustible interior finish which included wood paneling on walls and ceiling tiles left in concealed spaces after a building renovation also contributed to the magnitude of the fire. Impact on Regulation and Practices NFPA 101®: Building Exits Code® There do not appear to be any changes to NFPA 101 directly related to this incident. Boardfor the Coordination ofModel Codes (BCMC) There do not be any recommended changes from the BCMC directly relating to this event. Uniform Building Code (UBC) There do not appear to be any changes to the UBC directly related to this incident. BOCA Building Code (BOCA) Changes to the automatic sprinkler requirements appeared in the 1 993 BOCA code. Sprinkler system were now required as follows: • In A- 1 (theaters), A-3 (amusement / entertainment spaces), and A-4 (churches / schools) where the fire area exceeds 12,000 ff ; • In A-2 (dance halls / clubs) where the fire area exceeds 5,000 (C or is located above or below the level of exit discharge. It is uncertain if these changes are directly related to this incident. Standard Building Code (SBC) There do not appear to be any changes to the SBC directly related to this incident. C.3.18 E2 Nightclub, Chicago, Illinois, 2003 In the early morning hours of February 17^'’, 2003 21 people were killed and 57 people were injured when a stampede occurred at the E2 nightclub in Chicago [23]. A fight had broken out on the dance floor between two women and escalated to include a larger group. Security guards sprayed pepper spray into the crowd triggering a stampede toward the front exit. The nightclub is located on the second floor of the building, so the front exit was a set of stairs leading down to the main exit door. The surge toward the main exit stairway resulted in the deaths of 12 women and 9 men. Most of the deaths occurred at the top of the stairs. The nightclub was on the second floor of a building. There was a restaurant on the first floor of the building that housed the nightclub that was not open at the time of the incident. The club had been ordered closed due to fire and structural building code violations months before the incident. However, the Chicago Fire Department estimated that 500 people were in the building that night. The following details regarding the incident are of note: C-30

• The club should have been closed due to numerous building code violations; • Alternate exits were not easily assessable to the patrons [24]; • A consultant hired by the lawyers representing some of the victims and their families found 20 code violations including that the two rear exit signs were not lighted and based on the width of the exit doors the second floor of the building could safely handle 240 to 300 people, which would mean that the club was overcrowded since the FD estimated there to be 500 occupants at the time [25]; • Although the violations involving the back exit doors did not contribute to the deaths, one of the back doors was locked and another was partially blocked by laundry bags. Impact on Regulation or Practices Because The Station fire occurred within 6 days of the E2 incident, the impact of E2 on egress codes is difficult to distinguish from the impact resulting from The Station. Within 5 months of the two tragedies, NFPA issued Tentative Interim Amendments (TIAs) to require trained crowd managers for existing and new assembly occupancies, to restrict festival seating in new and existing facilities if occupant load is greater than 250 unless a life-safety evaluation is conducted, and to require of the owner an means of egress inspection and record keeping. C.3.19 Summerland Fire, Isle of Man, United Kingdom, 1973 On August 2, 1973 a fire broke out in a kiosk outside the Summerland entertainment complex on the Isle of Man and killed 51 people [26]. It is believed that adolescents smoking in the kiosk started the fire. The burning kiosk fell against the adjacent building and ignited the outside of the building. The building was clad with combustible transparent acrylic sheeting called Oroglaso. When ignited, the material became molten and dripped on the people trying to escape. In addition to the combustible exterior, there was a flammable material used to line the inner walls for soundproofing purposes. These materials caused the fire to spread rapidly. Upon hearing of the fire, people began to leave, but an employees told the crowd that it was just a chip- pan fire and that there was no need to worry. Some of the people returned to their seats. It took the staff twenty-five minutes to contact the fire brigade. Later the fire burst into the building and the evacuation of the building became pandemonium. Emergency doors had been padlocked and there were turnstiles that could not handle the amount of people evacuating. The following details regarding this incident are of note: • It took twenty-five minutes for the staff to notify the fire brigade; • Combustible exterior sheeting as well as combustible interior finishes aided fire spread; • Emergency doors had been padlocked; • There were turnstiles that could not handle the size of the crowd. Impact on Regulation or Practices The aftermath of Summerland fire led to the tightening of fire regulations on public buildings across the Isle of Man and the United Kingdom. C.3.20 Stardust Cabaret, Dublin, Ireland, 1981 C-31

In the early morning hours of February 14'^, 1981, a fire spread through the Stardust Cabaret in Dublin, killing 48 young people and seriously injuring 128 [27]. It was originally intended that the building be used for cabarets and concerts, but it was subsequently used as a disco. The space consisted of a dancing area, a small stage, and two seating areas. The fire started in the back row of one of the seating areas. The fire spread rapidly from seat to seat in the area of origin and ultimately through the entire area due to the presence of a tier of seats containing quantities of combustible material abutting a wall lined with combustible carpet tiles, the presence of a low ceiling, and the presence of a large area of combustible seating. Although there were eight exits from the ballroom, five of these being principal emergency exits, forty-eight young people died because of the rapid fire spread. The investigation concluded that the fire was set deliberately and that the arsonist aided the fire spread by slashing the seats and igniting them or by lighting newspapers under a seat. There was adequate exit capacity in the Stardust, but the fire spread rapidly, resulting in the large death toll. Combustible seating and interior finishes aided the fire spread. impact on Regulations or Practices The Irish Government established a Tribunal to carry out a full investigation of the fire. The Tribunal made a significant range of recommendations that were examined by the Irish authorities. However, it was not confirmed whether the Stardust fire led to changes in regulation. C.3.21 Dance Hall Fire, Gothenburg, Sweden, 1998 During a Halloween party in 1998 at a second-floor dance hall in Gothenburg, Sweden, an arsonist initiated a fire in one of the two available exit stairways [28]. The fire spread through the stairwell, fuelled by combustible furniture and wall coverings within the stairwell. At the time of the fire, approximately 400 people were in the hall. Based on the size of the hall and the available exit door width, US codes of the time would have limited the occupant load to 3 12 people. The local fire brigade has indicated that, based on the exit door width, they would have limited the occupant load to 150. The dance hall was equipped with two separate exit doors at opposite ends of the space. Each exit door swung in the direction of egress travel. The main entrance/exit door was noncombustible, and was equipped with an automatic closer. The other door was constructed of combustible material, but had a 30-minute rating, and was equipped with an automatic closer. Because the fire was located in this second stairway, it was not used in the evacuation. It is not clear if this door remained open after the discovery of the fire. Both doors had an opening width of 3 1 .2 in. The large number of people in the yard surrounding the building hampered fire department access to the incident. Once inside the main entrance of the two-story building, firefighters discovered numerous victims on the stairway leading to the second floor. These victims were removed, and firefighters continued to the second floor, where the discovered a stack of additional victims in the exit doorway from the main hall. Victims, some alive and others unconscious were apparently stacked right up to the top doorjamb. As firefighters pulled the occupants out, others from inside the hall took their places on the pile. Eventually, the doorway was cleared, and the fire was quickly extinguished. Additional victims were later discovered in a small office where they had attempted to seek refuge when the discovered that the exit was blocked. Smoke had breached this room through failed glass panels near the ceiling. An occupant-use fire hose was available in the main entrance stairwell, but was not used. Its condition prior to the fire was not known. The building was not equipped with an alarm system or sprinklers. C-32

In total, 63 people died in this incident. None were older that 20 years. 43 of the victims were found piled up at the exit doorway. Another 20 victims were found in a small office. An additional 180 people were injured in the incident. The following details regarding this incident are of note: • Fire growth and spread was somewhat rapid due to the fuel loads within the stairwell where the fire was initiated and in the dance hall itself; • The hall was severely overcrowded, and even though two remote exits were provided, the sheer number of evacuating occupants caused a bottleneck in the one available exit door. It has been theorized that the exit capacity would have been sufficient had the occupant load restrictions been enforced; • The building was not equipped with a fire alarm or an automatic sprinkler system; • The occupant (the disc jockey) who first discovered the fire apparently immediately jumped out of a window, and did not notify the other occupants of the fire. It is unclear how much of a delay occurred between initial discovery of the fire and the commencement of a general evacuation; • Numerous people jumped from the high windows, 20 ft above the ground level. These windows were over 7 ft above the floor level in the dance hall, and were not viable exits; • Fire brigade arrival at the scene and access to the building were hampered by the crowds of people in the yard surrounding the building. Additionally, there were reports of assaults on firefighters, both in and out of the building, as they attempted to rescue occupants. Impact on Regulation or Practices There was some discussion after the investigation of the fire in relation to code requirements for public halls and auditoria. For example, it was questioned whether multiple "normal" exit door widths (0.8 m.) might be better than fewer wider exits (>1.2 m.) and whether the requirements for the floor surface hazard properties should be made more strict. Note that these discussions were related to public halls and auditoria. The "dance hall" in Gothenburg was not designed for this purpose and would hence not technically have been affected by such changes. C.3.22 De Hemel Fire, Volendam, The Netherlands, 2000/2001 A fire occurred during a New Year's eve celebration in a 125 m“ (1346 ft") cafe on the top floor of a three story building in The Netherlands [46]. Of the approximately 300 people present, fourteen died, primarily from smoke inhalation, and 200 were injured when the fire spread very rapidly through fir branches attached as holiday decorations to the ceiling of the cafe. Ignition of the branches occurred immediately when a sparkler held above the head of one of the patrons accidentally came in contact with the decorations. The fire quickly overpowered any attempts to extinguish it. There were two exits available from the cafe, but they were not obviously marked, and in any case, because the fire spread so rapidly, the exit doorways became blocked by those trying to escape. Two recommendations were made by TNO [46] as a result of their investigation into the fire: • to provide an organization that can learn from the mistakes already made (nationally and internationally) C-33

• to increase awareness of the dangers of using flammable materials and the need for suffieient escape routes C.4 DETAILS OF SUCCESSFUL INCIDENTS C.4.1 School Fire, California, 1992 A grease fire ignited on a stove in the home economics classroom of a single story 4,800 square-foot school building of unprotected ordinary construetion [30]. There was a delay in the activation of the alarm system because of a nonfunctioning smoke detector and failure of sehool personnel to use manual alarms. The students and staff were able to safely evacuate but the fire impinged on the room’s ceiling. Personnel saw smoke coming from the classroom and investigated but failed to initiate the alarm system. Building personnel attempted to extinguish the fire with portable extinguishers but the fire re-ignited. The fire department arrived and the building was still oceupied by approximately 1,000 students and staff. The fire department ordered the evacuation by the manual fire alarm system and extinguished the fire. The damage to the building was estimated to be $2,500 and there were no injuries because there were a limited number of students in the involved section. The following details regarding this ineident are of note: the smoke deteetion failed and there was a delayed evacuation of the building, but there were no injuries because of the limited number of occupants in the area of the fire. C.4.2 Nightclub Fire, Texas, 1992 At about 12:30 am on a weekend evening, a short cireuit oecurred in suspended sound equipment on the seeond floor of a crowded two-story nightclub occupied by hundreds of patrons [31]. The building was 10,000 square foot building of unprotected, noncombustible construction that was located in a mall and housed a two-story nightclub. The automatic sprinkler system operated immediately and quickly extinguished the fire, but smoke and water forced an evacuation of the building. The fire department arrived and found that four sprinklers had operated and extinguished the fire. Damage was limited to the electrical equipment and was estimated to be $150,000. Several of the occupants were treated for minor smoke inhalation but none were transported to a hospital. The following details regarding this incident are of note: four sprinklers quickly extinguished the fire and allowed for occupants to safely escape. C.4.3 School Fire, Oregon, 1992 An 1 1 -year-old child set a fire in a eloset of an unoccupied classroom. The fire quickly spread to the attic space of the building [32]. There were 450 students present when the fire occurred. It was discovered by a passerby and a teacher almost simultaneously. The teacher activated the manual evacuation alarm that alerted students and staff to evaeuate the building. The building was constructed in several stages during the 1940’s with a total of 37,500 square feet and consisted primarily of wood-frame components. The building was designed so that it circled an interior courtyard on three sides. In 1975, a partial sprinkler system was installed that covered common hallways and areas above classroom doors but there were no other suppression systems installed in the building. Damage to the building was limited to the attie area and to classrooms below seetions where the roof and eeiling collapsed. There were no injuries to students and staff during the evacuation. C-34

The following details regarding this incident are of note: the fire was started in a closet and quickly burned into the attic; the ceiling assembly provided protection to occupants as they escaped. C.4.4 School Fire, Massachusetts, 1992 Fireworks ignited a fire on the roof of a regional high school after an outside assembly for graduating students had begun [33]. A school official climbed to the roof and discovered an intense fire that involved the roof covering. An attempt was made using portable extinguishers before the fire department was notified, which delayed the response. The fire department limited and prevented the fire from spreading to the interior, which was confined to the tar and rubber covering of the built-up roof of brick, block, concrete and steel building. There were no injuries that resulted from the incident or the evacuation of the occupied school. The following details regarding this incident are of note: an exterior fire on the roof required the evacuation of the school; the building materials prevented the fire from spreading to the interior of the building. C.4.5 School Fire, Oregon, 1994 A fire occurred in a two-story middle school that was constructed of unprotected wood framing and a brick veneer on the exterior [34]. The school’s automatic smoke detection system alerted students and faculty of an electrical fire that started in the ceiling and roof voids. The building was not equipped with a sprinkler system but the detection system was connected to an automatic dialer, which notified the fire department. The fire department found the blaze in concealed wall voids and in the attic where it was spreading laterally over the classrooms. Firefighters made a trench cut, which helped stop the spread of fire. The fire was confined to one wing of the building and limited damage to classrooms, offices, lockers, and a bathroom. An investigation determined that an electrical conduit in the wall void that was placed directly against wood shiplap siding had heated the siding over a period of time. It eventually ignited at a spot level within the ceiling. There were no injuries. The following details regarding this incident are of note: fire occurred in a concealed space but a smoke detection system notified the occupants of the hidden danger. C.4.6 Restaurant Fire, Indiana, 1996 A grill fire damaged a restaurant when the flames spread to the ductwork and then to the concealed attic space [35]. The fire occurred in a single story 3,200 square foot facility that was constructed of unprotected, wood-frame construction. The building did contain a localized dry chemical system that was installed in the hood over the grill. The cook dropped a plastic container filled with an oil-based marinade on to the hot grill. The plastic container melted and the marinade ignited, which caused flames to flare up toward the hood and ductwork. The fire spread to the concealed attic space before the suppression system could be activated. An employee immediately called the fire department, which arrived to find flames extending from the roof ducts. Firefighters surrounded the building and prevented spread to two adjacent buildings. There were no injuries during the fire. The following details regarding this incident are of note: an accidental fire occurred on the grill and spread to the attic space in an unprotected building that did not injure any occupants. C-35

CAT Dinner Theater Fire, Florida, 1996 A fire occurred in a two-story, 20,000 square-foot building that was constructed of concrete walls and floors with unprotected steel roof with metal deck and built up roof covering [36]. The building contained a wet-pipe sprinkler system throughout, which was monitored by a central station alarm company. During a performance, someone fired a pyrotechnic device that ignited a burlap net attached to a curtain. The net ignited and smoke began to fill the auditorium that contained 400 children and teachers. Four sprinkler heads were activated that extinguished the fire. Almost simultaneously, an occupant and the alarm company notified the fire department that arrived to find the safe evacuation of the children and teachers. A majority of the loss of the contents was due to water damage to electronic equipment. There were no injuries to the occupants of the facility. The following details regarding this incident are of note: a pyrotechnic device ignited materials on the stage that was controlled by sprinklers. The 400 children and teachers were able to safely evacuate the auditorium without injury. C.4.8 Restaurant Fire, Michigan, 1996 A fire occurred in a single story 3,000 square-foot, single-story restaurant that was constructed of wood framed walls and a wood truss roof deck [37]. The building had no detection system or sprinklers but there were portable extinguishers installed in the building. An employee in the storage/break room area was waiting for her shift to start and noticed flames coming from the top of a cooler/freezer. She alerted other staff members, notified the fire department and evacuated patrons. An unsuccessful attempt was made by another employee to extinguish the fire using a portable extinguisher. The fire department arrived to find heavy smoke coming from the restaurant. The fire had spread to the concealed ceiling spaces and the wood trusses. Investigators believe the controls located at the top of the cooler/freezer malfunetioned, starting the fire. The restaurant was destroyed, but there were no injuries during the blaze. The following details regarding this incident are of note: a malfunctioning cooler/freezer sparked a fire that destroyed the restaurant that was discovered by an employee. There were no injuries during the evacuation, but the building was destroyed. C.4.9 Community Center Fire, Pennsylvania, 1997 An fire of electrical origin broke out between the fourth and fifth floors of a religious community center [38]. The building was five-stories tall and had a footprint of 10,000 square feet that contained a religious community center, a school and a synagogue. The building was constructed with heavy timber with exterior brick walls and a wooden roof deck that contained a built-up roof covering. There were smoke detectors and manual pull stations located throughout the building along with a partial sprinkler system in a second floor day care center. There were nearly 1 00 staff members and students present when an occupant discovered a fire who activated a manual pull station. A central station notified the fire department while the occupants began to evacuate. The fire was confined to the fourth and fifth floors of the auditorium. C-36

An investigation determined that the fire started in a fault in the wiring of a HVAC unit that ignited the structural framing in the concealed void between the fourth floor ceiling and the gymnasium roof Two firefighters and two civilians were injured. The following details regarding this incident are of note: an electrical fault in a community center lead to the injuries of two civilians and two firefighters along with extensive damage to two floors of the structure. C.4.10 Restaurant Fire, Massachusetts, 1997 A fire occurred in a 7,200 square-foot restaurant that was located in a one-and-a-half-story shopping mall located in Massachusetts that was constructed of unprotected noncombustible construction [39]. There were 25 occupants present when a fire in a portable chicken broiler, which was installed after the fire department inspection and was not protected by the chemical suppression system that protected all of the cooking surfaces ignited. All of the occupants safely evacuated the building. The burners ignited a grease buildup in the bottom of the broiler cabinet. The central station that monitors the wet-pipe sprinkler system received an alarm and notified the fire department. On arrival of the fire department they found a sprinkler located above the cabinet had extinguished the blaze. The following details regarding this incident are of note: sprinklers extinguished the fire before arrival of the fire department and occupants were assisted with their evacuation. C.4.11 School Fire, California, 1998 A fire occurred in an unoccupied classroom of an 8,800 square foot, eight-classroom school in California [40]. The fire spread in the attic and concealed spaces between the ceiling and roof of this single story elementary school that consisted of unprotected wood framing with a stucco exterior. The building did not have a fire detection system or sprinklers and the manual fire alarm was out of service when the fire occurred. The fire is believed to have been started by a short circuit or a circuit overload in fixed wiring in the attic. Teachers had reported several electrical malfunctions in the past prior to the fire. The discovery of the fire by a student lead to the notification of the fire department who arrived to find flames coming from the building’s roof and that two of the classrooms were fully involved. The fire spread horizontally because of the lack of fire stops and then burned through the ceiling to the classrooms below igniting the heavy fuel load. There were no injuries to the occupant during the fire. The following details regarding this incident are of note: a lack of a detection system and the unoccupied classroom allowed for the fire to grow within the attic space, but the ceiling assembly protected the occupants. C.4.12 Casino Fire, Nevada, 1998 A fire started from unknown causes on the roof behind the casino’s facade and then spread through the roof and down through the structure of a three-story casino and hotel [41]. The building was constructed with noncombustible construction and had a ground floor area of 30,000 square feet. The building had a complete-coverage heat and smoke detection system but there were no devices located in the area of origin of the fire. Additionally, there was a complete-coverage wet pipe sprinkler system but was not effective because it did not extend to the area of origin of the fire. C-37

The fire spread was too rapid to allow for extinguishment by handheld extinguishers but was limited to the casino by a firewall and doors that connected the hotel and casino. One civilian was injured. The following details regarding this incident are of note: • A fire occurred in the fa9ade and roof area that burned for a significant time in a concealed area before notification of the fire department. • The area of origin did not contain any suppression or detection devices. C.4.13 Restaurant Fire, New Jersey, 1998 A three-story restaurant sustained substantial damage as a result of a fire caused by carelessly discarded smoking materials [41]. The restaurant was built partially over a pier and the fire broke out under the pier. The fire spread up the side of the restaurant to a breezeway, and then moved into the kitchen above a drop ceiling. The restaurant was constructed of protected, wood-frame construction. A full-coverage smoke detection system activated and prompted evacuation. A partial wet-pipe sprinkler system also activated, but it could not control the fire. There was also a partial-preaction system under the pier that activated and prevented the fire from spreading along the underside of the pier. At the time of the fire the restaurant was in full operation and was hosting several parties. There were no injuries to occupants, but two fire fighters were injured. The following details regarding this incident are of note: • The smoke detection system activated and initiated evacuation of the building, so that no occupants were injured. • The partial sprinkler system could not control the fire and the fire spread above the sprinklers. C.4.14 Restaurant Fire, Michigan, 1998 A fire initiated in a broiler exhaust hood and then spread to concealed spaces during the operation of the restaurant [41]. The fire occurred in a two-story, unprotected wood-frame structure that had no fire or smoke detection or suppression system. There was a dry chemical extinguishing system that protected the exhaust hood system. An employee smelled smoke in the kitchen and found a fire in the baffle filters over the operating broiler. After the discovery of the fire the patrons were evacuated and the fire department was notified. Initially, two employees were able to control the fire using portable extinguishers but on the arrival of the fire department there was heavy smoke showing from the vents over the kitchen. The fire spread to the roof/ceiling space and could not be extinguished by the fire department. An investigation found that the fire originated in a broiler exhaust stack. The fire caused the supports to fail, which allowed the connections in the ductwork to fail and the fire to spread to the void and roof There were no injuries to the occupants. The following details regarding this incident are of note: • The fire occurred in a concealed space that protected the occupants but lead to the discovery of a significant fire that was not easily extinguishable. C-38

• There was a delay of the activation of the dry chemical system protecting the exhaust hood system because the blower was drawing heat and flames away from the fusible links in the hood. C.4.15 Theater Fire, Nevada, 1999 A fire broke out in the showroom/theater of a large 17-story hotel and casino [41]. The building was equipped with an automatic sprinkler system and smoke exhaust system. Staff noticed flames spreading up the drapes near the stage. Two employees attempted to pull the drapes to the floor while other staff activated the safety evacuation plan. Firefighters arrived within five minutes to find the evacuation of the theater and the fire that was extinguished by the sprinklers. The smoke exhaust system was used which limited smoke damage. The fire department evaluated five employees for minor smoke inhalation. An investigation of the fire determined that the fire began near a television monitor that was plugged into an electrical receptacle outlet. The components did not show any signs of fault but a similar monitor located on the other side of the stage had decorative drapes, which had a gold metal base that conducted electricity. The plug was not completely inserted into the receptacle and energized the hanging fabric. The following details regarding this incident are of note: sprinklers extinguished the fire while employees activated the safety evacuation plan, which led to the successful evacuation of the theater. C.4.16 Fine Line Music Cafe, Minneapolis, Minnesota, February 13, 2003 On February 17, 2003 the warm-up band was playing its encore when it set off a pyrotechnic display [43]. This started a fire in the ceiling of the club about 7:15 pm with an estimated crowd of 120 present in the building. The employees had just reviewed safety procedures the previous day and were quick and effective during the evacuation process. All of the occupants escaped and the fire was extinguished by the building’s sprinklers within 15 minutes. The Fine Line Music Cafe has a capacity of 720 people and occupies a 100-year-old Consortium Building located at 3 18 f* Avenue North in the warehouse District of Minneapolis, MN. No one was injured in the incident. The following details regarding this incident are of note: • The club had a sprinkler system and staff had reviewed the safety procedures the day before the event. • All of the occupants were outside of the building when the fire department arrived. C.5 REFERENCES FOR APPENDIX C [1] Heary, Monica, Theatre ofDeath, The Daily Telegraph, Sydney, Australia, 26 June 2001. [2] Chicago Public Library, “1903, December 30: Iroquois Theater Fire”. [3] Chertkoff, Jerome M. and Kushigian, Russell FI., Don 7 Panic: The Psychology ofEmergency Egress and Ingress, Praeger Publishers, Westport, CT. [4] McGunagle, Fred, Horror in Collinwood; 1 72 Students Die in City ’s Worst Disaster, Plain Dealer, Cleveland, Ohio, 29 March 1998. C-39

[5] Cote, Ron. Life Safety Code Handbook, Eighth Edition, Supplement 1 (Paul E. Teague, M.A.). National Fire Protection Association, Quincy, MA, 2000. [6] Daily Mining Gazette, “Italian Hall Confession”, March 16, 1982. [7] Callahan, Kevin. “Survivor Remembers Clinic Fire,” Plain Dealer, Cleveland, Ohio, May 13, 1994. [8] McGunagle, Fred. “123 Die in Clinic Disaster; Poison Gas Seeps into System; Explosion Rocks Building,” Plain Dealer, Cleveland, Ohio, 23 August 1998. [9] NFPA Fire Investigation Report, Dance Hall Fire (Rhythm Club), Natchez, Ml, April 23, 1940. As published in: “The Natchez Dance Hall Holocaust.” NFPA Quarterly, 34 #:70-75. 1940. [10] Second International Conference on Fire Research and Engineering. Gaithersburg, Maryland, USA. 3-8 August 1997. [11] Brownlee, Ken. A Date ‘Living in Infamy ’ Fire Years Later; The WinecoffHotel Fire, Atlanta, Dec. 7, 1946 Claims Magazine, December 2002. [12] Morehouse, Macon. “Focus on Winecoff Fire,” The Atlanta Journal and Constitution, Atlanta, Georgia, December 6, 1996. [13] Soto, Lucy. “Memories of Fear and Destruction,” The Atlanta Journal and Constitution, 6 December 1993. [14] NFPA Fire Investigation Report, Night Club Fire (The Upstairs Lounge), New Orleans, LA, June 24, 1973. As published in: “Upstairs Lounge Fire,” A. Elwood Willey, NFPA Journal, 68 #1: 16-

1. 1974.

[15] Lathrop, James K., Discotheque Fire Twenty-Four Dead, National Fire Protection Association, Quincy, MA, 1974. [16] NFPA Fire Investigation Report, Beverly Hills Supper Club Fire, Southgate, KY, May 28, 1977. Includes: “Tragedy in Kentucky,” Robert L. Best, Fire Journal. (1978) 72#1:21, 36-40; “Comparing the Club with the Code.” Fire Journal. (1978) 72# 1:21, 36-40; “Human Behavior in the Beverly Hills Fire,” Joseph A. Swartz, Fire Journal, (1979) 73#3:73-74, 108. [17] Wertheimer, Paul L., “The Who ” Rock Concert Tragedy: When Rock Concert Crowd Management Came ofAge, Engineering for Crowd Safety, 1993. [18] Bouchard, John, NFPA Investigation Report, National Fire Protection Association, Quincy, MA, 1984. [19] International Conference on Fire Research and Engineering. Orlando, Florida, USA. September 10-15, 1995. [20 ] NFPA Alert Bulletin, “Social Club Fire Bronx, New York”. Number 90-2, May 1990. [21] “Arson Suspected as 87 Die in New York Disco Blaze”. The Independent (London). March 26, 1990. [22] Isner, Michael, Fire Investigation Report: Private Club Fire, National Fire Protection Association, Quincy, MA, 1992. C-40

[23] Johnson, Mark, Chicago Club had been told to Close, Milwaukee Journal Sentinel, 18 February 2003. [24] Reed Business Information US Staff, Disasters Offer Lessonsfor Future, Consulting-Specifying Engineer, 1 March 2003. [25] Ciokajlo, Mickey and Deardorff, Julie, Expert Finds E2 Violations, Chicago Tribune, 20 February 2003. [26] Carter, Helen. “Isle of Man’s Forgotten Holiday Horror.” The Guardian, London, August 2, 2003. [27] Pigott, Pierce T. “The Fire at the Stardust, Dublin: The Public Inquiry and its Findings,” Fire Safety Journal, #7, 1984. [28] NFPA Fire Investigation Report, Dance Hall Fire, Gothenburg, Sweden, National Fire Protection Association, Quincy, MA, 1998. [29] Jiang, H. et. al. "The Use of Evacuation Simulation, Fire Simulation and Experimental Fire Data in Forensic Fire Analysis." Pedestrian and Evacuation Dynamics 2003: Proceedings of the 2nd International Conference. Greenwich, Uk. Ed. Galea, E. R. [30] “Firewatch: Students, Staff Evacuate Safely Despite Delay in Alarm.” NFPA Journal. November/December 1992. [31] “Firewatch: Sprinklers Extinguish Fire in Crowded Nightclub.” NFPA Journal. November/December 1992. [32] “Firewatch: 1 1 -Year-Old Ignites $1 Million Fire.” NFPA Journal. March/April 1992. [33] “Firewatch: Student Prank with Pyrotechnic Device Ignites School Roof” NFPA Journal. July/August 1992. [34] “Firewatch: Detectors Alert Occupants to Fire in School.” NFPA Journal. September/October 1994. [35] “Firewatch: Grill Fire Damages Restaurant.” NFPA Journal. September/October 1996. [36] “Firewatch: Sprinklers Extinguish Fire in Occupied Dinner Theater.” NFPA Journal. March/April 1996. [37] “Firewatch: Fire Destroys Restaurant, Patrons Evacuate Safely.” NFPA Journal. May/June 1996. [38] “Firewatch: Electrical Fire Damages Community Center.” NFPA Journal. September/October 1997. [39] “Firewatch: Sprinkler Controls Grease Fire.” NFPA Journal. July/August 1997. [40] “Firewatch: Fire in Concealed Space Damages Occupied School.” NFPA Journal. January/February 1998. [41] “1998 Large Loss Fires and Explosions.” NFPA Journal. November/December 1999. [42] “Firewatch: Drapes Ignite in Theater.” NFPA Journal. May/June 1999. [43] Chanen, David. Warm-up act sets Fine Line afire; No one hurt; club has heavy water damage. Star Tribune. Minneapolis, C-41

[44] Emmons, Howard. ‘Analysis OfA Tragedy’. Harvard University, Cambridge, Ma. Fire Technology, Vol 19, No. 2, 115-124, May 1983. [45] "Evaluation of Eimitations to Egress through Doorways in Emergency Situations," vol. 1, Ove Amp & Partners Massachusetts Inc., Job number 32979, Westborough MA, Febmary 18, 2004. [46] Lostetter, S.M.O., and Reijman, P.B., "Reconstmction of the Fire in 'de Hemel' in Volendam, New Years Eve 2000/2001," Interflam 20 C-42

Appendix D. Small Scale Laboratory Tests D.1 INTRODUCTION Computational fire models incorporate specific material properties in order to calculate fire development and growth for a given fire incident. These material properties, such as thermal conductivity, heat capacity, density, flame spread, and heat of combustion, are utilized by the model to predict if and when a component will ignite and how much energy or heat will be released as the component bums. The ignition and subsequent release of energy cause the fire to grow and spread throughout a stmcture. The type and composition of the materials that were identified as being present inside the nightclub were characterized generically as polyurethane foam, ceiling tiles, wood paneling, carpet, and an industrial pyrotechnic device. This materials testing conducted by NIST and described in this appendix did not include any materials actually recovered from the nightclub. D.1.1 Previous Research on Combustion of Polyurethane Foam Since the ignitability and flame spread characteristics of polyurethane foam played a critical role in the early fire development, we examined the previous research that had been done involving the combustion of polyurethane foam. Approximately 200 journal publications, reports, and presentations dating back to the 1960s were identified, dealing primarily with rigid polyurethane foam constmction materials, furniture flammability, and the toxicity of combustion products. A smaller number of articles were identified that dealt with reconstmction of actual fires, codes and standards, and miscellaneous topics, including detector response, patents, and computer models. The rigid foam articles typically focused on describing the combustion of rigid polyurethane foam or assemblies of rigid polyurethane foam with interior walls, exterior walls, and roofing panels. None of these provided much insight into the combustion properties of flexible polyurethane foam because rigid polyurethane foam has significantly different mechanical properties, including surface finish and flexibility. The articles that discussed furniture flammability typically described either the transition from smoldering ignition to flaming ignition, or the performance of assembled systems such as a foam cushion covered by cotton or polyester material or complete chairs or mattresses. While the research involving the transition from smoldering to flaming ignition did provide some data on ignition temperatures of polyurethane foam, the transition was typically investigated at low heat flux rates (~ 6 kW/m ) [ 1 ] and the smoldering occurred over a relatively long time period. In the nightclub fire, the transition from impingement by hot metallic particles to flaming foam occurred in less than 10 s and, once flaming ignition had taken place, the flames spread aided by much higher heat fluxes (> 25 kW/m ) Heat release data was typically not included in the early research. Often, burning length or mass loss rate was reported, but one is forced to assume a density and heat of combustion for the foam in order to convert the data to heat release rates. Flame spread data was also difficult to interpret because it typically involved relatively small samples of foam and poorly characterized heat flux and flow rates. While the foam was often described as being polyurethane, additional details were not always included as to the chemical structure, whether the foam was polyether or polyester, or whether or not the shape was convoluted. D-1

Schmitt [2] discussed the thermal degradation of polyurethane (possibly polyester polyurethane) packing foam in flowing helium and flowing air. The ignition temperature reported by Schmitt varied between 320 C and 329 C at an air veloeity of 5 em/s. Schmitt also reported relative amounts of hydrogen cyanide in gases, between 1 x 10"^ (vol %) and 50 x 10'^(vol %) that were eolleeted at 45 min, 75 min, and 100 min into the degradation experiments. The sample location, sample rate, and ventilation/dilution factors were not described in detail. Research on a polyether polyurethane foam with a phosphate-based fire retardant (classified at the time as “self-extinguishing”) was conducted by Roberts [3]. He reported the values of density (40 kg/m^), specific heat (1.1 kJ kg ' K''), and thermal conduetivity (0.000022 kJ m 's 'K''). The foam exhibited twice the density of the foam that had been mounted on the walls of the nightclub. Roberts’ foam pyrolyzed and left a char layer from 20 % to 60 % of initial mass. This was significantly different than the negligible residue that remained after eone ealorimeter tests on the polyether- or polyester- polyurethane foam tested by NIST. Mass loss rates were reported, but the mass loss rates exeluded the mass loss due to blowing agent which could account for up to 15% of the foam mass. Roberts did conelude that the burning rate of polyurethane was more sensitive to incident heat flux than the burning rate of beech wood. The author also concluded that “the observed behavior of polyurethane illustrates the need for assessing its fire resistance by means of tests that submit samples to realistie levels of applied heat flux”. In research on four different flexible polyurethane foams. Stark et al. [4] demonstrated that burning polyurethane ean rapidly inerease upper layer temperatures, deplete the oxygen, and produce signifieant amounts of hydrogen cyanide. In tests that burned between 0.8 kg and 127 kg of polyether polyurethane in a small room (approximately 40 m^). Stark observed upper layer gas temperature of 850 C, oxygen eoneentrations of less than 0.5 %, and hydrogen eyanide volume fractions exceeding 500 x lO '’. These values were recorded between 90 s and 120 s after ignition. However, the research did not include data for ignition temperatures, heat release rate, thermal fluxes, or flame spread. Previous work conducted at NIST (National Bureau of Standards) by Lee [5] used polyurethane foam as part of an investigation into the reproducibility of a Radiant Panel Test, ASTM E 162-67. The density of polyurethane foam was reported as 60 kg/m or about three times greater than the foam that was used in the full-scale mockup bums at NIST. Because the research focused on the reprodueibility of the tests between different testing laboratories, only limited data were included on the flame spread characteristics including flame-spread factor, Fs, and flame-spread index, E. Because it is not clear whether the foam samples were polyether or polyester types and the density was much higher than the foam mounted in the full-scale moekup tests, these data eould not be ineorporated into the current computer simulations. Stone et al. [6] focused on the smoke generation of non-eombustion modified and combustion modified polyether- and polyester-polyurethane foam when the foams were exposed to 10 kW/m*" to 25 kW/m of radiant flux. Unfortunately, the researeh did not include data for ignition temperatures, heat release rate, or flame spread. A series of tests condueted by Jayakody et al.[7] on flexible, molded polyether polyurethane foams, both non-fire retardant and fire retardant examined the impaet of 1 7 different fire retardants on fire characteristies. The non-fire retardant polyether polyurethane foam was ineluded as the baseline or control foam in a series of eone ealorimeter and Bunsen burner tests. The test matrix included a range of fire retardant additives, from antimony oxide to graphite powder, but did not use any fire retardant polyester polyurethane foams. The cone calorimeter data included peak and average heat release rate. D-2

time to ignition, and average carbon monoxide and carbon dioxide yields. One test was reported at 25 kW/m“ heat flux exposure and a second test at 35 kW/m“ (see Table D-5). The literature search identified a significant amount of research that had been conducted on various polyurethane foams, but the need to conduct small-scale tests on the foams similar to what was thought to be in The Station and what was used in the full-scale mock-up of the platform area was apparent as a prerequisite to proper interpretation of the full-scale test and prediction of the fire spread in the actual nightclub. D.1.2 Contribution of Different Fuels The contribution of a specific fuel is dependent on the relative amounts of the fuel and how quickly the fuel becomes involved in the fire. In addition to the polyurethane foam, other materials were present in the building that contributed to the fire spread and heat release. Wood was used in the flooring, wall paneling, and structural members (studs, joists and rafters), and provided the bulk of the energy released. The location of the fuel also impacted when a how rapidly a specific fuel became a contributor to the heat release rate. For instance, wood paneling near the ceiling became involved more quickly than wood flooring. Carpeting was used on the platform and on a portion of the floor, and also contributed to the heat release and fire spread. Small-scale tests were run on wood paneling and on nylon carpet to provide input to the computational model. While the ceiling panels were not thought to contribute significantly to the fire spread, they were subjected to cone calorimeter testing for completeness. D.2 TEST SERIES Five test series were conducted in this investigation: small scale heat release measurements using a cone calorimeter; ignition temperature determination by Southwest Research Institute; real-scale heat release and flame spread measurements of foam covered wall panels; heat flux and temperature measurements of pyrotechnic devices impinging on surfaces; and fire growth measurements in real-scale mockups of the raised platform (or stage), main floor, and alcove. This appendix describes the cone calorimeter and ignition temperature tests. The other test series are described in subsequent appendices: foam covered wall panels (Appendix E), pyrotechnic devices (Appendix F), and real-scale mockup (Appendix G). D.2.1 Cone Calorimeter Test Series Cone calorimeter experiments were conducted on five different materials at five different levels of external heat flux. The tests conducted on the polyether- and polyester-polyurethane foams and the external fluxes that were imposed on the samples are tabulated in Table D- 1 . Similar information for the wood, carpet, and ceiling tiles is located in Table D-2. The data from the cone calorimeter is summarized in tables and is also plotted graphically for each of the 38 cone tests. The test protocol detailed in ASTM E 1354 [8] was used for these experiments. The E- 1354 test method utilizes a cone calorimeter (Figure D-1) to collect data on heat release rate, mass loss rate, optical density of smoke, and gas concentrations in combustion products. The cone calorimeter exposes relatively small samples (10 cm x 10 cm) to a uniform thermal flux. These samples were stored in a controlled humidity (50 % relative humidity) and temperature (23 C) room for at least tu^o weeks prior to testing. Each sample was wrapped in an aluminum foil, except for the exposed side, and positioned in a stainless steel specimen holder (Figure D-2). The thermal flux which is generated via a cone shaped electrical resistance heater was set to the desired test value of 20 kW/m", 35 kW/m*", D-3

Table D-1. Cone Calorimeter Tests for Polyurethane Foams Material Thermal Flux kW/m^ Test ID Manufacturer Polyurethane Foam (Ester) Convoluted / Egg Crate Non-Fire Retardant Gray Color 35 PUF-NFR-A-1 A* 35 PUF-NFR-A-2 35 PUF-NFR-A-3 Polyurethane Foam (Ether) Convoluted / Egg Crate Non-Fire Retardant Gray Color 20 PUF-NFR-B-13 20 PUF-NFR-B-14 20 PUF-NFR-B-15 35 PUF-NFR-B-1 B* 35 PUF-NFR-B-2 35 PUF-NFR-B-3 35 PUF-NFR-B-4 35 PUF-NFR-B-5 35 PUF-NFR-B-6 40 PUF-NFR-B-1 6 40 PUF-NFR-B-1 7 40 PUF-NFR-B-18 60 PUF-NFR-B-1 9 60 PUF-NFR-B-20 60 PUF-NFR-B-2 1 70 PUF-NFR-B-7 70 PUF-NFR-B-8 70 PUF-NFR-B-9 70 PUF-NFR-B-10 70 PUF-NFR-B-1 1 Polyurethane Foam (Ether) Convoluted / Egg Crate Fire Retardant Gray Color 35 PUF-FR-1 C* 35 PUF-FR-2 35 PUF-FR-3

• Distributor purchases foam from a number of different sources based on price and availability. When

foam arrives at warehouse, new stock is intermingled with old stock. Labeling on single pieces of foam identifies type of foam, such as polyurethane (ester), but does not provide information on manufacturer. Distributor unable to identify specific manufacturer of purchased foam. Fire retardant foam was purchased in single lot. Non-fire retardant foam purchased in two lots. Cannot rule out possibility that individual foam within the same purchase came from different sources. D-4

Table D-2. Cone Calorimelter Tests for Wood, Carpet, and Ceiling Tile. Material Thermal Flux kW/m^ Test ID Wood Paneling 5 mm thick Plywood Substrate 35 WP-01 35 WP-02 35 WP-03 70 WP-04 70 WP-05 70 WP-06 Carpet Flooring 100% Filament Olefin Ave. Tufted Face Weight 39 oz. Polyester short nap 0.25” thick Beige color 35 CF-01 35 CF-02 35 CF-03 70 CF-04 70 CF-05 70 CF-06 Ceiling Tile - 942 B Textured 610 mm X 1219 mm x 16 mm (24 in X 48 in X 0.6250 in) 35 CT-01 35 CT-02 35 CT-03 70 CT-04 70 CT-05 70 CT-06 40 kW/m , 60 kW/m", or 70 kW/m', and verified using a heat flux meter. The sample in the specimen holder was then positioned horizontally on the load cell and exposed to the thermal flux. An electric spark was used to ignite the combustible gases near the surface of the sample. A sample of polyurethane foam that was ignited under the cone is shown in Figure D-3. The smoke and combustion products were drawn through the center of the cone heater and into the instrumented exhaust duct. The load cell tracked mass loss rate throughout each bum. The small amount of residue left in the aluminum tray afterthe cone tests of three polyurethane foam samples is shown in Figure D-4. Additional instmments allowed the optical density of the smoke and gas concentrations to be monitored continuously. The distance between the top surface of the sample and the cone housing was 25 mm. The energy release per mass of oxygen depleted was assumed to be a constant 13.1 MJ/kg. While the cone calorimeter can provide heat release rate as a function of thermal flux, the impact of ventilation, comer geometries, and composite assemblies are difficult to characterize. A test plus two replicates of each sample (total of three tests) were conducted with the cone calorimeter providing an external heat flux of 20 kW/m^, 35 kW/m“, 40 kW/m^, 60 kW/m“, or 70 kW/m“. The lower thermal fluxes represent a radiation exposure the materials might experience early in the fire development. The higher thermal fluxes simulate conditions that the material might encounter near the peak heat release rate in the fire. D-5

Figure D-1. Cone Calorimeter - Test Chamber (right side), computer display (center), and gas analyzers (left side). Figure D-2. Sample of Polyurethane Foam Placed in Aluminum Foil Tray on Top of Horizontal Sample Holder. D-6

Figure D-3. Test Specimen - Exposed to thermai fiux from cone shaped heater, combustion products drawn through center of cone, sampie positioned on ioad ceii. NIST photo 1 Figure D-4. Burn Residue of Poiyurethane Foam after Cone Caiorimeter Test. D-7

The data that were collected during the cone calorimeter tests are summarized in tables in Section D.2.8 of this appendix. The data tables provide the time to sustained ignition, peak heat release rate, time to peak heat release rate, total heat release, 60 s average heat release rate, total mass loss, average mass loss rate, average effective heat of combustion, average smoke yield, average carbon dioxide yield, average carbon monoxide yield, time to ignition, time to flameout, and a number of specimen properties. D.2.2 Polyurethane Plastics and Flammability Ratings Polyurethane refers to a large category of materials including surface coatings, elastomers, and foams, rigid or flexible, and thermoplastic or thermosetting. While large quantities of polyurethanes are used to manufacture adhesives and protective coatings, the foam type of polyurethane is widely used in the production of upholstered furniture, bedding, sponges, toys, wearing apparel, and medical dressings. Rigid urethane foams are used for insulation in building constructions. Flexible polyurethane foams are used in packaging materials and acoustical insulation panels. The urethane linkage, which all polyurethanes have in common, involves the reaction of an isocyanate group with a hydroxyl-containing group. A more detailed description of urethane formation chemistry is in Appendix H. Fire retardant additives or compounds can be incorporated into polyurethane foam during the manufacturing procedure or can be applied to the foam in a post-production process. The molecular structure of polyurethane foam can also be adjusted to provide improved fire resistant properties. The polyurethane foam material itself is still a hydrocarbon compound, a long chain carbon based material that can act as a fuel source. Fire performance tests, such as Flammability of Plastic Materials for Parts in Devices and Appliances (Underwriters Laboratories UL 94) have been developed to measure flammability characteristics of plastic materials. However, UL 94 specifically is not intended for foam plastics used in building construction or finish materials. Three of the UL 94 flame classifications relate to low density foam materials; HF-1, HF-2, and HBF. In each test, a small sample is positioned horizontally and exposed to a flame for 60 seconds. After the 60 second flame exposure, the flame is removed and the time required for the flaming to cease (after-flame) and the flaming and glowing to cease (after-glow) are monitored. The distance the flame travels across the sample is also recorded. Foams rated as HBF can sustain a limited flame spread; foams rated as HF-2 must self-extinguish in less than 30 s, but their drips are sufficient to ignite cotton fabric; an HF-1 rating is similar to HF-2, except that any dripping materials do not ignite a cotton fabric placed underneath the foam sample. The fire retardant foam from supplier C was identified by the supplier as being rated HF-1 ; the polyurethane foams from Lots A and B were not rated, and are thus considered non-fire retardant. Fire retardant polyurethane foams may not ignite as quickly as non-fire retardant foams, and they also may have lower peak heat release rates than non-fire retardant foams. The classification of a foam as "fire retardant," however, does not prevent it from igniting and contributing to the fuel load and fire spread once the material is exposed to the high temperatures and high thermal flux conditions of a room fire. Both fire retardant foam and non-fire retardant foam were included in the cone calorimeter tests to help characterize time to ignition and heat release rate for each. D.2.3 Test Results -- Non-fire Retardant Polyurethane Foam Both polyether and polyester formulations of polyurethane can be used as packaging materials. The polyurethane foam which is offered for packaging typically does not include any fire retardant additives or incorporate any fire retardant compounds into the urethane structure. As a packaging material, the D-8

polyurethane foam (ether and ester) is commercially available in a range of sizes including 1.22 m (4 ft) x 2.44 m (8 ft) sheets. The gray colored foam can be obtained in several geometries including solid blocks, uniform thickness sheets, and convoluted or “egg-crate” sheets. In The Station nightclub, polyurethane foam had been installed on the rear wall, raised platform (stage) wall, and in the alcove as a sound attenuation material (see Figure 4-1). Photographs of the nightclub interior do not clearly demonstrate whether staples, nails, organic adhesive or some combination of all three were used to mount the foam on the wall. The polyurethane foam appeared to have been mounted over the top of the previous wall material, which, depending on the location may have been either wood paneling, gypsum board, or rigid polystyrene foam between vertical wood studs. The foam was installed in either full 1 .22 m x 2.44 m sheets or was trimmed to fit the raised platform (stage), alcove, or rear wall geometry. Each 1.22 m X 2.44 m sheet was supplied in a compressed roll, approximately 0.30 m (12 in) in diameter and 0.41 m (16 in) wide. After removing the wrapping, each compressed roll expanded to a 1 .22 m x 2.44 m sheet. While the rear surface of each sheet was flat, the front side was convoluted. These convolutions were a series of peaks and depressions that resembled the surface of a continuous egg crate. There were approximately 36 peaks and 36 depressions per 0.09 m (1 ft ). Peak to peak spacing was approximate 0.05 m (2 in) for all the foam (Figure D-5 and D-6). The thickest dimension of the foam was measured from the tip of a peak to the back surface. The thinnest dimension of the foam was measured from the bottom of a depression to the back surface. There were noticeable differences in thickest and thinnest dimensions between the foam purchased from supplier A and supplier B. Foam from supplier A was measured at 0.04 m (1.5 in) and 0.009 m (0.35 in) at its thickest and thinnest dimensions, respectively (Figure D-5). Foam obtained from supplier B was measured at 0.03 m (1.2 in) and 0.015 m (0.6 in) at its thickest and thinnest dimensions, respectively (Figure D-6). Twenty-three test samples were exposed to thermal fluxes ranging from 20 kW/m to 70 kW/m". The heat release rate for each sample is plotted versus time in Figures D-7 through D-13. The non-fire retardant polyurethane foam samples exposed to an external heat flux of 20 kW/m“ reached peak heat release rates from 440 kW/m" to 460 kW/m in approximately 50 seconds. The average time to sustained ignition was 14 seconds (Table D-3). When exposed to 35 kW/m" of external heat flux, the non-fire retardant polyurethane foam reached its peak heat release rate in approximately 30 seconds. Peak heat release rates for all nine foam samples ranged from 520 kW/m“ to 680 kW/m“ with an average of about 590 kW/m . There did not appear to be a significant difference in the range of peak heat release rates between the two suppliers. The average time to sustained ignition was 6 seconds and average time to peak heat release rate was 30 seconds. Samples of the non-fire retardant foam, PUF-NFR-B, were exposed to external heat fluxes of 40 kW/m“ and 60 kW/m , reaching peak heat release rates in approximately 29 seconds and 24 seconds, respectively. Peak heat release rates for the three 40 kW/m foam samples ranged from 700 kW/m" to 880 kW/m^ with an average of about 820 kW/m^. The three 60 kW/m^ exposures produced peak heat release rates ranging from 1000 kW/m“ to 1300 kW/m' with an average of about 1150 kW/m“. The average time to sustained ignition was 4 seconds and 3 seconds for the 40 kW/m*" and 60 kW/m" exposures, respectively. When exposed to70 kW/m“ of external heat flux, the non-fire retardant polyurethane foam reached its peak heat release rate in approximately 20 seconds. Peak heat release rates for all five foam samples ranged from 810 kW/m“ to 1094 kW/m“ with an average of 970 kW/m“ At the higher flux it required an average 3 seconds to reach sustained ignition and an average of 21 seconds to reach the peak heat release rate. D-9

PUF-NFR-A Non Fire Retardant 0.10 m (3.9 in) 0.03 m (1.2 in) 0.015 m (0.6 in) Figure D-5. Photograph and Dimensioned Diagram of Non Fire Retardant Foam Lot A (PUF-NFR-A). Figure D-6. Photograph and Dimensioned Diagram of Non Fire Retardant Foam Lot B (PUF-NFR-B). D-IO

0 20 40 60 80 100 120 Time (s) Figure D-7. Heat Release Rate versus Time for Polyurethane Foam Exposed to 35 kW/m^ of External Heat Flux. Samples PUF-NFR-A-01, PUF-NFR-A-02, and PUF-NFR-A-03. Figure D-8. Heat Release Rate versus Time for Polyurethane Foam Exposed to 20 kW/m^ of External Heat Flux (PUF-NFR-B). Samples PUF-NFR-B-13, PUF-NFR-B-14, and PUF- NFR-B-15. D-ll

Figure D-9. Heat Release Rate versus Time for Polyurethane Foam Exposed to 35 kW/m^ of External Heat Flux (PUF-NFR-B). Samples PUF-NFR-B-01, PUF-NFR-B-02, and PUF- NFR-B-03. Figure D-10. Heat Release Rate versus Time for Polyurethane Foam Exposed to 35 kW/m^ of External Heat Flux (PUF-NFR-B). Samples PUF-NFR-B-04, PUF-NFR-B-05, and PUF-NFR-B-06. D-12

Time (s) Figure D-11. Heat Release Rate versus Time for Polyurethane Foam Exposed to 40 kW/m^ of External Heat Flux (PUF-NFR-B). Samples PUF-NFR-B-16, PUF-NFR-B-17, and PUF-NFR-B-18. 0 10 20 30 40 50 60 70 80 Time (s) Figure D-12. Heat Release Rate versus Time for Polyurethane Foam Exposed to 60 kW/m^ of External Heat Flux (PUF-NFR-B). Samples PUF-NFR-B-19, PUF-NFR-B-20, and PUF-NFR-B-21. D-13

Figure D-13. Heat Release Rate versus Time for Polyurethane Foam Exposed to 70 kW/m^ of External Heat Flux (PUF-NFR-B). Samples PUF-NFR-B-07, PUF-NFR-B-08, PUF- NFR-B-09, PUF-NFR-B-10, and PUF-NFR-B-11. D.2.4 Test Results -- Fire Retardant Polyurethane Foam Polyether polyurethane foam which is intended for packaging applications typically does not have additional fire retardant qualities, either through additives included in the manufacturing process or post- production treatments. It is still useful to characterize the perfomiance of fire retardant foam in order to understand how the fire growth and spread differ from the non-fire retardant foam. NIST purchased a number of 1 .22 m (4 ft) x 2.44 m (8 ft) sheets of fire retardant polyester polyurethane foam from a commercial supplier. Unfortunately, the distributor was not able to identify the manufacturer of the foam. As with the non-fire retardant foam, the fire retardant foam was supplied in compressed rolls, which were allowed to expand to a 1.22 m x 2.44 m sheet. Both the non-fire retardant and fire retardant foams were similar in the size, distribution, and number of peaks and depressions. There were approximately 36 peaks and 36 depressions per 0.09 m“ (1 ft "). The thickest dimension of the foam was measured from the tip of a peak to the back surface. The thinnest dimension of the foam was measured from the bottom of a depression to the back surface. The fire retardant foam more closely resembled the non fire retardant foam obtained in the first lot (B). Fire retardant foam was measured at 0.03 m (1.5 in) and 0.010 m (0.4 in) at its thickest and thinnest dimensions, respectively (Figure D-14). The heat release rate for each sample is plotted versus time in Figure D-15. When exposed to 35 kW/m*" of external heat flux, the fire retardant polyurethane foam reached its peak heat release rate in approximately 36 seconds. Peak heat release rates for all three foam samples ranged from 430 kW/m to 480 kW/m“ with an average of 453 kW/m^. Each of the three fire retardant samples exhibited lower peak heat release rates than for the non-fire retardant foam samples. It required about twice as long for the fire D-14

retardant foam, 13 seconds, to reach sustained ignition as required by the non-fire retardant foam (Table D-3). The time to peak heat release was longer for the fire retardant foam, increasing by about 20 %. PUF-FR Fire Retardant NIST nhoto 0.10 m (3.9 in) 0.03 m (1.2 in) 0.01 m (0.4 in) Figure D-14. Photograph and Dimensioned Diagram of Fire Retardant Foam (PUF-FR). 0 20 40 60 80 100 120 Time (s) Figure D-15. Heat Release Rate versus Time for Fire Retarded Polyurethane Foam Exposed to 35 kW/m^ of External Heat Flux. Samples PUF-FR-01, PUF-FR-02, and PUF- FR-03. D-15

Table D-3 Time to Sustained Ignition, Time to Peak HRR, and Peak HRR for Polyurethane Foam Tested at National Institute of Standards and Technology. ID External Thermal Flux kW/m^ Time to Sustained Ignition, Seconds Time to Peak Heat Release, Seconds Peak Heat Release Rate kW/m^ PUF-FR-l 35 11 35 452 PUF-FR-2 35 11 35 432 PUF-FR-3 35 16 37 476 Average 13 36 453 PUF-NFR-A-1 35 9 32 620 PUF-NFR-A-2 35 7 30 676 PUF-NFR-A-3 35 6 28 520 Average 7 30 605 PUF-NFR-B-13 20 8 41 457 PUF-NFR-B-14 20 12 44 437 PUF-NFR-B-15 20 22 50 456 Average 14 45 450 PUF-NFR-B-1 35 4 26 519 PUF-NFR-B-2 35 5 26 532 PUF-NFR-B-3 35 9 33 541 PUF-NFR-B-4 35 5 32 577 PUF-NFR-B-5 35 5 29 637 PUF-NFR-B-6 35 5 32 644 Average 6 30 586 PUF-NFR-B-1 6 40 4 28 706 PUF-NFR-B-1 7 40 3 30 878 PUF-NFR-B-1 8 40 4 29 877 Average 4 29 820 PUF-NFR-B-1 9 60 4 24 993 PUF-NFR-B-20 60 3 24 1170 PUF-NFR-B-2 1 60 3 23 1299 Average 3 24 1154 PUF-NFR-B-7 70 4 18 806 PUF-NFR-B-8 70 3 20 820 PUF-NFR-B-9 70 3 21 881 PUF-NFR-B-10 70 3 22 1083 PUF-NFR-B-1 1 70 3 20 1094 Average 3 21 970 D-16

D.2.5 ATF Test Results - Polyether Polyurethane Foam from the Nightclub A roll of gray convoluted foam was recovered from the basement of the burnt out nightclub one day after the fire and turned over to the West Warwick Police Department as evidence. The foam did not appear to have been painted or to have been mounted on any surface. Samples from this recovered foam were tested by the Bureau of Alcohol, Tobacco, and Firearms (ATF) in a cone calorimeter at the ATF Fire Laboratory in Maryland. The time to sustained ignition, time to peak heat release rate, and the peak heat release rate for thermal flux exposures of 20 kW/m", 40 kW/m^, and 60 kW/m“ reported by ATF [9] are shown in Table D-4. For the 20 kW/m^ flux exposure the ATF polyether foam required 9 seconds for sustained ignition which is less than the 22 seconds the NIST polyether foam required at 20 kW/m . The time to peak heat release rate was also longer for the NIST foam, 50 seconds, than for the ATF foam, 37 seconds. For the ATF foam, the average peak heat release rate at 20 kW/m , 260 kW/m“, was about half of the peak release rate for the NIST foam. The 40 kW/m heat flux exposure for the ATF foam resulted in a peak heat release rate of 297 kW/m“, less than half that observed for the NIST polyether foam. The time to peak heat release rate was 3 seconds and 29 seconds for the ATF and NIST foams, respectively. The time to sustained ignition was 3 seconds for the ATF tests and 4 seconds for the NIST samples. For the highest rate of external thermal flux tested by ATF, 60 kW/m , the peak heat release rate, 415 kW/m", was about a third of the value of 1154 kW/m" that was reported during the NIST cone calorimeter testing at 60 kW/m“. The time to sustained ignition was 1 second for the ATF polyether samples as compared to 3 seconds for the NIST tests, and the time to peak heat release was 26 seconds and 23 seconds for the ATF and NIST samples, respectively. Table D-4 Time to Sustained Ignition, Time to Peak HRR, and Peak HRR for Polyurethane Foam Tested at ATF [13]. Sample ID External Thermal Flux kW/m^ Time to Sustained Ignition, Seconds Time to Peak Heat Release Rate, Seconds Peak Heat Release Rate kW/m^ 03F00 11-01 20 9 35 257 03F00 11-02 20 8 39 267 03F00 11-03 20 11 37 257 Average 9 37 260 03F00 11-04 40 2 29 301 03F0011-05 40 3 31 291 03F0011-06 40 3 32 298 Average 3 31 297 03F0011-07 60 1 25 453 03F0011-08 60 2 29 415 03F0011-09 60 1 25 377 Average 1 26 415 D-17

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D.2.6 Polyether Polyurethane Foam Tested by Jayakody et al. [ 7] Jayakody et al.[7] conducted cone calorimetry tests on polyether polyurethane foam to examine the impact or effectiveness of different fire retardant chemical additives. The baseline or "control" foam for this set of experiments was a polyether polyurethane foam. For the non-fire retardant foam, the paper only identified one test at 25 kW/m“ and one test at 35 kW/m , so only one value of time to sustained ignition and the peak heat release is reported for each flux exposure in Table D-5. Foams with 17 different additives were exposed to heat fluxes of 25 kW/m" , while samples with 15 different additives were tested at 35 kW/m . Since there were a wide range of additives for the fire retardant foams, 17 tests at 25 kW/m^ and 15 tests at 35 kW/m“ , the values for all the tests were averaged and the range of values and average values were tabulated in Table D-5 . Overall, the limited data for non-fire retardant polyether polyurethane foam collected by Jayakody et al. appear closer to the results of the NIST polyether polyurethane test than to the foam data collected by ATF. (i) Non-Fire Retardant Foam For the 25 kW/m flux exposure the baseline polyether foam (non-fire retardant) required 16 seconds for sustained ignition which is more than the 14 seconds the NIST polyether foam required at 20 kW/m^. For the Jayakody foam (non-fire retardant), the average peak heat release rate at 25 kW/m", 412 kW/m", was slightly less than the peak release rate for the NIST foam, 450 kW/ m". The 35 kW/m^ heat flux exposure for the non-fire retardant foam resulted in a peak heat release rate of rate of 563 kW/m“, about the same as that observed for the NIST polyether foam. (li) Fire Retardant Foam It is important to note that the NIST fire retardant foam was a polyester polyurethane foam while the Jayakody fire retardant foams were a combination of polyether polyurethane and chemical additives. The 25 kW/m“ heat flux exposure for the fire retardant foam resulted in an average peak heat release rate of 9 9 9 337 kW/m" with a range of 234 kW/m to 465 kW/m“. The average time to ignition was 20 seconds with a range of 1 1 seconds to 28 seconds. At the higher heat flux exposure of 35 kW/m", average time to ignition was 9 seconds with a range of 5 seconds to 14 seconds. The fire retardant foam tested by NIST averaged about 13 seconds to ignition, slightly longer than the average of Jayakody foams, but still with the range of values for the Jayakody foams. At the higher heat flux, average peak heat release rate was 501 kW/m", with a wide range of 241 kW/m" to 870 kW/m". The average peak heat release rate for the NIST polyester polyurethane foam was 453 kW/m“, which was lower than the average value of the Jayakody foams, but again still within the range that was exhibited by the Jayakody foams. D.2.7 Test Results - Acoustical Ceiling Tiles A suspended or dropped ceiling had been installed in the nightclub except for in the sunroom, the raised platform (stage) area, and the dance floor areas (refer to Fig. 4-3). Each 0.61 m (2 ft) x 1.22 m (4 ft) x .016 m (0.625 in) panel had been installed or dropped into a metal grid support system. Photographs of the nightclub interior clearly demonstrate that the ceiling tiles had been painted black. It was not clear from the photographs whether the paint had been applied by brush, roller, or spray can. The surface of the tiles had a glittery appearance that may have been a result of the wet paint being dusted with glitter or sparkle dust. Some of the glitter would have become partially embedded in the wet paint and would have D-18

Table D-5 Time to Sustained ignition, Time to Peak Y Polyurethane Foam Tested by Jakakod) iRR, and Peak HRR for f et al. [7] Sample ID External Thermal Flux kW/m^ Range of Times to Sustained Ignition, Seconds Average of Times to Sustained Ignition, Seconds Range of Peak Heat Release Rates, kW/m^ Average of Peak Heat Release Rates kW/m^ Non Fire Retardant Polyether PUF CJ4-8 25

16

- 412 Non Fire Retardant Polyether PUF CJ4-8 35

7

- 563 Fire Retardant Polyether PUF Multiple Additives* 25 11 to 39 20 234 to 465 337 Fire Retardant Polyether PUF Multiple Additives** 35 5 to 14 9 241 to 870 501 * Polyether polyurethane foam with a range of 17 fire retardant chemical additives. Details provided in Jakakody et al. [7] ** Polyether polyurethane foam with a range of 15 fire retardant chemical additives. CEILING TILE

• CT

Figure D-16. Photograph of Acoustical Tile Showing Factory Painted Surface. D-19

provided a more glittery or sparkling appearance that was observed in some of the video of the nightclub interior. Labeling found on a surviving acoustical tile indicated that that the surviving tile was a mineral fiber type of material, a 942 (residential coding) or 755 (commercial coding). Samples of 942B acoustical tiles were purchased from a local supplier for these cone calorimeter tests. The front side of each panel (Figure D-16) exhibited a factory-applied coat of white vinyl-latex paint while the rear side of each panel was unpainted. Samples that measured 0.1 m x 0. 1 m were cut from the larger panels. These samples were then stored in a controlled humidity (50 % relative humidity) and temperature (23 C) room for at least two weeks. Each sample was wrapped in an aluminum foil, except for the exposed side, and positioned in the cone calorimeter. In all tests, the painted side was exposed to the thermal flux. Three test samples were exposed to thermal flux at 35 kW/m‘. Each test was terminated after 3 min of exposure when none of the three samples ignited (Table D-6). An additional three test samples were exposed to thermal flux at 70 kW/m*". The heat release rate for each sample is plotted versus time in Figure D-17. The heat release curves show an initial peak, a period of decline, and then a second peak. The second peak was observed because as the material initially bums, some of the energy released by the combustion process is lost or conducted away into the unbumed portion of the sample. As the test continued, the temperature of the unbumed sample gradually increased with the continual heating from either the external flux or the combustion of the fuel itself. Eventually, the temperature of the material increased to the point where much less energy is lost through conduction. At this point, the energy, which was previously being conducted away, became available to increase the pyrolysis and subsequent burning of the fuel. This increase in the pyrolysis and burning resulted in a second peak in the heat release rate. Sometimes, if a sample contained some components that would ignite at a substantially lower temperature, these components would bum first and other components that had a higher ignition temperature would remain. As the sample temperature continued to increase and eventually reached the ignition temperature of the remaining components, even the higher ignition temperature fuel would begin to bum. This additional burning would have caused an increase in the heat release rate at some time after the initial peak due to the burning of the low temperature components. When exposed to 35 kW/m“ of external heat flux, the ceiling tiles did not ignite. As the thermal flux was increased to70 kW/m“, ignition did occur and the samples reached their peak heat release rate in approximately 20 seconds. Peak heat release rates for all three ceiling tile samples ranged from 55 kW/m^ to 61 kW/m“ with an average of 57 kW/m". D.2.8 Wood Paneling Wood paneling had been installed in the nightclub around the raised platform area, around the sunroom, back bar area, and entry way (Figure 4-4). It is not clear whether or not there were any areas where polyurethane foam had been installed over wood paneling. Interior photographs of the nightclub did not provide sufficient infomiation to identify the specific brand or type of paneling. A veneer type paneling, which utilizes a plywood substrate, was selected as being most representative of the fuel load contributed by the paneling. The wood paneling was purchased from a local retailer in 1 .22m (4 ft) X 2.44 m (8 ft) sheets. The 0.0005 m (0.0125 in) birch veneer was laminated to a 0.005 m (0.25 in) thick three-ply Euan mahogany backer layer. The front side of each panel (Figure D-18) had a glossy coat of finish while the rear side of each panel was unfinished plywood. Samples that measured 0.1 m X 0.1 m were cut from the larger panels. These samples were then stored in a controlled humidity (50 % relative humidity) and temperature (23 C) room for at least two weeks. Then, each sample was D-20

Time (s) Figure D-17. Heat Release Rate versus Time for Ceiling Tile Exposed to 70 kW/m^ of External Heat Flux. Samples are CT-04, CT-05, and CT06. Wood

• WP

Figure D-18. Photograph of Wood Panel Sample Showing Veneer Surface. D-21

wrapped in an aluminum foil, except for the exposed side, and positioned in the cone calorimeter. In all tests, veneer side was exposed to the thermal flux. When exposed to 35 kW/m" of external heat flux, the wood paneling reached its average peak heat release rate, 440 kW/m“ in approximately 130 s (Figure D-19). Peak heat release rates for all three wood samples ranged from 413 kW/m*" to 460 kW/m". At the lower themial flux, each sample required about 40 seconds to achieve sustained ignition. At the higher flux rate of 70 kW/m“, the wood panel samples required much less time, on average 15 seconds, to sustain ignition (Figure D-20). The higher external flux resulted in a higher average peak heat release rate of 530 kW/m", but required substantially less time, 85 seconds, to achieve the peak value. The heat release curves exhibited a two-peak shape, with the second peak much greater than the first peak. Each wood panel sample charred significantly as it burned and the char represented a greater fraction of the total available fuel than that which was burned early in the test. In the higher thermal flux exposure, the additional flux caused more of the fuel to be burned early in the test, so the two peaks were closer in value. Figure D-19. Heat Release Rate versus Time for Wood Paneling Exposed to 35 kW/m^ of External Heat Flux (WP). Samples are WP-01, WP-02, and WP-03. D-22

Figure D-20. Heat Release Rate versus Time for Wood Paneling Exposed to 70 kW/m^ of External Heat Flux (WP). Samples are WP-04, WP-05, and WP-06. D.2.9 Test Results -- Carpet Flooring Carpet flooring had been installed in the nightclub on the elevated section along the rear wall and around the raised platform area. (Figure 4-5). Interior photographs of the nightclub did not provide sufficient information to identify the specific brand or type of carpeting. A closed-loop olefin carpet with a binding layer was selected as representing the fuel load contributed by the carpeting. The carpet was purchased from a local supplier in a 3.2 m (12 ft) wide x 15.7 m (50 ft) long continuous roll. The 0.006 m (0.25 in) nylon pile was embedded in a 0.002 m (0.1 in) thick binding layer. Samples that measured 0.1 m x 0. 1 m were cut from the roll (Figure D-2 1 ). These samples were then stored in a controlled humidity (50 % relative humidity) and temperature (23 C) room for at least two weeks. Then each sample was wrapped in an aluminum foil, except for the exposed side, and positioned in the cone calorimeter. In all tests, the olefin pile side was exposed to the thermal flux. When exposed to 35 kW/m‘ of external heat flux (Figure D-22), the peak heat release rates for the three carpet samples ranged from 474 kW/m" to 718 kW/m". The carpet required about 54 seconds, on average, to achieve sustained ignition, and approximately 1 90 seconds to reach its peak heat release rate (Figure D-22). Three additional test samples were exposed to thermal flux at 70 kW/m“ (Figure D-23) when exposed to the higher external heat flux, the carpeting reached its peak heat release rate in about D-23

half the time. Peak heat release rates for all three-carpet samples ranged from 1290 kW/m to 1450 kW/m*", with an average of 1370 kW/m“. For the lower flux exposure, the heat release curve exhibited a relatively brief step at around 200 kW/m“ and then increased gradually to a single broad peak. As the carpet initially began to bum, some of the energy released was conducted into the olefin pile, but instead of producing a char, the polymer melted and formed a more uniform density fuel. As the burning continued, it increased at a relatively steady rate, reached its peak and decreased at a more rapid rate. At the higher flux exposure, the additional energy from the internal heating caused the melting to occur more rapidly, so the initial step seen at the lower flux was not observed. Carpet

• CF

Figure D-21. Photograph of Carpet Sample Showing Olefin Pile. D-24

Figure D-22. Heat Release Rate versus Time for Carpet Sample Exposed to 35 kW/m^ of External Heat Flux (CF). Samples are CF-01, CF-02, and CF-03. Time (s) Figure D-23. Heat Release Rate versus Time for Carpet Sample Exposed to 70 kW/m^ of External Heat Flux (CF). Samples are CF-04, CF-05, and CF-06. D-25

Table D-6 Cone Calorimeter Results for Ceiling Tile, Wood Panels, & Carpet Sample ID External Thermal Flux, kW/m^ Time to Sustained Ignition, seconds Time to Peak Heat Release Rate, seconds Peak Heat Release Rate kW/m^ CT-01 30 Did not ignite CT-02 30 Did not ignite CT-03 30 Did not ignite CT-04 70 9 21 55 CT-05 70 7 19 56 CT-06 70 8 20 61 Average 8 20 57 WP-01 35 43 126 460 WP-02 35 43 129 439 WP-03 35 37 131 413 Average 41 129 437 WP-04 70 14 84 531 WP-05 70 16 84 543 WP-06 70 14 85 509 Average 15 85 526 CF-01 35 38 221 474 CF-02 35 68 178 718 CF-03 35 40 206 536 Average 54 192 627 CF-04 70 20 79 1378 CF-05 70 19 79 1289 CF-06 70 20 76 1447 Average 20 78 1371 D-26

D.3 SUMMARY TABLES The materials that were tested and the sample identifiers that were used throughout the cone calorimeter test series are listed in Table D-7. The data that were collected is summarized in Tables D-8 through D-

1. The data tables provide the time to sustained ignition, peak heart release rate, time to peak heat

release rate, total heat release, 60 s average heat release rate, total mass loss, average mass loss rate, average effective heat of combustion, average smoke yield, average carbon dioxide yield, average carbon monoxide yield, time to ignition, time to flameout, and a number of specimen properties. Each table groups a specific material that was exposed to a specific external heat flux. Table D-7. Material Identification for Cone Calorimeter Experiments Sample ID Material Fire Retardant/Non- Retardant Description PUF-FR Polyurethane Foam (Ester) Fire Retardant Convoluted / Egg Crate Gray Color PUF-NFR-A Polyurethane Foam (Ether) Non-Fire Retardant Convoluted / Egg Crate Gray Color- Lot A PUF-NFR-B Polyurethane Foam (Ether) Non-Fire Retardant Convoluted / Egg Crate Gray Color- Lot B CT-FR Ceiling Tile Fire Retardant 942 B (Commercial Equivalent 755) Textured WP Wood Paneling Non-Fire Retardant 5 mm thick Plywood Substrate Antique Birch Finish CF Carpet Non-Fire Retardant 100% Filament Olefin Color: Pottery (Beige) D-27

Table D-8. Cone Calorimeter Data for Polyurethane Foam at 35 kW/m^ (PUF-NFR-A). Polyurethane Foam External Heat Flux 35 kW/m^ PUF-NFR- A-01 PUF-NFR- A-2 PUF-NFR- A-3 Average Test Results: Time to Sustained Ignition (s): 9.00 7 6 7.3 Peak Heat Release Rate (kW/m^): 620 676 520 605 Time to Peak Heat Release Rate (s): 32.0 30 28 30.0 Total Heat Release (MJ/m^): 15.6 16.3 15.4 15.8 60 s Average Heat Release Rate (kW/m^): 262 268 248 259 Total Mass Loss (g): 6.25 6.2 5.94 6.13 Average Mass Loss Rate (g/s): 0.174 0.148 0.117 0.146 Average Effective Heat of Combustion (MJ/kg): 24.9 26.4 25.9 25.7 Average Smoke Extinction Area (m^/kg): 206 285 235 242 Average CO 2 yield (g/g): 1.56 1.88 2.03 1.8 Average CO yield (g/g): 0.0136 0.0112 0.0129 0.0126 Specimen: Initial mass (g): 9.3 9.2 9.8 9.4 Thickness (mm): 25 25 25 25.0 Surface area (cm^): 100 100 100 100.0 Test start time (s): 123 89 79 97.0 Time to ignition (s): 9 7 6 7.3 Time to flameout (s): 46 48 55 49.7 D-28

Table D-9. Cone Calorimeter Data for Fire Retardant Polyurethane Foam at 20 kW/m^ (PUF-NFR-B). Polyurethane Foam External Heat Flux 20 kW/m^ PUF-NFR- B-13 PUF-NFR- B-14 PUF-NFR- B-15 Average Test Results: Time to Sustained Ignition (s): 8 12 22 14.0 Peak Heat Release Rate (kW/m^): 457 437 456 450 Time to Peak Heat Release Rate (s): 41 44 50 45.0 Total Heat Release (MJ/m^): 9.87 10.33 10.0 10.1 60 s Average Heat Release Rate (kW/m^): 206 205 192 201 Total Mass Loss (g): 4.55 4.48 4.05 4.4 Average Mass Loss Rate (g/s): 0.114 0.118 0.11 0.114 Average Effective Heat of Combustion (MJ/kg): 21.7 23.0 24.8 23.2 Average Smoke Extinction Area (m^/kg): 323 343 385 350 Average CO2 yield (g/g): 0 0 0 0 Average CO yield (g/g): 0.0103 0.012 0.0135 0.0119 Specimen: Initial mass (g): 6.7 6.7 6.7 6.7 Thickness (mm): 25 25 25 25.0 Surface area (cm^): 100 100 100 100 Test start time (s): 82 92 83 85.7 Time to ignition (s): 8 12 22 14.0 D-29

Table D-10a. Cone Calorimeter Data for Polyurethane Foam at 35 kW/m^ (PUF-NFR-B). Data and Averages are continued in Table D-9b. Polyurethane Foam External Heat Flux 36 kW/m^ Test Results: Time to Sustained Ignition (s): Peak Heat Release Rate (kW/m^): Time to Peak Heat Release Rate (s): Total Heat Release (MJ/m^): 60 s Average Heat Release Rate (kW/m^): Total Mass Loss (g): Average Mass Loss Rate (g/s): Average Effective Heat of Combustion (MJ/kg): Average Smoke Extinction Area (m^/kg): Average CO2 yield (g/g): Average CO yield (g/g): Specimen: Initial mass (g): Thickness (mm): Surface area (cm^): Test start time (s): Time to ignition (s): Time to flameout (s): PUF-NFR- B-01 PUF-NFR- B-02 PUF-NFR- B-03 PUF-NFR B-04 4 5 9 5 519 532 541 577 26 26 33 32 11.0 11.2 11.9 10.7 213 228 203 213 4.47 4.43 4.31 4.27 0.135 0.148 0.13 0.142 24.7 25.4 27.5 25.0 354 345 331 379 0.86 0.87 1.3 0.91 0.0064 0.0071 0.0094 0.0111 9.1 9.3 9.5 9.2 30 30 30 25 100 100 100 100 87 75 74 84 4 5 9 5 37 37 44 36 D-30

Table D-10b. Cone Calorimeter Data for Polyurethane Foam at 35 kW/m^ (PUF-NFR-B). Data and Averages are continued from Table D-9a. PUF-NFR- PUF-NFR- Average (for PUF-NFR-B Polyurethane Foam External Heat Flux 36 kW/m^ B-05 B-06 -01 through -06) Test Results; Time to Sustained Ignition (s): 5 5 5.5 Peak Heat Release Rate (kW/m^): 637 644 575 Time to Peak Heat Release Rate (s): 29 32 29.7 Total Heat Release (MJ/m^): 11.0 10.2 11.0 60 s Average Heat Release Rate (kW/m^): 211 211 213 Total Mass Loss (g): 4.43 4.51 4.4 Average Mass Loss Rate (g/s): 0.148 0.15 0.142 Average Effective Heat of Combustion (MJ/kg): 24.8 22.7 25.0 Average Smoke Extinction Area (m^/kg): 489 326 371 Average CO2 yield (g/g): 0.89 0.69 0.92 Average CO yield (g/g): 0.0103 0.0073 0.0086 Specimen: Initial mass (g): 9 9.2 9.2 Thickness (mm): 25 25 27.5 Surface area (cm^): 100 100 100 Test start time (s): 81 78 79.8 Time to ignition (s): 5 5 5.5 Time to flameout (s): 35 36 37.5 D-31

Table D-11. Cone Calorimeter Data for Fire Retardant Polyurethane Foam at 40 kW/m^ (PUF-NFR-B). PUF-NFR- PUF-NFR- PUF-NFR- Polyurethane Foam External Heat Flux 40 kW/m^ B-16 B-17 B-18 Average Test Results: Time to Sustained Ignition (s): 4 3 4 3.7 Peak Heat Release Rate (kW/m^): 706 878 877 820 Time to Peak Heat Release Rate (s): 28 30 29 29 Total Heat Release (MJ/m^): 10.6 8.87 9.78 9.8 60 s Average Heat Release Rate (kW/m^): 219 239 242 233 Total Mass Loss (g): 4.67 4.64 4.48 4.6 Average Mass Loss Rate (g/s): Average Effective Heat of Combustion 0.156 0.172 0.166 0.165 (MJ/kg): 22.8 19.1 21.8 21.2 Average Smoke Extinction Area (m^/kg); 264 372 320 319 Average CO 2 yield (g/g): 0.04 0 0 0.01 Average CO yield (g/g): 0.0108 0.007 0.0081 0.0086 Specimen: Initial mass (g): 0.7 6.8 6.7 4.7 Thickness (mm): 25 25 25 25 Surface area (cm^): 100 100 100 100 Test start time (s): 81 84 81 82 Time to ignition (s): 4 3 4 3.7 D-32

Table D-12. Cone Calorimeter Data for Fire Retardant Polyurethane Foam at 60 kW/m^ (PUF-NFR-B). PUF-NFR- PUF-NFR- PUF-NFR- Polyurethane Foam External Heat Flux 60 kW/m^ B-19 B-20 B-21 Average Test Results: Time to Sustained Ignition (s): 4 3 3 3.3 Peak Heat Release Rate (kW/m^): 993 1170 1299 1154 Time to Peak Heat Release Rate (s): 24 24 23 24 Total Heat Release (MJ/m^): 11.5 14.5 7.49 11.2 60 s Average Heat Release Rate (kW/m^): 252 268 264 261 Total Mass Loss (g): 4.54 4.43 4.28 4.4 Average Mass Loss Rate (g/s): Average Effective Heat of Combustion 0.189 0.153 0.225 0.189 (MJ/kg): 25.2 32.8 17.5 25.2 Average Smoke Extinction Area (m^/kg): 330 342 319 330 Average CO2 yield (g/g): 0 0.74 0 0.25 Average CO yield (g/g): 0.0118 0.0302 0.0043 0.0154 Specimen: Initial mass (g): 6.8 6.8 6.7 6.8 Thickness (mm): 25 25 25 25 Surface area (cm^): 100 100 100 100 Test start time (s): 85 84 96 88 Time to ignition (s): 4 3 3 3.3 D-33

Table D-13a. Cone Calorimeter Data for Polyurethane Foam at 70 kW/m^ (PUF-NFR-B). Data and Averages are continued in Table D-12b. PUF-NFR-B-07 PUF-NFR-B-08 PUF-NFR-B-09 4 3 3 Polyurethane Foam External Heat Flux 71 kW/m^ Test Results; Time to Sustained Ignition (s): Peak Heat Release Rate (kW/m^): Time to Peak Heat Release Rate (s); Total Heat Release (MJ/m^): 60 s Average Heat Release Rate (kW/m^): Total Mass Loss (g); Average Mass Loss Rate (g/s): Average Effective Heat of Combustion (MJ/kg): Average Smoke Extinction Area (m^/kg): Average CO2 yield (g/g): Average CO yield (g/g): Specimen: Initial mass (g): Thickness (mm): Surface area (cm^): Test start time (s): Time to ignition (s): Time to flameout (s): 806 820 881 18 20 21 11.8 11.1 13.0 248 257 0.84 3.8 4.39 4.35 0.181 0.209 0.181 31.0 25.3 29.8 429 318 395 0.64 0.35 0.67 0.0085 0.003 0.0073 9.2 9.1 9.1 30 30 30 100 100 100 104 78 77 4 3 3 25 25 27 D-34

Table D-13b. Cone Calorimeter Data for Polyurethane Foam at 70 kW/m^ (PUF-NFR-B). Data and Averages are continued in Table D-12a. PUF-NFR-B- Average (PUF- NFR-B -01 to Polyurethane Foam External Heat Flux 71 kW/m^ 10 PUF-NFR-B-11 11) Test Results: Time to Sustained Ignition (s): 3 3 3.2 Peak Heat Release Rate (kW/m^): 1083 1094 937 Time to Peak Heat Release Rate (s): 22 20 20.2 Total Heat Release (MJ/m^): 12.6 11.8 12.0 60 s Average Heat Release Rate (kW/m^): 264 243 203 Total Mass Loss (g): 4.66 4.49 4.3 Average Mass Loss Rate (g/s): 0.194 0.214 0.196 Average Effective Heat of Combustion (MJ/kg): 27.1 26.2 27.9 Average Smoke Extinction Area (m^/kg): 410 366 384 Average CO2 yield (g/g): 0.44 0.35 0.49 Average CO yield (g/g): 0.0076 0.0062 0.0065 Specimen: Initial mass (g): 9.1 9 9.1 Thickness (mm): 25 25 28.0 Surface area (cm^): 100 100 100 Test start time (s): 91 87 87.4 Time to ignition (s): 3 3 3.2 Time to flameout (s): 26 23 25.2 D-35

Table D-14. Cone Calorimeter Data for Fire Retardant Polyurethane Foam at 35 kW/m^ (PUF-FR). Polyurethane Foam External Heat Flux 35 kW/m^ PUF-FR-01 PUF-FR-02 PUF-FR-03 Average Test Results: Time to Sustained Ignition (s): 11.00 11 16 12.7 Peak Heat Release Rate (kW/m^): 452 432 476 453 Time to Peak Heat Release Rate (s): 35.0 35 37 35.7 Total Heat Release (MJ/m^): 8.69 8.5 8.58 8.6 60 s Average Heat Release Rate (kW/m^): 155 150 151 152 Total Mass Loss (g): 5.95 5.86 5.67 5.83 Average Mass Loss Rate (g/s): 0.198 0.178 0.189 0.188 Average Effective Heat of Combustion (MJ/kg): 14.6 14.5 15.13 14.7 Average Smoke Extinction Area (m^/kg): 539 474 542 518 Average CO2 yield (g/g): 0.61 0.65 0.66 0.6 Average CO yield (g/g): 0.0618 0.0625 0.0623 0.0622 Specimen: Initial mass (g): 8.9 8.7 8.7 8.8 Thickness (mm): 25 25 25 25.0 Surface area (cm^): 100 100 100 100 Test start time (s): 78 75 76 76.3 Time to ignition (s): 11 11 16 12.7 Time to flameout (s): 42 46 46 44.7 D-36

Table D-15. Cone Calorimeter Data for Wood Paneling at 35 kW/m^ (WP). Wood Paneling External Heat Flux 35 kW/m^ Test Results: Time to Sustained Ignition (s): Peak Heat Release Rate (kW/m^): Time to Peak Heat Release Rate (s): Total Heat Release (MJ/m^): 60 s Average Heat Release Rate (kW/m^): Total Mass Loss (g): Average Mass Loss Rate (g/s); Average Effective Heat of Combustion (MJ/kg): Average Smoke Extinction Area (m^/kg): Average CO2 yield (g/g): Average CO yield (g/g): Specimen: Initial mass (g): Thickness (mm): Surface area (cm^): Test start time (s): Time to ignition (s): Time to flameout (s): WP-01 WP-02 WP-03 Average 43.0 43 37 41.0 460 439 413 437 126 129 131 129 31.2 30.8 30.9 31.0 207 0.52 206 138.1 20.7 21.2 21.6 21.1 0.187 0.191 0.189 0.189 15.0 14.6 14.3 14.7 94.1 11.27 111.68 72.4 1.48 1.41 1.36 1.42 0.0054 0.0047 0.0043 0.0048 28.8 28.8 29.3 29.0 6 6 6 6.0 100 100 100 100 80 77 84 80.3 43 43 37 41.0 154 155 151 153 D-37

Table D-16. Cone Calorimeter Data for Wood Paneling at 70 kW/m^ (WP). Wood Paneling External Heat Flux 70 kW/m^ Test Results: Time to Sustained Ignition (s): Peak Heat Release Rate (kW/m^): Time to Peak Heat Release Rate (s): Total Heat Release (MJ/m^): 60 s Average Heat Release Rate (kW/m^): Total Mass Loss (g): Average Mass Loss Rate (g/s): Average Effective Heat of Combustion (MJ/kg): Average Smoke Extinction Area (m^/kg): Average CO2 yield (g/g): Average CO yield (g/g): Specimen: Initial mass (g): Thickness (mm): Surface area (cm^): Test start time (s): Time to ignition (s): Time to flameout (s): WP-04 WP-05 WP-06 Average 14.00 16 14 14.7 531 542 509 528 84.0 84 85 84.3 35.4 33.1 34.8 34.4 348 368 353 356 23.2 21.7 22.8 22.6 0.249 0.259 0.254 0.254 15.3 15.2 15.2 15.2 92.8 93.0 95.1 93.6 1.47 1.43 1.43 1.44 0.0056 0.0055 0.0055 0.0055 30 28.6 29.5 29.4 6 6 6 6.0 100 100 100 100 86 83 79 82.7 14 16 14 14.7 105 99 104 103 D-38

Table D-17. Cone Calorimeter Data for Ceiling Tile at 35 kW/m^ (CT). Ceiling Tile External Heat Flux 35 kW/m^ CT-01 CF-02 CT-03 Average Test Results: Time to Sustained Ignition (s): Did not ignite Did not ignite Did not ignite Peak Heat Release Rate (kW/m^): Did not ignite Did not ignite Did not ignite Time to Peak Heat Release Rate (s): Did not ignite Did not ignite Did not ignite Total Heat Release (MJ/m^): Did not ignite Did not ignite Did not ignite 60 s Average Heat Release Rate (kW/m^): Did not ignite Did not ignite Did not ignite Total Mass Loss (g): Did not ignite Did not ignite Did not ignite Average Mass Loss Rate (g/s): Did not ignite Did not ignite Did not ignite Average Effective Heat of Combustion (MJ/kg): Did not ignite Did not ignite Did not ignite Average Smoke Extinction Area (m^/kg): Did not ignite Did not ignite Did not ignite Average CO2 yield (g/g): Did not ignite Did not ignite Did not ignite Average CO yield (g/g): Did not ignite Did not ignite Did not ignite Specimen: Initial mass (g): 33.8 33.5 33.5 33.6 Thickness (mm): 15 15 15 15.0 Surface area (cm^): 100 100 100 100.0 Test start time (s): 83 84 112 93.0 Time to ignition (s): Did not ignite Did not ignite Did not ignite Time to flameout (s); Did not ignite Did not ignite Did not ignite D-39

Table D-18. Cone Calorimeter Data for Ceiling Tile at 70 kW/m^ (CT). Ceiling Tile External Heat Flux 70 kW/m^ Test Results: Time to Sustained Ignition (s); Peak Heat Release Rate (kW/m^): Time to Peak Heat Release Rate (s): Total Heat Release (MJ/m^): 60 s Average Heat Release Rate (kW/m^): Total Mass Loss (g): Average Mass Loss Rate (g/s): Average Effective Heat of Combustion (MJ/kg): Average Smoke Extinction Area (m^/kg); Average CO2 yield (g/g): Average CO yield (g/g): Specimen: Initial mass (g): Thickness (mm): Surface area (cm^): Test start time (s): Time to ignition (s): Time to flameout (s): CT-04 CT-05 CT-06 Average 9.00 7 8 8.0 55.4 56.4 61.0 57.6 21.0 19 20 20.0 7.52 7.15 7.79 7.5 44.3 44.5 45.2 44.7 6.54 6.68 6.76 6.66 0.031 0.036 0.033 0.033 11.5 10.7 11.5 11.2 1.64 0 23.3 8.3 0.00 0 0.0339 0.0113 0.0411 0.0252 0 0.0221 33.8 34.2 34.1 34.0 15 15 15 15.0 100 100 100 100 95 91 105 97.0 9 7 8 8.0 221 194 213 209 D-40

Table D-19. Cone Calorimeter Data for Carpet Flooring at 35 kW/m^ (CF). Carpet Flooring External Heat Flux 35 kW/m^ CF-01 CF-02 CF-03 Average Test Results: Time to Sustained Ignition (s): 38 68 40 48.7 Peak Heat Release Rate (kW/m^): 474 718 536 576 Time to Peak Heat Release Rate (s): 221 178 206 202 Total Heat Release (MJ/m^): 67.6 71.4 71.8 70.3 60 s Average Heat Release Rate (kW/m^): 139 246 111 166 Total Mass Loss (g): 12.2 16.6 18.0 15.6 Average Mass Loss Rate (g/s): 0.052 0.102 0.068 0.074 Average Effective Heat of Combustion (MJ/kg): 55.3 43.1 40.0 46.1 Average Smoke Extinction Area (m^/kg): 1118 792 816 908 Average CO2 yield (g/g): 3.87 3.07 2.86 3.27 Average CO yield (g/g): 0.0584 0.0437 0.0424 0.0482 Specimen: Initial mass (g): 28.7 29.2 30.2 29.4 Thickness (mm): 11 11 11 11.0 Surface area (cm^): 100 100 100 100 Test start time (s): 111 79 84 91.3 Time to ignition (s): 38 68 40 48.7 Time to flameout (s): 272 229 302 267 D-41

Table D-20. Cone Calorimeter Data for Carpet Flooring at 70 kW/m^ (CF). Carpet Flooring External Heat Flux 70 kW/m^ CF-04 CF-05 CF-06 Average Test Results: Time to Sustained Ignition (s): 20.0 19 20 19.7 Peak Heat Release Rate (kW/m^); 1378 1288 1447 1371 Time to Peak Heat Release Rate (s): 79.0 79 76 78.0 Total Heat Release (MJ/m^): 74.6 70.0 73.4 72.6 60 s Average Heat Release Rate (kW/m^): 706 548 677 644 Total Mass Loss (g): 17.0 16.6 20.8 18.2 Average Mass Loss Rate (g/s): 0.172 0.132 0.224 0.176 Average Effective Heat of Combustion (MJ/kg): 43.84 41.94 35.28 40.4 Average Smoke Extinction Area (m^/kg): 842.12 987.34 768.5 866.0 Average CO2 yield (g/g): 3.36 3.13 2.6 3.03 Average CO yield (g/g): 0.0581 0.0531 0.0457 0.0523 Specimen: Initial mass (g): 28.9 29.7 29.4 29.3 Thickness (mm): 11 11 11 11.0 Surface area (cm^): 100 100 100 100 Test start time (s): 91 91 85 89.0 Time to ignition (s): 20 19 20 19.7 Time to flameout (s): 120 147 112 126 D-42

D.4 IGNITION TEMPERATURE TESTS Ignition temperatures for polyurethane plastics were required for simulation of the mockup experiments and then for the simulation of the full nightclub. ASTM D 1929 [3] provides a laboratory determination of the spontaneous ignition temperature (SIT) and flash ignition temperature (FIT) for plastics. Southwest Research Institute (SwRI) was contracted to conduct analyses on PUF-NFR-B samples to determine ignition temperatures. This is the same polyurethane foam that was installed in the full-scale mockup. The results of the SIT tests were used in the computer fire model simulation of the mockup tests. The report from SwRI included in this appendix describes the test protocol as well as the test results for the foam samples. D-43

SOUTHWEST RESEARCH INSTITUTE® 6220 CULEBRA RD. 78238-5166 • P.O DRAWER 2851 0 78228-0510 • SAN ANTONIO. TEXAS, USA • (210)684-5111 • WWW.SWRI.ORG CHEMISTRY AND CHEMICAL ENGINEERING DIVISION DEPARTMENT OF FIRE TECHNOLOGY WWW.FIRE.SWRI.ORG FAX (210) 522-3377 §u IS i j OUAUTV SYSTEM REGISTERED TO i ISO 900^2000 ASTM D 1929 - 96 (Reapproved 2001) Standard Test Method for Determining Ignition Temperature of Plastics Material ID: PUF-NFR-B Final Report SwRI® Project No.: 01.10934.01.602a[l] Consisting of 5 Pages Test Date: October 14, 2004 Report Date: June 9, 2005 Prepared for: National Institute of Standards and Technology Building and Fire Research Laboratory 100 Bureau Drive, MS 8661 Gaithersburg, MD 20899-8661 Prepared by: Karen C. Carpenter Engineer Material Flammability Section Marc Lj. Janssens, Ph.D. Direct Department of Fire Technology HOUSTON, TEXAS (713)977-1377 • WASHINGTON, DC (301) 881-0226 This report is for the information of the client. It may be used in its entirety for the purpose of securing product acceptance from duly CONSTITUTED APPROVAL AUTHORITIES. THIS REPORT SHALL NOT BE REPRODUCED EXCEPT IN FULL, WITHOUT THE WRITTEN APPROVAL OF SWRI NEITHER THIS REPORT NOR THE NAME OF THE INSTITUTE SHAa BE USED IN PUBLICITY OR ADVERTISING. D-44

Introduction ASTM D 1929 covers a laboratory determination of the spontaneous ignition temperature (SIT) and flash ignition temperature (FIT) of plastics using a hot-air furnace. The hot-air ignition furnace consists primarily of an electrical heating unit and specimen holder. The furnace tube is a vertical tube with an inside diameter of 100 ± 5 mm and a length of 230 ± 20 mm, made of ceramic that will withstand at least 750°C. The inner ceramic tube, with an inside diameter of 75 ± 5 mm, a length of 230 ± 20 mm, and a thickness of approximately 3 mm, is placed inside the furnace tube and positioned 20 ± 2 mm above the furnace floor on spaeer blocks. The pilot flame is located immediately above the opening. The test apparatus is shown in Fig. 1 below. ,50 turns No. 16 Nichrome wire, embedtfled in cement Figure 1. Schematic of SwRI’s Hot-Air Furnace. SIT is the minimum temperature at which the self-heating properties of the specimen lead to ignition or ignition oecurs of itself, under specified test conditions, in the absence of any additional flame ignition source. The lowest air temperature at which the specimen bums during a 10-min period is recorded as the spontaneous ignition temperature. FIT is the minimum temperature at which, under specified test conditions, sufficient flammable gases are emitted to ignite momentarily upon application of a small external pilot flame. The lowest air temperature at which a flash is observed during a 10-min period is recorded as the flash ignition temperature. D-45

Sample Identification and Preparation The National Institute of Standards and Testing (NIST), located in Gaithersburg, Maryland, provided a material identified as PUF-NFR-B for testing in accordance with ASTM D 1929. The material was described by the Client as “Polyurethane foam, convoluted, ether non-fire retardanf ’ and was gray in color. Per NIST, the density of the material was 22 kg/m^. The material consisted of peaks and valleys with the peaks measuring 29 mm and the valleys measuring 10 mm. The material was received at SwRl on October 11, 2004. Upon receipt, samples were prepared for testing and conditioned in a controlled environment maintained at 23 ± 2°C (73 ± 5°F) and 50 ± 5% relative humidity for not less than 40 hours prior to testing. Tests were conducted October 14, 2004. Sample preparation was in general accordance with ASTM D 1929. Because the density of the material was less than 100 kg/m , the test samples were prepared according to size instead of the normal 3-g weight. In accordance with ASTM D 1929, each test specimen was cut to 20 x 20 mm. Due to the uneven shape of the material (see Figure 1), the required height of 50 mm could not be achieved by stacking the samples and the 20 x 20-mm samples were left at the 10-29 mm height. Results Table 1 contains the results for the material provided by NIST. Test results are accurate to ± 5°C. A complete set of results and observations are presented at the end of this report. These test results relate only to the behavior of test specimens under the particular conditions of the test. They are not intended to be used, and shall not be used, to assess the potential fire hazards of a material in use. Table 1. Ignition Temperature Data. Material ID SIT FIT PUF-NFR-B 410 °C 370 °C 770 °F 698 °F Figure

1. PUF-NFR-B.

D-46

SOUTHWEST RESEARCH INSTITUTE ASTM D 1929 TEST DATA SHEET

• SPONTANEOUS IGNITION

Client: Operator: Test Date(s): National Institute of Standards and Technology J. Anderson October 14, 2004 Ignition Type: Receipt Date: Date Prepared by SwRI: Spontaneous October 1 1 , 2004 October 14, 2004 Material ID: Description: PUF-NFR-B Polyurethane foam, convoluted, ether, non fire- retardant Color: Original Thickness: Average Sample Mass: Gray 10 mm -29 mm 0.35 g SPONTANEOUS IGNITION TEMPERATURE (°C) : 410

• Information/instructions provided by the Client

RESULTS Test ID Initial Mass (g) Final Mass (g) Mass Loss (g) Initial Temperature (°C) Sample Air Furnace Final Temperature (°C) Sample Air Furnace Ignition 2884-2 0.34 0.07 0.27 347 350 392 345 350 391 No 2884-3 0.35 0.04 0.31 398 400 448 395 402 440 No 2884-4 0.35 0.03 0.32 450 450 494 778 465 494 Yes 2884-5 0.36 0.02 0.34 438 440 483 921 455 483 Yes 2884-6 0.34 0.02 0.32 427 430 469 848 448 470 Yes 2884-7 0.35 0.03 0.32 417 420 461 839 437 462 Yes 2884-8 0.34 0.02 0.32 405 410 450 817 423 449 Yes SPONTANEOUS IGNITION OBSERVATIONS Insertion Time (min:sec) Combustion Time (min:sec) Observed Soot (min:sec) Observed Smoke (min:sec) Observed Foam Observed Melt Observed Bubbling Total Test Time (min:sec) 2884-2 1:20 None None 1:30 None None None 11:20 2884-3 1:10 None None 1:16 None None None 11:10 2884-4 1:11 Flaming at 1:49 1:49 1:13 None None None 1:49 2884-5 1:14 Flaming at 2:00 2:01 1:16 None None None 2:01 2884-6 1:15 Flaming at 1:59 1:17 1:18 None None None 1:59 2884-7 1:10 Flaming at 1:45 1:12 1:14 None None None 1:45 2884-8 1:08 Flaming at 2:09 2:12 1:14 None None None 3:00 Test ID 2884-8 —— Sample T (°C) Air T (°C) " Furnace T (°C) D-47

SOUTHWEST RESEARCH INSTITUTE ASTM D 1929 TEST DATA SHEET

• FLASH IGNITION

Client: National Institute of Standards and Technology Operator: J. Anderson Test Date(s): October 14, 2004 Ignition Type: Receipt Date: Date Prepared by SwRI: Flash October 1 1 , 2004 October 14, 2004 Material ID: PUF-NFR-B Description: Polyurethane foam, convoluted, ether, non fire- retardant Color: Original Thickness: Average Sample Mass: Gray 10 mm -29 mm 0.35 g

• Information/instructions provided by the Client

FLASH IGNITION TEMPERATURE (’’C) : 370 RESULTS Test ID Initial Mass (g) Final Mass (g) Mass Loss (g) Initial Temperature (°C) Sample Air Furnace Final Temperature (°C) Sample Air Furnace Ignition 2884-9 0.35 0.06 0.29 349 350 390 356 353 392 No 2884-10 0.36 0.02 0.34 368 370 417 366 381 417 Yes 2884-1 1 0.34 0.03 0.31 356 360 398 360 362 399 No FLASH IGNITION OBSERVATIONS Insertion Time Combustion Observed Observed Observed Observed Observed Total Test Time Type Soot Smoke Foam Melt Bubbling (min:sec) (min:sec) (min:sec) (min:sec) (min:sec) (min:sec) (min:sec) 2884-9 1:12 None None None None None None 11:12 2884-10 1:18 Flaming at 3:02 None 3:10 None None None 3:30 2884-1 1 1:16 None None None None None None 11:16 Test ID 2884-10 700 , I 600 I 500 0 i ' I ' ' ' ' ' ' I ' ' '

'

‘ I 'I 0.0 2.0 4.0 6.0 8.0 10.0 12.0 Time (min) — Sample T(°C) * -AirT(°C) Furnace T (°C) D-48

D.5 SUMMARY OF SMALL SCALE TESTS The cone calorimeter was used to measure time to ignition and heat release rates for fire retardant and non fire retardant polyurethane foams, wood paneling, carpet flooring, and ceiling tiles. Each of the materials were exposed to a range of different thermal flux rates in order to simulate exposure during early and late stages of fire spread. Some of the data from these tests were incorporated into the computer modeling of the full-scale mockup experiments and the computer simulation of the full nightclub. The ignition temperatures for polyurethane foam were measured by Southwest Research Institute using a standard ASTM 1929 test protocol. This work measured spontaneous and flash ignition temperatures of 410 °C and 370 C, respectively. The flash ignition temperature was incorporated into the computer simulations for both the full-scale mockup and full nightclub. D.6 REFERENCES FOR APPENDIX D [1] Anderson, M.K., Sleight, R.T., and Torero, J.L., Downward Smolder of Polyurethane Foam; Ignition Signatures, Fire Safety Journal, Vol. 35, No. 2, 131-147, 2000. [2] Schmitt, C.R., Thermal Degradation and Toxicity Aspects of Various Polymeric Materials, Oak Ridge Y-12, TN, Atomic Energy Commission, Washington DC, Y-1734, 25 p. June 9, 1971. [3] Roberts, A.F., Polyurethane Foam: Some Studies Relating to Its Behavior in Fires, Fire Tech., Vol.7, No. 3, 189-200, August 1971. [4] Stark, G.W.V., Field, P., and Pitt, A., Hazard From Fires of Small Loads of Flexible Polyurethane Foam, FR Note 1017; Fire Research Station, Borehamwood, England, 29 p. August 1974. [5] Lee, T.G., Reproducibility of the Radiant Panel Test Method (ASTM E 162-67) Using Polyurethane Foam, Neoprene, and Hardboard Specimens, NBSIR 77-1222, National Bureau of Standards, Gaithersburg, MD, p 35, March 1977. [6] Stone, H., Pcolinsky, M., Jr., and Kapes, M, Polyurethane Foam in the NBS Smoke Chamber: Effect of Variation in Conditions and Formulation, Journal of Cellular Plastics, Vol. 23, No.4, 367-382, July/August 1987. [7] Jayakody, C., Myers, D., Sorathia, U., and Nelson, G.L., Fire-Retardant Characteristics of Water- Blown Molded Flexible Polyurethane Foam Materials, Journal of Fire Sciences, Vol. 18, 2000, 430- 455, November/December 2000. [8. ASTM E 1354-04a, Standard Test Methodfor Heat and Visible Smoke Release Ratesfor Materials and Products Using an Oxygen Consumption Calorimeter, ASTM International, West Conshohocken, PA, 2004. [9] Zicherman, J.B., The Fire Incident at “The Station”, Report FCA NO 04-5667, Fire Cause Analysis, 213 W. Cutting Blvd., Richmond, CA 94804, November 10, 2003. [10] ASTM D 1929 - Standard Test Methodfor Determining Ignition Temperatures ofPlastics, ASTM International, West Conshohocken, PA, 2004. D-49

Appendix E. Foam covered Wall Panel Tests E.1 geometry The video taken inside the nightclub demonstrated how quickly the foam ignited and how quickly the fire developed. The cellular structure of the polyurethane foam provides a very low density fuel layer that bums quickly. A series of wall bums were conducted to provide insight into how the geometry impacted the growth and spread of the fire. These data assisted in the design of the mockup experiments and provided guidance for the simulation of the entire nightclub. Ignition of the foam on the wall of the nightclub by the gerbs occurred at the edge of an exterior comer of the dmmmers alcove, as described in Chapter 4. During the first 15 seconds of the fire, flames spread quickly upward and less quickly downward and laterally. To simulate this arrangement, two 0.064 m (0.25 in) thick plywood backer board panels, each 1.22 m (4 ft) x 2.44 m (8 ft), were mounted perpendicular to each other to form an external comer as shown in Figure E-1. The panels were supported on 2 X 4 studs and covered with a full sheet of non-fire retardant polyurethane foam (1.22 m x 2.44 m x 0.025 m) from lot A. The plywood was screwed to the studs and the foam was mounted to the plywood using staples and adhesive. 1 ( m ) Figure E-1. Photograph and Dimensioned Diagram of External Corner A second experiment used the identical 1.22 m (4 ft) x 2.44 m (8 ft) panels (0.025 m thick non-fire retarded lot A polyurethane foam on 0.064 m (0.25 in) thick plywood backer board, supported on 2 x 4 studs), but arranged to simulate an internal comer. (See Figure E-2.) An internal comer leads to faster flame spread than an external comer since in the former arrangement each surface is exposed to radiant heating from the adjacent wall. In both the mock-up and the actual nightclub fire, flame spread was enhanced further by the presence of the hot layer that built up at the ceiling. The comer arrangements examined here were open to the environment at the top (no ceiling); hence, the flame spread did not continue to accelerate. E-1

(4ft) (4ft) Figure E-2. Photograph and Dimensioned Diagram of Internal Corner A propane torch was used to ignite the comer of the foam at 0.61 m (24 in) above the floor. While this was lower than the point of ignition in the nightclub, the purpose of these experiments was not to duplicate the fire growth, but to provide a controlled environment in which flame spread measurements (upward, downward, and lateral) could be accurately determined. The fire was videotaped from two directions, and the radiant heat flux and total heat release rate were measured. Figure E-3 includes a video of the external comer bum and internal comer bum, side by side, with a clock. Figure E-3. Video of External and Internal Corner Burns E-2

E.2 DESCRIPTION OF THE FIRES AND HEAT RELEASE RATES E.2.1 External Corner Configuration Figures E-3 (right video) and E-5 show the progression of fire in the external comer configuration for the first 610 seconds of the test. The flame spread can be broken into four distinct phases. In the first phase, the fire spreads upward rapidly, with flames reaching the top of the panel before they have had much chance to spread downward or laterally. Once the flames have reached the top of the panel, lateral spread occurs in the second phase, resulting in a vee-shaped flame with the vertex at the comer slightly below the point of ignition. The polyurethane melts and flows down the comer in the third phase, rapidly causing the flame to extend to the ground and to create a small pool fire. In the fourth phase, the flame extends from the floor to the upper edge of the panel, forming a line fire which spread laterally along the bottom and top edges. The flame on the upper horizontal edge reaches the vertical extent of the panel first, at which time the fire spreads downward until all of the foam is consumed. By the end of the test, the plywood backing can be seen to be burning near the initial point of ignition. Since the wall panels were burned under an instmmented calorimetry hood, it was possible to utilize oxygen depletion measurements to calculate the heat release rate. The results for the external comer are plotted as the blue line in Fig. E-4. The heat release rate reached a peak value of 200 kW between 160 and 180 seconds after ignition. From the photos in Fig. E-3 taken 120 and 180 seconds into the bum, one can attribute this peak to the pool fire enhanced burning during the third phase of flame spread. The heat release rate included the energy released by all the fuel. Initially, the burning of the foam contributed most of the energy released by the fire while the wood contributed more energy as the foam was consumed. During phase 4, the heat release rate gradually reduces to about half its maximum value until Time, s Figure E-4. Heat release rate versus time for external and internal corner configurations of foam covered wall panels. E-3

0 seconds 10 seconds 20 seconds 30 seconds 60 seconds 360 seconds 420 seconds 480 seconds 540 seconds 610 seconds Figure E-5. Flame spread over polyurethane foam covered panels, external corner configuration. 90 seconds 120 seconds 180 seconds 240 seconds 300 seconds E-4

CM E X3 Li. OX Time, s Figure E-6. Heat flux versus time for external corner burn. almost all of the foam has been consumed at 540 seconds. The increase in heat release rate seen in Fig. E-4 after this point in time is due to the burning of the plywood panel. The irradiation perpendicular to and 2 m from the burning surface mirrors the heat release rate, as shown in Fig. E-6, attaining a value slightly above and below 1 kW/m^ from measurements 0.91 m and 1.83 m, respectively, above the bottom of the panel. The total energy contributed by the foam to the fire can be estimated from the area under the blue curve in Fig. E-4 to be 60 MJ to 70 MJ. This compares to any energy content of about 95 MJ for two 1.22 m x 2.44 m X 0.025 m thick panels of foam, using a heat release per unit area of 15.8 MJ/m^ as measured in the cone calorimeter with an incident flux of 35 kW/m^. The difference in total energy may be attributable to residual foam on the panel, liquid fuel that remained unbumed on the floor, or less complete combustion of the panels as compared to the cone calorimeter sample irradiated at 35 kW/m“. E.2.2 Internal Corner Configuration The internal corner test was conducted in the same manner as the test described above. Figure E-8 captures the fire during the first 400 seconds of the test. The same four phases of fire growth can be seen in Fig. E-5, however the rate of growth is considerably faster than occurred in the external comer configuration (compare left and right videos in Fig. E-3), as would be expected due to the enhanced feedback from the adjacent panel. The third phase, in which the melting foam forms a pool at the comer E-5

and rapidly drives the downward spread to the floor, occurs around 40 seconds into the internal comer test, as compared to some time around 120 seconds in the external comer test. The pool fire continues to bum and grow while the line fire associated with the fourth phase is established. By 400 seconds, the plywood backing is fully involved. A careful inspection of Fig. E-5 reveals what appears to be a continuously burning melt pool along the bottom edge of the panels as late as 400 seconds into the test. The heat release rate from the internal comer test is plotted as the red line in Fig. E-4. The irradiation measured perpendicular to and 2 m away from the panel is plotted in Fig. E-7. The shapes of the first 200 seconds for both plots are similar to what was found during the first 500 seconds of the external comer test, although the magnitudes are larger for the internal comer fire; that is, a peak heat release rate in excess of 200 kW, corresponding to the phase 3 burning, occurs early, followed by a gradual decrease to about half the peak heat release rate, and the heat flux from the surface during this period is a bit over 1 kW/m . Beyond 200 seconds, the internal comer test undergoes a more complicated behavior, as the pool fire at the base of the panel grows. The vertical arrow at 310 seconds marks the time when no more foam was visible on the wall panels. The pool fire from the melted foam reached a maximum heat release rate of 650 kW about 360 seconds into the bum. The increase in the fire size after 420 seconds is caused by the burning plywood along the vertical comer. The fire was extinguished at 490 seconds. [Note that while the shape of the flame seen in Fig. E-8 at 400 seconds is reminiscent of the M-shaped pyrolysis region reported by Qian et al.[l], inspection of the panels following their extinguishment revealed that the dark region seen in the photo along the vertical comer was due to complete burnout of the thin plywood panel.] The total energy released by the fire can be estimated by integrating the area under the red curve in Fig. E-4. There is a substantial uncertainty in how much of the power to attribute to the foam and how much to the wood for times longer than 300 seconds. If one assumes that that the measured heat release rate between 310 and 410 seconds is due primarily to the liquid fuel at the base of the wood panels, then the total energy released by the foam would be about 1 06 MJ, which is greater than the 95 MJ of energy Csl E §

LL (UOX 0 100 200 300 400 500 600 700 800 Time, s Figure E-7. Heat flux versus time for external corner burn. E-6

0 seconds 5 seconds 10 seconds 20 seconds 30 seconds 40 seconds 60 seconds 90 seconds 120 seconds 150 seconds 180 seconds 240 seconds 290 seconds 350 seconds 400 seconds Figure E-8. Flame spread over polyurethane foam covered panels, internal corner configuration. E-7

estimated to be in the two foam panels. The burning wood accounts for much of this discrepancy, although it is also likely that the internal comer would produce more complete combustion than the external comer due to the enhanced radiant interchange between the two adjacent panels. E.3 FLAME SPREAD RATES E3.1 External Corner Configuration The speed at which the flames travel across the foam surface during each of the four phases of the fire can be estimated from the video record. While it is not possible to see through the flame to the pyrolysis zone during the first phase, when upward flame spread is dominant, the brightest portion of the flame can be used as a marker of the pyrolysis zone to roughly estimate the upward flame spread rate. The position of the leading edge of the flame in countercurrent regions provides a more accurate measure of the movement of the bulk of the pyrolysis zone as long as the time required to bum through the thickness of the foam is much less than the time for the flame to move across the surface. This is a reasonable assumption for a relatively thin sheet of low density, highly porous material like polyurethane foam, and is confirmed by inspection of the burned out regions behind the countercurrent flames. Figure E-9 is a plot of the position of the flame along the boundaries of the panel as a function of time, showing the upward, downward (initially on the right of the panel, and later along the left edge), and lateral flame spread (along the top and bottom, respectively) as a function of time and position. The dotted lines in the figure are drawn to represent the approximately steady region of flame spread, and their E E c _o ’(/) o Q. 1800 1600 1400 1200 1000 800 600 400 200 0 -200 -400 -600 -800 0 50 100 150 200 250 300 350 400 450 500 1 1 1 1 A 1 1 < N

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Table E-1. Approximate flame spread rates over flexible polyurethane foam panels configured as vertical corners Burning Phase Direction of Spread External Comer Internal Comer I Upward (co-current) 63 mm/s 135 mm/s II Downward (counter-current) 2.3 mm/s 6.4 mm/s II -IV Lateral, top (counter-current) 6.8 mm/s 24 mm/s IV Lateral, bottom (counter-current) 2.2 mm/s 4.4 mm/s IV Downward (counter-current) 7.0 mm/s 14 mm/s II, IV Normal (counter-current) 7.2

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15-25 mm/s slopes correspond to the respective spread rates. Table E-1 provides a summary of the estimated spread rates for the external comer configuration. The last row is the normal flame speed (the vector sum of the horizontal and vertical components) during the later phases of burning. The flame speed decreases from a maximum of 63 mm/s in the upward direction to just over 2 mm/s in the downward and lateral direction along the bottom edge of the panel. The normal flames speed during the steady burning period is 7.2 to 7.3 mm/s. o czoa 0) 0) E Figure E-10. Flame spread across foam covered wall panel (m^/s). E-9

The video images were processed to track the unbumed portion of the panel not covered by flames to provide an estimate of the surface area burning rate. The result is shown as the blue line in Fig. E-10. Following a small spurt during the initial rapid upward flame spread, the area burning rate drops and then slowly increases in the second and third phases to reach a peak of 0.013 m“/s about 140 seconds into the fire. The area burning rate gradually declines over the phase 4 period as the line of fire shortens about linearly with time. From the estimated downward and lateral flame speeds listed in Table E-1 and assuming the shape of the unbumed foam remains approximately congment to a triangle formed by the edges and diagonal of the panel, the area burning rate can be expressed as (Xq Vy + Yq Vx)/2 - Vx Vy (t - to), where Xo and Yo are the lengths of the sides of the panel, Vx and Vy are the components of the normal flame velocity, and to is the time when the flame begins moving downward along the outer edge of the panel. Using this fonnulation the area burning rate diminishes from 0.0070 m7s at 200 seconds to 0.0024 m“/s at 500 seconds, consistent with the more accurate calculation represented by Fig. E-10. E.3.2 Internal Corner A similar analysis was conducted for the flame spreading over the polyurethane foam panels in the internal comer configuration. Figure E-1 1 shows the position of the flame, relative to the initial ignition point, as a function time. The same flame spread regions can be identified as with the external comer test. The time axis in Fig. E-1 1 has been expanded by a factor of two over Fig. E-9, indicative of the faster flame spread associated with the internal comer. The last column in Table E-1 lists the flame spread rates, taken from the slopes of the curves in Fig. E-1 1, for different directions throughout the duration of the test. The table entries are two to three times faster than for the external comer, with the biggest difference being the lateral spread across the top of the panels (compare 24 mm/s to 6.8 mm/s). This is the region which is exposed to the largest flames and the highest view factor to enhance the surface irradiation. The red line in Fig. E-10 is a plot of the area burning rate determine by processing the video images such as those seen in Fig. E-3 and E-8. The initial peak exceeds 0.05 m /s, which undoubtedly is an over estimate since the quickly growing flames conceal a portion of the foam panel that has not had time to be completely consumed. Applying the same formulation [(Xq Vy + Yq Vx)/2

• Vx Vy (t - to)] developed in

section E.3. 1 for the area burning rate, a lateral flame speed of 4.4 m/s, and a downward flame speed of 14 mm/s, the flame spread can be estimated to decrease from 0.014 m7s at 90 seconds to 0.001 m /s at 300 seconds, again consistent with Fig. E-10. E.4 COMPARISON OF RESULTS TO MOCK-UP AND OTHER STUDIES E.4.1 Fire Spread in Platform Area Mock-up Experiment The geometry of the foam panels used in the full-scale mock-up of the dmmmer's alcove and the area around the platform was considerably more complex than the simple comers used in the flame spread experiments described above. The most significant complication comes from the ceiling, which produces horizontal edges and three-dimensional comers that affect the heat feedback and the flame spread mechanisms. The second significant effect of the ceiling is that it traps the combustion products and heat, leading to a vitiated environment and a rapidly increasing source of thermal radiation, either of which can greatly alter the flame spread rate. E-10

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A upward downward, left Adownward, right lateral, top O lateral, bottom 0 50 100 150 200 250 Time, seconds Figure E-11. Flame position relative to ignition point on internal corner configuration If the video of the fire spread across the face of the east wall along the back of the platform is analyzed in the same manner as the fire spread across the comer panels, the following estimates of flame spread can be achieved: • upward spread rate (0-10 seconds): 60 mm/s to 100 mm/s • downward spread rate (0-20 seconds): 4 mm/s to 5 mm/s • lateral spread rate (10-25 seconds): 1 1 mm/s to 26 mm/s The lateral spread rate was computed from the increase in the full width of the fire plume, and then reduced by a factor of two to make it comparable to the flame spread in one direction from the comer panel experiments. The lateral flame speed was also determined by tracking the time it took for the thermal wave to reach thermocouples mounted in the foam 300 mm below the ceiling ,every 300 mm along the back wall. Fifteen seconds after ignition, the lateral flame spread rate was 1 1 mm/s; by 45 seconds after ignition the lateral spread rate had increased to 1 8 mm/s, in agreement with the video record. One would expect the flame spread during the initial portion of the fire to be closer to the external comer panel experiments; however, the results for the mock-up in the upward, downward, and lateral flame E-11

spread rates lie between those measured in the internal and external comers. It should be noted that the non-fire retarded polyurethane foam used in the mock-up was from lot B, while the foam used in the comer panel experiments was from lot A. While the mass per unit area of the lot A foam was 50 % greater than the lot B foam, cone calorimeter measurements of the peak heat release rates and times to ignition with an irradiation of 35 kW/im were within 5 % of each other. Dripping of the melted foam along the external comers of the alcove occurred about 25 seconds after ignition. Because the initial point of ignition was much higher in the mock-up than in the comer panel experiments, phase II burning that became prevalent in the latter did not play a roll in the spreading the fire to the floor of the platform. The lateral flame spread in the northerly direction along the east wall at the back of the platform stalled around 30 seconds after ignition. This appeared to be due to the high rate of air being entrained into the vigorously burning alcove, and the resulting high air velocity mnning counter to the flame along the back wall. Because the mass loading was less with the lot B foam, the stalled flame allowed the fuel to be consumed without spreading. Thus, the lateral spread mechanism observed in the panel tests did not contribute much to the fire development along the back wall of the platform in the mock-up for more than 30 seconds into the test. Between 40 seconds and 60 seconds after ignition, most of the action occurred in the alcove, where the heat was transferred effectively to the foam due to intense radiation and high gas temperatures. The hot upper layer developed quickly between 60 seconds and 75 seconds, reaching close to 600 °C almost 'J • everywhere throughout the room. Radiant heat fluxes were measured in excess of 40 kW/m" during this period, much higher than imposed by the spreading flame in the comer panel experiments, and above the flux necessary for ignition within a few seconds. E.4.2 Comparison to Previous Flame Spread Studies Flame spread is a classic problem for fire science that has been investigated for decades, both theoretically and experimentally. The orientation of the fuel, the direction of the flame spread relative to the air flow, the geometry and properties of the fuel, and the temperature and composition of the environment all play a significant role. For the present discussion, we are interested primarily in counter- current flame spread over vertical walls, with fuels similar to polyurethane. Quinterre and Flarkleroad [2] focused on a method for measuring lateral flame spread over a wide variety of materials. They examined several foams, designated as (1) polyurethane S353M, (2) 25 mm flexible foam, and (3) 25 mm rigid foam. Lateral spread rates of the rigid foam, measured in the LIFT apparatus [4], increased from under 2 mm/s with irradiance levels below 10 kW/m“ to over 10 mm/s with irradiance levels around 15 kW/m“. The minimum heat flux necessary for unpiloted ignition was 20 kW/m . At this flux level the ignition delay time was around 5 seconds, dropping to about a second at 30 kW/m". The 25 mm flexible foam had a much greater lateral spread rate, exceeding a value of 25 mm/s for incident fluxes less than 10 kW/m^. There is no indication in the report of chemical composition or either the rigid or flexible foams. The one material specifically identified as polyurethane (S353M) was not identified as either rigid or flexible, although it behaved more like the undesignated flexible foam. Cleary and Quintiere [3] performed additional experiments on foam plastics using several different flammability test methods. For one non-fire retarded polyurethane foam tested in the LIFT apparatus, they measured a maximum flame spread rate of over 40 mm/s with an incident flux of about 10 kW/m*", the highest flame spread rate at that flux level of all the materials evaluated. E-12

In both of the above studies, the flame spread velocity (vl) is assumed to be inversely proportional to the product of the effective thermal conductivity (k), density (p) and specific heat (c) of the foam according to the relationship [2] VL = OhV(kpc)/(q",g-q"y where h is the heat transfer coefficient to the surface, qjg is the heat flux necessary to ignite the material in a finite period of time, q"e is the imposed heat flux, and O is a flame heating parameter. An effective value is used for (kpc) because the properties change with temperature and the extent of pyrolysis. The ignition delay time measured in the cone calorimeter, tig, can be used to estimate (kpc) from the following relationship [2]: kpc = 4/tt [q"e/(Tig - Ts)]" fg where (Tig - Tg) is the difference between the ignition temperature and the initial surface temperature of the material. For the PUF-NFR-B, at 35 kW/m the time to sustained ignition was 6 seconds. Using an ignition temperature of 370 °C as measured by Southwest Research Institute for this foam, kpc is calculated to be 0.075 (kW/m^-°C)“-s. This compares to 0.001 (kW/m^-°C)“-s computed from the reference values in Table 4.1, and to 0.036 (kW/m“-°C)“-s as tabulated by Cleary and Quintiere [3] for their non-fire retarded polyurethane foam. For this same foam they found O to be equal to 3.1 kW^/m^ 'y and q"ig to be 14.5 kW/m"; for other polyurethanes O may be twice as high. With these values, and a natural convections coefficient taken as 0.015 kW/m^-^C, the lateral flame speed (mm/s) can be related to the irradiation (kW/m^") by Vl= 124/(14.5

• q"e)“

To the extent this relationship approximately holds for the PUF-NFR-A material studied in the comer panel configuration, to achieve the lateral spread rate observed in the external comer test (6.8 mm/s) would require a radiant flux from the flame to the surface of about 10 kW/m*^. The internal comer test produced a lateral spread rate of 24 mm/s, corresponding to 33 kW/m“. If a value for O were increased to 6 kWVm^, the required heat flux from the flame to sustain a 24 mm/s lateral flame spread would decrease to 24 kW/m^. E.5 REFERENCES FOR APPENDIX E [1] Qian, C., Ishida, H., and Saito, K., "Upward Flame Spread along PMMA Vertical Comer Walls Part II: Mechanism of "M" Shape Pyrolysis Front Formation," Combustion and Flame 99: 331- 338 (1994). [2] Quintiere, J., and Harkleroad, M., "New Concepts for Measuring Flame Spread Properties," NBSIR 84-2943, National Bureau of Standards, November 1984. [3] Cleary, T., and Quintiere, J., "Flammability Characterization of Foam Plastics," NISTIR 4664, National Institute of Standards and Technology, October 1991. [4] ASTM E 1321 -97a, Standard Test Methodfor Determining Material Ignition and Flame Spread Properties, ASTM International, West Conshohocken, PA, 2004. E-13

E-14

Appendix F. Pyrotechnic Device Test Series F.1 pyrotechnic gerbs A series of full-scale experiments was conducted to document the thermal characteristics of a discharging pyrotechnic device like those that were ignited on stage in the nightclub on Feb. 20, 2003. At the beginning of the show, four separate pyrotechnic devices, or gerbs, were discharged on the platform in front of the alcove. Two gerbs, which had been positioned on the floor of the platform, discharged vertically along the centerline of the alcove opening. Two additional pyrotechnic gerbs, which were located near the other two gerbs on the platform floor, sprayed white “sparks” at a 45 degree angle to both the left and right sides of the alcove. The WPRJ-TV video of the nightclub interior showed that glowing particles or “sparks” ignited the foam on both sides of the alcove in approximately 10 seconds. The throw, or distance the hot particles traveled, the period of “spark” discharge, and the white appearance of hot particles, were consistent with a pyrotechnic device called a Silver 15x15 Stage Gerb. Forty silver 15x15 gerbs were purchased from a commercial manufacturer of stage pyrotechnics. Each gerb consisted of a cardboard tube approximately 0.022 m (0.88 in) in diameter and 015 m (6 in) long (Figure F-1) The gerbs were constructed and ignited as described in the following manner. A non-combustible material was placed inside the tube filling up the upper 0.1 m (4 in) of the gerb. The non-combustible material formed a solid plug near the bottom center of the tube, but provided a hollowed-out cavity for the upper part of the gerb. The hollowed out portion of plug was filled with a mixture of energetic materials and metal compounds. When the energetic materials were ignited, the non-combustible material prevented the hot material from discharging out the bottom or through the walls of the gerb. The hot gases and metallic compounds were sprayed out the upper end of the gerb. The duration of the discharge was determined by the amount of the energetic material placed in the tube. The color of the sparks was determined by the type of metal compound that was mixed in with the energetic materials. Titanium particles were added to provide a white- or silver-colored sparks. The inclusion of ferro-titanium particles would produce yellow- or gold-colored sparks. Once the gerbs were positioned on the platform, an electrical match was inserted through the cap at the top end of the tube. An electric match consisted of a short section of resistance wire coated with a flammable chemical. When a current was passed through the wire, it heated up and ignited the coating, which in turn ignited the energetic materials in the gerb. The initial combustion generated enough gas pressure to pop the plastic cap off the end of the cardboard tube and to spray hot gases and sparks to approximately 15 ft (4.5 m) for a period of approximately 15 seconds (hence the term 15 x 15) For the NIST tests, each gerb or pair of gerbs was discharged either along or against a gypsum board wall. The wall had been painted black to enhance the contrast with the white sparks. A grid of 0.3 m ( 1 ft) squares was painted on the wall. Gerbs were discharged in a plane parallel to the wall at an angle of either 45 degrees (Figure F-2) or 90 degrees (Figure F-3) from the horizon. Gerbs were also discharged against the wall in a plane perpendicular to the wall (Figure F-4). Heat flux gauges and thermocouples were embedded in the gypsum wall to monitor the heat flux and gas temperatures. In Figures F-5, F-6, and F-7, one can see how the instrumentation was positioned so that the spark discharge was centered F-1

1. 0064 m
2. 022 m

Figure F-1. Photograph of Silver 15x15 Stage Gerb and Cross-Sectional Schematic. Figure F-2. Single Gerb at 45 Degrees and in Plane Parallel to Wall . F-2

Figure F-3. Two Gerbs at 90 degrees and in Plane Parallel to Wall. Figure F-4. Single Gerb at 45 degrees and in a Plane Perpendicular to Wail. F-3

Figure F-5. Instrumentation Diagram for a Single Gerb at 45 Degrees and in Plane Parallel to Wall . rsi B ID CO ro t2. E . ' B o i i o aT.'' f 'c' i o 1o m _ IRBi -^1 1 0.3 m (1 ft) 11 4.88 m (16 ft) @ Thermocouple (Jr) Heat Flux Gauge Figure F-6. Instrumentation Diagram for Two Gerbs at 90 degrees and in Plane Parallel to Wall. F-4

3 06 m (10 (t> 1 ^ 3.05 m O I3x3 'tc) E „ oO 1 i;? t E 5> 1 ° 0.3 m (1 ft) 4.88 m (16 ft) @ Thermocouple @ Heat Flux Gauge FRONT VIEW Gypsum Wall with Gnd SIDE VIEW Figure F-7. Instrumentation Diagram for a Single Gerb at 45 degrees and in a Plane Perpendicular to Wall. F-5

over the flux gauges and thermocouples. Electric matches were used to ignite the gerbs. Each discharge was video taped using a standard mini-DV digital video camera and an infrared camera. The infrared camera utilized a barium-strontium-titanate solid-state detector with a spectral response of 8 pm to 14 pm. The IR camera was included in these experiments to provide a qualitative image of the hot gas plume as well as the spray of the white sparks. F.2 45 DEGREE DISCHARGE TESTS As seen in Figs. F-2 and F-4, tests were conducted with gerbs discharged at an angle of 45 degrees to the horizon, either parallel to or perpendicular to the wall Each discharge was recorded using a standard video camera and an infrared camera. For a 45 degree discharge in a plane parallel to the wall, pairs of visible and infrared images are shown for Os, 2 seconds, 5 seconds, 14 seconds, 15 seconds, and 16 seconds in Figures F-8 to F-13. The visible images show that each gerb discharged a spray of white sparks for at least 14.5 seconds, but no more than 16 s. While most of the sparks were thrown less than 2.74 m (9 ft), a limited number of sparks traveled in excess of 4.6 m (15 ft) from the tip of the gerb. The infrared images show a central core of hot gases, a plume of warm gases that does not travel as far as the hot metallic particles. The buoyant hot gases developed a vertical trajectory within 1.2 m (4 ft) of the gerb tip. Temperatures and heat fluxes in the plume are plotted in Figs. F-14 and F-15. Figure F-8. Standard Video and infrared Video Images of Gerb Discharge at 0 s. Figure F-9. Standard Video and Infrared Video images of Gerb Discharge at 2 s. F-6

Figure F-10. Standard Video and infrared Video Images of Gerb Discharge at 5 s. Figure F-11. Standard Video and Infrared Video Images of Gerb Discharge at 14 s. Figure F-12. Standard Video and Infrared Video Images of Gerb Discharge at 15 s. F-7

IIIIIII Figure F-13. Standard Video and Infrared Video Images of Gerb Discharge. Time is 16 seconds after ignition. O o E 0) Single Gerb - 45 Degree/Parallel Orientation Figure F-14. Temperatures versus Time for Single Gerb Discharged at 45 Degrees in Plane Parallel to Wall. F-8

Single Gerb -45 Degree Parallel Orientation Figure F-15. Temperatures versus Time for Single Gerb Discharged at 45 Degrees in Plane Parallel to Wall. Testing also was done with a gerb discharging at a 45 degree angle from the horizon and in a plane perpendicular to the wall. The wall was either gypsum board, plywood, non-fire retarded polyurethane covered plywood, or fire retarded polyurethane covered plywood. The results of these tests are presented in Chapter 4, section 4.5. The temperatures measured in the plume for the one case that led to burning of the wall, the non-fire retarded polyurethane foam, are plotted in Fig. F- 16a and F-16b. The high temperatures reached 20 seconds into the test (120 seconds on the figure since ignition of the gerb occurred at 100 seconds) are clearly indicative of flaming combustion. Fig. F- 16b shows the temperature scale greatly expanded, with the centerline temperature peaking 7 seconds after ignition, followed by a rapid increase in temperature elsewhere in the plume even as the centerline cools due to the end of the discharge from the gerb. Since the alcove in the nightclub was 3.0 m ( 10 ft) wide and the gerbs were positioned at the center of the alcove opening, white sparks would have easily reached both sides of the alcove. The plume of hot gases would probably not have directly impinged on the side walls of the alcove. The hot gases would instead have traveled diagonally across the alcove opening and as the plume approached the side walls, the plume would have moved vertically to impinge on the wall above the alcove opening. F-9

Polyurethane Foam

• One Gerb -45 “/Perpendicular Orientation

Figure F-16a. Temperatures versus Time for Single Gerb Discharged at 45 Degrees in Plane Perpendicular to Wall. Polyurethane Foam

• One Gerb
• 45 “/Perpendicular Orientation

Figure F-16b. Temperatures versus Time for Single Gerb Discharged at 45 Degrees in Plane Perpendicular to Wall. F-IO

F.3 90 DEGREE DISCHARGE TESTS A pair of gerbs was positioned to discharge in a direction 90 degrees from the horizon and parallel to the wall (see Fig. F-17). Visible and infrared images are shown 2 seconds, 5 seconds, 14 seconds, 15 seconds, and 16 seconds after ignition of the gerbs in Figure F-18 to F-22. The visible images demonstrate that both gerbs discharged for at least 14.5 seconds, but no more than 16 s. The spray pattern of sparks appeared similar to that of the gerbs, which had been positioned at 45 degrees. Most of the sparks traveled less than 2.74 m (9 ft), but some hot sparks were thrown in excess of 4.6 m (15 ft). The infrared images again demonstrate a central core of hot gases; in this vertical configuration, the plume of combustion gases is aligned with the trajectory of the hot sparks. The temperatures and heat fluxes are plotted in Figures F-23 and F-24. Since the alcove in the nightclub was 2.0 m (6.5 ft) tall and the gerbs were positioned at the center of the alcove opening, white sparks would have easily reached the top of the alcove. The plume of hot gases would have directly impinged on the foam at the top of the alcove opening. (It is worth noting that the pair of gerbs directed vertically on the platform of the nightclub on Feb. 20, 2003, did not ignite the foam at the top of the alcove.) I Figure F-17. Standard Video and Infrared Video Images of Gerb Discharge at 0 s. F-ll

Figure F-18. Standard Video and Infrared Video Images of Gerb Discharge at 2 seconds. Figure F-19. Standard Video and Infrared Video Images of Gerb Discharge at 5 seconds. F-12

Figure F-20. Standard Video and infrared Video images of Gerb Discharge at 14 Figure F-21. Standard Video and Infrared Video images of Gerb Discharge at 15 seconds. F-13 Tempe884F ^ ^ T einp8e84F

Figure F-22. Standard Video and Infrared Video Images of Gerb Discharge at 16 seconds. o o oT 3 ra u. a> Q. E (I) Two Gerbs

• Vertical/Parallel Orientation

Figure F-23. Temperatures versus Time for Two Gerbs Discharged at 90 Degrees in Plane Parallel to Wall.. F-14

04 E §

<

U. re 0)X re E 0 90 100 110 120 130 140 150 Time, s Figure F-24. Heat Fluxes versus Time for Two Gerbs Discharged at 90 Degrees in Plane Parallel to Wall. F-15

F-16

Appendix G. Real-scale Platform Area Mock-up Experiments This appendix contains additional data on the fire growth in the full-scale mock-up fire tests described in Chapter 4, and is compiled here for reference. Some material from Chapter 4 is repeated for the benefit of the reader. In order to allow the combustion gases to be exhausted into an instrumented hood, the full- scale mock-up experiments were conducted with the platform section oriented to the east of the dance floor. In the actual nightclub, the platform section was west of the dance floor. In order to be consistent, the mock-up data will be presented using the orientation of the actual nightclub. G.1 INSTRUMENTATION AND EXPERIMENTAL PROCEDURE The test room was equipped with thermocouples, video cameras, heat flux gauges, bi-directional probes, and gas extraction probes to measure carbon monoxide (CO), carbon dioxide (CO2), oxygen (O2 ), and hydrogen cyanide (HCN). In addition, fixed temperature and rate-of-rise heat detectors were installed, as were sprinklers. In one test, the sprinklers were not supplied with water but were monitored for time to activation. Figure G-1 is a schematic floor plan of the instrumentation positions. 2.85 m 3.66 m Rear Wall 1.83 m M 1.67 m 3.66 m t ;tc' TC JC Main Floor 2.74 m I I 1.67 m I I ^ Station C Station D 0 . ® ® 2® a® TC Raised ® Platform 1 .2 m — ® statics ^ Station A ® ® 3©

®

• -S© ®+

Alcove t North ^2.35 m 4.25 m Front Wall 7.1 m n WATER SPRINKLER ® THERMOCOUPLE © GAS SAMPLING ® HEAT FLUX ® VIDEO CAMERA Figure G-1. Schematic floor plan with instrumentation positions. G-l Two full-scale experiments were conducted: one with and one without sprinklers. Prior to ignition, each of the analyzers was zeroed and calibrated and the data acquisition system and videos were started to collect background data. Data for 194 channels were recorded at one second intervals. Ignition of the foam was initiated with electric matches simultaneously at two locations on the outer comers of the alcove, 1.8 m above the raised floor area. The fire gases that emerged from the open door on the south end of the test room were captured in the hood of the oxygen depletion calorimeter. The data were reduced and plotted versus time for each of the channels. G.2 TEMPERATURE MEASUREMENTS The temperatures were measured with 0.5 1 mm nominal diameter bare bead. Type K thermocouples. The thermocouple array over the platform floor area had a thermocouple located at 0.025 m, 0.30 m, 0.61 m, 0.91 m, 1.22 m, 1.52 m, 1.83 m, 2.13 m, 2.44 m, 2.74 m, 3.05 m, 3.35 m, and 3,66 m below the ceiling. 2.35 m 4.25 m 7.1 m ® THERMOCOUPLE Figure G-2. Schematic floor plan with thermocouple positions. For the platform floor thermocouple array, the themiocouple that was located 3.66 m below the ceiling, was positioned on the platform floor. The two-thermocouple arrays on the main floor also had a thermocouple located at 3.66 m below the ceiling, but in each case, the thermocouple was positioned

1. 1 5 m above the main floor.

Vertical thermocouple arrays were installed in the center of each wall of the alcove. Each array had a thermocouple located at 0.30 m, 0.61 m, 0.91 m, 1.22 m, 1.52 m, and 1.83 m below the ceiling of the alcove. A horizontal thermocouple array was installed 0.30 m below the ceiling. The array began at the centerline of the alcove opening and continued north along the rear wall, and then followed the platform wall west for 6.1 m. The thermocouples were spaced approximately 0.30 m apart. G-2

In addition, thermocouples were located adjacent to the sprinklers. Temperatures versus time are plotted in Figures 4-22 through 4-28. Thermocouples were installed near the ignition points on both sides of the alcove opening, 1.8 m above the floor of the platform. As shown in Figure G-3, in the unsprinklered compartment bum, the temperatures near the ignition point stage-left began to increase rapidly in less than 10 seconds and it then dropped to about 100 °C. After about 30 seconds, both stage-right and stage-left thermocouples began to increase to temperatures in excess of 600 C. The initial peak and subsequent drop and then rapid increase were probably due to movement of the flame sheet or thermal plume. If the thin flame sheet was near the thermocouple bead, a high temperature would be recorded, but if the plume of hot gases moved and caused the bead to be in the fuel rich interior of the plume, lower temperatures could have been recorded. Slightly different temperature behavior was recorded in the sprinklered test (Figure G-4). Initially both stage-left and stage-right temperatures increased rapidly as the stage-left thermocouple had in the unsprinklered test, but as sprinklered bum temperatures dropped back to about 100 °C, the sprinklers activated and caused the temperatures to decrease to near ambient temperatures. Three thermocouple arrays were installed in the alcove, stage-right wall, stage-left wall, and rear wall of the alcove (Figures G-5, G-7, and G-9). The temperatures recorded by each of three thermocouple arrays were similar. In the unsprinklered test bums, the temperatures began to increase within 30 seconds after ignition. By 60 seconds to 70 seconds after ignition, temperatures exceeded 800 °C . In the sprinklered compartment bums (Figures G-6, G-8, and G-10), the temperatures also began to increase in approximately 30 seconds, but the temperatures had only increased to about 40 °C to 60 °C before the sprinklers activated and the temperature gradually decreased to ambient temperatures. One thermocouple array was installed from ceiling to floor on the platform. Location B. For the unsprinklered case (Figure 4-22), the temperature at the ceiling began to increase within 10 seconds and continued to increase to over 800 °C in approximately 50 s. As the hot gases began to form an upper layer, the layer began to descend and in just over 1 10 seconds, the temperature at the floor of the platform had increased to over 600 . In less than 60 seconds, the temperature had exceeded 50 °C at the 1.4 m (4.5 ft) above the floor (2.4 m below the ceiling) elevation. For the sprinklered test bum (Figure 4-25), the ceiling thermocouple recorded temperatures in excess of 360 °C in less than 25 seconds, but had decreased to ambient in less than 40 seconds. The activation of the sprinklers caused the other thermocouples at lower elevations to record near ambient temperatures throughout the test bum. The thermocouple array at Location C was installed 6.7 m from the foam covered platfonn wall. Location C thermocouples were an additional 3 m further away from the platform wall than the thermocouples at Location B. Since the thermocouples at Location C were further away from the fire source than the thermocouples at Location B, the temperatures might be expected to increase more slowly than at Location B. For the unsprinklered thermocouples (Figure 4-23), the temperatures did require slightly longer to begin to increase, about 15 seconds, and required approximately 70 seconds to reach peak temperatures of 800 °C. The temperatures at 3.6 m below the ceiling did not begin to increase until 60 seconds after ignition and then the temperatures reached peak values of approximately 100 °C in 90 s. The temperatures near the floor at Location C were significantly lower that the values recorded at the floor on the platform. Location B. In less than 70 seconds, the temperature had exceeded 50 °C at the 1 .4 m (4.5 ft) above the floor (2.4 m below the ceiling) elevation. For the sprinklered test bum (Figure 4- 26), the ceiling temperatures reached a peak temperature of 170 °C in about 20 seconds and declined to G-3

Figure G-3. Temperatures versus Time for Unsprinklered Mockup Test. Thermocouples positioned on right and left side of alcove opening 1.8 m (5.t ft) above platform floor at ignition points. Figure G-4. Temperatures versus Time for Sprinklered Mockup Test Thermocouples positioned on right and left side of alcove opening 1.8 m (5.5 ft) above platform floor at ignition points. G-4

near ambient temperatures within 60 seconds. Thermocouples at lower elevations appeared to remain at near ambient temperatures throughout the test. The thermocouple array at Location D was installed 8.5 m from the foam covered platform wall. Location D thermocouples were an additional 1.8 m further away from the platform wall than the thermocouples at Location C. Again, as the distance between the thermocouple array and the fire increased, the temperatures were expected to increase more slowly that the arrays that were located closer to the fire. For the unsprinklered thermocouples (Figure 4-24), the temperatures did require slightly longer to begin to increase, about 20 seconds, and required approximately 80 seconds to reach peak temperatures of 700 C. The temperatures at 3.6 m below the ceiling did not begin to increase until 70 seconds after ignition and then the temperatures reached peak values of approximately 100 C in 90 s. The temperatures near the floor at Location D were about the same as that the values recorded at the floor on the platform. Location C. In less than 70 seconds, the temperature had exceeded 50 C at the 1.4 m (4.5 ft) above the floor (2.4 m below the ceiling) elevation. For the sprinklered test bum (Figure 4-27), the ceiling temperatures reached a peak temperature of 130 C in about 20 seconds and declined to near ambient temperatures within 60 seconds. Thermocouples at lower elevations appeared to remain at near ambient temperatures throughout the test. G-5

Figure G-5. Temperatures versus Time for Unsprinklered Mockup Test. Thermocouples positioned in Alcove (A-SR) on wall (stage-right). oO 0 u.3 (U 0 Q. E0 h" (/)0o 100 80 60 40 20 ..r® a o 0.3 m below alcove ceiling 0,6 m below alcove ceilling + 1 .5 m below alcove ceiling LI 1.8 m below alcove ceiling 50 100 150 Time (s) 200 Figure G-6. Temperatures versus Time for Sprinklered Mockup Test. Thermocouples positioned in Alcove (A-SR) on wall (stage-right). G-6

Figure G-7. Unsprinklered Mockup Test. Alcove (A-SB) on rear wall Figure G-8. Sprinklered Mockup Test. Alcove (A-SB) on rear wall. G-7

1000 600 400 o 0.3 m below alcove ceiling P 0.6 m below alcove ceiling : , ; I !. . A . ih . ^ I I I'hi ' J + 1.5 m below alcove ceiling 1.8 m below alcove ceiling 50 100 150 Time (s) 200 Figure G-9. Temperatures versus Time for Unsprinklered Mockup Test. Thermocouples positioned in Alcove (A-SL) on wall (stage-left). 100 oO 0) L-3 (Q i_O Q. E 0) I- (/) O o 0.3 m below alcove ceiling 0.6 m below alcove ceiling + 1 .5 m below alcove ceiling 1 .8 m below alcove ceiling Figure G-10. Temperatures versus Time for Sprinklered Mockup Test. Thermocouples positioned in Alcove (A-SL) on wall (stage-left). G-8

G.3 GAS MEASUREMENTS The gas sampling ports were co-located with the heat flux sensors on the main floor area (Figure 4-63). The gases were pulled through 9.4 mm ID tubing to chemical analyzers after passing through moisture and particulate filters. Carbon monoxide and carbon dioxide concentrations were monitored using non- dispersive infrared gas analyzers while the oxygen concentrations were measured using paramagnetic analyzers. Hydrogen cyanide concentrations were monitored using impingers and real-time gas analyzers, which utilized an off-the-shelf cyanide combination electrode. Each impinger utilized 0.1 M KOH as the trapping solution and samples were analyzed according to NIOSH Method 7904 [1] During the sampling process, the gas sample for the oxygen, carbon monoxide, and carbon dioxide analysis was drawn through a cold trap which removed the water vapor. The oxygen, carbon monoxide, and carbon dioxide concentrations were recorded by each analyser on a dry or Orsat basis. The hydrogen cyanide sample gas utilized a different sampling train and did not pass through a cold trap. Since the hydrogen cyanide samples were monitored on a wet basis, the oxygen, carbon monoxide, and carbon dioxide concentrations were corrected for the water removed by the cold trap. For complete combustion of low methane, two moles of water are generated for each mole of carbon dioxide produced. For larger hydrocarbon molecules, the ratio of moles of water produced for each mole of carbon dioxide decreases to a 1:1 ratio, assuming the carbon to hydrogen ratio approaches 1 :2. It was assumed that for every mole of carbon dioxide or carbon monoxide generated that a mole of water was also generated. This assumption was used to correct the dry or Orsat basis analyzer data to a wet basis. By adding the water vapor back into the gas sample, the concentrations of oxygen, carbon monoxide, and carbon dioxide decreased. The relative uncertainty in the volume fraction measurement is estimated to be +/- 20 %. Carbon dioxide gas concentrations versus time are plotted in Figures G-12 and G- 13. For the unsprinklered tests, carbon dioxide concentrations at both Locations C and D began to increase 80 seconds after ignition and reached peak values of 12 % approximately 100 seconds after ignition. The fluctuations that were observed in the oxygen concentrations were also seen in the carbon dioxide concentrations. For the sprinklered compartment experiments, the carbon dioxide concentrations did not appear to increase above ambient concentrations. G.4 HEAT FLUX MEASUREMENTS AND HEAT DETECTOR RESPONSE Three elliptical radiometers were installed in the ceiling of the test cell viewing downward at Location B, C, and D (Figure G-14). In addition to the radiometer at Location B, a total heat flux gauge with an upward view was installed flush with the platform floor. At Locations C and D, two additional total heat flux gauges were installed 1.5 m above the floor. One total heat flux gauge was position to have an upward view, while the other gauge had a view of the alcove. The heat flux sensors were water-cooled Schmidt-Boelter type transducers. Heat flux versus time is plotted in Figure G-15 through Figure G-23. The uncertainty in the heat flux values reported is estimated to be +/- 20 %. The three radiometers were plotted together in Figure G-15. As the distance between the radiometer and the fire source increased, the peak radiation flux decreased. For Locations B, C, and D, peak radiation levels were approximately 60 kW/m“, 50 kW/m", and 20 kW/m^, respectively. Unsprinklered and sprinklered radiation and total heat fluxes are plotted in Figures G-16 through G-23. In each sprinklered test at Locations C and D, neither radiation nor total heat flux reached significantly higher fluxes than background. Only at Location B, was there a slight increase in radiation or total heat flux at about 20 s. G-9

1. 26 m

t 2.74 m Main Floor Raised Platform Location Location Alcove D C 0 0 -^2.35 m © GAS SAMPLING 4.25 m

• <

1. 53 m

Figure G-11. Schematic floor plan with gas sampling locations. G-IO

Figure G-12. Carbon dioxide volume fraction versus time for unsprinklered and sprinklered mockup test. Gas sampling probe positioned on main floor (Location C) at 1.4 m (4.5 ft) above floor. Time (s) Figure G-13. Carbon dioxide volume fraction versus time for unsprinklered and sprinklered mockup test. Gas sampling probe positioned on main floor (Location D) at 1.4 m (4.5 ft) above floor. G-ll

Figure G-14. Schematic floor plan with heat flux and heat detector locations. 0 50 100 150 200 Time (s) Figure G-15. Radiation fluxes versus time for unsprinklered mockup test. Gauges positioned flush with ceiling (3.8 m above floor) at locations B, C, and D. G-12

Figure G-16. Heat Fluxes versus Time for Unsprinklered and Sprinklered Mockup. Gauges positioned facing alcove (1.44 m above floor) at location C. Figure G-17. Heat Fluxes versus Time for Unsprinklered and Sprinklered Mockup. Gauges positioned facing alcove (1.44 m above floor) at location D. G-13

100 CM 80 60 40 20 0 0 50 100 150 200 Time (s) Main Floof (1.44 m above floor) Sprinklered o c? , o 6 o o oo Main Floor (1.44 mi above floor) Un-Sprinklered T O-ODX Mllllii Figure G-18. Heat Fluxes versus Time for Unsprinklered and Sprinklered Mockup. Gauges positioned facing ceiling (1.44 m above floor) at location C. Figure G-19. Heat Fluxes versus Time for Unsprinklered and Sprinklered Mockup. Gauges positioned facing ceiling (1.44 m above floor) at location D. G-14

Figure G-20. Radiation Fluxes versus Time for Unsprinklered and Sprinklered Mockup. Gauges positioned flush with ceiling, facing down (3.8 m above floor) at location C. Figure G-21. Radiation Fluxes versus Time for Unsprinklered and Sprinklered Mockup. Gauges positioned flush with ceiling, facing down (3.8 m above floor) at location 0. G-15

Figure G-22. Radiation Fluxes versus Time for Unsprinklered and Sprinklered Mockup. Gauges positioned flush with ceiling, facing down (3.8 m above floor) at location B. 100 X3 0 50 100 150 200 Time (s) Figure G-23. Heat Fluxes versus Time for Unsprinklered and Sprinklered Mockup. Gauges positioned flush with raised floor of platform, facing up at location B. G-16

G.4 References for Appendix G [1] "Cyanides, Aerosol and Gas, Method 7904," NIOSH Manual ofAnalytical Methods, Fourth Edition, 8/15/94. G-17

G-18

Appendix H. Polyurethane Foam - Chemistry H.1 polyurethane plastics Polyurethane refers to a large category of materials including surface coatings, elastomers, and foams, rigid or flexible, and thermoplastic or thermosetting [1,2]. While large quantities of polyurethanes are used to manufacture adhesives and protective coatings, the foam type of polyurethane is widely used in the production of upholstered furniture, bedding, sponges, toys, wearing apparel, and medical dressings. Rigid urethane foams are used for insulation in building constructions. Flexible polyurethane foams are used in packaging materials and acoustical insulation panels. The urethane linkage, which all polyurethanes have in common, involves the reaction of an isocyanate group with a hydroxyl-containing group. Common hydroxyl-bearing groups include polyether alcohols, polyester alcohols, carboxylic acids, and amines. The chemical structure, such as the length and side branching, of the hydroxyl-bearing group plays an important role in the properties of the final foam product. In general, short chain length compounds with tri- and trifunctional-alcohols, are used to produce more rigid foams while longer chain length compounds with trifunctional-alcohols are used to generate more flexible foams [3]. However, additional hydroxyl-containing compounds including glycerol, castor oil, raw sugar, sorbitol, isocyanate, and phenols can be incorporated to produce plastics with increased flexibility, increased rigidity, and increased heat resistance. If a polyether alcohol was selected as the primary hydroxyl-containing group, the resulting foam may be referred to as polyether polyurethane foam. Choosing a polyester alcohol as the hydroxyl bearing reactant will generate polyester polyurethane foam. Although the flammability of polyurethanes might be expected to be lower than those of many other polymers owing to their significant nitrogen content and the cross-linking usually present, in practice the fire performance of polyurethane-based materials is often poor due to the thin-walled structure and low density of the plastic foam [4]. The flame resistance properties of polyurethane foams can be improved by either incorporating additives into the foam or by careful selection of the hydroxyl-containing reactant. Flame retardant additives may be inorganic, such as diammonium phosphate, or organic compounds containing chlorine, bromine or phosphorus. The fire-retardants typically work either by vaporizing when heated and displacing the oxygen or by releasing moisture that absorbs energy and delays ignition. These additives can be mixed in with the product as it is manufactured or applied to the surface after production. But, the low degree of permanency and the adverse impact on the physical properties of the foam, stimulated development of a second method of improving flame resistance. The second method involves choosing the hydroxyl-bearing reactant to contain flame resistant groups such as chlorine, bromine, or phosphorus, or to contain copolymers that contain heat resistant groups such as isocyanurates, cyclic imides, or other nitrogen heterocycles [5]. The second method incorporates the flame retardant groups into the polymer structure itself, insuring even distribution and more permanence of the flame retardant compounds. H.2 POLYURETHANE CHEMISTRY As a group of plastics, polyurethane encompasses a large number of materials including foams, elastomers, and surface coatings. The final properties of polyurethane, such as flexible, semi-flexible, or H-1

rigid, thermoplastic or thermosetting, and closed cell or open cell, is determined by the starting materials, how the polymer is processed or produced, extent of crosslinking, and additives. Polyurethane is typically produced by reacting an isocyanate component with a polyol. Examples of three common isocyanate compounds, toluene-2,4-diisocyanate, toluene-2,6-diisocyanate, and diphenylmethane-4,4’ -diisocyanate (Figure H-1). The isocyanate functional groups are also highlighted for each compound. A polyol is a hydrocarbon with a number of alcohol functional groups. Simple alcohols such as ethyl alcohol (Figure H-2) may have only one alcohol functional group, but longer chain alcohols may have multiple alcohol groups (Figure H-2). As the isocyanate functional group reacts with an alcohol group (Figure H-3), the urethane linkage is formed. The chemical structure of the isocyanate and polyol components help determine the type and properties of the polyurethane. In addition to alcohol functional groups, polyols also incorporate other functional groups including ether and ester linkages. Examples of ether and ester functional groups are shown in Figure H-4. If the polyol incorporates multiple ether groups, such as polyethylene oxide or polypropylene oxide, then the resulting polyurethane will have a number of ether linkages and is typically referred to as a polyether polyurethane. Short carbon chain polyether alcohols with tri- and multi-functional groups; result in more rigid polyurethane foam. Long chain hydrocarbons with trifunctional groups are used to create more flexible foams. If the polyol incorporates multiple ester groups, then the resulting polyurethane will have a number of ester linkages and is termed as polyester polyurethane foam. Other polyols, including glycerol, sorbitol, raw sugar, and modified castor oils can be incorporated in the polyurethane making process to effect the degree of crosslinking, length of chains, increase elasticity, and increase heat resistance. If additional isocyanate is added and allowed to react with other isocyanate functional groups, isocyanurate rings can be formed. These rings produce a more stable chemical structure that can increase rigidity, improve thennal stability, and decrease flammability. If additional isocyanate is added along with water or carboxylic acid, the resulting reaction will release carbon dioxide during the reaction. The gaseous carbon dioxide will act as a blowing agent and create the open-cell structure that is characteristic of foams. H-2

TOLUENE-2,4-DIISOCYANATE TOLUENE-2,6-DIISOCYANATE GROUPS OCN NCO DIPHENYLMETHANE-4,4’-DIISOCYANATE ^0= .NA- UNc ^IOnAL V.. O-P or CJP Figure H-1. Isocyanate Compounds used in Polyurethane Production. H-3

CH5—CH^— OH ch3-^ch—OH ; . I ETHYL ALCOHOL ALCOHOL FUNCTIONAL GROUP OH OH HO CH 2— CH CH CH 2 OH POLYOL I HO l_ _ 4 ALCOHOL GROUPS CH I OH I I OH I I 2, I CH-L-LcH-MCH- I 1 ' 2 OH L Figure H-2. Example of Alcohol Functional Groups. H-4

TOLUENE-2,6-DIISOCYANATE POLYOL TOLUENE-2,4-DIISOCYANATE OCN OCN OCN GROUP GROUP Figure H-3. Reacting Isocyanate Compounds with Polyols to Form Polyurethane. H-5

CH5— CH^— O CH^— CH3 ETHYL ETHER r , CH3-^CH^—O CH2— CH3 ETHER FUNCTIONAL GROUP CH, CH;;— C CH2— CH3 ACETYL ACETATE CH3—CH;—C^ I ' CH2— CH3 ESTER FUNCTIONAL GROUP Figure H-4. Examples of Ether and Ester Functional Groups. H-6

H.3 REFERENCES FOR APPENDIX H [1] “Polyurethanes,” in Fire Retardant Materials, Edited by A.R. Horrocks and D. Price, Woodhead Publishing Limited, Cambridge England, 2001, pp. 243-245. [2] Fire Protection Handbook, Seventeenth Edition, A.E. Cote, Editor-in-Chief, National Fire Protection Association, Quincy, MA, p. 3-111, 2001. [3] Troitzsch, J., “The Burning of Plastics”, Chapter 4 in International Plastics Flammability Handbook, Second Edition, Hanser Publishers, New York, NY, 1983, pp 16 - 30. [4] “Polyurethanes,” in Fire Retardant Materials, Edited by A.R. Horrocks and D. Price, Woodhead Publishing Limited, Cambridge England, 2001, p. 244. [5] Frisch, K.C., and Reegen, S.L., “Relationship Between Chemical Structure and Flammability Resistance of Polyurethanes,” in Flame-Retardant Polymeric materials. Edited by M. Lewin, S.M. Atlas, and E.M. Pearce, Plenum Press, New York, NY, 1975, pp. 291-336. H-7

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Appendix I. Pyrolysis of Polyurethane Foam 1.1 Laboratory Report Number 2004-CC-045 This work was contracted with the US Army Aberdeen Test Center and coordinated by Dr. Steven H. Hoke of the Chromatography Analysis Division. U, S. Army Aberdeen Test Center 400 Colleran Road Aberdeen Proving Ground, MD 21005-5059 WARFIGHTER CORE APPLIED SCIENCES TEAM CHEMISTRY UNIT Attn: Steven H. Hoke, Ph.D. USACHPPM Chromatography Analysis Division 400 Colleran Road Bldg AA-363 APG, MD 21005 Project Number: None Report Number: 2004-CC-045a (amended 6 December 2004) Title: Combustion of Foam Panels This report shall not be reproduced except in its entirety without the written approval of the Chemistry Unit. The results relate only to the specific samples/test item/test scenario identified within this report. Authorized for Release: Signature Date: 6 December 2004 Judith D. Galloway Chief, Chemistry Unit l-l

CSTE-DTC-AT-WC-C (70-1 Or) 13 November 2003 MEMORANDUM FOR USACHPPM Chromatography Analysis Division, ATTN: Steven H. Hoke, Ph.D SUBJECT: Combustion of Foam Panels, Laboratory Report Number 2004-CC-045 1. References: a. Chemistry Team Internal Operating Procedure No. 360, Operation of 760 Fourier Transform Infrared Spectrometer with MCT-A detector. b. Chemistry Team Internal Operating Procedure No. 361, FTIR Analysis of Solids using the Brill Pyrolysis Cell.

1. Two samples from foam panels were received by the Chemistry Unit. The

samples were assigned sample numbers 0310027-01 and 0310027-02. See Tables 1 and 2, section 1.3, below for sample descriptions. The combustion products given off when these foam panels burn has become a concern. Identification of combustion products in air (21% oxygen) was requested. 3. Initial work with these samples focused on identification of the foam and adhesive on the foam. Next the foam was pyrolized in nitrogen. The final analytical determination was combustion of the foam in air. Most of the identification analysis was performed with the Continuum microscope linked with a Thermo-Nicolet Magnum FTIR optical bench. Pyrolysis and combustion were performed with a CDS pyrolysis (Brill) cell fitted in the sample compartment of the FTIR bench.

1. The samples were received wet with water. They were air dried before analysis

was begun. The identification analysis was performed using a FTIR spectrometer and an Attenuated Total Reflectance accessory (ATR) and the infrared microscope accessory (Thermo Continuum). The photographs and infrared spectra are in Figures 1 to 10, section 1.4. 5. Identification of the foam type was performed by running the infrared spectrum of the unburned foam sample 0310027-01 (Figures 1 and 2). The spectrum produced (Figure 3.) closely matched polyether urethane foam (Figure 4.). Since foam is a polymer product made with various monomers in various ratios an exact match is not possible. This match shows the basic components that make up the bulk of the material. This foam is therefore a polyether urethane co-polymer product. 1-2

CSTE-DTC-AT-WC-C (70-1 Or) MEMORANDUM FOR USACHPPM Chromatography Analysis Division SUBJECT: Combustion of Foam Panels, Laboratory Report Number 2004-CC-045

1. The picture of a foam cell in Figure 2. shows that each cell

is covered with a thick oily liquid. This liquid is not visible to the naked eye as shown in the picture in Figure 1. Identification of this liquid is essential as it is a significant component of the foam. The spectrum produced by the liquid (Figure 5.) closely matched polypropylene glycol (Figure 6.). 7. Figure 7. is a picture of the burned foam sample 0310027-02 with adhesive on the outer surface. The adhesive side of the foam was positioned against the ATR accessory and the infrared spectrum acquired (Figure 8). The library search produced the match seen in Figure 9. The best match is a latex rubber based mineral filled adhesive. A second library search was performed against a library of minerals and the library match shown in figure 10 was produced. The mineral filling in the adhesive is a silicate class compound similar to the natural mineral Kaolinite (see information with Figure 10).

1. The identification of the combustion products produced by the foam sample

0310027-01 was determined using Pyrolysis/Fourier Transform Infrared (FTIR) spectroscopy (reference la and 1b). See section 1.2 for an explanation of this technique. This type of analysis involves rapidly heating a small amount of the sample and monitoring the gas phase above the heated sample with FTIR spectroscopy. Gas products were identified using a Nicolet 760 FTIR spectrometer with an MCT-A detector. The sample was pyrolized (reference 1b) in a CDS Brill Cell, which fits into the sample compartment of the FTIR spectrometer so the gas products from heating could be identified in near real-time. The Brill Cell was connected to a CDS 2000 Pyrolizer equipped with a CDS FTIR probe rod. The probe rod contains a small electrically heated ribbon upon which the samples were placed. (The ribbon can be heated up to 1350°C at a variety of heating rates from 1 °C/min to 1 ,000,000 °C/sec. The samples (~2 mg each) were heated at 20 °C for 2 seconds then heated at a rate of 300 °C/second up to 1000 °C and held at 1000 °C for 30 seconds for this combustion study. Pyrolysis was also performed on these samples. Plots of the evolved gas phase spectra were then made. The gas spectra were searched against a database and identified.

1. Infrared spectra of pyrolysis and combustion of the samples are in Figures

1 through 19, section 1.4. Descriptive data on the samples is in Tables 1 and 2, section 1.3. Identification of the pyrolysis and combustion products is in Table 3. Since the two foam samples were identical only samples, 0310027-0, was pyrolyzed and combusted. 1-3

CSTE-DTC-AT-WC-C (70-1 Or) MEMORANDUM FOR CHPPM Chromatography Analysis Division SUBJECT: Combustion of Foam Panels, Laboratory Report Number 2004-CC-045 10. Pyrolysis occurs when the sample is heated in a 100% nitrogen atmosphere. Initial pyrolysis products are produced about 8 seconds into the 30 second heating time. Initial products frequently contain vaporized parent molecules (the starting compound). Final pyrolysis products are what are present at the end of the run (29 to 31 seconds). The parent molecule is often converted completely into lighter weight molecules by this time. 1 1 . The pyrolysis of foam is shown in Figures 11 to 14. The fully pyrolized foam is displayed in figure 1 1 . A large absorption at -2270 cm'^ is produced in this spectrum. The best library match; methyl isocyanate, is shown in figure 12. Figure 13. is the infrared spectrum of the pyrolized foam with all of the major absorption peaks labeled. Note that due to a lack of oxygen the amounts of carbon dioxide and carbon monoxide are low. 12. Figure 14 shows the foam pyrolysis progression. Initially the isocyanate compound (which is thought to be a mixture of Cl to C4 isocyanates) and foam vapor is detected, next carbon monoxide and carbon dioxide are formed from the foam vapor. The final pyrolysis products are an Isocyanate Compound (HyCxNCO), and much lesser quantities of Carbon Dioxide (CO2 ), Carbon Monoxide (CO), Ethylene (C2H4 ), Acetylene (C2H 2 ), Hydrogen Cyanide (HCN) and Vaporized Foam. The more oxygen starved the combustion of foam the more the gases produced will favor the final pyrolysis products. Not all of the foam is consumed in this pyrolysis. See section 1.5. for more information on the reaction mechanism and isocyanate compounds.

1. Combustion occurs when the sample is heated in an oxygen atmosphere.

Initial combustion products are produced about 8 seconds into the 30 second heating time. Initial products frequently contain vaporized parent molecules (the starting compound). Final combustion products are what are present at the end of the run (29 to 31 seconds). The parent molecule is often converted completely into carbon dioxide and water vapor by this time.

1. The combustion of the foam

is shown in Figures 15 through 18. The fully combusted foam is displayed in figure 15. A large absorption at -2270 cm'^ is produced in this spectrum. The best library match; an isocyanate compound, is shown in figure 16 along with the major gases that are produced in this combustion. Figure 17 is the infrared spectrum of the combusted foam with all of the major absorption peaks labeled. 1-4

CSTE-DTC-AT-WC-C (70-1 Or) MEMORANDUM FOR CHPPM Chromatography Analysis Division SUBJECT: Combustion of Foam Panels, Laboratory Report Number 2004-CC-045 15. Figure 18 shows the foam combustion progression. The initial combustion products are the isocyanate compound (which is thought to be a mixture of Cl to C4 isocyanates) and foam vapor. At this point (about 6 seconds into the combustion) the products are the same as pyrolysis. As the combustion progresses (see middle and lower spectra on Figure 18.) large quantities of carbon dioxide and carbon monoxide are produced. The final products are the Isocyanate Compound (HyCxNCO), Carbon Dioxide (CO2), Carbon Monoxide (CO), Methane (CH4), Ethylene (C2H4 ), Acetylene (C2H 2 ), Hydrogen Cyanide (HCN), and Vaporized Foam. Combustion is incomplete as evidenced by the presents of carbon monoxide and foam vapor. See section 1.5. for more information on the reaction mechanism and isocyanate compounds.

1. Figure 19.

is included to show some of the major functional chemical groups in the original foam. The aliphatic hydrocarbons produce Methane (CH4 ), Ethylene (C2H 4 ), Acetylene (C2H 2 ), as they break down into smaller molecules during combustion. As these smaller molecules are oxidized (combusted) they form Carbon Dioxide (CO2 ) and Carbon Monoxide (CO). The isocyanate compound is released from the polymer backbone by the heat of combustion and forms the mixture of Cl to C4 isocyanates. The nitrile compound is the most likely source of the hydrogen cyanide. The ether and urethane (not labeled) parts of the foam also form isocyanates (see section 1.5 explanation of thermal degradation mechanisms). All other parts on the foam contribute to the Carbon Dioxide (CO2 ) and Carbon Monoxide (CO) seen in the combustion spectra.

1. The POC for this report is Paul Marsh, (410) 278-3024.

1-5

1. 2

Analytical Method: Fourier Transform Infrared Spectroscopy With Brill Pyrolysis Cell Fourier transform infrared spectroscopy (FTIR) is an analytical technique that exploits the infrared light absorbing characteristics of chemical compounds. Most major chemical functional groups i.e., alcohols, hydrocarbons, ethers etc., have specific absorption bands in the infrared region of the light spectrum. From noting which infrared frequencies a sample absorbs, the chemical structure of a sample can be determined. Quantitative information can be determined from the intensity of the absorption bands. An FTIR spectrophotometer is the instrument used to scan the infrared light region. The instrument produces a plot of absorption vs. infrared frequency. The major parts of an FTIR spectrophotometer with Brill Pyrolysis Cell are as follows: 1 . Source of infrared light (glowbar) 2. Interferometer (frequency modulator) 3. Brill pyrolysis Gas Cell (sample is held in the cell) with heated probe 4. Detector of infrared light (MCT semiconductor)

1. Computer controller with Data Base of infrared spectra

The Brill Pyrolysis Cell is an accessory that fits into the sample compartment of the FTIR spectrometer. The accessory has two parts the gas cell and pyrolysis probe. The pyrolysis probe has a filament (ribbon) that can be rapidly heated to greater than 1000 degrees Celsius. The sample is placed on this ribbon and the probe is placed in the gas cell. The gas cell is a fixed volume container that holds all the gases produced by the pyrolysis of the sample. The atmosphere in the cell can be selected to match the experiment i.e. nitrogen for pyrolysis or nitrogen oxygen mixture for combustion. The cell can be set for static or dynamic flow. The infrared beam passes through the cell and the gases are detected by the FTIR. To determine the chemical makeup of samples, they must be compared to reference standards. Libraries of gas samples are available to identify the gases detected. 1-6

1. 3

Sample Identification and Expected Products Table

1. Foam Sample Identification

Sample Number Common Name Description 0310027-01 Gray polyether urethane foam New Unburned foam 0310027-02 Gray polyether urethane foam Piece 1 Foam with adhesive Piece 2 Burned Foam Table 2. Foam Sample Descriptions Sample Number Description 0310027-01 RI1 Northwall Unburned 9/5/03 0310027-02 RI1 Drummer’s Box Burnt Foam 9/5/03 Table 3. Foam Pyrolysis and Combustion Products Sample Number Test Expected Combustion Products 0310027-01 Pyrolysis Isocyanate Compound (HxCxNCO), Carbon Dioxide (CO2 ), Carbon Monoxide (CO), Ethylene (C2H 4 ), Acetylene (C2H 2 ), Hydrogen Cyanide (HCN), Vaporized Foam 0310027-01 Combustion Isocyanate Compound (HxCxNCO), Carbon Dioxide (CO2 ), Carbon Monoxide (CO), Methane (CH 4 ), Ethylene (C2H 4 ), Acetylene (C2H 2 ), Hydrogen Cyanide (HCN), Vaporized Foam 1-7

1. 4

Identification Figure

1. Sample 0310027-01 unburned foam.

Figure 2. Microscope picture of sample 0310027-01 unburned foam at 100X magnification. This is a picture of one foam cell. All of the foam cells outer edges are covered in a thick clear liquid. This cell has the liquid actually spanning the open area of the cell. 1-8

0,32-Sample 0310027-01 cell and oil Mon Nov 10 12:57:23 2003 (GMT-05:00) Figure 3. Infrared spectrum of sample unburned gray foam. Sample unburnt foam Tue Oct 28 09:22:44 2003 (GMT-05:00) 10 - Polyether urethane, PPO+MBI 0 . 8 - 0 .6 - Figure 4. Infrared spectrum of sample unburned gray foam (top), polyether urethane foam (bottom). 1500 1000 1500 1000 best library match 1-9

Figure 5. Infrared spectrum of sample oil on unburned gray foam. Figure 6. Infrared spectrum of sample oil on unburned gray foam (top), best library match polypropylene glycol (bottom). I-IO

Absorbance Figure 7. Sample 0310027-02 piecel foam with adhesive. Figure 8. Infrared spectrum of sample foam adhesive. I-ll

Sample NIST Foam Burned.SPA Sample NIST Foam Burned Tue Oct 28 09:55:02 2003 (GMT-05:00) Wavenumber (cm-1) Figure 9. Infrared spectrum of foam adhesive (top), best library match a mineral filled latex based adhesive (bottom). Database Information: WELDWOOD MULTI-PURPOSE FLOOR ADHESIVE Chemical Description= LATEX-BASED ADHESIVE Content= Solids Content= 55% Density= (Specific Gravity)= 1.17 g/ml FlashPt= (PMCC) 100 °C Flash and Fire Weight= 9.5 LBS/GAL 1-12

Figure 1 0. Infrared spectrum of sample foam adhesive (top), Best library match of the mineral filler kaolinite Al 2Si205 (0 H)4 , (bottom). Database Information on KAOLINITE: • Chemistry: Al2Si20s(0H)4. Aluminum Silicate Hydroxide • Uses: In the production of ceramics, as a filler for paint, rubber and plastics and the largest use is in the paper industry to produce a glossy paper such as is used in most magazines. 1-13

Pyrolysis Figure 11. Infrared spectrum of foam pyrolysis. The isocyanate peak 2270 cm'^ is from a class of compounds with the general formula HxCxHNO. These compounds are very toxic. Wavenumbers (cm-1) Figure 12. Infrared spectrum of sample pyrolized foam (top). Best library match is methyl isocyanate (peak -2270 cm'^). This is a match to a class of isocyanate compounds. Methyl, Propyl, and even Butyl isocyanate have spectra that cannot be distinguished at this resolution. 1-14

Gray Foam Pyrolysis Spectrum Figure 13. Infrared spectrum of gray foam pyrolysis with gases labeled. The more oxygen starved the combustion the more the final products will be similar to the pyrolysis products. Figure 14. Infrared spectrum of foam pyrolysis progression. 1-15

Combustion Figure 15. Infrared spectrum of foam combustion in air. Figure 16. Infrared spectrum of foam combustion (top) and identified gases below. 1-16

Figure 18. infrared spectrum of foam combustion progression. Note the growth of the carbon monoxide peak (centered at 2150 cm'^) as the combustion progresses from 5 to 30 seconds. The isocyanate compound peak (-2270 cm’^) dominates each spectrum. The polypropylene peak (-1100 cm'^) is decreasing showing that the oily polypropylene glycol compound is being consumed as the combustion progresses. 1-17

Absorbance Figure 19. Infrared spectrum of gray polyether urethane foam with major structures labeled. 1-18

1. 5

Background Information 0 I ! -i- 1 I y_K— -O Ure:ha;ie- Ether Figure 1 . Basic chemical structure of polyether urethane foam. The chemical structure of the foam as shown in Figure 1 . consists of two parts. The left side of the figure shows the urethane (OC=ONH) structure, the right side shows the ether (O—C—O) structure. Tlic thermal degradation mechanism of [>ol\ iiiethane is \’cr\ complicated. It has Lx"en suggested that pohenrethanes break down by a combination of three independent pathwa)s: ( I ) dissociation to the original poK’ol and isoc>anate; (2 1 formation of a jsnmary amine, an alkene. and a carbon dioxide m a concerted reaction m\ ol\ ing a six- membered cyclic transition state: formation of a secondary amine and carbon dioxide through a four-membered ring transition state, as shown m Scheme 2.2.[ 143-14^] () II R— Nil—i— OR’ ^ R-N=i =o R'-Oll ill + OCo 1 .0 Reference: pg 50 of http://scholar.lib.vt.edu/theses/available/etd-72698- 1 3572/unrestricted/Disswhl2.odf From the referenced combustion mechanism above pathway 1 which produces isocyanates must be the dominant combustion pathway. The large isocyanate peak in both the pyrolysis and combustion spectra of Figure 2. support this. 1-19

Figure 2. Infrared spectrum of foam pyrolysis gases (top) and combustion gases (bottom). The dominate peak in each spectrum is the peak at -2270 cm'^). This peak most closely matches isocyanate compounds (see figure 3). The related isocyanide compounds are not a good match (see figure 4) because their absorbance is too far from 2270 cm‘ 1-20

10"Methyl isocyanate, H3C-N=C=0 CAS# 624-83-9 10

• Ethyl isocyanate, H3CH2C-N=C=0 CAS# 109-90-0

10

• Propyl isocyanate, H3CH2CH2C-N=C=0 CAS# 110-78-1

1. 0

Isopropyl isocyanate, (H3C)2HC-N=C=0 CAS# 1795-48-8 3500 3000 2500 2000 Wavenumbers (cm-1) 2267 / 2263 A. 1500 1000 Figure 3. Infrared spectra of selected isocyanate compounds all with absorbances in the 2270 +/- 9 cm'^ range. These are some of the most likely compounds to match the 2270 cm ^ peak in the pyrolysis and combustion spectra (Figure 2.). ; Hexyl isocyanide, H11C6-C=N CAS# 15586-23-9 Figure 4. Infrared spectra of selected isocyanide compounds. These have a slightly different structure than the isocyanate compounds in Figure 3. These do not match the 2270 cm'^ peak in the pyrolysis and combustion spectra (Figure 2.). 1-21

Appendix J. Hydrogen Cyanide Analysis J.1 HYDROGEN CYANIDE REPORT This work was contracted with the US Army Aberdeen Test Center and performed by Dr. Steven H. Hoke of the Chromatography Analysis Division. TEST #: 1 Sprinkler September 5, 2003 TEST #: 2 No Sprinkler September 10, 2003 ORGANIZATION: NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, GAITHERSBURG, MD TEST FIXTURE: Rhode Island Test SETUP: Two sampling positions were used to conduct real-time hydrogen cyanide analysis on two different test days at NIST. The two sampling positions were designated position 1 (West - NIST Location D) and position 2 (East- NIST Location C), and were 3.66 m and 1.83 m west of the stage, respectively. Each sample position was located 1.5 m off the floor and 2.74 m from the south wall of the compartment (Figure J-1). Position 2, East NIST Sampling Location C Position 1, West 1ST Sampling Location D Figure J-1. Sampling positions inside Rliode Island test fixture. J-1

The Sampling equipment was located on a table just outside the south wall of the compartment. Air samples were taken through a 'A-in. o.d. 304 stainless steel tubing. An additional 3 ft. of stainless steel tubing was placed on the outside to provide for cooling of the hot sample gases. A stainless steel 4-port sampling manifold using Swagelok tees was attached to the end of each sample line. Red silicone tubing was used to attach samplers to the manifold (Figure J-2). Figure J-2. Sampling set up at Position 1 for test 1. At each sampling position two impinger samples were taken, one with a filter and one without. Each of these impingers used 0.1 M KOH as trapping solution. For the first test two mini gas real-time cyanide analyzers were used at position 1 and a suitcase-size version of the analyzer was used at position 2. For test 2 a mini gas analyzer was used at each position. Airflow rates were measured and recorded before each test. Voltage signals from the analyzers were recorded on data loggers and also sent to the main control computer. With the high gas temperatures anticipated a 3 -ft. extension of stainless steel tubing was attached between the exterior wall and the sampling manifold. To determine the cooling effect this had on the sample gases, a T type thermocouple was attached to the stainless steel tubing just outside the wall and one just before the sampling manifold. A Fluke model 2635A Hydra Series II Data Bucket collected data from each of the J-2

two thermocouples. This data was only collected for the second test because higher temperatures were anticipated. After the second test both of the 9-ft. stainless steel lines were removed from the test fixture and rinsed in a vertical position with 10 mL of 0.1 M KOH. Upon returning to the laboratory the filters were weighed and then placed in a screw cap-polypropylene test tube with 10 mL of 0.1 M KOH. After each test the contents of the impingers were transferred to a test tube and labeled. Impinger samples were analyzed according to XIOSH Method 7904. The real-time mini gas analyzers as described elsewhere (Paper submitted to J. Process Anal. Chem. for publication) were modified to use an off-the-shelf cyanide combination electrode and 0. 1 M KOH as the trapping solution. Calibration standards were prepared in 0.1 M KOH using KCN at levels of 2, 5, 10, and 30-ppm cyanide. This corresponds to an upper and lower calibration limit in air of 153 and 10 ppm HCX, respectively. The gas analyzer showed linearity up to 1284 ppm HCN in air, so the high values obtained during the second test can be considered valid. RESULTS: Figures J-3 to J-5 show real-time results from the three HCN gas analyzers used for test 1 conducted on 5 Sept 03. The automatic sprinkler system activated at about 25 sec.; therefore, there was very little HCX produced. Test Number NIST 1 Septemoer 5. 2003 Analyzer Number Position 1A, MG1 -500 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 Time (seconds) Figure J-3. Hydrogen cyanide response from mini gas analyzer located at position 1. J-3

Test Number NIST 1 September 5, 2003 Analyzer Number Position IB, MG2 Figure J-4. Hydrogen cyanide response from mini gas analyzer located at position 1. Test Number NIST 1 September 5, 2003 Analyzer Number Position 2B Time (seconds) Figure J-5. Hydrogen cyanide response from large gas analyzer located at position 2. J-4

Figures 3-6 and 3-7 show real-time results from the two mini gas HCN analyzers used for test 2 conducted on 10 Sept 03. This fire burned much longer and as indicated by the response produced much higher values of HCN. Test Number NIST 2 Position 1 September 10, 2003 Analyzer Number MG1 Figure J-6. Hydrogen cyanide response from mini gas 1 located at position 1 Test Number NIST 2 Position 2 September 10. 2003 Analyzer Number MG2 Figure J-7. Hydrogen cyanide response from mini gas 2 located at position 2. J-5

Impinger and filter samples were analyzed according to NIOSH method 7904. Table J-1. Impinger data for Rhode Island Tests. (All values reported in ppm HCN for the indicated run time. ) Position Test Date Impinger ppm HCN Impinger (Filter) ppm HCN Filter ppm HCN Run Time 1 (West) (NIST Sample Location D) 5 Sept 03 5.0 4.7 BDL 8 min. 2 (East) (NIST Sample Location D) 5 Sept 03 5.1 5.0 BDL 8 min. I (West) (NIST Sample Location D) 10 Sept 03 213 153 BDL 1 .67 min. 2 (East) (NIST Sample Location D) 10 Sept 03 248 176 BDL 1 .67 min. BDL= Below Detection Limit of 2.5 ppm. For example at Position Ion 5 Sept 03 the impinger measured an 8-min. TWA of 5 ppm HCN. At Position 1 on 10 Sept 03, a TWA of 213 ppm HCN was measured over a time of 1.67 min. The impinger values may be low compared to the gas analyzer values because the impinger bubbler may not quantitatively collect aerosol fomis of HCN. The impingers behind the filters were expected to be lower than those of the impingers with no filters because any HCN collected on the filters, as aerosols would not be part of the impinger measurement. Because of the large amount of particulate matter on the filter, it was decided to estimate the total weight on the filter prior to cyanide analysis. However, any aerosol forms of HCN on the filters from test 2 were lost because of the time required to obtain filter weights. The filters were photographed after the second test because they appeared to have a large amount of particulate matter on them (photographs were not available to include in this report). For this reason it was J-6

decided to weigh the filters in an attempt to estimate exposure to total particulate matter. Since the filters were not pre-weighed, six new filters were weighed from the same pack to establish a tare weight. The weight of the filter from position 1 was significantly different from the mean so that % of the time we would be wrong in making that assumption. The difference between the mean filter weight and that of position 1 was 24.540 mg. This calculates to an exposure level of 12,649 mg/m^. This is considerably higher than the OSHA PEL TWA of 15 mgW (see attachment J-1). The weight of the filter from position 2 was not significantly different from the mean. The data from the two thermocouples was recorded at 10-sec. intervals. The figure below shows that the 3- ft. extension successfully cooled the sample gases prior to entering any of the sampling devices. Temperature Drop Across Cooling Tube NIST 10 Sept 03 Time (Seconds) After the first test one of the 9-ft. lines was rinsed with 1 0 mL of 0. 1 M KOH. After test 2 both of the 9-ft. stainless steel sample lines were rinsed. For the second test both of the rinses has a yellow tinge; however, line 2 rinse was much darker. Analysis of all three samples for anions by ion chromatography showed a small amount of chloride and a very large amount of sulfate ion. The amount of HCN measured in the rinse samples represented only a few percent of the total HCN measured. Two foam samples, one unbumed and one partially burned, from the test on 5 Sept 03, were submitted to the FTIR lab at the Aberdeen Test Center for analysis. The pyrolysis and combustion analysis both showed the presence of hydrogen cyanide and organo ioscyanates, which could include methyl isocyanate. According to NIOSH and OSHA methyl isocyanate is much more of an exposure hazard than hydrogen cyanide (Appendix FF-2 and FF-3). J-7

The attached report summarizes the FTIR work. This FTIR technique could be a valuable tool for predicting the types of compounds to sample for prior to conducting the actual test bum. In this way the proper sampling devices could be obtained and the calibration ranges could be adjusted to match anticipated levels of combustion products produced in a fire. Steven H. Hoke Ph.D., CIH USACHPPM Bldg. 363 APG, MD 21005-5059 Phone 410-278-2269 Fax 410-278-9622 Steven.hoke@apg.amedd.army.mil J-8

J.2 NIOSH POCKET GUIDE TO CHEMICAL HAZARDS J.2.1 Particulates not otherwise regulated CAS RTECS Synonyms & Trade Names "Inert" dusts, Nuisance dusts, PNOR [Note: Includes all inert or nuisance dusts, whether mineral, inorganic, not listed specifically in 1 9 1 0. 1 000.] DOD ID & GuideExposure Limits NIOSH REL: See Appendix D OSHA PEL: TWA 15 mg/m^ (total) TWA 5 mg/m^ (resp) IDLH N.D. See: IDLH INDEX Conversion Physical Description Dusts from solid substances without specific occupational exposure standards. Properties vary depending upon the specific solid. Incompatibilities & Reactivities Varies Measurement Methods NIOSH 0500, 0600 See; NMAM or OSHA Methods Personal Protection & Sanitation Skin: No recommendation Eyes; No recommendation Wash skin: No recommendation Remove: No recommendation Change; No recommendation First Aid (See procedures) Eye: Irrigate immediately Breathing; Fresh air Important additional information about respirator selection Respirator Recommendations To be added later Exposure Routes inhalation, skin and/or eye contact Symptoms Irritation eyes, skin, throat, upper respiratory system Target Organs Eyes, skin, respiratory system See also: INTRODUCTION J-9

J.2.2 Methyl isocyanate CAS 624-83-9 CH 3NCO RTECS NQ94500Q0 Synonyms & Trade Names Methyl ester of isoeyanie aeid, MIC DOT ID & Guide 2480 155 Exposure Limits NIOSH REL: TWA 0.02 ppm (0.05 mgW) [skin] OSHA PEL: TWA 0.02 ppm (0.05 mg/m^) [skin] IDLH 3 ppm See; 624839 Conversion 1 ppm = 2.34 mg/m^ Physical Description: Colorless liquid with a sharp, pungent odor. MW: 57.1 BP:102

• 104°F

FRZ; -49°F Sol (59°F): 10% VP: 348 mmHg IP: 10.67 eV Sp.Gr: 0.96 Fl.P: 19°F UEL: 26% EEL: 5.3% Class IB Flammable Liquid; Fl.P. below 73°F and BP at or above 100°F. Incompatibilities & Reactivities Water, oxidizers, aeids, alkalis, amines, iron, tin, eopper [Note: Usually eontains inhibitors to prevent polymerization.] Measurement Methods OSHA 54_ See: NMAM or OSHA Methods Personal Protection & Sanitation Skin: Prevent skin contaet Eyes: Prevent eye contact Wash skin: When contaminated Remove: When wet (flammable) Change: No recommendation Provide: Eyewash, Quick drench First Aid (See procedures) Eye: Irrigate immediately Skin: Water flush immediately Breathing: Respiratory support Swallow: Medical attention immediately Important additional infonuation about respirator selection Respirator Recommendations NIOSH/OSHA Up to 0.2 ppm: (APF = 10) Any supplied-air respirator* Up to 0.5 ppm: (APF = 25) Any supplied-air respirator operated in a continuous-flow mode* Up to 1 ppm: (APF = 50) Any self-contained breathing apparatus with a full facepiece/(APF = 50) Any supplied-air respirator with a full facepiece Up to 3 ppm: (APF = 2000) Any supplied-air respirator that has a full facepiece and is operated in a pressure-demand or other positive-pressure mode Emergency or planned entry into unknown concentrations or IDLH conditions; (APF = 10,000) Any self- contained breathing apparatus that has a full facepiece and is operated in a pressure-demand or other positive-pressure mode/(APF = 10,000) Any supplied-air respirator that has a full facepiece and is operated in a pressure-demand or other positive-pressure mode in combination with an auxiliary self-contained positive-pressure breathing apparatus Escape: (APF = 50) Any air-purifying, fiill-facepiece respirator (gas mask) with a chin-style, front- or back-mounted organic vapor canister/Any appropriate escape-type, self-contained breathing apparatus Exposure Routes inhalation, skin absorption, ingestion, skin and/or eye contact Symptoms Irritation eyes, skin, nose, throat; respiratory sensitization, cough, pulmonary secretions, chest pain, dyspnea (breathing difficulty); asthma; eye, skin damage; in animals: pulmonary edema Target Organs Eyes, skin, respiratory system See also: INTRODUCTION See ICSC CARD: 0004 See MEDICAL TESTS: 0143 J-10

J.2.3 Hydrogen cyanide CAS 74-90-8 HCN RTECS MW6825000 Synonyms & Trade Names Formonitrile, Hydrocyanic acid, Prussic acid DOT ID & Guide 1051 117 (>20% solution) 1051 1 17 (anhydrous) 1613 15^(

Appendix K. Code Comparison Tables mc< E c/3 E c/3 £

• m

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• "o

o "c T3 ^ E ^ Cl CL Cl c: (/) CO 0) O ^ o ^ c o CO D c i: CD CO 3 O Q. Cl CO

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